Split (1)

train · 2.08M rows

ROW_ID string	SUBJECT_ID string	HADM_ID string	CHARTDATE string	CATEGORY string	DESCRIPTION string	TEXT string	MASK_LABEL string	binary_label string	input_text string	Chunks string
125	24470	174469.0	2130-12-31	Discharge summary	Report	Admission Date: [2130-12-24] Discharge Date: [2130-12-31] Date of Birth: [2051-1-26] Sex: M Service: MEDICINE Allergies: Amiodarone / Quinidine / Procainamide / Quinine / Codeine Attending:[First Name3 (LF) 425] Chief Complaint: hypotension, hyperkalemia Major Surgical or Invasive Procedure: Hemodialysis catheter placement History of Present Illness: Mr. [Known lastname 1349] is a 78-year-old male with a history of ventricular fibrillation arrest in [2108], status post ICD placement, dilated cardiomyopathy, atrial fibrillation, hypertension, and CVA who presented to the [Hospital1 18] ED complaining of 8 lb weight gain with increased edema of LE over one week despite compliance with medications. Decreased po intake over past week. No SOB, chest pain, syncope, fatigue. Found to be hypotensive and hyperkalemic in the ED. ROS positive for epistaxis (was taking Afrin for this), occasional nausea and nonbloody/nonbilious vomitting. Past Medical History: 1. Ventricular fibrillation arrest in [2108] - has had ICD placement. 2. Dilated cardiomyopathy. Echocardiogram in [2126-2-27] showed an ejection fraction of 20% with inferoapical hypokinesis plus right ventricular hypokinesis. 3. Atrial fibrillation, status post DC cardioversion in [2114], on coumadin. 4. Hypertension. 5. Hypothyroidism. 6. Cerebral vascular accident in [2117]. 7. Rheumatoid arthritis. 8. Positive lupus anticoagulant. Social History: Mr. [Known lastname 1349] lives with his wife. [Name (NI) ] denies any tobacco or drug use. He does note occasional alcohol use. Physical Exam: T 97.0. Blood pressure 84/54. Heart rate 81. Respiratory rate 10. Oxygen saturation 100% on RA. In general, in no acute distress, alert and oriented times three, overweight man. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Oropharynx is pink without lesions, mucous membranes dry. Nares with dry blood. Neck is supple. Unable to determine JVD secondary to excess soft tissue at neck. No lymphadenopathy. Chest clear to auscultation bilaterally. Cardiovascular: RRR, S1, S2 are faint. A 2/6 systolic ejection murmur at the apex. Abdomen soft, nontender, nondistended. Extremities: 1+ pitting edema bilaterally. No clubbing or cyanosis. Dorsalis pedis pulses are 1+ bilaterally. Neurologically, alert and oriented times three. Cranial nerves II through III are intact. Strength is [5-3] in upper and lower extremities bilaterally. Sensation to light touch is intact. Deep tendon reflexes are decreased bilaterally but equal. Pertinent Results: [2130-12-24] 01:30PM PT-25.5* PTT-56.8* INR(PT)-4.1 [2130-12-24] 01:30PM NEUTS-94.2* BANDS-0 LYMPHS-2.3* MONOS-3.0 EOS-0.4 BASOS-0 [2130-12-24] 01:30PM WBC-10.0 RBC-2.45# HGB-8.1# HCT-24.3# MCV-99 MCH-33.0* MCHC-33.3 RDW-15.5 [2130-12-24] 01:30PM DIGOXIN-0.3* [2130-12-24] 01:30PM TSH-3.3 [2130-12-24] 01:30PM calTIBC-267 FERRITIN-786* TRF-205 [2130-12-24] 01:30PM ALBUMIN-4.0 CALCIUM-8.5 PHOSPHATE-10.8# MAGNESIUM-2.3 IRON-104 [2130-12-24] 01:30PM CK-MB-22 MB INDX-3.7 cTropnT-0.36* [2130-12-24] 01:30PM LIPASE-96* [2130-12-24] 01:30PM ALT(SGPT)-38 AST(SGOT)-46* CK(CPK)-595* ALK PHOS-192* AMYLASE-137* TOT BILI-0.6 [2130-12-24] 01:30PM GLUCOSE-123* UREA N-272* CREAT-5.4# SODIUM-126 POTASSIUM-7.5* CHLORIDE-92* TOTAL CO2-16* ANION GAP-26* [2130-12-24] 02:02PM LACTATE-1.8 K+-7.5* [2130-12-24] 02:02PM TYPE-[Last Name (un) ] PO2-60* PCO2-42 PH-7.21* TOTAL CO2-18* BASE XS--10 COMMENTS-GREEN TOP [2130-12-24] 03:54PM K+-6.6* [2130-12-24] 05:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-4 [2130-12-24] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2130-12-24] 05:00PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.011 [2130-12-24] 05:00PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO OSMOLAL-371 [2130-12-24] 05:00PM URINE HOURS-RANDOM UREA N-577 CREAT-89 SODIUM-27 TOT PROT-15 PROT/CREA-0.2 [2130-12-24] 10:40PM PT-33.0* PTT-150* INR(PT)-6.9 [2130-12-24] 10:40PM PLT COUNT-79* [2130-12-24] 10:40PM WBC-7.4 RBC-2.52* HGB-8.2* HCT-24.1* MCV-96 MCH-32.7* MCHC-34.2 RDW-15.2 [2130-12-24] 10:40PM PEP-NO SPECIFI [2130-12-24] 10:40PM calTIBC-264 HAPTOGLOB-143 FERRITIN-761* TRF-203 [2130-12-24] 10:40PM TOT PROT-6.6 CALCIUM-8.1* PHOSPHATE-5.2# MAGNESIUM-1.8 URIC ACID-3.4 IRON-90 [2130-12-24] 10:40PM CK-MB-20 MB INDX-3.9 cTropnT-0.34* [2130-12-24] 10:40PM LD(LDH)-326* CK(CPK)-517* TOT BILI-0.7 [2130-12-24] 10:40PM GLUCOSE-140* UREA N-135* CREAT-2.8# SODIUM-137 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17 Brief Hospital Course: In ED, noted to have renal failure, K+ 7.5 with EKG changes, given HCO3, 1L IVF, insulin, kayexelate, and transferred to MICU. . In MICU, interrogation of ICD showed no VT or VF but multiple episodes of NSVT. Pt tolerated two treatments of HD for uremia/hyperkalemia. He was started on hydrocortisone/fludrocortisone for adrenal insufficiency. Pt was evaluated for retroperitoneal hematoma/femoral hematoma w/ femoral US/Abd CT which and showed femoral hematoma. He received 3 units of PRBCs for decreased HCT and femoral hematoma. [12-26] during HD treatment, pt developed VT w/ recurrent ICD shocks, rhythm converted to VF, received lidocaine and amiodarone boluses, ICD was reprogrammed. Pt then transferred to CCU service for further observation. While in the CCU pt had further episodes of VT and so antiarrhythmic regimen was changed. Patient became hypotensive in am of [2130-12-30] felt to be septic secondary to line sepsis from femoral cath. Patient started on Neo for pressure support. Patient mental status continued to deteriorate throughout day and into night. After lengthy discussion with family,family wished to make patient CMO. Patient ICD was turned off on [2130-12-30] so it would still pace but would not intervene if patient had arrythmia. Patient kept on morphine drip for comfort and all other meds d/c'd. The patient became more hypotensive and expired on [2130-12-31]. Medications on Admission: Home meds: lasix 120 [Hospital1 ], prilosec, diovan 80, coumadin, allopurinol 100, synthroid 25, prednisone 5, aldactone, dig .125, astelin Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA Completed by:[2131-1-4*]	Admission Date: <Date>2002-8-26</Date> Discharge Date: <Date>1970-7-30</Date> Date of Birth: <Date>1998-1-12</Date> Sex: M Service: MEDICINE Allergies: Amiodarone / Quinidine / Procainamide / Quinine / Codeine Attending:<Name>Charlotte</Name> Chief Complaint: hypotension, hyperkalemia Major Surgical or Invasive Procedure: Hemodialysis catheter placement History of Present Illness: Mr. <Name>Luu</Name> is a 78-year-old male with a history of ventricular fibrillation arrest in <Year>1964</Year>, status post ICD placement, dilated cardiomyopathy, atrial fibrillation, hypertension, and CVA who presented to the <Hospital>Ward, Spence and Collins Health System</Hospital> ED complaining of 8 lb weight gain with increased edema of LE over one week despite compliance with medications. Decreased po intake over past week. No SOB, chest pain, syncope, fatigue. Found to be hypotensive and hyperkalemic in the ED. ROS positive for epistaxis (was taking Afrin for this), occasional nausea and nonbloody/nonbilious vomitting. Past Medical History: 1. Ventricular fibrillation arrest in <Year>1964</Year> - has had ICD placement. 2. Dilated cardiomyopathy. Echocardiogram in <Date>1904-7-18</Date> showed an ejection fraction of 20% with inferoapical hypokinesis plus right ventricular hypokinesis. 3. Atrial fibrillation, status post DC cardioversion in <Year>1964</Year>, on coumadin. 4. Hypertension. 5. Hypothyroidism. 6. Cerebral vascular accident in <Year>1964</Year>. 7. Rheumatoid arthritis. 8. Positive lupus anticoagulant. Social History: Mr. <Name>Luu</Name> lives with his wife. <Name>Harold Hall</Name> denies any tobacco or drug use. He does note occasional alcohol use. Physical Exam: T 97.0. Blood pressure 84/54. Heart rate 81. Respiratory rate 10. Oxygen saturation 100% on RA. In general, in no acute distress, alert and oriented times three, overweight man. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Oropharynx is pink without lesions, mucous membranes dry. Nares with dry blood. Neck is supple. Unable to determine JVD secondary to excess soft tissue at neck. No lymphadenopathy. Chest clear to auscultation bilaterally. Cardiovascular: RRR, S1, S2 are faint. A 2/6 systolic ejection murmur at the apex. Abdomen soft, nontender, nondistended. Extremities: 1+ pitting edema bilaterally. No clubbing or cyanosis. Dorsalis pedis pulses are 1+ bilaterally. Neurologically, alert and oriented times three. Cranial nerves II through III are intact. Strength is <Date>7-2</Date> in upper and lower extremities bilaterally. Sensation to light touch is intact. Deep tendon reflexes are decreased bilaterally but equal. Pertinent Results: <Date>2002-8-26</Date> 01:30PM PT-25.5* PTT-56.8* INR(PT)-4.1 <Date>2002-8-26</Date> 01:30PM NEUTS-94.2* BANDS-0 LYMPHS-2.3* MONOS-3.0 EOS-0.4 BASOS-0 <Date>2002-8-26</Date> 01:30PM WBC-10.0 RBC-2.45# HGB-8.1# HCT-24.3# MCV-99 MCH-33.0* MCHC-33.3 RDW-15.5 <Date>2002-8-26</Date> 01:30PM DIGOXIN-0.3* <Date>2002-8-26</Date> 01:30PM TSH-3.3 <Date>2002-8-26</Date> 01:30PM calTIBC-267 FERRITIN-786* TRF-205 <Date>2002-8-26</Date> 01:30PM ALBUMIN-4.0 CALCIUM-8.5 PHOSPHATE-10.8# MAGNESIUM-2.3 IRON-104 <Date>2002-8-26</Date> 01:30PM CK-MB-22 MB INDX-3.7 cTropnT-0.36* <Date>2002-8-26</Date> 01:30PM LIPASE-96* <Date>2002-8-26</Date> 01:30PM ALT(SGPT)-38 AST(SGOT)-46* CK(CPK)-595* ALK PHOS-192* AMYLASE-137* TOT BILI-0.6 <Date>2002-8-26</Date> 01:30PM GLUCOSE-123* UREA N-272* CREAT-5.4# SODIUM-126 POTASSIUM-7.5* CHLORIDE-92* TOTAL CO2-16* ANION GAP-26* <Date>2002-8-26</Date> 02:02PM LACTATE-1.8 K+-7.5* <Date>2002-8-26</Date> 02:02PM TYPE-<Name>Olles</Name> PO2-60* PCO2-42 PH-7.21* TOTAL CO2-18* BASE XS--10 COMMENTS-GREEN TOP <Date>2002-8-26</Date> 03:54PM K+-6.6* <Date>2002-8-26</Date> 05:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-4 <Date>2002-8-26</Date> 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG <Date>2002-8-26</Date> 05:00PM URINE COLOR-Straw APPEAR-Clear SP <Name>Davis</Name>-1.011 <Date>2002-8-26</Date> 05:00PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO OSMOLAL-371 <Date>2002-8-26</Date> 05:00PM URINE HOURS-RANDOM UREA N-577 CREAT-89 SODIUM-27 TOT PROT-15 PROT/CREA-0.2 <Date>2002-8-26</Date> 10:40PM PT-33.0* PTT-150* INR(PT)-6.9 <Date>2002-8-26</Date> 10:40PM PLT COUNT-79* <Date>2002-8-26</Date> 10:40PM WBC-7.4 RBC-2.52* HGB-8.2* HCT-24.1* MCV-96 MCH-32.7* MCHC-34.2 RDW-15.2 <Date>2002-8-26</Date> 10:40PM PEP-NO SPECIFI <Date>2002-8-26</Date> 10:40PM calTIBC-264 HAPTOGLOB-143 FERRITIN-761* TRF-203 <Date>2002-8-26</Date> 10:40PM TOT PROT-6.6 CALCIUM-8.1* PHOSPHATE-5.2# MAGNESIUM-1.8 URIC ACID-3.4 IRON-90 <Date>2002-8-26</Date> 10:40PM CK-MB-20 MB INDX-3.9 cTropnT-0.34* <Date>2002-8-26</Date> 10:40PM LD(LDH)-326* CK(CPK)-517* TOT BILI-0.7 <Date>2002-8-26</Date> 10:40PM GLUCOSE-140* UREA N-135* CREAT-2.8*# SODIUM-137 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17 Brief Hospital Course: In ED, noted to have renal failure, K+ 7.5 with EKG changes, given HCO3, 1L IVF, insulin, kayexelate, and transferred to MICU. . In MICU, interrogation of ICD showed no VT or VF but multiple episodes of NSVT. Pt tolerated two treatments of HD for uremia/hyperkalemia. He was started on hydrocortisone/fludrocortisone for adrenal insufficiency. Pt was evaluated for retroperitoneal hematoma/femoral hematoma w/ femoral US/Abd CT which and showed femoral hematoma. He received 3 units of PRBCs for decreased HCT and femoral hematoma. <Date>11-29</Date> during HD treatment, pt developed VT w/ recurrent ICD shocks, rhythm converted to VF, received lidocaine and amiodarone boluses, ICD was reprogrammed. Pt then transferred to CCU service for further observation. While in the CCU pt had further episodes of VT and so antiarrhythmic regimen was changed. Patient became hypotensive in am of <Date>1948-5-20</Date> felt to be septic secondary to line sepsis from femoral cath. Patient started on Neo for pressure support. Patient mental status continued to deteriorate throughout day and into night. After lengthy discussion with family,family wished to make patient CMO. Patient ICD was turned off on <Date>1948-5-20</Date> so it would still pace but would not intervene if patient had arrythmia. Patient kept on morphine drip for comfort and all other meds d/c'd. The patient became more hypotensive and expired on <Date>1970-7-30</Date>. Medications on Admission: Home meds: lasix 120 <Hospital>Sanford, Mendez and Smith Health System</Hospital>, prilosec, diovan 80, coumadin, allopurinol 100, synthroid 25, prednisone 5, aldactone, dig .125, astelin Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA Completed 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Date: 2002-8-26 Discharge Date: 1970-7-30 Date of Birth: 1998-1-12 Sex: M Service: MEDICINE Allergies: Amiodarone / Quinidine / Procainamide / Quinine / Codeine Attending:Charlotte Chief Complaint: hypotension, hyperkalemia Major Surgical or Invasive Procedure: Hemodialysis catheter placement History of Present Illness: Mr. Luu is a 78-year-old male with a history of ventricular fibrillation arrest in 1964, status post ICD placement, dilated cardiomyopathy, atrial fibrillation, hypertension, and CVA who presented to the Ward, Spence and Collins Health System ED complaining of 8 lb weight gain with increased edema of LE over one week despite compliance with medications. Decreased po intake over past week. No SOB, chest pain, syncope, fatigue. Found to be hypotensive and hyperkalemic in the ED. ROS positive for epistaxis (was taking Afrin for this), occasional nausea and nonbloody/nonbilious vomitting. Past Medical History: 1. Ventricular fibrillation arrest in 1964 - has had ICD placement. 2. Dilated cardiomyopathy. Echocardiogram in 1904-7-18 showed an ejection fraction of 20% with inferoapical hypokinesis plus right ventricular hypokinesis. 3. Atrial fibrillation, status post DC cardioversion in 1964, on coumadin. 4. Hypertension. 5. Hypothyroidism. 6. Cerebral vascular accident in 1964. 7. Rheumatoid arthritis. 8. Positive lupus anticoagulant. Social History: Mr. Luu lives with his wife. Harold Hall denies any tobacco or drug use. He does note occasional alcohol use. Physical Exam: T 97.0. Blood pressure 84/54. Heart rate 81. Respiratory rate 10. Oxygen saturation 100% on RA. In general, in no acute distress, alert and oriented times three, overweight man. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Oropharynx is pink without lesions, mucous membranes dry. Nares with dry blood. Neck is supple. Unable to determine JVD secondary to excess soft tissue at neck. No lymphadenopathy. Chest clear to auscultation bilaterally. Cardiovascular: RRR, S1, S2 are faint. A 2/6 systolic ejection murmur at the apex. Abdomen soft, nontender, nondistended. Extremities: 1+ pitting edema bilaterally. No clubbing or cyanosis. Dorsalis pedis pulses are 1+ bilaterally. Neurologically, alert and oriented times three. Cranial nerves II through III are intact. Strength is 7-2 in upper and lower extremities bilaterally. Sensation to light touch is intact. Deep tendon reflexes are decreased bilaterally but equal. Pertinent Results: 2002-8-26 01:30PM PT-25.5* PTT-56.8* INR(PT)-4.1 2002-8-26 01:30PM NEUTS-94.2* BANDS-0 LYMPHS-2.3* MONOS-3.0 EOS-0.4 BASOS-0 2002-8-26 01:30PM WBC-10.0 RBC-2.45# HGB-8.1# HCT-24.3# MCV-99 MCH-33.0* MCHC-33.3 RDW-15.5 2002-8-26 01:30PM DIGOXIN-0.3* 2002-8-26 01:30PM TSH-3.3 2002-8-26 01:30PM calTIBC-267 FERRITIN-786* TRF-205 2002-8-26 01:30PM ALBUMIN-4.0 CALCIUM-8.5 PHOSPHATE-10.8# MAGNESIUM-2.3 IRON-104 2002-8-26 01:30PM CK-MB-22 MB INDX-3.7 cTropnT-0.36* 2002-8-26 01:30PM LIPASE-96* 2002-8-26 01:30PM ALT(SGPT)-38 AST(SGOT)-46* CK(CPK)-595* ALK PHOS-192* AMYLASE-137* TOT BILI-0.6 2002-8-26 01:30PM GLUCOSE-123* UREA N-272* CREAT-5.4# SODIUM-126 POTASSIUM-7.5* CHLORIDE-92* TOTAL CO2-16* ANION GAP-26* 2002-8-26 02:02PM LACTATE-1.8 K+-7.5* 2002-8-26 02:02PM TYPE-Olles PO2-60* PCO2-42 PH-7.21* TOTAL CO2-18* BASE XS--10 COMMENTS-GREEN TOP 2002-8-26 03:54PM K+-6.6* 2002-8-26 05:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-4 2002-8-26 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 2002-8-26 05:00PM URINE COLOR-Straw APPEAR-Clear SP Davis-1.011 2002-8-26 05:00PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO OSMOLAL-371 2002-8-26 05:00PM URINE HOURS-RANDOM UREA N-577 CREAT-89 SODIUM-27 TOT PROT-15 PROT/CREA-0.2 2002-8-26 10:40PM PT-33.0* PTT-150* INR(PT)-6.9 2002-8-26 10:40PM PLT COUNT-79* 2002-8-26 10:40PM WBC-7.4 RBC-2.52* HGB-8.2* HCT-24.1* MCV-96 MCH-32.7* MCHC-34.2 RDW-15.2 2002-8-26 10:40PM PEP-NO SPECIFI 2002-8-26 10:40PM calTIBC-264 HAPTOGLOB-143 FERRITIN-761* TRF-203 2002-8-26 10:40PM TOT PROT-6.6 CALCIUM-8.1* PHOSPHATE-5.2# MAGNESIUM-1.8 URIC ACID-3.4 IRON-90 2002-8-26 10:40PM CK-MB-20 MB INDX-3.9 cTropnT-0.34* 2002-8-26 10:40PM LD(LDH)-326* CK(CPK)-517* TOT BILI-0.7 2002-8-26 10:40PM GLUCOSE-140* UREA N-135* CREAT-2.8*# SODIUM-137 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17 Brief Hospital Course: In ED, noted to have renal failure, K+ 7.5 with EKG changes, given HCO3, 1L IVF, insulin, kayexelate, and transferred to MICU. . In MICU, interrogation of ICD showed no VT or VF but multiple episodes of NSVT. Pt tolerated two treatments of HD for uremia/hyperkalemia. He was started on hydrocortisone/fludrocortisone for adrenal insufficiency. Pt was evaluated for retroperitoneal hematoma/femoral hematoma w/ femoral US/Abd CT which and showed femoral hematoma. He received 3 units of PRBCs for decreased HCT and femoral hematoma. 11-29 during HD treatment, pt developed VT w/ recurrent ICD shocks, rhythm converted to VF, received lidocaine and amiodarone boluses, ICD was reprogrammed. Pt then transferred to CCU service for further observation. While in the CCU pt had further episodes of VT and so antiarrhythmic regimen was changed. Patient became hypotensive in am of 1948-5-20 felt to be septic secondary to line sepsis from femoral cath. Patient started on Neo for pressure support. Patient mental status continued to deteriorate throughout day and into night. After lengthy discussion with family,family wished to make patient CMO. Patient ICD was turned off on 1948-5-20 so it would still pace but would not intervene if patient had arrythmia. Patient kept on morphine drip for comfort and all other meds d/c'd. The patient became more hypotensive and expired on 1970-7-30. Medications on Admission: Home meds: lasix 120 Sanford, Mendez and Smith Health System, prilosec, diovan 80, coumadin, allopurinol 100, synthroid 25, prednisone 5, aldactone, dig .125, astelin Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA Completed by:2002-11-20	['Admission Date: 2002-8-26 Discharge Date: 1970-7-30\n\nDate of Birth: 1998-1-12 Sex: M\n\nService: MEDICINE\n\nAllergies:\nAmiodarone / Quinidine / Procainamide / Quinine / Codeine\n\nAttending:Charlotte\nChief Complaint:\nhypotension, hyperkalemia\n\nMajor Surgical or Invasive Procedure:\nHemodialysis catheter placement\n\nHistory of Present Illness:\nMr. Luu is a 78-year-old male with a history of ventricular\nfibrillation arrest in 1964, status post ICD placement, dilated\ncardiomyopathy,\natrial fibrillation, hypertension, and CVA who presented to the\nWard, Spence and Collins Health System ED complaining of 8 lb weight gain with increased edema of\nLE over one week despite compliance with medications. Decreased\npo intake over past week. No SOB, chest pain, syncope, fatigue.\nFound to be hypotensive and hyperkalemic in the ED.', ' ROS\npositive for epistaxis (was taking Afrin for this), occasional\nnausea and nonbloody/nonbilious vomitting.\n\nPast Medical History:\n1. Ventricular fibrillation arrest in 1964 - has had ICD\nplacement.\n2. Dilated cardiomyopathy. Echocardiogram in 1904-7-18\nshowed an ejection fraction of 20% with inferoapical\nhypokinesis plus right ventricular hypokinesis.\n3. Atrial fibrillation, status post DC cardioversion in\n1964, on coumadin.\n4. Hypertension.\n5. Hypothyroidism.\n6. Cerebral vascular accident in 1964.\n7. Rheumatoid arthritis.\n8. Positive lupus anticoagulant.\n\n\nSocial History:\nMr. Luu lives with his wife. Harold Hall denies any tobacco or drug\nuse. He does note occasional alcohol use.\n\n\nPhysical Exam:\nT 97.0. Blood pressure 84/54. Heart rate 81. Respiratory rate\n10. Oxygen\nsaturation 100% on RA.', ' In general, in no acute\ndistress, alert and oriented times three, overweight man. Head,\neyes, ears, nose and throat: Normocephalic, atraumatic. Pupils\nare equal,\nround, and reactive to light and accommodation. Oropharynx\nis pink without lesions, mucous membranes dry. Nares with dry\nblood. Neck is supple. Unable to determine JVD secondary to\nexcess soft tissue at neck. No lymphadenopathy. Chest clear to\nauscultation\nbilaterally. Cardiovascular: RRR, S1, S2\nare faint. A 2/6 systolic ejection murmur at the apex.\nAbdomen soft, nontender, nondistended. Extremities: 1+\npitting edema bilaterally. No clubbing or cyanosis.\nDorsalis pedis pulses are 1+ bilaterally. Neurologically,\nalert and oriented times three. Cranial nerves II through\nIII are intact. Strength is 7-2 in upper and lower\nextremities bilaterally.', ' Sensation to light touch is intact.\nDeep tendon reflexes are decreased bilaterally but equal.\n\n\nPertinent Results:\n2002-8-26 01:30PM PT-25.5* PTT-56.8* INR(PT)-4.1\n2002-8-26 01:30PM NEUTS-94.2* BANDS-0 LYMPHS-2.3* MONOS-3.0\nEOS-0.4 BASOS-0\n2002-8-26 01:30PM WBC-10.0 RBC-2.45# HGB-8.1# HCT-24.3#\nMCV-99 MCH-33.0* MCHC-33.3 RDW-15.5\n2002-8-26 01:30PM DIGOXIN-0.3\n2002-8-26 01:30PM TSH-3.3\n2002-8-26 01:30PM calTIBC-267 FERRITIN-786 TRF-205\n2002-8-26 01:30PM ALBUMIN-4.0 CALCIUM-8.5 PHOSPHATE-10.8#\nMAGNESIUM-2.3 IRON-104\n2002-8-26 01:30PM CK-MB-22 MB INDX-3.7 cTropnT-0.36\n2002-8-26 01:30PM LIPASE-96\n2002-8-26 01:30PM ALT(SGPT)-38 AST(SGOT)-46* CK(CPK)-595* ALK\nPHOS-192* AMYLASE-137* TOT BILI-0.6\n2002-8-26 01:30PM GLUCOSE-123* UREA N-272* CREAT-5.4#\nSODIUM-126 POTASSIUM-7.', '5* CHLORIDE-92* TOTAL CO2-16* ANION\nGAP-26\n2002-8-26 02:02PM LACTATE-1.8 K+-7.5\n2002-8-26 02:02PM TYPE-Olles PO2-60* PCO2-42 PH-7.21* TOTAL\nCO2-18* BASE XS--10 COMMENTS-GREEN TOP\n2002-8-26 03:54PM K+-6.6\n2002-8-26 05:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE\nEPI-4\n2002-8-26 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0\nLEUK-NEG\n2002-8-26 05:00PM URINE COLOR-Straw APPEAR-Clear SP Davis-1.011\n2002-8-26 05:00PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO\nOSMOLAL-371\n2002-8-26 05:00PM URINE HOURS-RANDOM UREA N-577 CREAT-89\nSODIUM-27 TOT PROT-15 PROT/CREA-0.2\n2002-8-26 10:40PM PT-33.0 PTT-150* INR(PT)-6.9\n2002-8-26 10:40PM PLT COUNT-79\n2002-8-26 10:40PM WBC-7.4 RBC-2.52 HGB-8.2* HCT-24.1* MCV-96\nMCH-32.7* MCHC-34.2 RDW-15.', '2\n2002-8-26 10:40PM PEP-NO SPECIFI\n2002-8-26 10:40PM calTIBC-264 HAPTOGLOB-143 FERRITIN-761\nTRF-203\n2002-8-26 10:40PM TOT PROT-6.6 CALCIUM-8.1 PHOSPHATE-5.2#\nMAGNESIUM-1.8 URIC ACID-3.4 IRON-90\n2002-8-26 10:40PM CK-MB-20 MB INDX-3.9 cTropnT-0.34\n2002-8-26 10:40PM LD(LDH)-326 CK(CPK)-517* TOT BILI-0.7\n2002-8-26 10:40PM GLUCOSE-140* UREA N-135* CREAT-2.8*#\nSODIUM-137 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17\n\nBrief Hospital Course:\nIn ED, noted to have renal failure, K+ 7.5 with EKG changes,\ngiven HCO3, 1L IVF, insulin, kayexelate, and transferred to\nMICU.\n.\nIn MICU, interrogation of ICD showed no VT or VF but multiple\nepisodes of NSVT. Pt tolerated two treatments of HD for\nuremia/hyperkalemia. He was started on\nhydrocortisone/fludrocortisone for adrenal insufficiency.', ' Pt was\nevaluated for retroperitoneal hematoma/femoral hematoma w/\nfemoral US/Abd CT which and showed femoral hematoma. He received\n3 units of PRBCs for decreased HCT and femoral hematoma. 11-29\nduring HD treatment, pt developed VT w/ recurrent ICD shocks,\nrhythm converted to VF, received lidocaine and amiodarone\nboluses, ICD was reprogrammed. Pt then transferred to CCU\nservice for further observation. While in the CCU pt had\nfurther episodes of VT and so antiarrhythmic regimen was\nchanged.\nPatient became hypotensive in am of 1948-5-20 felt to be septic\nsecondary to line sepsis from femoral cath. Patient started on\nNeo for pressure support. Patient mental status continued to\ndeteriorate throughout day and into night. After lengthy\ndiscussion with family,family wished to make patient CMO.\nPatient ICD was turned off on 1948-5-20 so it would still pace but\nwould not intervene if patient had arrythmia.', " Patient kept on\nmorphine drip for comfort and all other meds d/c'd. The patient\nbecame more hypotensive and expired on 1970-7-30.\n\nMedications on Admission:\nHome meds: lasix 120 Sanford, Mendez and Smith Health System, prilosec, diovan 80, coumadin,\nallopurinol 100, synthroid 25, prednisone 5, aldactone, dig\n.125, astelin\n\nDischarge Medications:\nNA\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\nNA\n\nDischarge Condition:\nNA\n\nDischarge Instructions:\nNA\n\nFollowup Instructions:\nNA\n\n\nCompleted by:2002-11-20"]
126	42753	121343.0	2168-04-19	Discharge summary	Report	Admission Date: [2168-4-5] Discharge Date: [2168-4-20] Date of Birth: [2127-1-17] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 1350] Chief Complaint: Transferred from OSH intubated with progressive loss of function. Found to have cerivcal discitis, epidural abscess, pharangeal abscesses and bacteremia. Major Surgical or Invasive Procedure: [2168-4-5] C5-T1 lami for epidural abscess - White [2168-4-8] ACDF, posterior I&D [2168-4-11] C3-T1 PISF, L ICBG, Incisional Vac [4-14] Trach and PEG [4-18] Right PICC line placement History of Present Illness: HPI: 41M h/o IVDA with 3d progressive neck and upper back pain and 1d of rapidly progressive UE/LE weakness, numbness. Progressive symptosm [4-7] with epidural abscess on MRI Past Medical History: Not Known Social History: Living with a friend. [Name (NI) 1351], no children. On SSI benefits for asthma and neuropathy. Smokes occasional cigarettes, no EtOH. Family History: Parents with DM. Father with [Name2 (NI) 499] CA. Physical Exam: Trach in place Anterior, Posterior, ICBG wounds clean and dry C5 3/5 strength C6 3/5 strength SITIL grossly BUE and BLE C7-S1 No demonstrated motor Pertinent Results: [2168-4-5] 04:56PM TYPE-ART PO2-95 PCO2-34* PH-7.45 TOTAL CO2-24 BASE XS-0 [2168-4-5] 04:56PM freeCa-1.04* [2168-4-5] 08:13AM URINE COLOR-Amber APPEAR-Cloudy SP [Last Name (un) 155]-1.032 [2168-4-5] 08:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG [2168-4-5] 08:13AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-<1 [2168-4-5] 08:13AM URINE AMORPH-MOD [2168-4-5] 07:40AM TYPE-ART PO2-280* PCO2-53* PH-7.39 TOTAL CO2-33* BASE XS-6 [2168-4-5] 07:40AM GLUCOSE-196* LACTATE-1.0 Brief Hospital Course: The patient was taken to the OR rapidly for decompression of his spinal cord. His procedures are as follows: [2168-4-5] C5-T1 lami for epidural abscess - White [2168-4-8] ACDF, posterior I&D [2168-4-11] C3-T1 PISF, L ICBG, Incisional Vac [4-14] Trach and PEG He was seen by PT, infectious disease, Speach and Swallow, Trauma ICU team, Dr. [Last Name (STitle) 1007] and Dr. [Last Name (STitle) 1352] of the spine team, the PICC placement team and ENT for managment of his complex spinal cord issues. He was discharged from the ICU to the floor on [2168-4-18] and received his picc line. He was discharged in stable condition on heparin DVT prophylaxis and IV Nafcillin via his PICC with follow up with Spine and Infectious Disease. He was discharged to spinal cord rehab. Medications on Admission: No Known Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for nausea. 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 4. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 5. Nafcillin 2 g IV Q6H epidural abcess 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 9. Lorazepam 0.5-2 mg IV Q2-4 HOUR PRN agitation hold for rr<10 or somnolence 10. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 12. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for nausea. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Tolerated in house. 20. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: MSSA bacteremia with C5-C7 epidural abscess, discitis C6 level (C5 3/5 strength, C6 3/5 Strength). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Discharge diagnosis: MSSA bacteremia with C5-C7 epidural abscess Prescribed Antibiotic Information 1.) Nafcillin 2 g IV q 6 hrs ([4-10] - laboratory monitoring required weekly CBCd, BMP, LFT's, ESR, CRP Other medications of note for drug inteactions, other oral antibiotics taken in conjunction etc. access changes comments All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 1353] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 1354] Daily wound checks - Hip Bone graft, Anterior and Posterior Cervical Spine wounds Physical Therapy: OOB WBAT C collar for oob activities Treatments Frequency: daily wound checks Agressive spinal cord rehab anticipated 6-8 weeks of Nafcillin via PICC Followup Instructions: PLease follow up with ID in 1 month. See above instructions for weekly labs to be faxed to the [Hospital ] clinic. Please follow up with Dr. [Last Name (STitle) 1007] in 2 weeks.	Admission Date: <Date>1963-7-28</Date> Discharge Date: <Date>1950-12-30</Date> Date of Birth: <Date>1909-6-28</Date> Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Doctor Name>Dr.Hall</Doctor Name> Chief Complaint: Transferred from OSH intubated with progressive loss of function. Found to have cerivcal discitis, epidural abscess, pharangeal abscesses and bacteremia. Major Surgical or Invasive Procedure: <Date>1963-7-28</Date> C5-T1 lami for epidural abscess - White <Date>1909-8-22</Date> ACDF, posterior I&D <Date>1909-12-20</Date> C3-T1 PISF, L ICBG, Incisional Vac <Date>6-23</Date> Trach and PEG <Date>2-22</Date> Right PICC line placement History of Present Illness: HPI: 41M h/o IVDA with 3d progressive neck and upper back pain and 1d of rapidly progressive UE/LE weakness, numbness. Progressive symptosm <Date>3-19</Date> with epidural abscess on MRI Past Medical History: Not Known Social History: Living with a friend. <Name>Tyler Lyna</Name>, no children. On SSI benefits for asthma and neuropathy. Smokes occasional cigarettes, no EtOH. Family History: Parents with DM. Father with <Name>Maryanne Mao</Name> CA. Physical Exam: Trach in place Anterior, Posterior, ICBG wounds clean and dry C5 3/5 strength C6 3/5 strength SITIL grossly BUE and BLE C7-S1 No demonstrated motor Pertinent Results: <Date>1963-7-28</Date> 04:56PM TYPE-ART PO2-95 PCO2-34* PH-7.45 TOTAL CO2-24 BASE XS-0 <Date>1963-7-28</Date> 04:56PM freeCa-1.04* <Date>1963-7-28</Date> 08:13AM URINE COLOR-Amber APPEAR-Cloudy SP <Name>Cobbs</Name>-1.032 <Date>1963-7-28</Date> 08:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG <Date>1963-7-28</Date> 08:13AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-<1 <Date>1963-7-28</Date> 08:13AM URINE AMORPH-MOD <Date>1963-7-28</Date> 07:40AM TYPE-ART PO2-280* PCO2-53* PH-7.39 TOTAL CO2-33* BASE XS-6 <Date>1963-7-28</Date> 07:40AM GLUCOSE-196* LACTATE-1.0 Brief Hospital Course: The patient was taken to the OR rapidly for decompression of his spinal cord. His procedures are as follows: <Date>1963-7-28</Date> C5-T1 lami for epidural abscess - White <Date>1909-8-22</Date> ACDF, posterior I&D <Date>1909-12-20</Date> C3-T1 PISF, L ICBG, Incisional Vac <Date>6-23</Date> Trach and PEG He was seen by PT, infectious disease, Speach and Swallow, Trauma ICU team, Dr. <Name>Feguson</Name> and Dr. <Name>Edward</Name> of the spine team, the PICC placement team and ENT for managment of his complex spinal cord issues. He was discharged from the ICU to the floor on <Date>1971-11-16</Date> and received his picc line. He was discharged in stable condition on heparin DVT prophylaxis and IV Nafcillin via his PICC with follow up with Spine and Infectious Disease. He was discharged to spinal cord rehab. Medications on Admission: No Known Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for nausea. 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 4. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 5. Nafcillin 2 g IV Q6H epidural abcess 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 9. Lorazepam 0.5-2 mg IV Q2-4 HOUR PRN agitation hold for rr<10 or somnolence 10. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 12. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for nausea. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Tolerated in house. 20. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: <Hospital>Murphy, Rodriguez and Henderson Medical Center</Hospital> - <Location>91261 Taylor Plains South Joshua, WI 90072</Location> Discharge Diagnosis: MSSA bacteremia with C5-C7 epidural abscess, discitis C6 level (C5 3/5 strength, C6 3/5 Strength). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Discharge diagnosis: MSSA bacteremia with C5-C7 epidural abscess Prescribed Antibiotic Information 1.) Nafcillin 2 g IV q 6 hrs (<Date>10-19</Date> - laboratory monitoring required weekly CBCd, BMP, LFT's, ESR, CRP Other medications of note for drug inteactions, other oral antibiotics taken in conjunction etc. access changes comments All laboratory results should be faxed to Infectious disease R.Ns. at (<Telephone>243-151-2420</Telephone> All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at (<Telephone>616-712-9723</Telephone> Daily wound checks - Hip Bone graft, Anterior and Posterior Cervical Spine wounds Physical Therapy: OOB WBAT C collar for oob activities Treatments Frequency: daily wound checks Agressive spinal cord rehab anticipated 6-8 weeks of Nafcillin via PICC Followup Instructions: PLease follow up with ID in 1 month. See above instructions for weekly labs to be faxed to the <Hospital>Coffey and Sons Hospital</Hospital> clinic. Please follow up with Dr. <Name>Feguson</Name> in 2 weeks.	00000000000000000111111111000000000000000000000000000000001111111111000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000001111111110000000000000000000001111111111000000000000000000000000000000000000111100000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000001111111110000000000000000000000000000000000000000000001111100000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000111111111000000000000000000000111111111100000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111100000000000000000000000000000000000011111110000000000000000	Admission Date: 1963-7-28 Discharge Date: 1950-12-30 Date of Birth: 1909-6-28 Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Dr.Hall Chief Complaint: Transferred from OSH intubated with progressive loss of function. Found to have cerivcal discitis, epidural abscess, pharangeal abscesses and bacteremia. Major Surgical or Invasive Procedure: 1963-7-28 C5-T1 lami for epidural abscess - White 1909-8-22 ACDF, posterior I&D 1909-12-20 C3-T1 PISF, L ICBG, Incisional Vac 6-23 Trach and PEG 2-22 Right PICC line placement History of Present Illness: HPI: 41M h/o IVDA with 3d progressive neck and upper back pain and 1d of rapidly progressive UE/LE weakness, numbness. Progressive symptosm 3-19 with epidural abscess on MRI Past Medical History: Not Known Social History: Living with a friend. Tyler Lyna, no children. On SSI benefits for asthma and neuropathy. Smokes occasional cigarettes, no EtOH. Family History: Parents with DM. Father with Maryanne Mao CA. Physical Exam: Trach in place Anterior, Posterior, ICBG wounds clean and dry C5 3/5 strength C6 3/5 strength SITIL grossly BUE and BLE C7-S1 No demonstrated motor Pertinent Results: 1963-7-28 04:56PM TYPE-ART PO2-95 PCO2-34* PH-7.45 TOTAL CO2-24 BASE XS-0 1963-7-28 04:56PM freeCa-1.04* 1963-7-28 08:13AM URINE COLOR-Amber APPEAR-Cloudy SP Cobbs-1.032 1963-7-28 08:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG 1963-7-28 08:13AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-1963-7-28 08:13AM URINE AMORPH-MOD 1963-7-28 07:40AM TYPE-ART PO2-280* PCO2-53* PH-7.39 TOTAL CO2-33* BASE XS-6 1963-7-28 07:40AM GLUCOSE-196* LACTATE-1.0 Brief Hospital Course: The patient was taken to the OR rapidly for decompression of his spinal cord. His procedures are as follows: 1963-7-28 C5-T1 lami for epidural abscess - White 1909-8-22 ACDF, posterior I&D 1909-12-20 C3-T1 PISF, L ICBG, Incisional Vac 6-23 Trach and PEG He was seen by PT, infectious disease, Speach and Swallow, Trauma ICU team, Dr. Feguson and Dr. Edward of the spine team, the PICC placement team and ENT for managment of his complex spinal cord issues. He was discharged from the ICU to the floor on 1971-11-16 and received his picc line. He was discharged in stable condition on heparin DVT prophylaxis and IV Nafcillin via his PICC with follow up with Spine and Infectious Disease. He was discharged to spinal cord rehab. Medications on Admission: No Known Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for nausea. 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 4. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 5. Nafcillin 2 g IV Q6H epidural abcess 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 9. Lorazepam 0.5-2 mg IV Q2-4 HOUR PRN agitation hold for rrMurphy, Rodriguez and Henderson Medical Center - 91261 Taylor Plains South Joshua, WI 90072 Discharge Diagnosis: MSSA bacteremia with C5-C7 epidural abscess, discitis C6 level (C5 3/5 strength, C6 3/5 Strength). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Discharge diagnosis: MSSA bacteremia with C5-C7 epidural abscess Prescribed Antibiotic Information 1.) Nafcillin 2 g IV q 6 hrs (10-19 - laboratory monitoring required weekly CBCd, BMP, LFT's, ESR, CRP Other medications of note for drug inteactions, other oral antibiotics taken in conjunction etc. access changes comments All laboratory results should be faxed to Infectious disease R.Ns. at (243-151-2420 All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at (616-712-9723 Daily wound checks - Hip Bone graft, Anterior and Posterior Cervical Spine wounds Physical Therapy: OOB WBAT C collar for oob activities Treatments Frequency: daily wound checks Agressive spinal cord rehab anticipated 6-8 weeks of Nafcillin via PICC Followup Instructions: PLease follow up with ID in 1 month. See above instructions for weekly labs to be faxed to the Coffey and Sons Hospital clinic. Please follow up with Dr. Feguson in 2 weeks.	['Admission Date: 1963-7-28 Discharge Date: 1950-12-30\n\nDate of Birth: 1909-6-28 Sex: M\n\nService: ORTHOPAEDICS\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Dr.Hall\nChief Complaint:\nTransferred from OSH intubated with progressive loss of\nfunction. Found to have cerivcal discitis, epidural abscess,\npharangeal abscesses and bacteremia.\n\nMajor Surgical or Invasive Procedure:\n1963-7-28 C5-T1 lami for epidural abscess - White\n1909-8-22 ACDF, posterior I&D\n1909-12-20 C3-T1 PISF, L ICBG, Incisional Vac\n6-23 Trach and PEG\n2-22 Right PICC line placement\n\n\nHistory of Present Illness:\nHPI: 41M h/o IVDA with 3d progressive neck and upper back pain\nand 1d of rapidly progressive UE/LE weakness, numbness.\nProgressive symptosm 3-19 with epidural abscess on MRI\n\n\nPast Medical History:\nNot Known\n\nSocial History:\nLiving with a friend.', ' Tyler Lyna, no children. On SSI benefits for\nasthma and neuropathy. Smokes occasional cigarettes, no EtOH.\n\n\nFamily History:\nParents with DM. Father with Maryanne Mao CA.\n\nPhysical Exam:\nTrach in place\nAnterior, Posterior, ICBG wounds clean and dry\nC5 3/5 strength\nC6 3/5 strength\nSITIL grossly BUE and BLE\nC7-S1 No demonstrated motor\n\nPertinent Results:\n1963-7-28 04:56PM TYPE-ART PO2-95 PCO2-34* PH-7.45 TOTAL CO2-24\nBASE XS-0\n1963-7-28 04:56PM freeCa-1.04\n1963-7-28 08:13AM URINE COLOR-Amber APPEAR-Cloudy SP Cobbs-1.032\n1963-7-28 08:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75\nGLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG\n1963-7-28 08:13AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE\nEPI-1963-7-28 08:13AM URINE AMORPH-MOD\n1963-7-28 07:40AM TYPE-ART PO2-280 PCO2-53* PH-7.', '39 TOTAL\nCO2-33* BASE XS-6\n1963-7-28 07:40AM GLUCOSE-196* LACTATE-1.0\n\nBrief Hospital Course:\nThe patient was taken to the OR rapidly for decompression of his\nspinal cord. His procedures are as follows:\n\n1963-7-28 C5-T1 lami for epidural abscess - White\n1909-8-22 ACDF, posterior I&D\n1909-12-20 C3-T1 PISF, L ICBG, Incisional Vac\n6-23 Trach and PEG\n\nHe was seen by PT, infectious disease, Speach and Swallow,\nTrauma ICU team, Dr. Feguson and Dr. Edward of the spine team,\nthe PICC placement team and ENT for managment of his complex\nspinal cord issues. He was discharged from the ICU to the floor\non 1971-11-16 and received his picc line. He was discharged in\nstable condition on heparin DVT prophylaxis and IV Nafcillin via\nhis PICC with follow up with Spine and Infectious Disease. He\nwas discharged to spinal cord rehab.', '\n\nMedications on Admission:\nNo Known\n\nDischarge Medications:\n1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for\nnausea.\n2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:\n2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.\n\n3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3\ntimes a day).\n4. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\nTemporary Central Access-ICU: Flush with 10mL Normal Saline\ndaily and PRN.\n5. Nafcillin 2 g IV Q6H epidural abcess\n6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3\nhours) as needed for pain.\n7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\nPICC, heparin dependent: Flush with 10mL Normal Saline followed\nby Heparin as above daily and PRN per lumen.', "\n8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\nPICC, non-heparin dependent: Flush with 10 mL Normal Saline\ndaily and PRN per lumen.\n9. Lorazepam 0.5-2 mg IV Q2-4 HOUR PRN agitation\nhold for rrMurphy, Rodriguez and Henderson Medical Center - 91261 Taylor Plains\nSouth Joshua, WI 90072\n\nDischarge Diagnosis:\nMSSA bacteremia with C5-C7 epidural abscess, discitis\nC6 level (C5 3/5 strength, C6 3/5 Strength).\n\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or\nwheelchair.\n\n\nDischarge Instructions:\nDischarge diagnosis: MSSA bacteremia with C5-C7 epidural abscess\n\nPrescribed Antibiotic Information\n1.) Nafcillin 2 g IV q 6 hrs (10-19 -\n\nlaboratory monitoring required\nweekly CBCd, BMP, LFT's, ESR, CRP\n\nOther medications of note for drug inteactions, other oral\nantibiotics taken in conjunction etc.", '\naccess changes\ncomments\n\nAll laboratory results should be faxed to Infectious disease\nR.Ns. at (243-151-2420\nAll questions regarding outpatient antibiotics should be\ndirected\nto the infectious disease R.Ns. at (616-712-9723\n\nDaily wound checks - Hip Bone graft, Anterior and Posterior\nCervical Spine wounds\nPhysical Therapy:\nOOB WBAT\nC collar for oob activities\nTreatments Frequency:\ndaily wound checks\nAgressive spinal cord rehab\nanticipated 6-8 weeks of Nafcillin via PICC\n\nFollowup Instructions:\nPLease follow up with ID in 1 month. See above instructions for\nweekly labs to be faxed to the Coffey and Sons Hospital clinic.\n\nPlease follow up with Dr. Feguson in 2 weeks.\n\n\n\n']
127	25486	153955.0	2174-09-02	Discharge summary	Report	Admission Date: [2174-8-31] Discharge Date: [2174-9-2] Date of Birth: [2115-1-22] Sex: F Service: NSU PRIMARY DIAGNOSIS: Right middle cerebral artery aneurysm. HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 1356] is a pleasant 59-year- old woman who had previously seen Dr. [Last Name (STitle) 1132] in clinic. She had previously had an MRI for work-up of questionable TIA spells. She describes episodes of lightheadedness, dizziness, as well as right leg weakness when climbing stairs. Ultimately, she was found to have a right MCA aneurysm. She presents to the [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) 1357] coiling of her aneurysm and angiogram. PAST MEDICAL HISTORY: Fibromyalgia dysplasia. Gastroesophageal reflux. Esophagitis. Depression. Arthritis. History of epistaxis. PAST SURGICAL HISTORY: Status post [Last Name (un) 1358] fundoplication in [2162]. Status post cholecystectomy. Status post hysterectomy. Status post varicose vein ligation. Status post left knee surgery. MEDICATIONS AT HOME: 1. Nicotine 21 mg TD qd. 2. Zofran. 3. Colace. 4. Nortriptyline. 5. Trazodone. COURSE IN HOSPITAL: The patient was admitted for [Year (4 digits) 1357] coiling of right MCA aneurysm. She was taken to the operating room on [2174-8-31]. She was placed under general anesthesia and intubated. She tolerated the procedure well with no complications. The angiogram showed right MCA aneurysm, confirming the preop diagnosis. There was a 4 mm right MCA bifurcation aneurysm that was coiled using GDC and Matrix coils. She tolerated the procedure well without complications. She was extubated and then brought to the recovery room. Postoperatively, she remained afebrile with stable vital signs. She was following all commands and doing well. She had some slight weakness on the left leg. She received 3 days of aspirin. The left leg was not in the cerebral territory that was treated. Accordingly a spinal MRI was obtained which was negative. Her postoperative left leg weakness resolved by postop day 2. She continued to have gradual improvement until full recovery was obtained. Her course in the hospital otherwise remained uneventful. She remained afebrile with stable vital signs. She was transferred out of the unit on postoperative day 1. She was alert and oriented throughout. She had equal and symmetric pupils. She had a symmetric face with full extraocular movements. Her tongue was midline. She had no drift. She had full grips. She had no hematoma. She had good distal pulses. Her lines were removed when she was transferred to the floor. She was ambulating independently. Given her left lower extremity weakness, she was planned for a screening MRI of the lumbar spine, as well as cervical and thoracic sagittal images. The patient was currently stable for discharge home. She was doing well and tolerating good PO intake. She had been ambulating independently. She had been voiding independently without difficulty. She had been asked to call Dr [Last Name (STitle) 1132] in 1- 2 weeks. She was continued on her preop medication. [Name6 (MD) ] [Last Name (NamePattern4) 1359], [MD Number(1) 1360] Dictated By:[Last Name (NamePattern1) 1361] MEDQUIST36 D: [2174-9-2] 09:49:13 T: [2174-9-2] 10:30:55 Job#: [Job Number 1362]	Admission Date: <Date>1954-7-27</Date> Discharge Date: <Date>1934-12-31</Date> Date of Birth: <Date>2021-6-2</Date> Sex: F Service: NSU PRIMARY DIAGNOSIS: Right middle cerebral artery aneurysm. HISTORY OF PRESENT ILLNESS: Ms. <Name>Ahmed</Name> is a pleasant 59-year- old woman who had previously seen Dr. <Name>Pegram</Name> in clinic. She had previously had an MRI for work-up of questionable TIA spells. She describes episodes of lightheadedness, dizziness, as well as right leg weakness when climbing stairs. Ultimately, she was found to have a right MCA aneurysm. She presents to the <Hospital>Hodges, Duarte and Schmidt Clinic</Hospital> <Name>Shirley</Name> <Name>Ignacio</Name> coiling of her aneurysm and angiogram. PAST MEDICAL HISTORY: Fibromyalgia dysplasia. Gastroesophageal reflux. Esophagitis. Depression. Arthritis. History of epistaxis. PAST SURGICAL HISTORY: Status post <Name>Recinos</Name> fundoplication in <Year>1986</Year>. Status post cholecystectomy. Status post hysterectomy. Status post varicose vein ligation. Status post left knee surgery. MEDICATIONS AT HOME: 1. Nicotine 21 mg TD qd. 2. Zofran. 3. Colace. 4. Nortriptyline. 5. Trazodone. COURSE IN HOSPITAL: The patient was admitted for <Year>2014</Year> coiling of right MCA aneurysm. She was taken to the operating room on <Date>1954-7-27</Date>. She was placed under general anesthesia and intubated. She tolerated the procedure well with no complications. The angiogram showed right MCA aneurysm, confirming the preop diagnosis. There was a 4 mm right MCA bifurcation aneurysm that was coiled using GDC and Matrix coils. She tolerated the procedure well without complications. She was extubated and then brought to the recovery room. Postoperatively, she remained afebrile with stable vital signs. She was following all commands and doing well. She had some slight weakness on the left leg. She received 3 days of aspirin. The left leg was not in the cerebral territory that was treated. Accordingly a spinal MRI was obtained which was negative. Her postoperative left leg weakness resolved by postop day 2. She continued to have gradual improvement until full recovery was obtained. Her course in the hospital otherwise remained uneventful. She remained afebrile with stable vital signs. She was transferred out of the unit on postoperative day 1. She was alert and oriented throughout. She had equal and symmetric pupils. She had a symmetric face with full extraocular movements. Her tongue was midline. She had no drift. She had full grips. She had no hematoma. She had good distal pulses. Her lines were removed when she was transferred to the floor. She was ambulating independently. Given her left lower extremity weakness, she was planned for a screening MRI of the lumbar spine, as well as cervical and thoracic sagittal images. The patient was currently stable for discharge home. She was doing well and tolerating good PO intake. She had been ambulating independently. She had been voiding independently without difficulty. She had been asked to call Dr <Name>Pegram</Name> in 1- 2 weeks. She was continued on her preop medication. <Name>Ubaldo Naegelin</Name> <Name>Ignacio</Name>, <MD Number>33585862</MD Number> Dictated By:<Name>Lyna</Name> MEDQUIST36 D: <Date>1934-12-31</Date> 09:49:13 T: <Date>1934-12-31</Date> 10:30:55 Job#: <Job Number>Shah, Scott and Mathis-1969-048012</Job Number>	0000000000000000111111111000000000000000000000000111111111100000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111110111111101111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111100000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111011111110011111111000000000000001111000000000000000011111111110000000000000011111111110000000000000000011111111111111111111111111111111110	Admission Date: 1954-7-27 Discharge Date: 1934-12-31 Date of Birth: 2021-6-2 Sex: F Service: NSU PRIMARY DIAGNOSIS: Right middle cerebral artery aneurysm. HISTORY OF PRESENT ILLNESS: Ms. Ahmed is a pleasant 59-year- old woman who had previously seen Dr. Pegram in clinic. She had previously had an MRI for work-up of questionable TIA spells. She describes episodes of lightheadedness, dizziness, as well as right leg weakness when climbing stairs. Ultimately, she was found to have a right MCA aneurysm. She presents to the Hodges, Duarte and Schmidt Clinic Shirley Ignacio coiling of her aneurysm and angiogram. PAST MEDICAL HISTORY: Fibromyalgia dysplasia. Gastroesophageal reflux. Esophagitis. Depression. Arthritis. History of epistaxis. PAST SURGICAL HISTORY: Status post Recinos fundoplication in 1986. Status post cholecystectomy. Status post hysterectomy. Status post varicose vein ligation. Status post left knee surgery. MEDICATIONS AT HOME: 1. Nicotine 21 mg TD qd. 2. Zofran. 3. Colace. 4. Nortriptyline. 5. Trazodone. COURSE IN HOSPITAL: The patient was admitted for 2014 coiling of right MCA aneurysm. She was taken to the operating room on 1954-7-27. She was placed under general anesthesia and intubated. She tolerated the procedure well with no complications. The angiogram showed right MCA aneurysm, confirming the preop diagnosis. There was a 4 mm right MCA bifurcation aneurysm that was coiled using GDC and Matrix coils. She tolerated the procedure well without complications. She was extubated and then brought to the recovery room. Postoperatively, she remained afebrile with stable vital signs. She was following all commands and doing well. She had some slight weakness on the left leg. She received 3 days of aspirin. The left leg was not in the cerebral territory that was treated. Accordingly a spinal MRI was obtained which was negative. Her postoperative left leg weakness resolved by postop day 2. She continued to have gradual improvement until full recovery was obtained. Her course in the hospital otherwise remained uneventful. She remained afebrile with stable vital signs. She was transferred out of the unit on postoperative day 1. She was alert and oriented throughout. She had equal and symmetric pupils. She had a symmetric face with full extraocular movements. Her tongue was midline. She had no drift. She had full grips. She had no hematoma. She had good distal pulses. Her lines were removed when she was transferred to the floor. She was ambulating independently. Given her left lower extremity weakness, she was planned for a screening MRI of the lumbar spine, as well as cervical and thoracic sagittal images. The patient was currently stable for discharge home. She was doing well and tolerating good PO intake. She had been ambulating independently. She had been voiding independently without difficulty. She had been asked to call Dr Pegram in 1- 2 weeks. She was continued on her preop medication. Ubaldo Naegelin Ignacio, 33585862 Dictated By:Lyna MEDQUIST36 D: 1934-12-31 09:49:13 T: 1934-12-31 10:30:55 Job#: Shah, Scott and Mathis-1969-048012	['Admission Date: 1954-7-27 Discharge Date: 1934-12-31\n\nDate of Birth: 2021-6-2 Sex: F\n\nService: NSU\n\n\nPRIMARY DIAGNOSIS: Right middle cerebral artery aneurysm.\n\nHISTORY OF PRESENT ILLNESS: Ms. Ahmed is a pleasant 59-year-\nold woman who had previously seen Dr. Pegram in clinic. She\nhad previously had an MRI for work-up of questionable TIA\nspells. She describes episodes of lightheadedness,\ndizziness, as well as right leg weakness when climbing\nstairs. Ultimately, she was found to have a right MCA\naneurysm. She presents to the Hodges, Duarte and Schmidt Clinic Shirley\nIgnacio coiling of her aneurysm and angiogram.\n\nPAST MEDICAL HISTORY: Fibromyalgia dysplasia.\n\nGastroesophageal reflux.\n\nEsophagitis.\n\nDepression.\n\nArthritis.\n\nHistory of epistaxis.\n\nPAST SURGICAL HISTORY: Status post Recinos fundoplication in\n1986.', '\n\nStatus post cholecystectomy.\n\nStatus post hysterectomy.\n\nStatus post varicose vein ligation.\n\nStatus post left knee surgery.\n\nMEDICATIONS AT HOME:\n1. Nicotine 21 mg TD qd.\n2. Zofran.\n3. Colace.\n4. Nortriptyline.\n5. Trazodone.\n\n\nCOURSE IN HOSPITAL: The patient was admitted for 2014\ncoiling of right MCA aneurysm. She was taken to the\noperating room on 1954-7-27. She was placed under\ngeneral anesthesia and intubated. She tolerated the\nprocedure well with no complications. The angiogram showed\nright MCA aneurysm, confirming the preop diagnosis. There\nwas a 4 mm right MCA bifurcation aneurysm that was coiled\nusing GDC and Matrix coils. She tolerated the procedure well\nwithout complications. She was extubated and then brought to\nthe recovery room.\n\nPostoperatively, she remained afebrile with stable vital\nsigns.', ' She was following all commands and doing well. She\nhad some slight weakness on the left leg. She received 3\ndays of aspirin. The left leg was not in the cerebral territory\nthat was treated. Accordingly a spinal MRI was obtained which\nwas negative.\n\nHer postoperative left leg weakness resolved by postop day\n2. She continued to have gradual improvement until full\nrecovery was obtained. Her course in the hospital otherwise\nremained uneventful. She remained afebrile with stable vital\nsigns. She was transferred out of the unit on postoperative\nday 1. She was alert and oriented throughout. She had equal\nand symmetric pupils. She had a symmetric face with full\nextraocular movements. Her tongue was midline. She had no\ndrift. She had full grips. She had no hematoma. She had\ngood distal pulses.', '\n\nHer lines were removed when she was transferred to the floor.\nShe was ambulating independently. Given her left lower\nextremity weakness, she was planned for a screening MRI of\nthe lumbar spine, as well as cervical and thoracic sagittal\nimages.\n\nThe patient was currently stable for discharge home. She was\ndoing well and tolerating good PO intake. She had been\nambulating independently. She had been voiding independently\nwithout difficulty. She had been asked to call Dr Pegram in 1-\n2 weeks. She was continued on her preop medication.\n\n\n\n Ubaldo Naegelin Ignacio, 33585862\n\nDictated By:Lyna\nMEDQUIST36\nD: 1934-12-31 09:49:13\nT: 1934-12-31 10:30:55\nJob#: Shah, Scott and Mathis-1969-048012\n']
128	56225	138677.0	2197-12-01	Discharge summary	Report	Admission Date: [2197-11-27] Discharge Date: [2197-12-1] Date of Birth: [2130-8-26] Sex: M Service: MEDICINE Allergies: Horse Blood Extract / Bactrim Ds / Adhesive Tape / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1363] Chief Complaint: Somnolence. Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 67 y.o male with bladder cancer with large pelvic masses, recent chemo tue (taxol, gemzar) now presenting with n/v/d/ new afib with RVR, metastatic disease. Pt is HD m/w/f . Pt denies pain, but is unable to report other ROS. States he's tired. . In the [Name (NI) ], pt at first refused IV, got EJ, removed it, an another was placed. Pt s/p 3L IVF. HR 100-170's, not given any nodal agents for rate control. PT found to be neutropenic. RUQ-new liver masses/sacral/iliac, R.sided hydroureter, has neobladder. Pt given vanco, cefepime, flagyl. Somnolent, head CT negative. Tmax 100.2 . Past Medical History: CAD HTN Hyperlipidemia ESRD on HD Bladder Cancer in [2181] Depression Restless Leg Syndrome Social History: Patient lives at home with girlfriend; no smoking history, no etoh. Uses marijuana for appetite. Son lives in [State 531]. Has 2 daughters one of whom is expecting in [Name (NI) 404]. Family History: Dad died of CVA in his 90s, no hx of MI in family. Physical Exam: Vitals: T. 98.2 BP 104/67, HR 115, RR 20, sat 92% on 4L GEN: lying in bed, somnolent, arousable to sternal rub, HEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, s1s2 3/6 systolic flow murmur. PULM: Lungs b/l coarse inspiratory rhonchi. no w/r ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/2+E, no palpable cords NEURO: somnolent, squeezes hand to commands. Pertinent Results: Admission labs [2197-11-26] 10:30PM BLOOD WBC-0.4# RBC-2.98 Hgb-8.0* Hct-26.2* MCV-88 MCH-27.0 MCHC-30.7* RDW-18.1* Plt Ct-52# [2197-11-26] 10:30PM BLOOD Neuts-41 Bands-1 Lymphs-32 Monos-24* Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [2197-11-26] 10:30PM BLOOD PT-44.7* PTT-46.3* INR(PT)-5.0* [2197-11-26] 10:30PM BLOOD Plt Smr-VERY LOW Plt Ct-52# [2197-11-26] 10:30PM BLOOD Gran Ct-130 [2197-11-26] 10:30PM BLOOD Glucose-100 UreaN-98* Creat-6.6* Na-139 K-4.8 Cl-92* HCO3-27 AnGap-25* [2197-11-26] 10:30PM BLOOD ALT-71* AST-114* LD(LDH)-501* CK(CPK)-127 AlkPhos-256* TotBili-3.8* DirBili-2.7* IndBili-1.1 [2197-11-26] 10:30PM BLOOD CK-MB-5 [2197-11-26] 10:30PM BLOOD cTropnT-0.09* [2197-11-26] 10:30PM BLOOD Albumin-2.3* Calcium-7.1* Phos-8.8# Mg-2.0 [2197-11-26] 10:37PM BLOOD Lactate-1.8 K-4.8 Pertinent Radiology: [2197-11-26] Liver Gallbladder US: IMPRESSION: 1. Multiple hepatic masses, the largest of which measures over 4 cm, and is suspicious for metastatic disease given the history. 2. Unchanged severe right hydronephrosis. 3. No gallbladder distention or CBD dilation. [2197-11-27] CT ABD/Pelvis: IMPRESSION: 1. Marked progression of metastatic disease, with new metastases in the liver as well as iliac and sacral bones. 2. Severe right hydroureteronephrosis, as in the prior study. 3. Limited evaluation of the central abdomen due to marked streak artifact from numerous surgical clips. 4. Bilateral lower lobe subsegmental atelectasis, as well as incompletely imaged nodular opacities suspicious for metastatic disease given the history. [2197-11-27] CT HEAD: IMPRESSION: No evidence of acute intracranial process. If there is high clinical suspicion for metastatic disease, MRI is more sensitive. [2197-11-27] LENI: IMPRESSION: Normal examination of the bilateral lower extremities. No evidence of DVT. [2197-11-28] CXR: Since [2197-11-26], cardiomegaly is unchanged. Prior sternotomy and abdominal clips are unchanged. Bilateral small pleural effusions are new. Bilateral increase in interstitial markings and hilar haziness are consistent with pulmonary edema. More confluent left lower lobe opacity could be due to pneumonia. Incidentally, old left rib fractures are unchanged. [2197-11-28] EKG: Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [2197-11-27] no significant change. Brief Hospital Course: A/P: Pt is a 67 y.o male with h.o bladder cancer now presenting with altered mental status and tachycardia. . MICU COURSE: 1) Tachycardia: patient presented with Afib. No obvious explanation. Assess for myocardial infarction. With thrombocytopenia and prolonged INR and renal failure, a PE is less likely. Would check A-a gradient on room air and obtain LENI's with peripheral edema. Also check thyroid function. -monitor on tele -ROMI . 2) Fever with neutropenia: concern about infection with neutropenia. CXR not impressive for infiltrate but there may be slight increase in markings at right base and left base. On broad spectrum antibiotics; will repeat CXR in AM. Blood cultures pending/urine cx pending. -neutropenic percautions. . 3) Anemia: probably related to marrow suppression. No evidence of GI bleeding. Guaiac stool. PIVs. IRON studies. . 4) Thrombocytopenia: likely related to bone marrow suppression. No evidence of bleeding now. Continue to monitor. Consider HIT ab. . 5) Hypotension: patient with hx of hypertension. Present BP likely relatively hypotensive now. Has dry mucus membranes and decreased tissue turgor. Will give additional fluids now. With renal failure, would watch bicarbonate with normal saline fluid resuscitation. Would not give lactated ringers because of anuria. [Month (only) 116] need D5W with bicarb as part of fluid resuscitation if serum bicarb begins to drop. . 6) Metastatic bladder ca: discuss future therapy with oncology. . 7) Altered mental status: ETiologies include intracranial mass/bleed but r/o with CT head. Other possibilities include toxic-metabolic including uremia/acute liver failure. Other possibilities include infection such as sepsis/meningitis. Other possibility includes medication/narcotic effect. Patient given narcan with some improvement. He is on narcotics at home and may have taken extra doses or may now have delayed metabolism because of liver [Month (only) 1364] and abnormal LFT's. Continue with narcan for now. Uremia may also be contributing to altered mental status. -toxic metabolic w/u and correction -frequent neuro exams -antibiotics -infectious w/u -consult renal for HD. . 8) Chronic renal failure: electrolytes and acid-base status acceptable. Mental status may be due, in part, to uremia. No volume overload now. No immediate need for dialysis. renal on board. . 9) Acidosis: combined anion gap acidosis, probably from uremia, and metabolic alkalosis, likely from volume depletion and vomiting. . Fen-NPO, lytes prn access-PIVs ppx-pneumoboots, PPI, bowel reg communication-pt's family code-DNR/DNI disp- ICU for now. . [11-27] -Bili mostly direct (2.7 out of 3.8) - Given now widespread [Month/Year (2) 1364] on CT abd/pelvis. Family met with Dr. [Last Name (STitle) 1365] (heme), [Doctor Last Name 1366] (renal) and has decided to make pt DNR/ DNI. Will most likely go to comfort care but would like to wait a few days and see if the pt "comes out of this" ie change in MS - EKG without change -FFP 4u given in afternoon -Pt with very limited access. Currently has 1 working PIV. Family not opposed to central access at this time but as it will excalate care at this time with risks of infxn and coagulopathy, will not place. -Pt with A fib and HR into 180's off and on in the afternoon. Started on Metoprolol 5IV Q 4hrs but still with intermittent tachycardia. Currently in sinus. - LENI's negative -Stools grossly bloody and guaiac +. Hct stable. -CE trending down -Considered starting lactulose to possibly improve MS [First Name (Titles) ] [Last Name (Titles) 1364] to liver and liver damage seen in coagulopathy but d/c'd as pt already having considerable diarrhea- C diff pending -Per renal, if family still wishes, will do HD in am -Got just 1L IVF bolus during evening. O2 Sat 95% on 2LNC and pt putting out little uring by ostomy (must be cathed by nursing) [11-28] - Family discussion -> decided to proceed with HD - bedside HD per renal yesterday - transfused 2 U with appropriate increase in Hct - Urine Cx with GNR >100K - Patient with pain in abd last night, given small dose morphine with good effect [11-29] - Pt made CMO overnight. - Pt given IVF and Morphine PRN . OMED COURSE Patient was transferred to OMED service from [Hospital Unit Name 153] on Thursday [11-30]. At the time of transfer the goals of care were comfort measures only. He was kept on a morphine drip, titrated to respiratory comfort. He was also started on Ativan prn for agitation. Palliative care consult was obtained. He passed away on the night of Friday [12-1] at approximately 6:15 PM. Immediate cause of death was respiratory failure. Secondary cause of death was metastatic bladder cancer. Medications on Admission: tylenol-codeine 300-30mg [1-18] Q4h prn ambien 10mg QHS amlodipine 5mg daily lipitor 40mg daily nephrocaps neurontin 300mg qhs imdur 60mg SR daily megace 15mg po daily toprol xl 50mg 0.5mg daily morphine 15mg [Hospital1 ] ms [Last Name (Titles) 1367] 15mg SR [Hospital1 ] nitro 0.4mg protonix 40mg daily mirapex 0.25mg qhs compazine 10mg Q6Hprn renagel 800mg , 2 tabls TID aspirin 81mg daily Discharge Medications: Deceased. Discharge Disposition: Expired Discharge Diagnosis: Metastatic Bladder Cancer. Discharge Condition: Deceased. Discharge Instructions: Deceased. Followup Instructions: Deceased. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 1368] Completed by:[2197-12-2*]	Admission Date: <Date>1940-5-3</Date> Discharge Date: <Date>1946-4-28</Date> Date of Birth: <Date>1959-12-19</Date> Sex: M Service: MEDICINE Allergies: Horse Blood Extract / Bactrim Ds / Adhesive Tape / Sulfa (Sulfonamides) Attending:<Name>Charlotte</Name> Chief Complaint: Somnolence. Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 67 y.o male with bladder cancer with large pelvic masses, recent chemo tue (taxol, gemzar) now presenting with n/v/d/ new afib with RVR, metastatic disease. Pt is HD m/w/f . Pt denies pain, but is unable to report other ROS. States he's tired. . In the <Name>Grace Blanks</Name>, pt at first refused IV, got EJ, removed it, an another was placed. Pt s/p 3L IVF. HR 100-170's, not given any nodal agents for rate control. PT found to be neutropenic. RUQ-new liver masses/sacral/iliac, R.sided hydroureter, has neobladder. Pt given vanco, cefepime, flagyl. Somnolent, head CT negative. Tmax 100.2 . Past Medical History: CAD HTN Hyperlipidemia ESRD on HD Bladder Cancer in <Year>1947</Year> Depression Restless Leg Syndrome Social History: Patient lives at home with girlfriend; no smoking history, no etoh. Uses marijuana for appetite. Son lives in <State>New Mexico</State>. Has 2 daughters one of whom is expecting in <Name>Shannon Ahmed</Name>. Family History: Dad died of CVA in his 90s, no hx of MI in family. Physical Exam: Vitals: T. 98.2 BP 104/67, HR 115, RR 20, sat 92% on 4L GEN: lying in bed, somnolent, arousable to sternal rub, HEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, s1s2 3/6 systolic flow murmur. PULM: Lungs b/l coarse inspiratory rhonchi. no w/r ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/2+E, no palpable cords NEURO: somnolent, squeezes hand to commands. Pertinent Results: Admission labs <Date>1960-10-8</Date> 10:30PM BLOOD WBC-0.4# RBC-2.98 Hgb-8.0* Hct-26.2* MCV-88 MCH-27.0 MCHC-30.7* RDW-18.1* Plt Ct-52# <Date>1960-10-8</Date> 10:30PM BLOOD Neuts-41 Bands-1 Lymphs-32 Monos-24* Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 <Date>1960-10-8</Date> 10:30PM BLOOD PT-44.7* PTT-46.3* INR(PT)-5.0* <Date>1960-10-8</Date> 10:30PM BLOOD Plt Smr-VERY LOW Plt Ct-52# <Date>1960-10-8</Date> 10:30PM BLOOD Gran Ct-130 <Date>1960-10-8</Date> 10:30PM BLOOD Glucose-100 UreaN-98* Creat-6.6* Na-139 K-4.8 Cl-92* HCO3-27 AnGap-25* <Date>1960-10-8</Date> 10:30PM BLOOD ALT-71* AST-114* LD(LDH)-501* CK(CPK)-127 AlkPhos-256* TotBili-3.8* DirBili-2.7* IndBili-1.1 <Date>1960-10-8</Date> 10:30PM BLOOD CK-MB-5 <Date>1960-10-8</Date> 10:30PM BLOOD cTropnT-0.09* <Date>1960-10-8</Date> 10:30PM BLOOD Albumin-2.3* Calcium-7.1* Phos-8.8*# Mg-2.0 <Date>1960-10-8</Date> 10:37PM BLOOD Lactate-1.8 K-4.8 Pertinent Radiology: <Date>1960-10-8</Date> Liver Gallbladder US: IMPRESSION: 1. Multiple hepatic masses, the largest of which measures over 4 cm, and is suspicious for metastatic disease given the history. 2. Unchanged severe right hydronephrosis. 3. No gallbladder distention or CBD dilation. <Date>1940-5-3</Date> CT ABD/Pelvis: IMPRESSION: 1. Marked progression of metastatic disease, with new metastases in the liver as well as iliac and sacral bones. 2. Severe right hydroureteronephrosis, as in the prior study. 3. Limited evaluation of the central abdomen due to marked streak artifact from numerous surgical clips. 4. Bilateral lower lobe subsegmental atelectasis, as well as incompletely imaged nodular opacities suspicious for metastatic disease given the history. <Date>1940-5-3</Date> CT HEAD: IMPRESSION: No evidence of acute intracranial process. If there is high clinical suspicion for metastatic disease, MRI is more sensitive. <Date>1940-5-3</Date> LENI: IMPRESSION: Normal examination of the bilateral lower extremities. No evidence of DVT. <Date>1931-2-6</Date> CXR: Since <Date>1960-10-8</Date>, cardiomegaly is unchanged. Prior sternotomy and abdominal clips are unchanged. Bilateral small pleural effusions are new. Bilateral increase in interstitial markings and hilar haziness are consistent with pulmonary edema. More confluent left lower lobe opacity could be due to pneumonia. Incidentally, old left rib fractures are unchanged. <Date>1931-2-6</Date> EKG: Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave abnormalities. Compared to the previous tracing of <Date>1940-5-3</Date> no significant change. Brief Hospital Course: A/P: Pt is a 67 y.o male with h.o bladder cancer now presenting with altered mental status and tachycardia. . MICU COURSE: 1) Tachycardia: patient presented with Afib. No obvious explanation. Assess for myocardial infarction. With thrombocytopenia and prolonged INR and renal failure, a PE is less likely. Would check A-a gradient on room air and obtain LENI's with peripheral edema. Also check thyroid function. -monitor on tele -ROMI . 2) Fever with neutropenia: concern about infection with neutropenia. CXR not impressive for infiltrate but there may be slight increase in markings at right base and left base. On broad spectrum antibiotics; will repeat CXR in AM. Blood cultures pending/urine cx pending. -neutropenic percautions. . 3) Anemia: probably related to marrow suppression. No evidence of GI bleeding. Guaiac stool. PIVs. IRON studies. . 4) Thrombocytopenia: likely related to bone marrow suppression. No evidence of bleeding now. Continue to monitor. Consider HIT ab. . 5) Hypotension: patient with hx of hypertension. Present BP likely relatively hypotensive now. Has dry mucus membranes and decreased tissue turgor. Will give additional fluids now. With renal failure, would watch bicarbonate with normal saline fluid resuscitation. Would not give lactated ringers because of anuria. <Month>December</Month> need D5W with bicarb as part of fluid resuscitation if serum bicarb begins to drop. . 6) Metastatic bladder ca: discuss future therapy with oncology. . 7) Altered mental status: ETiologies include intracranial mass/bleed but r/o with CT head. Other possibilities include toxic-metabolic including uremia/acute liver failure. Other possibilities include infection such as sepsis/meningitis. Other possibility includes medication/narcotic effect. Patient given narcan with some improvement. He is on narcotics at home and may have taken extra doses or may now have delayed metabolism because of liver <Month>September</Month> and abnormal LFT's. Continue with narcan for now. Uremia may also be contributing to altered mental status. -toxic metabolic w/u and correction -frequent neuro exams -antibiotics -infectious w/u -consult renal for HD. . 8) Chronic renal failure: electrolytes and acid-base status acceptable. Mental status may be due, in part, to uremia. No volume overload now. No immediate need for dialysis. renal on board. . 9) Acidosis: combined anion gap acidosis, probably from uremia, and metabolic alkalosis, likely from volume depletion and vomiting. . Fen-NPO, lytes prn access-PIVs ppx-pneumoboots, PPI, bowel reg communication-pt's family code-DNR/DNI disp- ICU for now. . <Date>2-2</Date> -Bili mostly direct (2.7 out of 3.8) - Given now widespread <Month>July</Month> on CT abd/pelvis. Family met with Dr. <Name>Thomas</Name> (heme), <Doctor Name>Dr.Caro</Doctor Name> (renal) and has decided to make pt DNR/ DNI. Will most likely go to comfort care but would like to wait a few days and see if the pt "comes out of this" ie change in MS - EKG without change -FFP 4u given in afternoon -Pt with very limited access. Currently has 1 working PIV. Family not opposed to central access at this time but as it will excalate care at this time with risks of infxn and coagulopathy, will not place. -Pt with A fib and HR into 180's off and on in the afternoon. Started on Metoprolol 5IV Q 4hrs but still with intermittent tachycardia. Currently in sinus. - LENI's negative -Stools grossly bloody and guaiac +. Hct stable. -CE trending down -Considered starting lactulose to possibly improve MS <Name>Karissa</Name> <Name>Atencio</Name> to liver and liver damage seen in coagulopathy but d/c'd as pt already having considerable diarrhea- C diff pending -Per renal, if family still wishes, will do HD in am -Got just 1L IVF bolus during evening. O2 Sat 95% on 2LNC and pt putting out little uring by ostomy (must be cathed by nursing) <Date>5-14</Date> - Family discussion -> decided to proceed with HD - bedside HD per renal yesterday - transfused 2 U with appropriate increase in Hct - Urine Cx with GNR >100K - Patient with pain in abd last night, given small dose morphine with good effect <Date>3-14</Date> - Pt made CMO overnight. - Pt given IVF and Morphine PRN . OMED COURSE Patient was transferred to OMED service from <Hospital>Smith, Reynolds and Hickman Clinic</Hospital> on Thursday <Date>1-27</Date>. At the time of transfer the goals of care were comfort measures only. He was kept on a morphine drip, titrated to respiratory comfort. He was also started on Ativan prn for agitation. Palliative care consult was obtained. He passed away on the night of Friday <Date>10-13</Date> at approximately 6:15 PM. Immediate cause of death was respiratory failure. Secondary cause of death was metastatic bladder cancer. Medications on Admission: tylenol-codeine 300-30mg <Date>9-4</Date> Q4h prn ambien 10mg QHS amlodipine 5mg daily lipitor 40mg daily nephrocaps neurontin 300mg qhs imdur 60mg SR daily megace 15mg po daily toprol xl 50mg 0.5mg daily morphine 15mg <Hospital>Waller, Barnes and Moore Clinic</Hospital> ms <Name>Smith</Name> 15mg SR <Hospital>Waller, Barnes and Moore Clinic</Hospital> nitro 0.4mg protonix 40mg daily mirapex 0.25mg qhs compazine 10mg Q6Hprn renagel 800mg , 2 tabls TID aspirin 81mg daily Discharge Medications: Deceased. Discharge Disposition: Expired Discharge Diagnosis: Metastatic Bladder Cancer. Discharge Condition: Deceased. Discharge Instructions: Deceased. Followup Instructions: Deceased. <Name>Delfina Tamaro</Name> <Name>Athanasios Hasan</Name> MD, <MD Number>36332010</MD Number> Completed 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Date: 1940-5-3 Discharge Date: 1946-4-28 Date of Birth: 1959-12-19 Sex: M Service: MEDICINE Allergies: Horse Blood Extract / Bactrim Ds / Adhesive Tape / Sulfa (Sulfonamides) Attending:Charlotte Chief Complaint: Somnolence. Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 67 y.o male with bladder cancer with large pelvic masses, recent chemo tue (taxol, gemzar) now presenting with n/v/d/ new afib with RVR, metastatic disease. Pt is HD m/w/f . Pt denies pain, but is unable to report other ROS. States he's tired. . In the Grace Blanks, pt at first refused IV, got EJ, removed it, an another was placed. Pt s/p 3L IVF. HR 100-170's, not given any nodal agents for rate control. PT found to be neutropenic. RUQ-new liver masses/sacral/iliac, R.sided hydroureter, has neobladder. Pt given vanco, cefepime, flagyl. Somnolent, head CT negative. Tmax 100.2 . Past Medical History: CAD HTN Hyperlipidemia ESRD on HD Bladder Cancer in 1947 Depression Restless Leg Syndrome Social History: Patient lives at home with girlfriend; no smoking history, no etoh. Uses marijuana for appetite. Son lives in New Mexico. Has 2 daughters one of whom is expecting in Shannon Ahmed. Family History: Dad died of CVA in his 90s, no hx of MI in family. Physical Exam: Vitals: T. 98.2 BP 104/67, HR 115, RR 20, sat 92% on 4L GEN: lying in bed, somnolent, arousable to sternal rub, HEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, s1s2 3/6 systolic flow murmur. PULM: Lungs b/l coarse inspiratory rhonchi. no w/r ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/2+E, no palpable cords NEURO: somnolent, squeezes hand to commands. Pertinent Results: Admission labs 1960-10-8 10:30PM BLOOD WBC-0.4# RBC-2.98 Hgb-8.0* Hct-26.2* MCV-88 MCH-27.0 MCHC-30.7* RDW-18.1* Plt Ct-52# 1960-10-8 10:30PM BLOOD Neuts-41 Bands-1 Lymphs-32 Monos-24* Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 1960-10-8 10:30PM BLOOD PT-44.7* PTT-46.3* INR(PT)-5.0* 1960-10-8 10:30PM BLOOD Plt Smr-VERY LOW Plt Ct-52# 1960-10-8 10:30PM BLOOD Gran Ct-130 1960-10-8 10:30PM BLOOD Glucose-100 UreaN-98* Creat-6.6* Na-139 K-4.8 Cl-92* HCO3-27 AnGap-25* 1960-10-8 10:30PM BLOOD ALT-71* AST-114* LD(LDH)-501* CK(CPK)-127 AlkPhos-256* TotBili-3.8* DirBili-2.7* IndBili-1.1 1960-10-8 10:30PM BLOOD CK-MB-5 1960-10-8 10:30PM BLOOD cTropnT-0.09* 1960-10-8 10:30PM BLOOD Albumin-2.3* Calcium-7.1* Phos-8.8*# Mg-2.0 1960-10-8 10:37PM BLOOD Lactate-1.8 K-4.8 Pertinent Radiology: 1960-10-8 Liver Gallbladder US: IMPRESSION: 1. Multiple hepatic masses, the largest of which measures over 4 cm, and is suspicious for metastatic disease given the history. 2. Unchanged severe right hydronephrosis. 3. No gallbladder distention or CBD dilation. 1940-5-3 CT ABD/Pelvis: IMPRESSION: 1. Marked progression of metastatic disease, with new metastases in the liver as well as iliac and sacral bones. 2. Severe right hydroureteronephrosis, as in the prior study. 3. Limited evaluation of the central abdomen due to marked streak artifact from numerous surgical clips. 4. Bilateral lower lobe subsegmental atelectasis, as well as incompletely imaged nodular opacities suspicious for metastatic disease given the history. 1940-5-3 CT HEAD: IMPRESSION: No evidence of acute intracranial process. If there is high clinical suspicion for metastatic disease, MRI is more sensitive. 1940-5-3 LENI: IMPRESSION: Normal examination of the bilateral lower extremities. No evidence of DVT. 1931-2-6 CXR: Since 1960-10-8, cardiomegaly is unchanged. Prior sternotomy and abdominal clips are unchanged. Bilateral small pleural effusions are new. Bilateral increase in interstitial markings and hilar haziness are consistent with pulmonary edema. More confluent left lower lobe opacity could be due to pneumonia. Incidentally, old left rib fractures are unchanged. 1931-2-6 EKG: Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave abnormalities. Compared to the previous tracing of 1940-5-3 no significant change. Brief Hospital Course: A/P: Pt is a 67 y.o male with h.o bladder cancer now presenting with altered mental status and tachycardia. . MICU COURSE: 1) Tachycardia: patient presented with Afib. No obvious explanation. Assess for myocardial infarction. With thrombocytopenia and prolonged INR and renal failure, a PE is less likely. Would check A-a gradient on room air and obtain LENI's with peripheral edema. Also check thyroid function. -monitor on tele -ROMI . 2) Fever with neutropenia: concern about infection with neutropenia. CXR not impressive for infiltrate but there may be slight increase in markings at right base and left base. On broad spectrum antibiotics; will repeat CXR in AM. Blood cultures pending/urine cx pending. -neutropenic percautions. . 3) Anemia: probably related to marrow suppression. No evidence of GI bleeding. Guaiac stool. PIVs. IRON studies. . 4) Thrombocytopenia: likely related to bone marrow suppression. No evidence of bleeding now. Continue to monitor. Consider HIT ab. . 5) Hypotension: patient with hx of hypertension. Present BP likely relatively hypotensive now. Has dry mucus membranes and decreased tissue turgor. Will give additional fluids now. With renal failure, would watch bicarbonate with normal saline fluid resuscitation. Would not give lactated ringers because of anuria. December need D5W with bicarb as part of fluid resuscitation if serum bicarb begins to drop. . 6) Metastatic bladder ca: discuss future therapy with oncology. . 7) Altered mental status: ETiologies include intracranial mass/bleed but r/o with CT head. Other possibilities include toxic-metabolic including uremia/acute liver failure. Other possibilities include infection such as sepsis/meningitis. Other possibility includes medication/narcotic effect. Patient given narcan with some improvement. He is on narcotics at home and may have taken extra doses or may now have delayed metabolism because of liver September and abnormal LFT's. Continue with narcan for now. Uremia may also be contributing to altered mental status. -toxic metabolic w/u and correction -frequent neuro exams -antibiotics -infectious w/u -consult renal for HD. . 8) Chronic renal failure: electrolytes and acid-base status acceptable. Mental status may be due, in part, to uremia. No volume overload now. No immediate need for dialysis. renal on board. . 9) Acidosis: combined anion gap acidosis, probably from uremia, and metabolic alkalosis, likely from volume depletion and vomiting. . Fen-NPO, lytes prn access-PIVs ppx-pneumoboots, PPI, bowel reg communication-pt's family code-DNR/DNI disp- ICU for now. . 2-2 -Bili mostly direct (2.7 out of 3.8) - Given now widespread July on CT abd/pelvis. Family met with Dr. Thomas (heme), Dr.Caro (renal) and has decided to make pt DNR/ DNI. Will most likely go to comfort care but would like to wait a few days and see if the pt "comes out of this" ie change in MS - EKG without change -FFP 4u given in afternoon -Pt with very limited access. Currently has 1 working PIV. Family not opposed to central access at this time but as it will excalate care at this time with risks of infxn and coagulopathy, will not place. -Pt with A fib and HR into 180's off and on in the afternoon. Started on Metoprolol 5IV Q 4hrs but still with intermittent tachycardia. Currently in sinus. - LENI's negative -Stools grossly bloody and guaiac +. Hct stable. -CE trending down -Considered starting lactulose to possibly improve MS Karissa Atencio to liver and liver damage seen in coagulopathy but d/c'd as pt already having considerable diarrhea- C diff pending -Per renal, if family still wishes, will do HD in am -Got just 1L IVF bolus during evening. O2 Sat 95% on 2LNC and pt putting out little uring by ostomy (must be cathed by nursing) 5-14 - Family discussion -> decided to proceed with HD - bedside HD per renal yesterday - transfused 2 U with appropriate increase in Hct - Urine Cx with GNR >100K - Patient with pain in abd last night, given small dose morphine with good effect 3-14 - Pt made CMO overnight. - Pt given IVF and Morphine PRN . OMED COURSE Patient was transferred to OMED service from Smith, Reynolds and Hickman Clinic on Thursday 1-27. At the time of transfer the goals of care were comfort measures only. He was kept on a morphine drip, titrated to respiratory comfort. He was also started on Ativan prn for agitation. Palliative care consult was obtained. He passed away on the night of Friday 10-13 at approximately 6:15 PM. Immediate cause of death was respiratory failure. Secondary cause of death was metastatic bladder cancer. Medications on Admission: tylenol-codeine 300-30mg 9-4 Q4h prn ambien 10mg QHS amlodipine 5mg daily lipitor 40mg daily nephrocaps neurontin 300mg qhs imdur 60mg SR daily megace 15mg po daily toprol xl 50mg 0.5mg daily morphine 15mg Waller, Barnes and Moore Clinic ms Smith 15mg SR Waller, Barnes and Moore Clinic nitro 0.4mg protonix 40mg daily mirapex 0.25mg qhs compazine 10mg Q6Hprn renagel 800mg , 2 tabls TID aspirin 81mg daily Discharge Medications: Deceased. Discharge Disposition: Expired Discharge Diagnosis: Metastatic Bladder Cancer. Discharge Condition: Deceased. Discharge Instructions: Deceased. Followup Instructions: Deceased. Delfina Tamaro Athanasios Hasan MD, 36332010 Completed by:1934-7-28	["Admission Date: 1940-5-3 Discharge Date: 1946-4-28\n\nDate of Birth: 1959-12-19 Sex: M\n\nService: MEDICINE\n\nAllergies:\nHorse Blood Extract / Bactrim Ds / Adhesive Tape / Sulfa\n(Sulfonamides)\n\nAttending:Charlotte\nChief Complaint:\nSomnolence.\n\nMajor Surgical or Invasive Procedure:\nNone.\n\nHistory of Present Illness:\nThis is a 67 y.o male with bladder cancer with large pelvic\nmasses, recent chemo tue (taxol, gemzar) now presenting with\nn/v/d/ new afib with RVR, metastatic disease. Pt is HD m/w/f\n.\nPt denies pain, but is unable to report other ROS. States he's\ntired.\n.\nIn the Grace Blanks, pt at first refused IV, got EJ, removed it, an\nanother was placed. Pt s/p 3L IVF. HR 100-170's, not given any\nnodal agents for rate control. PT found to be neutropenic.\nRUQ-new liver masses/sacral/iliac, R.", 'sided hydroureter, has\nneobladder. Pt given vanco, cefepime, flagyl. Somnolent, head CT\nnegative. Tmax 100.2\n.\n\n\nPast Medical History:\nCAD\nHTN\nHyperlipidemia\nESRD on HD\nBladder Cancer in 1947\nDepression\nRestless Leg Syndrome\n\n\nSocial History:\nPatient lives at home with girlfriend; no smoking history, no\netoh. Uses marijuana for appetite. Son lives in New Mexico. Has 2\ndaughters one of whom is expecting in Shannon Ahmed.\n\n\nFamily History:\nDad died of CVA in his 90s, no hx of MI in family.\n\nPhysical Exam:\nVitals: T. 98.2 BP 104/67, HR 115, RR 20, sat 92% on 4L\nGEN: lying in bed, somnolent, arousable to sternal rub,\nHEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM,\nOP Clear\nNECK: No JVD, carotid pulses brisk, no bruits, no cervical\nlymphadenopathy, trachea midline\nCOR: RRR, s1s2 3/6 systolic flow murmur.', '\nPULM: Lungs b/l coarse inspiratory rhonchi. no w/r\nABD: Soft, NT, ND, +BS, no HSM, no masses\nEXT: No C/C/2+E, no palpable cords\nNEURO: somnolent, squeezes hand to commands.\n\n\nPertinent Results:\nAdmission labs\n1960-10-8 10:30PM BLOOD WBC-0.4# RBC-2.98 Hgb-8.0* Hct-26.2\nMCV-88 MCH-27.0 MCHC-30.7 RDW-18.1* Plt Ct-52#\n1960-10-8 10:30PM BLOOD Neuts-41 Bands-1 Lymphs-32 Monos-24\nEos-0 Baso-0 Atyps-2 Metas-0 Myelos-0\n1960-10-8 10:30PM BLOOD PT-44.7* PTT-46.3* INR(PT)-5.0\n1960-10-8 10:30PM BLOOD Plt Smr-VERY LOW Plt Ct-52#\n1960-10-8 10:30PM BLOOD Gran Ct-130\n1960-10-8 10:30PM BLOOD Glucose-100 UreaN-98 Creat-6.6* Na-139\nK-4.8 Cl-92* HCO3-27 AnGap-25\n1960-10-8 10:30PM BLOOD ALT-71 AST-114* LD(LDH)-501* CK(CPK)-127\nAlkPhos-256* TotBili-3.8* DirBili-2.7* IndBili-1.1\n1960-10-8 10:30PM BLOOD CK-MB-5\n1960-10-8 10:30PM BLOOD cTropnT-0.', '09\n1960-10-8 10:30PM BLOOD Albumin-2.3 Calcium-7.1* Phos-8.8*#\nMg-2.0\n1960-10-8 10:37PM BLOOD Lactate-1.8 K-4.8\n\nPertinent Radiology:\n1960-10-8 Liver Gallbladder US:\nIMPRESSION:\n1. Multiple hepatic masses, the largest of which measures over 4\ncm, and is suspicious for metastatic disease given the history.\n2. Unchanged severe right hydronephrosis.\n3. No gallbladder distention or CBD dilation.\n\n1940-5-3 CT ABD/Pelvis:\nIMPRESSION:\n1. Marked progression of metastatic disease, with new metastases\nin the liver as well as iliac and sacral bones.\n2. Severe right hydroureteronephrosis, as in the prior study.\n3. Limited evaluation of the central abdomen due to marked\nstreak artifact\nfrom numerous surgical clips.\n4. Bilateral lower lobe subsegmental atelectasis, as well as\nincompletely\nimaged nodular opacities suspicious for metastatic disease given\nthe history.', '\n\n1940-5-3 CT HEAD:\nIMPRESSION: No evidence of acute intracranial process. If there\nis high\nclinical suspicion for metastatic disease, MRI is more\nsensitive.\n\n1940-5-3 LENI:\nIMPRESSION: Normal examination of the bilateral lower\nextremities. No\nevidence of DVT.\n\n1931-2-6 CXR:\nSince 1960-10-8, cardiomegaly is unchanged. Prior\nsternotomy and\nabdominal clips are unchanged.\nBilateral small pleural effusions are new. Bilateral increase in\ninterstitial markings and hilar haziness are consistent with\npulmonary edema. More confluent left lower lobe opacity could be\ndue to pneumonia.\nIncidentally, old left rib fractures are unchanged.\n\n1931-2-6 EKG:\nAtrial fibrillation with rapid ventricular response.\nNon-specific ST-T wave abnormalities. Compared to the previous\ntracing of 1940-5-3 no significant change.', "\n\nBrief Hospital Course:\nA/P: Pt is a 67 y.o male with h.o bladder cancer now presenting\nwith altered mental status and tachycardia.\n.\nMICU COURSE:\n1) Tachycardia: patient presented with Afib. No obvious\nexplanation. Assess for myocardial infarction. With\nthrombocytopenia and prolonged INR and renal failure, a PE is\nless likely. Would check A-a gradient on room air and obtain\nLENI's with peripheral edema. Also check thyroid function.\n-monitor on tele\n-ROMI\n.\n2) Fever with neutropenia: concern about infection with\nneutropenia. CXR not impressive for infiltrate but there may be\nslight increase in markings at right base and left base. On\nbroad spectrum antibiotics; will repeat CXR in AM. Blood\ncultures pending/urine cx pending.\n-neutropenic percautions.\n.\n3) Anemia: probably related to marrow suppression.", ' No evidence\nof GI bleeding. Guaiac stool. PIVs. IRON studies.\n.\n4) Thrombocytopenia: likely related to bone marrow suppression.\nNo evidence of bleeding now. Continue to monitor. Consider HIT\nab.\n.\n5) Hypotension: patient with hx of hypertension. Present BP\nlikely relatively hypotensive now. Has dry mucus membranes and\ndecreased tissue turgor. Will give additional fluids now. With\nrenal failure, would watch bicarbonate with normal saline fluid\nresuscitation. Would not give lactated ringers because of\nanuria. December need D5W with bicarb as part of fluid resuscitation\nif serum bicarb begins to drop.\n.\n6) Metastatic bladder ca: discuss future therapy with oncology.\n.\n7) Altered mental status: ETiologies include intracranial\nmass/bleed but r/o with CT head. Other possibilities include\ntoxic-metabolic including uremia/acute liver failure.', " Other\npossibilities include infection such as sepsis/meningitis. Other\npossibility includes medication/narcotic effect. Patient given\nnarcan with some improvement. He is on narcotics at home and may\nhave taken extra doses or may now have delayed metabolism\nbecause of liver September and abnormal LFT's. Continue with narcan\nfor now. Uremia may also be contributing to altered mental\nstatus.\n-toxic metabolic w/u and correction\n-frequent neuro exams\n-antibiotics\n-infectious w/u\n-consult renal for HD.\n.\n8) Chronic renal failure: electrolytes and acid-base status\nacceptable. Mental status may be due, in part, to uremia. No\nvolume overload now. No immediate need for dialysis. renal on\nboard.\n.\n9) Acidosis: combined anion gap acidosis, probably from uremia,\nand metabolic alkalosis, likely from volume depletion and\nvomiting.", '\n.\nFen-NPO, lytes prn\naccess-PIVs\nppx-pneumoboots, PPI, bowel reg\ncommunication-pt\'s family\ncode-DNR/DNI\ndisp- ICU for now.\n.\n2-2\n-Bili mostly direct (2.7 out of 3.8)\n- Given now widespread July on CT abd/pelvis. Family met with\nDr. Thomas (heme), Dr.Caro (renal) and has decided to make pt\nDNR/ DNI. Will most likely go to comfort care but would like to\nwait a few days and see if the pt "comes out of this" ie change\nin MS\n- EKG without change\n-FFP 4u given in afternoon\n-Pt with very limited access. Currently has 1 working PIV.\nFamily not opposed to central access at this time but as it will\nexcalate care at this time with risks of infxn and coagulopathy,\nwill not place.\n-Pt with A fib and HR into 180\'s off and on in the afternoon.\nStarted on Metoprolol 5IV Q 4hrs but still with intermittent\ntachycardia.', " Currently in sinus.\n- LENI's negative\n-Stools grossly bloody and guaiac +. Hct stable.\n-CE trending down\n-Considered starting lactulose to possibly improve MS Karissa Atencio\nto liver and liver damage seen in coagulopathy but d/c'd as pt\nalready having considerable diarrhea- C diff pending\n-Per renal, if family still wishes, will do HD in am\n-Got just 1L IVF bolus during evening. O2 Sat 95% on 2LNC and pt\nputting out little uring by ostomy (must be cathed by nursing)\n\n5-14\n- Family discussion -> decided to proceed with HD - bedside HD\nper renal yesterday\n- transfused 2 U with appropriate increase in Hct\n- Urine Cx with GNR >100K\n- Patient with pain in abd last night, given small dose morphine\nwith good effect\n\n3-14\n- Pt made CMO overnight.\n- Pt given IVF and Morphine PRN\n.\nOMED COURSE\nPatient was transferred to OMED service from Smith, Reynolds and Hickman Clinic on Thursday\n1-27.", ' At the time of transfer the goals of care were comfort\nmeasures only. He was kept on a morphine drip, titrated to\nrespiratory comfort. He was also started on Ativan prn for\nagitation. Palliative care consult was obtained. He passed\naway on the night of Friday 10-13 at approximately 6:15 PM.\nImmediate cause of death was respiratory failure. Secondary\ncause of death was metastatic bladder cancer.\n\nMedications on Admission:\ntylenol-codeine 300-30mg 9-4 Q4h prn\nambien 10mg QHS\namlodipine 5mg daily\nlipitor 40mg daily\nnephrocaps\nneurontin 300mg qhs\nimdur 60mg SR daily\nmegace 15mg po daily\ntoprol xl 50mg 0.5mg daily\nmorphine 15mg Waller, Barnes and Moore Clinic\nms Smith 15mg SR Waller, Barnes and Moore Clinic\nnitro 0.4mg\nprotonix 40mg daily\nmirapex 0.25mg qhs\ncompazine 10mg Q6Hprn\nrenagel 800mg , 2 tabls TID\naspirin 81mg daily\n\n\nDischarge Medications:\nDeceased.', '\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\nMetastatic Bladder Cancer.\n\n\nDischarge Condition:\nDeceased.\n\n\nDischarge Instructions:\nDeceased.\n\nFollowup Instructions:\nDeceased.\n\n\n Delfina Tamaro Athanasios Hasan MD, 36332010\n\nCompleted by:1934-7-28']
129	31294	101974.0	2119-03-31	Discharge summary	Report	Admission Date: [2119-1-17] Discharge Date: [2119-3-31] Date of Birth: [2073-3-6] Sex: M Service: SURGERY Allergies: Penicillins / Zofran / Toradol / Phenobarbital / Trazodone / Compazine / Oxycodone Attending:[First Name3 (LF) 695] Chief Complaint: encephalopathy Major Surgical or Invasive Procedure: Blood transfusion Paracentesis x2 ([1-17], [1-23]) [2119-3-14] liver transplant History of Present Illness: 45 y/o male with ESLD from HCV, HBC, and EtOH who had a TIPS done on [2119-1-5] who presented to the OSH yesterday with altered mental status. The patient was treated with lactulose at the OSH with some improvement in his encelpalopathy. There was concern that there was a problem with the TIPS and he was transferred to [Hospital1 18] for further workup. Denied chest pain, shortness of breath, fevers, chills. He reports abdominal pain slightly worse than his baseline. No melena or BRBPR. . Labs at the OSH significant for AST/ALT 186/124, TB 12, DB 5, Ammonia 330, Na 132. Past Medical History: # L4,L5,S1 fusion # Decompensated liver cirrhosis [1-28] to HCV, HBC, and alcohol c/b encephalopathy and ascites # Chronic pancreatitis # Non bleeding grade 2 esophageal varices in [4-3] # GERD-Barrett's esophagus # COPD # s/p incarcerated umbilical hernia repair [11-3], recent admission on [2118-12-26] to [2118-12-30] for concern for cellulitis around his surgical incision, started on clindamycin then vanc then bactrim for a total course of 7 days #OLT [2119-3-14] Social History: Married, but separated, has 3 children. Lives with roommates - limited support. Smokes a pack every 3 days. Quit cocaine and heroine in [2114]. Quit EtOH in [2101]. Family History: Family Hx: No known family history of hepatitis or liver disease Physical Exam: VS: 97.5 95/69 90 12 93%RA Gen: awake, oriented x 2 (able to state month and year, stated he was at B+W's) HEENT: NC/AT. PERRL, EOMI, MMM. OP clear. Neck: Supple, no LAD. CV: RRR, S1, S2 no m/r/g. Chest: CTAB no wheezes or crackles. ABD: Distended, + tense ascites, TTP diffusely Ext: WWP, no edema. + asterixis Pertinent Results: Upon admission, a CT of the abd/pelvis was done [2-1] demonstrating: 1. Large amount of ascites. Tiny amount of high-density fluid layers in the deep pelvis consistent with blood not changed from prior study at 2:13 a.m. today, [2119-2-1]. No subcapsular hepatic hematoma. 2. Small subcentimeter focus of arterial enhancement of hepatic segment VIII becomes isodense to liver parenchyma on the delayed phase. This is more conspicuous compared to [2118-12-27] and [2118-11-9]. Finding is non- specific but given cirrhosis a small focus of hepatocellular carcinoma cannot be excluded. Continued imaging surveillance is recommended. 3. Cirrhosis with splenomegaly indicating portal hypertension. 4. Patent TIPS. On [2-25] a ruq u/s was performed showing a patent TIPS with increased velocities, little changed. Head CT was negative and EEG was abnormal with findings consistent with moderate encephalopathy . There were no epileptiform features and no seizure activity. . [2-27] ct chest: 1. Abnormality in the right upper lobe demonstrates marked panlobular emphysematous changes. No evidence of pneumothorax. 2. Atelectasis within the right upper and bilateral lower lobes. No evidence of airspace consolidation. 3. Limited images through the upper abdomen show a large volume ascites, TIPS, and splenomegaly. Brief Hospital Course: Patient initially transfered from OSH with encephalopathy and concern for clotted TIPS. TIPS initially placed [2119-1-5]. Ultrasound showed patent TIPS and his mental status improved with lactulose and regular bowel movements. The patient was tapped for a large amount of ascites and it was negative for SBP. He continued to have waxing and [Doctor Last Name 688] encephalopathy, He required admission to the MICU twice for unresponsiveness, both times which he was intubated for airway protection, and given additional lactulose. His head CT on first MICU admission was negative for any acute process such as intracranial bleed. EEG findings were consistent with encephalopathy without seizure activity. An attempted Re-Do TIPS to divert blood through portal veins and not the TIPS was attempted, but technically unsuccessful and complicated by small hemoperitoneum that required transfusion but otherwise self-limited. He finally had successful TIPS revision on [2119-2-6]. He continued to receive therapeutic paracentesis. Ultrasound initially showed patent TIPS but subsequent ones showed increased velocities concerning for stenosis. He was restarted on diuretics because his sodium was improved from prior admissions, but these were held for worsening renal function. He was continued on 1500ml fluid restriction and Cipro for SBP prophylaxis. CVVHD was started. A CXR showed new right sided infiltrate and the patient had moderate growth of MRSA from his sputum with sparse growth of 2 colonies of GNR. He was treated with vancomycin and zosyn. On [3-14] he underwent Orthotopic deceased donor liver transplant (piggyback), portal vein-portal vein anastomosis, common bile duct-common bile duct anastomosis with no T-tube, branch patch (recipient) to celiac patch (donor)hepatic artery anastomosis. Surgeon was Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]. Please see operative report for further details. EBL was 2 liters replaced with PRBC, plt, FFP, cryo and cellsaver. Two JPs were placed. He was maintained on CVVHD during the case. He received HBIG intraop and on pod [12-31]. HBsAb titers were greater than 450. HBIG IM was given on pod 7 and 14. Entecavir was started immediately postop. This dose was renally dosed. Postop, he was transferred to the SICU per protocol. He was extubated on POD 2. CVVHD continue for ~ 2 days then lasix was started. He received prbc/plt/ffp on pod 0. Labs were monitored q 6 hours. US of the liver demonstrated difficulty detecting the expected hepatic arterial supply to the left lobe. Otherwise U/S was normal. LFTs trended down. The medial JP was removed on pod 5. The lateral JP continued to drain large amounts of ascites. Outputs were as high as 4.5liters per day. He received IV fluid replacements and albumin for JP outputs. Of note, creatinine started trending up off CVVHD as high as 4.3 from 2.7. Urine output averaged 1000-1200cc/day. Nephrology was consulted. It was felt that he had ATN on resolving hepatorenal syndrome. Fluconazole dose was renally dosed to 200mg qd as this was felt to increase the prograf level. Creatinine slowly trended down to 2.9. Hyperkalemia was a persistent problem that required treatment with insulin, dextrose, lasix and kayexalate. Hyperkalemia improved with improved renal function. A low potassium diet was ordered. The lateral JP was removed on [3-29] for outputs of 600cc. The transplant incision remained clean, dry and intact. His abdomen appeared a little distended PT evaluated him and initially recommended rehab, but he improved significant and it was felt that he would be safe for discharge to home. He was also started on insulin for hyperglycemia. Glargine and humalog sliding scale were given. Immunosuppression consisted of cellcept 1 gram [Hospital1 ], steroids were tapered to prednisone 20mg qd per protocol, and prograf was started on pod 1. Prograf was decreased to 2.5mg [Hospital1 ] per trough levels of [8-8].2. VNA services were arranged for home. Medications on Admission: 1. Morphine 30 mg SR [Hospital1 ] 2. Lactulose 30ML PO TID 3. Pantoprazole 40 mg Q24H 4. Folic Acid 1 mg DAILY 5. Oxycodone 5 mg Q6H as needed for Pain. 6. Colace 100 mg twice a day 7. Ciprofloxacin 250 mg Q24H 8. Entecavir 0.5 mg DAILY 9. Hexavitamin Daily --Of note, has been off diuretics since last admission [1-28] hyponatremia . Allergies: PCN, zofran, toradol, phenobarbital, trazadone Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 10. Entecavir 0.05 mg/mL Solution Sig: Three (3) ml PO DAILY (Daily). Disp:50 ml Refills:2 11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 MDI Refills:0 13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 16. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. 17. Insulin Syringes Low dose syringes for qid injections 25 guage needle supply: 1 box Refill: 1 Discharge Disposition: Home with Service Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: ESLD from HCV/HBV/ETOH cirrhosis Hepatic encephalopathy Hepatorenal syndrome ARF, improving malnutrition Chronic back pain Barrett's esophagus GERD COPD s/p incarcerated umbilical hernia repair Discharge Condition: good Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if fever, chills, nausea, vomiting, inability to take any of your medications, weight loss, jaundice, abdominal incision appears red, bleeds or has drainage. Labs every Monday and Thursday Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2119-4-5] 9:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2119-4-12] 9:40 Provider: [Name10 (NameIs) ],[Name11 (NameIs) 156] TRANSPLANT SOCIAL WORK Date/Time:[2119-4-12] 10:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2119-3-31]	Admission Date: <Date>1937-12-12</Date> Discharge Date: <Date>1994-5-15</Date> Date of Birth: <Date>1978-8-15</Date> Sex: M Service: SURGERY Allergies: Penicillins / Zofran / Toradol / Phenobarbital / Trazodone / Compazine / Oxycodone Attending:<Name>Grace</Name> Chief Complaint: encephalopathy Major Surgical or Invasive Procedure: Blood transfusion Paracentesis x2 (<Date>12-2</Date>, <Date>7-14</Date>) <Date>1920-2-1</Date> liver transplant History of Present Illness: 45 y/o male with ESLD from HCV, HBC, and EtOH who had a TIPS done on <Date>1949-4-8</Date> who presented to the OSH yesterday with altered mental status. The patient was treated with lactulose at the OSH with some improvement in his encelpalopathy. There was concern that there was a problem with the TIPS and he was transferred to <Hospital>Griffith, Cohen and Nichols Health System</Hospital> for further workup. Denied chest pain, shortness of breath, fevers, chills. He reports abdominal pain slightly worse than his baseline. No melena or BRBPR. . Labs at the OSH significant for AST/ALT 186/124, TB 12, DB 5, Ammonia 330, Na 132. Past Medical History: # L4,L5,S1 fusion # Decompensated liver cirrhosis <Date>2-4</Date> to HCV, HBC, and alcohol c/b encephalopathy and ascites # Chronic pancreatitis # Non bleeding grade 2 esophageal varices in <Date>7-11</Date> # GERD-Barrett's esophagus # COPD # s/p incarcerated umbilical hernia repair <Date>8-4</Date>, recent admission on <Date>1925-9-25</Date> to <Date>1987-10-13</Date> for concern for cellulitis around his surgical incision, started on clindamycin then vanc then bactrim for a total course of 7 days #OLT <Date>1920-2-1</Date> Social History: Married, but separated, has 3 children. Lives with roommates - limited support. Smokes a pack every 3 days. Quit cocaine and heroine in <Year>1952</Year>. Quit EtOH in <Year>1952</Year>. Family History: Family Hx: No known family history of hepatitis or liver disease Physical Exam: VS: 97.5 95/69 90 12 93%RA Gen: awake, oriented x 2 (able to state month and year, stated he was at B+W's) HEENT: NC/AT. PERRL, EOMI, MMM. OP clear. Neck: Supple, no LAD. CV: RRR, S1, S2 no m/r/g. Chest: CTAB no wheezes or crackles. ABD: Distended, + tense ascites, TTP diffusely Ext: WWP, no edema. + asterixis Pertinent Results: Upon admission, a CT of the abd/pelvis was done <Date>9-6</Date> demonstrating: 1. Large amount of ascites. Tiny amount of high-density fluid layers in the deep pelvis consistent with blood not changed from prior study at 2:13 a.m. today, <Date>2007-7-12</Date>. No subcapsular hepatic hematoma. 2. Small subcentimeter focus of arterial enhancement of hepatic segment VIII becomes isodense to liver parenchyma on the delayed phase. This is more conspicuous compared to <Date>1941-1-4</Date> and <Date>2014-9-29</Date>. Finding is non- specific but given cirrhosis a small focus of hepatocellular carcinoma cannot be excluded. Continued imaging surveillance is recommended. 3. Cirrhosis with splenomegaly indicating portal hypertension. 4. Patent TIPS. On <Date>5-18</Date> a ruq u/s was performed showing a patent TIPS with increased velocities, little changed. Head CT was negative and EEG was abnormal with findings consistent with moderate encephalopathy . There were no epileptiform features and no seizure activity. . <Date>9-15</Date> ct chest: 1. Abnormality in the right upper lobe demonstrates marked panlobular emphysematous changes. No evidence of pneumothorax. 2. Atelectasis within the right upper and bilateral lower lobes. No evidence of airspace consolidation. 3. Limited images through the upper abdomen show a large volume ascites, TIPS, and splenomegaly. Brief Hospital Course: Patient initially transfered from OSH with encephalopathy and concern for clotted TIPS. TIPS initially placed <Date>1949-4-8</Date>. Ultrasound showed patent TIPS and his mental status improved with lactulose and regular bowel movements. The patient was tapped for a large amount of ascites and it was negative for SBP. He continued to have waxing and <Doctor Name>Dr.Wilson</Doctor Name> encephalopathy, He required admission to the MICU twice for unresponsiveness, both times which he was intubated for airway protection, and given additional lactulose. His head CT on first MICU admission was negative for any acute process such as intracranial bleed. EEG findings were consistent with encephalopathy without seizure activity. An attempted Re-Do TIPS to divert blood through portal veins and not the TIPS was attempted, but technically unsuccessful and complicated by small hemoperitoneum that required transfusion but otherwise self-limited. He finally had successful TIPS revision on <Date>2002-11-23</Date>. He continued to receive therapeutic paracentesis. Ultrasound initially showed patent TIPS but subsequent ones showed increased velocities concerning for stenosis. He was restarted on diuretics because his sodium was improved from prior admissions, but these were held for worsening renal function. He was continued on 1500ml fluid restriction and Cipro for SBP prophylaxis. CVVHD was started. A CXR showed new right sided infiltrate and the patient had moderate growth of MRSA from his sputum with sparse growth of 2 colonies of GNR. He was treated with vancomycin and zosyn. On <Date>12-12</Date> he underwent Orthotopic deceased donor liver transplant (piggyback), portal vein-portal vein anastomosis, common bile duct-common bile duct anastomosis with no T-tube, branch patch (recipient) to celiac patch (donor)hepatic artery anastomosis. Surgeon was Dr. <Name>Grace</Name> <Initial>JA</Initial> <Name>Amaro</Name>. Please see operative report for further details. EBL was 2 liters replaced with PRBC, plt, FFP, cryo and cellsaver. Two JPs were placed. He was maintained on CVVHD during the case. He received HBIG intraop and on pod <Date>2-10</Date>. HBsAb titers were greater than 450. HBIG IM was given on pod 7 and 14. Entecavir was started immediately postop. This dose was renally dosed. Postop, he was transferred to the SICU per protocol. He was extubated on POD 2. CVVHD continue for ~ 2 days then lasix was started. He received prbc/plt/ffp on pod 0. Labs were monitored q 6 hours. US of the liver demonstrated difficulty detecting the expected hepatic arterial supply to the left lobe. Otherwise U/S was normal. LFTs trended down. The medial JP was removed on pod 5. The lateral JP continued to drain large amounts of ascites. Outputs were as high as 4.5liters per day. He received IV fluid replacements and albumin for JP outputs. Of note, creatinine started trending up off CVVHD as high as 4.3 from 2.7. Urine output averaged 1000-1200cc/day. Nephrology was consulted. It was felt that he had ATN on resolving hepatorenal syndrome. Fluconazole dose was renally dosed to 200mg qd as this was felt to increase the prograf level. Creatinine slowly trended down to 2.9. Hyperkalemia was a persistent problem that required treatment with insulin, dextrose, lasix and kayexalate. Hyperkalemia improved with improved renal function. A low potassium diet was ordered. The lateral JP was removed on <Date>12-5</Date> for outputs of 600cc. The transplant incision remained clean, dry and intact. His abdomen appeared a little distended PT evaluated him and initially recommended rehab, but he improved significant and it was felt that he would be safe for discharge to home. He was also started on insulin for hyperglycemia. Glargine and humalog sliding scale were given. Immunosuppression consisted of cellcept 1 gram <Hospital>Moon, Mitchell and Cooley Hospital</Hospital>, steroids were tapered to prednisone 20mg qd per protocol, and prograf was started on pod 1. Prograf was decreased to 2.5mg <Hospital>Moon, Mitchell and Cooley Hospital</Hospital> per trough levels of <Date>9-26</Date>.2. VNA services were arranged for home. Medications on Admission: 1. Morphine 30 mg SR <Hospital>Moon, Mitchell and Cooley Hospital</Hospital> 2. Lactulose 30ML PO TID 3. Pantoprazole 40 mg Q24H 4. Folic Acid 1 mg DAILY 5. Oxycodone 5 mg Q6H as needed for Pain. 6. Colace 100 mg twice a day 7. Ciprofloxacin 250 mg Q24H 8. Entecavir 0.5 mg DAILY 9. Hexavitamin Daily --Of note, has been off diuretics since last admission <Date>2-4</Date> hyponatremia . Allergies: PCN, zofran, toradol, phenobarbital, trazadone Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 10. Entecavir 0.05 mg/mL Solution Sig: Three (3) ml PO DAILY (Daily). Disp:50 ml Refills:2 11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 MDI Refills:0 13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 16. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. 17. Insulin Syringes Low dose syringes for qid injections 25 guage needle supply: 1 box Refill: 1 Discharge Disposition: Home with Service Facility: <Hospital>Morales Group Clinic</Hospital> & Rehab Center - <Hospital>Benson, Williams and Mays Medical Center</Hospital> Discharge Diagnosis: ESLD from HCV/HBV/ETOH cirrhosis Hepatic encephalopathy Hepatorenal syndrome ARF, improving malnutrition Chronic back pain Barrett's esophagus GERD COPD s/p incarcerated umbilical hernia repair Discharge Condition: good Discharge Instructions: Please call the Transplant Office <Telephone>252-428-4513</Telephone> if fever, chills, nausea, vomiting, inability to take any of your medications, weight loss, jaundice, abdominal incision appears red, bleeds or has drainage. Labs every Monday and Thursday Followup Instructions: Provider: <Name>Grace</Name> <Name>Martin</Name>, MD, PHD<MD Number>12800950</MD Number>:<Telephone>252-428-4513</Telephone> Date/Time:<Date>1973-2-19</Date> 9:40 Provider: <Name>Grace</Name> <Name>Martin</Name>, MD, PHD<MD Number>12800950</MD Number>:<Telephone>252-428-4513</Telephone> Date/Time:<Date>1992-10-17</Date> 9:40 Provider: <Name>Heather Caro</Name>,<Name>Xin Ivory</Name> TRANSPLANT SOCIAL WORK Date/Time:<Date>1992-10-17</Date> 10:30 <Name>Grace</Name> <Name>Martin</Name> MD, <MD Number>37047804</MD Number> Completed by:<Date>1994-5-15</Date>	000000000000000001111111111000000000000000000000000000000001111111110000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111001111001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000001110000000000000000000000111111111000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1937-12-12 Discharge Date: 1994-5-15 Date of Birth: 1978-8-15 Sex: M Service: SURGERY Allergies: Penicillins / Zofran / Toradol / Phenobarbital / Trazodone / Compazine / Oxycodone Attending:Grace Chief Complaint: encephalopathy Major Surgical or Invasive Procedure: Blood transfusion Paracentesis x2 (12-2, 7-14) 1920-2-1 liver transplant History of Present Illness: 45 y/o male with ESLD from HCV, HBC, and EtOH who had a TIPS done on 1949-4-8 who presented to the OSH yesterday with altered mental status. The patient was treated with lactulose at the OSH with some improvement in his encelpalopathy. There was concern that there was a problem with the TIPS and he was transferred to Griffith, Cohen and Nichols Health System for further workup. Denied chest pain, shortness of breath, fevers, chills. He reports abdominal pain slightly worse than his baseline. No melena or BRBPR. . Labs at the OSH significant for AST/ALT 186/124, TB 12, DB 5, Ammonia 330, Na 132. Past Medical History: # L4,L5,S1 fusion # Decompensated liver cirrhosis 2-4 to HCV, HBC, and alcohol c/b encephalopathy and ascites # Chronic pancreatitis # Non bleeding grade 2 esophageal varices in 7-11 # GERD-Barrett's esophagus # COPD # s/p incarcerated umbilical hernia repair 8-4, recent admission on 1925-9-25 to 1987-10-13 for concern for cellulitis around his surgical incision, started on clindamycin then vanc then bactrim for a total course of 7 days #OLT 1920-2-1 Social History: Married, but separated, has 3 children. Lives with roommates - limited support. Smokes a pack every 3 days. Quit cocaine and heroine in 1952. Quit EtOH in 1952. Family History: Family Hx: No known family history of hepatitis or liver disease Physical Exam: VS: 97.5 95/69 90 12 93%RA Gen: awake, oriented x 2 (able to state month and year, stated he was at B+W's) HEENT: NC/AT. PERRL, EOMI, MMM. OP clear. Neck: Supple, no LAD. CV: RRR, S1, S2 no m/r/g. Chest: CTAB no wheezes or crackles. ABD: Distended, + tense ascites, TTP diffusely Ext: WWP, no edema. + asterixis Pertinent Results: Upon admission, a CT of the abd/pelvis was done 9-6 demonstrating: 1. Large amount of ascites. Tiny amount of high-density fluid layers in the deep pelvis consistent with blood not changed from prior study at 2:13 a.m. today, 2007-7-12. No subcapsular hepatic hematoma. 2. Small subcentimeter focus of arterial enhancement of hepatic segment VIII becomes isodense to liver parenchyma on the delayed phase. This is more conspicuous compared to 1941-1-4 and 2014-9-29. Finding is non- specific but given cirrhosis a small focus of hepatocellular carcinoma cannot be excluded. Continued imaging surveillance is recommended. 3. Cirrhosis with splenomegaly indicating portal hypertension. 4. Patent TIPS. On 5-18 a ruq u/s was performed showing a patent TIPS with increased velocities, little changed. Head CT was negative and EEG was abnormal with findings consistent with moderate encephalopathy . There were no epileptiform features and no seizure activity. . 9-15 ct chest: 1. Abnormality in the right upper lobe demonstrates marked panlobular emphysematous changes. No evidence of pneumothorax. 2. Atelectasis within the right upper and bilateral lower lobes. No evidence of airspace consolidation. 3. Limited images through the upper abdomen show a large volume ascites, TIPS, and splenomegaly. Brief Hospital Course: Patient initially transfered from OSH with encephalopathy and concern for clotted TIPS. TIPS initially placed 1949-4-8. Ultrasound showed patent TIPS and his mental status improved with lactulose and regular bowel movements. The patient was tapped for a large amount of ascites and it was negative for SBP. He continued to have waxing and Dr.Wilson encephalopathy, He required admission to the MICU twice for unresponsiveness, both times which he was intubated for airway protection, and given additional lactulose. His head CT on first MICU admission was negative for any acute process such as intracranial bleed. EEG findings were consistent with encephalopathy without seizure activity. An attempted Re-Do TIPS to divert blood through portal veins and not the TIPS was attempted, but technically unsuccessful and complicated by small hemoperitoneum that required transfusion but otherwise self-limited. He finally had successful TIPS revision on 2002-11-23. He continued to receive therapeutic paracentesis. Ultrasound initially showed patent TIPS but subsequent ones showed increased velocities concerning for stenosis. He was restarted on diuretics because his sodium was improved from prior admissions, but these were held for worsening renal function. He was continued on 1500ml fluid restriction and Cipro for SBP prophylaxis. CVVHD was started. A CXR showed new right sided infiltrate and the patient had moderate growth of MRSA from his sputum with sparse growth of 2 colonies of GNR. He was treated with vancomycin and zosyn. On 12-12 he underwent Orthotopic deceased donor liver transplant (piggyback), portal vein-portal vein anastomosis, common bile duct-common bile duct anastomosis with no T-tube, branch patch (recipient) to celiac patch (donor)hepatic artery anastomosis. Surgeon was Dr. Grace JA Amaro. Please see operative report for further details. EBL was 2 liters replaced with PRBC, plt, FFP, cryo and cellsaver. Two JPs were placed. He was maintained on CVVHD during the case. He received HBIG intraop and on pod 2-10. HBsAb titers were greater than 450. HBIG IM was given on pod 7 and 14. Entecavir was started immediately postop. This dose was renally dosed. Postop, he was transferred to the SICU per protocol. He was extubated on POD 2. CVVHD continue for ~ 2 days then lasix was started. He received prbc/plt/ffp on pod 0. Labs were monitored q 6 hours. US of the liver demonstrated difficulty detecting the expected hepatic arterial supply to the left lobe. Otherwise U/S was normal. LFTs trended down. The medial JP was removed on pod 5. The lateral JP continued to drain large amounts of ascites. Outputs were as high as 4.5liters per day. He received IV fluid replacements and albumin for JP outputs. Of note, creatinine started trending up off CVVHD as high as 4.3 from 2.7. Urine output averaged 1000-1200cc/day. Nephrology was consulted. It was felt that he had ATN on resolving hepatorenal syndrome. Fluconazole dose was renally dosed to 200mg qd as this was felt to increase the prograf level. Creatinine slowly trended down to 2.9. Hyperkalemia was a persistent problem that required treatment with insulin, dextrose, lasix and kayexalate. Hyperkalemia improved with improved renal function. A low potassium diet was ordered. The lateral JP was removed on 12-5 for outputs of 600cc. The transplant incision remained clean, dry and intact. His abdomen appeared a little distended PT evaluated him and initially recommended rehab, but he improved significant and it was felt that he would be safe for discharge to home. He was also started on insulin for hyperglycemia. Glargine and humalog sliding scale were given. Immunosuppression consisted of cellcept 1 gram Moon, Mitchell and Cooley Hospital, steroids were tapered to prednisone 20mg qd per protocol, and prograf was started on pod 1. Prograf was decreased to 2.5mg Moon, Mitchell and Cooley Hospital per trough levels of 9-26.2. VNA services were arranged for home. Medications on Admission: 1. Morphine 30 mg SR Moon, Mitchell and Cooley Hospital 2. Lactulose 30ML PO TID 3. Pantoprazole 40 mg Q24H 4. Folic Acid 1 mg DAILY 5. Oxycodone 5 mg Q6H as needed for Pain. 6. Colace 100 mg twice a day 7. Ciprofloxacin 250 mg Q24H 8. Entecavir 0.5 mg DAILY 9. Hexavitamin Daily --Of note, has been off diuretics since last admission 2-4 hyponatremia . Allergies: PCN, zofran, toradol, phenobarbital, trazadone Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 10. Entecavir 0.05 mg/mL Solution Sig: Three (3) ml PO DAILY (Daily). Disp:50 ml Refills:2 11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 MDI Refills:0 13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 16. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. 17. Insulin Syringes Low dose syringes for qid injections 25 guage needle supply: 1 box Refill: 1 Discharge Disposition: Home with Service Facility: Morales Group Clinic & Rehab Center - Benson, Williams and Mays Medical Center Discharge Diagnosis: ESLD from HCV/HBV/ETOH cirrhosis Hepatic encephalopathy Hepatorenal syndrome ARF, improving malnutrition Chronic back pain Barrett's esophagus GERD COPD s/p incarcerated umbilical hernia repair Discharge Condition: good Discharge Instructions: Please call the Transplant Office 252-428-4513 if fever, chills, nausea, vomiting, inability to take any of your medications, weight loss, jaundice, abdominal incision appears red, bleeds or has drainage. Labs every Monday and Thursday Followup Instructions: Provider: Grace Martin, MD, PHD12800950:252-428-4513 Date/Time:1973-2-19 9:40 Provider: Grace Martin, MD, PHD12800950:252-428-4513 Date/Time:1992-10-17 9:40 Provider: Heather Caro,Xin Ivory TRANSPLANT SOCIAL WORK Date/Time:1992-10-17 10:30 Grace Martin MD, 37047804 Completed by:1994-5-15	['Admission Date: 1937-12-12 Discharge Date: 1994-5-15\n\nDate of Birth: 1978-8-15 Sex: M\n\nService: SURGERY\n\nAllergies:\nPenicillins / Zofran / Toradol / Phenobarbital / Trazodone /\nCompazine / Oxycodone\n\nAttending:Grace\nChief Complaint:\nencephalopathy\n\nMajor Surgical or Invasive Procedure:\nBlood transfusion\nParacentesis x2 (12-2, 7-14)\n1920-2-1 liver transplant\n\n\nHistory of Present Illness:\n45 y/o male with ESLD from HCV, HBC, and EtOH who had a TIPS\ndone on 1949-4-8 who presented to the OSH yesterday with altered\nmental status. The patient was treated with lactulose at the OSH\nwith some improvement in his encelpalopathy. There was concern\nthat there was a problem with the TIPS and he was transferred to\nGriffith, Cohen and Nichols Health System for further workup.', "\nDenied chest pain, shortness of breath, fevers, chills. He\nreports abdominal pain slightly worse than his baseline. No\nmelena or BRBPR.\n.\nLabs at the OSH significant for AST/ALT 186/124, TB 12, DB 5,\nAmmonia 330, Na 132.\n\n\nPast Medical History:\n# L4,L5,S1 fusion\n# Decompensated liver cirrhosis 2-4 to HCV, HBC, and alcohol c/b\nencephalopathy and ascites\n# Chronic pancreatitis\n# Non bleeding grade 2 esophageal varices in 7-11\n# GERD-Barrett's esophagus\n# COPD\n# s/p incarcerated umbilical hernia repair 8-4, recent\nadmission on 1925-9-25 to 1987-10-13 for concern for cellulitis\naround his surgical incision, started on clindamycin then vanc\nthen bactrim for a total course of 7 days\n#OLT 1920-2-1\n\n\nSocial History:\nMarried, but separated, has 3 children. Lives with roommates -\nlimited support. Smokes a pack every 3 days.", " Quit cocaine and\nheroine in 1952. Quit EtOH in 1952.\n\n\nFamily History:\nFamily Hx: No known family history of hepatitis or liver\ndisease\n\nPhysical Exam:\nVS: 97.5 95/69 90 12 93%RA\nGen: awake, oriented x 2 (able to state month and year, stated\nhe was at B+W's)\nHEENT: NC/AT. PERRL, EOMI, MMM. OP clear.\nNeck: Supple, no LAD.\nCV: RRR, S1, S2 no m/r/g.\nChest: CTAB no wheezes or crackles.\nABD: Distended, + tense ascites, TTP diffusely\nExt: WWP, no edema. + asterixis\n\nPertinent Results:\nUpon admission, a CT of the abd/pelvis was done 9-6\ndemonstrating:\n1. Large amount of ascites. Tiny amount of high-density fluid\nlayers in the deep pelvis consistent with blood not changed from\nprior study at 2:13 a.m. today, 2007-7-12. No subcapsular hepatic\nhematoma.\n2. Small subcentimeter focus of arterial enhancement of hepatic\nsegment VIII becomes isodense to liver parenchyma on the delayed\nphase.", ' This is more conspicuous compared to 1941-1-4 and 2014-9-29.\nFinding is non- specific but given cirrhosis a small focus of\nhepatocellular carcinoma cannot be excluded. Continued imaging\nsurveillance is recommended.\n3. Cirrhosis with splenomegaly indicating portal hypertension.\n4. Patent TIPS.\n\nOn 5-18 a ruq u/s was performed showing a patent TIPS with\nincreased velocities, little changed.\nHead CT was negative and EEG was abnormal with findings\nconsistent with moderate encephalopathy . There were no\nepileptiform features and no seizure activity.\n.\n9-15 ct chest:\n1. Abnormality in the right upper lobe demonstrates marked\npanlobular\nemphysematous changes. No evidence of pneumothorax.\n\n2. Atelectasis within the right upper and bilateral lower lobes.\nNo evidence\nof airspace consolidation.\n\n3.', ' Limited images through the upper abdomen show a large volume\nascites,\nTIPS, and splenomegaly.\n\n\nBrief Hospital Course:\n Patient initially transfered from OSH with encephalopathy and\nconcern for clotted TIPS. TIPS initially placed 1949-4-8.\nUltrasound showed patent TIPS and his mental status improved\nwith lactulose and regular bowel movements. The patient was\ntapped for a large amount of ascites and it was negative for\nSBP.\nHe continued to have waxing and Dr.Wilson encephalopathy, He\nrequired admission to the MICU twice for unresponsiveness, both\ntimes which he was intubated for airway protection, and given\nadditional lactulose. His head CT on first MICU admission was\nnegative for any acute process such as intracranial bleed. EEG\nfindings were consistent with encephalopathy without seizure\nactivity.', '\n\nAn attempted Re-Do TIPS to divert blood through portal veins and\nnot the TIPS was attempted, but technically unsuccessful and\ncomplicated by small hemoperitoneum that required transfusion\nbut otherwise self-limited. He finally had successful TIPS\nrevision on 2002-11-23.\n\nHe continued to receive therapeutic paracentesis. Ultrasound\ninitially showed patent TIPS but subsequent ones showed\nincreased velocities concerning for stenosis. He was restarted\non diuretics because his sodium was improved from prior\nadmissions, but these were held for worsening renal function.\nHe was continued on 1500ml fluid restriction and Cipro for SBP\nprophylaxis. CVVHD was started.\n\nA CXR showed new right sided infiltrate and the patient had\nmoderate growth of MRSA from his sputum with sparse growth of 2\ncolonies of GNR.', ' He was treated with vancomycin and zosyn.\n\nOn 12-12 he underwent Orthotopic deceased donor liver transplant\n(piggyback), portal vein-portal vein anastomosis, common bile\nduct-common bile duct anastomosis with no T-tube, branch patch\n(recipient) to celiac patch (donor)hepatic artery anastomosis.\nSurgeon was Dr. Grace JA Amaro. Please see operative report\nfor further details. EBL was 2 liters replaced with PRBC, plt,\nFFP, cryo and cellsaver. Two JPs were placed. He was maintained\non CVVHD during the case. He received HBIG intraop and on pod\n2-10. HBsAb titers were greater than 450. HBIG IM was given on\npod 7 and 14. Entecavir was started immediately postop. This\ndose was renally dosed.\n\nPostop, he was transferred to the SICU per protocol. He was\nextubated on POD 2. CVVHD continue for ~ 2 days then lasix was\nstarted.', ' He received prbc/plt/ffp on pod 0. Labs were monitored\nq 6 hours. US of the liver demonstrated difficulty detecting\nthe expected hepatic arterial supply to the left lobe. Otherwise\nU/S was normal. LFTs trended down. The medial JP was removed on\npod 5. The lateral JP continued to drain large amounts of\nascites. Outputs were as high as 4.5liters per day. He received\nIV fluid replacements and albumin for JP outputs. Of note,\ncreatinine started trending up off CVVHD as high as 4.3 from\n2.7. Urine output averaged 1000-1200cc/day. Nephrology was\nconsulted. It was felt that he had ATN on resolving hepatorenal\nsyndrome. Fluconazole dose was renally dosed to 200mg qd as this\nwas felt to increase the prograf level. Creatinine slowly\ntrended down to 2.9. Hyperkalemia was a persistent problem that\nrequired treatment with insulin, dextrose, lasix and kayexalate.', '\nHyperkalemia improved with improved renal function. A low\npotassium diet was ordered.\n\nThe lateral JP was removed on 12-5 for outputs of 600cc. The\ntransplant incision remained clean, dry and intact. His abdomen\nappeared a little distended\n\nPT evaluated him and initially recommended rehab, but he\nimproved significant and it was felt that he would be safe for\ndischarge to home. He was also started on insulin for\nhyperglycemia. Glargine and humalog sliding scale were given.\n\nImmunosuppression consisted of cellcept 1 gram Moon, Mitchell and Cooley Hospital, steroids\nwere tapered to prednisone 20mg qd per protocol, and prograf was\nstarted on pod 1. Prograf was decreased to 2.5mg Moon, Mitchell and Cooley Hospital per trough\nlevels of 9-26.2.\n\nVNA services were arranged for home.\n\n\nMedications on Admission:\n1.', ' Morphine 30 mg SR Moon, Mitchell and Cooley Hospital\n2. Lactulose 30ML PO TID\n3. Pantoprazole 40 mg Q24H\n4. Folic Acid 1 mg DAILY\n5. Oxycodone 5 mg Q6H as needed for Pain.\n6. Colace 100 mg twice a day\n7. Ciprofloxacin 250 mg Q24H\n8. Entecavir 0.5 mg DAILY\n9. Hexavitamin Daily\n--Of note, has been off diuretics since last admission 2-4\nhyponatremia\n.\nAllergies: PCN, zofran, toradol, phenobarbital, trazadone\n\n\nDischarge Medications:\n1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).\n\n2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO\nBID (2 times a day).\n5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).', '\n6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4\nhours) as needed.\nDisp:40 Tablet(s) Refills:0\n8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every\n24 hours).\n9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN\n(as needed).\n10. Entecavir 0.05 mg/mL Solution Sig: Three (3) ml PO DAILY\n(Daily).\nDisp:50 ml Refills:2\n11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY\nOTHER DAY (Every Other Day).\n12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation\nQ6H (every 6 hours) as needed.\nDisp:1 MDI Refills:0\n13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every\n12 hours).\n14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a\nday.', "\n15. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units\nSubcutaneous at bedtime.\n16. Insulin Lispro 100 unit/mL Solution Sig: follow sliding\nscale Subcutaneous four times a day.\n17. Insulin Syringes\nLow dose syringes for qid injections\n25 guage needle\nsupply: 1 box\nRefill: 1\n\n\nDischarge Disposition:\nHome with Service\n\nFacility:\nMorales Group Clinic & Rehab Center - Benson, Williams and Mays Medical Center\n\nDischarge Diagnosis:\nESLD from HCV/HBV/ETOH cirrhosis\nHepatic encephalopathy\nHepatorenal syndrome\nARF, improving\nmalnutrition\nChronic back pain\nBarrett's esophagus\nGERD\nCOPD\ns/p incarcerated umbilical hernia repair\n\n\nDischarge Condition:\ngood\n\n\nDischarge Instructions:\nPlease call the Transplant Office 252-428-4513 if fever, chills,\nnausea, vomiting, inability to take any of your medications,\nweight loss, jaundice, abdominal incision appears red, bleeds or\nhas drainage.", '\nLabs every Monday and Thursday\n\nFollowup Instructions:\nProvider: Grace Martin, MD, PHD12800950:252-428-4513\nDate/Time:1973-2-19 9:40\nProvider: Grace Martin, MD, PHD12800950:252-428-4513\nDate/Time:1992-10-17 9:40\nProvider: Heather Caro,Xin Ivory TRANSPLANT SOCIAL WORK Date/Time:1992-10-17\n10:30\n\n\n Grace Martin MD, 37047804\n\nCompleted by:1994-5-15']
130	96187	108082.0	2103-03-13	Discharge summary	Report	Admission Date: [2103-3-7] Discharge Date: [2103-3-13] Service: SURGERY Allergies: Codeine / Aspirin / Ibuprofen / Lipitor / Crestor Attending:[First Name3 (LF) 1390] Chief Complaint: fall down stairs, syncope Major Surgical or Invasive Procedure: Paravertebral block by Acute Pain Service History of Present Illness: This is a [Age over 90 ] y/o F, with h/o previous C7 vertebral body compression fx last year after a syncopal event while defecating, who presents to [Hospital1 18] ED after falling down flight of stairs today. Pt was carrying laundry up a flight of stairs and fell when she had a syncopal event. Pt aroused at bottom of stairs and called for help. At presentation she complained of right sided back pain. She had head, c-spine, and torso CT scan which showed multiple right sided rib fractures. Pt does have chronic neck pain after compression fx last year. She wears a neck brace as needed at night for comfort. She currently denies neck pain, headache, abdominal pain or distension, and additionally denies any chest pain or SOB or palpitations prior to the fall. Past Medical History: PMH: 1. A-fib 2. Type II DM 3. Hx of PE 20 yrs ago 4. Hyperlipidemia 5. Osteoporosis 6. Osteoarthritis 7. Anxiety 8. C7 compression fracture s/p fall PSH: None Social History: Patient lives at home, engages in water aerobics everyday, denies use of tobacco, alcohol, or IV drug use Family History: Father died from MI at age 50 Brother died from MI at age 37 Physical Exam: At discharge VS: Afebrile, VSS 96.2 87 158/82 16 98%2L Constitutional: Well appearing, no acute distress Neck: No masses CV: RRR, no murmurs. Resp: CTAB, no wheezes or crackles, IS 300. + TTP R ant/post chest. No crepitus. Abd: Soft, no TTP, nondistended, +BS Ext: Warm, distal pulses palpable bilaterally Skin: Face, neck and chest is normal Musculoskeletal: Normal to gait and station Spine, Pelvis and Extremities: Stable Psychiatric: Normal to judgment, insight, memory, mood and affect Pertinent Results: [2103-3-7] Lactate:3.8 UA negative 132 95 22 AGap=19 -------------328 4.8 23 0.8 CK: 270 MB: 5 Trop-T: <0.01 ALT: 70 AP: 55 Tbili: 0.7 Alb: AST: 102 LDH: Dbili: TProt: [Doctor First Name ]: Lip: Dig: 0.7 13.0 15.4 ----- 165 39.1 N:91 Band:5 L:2 M:2 E:0 Bas:0 Poiklo: OCCASIONAL Ovalocy: OCCASIONAL PT: 24.8 PTT: 24.5 INR: 2.4 . [2103-3-7] Carotid Duplex: 60-69% stenosis of L ICA, 40-59% stenosis of R ICA . [2103-3-6] CT head: no acute intracranial process . [2103-3-6] CT c-spine: interval C7 vertebral body height loss new since prior but could represent . [2103-3-6] CT abd/pelvis: 1. Multiple acute right rib fractures without evidence of flail chest or segmental fractures. 2. Asymmetric pulmonary edema, right greater than left, with trace right pleural effusion and bibasilar atelectasis. 3. 1.5 cm left lower lobe pulmonary nodule, not included in the field of view of the prior study. If clinically indicated, a three-month followup is recommended. 4. Unchanged left adnexal cyst. Brief Hospital Course: The patient was admitted to the trauma surgery service on [2103-3-7] after a syncopal episode causing a fall down stairs resulting in multiple broken ribs, but no other injuries. Neuro: Pain control was [Last Name ] problem for this patient during her hospitalization and the acute pain service was consulted to provide recommendations to better manage the patient's rib pain. She initially received IV pain medicaions, including a PCA, and also had a paravertebral block performed by APS. When tolerating oral intake, the patient was transitioned to oral pain medications, on a regimen including neurontin, lidoderm patch, standing tylenol, tramadol and dilaudid for break-through pain, with fair pain control. The pt also underwent carotid duplex ultrasound in the evaluation for syncope, which showed 60-69% stenosis of L ICA, 40-59% stenosis of R ICA. She will follow up with vascular surgery in 6 months for this, but this is not likely the cause of her syncope. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. She was kept on telemetry which was reassuring. ECG on admission was not thought to be consistent with STEMI. Additionally, cardiac enzymes were negative x 1. Vital signs were routinely monitored and were stable. She needs follow up with her regular doctor, as she may need an echo or holter monitoring as an out-patient. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. She did require 2L of O2 nasal cannula at discharge, this was thought to be due to poor deep breathing [2-20] mild persistent rib pain. Chest xrays did not reveal any pneumonia or fluid overload. The pt did have a 1.5 cm left lower lobe pulmonary nodule noted on CT chest. She will need follow up by her regular doctor, likely with repeat CT chest to eval for interval change. GI/GU: At admission, the patient was resuscitated with IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on HD#2. Intake and output were closely monitored and were normal. She did have some episodes of incontinence. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible with PT. At the time of discharge on HD#7, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, working with PT, voiding without assistance, and pain was fairly well controlled. Medications on Admission: Digoxin 250 mcg 6 out of 7 days of the week, Zetia 10', Lisinopril 5', Toprol XL 25', Coumadin, Vitamin C, Vitamin D, MVI Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK ([Doctor First Name ],MO,TU,WE,TH,FR). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q12 (): 12 hours with patch on, 12 hours with patch off. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every [4-24] hours as needed for pain for 30 days: Hold for sedation, RR < 12. 11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain for 30 days: Do not exceed more than 4g tylenol daily. 12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 30 days: Hold for sedation. 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 2.5 Tablet Sustained Release 24 hrs PO DAILY (Daily): Hold for SBP < 100 and HR < 60 . 14. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day) for 30 days. 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:0 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation for 10 days. Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] Discharge Diagnosis: Primary: 1) fall (trauma), 2) syncope, 3) right posterior [7-28] rib fractures, 4) right anterior 6th rib fx Secondary: 1) atrial fibrillation, 2) Osteoporosis, 3) diabetes mellitus II, 4) PE 20 years ago, 5) previous C7 fx Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to [Hospital1 18] to the trauma service after a fall due to losing consciousness. You were found to have 5 rib fractures on CT scan. The most important treatment for this kind of fracture is pain control to optimize deep breathing. There is no surgery or brace for support that is recommended. Optimization of pain control is imperative because splinting (weak breathing due to pain) can result in pneumonia. * You should expect to have rib pain for 4-6 weeks from your injury until your ribs have begun to heal. Please continue to take the pain medication prescribed until then. Please also continue to use the incentive spirometer (breathing machine) 10 times per hour in order to keep your lungs adequately inflated (like a balloon). * You had CT scan of your head, neck, abdomen and pelvis which revealed no other injuries. CT scan of the chest did show a small nodule in your left lung. You should follow up with your regular doctor to discuss imaging the lung in several months evaluate for growth. * In evaluation for your loss of consciousness, we did blood tests that look at heart strain or decreased blood flow (troponins) which were normal. Additionally you were kept on telemetry (continuous heart monitoring) which was reassuring. Finally, you underwent an ultrasound study of your carotids, which showed some degree of narrowing but not narrowing significant enough to have caused your syncopal episodes. You need to follow up with vascular surgery Dr. [Last Name (STitle) 1391] in 6 months for this. You may also need additional evaluation for heart monitoring, and should follow up with your regular doctor to discuss this. Please call your doctor, talk to your doctor at rehab or return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, chest pain, cough, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Followup Instructions: Call Dr.[Name (NI) 1392] office for a follow up appointment in 6 months, tell them that you will need carotid ultrasound prior to appointment. Phone: [Telephone/Fax (1) 1393]. Please also follow up with Dr. [Last Name (STitle) 853] in [2-21] weeks. Call ([Telephone/Fax (1) 1394] for an appointment. Please let your regular doctor know about this hospitalization and follow up with him or her in [1-20] weeks. You may need additional monitoring of your heart rhythm.	Admission Date: <Date>1978-3-11</Date> Discharge Date: <Date>1926-9-7</Date> Service: SURGERY Allergies: Codeine / Aspirin / Ibuprofen / Lipitor / Crestor Attending:<Name>Rebeca</Name> Chief Complaint: fall down stairs, syncope Major Surgical or Invasive Procedure: Paravertebral block by Acute Pain Service History of Present Illness: This is a <Age>30</Age> y/o F, with h/o previous C7 vertebral body compression fx last year after a syncopal event while defecating, who presents to <Hospital>Miranda, Cuevas and Haney Hospital</Hospital> ED after falling down flight of stairs today. Pt was carrying laundry up a flight of stairs and fell when she had a syncopal event. Pt aroused at bottom of stairs and called for help. At presentation she complained of right sided back pain. She had head, c-spine, and torso CT scan which showed multiple right sided rib fractures. Pt does have chronic neck pain after compression fx last year. She wears a neck brace as needed at night for comfort. She currently denies neck pain, headache, abdominal pain or distension, and additionally denies any chest pain or SOB or palpitations prior to the fall. Past Medical History: PMH: 1. A-fib 2. Type II DM 3. Hx of PE 20 yrs ago 4. Hyperlipidemia 5. Osteoporosis 6. Osteoarthritis 7. Anxiety 8. C7 compression fracture s/p fall PSH: None Social History: Patient lives at home, engages in water aerobics everyday, denies use of tobacco, alcohol, or IV drug use Family History: Father died from MI at age 50 Brother died from MI at age 37 Physical Exam: At discharge VS: Afebrile, VSS 96.2 87 158/82 16 98%2L Constitutional: Well appearing, no acute distress Neck: No masses CV: RRR, no murmurs. Resp: CTAB, no wheezes or crackles, IS 300. + TTP R ant/post chest. No crepitus. Abd: Soft, no TTP, nondistended, +BS Ext: Warm, distal pulses palpable bilaterally Skin: Face, neck and chest is normal Musculoskeletal: Normal to gait and station Spine, Pelvis and Extremities: Stable Psychiatric: Normal to judgment, insight, memory, mood and affect Pertinent Results: <Date>1978-3-11</Date> Lactate:3.8 UA negative 132 95 22 AGap=19 -------------328 4.8 23 0.8 CK: 270 MB: 5 Trop-T: <0.01 ALT: 70 AP: 55 Tbili: 0.7 Alb: AST: 102 LDH: Dbili: TProt: <Name>Lakisha</Name>: Lip: Dig: 0.7 13.0 15.4 ----- 165 39.1 N:91 Band:5 L:2 M:2 E:0 Bas:0 Poiklo: OCCASIONAL Ovalocy: OCCASIONAL PT: 24.8 PTT: 24.5 INR: 2.4 . <Date>1978-3-11</Date> Carotid Duplex: 60-69% stenosis of L ICA, 40-59% stenosis of R ICA . <Date>1953-2-23</Date> CT head: no acute intracranial process . <Date>1953-2-23</Date> CT c-spine: interval C7 vertebral body height loss new since prior but could represent . <Date>1953-2-23</Date> CT abd/pelvis: 1. Multiple acute right rib fractures without evidence of flail chest or segmental fractures. 2. Asymmetric pulmonary edema, right greater than left, with trace right pleural effusion and bibasilar atelectasis. 3. 1.5 cm left lower lobe pulmonary nodule, not included in the field of view of the prior study. If clinically indicated, a three-month followup is recommended. 4. Unchanged left adnexal cyst. Brief Hospital Course: The patient was admitted to the trauma surgery service on <Date>1978-3-11</Date> after a syncopal episode causing a fall down stairs resulting in multiple broken ribs, but no other injuries. Neuro: Pain control was <Name>Lofft</Name> problem for this patient during her hospitalization and the acute pain service was consulted to provide recommendations to better manage the patient's rib pain. She initially received IV pain medicaions, including a PCA, and also had a paravertebral block performed by APS. When tolerating oral intake, the patient was transitioned to oral pain medications, on a regimen including neurontin, lidoderm patch, standing tylenol, tramadol and dilaudid for break-through pain, with fair pain control. The pt also underwent carotid duplex ultrasound in the evaluation for syncope, which showed 60-69% stenosis of L ICA, 40-59% stenosis of R ICA. She will follow up with vascular surgery in 6 months for this, but this is not likely the cause of her syncope. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. She was kept on telemetry which was reassuring. ECG on admission was not thought to be consistent with STEMI. Additionally, cardiac enzymes were negative x 1. Vital signs were routinely monitored and were stable. She needs follow up with her regular doctor, as she may need an echo or holter monitoring as an out-patient. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. She did require 2L of O2 nasal cannula at discharge, this was thought to be due to poor deep breathing <Date>1-18</Date> mild persistent rib pain. Chest xrays did not reveal any pneumonia or fluid overload. The pt did have a 1.5 cm left lower lobe pulmonary nodule noted on CT chest. She will need follow up by her regular doctor, likely with repeat CT chest to eval for interval change. GI/GU: At admission, the patient was resuscitated with IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on HD#2. Intake and output were closely monitored and were normal. She did have some episodes of incontinence. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible with PT. At the time of discharge on HD#7, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, working with PT, voiding without assistance, and pain was fairly well controlled. Medications on Admission: Digoxin 250 mcg 6 out of 7 days of the week, Zetia 10', Lisinopril 5', Toprol XL 25', Coumadin, Vitamin C, Vitamin D, MVI Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK (<Name>Lakisha</Name>,MO,TU,WE,TH,FR). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q12 (): 12 hours with patch on, 12 hours with patch off. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every <Date>3-4</Date> hours as needed for pain for 30 days: Hold for sedation, RR < 12. 11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain for 30 days: Do not exceed more than 4g tylenol daily. 12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 30 days: Hold for sedation. 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 2.5 Tablet Sustained Release 24 hrs PO DAILY (Daily): Hold for SBP < 100 and HR < 60 . 14. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day) for 30 days. 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:0 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation for 10 days. Discharge Disposition: Extended Care Facility: Newbridge on the <Doctor Name>Dr.Heflin</Doctor Name> Discharge Diagnosis: Primary: 1) fall (trauma), 2) syncope, 3) right posterior <Date>10-13</Date> rib fractures, 4) right anterior 6th rib fx Secondary: 1) atrial fibrillation, 2) Osteoporosis, 3) diabetes mellitus II, 4) PE 20 years ago, 5) previous C7 fx Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to <Hospital>Miranda, Cuevas and Haney Hospital</Hospital> to the trauma service after a fall due to losing consciousness. You were found to have 5 rib fractures on CT scan. The most important treatment for this kind of fracture is pain control to optimize deep breathing. There is no surgery or brace for support that is recommended. Optimization of pain control is imperative because splinting (weak breathing due to pain) can result in pneumonia. * You should expect to have rib pain for 4-6 weeks from your injury until your ribs have begun to heal. Please continue to take the pain medication prescribed until then. Please also continue to use the incentive spirometer (breathing machine) 10 times per hour in order to keep your lungs adequately inflated (like a balloon). * You had CT scan of your head, neck, abdomen and pelvis which revealed no other injuries. CT scan of the chest did show a small nodule in your left lung. You should follow up with your regular doctor to discuss imaging the lung in several months evaluate for growth. * In evaluation for your loss of consciousness, we did blood tests that look at heart strain or decreased blood flow (troponins) which were normal. Additionally you were kept on telemetry (continuous heart monitoring) which was reassuring. Finally, you underwent an ultrasound study of your carotids, which showed some degree of narrowing but not narrowing significant enough to have caused your syncopal episodes. You need to follow up with vascular surgery Dr. <Name>Braswell</Name> in 6 months for this. You may also need additional evaluation for heart monitoring, and should follow up with your regular doctor to discuss this. Please call your doctor, talk to your doctor at rehab or return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, chest pain, cough, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Followup Instructions: Call Dr.<Name>Kenna Brown</Name> office for a follow up appointment in 6 months, tell them that you will need carotid ultrasound prior to appointment. Phone: <Telephone>811-226-1554</Telephone>. Please also follow up with Dr. <Name>Hang</Name> in <Date>3-18</Date> weeks. Call (<Telephone>135-293-5619</Telephone> for an appointment. Please let your regular doctor know about this hospitalization and follow up with him or her in <Date>10-6</Date> weeks. You may need additional monitoring of your heart rhythm.	000000000000000001111111110000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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111000000000000000000000000000000000000000000000000000000000000000000000	Admission Date: 1978-3-11 Discharge Date: 1926-9-7 Service: SURGERY Allergies: Codeine / Aspirin / Ibuprofen / Lipitor / Crestor Attending:Rebeca Chief Complaint: fall down stairs, syncope Major Surgical or Invasive Procedure: Paravertebral block by Acute Pain Service History of Present Illness: This is a 30 y/o F, with h/o previous C7 vertebral body compression fx last year after a syncopal event while defecating, who presents to Miranda, Cuevas and Haney Hospital ED after falling down flight of stairs today. Pt was carrying laundry up a flight of stairs and fell when she had a syncopal event. Pt aroused at bottom of stairs and called for help. At presentation she complained of right sided back pain. She had head, c-spine, and torso CT scan which showed multiple right sided rib fractures. Pt does have chronic neck pain after compression fx last year. She wears a neck brace as needed at night for comfort. She currently denies neck pain, headache, abdominal pain or distension, and additionally denies any chest pain or SOB or palpitations prior to the fall. Past Medical History: PMH: 1. A-fib 2. Type II DM 3. Hx of PE 20 yrs ago 4. Hyperlipidemia 5. Osteoporosis 6. Osteoarthritis 7. Anxiety 8. C7 compression fracture s/p fall PSH: None Social History: Patient lives at home, engages in water aerobics everyday, denies use of tobacco, alcohol, or IV drug use Family History: Father died from MI at age 50 Brother died from MI at age 37 Physical Exam: At discharge VS: Afebrile, VSS 96.2 87 158/82 16 98%2L Constitutional: Well appearing, no acute distress Neck: No masses CV: RRR, no murmurs. Resp: CTAB, no wheezes or crackles, IS 300. + TTP R ant/post chest. No crepitus. Abd: Soft, no TTP, nondistended, +BS Ext: Warm, distal pulses palpable bilaterally Skin: Face, neck and chest is normal Musculoskeletal: Normal to gait and station Spine, Pelvis and Extremities: Stable Psychiatric: Normal to judgment, insight, memory, mood and affect Pertinent Results: 1978-3-11 Lactate:3.8 UA negative 132 95 22 AGap=19 -------------328 4.8 23 0.8 CK: 270 MB: 5 Trop-T: Lakisha: Lip: Dig: 0.7 13.0 15.4 ----- 165 39.1 N:91 Band:5 L:2 M:2 E:0 Bas:0 Poiklo: OCCASIONAL Ovalocy: OCCASIONAL PT: 24.8 PTT: 24.5 INR: 2.4 . 1978-3-11 Carotid Duplex: 60-69% stenosis of L ICA, 40-59% stenosis of R ICA . 1953-2-23 CT head: no acute intracranial process . 1953-2-23 CT c-spine: interval C7 vertebral body height loss new since prior but could represent . 1953-2-23 CT abd/pelvis: 1. Multiple acute right rib fractures without evidence of flail chest or segmental fractures. 2. Asymmetric pulmonary edema, right greater than left, with trace right pleural effusion and bibasilar atelectasis. 3. 1.5 cm left lower lobe pulmonary nodule, not included in the field of view of the prior study. If clinically indicated, a three-month followup is recommended. 4. Unchanged left adnexal cyst. Brief Hospital Course: The patient was admitted to the trauma surgery service on 1978-3-11 after a syncopal episode causing a fall down stairs resulting in multiple broken ribs, but no other injuries. Neuro: Pain control was Lofft problem for this patient during her hospitalization and the acute pain service was consulted to provide recommendations to better manage the patient's rib pain. She initially received IV pain medicaions, including a PCA, and also had a paravertebral block performed by APS. When tolerating oral intake, the patient was transitioned to oral pain medications, on a regimen including neurontin, lidoderm patch, standing tylenol, tramadol and dilaudid for break-through pain, with fair pain control. The pt also underwent carotid duplex ultrasound in the evaluation for syncope, which showed 60-69% stenosis of L ICA, 40-59% stenosis of R ICA. She will follow up with vascular surgery in 6 months for this, but this is not likely the cause of her syncope. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. She was kept on telemetry which was reassuring. ECG on admission was not thought to be consistent with STEMI. Additionally, cardiac enzymes were negative x 1. Vital signs were routinely monitored and were stable. She needs follow up with her regular doctor, as she may need an echo or holter monitoring as an out-patient. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. She did require 2L of O2 nasal cannula at discharge, this was thought to be due to poor deep breathing 1-18 mild persistent rib pain. Chest xrays did not reveal any pneumonia or fluid overload. The pt did have a 1.5 cm left lower lobe pulmonary nodule noted on CT chest. She will need follow up by her regular doctor, likely with repeat CT chest to eval for interval change. GI/GU: At admission, the patient was resuscitated with IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on HD#2. Intake and output were closely monitored and were normal. She did have some episodes of incontinence. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible with PT. At the time of discharge on HD#7, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, working with PT, voiding without assistance, and pain was fairly well controlled. Medications on Admission: Digoxin 250 mcg 6 out of 7 days of the week, Zetia 10', Lisinopril 5', Toprol XL 25', Coumadin, Vitamin C, Vitamin D, MVI Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK (Lakisha,MO,TU,WE,TH,FR). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q12 (): 12 hours with patch on, 12 hours with patch off. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every 3-4 hours as needed for pain for 30 days: Hold for sedation, RR Dr.Heflin Discharge Diagnosis: Primary: 1) fall (trauma), 2) syncope, 3) right posterior 10-13 rib fractures, 4) right anterior 6th rib fx Secondary: 1) atrial fibrillation, 2) Osteoporosis, 3) diabetes mellitus II, 4) PE 20 years ago, 5) previous C7 fx Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to Miranda, Cuevas and Haney Hospital to the trauma service after a fall due to losing consciousness. You were found to have 5 rib fractures on CT scan. The most important treatment for this kind of fracture is pain control to optimize deep breathing. There is no surgery or brace for support that is recommended. Optimization of pain control is imperative because splinting (weak breathing due to pain) can result in pneumonia. * You should expect to have rib pain for 4-6 weeks from your injury until your ribs have begun to heal. Please continue to take the pain medication prescribed until then. Please also continue to use the incentive spirometer (breathing machine) 10 times per hour in order to keep your lungs adequately inflated (like a balloon). * You had CT scan of your head, neck, abdomen and pelvis which revealed no other injuries. CT scan of the chest did show a small nodule in your left lung. You should follow up with your regular doctor to discuss imaging the lung in several months evaluate for growth. * In evaluation for your loss of consciousness, we did blood tests that look at heart strain or decreased blood flow (troponins) which were normal. Additionally you were kept on telemetry (continuous heart monitoring) which was reassuring. Finally, you underwent an ultrasound study of your carotids, which showed some degree of narrowing but not narrowing significant enough to have caused your syncopal episodes. You need to follow up with vascular surgery Dr. Braswell in 6 months for this. You may also need additional evaluation for heart monitoring, and should follow up with your regular doctor to discuss this. Please call your doctor, talk to your doctor at rehab or return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, chest pain, cough, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Followup Instructions: Call Dr.Kenna Brown office for a follow up appointment in 6 months, tell them that you will need carotid ultrasound prior to appointment. Phone: 811-226-1554. Please also follow up with Dr. Hang in 3-18 weeks. Call (135-293-5619 for an appointment. Please let your regular doctor know about this hospitalization and follow up with him or her in 10-6 weeks. You may need additional monitoring of your heart rhythm.	['Admission Date: 1978-3-11 Discharge Date: 1926-9-7\n\n\nService: SURGERY\n\nAllergies:\nCodeine / Aspirin / Ibuprofen / Lipitor / Crestor\n\nAttending:Rebeca\nChief Complaint:\nfall down stairs, syncope\n\nMajor Surgical or Invasive Procedure:\nParavertebral block by Acute Pain Service\n\n\nHistory of Present Illness:\nThis is a 30 y/o F, with h/o previous C7 vertebral body\ncompression fx last year after a syncopal event while\ndefecating, who presents to Miranda, Cuevas and Haney Hospital ED after falling down flight\nof stairs today. Pt was carrying laundry up a flight of stairs\nand fell when she had a syncopal event. Pt aroused at bottom of\nstairs and called for help. At presentation she complained of\nright sided back pain. She had head, c-spine, and torso CT scan\nwhich showed multiple right sided rib fractures.', ' Pt does have\nchronic neck pain after compression fx last year. She wears a\nneck brace as needed at night for comfort. She currently denies\nneck pain, headache, abdominal pain or distension, and\nadditionally denies any chest pain or SOB or palpitations prior\nto the fall.\n\nPast Medical History:\nPMH:\n1. A-fib\n2. Type II DM\n3. Hx of PE 20 yrs ago\n4. Hyperlipidemia\n5. Osteoporosis\n6. Osteoarthritis\n7. Anxiety\n8. C7 compression fracture s/p fall\n\nPSH: None\n\nSocial History:\nPatient lives at home, engages in water aerobics everyday,\ndenies use of tobacco, alcohol, or IV drug use\n\n\nFamily History:\nFather died from MI at age 50\nBrother died from MI at age 37\n\nPhysical Exam:\nAt discharge\nVS: Afebrile, VSS\n96.2 87 158/82 16 98%2L\nConstitutional: Well appearing, no acute distress\nNeck: No masses\nCV: RRR, no murmurs.', '\nResp: CTAB, no wheezes or crackles, IS 300. + TTP R ant/post\nchest. No crepitus.\nAbd: Soft, no TTP, nondistended, +BS\nExt: Warm, distal pulses palpable bilaterally\nSkin: Face, neck and chest is normal\nMusculoskeletal: Normal to gait and station\nSpine, Pelvis and Extremities: Stable\nPsychiatric: Normal to judgment, insight, memory, mood and\naffect\n\n\nPertinent Results:\n1978-3-11\nLactate:3.8\nUA negative\n132 95 22 AGap=19\n-------------328\n4.8 23 0.8\nCK: 270 MB: 5 Trop-T: Lakisha: Lip:\nDig: 0.7\n 13.0\n15.4 ----- 165\n 39.1\n N:91 Band:5 L:2 M:2 E:0 Bas:0\nPoiklo: OCCASIONAL Ovalocy: OCCASIONAL\nPT: 24.8 PTT: 24.5 INR: 2.4\n.\n1978-3-11 Carotid Duplex: 60-69% stenosis of L ICA, 40-59%\nstenosis of R ICA\n.\n1953-2-23 CT head: no acute intracranial process\n.\n1953-2-23 CT c-spine: interval C7 vertebral body height loss new\nsince prior but could represent\n.', "\n1953-2-23 CT abd/pelvis: 1. Multiple acute right rib fractures\nwithout evidence of flail chest or\nsegmental fractures.\n2. Asymmetric pulmonary edema, right greater than left, with\ntrace right\npleural effusion and bibasilar atelectasis.\n3. 1.5 cm left lower lobe pulmonary nodule, not included in the\nfield of view\nof the prior study. If clinically indicated, a three-month\nfollowup is\nrecommended.\n4. Unchanged left adnexal cyst.\n\n\n\n\nBrief Hospital Course:\nThe patient was admitted to the trauma surgery service on\n1978-3-11 after a syncopal episode causing a fall down stairs\nresulting in multiple broken ribs, but no other injuries.\n\nNeuro: Pain control was Lofft problem for this patient during her\nhospitalization and the acute pain service was consulted to\nprovide recommendations to better manage the patient's rib pain.", '\nShe initially received IV pain medicaions, including a PCA, and\nalso had a paravertebral block performed by APS. When tolerating\noral intake, the patient was transitioned to oral pain\nmedications, on a regimen including neurontin, lidoderm patch,\nstanding tylenol, tramadol and dilaudid for break-through pain,\nwith fair pain control. The pt also underwent carotid duplex\nultrasound in the evaluation for syncope, which showed 60-69%\nstenosis of L ICA, 40-59% stenosis of R ICA. She will follow up\nwith vascular surgery in 6 months for this, but this is not\nlikely the cause of her syncope.\n\nCV: The patient was stable from a cardiovascular standpoint;\nvital signs were routinely monitored. She was kept on telemetry\nwhich was reassuring. ECG on admission was not thought to be\nconsistent with STEMI.', ' Additionally, cardiac enzymes were\nnegative x 1. Vital signs were routinely monitored and were\nstable. She needs follow up with her regular doctor, as she may\nneed an echo or holter monitoring as an out-patient.\n\nPulmonary: The patient was stable from a pulmonary standpoint;\nvital signs were routinely monitored. She did require 2L of O2\nnasal cannula at discharge, this was thought to be due to poor\ndeep breathing 1-18 mild persistent rib pain. Chest xrays did not\nreveal any pneumonia or fluid overload. The pt did have a 1.5 cm\nleft lower lobe pulmonary nodule noted on CT chest. She will\nneed follow up by her regular doctor, likely with repeat CT\nchest to eval for interval change.\n\nGI/GU: At admission, the patient was resuscitated with IV fluids\nuntil tolerating oral intake. Her diet was advanced when\nappropriate, which was tolerated well.', " She was also started on a\nbowel regimen to encourage bowel movement. Foley was removed on\nHD#2. Intake and output were closely monitored and were normal.\nShe did have some episodes of incontinence.\n\nProphylaxis: The patient received subcutaneous heparin during\nthis stay, and was encouraged to get up and ambulate as early as\npossible with PT.\n\nAt the time of discharge on HD#7, the patient was doing well,\nafebrile with stable vital signs, tolerating a regular diet,\nworking with PT, voiding without assistance, and pain was fairly\nwell controlled.\n\n\nMedications on Admission:\nDigoxin 250 mcg 6 out of 7 days of the week, Zetia 10',\nLisinopril 5', Toprol XL 25', Coumadin, Vitamin C, Vitamin D,\nMVI\n\nDischarge Medications:\n1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK\n(Lakisha,MO,TU,WE,TH,FR).", '\n3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:\nOne (1) Adhesive Patch, Medicated Topical Q12 (): 12 hours with\npatch on, 12 hours with patch off.\n6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for constipation.\n7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for\nconstipation.\n8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)\nInjection TID (3 times a day).\n9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours).\n10. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every 3-4\nhours as needed for pain for 30 days: Hold for sedation, RR Dr.', 'Heflin\n\nDischarge Diagnosis:\nPrimary: 1) fall (trauma), 2) syncope, 3) right posterior 10-13\nrib fractures, 4) right anterior 6th rib fx\n\nSecondary: 1) atrial fibrillation, 2) Osteoporosis, 3) diabetes\nmellitus II, 4) PE 20 years ago, 5) previous C7 fx\n\n\nDischarge Condition:\nMental Status:Clear and coherent\nLevel of Consciousness:Alert and interactive\nActivity Status:Out of Bed with assistance to chair or\nwheelchair\n\n\nDischarge Instructions:\nYou were admitted to Miranda, Cuevas and Haney Hospital to the trauma service after a fall\ndue to losing consciousness.\nYou were found to have 5 rib fractures on CT scan. The most\nimportant treatment for this kind of fracture is pain control to\noptimize deep breathing. There is no surgery or brace for\nsupport that is recommended. Optimization of pain control is\nimperative because splinting (weak breathing due to pain) can\nresult in pneumonia.', '\n* You should expect to have rib pain for 4-6 weeks from your\ninjury until your ribs have begun to heal. Please continue to\ntake the pain medication prescribed until then. Please also\ncontinue to use the incentive spirometer (breathing machine) 10\ntimes per hour in order to keep your lungs adequately inflated\n(like a balloon).\n* You had CT scan of your head, neck, abdomen and pelvis which\nrevealed no other injuries. CT scan of the chest did show a\nsmall nodule in your left lung. You should follow up with your\nregular doctor to discuss imaging the lung in several months\nevaluate for growth.\n* In evaluation for your loss of consciousness, we did blood\ntests that look at heart strain or decreased blood flow\n(troponins) which were normal. Additionally you were kept on\ntelemetry (continuous heart monitoring) which was reassuring.', '\nFinally, you underwent an ultrasound study of your carotids,\nwhich showed some degree of narrowing but not narrowing\nsignificant enough to have caused your syncopal episodes. You\nneed to follow up with vascular surgery Dr. Braswell in 6 months\nfor this. You may also need additional evaluation for heart\nmonitoring, and should follow up with your regular doctor to\ndiscuss this.\n\nPlease call your doctor, talk to your doctor at rehab or return\nto the ER if:\n* If you are vomiting and cannot keep in fluids or your\nmedications.\n* If you have shaking chills, fever greater than 101.5 (F)\ndegrees or 38 (C) degrees, chest pain, cough, shortness of\nbreath, or anything else that is troubling you.\n* Any serious change in your symptoms, or any new symptoms that\nconcern you.\n* Please resume all regular home medications and take any new\nmeds as ordered.', '\n* Do not drive or operate heavy machinery while taking any\nnarcotic pain medication. You may have constipation when taking\nnarcotic pain medications (oxycodone, percocet, vicodin,\nhydrocodone, dilaudid, etc.); you should continue drinking\nfluids, you may take stool softeners, and should eat foods that\nare high in fiber.\n\n\nFollowup Instructions:\nCall Dr.Kenna Brown office for a follow up appointment in 6\nmonths, tell them that you will need carotid ultrasound prior to\nappointment.\nPhone: 811-226-1554.\n\nPlease also follow up with Dr. Hang in 3-18 weeks. Call (135-293-5619 for an appointment.\n\nPlease let your regular doctor know about this hospitalization\nand follow up with him or her in 10-6 weeks. You may need\nadditional monitoring of your heart rhythm.\n\n\n\n']
131	96950	117509.0	2102-10-03	Discharge summary	Report	Admission Date: [2102-10-1] Discharge Date: [2102-10-3] Date of Birth: [2019-8-6] Sex: M Service: MEDICINE Allergies: Penicillins / Quinolones Attending:[Doctor First Name 1402] Chief Complaint: Syncope Major Surgical or Invasive Procedure: [First Name8 (NamePattern2) ] [Male First Name (un) 923] pacemaker placement History of Present Illness: 83 yo male with history of hyperlipidema, hypertension, bifascicular block on previous EKG presented to the ED with syncope. The patient was feeling lightheaded this evening. He called his daughter to discuss his symptoms. While he was on the phone, the line went dead for approx 3min. He reports he lost consciousness during that time. His daughter called EMS. He denied falling during the episode of LOC. When EMS arrived, he was found to be in complete heart block with a ventricular rate in the 20s. He was given atropine en route to the ED. . In the ED, initial vitals were T99.0, HR 30, BP 140/60, RR18, o2 100% on NRB. He was found to be in third degree heart block with a continued ventricular rate in the 30s. He was given atropine again. He sustained a brief episode of asystole and a temporary pacer wire was placed. He had appropriate capture and was paced at a rate of 80bpm. He was intubated for airway protection, given fentanyl and midazolam for sedation, then changed to propofol prior to transfer. . Unable to obtain review of systems secondary to sedation. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: left anterior fascicular block and right bundle branch block on recent EKG -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Obesity, central - History of alcohol abuse. - Status post ruptured rotator cuff: Injured shoulder 50 years ago when he slipped on ice. Specialists have told him he needs it replaced - History of diverticulitis - s/p hemi-colectomy in [5-16] Social History: Lives at home with his wife. [Name (NI) 1403] in real estate part time with son and son-in-law. -Tobacco history: quit smoking 20+ years ago -ETOH: Drinks roughly 12 alcoholic drinks per week, -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: intubated, sedated. HEENT: NCAT. Sclera anicteric. Right pupil is tear drop shaped, minimally reactive appears post surgical, left pupil is reactive. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with flat JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: midline scar, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: [2102-10-1] 10:05PM BLOOD WBC-10.7 RBC-4.13* Hgb-11.9* Hct-37.7* MCV-91 MCH-28.9 MCHC-31.6 RDW-16.5* Plt Ct-260 [2102-10-3] 07:00AM BLOOD WBC-6.9 RBC-3.87* Hgb-11.4* Hct-34.6* MCV-90 MCH-29.6 MCHC-33.1 RDW-17.2* Plt Ct-206 [2102-10-1] 10:05PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1 [2102-10-1] 10:05PM BLOOD Glucose-186* UreaN-29* Creat-1.0 Na-141 K-4.4 Cl-106 HCO3-22 AnGap-17 [2102-10-3] 07:00AM BLOOD Glucose-85 UreaN-19 Creat-0.8 Na-143 K-4.7 Cl-109* HCO3-25 AnGap-14 [2102-10-1] 10:05PM BLOOD CK(CPK)-40 [2102-10-2] 05:00AM BLOOD CK(CPK)-44 [2102-10-1] 10:05PM BLOOD cTropnT-0.02* [2102-10-2] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.08* [2102-10-1] 10:05PM BLOOD Calcium-8.3* Phos-5.8* Mg-2.1 [2102-10-2] 05:00AM BLOOD Triglyc-114 HDL-55 CHOL/HD-2.9 LDLcalc-82 EKG: On admission to the ED, third degree heart block with a sinus rate of 110 bpm, and ventricular escape rhythm at 22bpm with right bundle branch morphology, right-[Hospital1 ] axis. On admission to the CCU, pacer dependent at a rate of 80bpm. ECG: High degree A-V block. Again, given the inconsistent relationship between P waves and QRS complexes tracing is suggestive of complete heart block with ventricular or aberrantly conducted nodal escape rhythm. There is also a rightward axis deviation. Right bundle-branch block and non-specific ST-T wave abnormalities. Compared to the previous tracing #2 evidence for complete heart block is more clearly seen. TTE [2102-10-3]: The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 60-70%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2101-2-3], no major change is evident. CXR: FINDINGS: Left-sided dual-chamber pacemaker has been inserted, with leads intact and in standard positions, ending in the right atrium and right ventricle. There is no pneumothorax, focal consolidation, pleural effusion or pulmonary edema. Degenerative changes are noted in the thoracic spine. IMPRESSION: New left-sided pacemaker with leads in standard positions without evidence of pneumothorax. Brief Hospital Course: # Complete Heart Block: The patient had a know history of RBBB and LAFB. His current presentation was likely degenerative conduction disease, finally losing his posterior fasicle. He had no evidence of active ischemia. A TTE showed no focal wall motion abnormalities, cardiac biomarkers were flat, and ECGs showed no signs of ischemia. He was initially emergently intubated and tranvenously paced. He rapidly extubated and eventually had a PPM placed with little complication. He tolerated the procedure well and was discharged home on PO clindamycin. He will follow up with EP and the device clinic. He was started on 81mg of aspirin for primary prevention. #HTN: Not previously on medical management and remained normotensive in house. No medications started. #Hyperlipidemia: Lipid profile at goal when checked in house. No medications started. #Prophylaxis: HSC #Code: Full confirmed COMM: [Name (NI) 1404] [Name (NI) 14] (Wife) [Telephone/Fax (1) 1405] Medications on Admission: Aspirin 81mg QAM Pregabalin 75mg [Hospital1 ] Zyrtec 10mg QAM Omeprazole 20mg QAM Colace PRN Senna PRN Tylenol PRN Percocet PRN Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days. Disp:24 Capsule(s) Refills:0 3. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Complete Heart Block Discharge Condition: stable. Discharge Instructions: You had a rhythm problem with your heart called complete heart block. This was treated with a pacemaker that will regulate the electrical system of your heart from now on. You did not have a heart attack. Your echocardiogram showed no significant change or abnormality. This is a preliminary [Location (un) 1131] and will be reviewed by the attending cardiologist later in the day. . Medication changes: 1. Take a baby aspirin 81 mg daily. 2. Take Clindamycin for 3 days, this is an antibiotic that will prevent an infection at the pacer site. 3. Vicodin: to take for pain at the pacer site or shoulders . No lifting more than 5 pounds with your left arm or lifting you left arm over your head for 6 weeks. Keep the dressing dry, no showers or baths for 1 week. Do not change the pacer dressing unless it is damp. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2102-10-10] 2:00. [Hospital Ward Name 23] Clinical Center, [Location (un) 436]. [Hospital Ward Name 516], [Hospital1 18]. . [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) 62] Date/time: [11-10] at 3:20 pm. [Hospital Ward Name 23] Clinical Center, [Location (un) 436]. [Hospital Ward Name 516], [Hospital1 18].	Admission Date: <Date>1952-10-30</Date> Discharge Date: <Date>1987-1-19</Date> Date of Birth: <Date>1944-1-26</Date> Sex: M Service: MEDICINE Allergies: Penicillins / Quinolones Attending:<Name>Mark</Name> Chief Complaint: Syncope Major Surgical or Invasive Procedure: <Name>Felecia</Name> <Name>Lillie</Name> pacemaker placement History of Present Illness: 83 yo male with history of hyperlipidema, hypertension, bifascicular block on previous EKG presented to the ED with syncope. The patient was feeling lightheaded this evening. He called his daughter to discuss his symptoms. While he was on the phone, the line went dead for approx 3min. He reports he lost consciousness during that time. His daughter called EMS. He denied falling during the episode of LOC. When EMS arrived, he was found to be in complete heart block with a ventricular rate in the 20s. He was given atropine en route to the ED. . In the ED, initial vitals were T99.0, HR 30, BP 140/60, RR18, o2 100% on NRB. He was found to be in third degree heart block with a continued ventricular rate in the 30s. He was given atropine again. He sustained a brief episode of asystole and a temporary pacer wire was placed. He had appropriate capture and was paced at a rate of 80bpm. He was intubated for airway protection, given fentanyl and midazolam for sedation, then changed to propofol prior to transfer. . Unable to obtain review of systems secondary to sedation. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: left anterior fascicular block and right bundle branch block on recent EKG -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Obesity, central - History of alcohol abuse. - Status post ruptured rotator cuff: Injured shoulder 50 years ago when he slipped on ice. Specialists have told him he needs it replaced - History of diverticulitis - s/p hemi-colectomy in <Date>5-19</Date> Social History: Lives at home with his wife. <Name>Carolyn Naegelin</Name> in real estate part time with son and son-in-law. -Tobacco history: quit smoking 20+ years ago -ETOH: Drinks roughly 12 alcoholic drinks per week, -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: intubated, sedated. HEENT: NCAT. Sclera anicteric. Right pupil is tear drop shaped, minimally reactive appears post surgical, left pupil is reactive. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with flat JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: midline scar, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: <Date>1952-10-30</Date> 10:05PM BLOOD WBC-10.7 RBC-4.13* Hgb-11.9* Hct-37.7* MCV-91 MCH-28.9 MCHC-31.6 RDW-16.5* Plt Ct-260 <Date>1987-1-19</Date> 07:00AM BLOOD WBC-6.9 RBC-3.87* Hgb-11.4* Hct-34.6* MCV-90 MCH-29.6 MCHC-33.1 RDW-17.2* Plt Ct-206 <Date>1952-10-30</Date> 10:05PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1 <Date>1952-10-30</Date> 10:05PM BLOOD Glucose-186* UreaN-29* Creat-1.0 Na-141 K-4.4 Cl-106 HCO3-22 AnGap-17 <Date>1987-1-19</Date> 07:00AM BLOOD Glucose-85 UreaN-19 Creat-0.8 Na-143 K-4.7 Cl-109* HCO3-25 AnGap-14 <Date>1952-10-30</Date> 10:05PM BLOOD CK(CPK)-40 <Date>1907-7-19</Date> 05:00AM BLOOD CK(CPK)-44 <Date>1952-10-30</Date> 10:05PM BLOOD cTropnT-0.02* <Date>1907-7-19</Date> 05:00AM BLOOD CK-MB-NotDone cTropnT-0.08* <Date>1952-10-30</Date> 10:05PM BLOOD Calcium-8.3* Phos-5.8* Mg-2.1 <Date>1907-7-19</Date> 05:00AM BLOOD Triglyc-114 HDL-55 CHOL/HD-2.9 LDLcalc-82 EKG: On admission to the ED, third degree heart block with a sinus rate of 110 bpm, and ventricular escape rhythm at 22bpm with right bundle branch morphology, right-<Hospital>Macdonald-Bowman Medical Center</Hospital> axis. On admission to the CCU, pacer dependent at a rate of 80bpm. ECG: High degree A-V block. Again, given the inconsistent relationship between P waves and QRS complexes tracing is suggestive of complete heart block with ventricular or aberrantly conducted nodal escape rhythm. There is also a rightward axis deviation. Right bundle-branch block and non-specific ST-T wave abnormalities. Compared to the previous tracing #2 evidence for complete heart block is more clearly seen. TTE <Date>1987-1-19</Date>: The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 60-70%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of <Date>1901-11-9</Date>, no major change is evident. CXR: FINDINGS: Left-sided dual-chamber pacemaker has been inserted, with leads intact and in standard positions, ending in the right atrium and right ventricle. There is no pneumothorax, focal consolidation, pleural effusion or pulmonary edema. Degenerative changes are noted in the thoracic spine. IMPRESSION: New left-sided pacemaker with leads in standard positions without evidence of pneumothorax. Brief Hospital Course: # Complete Heart Block: The patient had a know history of RBBB and LAFB. His current presentation was likely degenerative conduction disease, finally losing his posterior fasicle. He had no evidence of active ischemia. A TTE showed no focal wall motion abnormalities, cardiac biomarkers were flat, and ECGs showed no signs of ischemia. He was initially emergently intubated and tranvenously paced. He rapidly extubated and eventually had a PPM placed with little complication. He tolerated the procedure well and was discharged home on PO clindamycin. He will follow up with EP and the device clinic. He was started on 81mg of aspirin for primary prevention. #HTN: Not previously on medical management and remained normotensive in house. No medications started. #Hyperlipidemia: Lipid profile at goal when checked in house. No medications started. #Prophylaxis: HSC #Code: Full confirmed COMM: <Name>Emily Thompson</Name> <Name>King Londrie</Name> (Wife) <Telephone>881-271-5559</Telephone> Medications on Admission: Aspirin 81mg QAM Pregabalin 75mg <Hospital>Macdonald-Bowman Medical Center</Hospital> Zyrtec 10mg QAM Omeprazole 20mg QAM Colace PRN Senna PRN Tylenol PRN Percocet PRN Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days. Disp:24 Capsule(s) Refills:0 3. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Complete Heart Block Discharge Condition: stable. Discharge Instructions: You had a rhythm problem with your heart called complete heart block. This was treated with a pacemaker that will regulate the electrical system of your heart from now on. You did not have a heart attack. Your echocardiogram showed no significant change or abnormality. This is a preliminary <Location>005 Green Forks New Mark, IN 65392</Location> and will be reviewed by the attending cardiologist later in the day. . Medication changes: 1. Take a baby aspirin 81 mg daily. 2. Take Clindamycin for 3 days, this is an antibiotic that will prevent an infection at the pacer site. 3. Vicodin: to take for pain at the pacer site or shoulders . No lifting more than 5 pounds with your left arm or lifting you left arm over your head for 6 weeks. Keep the dressing dry, no showers or baths for 1 week. Do not change the pacer dressing unless it is damp. Followup Instructions: Provider: <Name>Gaspar Jones</Name> CLINIC Phone:<Telephone>987-425-7034</Telephone> Date/Time:<Date>1948-4-20</Date> 2:00. <Hospital>Johnson-Kim Medical Center</Hospital> Clinical Center, <Location>96415 Gray Glen East Scottfort, WA 93788</Location>. <Hospital>Johnson Ltd Health System</Hospital>, <Hospital>Anderson Group Medical Center</Hospital>. . <Name>Valery</Name> <Name>Feudner</Name>, MD Phone: <Telephone>987-425-7034</Telephone> Date/time: <Date>2-15</Date> at 3:20 pm. <Hospital>Johnson-Kim Medical Center</Hospital> Clinical Center, <Location>96415 Gray Glen East Scottfort, WA 93788</Location>. <Hospital>Johnson Ltd Health System</Hospital>, <Hospital>Anderson Group Medical Center</Hospital>.	0000000000000000011111111110000000000000000000000000000000011111111100000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000111111101111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000111111111000000000000000000000000001111111111000000000000000000000000000001111111110000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1952-10-30 Discharge Date: 1987-1-19 Date of Birth: 1944-1-26 Sex: M Service: MEDICINE Allergies: Penicillins / Quinolones Attending:Mark Chief Complaint: Syncope Major Surgical or Invasive Procedure: Felecia Lillie pacemaker placement History of Present Illness: 83 yo male with history of hyperlipidema, hypertension, bifascicular block on previous EKG presented to the ED with syncope. The patient was feeling lightheaded this evening. He called his daughter to discuss his symptoms. While he was on the phone, the line went dead for approx 3min. He reports he lost consciousness during that time. His daughter called EMS. He denied falling during the episode of LOC. When EMS arrived, he was found to be in complete heart block with a ventricular rate in the 20s. He was given atropine en route to the ED. . In the ED, initial vitals were T99.0, HR 30, BP 140/60, RR18, o2 100% on NRB. He was found to be in third degree heart block with a continued ventricular rate in the 30s. He was given atropine again. He sustained a brief episode of asystole and a temporary pacer wire was placed. He had appropriate capture and was paced at a rate of 80bpm. He was intubated for airway protection, given fentanyl and midazolam for sedation, then changed to propofol prior to transfer. . Unable to obtain review of systems secondary to sedation. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: left anterior fascicular block and right bundle branch block on recent EKG -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Obesity, central - History of alcohol abuse. - Status post ruptured rotator cuff: Injured shoulder 50 years ago when he slipped on ice. Specialists have told him he needs it replaced - History of diverticulitis - s/p hemi-colectomy in 5-19 Social History: Lives at home with his wife. Carolyn Naegelin in real estate part time with son and son-in-law. -Tobacco history: quit smoking 20+ years ago -ETOH: Drinks roughly 12 alcoholic drinks per week, -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: intubated, sedated. HEENT: NCAT. Sclera anicteric. Right pupil is tear drop shaped, minimally reactive appears post surgical, left pupil is reactive. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with flat JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: midline scar, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: 1952-10-30 10:05PM BLOOD WBC-10.7 RBC-4.13* Hgb-11.9* Hct-37.7* MCV-91 MCH-28.9 MCHC-31.6 RDW-16.5* Plt Ct-260 1987-1-19 07:00AM BLOOD WBC-6.9 RBC-3.87* Hgb-11.4* Hct-34.6* MCV-90 MCH-29.6 MCHC-33.1 RDW-17.2* Plt Ct-206 1952-10-30 10:05PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1 1952-10-30 10:05PM BLOOD Glucose-186* UreaN-29* Creat-1.0 Na-141 K-4.4 Cl-106 HCO3-22 AnGap-17 1987-1-19 07:00AM BLOOD Glucose-85 UreaN-19 Creat-0.8 Na-143 K-4.7 Cl-109* HCO3-25 AnGap-14 1952-10-30 10:05PM BLOOD CK(CPK)-40 1907-7-19 05:00AM BLOOD CK(CPK)-44 1952-10-30 10:05PM BLOOD cTropnT-0.02* 1907-7-19 05:00AM BLOOD CK-MB-NotDone cTropnT-0.08* 1952-10-30 10:05PM BLOOD Calcium-8.3* Phos-5.8* Mg-2.1 1907-7-19 05:00AM BLOOD Triglyc-114 HDL-55 CHOL/HD-2.9 LDLcalc-82 EKG: On admission to the ED, third degree heart block with a sinus rate of 110 bpm, and ventricular escape rhythm at 22bpm with right bundle branch morphology, right-Macdonald-Bowman Medical Center axis. On admission to the CCU, pacer dependent at a rate of 80bpm. ECG: High degree A-V block. Again, given the inconsistent relationship between P waves and QRS complexes tracing is suggestive of complete heart block with ventricular or aberrantly conducted nodal escape rhythm. There is also a rightward axis deviation. Right bundle-branch block and non-specific ST-T wave abnormalities. Compared to the previous tracing #2 evidence for complete heart block is more clearly seen. TTE 1987-1-19: The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 60-70%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of 1901-11-9, no major change is evident. CXR: FINDINGS: Left-sided dual-chamber pacemaker has been inserted, with leads intact and in standard positions, ending in the right atrium and right ventricle. There is no pneumothorax, focal consolidation, pleural effusion or pulmonary edema. Degenerative changes are noted in the thoracic spine. IMPRESSION: New left-sided pacemaker with leads in standard positions without evidence of pneumothorax. Brief Hospital Course: # Complete Heart Block: The patient had a know history of RBBB and LAFB. His current presentation was likely degenerative conduction disease, finally losing his posterior fasicle. He had no evidence of active ischemia. A TTE showed no focal wall motion abnormalities, cardiac biomarkers were flat, and ECGs showed no signs of ischemia. He was initially emergently intubated and tranvenously paced. He rapidly extubated and eventually had a PPM placed with little complication. He tolerated the procedure well and was discharged home on PO clindamycin. He will follow up with EP and the device clinic. He was started on 81mg of aspirin for primary prevention. #HTN: Not previously on medical management and remained normotensive in house. No medications started. #Hyperlipidemia: Lipid profile at goal when checked in house. No medications started. #Prophylaxis: HSC #Code: Full confirmed COMM: Emily Thompson King Londrie (Wife) 881-271-5559 Medications on Admission: Aspirin 81mg QAM Pregabalin 75mg Macdonald-Bowman Medical Center Zyrtec 10mg QAM Omeprazole 20mg QAM Colace PRN Senna PRN Tylenol PRN Percocet PRN Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days. Disp:24 Capsule(s) Refills:0 3. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Complete Heart Block Discharge Condition: stable. Discharge Instructions: You had a rhythm problem with your heart called complete heart block. This was treated with a pacemaker that will regulate the electrical system of your heart from now on. You did not have a heart attack. Your echocardiogram showed no significant change or abnormality. This is a preliminary 005 Green Forks New Mark, IN 65392 and will be reviewed by the attending cardiologist later in the day. . Medication changes: 1. Take a baby aspirin 81 mg daily. 2. Take Clindamycin for 3 days, this is an antibiotic that will prevent an infection at the pacer site. 3. Vicodin: to take for pain at the pacer site or shoulders . No lifting more than 5 pounds with your left arm or lifting you left arm over your head for 6 weeks. Keep the dressing dry, no showers or baths for 1 week. Do not change the pacer dressing unless it is damp. Followup Instructions: Provider: Gaspar Jones CLINIC Phone:987-425-7034 Date/Time:1948-4-20 2:00. Johnson-Kim Medical Center Clinical Center, 96415 Gray Glen East Scottfort, WA 93788. Johnson Ltd Health System, Anderson Group Medical Center. . Valery Feudner, MD Phone: 987-425-7034 Date/time: 2-15 at 3:20 pm. Johnson-Kim Medical Center Clinical Center, 96415 Gray Glen East Scottfort, WA 93788. Johnson Ltd Health System, Anderson Group Medical Center.	['Admission Date: 1952-10-30 Discharge Date: 1987-1-19\n\nDate of Birth: 1944-1-26 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPenicillins / Quinolones\n\nAttending:Mark\nChief Complaint:\nSyncope\n\nMajor Surgical or Invasive Procedure:\nFelecia Lillie pacemaker placement\n\n\nHistory of Present Illness:\n83 yo male with history of hyperlipidema, hypertension,\nbifascicular block on previous EKG presented to the ED with\nsyncope. The patient was feeling lightheaded this evening. He\ncalled his daughter to discuss his symptoms. While he was on\nthe phone, the line went dead for approx 3min. He reports he\nlost consciousness during that time. His daughter called EMS.\nHe denied falling during the episode of LOC. When EMS arrived,\nhe was found to be in complete heart block with a ventricular\nrate in the 20s.', ' He was given atropine en route to the ED.\n.\nIn the ED, initial vitals were T99.0, HR 30, BP 140/60, RR18, o2\n100% on NRB. He was found to be in third degree heart block\nwith a continued ventricular rate in the 30s. He was given\natropine again. He sustained a brief episode of asystole and a\ntemporary pacer wire was placed. He had appropriate capture and\nwas paced at a rate of 80bpm. He was intubated for airway\nprotection, given fentanyl and midazolam for sedation, then\nchanged to propofol prior to transfer.\n.\nUnable to obtain review of systems secondary to sedation.\n\nPast Medical History:\n1. CARDIAC RISK FACTORS: (+) Dyslipidemia, (+) Hypertension\n2. CARDIAC HISTORY: left anterior fascicular block and right\nbundle branch block on recent EKG\n-CABG: none\n-PERCUTANEOUS CORONARY INTERVENTIONS: none\n-PACING/ICD: none\n3.', ' OTHER PAST MEDICAL HISTORY:\n- Obesity, central\n- History of alcohol abuse.\n- Status post ruptured rotator cuff: Injured shoulder 50 years\nago when he slipped on ice. Specialists have told him he needs\nit replaced\n- History of diverticulitis - s/p hemi-colectomy in 5-19\n\n\nSocial History:\nLives at home with his wife. Carolyn Naegelin in real estate part time with\nson and son-in-law.\n-Tobacco history: quit smoking 20+ years ago\n-ETOH: Drinks roughly 12 alcoholic drinks per week,\n-Illicit drugs: none\n\n\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death; otherwise non-contributory.\n\nPhysical Exam:\nGENERAL: intubated, sedated.\nHEENT: NCAT. Sclera anicteric. Right pupil is tear drop shaped,\nminimally reactive appears post surgical, left pupil is\nreactive.', ' Conjunctiva were pink, no pallor or cyanosis of the\noral mucosa. No xanthalesma.\nNECK: Supple with flat JVP\nCARDIAC: PMI located in 5th intercostal space, midclavicular\nline. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or\nS4.\nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. CTAB, no crackles,\nwheezes or rhonchi.\nABDOMEN: midline scar, soft, NTND. No HSM or tenderness. Abd\naorta not enlarged by palpation. No abdominial bruits.\nEXTREMITIES: No c/c/e. No femoral bruits.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES:\nRight: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+\nLeft: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+\n\nPertinent Results:\n1952-10-30 10:05PM BLOOD WBC-10.7 RBC-4.13* Hgb-11.9* Hct-37.7\nMCV-91 MCH-28.', '9 MCHC-31.6 RDW-16.5 Plt Ct-260\n1987-1-19 07:00AM BLOOD WBC-6.9 RBC-3.87* Hgb-11.4* Hct-34.6\nMCV-90 MCH-29.6 MCHC-33.1 RDW-17.2 Plt Ct-206\n1952-10-30 10:05PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1\n1952-10-30 10:05PM BLOOD Glucose-186* UreaN-29* Creat-1.0 Na-141\nK-4.4 Cl-106 HCO3-22 AnGap-17\n1987-1-19 07:00AM BLOOD Glucose-85 UreaN-19 Creat-0.8 Na-143\nK-4.7 Cl-109* HCO3-25 AnGap-14\n1952-10-30 10:05PM BLOOD CK(CPK)-40\n1907-7-19 05:00AM BLOOD CK(CPK)-44\n1952-10-30 10:05PM BLOOD cTropnT-0.02\n1907-7-19 05:00AM BLOOD CK-MB-NotDone cTropnT-0.08\n1952-10-30 10:05PM BLOOD Calcium-8.3* Phos-5.8* Mg-2.1\n1907-7-19 05:00AM BLOOD Triglyc-114 HDL-55 CHOL/HD-2.9 LDLcalc-82\n\nEKG: On admission to the ED, third degree heart block with a\nsinus rate of 110 bpm, and ventricular escape rhythm at 22bpm\nwith right bundle branch morphology, right-Macdonald-Bowman Medical Center axis.', ' On\nadmission to the CCU, pacer dependent at a rate of 80bpm.\nECG:\nHigh degree A-V block. Again, given the inconsistent\nrelationship between\nP waves and QRS complexes tracing is suggestive of complete\nheart block with ventricular or aberrantly conducted nodal\nescape rhythm. There is also a rightward axis deviation. Right\nbundle-branch block and non-specific ST-T wave abnormalities.\nCompared to the previous tracing #2 evidence for complete heart\nblock is more clearly seen.\n\nTTE 1987-1-19:\nThe left atrium is elongated. Left ventricular wall thicknesses\nand cavity size are normal. Due to suboptimal technical quality,\na focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF\n60-70%). Right ventricular chamber size and free wall motion are\nnormal.', ' The aortic root is mildly dilated at the sinus level.\nThe aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. The aortic valve is not well seen. No\naortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. There is a trivial/physiologic\npericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nCompared with the prior study (images reviewed) of 1901-11-9, no\nmajor change is evident.\n\nCXR:\nFINDINGS: Left-sided dual-chamber pacemaker has been inserted,\nwith leads\nintact and in standard positions, ending in the right atrium and\nright\nventricle. There is no pneumothorax, focal consolidation,\npleural effusion or pulmonary edema.', ' Degenerative changes are\nnoted in the thoracic spine.\n\nIMPRESSION: New left-sided pacemaker with leads in standard\npositions without evidence of pneumothorax.\n\n\nBrief Hospital Course:\n# Complete Heart Block: The patient had a know history of RBBB\nand LAFB. His current presentation was likely degenerative\nconduction disease, finally losing his posterior fasicle. He had\nno evidence of active ischemia. A TTE showed no focal wall\nmotion abnormalities, cardiac biomarkers were flat, and ECGs\nshowed no signs of ischemia. He was initially emergently\nintubated and tranvenously paced. He rapidly extubated and\neventually had a PPM placed with little complication. He\ntolerated the procedure well and was discharged home on PO\nclindamycin. He will follow up with EP and the device clinic. He\nwas started on 81mg of aspirin for primary prevention.', '\n\n#HTN: Not previously on medical management and remained\nnormotensive in house. No medications started.\n\n#Hyperlipidemia: Lipid profile at goal when checked in house. No\nmedications started.\n\n#Prophylaxis: HSC\n\n#Code: Full confirmed\n\nCOMM: Emily Thompson King Londrie (Wife) 881-271-5559\n\nMedications on Admission:\nAspirin 81mg QAM\nPregabalin 75mg Macdonald-Bowman Medical Center\nZyrtec 10mg QAM\nOmeprazole 20mg QAM\nColace PRN\nSenna PRN\nTylenol PRN\nPercocet PRN\n\n\nDischarge Medications:\n1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.\n2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H\n(every 6 hours) for 3 days.\nDisp:24 Capsule(s) Refills:0\n3. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a\nday as needed for pain.\nDisp:15 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nComplete Heart Block\n\n\nDischarge Condition:\nstable.', '\n\n\nDischarge Instructions:\nYou had a rhythm problem with your heart called complete heart\nblock. This was treated with a pacemaker that will regulate the\nelectrical system of your heart from now on. You did not have a\nheart attack. Your echocardiogram showed no significant change\nor abnormality. This is a preliminary 005 Green Forks\nNew Mark, IN 65392 and will be\nreviewed by the attending cardiologist later in the day.\n.\nMedication changes:\n1. Take a baby aspirin 81 mg daily.\n2. Take Clindamycin for 3 days, this is an antibiotic that will\nprevent an infection at the pacer site.\n3. Vicodin: to take for pain at the pacer site or shoulders\n.\nNo lifting more than 5 pounds with your left arm or lifting you\nleft arm over your head for 6 weeks. Keep the dressing dry, no\nshowers or baths for 1 week.', ' Do not change the pacer dressing\nunless it is damp.\n\nFollowup Instructions:\nProvider: Gaspar Jones CLINIC Phone:987-425-7034 Date/Time:1948-4-20\n2:00.\nJohnson-Kim Medical Center Clinical Center, 96415 Gray Glen\nEast Scottfort, WA 93788. Johnson Ltd Health System, Anderson Group Medical Center.\n.\nValery Feudner, MD Phone: 987-425-7034 Date/time: 2-15\nat 3:20 pm.\nJohnson-Kim Medical Center Clinical Center, 96415 Gray Glen\nEast Scottfort, WA 93788. Johnson Ltd Health System, Anderson Group Medical Center.\n\n\n\n']
132	96950	176286.0	2103-06-24	Discharge summary	Report	Admission Date: [2103-6-19] Discharge Date: [2103-6-24] Date of Birth: [2019-8-6] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Quinolones Attending:[First Name3 (LF) 1406] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2103-6-19] Coronary bypass grafting times 4(left internal mammary artery to left anterior descending artery, reverse saphenous vein graft to right coronary artery,sequential reverse saphenous vein graft to first and second obtuse marginal arteries). Permanent left ventricular epicardial lead placement History of Present Illness: This 83 year old white male with complaints of dyspnea on exertion and abnormal stress echo was referred for cardiac catheterization. This revealed severe coronary artery disease and he was referred for surgical intervention. Past Medical History: Hypertension Hyperlipidemia s/p St. [Male First Name (un) 923] PPM for CHB [9-15] Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy [5-/2102] s/p Back surgery [2101] s/p Appendectomy s/p Tonsillectomy Social History: Race:Caucasian Last Dental Exam: Lives with:wife Occupation:Retired Tobacco:quit 23 years ago, smoked x 50 years ETOH:[12-9] pint of hard alcohol a day Family History: noncontributory Physical Exam: admission: Pulse:70 Resp:13 O2 sat:97% RA B/P Right:156/662 Left:160/64 Height:5'1" Weight:163 lbs General: NAD, sitting comfortably in chair 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-I/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +1 Left:+1 DP Right:+2 Left:+2 PT [Name (NI) 167]: +2 Left:+2 Radial Right:+2 Left:+2 Carotid Bruit Right: none Left:none Pertinent Results: [2103-6-21] 05:10AM BLOOD WBC-11.8* RBC-2.98* Hgb-9.6* Hct-28.1* MCV-94 MCH-32.1* MCHC-34.0 RDW-14.5 Plt Ct-157 [2103-6-19] 03:22PM BLOOD WBC-16.2# RBC-3.43 Hgb-11.3* Hct-31.7* MCV-92 MCH-32.9* MCHC-35.7* RDW-14.4 Plt Ct-216 [2103-6-19] 03:22PM BLOOD UreaN-12 Creat-0.8 Na-141 K-4.4 Cl-109* HCO3-24 AnGap-12 Brief Hospital Course: Mr. [Known lastname 14] was a same day admit who was taken to the Operating Room where he underwent coronary artery bypass graft x 4 and permanent left ventricular epicardial lead placement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one beta-blockers and diuretics were initiated and he was diuresed towards his pre-op weight. Also on this day he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. Physical Therapy worked with him for strength and mobility. Wounds were clean and healing well at discharge. discharge restrictions, precations, medications and follow up were discussed with him prior to discharge. He was cleared for discharge to home on POD#5 by Dr. [First Name (STitle) ]. He will receive VNA and has private care at home as well. Medications on Admission: Norvasc 5mg po daily Lipitor 10mg po daily ASA 81mg po daily Vitamin D3 Lactobacillus Rhamnosus 10 billion cells cap- 1 cap po daily MVI Fish Oil Preservision 1 cap po daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery bypass graft x 4 Hypertension Hyperlipidemia s/p St. [Male First Name (un) 923] permanent pacemaker [9-15] Arthritis Diverticulitis s/p Left hemicolectomy [5-/2102] s/p Back surgery [2101] s/p Appendectomy s/p Tonsillectomy Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] Wednesday ([Telephone/Fax (1) 170]on [7-25] @ 1:00 PM Please call to schedule appointments with your Primary Care: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1407] ([Telephone/Fax (1) 1408]in [12-9] weeks Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [12-9] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2103-6-24]	Admission Date: <Date>1913-9-2</Date> Discharge Date: <Date>1940-5-15</Date> Date of Birth: <Date>1988-3-19</Date> Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Quinolones Attending:<Name>Natividad</Name> Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: <Date>1913-9-2</Date> Coronary bypass grafting times 4(left internal mammary artery to left anterior descending artery, reverse saphenous vein graft to right coronary artery,sequential reverse saphenous vein graft to first and second obtuse marginal arteries). Permanent left ventricular epicardial lead placement History of Present Illness: This 83 year old white male with complaints of dyspnea on exertion and abnormal stress echo was referred for cardiac catheterization. This revealed severe coronary artery disease and he was referred for surgical intervention. Past Medical History: Hypertension Hyperlipidemia s/p St. <Name>Billy</Name> PPM for CHB <Date>11-14</Date> Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy <Date>7-1920</Date> s/p Back surgery <Year>1918</Year> s/p Appendectomy s/p Tonsillectomy Social History: Race:Caucasian Last Dental Exam: Lives with:wife Occupation:Retired Tobacco:quit 23 years ago, smoked x 50 years ETOH:<Date>11-11</Date> pint of hard alcohol a day Family History: noncontributory Physical Exam: admission: Pulse:70 Resp:13 O2 sat:97% RA B/P Right:156/662 Left:160/64 Height:5'1" Weight:163 lbs General: NAD, sitting comfortably in chair 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-I/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +1 Left:+1 DP Right:+2 Left:+2 PT <Name>Emory Feguson</Name>: +2 Left:+2 Radial Right:+2 Left:+2 Carotid Bruit Right: none Left:none Pertinent Results: <Date>1970-7-20</Date> 05:10AM BLOOD WBC-11.8* RBC-2.98* Hgb-9.6* Hct-28.1* MCV-94 MCH-32.1* MCHC-34.0 RDW-14.5 Plt Ct-157 <Date>1913-9-2</Date> 03:22PM BLOOD WBC-16.2# RBC-3.43 Hgb-11.3* Hct-31.7* MCV-92 MCH-32.9* MCHC-35.7* RDW-14.4 Plt Ct-216 <Date>1913-9-2</Date> 03:22PM BLOOD UreaN-12 Creat-0.8 Na-141 K-4.4 Cl-109* HCO3-24 AnGap-12 Brief Hospital Course: Mr. <Name>Islam</Name> was a same day admit who was taken to the Operating Room where he underwent coronary artery bypass graft x 4 and permanent left ventricular epicardial lead placement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one beta-blockers and diuretics were initiated and he was diuresed towards his pre-op weight. Also on this day he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. Physical Therapy worked with him for strength and mobility. Wounds were clean and healing well at discharge. discharge restrictions, precations, medications and follow up were discussed with him prior to discharge. He was cleared for discharge to home on POD#5 by Dr. <Name>Kamran</Name>. He will receive VNA and has private care at home as well. Medications on Admission: Norvasc 5mg po daily Lipitor 10mg po daily ASA 81mg po daily Vitamin D3 Lactobacillus Rhamnosus 10 billion cells cap- 1 cap po daily MVI Fish Oil Preservision 1 cap po daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: <Hospital>Ferguson, Best and Price Health System</Hospital> Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery bypass graft x 4 Hypertension Hyperlipidemia s/p St. <Name>Billy</Name> permanent pacemaker <Date>11-14</Date> Arthritis Diverticulitis s/p Left hemicolectomy <Date>7-1920</Date> s/p Back surgery <Year>1918</Year> s/p Appendectomy s/p Tonsillectomy Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns <Telephone>595-171-1854</Telephone> Please call cardiac surgery office with any questions or concerns <Telephone>595-171-1854</Telephone>. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. <Name>Ivory</Name> Wednesday (<Telephone>595-171-1854</Telephone>on <Date>4-18</Date> @ 1:00 PM Please call to schedule appointments with your Primary Care: Dr. <Name>Idalia</Name> <Name>Shipley</Name> (<Telephone>598-775-5027</Telephone>in <Date>11-11</Date> weeks Cardiologist: Dr. <Name>Idalia</Name> <Name>Kenner</Name> in <Date>11-11</Date> weeks Please call cardiac surgery office with any questions or concerns <Telephone>595-171-1854</Telephone>. Answering service will contact on call person during off hours Completed by:<Date>1940-5-15</Date>	000000000000000001111111100000000000000000000000000000000111111111000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000001111100000000000000000000000000000000000000000000000001111110000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1913-9-2 Discharge Date: 1940-5-15 Date of Birth: 1988-3-19 Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Quinolones Attending:Natividad Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: 1913-9-2 Coronary bypass grafting times 4(left internal mammary artery to left anterior descending artery, reverse saphenous vein graft to right coronary artery,sequential reverse saphenous vein graft to first and second obtuse marginal arteries). Permanent left ventricular epicardial lead placement History of Present Illness: This 83 year old white male with complaints of dyspnea on exertion and abnormal stress echo was referred for cardiac catheterization. This revealed severe coronary artery disease and he was referred for surgical intervention. Past Medical History: Hypertension Hyperlipidemia s/p St. Billy PPM for CHB 11-14 Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy 7-1920 s/p Back surgery 1918 s/p Appendectomy s/p Tonsillectomy Social History: Race:Caucasian Last Dental Exam: Lives with:wife Occupation:Retired Tobacco:quit 23 years ago, smoked x 50 years ETOH:11-11 pint of hard alcohol a day Family History: noncontributory Physical Exam: admission: Pulse:70 Resp:13 O2 sat:97% RA B/P Right:156/662 Left:160/64 Height:5'1" Weight:163 lbs General: NAD, sitting comfortably in chair 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-I/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +1 Left:+1 DP Right:+2 Left:+2 PT Emory Feguson: +2 Left:+2 Radial Right:+2 Left:+2 Carotid Bruit Right: none Left:none Pertinent Results: 1970-7-20 05:10AM BLOOD WBC-11.8* RBC-2.98* Hgb-9.6* Hct-28.1* MCV-94 MCH-32.1* MCHC-34.0 RDW-14.5 Plt Ct-157 1913-9-2 03:22PM BLOOD WBC-16.2# RBC-3.43 Hgb-11.3* Hct-31.7* MCV-92 MCH-32.9* MCHC-35.7* RDW-14.4 Plt Ct-216 1913-9-2 03:22PM BLOOD UreaN-12 Creat-0.8 Na-141 K-4.4 Cl-109* HCO3-24 AnGap-12 Brief Hospital Course: Mr. Islam was a same day admit who was taken to the Operating Room where he underwent coronary artery bypass graft x 4 and permanent left ventricular epicardial lead placement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one beta-blockers and diuretics were initiated and he was diuresed towards his pre-op weight. Also on this day he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. Physical Therapy worked with him for strength and mobility. Wounds were clean and healing well at discharge. discharge restrictions, precations, medications and follow up were discussed with him prior to discharge. He was cleared for discharge to home on POD#5 by Dr. Kamran. He will receive VNA and has private care at home as well. Medications on Admission: Norvasc 5mg po daily Lipitor 10mg po daily ASA 81mg po daily Vitamin D3 Lactobacillus Rhamnosus 10 billion cells cap- 1 cap po daily MVI Fish Oil Preservision 1 cap po daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Ferguson, Best and Price Health System Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery bypass graft x 4 Hypertension Hyperlipidemia s/p St. Billy permanent pacemaker 11-14 Arthritis Diverticulitis s/p Left hemicolectomy 7-1920 s/p Back surgery 1918 s/p Appendectomy s/p Tonsillectomy Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns 595-171-1854 Please call cardiac surgery office with any questions or concerns 595-171-1854. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. Ivory Wednesday (595-171-1854on 4-18 @ 1:00 PM Please call to schedule appointments with your Primary Care: Dr. Idalia Shipley (598-775-5027in 11-11 weeks Cardiologist: Dr. Idalia Kenner in 11-11 weeks Please call cardiac surgery office with any questions or concerns 595-171-1854. Answering service will contact on call person during off hours Completed by:1940-5-15	['Admission Date: 1913-9-2 Discharge Date: 1940-5-15\n\nDate of Birth: 1988-3-19 Sex: M\n\nService: CARDIOTHORACIC\n\nAllergies:\nPenicillins / Quinolones\n\nAttending:Natividad\nChief Complaint:\nDyspnea on exertion\n\nMajor Surgical or Invasive Procedure:\n1913-9-2 Coronary bypass grafting times 4(left internal mammary\nartery to left anterior descending artery, reverse saphenous\nvein graft to right coronary artery,sequential reverse saphenous\nvein graft to first and second obtuse marginal arteries).\nPermanent left ventricular epicardial lead placement\n\n\nHistory of Present Illness:\nThis 83 year old white male with complaints of dyspnea on\nexertion and abnormal stress echo was referred for cardiac\ncatheterization. This revealed severe coronary artery disease\nand he was referred for surgical intervention.', '\n\nPast Medical History:\nHypertension\nHyperlipidemia\ns/p St. Billy PPM for CHB 11-14\nArthritis\nSleep apnea noted after administration of narcotics\nDiverticulitis s/p Left hemicolectomy 7-1920\ns/p Back surgery 1918\ns/p Appendectomy\ns/p Tonsillectomy\n\nSocial History:\nRace:Caucasian\nLast Dental Exam:\nLives with:wife\nOccupation:Retired\nTobacco:quit 23 years ago, smoked x 50 years\nETOH:11-11 pint of hard alcohol a day\n\nFamily History:\nnoncontributory\n\nPhysical Exam:\nadmission:\nPulse:70 Resp:13 O2 sat:97% RA\nB/P Right:156/662 Left:160/64\nHeight:5\'1" Weight:163 lbs\n\nGeneral: NAD, sitting comfortably in chair\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur-I/VI SEM\nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+ [x]\nExtremities: Warm [x], well-perfused [x] Edema Varicosities:\nNone [x]\nNeuro: Grossly intact\nPulses:\nFemoral Right: +1 Left:+1\nDP Right:+2 Left:+2\nPT Emory Feguson: +2 Left:+2\nRadial Right:+2 Left:+2\n\nCarotid Bruit Right: none Left:none\n\nPertinent Results:\n1970-7-20 05:10AM BLOOD WBC-11.', '8* RBC-2.98* Hgb-9.6* Hct-28.1\nMCV-94 MCH-32.1 MCHC-34.0 RDW-14.5 Plt Ct-157\n1913-9-2 03:22PM BLOOD WBC-16.2# RBC-3.43 Hgb-11.3* Hct-31.7\nMCV-92 MCH-32.9 MCHC-35.7* RDW-14.4 Plt Ct-216\n1913-9-2 03:22PM BLOOD UreaN-12 Creat-0.8 Na-141 K-4.4 Cl-109\nHCO3-24 AnGap-12\n\nBrief Hospital Course:\nMr. Islam was a same day admit who was taken to the Operating\nRoom where he underwent coronary artery bypass graft x 4 and\npermanent left ventricular epicardial lead placement. Please see\noperative report for surgical details.\n\nFollowing surgery he was transferred to the CVICU for invasive\nmonitoring in stable condition. Within 24 hours he was weaned\nfrom sedation, awoke neurologically intact and extubated.\n\nOn post-op day one beta-blockers and diuretics were initiated\nand he was diuresed towards his pre-op weight.', ' Also on this day\nhe was transferred to the telemetry floor for further care.\nChest tubes and epicardial pacing wires were removed per\nprotocol.\n\nPhysical Therapy worked with him for strength and mobility.\nWounds were clean and healing well at discharge. discharge\nrestrictions, precations, medications and follow up were\ndiscussed with him prior to discharge. He was cleared for\ndischarge to home on POD#5 by Dr. Kamran. He will receive VNA\nand has private care at home as well.\n\nMedications on Admission:\nNorvasc 5mg po daily\nLipitor 10mg po daily\nASA 81mg po daily\nVitamin D3\nLactobacillus Rhamnosus 10 billion cells cap- 1 cap po daily\nMVI\nFish Oil\nPreservision 1 cap po daily\n\nDischarge Medications:\n1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. Aspirin 81 mg Tablet, Delayed Release (E.', 'C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\n3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every\n4 hours) as needed for fever, pain.\n4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO\nQ4H (every 4 hours) as needed for pain.\nDisp:50 Tablet(s)* Refills:0\n5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\nML PO HS (at bedtime) as needed for constipation.\n6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\nDisp:60 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nFerguson, Best and Price Health System Homecare\n\nDischarge Diagnosis:\nCoronary Artery Disease\n s/p Coronary Artery bypass graft x 4\nHypertension\nHyperlipidemia\ns/p St. Billy permanent pacemaker 11-14\nArthritis\nDiverticulitis\ns/p Left hemicolectomy 7-1920\ns/p Back surgery 1918\ns/p Appendectomy\ns/p Tonsillectomy\n\n\nDischarge Condition:\nAlert and oriented x3, nonfocal\nAmbulating with steady gait\nIncisional pain managed with Percocet\n\nIncisions:\n\nSternal - healing well, no erythema or drainage\nLeg Left - healing well, no erythema or drainage.', '\n\n\nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild\nsoap, no baths or swimming until cleared by surgeon. Look at\nyour incisions daily for redness or drainage\n\nPlease NO lotions, cream, powder, or ointments to incisions\nEach morning you should weigh yourself and then in the evening\ntake your temperature, these should be written down on the chart\n\nNo driving for approximately one month until follow up with\nsurgeon\nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns 595-171-1854\n\nPlease call cardiac surgery office with any questions or\nconcerns 595-171-1854. Answering service will contact on call\nperson during off hours\n\nFollowup Instructions:\nYou are scheduled for the following appointments\n\nSurgeon: Dr. Ivory Wednesday (595-171-1854on 4-18 @ 1:00 PM\n\nPlease call to schedule appointments with your\n\nPrimary Care: Dr.', ' Idalia Shipley (598-775-5027in 11-11 weeks\nCardiologist: Dr. Idalia Kenner in 11-11 weeks\n\nPlease call cardiac surgery office with any questions or\nconcerns 595-171-1854. Answering service will contact on call\nperson during off hours\n\n\n\nCompleted by:1940-5-15']
133	96950	162129.0	2103-07-31	Discharge summary	Report	Admission Date: [2103-7-18] Discharge Date: [2103-7-31] Date of Birth: [2019-8-6] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Quinolones Attending:[First Name3 (LF) 1406] Chief Complaint: Sternal drainage Major Surgical or Invasive Procedure: [2103-7-18] Sternal debridement with placement of VAC dressing. [2103-7-23] Removal of infected epicardial pacing leads. Closure of the sternal wound dehiscence with four Synthes plates, bilateral pectoralis musculocutaneous advancement flap. History of Present Illness: 83-year-old male who underwent coronary artery bypass grafting along with placement of epicardial pacing wires on [2103-6-19]. He had been doing fairly well until 3 or 4 days prior to admission when he began having some drainage from his sternal incision. Upon examination on the day of admission, he had purulent drainage from the sternal incision and he also commented that he noted a sternal click recently. Based upon clinical findings, he was admitted for sternal exploration. Past Medical History: Coronary Artery Disease Hypertension Hyperlipidemia s/p St. [Male First Name (un) 923] PPM for CHB [9-15] Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy [5-/2102] s/p Back surgery [2101] s/p Appendectomy s/p Tonsillectomy Social History: Lives with: Wife Occupation: Retired Tobacco: Quit 23 years ago, smoked x 50 years ETOH: [12-9] pint of hard alcohol per day Family History: Noncontributory Physical Exam: HR 83 B/P R 89/49 L 87/52 RR 16 RA sat 98% General:having pain in neck and shoulders, traveling down left back Cardiac: RRR [x] Irregular [] Murmur-none Chest: Lungs clear bilateral [x] Abdomen: Soft [x] Nontender [x] Nondistended [x] Extremities: Warm [x] Well perfused [x] Edema: Right-none Left-none Sternal incision:frank pus draining with erythema, afebrile erythema no[] yes[x] drainage no[] yes[x] well approximated yes [x] no [] sternal click no[x] yes[] EVH site: RLE [] LLE [x] erythema no[x] yes[] drainage no[x] yes[] Pertinent Results: [2103-7-18] WBC-15.4# RBC-3.51 Hgb-10.9* Hct-32.8* Plt Ct-239# [2103-7-18] PT-13.2 PTT-34.8 INR(PT)-1.1 [2103-7-18] UreaN-72* Creat-3.5# Na-133 K-5.3 Cl-99 HCO3-22 AnGap-17 [2103-7-31] 05:00AM BLOOD WBC-10.8 RBC-2.81* Hgb-8.5* Hct-26.2* MCV-93 MCH-30.1 MCHC-32.3 RDW-16.4* Plt Ct-704* [2103-7-31] 05:00AM BLOOD Plt Ct-704* [2103-7-31] 05:00AM BLOOD PT-14.7* INR(PT)-1.3* [2103-7-31] 05:00AM BLOOD UreaN-49* Creat-1.1 Na-139 K-4.8 Cl-107 [2103-7-29] 05:38AM BLOOD Glucose-75 UreaN-44* Creat-1.5* Na-142 K-3.5 Cl-110* HCO3-23 AnGap-13 [2103-7-23] 10:00 am FOREIGN BODY PACING WIRES. FINAL REPORT [2103-7-26] WOUND CULTURE (Final [2103-7-26]): STAPH AUREUS COAG +. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S TISSUE Site: STERNUM FINAL REPORT [2103-7-22] GRAM STAIN (Final [2103-7-18]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. REPORTED BY PHONE TO [First Name5 (NamePattern1) 1409] [Last Name (NamePattern1) 1410] @ 11PM ON [2103-7-18]. TISSUE (Final [2103-7-21]): STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final [2103-7-22]): NO ANAEROBES ISOLATED. Brief Hospital Course: Admitted with sternal wound drainage and empirically started on intravenous antibiotics. He was concomintantly noted to have acute renal failure with an admission creatinine of 3.5. Medications were titrated accordingly. The following day, he was brought to the operating room for sternal debridement with placement of VAC dressing. Several days later, he returned to the operating room where Plastic surgery performed wound closure with bilateral pectoralis musculocutaneous advancement flaps. Please see operative notes for details. Operative wound cultures grew out Methicillin sensitive Staphylococcus aureus. Given the severity of his infection with retained hardware, 8 weeks of IV antibiotic therapy was recommended by the ID service, followed by life-long oral suppressive therapy. His antibiotic course will be: Cefazolin 2 grams every 8 hours x 8 weeks post-debridement([2103-7-23] to [2103-9-17]), followed by lifelong suppressive therapy for retained infected pacing wires. He continued to progress and was ready for discharge to rehab on [2103-7-31]. Medications on Admission: ATORVASTATIN [LIPITOR] 10 mg daily FUROSEMIDE 20 mg daily IPRATROPIUM-ALBUTEROL [COMBIVENT] LISINOPRIL 5 mg Tablet - 0.5 (One half) Tablet(s) by mouth daily METOPROLOL SUCCINATE - 25 mg daily ASPIRIN 81 mg Tablet - one Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) DOCUSATE SODIUM 100 mg twice a day LACTOBACILLUS RHAMNOSUS GG [CULTURELLE] 1 Capsule(s) by mouth daily MULTIVITAMIN Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): 75 mg tid . 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-9] Sprays Nasal QID (4 times a day) as needed for dry nares. 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily): and prn - for PICC line . 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Cefazolin 10 gram Recon Soln Sig: Two (2) gram Injection Q8H (every 8 hours): started [7-23] - 8 week course Follow up in [Hospital ] clinic prior to completion *All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 1354] or to on [Name8 (MD) 138] MD . 15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 16. right arm Right arm at elbow thrombophlebitis - area marked, continue to monitor and heat packs 4x a day call if questions/worsens/doesn't improve 17. Outpatient Lab Work Weekly CBC with differential, BUN, Cr, AST, ALT, Alk phos, Tbili, ESR, CRP results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 1353] Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: Sternal Wound Infection Acute Renal Failure Right arm thrombophlebitis Coronary Artery Disease, s/p CABG Hypertension Hyperlipidemia s/p St. [Male First Name (un) 923] PPM [2102-9-7] Discharge Condition: Alert and oriented x3 Generalized weakness, R>L LE strength and R=L LE strength - able to lift arms up but limited by shoulders Pivoting from bed to chair Incisional pain managed with ultram prn Incisions: Sternal - healing well, no erythema or drainage - JP to bulb suction Measure output daily and record - results to Dr [First Name (STitle) ] at follow up visit Edema +2 bilateral LE Right arm at elbow thrombophlebitis - area marked, continue to monitor and heat packs 4x a day Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Maintain JP to bulb suction and measure daily and record - send recorded amounts to Dr [First Name (STitle) ] at follow up visit - to remain in until removed by plastic surgery (Dr [First Name (STitle) ] Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving until cleared by primary care physician [Name9 (PRE) ] lifting more than 10 pounds for 6 weeks Right arm at elbow thrombophlebitis - area marked, continue to monitor and heat packs 4x a day Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Follow up appointments already scheduled [Doctor First Name 1412] [Name Initial (MD) ] [Name8 (MD) 1413], M.D. Date/Time:[2103-8-16] 2:50 DEVICE CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2103-11-23] 3:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2103-11-23] 4:00 Dr [First Name (STitle) ] [Apartment Address(1) 1414] [Location (un) ], [Numeric Identifier 1415] Phone: [Telephone/Fax (1) 1416] - Tuesday [8-7] at 2:45 pm Outpatient Lab Work Weekly CBC with differential, BUN, Cr, AST, ALT, Alk phos, Tbili, ESR, CRP results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 1353] Completed by:[2103-7-31**]	Admission Date: <Date>1914-2-1</Date> Discharge Date: <Date>1985-10-29</Date> Date of Birth: <Date>1956-2-28</Date> Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Quinolones Attending:<Name>Asha</Name> Chief Complaint: Sternal drainage Major Surgical or Invasive Procedure: <Date>1914-2-1</Date> Sternal debridement with placement of VAC dressing. <Date>2004-3-10</Date> Removal of infected epicardial pacing leads. Closure of the sternal wound dehiscence with four Synthes plates, bilateral pectoralis musculocutaneous advancement flap. History of Present Illness: 83-year-old male who underwent coronary artery bypass grafting along with placement of epicardial pacing wires on <Date>1989-6-28</Date>. He had been doing fairly well until 3 or 4 days prior to admission when he began having some drainage from his sternal incision. Upon examination on the day of admission, he had purulent drainage from the sternal incision and he also commented that he noted a sternal click recently. Based upon clinical findings, he was admitted for sternal exploration. Past Medical History: Coronary Artery Disease Hypertension Hyperlipidemia s/p St. <Name>Isabella</Name> PPM for CHB <Date>11-24</Date> Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy <Date>1-1919</Date> s/p Back surgery <Year>1971</Year> s/p Appendectomy s/p Tonsillectomy Social History: Lives with: Wife Occupation: Retired Tobacco: Quit 23 years ago, smoked x 50 years ETOH: <Date>2-3</Date> pint of hard alcohol per day Family History: Noncontributory Physical Exam: HR 83 B/P R 89/49 L 87/52 RR 16 RA sat 98% General:having pain in neck and shoulders, traveling down left back Cardiac: RRR [x] Irregular [] Murmur-none Chest: Lungs clear bilateral [x] Abdomen: Soft [x] Nontender [x] Nondistended [x] Extremities: Warm [x] Well perfused [x] Edema: Right-none Left-none Sternal incision:frank pus draining with erythema, afebrile erythema no[] yes[x] drainage no[] yes[x] well approximated yes [x] no [] sternal click no[x] yes[] EVH site: RLE [] LLE [x] erythema no[x] yes[] drainage no[x] yes[] Pertinent Results: <Date>1914-2-1</Date> WBC-15.4# RBC-3.51 Hgb-10.9* Hct-32.8* Plt Ct-239# <Date>1914-2-1</Date> PT-13.2 PTT-34.8 INR(PT)-1.1 <Date>1914-2-1</Date> UreaN-72* Creat-3.5# Na-133 K-5.3 Cl-99 HCO3-22 AnGap-17 <Date>1985-10-29</Date> 05:00AM BLOOD WBC-10.8 RBC-2.81* Hgb-8.5* Hct-26.2* MCV-93 MCH-30.1 MCHC-32.3 RDW-16.4* Plt Ct-704* <Date>1985-10-29</Date> 05:00AM BLOOD Plt Ct-704* <Date>1985-10-29</Date> 05:00AM BLOOD PT-14.7* INR(PT)-1.3* <Date>1985-10-29</Date> 05:00AM BLOOD UreaN-49* Creat-1.1 Na-139 K-4.8 Cl-107 <Date>1974-6-24</Date> 05:38AM BLOOD Glucose-75 UreaN-44* Creat-1.5* Na-142 K-3.5 Cl-110* HCO3-23 AnGap-13 <Date>2004-3-10</Date> 10:00 am FOREIGN BODY PACING WIRES. FINAL REPORT <Date>1968-9-26</Date> WOUND CULTURE (Final <Date>1968-9-26</Date>): STAPH AUREUS COAG +. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S TISSUE Site: STERNUM FINAL REPORT <Date>1945-3-1</Date> GRAM STAIN (Final <Date>1914-2-1</Date>): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. REPORTED BY PHONE TO <Name>Dennis</Name> <Name>Anderson</Name> @ 11PM ON <Date>1914-2-1</Date>. TISSUE (Final <Date>1992-10-6</Date>): STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final <Date>1945-3-1</Date>): NO ANAEROBES ISOLATED. Brief Hospital Course: Admitted with sternal wound drainage and empirically started on intravenous antibiotics. He was concomintantly noted to have acute renal failure with an admission creatinine of 3.5. Medications were titrated accordingly. The following day, he was brought to the operating room for sternal debridement with placement of VAC dressing. Several days later, he returned to the operating room where Plastic surgery performed wound closure with bilateral pectoralis musculocutaneous advancement flaps. Please see operative notes for details. Operative wound cultures grew out Methicillin sensitive Staphylococcus aureus. Given the severity of his infection with retained hardware, 8 weeks of IV antibiotic therapy was recommended by the ID service, followed by life-long oral suppressive therapy. His antibiotic course will be: Cefazolin 2 grams every 8 hours x 8 weeks post-debridement(<Date>2004-3-10</Date> to <Date>2022-6-16</Date>), followed by lifelong suppressive therapy for retained infected pacing wires. He continued to progress and was ready for discharge to rehab on <Date>1985-10-29</Date>. Medications on Admission: ATORVASTATIN [LIPITOR] 10 mg daily FUROSEMIDE 20 mg daily IPRATROPIUM-ALBUTEROL [COMBIVENT] LISINOPRIL 5 mg Tablet - 0.5 (One half) Tablet(s) by mouth daily METOPROLOL SUCCINATE - 25 mg daily ASPIRIN 81 mg Tablet - one Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) DOCUSATE SODIUM 100 mg twice a day LACTOBACILLUS RHAMNOSUS GG [CULTURELLE] 1 Capsule(s) by mouth daily MULTIVITAMIN Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): 75 mg tid . 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: <Date>2-3</Date> Sprays Nasal QID (4 times a day) as needed for dry nares. 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily): and prn - for PICC line . 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Cefazolin 10 gram Recon Soln Sig: Two (2) gram Injection Q8H (every 8 hours): started <Date>10-22</Date> - 8 week course Follow up in <Hospital>Myers Group Hospital</Hospital> clinic prior to completion *All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at (<Telephone>539-997-4571</Telephone> or to on <Name>Reza Kwan</Name> MD . 15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 16. right arm Right arm at elbow thrombophlebitis - area marked, continue to monitor and heat packs 4x a day call if questions/worsens/doesn't improve 17. Outpatient Lab Work Weekly CBC with differential, BUN, Cr, AST, ALT, Alk phos, Tbili, ESR, CRP results should be faxed to Infectious disease R.Ns. at (<Telephone>537-652-8264</Telephone> Discharge Disposition: Extended Care Facility: Newbridge on the <Doctor Name>Dr.Kaur</Doctor Name> - <Location>PSC 5008, Box 0657 APO AA 58681</Location> Discharge Diagnosis: Sternal Wound Infection Acute Renal Failure Right arm thrombophlebitis Coronary Artery Disease, s/p CABG Hypertension Hyperlipidemia s/p St. <Name>Isabella</Name> PPM <Date>1934-12-11</Date> Discharge Condition: Alert and oriented x3 Generalized weakness, R>L LE strength and R=L LE strength - able to lift arms up but limited by shoulders Pivoting from bed to chair Incisional pain managed with ultram prn Incisions: Sternal - healing well, no erythema or drainage - JP to bulb suction Measure output daily and record - results to Dr <Name>Jerry</Name> at follow up visit Edema +2 bilateral LE Right arm at elbow thrombophlebitis - area marked, continue to monitor and heat packs 4x a day Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Maintain JP to bulb suction and measure daily and record - send recorded amounts to Dr <Name>Jerry</Name> at follow up visit - to remain in until removed by plastic surgery (Dr <Name>Jerry</Name> Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving until cleared by primary care physician <Name>Joyce Turcios</Name> lifting more than 10 pounds for 6 weeks Right arm at elbow thrombophlebitis - area marked, continue to monitor and heat packs 4x a day Please call with any questions or concerns <Telephone>519-791-2403</Telephone> Please call cardiac surgery office with any questions or concerns <Telephone>519-791-2403</Telephone>. Answering service will contact on call person during off hours** Followup Instructions: Follow up appointments already scheduled <Name>Raymond</Name> <Name>Allison Davis</Name> <Name>Soledad Pleasant</Name>, M.D. Date/Time:<Date>2012-10-4</Date> 2:50 DEVICE CLINIC Phone:<Telephone>734-340-9150</Telephone> Date/Time:<Date>1991-12-10</Date> 3:30 <Name>Cruz</Name> <Name>Bludsworth</Name>, M.D. Phone:<Telephone>734-340-9150</Telephone> Date/Time:<Date>1991-12-10</Date> 4:00 Dr <Name>Jerry</Name> <Location>9033 Adams Harbor Suite 071 North Jamesside, VA 12351</Location> <Location>180 Cheryl Wells Justintown, NV 73393</Location>, <Numeric Identifier>6676167</Numeric Identifier> Phone: <Telephone>829-533-8294</Telephone> - Tuesday <Date>9-14</Date> at 2:45 pm Outpatient Lab Work Weekly CBC with differential, BUN, Cr, AST, ALT, Alk phos, Tbili, ESR, CRP results should be faxed to Infectious disease R.Ns. at (<Telephone>537-652-8264</Telephone> Completed by:<Date>1985-10-29</Date>	0000000000000000011111111000000000000000000000000000000001111111111000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000001111111111000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000011111111000000000001111111100000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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111111111111000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111000000000000000001111111111	Admission Date: 1914-2-1 Discharge Date: 1985-10-29 Date of Birth: 1956-2-28 Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Quinolones Attending:Asha Chief Complaint: Sternal drainage Major Surgical or Invasive Procedure: 1914-2-1 Sternal debridement with placement of VAC dressing. 2004-3-10 Removal of infected epicardial pacing leads. Closure of the sternal wound dehiscence with four Synthes plates, bilateral pectoralis musculocutaneous advancement flap. History of Present Illness: 83-year-old male who underwent coronary artery bypass grafting along with placement of epicardial pacing wires on 1989-6-28. He had been doing fairly well until 3 or 4 days prior to admission when he began having some drainage from his sternal incision. Upon examination on the day of admission, he had purulent drainage from the sternal incision and he also commented that he noted a sternal click recently. Based upon clinical findings, he was admitted for sternal exploration. Past Medical History: Coronary Artery Disease Hypertension Hyperlipidemia s/p St. Isabella PPM for CHB 11-24 Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy 1-1919 s/p Back surgery 1971 s/p Appendectomy s/p Tonsillectomy Social History: Lives with: Wife Occupation: Retired Tobacco: Quit 23 years ago, smoked x 50 years ETOH: 2-3 pint of hard alcohol per day Family History: Noncontributory Physical Exam: HR 83 B/P R 89/49 L 87/52 RR 16 RA sat 98% General:having pain in neck and shoulders, traveling down left back Cardiac: RRR [x] Irregular [] Murmur-none Chest: Lungs clear bilateral [x] Abdomen: Soft [x] Nontender [x] Nondistended [x] Extremities: Warm [x] Well perfused [x] Edema: Right-none Left-none Sternal incision:frank pus draining with erythema, afebrile erythema no[] yes[x] drainage no[] yes[x] well approximated yes [x] no [] sternal click no[x] yes[] EVH site: RLE [] LLE [x] erythema no[x] yes[] drainage no[x] yes[] Pertinent Results: 1914-2-1 WBC-15.4# RBC-3.51 Hgb-10.9* Hct-32.8* Plt Ct-239# 1914-2-1 PT-13.2 PTT-34.8 INR(PT)-1.1 1914-2-1 UreaN-72* Creat-3.5# Na-133 K-5.3 Cl-99 HCO3-22 AnGap-17 1985-10-29 05:00AM BLOOD WBC-10.8 RBC-2.81* Hgb-8.5* Hct-26.2* MCV-93 MCH-30.1 MCHC-32.3 RDW-16.4* Plt Ct-704* 1985-10-29 05:00AM BLOOD Plt Ct-704* 1985-10-29 05:00AM BLOOD PT-14.7* INR(PT)-1.3* 1985-10-29 05:00AM BLOOD UreaN-49* Creat-1.1 Na-139 K-4.8 Cl-107 1974-6-24 05:38AM BLOOD Glucose-75 UreaN-44* Creat-1.5* Na-142 K-3.5 Cl-110* HCO3-23 AnGap-13 2004-3-10 10:00 am FOREIGN BODY PACING WIRES. FINAL REPORT 1968-9-26 WOUND CULTURE (Final 1968-9-26): STAPH AUREUS COAG +. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 1945-3-1 GRAM STAIN (Final 1914-2-1): 1+ (Dennis Anderson @ 11PM ON 1914-2-1. TISSUE (Final 1992-10-6): STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 1945-3-1): NO ANAEROBES ISOLATED. Brief Hospital Course: Admitted with sternal wound drainage and empirically started on intravenous antibiotics. He was concomintantly noted to have acute renal failure with an admission creatinine of 3.5. Medications were titrated accordingly. The following day, he was brought to the operating room for sternal debridement with placement of VAC dressing. Several days later, he returned to the operating room where Plastic surgery performed wound closure with bilateral pectoralis musculocutaneous advancement flaps. Please see operative notes for details. Operative wound cultures grew out Methicillin sensitive Staphylococcus aureus. Given the severity of his infection with retained hardware, 8 weeks of IV antibiotic therapy was recommended by the ID service, followed by life-long oral suppressive therapy. His antibiotic course will be: Cefazolin 2 grams every 8 hours x 8 weeks post-debridement(2004-3-10 to 2022-6-16), followed by lifelong suppressive therapy for retained infected pacing wires. He continued to progress and was ready for discharge to rehab on 1985-10-29. Medications on Admission: ATORVASTATIN [LIPITOR] 10 mg daily FUROSEMIDE 20 mg daily IPRATROPIUM-ALBUTEROL [COMBIVENT] LISINOPRIL 5 mg Tablet - 0.5 (One half) Tablet(s) by mouth daily METOPROLOL SUCCINATE - 25 mg daily ASPIRIN 81 mg Tablet - one Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) DOCUSATE SODIUM 100 mg twice a day LACTOBACILLUS RHAMNOSUS GG [CULTURELLE] 1 Capsule(s) by mouth daily MULTIVITAMIN Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): 75 mg tid . 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: 2-3 Sprays Nasal QID (4 times a day) as needed for dry nares. 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily): and prn - for PICC line . 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Cefazolin 10 gram Recon Soln Sig: Two (2) gram Injection Q8H (every 8 hours): started 10-22 - 8 week course Follow up in Myers Group Hospital clinic prior to completion All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at (539-997-4571 or to on Reza Kwan MD . 15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 16. right arm Right arm at elbow thrombophlebitis - area marked, continue to monitor and heat packs 4x a day call if questions/worsens/doesn't improve 17. Outpatient Lab Work Weekly CBC with differential, BUN, Cr, AST, ALT, Alk phos, Tbili, ESR, CRP results should be faxed to Infectious disease R.Ns. at (537-652-8264 Discharge Disposition: Extended Care Facility: Newbridge on the Dr.Kaur - PSC 5008, Box 0657 APO AA 58681 Discharge Diagnosis: Sternal Wound Infection Acute Renal Failure Right arm thrombophlebitis Coronary Artery Disease, s/p CABG Hypertension Hyperlipidemia s/p St. Isabella PPM 1934-12-11 Discharge Condition: Alert and oriented x3 Generalized weakness, R>L LE strength and R=L LE strength - able to lift arms up but limited by shoulders Pivoting from bed to chair Incisional pain managed with ultram prn Incisions: Sternal - healing well, no erythema or drainage - JP to bulb suction Measure output daily and record - results to Dr Jerry at follow up visit Edema +2 bilateral LE Right arm at elbow thrombophlebitis - area marked, continue to monitor and heat packs 4x a day Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Maintain JP to bulb suction and measure daily and record - send recorded amounts to Dr Jerry at follow up visit - to remain in until removed by plastic surgery (Dr Jerry Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving until cleared by primary care physician Joyce Turcios lifting more than 10 pounds for 6 weeks Right arm at elbow thrombophlebitis - area marked, continue to monitor and heat packs 4x a day Please call with any questions or concerns 519-791-2403 Please call cardiac surgery office with any questions or concerns 519-791-2403. Answering service will contact on call person during off hours* Followup Instructions: Follow up appointments already scheduled Raymond Allison Davis Soledad Pleasant, M.D. Date/Time:2012-10-4 2:50 DEVICE CLINIC Phone:734-340-9150 Date/Time:1991-12-10 3:30 Cruz Bludsworth, M.D. Phone:734-340-9150 Date/Time:1991-12-10 4:00 Dr Jerry 9033 Adams Harbor Suite 071 North Jamesside, VA 12351 180 Cheryl Wells Justintown, NV 73393, 6676167 Phone: 829-533-8294 - Tuesday 9-14 at 2:45 pm Outpatient Lab Work Weekly CBC with differential, BUN, Cr, AST, ALT, Alk phos, Tbili, ESR, CRP results should be faxed to Infectious disease R.Ns. at (537-652-8264 Completed by:1985-10-29	['Admission Date: 1914-2-1 Discharge Date: 1985-10-29\n\nDate of Birth: 1956-2-28 Sex: M\n\nService: CARDIOTHORACIC\n\nAllergies:\nPenicillins / Quinolones\n\nAttending:Asha\nChief Complaint:\nSternal drainage\n\nMajor Surgical or Invasive Procedure:\n1914-2-1 Sternal debridement with placement of VAC dressing.\n2004-3-10 Removal of infected epicardial pacing leads. Closure of\nthe sternal wound dehiscence with four Synthes plates, bilateral\npectoralis musculocutaneous advancement flap.\n\n\nHistory of Present Illness:\n83-year-old male who underwent coronary artery bypass grafting\nalong with placement of epicardial pacing wires on 1989-6-28.\nHe had been doing fairly well until 3 or 4 days prior to\nadmission when he began having some drainage from his sternal\nincision. Upon examination on the day of admission, he had\npurulent drainage from the sternal incision and he also\ncommented that he noted a sternal click recently.', ' Based upon\nclinical findings, he was admitted for sternal exploration.\n\nPast Medical History:\nCoronary Artery Disease\nHypertension\nHyperlipidemia\ns/p St. Isabella PPM for CHB 11-24\nArthritis\nSleep apnea noted after administration of narcotics\nDiverticulitis s/p Left hemicolectomy 1-1919\ns/p Back surgery 1971\ns/p Appendectomy\ns/p Tonsillectomy\n\nSocial History:\nLives with: Wife\nOccupation: Retired\nTobacco: Quit 23 years ago, smoked x 50 years\nETOH: 2-3 pint of hard alcohol per day\n\n\nFamily History:\nNoncontributory\n\nPhysical Exam:\nHR 83 B/P R 89/49 L 87/52 RR 16 RA sat 98%\n\nGeneral:having pain in neck and shoulders, traveling down left\nback\nCardiac: RRR [x] Irregular [] Murmur-none\nChest: Lungs clear bilateral [x]\nAbdomen: Soft [x] Nontender [x] Nondistended [x]\nExtremities: Warm [x] Well perfused [x]\nEdema: Right-none Left-none\nSternal incision:frank pus draining with erythema, afebrile\n erythema no[] yes[x]\n drainage no[] yes[x]\n well approximated yes [x] no []\n sternal click no[x] yes[]\nEVH site: RLE [] LLE [x]\n erythema no[x] yes[]\n drainage no[x] yes[]\n\n\nPertinent Results:\n1914-2-1 WBC-15.', '4# RBC-3.51 Hgb-10.9* Hct-32.8* Plt Ct-239#\n1914-2-1 PT-13.2 PTT-34.8 INR(PT)-1.1\n1914-2-1 UreaN-72* Creat-3.5# Na-133 K-5.3 Cl-99 HCO3-22\nAnGap-17\n1985-10-29 05:00AM BLOOD WBC-10.8 RBC-2.81* Hgb-8.5* Hct-26.2\nMCV-93 MCH-30.1 MCHC-32.3 RDW-16.4 Plt Ct-704\n1985-10-29 05:00AM BLOOD Plt Ct-704\n1985-10-29 05:00AM BLOOD PT-14.7* INR(PT)-1.3\n1985-10-29 05:00AM BLOOD UreaN-49 Creat-1.1 Na-139 K-4.8 Cl-107\n1974-6-24 05:38AM BLOOD Glucose-75 UreaN-44* Creat-1.5* Na-142\nK-3.5 Cl-110* HCO3-23 AnGap-13\n\n2004-3-10 10:00 am FOREIGN BODY PACING WIRES.\n\n FINAL REPORT 1968-9-26\n\n WOUND CULTURE (Final 1968-9-26):\n STAPH AUREUS COAG +.\n Staphylococcus species may develop resistance during\nprolonged\n therapy with quinolones. Therefore, isolates that are\ninitially\n susceptible may become resistant within three to four\ndays after\n initiation of therapy.', ' Testing of repeat isolates may\nbe\n warranted.\n This isolate is presumed to be resistant to clindamycin\nbased on\n the detection of inducible resistance .\n\n SENSITIVITIES: MIC expressed in\nMCG/ML\n\n_________________________________________________________\n STAPH AUREUS COAG +\n \|\nCLINDAMYCIN----------- R\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ 1945-3-1\n\n GRAM STAIN (Final 1914-2-1):\n 1+ (Dennis Anderson @ 11PM ON 1914-2-1.\n\n TISSUE (Final 1992-10-6):\n STAPH AUREUS COAG +. MODERATE GROWTH.\n This isolate is presumed to be resistant to clindamycin\nbased on\n the detection of inducible resistance .\n Staphylococcus species may develop resistance during\nprolonged\n therapy with quinolones.', ' Therefore, isolates that are\ninitially\n susceptible may become resistant within three to four\ndays after\n initiation of therapy. Testing of repeat isolates may\nbe\n warranted.\n\n SENSITIVITIES: MIC expressed in\nMCG/ML\n\n_________________________________________________________\n STAPH AUREUS COAG +\n \|\nCLINDAMYCIN----------- R\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ 1945-3-1): NO ANAEROBES ISOLATED.\n\n\n\nBrief Hospital Course:\nAdmitted with sternal wound drainage and empirically started on\nintravenous antibiotics. He was concomintantly noted to have\nacute renal failure with an admission creatinine of 3.5.\nMedications were titrated accordingly. The following day, he was\nbrought to the operating room for sternal debridement with\nplacement of VAC dressing.', ' Several days later, he returned to\nthe operating room where Plastic surgery performed wound closure\nwith bilateral pectoralis musculocutaneous advancement flaps.\nPlease see operative notes for details. Operative wound cultures\ngrew out Methicillin sensitive Staphylococcus aureus. Given the\nseverity of his infection with retained hardware, 8 weeks of IV\nantibiotic therapy was recommended by the ID service, followed\nby life-long oral suppressive therapy. His antibiotic course\nwill be: Cefazolin 2 grams every 8 hours x 8 weeks\npost-debridement(2004-3-10 to 2022-6-16), followed by lifelong\nsuppressive therapy for retained infected pacing wires. He\ncontinued to progress and was ready for discharge to rehab on\n1985-10-29.\n\n\nMedications on Admission:\nATORVASTATIN [LIPITOR] 10 mg daily\nFUROSEMIDE 20 mg daily\nIPRATROPIUM-ALBUTEROL [COMBIVENT]\nLISINOPRIL 5 mg Tablet - 0.', '5 (One half) Tablet(s) by mouth daily\nMETOPROLOL SUCCINATE - 25 mg daily\nASPIRIN 81 mg Tablet - one Tablet(s) by mouth daily\nCHOLECALCIFEROL (VITAMIN D3)\nDOCUSATE SODIUM 100 mg twice a day\nLACTOBACILLUS RHAMNOSUS GG [CULTURELLE] 1 Capsule(s) by mouth\ndaily\nMULTIVITAMIN\n\nDischarge Medications:\n1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4\nhours) as needed for pain.\n2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day).\n3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml\nInjection TID (3 times a day).\n6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n7. Metoprolol Tartrate 50 mg Tablet Sig: 1.', '5 Tablets PO TID (3\ntimes a day): 75 mg tid .\n8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID\n(4 times a day).\n9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\n10. Sodium Chloride 0.65 % Aerosol, Spray Sig: 2-3 Sprays Nasal\nQID (4 times a day) as needed for dry nares.\n11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML\nIntravenous DAILY (Daily): and prn - for PICC line .\n12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:\nOne (1) Adhesive Patch, Medicated Topical DAILY (Daily).\n13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4\nhours) as needed for pain.\n14. Cefazolin 10 gram Recon Soln Sig: Two (2) gram Injection\nQ8H (every 8 hours): started 10-22 - 8 week course\nFollow up in Myers Group Hospital clinic prior to completion\nAll questions regarding outpatient\nantibiotics should be directed to the infectious disease R.', "Ns.\nat\n(539-997-4571 or to on Reza Kwan MD .\n15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10\ndays.\n16. right arm\nRight arm at elbow thrombophlebitis - area marked, continue to\nmonitor and heat packs 4x a day\ncall if questions/worsens/doesn't improve\n17. Outpatient Lab Work\nWeekly CBC with differential, BUN, Cr, AST, ALT, Alk phos,\nTbili, ESR, CRP\nresults should be faxed to Infectious disease\nR.Ns. at (537-652-8264\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nNewbridge on the Dr.Kaur - PSC 5008, Box 0657\nAPO AA 58681\n\nDischarge Diagnosis:\nSternal Wound Infection\nAcute Renal Failure\nRight arm thrombophlebitis\nCoronary Artery Disease, s/p CABG\nHypertension\nHyperlipidemia\ns/p St. Isabella PPM 1934-12-11\n\n\nDischarge Condition:\nAlert and oriented x3 Generalized weakness, R>L LE strength and\nR=L LE strength - able to lift arms up but limited by shoulders\nPivoting from bed to chair\nIncisional pain managed with ultram prn\nIncisions:\nSternal - healing well, no erythema or drainage - JP to bulb\nsuction\nMeasure output daily and record - results to Dr Jerry at follow\nup visit\nEdema +2 bilateral LE\nRight arm at elbow thrombophlebitis - area marked, continue to\nmonitor and heat packs 4x a day\n\n\nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild\nsoap, no baths or swimming until cleared by surgeon.", ' Look at\nyour incisions daily for redness or drainage\nPlease NO lotions, cream, powder, or ointments to incisions\nMaintain JP to bulb suction and measure daily and record - send\nrecorded amounts to Dr Jerry at follow up visit - to remain in\nuntil removed by plastic surgery (Dr Jerry\nEach morning you should weigh yourself and then in the evening\ntake your temperature, these should be written down on the chart\n\nNo driving until cleared by primary care physician\nJoyce Turcios lifting more than 10 pounds for 6 weeks\nRight arm at elbow thrombophlebitis - area marked, continue to\nmonitor and heat packs 4x a day\nPlease call with any questions or concerns 519-791-2403\n\nPlease call cardiac surgery office with any questions or\nconcerns 519-791-2403. Answering service will contact on call\nperson during off hours*\n\n\nFollowup Instructions:\nFollow up appointments already scheduled\nRaymond Allison Davis Soledad Pleasant, M.', 'D. Date/Time:2012-10-4 2:50\nDEVICE CLINIC Phone:734-340-9150 Date/Time:1991-12-10 3:30\nCruz Bludsworth, M.D. Phone:734-340-9150 Date/Time:1991-12-10\n4:00\nDr Jerry 9033 Adams Harbor Suite 071\nNorth Jamesside, VA 12351 180 Cheryl Wells\nJustintown, NV 73393, 6676167\nPhone: 829-533-8294 - Tuesday 9-14 at 2:45 pm\n\nOutpatient Lab Work\nWeekly CBC with differential, BUN, Cr, AST, ALT, Alk phos,\nTbili, ESR, CRP results should be faxed to Infectious disease\nR.Ns. at (537-652-8264\n\n\n\nCompleted by:1985-10-29']
134	96950	169823.0	2103-08-24	Discharge summary	Report	Admission Date: [2103-8-7] Discharge Date: [2103-8-24] Date of Birth: [2019-8-6] Sex: M Service: MEDICINE Allergies: Penicillins / Quinolones / Cefazolin Attending:[First Name3 (LF) 905] Chief Complaint: Acute Hypercarbic Respiratory Distress Major Surgical or Invasive Procedure: Bilateral thoracenteses S/p removal of chest wall drain History of Present Illness: Mr. [Known lastname 14] is an 84 year old gentleman with a PMH significant for recent CAD s/p CABG c/b sternal wound infection on antibiotics and CHB s/p PPM admitted for a lower extremity rash concerning for vasculitis and acute renal failure. The patient underwent CABG in [6-16], and was re-admitted to [Hospital1 18] on [2103-7-18] for sternal wound exploration with a drain placed with cultures speciated as MSSA. At that time, he was discharged on cefazolin with the plan for a prolonged 8 weeks of antimicrobial therapy. On [8-6], the ID service was contact[Name (NI) ] as the patient had developed a rash over his lower extremities concerning for a drug rash by his physician at rehab. At that time, given that he has a history of an unknown PCN reaction, he was converted to vancomycin. Today, he presented to the [Hospital 18] [Hospital ] clinic, and was found to have a rash concerning for vasculitis and ARF with a creatinine of 2 and a serum potassium of 5.7. He was then referred to the ED for futher management. . In the [Hospital1 18] ED, initial VS 97.7 60 133/48 20 95%RA. ECG was negative for peaked T waves, the patient received 30 mg kayexalate, had a negative CXR, and was admitted to Medicine for further management. On ROS, the patient reports that he has been feeling increasingly fatigued over the past week with decreased PO intake, but denies any f/c/s, n/v/d, abd pain, HA, palpitations. He is does not know when his rash developed. . On the floor, pt Cr 2.0--> 1.7 with gentle fluid repletion. However, overnight, pt developed respiratory distress thought to be 2.2 volume overload. He was given nebs and placed on 4L NC with good improvement in Os sats. Over the next 24 hours, his resp status continued to worsen requiring 6L NC. ABG 7.25/58/211/27. Given Nebs and 20mg IV lasix without improvement. He was then transfered to the MICU for BIPAP. Past Medical History: Coronary Artery Disease Hypertension Hyperlipidemia s/p St. [Male First Name (un) 923] PPM for CHB [9-15] Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy [5-/2102] s/p Back surgery [2101] s/p Appendectomy s/p Tonsillectomy Social History: Lives with: Wife Occupation: Retired Tobacco: Quit 23 years ago, smoked x 50 years ETOH: [12-9] pint of hard alcohol per day Family History: Noncontributory Physical Exam: Vitals: T:97.3 BP:113/76 P:71 R:13 O2: 100 on BIPAP PEEP 6 General: Alert, oriented, HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles b/l lower lungs R>L. no wheeze CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2103-8-7] 08:52PM URINE HOURS-RANDOM CREAT-126 SODIUM-24 POTASSIUM-31 [2103-8-7] 08:52PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.019 [2103-8-7] 08:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM [2103-8-7] 08:52PM URINE RBC-[5-17]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 RENAL EPI-0-2 [2103-8-7] 03:10PM PT-14.3* PTT-32.9 INR(PT)-1.2* [2103-8-7] 02:55PM URINE HOURS-RANDOM [2103-8-7] 02:55PM URINE GR HOLD-HOLD [2103-8-7] 02:55PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.021 [2103-8-7] 02:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2103-8-7] 02:55PM URINE RBC-[5-17]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [2103-8-7] 01:44PM LACTATE-0.6 K+-5.4* [2103-8-7] 01:35PM GLUCOSE-95 UREA N-87* CREAT-2.0* SODIUM-136 POTASSIUM-5.7* CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 [2103-8-7] 01:35PM estGFR-Using this [2103-8-7] 01:35PM CK(CPK)-19* [2103-8-7] 01:35PM cTropnT-0.03* [2103-8-7] 01:35PM CK-MB-2 [2103-8-7] 01:35PM WBC-6.9 RBC-2.92* HGB-8.1* HCT-28.0* MCV-96 MCH-27.8 MCHC-28.9# RDW-16.4 [2103-8-7] 01:35PM NEUTS-60.0 LYMPHS-26.6 MONOS-6.3 EOS-5.7* BASOS-1.4 [2103-8-7] 01:35PM PLT COUNT-661* [8-7] cxr UPRIGHT AP VIEW OF THE CHEST: Patient is status post sternal plating and left-sided pacemaker device with leads terminating in the right atrium and right ventricle. Several epicardial leads are unchanged. Cardiac, mediastinal and hilar contours are stable. Multiple external tubing and catheter devices are seen projecting over the left upper quadrant and left lung base. Patchy opacity in left lung base may reflect atelectasis. A trace left pleural effusion cannot be excluded. The right lung is grossly clear. There is no pneumonia. Surgical anchor is partly imaged projecting over the right humeral head. No acute osseous findings are seen. IMPRESSION: Patchy opacity in the left lung base, which could reflect atelectasis, but infection is not excluded. Probable trace left pleural effusion. [8-9] upper ext U/S Grey scale and Doppler son[Name (NI) 1417] of the left subclavian and right subclavian, IJ, axillary, basilic, and cephalic veins were taken. The lumen of the basilic vein continues to contain echogenic material from the proximal end. There is abnormal compressibility, flow, and augmentation of the basilic vein consistent with thrombosis of the basilic vein. Otherwise, the remainder of the veins demonstrate normal compressibility, flow, and augmentation. IMPRESSION: Basilic vein thrombosis, unchanged in comparison to prior study. These findings were discussed with Dr. [First Name (STitle) 547] [Name (STitle) 1418] of the patient's primary clinical team at approximately 11:30 a.m. on [2103-8-9]. The study and the report were reviewed by the staff radiologist. [8-9] renal u/s The right kidney measures approximately 10.2 cm. The left kidney measures approximately 9.8 cm. A small simple cyst measuring 1.8 x 1.6 x 1.7 cm is visualized in the upper pole of the right kidney. Otherwise, there is no hydronephrosis, stones, or masses. Of note are bilateral pleural effusions visualized. IMPRESSION: Normal renal son[Name (NI) ]. Evidence of bilateral pleural effusions was noted. These findings were discussed with Dr. [First Name (STitle) 547] [Name (STitle) 1418] of the patient's primary clinical team at approximately 11:30 a.m. on [2103-8-9]. The study and the report were reviewed by the staff radiologist. [8-9] chest x-ray SUPINE AP AND LATERAL RADIOGRAPH OF THE CHEST: There are layering bilateral pleural effusions, moderate on the left and small on the right, unchanged. There is bibasilar consolidation, significantly worst on the left and could reflect a combination of atelectasis, effusion, and/or pneumonia. There is no significant pulmonary edema or pneumothorax. Sternal plating hardware is unchanged, epicardial pacing leads are again visualized. There is a left chest wall pacer with right atrial and ventricular leads in unchanged location. Left midline catheter and mediastinal drain is unchanged. IMPRESSION: No significant change in moderate left and small right pleural effusion and large left basilar consolidation. [8-10] chest xray FINDINGS: As compared to the previous radiograph, there is no relevant change. Sternal fixators, unchanged course of pacemaker leads. Unchanged size of the cardiac silhouette, mild cardiomegaly with mild pulmonary edema and associated bilateral small pleural effusions. No evidence of newly appeared parenchymal opacities suggestive of pneumonia. Brief Hospital Course: Mr. [Known lastname 14] is an 84 yo s/p recent CABG with sternal wound infection admitted for presumed pre-renal ARF now with respiratory distress most likely [1-9] to volume overload. # Respiratory distress: Most likely [1-9] acute on chronic CHF. In the MICU, on BIPAP for 45 minutes. Recieved lasix throughout his stay (total of 200 mg IV) with partial response. He improved on Bipap and felt to have returned to baseline by morning. No evidence of MI; cardiac enzymes continued to hold at 0.03 (trop) and later echo showed stably decreased EF of 45-50%. During his course on the floor he had multiple episodes of shortness of breath with associated desturations; thought to have a large anxiety component causing hypertension and flash pulmonary edema; these resolved with IV lasix, morphine, and ativan. He was found to have large bilateral pleural effusions. On [8-15] his right lung was drained of 1.5 L and on [8-16] his left lung was drained of 1.2 L of transudative fluid. Cytology was negative for malignant cells. He was aggresively diuresed with IV lasix to doses up to 120mg IV bid (metolazone also used twice) with gradual improvement in his respiratory status and resolution of renal failure. He was then transitioned to an oral lasix regimen on [8-23] with continued good diuresis of net neg 1000cc a day and preserved renal function. He will continue 80mg of lasix twice a day for now with an initial goal of net negative 500-1000cc a day. He should have standing weights daily, strict I/O's and have his BUN/creatinine checked on [8-27] with lytes repleted as needed. his lasix dose should be adjusted based on volume status. His weight upon discharge was 80kg. O2sat stably 96-100% on 2L, in 90s on RA, and desats to 86% on RA with ambulation. Of note, anxiety (see below) likely plays a large component, and pt feels more comfortable on O2 NC despite above O2sat readings; small doses of ativan and morphine have been helpful in the past with episodes of respiratory distress. Please wean down oxygen supplementation slowly as tolerated. # ARF: [Month (only) 116] have had volume depletion in the setting of poor PO intake prior to admission, secondary to drug reaction to cefazolin (intrinsic renal failure), or poor forward flow in the setting of acute on chronic CHF. His creatinine improved with diuresis and was back to baseline prior to discharge. Currently still holding lisinopril and HCTZ due to active diuresis. Please check BUN creatinine on [8-27] and thereafter as needed to monitor renal function while actively diuresing. Would restart lisinopril and HCTZ when volume status stable. Would preferentially start lisinopril first given his CHF. # MSSA infection: He was on cefazolin with the plan for a prolonged 8 weeks of antimicrobial therapy followed by lifelong suppressive therapy for retained infected pacing wires however due to apparent drug reaction his regimen was switched to vanco on [8-10]. He was left with a 6 week course on vancomycin with an end date of [2103-9-17]. He should have a CBC with differential, chem 7 and vanc trough drawn on Thurs [8-30], Wednesday [9-5], and Thursday [9-13]; please fax these to [Hospital ] clinic [Telephone/Fax (1) 1419] to the attention of Dr. [Name (NI) 1420]. He will follow up with Dr. [Last Name (STitle) ] on [2103-9-13] and with Dr. [Name (NI) 1420] on [2103-10-5]. # Rash: Dermatology thought rash was likely leukocytoclastic vasculitis [1-9] ancef. Pt and family were not interested in biopsy so derm signed off. Would avoid use of cefazolin in future. Vancomycin started for continued treatment of pts infection. # Pain: Chronic, most likely secondary to deconditioning. Pt received oxycodnoe prn for pain. # Anxiety: His episodes of shortness of breath not associated with desaturations were most likley due to his anxiety. He was started on Ativan 0.5mg three times a day which he tolerated well and PRN Ativan. He felt that morphine po prn helped relieve some respiratory distress as well. Medications on Admission: Hydrochlorothiazide 12.5mg daily ASA 81mg daily Folgard Rx 2.2mg-25mg-1mg daily Ocuvite 1 daily Amlodipine 5mg daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 24 days: Dose given [8-24]. Start [8-26]. End date [9-17]. 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:12 Tablet(s) Refills:0 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for Cough. 13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-9] Sprays Nasal TID (3 times a day) as needed for dryness. 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Anxiety. 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:15 Tablet(s) Refills:0 17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). 18. Morphine 15 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for SOB. Disp:3 Tablet(s) Refills:0 19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Outpatient Lab Work Please check CBC with differential, Chem 7 and Vanc trough on Thurs [8-30], Wed [9-7], Thurs [9-13] and fax results to Dr. [Last Name (STitle) ]/[Hospital ] Clinic at [Telephone/Fax (1) 1419]. 21. Outpatient Lab Work Please check a chem 10 on Monday [8-27] and thereafter as needed to monitor kidney function. 22. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours. 23. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 24. Oxygen Has been on 2L NC here. Please titrate to maintain O2sat >94%. Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: Acute renal failure Vasculitis, likely cephalosporin-related Acute on chronic systolic congestive heart failure MSSA sternal wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory. Able to walk short distances (6 feet) with walker. Out of Bed with assistance to chair or wheelchair. O2sat 96-100 on 2L, satting in 90s on RA, desats to 86% on RA with ambulation Discharge Instructions: You were originally admitted for a progressive rash and renal failure. This was thought to be related to the original antibiotic (cefazolin) you were taking for the skin infection of your sternal incision site. You initially had a drain which was removed during your hospitalization. Your antibiotic was changed to vancomycin which you will take for a total of 6 weeks (End Date [9-17]); you will have weekly labs drawn and sent to the [Hospital ] clinic. You will also follow up with the ID specialist. You required transfer to the ICU for respiratory distress in the setting of fluid overload. You were given medications to help you get rid of the fluid and transferred back to the floor when you were stable. You underwent two thoracenteses to drain the fluid in your lungs. Your oxygen saturation improved with these measures. Gradually, your kidney function also improved. You will continue oral lasix. You should weigh yourself daily and call your physician regarding weight gain > 3 lbs in one day. Medication changes: - 6-week course of vancomycin to complete a total 8-week course of antibiotic treatment (End [9-17]) - Lisinopril held for now until renal function stable - Hydrochlorothiazide held for now until renal function is stable - Inrease Lasix 80mg twice a day, dose to be adjusted as needed by rehab physician [Name Initial (PRE) ] [Name10 (NameIs) 1421] treatments - Morphine tab as needed for shortness of breath - Ativan for anxiety - Fluticasone spray for nasal congestion - Ocean nasal spray as needed for nasal congestion - Guanefesin (Robitussin) as needed for cough - Oxygen therapy as needed Followup Instructions: You will be discharged to rehab. Please follow up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 1407], within 1-2 weeks of discharge from rehab. Department: INFECTIOUS DISEASE When: THURSDAY [2103-9-13] at 2:30 PM With: [Doctor First Name 1412] [Name Initial (MD) ] [Name8 (MD) 1413], M.D. [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: FRIDAY [2103-9-14] at 11:30 AM With: [Name6 (MD) 1423] [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 Department: CARDIAC SERVICES When: FRIDAY [2103-11-23] at 3:30 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910]	Admission Date: <Date>1948-7-20</Date> Discharge Date: <Date>1976-8-7</Date> Date of Birth: <Date>1996-7-31</Date> Sex: M Service: MEDICINE Allergies: Penicillins / Quinolones / Cefazolin Attending:<Name>Everardo</Name> Chief Complaint: Acute Hypercarbic Respiratory Distress Major Surgical or Invasive Procedure: Bilateral thoracenteses S/p removal of chest wall drain History of Present Illness: Mr. <Name>Chowdhury</Name> is an 84 year old gentleman with a PMH significant for recent CAD s/p CABG c/b sternal wound infection on antibiotics and CHB s/p PPM admitted for a lower extremity rash concerning for vasculitis and acute renal failure. The patient underwent CABG in <Date>11-13</Date>, and was re-admitted to <Hospital>Gomez-Burns Medical Center</Hospital> on <Date>1986-11-28</Date> for sternal wound exploration with a drain placed with cultures speciated as MSSA. At that time, he was discharged on cefazolin with the plan for a prolonged 8 weeks of antimicrobial therapy. On <Date>6-29</Date>, the ID service was contact<Name>Craig Bounds</Name> as the patient had developed a rash over his lower extremities concerning for a drug rash by his physician at rehab. At that time, given that he has a history of an unknown PCN reaction, he was converted to vancomycin. Today, he presented to the <Hospital>Jones, Dawson and Mahoney Health System</Hospital> <Hospital>Clark-Zamora Medical Center</Hospital> clinic, and was found to have a rash concerning for vasculitis and ARF with a creatinine of 2 and a serum potassium of 5.7. He was then referred to the ED for futher management. . In the <Hospital>Gomez-Burns Medical Center</Hospital> ED, initial VS 97.7 60 133/48 20 95%RA. ECG was negative for peaked T waves, the patient received 30 mg kayexalate, had a negative CXR, and was admitted to Medicine for further management. On ROS, the patient reports that he has been feeling increasingly fatigued over the past week with decreased PO intake, but denies any f/c/s, n/v/d, abd pain, HA, palpitations. He is does not know when his rash developed. . On the floor, pt Cr 2.0--> 1.7 with gentle fluid repletion. However, overnight, pt developed respiratory distress thought to be 2.2 volume overload. He was given nebs and placed on 4L NC with good improvement in Os sats. Over the next 24 hours, his resp status continued to worsen requiring 6L NC. ABG 7.25/58/211/27. Given Nebs and 20mg IV lasix without improvement. He was then transfered to the MICU for BIPAP. Past Medical History: Coronary Artery Disease Hypertension Hyperlipidemia s/p St. <Name>Mamie</Name> PPM for CHB <Date>11-3</Date> Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy <Date>1-1990</Date> s/p Back surgery <Year>2005</Year> s/p Appendectomy s/p Tonsillectomy Social History: Lives with: Wife Occupation: Retired Tobacco: Quit 23 years ago, smoked x 50 years ETOH: <Date>4-3</Date> pint of hard alcohol per day Family History: Noncontributory Physical Exam: Vitals: T:97.3 BP:113/76 P:71 R:13 O2: 100 on BIPAP PEEP 6 General: Alert, oriented, HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles b/l lower lungs R>L. no wheeze CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: <Date>1948-7-20</Date> 08:52PM URINE HOURS-RANDOM CREAT-126 SODIUM-24 POTASSIUM-31 <Date>1948-7-20</Date> 08:52PM URINE COLOR-Yellow APPEAR-Clear SP <Name>Ceja</Name>-1.019 <Date>1948-7-20</Date> 08:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM <Date>1948-7-20</Date> 08:52PM URINE RBC-<Date>5-18</Date>* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 RENAL EPI-0-2 <Date>1948-7-20</Date> 03:10PM PT-14.3* PTT-32.9 INR(PT)-1.2* <Date>1948-7-20</Date> 02:55PM URINE HOURS-RANDOM <Date>1948-7-20</Date> 02:55PM URINE GR HOLD-HOLD <Date>1948-7-20</Date> 02:55PM URINE COLOR-Yellow APPEAR-Clear SP <Name>Ceja</Name>-1.021 <Date>1948-7-20</Date> 02:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM <Date>1948-7-20</Date> 02:55PM URINE RBC-<Date>5-18</Date>* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 <Date>1948-7-20</Date> 01:44PM LACTATE-0.6 K+-5.4* <Date>1948-7-20</Date> 01:35PM GLUCOSE-95 UREA N-87* CREAT-2.0* SODIUM-136 POTASSIUM-5.7* CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 <Date>1948-7-20</Date> 01:35PM estGFR-Using this <Date>1948-7-20</Date> 01:35PM CK(CPK)-19* <Date>1948-7-20</Date> 01:35PM cTropnT-0.03* <Date>1948-7-20</Date> 01:35PM CK-MB-2 <Date>1948-7-20</Date> 01:35PM WBC-6.9 RBC-2.92* HGB-8.1* HCT-28.0* MCV-96 MCH-27.8 MCHC-28.9# RDW-16.4 <Date>1948-7-20</Date> 01:35PM NEUTS-60.0 LYMPHS-26.6 MONOS-6.3 EOS-5.7* BASOS-1.4 <Date>1948-7-20</Date> 01:35PM PLT COUNT-661* <Date>8-8</Date> cxr UPRIGHT AP VIEW OF THE CHEST: Patient is status post sternal plating and left-sided pacemaker device with leads terminating in the right atrium and right ventricle. Several epicardial leads are unchanged. Cardiac, mediastinal and hilar contours are stable. Multiple external tubing and catheter devices are seen projecting over the left upper quadrant and left lung base. Patchy opacity in left lung base may reflect atelectasis. A trace left pleural effusion cannot be excluded. The right lung is grossly clear. There is no pneumonia. Surgical anchor is partly imaged projecting over the right humeral head. No acute osseous findings are seen. IMPRESSION: Patchy opacity in the left lung base, which could reflect atelectasis, but infection is not excluded. Probable trace left pleural effusion. <Date>3-31</Date> upper ext U/S Grey scale and Doppler son<Name>Juvenal Anderson</Name> of the left subclavian and right subclavian, IJ, axillary, basilic, and cephalic veins were taken. The lumen of the basilic vein continues to contain echogenic material from the proximal end. There is abnormal compressibility, flow, and augmentation of the basilic vein consistent with thrombosis of the basilic vein. Otherwise, the remainder of the veins demonstrate normal compressibility, flow, and augmentation. IMPRESSION: Basilic vein thrombosis, unchanged in comparison to prior study. These findings were discussed with Dr. <Name>Jacki</Name> <Name>Orville Shipley</Name> of the patient's primary clinical team at approximately 11:30 a.m. on <Date>1943-10-13</Date>. The study and the report were reviewed by the staff radiologist. <Date>3-31</Date> renal u/s The right kidney measures approximately 10.2 cm. The left kidney measures approximately 9.8 cm. A small simple cyst measuring 1.8 x 1.6 x 1.7 cm is visualized in the upper pole of the right kidney. Otherwise, there is no hydronephrosis, stones, or masses. Of note are bilateral pleural effusions visualized. IMPRESSION: Normal renal son<Name>Craig Bounds</Name>. Evidence of bilateral pleural effusions was noted. These findings were discussed with Dr. <Name>Jacki</Name> <Name>Orville Shipley</Name> of the patient's primary clinical team at approximately 11:30 a.m. on <Date>1943-10-13</Date>. The study and the report were reviewed by the staff radiologist. <Date>3-31</Date> chest x-ray SUPINE AP AND LATERAL RADIOGRAPH OF THE CHEST: There are layering bilateral pleural effusions, moderate on the left and small on the right, unchanged. There is bibasilar consolidation, significantly worst on the left and could reflect a combination of atelectasis, effusion, and/or pneumonia. There is no significant pulmonary edema or pneumothorax. Sternal plating hardware is unchanged, epicardial pacing leads are again visualized. There is a left chest wall pacer with right atrial and ventricular leads in unchanged location. Left midline catheter and mediastinal drain is unchanged. IMPRESSION: No significant change in moderate left and small right pleural effusion and large left basilar consolidation. <Date>7-15</Date> chest xray FINDINGS: As compared to the previous radiograph, there is no relevant change. Sternal fixators, unchanged course of pacemaker leads. Unchanged size of the cardiac silhouette, mild cardiomegaly with mild pulmonary edema and associated bilateral small pleural effusions. No evidence of newly appeared parenchymal opacities suggestive of pneumonia. Brief Hospital Course: Mr. <Name>Chowdhury</Name> is an 84 yo s/p recent CABG with sternal wound infection admitted for presumed pre-renal ARF now with respiratory distress most likely <Date>11-25</Date> to volume overload. # Respiratory distress: Most likely <Date>11-25</Date> acute on chronic CHF. In the MICU, on BIPAP for 45 minutes. Recieved lasix throughout his stay (total of 200 mg IV) with partial response. He improved on Bipap and felt to have returned to baseline by morning. No evidence of MI; cardiac enzymes continued to hold at 0.03 (trop) and later echo showed stably decreased EF of 45-50%. During his course on the floor he had multiple episodes of shortness of breath with associated desturations; thought to have a large anxiety component causing hypertension and flash pulmonary edema; these resolved with IV lasix, morphine, and ativan. He was found to have large bilateral pleural effusions. On <Date>2-13</Date> his right lung was drained of 1.5 L and on <Date>3-26</Date> his left lung was drained of 1.2 L of transudative fluid. Cytology was negative for malignant cells. He was aggresively diuresed with IV lasix to doses up to 120mg IV bid (metolazone also used twice) with gradual improvement in his respiratory status and resolution of renal failure. He was then transitioned to an oral lasix regimen on <Date>3-5</Date> with continued good diuresis of net neg 1000cc a day and preserved renal function. He will continue 80mg of lasix twice a day for now with an initial goal of net negative 500-1000cc a day. He should have standing weights daily, strict I/O's and have his BUN/creatinine checked on <Date>1-22</Date> with lytes repleted as needed. his lasix dose should be adjusted based on volume status. His weight upon discharge was 80kg. O2sat stably 96-100% on 2L, in 90s on RA, and desats to 86% on RA with ambulation. Of note, anxiety (see below) likely plays a large component, and pt feels more comfortable on O2 NC despite above O2sat readings; small doses of ativan and morphine have been helpful in the past with episodes of respiratory distress. Please wean down oxygen supplementation slowly as tolerated. # ARF: <Month>March</Month> have had volume depletion in the setting of poor PO intake prior to admission, secondary to drug reaction to cefazolin (intrinsic renal failure), or poor forward flow in the setting of acute on chronic CHF. His creatinine improved with diuresis and was back to baseline prior to discharge. Currently still holding lisinopril and HCTZ due to active diuresis. Please check BUN creatinine on <Date>1-22</Date> and thereafter as needed to monitor renal function while actively diuresing. Would restart lisinopril and HCTZ when volume status stable. Would preferentially start lisinopril first given his CHF. # MSSA infection: He was on cefazolin with the plan for a prolonged 8 weeks of antimicrobial therapy followed by lifelong suppressive therapy for retained infected pacing wires however due to apparent drug reaction his regimen was switched to vanco on <Date>7-15</Date>. He was left with a 6 week course on vancomycin with an end date of <Date>1932-8-12</Date>. He should have a CBC with differential, chem 7 and vanc trough drawn on Thurs <Date>6-19</Date>, Wednesday <Date>6-18</Date>, and Thursday <Date>10-31</Date>; please fax these to <Hospital>Clark-Zamora Medical Center</Hospital> clinic <Telephone>812-160-1295</Telephone> to the attention of Dr. <Name>Tracy Feguson</Name>. He will follow up with Dr. <Name>Luu</Name> on <Date>1920-9-30</Date> and with Dr. <Name>Tracy Feguson</Name> on <Date>1984-7-3</Date>. # Rash: Dermatology thought rash was likely leukocytoclastic vasculitis <Date>11-25</Date> ancef. Pt and family were not interested in biopsy so derm signed off. Would avoid use of cefazolin in future. Vancomycin started for continued treatment of pts infection. # Pain: Chronic, most likely secondary to deconditioning. Pt received oxycodnoe prn for pain. # Anxiety: His episodes of shortness of breath not associated with desaturations were most likley due to his anxiety. He was started on Ativan 0.5mg three times a day which he tolerated well and PRN Ativan. He felt that morphine po prn helped relieve some respiratory distress as well. Medications on Admission: Hydrochlorothiazide 12.5mg daily ASA 81mg daily Folgard Rx 2.2mg-25mg-1mg daily Ocuvite 1 daily Amlodipine 5mg daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 24 days: Dose given <Date>11-7</Date>. Start <Date>5-16</Date>. End date <Date>4-5</Date>. 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:12 Tablet(s) Refills:0 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for Cough. 13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Sodium Chloride 0.65 % Aerosol, Spray Sig: <Date>4-3</Date> Sprays Nasal TID (3 times a day) as needed for dryness. 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Anxiety. 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:15 Tablet(s) Refills:0 17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal <Hospital>Lindsey Inc Medical Center</Hospital> (2 times a day). 18. Morphine 15 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for SOB. Disp:3 Tablet(s) Refills:0 19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Outpatient Lab Work Please check CBC with differential, Chem 7 and Vanc trough on Thurs <Date>6-19</Date>, Wed <Date>1-8</Date>, Thurs <Date>10-31</Date> and fax results to Dr. <Name>Luu</Name>/<Hospital>Clark-Zamora Medical Center</Hospital> Clinic at <Telephone>812-160-1295</Telephone>. 21. Outpatient Lab Work Please check a chem 10 on Monday <Date>1-22</Date> and thereafter as needed to monitor kidney function. 22. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours. 23. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 24. Oxygen Has been on 2L NC here. Please titrate to maintain O2sat >94%. Discharge Disposition: Extended Care Facility: Newbridge on the <Doctor Name>Dr.Lockett</Doctor Name> - <Location>7613 Burton Villages Apt. 670 West Morganville, ND 24507</Location> Discharge Diagnosis: Acute renal failure Vasculitis, likely cephalosporin-related Acute on chronic systolic congestive heart failure MSSA sternal wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory. Able to walk short distances (6 feet) with walker. Out of Bed with assistance to chair or wheelchair. O2sat 96-100 on 2L, satting in 90s on RA, desats to 86% on RA with ambulation Discharge Instructions: You were originally admitted for a progressive rash and renal failure. This was thought to be related to the original antibiotic (cefazolin) you were taking for the skin infection of your sternal incision site. You initially had a drain which was removed during your hospitalization. Your antibiotic was changed to vancomycin which you will take for a total of 6 weeks (End Date <Date>4-5</Date>); you will have weekly labs drawn and sent to the <Hospital>Clark-Zamora Medical Center</Hospital> clinic. You will also follow up with the ID specialist. You required transfer to the ICU for respiratory distress in the setting of fluid overload. You were given medications to help you get rid of the fluid and transferred back to the floor when you were stable. You underwent two thoracenteses to drain the fluid in your lungs. Your oxygen saturation improved with these measures. Gradually, your kidney function also improved. You will continue oral lasix. You should weigh yourself daily and call your physician regarding weight gain > 3 lbs in one day. Medication changes: - 6-week course of vancomycin to complete a total 8-week course of antibiotic treatment (End <Date>4-5</Date>) - Lisinopril held for now until renal function stable - Hydrochlorothiazide held for now until renal function is stable - Inrease Lasix 80mg twice a day, dose to be adjusted as needed by rehab physician <Name>Tyler Thompson</Name> <Name>Keith Turcios</Name> treatments - Morphine tab as needed for shortness of breath - Ativan for anxiety - Fluticasone spray for nasal congestion - Ocean nasal spray as needed for nasal congestion - Guanefesin (Robitussin) as needed for cough - Oxygen therapy as needed Followup Instructions: You will be discharged to rehab. Please follow up with your PCP, <Name>Lenling</Name>. <Name>Scheet</Name>, within 1-2 weeks of discharge from rehab. Department: INFECTIOUS DISEASE When: THURSDAY <Date>1920-9-30</Date> at 2:30 PM With: <Name>Eleanor</Name> <Name>Mattie Gauthier</Name> <Name>Cindy Kaur</Name>, M.D. <Telephone>714-288-1341</Telephone> Building: LM <Hospital>Martinez LLC Hospital</Hospital> <Hospital>Mckee, Moon and Espinoza Medical Center</Hospital> Campus: WEST Best Parking: <Hospital>Carson PLC Clinic</Hospital> Garage Department: INFECTIOUS DISEASE When: FRIDAY <Date>2021-12-1</Date> at 11:30 AM With: <Name>Travis Deng</Name> <Name>Marvin Pettway</Name>, MD <Telephone>714-288-1341</Telephone> Building: LM <Hospital>Carson PLC Clinic</Hospital> Bldg (<Name>Braswell</Name>) <Hospital>Mckee, Moon and Espinoza Medical Center</Hospital> Campus: WEST Best Parking: <Hospital>Carson PLC Clinic</Hospital> Garage Department: CARDIAC SERVICES When: FRIDAY <Date>1945-1-14</Date> at 3:30 AM With: DEVICE CLINIC <Telephone>985-892-4379</Telephone> Building: SC <Hospital>Brewer, Myers and Barry Hospital</Hospital> Clinical Ctr <Location>459 Contreras Grove Apt. 162 Robertsfort, MP 25918</Location> Campus: EAST Best Parking: <Hospital>Brewer, Myers and Barry Hospital</Hospital> Garage <Name>Iliana Belle</Name> <Name>Marvin Pettway</Name> MD <MD Number>07546706</MD 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Date: 1948-7-20 Discharge Date: 1976-8-7 Date of Birth: 1996-7-31 Sex: M Service: MEDICINE Allergies: Penicillins / Quinolones / Cefazolin Attending:Everardo Chief Complaint: Acute Hypercarbic Respiratory Distress Major Surgical or Invasive Procedure: Bilateral thoracenteses S/p removal of chest wall drain History of Present Illness: Mr. Chowdhury is an 84 year old gentleman with a PMH significant for recent CAD s/p CABG c/b sternal wound infection on antibiotics and CHB s/p PPM admitted for a lower extremity rash concerning for vasculitis and acute renal failure. The patient underwent CABG in 11-13, and was re-admitted to Gomez-Burns Medical Center on 1986-11-28 for sternal wound exploration with a drain placed with cultures speciated as MSSA. At that time, he was discharged on cefazolin with the plan for a prolonged 8 weeks of antimicrobial therapy. On 6-29, the ID service was contactCraig Bounds as the patient had developed a rash over his lower extremities concerning for a drug rash by his physician at rehab. At that time, given that he has a history of an unknown PCN reaction, he was converted to vancomycin. Today, he presented to the Jones, Dawson and Mahoney Health System Clark-Zamora Medical Center clinic, and was found to have a rash concerning for vasculitis and ARF with a creatinine of 2 and a serum potassium of 5.7. He was then referred to the ED for futher management. . In the Gomez-Burns Medical Center ED, initial VS 97.7 60 133/48 20 95%RA. ECG was negative for peaked T waves, the patient received 30 mg kayexalate, had a negative CXR, and was admitted to Medicine for further management. On ROS, the patient reports that he has been feeling increasingly fatigued over the past week with decreased PO intake, but denies any f/c/s, n/v/d, abd pain, HA, palpitations. He is does not know when his rash developed. . On the floor, pt Cr 2.0--> 1.7 with gentle fluid repletion. However, overnight, pt developed respiratory distress thought to be 2.2 volume overload. He was given nebs and placed on 4L NC with good improvement in Os sats. Over the next 24 hours, his resp status continued to worsen requiring 6L NC. ABG 7.25/58/211/27. Given Nebs and 20mg IV lasix without improvement. He was then transfered to the MICU for BIPAP. Past Medical History: Coronary Artery Disease Hypertension Hyperlipidemia s/p St. Mamie PPM for CHB 11-3 Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy 1-1990 s/p Back surgery 2005 s/p Appendectomy s/p Tonsillectomy Social History: Lives with: Wife Occupation: Retired Tobacco: Quit 23 years ago, smoked x 50 years ETOH: 4-3 pint of hard alcohol per day Family History: Noncontributory Physical Exam: Vitals: T:97.3 BP:113/76 P:71 R:13 O2: 100 on BIPAP PEEP 6 General: Alert, oriented, HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles b/l lower lungs R>L. no wheeze CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: 1948-7-20 08:52PM URINE HOURS-RANDOM CREAT-126 SODIUM-24 POTASSIUM-31 1948-7-20 08:52PM URINE COLOR-Yellow APPEAR-Clear SP Ceja-1.019 1948-7-20 08:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM 1948-7-20 08:52PM URINE RBC-5-18* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 RENAL EPI-0-2 1948-7-20 03:10PM PT-14.3* PTT-32.9 INR(PT)-1.2* 1948-7-20 02:55PM URINE HOURS-RANDOM 1948-7-20 02:55PM URINE GR HOLD-HOLD 1948-7-20 02:55PM URINE COLOR-Yellow APPEAR-Clear SP Ceja-1.021 1948-7-20 02:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM 1948-7-20 02:55PM URINE RBC-5-18* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 1948-7-20 01:44PM LACTATE-0.6 K+-5.4* 1948-7-20 01:35PM GLUCOSE-95 UREA N-87* CREAT-2.0* SODIUM-136 POTASSIUM-5.7* CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 1948-7-20 01:35PM estGFR-Using this 1948-7-20 01:35PM CK(CPK)-19* 1948-7-20 01:35PM cTropnT-0.03* 1948-7-20 01:35PM CK-MB-2 1948-7-20 01:35PM WBC-6.9 RBC-2.92* HGB-8.1* HCT-28.0* MCV-96 MCH-27.8 MCHC-28.9# RDW-16.4 1948-7-20 01:35PM NEUTS-60.0 LYMPHS-26.6 MONOS-6.3 EOS-5.7* BASOS-1.4 1948-7-20 01:35PM PLT COUNT-661* 8-8 cxr UPRIGHT AP VIEW OF THE CHEST: Patient is status post sternal plating and left-sided pacemaker device with leads terminating in the right atrium and right ventricle. Several epicardial leads are unchanged. Cardiac, mediastinal and hilar contours are stable. Multiple external tubing and catheter devices are seen projecting over the left upper quadrant and left lung base. Patchy opacity in left lung base may reflect atelectasis. A trace left pleural effusion cannot be excluded. The right lung is grossly clear. There is no pneumonia. Surgical anchor is partly imaged projecting over the right humeral head. No acute osseous findings are seen. IMPRESSION: Patchy opacity in the left lung base, which could reflect atelectasis, but infection is not excluded. Probable trace left pleural effusion. 3-31 upper ext U/S Grey scale and Doppler sonJuvenal Anderson of the left subclavian and right subclavian, IJ, axillary, basilic, and cephalic veins were taken. The lumen of the basilic vein continues to contain echogenic material from the proximal end. There is abnormal compressibility, flow, and augmentation of the basilic vein consistent with thrombosis of the basilic vein. Otherwise, the remainder of the veins demonstrate normal compressibility, flow, and augmentation. IMPRESSION: Basilic vein thrombosis, unchanged in comparison to prior study. These findings were discussed with Dr. Jacki Orville Shipley of the patient's primary clinical team at approximately 11:30 a.m. on 1943-10-13. The study and the report were reviewed by the staff radiologist. 3-31 renal u/s The right kidney measures approximately 10.2 cm. The left kidney measures approximately 9.8 cm. A small simple cyst measuring 1.8 x 1.6 x 1.7 cm is visualized in the upper pole of the right kidney. Otherwise, there is no hydronephrosis, stones, or masses. Of note are bilateral pleural effusions visualized. IMPRESSION: Normal renal sonCraig Bounds. Evidence of bilateral pleural effusions was noted. These findings were discussed with Dr. Jacki Orville Shipley of the patient's primary clinical team at approximately 11:30 a.m. on 1943-10-13. The study and the report were reviewed by the staff radiologist. 3-31 chest x-ray SUPINE AP AND LATERAL RADIOGRAPH OF THE CHEST: There are layering bilateral pleural effusions, moderate on the left and small on the right, unchanged. There is bibasilar consolidation, significantly worst on the left and could reflect a combination of atelectasis, effusion, and/or pneumonia. There is no significant pulmonary edema or pneumothorax. Sternal plating hardware is unchanged, epicardial pacing leads are again visualized. There is a left chest wall pacer with right atrial and ventricular leads in unchanged location. Left midline catheter and mediastinal drain is unchanged. IMPRESSION: No significant change in moderate left and small right pleural effusion and large left basilar consolidation. 7-15 chest xray FINDINGS: As compared to the previous radiograph, there is no relevant change. Sternal fixators, unchanged course of pacemaker leads. Unchanged size of the cardiac silhouette, mild cardiomegaly with mild pulmonary edema and associated bilateral small pleural effusions. No evidence of newly appeared parenchymal opacities suggestive of pneumonia. Brief Hospital Course: Mr. Chowdhury is an 84 yo s/p recent CABG with sternal wound infection admitted for presumed pre-renal ARF now with respiratory distress most likely 11-25 to volume overload. # Respiratory distress: Most likely 11-25 acute on chronic CHF. In the MICU, on BIPAP for 45 minutes. Recieved lasix throughout his stay (total of 200 mg IV) with partial response. He improved on Bipap and felt to have returned to baseline by morning. No evidence of MI; cardiac enzymes continued to hold at 0.03 (trop) and later echo showed stably decreased EF of 45-50%. During his course on the floor he had multiple episodes of shortness of breath with associated desturations; thought to have a large anxiety component causing hypertension and flash pulmonary edema; these resolved with IV lasix, morphine, and ativan. He was found to have large bilateral pleural effusions. On 2-13 his right lung was drained of 1.5 L and on 3-26 his left lung was drained of 1.2 L of transudative fluid. Cytology was negative for malignant cells. He was aggresively diuresed with IV lasix to doses up to 120mg IV bid (metolazone also used twice) with gradual improvement in his respiratory status and resolution of renal failure. He was then transitioned to an oral lasix regimen on 3-5 with continued good diuresis of net neg 1000cc a day and preserved renal function. He will continue 80mg of lasix twice a day for now with an initial goal of net negative 500-1000cc a day. He should have standing weights daily, strict I/O's and have his BUN/creatinine checked on 1-22 with lytes repleted as needed. his lasix dose should be adjusted based on volume status. His weight upon discharge was 80kg. O2sat stably 96-100% on 2L, in 90s on RA, and desats to 86% on RA with ambulation. Of note, anxiety (see below) likely plays a large component, and pt feels more comfortable on O2 NC despite above O2sat readings; small doses of ativan and morphine have been helpful in the past with episodes of respiratory distress. Please wean down oxygen supplementation slowly as tolerated. # ARF: March have had volume depletion in the setting of poor PO intake prior to admission, secondary to drug reaction to cefazolin (intrinsic renal failure), or poor forward flow in the setting of acute on chronic CHF. His creatinine improved with diuresis and was back to baseline prior to discharge. Currently still holding lisinopril and HCTZ due to active diuresis. Please check BUN creatinine on 1-22 and thereafter as needed to monitor renal function while actively diuresing. Would restart lisinopril and HCTZ when volume status stable. Would preferentially start lisinopril first given his CHF. # MSSA infection: He was on cefazolin with the plan for a prolonged 8 weeks of antimicrobial therapy followed by lifelong suppressive therapy for retained infected pacing wires however due to apparent drug reaction his regimen was switched to vanco on 7-15. He was left with a 6 week course on vancomycin with an end date of 1932-8-12. He should have a CBC with differential, chem 7 and vanc trough drawn on Thurs 6-19, Wednesday 6-18, and Thursday 10-31; please fax these to Clark-Zamora Medical Center clinic 812-160-1295 to the attention of Dr. Tracy Feguson. He will follow up with Dr. Luu on 1920-9-30 and with Dr. Tracy Feguson on 1984-7-3. # Rash: Dermatology thought rash was likely leukocytoclastic vasculitis 11-25 ancef. Pt and family were not interested in biopsy so derm signed off. Would avoid use of cefazolin in future. Vancomycin started for continued treatment of pts infection. # Pain: Chronic, most likely secondary to deconditioning. Pt received oxycodnoe prn for pain. # Anxiety: His episodes of shortness of breath not associated with desaturations were most likley due to his anxiety. He was started on Ativan 0.5mg three times a day which he tolerated well and PRN Ativan. He felt that morphine po prn helped relieve some respiratory distress as well. Medications on Admission: Hydrochlorothiazide 12.5mg daily ASA 81mg daily Folgard Rx 2.2mg-25mg-1mg daily Ocuvite 1 daily Amlodipine 5mg daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 24 days: Dose given 11-7. Start 5-16. End date 4-5. 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:12 Tablet(s) Refills:0 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for Cough. 13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Sodium Chloride 0.65 % Aerosol, Spray Sig: 4-3 Sprays Nasal TID (3 times a day) as needed for dryness. 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Anxiety. 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:15 Tablet(s) Refills:0 17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal Lindsey Inc Medical Center (2 times a day). 18. Morphine 15 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for SOB. Disp:3 Tablet(s) Refills:0 19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Outpatient Lab Work Please check CBC with differential, Chem 7 and Vanc trough on Thurs 6-19, Wed 1-8, Thurs 10-31 and fax results to Dr. Luu/Clark-Zamora Medical Center Clinic at 812-160-1295. 21. Outpatient Lab Work Please check a chem 10 on Monday 1-22 and thereafter as needed to monitor kidney function. 22. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours. 23. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 24. Oxygen Has been on 2L NC here. Please titrate to maintain O2sat >94%. Discharge Disposition: Extended Care Facility: Newbridge on the Dr.Lockett - 7613 Burton Villages Apt. 670 West Morganville, ND 24507 Discharge Diagnosis: Acute renal failure Vasculitis, likely cephalosporin-related Acute on chronic systolic congestive heart failure MSSA sternal wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory. Able to walk short distances (6 feet) with walker. Out of Bed with assistance to chair or wheelchair. O2sat 96-100 on 2L, satting in 90s on RA, desats to 86% on RA with ambulation Discharge Instructions: You were originally admitted for a progressive rash and renal failure. This was thought to be related to the original antibiotic (cefazolin) you were taking for the skin infection of your sternal incision site. You initially had a drain which was removed during your hospitalization. Your antibiotic was changed to vancomycin which you will take for a total of 6 weeks (End Date 4-5); you will have weekly labs drawn and sent to the Clark-Zamora Medical Center clinic. You will also follow up with the ID specialist. You required transfer to the ICU for respiratory distress in the setting of fluid overload. You were given medications to help you get rid of the fluid and transferred back to the floor when you were stable. You underwent two thoracenteses to drain the fluid in your lungs. Your oxygen saturation improved with these measures. Gradually, your kidney function also improved. You will continue oral lasix. You should weigh yourself daily and call your physician regarding weight gain > 3 lbs in one day. Medication changes: - 6-week course of vancomycin to complete a total 8-week course of antibiotic treatment (End 4-5) - Lisinopril held for now until renal function stable - Hydrochlorothiazide held for now until renal function is stable - Inrease Lasix 80mg twice a day, dose to be adjusted as needed by rehab physician Tyler Thompson Keith Turcios treatments - Morphine tab as needed for shortness of breath - Ativan for anxiety - Fluticasone spray for nasal congestion - Ocean nasal spray as needed for nasal congestion - Guanefesin (Robitussin) as needed for cough - Oxygen therapy as needed Followup Instructions: You will be discharged to rehab. Please follow up with your PCP, Lenling. Scheet, within 1-2 weeks of discharge from rehab. Department: INFECTIOUS DISEASE When: THURSDAY 1920-9-30 at 2:30 PM With: Eleanor Mattie Gauthier Cindy Kaur, M.D. 714-288-1341 Building: LM Martinez LLC Hospital Mckee, Moon and Espinoza Medical Center Campus: WEST Best Parking: Carson PLC Clinic Garage Department: INFECTIOUS DISEASE When: FRIDAY 2021-12-1 at 11:30 AM With: Travis Deng Marvin Pettway, MD 714-288-1341 Building: LM Carson PLC Clinic Bldg (Braswell) Mckee, Moon and Espinoza Medical Center Campus: WEST Best Parking: Carson PLC Clinic Garage Department: CARDIAC SERVICES When: FRIDAY 1945-1-14 at 3:30 AM With: DEVICE CLINIC 985-892-4379 Building: SC Brewer, Myers and Barry Hospital Clinical Ctr 459 Contreras Grove Apt. 162 Robertsfort, MP 25918 Campus: EAST Best Parking: Brewer, Myers and Barry Hospital Garage Iliana Belle Marvin Pettway MD 07546706	['Admission Date: 1948-7-20 Discharge Date: 1976-8-7\n\nDate of Birth: 1996-7-31 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPenicillins / Quinolones / Cefazolin\n\nAttending:Everardo\nChief Complaint:\nAcute Hypercarbic Respiratory Distress\n\nMajor Surgical or Invasive Procedure:\nBilateral thoracenteses\nS/p removal of chest wall drain\n\n\nHistory of Present Illness:\nMr. Chowdhury is an 84 year old gentleman with a PMH significant\nfor recent CAD s/p CABG c/b sternal wound infection on\nantibiotics and CHB s/p PPM admitted for a lower extremity rash\nconcerning for vasculitis and acute renal failure. The patient\nunderwent CABG in 11-13, and was re-admitted to Gomez-Burns Medical Center on 1986-11-28\nfor sternal wound exploration with a drain placed with cultures\nspeciated as MSSA.', ' At that time, he was discharged on cefazolin\nwith the plan for a prolonged 8 weeks of antimicrobial therapy.\nOn 6-29, the ID service was contactCraig Bounds as the patient had\ndeveloped a rash over his lower extremities concerning for a\ndrug rash by his physician at rehab. At that time, given that he\nhas a history of an unknown PCN reaction, he was converted to\nvancomycin. Today, he presented to the Jones, Dawson and Mahoney Health System Clark-Zamora Medical Center clinic, and was\nfound to have a rash concerning for vasculitis and ARF with a\ncreatinine of 2 and a serum potassium of 5.7. He was then\nreferred to the ED for futher management.\n.\nIn the Gomez-Burns Medical Center ED, initial VS 97.7 60 133/48 20 95%RA. ECG was\nnegative for peaked T waves, the patient received 30 mg\nkayexalate, had a negative CXR, and was admitted to Medicine for\nfurther management.', ' On ROS, the patient reports that he has\nbeen feeling increasingly fatigued over the past week with\ndecreased PO intake, but denies any f/c/s, n/v/d, abd pain, HA,\npalpitations. He is does not know when his rash developed.\n.\nOn the floor, pt Cr 2.0--> 1.7 with gentle fluid repletion.\nHowever, overnight, pt developed respiratory distress thought to\nbe 2.2 volume overload. He was given nebs and placed on 4L NC\nwith good improvement in Os sats. Over the next 24 hours, his\nresp status continued to worsen requiring 6L NC. ABG\n7.25/58/211/27. Given Nebs and 20mg IV lasix without\nimprovement. He was then transfered to the MICU for BIPAP.\n\n\nPast Medical History:\nCoronary Artery Disease\nHypertension\nHyperlipidemia\ns/p St. Mamie PPM for CHB 11-3\nArthritis\nSleep apnea noted after administration of narcotics\nDiverticulitis s/p Left hemicolectomy 1-1990\ns/p Back surgery 2005\ns/p Appendectomy\ns/p Tonsillectomy\n\nSocial History:\nLives with: Wife\nOccupation: Retired\nTobacco: Quit 23 years ago, smoked x 50 years\nETOH: 4-3 pint of hard alcohol per day\n\n\nFamily History:\nNoncontributory\n\nPhysical Exam:\nVitals: T:97.', '3 BP:113/76 P:71 R:13 O2: 100 on BIPAP PEEP 6\nGeneral: Alert, oriented,\nHEENT: Sclera anicteric, MMM, oropharynx clear\nNeck: supple, JVP not elevated, no LAD\nLungs: Crackles b/l lower lungs R>L. no wheeze\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops\nAbdomen: soft, non-tender, non-distended, bowel sounds present,\nno rebound tenderness or guarding, no organomegaly\nGU: foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema\n\nPertinent Results:\n1948-7-20 08:52PM URINE HOURS-RANDOM CREAT-126 SODIUM-24\nPOTASSIUM-31\n1948-7-20 08:52PM URINE COLOR-Yellow APPEAR-Clear SP Ceja-1.019\n1948-7-20 08:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150\nGLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM\n1948-7-20 08:52PM URINE RBC-5-18* WBC-0-2 BACTERIA-RARE\nYEAST-NONE EPI-0 RENAL EPI-0-2\n1948-7-20 03:10PM PT-14.', '3* PTT-32.9 INR(PT)-1.2\n1948-7-20 02:55PM URINE HOURS-RANDOM\n1948-7-20 02:55PM URINE GR HOLD-HOLD\n1948-7-20 02:55PM URINE COLOR-Yellow APPEAR-Clear SP Ceja-1.021\n1948-7-20 02:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75\nGLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM\n1948-7-20 02:55PM URINE RBC-5-18 WBC-0-2 BACTERIA-NONE\nYEAST-NONE EPI-0-2\n1948-7-20 01:44PM LACTATE-0.6 K+-5.4\n1948-7-20 01:35PM GLUCOSE-95 UREA N-87 CREAT-2.0* SODIUM-136\nPOTASSIUM-5.7* CHLORIDE-104 TOTAL CO2-25 ANION GAP-13\n1948-7-20 01:35PM estGFR-Using this\n1948-7-20 01:35PM CK(CPK)-19\n1948-7-20 01:35PM cTropnT-0.03\n1948-7-20 01:35PM CK-MB-2\n1948-7-20 01:35PM WBC-6.9 RBC-2.92* HGB-8.1* HCT-28.0* MCV-96\nMCH-27.8 MCHC-28.9# RDW-16.4\n1948-7-20 01:35PM NEUTS-60.0 LYMPHS-26.6 MONOS-6.3 EOS-5.', '7\nBASOS-1.4\n1948-7-20 01:35PM PLT COUNT-661\n\n8-8 cxr\n\nUPRIGHT AP VIEW OF THE CHEST: Patient is status post sternal\nplating and\nleft-sided pacemaker device with leads terminating in the right\natrium and\nright ventricle. Several epicardial leads are unchanged.\nCardiac,\nmediastinal and hilar contours are stable. Multiple external\ntubing and\ncatheter devices are seen projecting over the left upper\nquadrant and left\nlung base. Patchy opacity in left lung base may reflect\natelectasis. A trace left pleural effusion cannot be excluded.\nThe right lung is grossly clear. There is no pneumonia.\nSurgical anchor is partly imaged projecting over the right\nhumeral head. No acute osseous findings are seen.\n\nIMPRESSION: Patchy opacity in the left lung base, which could\nreflect\natelectasis, but infection is not excluded.', " Probable trace left\npleural\neffusion.\n\n3-31 upper ext U/S\nGrey scale and Doppler sonJuvenal Anderson of the left subclavian and\nright subclavian,\nIJ, axillary, basilic, and cephalic veins were taken. The lumen\nof the basilic vein continues to contain echogenic material from\nthe proximal end. There is abnormal compressibility, flow, and\naugmentation of the basilic vein consistent with thrombosis of\nthe basilic vein. Otherwise, the remainder of the veins\ndemonstrate normal compressibility, flow, and augmentation.\n\nIMPRESSION:\nBasilic vein thrombosis, unchanged in comparison to prior study.\n\n\nThese findings were discussed with Dr. Jacki Orville Shipley of the\npatient's primary\nclinical team at approximately 11:30 a.m. on 1943-10-13.\n\nThe study and the report were reviewed by the staff radiologist.", "\n\n\n3-31 renal u/s\nThe right kidney measures approximately 10.2 cm.\nThe left kidney measures approximately 9.8 cm.\n\nA small simple cyst measuring 1.8 x 1.6 x 1.7 cm is visualized\nin the upper pole of the right kidney. Otherwise, there is no\nhydronephrosis, stones, or masses. Of note are bilateral pleural\neffusions visualized.\n\nIMPRESSION:\nNormal renal sonCraig Bounds. Evidence of bilateral pleural effusions\nwas noted.\nThese findings were discussed with Dr. Jacki Orville Shipley of the\npatient's primary clinical team at approximately 11:30 a.m. on\n1943-10-13.\nThe study and the report were reviewed by the staff radiologist.\n\n\n3-31 chest x-ray\nSUPINE AP AND LATERAL RADIOGRAPH OF THE CHEST: There are\nlayering bilateral pleural effusions, moderate on the left and\nsmall on the right, unchanged.\nThere is bibasilar consolidation, significantly worst on the\nleft and could reflect a combination of atelectasis, effusion,\nand/or pneumonia.", ' There is no significant pulmonary edema or\npneumothorax. Sternal plating hardware is unchanged, epicardial\npacing leads are again visualized. There is a left chest wall\npacer with right atrial and ventricular leads in unchanged\nlocation. Left midline catheter and mediastinal drain is\nunchanged.\n\nIMPRESSION: No significant change in moderate left and small\nright pleural\neffusion and large left basilar consolidation.\n\n7-15 chest xray\nFINDINGS: As compared to the previous radiograph, there is no\nrelevant\nchange. Sternal fixators, unchanged course of pacemaker leads.\nUnchanged\nsize of the cardiac silhouette, mild cardiomegaly with mild\npulmonary edema and associated bilateral small pleural\neffusions. No evidence of newly appeared parenchymal opacities\nsuggestive of pneumonia.\n\n\nBrief Hospital Course:\nMr.', ' Chowdhury is an 84 yo s/p recent CABG with sternal wound\ninfection admitted for presumed pre-renal ARF now with\nrespiratory distress most likely 11-25 to volume overload.\n\n# Respiratory distress: Most likely 11-25 acute on chronic CHF.\nIn the MICU, on BIPAP for 45 minutes. Recieved lasix throughout\nhis stay (total of 200 mg IV) with partial response. He improved\non Bipap and felt to have returned to baseline by morning. No\nevidence of MI; cardiac enzymes continued to hold at 0.03 (trop)\nand later echo showed stably decreased EF of 45-50%. During his\ncourse on the floor he had multiple episodes of shortness of\nbreath with associated desturations; thought to have a large\nanxiety component causing hypertension and flash pulmonary\nedema; these resolved with IV lasix, morphine, and ativan. He\nwas found to have large bilateral pleural effusions.', " On 2-13 his\nright lung was drained of 1.5 L and on 3-26 his left lung was\ndrained of 1.2 L of transudative fluid. Cytology was negative\nfor malignant cells. He was aggresively diuresed with IV lasix\nto doses up to 120mg IV bid (metolazone also used twice) with\ngradual improvement in his respiratory status and resolution of\nrenal failure. He was then transitioned to an oral lasix\nregimen on 3-5 with continued good diuresis of net neg 1000cc a\nday and preserved renal function. He will continue 80mg of\nlasix twice a day for now with an initial goal of net negative\n500-1000cc a day. He should have standing weights daily, strict\nI/O's and have his BUN/creatinine checked on 1-22 with lytes\nrepleted as needed. his lasix dose should be adjusted based on\nvolume status. His weight upon discharge was 80kg.", ' O2sat stably\n96-100% on 2L, in 90s on RA, and desats to 86% on RA with\nambulation. Of note, anxiety (see below) likely plays a large\ncomponent, and pt feels more comfortable on O2 NC despite above\nO2sat readings; small doses of ativan and morphine have been\nhelpful in the past with episodes of respiratory distress.\nPlease wean down oxygen supplementation slowly as tolerated.\n\n# ARF: March have had volume depletion in the setting of poor PO\nintake prior to admission, secondary to drug reaction to\ncefazolin (intrinsic renal failure), or poor forward flow in the\nsetting of acute on chronic CHF. His creatinine improved with\ndiuresis and was back to baseline prior to discharge. Currently\nstill holding lisinopril and HCTZ due to active diuresis. Please\ncheck BUN creatinine on 1-22 and thereafter as needed to monitor\nrenal function while actively diuresing.', ' Would restart\nlisinopril and HCTZ when volume status stable. Would\npreferentially start lisinopril first given his CHF.\n\n# MSSA infection: He was on cefazolin with the plan for a\nprolonged 8 weeks of antimicrobial therapy followed by lifelong\nsuppressive therapy for retained infected pacing wires however\ndue to apparent drug reaction his regimen was switched to vanco\non 7-15. He was left with a 6 week course on vancomycin with an\nend date of 1932-8-12. He should have a CBC with\ndifferential, chem 7 and vanc trough drawn on Thurs 6-19,\nWednesday 6-18, and Thursday 10-31; please fax these to Clark-Zamora Medical Center clinic\n812-160-1295 to the attention of Dr. Tracy Feguson. He will\nfollow up with Dr. Luu on 1920-9-30 and with Dr.\nTracy Feguson on 1984-7-3.\n\n# Rash: Dermatology thought rash was likely leukocytoclastic\nvasculitis 11-25 ancef.', ' Pt and family were not interested in\nbiopsy so derm signed off. Would avoid use of cefazolin in\nfuture. Vancomycin started for continued treatment of pts\ninfection.\n\n# Pain: Chronic, most likely secondary to deconditioning. Pt\nreceived oxycodnoe prn for pain.\n\n# Anxiety: His episodes of shortness of breath not associated\nwith desaturations were most likley due to his anxiety. He was\nstarted on Ativan 0.5mg three times a day which he tolerated\nwell and PRN Ativan. He felt that morphine po prn helped relieve\nsome respiratory distress as well.\n\nMedications on Admission:\nHydrochlorothiazide 12.5mg daily\nASA 81mg daily\nFolgard Rx 2.2mg-25mg-1mg daily\nOcuvite 1 daily\nAmlodipine 5mg daily\n\nDischarge Medications:\n1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).', '\n3. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)\nIntravenous Q48H (every 48 hours) for 24 days: Dose given 11-7.\nStart 5-16. End date 4-5.\n4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\nhours) as needed for pain.\nDisp:12 Tablet(s) Refills:0\n5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3\ntimes a day) as needed for pain.\n6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3\ntimes a day).\n8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for constipation.\n10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\nML PO Q6H (every 6 hours) as needed for constipation.', '\n12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6\nhours) as needed for Cough.\n13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime) as needed for insomnia.\n14. Sodium Chloride 0.65 % Aerosol, Spray Sig: 4-3 Sprays Nasal\nTID (3 times a day) as needed for dryness.\n15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4\nhours) as needed for Anxiety.\n16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times\na day).\nDisp:15 Tablet(s) Refills:0\n17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)\nSpray Nasal Lindsey Inc Medical Center (2 times a day).\n18. Morphine 15 mg Tablet Sig: One (1) Tablet PO QHS (once a day\n(at bedtime)) as needed for SOB.\nDisp:3 Tablet(s) Refills:0\n19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times\na day).', '\n20. Outpatient Lab Work\nPlease check CBC with differential, Chem 7 and Vanc trough on\nThurs 6-19, Wed 1-8, Thurs 10-31 and fax results to Dr.\nLuu/Clark-Zamora Medical Center Clinic at 812-160-1295.\n21. Outpatient Lab Work\nPlease check a chem 10 on Monday 1-22 and thereafter as needed\nto monitor kidney function.\n22. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for\nNebulization Sig: One (1) Inhalation every four (4) hours.\n23. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for\nNebulization Sig: One (1) neb Inhalation every four (4) hours as\nneeded for shortness of breath or wheezing.\n24. Oxygen\nHas been on 2L NC here. Please titrate to maintain O2sat >94%.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nNewbridge on the Dr.Lockett - 7613 Burton Villages Apt. 670\nWest Morganville, ND 24507\n\nDischarge Diagnosis:\nAcute renal failure\nVasculitis, likely cephalosporin-related\nAcute on chronic systolic congestive heart failure\nMSSA sternal wound infection\n\n\nDischarge Condition:\nMental Status: Clear and coherent.', '\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory. Able to walk short distances (6\nfeet) with walker. Out of Bed with assistance to chair or\nwheelchair.\nO2sat 96-100 on 2L, satting in 90s on RA, desats to 86% on RA\nwith ambulation\n\n\nDischarge Instructions:\nYou were originally admitted for a progressive rash and renal\nfailure. This was thought to be related to the original\nantibiotic (cefazolin) you were taking for the skin infection of\nyour sternal incision site. You initially had a drain which was\nremoved during your hospitalization. Your antibiotic was\nchanged to vancomycin which you will take for a total of 6 weeks\n(End Date 4-5); you will have weekly labs drawn and sent to\nthe Clark-Zamora Medical Center clinic. You will also follow up with the ID specialist.', '\n\nYou required transfer to the ICU for respiratory distress in the\nsetting of fluid overload. You were given medications to help\nyou get rid of the fluid and transferred back to the floor when\nyou were stable. You underwent two thoracenteses to drain the\nfluid in your lungs. Your oxygen saturation improved with these\nmeasures. Gradually, your kidney function also improved. You\nwill continue oral lasix. You should weigh yourself daily and\ncall your physician regarding weight gain > 3 lbs in one day.\n\nMedication changes:\n- 6-week course of vancomycin to complete a total 8-week course\nof antibiotic treatment (End 4-5)\n- Lisinopril held for now until renal function stable\n- Hydrochlorothiazide held for now until renal function is\nstable\n- Inrease Lasix 80mg twice a day, dose to be adjusted as needed\nby rehab physician\nTyler Thompson Keith Turcios treatments\n- Morphine tab as needed for shortness of breath\n- Ativan for anxiety\n- Fluticasone spray for nasal congestion\n- Ocean nasal spray as needed for nasal congestion\n- Guanefesin (Robitussin) as needed for cough\n- Oxygen therapy as needed\n\nFollowup Instructions:\nYou will be discharged to rehab.', ' Please follow up with your\nPCP, Lenling. Scheet, within 1-2 weeks of discharge from rehab.\n\nDepartment: INFECTIOUS DISEASE\nWhen: THURSDAY 1920-9-30 at 2:30 PM\nWith: Eleanor Mattie Gauthier Cindy Kaur, M.D. 714-288-1341\nBuilding: LM Martinez LLC Hospital Mckee, Moon and Espinoza Medical Center\nCampus: WEST Best Parking: Carson PLC Clinic Garage\n\nDepartment: INFECTIOUS DISEASE\nWhen: FRIDAY 2021-12-1 at 11:30 AM\nWith: Travis Deng Marvin Pettway, MD 714-288-1341\nBuilding: LM Carson PLC Clinic Bldg (Braswell) Mckee, Moon and Espinoza Medical Center\nCampus: WEST Best Parking: Carson PLC Clinic Garage\n\nDepartment: CARDIAC SERVICES\nWhen: FRIDAY 1945-1-14 at 3:30 AM\nWith: DEVICE CLINIC 985-892-4379\nBuilding: SC Brewer, Myers and Barry Hospital Clinical Ctr 459 Contreras Grove Apt. 162\nRobertsfort, MP 25918\nCampus: EAST Best Parking: Brewer, Myers and Barry Hospital Garage\n\n\n Iliana Belle Marvin Pettway MD 07546706\n\n']
135	96950	190421.0	2103-09-13	Discharge summary	Report	Admission Date: [2103-8-30] Discharge Date: [2103-9-13] Date of Birth: [2019-8-6] Sex: M Service: MEDICINE Allergies: Penicillins / Quinolones / Cefazolin Attending:[First Name3 (LF) 425] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: CVVH Hemodialysis Tunneled HD catheter placement History of Present Illness: 84 yo m hx of CHF EF of 40% who was transfered form rehab due to worsening of SOB and ARF. He was recetly admitted from [Date range (1) 1424] and discharge to rehab. He was on lasix 80mg [Hospital1 ], then 2 days ago, lasix was adjusted to 80mg AM and 40mg PM. Per rehab his Cr has been trendeding up and his dypsnea has been worsening. At discharge his Cr was 0.9, then 1.1 and now 2.2 today. UO has been decreased per pt. Wt gains of 2 lbs over last few days. . During his last hopsitalization he was treated for a sternal wound infection from his CABG on [6-16]. On [7-23] he had a debridement and wound closer, with pacer lead removal on [7-23]. Epicardial leads were paritally removed. Old PPM remained in place. He also had a flap closure. Culture of his infeciton showed MSSA. He developed AIN, so his antibiotics were changed to vancomycin. He will be on lifelong suppresive therapy after his regiment of IV therapy. Hardware in the sternum is in place. His stay was complicated by CHF and ARF from diuresis, later this improved to a Cr of 0.9 and he was sent to rehab. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. . In the ED, initial vitals were 96.8 67 128/58 20 94% 3L NC. Pt was given 250mg IVF over 2 hours. Pt's oxygen was increased to 4L. On transfer temp 97.9 67 120/45 18 96% 4 liters. CXR with pulm edema. Pt admitted to [Hospital Unit Name 196]. . Past Medical History: -Coronary Artery Disease, s/p CABG (see below) -Hypertension -Hyperlipidemia -s/p St. [Male First Name (un) 923] PPM for Third degree heart block [9-15] -Arthritis -Sleep apnea noted after administration of narcotics -Diverticulitis s/p Left hemicolectomy [5-/2102] -s/p Back surgery [2101] -s/p Appendectomy -s/p Tonsillectomy -[2103-7-23] Sternal debridement, closure of the sternal wound dehiscence with four Synthes plates, bilateral pectoralis musculocutaneous advancement flap. -ARF due to questionable AIN due to cephalosporin or hemodynamically mediated ARF, in [2103-6-14] Social History: -Tobacco history: quit 25 yo ago -ETOH: 1 pint a day until CABG in [6-16] -Illicit drugs: none Lived with wife before going to rehab, now using a walker Family History: Noncontributory Physical Exam: GENERAL: Some tachypea with talking, otherwise NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at his chin while sitting at 45 degrees CARDIAC: Difficult to hear cardiac sounds, no murmur, sternal wound dressing in place small drainage LUNGS: Resp were slightly labored, pursed lip breathing, able to speak full sentences, no accessory muscle use. soft breath sounds, crackles half way up. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c. 2+ edema to the knees. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ radial, 2+ PT Pertient Discharge Physical Exam: General: NAD, [Last Name (un) 1425] HEENT: NCAT, Slcera anicteric. Neck: Supple Res: Clear to ascultation posteriorly on the R, with decreased breath sounds at the left base. Chest: Sternal Wound: c/i, tunnel catheter in place with no erythema or tenderness. Suture in place. Pertinent Results: Pertinent Labs: . [2103-8-30] 04:40PM BLOOD WBC-9.2 RBC-2.99* Hgb-8.8* Hct-27.3* MCV-92 MCH-29.5 MCHC-32.2 RDW-16.1* Plt Ct-300 [2103-8-31] 06:08AM BLOOD PT-13.5* PTT-31.5 INR(PT)-1.1 [2103-8-30] 04:40PM BLOOD Glucose-99 UreaN-46* Creat-2.1* Na-137 K-5.7* Cl-98 HCO3-35* AnGap-10 [2103-8-30] 04:40PM BLOOD Albumin-3.0* Calcium-8.8 Phos-4.9* Mg-2.3 [2103-8-31] 06:08AM BLOOD Vanco-18.1 [2103-9-1] 05:15AM BLOOD Vanco-28.0* . [8-31] CXR: Studies: The patient's sternotomy fixators are unchanged in appearance. The pacemakerleads are unchanged in appearance as well. The temporary pacemaker leads projecting at the expected location of the left epicardium are unchanged as well. Left PICC line tip is obscured by the pacemaker but is most likely not extending beyond the junction of the axillary vein and the subclavian vein. Bilateral pleural effusions have slightly improved. Bibasilar atelectases are unchanged. . [8-31] LENIs: IMPRESSION: No evidence of deep vein thrombosis in the right leg. [9-2] CXR Portable chest is compared to multiple prior examinations. Sternal plates, dual-lead pacer is present. Mild-to-moderate congestive failure, new from prior study from [2103-8-31]. Right IJ Cordis terminates in the superior vena cava. No pneumothorax. ECHO [9-3]: EF 30-35%. Suboptimal image quality. Regional left ventricular systolic dysfunction c/w multivessel CAD. Pulmonary artery systolic hypertension. Severe tricuspid regurgitation. Mild-moderate mitral regurgitation. Compared with the prior study (images reviewed) of [2103-8-14], regional left ventricular systolic dysfunction appears to be more extensive, and the severity of mitral regurgitation, tricuspid regurgitaiton, and PA systolic pressure are all increased. [9-9] AP-L & Decubitus CXR The decubitus images in both the left position show moderate bilateral pleural effusions. The right effusion is minimally more extensive than the left effusion. With respect to the sternal fixations, the size of the cardiac silhouette and the aspect of the lung parenchyma, today's images provide no new information. [9-10] Tunneled Catheter IMPRESSION: Uncomplicated placement of a tunneled hemodialysis catheter through the right internal jugular venous approach. The line is ready for use. [9-13] CXR: Summarized: Effusion on the Left, and decreased/absent Pleural Effusion on the R. For a full report, please see Radiology note. Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2103-9-13] 06:31 9.5 3.24* 9.4* 28.9* 89 29.2 32.7 15.9* 335 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2103-9-13] 06:31 1011 46 3.2* 136 3.8 100 28 12 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2103-9-13] 06:31 9.0 3.6 2.0 Brief Hospital Course: 84 yoM with hx of CAD s/p recent CABG c/b sternal wound MSSA infection, CHF and ARF, now presenting with dyspnea and [Last Name (un) ]. . Active Issues Upon Discharge: # [Last Name (un) ]: Thought to be multifactorial, with the underlying precipitant AIN secondary to the significant nephrotoxic antibiotic load the patient received for MSSA treatment; decreased effective circulatory volume due to CHF decompensation was likely to also be a contributor to pre-renal pathophysiology. On presentation, the patient was hyperkalemic, prompting the administration of Kayexalate, which normalized his potassium. Following consultation with Infectious Disease and Nephrology, IV vancomycin was stopped during the 6th of 8 weeks of treatment; at this time, the patient's vancomycin trough was supratherapeutic. To optimize volume status and forward flow, CVVH was started and continued until the patient was net -10L; the patient's home acetazolamide and furosemide were held. Hemodialysis was started and patient remained oliguric after two sessions. As a result, a tunneled hemodialysis catheter was placed and patient was set up for outpatient hemodialysis. Of note, he has made minimal urine during his hospital stay. His largest urine output was 250 cc. However, the day before discharge he had no urine output. - Leave R side suture above catheter in place until [2103-9-20]. - Dialysis as an outpatient. Last dialysis [2103-9-13]. . # Dyspnea: The patient was admitted with worsening heart failure symptoms with the most recent echo showing an EF of 40-45% in the setting of known COPD. Diuresis was initially attempted with IV Lasix and drip, but the patient was eventually transitioned to CVVH and diuresed aggressively with subsequent improvement of his clinical exam and symptoms; he remained rate controlled with metoprolol 50 mg TID (decreased from admission dose) and ACEi was held in the setting of [Last Name (un) ] but started upon discharge. During the hospitalization, he was kept on a COPD regimen of Guaifenesin, ipratropium / albuterol nebs, and fluticasone. CXR upon discharged showed L pleural effusion, with decreased/absent R pleural effusion. He has good ambulatory saturation and will require continued HD. It is expected that his left pleural effusion will decrease with continued HD. - HD as above . # MSSA Sternal wound infection: Infectious Disease was consulted; their recommendations were to stop IV Vancomycin on week 6 of 8 of therapy and to start Doxycycline Hyclate 100 mg PO Q12H PO (d1 [9-4]) for chronic suppressive therapy given his indwelling hardware. Plastic Surgery was consulted for serous wound drainage; their impression was that the wound was not infected and recommended to continue wound care and suppressive therapy without further changes. Patient will follow up with Plastics as an outpatient. - Continue Doxycycline (requires life long suppressive therapy) . # Anxiety: Patient become anxious at night, and states that he has fears regarding his estate planning and continued medical management. He was not given any benzodiazepines secondary to his history of hypercapnia. He was started on low dose olanzapine. - Continue olanzapine 2.5 mg - Please do not give benzodiazepines . Inactive Issues Upon Discharge: # Hypercapnia / Hypoxia: COPD = chronic retainer. Serial ABGs reassuring for decreased CO2, but O2 in 50s. Respiratory drive hypoxia driven. Normalized during hospitalization. - Please avoid central acting pain medications - Please avoid benzodiazepines . #Chronic Systolic Heart Failure: EF 30-35%, and mitral regurgitation, tricuspid regurgitaiton, and elevated PA systolic pressures. - Continue Metoprolol Succinate 100 mg daily - Continue Lisinopril 2.5 mg Daily . # CAD: - Continue Atorvastatin 10 mg PO/NG DAILY - Continue Aspirin 325 mg PO/NG DAILY . # AMS Change: Toxic metabolic delirium; hypoxia unlikely because AMS predated hypoxia. Likely multifactorial (low threshold given age, azotemia, ICU setting.) Resolved prior to discharge. . # Anemia: Stable during admission ~27. Normocytic. . # R LE swelling: Likely secondary to CHF; LENIs negative. . # Poor nutrition: A nutrition consult was placed. Albumin returned at 3. Speech and swallow cleared him for full solids and thin liquids. . # The patient remained full code during this admission. Medications on Admission: Atorvastatin 10 mg PO DAILY -Docusate Sodium 100 mg PO BID -Vancomycin in D5W 1 gram/200 mL. End date [9-17]. -Oxycodone 5 mg Tablet PO Q6H prn -Acetaminophen 1000 mg Tablet PO TID prn -Aspirin 325 mg Tablet PO DAILY -Metoprolol Tartrate 75 mg PO TID -Cholecalciferol 1000 unit PO DAILY -Calcium Carb 500mg [Hospital1 ] -Senna 17 mg Tablet PO HS and 8.6mg prn -MV 1 tab PO DAILY -Magnesium Hydroxide 400 mg/5 mL Suspension PO Q6H prn -Guaifenesin 100 mg/5 mL 5-10 MLs PO Q6H prn -Trazodone 50 mg PO HS prn -Sodium Chloride 0.65 % Aerosol, [12-9] Sprays Nasal TID prn -Clonazepam 0.5 mg PO BID scheduled and HS prn Anxiety. -Fluticasone 50 mcg/Actuation Spray [Hospital1 ] -Morphine 15 mg Tablet PO QHS HS prn SOB. -Morphine concentrated solution 4mg Q3H prn sob SL -Furosemide 80 mg PO BID, changed to 80AM and 40PM 2 days ago -DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution Q4H -Albuterol neb Q4H prn SOB -Bowel meds prn . Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 6. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insominia. 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-9] Sprays Nasal QID (4 times a day) as needed for dry nose. 13. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: [12-9] puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 14. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:0 15. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 16. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 17. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 18. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: ONLY TAKE ON DAYS THAT YOU DO NOT RECEIVE HEMODIALYSIS. Disp:30 Tablet(s) Refills:0 19. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day as needed for pain: pain at tunnelled site, please do not place over site or dressing. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Acute on chronic Diastolic congestive Heart failure exacerbation Acute kidney injury . Secondary: Coronary artery disease Hypertension dyslipidemia Pacemaker for complete heart block s/p recent sternal wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [Known lastname 14], It was a pleasure caring for you at [Hospital1 827]. You were admitted for worsening shortness of breath and also for decreasing kidney function. We helped remove fluid using medications and different types of dialysis. Unfortunately, your kidneys did not completely recover function and so we placed a hemodialysis catheter so that you can have hemodialysis as an outpatient. . Also while you were here, we started your antibiotic Doxycycline for your past chest wound infection. You will be on this indefinitely to prevent further infections. . We made the following changes to your medications: STOPPED Vancomycin and STARTED Doxycycline 100 mg twice daily STOPPED Metoprolol 75 mg three times daily and STARTED Toprol XL 100 mg daily. STOPPED Lasix. STARTED Lisinopril 2.5 mg daily (only take on days that you are not going to hemodialysis.) STOPPED Clonazepam and STARTED Olanzapine 2.5 mg daily. You were confused with clonazepam type medicine so we have discontinued them. STOPPED Fluticasone spray per your request . Your follow-up appointments are listed below. . Please also weigh yourself every morning before dialysis. Followup Instructions: HEMODIALYSIS: every Tues/Thurs/Sat . Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location: [Hospital1 1426] Plastic Surgery P.C. [Street Address(2) ], [Apartment Address(1) 1427] [Location (un) ], [Numeric Identifier 1428] Phone: ([Telephone/Fax (1) 1429] [9-20] at 4:15 PM . Department: INFECTIOUS DISEASE When: FRIDAY [2103-10-5] at 10:30 AM With: [Name6 (MD) 1423] [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 . Department: CARDIAC SERVICES When: Please call on Friday [9-14] for appt at number below With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2103-11-23] at 3:30 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2103-11-23] at 4:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2103-9-13]	Admission Date: <Date>1923-5-30</Date> Discharge Date: <Date>1992-2-24</Date> Date of Birth: <Date>1905-8-12</Date> Sex: M Service: MEDICINE Allergies: Penicillins / Quinolones / Cefazolin Attending:<Name>Nicki</Name> Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: CVVH Hemodialysis Tunneled HD catheter placement History of Present Illness: 84 yo m hx of CHF EF of 40% who was transfered form rehab due to worsening of SOB and ARF. He was recetly admitted from <Date Range>1997-6-29 to 2000-6-31</Date Range> and discharge to rehab. He was on lasix 80mg <Hospital>Murphy PLC Hospital</Hospital>, then 2 days ago, lasix was adjusted to 80mg AM and 40mg PM. Per rehab his Cr has been trendeding up and his dypsnea has been worsening. At discharge his Cr was 0.9, then 1.1 and now 2.2 today. UO has been decreased per pt. Wt gains of 2 lbs over last few days. . During his last hopsitalization he was treated for a sternal wound infection from his CABG on <Date>3-9</Date>. On <Date>11-14</Date> he had a debridement and wound closer, with pacer lead removal on <Date>11-14</Date>. Epicardial leads were paritally removed. Old PPM remained in place. He also had a flap closure. Culture of his infeciton showed MSSA. He developed AIN, so his antibiotics were changed to vancomycin. He will be on lifelong suppresive therapy after his regiment of IV therapy. Hardware in the sternum is in place. His stay was complicated by CHF and ARF from diuresis, later this improved to a Cr of 0.9 and he was sent to rehab. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. . In the ED, initial vitals were 96.8 67 128/58 20 94% 3L NC. Pt was given 250mg IVF over 2 hours. Pt's oxygen was increased to 4L. On transfer temp 97.9 67 120/45 18 96% 4 liters. CXR with pulm edema. Pt admitted to <Hospital>Hernandez-Baker Medical Center</Hospital>. . Past Medical History: -Coronary Artery Disease, s/p CABG (see below) -Hypertension -Hyperlipidemia -s/p St. <Name>Sandhya</Name> PPM for Third degree heart block <Date>10-13</Date> -Arthritis -Sleep apnea noted after administration of narcotics -Diverticulitis s/p Left hemicolectomy <Date>3-1970</Date> -s/p Back surgery <Year>1937</Year> -s/p Appendectomy -s/p Tonsillectomy -<Date>1958-5-7</Date> Sternal debridement, closure of the sternal wound dehiscence with four Synthes plates, bilateral pectoralis musculocutaneous advancement flap. -ARF due to questionable AIN due to cephalosporin or hemodynamically mediated ARF, in <Date>1905-4-16</Date> Social History: -Tobacco history: quit 25 yo ago -ETOH: 1 pint a day until CABG in <Date>3-9</Date> -Illicit drugs: none Lived with wife before going to rehab, now using a walker Family History: Noncontributory Physical Exam: GENERAL: Some tachypea with talking, otherwise NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at his chin while sitting at 45 degrees CARDIAC: Difficult to hear cardiac sounds, no murmur, sternal wound dressing in place small drainage LUNGS: Resp were slightly labored, pursed lip breathing, able to speak full sentences, no accessory muscle use. soft breath sounds, crackles half way up. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c. 2+ edema to the knees. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ radial, 2+ PT Pertient Discharge Physical Exam: General: NAD, <Name>Booker</Name> HEENT: NCAT, Slcera anicteric. Neck: Supple Res: Clear to ascultation posteriorly on the R, with decreased breath sounds at the left base. Chest: Sternal Wound: c/i, tunnel catheter in place with no erythema or tenderness. Suture in place. Pertinent Results: Pertinent Labs: . <Date>1923-5-30</Date> 04:40PM BLOOD WBC-9.2 RBC-2.99* Hgb-8.8* Hct-27.3* MCV-92 MCH-29.5 MCHC-32.2 RDW-16.1* Plt Ct-300 <Date>1946-7-13</Date> 06:08AM BLOOD PT-13.5* PTT-31.5 INR(PT)-1.1 <Date>1923-5-30</Date> 04:40PM BLOOD Glucose-99 UreaN-46* Creat-2.1* Na-137 K-5.7* Cl-98 HCO3-35* AnGap-10 <Date>1923-5-30</Date> 04:40PM BLOOD Albumin-3.0* Calcium-8.8 Phos-4.9* Mg-2.3 <Date>1946-7-13</Date> 06:08AM BLOOD Vanco-18.1 <Date>1920-2-28</Date> 05:15AM BLOOD Vanco-28.0* . <Date>6-22</Date> CXR: Studies: The patient's sternotomy fixators are unchanged in appearance. The pacemakerleads are unchanged in appearance as well. The temporary pacemaker leads projecting at the expected location of the left epicardium are unchanged as well. Left PICC line tip is obscured by the pacemaker but is most likely not extending beyond the junction of the axillary vein and the subclavian vein. Bilateral pleural effusions have slightly improved. Bibasilar atelectases are unchanged. . <Date>6-22</Date> LENIs: IMPRESSION: No evidence of deep vein thrombosis in the right leg. <Date>4-18</Date> CXR Portable chest is compared to multiple prior examinations. Sternal plates, dual-lead pacer is present. Mild-to-moderate congestive failure, new from prior study from <Date>1946-7-13</Date>. Right IJ Cordis terminates in the superior vena cava. No pneumothorax. ECHO <Date>2-17</Date>: EF 30-35%. Suboptimal image quality. Regional left ventricular systolic dysfunction c/w multivessel CAD. Pulmonary artery systolic hypertension. Severe tricuspid regurgitation. Mild-moderate mitral regurgitation. Compared with the prior study (images reviewed) of <Date>1976-9-22</Date>, regional left ventricular systolic dysfunction appears to be more extensive, and the severity of mitral regurgitation, tricuspid regurgitaiton, and PA systolic pressure are all increased. <Date>9-26</Date> AP-L & Decubitus CXR The decubitus images in both the left position show moderate bilateral pleural effusions. The right effusion is minimally more extensive than the left effusion. With respect to the sternal fixations, the size of the cardiac silhouette and the aspect of the lung parenchyma, today's images provide no new information. <Date>1-11</Date> Tunneled Catheter IMPRESSION: Uncomplicated placement of a tunneled hemodialysis catheter through the right internal jugular venous approach. The line is ready for use. <Date>8-30</Date> CXR: Summarized: Effusion on the Left, and decreased/absent Pleural Effusion on the R. For a full report, please see Radiology note. Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct <Date>1992-2-24</Date> 06:31 9.5 3.24* 9.4* 28.9* 89 29.2 32.7 15.9* 335 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap <Date>1992-2-24</Date> 06:31 1011 46 3.2* 136 3.8 100 28 12 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron <Date>1992-2-24</Date> 06:31 9.0 3.6 2.0 Brief Hospital Course: 84 yoM with hx of CAD s/p recent CABG c/b sternal wound MSSA infection, CHF and ARF, now presenting with dyspnea and <Name>Loveland</Name>. . Active Issues Upon Discharge: # <Name>Loveland</Name>: Thought to be multifactorial, with the underlying precipitant AIN secondary to the significant nephrotoxic antibiotic load the patient received for MSSA treatment; decreased effective circulatory volume due to CHF decompensation was likely to also be a contributor to pre-renal pathophysiology. On presentation, the patient was hyperkalemic, prompting the administration of Kayexalate, which normalized his potassium. Following consultation with Infectious Disease and Nephrology, IV vancomycin was stopped during the 6th of 8 weeks of treatment; at this time, the patient's vancomycin trough was supratherapeutic. To optimize volume status and forward flow, CVVH was started and continued until the patient was net -10L; the patient's home acetazolamide and furosemide were held. Hemodialysis was started and patient remained oliguric after two sessions. As a result, a tunneled hemodialysis catheter was placed and patient was set up for outpatient hemodialysis. Of note, he has made minimal urine during his hospital stay. His largest urine output was 250 cc. However, the day before discharge he had no urine output. - Leave R side suture above catheter in place until <Date>2005-12-8</Date>. - Dialysis as an outpatient. Last dialysis <Date>1992-2-24</Date>. . # Dyspnea: The patient was admitted with worsening heart failure symptoms with the most recent echo showing an EF of 40-45% in the setting of known COPD. Diuresis was initially attempted with IV Lasix and drip, but the patient was eventually transitioned to CVVH and diuresed aggressively with subsequent improvement of his clinical exam and symptoms; he remained rate controlled with metoprolol 50 mg TID (decreased from admission dose) and ACEi was held in the setting of <Name>Loveland</Name> but started upon discharge. During the hospitalization, he was kept on a COPD regimen of Guaifenesin, ipratropium / albuterol nebs, and fluticasone. CXR upon discharged showed L pleural effusion, with decreased/absent R pleural effusion. He has good ambulatory saturation and will require continued HD. It is expected that his left pleural effusion will decrease with continued HD. - HD as above . # MSSA Sternal wound infection: Infectious Disease was consulted; their recommendations were to stop IV Vancomycin on week 6 of 8 of therapy and to start Doxycycline Hyclate 100 mg PO Q12H PO (d1 <Date>11-23</Date>) for chronic suppressive therapy given his indwelling hardware. Plastic Surgery was consulted for serous wound drainage; their impression was that the wound was not infected and recommended to continue wound care and suppressive therapy without further changes. Patient will follow up with Plastics as an outpatient. - Continue Doxycycline (requires life long suppressive therapy) . # Anxiety: Patient become anxious at night, and states that he has fears regarding his estate planning and continued medical management. He was not given any benzodiazepines secondary to his history of hypercapnia. He was started on low dose olanzapine. - Continue olanzapine 2.5 mg - Please do not give benzodiazepines . Inactive Issues Upon Discharge: # Hypercapnia / Hypoxia: COPD = chronic retainer. Serial ABGs reassuring for decreased CO2, but O2 in 50s. Respiratory drive hypoxia driven. Normalized during hospitalization. - Please avoid central acting pain medications - Please avoid benzodiazepines . #Chronic Systolic Heart Failure: EF 30-35%, and mitral regurgitation, tricuspid regurgitaiton, and elevated PA systolic pressures. - Continue Metoprolol Succinate 100 mg daily - Continue Lisinopril 2.5 mg Daily . # CAD: - Continue Atorvastatin 10 mg PO/NG DAILY - Continue Aspirin 325 mg PO/NG DAILY . # AMS Change: Toxic metabolic delirium; hypoxia unlikely because AMS predated hypoxia. Likely multifactorial (low threshold given age, azotemia, ICU setting.) Resolved prior to discharge. . # Anemia: Stable during admission ~27. Normocytic. . # R LE swelling: Likely secondary to CHF; LENIs negative. . # Poor nutrition: A nutrition consult was placed. Albumin returned at 3. Speech and swallow cleared him for full solids and thin liquids. . # The patient remained full code during this admission. Medications on Admission: Atorvastatin 10 mg PO DAILY -Docusate Sodium 100 mg PO BID -Vancomycin in D5W 1 gram/200 mL. End date <Date>5-25</Date>. -Oxycodone 5 mg Tablet PO Q6H prn -Acetaminophen 1000 mg Tablet PO TID prn -Aspirin 325 mg Tablet PO DAILY -Metoprolol Tartrate 75 mg PO TID -Cholecalciferol 1000 unit PO DAILY -Calcium Carb 500mg <Hospital>Murphy PLC Hospital</Hospital> -Senna 17 mg Tablet PO HS and 8.6mg prn -MV 1 tab PO DAILY -Magnesium Hydroxide 400 mg/5 mL Suspension PO Q6H prn -Guaifenesin 100 mg/5 mL 5-10 MLs PO Q6H prn -Trazodone 50 mg PO HS prn -Sodium Chloride 0.65 % Aerosol, <Date>10-1</Date> Sprays Nasal TID prn -Clonazepam 0.5 mg PO BID scheduled and HS prn Anxiety. -Fluticasone 50 mcg/Actuation Spray <Hospital>Murphy PLC Hospital</Hospital> -Morphine 15 mg Tablet PO QHS HS prn SOB. -Morphine concentrated solution 4mg Q3H prn sob SL -Furosemide 80 mg PO BID, changed to 80AM and 40PM 2 days ago -DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution Q4H -Albuterol neb Q4H prn SOB -Bowel meds prn . Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 6. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insominia. 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: <Date>10-1</Date> Sprays Nasal QID (4 times a day) as needed for dry nose. 13. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: <Date>10-1</Date> puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 14. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:0 15. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 16. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 17. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 18. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: ONLY TAKE ON DAYS THAT YOU DO NOT RECEIVE HEMODIALYSIS. Disp:30 Tablet(s) Refills:0 19. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day as needed for pain: pain at tunnelled site, please do not place over site or dressing. Discharge Disposition: Extended Care Facility: <Hospital>Sherman LLC Clinic</Hospital> for the Aged - MACU Discharge Diagnosis: Primary: Acute on chronic Diastolic congestive Heart failure exacerbation Acute kidney injury . Secondary: Coronary artery disease Hypertension dyslipidemia Pacemaker for complete heart block s/p recent sternal wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr <Name>Smith</Name>, It was a pleasure caring for you at <Hospital>Stanton, Cunningham and Martinez Health System</Hospital>. You were admitted for worsening shortness of breath and also for decreasing kidney function. We helped remove fluid using medications and different types of dialysis. Unfortunately, your kidneys did not completely recover function and so we placed a hemodialysis catheter so that you can have hemodialysis as an outpatient. . Also while you were here, we started your antibiotic Doxycycline for your past chest wound infection. You will be on this indefinitely to prevent further infections. . We made the following changes to your medications: STOPPED Vancomycin and STARTED Doxycycline 100 mg twice daily STOPPED Metoprolol 75 mg three times daily and STARTED Toprol XL 100 mg daily. STOPPED Lasix. STARTED Lisinopril 2.5 mg daily (only take on days that you are not going to hemodialysis.) STOPPED Clonazepam and STARTED Olanzapine 2.5 mg daily. You were confused with clonazepam type medicine so we have discontinued them. STOPPED Fluticasone spray per your request . Your follow-up appointments are listed below. . Please also weigh yourself every morning before dialysis. Followup Instructions: HEMODIALYSIS: every Tues/Thurs/Sat . Dr. <Name>Michelle</Name> <Name>Shipley</Name> Location: <Hospital>Waters Group Health System</Hospital> Plastic Surgery P.C. <Location>345 Robert Ports East Teresaside, NE 93547</Location>, <Location>096 Gibson Trafficway New Donald, MT 43206</Location> <Location>71057 Susan Pass Suite 796 Lake Brendamouth, NM 93809</Location>, <Numeric Identifier>3304274</Numeric Identifier> Phone: (<Telephone>917-860-7887</Telephone> <Date>10-29</Date> at 4:15 PM . Department: INFECTIOUS DISEASE When: FRIDAY <Date>1921-2-15</Date> at 10:30 AM With: <Name>Gerald Deluna</Name> <Name>Logan Quinones</Name>, MD <Telephone>532-432-8871</Telephone> Building: LM <Hospital>Ortiz-Davis Clinic</Hospital> Bldg (<Name>Shipley</Name>) <Hospital>Vazquez-Jackson Medical Center</Hospital> Campus: WEST Best Parking: <Hospital>Ortiz-Davis Clinic</Hospital> Garage . Department: CARDIAC SERVICES When: Please call on Friday <Date>7-14</Date> for appt at number below With: <Name>Jessie</Name> <Name>Merino</Name>, M.D. <Telephone>646-263-6353</Telephone> Building: SC <Hospital>Ramos Ltd Health System</Hospital> Clinical Ctr <Location>71057 Susan Pass Suite 796 Lake Brendamouth, NM 93809</Location> Campus: EAST Best Parking: <Hospital>Ramos Ltd Health System</Hospital> Garage Department: CARDIAC SERVICES When: FRIDAY <Date>1970-4-4</Date> at 3:30 AM With: DEVICE CLINIC <Telephone>646-263-6353</Telephone> Building: SC <Hospital>Ramos Ltd Health System</Hospital> Clinical Ctr <Location>71057 Susan Pass Suite 796 Lake Brendamouth, NM 93809</Location> Campus: EAST Best Parking: <Hospital>Ramos Ltd Health System</Hospital> Garage Department: CARDIAC SERVICES When: FRIDAY <Date>1970-4-4</Date> at 4:00 PM With: <Name>Jessie</Name> <Name>Merino</Name>, M.D. <Telephone>646-263-6353</Telephone> Building: SC <Hospital>Ramos Ltd Health System</Hospital> Clinical Ctr <Location>71057 Susan Pass Suite 796 Lake Brendamouth, NM 93809</Location> Campus: EAST Best Parking: <Hospital>Ramos Ltd Health System</Hospital> Garage Completed 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Date: 1923-5-30 Discharge Date: 1992-2-24 Date of Birth: 1905-8-12 Sex: M Service: MEDICINE Allergies: Penicillins / Quinolones / Cefazolin Attending:Nicki Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: CVVH Hemodialysis Tunneled HD catheter placement History of Present Illness: 84 yo m hx of CHF EF of 40% who was transfered form rehab due to worsening of SOB and ARF. He was recetly admitted from 1997-6-29 to 2000-6-31 and discharge to rehab. He was on lasix 80mg Murphy PLC Hospital, then 2 days ago, lasix was adjusted to 80mg AM and 40mg PM. Per rehab his Cr has been trendeding up and his dypsnea has been worsening. At discharge his Cr was 0.9, then 1.1 and now 2.2 today. UO has been decreased per pt. Wt gains of 2 lbs over last few days. . During his last hopsitalization he was treated for a sternal wound infection from his CABG on 3-9. On 11-14 he had a debridement and wound closer, with pacer lead removal on 11-14. Epicardial leads were paritally removed. Old PPM remained in place. He also had a flap closure. Culture of his infeciton showed MSSA. He developed AIN, so his antibiotics were changed to vancomycin. He will be on lifelong suppresive therapy after his regiment of IV therapy. Hardware in the sternum is in place. His stay was complicated by CHF and ARF from diuresis, later this improved to a Cr of 0.9 and he was sent to rehab. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. . In the ED, initial vitals were 96.8 67 128/58 20 94% 3L NC. Pt was given 250mg IVF over 2 hours. Pt's oxygen was increased to 4L. On transfer temp 97.9 67 120/45 18 96% 4 liters. CXR with pulm edema. Pt admitted to Hernandez-Baker Medical Center. . Past Medical History: -Coronary Artery Disease, s/p CABG (see below) -Hypertension -Hyperlipidemia -s/p St. Sandhya PPM for Third degree heart block 10-13 -Arthritis -Sleep apnea noted after administration of narcotics -Diverticulitis s/p Left hemicolectomy 3-1970 -s/p Back surgery 1937 -s/p Appendectomy -s/p Tonsillectomy -1958-5-7 Sternal debridement, closure of the sternal wound dehiscence with four Synthes plates, bilateral pectoralis musculocutaneous advancement flap. -ARF due to questionable AIN due to cephalosporin or hemodynamically mediated ARF, in 1905-4-16 Social History: -Tobacco history: quit 25 yo ago -ETOH: 1 pint a day until CABG in 3-9 -Illicit drugs: none Lived with wife before going to rehab, now using a walker Family History: Noncontributory Physical Exam: GENERAL: Some tachypea with talking, otherwise NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at his chin while sitting at 45 degrees CARDIAC: Difficult to hear cardiac sounds, no murmur, sternal wound dressing in place small drainage LUNGS: Resp were slightly labored, pursed lip breathing, able to speak full sentences, no accessory muscle use. soft breath sounds, crackles half way up. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c. 2+ edema to the knees. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ radial, 2+ PT Pertient Discharge Physical Exam: General: NAD, Booker HEENT: NCAT, Slcera anicteric. Neck: Supple Res: Clear to ascultation posteriorly on the R, with decreased breath sounds at the left base. Chest: Sternal Wound: c/i, tunnel catheter in place with no erythema or tenderness. Suture in place. Pertinent Results: Pertinent Labs: . 1923-5-30 04:40PM BLOOD WBC-9.2 RBC-2.99* Hgb-8.8* Hct-27.3* MCV-92 MCH-29.5 MCHC-32.2 RDW-16.1* Plt Ct-300 1946-7-13 06:08AM BLOOD PT-13.5* PTT-31.5 INR(PT)-1.1 1923-5-30 04:40PM BLOOD Glucose-99 UreaN-46* Creat-2.1* Na-137 K-5.7* Cl-98 HCO3-35* AnGap-10 1923-5-30 04:40PM BLOOD Albumin-3.0* Calcium-8.8 Phos-4.9* Mg-2.3 1946-7-13 06:08AM BLOOD Vanco-18.1 1920-2-28 05:15AM BLOOD Vanco-28.0* . 6-22 CXR: Studies: The patient's sternotomy fixators are unchanged in appearance. The pacemakerleads are unchanged in appearance as well. The temporary pacemaker leads projecting at the expected location of the left epicardium are unchanged as well. Left PICC line tip is obscured by the pacemaker but is most likely not extending beyond the junction of the axillary vein and the subclavian vein. Bilateral pleural effusions have slightly improved. Bibasilar atelectases are unchanged. . 6-22 LENIs: IMPRESSION: No evidence of deep vein thrombosis in the right leg. 4-18 CXR Portable chest is compared to multiple prior examinations. Sternal plates, dual-lead pacer is present. Mild-to-moderate congestive failure, new from prior study from 1946-7-13. Right IJ Cordis terminates in the superior vena cava. No pneumothorax. ECHO 2-17: EF 30-35%. Suboptimal image quality. Regional left ventricular systolic dysfunction c/w multivessel CAD. Pulmonary artery systolic hypertension. Severe tricuspid regurgitation. Mild-moderate mitral regurgitation. Compared with the prior study (images reviewed) of 1976-9-22, regional left ventricular systolic dysfunction appears to be more extensive, and the severity of mitral regurgitation, tricuspid regurgitaiton, and PA systolic pressure are all increased. 9-26 AP-L & Decubitus CXR The decubitus images in both the left position show moderate bilateral pleural effusions. The right effusion is minimally more extensive than the left effusion. With respect to the sternal fixations, the size of the cardiac silhouette and the aspect of the lung parenchyma, today's images provide no new information. 1-11 Tunneled Catheter IMPRESSION: Uncomplicated placement of a tunneled hemodialysis catheter through the right internal jugular venous approach. The line is ready for use. 8-30 CXR: Summarized: Effusion on the Left, and decreased/absent Pleural Effusion on the R. For a full report, please see Radiology note. Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 1992-2-24 06:31 9.5 3.24* 9.4* 28.9* 89 29.2 32.7 15.9* 335 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap 1992-2-24 06:31 1011 46 3.2* 136 3.8 100 28 12 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron 1992-2-24 06:31 9.0 3.6 2.0 Brief Hospital Course: 84 yoM with hx of CAD s/p recent CABG c/b sternal wound MSSA infection, CHF and ARF, now presenting with dyspnea and Loveland. . Active Issues Upon Discharge: # Loveland: Thought to be multifactorial, with the underlying precipitant AIN secondary to the significant nephrotoxic antibiotic load the patient received for MSSA treatment; decreased effective circulatory volume due to CHF decompensation was likely to also be a contributor to pre-renal pathophysiology. On presentation, the patient was hyperkalemic, prompting the administration of Kayexalate, which normalized his potassium. Following consultation with Infectious Disease and Nephrology, IV vancomycin was stopped during the 6th of 8 weeks of treatment; at this time, the patient's vancomycin trough was supratherapeutic. To optimize volume status and forward flow, CVVH was started and continued until the patient was net -10L; the patient's home acetazolamide and furosemide were held. Hemodialysis was started and patient remained oliguric after two sessions. As a result, a tunneled hemodialysis catheter was placed and patient was set up for outpatient hemodialysis. Of note, he has made minimal urine during his hospital stay. His largest urine output was 250 cc. However, the day before discharge he had no urine output. - Leave R side suture above catheter in place until 2005-12-8. - Dialysis as an outpatient. Last dialysis 1992-2-24. . # Dyspnea: The patient was admitted with worsening heart failure symptoms with the most recent echo showing an EF of 40-45% in the setting of known COPD. Diuresis was initially attempted with IV Lasix and drip, but the patient was eventually transitioned to CVVH and diuresed aggressively with subsequent improvement of his clinical exam and symptoms; he remained rate controlled with metoprolol 50 mg TID (decreased from admission dose) and ACEi was held in the setting of Loveland but started upon discharge. During the hospitalization, he was kept on a COPD regimen of Guaifenesin, ipratropium / albuterol nebs, and fluticasone. CXR upon discharged showed L pleural effusion, with decreased/absent R pleural effusion. He has good ambulatory saturation and will require continued HD. It is expected that his left pleural effusion will decrease with continued HD. - HD as above . # MSSA Sternal wound infection: Infectious Disease was consulted; their recommendations were to stop IV Vancomycin on week 6 of 8 of therapy and to start Doxycycline Hyclate 100 mg PO Q12H PO (d1 11-23) for chronic suppressive therapy given his indwelling hardware. Plastic Surgery was consulted for serous wound drainage; their impression was that the wound was not infected and recommended to continue wound care and suppressive therapy without further changes. Patient will follow up with Plastics as an outpatient. - Continue Doxycycline (requires life long suppressive therapy) . # Anxiety: Patient become anxious at night, and states that he has fears regarding his estate planning and continued medical management. He was not given any benzodiazepines secondary to his history of hypercapnia. He was started on low dose olanzapine. - Continue olanzapine 2.5 mg - Please do not give benzodiazepines . Inactive Issues Upon Discharge: # Hypercapnia / Hypoxia: COPD = chronic retainer. Serial ABGs reassuring for decreased CO2, but O2 in 50s. Respiratory drive hypoxia driven. Normalized during hospitalization. - Please avoid central acting pain medications - Please avoid benzodiazepines . #Chronic Systolic Heart Failure: EF 30-35%, and mitral regurgitation, tricuspid regurgitaiton, and elevated PA systolic pressures. - Continue Metoprolol Succinate 100 mg daily - Continue Lisinopril 2.5 mg Daily . # CAD: - Continue Atorvastatin 10 mg PO/NG DAILY - Continue Aspirin 325 mg PO/NG DAILY . # AMS Change: Toxic metabolic delirium; hypoxia unlikely because AMS predated hypoxia. Likely multifactorial (low threshold given age, azotemia, ICU setting.) Resolved prior to discharge. . # Anemia: Stable during admission ~27. Normocytic. . # R LE swelling: Likely secondary to CHF; LENIs negative. . # Poor nutrition: A nutrition consult was placed. Albumin returned at 3. Speech and swallow cleared him for full solids and thin liquids. . # The patient remained full code during this admission. Medications on Admission: Atorvastatin 10 mg PO DAILY -Docusate Sodium 100 mg PO BID -Vancomycin in D5W 1 gram/200 mL. End date 5-25. -Oxycodone 5 mg Tablet PO Q6H prn -Acetaminophen 1000 mg Tablet PO TID prn -Aspirin 325 mg Tablet PO DAILY -Metoprolol Tartrate 75 mg PO TID -Cholecalciferol 1000 unit PO DAILY -Calcium Carb 500mg Murphy PLC Hospital -Senna 17 mg Tablet PO HS and 8.6mg prn -MV 1 tab PO DAILY -Magnesium Hydroxide 400 mg/5 mL Suspension PO Q6H prn -Guaifenesin 100 mg/5 mL 5-10 MLs PO Q6H prn -Trazodone 50 mg PO HS prn -Sodium Chloride 0.65 % Aerosol, 10-1 Sprays Nasal TID prn -Clonazepam 0.5 mg PO BID scheduled and HS prn Anxiety. -Fluticasone 50 mcg/Actuation Spray Murphy PLC Hospital -Morphine 15 mg Tablet PO QHS HS prn SOB. -Morphine concentrated solution 4mg Q3H prn sob SL -Furosemide 80 mg PO BID, changed to 80AM and 40PM 2 days ago -DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution Q4H -Albuterol neb Q4H prn SOB -Bowel meds prn . Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 6. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insominia. 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: 10-1 Sprays Nasal QID (4 times a day) as needed for dry nose. 13. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: 10-1 puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 14. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:0 15. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 16. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 17. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 18. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: ONLY TAKE ON DAYS THAT YOU DO NOT RECEIVE HEMODIALYSIS. Disp:30 Tablet(s) Refills:0 19. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day as needed for pain: pain at tunnelled site, please do not place over site or dressing. Discharge Disposition: Extended Care Facility: Sherman LLC Clinic for the Aged - MACU Discharge Diagnosis: Primary: Acute on chronic Diastolic congestive Heart failure exacerbation Acute kidney injury . Secondary: Coronary artery disease Hypertension dyslipidemia Pacemaker for complete heart block s/p recent sternal wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr Smith, It was a pleasure caring for you at Stanton, Cunningham and Martinez Health System. You were admitted for worsening shortness of breath and also for decreasing kidney function. We helped remove fluid using medications and different types of dialysis. Unfortunately, your kidneys did not completely recover function and so we placed a hemodialysis catheter so that you can have hemodialysis as an outpatient. . Also while you were here, we started your antibiotic Doxycycline for your past chest wound infection. You will be on this indefinitely to prevent further infections. . We made the following changes to your medications: STOPPED Vancomycin and STARTED Doxycycline 100 mg twice daily STOPPED Metoprolol 75 mg three times daily and STARTED Toprol XL 100 mg daily. STOPPED Lasix. STARTED Lisinopril 2.5 mg daily (only take on days that you are not going to hemodialysis.) STOPPED Clonazepam and STARTED Olanzapine 2.5 mg daily. You were confused with clonazepam type medicine so we have discontinued them. STOPPED Fluticasone spray per your request . Your follow-up appointments are listed below. . Please also weigh yourself every morning before dialysis. Followup Instructions: HEMODIALYSIS: every Tues/Thurs/Sat . Dr. Michelle Shipley Location: Waters Group Health System Plastic Surgery P.C. 345 Robert Ports East Teresaside, NE 93547, 096 Gibson Trafficway New Donald, MT 43206 71057 Susan Pass Suite 796 Lake Brendamouth, NM 93809, 3304274 Phone: (917-860-7887 10-29 at 4:15 PM . Department: INFECTIOUS DISEASE When: FRIDAY 1921-2-15 at 10:30 AM With: Gerald Deluna Logan Quinones, MD 532-432-8871 Building: LM Ortiz-Davis Clinic Bldg (Shipley) Vazquez-Jackson Medical Center Campus: WEST Best Parking: Ortiz-Davis Clinic Garage . Department: CARDIAC SERVICES When: Please call on Friday 7-14 for appt at number below With: Jessie Merino, M.D. 646-263-6353 Building: SC Ramos Ltd Health System Clinical Ctr 71057 Susan Pass Suite 796 Lake Brendamouth, NM 93809 Campus: EAST Best Parking: Ramos Ltd Health System Garage Department: CARDIAC SERVICES When: FRIDAY 1970-4-4 at 3:30 AM With: DEVICE CLINIC 646-263-6353 Building: SC Ramos Ltd Health System Clinical Ctr 71057 Susan Pass Suite 796 Lake Brendamouth, NM 93809 Campus: EAST Best Parking: Ramos Ltd Health System Garage Department: CARDIAC SERVICES When: FRIDAY 1970-4-4 at 4:00 PM With: Jessie Merino, M.D. 646-263-6353 Building: SC Ramos Ltd Health System Clinical Ctr 71057 Susan Pass Suite 796 Lake Brendamouth, NM 93809 Campus: EAST Best Parking: Ramos Ltd Health System Garage Completed by:1992-2-24	['Admission Date: 1923-5-30 Discharge Date: 1992-2-24\n\nDate of Birth: 1905-8-12 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPenicillins / Quinolones / Cefazolin\n\nAttending:Nicki\nChief Complaint:\nDyspnea\n\nMajor Surgical or Invasive Procedure:\nCVVH\nHemodialysis\nTunneled HD catheter placement\n\nHistory of Present Illness:\n84 yo m hx of CHF EF of 40% who was transfered form rehab due to\nworsening of SOB and ARF. He was recetly admitted from\n1997-6-29 to 2000-6-31 and discharge to rehab. He was on lasix 80mg Murphy PLC Hospital, then\n2 days ago, lasix was adjusted to 80mg AM and 40mg PM. Per rehab\nhis Cr has been trendeding up and his dypsnea has been\nworsening. At discharge his Cr was 0.9, then 1.1 and now 2.2\ntoday. UO has been decreased per pt. Wt gains of 2 lbs over last\nfew days.', '\n.\nDuring his last hopsitalization he was treated for a sternal\nwound infection from his CABG on 3-9. On 11-14 he had a\ndebridement and wound closer, with pacer lead removal on 11-14.\nEpicardial leads were paritally removed. Old PPM remained in\nplace. He also had a flap closure. Culture of his infeciton\nshowed MSSA. He developed AIN, so his antibiotics were changed\nto vancomycin. He will be on lifelong suppresive therapy after\nhis regiment of IV therapy. Hardware in the sternum is in place.\nHis stay was complicated by CHF and ARF from diuresis, later\nthis improved to a Cr of 0.9 and he was sent to rehab.\n.\nOn review of systems, he denies any prior history of stroke,\nTIA, deep venous thrombosis, pulmonary embolism, bleeding at the\ntime of surgery, myalgias, cough, hemoptysis, black stools or\nred stools.', " Denies recent fevers, chills or rigors. All of the\nother review of systems were negative.\n.\nCardiac review of systems is notable for absence of chest pain,\npalpitations, syncope or presyncope.\n.\nIn the ED, initial vitals were 96.8 67 128/58 20 94% 3L NC. Pt\nwas given 250mg IVF over 2 hours. Pt's oxygen was increased to\n4L. On transfer temp 97.9 67 120/45 18 96% 4 liters. CXR with\npulm edema. Pt admitted to Hernandez-Baker Medical Center.\n.\n\nPast Medical History:\n-Coronary Artery Disease, s/p CABG (see below)\n-Hypertension\n-Hyperlipidemia\n-s/p St. Sandhya PPM for Third degree heart block 10-13\n-Arthritis\n-Sleep apnea noted after administration of narcotics\n-Diverticulitis s/p Left hemicolectomy 3-1970\n-s/p Back surgery 1937\n-s/p Appendectomy\n-s/p Tonsillectomy\n-1958-5-7 Sternal debridement, closure of the sternal wound\ndehiscence with four Synthes plates, bilateral pectoralis\nmusculocutaneous advancement flap.", '\n-ARF due to questionable AIN due to cephalosporin or\nhemodynamically mediated ARF, in 1905-4-16\n\nSocial History:\n-Tobacco history: quit 25 yo ago\n-ETOH: 1 pint a day until CABG in 3-9\n-Illicit drugs: none\nLived with wife before going to rehab, now using a walker\n\nFamily History:\nNoncontributory\n\nPhysical Exam:\nGENERAL: Some tachypea with talking, otherwise NAD. Oriented x3.\nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were\npink, no pallor or cyanosis of the oral mucosa. No xanthalesma.\n\nNECK: Supple with JVP at his chin while sitting at 45 degrees\nCARDIAC: Difficult to hear cardiac sounds, no murmur, sternal\nwound dressing in place small drainage\nLUNGS: Resp were slightly labored, pursed lip breathing, able to\nspeak full sentences, no accessory muscle use. soft breath\nsounds, crackles half way up.', '\nABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n\nEXTREMITIES: No c/c. 2+ edema to the knees.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES: 2+ radial, 2+ PT\n\nPertient Discharge Physical Exam:\nGeneral: NAD, Booker\nHEENT: NCAT, Slcera anicteric.\nNeck: Supple\nRes: Clear to ascultation posteriorly on the R, with decreased\nbreath sounds at the left base.\nChest: Sternal Wound: c/i, tunnel catheter in place with no\nerythema or tenderness. Suture in place.\n\n\nPertinent Results:\nPertinent Labs:\n.\n1923-5-30 04:40PM BLOOD WBC-9.2 RBC-2.99* Hgb-8.8* Hct-27.3\nMCV-92 MCH-29.5 MCHC-32.2 RDW-16.1 Plt Ct-300\n1946-7-13 06:08AM BLOOD PT-13.5* PTT-31.5 INR(PT)-1.1\n1923-5-30 04:40PM BLOOD Glucose-99 UreaN-46* Creat-2.1* Na-137\nK-5.7* Cl-98 HCO3-35* AnGap-10\n1923-5-30 04:40PM BLOOD Albumin-3.', "0* Calcium-8.8 Phos-4.9* Mg-2.3\n1946-7-13 06:08AM BLOOD Vanco-18.1\n1920-2-28 05:15AM BLOOD Vanco-28.0\n.\n6-22 CXR:\nStudies:\nThe patient's sternotomy fixators are unchanged in appearance.\nThe pacemakerleads are unchanged in appearance as well. The\ntemporary pacemaker leads projecting at the expected location of\nthe left epicardium are unchanged as well. Left PICC line tip is\nobscured by the pacemaker but is most likely not extending\nbeyond the junction of the axillary vein and the subclavian\nvein. Bilateral pleural effusions have slightly improved.\nBibasilar atelectases are unchanged.\n.\n6-22 LENIs:\nIMPRESSION: No evidence of deep vein thrombosis in the right\nleg.\n\n4-18 CXR\nPortable chest is compared to multiple prior examinations.\nSternal plates,\ndual-lead pacer is present. Mild-to-moderate congestive failure,\nnew from\nprior study from 1946-7-13.", " Right IJ Cordis terminates in the\nsuperior vena cava. No pneumothorax.\n\nECHO 2-17: EF 30-35%. Suboptimal image quality. Regional left\nventricular systolic dysfunction c/w multivessel CAD. Pulmonary\nartery systolic hypertension. Severe tricuspid regurgitation.\nMild-moderate mitral regurgitation. Compared with the prior\nstudy (images reviewed) of 1976-9-22, regional left ventricular\nsystolic dysfunction appears to be more extensive, and the\nseverity of mitral regurgitation, tricuspid regurgitaiton, and\nPA systolic pressure are all increased.\n\n9-26 AP-L & Decubitus CXR\nThe decubitus images in both the left position show moderate\nbilateral pleural effusions. The right effusion is minimally\nmore extensive than the left effusion. With respect to the\nsternal fixations, the size of the cardiac silhouette and the\naspect of the lung parenchyma, today's images\nprovide no new information.", '\n\n1-11 Tunneled Catheter\nIMPRESSION: Uncomplicated placement of a tunneled hemodialysis\ncatheter\nthrough the right internal jugular venous approach. The line is\nready for\nuse.\n\n8-30 CXR: Summarized: Effusion on the Left, and decreased/absent\nPleural Effusion on the R. For a full report, please see\nRadiology note.\n\nDischarge Labs:\nCOMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct\n1992-2-24 06:31 9.5 3.24 9.4* 28.9* 89 29.2 32.7 15.9* 335\nRENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap\n1992-2-24 06:31 1011 46 3.2* 136 3.8 100 28 12\nCHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron\n1992-2-24 06:31 9.0 3.6 2.0\n\n\nBrief Hospital Course:\n84 yoM with hx of CAD s/p recent CABG c/b sternal wound MSSA\ninfection, CHF and ARF, now presenting with dyspnea and Loveland.', "\n.\nActive Issues Upon Discharge:\n# Loveland: Thought to be multifactorial, with the underlying\nprecipitant AIN secondary to the significant nephrotoxic\nantibiotic load the patient received for MSSA treatment;\ndecreased effective circulatory volume due to CHF decompensation\nwas likely to also be a contributor to pre-renal\npathophysiology. On presentation, the patient was hyperkalemic,\nprompting the administration of Kayexalate, which normalized his\npotassium. Following consultation with Infectious Disease and\nNephrology, IV vancomycin was stopped during the 6th of 8 weeks\nof treatment; at this time, the patient's vancomycin trough was\nsupratherapeutic. To optimize volume status and forward flow,\nCVVH was started and continued until the patient was net -10L;\nthe patient's home acetazolamide and furosemide were held.", '\nHemodialysis was started and patient remained oliguric after two\nsessions. As a result, a tunneled hemodialysis catheter was\nplaced and patient was set up for outpatient hemodialysis.\nOf note, he has made minimal urine during his hospital stay.\nHis largest urine output was 250 cc. However, the day before\ndischarge he had no urine output.\n- Leave R side suture above catheter in place until 2005-12-8.\n- Dialysis as an outpatient. Last dialysis 1992-2-24.\n.\n# Dyspnea: The patient was admitted with worsening heart failure\nsymptoms with the most recent echo showing an EF of 40-45% in\nthe setting of known COPD. Diuresis was initially attempted with\nIV Lasix and drip, but the patient was eventually transitioned\nto CVVH and diuresed aggressively with subsequent improvement of\nhis clinical exam and symptoms; he remained rate controlled with\nmetoprolol 50 mg TID (decreased from admission dose) and ACEi\nwas held in the setting of Loveland but started upon discharge.', '\nDuring the hospitalization, he was kept on a COPD regimen of\nGuaifenesin, ipratropium / albuterol nebs, and fluticasone. CXR\nupon discharged showed L pleural effusion, with decreased/absent\nR pleural effusion. He has good ambulatory saturation and will\nrequire continued HD. It is expected that his left pleural\neffusion will decrease with continued HD.\n- HD as above\n.\n# MSSA Sternal wound infection: Infectious Disease was\nconsulted; their recommendations were to stop IV Vancomycin on\nweek 6 of 8 of therapy and to start Doxycycline Hyclate 100 mg\nPO Q12H PO (d1 11-23) for chronic suppressive therapy given his\nindwelling hardware. Plastic Surgery was consulted for serous\nwound drainage; their impression was that the wound was not\ninfected and recommended to continue wound care and suppressive\ntherapy without further changes.', ' Patient will follow up with\nPlastics as an outpatient.\n- Continue Doxycycline (requires life long suppressive therapy)\n.\n# Anxiety: Patient become anxious at night, and states that he\nhas fears regarding his estate planning and continued medical\nmanagement. He was not given any benzodiazepines secondary to\nhis history of hypercapnia. He was started on low dose\nolanzapine.\n- Continue olanzapine 2.5 mg\n- Please do not give benzodiazepines\n.\nInactive Issues Upon Discharge:\n# Hypercapnia / Hypoxia: COPD = chronic retainer. Serial ABGs\nreassuring for decreased CO2, but O2 in 50s. Respiratory drive\nhypoxia driven. Normalized during hospitalization.\n- Please avoid central acting pain medications\n- Please avoid benzodiazepines\n.\n#Chronic Systolic Heart Failure: EF 30-35%, and mitral\nregurgitation, tricuspid regurgitaiton, and elevated PA systolic\npressures.', '\n- Continue Metoprolol Succinate 100 mg daily\n- Continue Lisinopril 2.5 mg Daily\n.\n# CAD:\n- Continue Atorvastatin 10 mg PO/NG DAILY\n- Continue Aspirin 325 mg PO/NG DAILY\n.\n# AMS Change: Toxic metabolic delirium; hypoxia unlikely because\nAMS predated hypoxia. Likely multifactorial (low threshold given\nage, azotemia, ICU setting.) Resolved prior to discharge.\n.\n# Anemia: Stable during admission ~27. Normocytic.\n.\n# R LE swelling: Likely secondary to CHF; LENIs negative.\n.\n# Poor nutrition: A nutrition consult was placed. Albumin\nreturned at 3. Speech and swallow cleared him for full solids\nand thin liquids.\n.\n# The patient remained full code during this admission.\n\nMedications on Admission:\nAtorvastatin 10 mg PO DAILY\n-Docusate Sodium 100 mg PO BID\n-Vancomycin in D5W 1 gram/200 mL. End date 5-25.', '\n-Oxycodone 5 mg Tablet PO Q6H prn\n-Acetaminophen 1000 mg Tablet PO TID prn\n-Aspirin 325 mg Tablet PO DAILY\n-Metoprolol Tartrate 75 mg PO TID\n-Cholecalciferol 1000 unit PO DAILY\n-Calcium Carb 500mg Murphy PLC Hospital\n-Senna 17 mg Tablet PO HS and 8.6mg prn\n-MV 1 tab PO DAILY\n-Magnesium Hydroxide 400 mg/5 mL Suspension PO Q6H prn\n-Guaifenesin 100 mg/5 mL 5-10 MLs PO Q6H prn\n-Trazodone 50 mg PO HS prn\n-Sodium Chloride 0.65 % Aerosol, 10-1 Sprays Nasal TID prn\n-Clonazepam 0.5 mg PO BID scheduled and HS prn Anxiety.\n-Fluticasone 50 mcg/Actuation Spray Murphy PLC Hospital\n-Morphine 15 mg Tablet PO QHS HS prn SOB.\n-Morphine concentrated solution 4mg Q3H prn sob SL\n-Furosemide 80 mg PO BID, changed to 80AM and 40PM 2 days ago\n-DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution Q4H\n-Albuterol neb Q4H prn SOB\n-Bowel meds prn\n.', '\n\nDischarge Medications:\n1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day) as needed for constipation.\n3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every\n6 hours) as needed for pain.\n4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n5. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)\nTablet PO once a day.\n6. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One\n(1) Tablet, Chewable PO BID (2 times a day).\n7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as\nneeded for constipation.\n8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\nML PO Q6H (every 6 hours) as needed for constipation.', '\n10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6\nhours) as needed for cough.\n11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime) as needed for insominia.\n12. Sodium Chloride 0.65 % Aerosol, Spray Sig: 10-1 Sprays Nasal\nQID (4 times a day) as needed for dry nose.\n13. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for\nNebulization Sig: 10-1 puff Inhalation every four (4) hours as\nneeded for shortness of breath or wheezing.\n14. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO\nQ12H (every 12 hours).\nDisp:60 Capsule(s) Refills:0\n15. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization\nSig: One (1) Inhalation every four (4) hours as needed for\nshortness of breath or wheezing.\n16. metoprolol succinate 100 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO once a day.', '\nDisp:30 Tablet Sustained Release 24 hr(s) Refills:0\n17. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:0\n18. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:\nONLY TAKE ON DAYS THAT YOU DO NOT RECEIVE HEMODIALYSIS.\nDisp:30 Tablet(s) Refills:0\n19. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:\nOne (1) patch Topical once a day as needed for pain: pain at\ntunnelled site, please do not place over site or dressing.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nSherman LLC Clinic for the Aged - MACU\n\nDischarge Diagnosis:\nPrimary:\nAcute on chronic Diastolic congestive Heart failure exacerbation\nAcute kidney injury\n.\nSecondary:\nCoronary artery disease\nHypertension\ndyslipidemia\nPacemaker for complete heart block\ns/p recent sternal wound infection\n\n\nDischarge Condition:\nMental Status: Clear and coherent.', '\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker\nor cane).\n\n\nDischarge Instructions:\nDear Mr Smith,\nIt was a pleasure caring for you at Stanton, Cunningham and Martinez Health System. You were admitted for worsening shortness of\nbreath and also for decreasing kidney function. We helped remove\nfluid using medications and different types of dialysis.\nUnfortunately, your kidneys did not completely recover function\nand so we placed a hemodialysis catheter so that you can have\nhemodialysis as an outpatient.\n.\nAlso while you were here, we started your antibiotic Doxycycline\nfor your past chest wound infection. You will be on this\nindefinitely to prevent further infections.\n.\nWe made the following changes to your medications:\nSTOPPED Vancomycin and STARTED Doxycycline 100 mg twice daily\nSTOPPED Metoprolol 75 mg three times daily and STARTED Toprol XL\n100 mg daily.', '\nSTOPPED Lasix.\nSTARTED Lisinopril 2.5 mg daily (only take on days that you are\nnot going to hemodialysis.)\nSTOPPED Clonazepam and STARTED Olanzapine 2.5 mg daily. You were\nconfused with clonazepam type medicine so we have discontinued\nthem.\nSTOPPED Fluticasone spray per your request\n.\nYour follow-up appointments are listed below.\n.\nPlease also weigh yourself every morning before dialysis.\n\nFollowup Instructions:\nHEMODIALYSIS: every Tues/Thurs/Sat\n.\nDr. Michelle Shipley\nLocation: Waters Group Health System Plastic Surgery P.C.\n345 Robert Ports\nEast Teresaside, NE 93547, 096 Gibson Trafficway\nNew Donald, MT 43206\n71057 Susan Pass Suite 796\nLake Brendamouth, NM 93809, 3304274\nPhone: (917-860-7887\n10-29 at 4:15 PM\n.\nDepartment: INFECTIOUS DISEASE\nWhen: FRIDAY 1921-2-15 at 10:30 AM\nWith: Gerald Deluna Logan Quinones, MD 532-432-8871\nBuilding: LM Ortiz-Davis Clinic Bldg (Shipley) Vazquez-Jackson Medical Center\nCampus: WEST Best Parking: Ortiz-Davis Clinic Garage\n.', '\nDepartment: CARDIAC SERVICES\nWhen: Please call on Friday 7-14 for appt at number below\nWith: Jessie Merino, M.D. 646-263-6353\nBuilding: SC Ramos Ltd Health System Clinical Ctr 71057 Susan Pass Suite 796\nLake Brendamouth, NM 93809\nCampus: EAST Best Parking: Ramos Ltd Health System Garage\n\nDepartment: CARDIAC SERVICES\nWhen: FRIDAY 1970-4-4 at 3:30 AM\nWith: DEVICE CLINIC 646-263-6353\nBuilding: SC Ramos Ltd Health System Clinical Ctr 71057 Susan Pass Suite 796\nLake Brendamouth, NM 93809\nCampus: EAST Best Parking: Ramos Ltd Health System Garage\n\nDepartment: CARDIAC SERVICES\nWhen: FRIDAY 1970-4-4 at 4:00 PM\nWith: Jessie Merino, M.D. 646-263-6353\nBuilding: SC Ramos Ltd Health System Clinical Ctr 71057 Susan Pass Suite 796\nLake Brendamouth, NM 93809\nCampus: EAST Best Parking: Ramos Ltd Health System Garage\n\n\n\nCompleted by:1992-2-24']
136	2003	181620.0	2139-02-05	Discharge summary	Report	Admission Date: [2139-2-4] Discharge Date: [2139-2-5] Date of Birth: [2078-10-16] Sex: M Service: MEDICINE Allergies: Diltiazem Attending:[First Name3 (LF) 1436] Chief Complaint: Epigastric pressure Major Surgical or Invasive Procedure: Cardiac catheterization with stent placed in the Left anterior descending artery. History of Present Illness: 60 M with PMH HTN, GERD presents with epigastric pressure x 2 weeks. Pain feels different from GERD, pressure-like, "under the xiphoid process", moderate severity, not associated with food or position. Worse with exertion (lifting objects or taking out trash), but started occurring at rest. Does not radiate. No CP, no SOB, no palps, no F/C/N/V/D, no diaphoresis. +frequent belching. Pt thought he bruised his sternum or pulled something. . He visited his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 1437] due to epigastric pressure, and saw Dr. [Last Name (STitle) 1438]. EKG showed T wave inversions anterolaterally, new compared with an EKG from [2137]. He was sent to the ED, T97, 107, RR 18, 139/87, 96% RA. EKG showed NSR, TWI V1-V6 and AVF. CXR negative, abdominal US showed fatty liver and fatty pancreas. . CK 113, MB 5, Troponin I 0.61 (normal 0-0.4), so MI likely at least 5 days old. Cr 1.1. He was treated with ASA, lopressor, NTP, and a heparin infusion. Last ETT was approximately 4 years ago, reportedly normal. Transferred from [Hospital ] Hospital for cardiac cath. Past Medical History: PMH: HTN GERD Osteoarthritis affecting lower back Left elbow tendonitis . PSH: Right inguinal hernia repair in childhood Cervical discectomy 3 years ago Umbilical hernia repair [2137] Social History: SHx: Retired schoolteacher, now substitutes. Lives with wife in [Location (un) 1439]. Has a 27 yo son and a 25 yo daughter. [Name (NI) ] past or present smoking hx, no EtOH Family History: Father had a fatal MI age 86. Physical Exam: 97.7 / 107/70 / 17 / 97 / 97% RA Gen: Nauseated, lying in bed post-cath HEENT: No JVD, no LAD, OP clear Lungs: CTA B Heart: RRR, no m/r/g Abdomen: Soft, +BS, ND, NT Groin: No hematoma, no bruit Extr: No c/c/e Neuro: [4-3] motor, 2+ DP bilaterally Pertinent Results: LABS: From OSH: INR 1.0 CK 113, MB 5 Trop I 0.61 Total chol 162 HDL 25 LDL 111 Triglycerides 224 . EKG: NSR 64, TWI V3-V6. . Abdomimal US: Fatty liver and fatty pancreas. . Cath: DES to LAD x3 LMCA - wnl LAD - 90% eccentric proximal; 90-95% mid-distal stenoses with TIMI 2 distal flow LCX - OM1 70% tubular; 50% mid-LCX before OM2/3 bifurcation RCA - 60% origin, large PL branch with 30% stenosis . . [2139-2-4] 06:47PM GLUCOSE-161* UREA N-15 CREAT-1.1 SODIUM-136 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16 [2139-2-4] 06:47PM CALCIUM-9.1 PHOSPHATE-2.4* MAGNESIUM-1.8 [2139-2-4] 06:47PM WBC-17.3* RBC-5.62 HGB-17.0 HCT-46.5 MCV-83 MCH-30.3 MCHC-36.6* RDW-13.2 [2139-2-4] 06:47PM PLT COUNT-247 [2139-2-4] 06:47PM PT-14.2* PTT-40.3* INR(PT)-1.3* [2139-2-4] 03:40PM GLUCOSE-175* UREA N-16 CREAT-1.1 SODIUM-135 POTASSIUM-2.9* CHLORIDE-103 TOTAL CO2-21* ANION GAP-14 [2139-2-4] 03:39PM TYPE-ART PO2-106* PCO2-34* PH-7.42 TOTAL CO2-23 BASE XS--1 [2139-2-4] 03:39PM HGB-16.3 calcHCT-49 O2 SAT-98 [2139-2-4] 03:07PM TYPE-ART PO2-229* PCO2-47* PH-7.27* TOTAL CO2-23 BASE XS--5 [2139-2-4] 03:07PM K+-2.6* [2139-2-4] 03:07PM HGB-14.2 calcHCT-43 O2 SAT-98 Brief Hospital Course: 60 M with PMH HTN, GERD presents with 3VD, DES to LAD x3, stenosis in LCX and RCA. . # Anaphylaxis to Diltiazem: During cardiac cath, pt was treated with diltiazem, to which he developed difficulty breathing. He was treated with benadryl, steroids, and H2 blockers, with resolution of shortness of [Year/Month/Day 1440]. Pt's symptoms resolved in the cath lab, and he did not require further treatment in the CCU. . # Cardiac: Cath showed: LMCA - wnl LAD - 90% eccentric proximal; 90-95% mid-distal stenoses with TIMI 2 distal flow LCX - OM1 70% tubular; 50% mid-LCX before OM2/3 bifurcation RCA - 60% origin, large PL branch with 30% stenosis . Pt was placed on integrilin post-cath, ASA, plavix, statin, BB. Pt was euvolemic, and TTE showed EF > 55%, LV thickness, LV cavity size, LV systolic function, and LV wall motion were all normal. Pt remained in NSR throughout admission on tele. . # GERD: Pt was placed on H2 blocker during admission for epigastric burning that resolved within hours. . # Osteoarthritis: Pt's osteoarthritis was inactive in house. . # DVT ppx: Pt was placed on heparin sc inhouse. Medications on Admission: Medications at Home: HCTZ 25 QD Diovan 160 QD Prilosec QD Mobic for OA pain (NSAID) . Medications started at OSH: ASA 325 QD Heparin gtt, 850 units/hr NTP Lopressor 25 [Hospital1 ] Plavix 300 mg x 1 on [2-3]. . ALL: NKDA Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Non ST elevation myocardial infarction Discharge Condition: Good. Patient pain free, ambulating without difficulty. Discharge Instructions: Please contact physician if develop chest pain/pressure, shortness of [Last Name (LF) 1440], [First Name3 (LF) 691] other questions/concerns. . Please take medications as directed. Do NOT stop Plavix or aspirin without talking to your cardiologist. Do NOT take diovan or hydrochlorothiazide (HCTZ) unless directed to re-start by your cardiologist. Your metoprolol dose will continue to be adjusted by your outpatient cardiologist to obtain optimum heart rate and blood pressure control. . Please follow up with appointments as directed. . Please refrain from heavy lifting or vigorous activity for 5 days. . Please refrain from driving for 3 days. Followup Instructions: Please follow up with your cardiologist in [12-1] weeks. . Please follow up with your primary care physician [Last Name (NamePattern4) ] [1-3] weeks. . Follow up with Dr. [Last Name (STitle) 1441] [Name (STitle) ] in one month. Completed by:[2139-2-22]	Admission Date: <Date>1922-7-15</Date> Discharge Date: <Date>1924-2-8</Date> Date of Birth: <Date>1959-12-30</Date> Sex: M Service: MEDICINE Allergies: Diltiazem Attending:<Name>Wade</Name> Chief Complaint: Epigastric pressure Major Surgical or Invasive Procedure: Cardiac catheterization with stent placed in the Left anterior descending artery. History of Present Illness: 60 M with PMH HTN, GERD presents with epigastric pressure x 2 weeks. Pain feels different from GERD, pressure-like, "under the xiphoid process", moderate severity, not associated with food or position. Worse with exertion (lifting objects or taking out trash), but started occurring at rest. Does not radiate. No CP, no SOB, no palps, no F/C/N/V/D, no diaphoresis. +frequent belching. Pt thought he bruised his sternum or pulled something. . He visited his PCP <Name>Miller</Name>. <Name>Amaro</Name> due to epigastric pressure, and saw Dr. <Name>Atencio</Name>. EKG showed T wave inversions anterolaterally, new compared with an EKG from <Year>1926</Year>. He was sent to the ED, T97, 107, RR 18, 139/87, 96% RA. EKG showed NSR, TWI V1-V6 and AVF. CXR negative, abdominal US showed fatty liver and fatty pancreas. . CK 113, MB 5, Troponin I 0.61 (normal 0-0.4), so MI likely at least 5 days old. Cr 1.1. He was treated with ASA, lopressor, NTP, and a heparin infusion. Last ETT was approximately 4 years ago, reportedly normal. Transferred from <Hospital>Ward, Lewis and Johnson Medical Center</Hospital> Hospital for cardiac cath. Past Medical History: PMH: HTN GERD Osteoarthritis affecting lower back Left elbow tendonitis . PSH: Right inguinal hernia repair in childhood Cervical discectomy 3 years ago Umbilical hernia repair <Year>1926</Year> Social History: SHx: Retired schoolteacher, now substitutes. Lives with wife in <Location>71311 Robert Flats Herreraland, SC 65082</Location>. Has a 27 yo son and a 25 yo daughter. <Name>Danilo Hasan</Name> past or present smoking hx, no EtOH Family History: Father had a fatal MI age 86. Physical Exam: 97.7 / 107/70 / 17 / 97 / 97% RA Gen: Nauseated, lying in bed post-cath HEENT: No JVD, no LAD, OP clear Lungs: CTA B Heart: RRR, no m/r/g Abdomen: Soft, +BS, ND, NT Groin: No hematoma, no bruit Extr: No c/c/e Neuro: <Date>10-13</Date> motor, 2+ DP bilaterally Pertinent Results: LABS: From OSH: INR 1.0 CK 113, MB 5 Trop I 0.61 Total chol 162 HDL 25 LDL 111 Triglycerides 224 . EKG: NSR 64, TWI V3-V6. . Abdomimal US: Fatty liver and fatty pancreas. . Cath: DES to LAD x3 LMCA - wnl LAD - 90% eccentric proximal; 90-95% mid-distal stenoses with TIMI 2 distal flow LCX - OM1 70% tubular; 50% mid-LCX before OM2/3 bifurcation RCA - 60% origin, large PL branch with 30% stenosis . . <Date>1922-7-15</Date> 06:47PM GLUCOSE-161* UREA N-15 CREAT-1.1 SODIUM-136 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16 <Date>1922-7-15</Date> 06:47PM CALCIUM-9.1 PHOSPHATE-2.4* MAGNESIUM-1.8 <Date>1922-7-15</Date> 06:47PM WBC-17.3* RBC-5.62 HGB-17.0 HCT-46.5 MCV-83 MCH-30.3 MCHC-36.6* RDW-13.2 <Date>1922-7-15</Date> 06:47PM PLT COUNT-247 <Date>1922-7-15</Date> 06:47PM PT-14.2* PTT-40.3* INR(PT)-1.3* <Date>1922-7-15</Date> 03:40PM GLUCOSE-175* UREA N-16 CREAT-1.1 SODIUM-135 POTASSIUM-2.9* CHLORIDE-103 TOTAL CO2-21* ANION GAP-14 <Date>1922-7-15</Date> 03:39PM TYPE-ART PO2-106* PCO2-34* PH-7.42 TOTAL CO2-23 BASE XS--1 <Date>1922-7-15</Date> 03:39PM HGB-16.3 calcHCT-49 O2 SAT-98 <Date>1922-7-15</Date> 03:07PM TYPE-ART PO2-229* PCO2-47* PH-7.27* TOTAL CO2-23 BASE XS--5 <Date>1922-7-15</Date> 03:07PM K+-2.6* <Date>1922-7-15</Date> 03:07PM HGB-14.2 calcHCT-43 O2 SAT-98 Brief Hospital Course: 60 M with PMH HTN, GERD presents with 3VD, DES to LAD x3, stenosis in LCX and RCA. . # Anaphylaxis to Diltiazem: During cardiac cath, pt was treated with diltiazem, to which he developed difficulty breathing. He was treated with benadryl, steroids, and H2 blockers, with resolution of shortness of <Year>1932</Year>. Pt's symptoms resolved in the cath lab, and he did not require further treatment in the CCU. . # Cardiac: Cath showed: LMCA - wnl LAD - 90% eccentric proximal; 90-95% mid-distal stenoses with TIMI 2 distal flow LCX - OM1 70% tubular; 50% mid-LCX before OM2/3 bifurcation RCA - 60% origin, large PL branch with 30% stenosis . Pt was placed on integrilin post-cath, ASA, plavix, statin, BB. Pt was euvolemic, and TTE showed EF > 55%, LV thickness, LV cavity size, LV systolic function, and LV wall motion were all normal. Pt remained in NSR throughout admission on tele. . # GERD: Pt was placed on H2 blocker during admission for epigastric burning that resolved within hours. . # Osteoarthritis: Pt's osteoarthritis was inactive in house. . # DVT ppx: Pt was placed on heparin sc inhouse. Medications on Admission: Medications at Home: HCTZ 25 QD Diovan 160 QD Prilosec QD Mobic for OA pain (NSAID) . Medications started at OSH: ASA 325 QD Heparin gtt, 850 units/hr NTP Lopressor 25 <Hospital>Wall PLC Clinic</Hospital> Plavix 300 mg x 1 on <Date>7-28</Date>. . ALL: NKDA Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Non ST elevation myocardial infarction Discharge Condition: Good. Patient pain free, ambulating without difficulty. Discharge Instructions: Please contact physician if develop chest pain/pressure, shortness of <Name>Kiel</Name>, <Name>Indira</Name> other questions/concerns. . Please take medications as directed. Do NOT stop Plavix or aspirin without talking to your cardiologist. Do NOT take diovan or hydrochlorothiazide (HCTZ) unless directed to re-start by your cardiologist. Your metoprolol dose will continue to be adjusted by your outpatient cardiologist to obtain optimum heart rate and blood pressure control. . Please follow up with appointments as directed. . Please refrain from heavy lifting or vigorous activity for 5 days. . Please refrain from driving for 3 days. Followup Instructions: Please follow up with your cardiologist in <Date>3-17</Date> weeks. . Please follow up with your primary care physician <Name>Miller</Name> <Date>4-30</Date> weeks. . Follow up with Dr. <Name>Loveland</Name> <Name>Felecia Deluna</Name> in one month. Completed by:<Date>1917-11-6</Date>	000000000000000001111111110000000000000000000000000000000011111111000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100111110000000000000000000000000000000000000000011111110000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111111111000000000000000000000000000000000000000011111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000011111111100000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1922-7-15 Discharge Date: 1924-2-8 Date of Birth: 1959-12-30 Sex: M Service: MEDICINE Allergies: Diltiazem Attending:Wade Chief Complaint: Epigastric pressure Major Surgical or Invasive Procedure: Cardiac catheterization with stent placed in the Left anterior descending artery. History of Present Illness: 60 M with PMH HTN, GERD presents with epigastric pressure x 2 weeks. Pain feels different from GERD, pressure-like, "under the xiphoid process", moderate severity, not associated with food or position. Worse with exertion (lifting objects or taking out trash), but started occurring at rest. Does not radiate. No CP, no SOB, no palps, no F/C/N/V/D, no diaphoresis. +frequent belching. Pt thought he bruised his sternum or pulled something. . He visited his PCP Miller. Amaro due to epigastric pressure, and saw Dr. Atencio. EKG showed T wave inversions anterolaterally, new compared with an EKG from 1926. He was sent to the ED, T97, 107, RR 18, 139/87, 96% RA. EKG showed NSR, TWI V1-V6 and AVF. CXR negative, abdominal US showed fatty liver and fatty pancreas. . CK 113, MB 5, Troponin I 0.61 (normal 0-0.4), so MI likely at least 5 days old. Cr 1.1. He was treated with ASA, lopressor, NTP, and a heparin infusion. Last ETT was approximately 4 years ago, reportedly normal. Transferred from Ward, Lewis and Johnson Medical Center Hospital for cardiac cath. Past Medical History: PMH: HTN GERD Osteoarthritis affecting lower back Left elbow tendonitis . PSH: Right inguinal hernia repair in childhood Cervical discectomy 3 years ago Umbilical hernia repair 1926 Social History: SHx: Retired schoolteacher, now substitutes. Lives with wife in 71311 Robert Flats Herreraland, SC 65082. Has a 27 yo son and a 25 yo daughter. Danilo Hasan past or present smoking hx, no EtOH Family History: Father had a fatal MI age 86. Physical Exam: 97.7 / 107/70 / 17 / 97 / 97% RA Gen: Nauseated, lying in bed post-cath HEENT: No JVD, no LAD, OP clear Lungs: CTA B Heart: RRR, no m/r/g Abdomen: Soft, +BS, ND, NT Groin: No hematoma, no bruit Extr: No c/c/e Neuro: 10-13 motor, 2+ DP bilaterally Pertinent Results: LABS: From OSH: INR 1.0 CK 113, MB 5 Trop I 0.61 Total chol 162 HDL 25 LDL 111 Triglycerides 224 . EKG: NSR 64, TWI V3-V6. . Abdomimal US: Fatty liver and fatty pancreas. . Cath: DES to LAD x3 LMCA - wnl LAD - 90% eccentric proximal; 90-95% mid-distal stenoses with TIMI 2 distal flow LCX - OM1 70% tubular; 50% mid-LCX before OM2/3 bifurcation RCA - 60% origin, large PL branch with 30% stenosis . . 1922-7-15 06:47PM GLUCOSE-161* UREA N-15 CREAT-1.1 SODIUM-136 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16 1922-7-15 06:47PM CALCIUM-9.1 PHOSPHATE-2.4* MAGNESIUM-1.8 1922-7-15 06:47PM WBC-17.3* RBC-5.62 HGB-17.0 HCT-46.5 MCV-83 MCH-30.3 MCHC-36.6* RDW-13.2 1922-7-15 06:47PM PLT COUNT-247 1922-7-15 06:47PM PT-14.2* PTT-40.3* INR(PT)-1.3* 1922-7-15 03:40PM GLUCOSE-175* UREA N-16 CREAT-1.1 SODIUM-135 POTASSIUM-2.9* CHLORIDE-103 TOTAL CO2-21* ANION GAP-14 1922-7-15 03:39PM TYPE-ART PO2-106* PCO2-34* PH-7.42 TOTAL CO2-23 BASE XS--1 1922-7-15 03:39PM HGB-16.3 calcHCT-49 O2 SAT-98 1922-7-15 03:07PM TYPE-ART PO2-229* PCO2-47* PH-7.27* TOTAL CO2-23 BASE XS--5 1922-7-15 03:07PM K+-2.6* 1922-7-15 03:07PM HGB-14.2 calcHCT-43 O2 SAT-98 Brief Hospital Course: 60 M with PMH HTN, GERD presents with 3VD, DES to LAD x3, stenosis in LCX and RCA. . # Anaphylaxis to Diltiazem: During cardiac cath, pt was treated with diltiazem, to which he developed difficulty breathing. He was treated with benadryl, steroids, and H2 blockers, with resolution of shortness of 1932. Pt's symptoms resolved in the cath lab, and he did not require further treatment in the CCU. . # Cardiac: Cath showed: LMCA - wnl LAD - 90% eccentric proximal; 90-95% mid-distal stenoses with TIMI 2 distal flow LCX - OM1 70% tubular; 50% mid-LCX before OM2/3 bifurcation RCA - 60% origin, large PL branch with 30% stenosis . Pt was placed on integrilin post-cath, ASA, plavix, statin, BB. Pt was euvolemic, and TTE showed EF > 55%, LV thickness, LV cavity size, LV systolic function, and LV wall motion were all normal. Pt remained in NSR throughout admission on tele. . # GERD: Pt was placed on H2 blocker during admission for epigastric burning that resolved within hours. . # Osteoarthritis: Pt's osteoarthritis was inactive in house. . # DVT ppx: Pt was placed on heparin sc inhouse. Medications on Admission: Medications at Home: HCTZ 25 QD Diovan 160 QD Prilosec QD Mobic for OA pain (NSAID) . Medications started at OSH: ASA 325 QD Heparin gtt, 850 units/hr NTP Lopressor 25 Wall PLC Clinic Plavix 300 mg x 1 on 7-28. . ALL: NKDA Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Non ST elevation myocardial infarction Discharge Condition: Good. Patient pain free, ambulating without difficulty. Discharge Instructions: Please contact physician if develop chest pain/pressure, shortness of Kiel, Indira other questions/concerns. . Please take medications as directed. Do NOT stop Plavix or aspirin without talking to your cardiologist. Do NOT take diovan or hydrochlorothiazide (HCTZ) unless directed to re-start by your cardiologist. Your metoprolol dose will continue to be adjusted by your outpatient cardiologist to obtain optimum heart rate and blood pressure control. . Please follow up with appointments as directed. . Please refrain from heavy lifting or vigorous activity for 5 days. . Please refrain from driving for 3 days. Followup Instructions: Please follow up with your cardiologist in 3-17 weeks. . Please follow up with your primary care physician Miller 4-30 weeks. . Follow up with Dr. Loveland Felecia Deluna in one month. Completed by:1917-11-6	['Admission Date: 1922-7-15 Discharge Date: 1924-2-8\n\nDate of Birth: 1959-12-30 Sex: M\n\nService: MEDICINE\n\nAllergies:\nDiltiazem\n\nAttending:Wade\nChief Complaint:\nEpigastric pressure\n\nMajor Surgical or Invasive Procedure:\nCardiac catheterization with stent placed in the Left anterior\ndescending artery.\n\n\nHistory of Present Illness:\n60 M with PMH HTN, GERD presents with epigastric pressure x 2\nweeks. Pain feels different from GERD, pressure-like, "under the\nxiphoid process", moderate severity, not associated with food or\nposition. Worse with exertion (lifting objects or taking out\ntrash), but started occurring at rest. Does not radiate. No CP,\nno SOB, no palps, no F/C/N/V/D, no diaphoresis. +frequent\nbelching. Pt thought he bruised his sternum or pulled something.\n\n.', '\nHe visited his PCP Miller. Amaro due to epigastric pressure, and\nsaw Dr. Atencio. EKG showed T wave inversions anterolaterally,\nnew\ncompared with an EKG from 1926. He was sent to the ED, T97, 107,\nRR 18, 139/87, 96% RA. EKG showed NSR, TWI V1-V6 and AVF. CXR\nnegative, abdominal US showed fatty liver and fatty pancreas.\n.\nCK 113, MB 5, Troponin I 0.61 (normal 0-0.4), so MI likely at\nleast 5 days old. Cr 1.1. He was treated with ASA, lopressor,\nNTP, and a heparin infusion. Last ETT was approximately 4 years\nago, reportedly normal. Transferred from Ward, Lewis and Johnson Medical Center Hospital for\ncardiac cath.\n\nPast Medical History:\nPMH:\nHTN\nGERD\nOsteoarthritis affecting lower back\nLeft elbow tendonitis\n.\nPSH:\nRight inguinal hernia repair in childhood\nCervical discectomy 3 years ago\nUmbilical hernia repair 1926\n\nSocial History:\nSHx: Retired schoolteacher, now substitutes.', ' Lives with wife in\n\n71311 Robert Flats\nHerreraland, SC 65082. Has a 27 yo son and a 25 yo daughter. Danilo Hasan past or present\nsmoking hx, no EtOH\n\nFamily History:\nFather had a fatal MI age 86.\n\nPhysical Exam:\n97.7 / 107/70 / 17 / 97 / 97% RA\nGen: Nauseated, lying in bed post-cath\nHEENT: No JVD, no LAD, OP clear\nLungs: CTA B\nHeart: RRR, no m/r/g\nAbdomen: Soft, +BS, ND, NT\nGroin: No hematoma, no bruit\nExtr: No c/c/e\nNeuro: 10-13 motor, 2+ DP bilaterally\n\nPertinent Results:\nLABS:\nFrom OSH:\nINR 1.0\nCK 113, MB 5\nTrop I 0.61\nTotal chol 162\nHDL 25\nLDL 111\nTriglycerides 224\n.\nEKG: NSR 64, TWI V3-V6.\n.\nAbdomimal US: Fatty liver and fatty pancreas.\n.\nCath: DES to LAD x3\nLMCA - wnl\nLAD - 90% eccentric proximal; 90-95% mid-distal stenoses with\nTIMI 2 distal flow\nLCX - OM1 70% tubular; 50% mid-LCX before OM2/3 bifurcation\nRCA - 60% origin, large PL branch with 30% stenosis\n.', '\n.\n1922-7-15 06:47PM GLUCOSE-161* UREA N-15 CREAT-1.1 SODIUM-136\nPOTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16\n1922-7-15 06:47PM CALCIUM-9.1 PHOSPHATE-2.4* MAGNESIUM-1.8\n1922-7-15 06:47PM WBC-17.3* RBC-5.62 HGB-17.0 HCT-46.5 MCV-83\nMCH-30.3 MCHC-36.6* RDW-13.2\n1922-7-15 06:47PM PLT COUNT-247\n1922-7-15 06:47PM PT-14.2* PTT-40.3* INR(PT)-1.3\n1922-7-15 03:40PM GLUCOSE-175 UREA N-16 CREAT-1.1 SODIUM-135\nPOTASSIUM-2.9* CHLORIDE-103 TOTAL CO2-21* ANION GAP-14\n1922-7-15 03:39PM TYPE-ART PO2-106* PCO2-34* PH-7.42 TOTAL\nCO2-23 BASE XS--1\n1922-7-15 03:39PM HGB-16.3 calcHCT-49 O2 SAT-98\n1922-7-15 03:07PM TYPE-ART PO2-229* PCO2-47* PH-7.27* TOTAL\nCO2-23 BASE XS--5\n1922-7-15 03:07PM K+-2.6\n1922-7-15 03:07PM HGB-14.2 calcHCT-43 O2 SAT-98\n\nBrief Hospital Course:\n60 M with PMH HTN, GERD presents with 3VD, DES to LAD x3,\nstenosis in LCX and RCA.', "\n.\n# Anaphylaxis to Diltiazem:\nDuring cardiac cath, pt was treated with diltiazem, to which he\ndeveloped difficulty breathing. He was treated with benadryl,\nsteroids, and H2 blockers, with resolution of shortness of\n1932. Pt's symptoms resolved in the cath lab, and he did not\nrequire further treatment in the CCU.\n.\n# Cardiac:\nCath showed:\nLMCA - wnl\nLAD - 90% eccentric proximal; 90-95% mid-distal stenoses with\nTIMI 2 distal flow\nLCX - OM1 70% tubular; 50% mid-LCX before OM2/3 bifurcation\nRCA - 60% origin, large PL branch with 30% stenosis\n.\nPt was placed on integrilin post-cath, ASA, plavix, statin, BB.\nPt was euvolemic, and TTE showed EF > 55%, LV thickness, LV\ncavity size, LV systolic function, and LV wall motion were all\nnormal. Pt remained in NSR throughout admission on tele.\n.\n# GERD:\nPt was placed on H2 blocker during admission for epigastric\nburning that resolved within hours.", "\n.\n# Osteoarthritis:\nPt's osteoarthritis was inactive in house.\n.\n# DVT ppx:\nPt was placed on heparin sc inhouse.\n\nMedications on Admission:\nMedications at Home:\nHCTZ 25 QD\nDiovan 160 QD\nPrilosec QD\nMobic for OA pain (NSAID)\n.\nMedications started at OSH:\nASA 325 QD\nHeparin gtt, 850 units/hr\nNTP\nLopressor 25 Wall PLC Clinic\nPlavix 300 mg x 1 on 7-28.\n.\nALL: NKDA\n\nDischarge Medications:\n1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\nDisp:30 Tablet, Delayed Release (E.C.)(s)* Refills:2\n2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:2\n3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\nDisp:60 Tablet(s) Refills:2\n4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).", '\nDisp:30 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nNon ST elevation myocardial infarction\n\n\nDischarge Condition:\nGood. Patient pain free, ambulating without difficulty.\n\n\nDischarge Instructions:\nPlease contact physician if develop chest pain/pressure,\nshortness of Kiel, Indira other questions/concerns.\n.\nPlease take medications as directed. Do NOT stop Plavix or\naspirin without talking to your cardiologist. Do NOT take\ndiovan or hydrochlorothiazide (HCTZ) unless directed to re-start\nby your cardiologist. Your metoprolol dose will continue to be\nadjusted by your outpatient cardiologist to obtain optimum heart\nrate and blood pressure control.\n.\nPlease follow up with appointments as directed.\n.\nPlease refrain from heavy lifting or vigorous activity for 5\ndays.', '\n.\nPlease refrain from driving for 3 days.\n\nFollowup Instructions:\nPlease follow up with your cardiologist in 3-17 weeks.\n.\nPlease follow up with your primary care physician Miller 4-30 weeks.\n.\nFollow up with Dr. Loveland Felecia Deluna in one month.\n\n\n\nCompleted by:1917-11-6']
137	5895	191223.0	2170-01-04	Discharge summary	Report	Admission Date: [2169-12-30] Discharge Date: Date of Birth: [2136-10-31] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: This is a 33-year-old female with a history of obesity, developmental delay, seizure disorder, depression, and ventricular septal defect who presented with a chief complaint of shortness of breath to the [Hospital1 69] Emergency Department on [12-30] after being initially evaluated at [Hospital3 1442] Hospital. The patient's symptoms began on [12-25] with five days of cough, temperatures to 101 Fahrenheit, shortness of breath, and wheezing. She went to her primary care physician three days prior to admission where the temperature was measured at 102.2 Fahrenheit, and after chest x-ray was negative for infiltrate she was diagnosed with bronchitis and treated with Bactrim-DS. She took this for three days, but on the day of admission the patient was found a home health aide to be increasingly short of breath, and the patient was taken to [Hospital3 1443] Hospital where she was satting 92% on 4 liters nasal cannula. A chest x-ray showed right lower lobe infiltrate. The patient was given 125 mg of Solu-Medrol, nebulizers, ceftriaxone 1 g and transferred to the [Hospital1 1444] where she was admitted to the Medical Intensive Care Unit. There, the patient was found to be 87% on 4 liters nasal cannula which improved to 93% on 100% face mask. The patient's saturations fell to 90% on 100% face mask and BiPAP 14/4 was tried. However, the patient did not tolerate the BiPAP well despite the fact that the saturations came back to approximately 95%. REVIEW OF SYSTEMS: On review of systems the patient has no history of asthma but is a heavy smoker at two to three packs per day for many years. Her membranous ventricular septal defect was diagnosed on cardiac echocardiogram performed in [2164]. PAST MEDICAL HISTORY: 1. Obesity. 2. Developmental delay. 3. Seizure disorder, status post motor vehicle accident. 4. Depression. 5. Ventricular septal defect. 6. Auditory hallucinations. 7. Melanoma on chest, status post excision. ALLERGIES: RISPERIDONE causing nausea. MEDICATIONS ON ADMISSION: Outpatient medications include Colace 100 mg p.o. b.i.d., Dilantin 300 mg p.o. q.a.m. and 400 mg p.o. q.p.m., Lactase 3 tablets p.o. t.i.d. with meals, lorazepam 0.5 mg p.o. t.i.d. p.r.n., perphenazine 4 mg p.o. t.i.d., venlafaxine 150 mg p.o. q.d., Zyprexa 10 mg p.o. t.i.d., Bactrim-DS since [12-27], Senna. SOCIAL HISTORY: A two to three pack per day smoker. Lives alone with home health services and advocate. FAMILY HISTORY: Breast cancer. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 99.2 Fahrenheit, heart rate 110, blood pressure 140s/50s, respirations 28 to 36, oxygen saturation 93% on 100% face mask. In general, alert, lying in bed, obese, in moderate respiratory distress. Head, ears, nose, eyes and throat revealed mucous membranes were moist. No lymphadenopathy. Heart was tachycardic but regular. No murmurs, rubs or gallops. Pulmonary revealed diffuse rhonchi, right greater than left, prolonged expiratory phase with wheezing diffusely. Abdomen was soft, nontender, and nondistended, with normal active bowel sounds. Extremities had no edema, no palpable cords, 2+ bilateral peripheral pulses. LABORATORY DATA ON PRESENTATION: White blood cell count 8.3, hematocrit 34.3, platelets 176, mean cell volume 88. Coagulations were INR 1.3, PTT 26.3, PT 13.5. Chem-7 as follows: Sodium of 134, potassium 3.3, chloride 96, bicarbonate 25, blood urea nitrogen 7, creatinine 0.6, with a glucose of 144. AST 28, ALT 31, alkaline phosphatase 207, total bilirubin 0.2. Urinalysis was nitrite negative, 6 to 10 red blood cells, 0 white blood cells, and rare bacteria. Arterial blood gas on 100% face mask was pH of 7.46, CO2 39, O2 56. RADIOLOGY/IMAGING: Chest x-ray revealed questions of right lower lobe infiltrate. Electrocardiogram from outside hospital with normal sinus rhythm at 110. No ST-T wave segment changes. HOSPITAL COURSE: 1. PULMONARY: The patient was admitted to the Medical Intensive Care Unit where she was found to wheezing, probably secondary to bronchospasm. Her saturations fell to 90% on 100% face mask. At this point arterial blood gas was sent revealing 7.46/39/56. The patient was started on BiPAP; however, she did not tolerated secondary to discomfort even though her saturations increased to approximately 95%. She was treated with Solu-Medrol 60 mg intravenously q.6h., albuterol nebulizers, and given ceftriaxone 1 g, followed by azithromycin 500 mg times one. At this point the patient's shortness of breath was subjectively improved, and the patient was transferred to the floor with an oxygen saturation of 92% to 95% on 100% nonrebreather. On the floor the patient's hypoxemia was thought to be secondary to viral etiology supported by the fact that she had only one day of sputum which cleared rapidly, either bronchospasm secondary to acute bronchitis, or viral-induced asthma seemed to have developed. The patient was maintained on azithromycin 250 mg times four days to complete the course and also continued initially on Solu-Medrol 60 mg q.6h. Albuterol and Atrovent nebulizers were continued. An echocardiogram with bubble study was performed to determine whether the patient had hypoxic pulmonary vasoconstriction resulting in reversal of her ventricular septal defect and thereby increasing her oxygen requirement, but this study was negative for ventricular septal defect. Dr. [Last Name (STitle) 1445] from Cardiology read the echocardiogram and felt that the ventricular septal defect had either closed completely or was too small to be functionally significant. On [1-2] Solu-Medrol was replaced with prednisone 60 mg p.o. q.d. and Flovent 2 puffs b.i.d. for loading purposes. Albuterol and Atrovent inhalers were started for beta agonist and anticholinergic activity, and the patient was taught in their use. Her oxygen saturation stabilized to the point where she was 92% to 94% on room air, peak flows increased from 150 to the 250 to the 350 range. Physical Therapy saw the patient, and the patient was able to walk well with an oxygen saturation going into the 89% to 92% on room air. At this point it was agreed she was ready for discharge. It was recommended that influenza vaccine be considered in this patient once she has recovered completely from her acute illness to prevent further episodes. Further use of peak flow monitoring and an initial set of pulmonary function tests would be useful as well; particularly if the patient does well and pulmonary function tests show minimal obstructive disease, treatment of her bronchospasm may need to be modified. 2. GASTROINTESTINAL: The patient was initially n.p.o. except medications, but her diet was advanced as tolerated. 3. PSYCHIATRY: Perphenazine, Zyprexa, and venlafaxine were continued. The patient reported no hallucinations or signs of depression in house. 4. NEUROLOGY: Dilantin level was high at 22.4 on admission. On [1-2] it was rechecked and found to be 20.4. It was held for the duration of her stay. No seizure activity was noted in house. 5. ACCESS: Peripheral IV. 6. PROPHYLAXIS: Protonix, Pneumo boots, encouragement out of bed to chair, physical therapy. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To home with services and physical therapy. MEDICATIONS ON DISCHARGE: 1. Prednisone taper 40 mg p.o. q.d. times three days; then 20 mg p.o. q.d. times three days; then 10 mg p.o. q.d. times three days; then 5 mg p.o. q.d. times three days; then off. 2. Albuterol inhaler 2 puffs to 4 puffs q.i.d. 3. Atrovent inhaler 2 puffs to 4 puffs q.i.d. 4. Flovent inhaler 2 puffs b.i.d. 5. Dilantin 300 mg p.o. q.a.m. and 400 mg p.o. q.p.m. 6. Colace 100 mg p.o. b.i.d. 7. Perphenazine 4 mg p.o. t.i.d. 8. Venlafaxine 150 mg p.o. q.d. 9. Zyprexa 10 mg p.o. t.i.d. 10. Lactase 3 tablets p.o. t.i.d. with meals. 11. Lorazepam 0.5 mg p.o. t.i.d. p.r.n. 12. Senna. DISCHARGE FOLLOWUP: The patient was to follow up with primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 1446] [Last Name (NamePattern1) ] within one to two weeks' time. [First Name11 (Name Pattern1) 640] [Initial (NamePattern1) ] [Last Name (NamePattern1) 1447], M.D. [MD Number(1) 1448] Dictated By:[Name8 (MD) 1449] MEDQUIST36 D: [2170-1-4] 15:33 T: [2170-1-10] 06:21 JOB#: [Job Number 1450]	Admission Date: <Date>1982-3-22</Date> Discharge Date: Date of Birth: <Date>2017-6-1</Date> Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: This is a 33-year-old female with a history of obesity, developmental delay, seizure disorder, depression, and ventricular septal defect who presented with a chief complaint of shortness of breath to the <Hospital>Smith, Hoover and Cantu Medical Center</Hospital> Emergency Department on <Date>5-31</Date> after being initially evaluated at <Hospital>Stanton-Harris Clinic</Hospital> Hospital. The patient's symptoms began on <Date>4-19</Date> with five days of cough, temperatures to 101 Fahrenheit, shortness of breath, and wheezing. She went to her primary care physician three days prior to admission where the temperature was measured at 102.2 Fahrenheit, and after chest x-ray was negative for infiltrate she was diagnosed with bronchitis and treated with Bactrim-DS. She took this for three days, but on the day of admission the patient was found a home health aide to be increasingly short of breath, and the patient was taken to <Hospital>Russell-Hicks Medical Center</Hospital> Hospital where she was satting 92% on 4 liters nasal cannula. A chest x-ray showed right lower lobe infiltrate. The patient was given 125 mg of Solu-Medrol, nebulizers, ceftriaxone 1 g and transferred to the <Hospital>Mendez-Kemp Clinic</Hospital> where she was admitted to the Medical Intensive Care Unit. There, the patient was found to be 87% on 4 liters nasal cannula which improved to 93% on 100% face mask. The patient's saturations fell to 90% on 100% face mask and BiPAP 14/4 was tried. However, the patient did not tolerate the BiPAP well despite the fact that the saturations came back to approximately 95%. REVIEW OF SYSTEMS: On review of systems the patient has no history of asthma but is a heavy smoker at two to three packs per day for many years. Her membranous ventricular septal defect was diagnosed on cardiac echocardiogram performed in <Year>2014</Year>. PAST MEDICAL HISTORY: 1. Obesity. 2. Developmental delay. 3. Seizure disorder, status post motor vehicle accident. 4. Depression. 5. Ventricular septal defect. 6. Auditory hallucinations. 7. Melanoma on chest, status post excision. ALLERGIES: RISPERIDONE causing nausea. MEDICATIONS ON ADMISSION: Outpatient medications include Colace 100 mg p.o. b.i.d., Dilantin 300 mg p.o. q.a.m. and 400 mg p.o. q.p.m., Lactase 3 tablets p.o. t.i.d. with meals, lorazepam 0.5 mg p.o. t.i.d. p.r.n., perphenazine 4 mg p.o. t.i.d., venlafaxine 150 mg p.o. q.d., Zyprexa 10 mg p.o. t.i.d., Bactrim-DS since <Date>10-2</Date>, Senna. SOCIAL HISTORY: A two to three pack per day smoker. Lives alone with home health services and advocate. FAMILY HISTORY: Breast cancer. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 99.2 Fahrenheit, heart rate 110, blood pressure 140s/50s, respirations 28 to 36, oxygen saturation 93% on 100% face mask. In general, alert, lying in bed, obese, in moderate respiratory distress. Head, ears, nose, eyes and throat revealed mucous membranes were moist. No lymphadenopathy. Heart was tachycardic but regular. No murmurs, rubs or gallops. Pulmonary revealed diffuse rhonchi, right greater than left, prolonged expiratory phase with wheezing diffusely. Abdomen was soft, nontender, and nondistended, with normal active bowel sounds. Extremities had no edema, no palpable cords, 2+ bilateral peripheral pulses. LABORATORY DATA ON PRESENTATION: White blood cell count 8.3, hematocrit 34.3, platelets 176, mean cell volume 88. Coagulations were INR 1.3, PTT 26.3, PT 13.5. Chem-7 as follows: Sodium of 134, potassium 3.3, chloride 96, bicarbonate 25, blood urea nitrogen 7, creatinine 0.6, with a glucose of 144. AST 28, ALT 31, alkaline phosphatase 207, total bilirubin 0.2. Urinalysis was nitrite negative, 6 to 10 red blood cells, 0 white blood cells, and rare bacteria. Arterial blood gas on 100% face mask was pH of 7.46, CO2 39, O2 56. RADIOLOGY/IMAGING: Chest x-ray revealed questions of right lower lobe infiltrate. Electrocardiogram from outside hospital with normal sinus rhythm at 110. No ST-T wave segment changes. HOSPITAL COURSE: 1. PULMONARY: The patient was admitted to the Medical Intensive Care Unit where she was found to wheezing, probably secondary to bronchospasm. Her saturations fell to 90% on 100% face mask. At this point arterial blood gas was sent revealing 7.46/39/56. The patient was started on BiPAP; however, she did not tolerated secondary to discomfort even though her saturations increased to approximately 95%. She was treated with Solu-Medrol 60 mg intravenously q.6h., albuterol nebulizers, and given ceftriaxone 1 g, followed by azithromycin 500 mg times one. At this point the patient's shortness of breath was subjectively improved, and the patient was transferred to the floor with an oxygen saturation of 92% to 95% on 100% nonrebreather. On the floor the patient's hypoxemia was thought to be secondary to viral etiology supported by the fact that she had only one day of sputum which cleared rapidly, either bronchospasm secondary to acute bronchitis, or viral-induced asthma seemed to have developed. The patient was maintained on azithromycin 250 mg times four days to complete the course and also continued initially on Solu-Medrol 60 mg q.6h. Albuterol and Atrovent nebulizers were continued. An echocardiogram with bubble study was performed to determine whether the patient had hypoxic pulmonary vasoconstriction resulting in reversal of her ventricular septal defect and thereby increasing her oxygen requirement, but this study was negative for ventricular septal defect. Dr. <Name>Tamaro</Name> from Cardiology read the echocardiogram and felt that the ventricular septal defect had either closed completely or was too small to be functionally significant. On <Date>11-7</Date> Solu-Medrol was replaced with prednisone 60 mg p.o. q.d. and Flovent 2 puffs b.i.d. for loading purposes. Albuterol and Atrovent inhalers were started for beta agonist and anticholinergic activity, and the patient was taught in their use. Her oxygen saturation stabilized to the point where she was 92% to 94% on room air, peak flows increased from 150 to the 250 to the 350 range. Physical Therapy saw the patient, and the patient was able to walk well with an oxygen saturation going into the 89% to 92% on room air. At this point it was agreed she was ready for discharge. It was recommended that influenza vaccine be considered in this patient once she has recovered completely from her acute illness to prevent further episodes. Further use of peak flow monitoring and an initial set of pulmonary function tests would be useful as well; particularly if the patient does well and pulmonary function tests show minimal obstructive disease, treatment of her bronchospasm may need to be modified. 2. GASTROINTESTINAL: The patient was initially n.p.o. except medications, but her diet was advanced as tolerated. 3. PSYCHIATRY: Perphenazine, Zyprexa, and venlafaxine were continued. The patient reported no hallucinations or signs of depression in house. 4. NEUROLOGY: Dilantin level was high at 22.4 on admission. On <Date>11-7</Date> it was rechecked and found to be 20.4. It was held for the duration of her stay. No seizure activity was noted in house. 5. ACCESS: Peripheral IV. 6. PROPHYLAXIS: Protonix, Pneumo boots, encouragement out of bed to chair, physical therapy. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To home with services and physical therapy. MEDICATIONS ON DISCHARGE: 1. Prednisone taper 40 mg p.o. q.d. times three days; then 20 mg p.o. q.d. times three days; then 10 mg p.o. q.d. times three days; then 5 mg p.o. q.d. times three days; then off. 2. Albuterol inhaler 2 puffs to 4 puffs q.i.d. 3. Atrovent inhaler 2 puffs to 4 puffs q.i.d. 4. Flovent inhaler 2 puffs b.i.d. 5. Dilantin 300 mg p.o. q.a.m. and 400 mg p.o. q.p.m. 6. Colace 100 mg p.o. b.i.d. 7. Perphenazine 4 mg p.o. t.i.d. 8. Venlafaxine 150 mg p.o. q.d. 9. Zyprexa 10 mg p.o. t.i.d. 10. Lactase 3 tablets p.o. t.i.d. with meals. 11. Lorazepam 0.5 mg p.o. t.i.d. p.r.n. 12. Senna. DISCHARGE FOLLOWUP: The patient was to follow up with primary care physician <Name>Starks</Name>. <Name>Shirley</Name> <Name>Kenner</Name> within one to two weeks' time. <Name>Diane</Name> <Initial>QO</Initial> <Name>Tennity</Name>, M.D. <MD Number>42656031</MD Number> Dictated By:<Name>Natividad Kenner</Name> MEDQUIST36 D: <Date>1974-8-8</Date> 15:33 T: <Date>2019-8-31</Date> 06:21 JOB#: <Job Number>Bartlett Inc-1906-277153</Job 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Date: 1982-3-22 Discharge Date: Date of Birth: 2017-6-1 Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: This is a 33-year-old female with a history of obesity, developmental delay, seizure disorder, depression, and ventricular septal defect who presented with a chief complaint of shortness of breath to the Smith, Hoover and Cantu Medical Center Emergency Department on 5-31 after being initially evaluated at Stanton-Harris Clinic Hospital. The patient's symptoms began on 4-19 with five days of cough, temperatures to 101 Fahrenheit, shortness of breath, and wheezing. She went to her primary care physician three days prior to admission where the temperature was measured at 102.2 Fahrenheit, and after chest x-ray was negative for infiltrate she was diagnosed with bronchitis and treated with Bactrim-DS. She took this for three days, but on the day of admission the patient was found a home health aide to be increasingly short of breath, and the patient was taken to Russell-Hicks Medical Center Hospital where she was satting 92% on 4 liters nasal cannula. A chest x-ray showed right lower lobe infiltrate. The patient was given 125 mg of Solu-Medrol, nebulizers, ceftriaxone 1 g and transferred to the Mendez-Kemp Clinic where she was admitted to the Medical Intensive Care Unit. There, the patient was found to be 87% on 4 liters nasal cannula which improved to 93% on 100% face mask. The patient's saturations fell to 90% on 100% face mask and BiPAP 14/4 was tried. However, the patient did not tolerate the BiPAP well despite the fact that the saturations came back to approximately 95%. REVIEW OF SYSTEMS: On review of systems the patient has no history of asthma but is a heavy smoker at two to three packs per day for many years. Her membranous ventricular septal defect was diagnosed on cardiac echocardiogram performed in 2014. PAST MEDICAL HISTORY: 1. Obesity. 2. Developmental delay. 3. Seizure disorder, status post motor vehicle accident. 4. Depression. 5. Ventricular septal defect. 6. Auditory hallucinations. 7. Melanoma on chest, status post excision. ALLERGIES: RISPERIDONE causing nausea. MEDICATIONS ON ADMISSION: Outpatient medications include Colace 100 mg p.o. b.i.d., Dilantin 300 mg p.o. q.a.m. and 400 mg p.o. q.p.m., Lactase 3 tablets p.o. t.i.d. with meals, lorazepam 0.5 mg p.o. t.i.d. p.r.n., perphenazine 4 mg p.o. t.i.d., venlafaxine 150 mg p.o. q.d., Zyprexa 10 mg p.o. t.i.d., Bactrim-DS since 10-2, Senna. SOCIAL HISTORY: A two to three pack per day smoker. Lives alone with home health services and advocate. FAMILY HISTORY: Breast cancer. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 99.2 Fahrenheit, heart rate 110, blood pressure 140s/50s, respirations 28 to 36, oxygen saturation 93% on 100% face mask. In general, alert, lying in bed, obese, in moderate respiratory distress. Head, ears, nose, eyes and throat revealed mucous membranes were moist. No lymphadenopathy. Heart was tachycardic but regular. No murmurs, rubs or gallops. Pulmonary revealed diffuse rhonchi, right greater than left, prolonged expiratory phase with wheezing diffusely. Abdomen was soft, nontender, and nondistended, with normal active bowel sounds. Extremities had no edema, no palpable cords, 2+ bilateral peripheral pulses. LABORATORY DATA ON PRESENTATION: White blood cell count 8.3, hematocrit 34.3, platelets 176, mean cell volume 88. Coagulations were INR 1.3, PTT 26.3, PT 13.5. Chem-7 as follows: Sodium of 134, potassium 3.3, chloride 96, bicarbonate 25, blood urea nitrogen 7, creatinine 0.6, with a glucose of 144. AST 28, ALT 31, alkaline phosphatase 207, total bilirubin 0.2. Urinalysis was nitrite negative, 6 to 10 red blood cells, 0 white blood cells, and rare bacteria. Arterial blood gas on 100% face mask was pH of 7.46, CO2 39, O2 56. RADIOLOGY/IMAGING: Chest x-ray revealed questions of right lower lobe infiltrate. Electrocardiogram from outside hospital with normal sinus rhythm at 110. No ST-T wave segment changes. HOSPITAL COURSE: 1. PULMONARY: The patient was admitted to the Medical Intensive Care Unit where she was found to wheezing, probably secondary to bronchospasm. Her saturations fell to 90% on 100% face mask. At this point arterial blood gas was sent revealing 7.46/39/56. The patient was started on BiPAP; however, she did not tolerated secondary to discomfort even though her saturations increased to approximately 95%. She was treated with Solu-Medrol 60 mg intravenously q.6h., albuterol nebulizers, and given ceftriaxone 1 g, followed by azithromycin 500 mg times one. At this point the patient's shortness of breath was subjectively improved, and the patient was transferred to the floor with an oxygen saturation of 92% to 95% on 100% nonrebreather. On the floor the patient's hypoxemia was thought to be secondary to viral etiology supported by the fact that she had only one day of sputum which cleared rapidly, either bronchospasm secondary to acute bronchitis, or viral-induced asthma seemed to have developed. The patient was maintained on azithromycin 250 mg times four days to complete the course and also continued initially on Solu-Medrol 60 mg q.6h. Albuterol and Atrovent nebulizers were continued. An echocardiogram with bubble study was performed to determine whether the patient had hypoxic pulmonary vasoconstriction resulting in reversal of her ventricular septal defect and thereby increasing her oxygen requirement, but this study was negative for ventricular septal defect. Dr. Tamaro from Cardiology read the echocardiogram and felt that the ventricular septal defect had either closed completely or was too small to be functionally significant. On 11-7 Solu-Medrol was replaced with prednisone 60 mg p.o. q.d. and Flovent 2 puffs b.i.d. for loading purposes. Albuterol and Atrovent inhalers were started for beta agonist and anticholinergic activity, and the patient was taught in their use. Her oxygen saturation stabilized to the point where she was 92% to 94% on room air, peak flows increased from 150 to the 250 to the 350 range. Physical Therapy saw the patient, and the patient was able to walk well with an oxygen saturation going into the 89% to 92% on room air. At this point it was agreed she was ready for discharge. It was recommended that influenza vaccine be considered in this patient once she has recovered completely from her acute illness to prevent further episodes. Further use of peak flow monitoring and an initial set of pulmonary function tests would be useful as well; particularly if the patient does well and pulmonary function tests show minimal obstructive disease, treatment of her bronchospasm may need to be modified. 2. GASTROINTESTINAL: The patient was initially n.p.o. except medications, but her diet was advanced as tolerated. 3. PSYCHIATRY: Perphenazine, Zyprexa, and venlafaxine were continued. The patient reported no hallucinations or signs of depression in house. 4. NEUROLOGY: Dilantin level was high at 22.4 on admission. On 11-7 it was rechecked and found to be 20.4. It was held for the duration of her stay. No seizure activity was noted in house. 5. ACCESS: Peripheral IV. 6. PROPHYLAXIS: Protonix, Pneumo boots, encouragement out of bed to chair, physical therapy. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To home with services and physical therapy. MEDICATIONS ON DISCHARGE: 1. Prednisone taper 40 mg p.o. q.d. times three days; then 20 mg p.o. q.d. times three days; then 10 mg p.o. q.d. times three days; then 5 mg p.o. q.d. times three days; then off. 2. Albuterol inhaler 2 puffs to 4 puffs q.i.d. 3. Atrovent inhaler 2 puffs to 4 puffs q.i.d. 4. Flovent inhaler 2 puffs b.i.d. 5. Dilantin 300 mg p.o. q.a.m. and 400 mg p.o. q.p.m. 6. Colace 100 mg p.o. b.i.d. 7. Perphenazine 4 mg p.o. t.i.d. 8. Venlafaxine 150 mg p.o. q.d. 9. Zyprexa 10 mg p.o. t.i.d. 10. Lactase 3 tablets p.o. t.i.d. with meals. 11. Lorazepam 0.5 mg p.o. t.i.d. p.r.n. 12. Senna. DISCHARGE FOLLOWUP: The patient was to follow up with primary care physician Starks. Shirley Kenner within one to two weeks' time. Diane QO Tennity, M.D. 42656031 Dictated By:Natividad Kenner MEDQUIST36 D: 1974-8-8 15:33 T: 2019-8-31 06:21 JOB#: Bartlett Inc-1906-277153	["Admission Date: 1982-3-22 Discharge Date:\n\nDate of Birth: 2017-6-1 Sex: F\n\nService: MICU\n\nHISTORY OF PRESENT ILLNESS: This is a 33-year-old female\nwith a history of obesity, developmental delay, seizure\ndisorder, depression, and ventricular septal defect who\npresented with a chief complaint of shortness of breath to\nthe Smith, Hoover and Cantu Medical Center Emergency Department\non 5-31 after being initially evaluated at Stanton-Harris Clinic Hospital.\n\nThe patient's symptoms began on 4-19 with five days of\ncough, temperatures to 101 Fahrenheit, shortness of breath,\nand wheezing. She went to her primary care physician three\ndays prior to admission where the temperature was measured at\n102.2 Fahrenheit, and after chest x-ray was negative for\ninfiltrate she was diagnosed with bronchitis and treated with\nBactrim-DS.", " She took this for three days, but on the day of\nadmission the patient was found a home health aide to be\nincreasingly short of breath, and the patient was taken to\nRussell-Hicks Medical Center Hospital where she was satting 92% on 4\nliters nasal cannula. A chest x-ray showed right lower lobe\ninfiltrate. The patient was given 125 mg of Solu-Medrol,\nnebulizers, ceftriaxone 1 g and transferred to the Mendez-Kemp Clinic where she was admitted to the\nMedical Intensive Care Unit.\n\nThere, the patient was found to be 87% on 4 liters nasal\ncannula which improved to 93% on 100% face mask. The\npatient's saturations fell to 90% on 100% face mask and BiPAP\n14/4 was tried. However, the patient did not tolerate the\nBiPAP well despite the fact that the saturations came back to\napproximately 95%.\n\nREVIEW OF SYSTEMS: On review of systems the patient has no\nhistory of asthma but is a heavy smoker at two to three packs\nper day for many years.", ' Her membranous ventricular septal\ndefect was diagnosed on cardiac echocardiogram performed in\n2014.\n\nPAST MEDICAL HISTORY:\n1. Obesity.\n2. Developmental delay.\n3. Seizure disorder, status post motor vehicle accident.\n4. Depression.\n5. Ventricular septal defect.\n6. Auditory hallucinations.\n7. Melanoma on chest, status post excision.\n\nALLERGIES: RISPERIDONE causing nausea.\n\nMEDICATIONS ON ADMISSION: Outpatient medications include\nColace 100 mg p.o. b.i.d., Dilantin 300 mg p.o. q.a.m. and\n400 mg p.o. q.p.m., Lactase 3 tablets p.o. t.i.d. with meals,\nlorazepam 0.5 mg p.o. t.i.d. p.r.n., perphenazine 4 mg p.o.\nt.i.d., venlafaxine 150 mg p.o. q.d., Zyprexa 10 mg p.o.\nt.i.d., Bactrim-DS since 10-2, Senna.\n\nSOCIAL HISTORY: A two to three pack per day smoker. Lives\nalone with home health services and advocate.', '\n\nFAMILY HISTORY: Breast cancer.\n\nPHYSICAL EXAMINATION ON PRESENTATION: Temperature 99.2\nFahrenheit, heart rate 110, blood pressure 140s/50s,\nrespirations 28 to 36, oxygen saturation 93% on 100% face\nmask. In general, alert, lying in bed, obese, in moderate\nrespiratory distress. Head, ears, nose, eyes and throat\nrevealed mucous membranes were moist. No lymphadenopathy.\nHeart was tachycardic but regular. No murmurs, rubs or\ngallops. Pulmonary revealed diffuse rhonchi, right greater\nthan left, prolonged expiratory phase with wheezing\ndiffusely. Abdomen was soft, nontender, and nondistended,\nwith normal active bowel sounds. Extremities had no edema,\nno palpable cords, 2+ bilateral peripheral pulses.\n\nLABORATORY DATA ON PRESENTATION: White blood cell count 8.3,\nhematocrit 34.3, platelets 176, mean cell volume 88.', '\nCoagulations were INR 1.3, PTT 26.3, PT 13.5. Chem-7 as\nfollows: Sodium of 134, potassium 3.3, chloride 96,\nbicarbonate 25, blood urea nitrogen 7, creatinine 0.6, with a\nglucose of 144. AST 28, ALT 31, alkaline phosphatase 207,\ntotal bilirubin 0.2. Urinalysis was nitrite negative, 6 to\n10 red blood cells, 0 white blood cells, and rare bacteria.\nArterial blood gas on 100% face mask was pH of 7.46, CO2 39,\nO2 56.\n\nRADIOLOGY/IMAGING: Chest x-ray revealed questions of right\nlower lobe infiltrate.\n\nElectrocardiogram from outside hospital with normal sinus\nrhythm at 110. No ST-T wave segment changes.\n\nHOSPITAL COURSE:\n\n1. PULMONARY: The patient was admitted to the Medical\nIntensive Care Unit where she was found to wheezing, probably\nsecondary to bronchospasm. Her saturations fell to 90% on\n100% face mask.', " At this point arterial blood gas was sent\nrevealing 7.46/39/56.\n\nThe patient was started on BiPAP; however, she did not\ntolerated secondary to discomfort even though her saturations\nincreased to approximately 95%. She was treated with\nSolu-Medrol 60 mg intravenously q.6h., albuterol nebulizers,\nand given ceftriaxone 1 g, followed by azithromycin 500 mg\ntimes one. At this point the patient's shortness of breath\nwas subjectively improved, and the patient was transferred to\nthe floor with an oxygen saturation of 92% to 95% on 100%\nnonrebreather.\n\nOn the floor the patient's hypoxemia was thought to be\nsecondary to viral etiology supported by the fact that she\nhad only one day of sputum which cleared rapidly, either\nbronchospasm secondary to acute bronchitis, or viral-induced\nasthma seemed to have developed.", ' The patient was maintained\non azithromycin 250 mg times four days to complete the course\nand also continued initially on Solu-Medrol 60 mg q.6h.\nAlbuterol and Atrovent nebulizers were continued. An\nechocardiogram with bubble study was performed to determine\nwhether the patient had hypoxic pulmonary vasoconstriction\nresulting in reversal of her ventricular septal defect and\nthereby increasing her oxygen requirement, but this study was\nnegative for ventricular septal defect. Dr. Tamaro from\nCardiology read the echocardiogram and felt that the\nventricular septal defect had either closed completely or was\ntoo small to be functionally significant.\n\nOn 11-7 Solu-Medrol was replaced with prednisone 60 mg\np.o. q.d. and Flovent 2 puffs b.i.d. for loading purposes.\nAlbuterol and Atrovent inhalers were started for beta agonist\nand anticholinergic activity, and the patient was taught in\ntheir use.', ' Her oxygen saturation stabilized to the point\nwhere she was 92% to 94% on room air, peak flows increased\nfrom 150 to the 250 to the 350 range. Physical Therapy saw\nthe patient, and the patient was able to walk well with an\noxygen saturation going into the 89% to 92% on room air. At\nthis point it was agreed she was ready for discharge.\n\nIt was recommended that influenza vaccine be considered in\nthis patient once she has recovered completely from her acute\nillness to prevent further episodes. Further use of peak\nflow monitoring and an initial set of pulmonary function\ntests would be useful as well; particularly if the patient\ndoes well and pulmonary function tests show minimal\nobstructive disease, treatment of her bronchospasm may need\nto be modified.\n\n2. GASTROINTESTINAL: The patient was initially n.', 'p.o.\nexcept medications, but her diet was advanced as tolerated.\n\n3. PSYCHIATRY: Perphenazine, Zyprexa, and venlafaxine were\ncontinued. The patient reported no hallucinations or signs\nof depression in house.\n\n4. NEUROLOGY: Dilantin level was high at 22.4 on admission.\nOn 11-7 it was rechecked and found to be 20.4. It was\nheld for the duration of her stay. No seizure activity was\nnoted in house.\n\n5. ACCESS: Peripheral IV.\n\n6. PROPHYLAXIS: Protonix, Pneumo boots, encouragement out\nof bed to chair, physical therapy.\n\nCONDITION AT DISCHARGE: Condition on discharge was stable.\n\nDISCHARGE STATUS: To home with services and physical\ntherapy.\n\nMEDICATIONS ON DISCHARGE:\n 1. Prednisone taper 40 mg p.o. q.d. times three days;\nthen 20 mg p.o. q.d. times three days; then 10 mg p.o. q.d.\ntimes three days; then 5 mg p.', "o. q.d. times three days; then\noff.\n 2. Albuterol inhaler 2 puffs to 4 puffs q.i.d.\n 3. Atrovent inhaler 2 puffs to 4 puffs q.i.d.\n 4. Flovent inhaler 2 puffs b.i.d.\n 5. Dilantin 300 mg p.o. q.a.m. and 400 mg p.o. q.p.m.\n 6. Colace 100 mg p.o. b.i.d.\n 7. Perphenazine 4 mg p.o. t.i.d.\n 8. Venlafaxine 150 mg p.o. q.d.\n 9. Zyprexa 10 mg p.o. t.i.d.\n10. Lactase 3 tablets p.o. t.i.d. with meals.\n11. Lorazepam 0.5 mg p.o. t.i.d. p.r.n.\n12. Senna.\n\nDISCHARGE FOLLOWUP: The patient was to follow up with\nprimary care physician Starks. Shirley Kenner within one to two weeks'\ntime.\n\n\n\n\n Diane QO Tennity, M.D. 42656031\n\nDictated By:Natividad Kenner\n\nMEDQUIST36\n\nD: 1974-8-8 15:33\nT: 2019-8-31 06:21\nJOB#: Bartlett Inc-1906-277153\n"]
138	10995	180500.0	2141-11-20	Discharge summary	Report	Admission Date: [2141-11-9] Discharge Date: [2141-11-20] Service: Vascular CHIEF COMPLAINT: Chest pain. Patient was initially evaluated at [Hospital 1474] Hospital and transferred here for further evaluation and treatment. Initial enzymes showed a total CPK of 4,120, CK MB 20 and troponin of 17.4. PAST MEDICAL HISTORY: Coronary artery disease, status post cath in [2131] showing ejection fraction of 56% with anterolateral apical akinesis. The RCA is 80% obstructed. The marginal branch of the RCA was 40% obstructed with diffuse disease. The mid LAD was 95%, diagonal I was 60%. The patient underwent angioplasty of the LAD. Patient was noted to have mild mitral regurg. A stress test done at that time showed dilated left ventricle with fixed defects and anterolateral septal wall with high grade EAE and equivocal changes. Previous MI was 5 years prior to 92. History of peptic ulcer disease. No previous surgeries, no known drug allergies. MEDICATIONS: On transfer to our institution, Lopressor 12.5 mg q 6 hours, Atenolol 25 mg q d, Nitro paste 1 inch q 4 hours, Captopril 17.5 mg. SOCIAL HISTORY: He is married, lives in [Location 1475], is 66 years old, is a former smoker of 40 pack years, no alcohol, semi retired and helps in a welding shop. PHYSICAL EXAMINATION: On admission, vital signs 97.5, 122/91, 70, 18, O2 saturation 98% on room air. The patient is alert, oriented and in no acute distress. HEENT: Showed constricted pupils secondary to narcotics, EOM's intact. Soft palate elevates. No teeth in the lower mandible, no icterus. Cardiovascular exam was a regular rate and rhythm with no murmurs, rubs or gallops. Neck without bruits. Lungs are clear to auscultation bilaterally. Abdomen is unremarkable. Extremities with intact pulses. LABORATORY DATA: On transfer included a CBC with white count 6.7, hematocrit 39.1, platelet count 196,000. Electrolytes, sodium 135, potassium 4.6, chloride 100, CO2 77, BUN 11, creatinine 0.1, glucose 114, PT and INR were normal, PTT were normal. CK totals were 0, 90 and peak to 412, MB were 82 and 6, MBI index was 20, troponin was 17.4. Urinalysis was negative. EKG showed a normal sinus rhythm with a normal axis deviation with inverted T's in V4 and V5 which were new. HOSPITAL COURSE: The patient was admitted to the cardiology service and was placed in Intensive Care Unit. IV Heparin and Nitroglycerin were begun. Serial CKs were obtained along with serial EKG's. Serial total CK's peaked at 533. MB fraction peaked at 9.2. Initial troponin level was greater than 50 and after the next 72 hours its level was 1.5. Normal is less than .03. Within the next 24 hours the patient underwent cardiac catheterization. The patient's right sided pressures, PA was 50/17, right atrial mean was 16, pulmonary wedge pressure was 16, left ventricular end diastolic pressure was 17. Cardiac output was 6.0, index was 3.3, EF was 30% with akinetic anterolateral and apex walls and hypokinetic antero basal wall and normal posterior and basal wall. The native vessels showed left main trunk disease of 30%, left anterior was proximal 30% and mid 90% left circumflex was mid 50%. Ramus intermedius was 90% which was angioplastied and stented and the right coronary showed an osteal lesion of 30%. There was concern of right external iliac artery dissection. The patient underwent a right femoral ultrasound which demonstrated triphasic flow in the right common femoral artery with plaque or flap proximal to the right SFA with stenosis and did have episodes of SVG and was begun on beta blockers. Aspirin and Plavix were continued post stenting. The groin was without bleeding and he had distal pulses. Dr. [Last Name (STitle) ], the cardiologist, requested that vascular be consulted regarding the findings on the right iliac SFA ultrasound. The patient, although study was abnormal but with intact distal pulses, the patient did note 72 hours after catheterization, onset of right calf and ankle foot pain with ambulation. The patient underwent a repeat peripheral arterial catheterization which demonstrated abdominal aorta with no significant disease, renal arteries bilaterally were normal, the right lower extremity iliac is without critical lesions, the previous noted dissection is not occlusive but the site is still delineated. The common femoral is normal, the SFA and profunda artery are normal, the popliteals occlude mid vessel and the anterior and tibial were not well visualized but appear thrombolytically occluded. There was three vessel runoff to the foot. The collaterals provide much of the distal flow. The patient was TPA'd, begun on Heparin and placed in the VICU. The patient had consequences of a right groin hematoma after the second right groin intervention and angiography which required pressure occlusion. The patient underwent on [11-14], a thrombectomy of the right tibial peroneal trunk and AT artery with patch angioplasty of the right popliteal artery. He tolerated the procedure well and was transferred to the VICU for continued monitoring and care. The patient required a unit of packed cells for hematocrit of 25, post transfusion hematocrit was 35. Total CK was 74. The patient was placed on peri-operative Kefzol and remained in the VICU in stable condition. On [11-15] the patient had an episode of hematemesis. An NG was placed with 300 cc of blood aspirated. The patient remained hemodynamically stable. Serial hematocrits were obtained and Plavix and Aspirin were held. GI was consulted. The patient underwent upper endoscopy which demonstrated a few non bleeding localized erosions in the esophagus at the GE junction consistent with NG trauma. There was bilious fluid in the stomach body and antrum. There is no active bleeding or coffee ground or bright red blood noted. There were few superficial non bleeding 2 mm ulcers ranging in size from 2 mm to 5 mm in the stomach. The duodenum was normal. Recommendations were to continue the Protonix at 40 mg q d, discontinue the NG tube, follow serial hematocrits. Please consider the risk/benefits of Aspirin and Plavix. If Aspirin and Plavix need to be continued, then we will put the patient on a higher dose of Protonix. The patient experienced episode of hypertension overnight on postoperative day #1 requiring adjustments in hypertensive medications and transfusion of packed red blood cells. On postoperative day #3 there were no overnight events. The patient continued on Protonix IV and Captopril and beta blockers. His hematocrit remained stable at 29. CKs were flat and serial hematocrits remained stable. The patient was then begun on Aspirin. Physical therapy saw the patient and felt that he would be able to be discharged to home after evaluating ambulation with stairs. The patient's hematocrits remained stable, groin remained stable. The patient was discharged in stable condition on [2141-11-20]. She is to follow-up with Dr. [Last Name (STitle) ] as instructed and see Dr. [Last Name (STitle) 1476] in two weeks time. DISCHARGE MEDICATIONS: Include Keflex 500 mg qid times 7 days, Aspirin 81 mg q d, Lopressor 25 mg [Hospital1 ], hold for systolic blood pressure less than 120, heart rate less than 60, Protonix 40 mg q d, Colace 100 mg [Hospital1 ], Percocet tablets [12-27] q 4 hours prn pain, Plavix 75 mg q d. DISCHARGE DIAGNOSIS: 1. Non Q wave MI status post angioplasty of the ramus intermedius with stenting. 2. Right groin hematoma, stabilized. 3. Right iliac external artery dissection, stabilized. 4. Thrombolic ischemia of the right leg, status post thrombectomy of the anterior tibial and peroneal trunk. 5. Hypertension controlled. 6. GI bleeding, stabilized. 7. Blood loss anemia, transfused, corrected. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1477], M.D. [MD Number(1) 1478] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2141-11-19] 16:01 T: [2141-11-19] 16:50 JOB#: [Job Number 1480]	Admission Date: <Date>1953-1-15</Date> Discharge Date: <Date>1903-12-22</Date> Service: Vascular CHIEF COMPLAINT: Chest pain. Patient was initially evaluated at <Hospital>King-Hall Health System</Hospital> Hospital and transferred here for further evaluation and treatment. Initial enzymes showed a total CPK of 4,120, CK MB 20 and troponin of 17.4. PAST MEDICAL HISTORY: Coronary artery disease, status post cath in <Year>2001</Year> showing ejection fraction of 56% with anterolateral apical akinesis. The RCA is 80% obstructed. The marginal branch of the RCA was 40% obstructed with diffuse disease. The mid LAD was 95%, diagonal I was 60%. The patient underwent angioplasty of the LAD. Patient was noted to have mild mitral regurg. A stress test done at that time showed dilated left ventricle with fixed defects and anterolateral septal wall with high grade EAE and equivocal changes. Previous MI was 5 years prior to 92. History of peptic ulcer disease. No previous surgeries, no known drug allergies. MEDICATIONS: On transfer to our institution, Lopressor 12.5 mg q 6 hours, Atenolol 25 mg q d, Nitro paste 1 inch q 4 hours, Captopril 17.5 mg. SOCIAL HISTORY: He is married, lives in <Location>16574 Nicolas Club Apt. 141 Perezland, NY 32467</Location>, is 66 years old, is a former smoker of 40 pack years, no alcohol, semi retired and helps in a welding shop. PHYSICAL EXAMINATION: On admission, vital signs 97.5, 122/91, 70, 18, O2 saturation 98% on room air. The patient is alert, oriented and in no acute distress. HEENT: Showed constricted pupils secondary to narcotics, EOM's intact. Soft palate elevates. No teeth in the lower mandible, no icterus. Cardiovascular exam was a regular rate and rhythm with no murmurs, rubs or gallops. Neck without bruits. Lungs are clear to auscultation bilaterally. Abdomen is unremarkable. Extremities with intact pulses. LABORATORY DATA: On transfer included a CBC with white count 6.7, hematocrit 39.1, platelet count 196,000. Electrolytes, sodium 135, potassium 4.6, chloride 100, CO2 77, BUN 11, creatinine 0.1, glucose 114, PT and INR were normal, PTT were normal. CK totals were 0, 90 and peak to 412, MB were 82 and 6, MBI index was 20, troponin was 17.4. Urinalysis was negative. EKG showed a normal sinus rhythm with a normal axis deviation with inverted T's in V4 and V5 which were new. HOSPITAL COURSE: The patient was admitted to the cardiology service and was placed in Intensive Care Unit. IV Heparin and Nitroglycerin were begun. Serial CKs were obtained along with serial EKG's. Serial total CK's peaked at 533. MB fraction peaked at 9.2. Initial troponin level was greater than 50 and after the next 72 hours its level was 1.5. Normal is less than .03. Within the next 24 hours the patient underwent cardiac catheterization. The patient's right sided pressures, PA was 50/17, right atrial mean was 16, pulmonary wedge pressure was 16, left ventricular end diastolic pressure was 17. Cardiac output was 6.0, index was 3.3, EF was 30% with akinetic anterolateral and apex walls and hypokinetic antero basal wall and normal posterior and basal wall. The native vessels showed left main trunk disease of 30%, left anterior was proximal 30% and mid 90% left circumflex was mid 50%. Ramus intermedius was 90% which was angioplastied and stented and the right coronary showed an osteal lesion of 30%. There was concern of right external iliac artery dissection. The patient underwent a right femoral ultrasound which demonstrated triphasic flow in the right common femoral artery with plaque or flap proximal to the right SFA with stenosis and did have episodes of SVG and was begun on beta blockers. Aspirin and Plavix were continued post stenting. The groin was without bleeding and he had distal pulses. Dr. <Name>Grose</Name>, the cardiologist, requested that vascular be consulted regarding the findings on the right iliac SFA ultrasound. The patient, although study was abnormal but with intact distal pulses, the patient did note 72 hours after catheterization, onset of right calf and ankle foot pain with ambulation. The patient underwent a repeat peripheral arterial catheterization which demonstrated abdominal aorta with no significant disease, renal arteries bilaterally were normal, the right lower extremity iliac is without critical lesions, the previous noted dissection is not occlusive but the site is still delineated. The common femoral is normal, the SFA and profunda artery are normal, the popliteals occlude mid vessel and the anterior and tibial were not well visualized but appear thrombolytically occluded. There was three vessel runoff to the foot. The collaterals provide much of the distal flow. The patient was TPA'd, begun on Heparin and placed in the VICU. The patient had consequences of a right groin hematoma after the second right groin intervention and angiography which required pressure occlusion. The patient underwent on <Date>12-12</Date>, a thrombectomy of the right tibial peroneal trunk and AT artery with patch angioplasty of the right popliteal artery. He tolerated the procedure well and was transferred to the VICU for continued monitoring and care. The patient required a unit of packed cells for hematocrit of 25, post transfusion hematocrit was 35. Total CK was 74. The patient was placed on peri-operative Kefzol and remained in the VICU in stable condition. On <Date>1-20</Date> the patient had an episode of hematemesis. An NG was placed with 300 cc of blood aspirated. The patient remained hemodynamically stable. Serial hematocrits were obtained and Plavix and Aspirin were held. GI was consulted. The patient underwent upper endoscopy which demonstrated a few non bleeding localized erosions in the esophagus at the GE junction consistent with NG trauma. There was bilious fluid in the stomach body and antrum. There is no active bleeding or coffee ground or bright red blood noted. There were few superficial non bleeding 2 mm ulcers ranging in size from 2 mm to 5 mm in the stomach. The duodenum was normal. Recommendations were to continue the Protonix at 40 mg q d, discontinue the NG tube, follow serial hematocrits. Please consider the risk/benefits of Aspirin and Plavix. If Aspirin and Plavix need to be continued, then we will put the patient on a higher dose of Protonix. The patient experienced episode of hypertension overnight on postoperative day #1 requiring adjustments in hypertensive medications and transfusion of packed red blood cells. On postoperative day #3 there were no overnight events. The patient continued on Protonix IV and Captopril and beta blockers. His hematocrit remained stable at 29. CKs were flat and serial hematocrits remained stable. The patient was then begun on Aspirin. Physical therapy saw the patient and felt that he would be able to be discharged to home after evaluating ambulation with stairs. The patient's hematocrits remained stable, groin remained stable. The patient was discharged in stable condition on <Date>1903-12-22</Date>. She is to follow-up with Dr. <Name>Grose</Name> as instructed and see Dr. <Name>Archie</Name> in two weeks time. DISCHARGE MEDICATIONS: Include Keflex 500 mg qid times 7 days, Aspirin 81 mg q d, Lopressor 25 mg <Hospital>Jacobs-Powers Clinic</Hospital>, hold for systolic blood pressure less than 120, heart rate less than 60, Protonix 40 mg q d, Colace 100 mg <Hospital>Jacobs-Powers Clinic</Hospital>, Percocet tablets <Date>4-30</Date> q 4 hours prn pain, Plavix 75 mg q d. DISCHARGE DIAGNOSIS: 1. Non Q wave MI status post angioplasty of the ramus intermedius with stenting. 2. Right groin hematoma, stabilized. 3. Right iliac external artery dissection, stabilized. 4. Thrombolic ischemia of the right leg, status post thrombectomy of the anterior tibial and peroneal trunk. 5. Hypertension controlled. 6. GI bleeding, stabilized. 7. Blood loss anemia, transfused, corrected. <Name>Lawrence</Name> <Name>Martin</Name>, M.D. <MD Number>35832691</MD Number> Dictated By:<Name>Olles</Name> MEDQUIST36 D: <Date>1939-6-11</Date> 16:01 T: <Date>1939-6-11</Date> 16:50 JOB#: <Job Number>Long, Barrett and Clark-1998-453835</Job 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Date: 1953-1-15 Discharge Date: 1903-12-22 Service: Vascular CHIEF COMPLAINT: Chest pain. Patient was initially evaluated at King-Hall Health System Hospital and transferred here for further evaluation and treatment. Initial enzymes showed a total CPK of 4,120, CK MB 20 and troponin of 17.4. PAST MEDICAL HISTORY: Coronary artery disease, status post cath in 2001 showing ejection fraction of 56% with anterolateral apical akinesis. The RCA is 80% obstructed. The marginal branch of the RCA was 40% obstructed with diffuse disease. The mid LAD was 95%, diagonal I was 60%. The patient underwent angioplasty of the LAD. Patient was noted to have mild mitral regurg. A stress test done at that time showed dilated left ventricle with fixed defects and anterolateral septal wall with high grade EAE and equivocal changes. Previous MI was 5 years prior to 92. History of peptic ulcer disease. No previous surgeries, no known drug allergies. MEDICATIONS: On transfer to our institution, Lopressor 12.5 mg q 6 hours, Atenolol 25 mg q d, Nitro paste 1 inch q 4 hours, Captopril 17.5 mg. SOCIAL HISTORY: He is married, lives in 16574 Nicolas Club Apt. 141 Perezland, NY 32467, is 66 years old, is a former smoker of 40 pack years, no alcohol, semi retired and helps in a welding shop. PHYSICAL EXAMINATION: On admission, vital signs 97.5, 122/91, 70, 18, O2 saturation 98% on room air. The patient is alert, oriented and in no acute distress. HEENT: Showed constricted pupils secondary to narcotics, EOM's intact. Soft palate elevates. No teeth in the lower mandible, no icterus. Cardiovascular exam was a regular rate and rhythm with no murmurs, rubs or gallops. Neck without bruits. Lungs are clear to auscultation bilaterally. Abdomen is unremarkable. Extremities with intact pulses. LABORATORY DATA: On transfer included a CBC with white count 6.7, hematocrit 39.1, platelet count 196,000. Electrolytes, sodium 135, potassium 4.6, chloride 100, CO2 77, BUN 11, creatinine 0.1, glucose 114, PT and INR were normal, PTT were normal. CK totals were 0, 90 and peak to 412, MB were 82 and 6, MBI index was 20, troponin was 17.4. Urinalysis was negative. EKG showed a normal sinus rhythm with a normal axis deviation with inverted T's in V4 and V5 which were new. HOSPITAL COURSE: The patient was admitted to the cardiology service and was placed in Intensive Care Unit. IV Heparin and Nitroglycerin were begun. Serial CKs were obtained along with serial EKG's. Serial total CK's peaked at 533. MB fraction peaked at 9.2. Initial troponin level was greater than 50 and after the next 72 hours its level was 1.5. Normal is less than .03. Within the next 24 hours the patient underwent cardiac catheterization. The patient's right sided pressures, PA was 50/17, right atrial mean was 16, pulmonary wedge pressure was 16, left ventricular end diastolic pressure was 17. Cardiac output was 6.0, index was 3.3, EF was 30% with akinetic anterolateral and apex walls and hypokinetic antero basal wall and normal posterior and basal wall. The native vessels showed left main trunk disease of 30%, left anterior was proximal 30% and mid 90% left circumflex was mid 50%. Ramus intermedius was 90% which was angioplastied and stented and the right coronary showed an osteal lesion of 30%. There was concern of right external iliac artery dissection. The patient underwent a right femoral ultrasound which demonstrated triphasic flow in the right common femoral artery with plaque or flap proximal to the right SFA with stenosis and did have episodes of SVG and was begun on beta blockers. Aspirin and Plavix were continued post stenting. The groin was without bleeding and he had distal pulses. Dr. Grose, the cardiologist, requested that vascular be consulted regarding the findings on the right iliac SFA ultrasound. The patient, although study was abnormal but with intact distal pulses, the patient did note 72 hours after catheterization, onset of right calf and ankle foot pain with ambulation. The patient underwent a repeat peripheral arterial catheterization which demonstrated abdominal aorta with no significant disease, renal arteries bilaterally were normal, the right lower extremity iliac is without critical lesions, the previous noted dissection is not occlusive but the site is still delineated. The common femoral is normal, the SFA and profunda artery are normal, the popliteals occlude mid vessel and the anterior and tibial were not well visualized but appear thrombolytically occluded. There was three vessel runoff to the foot. The collaterals provide much of the distal flow. The patient was TPA'd, begun on Heparin and placed in the VICU. The patient had consequences of a right groin hematoma after the second right groin intervention and angiography which required pressure occlusion. The patient underwent on 12-12, a thrombectomy of the right tibial peroneal trunk and AT artery with patch angioplasty of the right popliteal artery. He tolerated the procedure well and was transferred to the VICU for continued monitoring and care. The patient required a unit of packed cells for hematocrit of 25, post transfusion hematocrit was 35. Total CK was 74. The patient was placed on peri-operative Kefzol and remained in the VICU in stable condition. On 1-20 the patient had an episode of hematemesis. An NG was placed with 300 cc of blood aspirated. The patient remained hemodynamically stable. Serial hematocrits were obtained and Plavix and Aspirin were held. GI was consulted. The patient underwent upper endoscopy which demonstrated a few non bleeding localized erosions in the esophagus at the GE junction consistent with NG trauma. There was bilious fluid in the stomach body and antrum. There is no active bleeding or coffee ground or bright red blood noted. There were few superficial non bleeding 2 mm ulcers ranging in size from 2 mm to 5 mm in the stomach. The duodenum was normal. Recommendations were to continue the Protonix at 40 mg q d, discontinue the NG tube, follow serial hematocrits. Please consider the risk/benefits of Aspirin and Plavix. If Aspirin and Plavix need to be continued, then we will put the patient on a higher dose of Protonix. The patient experienced episode of hypertension overnight on postoperative day #1 requiring adjustments in hypertensive medications and transfusion of packed red blood cells. On postoperative day #3 there were no overnight events. The patient continued on Protonix IV and Captopril and beta blockers. His hematocrit remained stable at 29. CKs were flat and serial hematocrits remained stable. The patient was then begun on Aspirin. Physical therapy saw the patient and felt that he would be able to be discharged to home after evaluating ambulation with stairs. The patient's hematocrits remained stable, groin remained stable. The patient was discharged in stable condition on 1903-12-22. She is to follow-up with Dr. Grose as instructed and see Dr. Archie in two weeks time. DISCHARGE MEDICATIONS: Include Keflex 500 mg qid times 7 days, Aspirin 81 mg q d, Lopressor 25 mg Jacobs-Powers Clinic, hold for systolic blood pressure less than 120, heart rate less than 60, Protonix 40 mg q d, Colace 100 mg Jacobs-Powers Clinic, Percocet tablets 4-30 q 4 hours prn pain, Plavix 75 mg q d. DISCHARGE DIAGNOSIS: 1. Non Q wave MI status post angioplasty of the ramus intermedius with stenting. 2. Right groin hematoma, stabilized. 3. Right iliac external artery dissection, stabilized. 4. Thrombolic ischemia of the right leg, status post thrombectomy of the anterior tibial and peroneal trunk. 5. Hypertension controlled. 6. GI bleeding, stabilized. 7. Blood loss anemia, transfused, corrected. Lawrence Martin, M.D. 35832691 Dictated By:Olles MEDQUIST36 D: 1939-6-11 16:01 T: 1939-6-11 16:50 JOB#: Long, Barrett and Clark-1998-453835	['Admission Date: 1953-1-15 Discharge Date: 1903-12-22\n\n\nService: Vascular\n\nCHIEF COMPLAINT: Chest pain. Patient was initially\nevaluated at King-Hall Health System Hospital and transferred here for\nfurther evaluation and treatment. Initial enzymes showed a\ntotal CPK of 4,120, CK MB 20 and troponin of 17.4.\n\nPAST MEDICAL HISTORY: Coronary artery disease, status post\ncath in 2001 showing ejection fraction of 56% with\nanterolateral apical akinesis. The RCA is 80% obstructed.\nThe marginal branch of the RCA was 40% obstructed with\ndiffuse disease. The mid LAD was 95%, diagonal I was 60%.\nThe patient underwent angioplasty of the LAD. Patient was\nnoted to have mild mitral regurg. A stress test done at that\ntime showed dilated left ventricle with fixed defects and\nanterolateral septal wall with high grade EAE and equivocal\nchanges.', " Previous MI was 5 years prior to 92. History of\npeptic ulcer disease. No previous surgeries, no known drug\nallergies.\n\nMEDICATIONS: On transfer to our institution, Lopressor 12.5\nmg q 6 hours, Atenolol 25 mg q d, Nitro paste 1 inch q 4\nhours, Captopril 17.5 mg.\n\nSOCIAL HISTORY: He is married, lives in 16574 Nicolas Club Apt. 141\nPerezland, NY 32467, is 66\nyears old, is a former smoker of 40 pack years, no alcohol,\nsemi retired and helps in a welding shop.\n\nPHYSICAL EXAMINATION: On admission, vital signs 97.5,\n122/91, 70, 18, O2 saturation 98% on room air. The patient\nis alert, oriented and in no acute distress. HEENT: Showed\nconstricted pupils secondary to narcotics, EOM's intact.\nSoft palate elevates. No teeth in the lower mandible, no\nicterus. Cardiovascular exam was a regular rate and rhythm\nwith no murmurs, rubs or gallops.", " Neck without bruits.\nLungs are clear to auscultation bilaterally. Abdomen is\nunremarkable. Extremities with intact pulses.\n\nLABORATORY DATA: On transfer included a CBC with white count\n6.7, hematocrit 39.1, platelet count 196,000. Electrolytes,\nsodium 135, potassium 4.6, chloride 100, CO2 77, BUN 11,\ncreatinine 0.1, glucose 114, PT and INR were normal, PTT were\nnormal. CK totals were 0, 90 and peak to 412, MB were 82 and\n6, MBI index was 20, troponin was 17.4. Urinalysis was\nnegative. EKG showed a normal sinus rhythm with a normal\naxis deviation with inverted T's in V4 and V5 which were new.\n\nHOSPITAL COURSE: The patient was admitted to the cardiology\nservice and was placed in Intensive Care Unit. IV Heparin\nand Nitroglycerin were begun. Serial CKs were obtained along\nwith serial EKG's.", " Serial total CK's peaked at 533. MB\nfraction peaked at 9.2. Initial troponin level was greater\nthan 50 and after the next 72 hours its level was 1.5.\nNormal is less than .03. Within the next 24 hours the\npatient underwent cardiac catheterization. The patient's\nright sided pressures, PA was 50/17, right atrial mean was\n16, pulmonary wedge pressure was 16, left ventricular end\ndiastolic pressure was 17. Cardiac output was 6.0, index was\n3.3, EF was 30% with akinetic anterolateral and apex walls\nand hypokinetic antero basal wall and normal posterior and\nbasal wall. The native vessels showed left main trunk\ndisease of 30%, left anterior was proximal 30% and mid 90%\nleft circumflex was mid 50%. Ramus intermedius was 90% which\nwas angioplastied and stented and the right coronary showed\nan osteal lesion of 30%.", ' There was concern of right external\niliac artery dissection. The patient underwent a right\nfemoral ultrasound which demonstrated triphasic flow in the\nright common femoral artery with plaque or flap proximal to\nthe right SFA with stenosis and did have episodes of SVG and\nwas begun on beta blockers. Aspirin and Plavix were continued\npost stenting. The groin was without bleeding and he had\ndistal pulses. Dr. Grose, the cardiologist, requested that\nvascular be consulted regarding the findings on the right\niliac SFA ultrasound. The patient, although study was\nabnormal but with intact distal pulses, the patient did note\n72 hours after catheterization, onset of right calf and ankle\nfoot pain with ambulation. The patient underwent a repeat\nperipheral arterial catheterization which demonstrated\nabdominal aorta with no significant disease, renal arteries\nbilaterally were normal, the right lower extremity iliac is\nwithout critical lesions, the previous noted dissection is\nnot occlusive but the site is still delineated.', " The common\nfemoral is normal, the SFA and profunda artery are normal,\nthe popliteals occlude mid vessel and the anterior and tibial\nwere not well visualized but appear thrombolytically\noccluded. There was three vessel runoff to the foot. The\ncollaterals provide much of the distal flow. The patient was\nTPA'd, begun on Heparin and placed in the VICU. The patient\nhad consequences of a right groin hematoma after the second\nright groin intervention and angiography which required\npressure occlusion. The patient underwent on 12-12, a\nthrombectomy of the right tibial peroneal trunk and AT artery\nwith patch angioplasty of the right popliteal artery. He\ntolerated the procedure well and was transferred to the VICU\nfor continued monitoring and care. The patient required a\nunit of packed cells for hematocrit of 25, post transfusion\nhematocrit was 35.", ' Total CK was 74. The patient was placed\non peri-operative Kefzol and remained in the VICU in stable\ncondition. On 1-20 the patient had an episode of\nhematemesis. An NG was placed with 300 cc of blood\naspirated. The patient remained hemodynamically stable.\nSerial hematocrits were obtained and Plavix and Aspirin were\nheld. GI was consulted. The patient underwent upper\nendoscopy which demonstrated a few non bleeding localized\nerosions in the esophagus at the GE junction consistent with\nNG trauma. There was bilious fluid in the stomach body and\nantrum. There is no active bleeding or coffee ground or\nbright red blood noted. There were few superficial non\nbleeding 2 mm ulcers ranging in size from 2 mm to 5 mm in the\nstomach. The duodenum was normal. Recommendations were to\ncontinue the Protonix at 40 mg q d, discontinue the NG tube,\nfollow serial hematocrits.', " Please consider the risk/benefits\nof Aspirin and Plavix. If Aspirin and Plavix need to be\ncontinued, then we will put the patient on a higher dose of\nProtonix. The patient experienced episode of hypertension\novernight on postoperative day #1 requiring adjustments in\nhypertensive medications and transfusion of packed red blood\ncells. On postoperative day #3 there were no overnight\nevents. The patient continued on Protonix IV and Captopril\nand beta blockers. His hematocrit remained stable at 29.\nCKs were flat and serial hematocrits remained stable. The\npatient was then begun on Aspirin. Physical therapy saw the\npatient and felt that he would be able to be discharged to\nhome after evaluating ambulation with stairs. The patient's\nhematocrits remained stable, groin remained stable. The\npatient was discharged in stable condition on 1903-12-22.", ' She\nis to follow-up with Dr. Grose as instructed and see Dr.\nArchie in two weeks time.\n\nDISCHARGE MEDICATIONS: Include Keflex 500 mg qid times 7\ndays, Aspirin 81 mg q d, Lopressor 25 mg Jacobs-Powers Clinic, hold for\nsystolic blood pressure less than 120, heart rate less than\n60, Protonix 40 mg q d, Colace 100 mg Jacobs-Powers Clinic, Percocet tablets\n4-30 q 4 hours prn pain, Plavix 75 mg q d.\n\nDISCHARGE DIAGNOSIS:\n1. Non Q wave MI status post angioplasty of the ramus\nintermedius with stenting.\n2. Right groin hematoma, stabilized.\n3. Right iliac external artery dissection, stabilized.\n4. Thrombolic ischemia of the right leg, status post\nthrombectomy of the anterior tibial and peroneal trunk.\n5. Hypertension controlled.\n6. GI bleeding, stabilized.\n7. Blood loss anemia, transfused, corrected.', '\n\n\n\n\n Lawrence Martin, M.D. 35832691\n\nDictated By:Olles\nMEDQUIST36\n\nD: 1939-6-11 16:01\nT: 1939-6-11 16:50\nJOB#: Long, Barrett and Clark-1998-453835\n']
139	22486	160869.0	2200-07-15	Discharge summary	Report	Admission Date: [2200-7-10] Discharge Date: [2200-7-15] Date of Birth: [2150-10-11] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1481] Chief Complaint: Colitis with bleeding Major Surgical or Invasive Procedure: Right Colectomy History of Present Illness: 49 yo female who has had blood loss over a period of several months and has had abnormal colonoscopies which have shown some areas of stricturing. This has been unusual but is thought most likely to be due to Crohn's disease. She has been on steroids but still with problems. She presents now with a hematocrit of 20. She is a Jehovah's witness and will not accept any blood transfusions. After consultation with her General Medical physician and also with the hematology service, it was thought that it would not be possible to increase her hematocrit significantly prior to operation without at least a 1 month delay. It was also thought likely that any improvement in iron therapy would be off-set by continued bleeding. The patient and her partner understand the gravity of this situation and the need for operation under less than optimum circumstances. The patient has again expressed her wish that she not be given blood products, but she would accept certain other types of fluid. She presents now for right colectomy. Past Medical History: Neuralgia Rheumatoid arthritis Depression Social History: Patient is Jehovah's witness (okay with FFP, plts, cryo, albumin, and any product that does not have RBC's). Denies ETOH or recreational drug use. Smokes 1 pack per week. Physical Exam: Gen: NAD Chest: CTA bilaterally, no wheezes, rales, or rhonchi CV: RRR, no murmurs, rubs, or gallops Abd: +BS, soft, mild tender, nondistended, incision clean/dry/intact Pertinent Results: [2200-7-11] 03:08PM BLOOD Type-ART pO2-231* pCO2-37 pH-7.44 calHCO3-26 Base XS-1 [2200-7-11] 01:32PM BLOOD Type-ART pO2-154* pCO2-43 pH-7.41 calHCO3-28 Base XS-2 Intubat-NOT INTUBA [2200-7-11] 03:08PM BLOOD Glucose-137* Lactate-0.7 Na-137 K-3.6 Cl-106 [2200-7-11] 01:32PM BLOOD Glucose-101 Lactate-1.0 Na-138 K-3.5 Cl-107 [2200-7-11] 03:08PM BLOOD Hgb-6.0* calcHCT-18 [2200-7-11] 01:32PM BLOOD Hgb-5.5* calcHCT-17 [2200-7-11] 03:08PM BLOOD freeCa-1.08* [2200-7-11] 01:32PM BLOOD freeCa-1.14 Brief Hospital Course: 49 yo female with colitis resulting in anemia (HCt 20) s/p right colectomy on [2200-7-11]. She is Jehovah's witness and refused blood products. Intraoperatively, pt surgery went without complication and her estimated blood loss was 100ml. Post-operatively, patient was placed on O2 mask to maximize oxygenation and blood draws were not allowed. Pt progressed to tolerate PO intake well, ambulate, and bowel function returned. She was discharged on [2200-7-15] in good condition on steroid taper. Medications on Admission: Prednisone 40mg PO bid Bupropion 150mg po bid Nortryptiline 50mg po qd Risperidone 0.5mg po qhs Celexa 20mg po qd Mesalamine Iron Dextran Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO BID:PRN as needed for constipation. Disp:10 Capsule(s) Refills:0 3. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: then take 1.5 tablets daily for 3 days, then take 1 tablet daily for 3 days, then take half a tablet daily for 3 days (decrease by 2.5mg every three days). Disp:18 Tablet(s) Refills:0 4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 5. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO once a day. 7. Risperdal 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Colitis with bleeding Discharge Condition: Stable Discharge Instructions: Please resume your home medications. You may shower regularly. Call your physician or go to the emergency room if you experience fever >101.5, abdominal pain unrelieved by medication, or intractable nausea or vomiting. We have started you on prednisone (steroid) taper that decreases by 2.5mg every 3 days. Followup Instructions: Please call Dr.[Name (NI) 1482] office at ([Telephone/Fax (1) 1483] to schedule a follow-up appointment in [1-12] weeks. Completed by:[2200-7-15]	Admission Date: <Date>2013-12-16</Date> Discharge Date: <Date>1999-9-20</Date> Date of Birth: <Date>1933-2-29</Date> Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Taryn</Name> Chief Complaint: Colitis with bleeding Major Surgical or Invasive Procedure: Right Colectomy History of Present Illness: 49 yo female who has had blood loss over a period of several months and has had abnormal colonoscopies which have shown some areas of stricturing. This has been unusual but is thought most likely to be due to Crohn's disease. She has been on steroids but still with problems. She presents now with a hematocrit of 20. She is a Jehovah's witness and will not accept any blood transfusions. After consultation with her General Medical physician and also with the hematology service, it was thought that it would not be possible to increase her hematocrit significantly prior to operation without at least a 1 month delay. It was also thought likely that any improvement in iron therapy would be off-set by continued bleeding. The patient and her partner understand the gravity of this situation and the need for operation under less than optimum circumstances. The patient has again expressed her wish that she not be given blood products, but she would accept certain other types of fluid. She presents now for right colectomy. Past Medical History: Neuralgia Rheumatoid arthritis Depression Social History: Patient is Jehovah's witness (okay with FFP, plts, cryo, albumin, and any product that does not have RBC's). Denies ETOH or recreational drug use. Smokes 1 pack per week. Physical Exam: Gen: NAD Chest: CTA bilaterally, no wheezes, rales, or rhonchi CV: RRR, no murmurs, rubs, or gallops Abd: +BS, soft, mild tender, nondistended, incision clean/dry/intact Pertinent Results: <Date>1960-12-19</Date> 03:08PM BLOOD Type-ART pO2-231* pCO2-37 pH-7.44 calHCO3-26 Base XS-1 <Date>1960-12-19</Date> 01:32PM BLOOD Type-ART pO2-154* pCO2-43 pH-7.41 calHCO3-28 Base XS-2 Intubat-NOT INTUBA <Date>1960-12-19</Date> 03:08PM BLOOD Glucose-137* Lactate-0.7 Na-137 K-3.6 Cl-106 <Date>1960-12-19</Date> 01:32PM BLOOD Glucose-101 Lactate-1.0 Na-138 K-3.5 Cl-107 <Date>1960-12-19</Date> 03:08PM BLOOD Hgb-6.0* calcHCT-18 <Date>1960-12-19</Date> 01:32PM BLOOD Hgb-5.5* calcHCT-17 <Date>1960-12-19</Date> 03:08PM BLOOD freeCa-1.08* <Date>1960-12-19</Date> 01:32PM BLOOD freeCa-1.14 Brief Hospital Course: 49 yo female with colitis resulting in anemia (HCt 20) s/p right colectomy on <Date>1960-12-19</Date>. She is Jehovah's witness and refused blood products. Intraoperatively, pt surgery went without complication and her estimated blood loss was 100ml. Post-operatively, patient was placed on O2 mask to maximize oxygenation and blood draws were not allowed. Pt progressed to tolerate PO intake well, ambulate, and bowel function returned. She was discharged on <Date>1999-9-20</Date> in good condition on steroid taper. Medications on Admission: Prednisone 40mg PO bid Bupropion 150mg po bid Nortryptiline 50mg po qd Risperidone 0.5mg po qhs Celexa 20mg po qd Mesalamine Iron Dextran Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO BID:PRN as needed for constipation. Disp:10 Capsule(s) Refills:0 3. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: then take 1.5 tablets daily for 3 days, then take 1 tablet daily for 3 days, then take half a tablet daily for 3 days (decrease by 2.5mg every three days). Disp:18 Tablet(s) Refills:0 4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 5. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO once a day. 7. Risperdal 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Colitis with bleeding Discharge Condition: Stable Discharge Instructions: Please resume your home medications. You may shower regularly. Call your physician or go to the emergency room if you experience fever >101.5, abdominal pain unrelieved by medication, or intractable nausea or vomiting. We have started you on prednisone (steroid) taper that decreases by 2.5mg every 3 days. Followup Instructions: Please call Dr.<Name>Jacki Grose</Name> office at (<Telephone>696-716-2126</Telephone> to schedule a follow-up appointment in <Date>6-19</Date> weeks. Completed by:<Date>1999-9-20</Date>	00000000000000000111111111100000000000000000000000000000000111111111000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000111111111100000000000000000000000000000000000111111111100000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111100000000000011111111111100000000000000000000000000000000000000001111000000000000000000000000111111111	Admission Date: 2013-12-16 Discharge Date: 1999-9-20 Date of Birth: 1933-2-29 Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Taryn Chief Complaint: Colitis with bleeding Major Surgical or Invasive Procedure: Right Colectomy History of Present Illness: 49 yo female who has had blood loss over a period of several months and has had abnormal colonoscopies which have shown some areas of stricturing. This has been unusual but is thought most likely to be due to Crohn's disease. She has been on steroids but still with problems. She presents now with a hematocrit of 20. She is a Jehovah's witness and will not accept any blood transfusions. After consultation with her General Medical physician and also with the hematology service, it was thought that it would not be possible to increase her hematocrit significantly prior to operation without at least a 1 month delay. It was also thought likely that any improvement in iron therapy would be off-set by continued bleeding. The patient and her partner understand the gravity of this situation and the need for operation under less than optimum circumstances. The patient has again expressed her wish that she not be given blood products, but she would accept certain other types of fluid. She presents now for right colectomy. Past Medical History: Neuralgia Rheumatoid arthritis Depression Social History: Patient is Jehovah's witness (okay with FFP, plts, cryo, albumin, and any product that does not have RBC's). Denies ETOH or recreational drug use. Smokes 1 pack per week. Physical Exam: Gen: NAD Chest: CTA bilaterally, no wheezes, rales, or rhonchi CV: RRR, no murmurs, rubs, or gallops Abd: +BS, soft, mild tender, nondistended, incision clean/dry/intact Pertinent Results: 1960-12-19 03:08PM BLOOD Type-ART pO2-231* pCO2-37 pH-7.44 calHCO3-26 Base XS-1 1960-12-19 01:32PM BLOOD Type-ART pO2-154* pCO2-43 pH-7.41 calHCO3-28 Base XS-2 Intubat-NOT INTUBA 1960-12-19 03:08PM BLOOD Glucose-137* Lactate-0.7 Na-137 K-3.6 Cl-106 1960-12-19 01:32PM BLOOD Glucose-101 Lactate-1.0 Na-138 K-3.5 Cl-107 1960-12-19 03:08PM BLOOD Hgb-6.0* calcHCT-18 1960-12-19 01:32PM BLOOD Hgb-5.5* calcHCT-17 1960-12-19 03:08PM BLOOD freeCa-1.08* 1960-12-19 01:32PM BLOOD freeCa-1.14 Brief Hospital Course: 49 yo female with colitis resulting in anemia (HCt 20) s/p right colectomy on 1960-12-19. She is Jehovah's witness and refused blood products. Intraoperatively, pt surgery went without complication and her estimated blood loss was 100ml. Post-operatively, patient was placed on O2 mask to maximize oxygenation and blood draws were not allowed. Pt progressed to tolerate PO intake well, ambulate, and bowel function returned. She was discharged on 1999-9-20 in good condition on steroid taper. Medications on Admission: Prednisone 40mg PO bid Bupropion 150mg po bid Nortryptiline 50mg po qd Risperidone 0.5mg po qhs Celexa 20mg po qd Mesalamine Iron Dextran Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO BID:PRN as needed for constipation. Disp:10 Capsule(s) Refills:0 3. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: then take 1.5 tablets daily for 3 days, then take 1 tablet daily for 3 days, then take half a tablet daily for 3 days (decrease by 2.5mg every three days). Disp:18 Tablet(s) Refills:0 4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 5. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO once a day. 7. Risperdal 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Colitis with bleeding Discharge Condition: Stable Discharge Instructions: Please resume your home medications. You may shower regularly. Call your physician or go to the emergency room if you experience fever >101.5, abdominal pain unrelieved by medication, or intractable nausea or vomiting. We have started you on prednisone (steroid) taper that decreases by 2.5mg every 3 days. Followup Instructions: Please call Dr.Jacki Grose office at (696-716-2126 to schedule a follow-up appointment in 6-19 weeks. Completed by:1999-9-20	["Admission Date: 2013-12-16 Discharge Date: 1999-9-20\n\nDate of Birth: 1933-2-29 Sex: F\n\nService: SURGERY\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Taryn\nChief Complaint:\nColitis with bleeding\n\nMajor Surgical or Invasive Procedure:\nRight Colectomy\n\n\nHistory of Present Illness:\n49 yo female who has had blood loss over a period of several\nmonths and has had abnormal colonoscopies which have shown some\nareas of stricturing. This has been unusual but is thought most\nlikely to be due to Crohn's disease. She has\nbeen on steroids but still with problems. She presents now with\na hematocrit of 20. She is a Jehovah's witness and will not\naccept any blood transfusions. After consultation with her\nGeneral Medical physician and also with the hematology service,\nit was thought that it would not be possible to increase her\nhematocrit significantly prior to operation without at least a 1\nmonth delay.", " It was also thought likely that any improvement in\niron therapy would be off-set by continued bleeding. The patient\nand her partner understand the gravity of this situation and the\nneed for operation under less than optimum circumstances. The\npatient has again expressed her wish that she not be given blood\nproducts, but she would accept certain other types of fluid. She\npresents\nnow for right colectomy.\n\nPast Medical History:\nNeuralgia\nRheumatoid arthritis\nDepression\n\nSocial History:\nPatient is Jehovah's witness (okay with FFP, plts, cryo,\nalbumin, and any product that does not have RBC's). Denies ETOH\nor recreational drug use. Smokes 1 pack per week.\n\nPhysical Exam:\nGen: NAD\nChest: CTA bilaterally, no wheezes, rales, or rhonchi\nCV: RRR, no murmurs, rubs, or gallops\nAbd: +BS, soft, mild tender, nondistended, incision\nclean/dry/intact\n\n\nPertinent Results:\n1960-12-19 03:08PM BLOOD Type-ART pO2-231* pCO2-37 pH-7.", "44\ncalHCO3-26 Base XS-1\n1960-12-19 01:32PM BLOOD Type-ART pO2-154* pCO2-43 pH-7.41\ncalHCO3-28 Base XS-2 Intubat-NOT INTUBA\n1960-12-19 03:08PM BLOOD Glucose-137* Lactate-0.7 Na-137 K-3.6\nCl-106\n1960-12-19 01:32PM BLOOD Glucose-101 Lactate-1.0 Na-138 K-3.5\nCl-107\n1960-12-19 03:08PM BLOOD Hgb-6.0* calcHCT-18\n1960-12-19 01:32PM BLOOD Hgb-5.5* calcHCT-17\n1960-12-19 03:08PM BLOOD freeCa-1.08\n1960-12-19 01:32PM BLOOD freeCa-1.14\n\nBrief Hospital Course:\n49 yo female with colitis resulting in anemia (HCt 20) s/p right\ncolectomy on 1960-12-19. She is Jehovah's witness and refused blood\nproducts. Intraoperatively, pt surgery went without\ncomplication and her estimated blood loss was 100ml.\nPost-operatively, patient was placed on O2 mask to maximize\noxygenation and blood draws were not allowed. Pt progressed to\ntolerate PO intake well, ambulate, and bowel function returned.", '\nShe was discharged on 1999-9-20 in good condition on steroid taper.\n\nMedications on Admission:\nPrednisone 40mg PO bid\nBupropion 150mg po bid\nNortryptiline 50mg po qd\nRisperidone 0.5mg po qhs\nCelexa 20mg po qd\nMesalamine\nIron Dextran\n\nDischarge Medications:\n1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours\nas needed for pain.\nDisp:30 Tablet(s)* Refills:0\n2. Colace 100 mg Capsule Sig: One (1) Capsule PO BID:PRN as\nneeded for constipation.\nDisp:10 Capsule(s) Refills:0\n3. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for\n3 days: then take 1.5 tablets daily for 3 days, then take 1\ntablet daily for 3 days, then take half a tablet daily for 3\ndays (decrease by 2.5mg every three days).\nDisp:18 Tablet(s) Refills:0\n4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet\nSustained Release PO twice a day.', '\n5. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.\n6. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO once a\nday.\n7. Risperdal 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nColitis with bleeding\n\n\nDischarge Condition:\nStable\n\nDischarge Instructions:\nPlease resume your home medications. You may shower regularly.\nCall your physician or go to the emergency room if you\nexperience fever >101.5, abdominal pain unrelieved by\nmedication, or intractable nausea or vomiting. We have started\nyou on prednisone (steroid) taper that decreases by 2.5mg every\n3 days.\n\nFollowup Instructions:\nPlease call Dr.Jacki Grose office at (696-716-2126 to schedule\na follow-up appointment in 6-19 weeks.\n\n\n\nCompleted by:1999-9-20']
140	65055	153824.0	2113-07-31	Discharge summary	Report	Admission Date: [2113-7-25] Discharge Date: [2113-7-31] Date of Birth: [2030-11-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: Acute mental status change Major Surgical or Invasive Procedure: Embolectomy [2113-7-27] History of Present Illness: Pt's a 82 yo F with h/o HTN, h/o of prox a-fib, (not on coumadin), mood disorder on depakote (has had since CVA 4 yrs prior), with prior L inferior division MCA infarct now presenting with altered mental status. Pt basically at baseline AA0x2, has been reclusive living alone with mood disorder since her stroke - but has family heavily involved in her care - including ex-husband who visits daily. Pt basically has been at her baseline (which is described as more aggressive - usually asking her family to leave within 10-15minutes of being around her), but then 3-4 days ago noted being more lethargic - less aggressive but without any other notable complaints per ex-husband who saw pt then (no report of CP, F/C, HA, SOB as best assessed). Family getting concerned - were thinking would be needing more higher level care placement as pt generally weaker (no focal weaknesses) - but Sunday started appearing at baseline again. Pt was seen Monday early and was doing well (has called ex-husband roughly around 2pm and noted again at her baseline) - however when home aide came by apartment today in the morning - pt did not respond to door - found lethargic with emesis/stool/urine around her. No further information able to be obtained related to any events preceding to the evident n/v, bowel/stool incontinance. <br> Pt denies any cp, ha symptoms - can not elaborate further - was sent to ED - noted aggitated, +echolalia described in ED and from home aide initially - all consistant per family with her prior CVA 4 yrs prior. CT head without sig changes - however noted poor quality due to aggitation - neurology consulted. Noted trop elevated 1.12 - cardiology called - stated will not cath at present but for full medical treatment. Pt had been put in restraints in ED with foley placed - pt was subsequently severely aggitated. On arrival to floor - pt much calmer - not in restraints - family at bedside. <br> In [Name (NI) ] pt treated with hep gtt, ASA/Plavix (though pt refused to take), IV metoprolol (due to declining po meds), and vanc 1g/ceftriaxone 1g - for emperic treatment with leukocytosis (d/w ED resident - they stated just emperic tx with leukocytosis - were not aiming towards meningitis at time or any focal infection). <br> ROS: pt unable to appropriately respond to full questions. Past Medical History: -HTN -prox atrial fibrillation -mood disorder - on depakote -CVA 4yrs prior as above frequent UTIs reported in past anxiety h/o HSV I around mouth, s/p valtrex right cataract surgery Social History: lives alone, divorced, though ex-husband visits daily, 2 children, no tob/etoh/drugs. Russian speaking. Since stroke, pt more reclusive with h/o of mood disorder, but family very involved with care - pt lives by herself - but gets assistance from family for all IDLS, and for help with food preparation, bathing - pt able to go to restroom and does take medications by herself (as arranged in pill box by family). <br> Pt does not have officially assigned HCP - however 2 daughters collectively have been making decisions on her care since her stroke 4 yrs prior. NOK: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 1484] Cell) [Telephone/Fax (1) 1485], [First Name5 (NamePattern1) ] [Known lastname 1486] [Telephone/Fax (1) 1487] (cell), [Telephone/Fax (1) 1488] (work). Ex-Husband (but also highly involved in daily care of patient - [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 1484] [Telephone/Fax (1) 1489]. Family History: HTN, no seizures or strokes Physical Exam: Discharge Vitals: 97.1 150/88 (generally SBP 100-120) 81 18 97RA Gen: Elderly female, NAD. HEENT: PERRL, EOMI. No scleral icterus. No conjunctival injection. Mucous membranes moist. No oral ulcers. Neck: Supple, no JVP Lungs: CTA bilaterally anteriorly, no wheezes, rales, rhonchi. Normal respiratory effort. CV: irreg irreg, no murmurs, rubs, gallops. Abdomen: soft, NT, ND, NABS Extremities: L arm with significant post-surgical eccymosis, without hematoma or bleeding. Ecchymosis stable, with gradual dilutional spread. Neurological: CN2-12 grossly intact. No focal defecits. Pertinent Results: [2113-7-25] 04:46PM LACTATE-2.8* [2113-7-25] 01:18PM GLUCOSE-170* LACTATE-4.8* [2113-7-25] 01:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2113-7-25] 01:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2113-7-25] 01:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [2113-7-25] 01:15PM URINE GRANULAR-<1 HYALINE-<1 [2113-7-25] 01:15PM URINE MUCOUS-FEW [2113-7-25] 01:10PM GLUCOSE-175* UREA N-20 CREAT-0.8 SODIUM-139 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-25 ANION GAP-21* [2113-7-25] 01:10PM ALT(SGPT)-34 AST(SGOT)-132* CK(CPK)-6902* ALK PHOS-61 TOT BILI-1.2 [2113-7-25] 01:10PM LIPASE-12 [2113-7-25] 01:10PM cTropnT-1.12* [2113-7-25] 01:10PM CK-MB-237* MB INDX-3.4 [2113-7-25] 01:10PM ALBUMIN-4.5 CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-2.0 [2113-7-25] 01:10PM WBC-15.4* RBC-5.10 HGB-15.7 HCT-45.9 MCV-90# MCH-30.8# MCHC-34.2 RDW-13.0 [2113-7-25] 01:10PM NEUTS-87.8* LYMPHS-7.0* MONOS-4.5 EOS-0.6 BASOS-0.2 [2113-7-25] 01:10PM PLT COUNT-196 [2113-7-25] 01:10PM PT-12.5 PTT-21.9* INR(PT)-1.1 <br> Discharge labs: [2113-7-31] 09:25AM BLOOD WBC-7.9 RBC-4.07* Hgb-12.5 Hct-36.7 MCV-90 MCH-30.8 MCHC-34.1 RDW-13.5 Plt Ct-272 [2113-7-31] 09:25AM BLOOD Glucose-270* UreaN-11 Creat-0.7 Na-142 K-4.3 Cl-106 HCO3-32 AnGap-8 [2113-7-31] 09:25AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.1 [2113-7-28] 01:19AM BLOOD VitB12-181* [2113-7-28] 01:19AM BLOOD TSH-2.1 [2113-7-29] 06:55AM BLOOD Valproa-19* [2113-7-30] 07:10PM BLOOD PT-18.9* PTT-150* INR(PT)-1.7* [2113-7-31] 02:00AM BLOOD PT-16.4* PTT-26.0 INR(PT)-1.5* [2113-7-31] 09:25AM BLOOD PT-19.6* PTT->150 INR(PT)-1.8* [2113-7-31] 10:35AM BLOOD PT-21.3* PTT->150* INR(PT)-2.0* [2113-7-25] 01:10PM BLOOD ALT-34 AST-132* CK(CPK)-6902* AlkPhos-61 TotBili-1.2 [2113-7-26] 06:30AM BLOOD CK(CPK)-4823* [2113-7-29] 08:10PM BLOOD CK(CPK)-1455* [2113-7-25] 01:10PM BLOOD cTropnT-1.12* [2113-7-30] 03:25AM BLOOD CK-MB-12* cTropnT-0.45* [2113-7-30] 11:58AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.009 [2113-7-30] 11:58AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR . Blood cultures: neg x 2 Urine culture: negative x1, pending x 1 RPR negative <br> CXR: IMPRESSION: 1. Enlargement of the cardiac silhouette, without evidence of pulmonary edema and without change compared to [2109], suggesting possible cardiomyopathy. 2. Slight increased, now moderate-sized hiatal hernia. <br> [7-25] EKG compared to 05' EKG - nsr, new TWI in avL, +min st dep v4-6 - otherwise no other acute st/tw changes. <br> Non-contrast Head CT: IMPRESSION: No acute hemorrhage or obvious major acute area of infarction. If acute infarction is of clinical concern, MR has improved sensitivity in comparison to non-contrast head CT. Chronic infarct in left MCA distribution. <br> Cardiac Echo: Conclusions The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid to distal anterior septum, anterior wall and apex. A left ventricular mass/thrombus cannot be excluded. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Focal LV systolic dysfunction consistent with LAD infarction. Mild aortic regurgitation. <br> [7-26] CXR: The patient's radiograph currently demonstrates new bilateral perihilar opacities consistent with interval development of pulmonary edema. There are bilateral pleural effusions also developed in the meantime interval, most likely small to moderate. There is no pneumothorax and there is no change in the cardiomediastinal silhouette. . LLE LENI: Preliminary Report !! WET READ !! No DVT LLE. Brief Hospital Course: 82 yo F with h/o HTN, h/o of prox a-fib, (not on coumadin), mood disorder on depakote (has had since CVA 4 yrs prior), with prior L inferior division MCA infarct now presenting with altered mental status with troponin elevation. <br> # AMS/NSTEMI: Patient began to have mental status changes [4-5] days prior to admission, then was found on the floor with emesis/stool/urine around her. In ED, had altered MS with new inferolateral ST depressions and T-wave inversions in aVL on ECG, elevated troponin and no acute changes on CT Head. Neurology was consulted for possible metabolic encephalopathy, either due to effect of medications (on depakote at home) or infection (T to 100.4 and leucocytosis). Her family declined a lumbar puncture. ACS protocol was initiated with IV heparin and betablockers, while patient refused PO medications. The family chose not to undergo catheterization, opting for more conservative medical management. The morning of [2113-7-26] the patient was noted to be in atrial fibrillation with rapid ventricular response with decreased urine output and new pulmonary edema on CXR. Echocardiogram that day showed akinesis of the mid to distal anterior septum, anterior wall and apex. Diuresis was undertaken. Then at 1700, the patient's left hand was noted to become cold, blue and painful. Vascular surgery was consulted, the patient was transferred to the CCU. She was also started on a high dose statin and a small dose of an ACE inhibitor. Neurology recommended that she have a non-emergent MRI head to r/o embolic stroke not visualized on head CT, however family declined as it would not likely change management. <br> # Anticoagulation: Patient has multiple indications for being maintained on anticoagulation, and at the time of discharge, pt is currently on a heparin drip while bridging to therapeutic INR. Considering thromboembolism to her arm requiring embolectomy, her atrial fibrillation, and her history of strokes in the past, I recommend overlapping her heparin drip with a therapeutic INR x 48 hours. Please note that at the time of discharge, her INR measured 2, however this is likely OVERestimated, as her PTT at the time was >150, and at that level of anticoagulation can falsely elevate the INR. I recommend obtaining a repeat INR upon admission. Please titrate coumadin dosing prn for goal INR [3-7]. <br> # Left hand ischemia: Patient was noted [7-26] to have a palpable brachial pulse and absent radial pulse on the left side. Most probably cause was felt to be an arterial clot in the setting of atrial fibrillation. The patient had already been started on a heparin drip for ACS and this was continued. The vascular surgery team was consulted regarding the limb ischemia and embolectomy was felt to be indicated as she continued to have cyanosis of her left hand despite being on the heparin drip. She had a successful embolectomy on [7-27] of the left brachial artery under local anesthesia. Her post-op course was complicated by a large 8cm hematoma at the entry site in the left arm, which was followed closely by vascular surgery, as no urgent need for hematoma evacuation was indicated overnight. Given a stable hematocrit, the patient was continued on IV Heparin for anticoagulation for her recent NSTEMI as well as her history of Afib. <br> # Atrial Fib - Patient has a history of paroxysmal a-fib, but was not on coumadin due to a high risk of falls. She was found to be in atrial fibrillation with RVR the morning of [7-26], but since has been adequately rate controlled with metoprolol. Given her recent embolic event to her left arm, she was started on coumadin with a heparin bridge. To avoid an excessive bleeding risk, her Plavix was discontinued(patient was started on aspirin and plavix after an MCA CVA apprx 3 years ago) and her Aspirin dose was reduced to 81mg daily. <br> # Mood disorder: Patient has had behavioral problems since a CVA three years ago. After admission her mental status apparently returned to baseline. She was continued on home doses of Depakote, Paxil and Zyprexa. Restraints and foley catheter were avoided. <br> # Pulmonary edema - patient was diuresed with IV Lasix. She is incontinent and did not have a foley catheter, making it difficult to measure her fluid balance, but she appeared to be euvolemic and breathing comfortably at the time of discharge. <br> # HTN - Patient was adequately controlled with metoprolol and lisinopril. <br> Prophylaxis - patient maintained on famotidine and SQ heparin. <br> NOK: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 1484] (Cell) [Telephone/Fax (1) 1485], [First Name5 (NamePattern1) ] [Known lastname 1486] [Telephone/Fax (1) 1487] (cell), [Telephone/Fax (1) 1488] (work). Ex-Husband (but also highly involved in daily care of patient - [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 1484] [Telephone/Fax (1) 1489]. Code: FULL DISPO: pt discharged to [Hospital 100] Rehab LTAC Medications on Admission: Confirmed with family [7-25]: Aspirin 81 mg po q day Lisinopril 10 mg po q day Depakote 250 mg po BID metoprolol 25 mg po BID zyprexa 5 mg po q day Paxil 10 mg po q am Vitamin C 500 mg po BID Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: per protocol units Intravenous contin: Please continue heparin gtt until INR [3-7] for 48 hours. 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) mL Injection DAILY (Daily) for 4 days. 12. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup Sig: Two [Age over 90 1230]y (250) mg PO Q12H (every 12 hours). 13. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day): hold for loose stools. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever. 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: -Altered mental status -Non ST-elevation myocardial infarction -Left arm ischemia -B12 deficiency. Discharge Condition: Good Discharge Instructions: You were admitted with altered metntal status. You ruled in for a heart attack but the decision was made to pursue conservative management. Your heart went into a rapid rate and a blood clot traveled to your left arm causeing a blockage. You were taken to the OR for removal of the clot. You were put on a heparin drip and will need to be on long term anticoagulation with coumadin to prevent further blood clots. You were also noted to have low B12 level which can contribute to altered mental status and you being given b12 supplementation Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2113-8-9] 3:15 [Hospital ] Medical Office Building; [Location (un) 442].	Admission Date: <Date>1945-12-27</Date> Discharge Date: <Date>1995-3-21</Date> Date of Birth: <Date>1955-4-25</Date> Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Stephanie</Name> Chief Complaint: Acute mental status change Major Surgical or Invasive Procedure: Embolectomy <Date>2013-7-12</Date> History of Present Illness: Pt's a 82 yo F with h/o HTN, h/o of prox a-fib, (not on coumadin), mood disorder on depakote (has had since CVA 4 yrs prior), with prior L inferior division MCA infarct now presenting with altered mental status. Pt basically at baseline AA0x2, has been reclusive living alone with mood disorder since her stroke - but has family heavily involved in her care - including ex-husband who visits daily. Pt basically has been at her baseline (which is described as more aggressive - usually asking her family to leave within 10-15minutes of being around her), but then 3-4 days ago noted being more lethargic - less aggressive but without any other notable complaints per ex-husband who saw pt then (no report of CP, F/C, HA, SOB as best assessed). Family getting concerned - were thinking would be needing more higher level care placement as pt generally weaker (no focal weaknesses) - but Sunday started appearing at baseline again. Pt was seen Monday early and was doing well (has called ex-husband roughly around 2pm and noted again at her baseline) - however when home aide came by apartment today in the morning - pt did not respond to door - found lethargic with emesis/stool/urine around her. No further information able to be obtained related to any events preceding to the evident n/v, bowel/stool incontinance. <br> Pt denies any cp, ha symptoms - can not elaborate further - was sent to ED - noted aggitated, +echolalia described in ED and from home aide initially - all consistant per family with her prior CVA 4 yrs prior. CT head without sig changes - however noted poor quality due to aggitation - neurology consulted. Noted trop elevated 1.12 - cardiology called - stated will not cath at present but for full medical treatment. Pt had been put in restraints in ED with foley placed - pt was subsequently severely aggitated. On arrival to floor - pt much calmer - not in restraints - family at bedside. <br> In <Name>Sachin Mao</Name> pt treated with hep gtt, ASA/Plavix (though pt refused to take), IV metoprolol (due to declining po meds), and vanc 1g/ceftriaxone 1g - for emperic treatment with leukocytosis (d/w ED resident - they stated just emperic tx with leukocytosis - were not aiming towards meningitis at time or any focal infection). <br> ROS: pt unable to appropriately respond to full questions. Past Medical History: -HTN -prox atrial fibrillation -mood disorder - on depakote -CVA 4yrs prior as above frequent UTIs reported in past anxiety h/o HSV I around mouth, s/p valtrex right cataract surgery Social History: lives alone, divorced, though ex-husband visits daily, 2 children, no tob/etoh/drugs. Russian speaking. Since stroke, pt more reclusive with h/o of mood disorder, but family very involved with care - pt lives by herself - but gets assistance from family for all IDLS, and for help with food preparation, bathing - pt able to go to restroom and does take medications by herself (as arranged in pill box by family). <br> Pt does not have officially assigned HCP - however 2 daughters collectively have been making decisions on her care since her stroke 4 yrs prior. NOK: <Name>Jere</Name> <Name>Anderson</Name> Cell) <Telephone>223-277-3856</Telephone>, <Name>Jere</Name> <Name>Meraz</Name> <Telephone>163-229-4045</Telephone> (cell), <Telephone>680-260-5072</Telephone> (work). Ex-Husband (but also highly involved in daily care of patient - <Name>Jere</Name> <Name>Anderson</Name> <Telephone>679-593-1249</Telephone>. Family History: HTN, no seizures or strokes Physical Exam: Discharge Vitals: 97.1 150/88 (generally SBP 100-120) 81 18 97RA Gen: Elderly female, NAD. HEENT: PERRL, EOMI. No scleral icterus. No conjunctival injection. Mucous membranes moist. No oral ulcers. Neck: Supple, no JVP Lungs: CTA bilaterally anteriorly, no wheezes, rales, rhonchi. Normal respiratory effort. CV: irreg irreg, no murmurs, rubs, gallops. Abdomen: soft, NT, ND, NABS Extremities: L arm with significant post-surgical eccymosis, without hematoma or bleeding. Ecchymosis stable, with gradual dilutional spread. Neurological: CN2-12 grossly intact. No focal defecits. Pertinent Results: <Date>1945-12-27</Date> 04:46PM LACTATE-2.8* <Date>1945-12-27</Date> 01:18PM GLUCOSE-170* LACTATE-4.8* <Date>1945-12-27</Date> 01:15PM URINE COLOR-Yellow APPEAR-Clear SP <Name>Poff</Name>-1.017 <Date>1945-12-27</Date> 01:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG <Date>1945-12-27</Date> 01:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 <Date>1945-12-27</Date> 01:15PM URINE GRANULAR-<1 HYALINE-<1 <Date>1945-12-27</Date> 01:15PM URINE MUCOUS-FEW <Date>1945-12-27</Date> 01:10PM GLUCOSE-175* UREA N-20 CREAT-0.8 SODIUM-139 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-25 ANION GAP-21* <Date>1945-12-27</Date> 01:10PM ALT(SGPT)-34 AST(SGOT)-132* CK(CPK)-6902* ALK PHOS-61 TOT BILI-1.2 <Date>1945-12-27</Date> 01:10PM LIPASE-12 <Date>1945-12-27</Date> 01:10PM cTropnT-1.12* <Date>1945-12-27</Date> 01:10PM CK-MB-237* MB INDX-3.4 <Date>1945-12-27</Date> 01:10PM ALBUMIN-4.5 CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-2.0 <Date>1945-12-27</Date> 01:10PM WBC-15.4* RBC-5.10 HGB-15.7 HCT-45.9 MCV-90# MCH-30.8# MCHC-34.2 RDW-13.0 <Date>1945-12-27</Date> 01:10PM NEUTS-87.8* LYMPHS-7.0* MONOS-4.5 EOS-0.6 BASOS-0.2 <Date>1945-12-27</Date> 01:10PM PLT COUNT-196 <Date>1945-12-27</Date> 01:10PM PT-12.5 PTT-21.9* INR(PT)-1.1 <br> Discharge labs: <Date>1995-3-21</Date> 09:25AM BLOOD WBC-7.9 RBC-4.07* Hgb-12.5 Hct-36.7 MCV-90 MCH-30.8 MCHC-34.1 RDW-13.5 Plt Ct-272 <Date>1995-3-21</Date> 09:25AM BLOOD Glucose-270* UreaN-11 Creat-0.7 Na-142 K-4.3 Cl-106 HCO3-32 AnGap-8 <Date>1995-3-21</Date> 09:25AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.1 <Date>1904-3-9</Date> 01:19AM BLOOD VitB12-181* <Date>1904-3-9</Date> 01:19AM BLOOD TSH-2.1 <Date>1954-9-29</Date> 06:55AM BLOOD Valproa-19* <Date>1936-5-18</Date> 07:10PM BLOOD PT-18.9* PTT-150* INR(PT)-1.7* <Date>1995-3-21</Date> 02:00AM BLOOD PT-16.4* PTT-26.0 INR(PT)-1.5* <Date>1995-3-21</Date> 09:25AM BLOOD PT-19.6* PTT->150 INR(PT)-1.8* <Date>1995-3-21</Date> 10:35AM BLOOD PT-21.3* PTT->150* INR(PT)-2.0* <Date>1945-12-27</Date> 01:10PM BLOOD ALT-34 AST-132* CK(CPK)-6902* AlkPhos-61 TotBili-1.2 <Date>2002-10-18</Date> 06:30AM BLOOD CK(CPK)-4823* <Date>1954-9-29</Date> 08:10PM BLOOD CK(CPK)-1455* <Date>1945-12-27</Date> 01:10PM BLOOD cTropnT-1.12* <Date>1936-5-18</Date> 03:25AM BLOOD CK-MB-12* cTropnT-0.45* <Date>1936-5-18</Date> 11:58AM URINE Color-Yellow Appear-Clear Sp <Name>Chowdhury</Name>-1.009 <Date>1936-5-18</Date> 11:58AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR . Blood cultures: neg x 2 Urine culture: negative x1, pending x 1 RPR negative <br> CXR: IMPRESSION: 1. Enlargement of the cardiac silhouette, without evidence of pulmonary edema and without change compared to <Year>1962</Year>, suggesting possible cardiomyopathy. 2. Slight increased, now moderate-sized hiatal hernia. <br> <Date>4-20</Date> EKG compared to 05' EKG - nsr, new TWI in avL, +min st dep v4-6 - otherwise no other acute st/tw changes. <br> Non-contrast Head CT: IMPRESSION: No acute hemorrhage or obvious major acute area of infarction. If acute infarction is of clinical concern, MR has improved sensitivity in comparison to non-contrast head CT. Chronic infarct in left MCA distribution. <br> Cardiac Echo: Conclusions The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid to distal anterior septum, anterior wall and apex. A left ventricular mass/thrombus cannot be excluded. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Focal LV systolic dysfunction consistent with LAD infarction. Mild aortic regurgitation. <br> <Date>2-10</Date> CXR: The patient's radiograph currently demonstrates new bilateral perihilar opacities consistent with interval development of pulmonary edema. There are bilateral pleural effusions also developed in the meantime interval, most likely small to moderate. There is no pneumothorax and there is no change in the cardiomediastinal silhouette. . LLE LENI: Preliminary Report !! WET READ !! No DVT LLE. Brief Hospital Course: 82 yo F with h/o HTN, h/o of prox a-fib, (not on coumadin), mood disorder on depakote (has had since CVA 4 yrs prior), with prior L inferior division MCA infarct now presenting with altered mental status with troponin elevation. <br> # AMS/NSTEMI: Patient began to have mental status changes <Date>10-12</Date> days prior to admission, then was found on the floor with emesis/stool/urine around her. In ED, had altered MS with new inferolateral ST depressions and T-wave inversions in aVL on ECG, elevated troponin and no acute changes on CT Head. Neurology was consulted for possible metabolic encephalopathy, either due to effect of medications (on depakote at home) or infection (T to 100.4 and leucocytosis). Her family declined a lumbar puncture. ACS protocol was initiated with IV heparin and betablockers, while patient refused PO medications. The family chose not to undergo catheterization, opting for more conservative medical management. The morning of <Date>2002-10-18</Date> the patient was noted to be in atrial fibrillation with rapid ventricular response with decreased urine output and new pulmonary edema on CXR. Echocardiogram that day showed akinesis of the mid to distal anterior septum, anterior wall and apex. Diuresis was undertaken. Then at 1700, the patient's left hand was noted to become cold, blue and painful. Vascular surgery was consulted, the patient was transferred to the CCU. She was also started on a high dose statin and a small dose of an ACE inhibitor. Neurology recommended that she have a non-emergent MRI head to r/o embolic stroke not visualized on head CT, however family declined as it would not likely change management. <br> # Anticoagulation: Patient has multiple indications for being maintained on anticoagulation, and at the time of discharge, pt is currently on a heparin drip while bridging to therapeutic INR. Considering thromboembolism to her arm requiring embolectomy, her atrial fibrillation, and her history of strokes in the past, I recommend overlapping her heparin drip with a therapeutic INR x 48 hours. Please note that at the time of discharge, her INR measured 2, however this is likely OVERestimated, as her PTT at the time was >150, and at that level of anticoagulation can falsely elevate the INR. I recommend obtaining a repeat INR upon admission. Please titrate coumadin dosing prn for goal INR <Date>6-5</Date>. <br> # Left hand ischemia: Patient was noted <Date>2-10</Date> to have a palpable brachial pulse and absent radial pulse on the left side. Most probably cause was felt to be an arterial clot in the setting of atrial fibrillation. The patient had already been started on a heparin drip for ACS and this was continued. The vascular surgery team was consulted regarding the limb ischemia and embolectomy was felt to be indicated as she continued to have cyanosis of her left hand despite being on the heparin drip. She had a successful embolectomy on <Date>1-25</Date> of the left brachial artery under local anesthesia. Her post-op course was complicated by a large 8cm hematoma at the entry site in the left arm, which was followed closely by vascular surgery, as no urgent need for hematoma evacuation was indicated overnight. Given a stable hematocrit, the patient was continued on IV Heparin for anticoagulation for her recent NSTEMI as well as her history of Afib. <br> # Atrial Fib - Patient has a history of paroxysmal a-fib, but was not on coumadin due to a high risk of falls. She was found to be in atrial fibrillation with RVR the morning of <Date>2-10</Date>, but since has been adequately rate controlled with metoprolol. Given her recent embolic event to her left arm, she was started on coumadin with a heparin bridge. To avoid an excessive bleeding risk, her Plavix was discontinued(patient was started on aspirin and plavix after an MCA CVA apprx 3 years ago) and her Aspirin dose was reduced to 81mg daily. <br> # Mood disorder: Patient has had behavioral problems since a CVA three years ago. After admission her mental status apparently returned to baseline. She was continued on home doses of Depakote, Paxil and Zyprexa. Restraints and foley catheter were avoided. <br> # Pulmonary edema - patient was diuresed with IV Lasix. She is incontinent and did not have a foley catheter, making it difficult to measure her fluid balance, but she appeared to be euvolemic and breathing comfortably at the time of discharge. <br> # HTN - Patient was adequately controlled with metoprolol and lisinopril. <br> Prophylaxis - patient maintained on famotidine and SQ heparin. <br> NOK: <Name>Jere</Name> <Name>Anderson</Name> (Cell) <Telephone>223-277-3856</Telephone>, <Name>Jere</Name> <Name>Meraz</Name> <Telephone>163-229-4045</Telephone> (cell), <Telephone>680-260-5072</Telephone> (work). Ex-Husband (but also highly involved in daily care of patient - <Name>Jere</Name> <Name>Anderson</Name> <Telephone>679-593-1249</Telephone>. Code: FULL DISPO: pt discharged to <Hospital>Mack-Thomas Clinic</Hospital> Rehab LTAC Medications on Admission: Confirmed with family <Date>4-20</Date>: Aspirin 81 mg po q day Lisinopril 10 mg po q day Depakote 250 mg po BID metoprolol 25 mg po BID zyprexa 5 mg po q day Paxil 10 mg po q am Vitamin C 500 mg po BID Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: per protocol units Intravenous contin: Please continue heparin gtt until INR <Date>6-5</Date> for 48 hours. 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) mL Injection DAILY (Daily) for 4 days. 12. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup Sig: Two <Age>41</Age>y (250) mg PO Q12H (every 12 hours). 13. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day): hold for loose stools. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever. 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: <Hospital>Robinson, Williams and Jones Hospital</Hospital> for the Aged - MACU Discharge Diagnosis: -Altered mental status -Non ST-elevation myocardial infarction -Left arm ischemia -B12 deficiency. Discharge Condition: Good Discharge Instructions: You were admitted with altered metntal status. You ruled in for a heart attack but the decision was made to pursue conservative management. Your heart went into a rapid rate and a blood clot traveled to your left arm causeing a blockage. You were taken to the OR for removal of the clot. You were put on a heparin drip and will need to be on long term anticoagulation with coumadin to prevent further blood clots. You were also noted to have low B12 level which can contribute to altered mental status and you being given b12 supplementation Weigh yourself every morning, <Name>Cruz Moblo</Name> MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Provider: <Name>Bryan Dortch</Name> <Name>Blanks</Name>, MD Phone:<Telephone>221-773-1899</Telephone> Date/Time:<Date>1968-11-11</Date> 3:15 <Hospital>Johnson and Sons Clinic</Hospital> Medical Office Building; <Location>044 Crystal Hollow South Brandon, NE 12159</Location>.	00000000000000000111111111100000000000000000000000000000000111111111000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111011111111000000011111111111100111101111101111111111110000000001111111111110000000000000000000000000000000000000000000000000000000000000000000000000011110111111110111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000111111111100000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000111100000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000011111111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Date: 1945-12-27 Discharge Date: 1995-3-21 Date of Birth: 1955-4-25 Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Stephanie Chief Complaint: Acute mental status change Major Surgical or Invasive Procedure: Embolectomy 2013-7-12 History of Present Illness: Pt's a 82 yo F with h/o HTN, h/o of prox a-fib, (not on coumadin), mood disorder on depakote (has had since CVA 4 yrs prior), with prior L inferior division MCA infarct now presenting with altered mental status. Pt basically at baseline AA0x2, has been reclusive living alone with mood disorder since her stroke - but has family heavily involved in her care - including ex-husband who visits daily. Pt basically has been at her baseline (which is described as more aggressive - usually asking her family to leave within 10-15minutes of being around her), but then 3-4 days ago noted being more lethargic - less aggressive but without any other notable complaints per ex-husband who saw pt then (no report of CP, F/C, HA, SOB as best assessed). Family getting concerned - were thinking would be needing more higher level care placement as pt generally weaker (no focal weaknesses) - but Sunday started appearing at baseline again. Pt was seen Monday early and was doing well (has called ex-husband roughly around 2pm and noted again at her baseline) - however when home aide came by apartment today in the morning - pt did not respond to door - found lethargic with emesis/stool/urine around her. No further information able to be obtained related to any events preceding to the evident n/v, bowel/stool incontinance. Pt denies any cp, ha symptoms - can not elaborate further - was sent to ED - noted aggitated, +echolalia described in ED and from home aide initially - all consistant per family with her prior CVA 4 yrs prior. CT head without sig changes - however noted poor quality due to aggitation - neurology consulted. Noted trop elevated 1.12 - cardiology called - stated will not cath at present but for full medical treatment. Pt had been put in restraints in ED with foley placed - pt was subsequently severely aggitated. On arrival to floor - pt much calmer - not in restraints - family at bedside. In Sachin Mao pt treated with hep gtt, ASA/Plavix (though pt refused to take), IV metoprolol (due to declining po meds), and vanc 1g/ceftriaxone 1g - for emperic treatment with leukocytosis (d/w ED resident - they stated just emperic tx with leukocytosis - were not aiming towards meningitis at time or any focal infection). ROS: pt unable to appropriately respond to full questions. Past Medical History: -HTN -prox atrial fibrillation -mood disorder - on depakote -CVA 4yrs prior as above frequent UTIs reported in past anxiety h/o HSV I around mouth, s/p valtrex right cataract surgery Social History: lives alone, divorced, though ex-husband visits daily, 2 children, no tob/etoh/drugs. Russian speaking. Since stroke, pt more reclusive with h/o of mood disorder, but family very involved with care - pt lives by herself - but gets assistance from family for all IDLS, and for help with food preparation, bathing - pt able to go to restroom and does take medications by herself (as arranged in pill box by family). Pt does not have officially assigned HCP - however 2 daughters collectively have been making decisions on her care since her stroke 4 yrs prior. NOK: Jere Anderson Cell) 223-277-3856, Jere Meraz 163-229-4045 (cell), 680-260-5072 (work). Ex-Husband (but also highly involved in daily care of patient - Jere Anderson 679-593-1249. Family History: HTN, no seizures or strokes Physical Exam: Discharge Vitals: 97.1 150/88 (generally SBP 100-120) 81 18 97RA Gen: Elderly female, NAD. HEENT: PERRL, EOMI. No scleral icterus. No conjunctival injection. Mucous membranes moist. No oral ulcers. Neck: Supple, no JVP Lungs: CTA bilaterally anteriorly, no wheezes, rales, rhonchi. Normal respiratory effort. CV: irreg irreg, no murmurs, rubs, gallops. Abdomen: soft, NT, ND, NABS Extremities: L arm with significant post-surgical eccymosis, without hematoma or bleeding. Ecchymosis stable, with gradual dilutional spread. Neurological: CN2-12 grossly intact. No focal defecits. Pertinent Results: 1945-12-27 04:46PM LACTATE-2.8* 1945-12-27 01:18PM GLUCOSE-170* LACTATE-4.8* 1945-12-27 01:15PM URINE COLOR-Yellow APPEAR-Clear SP Poff-1.017 1945-12-27 01:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 1945-12-27 01:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 1945-12-27 01:15PM URINE GRANULAR-1945-12-27 01:15PM URINE MUCOUS-FEW 1945-12-27 01:10PM GLUCOSE-175* UREA N-20 CREAT-0.8 SODIUM-139 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-25 ANION GAP-21* 1945-12-27 01:10PM ALT(SGPT)-34 AST(SGOT)-132* CK(CPK)-6902* ALK PHOS-61 TOT BILI-1.2 1945-12-27 01:10PM LIPASE-12 1945-12-27 01:10PM cTropnT-1.12* 1945-12-27 01:10PM CK-MB-237* MB INDX-3.4 1945-12-27 01:10PM ALBUMIN-4.5 CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-2.0 1945-12-27 01:10PM WBC-15.4* RBC-5.10 HGB-15.7 HCT-45.9 MCV-90# MCH-30.8# MCHC-34.2 RDW-13.0 1945-12-27 01:10PM NEUTS-87.8* LYMPHS-7.0* MONOS-4.5 EOS-0.6 BASOS-0.2 1945-12-27 01:10PM PLT COUNT-196 1945-12-27 01:10PM PT-12.5 PTT-21.9* INR(PT)-1.1 Discharge labs: 1995-3-21 09:25AM BLOOD WBC-7.9 RBC-4.07* Hgb-12.5 Hct-36.7 MCV-90 MCH-30.8 MCHC-34.1 RDW-13.5 Plt Ct-272 1995-3-21 09:25AM BLOOD Glucose-270* UreaN-11 Creat-0.7 Na-142 K-4.3 Cl-106 HCO3-32 AnGap-8 1995-3-21 09:25AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.1 1904-3-9 01:19AM BLOOD VitB12-181* 1904-3-9 01:19AM BLOOD TSH-2.1 1954-9-29 06:55AM BLOOD Valproa-19* 1936-5-18 07:10PM BLOOD PT-18.9* PTT-150* INR(PT)-1.7* 1995-3-21 02:00AM BLOOD PT-16.4* PTT-26.0 INR(PT)-1.5* 1995-3-21 09:25AM BLOOD PT-19.6* PTT->150 INR(PT)-1.8* 1995-3-21 10:35AM BLOOD PT-21.3* PTT->150* INR(PT)-2.0* 1945-12-27 01:10PM BLOOD ALT-34 AST-132* CK(CPK)-6902* AlkPhos-61 TotBili-1.2 2002-10-18 06:30AM BLOOD CK(CPK)-4823* 1954-9-29 08:10PM BLOOD CK(CPK)-1455* 1945-12-27 01:10PM BLOOD cTropnT-1.12* 1936-5-18 03:25AM BLOOD CK-MB-12* cTropnT-0.45* 1936-5-18 11:58AM URINE Color-Yellow Appear-Clear Sp Chowdhury-1.009 1936-5-18 11:58AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR . Blood cultures: neg x 2 Urine culture: negative x1, pending x 1 RPR negative CXR: IMPRESSION: 1. Enlargement of the cardiac silhouette, without evidence of pulmonary edema and without change compared to 1962, suggesting possible cardiomyopathy. 2. Slight increased, now moderate-sized hiatal hernia. 4-20 EKG compared to 05' EKG - nsr, new TWI in avL, +min st dep v4-6 - otherwise no other acute st/tw changes. Non-contrast Head CT: IMPRESSION: No acute hemorrhage or obvious major acute area of infarction. If acute infarction is of clinical concern, MR has improved sensitivity in comparison to non-contrast head CT. Chronic infarct in left MCA distribution. Cardiac Echo: Conclusions The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid to distal anterior septum, anterior wall and apex. A left ventricular mass/thrombus cannot be excluded. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Focal LV systolic dysfunction consistent with LAD infarction. Mild aortic regurgitation. 2-10 CXR: The patient's radiograph currently demonstrates new bilateral perihilar opacities consistent with interval development of pulmonary edema. There are bilateral pleural effusions also developed in the meantime interval, most likely small to moderate. There is no pneumothorax and there is no change in the cardiomediastinal silhouette. . LLE LENI: Preliminary Report !! WET READ !! No DVT LLE. Brief Hospital Course: 82 yo F with h/o HTN, h/o of prox a-fib, (not on coumadin), mood disorder on depakote (has had since CVA 4 yrs prior), with prior L inferior division MCA infarct now presenting with altered mental status with troponin elevation. # AMS/NSTEMI: Patient began to have mental status changes 10-12 days prior to admission, then was found on the floor with emesis/stool/urine around her. In ED, had altered MS with new inferolateral ST depressions and T-wave inversions in aVL on ECG, elevated troponin and no acute changes on CT Head. Neurology was consulted for possible metabolic encephalopathy, either due to effect of medications (on depakote at home) or infection (T to 100.4 and leucocytosis). Her family declined a lumbar puncture. ACS protocol was initiated with IV heparin and betablockers, while patient refused PO medications. The family chose not to undergo catheterization, opting for more conservative medical management. The morning of 2002-10-18 the patient was noted to be in atrial fibrillation with rapid ventricular response with decreased urine output and new pulmonary edema on CXR. Echocardiogram that day showed akinesis of the mid to distal anterior septum, anterior wall and apex. Diuresis was undertaken. Then at 1700, the patient's left hand was noted to become cold, blue and painful. Vascular surgery was consulted, the patient was transferred to the CCU. She was also started on a high dose statin and a small dose of an ACE inhibitor. Neurology recommended that she have a non-emergent MRI head to r/o embolic stroke not visualized on head CT, however family declined as it would not likely change management. # Anticoagulation: Patient has multiple indications for being maintained on anticoagulation, and at the time of discharge, pt is currently on a heparin drip while bridging to therapeutic INR. Considering thromboembolism to her arm requiring embolectomy, her atrial fibrillation, and her history of strokes in the past, I recommend overlapping her heparin drip with a therapeutic INR x 48 hours. Please note that at the time of discharge, her INR measured 2, however this is likely OVERestimated, as her PTT at the time was >150, and at that level of anticoagulation can falsely elevate the INR. I recommend obtaining a repeat INR upon admission. Please titrate coumadin dosing prn for goal INR 6-5. # Left hand ischemia: Patient was noted 2-10 to have a palpable brachial pulse and absent radial pulse on the left side. Most probably cause was felt to be an arterial clot in the setting of atrial fibrillation. The patient had already been started on a heparin drip for ACS and this was continued. The vascular surgery team was consulted regarding the limb ischemia and embolectomy was felt to be indicated as she continued to have cyanosis of her left hand despite being on the heparin drip. She had a successful embolectomy on 1-25 of the left brachial artery under local anesthesia. Her post-op course was complicated by a large 8cm hematoma at the entry site in the left arm, which was followed closely by vascular surgery, as no urgent need for hematoma evacuation was indicated overnight. Given a stable hematocrit, the patient was continued on IV Heparin for anticoagulation for her recent NSTEMI as well as her history of Afib. # Atrial Fib - Patient has a history of paroxysmal a-fib, but was not on coumadin due to a high risk of falls. She was found to be in atrial fibrillation with RVR the morning of 2-10, but since has been adequately rate controlled with metoprolol. Given her recent embolic event to her left arm, she was started on coumadin with a heparin bridge. To avoid an excessive bleeding risk, her Plavix was discontinued(patient was started on aspirin and plavix after an MCA CVA apprx 3 years ago) and her Aspirin dose was reduced to 81mg daily. # Mood disorder: Patient has had behavioral problems since a CVA three years ago. After admission her mental status apparently returned to baseline. She was continued on home doses of Depakote, Paxil and Zyprexa. Restraints and foley catheter were avoided. # Pulmonary edema - patient was diuresed with IV Lasix. She is incontinent and did not have a foley catheter, making it difficult to measure her fluid balance, but she appeared to be euvolemic and breathing comfortably at the time of discharge. # HTN - Patient was adequately controlled with metoprolol and lisinopril. Prophylaxis - patient maintained on famotidine and SQ heparin. NOK: Jere Anderson (Cell) 223-277-3856, Jere Meraz 163-229-4045 (cell), 680-260-5072 (work). Ex-Husband (but also highly involved in daily care of patient - Jere Anderson 679-593-1249. Code: FULL DISPO: pt discharged to Mack-Thomas Clinic Rehab LTAC Medications on Admission: Confirmed with family 4-20: Aspirin 81 mg po q day Lisinopril 10 mg po q day Depakote 250 mg po BID metoprolol 25 mg po BID zyprexa 5 mg po q day Paxil 10 mg po q am Vitamin C 500 mg po BID Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: per protocol units Intravenous contin: Please continue heparin gtt until INR 6-5 for 48 hours. 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) mL Injection DAILY (Daily) for 4 days. 12. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup Sig: Two 41y (250) mg PO Q12H (every 12 hours). 13. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day): hold for loose stools. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever. 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: Robinson, Williams and Jones Hospital for the Aged - MACU Discharge Diagnosis: -Altered mental status -Non ST-elevation myocardial infarction -Left arm ischemia -B12 deficiency. Discharge Condition: Good Discharge Instructions: You were admitted with altered metntal status. You ruled in for a heart attack but the decision was made to pursue conservative management. Your heart went into a rapid rate and a blood clot traveled to your left arm causeing a blockage. You were taken to the OR for removal of the clot. You were put on a heparin drip and will need to be on long term anticoagulation with coumadin to prevent further blood clots. You were also noted to have low B12 level which can contribute to altered mental status and you being given b12 supplementation Weigh yourself every morning, Cruz Moblo MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Provider: Bryan Dortch Blanks, MD Phone:221-773-1899 Date/Time:1968-11-11 3:15 Johnson and Sons Clinic Medical Office Building; 044 Crystal Hollow South Brandon, NE 12159.	["Admission Date: 1945-12-27 Discharge Date: 1995-3-21\n\nDate of Birth: 1955-4-25 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Stephanie\nChief Complaint:\nAcute mental status change\n\nMajor Surgical or Invasive Procedure:\nEmbolectomy 2013-7-12\n\n\nHistory of Present Illness:\nPt's a 82 yo F with h/o HTN, h/o of prox a-fib, (not on\ncoumadin), mood disorder on depakote (has had since CVA 4 yrs\nprior), with prior L inferior division MCA infarct now\npresenting with altered mental status. Pt basically at baseline\nAA0x2, has been reclusive living alone with mood disorder since\nher stroke - but has family heavily involved in her care -\nincluding ex-husband who visits daily. Pt basically has been at\nher baseline (which is described as more aggressive - usually\nasking her family to leave within 10-15minutes of being around\nher), but then 3-4 days ago noted being more lethargic - less\naggressive but without any other notable complaints per\nex-husband who saw pt then (no report of CP, F/C, HA, SOB as\nbest assessed).", ' Family getting concerned - were thinking would\nbe needing more higher level care placement as pt generally\nweaker (no focal weaknesses) - but Sunday started appearing at\nbaseline again. Pt was seen Monday early and was doing well\n(has called ex-husband roughly around 2pm and noted again at her\nbaseline) - however when home aide came by apartment today in\nthe morning - pt did not respond to door - found lethargic with\nemesis/stool/urine around her. No further information able to\nbe obtained related to any events preceding to the evident n/v,\nbowel/stool incontinance.\n\n\nPt denies any cp, ha symptoms - can not elaborate further - was\nsent to ED - noted aggitated, +echolalia described in ED and\nfrom home aide initially - all consistant per family with her\nprior CVA 4 yrs prior. CT head without sig changes - however\nnoted poor quality due to aggitation - neurology consulted.', '\nNoted trop elevated 1.12 - cardiology called - stated will not\ncath at present but for full medical treatment. Pt had been put\nin restraints in ED with foley placed - pt was subsequently\nseverely aggitated. On arrival to floor - pt much calmer - not\nin restraints - family at bedside.\n\n\nIn Sachin Mao pt treated with hep gtt, ASA/Plavix (though pt refused to\ntake), IV metoprolol (due to declining po meds), and vanc\n1g/ceftriaxone 1g - for emperic treatment with leukocytosis (d/w\nED resident - they stated just emperic tx with leukocytosis -\nwere not aiming towards meningitis at time or any focal\ninfection).\n\n\nROS: pt unable to appropriately respond to full questions.\n\nPast Medical History:\n-HTN\n-prox atrial fibrillation\n-mood disorder - on depakote\n-CVA 4yrs prior as above\nfrequent UTIs reported in past\nanxiety\nh/o HSV I around mouth, s/p valtrex\nright cataract surgery\n\nSocial History:\nlives alone, divorced, though ex-husband visits daily, 2\nchildren, no tob/etoh/drugs.', ' Russian speaking. Since stroke, pt\nmore reclusive with h/o of mood disorder, but family very\ninvolved with care - pt lives by herself - but gets assistance\nfrom family for all IDLS, and for help with food preparation,\nbathing - pt able to go to restroom and does take medications by\nherself (as arranged in pill box by family).\n\n\nPt does not have officially assigned HCP - however 2 daughters\ncollectively have been making decisions on her care since her\nstroke 4 yrs prior.\nNOK: Jere Anderson Cell) 223-277-3856, Jere Meraz 163-229-4045\n(cell), 680-260-5072 (work). Ex-Husband (but also highly\ninvolved in daily care of patient - Jere Anderson 679-593-1249.\n\n\nFamily History:\nHTN, no seizures or strokes\n\n\nPhysical Exam:\nDischarge Vitals: 97.1 150/88 (generally SBP 100-120) 81 18\n97RA\nGen: Elderly female, NAD.', '\nHEENT: PERRL, EOMI. No scleral icterus. No conjunctival\ninjection. Mucous membranes moist. No oral ulcers.\nNeck: Supple, no JVP\nLungs: CTA bilaterally anteriorly, no wheezes, rales, rhonchi.\nNormal respiratory effort.\nCV: irreg irreg, no murmurs, rubs, gallops.\nAbdomen: soft, NT, ND, NABS\nExtremities: L arm with significant post-surgical eccymosis,\nwithout hematoma or bleeding. Ecchymosis stable, with gradual\ndilutional spread.\nNeurological: CN2-12 grossly intact. No focal defecits.\n\n\nPertinent Results:\n1945-12-27 04:46PM LACTATE-2.8\n1945-12-27 01:18PM GLUCOSE-170 LACTATE-4.8\n1945-12-27 01:15PM URINE COLOR-Yellow APPEAR-Clear SP Poff-1.017\n1945-12-27 01:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30\nGLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0\nLEUK-NEG\n1945-12-27 01:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE\nEPI-0-2\n1945-12-27 01:15PM URINE GRANULAR-1945-12-27 01:15PM URINE MUCOUS-FEW\n1945-12-27 01:10PM GLUCOSE-175 UREA N-20 CREAT-0.', '8 SODIUM-139\nPOTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-25 ANION GAP-21\n1945-12-27 01:10PM ALT(SGPT)-34 AST(SGOT)-132 CK(CPK)-6902* ALK\nPHOS-61 TOT BILI-1.2\n1945-12-27 01:10PM LIPASE-12\n1945-12-27 01:10PM cTropnT-1.12\n1945-12-27 01:10PM CK-MB-237 MB INDX-3.4\n1945-12-27 01:10PM ALBUMIN-4.5 CALCIUM-9.8 PHOSPHATE-3.3\nMAGNESIUM-2.0\n1945-12-27 01:10PM WBC-15.4* RBC-5.10 HGB-15.7 HCT-45.9 MCV-90#\nMCH-30.8# MCHC-34.2 RDW-13.0\n1945-12-27 01:10PM NEUTS-87.8* LYMPHS-7.0* MONOS-4.5 EOS-0.6\nBASOS-0.2\n1945-12-27 01:10PM PLT COUNT-196\n1945-12-27 01:10PM PT-12.5 PTT-21.9* INR(PT)-1.1\n\nDischarge labs:\n\n1995-3-21 09:25AM BLOOD WBC-7.9 RBC-4.07* Hgb-12.5 Hct-36.7\nMCV-90 MCH-30.8 MCHC-34.1 RDW-13.5 Plt Ct-272\n1995-3-21 09:25AM BLOOD Glucose-270* UreaN-11 Creat-0.7 Na-142\nK-4.3 Cl-106 HCO3-32 AnGap-8\n1995-3-21 09:25AM BLOOD Calcium-9.', '8 Phos-3.1 Mg-2.1\n1904-3-9 01:19AM BLOOD VitB12-181\n1904-3-9 01:19AM BLOOD TSH-2.1\n1954-9-29 06:55AM BLOOD Valproa-19\n1936-5-18 07:10PM BLOOD PT-18.9* PTT-150* INR(PT)-1.7\n1995-3-21 02:00AM BLOOD PT-16.4 PTT-26.0 INR(PT)-1.5\n1995-3-21 09:25AM BLOOD PT-19.6 PTT->150 INR(PT)-1.8\n1995-3-21 10:35AM BLOOD PT-21.3 PTT->150* INR(PT)-2.0\n1945-12-27 01:10PM BLOOD ALT-34 AST-132 CK(CPK)-6902* AlkPhos-61\nTotBili-1.2\n2002-10-18 06:30AM BLOOD CK(CPK)-4823\n1954-9-29 08:10PM BLOOD CK(CPK)-1455\n1945-12-27 01:10PM BLOOD cTropnT-1.12\n1936-5-18 03:25AM BLOOD CK-MB-12 cTropnT-0.45*\n1936-5-18 11:58AM URINE Color-Yellow Appear-Clear Sp Chowdhury-1.009\n1936-5-18 11:58AM URINE Blood-NEG Nitrite-NEG Protein-NEG\nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR\n.\nBlood cultures: neg x 2\nUrine culture: negative x1, pending x 1\nRPR negative\n\n\n\nCXR: IMPRESSION:\n1.', " Enlargement of the cardiac silhouette, without evidence of\npulmonary edema and without change compared to 1962, suggesting\npossible cardiomyopathy.\n2. Slight increased, now moderate-sized hiatal hernia.\n\n\n4-20 EKG compared to 05' EKG - nsr, new TWI in avL, +min st dep\nv4-6 - otherwise no other acute st/tw changes.\n\n\nNon-contrast Head CT:\nIMPRESSION: No acute hemorrhage or obvious major acute area of\ninfarction.\nIf acute infarction is of clinical concern, MR has improved\nsensitivity in comparison to non-contrast head CT.\nChronic infarct in left MCA distribution.\n\nCardiac Echo:\nConclusions\nThe left atrium is dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. There is\nmoderate regional left ventricular systolic dysfunction with\nakinesis of the mid to distal anterior septum, anterior wall and\napex.", " A left ventricular mass/thrombus cannot be excluded. Right\nventricular chamber size and free wall motion are normal. There\nis no aortic valve stenosis. Mild (1+) aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is\nno mitral valve prolapse. Trivial mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nIMPRESSION: Focal LV systolic dysfunction consistent with LAD\ninfarction. Mild aortic regurgitation.\n\n\n2-10 CXR: The patient's radiograph currently demonstrates new\nbilateral perihilar opacities consistent with interval\ndevelopment of pulmonary edema. There are bilateral pleural\neffusions also developed in the meantime interval, most likely\nsmall to moderate. There is no pneumothorax and there is no\nchange in the cardiomediastinal silhouette.\n.\nLLE LENI: Preliminary Report !! WET READ !! No DVT LLE.", '\n\n\nBrief Hospital Course:\n82 yo F with h/o HTN, h/o of prox a-fib, (not on coumadin), mood\ndisorder on depakote (has had since CVA 4 yrs prior), with prior\nL inferior division MCA infarct now presenting with altered\nmental status with troponin elevation.\n\n# AMS/NSTEMI: Patient began to have mental status changes 10-12\ndays prior to admission, then was found on the floor with\nemesis/stool/urine around her. In ED, had altered MS with new\ninferolateral ST depressions and T-wave inversions in aVL on\nECG, elevated troponin and no acute changes on CT Head.\nNeurology was consulted for possible metabolic encephalopathy,\neither due to effect of medications (on depakote at home) or\ninfection (T to 100.4 and leucocytosis). Her family declined a\nlumbar puncture. ACS protocol was initiated with IV heparin and\nbetablockers, while patient refused PO medications.', " The family\nchose not to undergo catheterization, opting for more\nconservative medical management.\nThe morning of 2002-10-18 the patient was noted to be in atrial\nfibrillation with rapid ventricular response with decreased\nurine output and new pulmonary edema on CXR. Echocardiogram\nthat day showed akinesis of the mid to distal anterior septum,\nanterior wall and apex. Diuresis was undertaken. Then at 1700,\nthe patient's left hand was noted to become cold, blue and\npainful. Vascular surgery was consulted, the patient was\ntransferred to the CCU. She was also started on a high dose\nstatin and a small dose of an ACE inhibitor. Neurology\nrecommended that she have a non-emergent MRI head to r/o embolic\nstroke not visualized on head CT, however family declined as it\nwould not likely change management.", '\n\n# Anticoagulation: Patient has multiple indications for being\nmaintained on anticoagulation, and at the time of discharge, pt\nis currently on a heparin drip while bridging to therapeutic\nINR. Considering thromboembolism to her arm requiring\nembolectomy, her atrial fibrillation, and her history of strokes\nin the past, I recommend overlapping her heparin drip with a\ntherapeutic INR x 48 hours. Please note that at the time of\ndischarge, her INR measured 2, however this is likely\nOVERestimated, as her PTT at the time was >150, and at that\nlevel of anticoagulation can falsely elevate the INR. I\nrecommend obtaining a repeat INR upon admission. Please titrate\ncoumadin dosing prn for goal INR 6-5.\n\n\n# Left hand ischemia: Patient was noted 2-10 to have a palpable\nbrachial pulse and absent radial pulse on the left side.', ' Most\nprobably cause was felt to be an arterial clot in the setting of\natrial fibrillation. The patient had already been started on a\nheparin drip for ACS and this was continued. The vascular\nsurgery team was consulted regarding the limb ischemia and\nembolectomy was felt to be indicated as she continued to have\ncyanosis of her left hand despite being on the heparin drip.\nShe had a successful embolectomy on 1-25 of the left brachial\nartery under local anesthesia. Her post-op course was\ncomplicated by a large 8cm hematoma at the entry site in the\nleft arm, which was followed closely by vascular surgery, as no\nurgent need for hematoma evacuation was indicated overnight.\nGiven a stable hematocrit, the patient was continued on IV\nHeparin for anticoagulation for her recent NSTEMI as well as her\nhistory of Afib.', '\n\n\n# Atrial Fib - Patient has a history of paroxysmal a-fib, but\nwas not on coumadin due to a high risk of falls. She was found\nto be in atrial fibrillation with RVR the morning of 2-10, but\nsince has been adequately rate controlled with metoprolol.\nGiven her recent embolic event to her left arm, she was started\non coumadin with a heparin bridge. To avoid an excessive\nbleeding risk, her Plavix was discontinued(patient was started\non aspirin and plavix after an MCA CVA apprx 3 years ago) and\nher Aspirin dose was reduced to 81mg daily.\n\n\n# Mood disorder: Patient has had behavioral problems since a CVA\nthree years ago. After admission her mental status apparently\nreturned to baseline. She was continued on home doses of\nDepakote, Paxil and Zyprexa. Restraints and foley catheter were\navoided.', '\n\n\n# Pulmonary edema - patient was diuresed with IV Lasix. She is\nincontinent and did not have a foley catheter, making it\ndifficult to measure her fluid balance, but she appeared to be\neuvolemic and breathing comfortably at the time of discharge.\n\n# HTN - Patient was adequately controlled with metoprolol and\nlisinopril.\n\nProphylaxis - patient maintained on famotidine and SQ heparin.\n\nNOK: Jere Anderson (Cell) 223-277-3856, Jere Meraz\n163-229-4045 (cell), 680-260-5072 (work). Ex-Husband (but also\nhighly involved in daily care of patient - Jere Anderson\n679-593-1249.\nCode: FULL\nDISPO: pt discharged to Mack-Thomas Clinic Rehab LTAC\n\nMedications on Admission:\nConfirmed with family 4-20:\nAspirin 81 mg po q day\nLisinopril 10 mg po q day\nDepakote 250 mg po BID\nmetoprolol 25 mg po BID\nzyprexa 5 mg po q day\nPaxil 10 mg po q am\nVitamin C 500 mg po BID\n\n\nDischarge Medications:\n1.', ' Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for\nConstipation.\n2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for Constipation.\n3. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4\nPM.\n9. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral\nSolution Sig: per protocol units Intravenous contin: Please\ncontinue heparin gtt until INR 6-5 for 48 hours.', '\n10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID\n(3 times a day).\n11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) mL\nInjection DAILY (Daily) for 4 days.\n12. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup Sig: Two\n41y (250) mg PO Q12H (every 12 hours).\n13. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg\nPO BID (2 times a day): hold for loose stools.\n14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H\n(every 4 hours) as needed for pain or fever.\n15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\nPeripheral line: Flush with 3 mL Normal Saline every 8 hours and\nPRN.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nRobinson, Williams and Jones Hospital for the Aged - MACU\n\nDischarge Diagnosis:\n-Altered mental status\n-Non ST-elevation myocardial infarction\n-Left arm ischemia\n-B12 deficiency.', '\n\n\nDischarge Condition:\nGood\n\n\nDischarge Instructions:\nYou were admitted with altered metntal status. You ruled in for\na heart attack but the decision was made to pursue conservative\nmanagement. Your heart went into a rapid rate and a blood clot\ntraveled to your left arm causeing a blockage. You were taken to\nthe OR for removal of the clot. You were put on a heparin drip\nand will need to be on long term anticoagulation with coumadin\nto prevent further blood clots. You were also noted to have low\nB12 level which can contribute to altered mental status and you\nbeing given b12 supplementation\n\nWeigh yourself every morning, Cruz Moblo MD if weight > 3 lbs.\nAdhere to 2 gm sodium diet\nFluid Restriction:\n\nFollowup Instructions:\nProvider: Bryan Dortch Blanks, MD Phone:221-773-1899\nDate/Time:1968-11-11 3:15\nJohnson and Sons Clinic Medical Office Building; 044 Crystal Hollow\nSouth Brandon, NE 12159.', '\n\n\n\n']
141	18363	117258.0	2179-03-24	Discharge summary	Report	Admission Date: [2179-3-18] Discharge Date: [2179-3-24] Date of Birth: [2105-12-17] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 949] Chief Complaint: hypothermia, sepsis Major Surgical or Invasive Procedure: EGD flex sig History of Present Illness: 73yo F with PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices, who was discharged 2 days prior to admission with AMS thought to be related to hepatic encephalopathy. At that time she was also found to have hypoglycemia, PNA (tx w/ Azithro), and a UTI (tx w/ Bactrim). She was referred from clinic at [Hospital Unit Name ] with chief complaint of BRBPR. She noted 2 painless BM's with BRBPR, and blood was noted on rectal exam without melena. She denied any CP or SOB, but does note feeling weak. She does note some decreased urine output lately, as well as increased LE edema and abdominal distention. She notes abdominal 'fullness' for the last few weeks, but denies nausea/vomiting. She notes some lightheadedness and thirst while in the ED. . In the ED she was initially normotensive, but was later found to have SBP's in the 70's (baseline SBP in 90's). She was also noted to be hypothermic with core temp of 93.4. Because of concern for sepsis an IJ was placed and she was placed on sepsis protocol. She was given Vanc/CTX/Flagyl and hydrocort, and was also noted to have worsening renal function with a Cr of 2.1 from NL baseline. Because of an initial potassium of 6.9, she was given D50/insulin/kayexylate. She was admitted to the MICU for further monitoring. Past Medical History: 1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.[Last Name (STitle) 497] 2. Liver cirrhosis 3. Hypothyroidism 4. Osteopenia 5. Status post cholecystectomy 6. History of ankle fractures 7. Hypertension Social History: Tobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use, married with three children. Lives at home with husband Family History: No family history of strokes, seizures. Mother and father died in 90s. Physical Exam: vitals (ED)- T=93.4(now ax95), HR=77, BP=114/33-70/48, RR=16, O2sat 95%RA General - alert, interactive, in NAD HEENT- PERRL, sclerae mildly icteric(?), mucosa slightly dry Neck- supple, no JVD noted Lungs- mild end-exp wheezes bil, otherwise CTA Heart- RRR, 2/6 SEM heard best at LUSB Abd- +BS's, distended, tympanitic, mild/mod diffuse tenderness, no rebound/guarding; rectal exam in ED w/ BRBPR guaiac+ Ext- 3+ pitting LE edema b/l Neuro- AAO x 3, follows commands, +asterixis Pertinent Results: CT abdomen: 1. Diffuse anasarca with soft tissue edema as well as ascites and nonspecific mesenteric stranding. Ascites is increased compared to the previous study. 2. Limited evaluation of the bowel with no definite wall thickening. There is no pneumatosis or free air. Patency within mesenteric vessels cannot be assessed without IV contrast. 3. Acute right posterior rib fracture that does not appear to be present on the study of [2179-1-20]. No evidence of pneumothorax in the imaged portions of the lungs. CXR: The lungs are hyperinflated and the diaphragms are flattened, consistent with COPD. Heart size is at the upper limits of normal with left ventricular configuration. The aorta is calcified and unfolded. There is no CHF, frank consolidation or effusion. Again seen is eventration of the left hemidiaphragm posteriorly. There is probably some associated atelectasis, but no definite pneumonic infiltrate. RUQ: Targeted examination was performed. There is small ascites. Hepatic veins appear patent. The portal vein appears patent with hepatopetal flow. Hepatic arteries appear patent. No spot marked for tap. Brief Hospital Course: 73 y/o F with PBC, decompensated cirrhosis with now presents with weakness, ARF, hypothermia, and hypotension. . HYPOTENSION/HYPOTHERMIA: On admission there was some concern that the patient was septic given her hypotermia and hypotension. She is known to have a low baseline SBP in the ~90's and may have low temp at baseline. Given her tenuous state, she was covered empirically with CTX and Flagyl. Naldol and diuretics were held. An abdominal U/S was obtained and showed ascites fluid, but of insufficicent quantity to tap. Her CXR and UA were negative for evidence of infection. In light of the patient's persistent hypotension and hypothermia, patient was transferred to the ICU where she was started on levophed and vasopressin. An abdominal CT was ordered to assess for possible obstruction and a surgery consult was obtained. The CT scan showed diffuse anasarca, ascites, and no convincing evidence of obstruction although the study was limited [2-11] lack of IV contrast. There was also an incidental finding of a new right posterior rib fracture. Her clinical condition gradually improved and she was weaned off pressors on ICU day 4 with a baseline SBP of 90/50. CTX and flagyl were d/c'd and patient was called out to the floor on [3-22]. . ARF: Patient was found to have a creatinine of 2.1 in the setting of decreased UO and increased abdominal distention. Her urine lytes were consistent with a sodium-avid state, either a pre-renal etiology or hepatorenal syndrome. Later labs were consistent with a ATN vs HRS. Nephrology was consulted and agreed with treating with ocreaotide. Patient was found to have a Klebsiella UTI, which was treated with a seven day course of bactrim, and candiduria. She did receive 2 units of PRBC and albumin in order to improve her UOP without worsening her anasarca. Her creatinine gradually improved and was still trending down on day of discharge. . ABDOMINAL DISTENTION: Initially thought to be [2-11] ascites but abd U/S showed only a small amount of fluid. There was no evidence of obstruction/ileus on CT and patient continued to pass stool asd flatus. Transplant surgery was consulted and patient was made NPO. Eventually the distention was attributed to bowel wall edema in the setting of total body anasarca. Patient was started on lasix and aldactone. . BRBPR: Her initial presentation was for painless BRBPR, but her Hct has remained stable. In the MICU she had a maroon stool. NGT was placed and lavage was negative, with stable f/u Hct. This seemed to be consistent with a lower source such as an AVM, diverticular bleed, or hemorroids. Patient underwent an EGD which showed 1 non-bleeding cord of grade III varices, which was banded, and no evidence of active bleed. Patient also had a sigmoidoscopy which showed medium grade 1 hemorroids. . PULMONARY: Patient has some very mild hypoxia likely related to abdominal distention vs cardiac asthma vs reactive airways. She maintained her oxygen saturations and did not require intubation. . PPx: Patient maintained of PPI, Lactulose, and pneumoboots for DVT prophylaxis. . DISPO: Patient was discharged home with services in stable condition with close follow up with her PCP, [Name10 (NameIs) ] hepatologist, and Dr. [Last Name (STitle) 118] of nephrology. Medications on Admission: Synthroid 75mcg QD Protonix 40mg Ursodiol 500AM/750PM Nadolol 20mg QD Colace 100mg [Hospital1 ] Folate CaCO3 Rifaximin 400mg TID Lactulose 30mg [Hospital1 ] Lasix 40mg QD Aldactobe 100mg HS Bactrim 1 tab [Hospital1 ] until [3-22] for UTI Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:100 ML(s) Refills:0 6. 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 7. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). Disp:60 Tablet(s) Refills:2 8. Ursodiol 250 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). Disp:90 Tablet(s) Refills:2 9. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD () for 1 days. Disp:1 Tablet(s) Refills:0 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 2 doses: start after done with 20mg dose. Disp:2 Tablet(s) Refills:0 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 2 days: start after done with 10mg dose. Disp:2 Tablet(s) Refills:0 13. Outpatient Lab Work CBC, CHEM 10, LFTS, and PT, PTT, INR Please have this bloodwork performed on [2179-3-26] and have the results faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office at the [Hospital1 771] Department of Hepatology Discharge Disposition: Home with Service Facility: [First Name8 (NamePattern2) 1495] [Doctor Last Name 122] Discharge Diagnosis: Variceal Bleed s/p banding Sepsis Acute Renal Failure Anasarca Primary Billary Cirrhosis Discharge Condition: stable Discharge Instructions: Please take all medications as perscribed. Please report to the [Hospital1 18] emergency room with any fevers, chills, nausea, vomiting, abdominal pain, bright red blood per rectum, hemetamesis. Please keep all follow up appointments. Followup Instructions: [First Name5 (NamePattern1) 1494] [Last Name (NamePattern1) 1496]- Primary Care Physician- [0-0-]/28/06 at 12:15PM- please have your CBC, Chem 10 and Liver Function Tests, and coagulation studies checked at that visit and have results faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office. Please also have the blood work checked on [2179-3-26] faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497]-Hepatology-[Hospital 1497] clinic will call you within 24H to schedule your follow up appointment, but if you do not hear from them within 24H, please call the clinic yourself. [First Name4 (NamePattern1) 429] [Last Name (NamePattern1) 118]-Nephrology-[Telephone/Fax (1) 60]-[2179-04-05] at 12:30 PM	Admission Date: <Date>1957-10-9</Date> Discharge Date: <Date>1975-5-28</Date> Date of Birth: <Date>2002-11-4</Date> Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:<Name>Tyler</Name> Chief Complaint: hypothermia, sepsis Major Surgical or Invasive Procedure: EGD flex sig History of Present Illness: 73yo F with PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices, who was discharged 2 days prior to admission with AMS thought to be related to hepatic encephalopathy. At that time she was also found to have hypoglycemia, PNA (tx w/ Azithro), and a UTI (tx w/ Bactrim). She was referred from clinic at <Hospital>Robinson-Salinas Medical Center</Hospital> with chief complaint of BRBPR. She noted 2 painless BM's with BRBPR, and blood was noted on rectal exam without melena. She denied any CP or SOB, but does note feeling weak. She does note some decreased urine output lately, as well as increased LE edema and abdominal distention. She notes abdominal 'fullness' for the last few weeks, but denies nausea/vomiting. She notes some lightheadedness and thirst while in the ED. . In the ED she was initially normotensive, but was later found to have SBP's in the 70's (baseline SBP in 90's). She was also noted to be hypothermic with core temp of 93.4. Because of concern for sepsis an IJ was placed and she was placed on sepsis protocol. She was given Vanc/CTX/Flagyl and hydrocort, and was also noted to have worsening renal function with a Cr of 2.1 from NL baseline. Because of an initial potassium of 6.9, she was given D50/insulin/kayexylate. She was admitted to the MICU for further monitoring. Past Medical History: 1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.<Name>Feudner</Name> 2. Liver cirrhosis 3. Hypothyroidism 4. Osteopenia 5. Status post cholecystectomy 6. History of ankle fractures 7. Hypertension Social History: Tobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use, married with three children. Lives at home with husband Family History: No family history of strokes, seizures. Mother and father died in 90s. Physical Exam: vitals (ED)- T=93.4(now ax95), HR=77, BP=114/33-70/48, RR=16, O2sat 95%RA General - alert, interactive, in NAD HEENT- PERRL, sclerae mildly icteric(?), mucosa slightly dry Neck- supple, no JVD noted Lungs- mild end-exp wheezes bil, otherwise CTA Heart- RRR, 2/6 SEM heard best at LUSB Abd- +BS's, distended, tympanitic, mild/mod diffuse tenderness, no rebound/guarding; rectal exam in ED w/ BRBPR guaiac+ Ext- 3+ pitting LE edema b/l Neuro- AAO x 3, follows commands, +asterixis Pertinent Results: CT abdomen: 1. Diffuse anasarca with soft tissue edema as well as ascites and nonspecific mesenteric stranding. Ascites is increased compared to the previous study. 2. Limited evaluation of the bowel with no definite wall thickening. There is no pneumatosis or free air. Patency within mesenteric vessels cannot be assessed without IV contrast. 3. Acute right posterior rib fracture that does not appear to be present on the study of <Date>1982-7-11</Date>. No evidence of pneumothorax in the imaged portions of the lungs. CXR: The lungs are hyperinflated and the diaphragms are flattened, consistent with COPD. Heart size is at the upper limits of normal with left ventricular configuration. The aorta is calcified and unfolded. There is no CHF, frank consolidation or effusion. Again seen is eventration of the left hemidiaphragm posteriorly. There is probably some associated atelectasis, but no definite pneumonic infiltrate. RUQ: Targeted examination was performed. There is small ascites. Hepatic veins appear patent. The portal vein appears patent with hepatopetal flow. Hepatic arteries appear patent. No spot marked for tap. Brief Hospital Course: 73 y/o F with PBC, decompensated cirrhosis with now presents with weakness, ARF, hypothermia, and hypotension. . HYPOTENSION/HYPOTHERMIA: On admission there was some concern that the patient was septic given her hypotermia and hypotension. She is known to have a low baseline SBP in the ~90's and may have low temp at baseline. Given her tenuous state, she was covered empirically with CTX and Flagyl. Naldol and diuretics were held. An abdominal U/S was obtained and showed ascites fluid, but of insufficicent quantity to tap. Her CXR and UA were negative for evidence of infection. In light of the patient's persistent hypotension and hypothermia, patient was transferred to the ICU where she was started on levophed and vasopressin. An abdominal CT was ordered to assess for possible obstruction and a surgery consult was obtained. The CT scan showed diffuse anasarca, ascites, and no convincing evidence of obstruction although the study was limited <Date>4-4</Date> lack of IV contrast. There was also an incidental finding of a new right posterior rib fracture. Her clinical condition gradually improved and she was weaned off pressors on ICU day 4 with a baseline SBP of 90/50. CTX and flagyl were d/c'd and patient was called out to the floor on <Date>1-10</Date>. . ARF: Patient was found to have a creatinine of 2.1 in the setting of decreased UO and increased abdominal distention. Her urine lytes were consistent with a sodium-avid state, either a pre-renal etiology or hepatorenal syndrome. Later labs were consistent with a ATN vs HRS. Nephrology was consulted and agreed with treating with ocreaotide. Patient was found to have a Klebsiella UTI, which was treated with a seven day course of bactrim, and candiduria. She did receive 2 units of PRBC and albumin in order to improve her UOP without worsening her anasarca. Her creatinine gradually improved and was still trending down on day of discharge. . ABDOMINAL DISTENTION: Initially thought to be <Date>4-4</Date> ascites but abd U/S showed only a small amount of fluid. There was no evidence of obstruction/ileus on CT and patient continued to pass stool asd flatus. Transplant surgery was consulted and patient was made NPO. Eventually the distention was attributed to bowel wall edema in the setting of total body anasarca. Patient was started on lasix and aldactone. . BRBPR: Her initial presentation was for painless BRBPR, but her Hct has remained stable. In the MICU she had a maroon stool. NGT was placed and lavage was negative, with stable f/u Hct. This seemed to be consistent with a lower source such as an AVM, diverticular bleed, or hemorroids. Patient underwent an EGD which showed 1 non-bleeding cord of grade III varices, which was banded, and no evidence of active bleed. Patient also had a sigmoidoscopy which showed medium grade 1 hemorroids. . PULMONARY: Patient has some very mild hypoxia likely related to abdominal distention vs cardiac asthma vs reactive airways. She maintained her oxygen saturations and did not require intubation. . PPx: Patient maintained of PPI, Lactulose, and pneumoboots for DVT prophylaxis. . DISPO: Patient was discharged home with services in stable condition with close follow up with her PCP, <Name>Sharon Quinones</Name> hepatologist, and Dr. <Name>Finateri</Name> of nephrology. Medications on Admission: Synthroid 75mcg QD Protonix 40mg Ursodiol 500AM/750PM Nadolol 20mg QD Colace 100mg <Hospital>Cochran PLC Health System</Hospital> Folate CaCO3 Rifaximin 400mg TID Lactulose 30mg <Hospital>Cochran PLC Health System</Hospital> Lasix 40mg QD Aldactobe 100mg HS Bactrim 1 tab <Hospital>Cochran PLC Health System</Hospital> until <Date>1-10</Date> for UTI Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:100 ML(s) Refills:0 6. 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 7. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). Disp:60 Tablet(s) Refills:2 8. Ursodiol 250 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). Disp:90 Tablet(s) Refills:2 9. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD () for 1 days. Disp:1 Tablet(s) Refills:0 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 2 doses: start after done with 20mg dose. Disp:2 Tablet(s) Refills:0 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 2 days: start after done with 10mg dose. Disp:2 Tablet(s) Refills:0 13. Outpatient Lab Work CBC, CHEM 10, LFTS, and PT, PTT, INR Please have this bloodwork performed on <Date>1908-7-18</Date> and have the results faxed to Dr. <Name>Jackson</Name> <Name>Lees</Name> office at the <Hospital>Kennedy, Garner and Howard Health System</Hospital> Department of Hepatology Discharge Disposition: Home with Service Facility: <Name>German</Name> <Doctor Name>Dr.Blanks</Doctor Name> Discharge Diagnosis: Variceal Bleed s/p banding Sepsis Acute Renal Failure Anasarca Primary Billary Cirrhosis Discharge Condition: stable Discharge Instructions: Please take all medications as perscribed. Please report to the <Hospital>Johnson LLC Medical Center</Hospital> emergency room with any fevers, chills, nausea, vomiting, abdominal pain, bright red blood per rectum, hemetamesis. Please keep all follow up appointments. Followup Instructions: <Name>Fannie</Name> <Name>Porras</Name>- Primary Care Physician- <Date>2-1919</Date>/28/06 at 12:15PM- please have your CBC, Chem 10 and Liver Function Tests, and coagulation studies checked at that visit and have results faxed to Dr. <Name>Jackson</Name> <Name>Lees</Name> office. Please also have the blood work checked on <Date>1908-7-18</Date> faxed to Dr. <Name>Jackson</Name> <Name>Lees</Name> office. <Name>Jackson</Name> <Name>Martin</Name>-Hepatology-<Hospital>Ramirez-Gilbert Health System</Hospital> clinic will call you within 24H to schedule your follow up appointment, but if you do not hear from them within 24H, please call the clinic yourself. <Name>Nicholas</Name> <Name>Chin</Name>-Nephrology-<Telephone>589-414-3435</Telephone>-<Date>1944-8-21</Date> at 12:30 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00000000	Admission Date: 1957-10-9 Discharge Date: 1975-5-28 Date of Birth: 2002-11-4 Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:Tyler Chief Complaint: hypothermia, sepsis Major Surgical or Invasive Procedure: EGD flex sig History of Present Illness: 73yo F with PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices, who was discharged 2 days prior to admission with AMS thought to be related to hepatic encephalopathy. At that time she was also found to have hypoglycemia, PNA (tx w/ Azithro), and a UTI (tx w/ Bactrim). She was referred from clinic at Robinson-Salinas Medical Center with chief complaint of BRBPR. She noted 2 painless BM's with BRBPR, and blood was noted on rectal exam without melena. She denied any CP or SOB, but does note feeling weak. She does note some decreased urine output lately, as well as increased LE edema and abdominal distention. She notes abdominal 'fullness' for the last few weeks, but denies nausea/vomiting. She notes some lightheadedness and thirst while in the ED. . In the ED she was initially normotensive, but was later found to have SBP's in the 70's (baseline SBP in 90's). She was also noted to be hypothermic with core temp of 93.4. Because of concern for sepsis an IJ was placed and she was placed on sepsis protocol. She was given Vanc/CTX/Flagyl and hydrocort, and was also noted to have worsening renal function with a Cr of 2.1 from NL baseline. Because of an initial potassium of 6.9, she was given D50/insulin/kayexylate. She was admitted to the MICU for further monitoring. Past Medical History: 1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.Feudner 2. Liver cirrhosis 3. Hypothyroidism 4. Osteopenia 5. Status post cholecystectomy 6. History of ankle fractures 7. Hypertension Social History: Tobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use, married with three children. Lives at home with husband Family History: No family history of strokes, seizures. Mother and father died in 90s. Physical Exam: vitals (ED)- T=93.4(now ax95), HR=77, BP=114/33-70/48, RR=16, O2sat 95%RA General - alert, interactive, in NAD HEENT- PERRL, sclerae mildly icteric(?), mucosa slightly dry Neck- supple, no JVD noted Lungs- mild end-exp wheezes bil, otherwise CTA Heart- RRR, 2/6 SEM heard best at LUSB Abd- +BS's, distended, tympanitic, mild/mod diffuse tenderness, no rebound/guarding; rectal exam in ED w/ BRBPR guaiac+ Ext- 3+ pitting LE edema b/l Neuro- AAO x 3, follows commands, +asterixis Pertinent Results: CT abdomen: 1. Diffuse anasarca with soft tissue edema as well as ascites and nonspecific mesenteric stranding. Ascites is increased compared to the previous study. 2. Limited evaluation of the bowel with no definite wall thickening. There is no pneumatosis or free air. Patency within mesenteric vessels cannot be assessed without IV contrast. 3. Acute right posterior rib fracture that does not appear to be present on the study of 1982-7-11. No evidence of pneumothorax in the imaged portions of the lungs. CXR: The lungs are hyperinflated and the diaphragms are flattened, consistent with COPD. Heart size is at the upper limits of normal with left ventricular configuration. The aorta is calcified and unfolded. There is no CHF, frank consolidation or effusion. Again seen is eventration of the left hemidiaphragm posteriorly. There is probably some associated atelectasis, but no definite pneumonic infiltrate. RUQ: Targeted examination was performed. There is small ascites. Hepatic veins appear patent. The portal vein appears patent with hepatopetal flow. Hepatic arteries appear patent. No spot marked for tap. Brief Hospital Course: 73 y/o F with PBC, decompensated cirrhosis with now presents with weakness, ARF, hypothermia, and hypotension. . HYPOTENSION/HYPOTHERMIA: On admission there was some concern that the patient was septic given her hypotermia and hypotension. She is known to have a low baseline SBP in the ~90's and may have low temp at baseline. Given her tenuous state, she was covered empirically with CTX and Flagyl. Naldol and diuretics were held. An abdominal U/S was obtained and showed ascites fluid, but of insufficicent quantity to tap. Her CXR and UA were negative for evidence of infection. In light of the patient's persistent hypotension and hypothermia, patient was transferred to the ICU where she was started on levophed and vasopressin. An abdominal CT was ordered to assess for possible obstruction and a surgery consult was obtained. The CT scan showed diffuse anasarca, ascites, and no convincing evidence of obstruction although the study was limited 4-4 lack of IV contrast. There was also an incidental finding of a new right posterior rib fracture. Her clinical condition gradually improved and she was weaned off pressors on ICU day 4 with a baseline SBP of 90/50. CTX and flagyl were d/c'd and patient was called out to the floor on 1-10. . ARF: Patient was found to have a creatinine of 2.1 in the setting of decreased UO and increased abdominal distention. Her urine lytes were consistent with a sodium-avid state, either a pre-renal etiology or hepatorenal syndrome. Later labs were consistent with a ATN vs HRS. Nephrology was consulted and agreed with treating with ocreaotide. Patient was found to have a Klebsiella UTI, which was treated with a seven day course of bactrim, and candiduria. She did receive 2 units of PRBC and albumin in order to improve her UOP without worsening her anasarca. Her creatinine gradually improved and was still trending down on day of discharge. . ABDOMINAL DISTENTION: Initially thought to be 4-4 ascites but abd U/S showed only a small amount of fluid. There was no evidence of obstruction/ileus on CT and patient continued to pass stool asd flatus. Transplant surgery was consulted and patient was made NPO. Eventually the distention was attributed to bowel wall edema in the setting of total body anasarca. Patient was started on lasix and aldactone. . BRBPR: Her initial presentation was for painless BRBPR, but her Hct has remained stable. In the MICU she had a maroon stool. NGT was placed and lavage was negative, with stable f/u Hct. This seemed to be consistent with a lower source such as an AVM, diverticular bleed, or hemorroids. Patient underwent an EGD which showed 1 non-bleeding cord of grade III varices, which was banded, and no evidence of active bleed. Patient also had a sigmoidoscopy which showed medium grade 1 hemorroids. . PULMONARY: Patient has some very mild hypoxia likely related to abdominal distention vs cardiac asthma vs reactive airways. She maintained her oxygen saturations and did not require intubation. . PPx: Patient maintained of PPI, Lactulose, and pneumoboots for DVT prophylaxis. . DISPO: Patient was discharged home with services in stable condition with close follow up with her PCP, Sharon Quinones hepatologist, and Dr. Finateri of nephrology. Medications on Admission: Synthroid 75mcg QD Protonix 40mg Ursodiol 500AM/750PM Nadolol 20mg QD Colace 100mg Cochran PLC Health System Folate CaCO3 Rifaximin 400mg TID Lactulose 30mg Cochran PLC Health System Lasix 40mg QD Aldactobe 100mg HS Bactrim 1 tab Cochran PLC Health System until 1-10 for UTI Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:100 ML(s) Refills:0 6. 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 7. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). Disp:60 Tablet(s) Refills:2 8. Ursodiol 250 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). Disp:90 Tablet(s) Refills:2 9. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD () for 1 days. Disp:1 Tablet(s) Refills:0 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 2 doses: start after done with 20mg dose. Disp:2 Tablet(s) Refills:0 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 2 days: start after done with 10mg dose. Disp:2 Tablet(s) Refills:0 13. Outpatient Lab Work CBC, CHEM 10, LFTS, and PT, PTT, INR Please have this bloodwork performed on 1908-7-18 and have the results faxed to Dr. Jackson Lees office at the Kennedy, Garner and Howard Health System Department of Hepatology Discharge Disposition: Home with Service Facility: German Dr.Blanks Discharge Diagnosis: Variceal Bleed s/p banding Sepsis Acute Renal Failure Anasarca Primary Billary Cirrhosis Discharge Condition: stable Discharge Instructions: Please take all medications as perscribed. Please report to the Johnson LLC Medical Center emergency room with any fevers, chills, nausea, vomiting, abdominal pain, bright red blood per rectum, hemetamesis. Please keep all follow up appointments. Followup Instructions: Fannie Porras- Primary Care Physician- 2-1919/28/06 at 12:15PM- please have your CBC, Chem 10 and Liver Function Tests, and coagulation studies checked at that visit and have results faxed to Dr. Jackson Lees office. Please also have the blood work checked on 1908-7-18 faxed to Dr. Jackson Lees office. Jackson Martin-Hepatology-Ramirez-Gilbert Health System clinic will call you within 24H to schedule your follow up appointment, but if you do not hear from them within 24H, please call the clinic yourself. Nicholas Chin-Nephrology-589-414-3435-1944-8-21 at 12:30 PM	["Admission Date: 1957-10-9 Discharge Date: 1975-5-28\n\nDate of Birth: 2002-11-4 Sex: F\n\nService: MEDICINE\n\nAllergies:\nHeparin Agents\n\nAttending:Tyler\nChief Complaint:\nhypothermia, sepsis\n\nMajor Surgical or Invasive Procedure:\nEGD\nflex sig\n\nHistory of Present Illness:\n73yo F with PBC, decompensated cirrhosis c/b encephalopathy,\nascites, and esoph varices, who was discharged 2 days prior to\nadmission with AMS thought to be related to hepatic\nencephalopathy. At that time she was also found to have\nhypoglycemia, PNA (tx w/ Azithro), and a UTI (tx w/ Bactrim).\nShe was referred from clinic at Robinson-Salinas Medical Center with chief\ncomplaint of BRBPR. She noted 2 painless BM's with BRBPR, and\nblood was noted on rectal exam without melena. She denied any CP\nor SOB, but does note feeling weak.", " She does note some decreased\nurine output lately, as well as increased LE edema and abdominal\ndistention. She notes abdominal 'fullness' for the last few\nweeks, but denies nausea/vomiting. She notes some\nlightheadedness and thirst while in the ED.\n.\nIn the ED she was initially normotensive, but was later found to\nhave SBP's in the 70's (baseline SBP in 90's). She was also\nnoted to be hypothermic with core temp of 93.4. Because of\nconcern for sepsis an IJ was placed and she was placed on sepsis\nprotocol. She was given Vanc/CTX/Flagyl and hydrocort, and was\nalso noted to have worsening renal function with a Cr of 2.1\nfrom NL baseline. Because of an initial potassium of 6.9, she\nwas given D50/insulin/kayexylate. She was admitted to the MICU\nfor further monitoring.\n\nPast Medical History:\n1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.", "Feudner\n2. Liver cirrhosis\n3. Hypothyroidism\n4. Osteopenia\n5. Status post cholecystectomy\n6. History of ankle fractures\n7. Hypertension\n\nSocial History:\nTobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use,\nmarried with three children. Lives at home with husband\n\n\nFamily History:\nNo family history of strokes, seizures. Mother and father died\nin 90s.\n\nPhysical Exam:\nvitals (ED)- T=93.4(now ax95), HR=77, BP=114/33-70/48, RR=16,\nO2sat 95%RA\nGeneral - alert, interactive, in NAD\nHEENT- PERRL, sclerae mildly icteric(?), mucosa slightly dry\nNeck- supple, no JVD noted\nLungs- mild end-exp wheezes bil, otherwise CTA\nHeart- RRR, 2/6 SEM heard best at LUSB\nAbd- +BS's, distended, tympanitic, mild/mod diffuse tenderness,\nno\nrebound/guarding; rectal exam in ED w/ BRBPR guaiac+\nExt- 3+ pitting LE edema b/l\nNeuro- AAO x 3, follows commands, +asterixis\n\nPertinent Results:\nCT abdomen:\n1.", ' Diffuse anasarca with soft tissue edema as well as ascites\nand nonspecific mesenteric stranding. Ascites is increased\ncompared to the previous study.\n2. Limited evaluation of the bowel with no definite wall\nthickening. There is no pneumatosis or free air. Patency within\nmesenteric vessels cannot be assessed without IV contrast.\n3. Acute right posterior rib fracture that does not appear to be\npresent on the study of 1982-7-11. No evidence of pneumothorax in\nthe imaged portions of the lungs.\n\nCXR: The lungs are hyperinflated and the diaphragms are\nflattened, consistent with COPD. Heart size is at the upper\nlimits of normal with left ventricular configuration. The aorta\nis calcified and unfolded. There is no CHF, frank consolidation\nor effusion. Again seen is eventration of the left hemidiaphragm\nposteriorly.', " There is probably some associated atelectasis, but\nno definite pneumonic infiltrate.\n\nRUQ: Targeted examination was performed. There is small ascites.\nHepatic veins appear patent. The portal vein appears patent with\nhepatopetal flow. Hepatic arteries appear patent. No spot marked\nfor tap.\n\n\nBrief Hospital Course:\n73 y/o F with PBC, decompensated cirrhosis with now presents\nwith weakness, ARF, hypothermia, and hypotension.\n.\nHYPOTENSION/HYPOTHERMIA: On admission there was some concern\nthat the patient was septic given her hypotermia and\nhypotension. She is known to have a low baseline SBP in the\n~90's and may have low temp at baseline. Given her tenuous\nstate, she was covered empirically with CTX and Flagyl. Naldol\nand diuretics were held. An abdominal U/S was obtained and\nshowed ascites fluid, but of insufficicent quantity to tap.", " Her\nCXR and UA were negative for evidence of infection. In light of\nthe patient's persistent hypotension and hypothermia, patient\nwas transferred to the ICU where she was started on levophed and\nvasopressin. An abdominal CT was ordered to assess for possible\nobstruction and a surgery consult was obtained. The CT scan\nshowed diffuse anasarca, ascites, and no convincing evidence of\nobstruction although the study was limited 4-4 lack of IV\ncontrast. There was also an incidental finding of a new right\nposterior rib fracture. Her clinical condition gradually\nimproved and she was weaned off pressors on ICU day 4 with a\nbaseline SBP of 90/50. CTX and flagyl were d/c'd and patient\nwas called out to the floor on 1-10.\n.\nARF: Patient was found to have a creatinine of 2.1 in the\nsetting of decreased UO and increased abdominal distention.", ' Her\nurine lytes were consistent with a sodium-avid state, either a\npre-renal etiology or hepatorenal syndrome. Later labs were\nconsistent with a ATN vs HRS. Nephrology was consulted and\nagreed with treating with ocreaotide. Patient was found to have\na Klebsiella UTI, which was treated with a seven day course of\nbactrim, and candiduria. She did receive 2 units of PRBC and\nalbumin in order to improve her UOP without worsening her\nanasarca. Her creatinine gradually improved and was still\ntrending down on day of discharge.\n.\nABDOMINAL DISTENTION: Initially thought to be 4-4 ascites but\nabd U/S showed only a small amount of fluid. There was no\nevidence of obstruction/ileus on CT and patient continued to\npass stool asd flatus. Transplant surgery was consulted and\npatient was made NPO. Eventually the distention was attributed\nto bowel wall edema in the setting of total body anasarca.', '\nPatient was started on lasix and aldactone.\n.\nBRBPR: Her initial presentation was for painless BRBPR, but her\nHct has remained stable. In the MICU she had a maroon stool.\nNGT was placed and lavage was negative, with stable f/u Hct.\nThis seemed to be consistent with a lower source such as an AVM,\ndiverticular bleed, or hemorroids. Patient underwent an EGD\nwhich showed 1 non-bleeding cord of grade III varices, which was\nbanded, and no evidence of active bleed. Patient also had a\nsigmoidoscopy which showed medium grade 1 hemorroids.\n.\nPULMONARY: Patient has some very mild hypoxia likely related to\nabdominal distention vs cardiac asthma vs reactive airways. She\nmaintained her oxygen saturations and did not require\nintubation.\n.\nPPx: Patient maintained of PPI, Lactulose, and pneumoboots for\nDVT prophylaxis.', '\n.\nDISPO: Patient was discharged home with services in stable\ncondition with close follow up with her PCP, Sharon Quinones hepatologist,\nand Dr. Finateri of nephrology.\n\n\nMedications on Admission:\nSynthroid 75mcg QD\nProtonix 40mg\nUrsodiol 500AM/750PM\nNadolol 20mg QD\nColace 100mg Cochran PLC Health System\nFolate\nCaCO3\nRifaximin 400mg TID\nLactulose 30mg Cochran PLC Health System\nLasix 40mg QD\nAldactobe 100mg HS\nBactrim 1 tab Cochran PLC Health System until 1-10 for UTI\n\nDischarge Medications:\n1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:2\n2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\nDisp:30 Tablet(s) Refills:2\n3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\nDisp:60 Tablet(s) Refills:2\n4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a\nday).', '\nDisp:180 Tablet(s) Refills:2\n5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every\n6 hours) as needed.\nDisp:100 ML(s) Refills:0\n6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:2\n7. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO QAM (once a day\n(in the morning)).\nDisp:60 Tablet(s) Refills:2\n8. Ursodiol 250 mg Tablet Sig: Three (3) Tablet PO QPM (once a\nday (in the evening)).\nDisp:90 Tablet(s) Refills:2\n9. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).\nDisp:30 Tablet(s) Refills:2\n10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD () for 1\ndays.\nDisp:1 Tablet(s) Refills:0\n11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 2\ndoses: start after done with 20mg dose.', '\nDisp:2 Tablet(s) Refills:0\n12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 2\ndays: start after done with 10mg dose.\nDisp:2 Tablet(s) Refills:0\n13. Outpatient Lab Work\nCBC, CHEM 10, LFTS, and PT, PTT, INR\n\nPlease have this bloodwork performed on 1908-7-18 and have the\nresults faxed to Dr. Jackson Lees office at the Kennedy, Garner and Howard Health System Department of Hepatology\n\n\nDischarge Disposition:\nHome with Service\n\nFacility:\nGerman Dr.Blanks\n\nDischarge Diagnosis:\nVariceal Bleed s/p banding\nSepsis\nAcute Renal Failure\nAnasarca\nPrimary Billary Cirrhosis\n\n\nDischarge Condition:\nstable\n\n\nDischarge Instructions:\nPlease take all medications as perscribed. Please report to the\nJohnson LLC Medical Center emergency room with any fevers, chills, nausea, vomiting,\nabdominal pain, bright red blood per rectum, hemetamesis.', '\n\nPlease keep all follow up appointments.\n\nFollowup Instructions:\nFannie Porras- Primary Care Physician- 2-1919/28/06\nat 12:15PM- please have your CBC, Chem 10 and Liver Function\nTests, and coagulation studies checked at that visit and have\nresults faxed to Dr. Jackson Lees office.\n\nPlease also have the blood work checked on 1908-7-18 faxed to Dr.\nJackson Lees office.\n\nJackson Martin-Hepatology-Ramirez-Gilbert Health System clinic will call you\nwithin 24H to schedule your follow up appointment, but if you do\nnot hear from them within 24H, please call the clinic yourself.\n\nNicholas Chin-Nephrology-589-414-3435-1944-8-21 at 12:30 PM\n\n\n\n']
142	18363	196681.0	2179-04-15	Discharge summary	Report	Admission Date: [2179-3-31] Discharge Date: [2179-4-15] Date of Birth: [2105-12-17] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 943] Chief Complaint: dizziness x 1 day Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo F with h/o PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices who presents with c/o lightheadedness, dizziness x 1 day. Feels weak with decreased energy level. Of note, recently discharged on [2179-3-24] after hypotensive/hypothermic episode w/ suspected sepsis, treated empirically with a course of ceftriaxone, flagyl and stress-dose steroids. No infectious source was identified. Discharged to home to complete prednisone taper. . In ED today, found to be hypotensive (SBP's in 80's) and hypothermic (31 C rectal temp). EKG w/ bradycardia to 40's. Plt 18. INR 1.5. given rewarming blankets. b/l EJ PIV placed. given 3L IVF's followed by peripheral dopa in ED. Recieved empiric steroids w/ dex for ?adrenal insuff. Vanco, levo, flagyl initiated. Given plt, coags, then right femoral line placed. . Denies N/V/Abd pain. + Loose stools x 7 days. No BRBPR . Admit to MICU for hypotension, sepsis w/u Past Medical History: 1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.[Last Name (STitle) 497] 2. Liver cirrhosis 3. Hypothyroidism 4. Osteopenia 5. Status post cholecystectomy 6. History of ankle fractures 7. Hypertension Social History: Tobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use, married with three children. Lives at home with husband Family History: No family history of strokes, seizures. Mother and father died in 90s. Physical Exam: T 33.9, BP 101/47, HR 45, RR 18, 98% RA gen- sleepy but arousable, garbled speech, non-toxic appearing heent-EOMI. Pupils 4->2 b/l. MM dry neck- diff to assess jvp 2/2 body habitus, b/l EJ's in place CV- brady. regular. no murmurs Pulm- anteriorly clear to auscultation w/o ronchi,rales,wheezes Abd- distended w/ dull flanks. non-tender to palpation. eXt- 3+ periph edema b/l. ext warm (bear hugger in place) neuro- follows commands, grip strength equal b/l, moving all extremities, oriented to person, [Hospital 1498] hospital; no asterixis. skin- superficial ulcerations on r elbow, hand. rect- yellow-brown stool, trace guaiac positive Pertinent Results: [2179-3-31] 09:20PM GLUCOSE-90 UREA N-46* CREAT-1.0 SODIUM-143 POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13 [2179-3-31] 09:20PM ALT(SGPT)-70* AST(SGOT)-90* CK(CPK)-112 ALK PHOS-154* AMYLASE-107* TOT BILI-3.6* [2179-3-31] 09:20PM cTropnT-<0.01 [2179-3-31] 09:20PM CK-MB-12* MB INDX-10.7* [2179-3-31] 09:20PM ALBUMIN-3.4 CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.1 [2179-3-31] 09:20PM WBC-5.6 RBC-3.51* HGB-10.7* HCT-32.5* MCV-93 MCH-30.5 MCHC-33.0 RDW-21.0* [2179-3-31] 09:20PM NEUTS-82.7* BANDS-0 LYMPHS-7.7* MONOS-3.8 EOS-5.3* BASOS-0.5 [2179-3-31] 09:20PM PLT COUNT-99# [2179-3-31] 09:20PM PT-15.6 PTT-35.8* INR(PT)-1.4* [2179-3-31] 07:16PM LACTATE-1.7 [2179-3-31] 07:02PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.010 [2179-3-31] 07:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2179-3-31] 07:02PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-MOD EPI-0 [2179-3-31] 05:36PM GLUCOSE-98 UREA N-49* CREAT-1.1 SODIUM-142 POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13 [2179-3-31] 05:36PM AST(SGOT)-96* CK(CPK)-114 ALK PHOS-155* TOT BILI-3.4* [2179-3-31] 05:36PM CK-MB-13* MB INDX-11.4* cTropnT-0.02* [2179-3-31] 05:36PM ALBUMIN-2.9* [2179-3-31] 05:36PM TSH-1.9 [2179-3-31] 05:36PM FREE T4-1.4 [2179-3-31] 05:36PM CORTISOL-9.2 [2179-3-31] 05:36PM WBC-4.5 RBC-3.61* HGB-11.2* HCT-33.4* MCV-93 MCH-31.0 MCHC-33.4 RDW-20.9* [2179-3-31] 05:36PM NEUTS-75.3* LYMPHS-13.4* MONOS-5.6 EOS-5.5* BASOS-0.3 [2179-3-31] 05:36PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-2+ MICROCYT-1+ [2179-3-31] 05:36PM PLT SMR-RARE PLT COUNT-18# LPLT-2+ [2179-3-31] 05:36PM PT-16.4 PTT-38.5* INR(PT)-1.5* CXR- RUL opacity EKG- sinus brady 49 bpm, LAD, QT 489, no ST/T changes, no block . Recent Studies: CT abd [3-19]- 1. Diffuse anasarca with soft tissue edema as well as ascites and nonspecific mesenteric stranding. Ascites is increased compared to the previous study. 2. Limited evaluation of the bowel with no definite wall thickening. There is no pneumatosis or free air. Patency within mesenteric vessels cannot be assessed without IV contrast. 3. Acute right posterior rib fracture that does not appear to be present on the study of [2179-1-20]. No evidence of pneumothorax in the imaged portions of the lungs . RUQ U/S [2179-3-18] 1. Patent portal vein with hepatopetal flow. 2. Small amount of ascites. . EGD [2179-3-19]: No active bleeding in esophagus, stomach, duodenum Mosaiac pattern in stomach c/w portal gastropathy . Colonoscopy [2179-3-19]: grade 1 internal hemmoroids few diverticula. no ischemic colitis Brief Hospital Course: Hospital Course: 73 y/o F w/ PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices who presents with c/o lightheadedness, dizziness x 1 day, found to be hypotensive, hypothermic requiring the ICU. She was called out to the floor but remained medically tenuous and elected to be made CMO. . # Hypotension/hypothermia: On admission the likely causes were felt to be adrenal insufficiency and sepsis. [First Name9 (NamePattern2) 1499] [Last Name (un) 104]-stim test, the patient was started on fludro and hydrocort empirically presuming her to be adrenally insufficient. She was also covered broadly with vanc,levo, flagyl as concerned for sepsis and question of PNA on CXR. Her abdominal ultrasound was negative for significant ascites for diagnostic paracentesis. Blood cultures from admission returned positive for streptococcus and flagyl was discontinued. With antibiotics and steroids, pt was weaned off dopamine and blood pressure remained stable for pt to go to the floor. Once on the floor she was weaned off iv steroids and then completed a taper of po steroids. She also completed a course of levofloxacin and vanc. . # Primary biliary Cirrhosis- Initially the patient's medications were held in the setting of sepsis. However, once on the floor, her ursodiol, lactulose, rifaximin, and diuretics were resumed. Her diuretics were titrated up as her renal function could tolerate it. Her ursodiol was discontinued as it was felt to be of little benefit. Her rifaximin and lactulose were discontinued when the patient elected to be CMO. Her diuretics were continued anticipating that they would provide some relief, given her fluid burden. . # ARF- This was likely [2-11] hypotension, some component of acute renal failure on hepatorenal syndrome. She was placed on midodrine and octreotide and with improved hypotension, her urine out-pt increased. However, her creatinine elevated and remained persistently elevated on increased diuretics for her anasarca. . # Thrombocytopenia- The patient had progressively lowering platelets throughout the admission. Further work-up was done and her labwork was also revealed to possibly be c/w DIC. However, on discussion with heme/onc, it was felt that her low platelets, low fibrinogen, and elevated coags were in fact related to her end stage liver disease. . # hypothyroidsm: The patient was continued on her levothyroxine throughout the admission. . # FEN: Once her mental status was improved on the floor she was maintained on a regular diet. Her electrolytes were followed daily. . # PPx - She was placed on a PPI and sc heparin during the admission. . # Communication/Dispo - Several discussions were held with Ms. [Known lastname 1500] family regarding her medical course and prognosis. She and her family agreed that she be made DNR/DNI on [2179-4-5]. A later discussion was held with the patient, her family, the medical team, palliative care team, and social work. The patient and her family expressed understanding that the pt was not a liver transplant candidate and that recovery of her independence prior to admission would be unlikely. At that time, given her prognosis, the patient decided to be made CMO with anticipation for discharge to a [Hospital1 1501] with hospice. Medications on Admission: Levothyroxine 75 mcg PO DAILY Furosemide 40 mg PO DAILY Spironolactone 100mg PO DAILY (recently increased from 50 mg [3-30]) Rifaximin 400mg PO TID Lactulose(30) ML PO Q6H prn (once/day per pt) Pantoprazole 40 mg PO Q24H Ursodiol 500mg PO QAM Ursodiol 750 mg QPM Nadolol 10 mg PO DAILY Citracal lD 2 pills [Hospital1 ] Prednisone taper- completed on: [3-29] Discharge Disposition: Extended Care Facility: [Last Name (un) 1502] Family Hospice House - [Location (un) ] Discharge Diagnosis: Primary: primary biliary cirrhosis, encephalopathy Secondary: hypothyroidism, osteopenia Discharge Condition: Ms. [Known lastname 1500] needs related to comfort are continuing to be addressed. Discharge Instructions: You will be discharged to a specialized nursing facility. If you have any needs related to your comfort there, you should feel free to address them with the staff of the facility. Followup Instructions: You will be followed closely by your health care providers at your specialized nursing facility. You will also be followed closely by the hospice providers.	Admission Date: <Date>1926-5-18</Date> Discharge Date: <Date>2006-12-1</Date> Date of Birth: <Date>1947-1-25</Date> Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:<Name>Judith</Name> Chief Complaint: dizziness x 1 day Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo F with h/o PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices who presents with c/o lightheadedness, dizziness x 1 day. Feels weak with decreased energy level. Of note, recently discharged on <Date>1908-11-17</Date> after hypotensive/hypothermic episode w/ suspected sepsis, treated empirically with a course of ceftriaxone, flagyl and stress-dose steroids. No infectious source was identified. Discharged to home to complete prednisone taper. . In ED today, found to be hypotensive (SBP's in 80's) and hypothermic (31 C rectal temp). EKG w/ bradycardia to 40's. Plt 18. INR 1.5. given rewarming blankets. b/l EJ PIV placed. given 3L IVF's followed by peripheral dopa in ED. Recieved empiric steroids w/ dex for ?adrenal insuff. Vanco, levo, flagyl initiated. Given plt, coags, then right femoral line placed. . Denies N/V/Abd pain. + Loose stools x 7 days. No BRBPR . Admit to MICU for hypotension, sepsis w/u Past Medical History: 1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.<Name>Harris</Name> 2. Liver cirrhosis 3. Hypothyroidism 4. Osteopenia 5. Status post cholecystectomy 6. History of ankle fractures 7. Hypertension Social History: Tobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use, married with three children. Lives at home with husband Family History: No family history of strokes, seizures. Mother and father died in 90s. Physical Exam: T 33.9, BP 101/47, HR 45, RR 18, 98% RA gen- sleepy but arousable, garbled speech, non-toxic appearing heent-EOMI. Pupils 4->2 b/l. MM dry neck- diff to assess jvp 2/2 body habitus, b/l EJ's in place CV- brady. regular. no murmurs Pulm- anteriorly clear to auscultation w/o ronchi,rales,wheezes Abd- distended w/ dull flanks. non-tender to palpation. eXt- 3+ periph edema b/l. ext warm (bear hugger in place) neuro- follows commands, grip strength equal b/l, moving all extremities, oriented to person, <Hospital>Bryant, Munoz and White Clinic</Hospital> hospital; no asterixis. skin- superficial ulcerations on r elbow, hand. rect- yellow-brown stool, trace guaiac positive Pertinent Results: <Date>1926-5-18</Date> 09:20PM GLUCOSE-90 UREA N-46* CREAT-1.0 SODIUM-143 POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13 <Date>1926-5-18</Date> 09:20PM ALT(SGPT)-70* AST(SGOT)-90* CK(CPK)-112 ALK PHOS-154* AMYLASE-107* TOT BILI-3.6* <Date>1926-5-18</Date> 09:20PM cTropnT-<0.01 <Date>1926-5-18</Date> 09:20PM CK-MB-12* MB INDX-10.7* <Date>1926-5-18</Date> 09:20PM ALBUMIN-3.4 CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.1 <Date>1926-5-18</Date> 09:20PM WBC-5.6 RBC-3.51* HGB-10.7* HCT-32.5* MCV-93 MCH-30.5 MCHC-33.0 RDW-21.0* <Date>1926-5-18</Date> 09:20PM NEUTS-82.7* BANDS-0 LYMPHS-7.7* MONOS-3.8 EOS-5.3* BASOS-0.5 <Date>1926-5-18</Date> 09:20PM PLT COUNT-99# <Date>1926-5-18</Date> 09:20PM PT-15.6 PTT-35.8* INR(PT)-1.4* <Date>1926-5-18</Date> 07:16PM LACTATE-1.7 <Date>1926-5-18</Date> 07:02PM URINE COLOR-Yellow APPEAR-Clear SP <Name>Cobbs</Name>-1.010 <Date>1926-5-18</Date> 07:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR <Date>1926-5-18</Date> 07:02PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-MOD EPI-0 <Date>1926-5-18</Date> 05:36PM GLUCOSE-98 UREA N-49* CREAT-1.1 SODIUM-142 POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13 <Date>1926-5-18</Date> 05:36PM AST(SGOT)-96* CK(CPK)-114 ALK PHOS-155* TOT BILI-3.4* <Date>1926-5-18</Date> 05:36PM CK-MB-13* MB INDX-11.4* cTropnT-0.02* <Date>1926-5-18</Date> 05:36PM ALBUMIN-2.9* <Date>1926-5-18</Date> 05:36PM TSH-1.9 <Date>1926-5-18</Date> 05:36PM FREE T4-1.4 <Date>1926-5-18</Date> 05:36PM CORTISOL-9.2 <Date>1926-5-18</Date> 05:36PM WBC-4.5 RBC-3.61* HGB-11.2* HCT-33.4* MCV-93 MCH-31.0 MCHC-33.4 RDW-20.9* <Date>1926-5-18</Date> 05:36PM NEUTS-75.3* LYMPHS-13.4* MONOS-5.6 EOS-5.5* BASOS-0.3 <Date>1926-5-18</Date> 05:36PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-2+ MICROCYT-1+ <Date>1926-5-18</Date> 05:36PM PLT SMR-RARE PLT COUNT-18# LPLT-2+ <Date>1926-5-18</Date> 05:36PM PT-16.4 PTT-38.5* INR(PT)-1.5* CXR- RUL opacity EKG- sinus brady 49 bpm, LAD, QT 489, no ST/T changes, no block . Recent Studies: CT abd <Date>12-22</Date>- 1. Diffuse anasarca with soft tissue edema as well as ascites and nonspecific mesenteric stranding. Ascites is increased compared to the previous study. 2. Limited evaluation of the bowel with no definite wall thickening. There is no pneumatosis or free air. Patency within mesenteric vessels cannot be assessed without IV contrast. 3. Acute right posterior rib fracture that does not appear to be present on the study of <Date>1941-7-7</Date>. No evidence of pneumothorax in the imaged portions of the lungs . RUQ U/S <Date>2021-11-14</Date> 1. Patent portal vein with hepatopetal flow. 2. Small amount of ascites. . EGD <Date>1900-3-27</Date>: No active bleeding in esophagus, stomach, duodenum Mosaiac pattern in stomach c/w portal gastropathy . Colonoscopy <Date>1900-3-27</Date>: grade 1 internal hemmoroids few diverticula. no ischemic colitis Brief Hospital Course: Hospital Course: 73 y/o F w/ PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices who presents with c/o lightheadedness, dizziness x 1 day, found to be hypotensive, hypothermic requiring the ICU. She was called out to the floor but remained medically tenuous and elected to be made CMO. . # Hypotension/hypothermia: On admission the likely causes were felt to be adrenal insufficiency and sepsis. <Name>Barbara</Name> <Name>Belle</Name>-stim test, the patient was started on fludro and hydrocort empirically presuming her to be adrenally insufficient. She was also covered broadly with vanc,levo, flagyl as concerned for sepsis and question of PNA on CXR. Her abdominal ultrasound was negative for significant ascites for diagnostic paracentesis. Blood cultures from admission returned positive for streptococcus and flagyl was discontinued. With antibiotics and steroids, pt was weaned off dopamine and blood pressure remained stable for pt to go to the floor. Once on the floor she was weaned off iv steroids and then completed a taper of po steroids. She also completed a course of levofloxacin and vanc. . # Primary biliary Cirrhosis- Initially the patient's medications were held in the setting of sepsis. However, once on the floor, her ursodiol, lactulose, rifaximin, and diuretics were resumed. Her diuretics were titrated up as her renal function could tolerate it. Her ursodiol was discontinued as it was felt to be of little benefit. Her rifaximin and lactulose were discontinued when the patient elected to be CMO. Her diuretics were continued anticipating that they would provide some relief, given her fluid burden. . # ARF- This was likely <Date>11-26</Date> hypotension, some component of acute renal failure on hepatorenal syndrome. She was placed on midodrine and octreotide and with improved hypotension, her urine out-pt increased. However, her creatinine elevated and remained persistently elevated on increased diuretics for her anasarca. . # Thrombocytopenia- The patient had progressively lowering platelets throughout the admission. Further work-up was done and her labwork was also revealed to possibly be c/w DIC. However, on discussion with heme/onc, it was felt that her low platelets, low fibrinogen, and elevated coags were in fact related to her end stage liver disease. . # hypothyroidsm: The patient was continued on her levothyroxine throughout the admission. . # FEN: Once her mental status was improved on the floor she was maintained on a regular diet. Her electrolytes were followed daily. . # PPx - She was placed on a PPI and sc heparin during the admission. . # Communication/Dispo - Several discussions were held with Ms. <Name>Booker</Name> family regarding her medical course and prognosis. She and her family agreed that she be made DNR/DNI on <Date>1913-2-25</Date>. A later discussion was held with the patient, her family, the medical team, palliative care team, and social work. The patient and her family expressed understanding that the pt was not a liver transplant candidate and that recovery of her independence prior to admission would be unlikely. At that time, given her prognosis, the patient decided to be made CMO with anticipation for discharge to a <Hospital>Garcia Inc Clinic</Hospital> with hospice. Medications on Admission: Levothyroxine 75 mcg PO DAILY Furosemide 40 mg PO DAILY Spironolactone 100mg PO DAILY (recently increased from 50 mg <Date>3-16</Date>) Rifaximin 400mg PO TID Lactulose(30) ML PO Q6H prn (once/day per pt) Pantoprazole 40 mg PO Q24H Ursodiol 500mg PO QAM Ursodiol 750 mg QPM Nadolol 10 mg PO DAILY Citracal lD 2 pills <Hospital>Brown, Chan and Jones Clinic</Hospital> Prednisone taper- completed on: <Date>10-29</Date> Discharge Disposition: Extended Care Facility: <Name>Jones</Name> Family Hospice House - <Location>851 Carroll Gateway Port Ashleyfort, HI 81307</Location> Discharge Diagnosis: Primary: primary biliary cirrhosis, encephalopathy Secondary: hypothyroidism, osteopenia Discharge Condition: Ms. <Name>Booker</Name> needs related to comfort are continuing to be addressed. Discharge Instructions: You will be discharged to a specialized nursing facility. If you have any needs related to your comfort there, you should feel free to address them with the staff of the facility. Followup Instructions: You will be followed closely by your health care providers at your specialized nursing facility. You will also be followed closely by the hospice providers.	000000000000000001111111110000000000000000000000000000000011111111100000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000001111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000111111111000000000000000000000000000000000000000000011111111100000000000000000000000111111111000000000000000000000000000000000000000000000111110000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000001111111110000000000000000000000001111111110000000000000000000111111111000000000000000000000001111111110000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1926-5-18 Discharge Date: 2006-12-1 Date of Birth: 1947-1-25 Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:Judith Chief Complaint: dizziness x 1 day Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo F with h/o PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices who presents with c/o lightheadedness, dizziness x 1 day. Feels weak with decreased energy level. Of note, recently discharged on 1908-11-17 after hypotensive/hypothermic episode w/ suspected sepsis, treated empirically with a course of ceftriaxone, flagyl and stress-dose steroids. No infectious source was identified. Discharged to home to complete prednisone taper. . In ED today, found to be hypotensive (SBP's in 80's) and hypothermic (31 C rectal temp). EKG w/ bradycardia to 40's. Plt 18. INR 1.5. given rewarming blankets. b/l EJ PIV placed. given 3L IVF's followed by peripheral dopa in ED. Recieved empiric steroids w/ dex for ?adrenal insuff. Vanco, levo, flagyl initiated. Given plt, coags, then right femoral line placed. . Denies N/V/Abd pain. + Loose stools x 7 days. No BRBPR . Admit to MICU for hypotension, sepsis w/u Past Medical History: 1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.Harris 2. Liver cirrhosis 3. Hypothyroidism 4. Osteopenia 5. Status post cholecystectomy 6. History of ankle fractures 7. Hypertension Social History: Tobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use, married with three children. Lives at home with husband Family History: No family history of strokes, seizures. Mother and father died in 90s. Physical Exam: T 33.9, BP 101/47, HR 45, RR 18, 98% RA gen- sleepy but arousable, garbled speech, non-toxic appearing heent-EOMI. Pupils 4->2 b/l. MM dry neck- diff to assess jvp 2/2 body habitus, b/l EJ's in place CV- brady. regular. no murmurs Pulm- anteriorly clear to auscultation w/o ronchi,rales,wheezes Abd- distended w/ dull flanks. non-tender to palpation. eXt- 3+ periph edema b/l. ext warm (bear hugger in place) neuro- follows commands, grip strength equal b/l, moving all extremities, oriented to person, Bryant, Munoz and White Clinic hospital; no asterixis. skin- superficial ulcerations on r elbow, hand. rect- yellow-brown stool, trace guaiac positive Pertinent Results: 1926-5-18 09:20PM GLUCOSE-90 UREA N-46* CREAT-1.0 SODIUM-143 POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13 1926-5-18 09:20PM ALT(SGPT)-70* AST(SGOT)-90* CK(CPK)-112 ALK PHOS-154* AMYLASE-107* TOT BILI-3.6* 1926-5-18 09:20PM cTropnT-1926-5-18 09:20PM CK-MB-12* MB INDX-10.7* 1926-5-18 09:20PM ALBUMIN-3.4 CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.1 1926-5-18 09:20PM WBC-5.6 RBC-3.51* HGB-10.7* HCT-32.5* MCV-93 MCH-30.5 MCHC-33.0 RDW-21.0* 1926-5-18 09:20PM NEUTS-82.7* BANDS-0 LYMPHS-7.7* MONOS-3.8 EOS-5.3* BASOS-0.5 1926-5-18 09:20PM PLT COUNT-99# 1926-5-18 09:20PM PT-15.6 PTT-35.8* INR(PT)-1.4* 1926-5-18 07:16PM LACTATE-1.7 1926-5-18 07:02PM URINE COLOR-Yellow APPEAR-Clear SP Cobbs-1.010 1926-5-18 07:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR 1926-5-18 07:02PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-MOD EPI-0 1926-5-18 05:36PM GLUCOSE-98 UREA N-49* CREAT-1.1 SODIUM-142 POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13 1926-5-18 05:36PM AST(SGOT)-96* CK(CPK)-114 ALK PHOS-155* TOT BILI-3.4* 1926-5-18 05:36PM CK-MB-13* MB INDX-11.4* cTropnT-0.02* 1926-5-18 05:36PM ALBUMIN-2.9* 1926-5-18 05:36PM TSH-1.9 1926-5-18 05:36PM FREE T4-1.4 1926-5-18 05:36PM CORTISOL-9.2 1926-5-18 05:36PM WBC-4.5 RBC-3.61* HGB-11.2* HCT-33.4* MCV-93 MCH-31.0 MCHC-33.4 RDW-20.9* 1926-5-18 05:36PM NEUTS-75.3* LYMPHS-13.4* MONOS-5.6 EOS-5.5* BASOS-0.3 1926-5-18 05:36PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-2+ MICROCYT-1+ 1926-5-18 05:36PM PLT SMR-RARE PLT COUNT-18# LPLT-2+ 1926-5-18 05:36PM PT-16.4 PTT-38.5* INR(PT)-1.5* CXR- RUL opacity EKG- sinus brady 49 bpm, LAD, QT 489, no ST/T changes, no block . Recent Studies: CT abd 12-22- 1. Diffuse anasarca with soft tissue edema as well as ascites and nonspecific mesenteric stranding. Ascites is increased compared to the previous study. 2. Limited evaluation of the bowel with no definite wall thickening. There is no pneumatosis or free air. Patency within mesenteric vessels cannot be assessed without IV contrast. 3. Acute right posterior rib fracture that does not appear to be present on the study of 1941-7-7. No evidence of pneumothorax in the imaged portions of the lungs . RUQ U/S 2021-11-14 1. Patent portal vein with hepatopetal flow. 2. Small amount of ascites. . EGD 1900-3-27: No active bleeding in esophagus, stomach, duodenum Mosaiac pattern in stomach c/w portal gastropathy . Colonoscopy 1900-3-27: grade 1 internal hemmoroids few diverticula. no ischemic colitis Brief Hospital Course: Hospital Course: 73 y/o F w/ PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices who presents with c/o lightheadedness, dizziness x 1 day, found to be hypotensive, hypothermic requiring the ICU. She was called out to the floor but remained medically tenuous and elected to be made CMO. . # Hypotension/hypothermia: On admission the likely causes were felt to be adrenal insufficiency and sepsis. Barbara Belle-stim test, the patient was started on fludro and hydrocort empirically presuming her to be adrenally insufficient. She was also covered broadly with vanc,levo, flagyl as concerned for sepsis and question of PNA on CXR. Her abdominal ultrasound was negative for significant ascites for diagnostic paracentesis. Blood cultures from admission returned positive for streptococcus and flagyl was discontinued. With antibiotics and steroids, pt was weaned off dopamine and blood pressure remained stable for pt to go to the floor. Once on the floor she was weaned off iv steroids and then completed a taper of po steroids. She also completed a course of levofloxacin and vanc. . # Primary biliary Cirrhosis- Initially the patient's medications were held in the setting of sepsis. However, once on the floor, her ursodiol, lactulose, rifaximin, and diuretics were resumed. Her diuretics were titrated up as her renal function could tolerate it. Her ursodiol was discontinued as it was felt to be of little benefit. Her rifaximin and lactulose were discontinued when the patient elected to be CMO. Her diuretics were continued anticipating that they would provide some relief, given her fluid burden. . # ARF- This was likely 11-26 hypotension, some component of acute renal failure on hepatorenal syndrome. She was placed on midodrine and octreotide and with improved hypotension, her urine out-pt increased. However, her creatinine elevated and remained persistently elevated on increased diuretics for her anasarca. . # Thrombocytopenia- The patient had progressively lowering platelets throughout the admission. Further work-up was done and her labwork was also revealed to possibly be c/w DIC. However, on discussion with heme/onc, it was felt that her low platelets, low fibrinogen, and elevated coags were in fact related to her end stage liver disease. . # hypothyroidsm: The patient was continued on her levothyroxine throughout the admission. . # FEN: Once her mental status was improved on the floor she was maintained on a regular diet. Her electrolytes were followed daily. . # PPx - She was placed on a PPI and sc heparin during the admission. . # Communication/Dispo - Several discussions were held with Ms. Booker family regarding her medical course and prognosis. She and her family agreed that she be made DNR/DNI on 1913-2-25. A later discussion was held with the patient, her family, the medical team, palliative care team, and social work. The patient and her family expressed understanding that the pt was not a liver transplant candidate and that recovery of her independence prior to admission would be unlikely. At that time, given her prognosis, the patient decided to be made CMO with anticipation for discharge to a Garcia Inc Clinic with hospice. Medications on Admission: Levothyroxine 75 mcg PO DAILY Furosemide 40 mg PO DAILY Spironolactone 100mg PO DAILY (recently increased from 50 mg 3-16) Rifaximin 400mg PO TID Lactulose(30) ML PO Q6H prn (once/day per pt) Pantoprazole 40 mg PO Q24H Ursodiol 500mg PO QAM Ursodiol 750 mg QPM Nadolol 10 mg PO DAILY Citracal lD 2 pills Brown, Chan and Jones Clinic Prednisone taper- completed on: 10-29 Discharge Disposition: Extended Care Facility: Jones Family Hospice House - 851 Carroll Gateway Port Ashleyfort, HI 81307 Discharge Diagnosis: Primary: primary biliary cirrhosis, encephalopathy Secondary: hypothyroidism, osteopenia Discharge Condition: Ms. Booker needs related to comfort are continuing to be addressed. Discharge Instructions: You will be discharged to a specialized nursing facility. If you have any needs related to your comfort there, you should feel free to address them with the staff of the facility. Followup Instructions: You will be followed closely by your health care providers at your specialized nursing facility. You will also be followed closely by the hospice providers.	["Admission Date: 1926-5-18 Discharge Date: 2006-12-1\n\nDate of Birth: 1947-1-25 Sex: F\n\nService: MEDICINE\n\nAllergies:\nHeparin Agents\n\nAttending:Judith\nChief Complaint:\ndizziness x 1 day\n\nMajor Surgical or Invasive Procedure:\nNone\n\n\nHistory of Present Illness:\n73 yo F with h/o PBC, decompensated cirrhosis c/b\nencephalopathy, ascites, and esoph varices who presents with c/o\nlightheadedness, dizziness x 1 day. Feels weak with decreased\nenergy level. Of note, recently discharged on 1908-11-17 after\nhypotensive/hypothermic episode w/ suspected sepsis, treated\nempirically with a course of ceftriaxone, flagyl and stress-dose\nsteroids. No infectious source was identified. Discharged to\nhome to complete prednisone taper.\n.\nIn ED today, found to be hypotensive (SBP's in 80's) and\nhypothermic (31 C rectal temp).", " EKG w/ bradycardia to 40's. Plt\n18. INR 1.5. given rewarming blankets. b/l EJ PIV placed. given\n3L IVF's followed by peripheral dopa in ED. Recieved empiric\nsteroids w/ dex for ?adrenal insuff. Vanco, levo, flagyl\ninitiated. Given plt, coags, then right femoral line placed.\n.\nDenies N/V/Abd pain. + Loose stools x 7 days. No BRBPR\n.\nAdmit to MICU for hypotension, sepsis w/u\n\n\nPast Medical History:\n1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.Harris\n2. Liver cirrhosis\n3. Hypothyroidism\n4. Osteopenia\n5. Status post cholecystectomy\n6. History of ankle fractures\n7. Hypertension\n\nSocial History:\nTobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use,\n\nmarried with three children. Lives at home with husband\n\n\nFamily History:\nNo family history of strokes, seizures. Mother and father died\nin 90s.", "\n\nPhysical Exam:\nT 33.9, BP 101/47, HR 45, RR 18, 98% RA\ngen- sleepy but arousable, garbled speech, non-toxic appearing\nheent-EOMI. Pupils 4->2 b/l. MM dry\nneck- diff to assess jvp 2/2 body habitus, b/l EJ's in place\nCV- brady. regular. no murmurs\nPulm- anteriorly clear to auscultation w/o ronchi,rales,wheezes\n\nAbd- distended w/ dull flanks. non-tender to palpation.\neXt- 3+ periph edema b/l. ext warm (bear hugger in place)\nneuro- follows commands, grip strength equal b/l, moving all\nextremities, oriented to person, Bryant, Munoz and White Clinic hospital; no asterixis.\n\nskin- superficial ulcerations on r elbow, hand.\nrect- yellow-brown stool, trace guaiac positive\n\n\nPertinent Results:\n1926-5-18 09:20PM GLUCOSE-90 UREA N-46* CREAT-1.0 SODIUM-143\nPOTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13\n1926-5-18 09:20PM ALT(SGPT)-70* AST(SGOT)-90* CK(CPK)-112 ALK\nPHOS-154* AMYLASE-107* TOT BILI-3.", '6\n1926-5-18 09:20PM cTropnT-1926-5-18 09:20PM CK-MB-12 MB INDX-10.7\n1926-5-18 09:20PM ALBUMIN-3.4 CALCIUM-9.1 PHOSPHATE-3.3\nMAGNESIUM-2.1\n1926-5-18 09:20PM WBC-5.6 RBC-3.51 HGB-10.7* HCT-32.5* MCV-93\nMCH-30.5 MCHC-33.0 RDW-21.0\n1926-5-18 09:20PM NEUTS-82.7 BANDS-0 LYMPHS-7.7* MONOS-3.8\nEOS-5.3* BASOS-0.5\n1926-5-18 09:20PM PLT COUNT-99#\n1926-5-18 09:20PM PT-15.6 PTT-35.8* INR(PT)-1.4\n1926-5-18 07:16PM LACTATE-1.7\n1926-5-18 07:02PM URINE COLOR-Yellow APPEAR-Clear SP Cobbs-1.010\n1926-5-18 07:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0\nLEUK-TR\n1926-5-18 07:02PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-MOD\nEPI-0\n1926-5-18 05:36PM GLUCOSE-98 UREA N-49 CREAT-1.1 SODIUM-142\nPOTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13\n1926-5-18 05:36PM AST(SGOT)-96* CK(CPK)-114 ALK PHOS-155* TOT\nBILI-3.', '4\n1926-5-18 05:36PM CK-MB-13 MB INDX-11.4* cTropnT-0.02\n1926-5-18 05:36PM ALBUMIN-2.9\n1926-5-18 05:36PM TSH-1.9\n1926-5-18 05:36PM FREE T4-1.4\n1926-5-18 05:36PM CORTISOL-9.2\n1926-5-18 05:36PM WBC-4.5 RBC-3.61* HGB-11.2* HCT-33.4* MCV-93\nMCH-31.0 MCHC-33.4 RDW-20.9\n1926-5-18 05:36PM NEUTS-75.3 LYMPHS-13.4* MONOS-5.6 EOS-5.5\nBASOS-0.3\n1926-5-18 05:36PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-2+\nMICROCYT-1+\n1926-5-18 05:36PM PLT SMR-RARE PLT COUNT-18# LPLT-2+\n1926-5-18 05:36PM PT-16.4* PTT-38.5* INR(PT)-1.5*\n\nCXR- RUL opacity\nEKG- sinus brady 49 bpm, LAD, QT 489, no ST/T changes, no block\n\n.\nRecent Studies:\nCT abd 12-22-\n1. Diffuse anasarca with soft tissue edema as well as ascites\nand nonspecific mesenteric stranding. Ascites is increased\ncompared to the previous study.\n2.', ' Limited evaluation of the bowel with no definite wall\nthickening. There is no pneumatosis or free air. Patency within\nmesenteric vessels cannot be assessed without IV contrast.\n3. Acute right posterior rib fracture that does not appear to be\npresent on the study of 1941-7-7. No evidence of pneumothorax in\nthe imaged portions of the lungs\n.\nRUQ U/S 2021-11-14\n1. Patent portal vein with hepatopetal flow.\n2. Small amount of ascites.\n.\nEGD 1900-3-27:\nNo active bleeding in esophagus, stomach, duodenum\nMosaiac pattern in stomach c/w portal gastropathy\n.\nColonoscopy 1900-3-27:\ngrade 1 internal hemmoroids\nfew diverticula. no ischemic colitis\n\n\nBrief Hospital Course:\nHospital Course: 73 y/o F w/ PBC, decompensated cirrhosis c/b\nencephalopathy, ascites, and esoph varices who presents with c/o\nlightheadedness, dizziness x 1 day, found to be hypotensive,\nhypothermic requiring the ICU.', ' She was called out to the floor\nbut remained medically tenuous and elected to be made CMO.\n.\n# Hypotension/hypothermia: On admission the likely causes were\nfelt to be adrenal insufficiency and sepsis. Barbara\nBelle-stim test, the patient was started on fludro and hydrocort\nempirically presuming her to be adrenally insufficient. She was\nalso covered broadly with vanc,levo, flagyl as concerned for\nsepsis and question of PNA on CXR. Her abdominal ultrasound was\nnegative for significant ascites for diagnostic paracentesis.\nBlood cultures from admission returned positive for\nstreptococcus and flagyl was discontinued. With antibiotics and\nsteroids, pt was weaned off dopamine and blood pressure remained\nstable for pt to go to the floor. Once on the floor she was\nweaned off iv steroids and then completed a taper of po\nsteroids.', " She also completed a course of levofloxacin and vanc.\n\n.\n# Primary biliary Cirrhosis- Initially the patient's medications\nwere held in the setting of sepsis. However, once on the floor,\nher ursodiol, lactulose, rifaximin, and diuretics were resumed.\nHer diuretics were titrated up as her renal function could\ntolerate it. Her ursodiol was discontinued as it was felt to be\nof little benefit. Her rifaximin and lactulose were discontinued\nwhen the patient elected to be CMO. Her diuretics were continued\nanticipating that they would provide some relief, given her\nfluid burden.\n.\n# ARF- This was likely 11-26 hypotension, some component of acute\nrenal failure on hepatorenal syndrome. She was placed on\nmidodrine and octreotide and with improved hypotension, her\nurine out-pt increased. However, her creatinine elevated and\nremained persistently elevated on increased diuretics for her\nanasarca.", '\n.\n# Thrombocytopenia- The patient had progressively lowering\nplatelets throughout the admission. Further work-up was done and\nher labwork was also revealed to possibly be c/w DIC. However,\non discussion with heme/onc, it was felt that her low platelets,\nlow fibrinogen, and elevated coags were in fact related to her\nend stage liver disease.\n.\n# hypothyroidsm: The patient was continued on her levothyroxine\nthroughout the admission.\n.\n# FEN: Once her mental status was improved on the floor she was\nmaintained on a regular diet. Her electrolytes were followed\ndaily.\n.\n# PPx - She was placed on a PPI and sc heparin during the\nadmission.\n.\n# Communication/Dispo - Several discussions were held with Ms.\nBooker family regarding her medical course and prognosis. She\nand her family agreed that she be made DNR/DNI on 1913-2-25.', ' A\nlater discussion was held with the patient, her family, the\nmedical team, palliative care team, and social work. The patient\nand her family expressed understanding that the pt was not a\nliver transplant candidate and that recovery of her independence\nprior to admission would be unlikely. At that time, given her\nprognosis, the patient decided to be made CMO with anticipation\nfor discharge to a Garcia Inc Clinic with hospice.\n\n\nMedications on Admission:\nLevothyroxine 75 mcg PO DAILY\nFurosemide 40 mg PO DAILY\nSpironolactone 100mg PO DAILY (recently increased from 50 mg\n3-16)\nRifaximin 400mg PO TID\nLactulose(30) ML PO Q6H prn (once/day per pt)\nPantoprazole 40 mg PO Q24H\nUrsodiol 500mg PO QAM\nUrsodiol 750 mg QPM\nNadolol 10 mg PO DAILY\nCitracal lD 2 pills Brown, Chan and Jones Clinic\nPrednisone taper- completed on: 10-29\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nJones Family Hospice House - 851 Carroll Gateway\nPort Ashleyfort, HI 81307\n\nDischarge Diagnosis:\nPrimary: primary biliary cirrhosis, encephalopathy\n\nSecondary: hypothyroidism, osteopenia\n\n\nDischarge Condition:\nMs.', ' Booker needs related to comfort are continuing to be\naddressed.\n\n\nDischarge Instructions:\nYou will be discharged to a specialized nursing facility. If you\nhave any needs related to your comfort there, you should feel\nfree to address them with the staff of the facility.\n\nFollowup Instructions:\nYou will be followed closely by your health care providers at\nyour specialized nursing facility. You will also be followed\nclosely by the hospice providers.\n\n\n\n']
143	29187	141931.0	2142-06-08	Discharge summary	Report	Admission Date: [2142-5-31] Discharge Date: [2142-6-8] Date of Birth: [2070-2-24] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain, dyspnea on exertion Major Surgical or Invasive Procedure: [2142-5-31] Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary to left anterior descending artery, with vein grafts to ramus intermedius, obtuse marginal and PDA. History of Present Illness: This is a 72 year old with known coronary artery disease. Over the last several months, he began to experience worsening chest pain and dyspnea on exertion. He recently underwent stress testng which was positive for ischemia. Stress ECHO in [Month (only) 216] [2140] was notable for an LVEF of 55-60%. Subsequent cardiac catheterization on [2142-5-11] revealed severe three vessel coronary artery disease. Based upon the above results, he was referred for coronary surgical intervention. Past Medical History: Coronary Artery Disease History of PTCA(ramus) [2128] History of Myocardial Infarction [2125] Diabetes Mellitus Type II Hypertension Hyperlipidemia History of Prostate Cancer - s/p Radical Prostatectomy Arthritis Gout Tonsillectomy Social History: Married with grown children. He is a very active volunteer. He worked at the Mass Transit Authority prior to retiring/ Social history is significant for the absence of current tobacco use, quit in [2091]. There is no history of alcohol abuse and no current alcohol use. Family History: There is no family history of premature coronary artery disease or sudden death. His father had CHF in his 80s. Physical Exam: Vitals: BP 167/80, HR 56, RR 18 General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, no carotid bruits Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2142-6-8] 06:50AM BLOOD WBC-8.6 RBC-3.41* Hgb-10.1* Hct-31.0* MCV-91 MCH-29.6 MCHC-32.6 RDW-14.6 Plt Ct-455* [2142-6-8] 06:50AM BLOOD PT-24.3* INR(PT)-2.4* [2142-6-8] 06:50AM BLOOD Glucose-120* UreaN-32* Creat-1.8* Na-138 K-4.7 Cl-101 HCO3-28 AnGap-14 RADIOLOGY Final Report CHEST (PA & LAT) [2142-6-8] 9:23 AM CHEST (PA & LAT) Reason: evaluate ?pneumomediastinum [Hospital 93] MEDICAL CONDITION: 72 year old man with h/o MI [2125], presented for cath found to have 3VD. REASON FOR THIS EXAMINATION: evaluate ?pneumomediastinum INDICATIONS: 72-year-old man with recent coronary artery bypass graft surgery. CHEST, PA AND LATERA: Cardiac and mediastinal contours are [Year (4 digits) 1506]. There is persistent large left-sided pleural effusion with atelectasis. A small [Year (4 digits) 1506] right pleural effusion is also noted. A tiny focus of air in the anterior mediastinum persists. IMPRESSION: Similar large left-sided pleural effusion. Tiny post-operative air collection of 8 mm in diameter, [Year (4 digits) 1506]. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1507] DR. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1508]Cardiology Report ECHO Study Date of [2142-5-31] PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for CABG procedure Height: (in) 71 Weight (lb): 206 BSA (m2): 2.14 m2 BP (mm Hg): 135/76 HR (bpm): 56 Status: Inpatient Date/Time: [2142-5-31] at 10:07 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) ] R. [Doctor Last Name ] MEASUREMENTS: Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A Ratio: 2.33 INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF. No resting LVOT gradient. LV WALL MOTION: Regional LV wall motion abnormalities include: mid anteroseptal - hypo; anterior apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: Prebypass 1. No atrial septal defect is seen by 2D or color Doppler. 2.There is mild regional left ventricular systolic dysfunction with mild hypokinesia of the apex of the anterior wall, mid and apical portions of the anterior septum. Overall left ventricular systolic function is mildly depressed. 3. Right ventricular chamber size and free wall motion are normal. 4.There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The mitral annulus is not dilated. Post bypass: Pt is being AV paced and is on an infusion of phenylephrine 1. Biventricular function is preserved. 2. MR [First Name (Titles) ] [Last Name (Titles) 1506] in severity 3. Aorta and interatrial septum are intact post decannulation 4. Other findings are [Last Name (Titles) 1506] Electronically signed by [Name6 (MD) 1509] [Name8 (MD) 1510], MD on [2142-6-1] 13:19. Brief Hospital Course: Mr. [Known lastname 1503] was admitted and underwent coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the SDU on postoperative day one. Given his renal insufficiency, BUN and creatinine were monitored very closely. His creatinine peaked to 2.2 on postoperative day two. By discharge, his renal function returned to baseline. He was also noted to have diffuse ST elevation on electrocardiogram consistent with pericarditis and eventually went on to develop atrial flutter. Beta blockade was advanced. K and Mg levels were monitored and repleted per protocol. He otherwise continued to make clinical improvements with diuresis and physical therapy. He developed LUE thrombophlebitis on POD#7 and was treated with Vanco and evaluated by Vasc. [Doctor First Name ]. who felt surgical intervention was not indicated. His forearm improved and he was discharged to home on POD#8 in stable condition. He was anticoagulated with coumadin and will have his INR followed by Dr. [First Name (STitle) 1511]. Medications on Admission: Aspirin 325 qd, Lisinopril 10 qd, Lovastatin 20 qd, Metformin 500 qd, Toprol XL 25 qd, Tricor 145 qd, Caltrate 600 [Hospital1 ], Centrum qd, Glucosamine qd Discharge Medications: 1. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days: For left forearm phlebitis. Disp:28 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:40 Tablet(s) Refills:0 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:0 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:90 Tablet Sustained Release 24 hr(s) Refills:0 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400mg daily for one week, then 200mg daily. Disp:60 Tablet(s) Refills:0 9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: Please take coumadin as directed by Dr. [First Name (STitle) 1511]. Disp:30 Tablet(s) Refills:0 10. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: please take as directed by Dr. [First Name (STitle) 1511]. Disp:60 Tablet(s) Refills:0 11. Outpatient Lab Work Please draw an INR on saturday [2142-6-8] and fax results to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1511] at ([Telephone/Fax (1) 1512]. Phone number ([Telephone/Fax (1) 1513]. Discharge Disposition: Home With Service Facility: [Location (un) 1514] Regional VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Postop Atrial Flutter History of PTCA [2128] History of Myocardial Infarction [2125] Diabetes Mellitus Type II Hypertension Hyperlipidemia History of Prostate Cancer - s/p Prostatectomy Arthritis Gout Discharge Condition: Stable Discharge Instructions: Patient should shower daily, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call cardiac surgeon if start to experience fevers, sternal drainage and/or wound erythema. Followup Instructions: Dr. [Last Name (STitle) ] in [3-15] weeks, call for appt Dr. [Last Name (STitle) 120] in [1-13] weeks, call for appt Dr. [First Name (STitle) 1511] in [1-13] weeks, call for appt Completed by:[2142-6-11]	Admission Date: <Date>1925-2-9</Date> Discharge Date: <Date>1968-2-3</Date> Date of Birth: <Date>1974-5-6</Date> Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Linda</Name> Chief Complaint: Chest pain, dyspnea on exertion Major Surgical or Invasive Procedure: <Date>1925-2-9</Date> Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary to left anterior descending artery, with vein grafts to ramus intermedius, obtuse marginal and PDA. History of Present Illness: This is a 72 year old with known coronary artery disease. Over the last several months, he began to experience worsening chest pain and dyspnea on exertion. He recently underwent stress testng which was positive for ischemia. Stress ECHO in <Month>November</Month> <Year>1967</Year> was notable for an LVEF of 55-60%. Subsequent cardiac catheterization on <Date>1912-11-29</Date> revealed severe three vessel coronary artery disease. Based upon the above results, he was referred for coronary surgical intervention. Past Medical History: Coronary Artery Disease History of PTCA(ramus) <Year>1967</Year> History of Myocardial Infarction <Year>1967</Year> Diabetes Mellitus Type II Hypertension Hyperlipidemia History of Prostate Cancer - s/p Radical Prostatectomy Arthritis Gout Tonsillectomy Social History: Married with grown children. He is a very active volunteer. He worked at the Mass Transit Authority prior to retiring/ Social history is significant for the absence of current tobacco use, quit in <Year>1967</Year>. There is no history of alcohol abuse and no current alcohol use. Family History: There is no family history of premature coronary artery disease or sudden death. His father had CHF in his 80s. Physical Exam: Vitals: BP 167/80, HR 56, RR 18 General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, no carotid bruits Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: <Date>1968-2-3</Date> 06:50AM BLOOD WBC-8.6 RBC-3.41* Hgb-10.1* Hct-31.0* MCV-91 MCH-29.6 MCHC-32.6 RDW-14.6 Plt Ct-455* <Date>1968-2-3</Date> 06:50AM BLOOD PT-24.3* INR(PT)-2.4* <Date>1968-2-3</Date> 06:50AM BLOOD Glucose-120* UreaN-32* Creat-1.8* Na-138 K-4.7 Cl-101 HCO3-28 AnGap-14 RADIOLOGY Final Report CHEST (PA & LAT) <Date>1968-2-3</Date> 9:23 AM CHEST (PA & LAT) Reason: evaluate ?pneumomediastinum <Hospital>Brooks, Harper and Brown Health System</Hospital> MEDICAL CONDITION: 72 year old man with h/o MI <Year>1967</Year>, presented for cath found to have 3VD. REASON FOR THIS EXAMINATION: evaluate ?pneumomediastinum INDICATIONS: 72-year-old man with recent coronary artery bypass graft surgery. CHEST, PA AND LATERA: Cardiac and mediastinal contours are <Year>1930</Year>. There is persistent large left-sided pleural effusion with atelectasis. A small <Year>1930</Year> right pleural effusion is also noted. A tiny focus of air in the anterior mediastinum persists. IMPRESSION: Similar large left-sided pleural effusion. Tiny post-operative air collection of 8 mm in diameter, <Year>1930</Year>. The study and the report were reviewed by the staff radiologist. DR. <Name>Babette</Name> <Initial>DK</Initial> <Name>Kuykendall</Name> DR. <Name>Jessie</Name> <Name>Latasha</Name>Cardiology Report ECHO Study Date of <Date>1925-2-9</Date> PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for CABG procedure Height: (in) 71 Weight (lb): 206 BSA (m2): 2.14 m2 BP (mm Hg): 135/76 HR (bpm): 56 Status: Inpatient Date/Time: <Date>1925-2-9</Date> at 10:07 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. <Name>Lakisha</Name> R. <Doctor Name>Dr.White</Doctor Name> MEASUREMENTS: Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A Ratio: 2.33 INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF. No resting LVOT gradient. LV WALL MOTION: Regional LV wall motion abnormalities include: mid anteroseptal - hypo; anterior apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: Prebypass 1. No atrial septal defect is seen by 2D or color Doppler. 2.There is mild regional left ventricular systolic dysfunction with mild hypokinesia of the apex of the anterior wall, mid and apical portions of the anterior septum. Overall left ventricular systolic function is mildly depressed. 3. Right ventricular chamber size and free wall motion are normal. 4.There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The mitral annulus is not dilated. Post bypass: Pt is being AV paced and is on an infusion of phenylephrine 1. Biventricular function is preserved. 2. MR <Name>Cruz</Name> <Name>Quinones</Name> in severity 3. Aorta and interatrial septum are intact post decannulation 4. Other findings are <Name>Quinones</Name> Electronically signed by <Name>Dawn Hazelwood</Name> <Name>Pamela Young</Name>, MD on <Date>1904-5-5</Date> 13:19. Brief Hospital Course: Mr. <Name>Ahmed</Name> was admitted and underwent coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the SDU on postoperative day one. Given his renal insufficiency, BUN and creatinine were monitored very closely. His creatinine peaked to 2.2 on postoperative day two. By discharge, his renal function returned to baseline. He was also noted to have diffuse ST elevation on electrocardiogram consistent with pericarditis and eventually went on to develop atrial flutter. Beta blockade was advanced. K and Mg levels were monitored and repleted per protocol. He otherwise continued to make clinical improvements with diuresis and physical therapy. He developed LUE thrombophlebitis on POD#7 and was treated with Vanco and evaluated by Vasc. <Name>Kaushik</Name>. who felt surgical intervention was not indicated. His forearm improved and he was discharged to home on POD#8 in stable condition. He was anticoagulated with coumadin and will have his INR followed by Dr. <Name>Sharon</Name>. Medications on Admission: Aspirin 325 qd, Lisinopril 10 qd, Lovastatin 20 qd, Metformin 500 qd, Toprol XL 25 qd, Tricor 145 qd, Caltrate 600 <Hospital>Williams-Shaw Medical Center</Hospital>, Centrum qd, Glucosamine qd Discharge Medications: 1. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days: For left forearm phlebitis. Disp:28 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:40 Tablet(s) Refills:0 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:0 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:90 Tablet Sustained Release 24 hr(s) Refills:0 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400mg daily for one week, then 200mg daily. Disp:60 Tablet(s) Refills:0 9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: Please take coumadin as directed by Dr. <Name>Sharon</Name>. Disp:30 Tablet(s) Refills:0 10. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: please take as directed by Dr. <Name>Sharon</Name>. Disp:60 Tablet(s) Refills:0 11. Outpatient Lab Work Please draw an INR on saturday <Date>1968-2-3</Date> and fax results to Dr. <Name>Jessie</Name> <Name>Medrano</Name> at (<Telephone>774-964-8282</Telephone>. Phone number (<Telephone>623-370-3179</Telephone>. Discharge Disposition: Home With Service Facility: <Location>9557 Atkinson Expressway South Erin, MD 66588</Location> Regional VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Postop Atrial Flutter History of PTCA <Year>1967</Year> History of Myocardial Infarction <Year>1967</Year> Diabetes Mellitus Type II Hypertension Hyperlipidemia History of Prostate Cancer - s/p Prostatectomy Arthritis Gout Discharge Condition: Stable Discharge Instructions: Patient should shower daily, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call cardiac surgeon if start to experience fevers, sternal drainage and/or wound erythema. Followup Instructions: Dr. <Name>Smith</Name> in <Date>10-12</Date> weeks, call for appt Dr. <Name>Camargo</Name> in <Date>6-5</Date> weeks, call for appt Dr. <Name>Sharon</Name> in <Date>6-5</Date> weeks, call for appt Completed by:<Date>1973-4-9</Date>	000000000000000001111111100000000000000000000000000000000111111110000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111101111000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111111100000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000011111110110111111111100000111111011111110000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111000011111111000000000000000000000000000000000000000000000000000000000000>000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000111111111111110111111111111000000001111111100000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111000000000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Date: 1925-2-9 Discharge Date: 1968-2-3 Date of Birth: 1974-5-6 Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Linda Chief Complaint: Chest pain, dyspnea on exertion Major Surgical or Invasive Procedure: 1925-2-9 Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary to left anterior descending artery, with vein grafts to ramus intermedius, obtuse marginal and PDA. History of Present Illness: This is a 72 year old with known coronary artery disease. Over the last several months, he began to experience worsening chest pain and dyspnea on exertion. He recently underwent stress testng which was positive for ischemia. Stress ECHO in November 1967 was notable for an LVEF of 55-60%. Subsequent cardiac catheterization on 1912-11-29 revealed severe three vessel coronary artery disease. Based upon the above results, he was referred for coronary surgical intervention. Past Medical History: Coronary Artery Disease History of PTCA(ramus) 1967 History of Myocardial Infarction 1967 Diabetes Mellitus Type II Hypertension Hyperlipidemia History of Prostate Cancer - s/p Radical Prostatectomy Arthritis Gout Tonsillectomy Social History: Married with grown children. He is a very active volunteer. He worked at the Mass Transit Authority prior to retiring/ Social history is significant for the absence of current tobacco use, quit in 1967. There is no history of alcohol abuse and no current alcohol use. Family History: There is no family history of premature coronary artery disease or sudden death. His father had CHF in his 80s. Physical Exam: Vitals: BP 167/80, HR 56, RR 18 General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, no carotid bruits Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: 1968-2-3 06:50AM BLOOD WBC-8.6 RBC-3.41* Hgb-10.1* Hct-31.0* MCV-91 MCH-29.6 MCHC-32.6 RDW-14.6 Plt Ct-455* 1968-2-3 06:50AM BLOOD PT-24.3* INR(PT)-2.4* 1968-2-3 06:50AM BLOOD Glucose-120* UreaN-32* Creat-1.8* Na-138 K-4.7 Cl-101 HCO3-28 AnGap-14 RADIOLOGY Final Report CHEST (PA & LAT) 1968-2-3 9:23 AM CHEST (PA & LAT) Reason: evaluate ?pneumomediastinum Brooks, Harper and Brown Health System MEDICAL CONDITION: 72 year old man with h/o MI 1967, presented for cath found to have 3VD. REASON FOR THIS EXAMINATION: evaluate ?pneumomediastinum INDICATIONS: 72-year-old man with recent coronary artery bypass graft surgery. CHEST, PA AND LATERA: Cardiac and mediastinal contours are 1930. There is persistent large left-sided pleural effusion with atelectasis. A small 1930 right pleural effusion is also noted. A tiny focus of air in the anterior mediastinum persists. IMPRESSION: Similar large left-sided pleural effusion. Tiny post-operative air collection of 8 mm in diameter, 1930. The study and the report were reviewed by the staff radiologist. DR. Babette DK Kuykendall DR. Jessie LatashaCardiology Report ECHO Study Date of 1925-2-9 PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for CABG procedure Height: (in) 71 Weight (lb): 206 BSA (m2): 2.14 m2 BP (mm Hg): 135/76 HR (bpm): 56 Status: Inpatient Date/Time: 1925-2-9 at 10:07 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. Lakisha R. Dr.White MEASUREMENTS: Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Ascending: 3.1 cm (nl Cruz Quinones in severity 3. Aorta and interatrial septum are intact post decannulation 4. Other findings are Quinones Electronically signed by Dawn Hazelwood Pamela Young, MD on 1904-5-5 13:19. Brief Hospital Course: Mr. Ahmed was admitted and underwent coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the SDU on postoperative day one. Given his renal insufficiency, BUN and creatinine were monitored very closely. His creatinine peaked to 2.2 on postoperative day two. By discharge, his renal function returned to baseline. He was also noted to have diffuse ST elevation on electrocardiogram consistent with pericarditis and eventually went on to develop atrial flutter. Beta blockade was advanced. K and Mg levels were monitored and repleted per protocol. He otherwise continued to make clinical improvements with diuresis and physical therapy. He developed LUE thrombophlebitis on POD#7 and was treated with Vanco and evaluated by Vasc. Kaushik. who felt surgical intervention was not indicated. His forearm improved and he was discharged to home on POD#8 in stable condition. He was anticoagulated with coumadin and will have his INR followed by Dr. Sharon. Medications on Admission: Aspirin 325 qd, Lisinopril 10 qd, Lovastatin 20 qd, Metformin 500 qd, Toprol XL 25 qd, Tricor 145 qd, Caltrate 600 Williams-Shaw Medical Center, Centrum qd, Glucosamine qd Discharge Medications: 1. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days: For left forearm phlebitis. Disp:28 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:40 Tablet(s) Refills:0 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:0 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:90 Tablet Sustained Release 24 hr(s) Refills:0 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400mg daily for one week, then 200mg daily. Disp:60 Tablet(s) Refills:0 9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: Please take coumadin as directed by Dr. Sharon. Disp:30 Tablet(s) Refills:0 10. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: please take as directed by Dr. Sharon. Disp:60 Tablet(s) Refills:0 11. Outpatient Lab Work Please draw an INR on saturday 1968-2-3 and fax results to Dr. Jessie Medrano at (774-964-8282. Phone number (623-370-3179. Discharge Disposition: Home With Service Facility: 9557 Atkinson Expressway South Erin, MD 66588 Regional VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Postop Atrial Flutter History of PTCA 1967 History of Myocardial Infarction 1967 Diabetes Mellitus Type II Hypertension Hyperlipidemia History of Prostate Cancer - s/p Prostatectomy Arthritis Gout Discharge Condition: Stable Discharge Instructions: Patient should shower daily, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call cardiac surgeon if start to experience fevers, sternal drainage and/or wound erythema. Followup Instructions: Dr. Smith in 10-12 weeks, call for appt Dr. Camargo in 6-5 weeks, call for appt Dr. Sharon in 6-5 weeks, call for appt Completed by:1973-4-9	['Admission Date: 1925-2-9 Discharge Date: 1968-2-3\n\nDate of Birth: 1974-5-6 Sex: M\n\nService: CARDIOTHORACIC\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Linda\nChief Complaint:\nChest pain, dyspnea on exertion\n\nMajor Surgical or Invasive Procedure:\n1925-2-9 Four Vessel Coronary Artery Bypass Grafting utilizing\nthe left internal mammary to left anterior descending artery,\nwith vein grafts to ramus intermedius, obtuse marginal and PDA.\n\n\nHistory of Present Illness:\nThis is a 72 year old with known coronary artery disease. Over\nthe last several months, he began to experience worsening chest\npain and dyspnea on exertion. He recently underwent stress\ntestng which was positive for ischemia. Stress ECHO in November\n1967 was notable for an LVEF of 55-60%.', ' Subsequent cardiac\ncatheterization on 1912-11-29 revealed severe three vessel coronary\nartery disease. Based upon the above results, he was referred\nfor coronary surgical intervention.\n\nPast Medical History:\nCoronary Artery Disease\nHistory of PTCA(ramus) 1967\nHistory of Myocardial Infarction 1967\nDiabetes Mellitus Type II\nHypertension\nHyperlipidemia\nHistory of Prostate Cancer - s/p Radical Prostatectomy\nArthritis\nGout\nTonsillectomy\n\n\nSocial History:\nMarried with grown children. He is a very active volunteer. He\nworked at the Mass Transit Authority prior to retiring/ Social\nhistory is significant for the absence of current tobacco use,\nquit in 1967. There is no history of alcohol abuse and no\ncurrent alcohol use.\n\n\nFamily History:\nThere is no family history of premature coronary artery disease\nor sudden death.', ' His father had CHF in his 80s.\n\n\nPhysical Exam:\nVitals: BP 167/80, HR 56, RR 18\nGeneral: well developed male in no acute distress\nHEENT: oropharynx benign,\nNeck: supple, no JVD, no carotid bruits\nHeart: regular rate, normal s1s2, no murmur or rub\nLungs: clear bilaterally\nAbdomen: soft, nontender, normoactive bowel sounds\nExt: warm, no edema, no varicosities\nPulses: 2+ distally\nNeuro: nonfocal\n\n\nPertinent Results:\n1968-2-3 06:50AM BLOOD WBC-8.6 RBC-3.41* Hgb-10.1* Hct-31.0\nMCV-91 MCH-29.6 MCHC-32.6 RDW-14.6 Plt Ct-455\n1968-2-3 06:50AM BLOOD PT-24.3* INR(PT)-2.4\n1968-2-3 06:50AM BLOOD Glucose-120 UreaN-32* Creat-1.8* Na-138\nK-4.7 Cl-101 HCO3-28 AnGap-14\nRADIOLOGY Final Report\n\nCHEST (PA & LAT) 1968-2-3 9:23 AM\n\nCHEST (PA & LAT)\n\nReason: evaluate ?pneumomediastinum\n\nBrooks, Harper and Brown Health System MEDICAL CONDITION:\n72 year old man with h/o MI 1967, presented for cath found to\nhave 3VD.', '\nREASON FOR THIS EXAMINATION:\nevaluate ?pneumomediastinum\nINDICATIONS: 72-year-old man with recent coronary artery bypass\ngraft surgery.\n\nCHEST, PA AND LATERA: Cardiac and mediastinal contours are\n1930. There is persistent large left-sided pleural effusion\nwith atelectasis. A small 1930 right pleural effusion is\nalso noted. A tiny focus of air in the anterior mediastinum\npersists.\n\nIMPRESSION: Similar large left-sided pleural effusion. Tiny\npost-operative air collection of 8 mm in diameter, 1930.\n\nThe study and the report were reviewed by the staff radiologist.\nDR. Babette DK Kuykendall\nDR. Jessie LatashaCardiology Report ECHO Study Date of 1925-2-9\n\n\n\nPATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG procedure\nHeight: (in) 71\nWeight (lb): 206\nBSA (m2): 2.14 m2\nBP (mm Hg): 135/76\nHR (bpm): 56\nStatus: Inpatient\nDate/Time: 1925-2-9 at 10:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTape Number: 2007AW1-:\nTest Location: Anesthesia West OR cardiac\nTechnical Quality: Adequate\n\n\n\n\nREFERRING DOCTOR: DR.', ' Lakisha R. Dr.White\n\nMEASUREMENTS:\nLeft Ventricle - Ejection Fraction: 50% (nl >=55%)\nAorta - Ascending: 3.1 cm (nl Cruz Quinones in severity\n\n3. Aorta and interatrial septum are intact post decannulation\n\n4. Other findings are Quinones\n\nElectronically signed by Dawn Hazelwood Pamela Young, MD on 1904-5-5 13:19.\n\n\n\n\n\n\n\n\n\n\n\n\n\nBrief Hospital Course:\nMr. Ahmed was admitted and underwent coronary artery bypass\ngrafting surgery. For surgical details, please see seperate\ndictated operative note. Following the operation, he was brought\nto the CSRU for invasive monitoring. Within 24 hours, he awoke\nneurologically intact and was extubated without incident. He\nmaintained stable hemodynamics and transferred to the SDU on\npostoperative day one. Given his renal insufficiency, BUN and\ncreatinine were monitored very closely.', ' His creatinine peaked to\n2.2 on postoperative day two. By discharge, his renal function\nreturned to baseline. He was also noted to have diffuse ST\nelevation on electrocardiogram consistent with pericarditis and\neventually went on to develop atrial flutter. Beta blockade was\nadvanced. K and Mg levels were monitored and repleted per\nprotocol. He otherwise continued to make clinical improvements\nwith diuresis and physical therapy. He developed LUE\nthrombophlebitis on POD#7 and was treated with Vanco and\nevaluated by Vasc. Kaushik. who felt surgical intervention was not\nindicated. His forearm improved and he was discharged to home\non POD#8 in stable condition. He was anticoagulated with\ncoumadin and will have his INR followed by Dr. Sharon.\n\nMedications on Admission:\nAspirin 325 qd, Lisinopril 10 qd, Lovastatin 20 qd, Metformin\n500 qd, Toprol XL 25 qd, Tricor 145 qd, Caltrate 600 Williams-Shaw Medical Center,\nCentrum qd, Glucosamine qd\n\nDischarge Medications:\n1.', ' Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a\nday for 7 days: For left forearm phlebitis.\nDisp:28 Capsule(s) Refills:0\n2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:0\n3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3\nhours) as needed.\nDisp:40 Tablet(s) Refills:0\n4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:0\n5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO\ndaily ().\nDisp:30 Tablet(s) Refills:0\n6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for\n7 days.\nDisp:7 Tablet(s) Refills:0\n7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three\n(3) Tablet Sustained Release 24 hr PO once a day.', '\nDisp:90 Tablet Sustained Release 24 hr(s) Refills:0\n8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:\ntake 400mg daily for one week, then 200mg daily.\nDisp:60 Tablet(s) Refills:0\n9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day:\nPlease take coumadin as directed by Dr. Sharon.\nDisp:30 Tablet(s) Refills:0\n10. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day:\nplease take as directed by Dr. Sharon.\nDisp:60 Tablet(s) Refills:0\n11. Outpatient Lab Work\nPlease draw an INR on saturday 1968-2-3 and fax results to Dr.\nJessie Medrano at (774-964-8282. Phone number (623-370-3179.\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n9557 Atkinson Expressway\nSouth Erin, MD 66588 Regional VNA\n\nDischarge Diagnosis:\nCoronary Artery Disease - s/p CABG\nPostop Atrial Flutter\nHistory of PTCA 1967\nHistory of Myocardial Infarction 1967\nDiabetes Mellitus Type II\nHypertension\nHyperlipidemia\nHistory of Prostate Cancer - s/p Prostatectomy\nArthritis\nGout\n\n\nDischarge Condition:\nStable\n\n\nDischarge Instructions:\nPatient should shower daily, no baths.', ' No creams, lotions or\nointments to incisions. No driving for at least one month. No\nlifting more than 10 lbs for at least 10 weeks from the date of\nsurgery. Monitor wounds for signs of infection. Please call\ncardiac surgeon if start to experience fevers, sternal drainage\nand/or wound erythema.\n\n\nFollowup Instructions:\nDr. Smith in 10-12 weeks, call for appt\nDr. Camargo in 6-5 weeks, call for appt\nDr. Sharon in 6-5 weeks, call for appt\n\n\n\nCompleted by:1973-4-9']
144	66017	135364.0	2150-06-26	Discharge summary	Report	Admission Date: [2150-6-19] Discharge Date: [2150-6-26] Date of Birth: [2099-8-8] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1515] Chief Complaint: s/p Cardiac Arrest Major Surgical or Invasive Procedure: Endotracheal intubation ICD placement History of Present Illness: 50F with hx of coronary vasospasm, HTN that presents from an OSH after having suffered a cardiac arrest in the field, s/p CPR with shock x1. Of note the pt was admitted to the [Hospital1 1516] service at [Hospital1 18] from [Date range (3) 1517] after a month of increasing chest discomfort concerning for coronary ischemia. While hospitalized, she had dynamic ST depressions in V3-V6 during anginal episodes and elevated trop to 0.16. At that time workup included both cardiac cath (X2) and CT of the coronary arteries. Cath suggested isolated bilateral coronary ostial stenosis. CTA was without evidence of atherosclerosis. At the time it was thought the pt suffered from cardiac vasospasm and not CAD. The pt was placed on diltiazem, Imdur, and amlodipine. The pt followed up in cardiology clinic [5-25] and at the time was feeling with only 2 lesss severe episodes of retrosternal chest pressure, [4-12], that occurred spontaneously without exertion, lasting 10 min with complete resolution. The pt had been able to participate in aerobic exercise, 45 minutes and endorsed 40lbs wt loss while on Weight Watchers program. The pt was last seen by her PCP [Last Name (NamePattern4) ] [2150-6-8], Dr. [Last Name (STitle) 1057], at which time she was feeling well. At the time she reported LE edema since initiating amlodipine. This morning the pt was bringing her children to school. Family notes that patient has had increased chest discomfort this week and using nitroglycerin at work. Her daughter notes chest pain this morning which resolved prior to taking her daughter to school. EMS reports that arrived on scene with bystander CPR in progress (approx 7:45). Arrest was confirmed. The pt was shocked once. CPR was continued and on second analysis, no shock was advised. At that time the pt was noted to move, Amiodarone 150mg was loaded and subsequently transferred to an OSH. On arrival to the OSH, (hx obtained by [Hospital 1281] Hospital ED physician [Last Name (NamePattern4) ]. [Last Name (STitle) 1518] via phone), initial vitals 108/55 HR 147, Wt 99.7kg. The pt was intubated (two attempts made). HR ranged from 123 to 151, with SBPs 108/55 to 174/74. 140's to 150's. Exam was notable for pt as unresponsive but was reaching for the tube. She did not respond to commandy prior to being intubated with Succinylcholine 150mg, Versed 4mg, Vecuronium 10mg and put on a propofol gtt. No acute EKG changes. Wbc 20. ck/trop neg. CXR/CT of chest shows large aspiration pneumonia CT Head/CT C-spine unremarkable. The pt was given Ceftiaxone 1gm, Clindamycin 600mg, Azithromycin 500mg. 18G. Small lac to back of head- going to get some staples prior to transfer. Vitals prior to transfer were HR 124 117/57. In the CCU, the patient is intubated. When propofol is weaned patient moves all extremities however does not respond to commands or follow directions. On review of systems, unable to be obtained from patient. Family reports that she was in her usual state of health and went to the beach this past weekend. Besides chest pain episodes noted above no other symptoms were reported by the patient. Family notes patient to be a non reporter. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (-)HTN 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: h/o cholecystitis s/p cholecystectomy Social History: Works in NICU at [Hospital1 18] -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Paternal grandfather with MI at age 50. Father with hypertension. Physical Exam: Admission Labs VS: 122/58 95 100% GENERAL: Intubated, Sedated HEENT: NCAT. Sclera anicteric. PERRL. Laceration on back of head with staples in place. NECK: Supple with JVP at base of neck. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ On discharge: GENERAL: comfortable, NAD HEENT: NCAT. Sclera anicteric. PERRL. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: 2+ pitting edema in BLE SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: On admission: [2150-6-19] 12:51PM BLOOD WBC-25.6# RBC-4.47 Hgb-12.3 Hct-34.9 MCV-78* MCH-27.6 MCHC-35.3* RDW-14.5 Plt Ct-355 [2150-6-20] 05:14AM BLOOD WBC-15.7* RBC-4.16* Hgb-11.5* Hct-31.9* MCV-77* MCH-27.6 MCHC-35.9* RDW-14.7 Plt Ct-218 [2150-6-26] 05:20AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.1* Hct-25.7* MCV-79* MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223 [2150-6-19] 12:51PM BLOOD Glucose-154* UreaN-18 Creat-0.5 Na-141 K-3.5 Cl-110* HCO3-20* AnGap-15 [2150-6-20] 12:45AM BLOOD Glucose-99 UreaN-17 Creat-0.4 Na-139 K-4.9 Cl-111* HCO3-19* AnGap-14 [2150-6-20] 02:00PM BLOOD Glucose-84 UreaN-16 Creat-0.3* Na-140 K-3.5 Cl-112* HCO3-18* AnGap-14 [2150-6-20] 08:30PM BLOOD Glucose-127* UreaN-17 Creat-0.3* Na-143 K-2.8* Cl-113* HCO3-18* AnGap-15 [2150-6-21] 02:08AM BLOOD Glucose-81 UreaN-16 Creat-0.4 Na-140 K-4.5 Cl-112* HCO3-20* AnGap-13 [2150-6-19] 12:51PM BLOOD CK-MB-20* MB Indx-14.8* cTropnT-0.71* [2150-6-19] 06:43PM BLOOD CK-MB-24* cTropnT-0.32* [2150-6-20] 05:14AM BLOOD CK-MB-23* cTropnT-0.18* [2150-6-20] 08:30PM BLOOD CK-MB-18* MB Indx-6.1* cTropnT-0.11* [2150-6-19] 12:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG On discharge: [2150-6-26] 05:20AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.1* Hct-25.7* MCV-79* MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223 [2150-6-26] 05:20AM BLOOD Glucose-97 UreaN-7 Creat-0.4 Na-144 K-3.4 Cl-110* HCO3-24 AnGap-13 [2150-6-23] 03:10AM BLOOD ALT-30 AST-21 AlkPhos-89 TotBili-0.8 [2150-6-26] 05:20AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 [Month/Day/Year ] ([2150-6-19]) Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild to moderate mitral regurgitation with normal valve morphology. Pulmonary artery systolic hypertension. Increased PCWP. Upper Extremity Ultrasound ([2150-6-25]) Nonocclusive thrombus seen within one of the superficial veins, the cephalic vein, in a segment of the left upper arm. There is no evidence of deep vein thrombosis in the left arm. CXR ([2150-6-25]) In comparison with study of [6-22], there has been placement of a pacemaker device with leads in the region of the right atrium and apex of the right ventricle. The degree of pulmonary vascular congestion has substantially improved. Mild blunting of the right costophrenic angle persists. No evidence of acute focal pneumonia or pneumothorax. Right subclavian catheter extends to the lower portion of the SVC. microbiology: RESPIRATORY CULTURE (Final) - [2150-6-19] MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S GRAM STAIN (Final [2150-6-21]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [2150-6-23]): RARE GROWTH Commensal Respiratory Flora. Blood cultures [6-21] and [6-22]: NGTD [6-19] final: NG Urine culture final ([6-19] and [6-21]): NG Brief Hospital Course: 50 year old female with history of coronary vasospasm presents following a cardiac arrest of unclear etiology. # s/p Cardiac Arrest: Witnessed VF arrest in the field with bystander CPR. EMS confirmed pulselessness and AED advised shock. ECG here without concerning ECG changes for ischemia. Given history of vasospasm may be secondary to vasospasm leading to ischemia and subsequent VT/VF arrest. She was placed on arctic cooling to protect cerebral function s/p cardiac arrest. [Month/Year (2) ] showed normal structure and function. EEG showed abnormal temporal lobe epileptiform but otherwise normal. She was started on aspirin, amlodipine, isosorbide mononitrate, and simvastatin. She was noted to have ST elevation in V2-V4 on [2150-6-20] during rewarming phase with subsequent VF arrest s/p 1 round of CPR and shock with ROSC - K returned at 2.7. She was following commands and thus decision was made not to reinitiate cooling protocol. She was started on IV nitro and diltiazem drip which resolved the ST elevation in anteroseptal leads. After extubation and improvement in her mental status, her regimen was transitioned to nifedipine 60 mg po qdaily, imdur 60 mg po qdaily, verapamil ER 360 mg [Hospital1 ]. EP was consulted and felt the presentation could be due to long QT syndrome. She underwent ICD placement on [6-24] - infectious prophylaxis was with Vancomycin. CXR showed no evidence of pneumothorax. . # Neuroprotection s/p arrest: Interval between arrest and initiation of cooling was 5 hours. On presentation with propofol wean patient without purposeful movement. CT head negative from OSH. Artic Sun therapeutic cooling protocol with goal core body temperature 33 degrees x 18 hours. Patient sedated with fentanyl and midazolam and eventually need paralysis with cisatracurium. She was warmed per protocol and was oriented and following commands appropriately within 48 hours. . # CORONARIES: Prior cardiac caths in [Month (only) ] x2 both suggestive of coronary vasospasm without flow limiting lesions. Has been on amlodipine 10mg, dilt 240mg, and imdur 30mg as outpatient. ECG at OSH unchanged from baseline. Regimen was changed to above (see #1). # PUMP: No prior [Month (only) ] or LV gram in [Hospital1 18] system. Pt with hx of HTN that was potentially thought to be white coat but unclear. [Name2 (NI) ] showed normal function. # RHYTHM: No prior hx of arrhythmias however likely VF/VT arrest on presentation and subsequent episode of VF in ICU. Thought to be [2-4] coronary vasospasm. Long QT syndrome was also considered and genetic testing will be pursued by EP and discussed and followed up. # Pulmonary Infiltrates: Pt with evidence of diffuse infiltrates on OSH CXR and CT. Right upper load with air bronchograms concerning for pneumonia, however bilateral pathcy infiltrates concerning for early ARDS. Was placed on CTX/Clindamycin/Azithromycin at OSH for suspected CAP/Aspiration. Transitioned to IV unasyn and then IV nafcillin. Nafcillin was changed to Augmentin on [6-24] and again to Bactrim on [6-25]. Patient discharged wtih 7 day course of Bactrim [Hospital1 ]. # Cloudy Urine: Urine appears "dirty" when foley catheter placed. Continued on IV unasyn. Urine cultures were negative. No further antibiotic coverage needed and patient remained asymptomatic. #dizziness: Pt complained of dizziness consistent with vertigo. Pt received meclizine with improvement in her symptoms. No evidence of orthostasis. Pt was ambulating without difficulty prior to discharge. Pt will follow up with PCP regarding these symptoms. #hypokalemia: Mild evidence of hypokalemia requiring po potassium supplementation. Pt was discharged with oral potassium supplementation and spironolactone were started to help maintain a normal postassium level. Pt planned follow potassium level 2 days after discharge. #lower extremity edema: [Location (un) ] likely secondary to calcium channel blocker use stable from admission. She was kept on subQ heparin for DVT prophylaxis. She remained full code. Communication was with her husband. Medications on Admission: Aspirin 81mg daily (7am [2150-6-19]) Zocor 40mg daily (7am [2150-6-19]) Norvasc 10mg daily (7am [2150-6-19]) Diltiazem HCL 240mg daily (7am [2150-6-19]) Isosorbide mononitrate 30mg daily (7am [2150-6-19]) NTG Discharge Medications: 1. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO at bedtime. Disp:30 Tablet Extended Release(s) Refills:2 2. isosorbide mononitrate 60 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 3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for ICD pain. 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. verapamil 360 mg Cap,Ext Release Pellets 24 hr Sig: One (1) Cap,Ext Release Pellets 24 hr PO twice a day. Disp:60 Cap,Ext Release Pellets 24 hr(s) Refills:2 7. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for dizziness. Disp:30 Tablet(s) Refills:0 8. Outpatient Lab Work Please check Chem-7 and CBC on Monday [6-29] with results to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 62] 9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. Disp:30 Tablet, ER Particles/Crystals(s) Refills:2 10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Vasospasm Ventricular fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had more spasm in your coronary arteries and had a ventricular fibrillation arrest. You were brought to [Hospital 1281] hospital initially and then transferred to [Hospital1 18] for care. You underwent an arctic sun cooling protocol and have recovered well from the episode. There may be some correlation with a prolonged QT and hypokalemia as well. Your telemetry shows only short runs of VT (3-4 beats) that are rare. You had an ICD placed that will shock you out of any prolonged runs of VT. Please call the EP fellow on call if this happens. You had a staph pneumonia that is being treated with antibiotics. . We made the following changes in your medicines: 1. STOP taking aspirin, norvasc, diltiazem and zocor. 2. START taking Verapamil to prevent coronary vasospasm 3. START taking Nifedipine to prevent coronary vasospasm, please take this at night 4. Increase the Imdur to 60 mg daily 5. Start taking spironolactone to increase your potassium 6. STart taking potassium supplements to keep your potassium up 7. Take meclizine as needed to prevent dizziness. 8. Take Bactrim twice daily for one week to treat the pneumonia 9. Take acetaminophen as needed for ICD pain. Followup Instructions: Department: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] When: WEDNESDAY [2150-7-1] at 9:30 AM With: Dr [First Name4 (NamePattern1) 1060] [Last Name (NamePattern1) 1520] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] South [Hospital ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage NOTE: A) Please discuss at this appt if you need to come in for your previously scheduled appt for next week [7-9]. B) This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [Name10 (NameIs) 616] this visit, you will see your regular primary care doctor in follow up. Department: [Hospital3 249] When: THURSDAY [2150-7-9] at 11:00 AM With: [First Name11 (Name Pattern1) 1521] [Last Name (NamePattern1) 1522], NP [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2150-7-27] at 3:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], 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: CARDIAC SERVICES When: TUESDAY [2150-8-4] at 1:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: WEDNESDAY [2150-7-1] at 9:00 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2150-6-26]	Admission Date: <Date>1970-12-3</Date> Discharge Date: <Date>1901-5-16</Date> Date of Birth: <Date>1936-7-27</Date> Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Millicent</Name> Chief Complaint: s/p Cardiac Arrest Major Surgical or Invasive Procedure: Endotracheal intubation ICD placement History of Present Illness: 50F with hx of coronary vasospasm, HTN that presents from an OSH after having suffered a cardiac arrest in the field, s/p CPR with shock x1. Of note the pt was admitted to the <Hospital>Thomas-Holmes Hospital</Hospital> service at <Hospital>Ball-Horton Health System</Hospital> from <Date Range>1953-11-25 to 2006-1-6</Date Range> after a month of increasing chest discomfort concerning for coronary ischemia. While hospitalized, she had dynamic ST depressions in V3-V6 during anginal episodes and elevated trop to 0.16. At that time workup included both cardiac cath (X2) and CT of the coronary arteries. Cath suggested isolated bilateral coronary ostial stenosis. CTA was without evidence of atherosclerosis. At the time it was thought the pt suffered from cardiac vasospasm and not CAD. The pt was placed on diltiazem, Imdur, and amlodipine. The pt followed up in cardiology clinic <Date>10-20</Date> and at the time was feeling with only 2 lesss severe episodes of retrosternal chest pressure, <Date>2-3</Date>, that occurred spontaneously without exertion, lasting 10 min with complete resolution. The pt had been able to participate in aerobic exercise, 45 minutes and endorsed 40lbs wt loss while on Weight Watchers program. The pt was last seen by her PCP <Name>Son</Name> <Date>2014-9-22</Date>, Dr. <Name>Lenling</Name>, at which time she was feeling well. At the time she reported LE edema since initiating amlodipine. This morning the pt was bringing her children to school. Family notes that patient has had increased chest discomfort this week and using nitroglycerin at work. Her daughter notes chest pain this morning which resolved prior to taking her daughter to school. EMS reports that arrived on scene with bystander CPR in progress (approx 7:45). Arrest was confirmed. The pt was shocked once. CPR was continued and on second analysis, no shock was advised. At that time the pt was noted to move, Amiodarone 150mg was loaded and subsequently transferred to an OSH. On arrival to the OSH, (hx obtained by <Hospital>Gray-Williams Medical Center</Hospital> Hospital ED physician <Name>Son</Name>. <Name>Benavidez</Name> via phone), initial vitals 108/55 HR 147, Wt 99.7kg. The pt was intubated (two attempts made). HR ranged from 123 to 151, with SBPs 108/55 to 174/74. 140's to 150's. Exam was notable for pt as unresponsive but was reaching for the tube. She did not respond to commandy prior to being intubated with Succinylcholine 150mg, Versed 4mg, Vecuronium 10mg and put on a propofol gtt. No acute EKG changes. Wbc 20. ck/trop neg. CXR/CT of chest shows large aspiration pneumonia CT Head/CT C-spine unremarkable. The pt was given Ceftiaxone 1gm, Clindamycin 600mg, Azithromycin 500mg. 18G. Small lac to back of head- going to get some staples prior to transfer. Vitals prior to transfer were HR 124 117/57. In the CCU, the patient is intubated. When propofol is weaned patient moves all extremities however does not respond to commands or follow directions. On review of systems, unable to be obtained from patient. Family reports that she was in her usual state of health and went to the beach this past weekend. Besides chest pain episodes noted above no other symptoms were reported by the patient. Family notes patient to be a non reporter. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (-)HTN 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: h/o cholecystitis s/p cholecystectomy Social History: Works in NICU at <Hospital>Ball-Horton Health System</Hospital> -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Paternal grandfather with MI at age 50. Father with hypertension. Physical Exam: Admission Labs VS: 122/58 95 100% GENERAL: Intubated, Sedated HEENT: NCAT. Sclera anicteric. PERRL. Laceration on back of head with staples in place. NECK: Supple with JVP at base of neck. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ On discharge: GENERAL: comfortable, NAD HEENT: NCAT. Sclera anicteric. PERRL. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: 2+ pitting edema in BLE SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: On admission: <Date>1970-12-3</Date> 12:51PM BLOOD WBC-25.6# RBC-4.47 Hgb-12.3 Hct-34.9 MCV-78* MCH-27.6 MCHC-35.3* RDW-14.5 Plt Ct-355 <Date>2015-12-19</Date> 05:14AM BLOOD WBC-15.7* RBC-4.16* Hgb-11.5* Hct-31.9* MCV-77* MCH-27.6 MCHC-35.9* RDW-14.7 Plt Ct-218 <Date>1901-5-16</Date> 05:20AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.1* Hct-25.7* MCV-79* MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223 <Date>1970-12-3</Date> 12:51PM BLOOD Glucose-154* UreaN-18 Creat-0.5 Na-141 K-3.5 Cl-110* HCO3-20* AnGap-15 <Date>2015-12-19</Date> 12:45AM BLOOD Glucose-99 UreaN-17 Creat-0.4 Na-139 K-4.9 Cl-111* HCO3-19* AnGap-14 <Date>2015-12-19</Date> 02:00PM BLOOD Glucose-84 UreaN-16 Creat-0.3* Na-140 K-3.5 Cl-112* HCO3-18* AnGap-14 <Date>2015-12-19</Date> 08:30PM BLOOD Glucose-127* UreaN-17 Creat-0.3* Na-143 K-2.8* Cl-113* HCO3-18* AnGap-15 <Date>1981-5-26</Date> 02:08AM BLOOD Glucose-81 UreaN-16 Creat-0.4 Na-140 K-4.5 Cl-112* HCO3-20* AnGap-13 <Date>1970-12-3</Date> 12:51PM BLOOD CK-MB-20* MB Indx-14.8* cTropnT-0.71* <Date>1970-12-3</Date> 06:43PM BLOOD CK-MB-24* cTropnT-0.32* <Date>2015-12-19</Date> 05:14AM BLOOD CK-MB-23* cTropnT-0.18* <Date>2015-12-19</Date> 08:30PM BLOOD CK-MB-18* MB Indx-6.1* cTropnT-0.11* <Date>1970-12-3</Date> 12:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG On discharge: <Date>1901-5-16</Date> 05:20AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.1* Hct-25.7* MCV-79* MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223 <Date>1901-5-16</Date> 05:20AM BLOOD Glucose-97 UreaN-7 Creat-0.4 Na-144 K-3.4 Cl-110* HCO3-24 AnGap-13 <Date>1969-8-10</Date> 03:10AM BLOOD ALT-30 AST-21 AlkPhos-89 TotBili-0.8 <Date>1901-5-16</Date> 05:20AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 <Month>September</Month> (<Date>1970-12-3</Date>) Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild to moderate mitral regurgitation with normal valve morphology. Pulmonary artery systolic hypertension. Increased PCWP. Upper Extremity Ultrasound (<Date>1940-12-12</Date>) Nonocclusive thrombus seen within one of the superficial veins, the cephalic vein, in a segment of the left upper arm. There is no evidence of deep vein thrombosis in the left arm. CXR (<Date>1940-12-12</Date>) In comparison with study of <Date>8-31</Date>, there has been placement of a pacemaker device with leads in the region of the right atrium and apex of the right ventricle. The degree of pulmonary vascular congestion has substantially improved. Mild blunting of the right costophrenic angle persists. No evidence of acute focal pneumonia or pneumothorax. Right subclavian catheter extends to the lower portion of the SVC. microbiology: RESPIRATORY CULTURE (Final) - <Date>1970-12-3</Date> MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S GRAM STAIN (Final <Date>1981-5-26</Date>): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final <Date>1969-8-10</Date>): RARE GROWTH Commensal Respiratory Flora. Blood cultures <Date>1-22</Date> and <Date>8-31</Date>: NGTD <Date>5-15</Date> final: NG Urine culture final (<Date>5-15</Date> and <Date>1-22</Date>): NG Brief Hospital Course: 50 year old female with history of coronary vasospasm presents following a cardiac arrest of unclear etiology. # s/p Cardiac Arrest: Witnessed VF arrest in the field with bystander CPR. EMS confirmed pulselessness and AED advised shock. ECG here without concerning ECG changes for ischemia. Given history of vasospasm may be secondary to vasospasm leading to ischemia and subsequent VT/VF arrest. She was placed on arctic cooling to protect cerebral function s/p cardiac arrest. <Month>May</Month> showed normal structure and function. EEG showed abnormal temporal lobe epileptiform but otherwise normal. She was started on aspirin, amlodipine, isosorbide mononitrate, and simvastatin. She was noted to have ST elevation in V2-V4 on <Date>2015-12-19</Date> during rewarming phase with subsequent VF arrest s/p 1 round of CPR and shock with ROSC - K returned at 2.7. She was following commands and thus decision was made not to reinitiate cooling protocol. She was started on IV nitro and diltiazem drip which resolved the ST elevation in anteroseptal leads. After extubation and improvement in her mental status, her regimen was transitioned to nifedipine 60 mg po qdaily, imdur 60 mg po qdaily, verapamil ER 360 mg <Hospital>Phillips-Schwartz Hospital</Hospital>. EP was consulted and felt the presentation could be due to long QT syndrome. She underwent ICD placement on <Date>6-6</Date> - infectious prophylaxis was with Vancomycin. CXR showed no evidence of pneumothorax. . # Neuroprotection s/p arrest: Interval between arrest and initiation of cooling was 5 hours. On presentation with propofol wean patient without purposeful movement. CT head negative from OSH. Artic Sun therapeutic cooling protocol with goal core body temperature 33 degrees x 18 hours. Patient sedated with fentanyl and midazolam and eventually need paralysis with cisatracurium. She was warmed per protocol and was oriented and following commands appropriately within 48 hours. . # CORONARIES: Prior cardiac caths in <Month>November</Month> x2 both suggestive of coronary vasospasm without flow limiting lesions. Has been on amlodipine 10mg, dilt 240mg, and imdur 30mg as outpatient. ECG at OSH unchanged from baseline. Regimen was changed to above (see #1). # PUMP: No prior <Month>November</Month> or LV gram in <Hospital>Ball-Horton Health System</Hospital> system. Pt with hx of HTN that was potentially thought to be white coat but unclear. <Name>Chloe Benavidez</Name> showed normal function. # RHYTHM: No prior hx of arrhythmias however likely VF/VT arrest on presentation and subsequent episode of VF in ICU. Thought to be <Date>7-6</Date> coronary vasospasm. Long QT syndrome was also considered and genetic testing will be pursued by EP and discussed and followed up. # Pulmonary Infiltrates: Pt with evidence of diffuse infiltrates on OSH CXR and CT. Right upper load with air bronchograms concerning for pneumonia, however bilateral pathcy infiltrates concerning for early ARDS. Was placed on CTX/Clindamycin/Azithromycin at OSH for suspected CAP/Aspiration. Transitioned to IV unasyn and then IV nafcillin. Nafcillin was changed to Augmentin on <Date>6-6</Date> and again to Bactrim on <Date>5-28</Date>. Patient discharged wtih 7 day course of Bactrim <Hospital>Phillips-Schwartz Hospital</Hospital>. # Cloudy Urine: Urine appears "dirty" when foley catheter placed. Continued on IV unasyn. Urine cultures were negative. No further antibiotic coverage needed and patient remained asymptomatic. #dizziness: Pt complained of dizziness consistent with vertigo. Pt received meclizine with improvement in her symptoms. No evidence of orthostasis. Pt was ambulating without difficulty prior to discharge. Pt will follow up with PCP regarding these symptoms. #hypokalemia: Mild evidence of hypokalemia requiring po potassium supplementation. Pt was discharged with oral potassium supplementation and spironolactone were started to help maintain a normal postassium level. Pt planned follow potassium level 2 days after discharge. #lower extremity edema: <Location>47478 Payne Meadows East Michaeltown, DC 55812</Location> likely secondary to calcium channel blocker use stable from admission. She was kept on subQ heparin for DVT prophylaxis. She remained full code. Communication was with her husband. Medications on Admission: Aspirin 81mg daily (7am <Date>1970-12-3</Date>) Zocor 40mg daily (7am <Date>1970-12-3</Date>) Norvasc 10mg daily (7am <Date>1970-12-3</Date>) Diltiazem HCL 240mg daily (7am <Date>1970-12-3</Date>) Isosorbide mononitrate 30mg daily (7am <Date>1970-12-3</Date>) NTG Discharge Medications: 1. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO at bedtime. Disp:30 Tablet Extended Release(s) Refills:2 2. isosorbide mononitrate 60 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 3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for ICD pain. 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. verapamil 360 mg Cap,Ext Release Pellets 24 hr Sig: One (1) Cap,Ext Release Pellets 24 hr PO twice a day. Disp:60 Cap,Ext Release Pellets 24 hr(s) Refills:2 7. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for dizziness. Disp:30 Tablet(s) Refills:0 8. Outpatient Lab Work Please check Chem-7 and CBC on Monday <Date>2-20</Date> with results to Dr. <Name>Feguson</Name> at <Telephone>678-531-5078</Telephone> 9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. Disp:30 Tablet, ER Particles/Crystals(s) Refills:2 10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Discharge Disposition: Home With Service Facility: <Company>Combs Group</Company> Discharge Diagnosis: Coronary Vasospasm Ventricular fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had more spasm in your coronary arteries and had a ventricular fibrillation arrest. You were brought to <Hospital>Gray-Williams Medical Center</Hospital> hospital initially and then transferred to <Hospital>Ball-Horton Health System</Hospital> for care. You underwent an arctic sun cooling protocol and have recovered well from the episode. There may be some correlation with a prolonged QT and hypokalemia as well. Your telemetry shows only short runs of VT (3-4 beats) that are rare. You had an ICD placed that will shock you out of any prolonged runs of VT. Please call the EP fellow on call if this happens. You had a staph pneumonia that is being treated with antibiotics. . We made the following changes in your medicines: 1. STOP taking aspirin, norvasc, diltiazem and zocor. 2. START taking Verapamil to prevent coronary vasospasm 3. START taking Nifedipine to prevent coronary vasospasm, please take this at night 4. Increase the Imdur to 60 mg daily 5. Start taking spironolactone to increase your potassium 6. STart taking potassium supplements to keep your potassium up 7. Take meclizine as needed to prevent dizziness. 8. Take Bactrim twice daily for one week to treat the pneumonia 9. Take acetaminophen as needed for ICD pain. Followup Instructions: Department: <Company>Copeland Inc</Company> POST <Hospital>Mayer, Thompson and Green Clinic</Hospital> CLINIC <Telephone>759-484-8813</Telephone> When: WEDNESDAY <Date>1959-11-14</Date> at 9:30 AM With: Dr <Name>Angus</Name> <Name>Heflin</Name> Building: SC <Hospital>Reed PLC Health System</Hospital> Clinical Ctr <Location>59522 Gary Avenue Suite 542 Port Reginaburgh, IL 67601</Location> South <Hospital>Mendoza Group Medical Center</Hospital> Campus: EAST Best Parking: <Hospital>Reed PLC Health System</Hospital> Garage NOTE: A) Please discuss at this appt if you need to come in for your previously scheduled appt for next week <Date>1-21</Date>. B) This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. <Name>Retha Cobbs</Name> this visit, you will see your regular primary care doctor in follow up. Department: <Hospital>Mitchell Group Health System</Hospital> When: THURSDAY <Date>1902-2-31</Date> at 11:00 AM With: <Name>Lisa</Name> <Name>Pichardo</Name>, NP <Telephone>759-484-8813</Telephone> Building: SC <Hospital>Reed PLC Health System</Hospital> Clinical Ctr <Location>59522 Gary Avenue Suite 542 Port Reginaburgh, IL 67601</Location> Campus: EAST Best Parking: <Hospital>Reed PLC Health System</Hospital> Garage Department: CARDIAC SERVICES When: MONDAY <Date>1974-9-9</Date> at 3:40 PM With: <Name>Tammy</Name> <Name>Scheet</Name>, MD <Telephone>678-531-5078</Telephone> Building: SC <Hospital>Reed PLC Health System</Hospital> Clinical Ctr <Location>47478 Payne Meadows East Michaeltown, DC 55812</Location> Campus: EAST Best Parking: <Hospital>Reed PLC Health System</Hospital> Garage Department: CARDIAC SERVICES When: TUESDAY <Date>1914-8-6</Date> at 1:40 PM With: <Name>Tammy</Name> <Name>Yuen</Name>, M.D. <Telephone>678-531-5078</Telephone> Building: SC <Hospital>Reed PLC Health System</Hospital> Clinical Ctr <Location>47478 Payne Meadows East Michaeltown, DC 55812</Location> Campus: EAST Best Parking: <Hospital>Reed PLC Health System</Hospital> Garage Department: CARDIAC SERVICES When: WEDNESDAY <Date>1959-11-14</Date> at 9:00 AM With: DEVICE CLINIC <Telephone>678-531-5078</Telephone> Building: SC <Hospital>Reed PLC Health System</Hospital> Clinical Ctr <Location>47478 Payne Meadows East Michaeltown, DC 55812</Location> Campus: EAST Best Parking: <Hospital>Reed PLC Health System</Hospital> Garage Completed 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Date: 1970-12-3 Discharge Date: 1901-5-16 Date of Birth: 1936-7-27 Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Millicent Chief Complaint: s/p Cardiac Arrest Major Surgical or Invasive Procedure: Endotracheal intubation ICD placement History of Present Illness: 50F with hx of coronary vasospasm, HTN that presents from an OSH after having suffered a cardiac arrest in the field, s/p CPR with shock x1. Of note the pt was admitted to the Thomas-Holmes Hospital service at Ball-Horton Health System from 1953-11-25 to 2006-1-6 after a month of increasing chest discomfort concerning for coronary ischemia. While hospitalized, she had dynamic ST depressions in V3-V6 during anginal episodes and elevated trop to 0.16. At that time workup included both cardiac cath (X2) and CT of the coronary arteries. Cath suggested isolated bilateral coronary ostial stenosis. CTA was without evidence of atherosclerosis. At the time it was thought the pt suffered from cardiac vasospasm and not CAD. The pt was placed on diltiazem, Imdur, and amlodipine. The pt followed up in cardiology clinic 10-20 and at the time was feeling with only 2 lesss severe episodes of retrosternal chest pressure, 2-3, that occurred spontaneously without exertion, lasting 10 min with complete resolution. The pt had been able to participate in aerobic exercise, 45 minutes and endorsed 40lbs wt loss while on Weight Watchers program. The pt was last seen by her PCP Son 2014-9-22, Dr. Lenling, at which time she was feeling well. At the time she reported LE edema since initiating amlodipine. This morning the pt was bringing her children to school. Family notes that patient has had increased chest discomfort this week and using nitroglycerin at work. Her daughter notes chest pain this morning which resolved prior to taking her daughter to school. EMS reports that arrived on scene with bystander CPR in progress (approx 7:45). Arrest was confirmed. The pt was shocked once. CPR was continued and on second analysis, no shock was advised. At that time the pt was noted to move, Amiodarone 150mg was loaded and subsequently transferred to an OSH. On arrival to the OSH, (hx obtained by Gray-Williams Medical Center Hospital ED physician Son. Benavidez via phone), initial vitals 108/55 HR 147, Wt 99.7kg. The pt was intubated (two attempts made). HR ranged from 123 to 151, with SBPs 108/55 to 174/74. 140's to 150's. Exam was notable for pt as unresponsive but was reaching for the tube. She did not respond to commandy prior to being intubated with Succinylcholine 150mg, Versed 4mg, Vecuronium 10mg and put on a propofol gtt. No acute EKG changes. Wbc 20. ck/trop neg. CXR/CT of chest shows large aspiration pneumonia CT Head/CT C-spine unremarkable. The pt was given Ceftiaxone 1gm, Clindamycin 600mg, Azithromycin 500mg. 18G. Small lac to back of head- going to get some staples prior to transfer. Vitals prior to transfer were HR 124 117/57. In the CCU, the patient is intubated. When propofol is weaned patient moves all extremities however does not respond to commands or follow directions. On review of systems, unable to be obtained from patient. Family reports that she was in her usual state of health and went to the beach this past weekend. Besides chest pain episodes noted above no other symptoms were reported by the patient. Family notes patient to be a non reporter. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (-)HTN 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: h/o cholecystitis s/p cholecystectomy Social History: Works in NICU at Ball-Horton Health System -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Paternal grandfather with MI at age 50. Father with hypertension. Physical Exam: Admission Labs VS: 122/58 95 100% GENERAL: Intubated, Sedated HEENT: NCAT. Sclera anicteric. PERRL. Laceration on back of head with staples in place. NECK: Supple with JVP at base of neck. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ On discharge: GENERAL: comfortable, NAD HEENT: NCAT. Sclera anicteric. PERRL. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: 2+ pitting edema in BLE SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: On admission: 1970-12-3 12:51PM BLOOD WBC-25.6# RBC-4.47 Hgb-12.3 Hct-34.9 MCV-78* MCH-27.6 MCHC-35.3* RDW-14.5 Plt Ct-355 2015-12-19 05:14AM BLOOD WBC-15.7* RBC-4.16* Hgb-11.5* Hct-31.9* MCV-77* MCH-27.6 MCHC-35.9* RDW-14.7 Plt Ct-218 1901-5-16 05:20AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.1* Hct-25.7* MCV-79* MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223 1970-12-3 12:51PM BLOOD Glucose-154* UreaN-18 Creat-0.5 Na-141 K-3.5 Cl-110* HCO3-20* AnGap-15 2015-12-19 12:45AM BLOOD Glucose-99 UreaN-17 Creat-0.4 Na-139 K-4.9 Cl-111* HCO3-19* AnGap-14 2015-12-19 02:00PM BLOOD Glucose-84 UreaN-16 Creat-0.3* Na-140 K-3.5 Cl-112* HCO3-18* AnGap-14 2015-12-19 08:30PM BLOOD Glucose-127* UreaN-17 Creat-0.3* Na-143 K-2.8* Cl-113* HCO3-18* AnGap-15 1981-5-26 02:08AM BLOOD Glucose-81 UreaN-16 Creat-0.4 Na-140 K-4.5 Cl-112* HCO3-20* AnGap-13 1970-12-3 12:51PM BLOOD CK-MB-20* MB Indx-14.8* cTropnT-0.71* 1970-12-3 06:43PM BLOOD CK-MB-24* cTropnT-0.32* 2015-12-19 05:14AM BLOOD CK-MB-23* cTropnT-0.18* 2015-12-19 08:30PM BLOOD CK-MB-18* MB Indx-6.1* cTropnT-0.11* 1970-12-3 12:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG On discharge: 1901-5-16 05:20AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.1* Hct-25.7* MCV-79* MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223 1901-5-16 05:20AM BLOOD Glucose-97 UreaN-7 Creat-0.4 Na-144 K-3.4 Cl-110* HCO3-24 AnGap-13 1969-8-10 03:10AM BLOOD ALT-30 AST-21 AlkPhos-89 TotBili-0.8 1901-5-16 05:20AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 September (1970-12-3) Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild to moderate mitral regurgitation with normal valve morphology. Pulmonary artery systolic hypertension. Increased PCWP. Upper Extremity Ultrasound (1940-12-12) Nonocclusive thrombus seen within one of the superficial veins, the cephalic vein, in a segment of the left upper arm. There is no evidence of deep vein thrombosis in the left arm. CXR (1940-12-12) In comparison with study of 8-31, there has been placement of a pacemaker device with leads in the region of the right atrium and apex of the right ventricle. The degree of pulmonary vascular congestion has substantially improved. Mild blunting of the right costophrenic angle persists. No evidence of acute focal pneumonia or pneumothorax. Right subclavian catheter extends to the lower portion of the SVC. microbiology: RESPIRATORY CULTURE (Final) - 1970-12-3 MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 1981-5-26): >25 PMNs and 1969-8-10): RARE GROWTH Commensal Respiratory Flora. Blood cultures 1-22 and 8-31: NGTD 5-15 final: NG Urine culture final (5-15 and 1-22): NG Brief Hospital Course: 50 year old female with history of coronary vasospasm presents following a cardiac arrest of unclear etiology. # s/p Cardiac Arrest: Witnessed VF arrest in the field with bystander CPR. EMS confirmed pulselessness and AED advised shock. ECG here without concerning ECG changes for ischemia. Given history of vasospasm may be secondary to vasospasm leading to ischemia and subsequent VT/VF arrest. She was placed on arctic cooling to protect cerebral function s/p cardiac arrest. May showed normal structure and function. EEG showed abnormal temporal lobe epileptiform but otherwise normal. She was started on aspirin, amlodipine, isosorbide mononitrate, and simvastatin. She was noted to have ST elevation in V2-V4 on 2015-12-19 during rewarming phase with subsequent VF arrest s/p 1 round of CPR and shock with ROSC - K returned at 2.7. She was following commands and thus decision was made not to reinitiate cooling protocol. She was started on IV nitro and diltiazem drip which resolved the ST elevation in anteroseptal leads. After extubation and improvement in her mental status, her regimen was transitioned to nifedipine 60 mg po qdaily, imdur 60 mg po qdaily, verapamil ER 360 mg Phillips-Schwartz Hospital. EP was consulted and felt the presentation could be due to long QT syndrome. She underwent ICD placement on 6-6 - infectious prophylaxis was with Vancomycin. CXR showed no evidence of pneumothorax. . # Neuroprotection s/p arrest: Interval between arrest and initiation of cooling was 5 hours. On presentation with propofol wean patient without purposeful movement. CT head negative from OSH. Artic Sun therapeutic cooling protocol with goal core body temperature 33 degrees x 18 hours. Patient sedated with fentanyl and midazolam and eventually need paralysis with cisatracurium. She was warmed per protocol and was oriented and following commands appropriately within 48 hours. . # CORONARIES: Prior cardiac caths in November x2 both suggestive of coronary vasospasm without flow limiting lesions. Has been on amlodipine 10mg, dilt 240mg, and imdur 30mg as outpatient. ECG at OSH unchanged from baseline. Regimen was changed to above (see #1). # PUMP: No prior November or LV gram in Ball-Horton Health System system. Pt with hx of HTN that was potentially thought to be white coat but unclear. Chloe Benavidez showed normal function. # RHYTHM: No prior hx of arrhythmias however likely VF/VT arrest on presentation and subsequent episode of VF in ICU. Thought to be 7-6 coronary vasospasm. Long QT syndrome was also considered and genetic testing will be pursued by EP and discussed and followed up. # Pulmonary Infiltrates: Pt with evidence of diffuse infiltrates on OSH CXR and CT. Right upper load with air bronchograms concerning for pneumonia, however bilateral pathcy infiltrates concerning for early ARDS. Was placed on CTX/Clindamycin/Azithromycin at OSH for suspected CAP/Aspiration. Transitioned to IV unasyn and then IV nafcillin. Nafcillin was changed to Augmentin on 6-6 and again to Bactrim on 5-28. Patient discharged wtih 7 day course of Bactrim Phillips-Schwartz Hospital. # Cloudy Urine: Urine appears "dirty" when foley catheter placed. Continued on IV unasyn. Urine cultures were negative. No further antibiotic coverage needed and patient remained asymptomatic. #dizziness: Pt complained of dizziness consistent with vertigo. Pt received meclizine with improvement in her symptoms. No evidence of orthostasis. Pt was ambulating without difficulty prior to discharge. Pt will follow up with PCP regarding these symptoms. #hypokalemia: Mild evidence of hypokalemia requiring po potassium supplementation. Pt was discharged with oral potassium supplementation and spironolactone were started to help maintain a normal postassium level. Pt planned follow potassium level 2 days after discharge. #lower extremity edema: 47478 Payne Meadows East Michaeltown, DC 55812 likely secondary to calcium channel blocker use stable from admission. She was kept on subQ heparin for DVT prophylaxis. She remained full code. Communication was with her husband. Medications on Admission: Aspirin 81mg daily (7am 1970-12-3) Zocor 40mg daily (7am 1970-12-3) Norvasc 10mg daily (7am 1970-12-3) Diltiazem HCL 240mg daily (7am 1970-12-3) Isosorbide mononitrate 30mg daily (7am 1970-12-3) NTG Discharge Medications: 1. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO at bedtime. Disp:30 Tablet Extended Release(s) Refills:2 2. isosorbide mononitrate 60 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 3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for ICD pain. 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. verapamil 360 mg Cap,Ext Release Pellets 24 hr Sig: One (1) Cap,Ext Release Pellets 24 hr PO twice a day. Disp:60 Cap,Ext Release Pellets 24 hr(s) Refills:2 7. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for dizziness. Disp:30 Tablet(s) Refills:0 8. Outpatient Lab Work Please check Chem-7 and CBC on Monday 2-20 with results to Dr. Feguson at 678-531-5078 9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. Disp:30 Tablet, ER Particles/Crystals(s) Refills:2 10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Discharge Disposition: Home With Service Facility: Combs Group Discharge Diagnosis: Coronary Vasospasm Ventricular fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had more spasm in your coronary arteries and had a ventricular fibrillation arrest. You were brought to Gray-Williams Medical Center hospital initially and then transferred to Ball-Horton Health System for care. You underwent an arctic sun cooling protocol and have recovered well from the episode. There may be some correlation with a prolonged QT and hypokalemia as well. Your telemetry shows only short runs of VT (3-4 beats) that are rare. You had an ICD placed that will shock you out of any prolonged runs of VT. Please call the EP fellow on call if this happens. You had a staph pneumonia that is being treated with antibiotics. . We made the following changes in your medicines: 1. STOP taking aspirin, norvasc, diltiazem and zocor. 2. START taking Verapamil to prevent coronary vasospasm 3. START taking Nifedipine to prevent coronary vasospasm, please take this at night 4. Increase the Imdur to 60 mg daily 5. Start taking spironolactone to increase your potassium 6. STart taking potassium supplements to keep your potassium up 7. Take meclizine as needed to prevent dizziness. 8. Take Bactrim twice daily for one week to treat the pneumonia 9. Take acetaminophen as needed for ICD pain. Followup Instructions: Department: Copeland Inc POST Mayer, Thompson and Green Clinic CLINIC 759-484-8813 When: WEDNESDAY 1959-11-14 at 9:30 AM With: Dr Angus Heflin Building: SC Reed PLC Health System Clinical Ctr 59522 Gary Avenue Suite 542 Port Reginaburgh, IL 67601 South Mendoza Group Medical Center Campus: EAST Best Parking: Reed PLC Health System Garage NOTE: A) Please discuss at this appt if you need to come in for your previously scheduled appt for next week 1-21. B) This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. Retha Cobbs this visit, you will see your regular primary care doctor in follow up. Department: Mitchell Group Health System When: THURSDAY 1902-2-31 at 11:00 AM With: Lisa Pichardo, NP 759-484-8813 Building: SC Reed PLC Health System Clinical Ctr 59522 Gary Avenue Suite 542 Port Reginaburgh, IL 67601 Campus: EAST Best Parking: Reed PLC Health System Garage Department: CARDIAC SERVICES When: MONDAY 1974-9-9 at 3:40 PM With: Tammy Scheet, MD 678-531-5078 Building: SC Reed PLC Health System Clinical Ctr 47478 Payne Meadows East Michaeltown, DC 55812 Campus: EAST Best Parking: Reed PLC Health System Garage Department: CARDIAC SERVICES When: TUESDAY 1914-8-6 at 1:40 PM With: Tammy Yuen, M.D. 678-531-5078 Building: SC Reed PLC Health System Clinical Ctr 47478 Payne Meadows East Michaeltown, DC 55812 Campus: EAST Best Parking: Reed PLC Health System Garage Department: CARDIAC SERVICES When: WEDNESDAY 1959-11-14 at 9:00 AM With: DEVICE CLINIC 678-531-5078 Building: SC Reed PLC Health System Clinical Ctr 47478 Payne Meadows East Michaeltown, DC 55812 Campus: EAST Best Parking: Reed PLC Health System Garage Completed by:1901-5-16	['Admission Date: 1970-12-3 Discharge Date: 1901-5-16\n\nDate of Birth: 1936-7-27 Sex: F\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Millicent\nChief Complaint:\ns/p Cardiac Arrest\n\nMajor Surgical or Invasive Procedure:\nEndotracheal intubation\nICD placement\n\n\nHistory of Present Illness:\n50F with hx of coronary vasospasm, HTN that presents from an OSH\nafter having suffered a cardiac arrest in the field, s/p CPR\nwith shock x1.\n\nOf note the pt was admitted to the Thomas-Holmes Hospital service at Ball-Horton Health System from\n1953-11-25 to 2006-1-6 after a month of increasing chest discomfort\nconcerning for coronary ischemia. While hospitalized, she had\ndynamic ST depressions in V3-V6 during anginal episodes and\nelevated trop to 0.', '16. At that time workup included both cardiac\ncath (X2) and CT of the coronary arteries. Cath suggested\nisolated bilateral coronary ostial stenosis. CTA was without\nevidence of atherosclerosis. At the time it was thought the pt\nsuffered from cardiac vasospasm and not CAD. The pt was placed\non diltiazem, Imdur, and amlodipine. The pt followed up in\ncardiology clinic 10-20 and at the time was feeling with only 2\nlesss severe episodes of retrosternal chest pressure, 2-3, that\noccurred spontaneously without exertion, lasting 10 min with\ncomplete resolution. The pt had been able to participate in\naerobic exercise, 45 minutes and endorsed 40lbs wt loss while on\nWeight Watchers program. The pt was last seen by her PCP Son\n2014-9-22, Dr. Lenling, at which time she was feeling well. At the\ntime she reported LE edema since initiating amlodipine.', '\n\nThis morning the pt was bringing her children to school. Family\nnotes that patient has had increased chest discomfort this week\nand using nitroglycerin at work. Her daughter notes chest pain\nthis morning which resolved prior to taking her daughter to\nschool. EMS reports that arrived on scene with bystander CPR in\nprogress (approx 7:45). Arrest was confirmed. The pt was shocked\nonce. CPR was continued and on second analysis, no shock was\nadvised. At that time the pt was noted to move, Amiodarone 150mg\nwas loaded and subsequently transferred to an OSH.\n\nOn arrival to the OSH, (hx obtained by Gray-Williams Medical Center Hospital ED\nphysician Son. Benavidez via phone), initial vitals 108/55 HR 147,\nWt 99.7kg. The pt was intubated (two attempts made). HR ranged\nfrom 123 to 151, with SBPs 108/55 to 174/74.', " 140's to 150's.\nExam was notable for pt as unresponsive but was reaching for the\ntube. She did not respond to commandy prior to being intubated\nwith Succinylcholine 150mg, Versed 4mg, Vecuronium 10mg and put\non a propofol gtt. No acute EKG changes. Wbc 20. ck/trop neg.\nCXR/CT of chest shows large aspiration pneumonia CT Head/CT\nC-spine unremarkable. The pt was given Ceftiaxone 1gm,\nClindamycin 600mg, Azithromycin 500mg. 18G. Small lac to back of\nhead- going to get some staples prior to transfer. Vitals prior\nto transfer were HR 124 117/57.\n\nIn the CCU, the patient is intubated. When propofol is weaned\npatient moves all extremities however does not respond to\ncommands or follow directions.\n\nOn review of systems, unable to be obtained from patient. Family\nreports that she was in her usual state of health and went to\nthe beach this past weekend.", ' Besides chest pain episodes noted\nabove no other symptoms were reported by the patient. Family\nnotes patient to be a non reporter.\n\nPast Medical History:\n1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (-)HTN\n2. CARDIAC HISTORY:\n-CABG: None.\n-PERCUTANEOUS CORONARY INTERVENTIONS: None.\n-PACING/ICD: None.\n3. OTHER PAST MEDICAL HISTORY:\nh/o cholecystitis s/p cholecystectomy\n\n\nSocial History:\nWorks in NICU at Ball-Horton Health System\n-Tobacco history: none\n-ETOH: none\n-Illicit drugs: none\n\n\nFamily History:\nPaternal grandfather with MI at age 50. Father with\nhypertension.\n\nPhysical Exam:\nAdmission Labs\nVS: 122/58 95 100%\nGENERAL: Intubated, Sedated\nHEENT: NCAT. Sclera anicteric. PERRL. Laceration on back of head\nwith staples in place.\nNECK: Supple with JVP at base of neck.\nCARDIAC: PMI located in 5th intercostal space, midclavicular\nline.', ' RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or\nS4.\nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. CTAB, no crackles,\nwheezes or rhonchi.\nABDOMEN: Soft, obese, NTND. No HSM or tenderness.\nEXTREMITIES: No c/c/e.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES:\nRight: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\nLeft: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n\nOn discharge:\nGENERAL: comfortable, NAD\nHEENT: NCAT. Sclera anicteric. PERRL.\nCARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3\nor S4.\nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. CTAB, no crackles,\nwheezes or rhonchi.\nABDOMEN: Soft, NTND.\nEXTREMITIES: 2+ pitting edema in BLE\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.', '\n\n\n\nPertinent Results:\nOn admission:\n1970-12-3 12:51PM BLOOD WBC-25.6# RBC-4.47 Hgb-12.3 Hct-34.9\nMCV-78* MCH-27.6 MCHC-35.3* RDW-14.5 Plt Ct-355\n2015-12-19 05:14AM BLOOD WBC-15.7* RBC-4.16* Hgb-11.5* Hct-31.9\nMCV-77 MCH-27.6 MCHC-35.9* RDW-14.7 Plt Ct-218\n1901-5-16 05:20AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.1* Hct-25.7\nMCV-79 MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223\n\n1970-12-3 12:51PM BLOOD Glucose-154* UreaN-18 Creat-0.5 Na-141\nK-3.5 Cl-110* HCO3-20* AnGap-15\n2015-12-19 12:45AM BLOOD Glucose-99 UreaN-17 Creat-0.4 Na-139\nK-4.9 Cl-111* HCO3-19* AnGap-14\n2015-12-19 02:00PM BLOOD Glucose-84 UreaN-16 Creat-0.3* Na-140\nK-3.5 Cl-112* HCO3-18* AnGap-14\n2015-12-19 08:30PM BLOOD Glucose-127* UreaN-17 Creat-0.3* Na-143\nK-2.8* Cl-113* HCO3-18* AnGap-15\n1981-5-26 02:08AM BLOOD Glucose-81 UreaN-16 Creat-0.', '4 Na-140\nK-4.5 Cl-112* HCO3-20* AnGap-13\n\n1970-12-3 12:51PM BLOOD CK-MB-20* MB Indx-14.8* cTropnT-0.71\n1970-12-3 06:43PM BLOOD CK-MB-24 cTropnT-0.32\n2015-12-19 05:14AM BLOOD CK-MB-23 cTropnT-0.18\n2015-12-19 08:30PM BLOOD CK-MB-18 MB Indx-6.1* cTropnT-0.11\n\n1970-12-3 12:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG\nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n\nOn discharge:\n1901-5-16 05:20AM BLOOD WBC-6.3 RBC-3.24 Hgb-9.1* Hct-25.7\nMCV-79 MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223\n1901-5-16 05:20AM BLOOD Glucose-97 UreaN-7 Creat-0.4 Na-144 K-3.4\nCl-110* HCO3-24 AnGap-13\n1969-8-10 03:10AM BLOOD ALT-30 AST-21 AlkPhos-89 TotBili-0.8\n1901-5-16 05:20AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9\n\nSeptember (1970-12-3)\nNormal biventricular cavity sizes with preserved global and\nregional biventricular systolic function.', ' Mild to moderate\nmitral regurgitation with normal valve morphology. Pulmonary\nartery systolic hypertension. Increased PCWP.\n\nUpper Extremity Ultrasound (1940-12-12)\nNonocclusive thrombus seen within one of the superficial veins,\nthe cephalic vein, in a segment of the left upper arm. There is\nno evidence\nof deep vein thrombosis in the left arm.\n\nCXR (1940-12-12)\nIn comparison with study of 8-31, there has been placement of a\npacemaker device with leads in the region of the right atrium\nand apex of the right ventricle. The degree of pulmonary\nvascular congestion has substantially improved. Mild blunting of\nthe right costophrenic angle persists. No evidence of acute\nfocal pneumonia or pneumothorax. Right subclavian catheter\nextends to the lower portion of the SVC.\n\nmicrobiology:\nRESPIRATORY CULTURE (Final) - 1970-12-3\n MODERATE GROWTH Commensal Respiratory Flora.', '\n STAPH AUREUS COAG +. MODERATE GROWTH.\n SENSITIVITIES: MIC expressed in MCG/ML\n STAPH AUREUS COAG +\nCLINDAMYCIN----------- R\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ 1981-5-26):\n >25 PMNs and 1969-8-10):\n RARE GROWTH Commensal Respiratory Flora.\n\nBlood cultures\n1-22 and 8-31: NGTD\n5-15 final: NG\n\nUrine culture final (5-15 and 1-22): NG\n\n\nBrief Hospital Course:\n50 year old female with history of coronary vasospasm presents\nfollowing a cardiac arrest of unclear etiology.\n\n# s/p Cardiac Arrest: Witnessed VF arrest in the field with\nbystander CPR. EMS confirmed pulselessness and AED advised\nshock. ECG here without concerning ECG changes for ischemia.\nGiven history of vasospasm may be secondary to vasospasm leading\nto ischemia and subsequent VT/VF arrest.', ' She was placed on\narctic cooling to protect cerebral function s/p cardiac arrest.\nMay showed normal structure and function. EEG showed abnormal\ntemporal lobe epileptiform but otherwise normal. She was\nstarted on aspirin, amlodipine, isosorbide mononitrate, and\nsimvastatin. She was noted to have ST elevation in V2-V4 on\n2015-12-19 during rewarming phase with subsequent VF arrest s/p 1\nround of CPR and shock with ROSC - K returned at 2.7. She was\nfollowing commands and thus decision was made not to reinitiate\ncooling protocol. She was started on IV nitro and diltiazem\ndrip which resolved the ST elevation in anteroseptal leads.\nAfter extubation and improvement in her mental status, her\nregimen was transitioned to nifedipine 60 mg po qdaily, imdur 60\nmg po qdaily, verapamil ER 360 mg Phillips-Schwartz Hospital.', ' EP was consulted and felt\nthe presentation could be due to long QT syndrome. She underwent\nICD placement on 6-6 - infectious prophylaxis was with\nVancomycin. CXR showed no evidence of pneumothorax.\n.\n# Neuroprotection s/p arrest: Interval between arrest and\ninitiation of cooling was 5 hours. On presentation with propofol\nwean patient without purposeful movement. CT head negative from\nOSH. Artic Sun therapeutic cooling protocol with goal core body\ntemperature 33 degrees x 18 hours. Patient sedated with fentanyl\nand midazolam and eventually need paralysis with cisatracurium.\nShe was warmed per protocol and was oriented and following\ncommands appropriately within 48 hours.\n.\n# CORONARIES: Prior cardiac caths in November x2 both suggestive of\ncoronary vasospasm without flow limiting lesions. Has been on\namlodipine 10mg, dilt 240mg, and imdur 30mg as outpatient.', ' ECG\nat OSH unchanged from baseline. Regimen was changed to above\n(see #1).\n\n# PUMP: No prior November or LV gram in Ball-Horton Health System system. Pt with hx of\nHTN that was potentially thought to be white coat but unclear.\nChloe Benavidez showed normal function.\n\n# RHYTHM: No prior hx of arrhythmias however likely VF/VT arrest\non presentation and subsequent episode of VF in ICU. Thought to\nbe 7-6 coronary vasospasm. Long QT syndrome was also considered\nand genetic testing will be pursued by EP and discussed and\nfollowed up.\n\n# Pulmonary Infiltrates: Pt with evidence of diffuse infiltrates\non OSH CXR and CT. Right upper load with air bronchograms\nconcerning for pneumonia, however bilateral pathcy infiltrates\nconcerning for early ARDS. Was placed on\nCTX/Clindamycin/Azithromycin at OSH for suspected\nCAP/Aspiration.', ' Transitioned to IV unasyn and then IV nafcillin.\nNafcillin was changed to Augmentin on 6-6 and again to Bactrim\non 5-28. Patient discharged wtih 7 day course of Bactrim Phillips-Schwartz Hospital.\n\n# Cloudy Urine: Urine appears "dirty" when foley catheter\nplaced. Continued on IV unasyn. Urine cultures were negative. No\nfurther antibiotic coverage needed and patient remained\nasymptomatic.\n\n#dizziness: Pt complained of dizziness consistent with vertigo.\nPt received meclizine with improvement in her symptoms. No\nevidence of orthostasis. Pt was ambulating without difficulty\nprior to discharge. Pt will follow up with PCP regarding these\nsymptoms.\n\n#hypokalemia: Mild evidence of hypokalemia requiring po\npotassium supplementation. Pt was discharged with oral potassium\nsupplementation and spironolactone were started to help maintain\na normal postassium level.', ' Pt planned follow potassium level 2\ndays after discharge.\n\n#lower extremity edema: 47478 Payne Meadows\nEast Michaeltown, DC 55812 likely secondary to calcium channel\nblocker use stable from admission.\n\nShe was kept on subQ heparin for DVT prophylaxis. She remained\nfull code. Communication was with her husband.\n\n\nMedications on Admission:\nAspirin 81mg daily (7am 1970-12-3)\nZocor 40mg daily (7am 1970-12-3)\nNorvasc 10mg daily (7am 1970-12-3)\nDiltiazem HCL 240mg daily (7am 1970-12-3)\nIsosorbide mononitrate 30mg daily (7am 1970-12-3)\nNTG\n\n\nDischarge Medications:\n1. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet\nExtended Release PO at bedtime.\nDisp:30 Tablet Extended Release(s) Refills:2\n2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr\nSig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).', '\nDisp:30 Tablet Extended Release 24 hr(s) Refills:2\n3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\nhours) as needed for ICD pain.\n4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)\nTablet PO BID (2 times a day) for 7 days.\nDisp:14 Tablet(s) Refills:0\n5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:2\n6. verapamil 360 mg Cap,Ext Release Pellets 24 hr Sig: One (1)\nCap,Ext Release Pellets 24 hr PO twice a day.\nDisp:60 Cap,Ext Release Pellets 24 hr(s) Refills:2\n7. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times\na day) as needed for dizziness.\nDisp:30 Tablet(s) Refills:0\n8. Outpatient Lab Work\nPlease check Chem-7 and CBC on Monday 2-20 with results to\nDr. Feguson at 678-531-5078\n9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:\nOne (1) Tablet, ER Particles/Crystals PO once a day.', '\nDisp:30 Tablet, ER Particles/Crystals(s) Refills:2\n10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet\nSublingual as directed as needed for chest pain.\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nCombs Group\n\nDischarge Diagnosis:\nCoronary Vasospasm\nVentricular fibrillation\n\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n\nDischarge Instructions:\nYou had more spasm in your coronary arteries and had a\nventricular fibrillation arrest. You were brought to Gray-Williams Medical Center\nhospital initially and then transferred to Ball-Horton Health System for care. You\nunderwent an arctic sun cooling protocol and have recovered well\nfrom the episode. There may be some correlation with a prolonged\nQT and hypokalemia as well.', ' Your telemetry shows only short runs\nof VT (3-4 beats) that are rare. You had an ICD placed that will\nshock you out of any prolonged runs of VT. Please call the EP\nfellow on call if this happens. You had a staph pneumonia that\nis being treated with antibiotics.\n.\nWe made the following changes in your medicines:\n1. STOP taking aspirin, norvasc, diltiazem and zocor.\n2. START taking Verapamil to prevent coronary vasospasm\n3. START taking Nifedipine to prevent coronary vasospasm, please\ntake this at night\n4. Increase the Imdur to 60 mg daily\n5. Start taking spironolactone to increase your potassium\n6. STart taking potassium supplements to keep your potassium up\n7. Take meclizine as needed to prevent dizziness.\n8. Take Bactrim twice daily for one week to treat the pneumonia\n9. Take acetaminophen as needed for ICD pain.', '\n\nFollowup Instructions:\nDepartment: Copeland Inc POST Mayer, Thompson and Green Clinic CLINIC 759-484-8813\nWhen: WEDNESDAY 1959-11-14 at 9:30 AM\nWith: Dr Angus Heflin\nBuilding: SC Reed PLC Health System Clinical Ctr 59522 Gary Avenue Suite 542\nPort Reginaburgh, IL 67601 South Mendoza Group Medical Center\nCampus: EAST Best Parking: Reed PLC Health System Garage\nNOTE:\nA) Please discuss at this appt if you need to come in for your\npreviously scheduled appt for next week 1-21.\nB) This appointment is with a hospital-based doctor as part of\nyour transition from the hospital back to your primary care\nprovider. Retha Cobbs this visit, you will see your regular primary\ncare doctor in follow up.\n\nDepartment: Mitchell Group Health System\nWhen: THURSDAY 1902-2-31 at 11:00 AM\nWith: Lisa Pichardo, NP 759-484-8813\nBuilding: SC Reed PLC Health System Clinical Ctr 59522 Gary Avenue Suite 542\nPort Reginaburgh, IL 67601\nCampus: EAST Best Parking: Reed PLC Health System Garage\n\nDepartment: CARDIAC SERVICES\nWhen: MONDAY 1974-9-9 at 3:40 PM\nWith: Tammy Scheet, MD 678-531-5078\nBuilding: SC Reed PLC Health System Clinical Ctr 47478 Payne Meadows\nEast Michaeltown, DC 55812\nCampus: EAST Best Parking: Reed PLC Health System Garage\n\nDepartment: CARDIAC SERVICES\nWhen: TUESDAY 1914-8-6 at 1:40 PM\nWith: Tammy Yuen, M.', 'D. 678-531-5078\nBuilding: SC Reed PLC Health System Clinical Ctr 47478 Payne Meadows\nEast Michaeltown, DC 55812\nCampus: EAST Best Parking: Reed PLC Health System Garage\n\nDepartment: CARDIAC SERVICES\nWhen: WEDNESDAY 1959-11-14 at 9:00 AM\nWith: DEVICE CLINIC 678-531-5078\nBuilding: SC Reed PLC Health System Clinical Ctr 47478 Payne Meadows\nEast Michaeltown, DC 55812\nCampus: EAST Best Parking: Reed PLC Health System Garage\n\n\n\nCompleted by:1901-5-16']
145	1217	145268.0	2125-04-12	Discharge summary	Report	Admission Date: [2125-4-5] Discharge Date: [2125-4-12] Date of Birth: [2072-2-15] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 53-year-old gentleman who went to see his primary care physician for his yearly physical. At that time, he reported a 1-year history of burning substernal chest pain with exertion. He underwent an exercise treadmill test which was positive and subsequently underwent cardiac catheterization which showed an ejection fraction of 55%, 90% left main coronary artery, 90% proximal left anterior descending artery, 60% to 80% left circumflex, and a proximally occluded right coronary artery. The patient was referred to Dr. [Last Name (STitle) 1537] for urgent coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia 3. Gastroesophageal reflux disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg by mouth once per day. 2. Lipitor 40 mg by mouth once per day. 3. Zantac 150 mg by mouth twice per day. SOCIAL HISTORY: The patient lives at home with his wife and his two children. He works in construction. Positive tobacco with half a pack per day for 40 years. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to [Hospital1 69] and taken to the operating room on [2125-4-6] with Dr. [Last Name (STitle) 1537] for a coronary artery bypass graft times three. Left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to posterior descending artery. The patient had an intra-aortic balloon pump placed in the Cardiac Catheterization Laboratory due to his difficult anatomy and that remained during his surgery. The patient was transferred to the Intensive Care Unit in stable condition on a Neo-Synephrine infusion. Postoperatively, the patient requried a moderate amount of volume resuscitation. Due to his elevated filling pressures and some minor postoperative electrocardiogram changes, a transesophageal echocardiogram was performed at the bedside which showed a normal ejection fraction with no wall motion abnormalities. The patient's hemodynamics improved over the next couple of hours. On postoperative day one, the patient was weaned and extubated from mechanical ventilation. The intra-aortic balloon pump was removed without difficulty. The Neo-Synephrine was weaned to off. On postoperative day two, the patient was started on Lopressor which he tolerated well. On postoperative day three, the patient's chest tubes were removed without difficulty as well as his pacing wires. On postoperative day four, the patient's hematocrit was noted to be down to 21. The patient was not symptomatic and had stable vital signs. It was discussed with Dr. [Last Name (STitle) 1537], and a transfusion was deferred. On postoperative day five, the patient continued to ambulate with Physical Therapy. On postoperative day six, the patient's hematocrit was noted to be down to 20.8. The decision was made to transfuse the patient; however, the patient refused a blood transfusion. The risks of refusing a transfusion were discussed with him. As the patient remained hemodynamically stable, with no evidence of orthostasis, a stable blood pressure, and stable oxygen saturation, the blood transfusion was deferred. The patient had been started on iron and vitamin C. On postoperative day seven, the patient worked with Physical Therapy and was able to walk 500 feet and climb one flight of stairs. The patient's hematocrit had risen to 21.1, and it was felt the patient was appropriate for discharge to home. CONDITION AT DISCHARGE: Temperature maximum was 99.2, pulse was 82 (in sinus rhythm), blood pressure was 119/66, respiratory rate was 16, and oxygen saturation 96% on room air. Laboratory data red white blood cell count was 9.2, hematocrit was 21.1, and platelet count was 330. Potassium was 4, blood urea nitrogen was 27, and creatinine was 1. Neurologically, the patient was awake, alert, and oriented times three. Heart regular in rate and rhythm without murmurs. Breath sounds were clear bilaterally. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Tolerating a regular diet. The sternal incision was clean, dry, and intact. The sternum was stable. Lower extremities revealed 1 to 2+ pitting edema. Vein harvest site was clean, dry, and intact. There was no erythema or drainage. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass graft. 3. Postoperative anemia. MEDICATIONS ON ADMISSION: 1. Lopressor 75 mg by mouth twice per day. 2. Lasix 20 mg by mouth twice per day (times seven days). 3. Potassium chloride 10 mEq by mouth twice per day (times seven days). 4. Colace 100 mg by mouth twice per day. 5. Zantac 150 mg by mouth twice per day. 6. Enteric-coated aspirin 325 mg by mouth every day. 7. Lipitor 40 mg by mouth once per day. 8. Niferex 150 mg by mouth once per day. 9. Vitamin C 500 mg by mouth twice per day. 10. Ibuprofen 600 mg by mouth q.6h. as needed. 11. Dilaudid 2 mg to 6 mg by mouth q.6h. as needed. 12. Multivitamin one tablet by mouth once per day. DISCHARGE STATUS: The patient to be discharged to home. CONDITION AT DISCHARGE: Stable. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [Last Name (STitle) 1538] in one to two weeks. 2. The patient was to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] in three to four weeks. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 1541] MEDQUIST36 D: [2125-4-12] 16:25 T: [2125-4-12] 16:50 JOB#: [Job Number 1542]	Admission Date: <Date>1916-10-27</Date> Discharge Date: <Date>1991-5-8</Date> Date of Birth: <Date>1970-1-10</Date> Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 53-year-old gentleman who went to see his primary care physician for his yearly physical. At that time, he reported a 1-year history of burning substernal chest pain with exertion. He underwent an exercise treadmill test which was positive and subsequently underwent cardiac catheterization which showed an ejection fraction of 55%, 90% left main coronary artery, 90% proximal left anterior descending artery, 60% to 80% left circumflex, and a proximally occluded right coronary artery. The patient was referred to Dr. <Name>Lockett</Name> for urgent coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia 3. Gastroesophageal reflux disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg by mouth once per day. 2. Lipitor 40 mg by mouth once per day. 3. Zantac 150 mg by mouth twice per day. SOCIAL HISTORY: The patient lives at home with his wife and his two children. He works in construction. Positive tobacco with half a pack per day for 40 years. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to <Hospital>Fisher, Cox and Osborn Hospital</Hospital> and taken to the operating room on <Date>2009-2-20</Date> with Dr. <Name>Lockett</Name> for a coronary artery bypass graft times three. Left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to posterior descending artery. The patient had an intra-aortic balloon pump placed in the Cardiac Catheterization Laboratory due to his difficult anatomy and that remained during his surgery. The patient was transferred to the Intensive Care Unit in stable condition on a Neo-Synephrine infusion. Postoperatively, the patient requried a moderate amount of volume resuscitation. Due to his elevated filling pressures and some minor postoperative electrocardiogram changes, a transesophageal echocardiogram was performed at the bedside which showed a normal ejection fraction with no wall motion abnormalities. The patient's hemodynamics improved over the next couple of hours. On postoperative day one, the patient was weaned and extubated from mechanical ventilation. The intra-aortic balloon pump was removed without difficulty. The Neo-Synephrine was weaned to off. On postoperative day two, the patient was started on Lopressor which he tolerated well. On postoperative day three, the patient's chest tubes were removed without difficulty as well as his pacing wires. On postoperative day four, the patient's hematocrit was noted to be down to 21. The patient was not symptomatic and had stable vital signs. It was discussed with Dr. <Name>Lockett</Name>, and a transfusion was deferred. On postoperative day five, the patient continued to ambulate with Physical Therapy. On postoperative day six, the patient's hematocrit was noted to be down to 20.8. The decision was made to transfuse the patient; however, the patient refused a blood transfusion. The risks of refusing a transfusion were discussed with him. As the patient remained hemodynamically stable, with no evidence of orthostasis, a stable blood pressure, and stable oxygen saturation, the blood transfusion was deferred. The patient had been started on iron and vitamin C. On postoperative day seven, the patient worked with Physical Therapy and was able to walk 500 feet and climb one flight of stairs. The patient's hematocrit had risen to 21.1, and it was felt the patient was appropriate for discharge to home. CONDITION AT DISCHARGE: Temperature maximum was 99.2, pulse was 82 (in sinus rhythm), blood pressure was 119/66, respiratory rate was 16, and oxygen saturation 96% on room air. Laboratory data red white blood cell count was 9.2, hematocrit was 21.1, and platelet count was 330. Potassium was 4, blood urea nitrogen was 27, and creatinine was 1. Neurologically, the patient was awake, alert, and oriented times three. Heart regular in rate and rhythm without murmurs. Breath sounds were clear bilaterally. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Tolerating a regular diet. The sternal incision was clean, dry, and intact. The sternum was stable. Lower extremities revealed 1 to 2+ pitting edema. Vein harvest site was clean, dry, and intact. There was no erythema or drainage. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass graft. 3. Postoperative anemia. MEDICATIONS ON ADMISSION: 1. Lopressor 75 mg by mouth twice per day. 2. Lasix 20 mg by mouth twice per day (times seven days). 3. Potassium chloride 10 mEq by mouth twice per day (times seven days). 4. Colace 100 mg by mouth twice per day. 5. Zantac 150 mg by mouth twice per day. 6. Enteric-coated aspirin 325 mg by mouth every day. 7. Lipitor 40 mg by mouth once per day. 8. Niferex 150 mg by mouth once per day. 9. Vitamin C 500 mg by mouth twice per day. 10. Ibuprofen 600 mg by mouth q.6h. as needed. 11. Dilaudid 2 mg to 6 mg by mouth q.6h. as needed. 12. Multivitamin one tablet by mouth once per day. DISCHARGE STATUS: The patient to be discharged to home. CONDITION AT DISCHARGE: Stable. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. <Name>Londrie</Name> in one to two weeks. 2. The patient was to follow up with Dr. <Name>May</Name> <Name>Prieto</Name> in three to four weeks. <Name>Octavia</Name> <Name>Abdullah</Name>, M.D. <MD Number>04713450</MD Number> Dictated By:<Name>William</Name> MEDQUIST36 D: <Date>1991-5-8</Date> 16:25 T: <Date>1991-5-8</Date> 16:50 JOB#: <Job Number>Carey-Guerrero-1956-104486</Job 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0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111100000000000000000000000000000000000000000000000000000000000000001110111111000000000000000000000000000000000000000000000000000000000011111110111111110000000011111111000000000000001111111000000000000000001111111100000000000011111111000000000000000111111111111111111111111110	Admission Date: 1916-10-27 Discharge Date: 1991-5-8 Date of Birth: 1970-1-10 Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 53-year-old gentleman who went to see his primary care physician for his yearly physical. At that time, he reported a 1-year history of burning substernal chest pain with exertion. He underwent an exercise treadmill test which was positive and subsequently underwent cardiac catheterization which showed an ejection fraction of 55%, 90% left main coronary artery, 90% proximal left anterior descending artery, 60% to 80% left circumflex, and a proximally occluded right coronary artery. The patient was referred to Dr. Lockett for urgent coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia 3. Gastroesophageal reflux disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg by mouth once per day. 2. Lipitor 40 mg by mouth once per day. 3. Zantac 150 mg by mouth twice per day. SOCIAL HISTORY: The patient lives at home with his wife and his two children. He works in construction. Positive tobacco with half a pack per day for 40 years. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to Fisher, Cox and Osborn Hospital and taken to the operating room on 2009-2-20 with Dr. Lockett for a coronary artery bypass graft times three. Left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to posterior descending artery. The patient had an intra-aortic balloon pump placed in the Cardiac Catheterization Laboratory due to his difficult anatomy and that remained during his surgery. The patient was transferred to the Intensive Care Unit in stable condition on a Neo-Synephrine infusion. Postoperatively, the patient requried a moderate amount of volume resuscitation. Due to his elevated filling pressures and some minor postoperative electrocardiogram changes, a transesophageal echocardiogram was performed at the bedside which showed a normal ejection fraction with no wall motion abnormalities. The patient's hemodynamics improved over the next couple of hours. On postoperative day one, the patient was weaned and extubated from mechanical ventilation. The intra-aortic balloon pump was removed without difficulty. The Neo-Synephrine was weaned to off. On postoperative day two, the patient was started on Lopressor which he tolerated well. On postoperative day three, the patient's chest tubes were removed without difficulty as well as his pacing wires. On postoperative day four, the patient's hematocrit was noted to be down to 21. The patient was not symptomatic and had stable vital signs. It was discussed with Dr. Lockett, and a transfusion was deferred. On postoperative day five, the patient continued to ambulate with Physical Therapy. On postoperative day six, the patient's hematocrit was noted to be down to 20.8. The decision was made to transfuse the patient; however, the patient refused a blood transfusion. The risks of refusing a transfusion were discussed with him. As the patient remained hemodynamically stable, with no evidence of orthostasis, a stable blood pressure, and stable oxygen saturation, the blood transfusion was deferred. The patient had been started on iron and vitamin C. On postoperative day seven, the patient worked with Physical Therapy and was able to walk 500 feet and climb one flight of stairs. The patient's hematocrit had risen to 21.1, and it was felt the patient was appropriate for discharge to home. CONDITION AT DISCHARGE: Temperature maximum was 99.2, pulse was 82 (in sinus rhythm), blood pressure was 119/66, respiratory rate was 16, and oxygen saturation 96% on room air. Laboratory data red white blood cell count was 9.2, hematocrit was 21.1, and platelet count was 330. Potassium was 4, blood urea nitrogen was 27, and creatinine was 1. Neurologically, the patient was awake, alert, and oriented times three. Heart regular in rate and rhythm without murmurs. Breath sounds were clear bilaterally. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Tolerating a regular diet. The sternal incision was clean, dry, and intact. The sternum was stable. Lower extremities revealed 1 to 2+ pitting edema. Vein harvest site was clean, dry, and intact. There was no erythema or drainage. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass graft. 3. Postoperative anemia. MEDICATIONS ON ADMISSION: 1. Lopressor 75 mg by mouth twice per day. 2. Lasix 20 mg by mouth twice per day (times seven days). 3. Potassium chloride 10 mEq by mouth twice per day (times seven days). 4. Colace 100 mg by mouth twice per day. 5. Zantac 150 mg by mouth twice per day. 6. Enteric-coated aspirin 325 mg by mouth every day. 7. Lipitor 40 mg by mouth once per day. 8. Niferex 150 mg by mouth once per day. 9. Vitamin C 500 mg by mouth twice per day. 10. Ibuprofen 600 mg by mouth q.6h. as needed. 11. Dilaudid 2 mg to 6 mg by mouth q.6h. as needed. 12. Multivitamin one tablet by mouth once per day. DISCHARGE STATUS: The patient to be discharged to home. CONDITION AT DISCHARGE: Stable. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. Londrie in one to two weeks. 2. The patient was to follow up with Dr. May Prieto in three to four weeks. Octavia Abdullah, M.D. 04713450 Dictated By:William MEDQUIST36 D: 1991-5-8 16:25 T: 1991-5-8 16:50 JOB#: Carey-Guerrero-1956-104486	['Admission Date: 1916-10-27 Discharge Date: 1991-5-8\n\nDate of Birth: 1970-1-10 Sex: M\n\nService: Cardiac Surgery\n\nHISTORY OF PRESENT ILLNESS: This is a 53-year-old gentleman\nwho went to see his primary care physician for his yearly\nphysical. At that time, he reported a 1-year history of\nburning substernal chest pain with exertion. He underwent an\nexercise treadmill test which was positive and subsequently\nunderwent cardiac catheterization which showed an ejection\nfraction of 55%, 90% left main coronary artery, 90% proximal\nleft anterior descending artery, 60% to 80% left circumflex,\nand a proximally occluded right coronary artery. The patient\nwas referred to Dr. Lockett for urgent coronary artery bypass\ngrafting.\n\nPAST MEDICAL HISTORY:\n1. Hypertension.\n2. Hypercholesterolemia\n3.', ' Gastroesophageal reflux disease.\n\nALLERGIES: No known drug allergies.\n\nMEDICATIONS ON ADMISSION:\n1. Hydrochlorothiazide 25 mg by mouth once per day.\n2. Lipitor 40 mg by mouth once per day.\n3. Zantac 150 mg by mouth twice per day.\n\nSOCIAL HISTORY: The patient lives at home with his wife and\nhis two children. He works in construction. Positive\ntobacco with half a pack per day for 40 years.\n\nBRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted\nto Fisher, Cox and Osborn Hospital and taken to the\noperating room on 2009-2-20 with Dr. Lockett for a coronary\nartery bypass graft times three. Left internal mammary\nartery to left anterior descending artery, saphenous vein\ngraft to obtuse marginal, and saphenous vein graft to\nposterior descending artery. The patient had an intra-aortic\nballoon pump placed in the Cardiac Catheterization Laboratory\ndue to his difficult anatomy and that remained during his\nsurgery.', "\n\nThe patient was transferred to the Intensive Care Unit in\nstable condition on a Neo-Synephrine infusion.\nPostoperatively, the patient requried a moderate amount of\nvolume resuscitation.\n\nDue to his elevated filling pressures and some minor\npostoperative electrocardiogram changes, a transesophageal\nechocardiogram was performed at the bedside which showed a\nnormal ejection fraction with no wall motion abnormalities.\nThe patient's hemodynamics improved over the next couple of\nhours. On postoperative day one, the patient was weaned and\nextubated from mechanical ventilation. The intra-aortic\nballoon pump was removed without difficulty. The\nNeo-Synephrine was weaned to off.\n\nOn postoperative day two, the patient was started on\nLopressor which he tolerated well. On postoperative day\nthree, the patient's chest tubes were removed without\ndifficulty as well as his pacing wires.", "\n\nOn postoperative day four, the patient's hematocrit was noted\nto be down to 21. The patient was not symptomatic and had\nstable vital signs. It was discussed with Dr. Lockett, and a\ntransfusion was deferred.\n\nOn postoperative day five, the patient continued to ambulate\nwith Physical Therapy.\n\nOn postoperative day six, the patient's hematocrit was noted\nto be down to 20.8. The decision was made to transfuse the\npatient; however, the patient refused a blood transfusion.\nThe risks of refusing a transfusion were discussed with him.\nAs the patient remained hemodynamically stable, with no\nevidence of orthostasis, a stable blood pressure, and stable\noxygen saturation, the blood transfusion was deferred. The\npatient had been started on iron and vitamin C.\n\nOn postoperative day seven, the patient worked with Physical\nTherapy and was able to walk 500 feet and climb one flight of\nstairs.", " The patient's hematocrit had risen to 21.1, and it\nwas felt the patient was appropriate for discharge to home.\n\nCONDITION AT DISCHARGE: Temperature maximum was 99.2, pulse\nwas 82 (in sinus rhythm), blood pressure was 119/66,\nrespiratory rate was 16, and oxygen saturation 96% on room\nair. Laboratory data red white blood cell count was 9.2,\nhematocrit was 21.1, and platelet count was 330. Potassium\nwas 4, blood urea nitrogen was 27, and creatinine was 1.\nNeurologically, the patient was awake, alert, and oriented\ntimes three. Heart regular in rate and rhythm without\nmurmurs. Breath sounds were clear bilaterally. The abdomen\nwas soft, nontender, and nondistended. Positive bowel\nsounds. Tolerating a regular diet. The sternal incision was\nclean, dry, and intact. The sternum was stable.", ' Lower\nextremities revealed 1 to 2+ pitting edema. Vein harvest\nsite was clean, dry, and intact. There was no erythema or\ndrainage.\n\nDISCHARGE DIAGNOSES:\n1. Coronary artery disease.\n2. Status post coronary artery bypass graft.\n3. Postoperative anemia.\n\nMEDICATIONS ON ADMISSION:\n 1. Lopressor 75 mg by mouth twice per day.\n 2. Lasix 20 mg by mouth twice per day (times seven days).\n 3. Potassium chloride 10 mEq by mouth twice per day (times\nseven days).\n 4. Colace 100 mg by mouth twice per day.\n 5. Zantac 150 mg by mouth twice per day.\n 6. Enteric-coated aspirin 325 mg by mouth every day.\n 7. Lipitor 40 mg by mouth once per day.\n 8. Niferex 150 mg by mouth once per day.\n 9. Vitamin C 500 mg by mouth twice per day.\n10. Ibuprofen 600 mg by mouth q.6h. as needed.\n11. Dilaudid 2 mg to 6 mg by mouth q.', '6h. as needed.\n12. Multivitamin one tablet by mouth once per day.\n\nDISCHARGE STATUS: The patient to be discharged to home.\n\nCONDITION AT DISCHARGE: Stable.\n\nDISCHARGE INSTRUCTIONS/FOLLOWUP:\n1. The patient was to follow up with Dr. Londrie in one to\ntwo weeks.\n2. The patient was to follow up with Dr. May Prieto in\nthree to four weeks.\n\n\n\n\n\n Octavia Abdullah, M.D. 04713450\n\nDictated By:William\nMEDQUIST36\n\nD: 1991-5-8 16:25\nT: 1991-5-8 16:50\nJOB#: Carey-Guerrero-1956-104486\n']
146	7234	169137.0	2160-02-24	Discharge summary	Report	Admission Date: [2160-2-19] Discharge Date: [2160-2-24] Date of Birth: [2095-10-21] Sex: M Service: EP SERVICE CHIEF COMPLAINT: Syncope. HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with an extensive cardiac history including coronary artery disease, status post myocardial infarction times two, status post multiple interventions, congestive heart failure with an ejection fraction less than 20%, ventricular tachycardia, status post AICD placement in [2157], who presented to the Emergency Department after syncopal episodes and AICD firing. The patient noted three days prior to admission, feeling of palpitations especially when lying down for bed. On the day of admission, the patient became lightheaded a while, bending down to tie his shoes and felt some palpitations. He then felt a shock from his ICD. He, thereafter, awoke on the floor. Over the course of the day, he had three more episodes, a feeling of palpitations, and lightheadedness followed by a shock and then losing consciousness. In the Emergency Department, the patient was observed to have an irregular wide complex tachycardia consistent with atrial fibrillation in the setting of his underlying left bundle branch block. While in the Emergency Department, he developed transient regular wide complex tachycardia to approximately 170 beats per minute. His ICD fired during this rhythm and was subsequently degenerated into a ventricular fibrillation, prompting the ICD to fire again, recovering the rhythm back to atrial fibrillation. An amiodarone load was begun and the patient appeared to spontaneously convert to sinus rhythm with left bundle branch block. The ICD settings were increased while the patient was in the Emergency Department so that the first shock administered was increased from 12 to 24 joules. The patient was admitted to the Coronary Care Unit for continued intravenous amiodarone loading and further evaluation. PAST MEDICAL HISTORY: Coronary artery disease, status post myocardial infarction in [2136] and [2150]. He is status post multiple percutaneous transluminal coronary angioplasty and stents. Last catheterization on [11/2159] showed an ejection fraction of 15% with anterolateral apical and inferior akinesis. He had 2+ mitral regurgitation. He had a 40% distal left main lesion, left anterior descending flow was occluded. He had a 90% lesion at the left circumflex OM1 bifurcation. He had 50% R-PLV. Left circumflex was stented with percutaneous transluminal coronary angioplasty of a jailed OM1. Congestive heart failure, his last echocardiogram was [2155] with ejection fraction of 20% with global hypokinesis, akinesis. He has mild to moderate mitral regurgitation, ventricular tachycardia, status post single lead AICD in [2157], hypercholesterolemia, hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea with a CPEP machine at home. MEDICATIONS ON ADMISSION: Flovent 220 mcg 2 puffs b.i.d., Procainamide 1500 mg po t.i.d., Captopril 50 mg po t.i.d., Lopressor 37.5 po b.i.d., Lipitor 20 mg po q.h.s., Lasix 60 mg po b.i.d., potassium chloride, Isordil 10 mg po t.i.d., aspirin 325 mg po q.d., Wellbutrin 100 mg po b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a retired policeman and works as a private investigator. He has a 60-70 pack year smoking history and quit in [2155]. He uses alcohol infrequently. He is married, but separated, and has two children. FAMILY HISTORY: His father for hypercholesterolemia and coronary artery disease. PHYSICAL EXAM ON ADMISSION: Temperature of 98.1. Pulse 82. Respiratory rate of 16. Blood pressure 120/74. O2 saturation of 96% on room air. On general exam, he is ruddy appearing, awake, alert, conversive white male in no acute distress. On head, eyes, ears, nose and throat exam, he is normocephalic, atraumatic. Pupils equal, round and reactive to light. Sclerae are anicteric. His mucous membranes were moist. His neck was supple with no lymphadenopathy or thyromegaly and no carotid bruits. Chest was clear to auscultation bilaterally. On cardiovascular exam, he had a regular rate and rhythm with normal S1, S2, soft systolic murmur at the upper sternal border with no rubs or gallops. His abdomen was soft, obese, nontender, nondistended with normal active bowel sounds. He had no hepatosplenomegaly. Extremities had no edema. Rectal exam, guaiac negative brown stool per Emergency Department report. LABORATORIES ON ADMISSION: White blood cell count of 12.8, hematocrit of 44, platelets of 176, sodium of 137, potassium 4.3, chloride of 100, bicarbonate of 25, BUN of 20, creatinine of 1.2, glucose of 96, CK of 47, magnesium of 2.1, Electrocardiogram showed regular wide complex tachycardia rate 116 with a leftward axis and left bundle branch block. Chest x-ray showed ICD in place in the left chest with some cardiomegaly, mild pulmonary vascular redistribution. HOSPITAL COURSE: The patient was admitted from the Emergency Department and was loaded on amiodarone intravenous in the Coronary Care Unit. The patient was brought to the EP laboratory for further evaluation of his dysrhythmias. The Procainamide was discontinued. In the EP laboratory, both atrial fibrillation and aflutter were found and the aflutter was ablated. The patient was also found to have ventricular tachycardias and these were not amenable to ablation. On the following day, the patient also underwent an upgrade of his ICD to a DDD pacemaker. The ICD was upgraded to a GEM3-AT7276 with [Company 1543] 5076 in the [Company 1543] 6937 with leads to the SVCRA junction and the RA appendage as well as to the right ventricle. The patient remained in stable condition throughout his hospital course. He did have occasional episodes of very brief tachycardia that were asymptomatic and with the upgrade of the ICD and pacemaker, any future episodes should be able to be recorded to distinguish between a ventricular versus a supraventricular cause of his tachycardia. The patient is being discharged to continue his Amiodarone load at 400 mg b.i.d. for one week, then 600 mg q.d. for three weeks and then to 200 mg q.d. The patient will continue with antibiotic prophylaxis, his Keflex for a total of 48 hours. He is also being started on a very low dose of Coumadin with follow-up INR within the next two days. The patient will have follow-up with the [Hospital ] Clinic on the week after discharge and he will also follow-up with Dr. [Last Name (STitle) ] in the following week. He is instructed not to drive or use his left arm until further instructions. Furthermore, he is instructed not to drive due to the issue of the syncope. DISCHARGE MEDICATIONS: 1. Amiodarone as described above. 2. Keflex 500 mg po q. 6. for another three doses. 3. Coumadin 2.5 mg q.h.s. until further notice. 4. Captopril 50 mg po t.i.d. 5. Lasix 60 mg po q.d. 6. Isordil 10 mg po t.i.d. 7. Aspirin 325 mg po q.d. 8. Wellbutrin 100 mg po b.i.d. 9. KCL as further directed. [Known firstname ] [Last Name (NamePattern4) 1544], M.D. [MD Number(1) 1545] Dictated By:[Name8 (MD) 1546] MEDQUIST36 D: [2160-2-23] 20:33 T: [2160-2-23] 20:33 JOB#: [Job Number 1547]	Admission Date: <Date>1955-9-29</Date> Discharge Date: <Date>1919-12-12</Date> Date of Birth: <Date>1952-6-27</Date> Sex: M Service: EP SERVICE CHIEF COMPLAINT: Syncope. HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with an extensive cardiac history including coronary artery disease, status post myocardial infarction times two, status post multiple interventions, congestive heart failure with an ejection fraction less than 20%, ventricular tachycardia, status post AICD placement in <Year>1920</Year>, who presented to the Emergency Department after syncopal episodes and AICD firing. The patient noted three days prior to admission, feeling of palpitations especially when lying down for bed. On the day of admission, the patient became lightheaded a while, bending down to tie his shoes and felt some palpitations. He then felt a shock from his ICD. He, thereafter, awoke on the floor. Over the course of the day, he had three more episodes, a feeling of palpitations, and lightheadedness followed by a shock and then losing consciousness. In the Emergency Department, the patient was observed to have an irregular wide complex tachycardia consistent with atrial fibrillation in the setting of his underlying left bundle branch block. While in the Emergency Department, he developed transient regular wide complex tachycardia to approximately 170 beats per minute. His ICD fired during this rhythm and was subsequently degenerated into a ventricular fibrillation, prompting the ICD to fire again, recovering the rhythm back to atrial fibrillation. An amiodarone load was begun and the patient appeared to spontaneously convert to sinus rhythm with left bundle branch block. The ICD settings were increased while the patient was in the Emergency Department so that the first shock administered was increased from 12 to 24 joules. The patient was admitted to the Coronary Care Unit for continued intravenous amiodarone loading and further evaluation. PAST MEDICAL HISTORY: Coronary artery disease, status post myocardial infarction in <Year>1920</Year> and <Year>1920</Year>. He is status post multiple percutaneous transluminal coronary angioplasty and stents. Last catheterization on <Date>7/1934</Date> showed an ejection fraction of 15% with anterolateral apical and inferior akinesis. He had 2+ mitral regurgitation. He had a 40% distal left main lesion, left anterior descending flow was occluded. He had a 90% lesion at the left circumflex OM1 bifurcation. He had 50% R-PLV. Left circumflex was stented with percutaneous transluminal coronary angioplasty of a jailed OM1. Congestive heart failure, his last echocardiogram was <Year>1920</Year> with ejection fraction of 20% with global hypokinesis, akinesis. He has mild to moderate mitral regurgitation, ventricular tachycardia, status post single lead AICD in <Year>1920</Year>, hypercholesterolemia, hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea with a CPEP machine at home. MEDICATIONS ON ADMISSION: Flovent 220 mcg 2 puffs b.i.d., Procainamide 1500 mg po t.i.d., Captopril 50 mg po t.i.d., Lopressor 37.5 po b.i.d., Lipitor 20 mg po q.h.s., Lasix 60 mg po b.i.d., potassium chloride, Isordil 10 mg po t.i.d., aspirin 325 mg po q.d., Wellbutrin 100 mg po b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a retired policeman and works as a private investigator. He has a 60-70 pack year smoking history and quit in <Year>1920</Year>. He uses alcohol infrequently. He is married, but separated, and has two children. FAMILY HISTORY: His father for hypercholesterolemia and coronary artery disease. PHYSICAL EXAM ON ADMISSION: Temperature of 98.1. Pulse 82. Respiratory rate of 16. Blood pressure 120/74. O2 saturation of 96% on room air. On general exam, he is ruddy appearing, awake, alert, conversive white male in no acute distress. On head, eyes, ears, nose and throat exam, he is normocephalic, atraumatic. Pupils equal, round and reactive to light. Sclerae are anicteric. His mucous membranes were moist. His neck was supple with no lymphadenopathy or thyromegaly and no carotid bruits. Chest was clear to auscultation bilaterally. On cardiovascular exam, he had a regular rate and rhythm with normal S1, S2, soft systolic murmur at the upper sternal border with no rubs or gallops. His abdomen was soft, obese, nontender, nondistended with normal active bowel sounds. He had no hepatosplenomegaly. Extremities had no edema. Rectal exam, guaiac negative brown stool per Emergency Department report. LABORATORIES ON ADMISSION: White blood cell count of 12.8, hematocrit of 44, platelets of 176, sodium of 137, potassium 4.3, chloride of 100, bicarbonate of 25, BUN of 20, creatinine of 1.2, glucose of 96, CK of 47, magnesium of 2.1, Electrocardiogram showed regular wide complex tachycardia rate 116 with a leftward axis and left bundle branch block. Chest x-ray showed ICD in place in the left chest with some cardiomegaly, mild pulmonary vascular redistribution. HOSPITAL COURSE: The patient was admitted from the Emergency Department and was loaded on amiodarone intravenous in the Coronary Care Unit. The patient was brought to the EP laboratory for further evaluation of his dysrhythmias. The Procainamide was discontinued. In the EP laboratory, both atrial fibrillation and aflutter were found and the aflutter was ablated. The patient was also found to have ventricular tachycardias and these were not amenable to ablation. On the following day, the patient also underwent an upgrade of his ICD to a DDD pacemaker. The ICD was upgraded to a GEM3-AT7276 with <Company>Webb Ltd</Company> 5076 in the <Company>Webb Ltd</Company> 6937 with leads to the SVCRA junction and the RA appendage as well as to the right ventricle. The patient remained in stable condition throughout his hospital course. He did have occasional episodes of very brief tachycardia that were asymptomatic and with the upgrade of the ICD and pacemaker, any future episodes should be able to be recorded to distinguish between a ventricular versus a supraventricular cause of his tachycardia. The patient is being discharged to continue his Amiodarone load at 400 mg b.i.d. for one week, then 600 mg q.d. for three weeks and then to 200 mg q.d. The patient will continue with antibiotic prophylaxis, his Keflex for a total of 48 hours. He is also being started on a very low dose of Coumadin with follow-up INR within the next two days. The patient will have follow-up with the <Hospital>Rodriguez, Singleton and Huynh Medical Center</Hospital> Clinic on the week after discharge and he will also follow-up with Dr. <Name>Kibler</Name> in the following week. He is instructed not to drive or use his left arm until further instructions. Furthermore, he is instructed not to drive due to the issue of the syncope. DISCHARGE MEDICATIONS: 1. Amiodarone as described above. 2. Keflex 500 mg po q. 6. for another three doses. 3. Coumadin 2.5 mg q.h.s. until further notice. 4. Captopril 50 mg po t.i.d. 5. Lasix 60 mg po q.d. 6. Isordil 10 mg po t.i.d. 7. Aspirin 325 mg po q.d. 8. Wellbutrin 100 mg po b.i.d. 9. KCL as further directed. <Name>Tyler</Name> <Name>Chau</Name>, M.D. <MD Number>09596034</MD Number> Dictated By:<Name>Indira Yuen</Name> MEDQUIST36 D: <Date>1997-1-29</Date> 20:33 T: <Date>1997-1-29</Date> 20:33 JOB#: <Job Number>Graves, Dickerson and Clark-1975-560332</Job 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Date: 1955-9-29 Discharge Date: 1919-12-12 Date of Birth: 1952-6-27 Sex: M Service: EP SERVICE CHIEF COMPLAINT: Syncope. HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with an extensive cardiac history including coronary artery disease, status post myocardial infarction times two, status post multiple interventions, congestive heart failure with an ejection fraction less than 20%, ventricular tachycardia, status post AICD placement in 1920, who presented to the Emergency Department after syncopal episodes and AICD firing. The patient noted three days prior to admission, feeling of palpitations especially when lying down for bed. On the day of admission, the patient became lightheaded a while, bending down to tie his shoes and felt some palpitations. He then felt a shock from his ICD. He, thereafter, awoke on the floor. Over the course of the day, he had three more episodes, a feeling of palpitations, and lightheadedness followed by a shock and then losing consciousness. In the Emergency Department, the patient was observed to have an irregular wide complex tachycardia consistent with atrial fibrillation in the setting of his underlying left bundle branch block. While in the Emergency Department, he developed transient regular wide complex tachycardia to approximately 170 beats per minute. His ICD fired during this rhythm and was subsequently degenerated into a ventricular fibrillation, prompting the ICD to fire again, recovering the rhythm back to atrial fibrillation. An amiodarone load was begun and the patient appeared to spontaneously convert to sinus rhythm with left bundle branch block. The ICD settings were increased while the patient was in the Emergency Department so that the first shock administered was increased from 12 to 24 joules. The patient was admitted to the Coronary Care Unit for continued intravenous amiodarone loading and further evaluation. PAST MEDICAL HISTORY: Coronary artery disease, status post myocardial infarction in 1920 and 1920. He is status post multiple percutaneous transluminal coronary angioplasty and stents. Last catheterization on 7/1934 showed an ejection fraction of 15% with anterolateral apical and inferior akinesis. He had 2+ mitral regurgitation. He had a 40% distal left main lesion, left anterior descending flow was occluded. He had a 90% lesion at the left circumflex OM1 bifurcation. He had 50% R-PLV. Left circumflex was stented with percutaneous transluminal coronary angioplasty of a jailed OM1. Congestive heart failure, his last echocardiogram was 1920 with ejection fraction of 20% with global hypokinesis, akinesis. He has mild to moderate mitral regurgitation, ventricular tachycardia, status post single lead AICD in 1920, hypercholesterolemia, hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea with a CPEP machine at home. MEDICATIONS ON ADMISSION: Flovent 220 mcg 2 puffs b.i.d., Procainamide 1500 mg po t.i.d., Captopril 50 mg po t.i.d., Lopressor 37.5 po b.i.d., Lipitor 20 mg po q.h.s., Lasix 60 mg po b.i.d., potassium chloride, Isordil 10 mg po t.i.d., aspirin 325 mg po q.d., Wellbutrin 100 mg po b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a retired policeman and works as a private investigator. He has a 60-70 pack year smoking history and quit in 1920. He uses alcohol infrequently. He is married, but separated, and has two children. FAMILY HISTORY: His father for hypercholesterolemia and coronary artery disease. PHYSICAL EXAM ON ADMISSION: Temperature of 98.1. Pulse 82. Respiratory rate of 16. Blood pressure 120/74. O2 saturation of 96% on room air. On general exam, he is ruddy appearing, awake, alert, conversive white male in no acute distress. On head, eyes, ears, nose and throat exam, he is normocephalic, atraumatic. Pupils equal, round and reactive to light. Sclerae are anicteric. His mucous membranes were moist. His neck was supple with no lymphadenopathy or thyromegaly and no carotid bruits. Chest was clear to auscultation bilaterally. On cardiovascular exam, he had a regular rate and rhythm with normal S1, S2, soft systolic murmur at the upper sternal border with no rubs or gallops. His abdomen was soft, obese, nontender, nondistended with normal active bowel sounds. He had no hepatosplenomegaly. Extremities had no edema. Rectal exam, guaiac negative brown stool per Emergency Department report. LABORATORIES ON ADMISSION: White blood cell count of 12.8, hematocrit of 44, platelets of 176, sodium of 137, potassium 4.3, chloride of 100, bicarbonate of 25, BUN of 20, creatinine of 1.2, glucose of 96, CK of 47, magnesium of 2.1, Electrocardiogram showed regular wide complex tachycardia rate 116 with a leftward axis and left bundle branch block. Chest x-ray showed ICD in place in the left chest with some cardiomegaly, mild pulmonary vascular redistribution. HOSPITAL COURSE: The patient was admitted from the Emergency Department and was loaded on amiodarone intravenous in the Coronary Care Unit. The patient was brought to the EP laboratory for further evaluation of his dysrhythmias. The Procainamide was discontinued. In the EP laboratory, both atrial fibrillation and aflutter were found and the aflutter was ablated. The patient was also found to have ventricular tachycardias and these were not amenable to ablation. On the following day, the patient also underwent an upgrade of his ICD to a DDD pacemaker. The ICD was upgraded to a GEM3-AT7276 with Webb Ltd 5076 in the Webb Ltd 6937 with leads to the SVCRA junction and the RA appendage as well as to the right ventricle. The patient remained in stable condition throughout his hospital course. He did have occasional episodes of very brief tachycardia that were asymptomatic and with the upgrade of the ICD and pacemaker, any future episodes should be able to be recorded to distinguish between a ventricular versus a supraventricular cause of his tachycardia. The patient is being discharged to continue his Amiodarone load at 400 mg b.i.d. for one week, then 600 mg q.d. for three weeks and then to 200 mg q.d. The patient will continue with antibiotic prophylaxis, his Keflex for a total of 48 hours. He is also being started on a very low dose of Coumadin with follow-up INR within the next two days. The patient will have follow-up with the Rodriguez, Singleton and Huynh Medical Center Clinic on the week after discharge and he will also follow-up with Dr. Kibler in the following week. He is instructed not to drive or use his left arm until further instructions. Furthermore, he is instructed not to drive due to the issue of the syncope. DISCHARGE MEDICATIONS: 1. Amiodarone as described above. 2. Keflex 500 mg po q. 6. for another three doses. 3. Coumadin 2.5 mg q.h.s. until further notice. 4. Captopril 50 mg po t.i.d. 5. Lasix 60 mg po q.d. 6. Isordil 10 mg po t.i.d. 7. Aspirin 325 mg po q.d. 8. Wellbutrin 100 mg po b.i.d. 9. KCL as further directed. Tyler Chau, M.D. 09596034 Dictated By:Indira Yuen MEDQUIST36 D: 1997-1-29 20:33 T: 1997-1-29 20:33 JOB#: Graves, Dickerson and Clark-1975-560332	['Admission Date: 1955-9-29 Discharge Date: 1919-12-12\n\nDate of Birth: 1952-6-27 Sex: M\n\nService: EP SERVICE\n\nCHIEF COMPLAINT: Syncope.\n\nHISTORY OF PRESENT ILLNESS: This is a 64-year-old man with\nan extensive cardiac history including coronary artery\ndisease, status post myocardial infarction times two, status\npost multiple interventions, congestive heart failure with an\nejection fraction less than 20%, ventricular tachycardia,\nstatus post AICD placement in 1920, who presented to the\nEmergency Department after syncopal episodes and AICD firing.\nThe patient noted three days prior to admission, feeling of\npalpitations especially when lying down for bed. On the day\nof admission, the patient became lightheaded a while, bending\ndown to tie his shoes and felt some palpitations. He then\nfelt a shock from his ICD.', ' He, thereafter, awoke on the\nfloor. Over the course of the day, he had three more\nepisodes, a feeling of palpitations, and lightheadedness\nfollowed by a shock and then losing consciousness.\n\nIn the Emergency Department, the patient was observed to have\nan irregular wide complex tachycardia consistent with atrial\nfibrillation in the setting of his underlying left bundle\nbranch block. While in the Emergency Department, he\ndeveloped transient regular wide complex tachycardia to\napproximately 170 beats per minute. His ICD fired during\nthis rhythm and was subsequently degenerated into a\nventricular fibrillation, prompting the ICD to fire again,\nrecovering the rhythm back to atrial fibrillation. An\namiodarone load was begun and the patient appeared to\nspontaneously convert to sinus rhythm with left bundle branch\nblock.', ' The ICD settings were increased while the patient was\nin the Emergency Department so that the first shock\nadministered was increased from 12 to 24 joules. The patient\nwas admitted to the Coronary Care Unit for continued\nintravenous amiodarone loading and further evaluation.\n\nPAST MEDICAL HISTORY: Coronary artery disease, status post\nmyocardial infarction in 1920 and 1920. He is status post\nmultiple percutaneous transluminal coronary angioplasty and\nstents. Last catheterization on 7/1934 showed an ejection\nfraction of 15% with anterolateral apical and inferior\nakinesis. He had 2+ mitral regurgitation. He had a 40%\ndistal left main lesion, left anterior descending flow was\noccluded. He had a 90% lesion at the left circumflex OM1\nbifurcation. He had 50% R-PLV. Left circumflex was stented\nwith percutaneous transluminal coronary angioplasty of a\njailed OM1.', ' Congestive heart failure, his last\nechocardiogram was 1920 with ejection fraction of 20% with\nglobal hypokinesis, akinesis. He has mild to moderate mitral\nregurgitation, ventricular tachycardia, status post single\nlead AICD in 1920, hypercholesterolemia, hypertension,\nchronic obstructive pulmonary disease, obstructive sleep\napnea with a CPEP machine at home.\n\nMEDICATIONS ON ADMISSION: Flovent 220 mcg 2 puffs b.i.d.,\nProcainamide 1500 mg po t.i.d., Captopril 50 mg po t.i.d.,\nLopressor 37.5 po b.i.d., Lipitor 20 mg po q.h.s., Lasix 60\nmg po b.i.d., potassium chloride, Isordil 10 mg po t.i.d.,\naspirin 325 mg po q.d., Wellbutrin 100 mg po b.i.d.\n\nALLERGIES: No known drug allergies.\n\nSOCIAL HISTORY: He is a retired policeman and works as a\nprivate investigator. He has a 60-70 pack year smoking\nhistory and quit in 1920.', ' He uses alcohol infrequently. He\nis married, but separated, and has two children.\n\nFAMILY HISTORY: His father for hypercholesterolemia and\ncoronary artery disease.\n\nPHYSICAL EXAM ON ADMISSION: Temperature of 98.1. Pulse 82.\nRespiratory rate of 16. Blood pressure 120/74. O2 saturation\nof 96% on room air. On general exam, he is ruddy appearing,\nawake, alert, conversive white male in no acute distress. On\nhead, eyes, ears, nose and throat exam, he is normocephalic,\natraumatic. Pupils equal, round and reactive to light.\nSclerae are anicteric. His mucous membranes were moist. His\nneck was supple with no lymphadenopathy or thyromegaly and no\ncarotid bruits. Chest was clear to auscultation bilaterally.\nOn cardiovascular exam, he had a regular rate and rhythm with\nnormal S1, S2, soft systolic murmur at the upper sternal\nborder with no rubs or gallops.', ' His abdomen was soft, obese,\nnontender, nondistended with normal active bowel sounds. He\nhad no hepatosplenomegaly. Extremities had no edema. Rectal\nexam, guaiac negative brown stool per Emergency Department\nreport.\n\nLABORATORIES ON ADMISSION: White blood cell count of 12.8,\nhematocrit of 44, platelets of 176, sodium of 137, potassium\n4.3, chloride of 100, bicarbonate of 25, BUN of 20,\ncreatinine of 1.2, glucose of 96, CK of 47, magnesium of 2.1,\n\nElectrocardiogram showed regular wide complex tachycardia\nrate 116 with a leftward axis and left bundle branch block.\n\nChest x-ray showed ICD in place in the left chest with some\ncardiomegaly, mild pulmonary vascular redistribution.\n\nHOSPITAL COURSE: The patient was admitted from the Emergency\nDepartment and was loaded on amiodarone intravenous in the\nCoronary Care Unit.', ' The patient was brought to the EP\nlaboratory for further evaluation of his dysrhythmias. The\nProcainamide was discontinued. In the EP laboratory, both\natrial fibrillation and aflutter were found and the aflutter\nwas ablated. The patient was also found to have ventricular\ntachycardias and these were not amenable to ablation. On the\nfollowing day, the patient also underwent an upgrade of his\nICD to a DDD pacemaker. The ICD was upgraded to a\nGEM3-AT7276 with Webb Ltd 5076 in the Webb Ltd 6937 with\nleads to the SVCRA junction and the RA appendage as well as\nto the right ventricle. The patient remained in stable\ncondition throughout his hospital course. He did have\noccasional episodes of very brief tachycardia that were\nasymptomatic and with the upgrade of the ICD and pacemaker,\nany future episodes should be able to be recorded to\ndistinguish between a ventricular versus a supraventricular\ncause of his tachycardia.', '\n\nThe patient is being discharged to continue his Amiodarone\nload at 400 mg b.i.d. for one week, then 600 mg q.d. for\nthree weeks and then to 200 mg q.d. The patient will\ncontinue with antibiotic prophylaxis, his Keflex for a total\nof 48 hours. He is also being started on a very low dose of\nCoumadin with follow-up INR within the next two days. The\npatient will have follow-up with the Rodriguez, Singleton and Huynh Medical Center Clinic on the week\nafter discharge and he will also follow-up with Dr. Kibler in\nthe following week. He is instructed not to drive or use his\nleft arm until further instructions. Furthermore, he is\ninstructed not to drive due to the issue of the syncope.\n\nDISCHARGE MEDICATIONS:\n1. Amiodarone as described above.\n2. Keflex 500 mg po q. 6. for another three doses.', '\n3. Coumadin 2.5 mg q.h.s. until further notice.\n4. Captopril 50 mg po t.i.d.\n5. Lasix 60 mg po q.d.\n6. Isordil 10 mg po t.i.d.\n7. Aspirin 325 mg po q.d.\n8. Wellbutrin 100 mg po b.i.d.\n9. KCL as further directed.\n\n\n Tyler Chau, M.D. 09596034\n\nDictated By:Indira Yuen\n\nMEDQUIST36\n\nD: 1997-1-29 20:33\nT: 1997-1-29 20:33\nJOB#: Graves, Dickerson and Clark-1975-560332\n']
147	7234	128174.0	2161-01-10	Discharge summary	Report	Admission Date: [2160-12-25] Discharge Date: [2161-1-10] Date of Birth: [2095-10-21] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with a history of ischemic dilated cardiomyopathy who presents with five days of shortness of breath. He developed the shortness of breath in the setting of cough, lethargy and subjective fevers. He presents to the Emergency Room where he was found to be significant dyspneic. Physical examination revealed evidence of pulmonary edema and a chest x-ray showed bilateral infiltrates. His oxygen saturation was 86% on room air. His ABG was 7.54, 48, 27. He was given supplemental oxygen and 60 mg of IV Lasix with a good response and his oxygen saturation increased to 90% on three liters. He was admitted to the cardiac floor with a diagnosis of a CHF exacerbation. About one hour after arriving on the floor, about five hours after presentation, he was found to be acutely hypoxic with an oxygen saturation in the low 80's despite being on 100% non rebreather. EKG showed possible inferior ST elevations in the setting of a paced left bundle branch block. He continued to be hypoxic despite an additional 200 mg IV of Lasix, Heparin and a Nitro drip. For this reason he was emergently intubated and transferred to the CCU. On arrival to the CCU he was noted to have a temperature of 103.5. His heart rate was increased and his blood pressure was low. His urine output dropped off. He was started on Dopamine and his Nitro drip was stopped. He was also started on Vanco, Levo and Flagyl. As he defervesced, his vital signs stabilized and he began to have normal urine output again. PAST MEDICAL HISTORY: 1) Coronary artery disease status post anterior MI times two in [2136], in [2145] with an IMI in [2150]. Cath in [2160-7-16] revealed two vessel coronary artery disease with a left ventricular apical aneurysm. 2) Congestive heart failure with an EF of 20%. 3) Status post AICD placement for monomorphic ventricular tachycardia upgraded in [2160-2-14]. 4) Atrial fibrillation, status post ablation in [2160-2-14], currently on Amiodarone. 5) Hypertension. 6) Hypercholesterolemia. 7) Chronic obstructive pulmonary disease. 8) Obstructive sleep apnea on bi-pap of 15 and 10 at home. MEDICATIONS: Amiodarone 400 mg q day, Lasix 120 mg q a.m., Lipitor 20 mg q day, Aspirin 81 mg q day, Potassium Chloride 16 mEq q day, Captopril 12.5 mg tid, recently decreased from 25 mg tid, Coreg 18.75 mg [Hospital1 ], Xanax 0.25 mg tid, Multivitamin, Vitamin E, Coumadin 2.5 mg q day except for 5 mg on Tuesday and Saturday, Zaroxolyn 2.5 mg po q week, Mirapex 0.125 mg q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Works as a private investigator. Is separated from his wife. [Name (NI) ] a 55 pack year history of smoking and quit in [2155]. Uses alcohol socially. Has no history of drug abuse. PHYSICAL EXAMINATION: This is a 65-year-old man who was intubated and sedated with a blood pressure of 93/42 on 5 of Dopamine. Heart rate is 60 and he is satting 100% on 100% FIO2. His HEENT exam is unremarkable. His neck is supple with bounding carotid pulses. His chest is clear anterolaterally. His heart is regular with no murmurs, rubs or gallops. His abdomen is benign. His extremities are without edema with 2+ distal pulses. His neuro exam is non focal. LABORATORY DATA: He has a white count of 18.8, hematocrit 26.6 and platelet count 286,000. His dip shows 96% polys, 2% lymphs and 2% monos. His Chem 7 is remarkable for a sodium of 130 and a creatinine of 2.2, up from his baseline of 2.0. His INR is 3.6 on Coumadin. His fibrinogen is 519 and d-dimer is less than 500. His reticulocyte count is 1.6. His EKG showed a paced left bundle branch block with a rate of about 70. HOSPITAL COURSE: Mr. [Known lastname 1549] was admitted to the coronary care unit and started on antibiotics for presumed pneumonia given his presentation with cough and fever. He was intubated for hypoxic respiratory distress. He was maintained on pressors for his hypotension. He was continued on the Levofloxacin of his antibiotics an defervesced after about 24 hours. He was diuresed about 3 liters and his pressors were able to be weaned off. He was successfully extubated two days after intubation. The next day his Captopril was restarted at 6.25 mg. He tolerated his first dose. With his second dose, his blood pressure dropped into the 70's/30's. He was started on Dopamine and Levophed. At this point he spiked a fever. Fluid boluses were given to try to augment his pressure. However, he again began to suffer from hypoxic respiratory arrest with a gas of 7.4, 32 and 47. A PA catheter was placed to better assess his hemodynamics. His CVP was 8, wedge pressure was 35, cardiac index was 2.0. At this point Dobutamine was started in addition to the Dopamine and Levophed. He was reintubated. His PA pressures were in the 70's/40's. His systolic blood pressure was in the 70's and diastolic blood pressure was in the 50's. He received Lasix and Morphine overnight. He spiked again the following day. He was diuresed down to [Initials (NamePattern4) ] [Last Name (NamePattern4) 1554] in the low 20's and a pulmonary capillary wedge pressure of 17. On the Dobutamine he was able to be weaned. He had cardiac index of 2.1 to 2.2 and was able to be weaned off of pressors. Vancomycin was started with concern for either nosocomial pneumonia or line infection. On the Vancomycin, he defervesced. LFTs were checked to see if there was any hidden source of infection that we might be missing. His LFTs, amylase and lipase were increased and abdominal CT was obtained which showed no signs of pancreatic inflammation or liver or gallbladder pathology. After his pressors were weaned off, he was also weaned off the Dobutamine. His Swan was removed and he was successfully extubated again five days after his second intubation. He did well initially but was approximately 1?????? liters positive by the next morning and had an episode where he desatted with an increase in his respiratory rate. He did not respond to a 60 mg shot of IV Lasix and his sats continued to drop into the 80's. He was reintubated a third time. At this point his blood pressure once again dropped and he was restarted on Dopamine. After this he spiked again. Over the next three days he was continued to be diuresed and he was kept on minimal sedation to try to avoid any medicine that would lower his blood pressure. Frequent family meetings were held during his course. Decision was made to have one last try with Milrinone to try to improve his cardiac index. On Milrinone he was able to be weaned off of pressors and he had good Swan parameters as the Swan was refloated after his third intubation. However, multiple attempts to wean him off the ventilator failed. The team addressed the possibility of trach placement in a long-term wean with the family. The family stated that he would not have wanted that kind of quality of life and so the decision was made to withdraw ventilatory support. He passed away peacefully with his family at his side on [2161-1-10] at 3:05 p.m. [Known firstname ] [Last Name (NamePattern4) 1544], M.D. [MD Number(1) 1545] Dictated By:[Name8 (MD) 1552] MEDQUIST36 D: [2161-1-27] 21:22 T: [2161-1-29] 16:36 JOB#: [Job Number 1555]	Admission Date: <Date>1980-8-5</Date> Discharge Date: <Date>1949-7-13</Date> Date of Birth: <Date>1973-1-16</Date> Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with a history of ischemic dilated cardiomyopathy who presents with five days of shortness of breath. He developed the shortness of breath in the setting of cough, lethargy and subjective fevers. He presents to the Emergency Room where he was found to be significant dyspneic. Physical examination revealed evidence of pulmonary edema and a chest x-ray showed bilateral infiltrates. His oxygen saturation was 86% on room air. His ABG was 7.54, 48, 27. He was given supplemental oxygen and 60 mg of IV Lasix with a good response and his oxygen saturation increased to 90% on three liters. He was admitted to the cardiac floor with a diagnosis of a CHF exacerbation. About one hour after arriving on the floor, about five hours after presentation, he was found to be acutely hypoxic with an oxygen saturation in the low 80's despite being on 100% non rebreather. EKG showed possible inferior ST elevations in the setting of a paced left bundle branch block. He continued to be hypoxic despite an additional 200 mg IV of Lasix, Heparin and a Nitro drip. For this reason he was emergently intubated and transferred to the CCU. On arrival to the CCU he was noted to have a temperature of 103.5. His heart rate was increased and his blood pressure was low. His urine output dropped off. He was started on Dopamine and his Nitro drip was stopped. He was also started on Vanco, Levo and Flagyl. As he defervesced, his vital signs stabilized and he began to have normal urine output again. PAST MEDICAL HISTORY: 1) Coronary artery disease status post anterior MI times two in <Year>1973</Year>, in <Year>1973</Year> with an IMI in <Year>1973</Year>. Cath in <Date>2004-10-29</Date> revealed two vessel coronary artery disease with a left ventricular apical aneurysm. 2) Congestive heart failure with an EF of 20%. 3) Status post AICD placement for monomorphic ventricular tachycardia upgraded in <Date>1986-1-6</Date>. 4) Atrial fibrillation, status post ablation in <Date>1986-1-6</Date>, currently on Amiodarone. 5) Hypertension. 6) Hypercholesterolemia. 7) Chronic obstructive pulmonary disease. 8) Obstructive sleep apnea on bi-pap of 15 and 10 at home. MEDICATIONS: Amiodarone 400 mg q day, Lasix 120 mg q a.m., Lipitor 20 mg q day, Aspirin 81 mg q day, Potassium Chloride 16 mEq q day, Captopril 12.5 mg tid, recently decreased from 25 mg tid, Coreg 18.75 mg <Hospital>Johnson-Fleming Hospital</Hospital>, Xanax 0.25 mg tid, Multivitamin, Vitamin E, Coumadin 2.5 mg q day except for 5 mg on Tuesday and Saturday, Zaroxolyn 2.5 mg po q week, Mirapex 0.125 mg q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Works as a private investigator. Is separated from his wife. <Name>Uma Son</Name> a 55 pack year history of smoking and quit in <Year>1973</Year>. Uses alcohol socially. Has no history of drug abuse. PHYSICAL EXAMINATION: This is a 65-year-old man who was intubated and sedated with a blood pressure of 93/42 on 5 of Dopamine. Heart rate is 60 and he is satting 100% on 100% FIO2. His HEENT exam is unremarkable. His neck is supple with bounding carotid pulses. His chest is clear anterolaterally. His heart is regular with no murmurs, rubs or gallops. His abdomen is benign. His extremities are without edema with 2+ distal pulses. His neuro exam is non focal. LABORATORY DATA: He has a white count of 18.8, hematocrit 26.6 and platelet count 286,000. His dip shows 96% polys, 2% lymphs and 2% monos. His Chem 7 is remarkable for a sodium of 130 and a creatinine of 2.2, up from his baseline of 2.0. His INR is 3.6 on Coumadin. His fibrinogen is 519 and d-dimer is less than 500. His reticulocyte count is 1.6. His EKG showed a paced left bundle branch block with a rate of about 70. HOSPITAL COURSE: Mr. <Name>Johnson</Name> was admitted to the coronary care unit and started on antibiotics for presumed pneumonia given his presentation with cough and fever. He was intubated for hypoxic respiratory distress. He was maintained on pressors for his hypotension. He was continued on the Levofloxacin of his antibiotics an defervesced after about 24 hours. He was diuresed about 3 liters and his pressors were able to be weaned off. He was successfully extubated two days after intubation. The next day his Captopril was restarted at 6.25 mg. He tolerated his first dose. With his second dose, his blood pressure dropped into the 70's/30's. He was started on Dopamine and Levophed. At this point he spiked a fever. Fluid boluses were given to try to augment his pressure. However, he again began to suffer from hypoxic respiratory arrest with a gas of 7.4, 32 and 47. A PA catheter was placed to better assess his hemodynamics. His CVP was 8, wedge pressure was 35, cardiac index was 2.0. At this point Dobutamine was started in addition to the Dopamine and Levophed. He was reintubated. His PA pressures were in the 70's/40's. His systolic blood pressure was in the 70's and diastolic blood pressure was in the 50's. He received Lasix and Morphine overnight. He spiked again the following day. He was diuresed down to <Initial>FV</Initial> <Name>Sakkas</Name> in the low 20's and a pulmonary capillary wedge pressure of 17. On the Dobutamine he was able to be weaned. He had cardiac index of 2.1 to 2.2 and was able to be weaned off of pressors. Vancomycin was started with concern for either nosocomial pneumonia or line infection. On the Vancomycin, he defervesced. LFTs were checked to see if there was any hidden source of infection that we might be missing. His LFTs, amylase and lipase were increased and abdominal CT was obtained which showed no signs of pancreatic inflammation or liver or gallbladder pathology. After his pressors were weaned off, he was also weaned off the Dobutamine. His Swan was removed and he was successfully extubated again five days after his second intubation. He did well initially but was approximately 1?????? liters positive by the next morning and had an episode where he desatted with an increase in his respiratory rate. He did not respond to a 60 mg shot of IV Lasix and his sats continued to drop into the 80's. He was reintubated a third time. At this point his blood pressure once again dropped and he was restarted on Dopamine. After this he spiked again. Over the next three days he was continued to be diuresed and he was kept on minimal sedation to try to avoid any medicine that would lower his blood pressure. Frequent family meetings were held during his course. Decision was made to have one last try with Milrinone to try to improve his cardiac index. On Milrinone he was able to be weaned off of pressors and he had good Swan parameters as the Swan was refloated after his third intubation. However, multiple attempts to wean him off the ventilator failed. The team addressed the possibility of trach placement in a long-term wean with the family. The family stated that he would not have wanted that kind of quality of life and so the decision was made to withdraw ventilatory support. He passed away peacefully with his family at his side on <Date>1949-7-13</Date> at 3:05 p.m. <Name>Latrice</Name> <Name>Starks</Name>, M.D. <MD Number>08842517</MD Number> Dictated By:<Name>Zachary Abdullah</Name> MEDQUIST36 D: <Date>1923-6-11</Date> 21:22 T: <Date>1953-12-15</Date> 16:36 JOB#: <Job Number>Curtis, Harris and Williams-2015-054158</Job 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Date: 1980-8-5 Discharge Date: 1949-7-13 Date of Birth: 1973-1-16 Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with a history of ischemic dilated cardiomyopathy who presents with five days of shortness of breath. He developed the shortness of breath in the setting of cough, lethargy and subjective fevers. He presents to the Emergency Room where he was found to be significant dyspneic. Physical examination revealed evidence of pulmonary edema and a chest x-ray showed bilateral infiltrates. His oxygen saturation was 86% on room air. His ABG was 7.54, 48, 27. He was given supplemental oxygen and 60 mg of IV Lasix with a good response and his oxygen saturation increased to 90% on three liters. He was admitted to the cardiac floor with a diagnosis of a CHF exacerbation. About one hour after arriving on the floor, about five hours after presentation, he was found to be acutely hypoxic with an oxygen saturation in the low 80's despite being on 100% non rebreather. EKG showed possible inferior ST elevations in the setting of a paced left bundle branch block. He continued to be hypoxic despite an additional 200 mg IV of Lasix, Heparin and a Nitro drip. For this reason he was emergently intubated and transferred to the CCU. On arrival to the CCU he was noted to have a temperature of 103.5. His heart rate was increased and his blood pressure was low. His urine output dropped off. He was started on Dopamine and his Nitro drip was stopped. He was also started on Vanco, Levo and Flagyl. As he defervesced, his vital signs stabilized and he began to have normal urine output again. PAST MEDICAL HISTORY: 1) Coronary artery disease status post anterior MI times two in 1973, in 1973 with an IMI in 1973. Cath in 2004-10-29 revealed two vessel coronary artery disease with a left ventricular apical aneurysm. 2) Congestive heart failure with an EF of 20%. 3) Status post AICD placement for monomorphic ventricular tachycardia upgraded in 1986-1-6. 4) Atrial fibrillation, status post ablation in 1986-1-6, currently on Amiodarone. 5) Hypertension. 6) Hypercholesterolemia. 7) Chronic obstructive pulmonary disease. 8) Obstructive sleep apnea on bi-pap of 15 and 10 at home. MEDICATIONS: Amiodarone 400 mg q day, Lasix 120 mg q a.m., Lipitor 20 mg q day, Aspirin 81 mg q day, Potassium Chloride 16 mEq q day, Captopril 12.5 mg tid, recently decreased from 25 mg tid, Coreg 18.75 mg Johnson-Fleming Hospital, Xanax 0.25 mg tid, Multivitamin, Vitamin E, Coumadin 2.5 mg q day except for 5 mg on Tuesday and Saturday, Zaroxolyn 2.5 mg po q week, Mirapex 0.125 mg q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Works as a private investigator. Is separated from his wife. Uma Son a 55 pack year history of smoking and quit in 1973. Uses alcohol socially. Has no history of drug abuse. PHYSICAL EXAMINATION: This is a 65-year-old man who was intubated and sedated with a blood pressure of 93/42 on 5 of Dopamine. Heart rate is 60 and he is satting 100% on 100% FIO2. His HEENT exam is unremarkable. His neck is supple with bounding carotid pulses. His chest is clear anterolaterally. His heart is regular with no murmurs, rubs or gallops. His abdomen is benign. His extremities are without edema with 2+ distal pulses. His neuro exam is non focal. LABORATORY DATA: He has a white count of 18.8, hematocrit 26.6 and platelet count 286,000. His dip shows 96% polys, 2% lymphs and 2% monos. His Chem 7 is remarkable for a sodium of 130 and a creatinine of 2.2, up from his baseline of 2.0. His INR is 3.6 on Coumadin. His fibrinogen is 519 and d-dimer is less than 500. His reticulocyte count is 1.6. His EKG showed a paced left bundle branch block with a rate of about 70. HOSPITAL COURSE: Mr. Johnson was admitted to the coronary care unit and started on antibiotics for presumed pneumonia given his presentation with cough and fever. He was intubated for hypoxic respiratory distress. He was maintained on pressors for his hypotension. He was continued on the Levofloxacin of his antibiotics an defervesced after about 24 hours. He was diuresed about 3 liters and his pressors were able to be weaned off. He was successfully extubated two days after intubation. The next day his Captopril was restarted at 6.25 mg. He tolerated his first dose. With his second dose, his blood pressure dropped into the 70's/30's. He was started on Dopamine and Levophed. At this point he spiked a fever. Fluid boluses were given to try to augment his pressure. However, he again began to suffer from hypoxic respiratory arrest with a gas of 7.4, 32 and 47. A PA catheter was placed to better assess his hemodynamics. His CVP was 8, wedge pressure was 35, cardiac index was 2.0. At this point Dobutamine was started in addition to the Dopamine and Levophed. He was reintubated. His PA pressures were in the 70's/40's. His systolic blood pressure was in the 70's and diastolic blood pressure was in the 50's. He received Lasix and Morphine overnight. He spiked again the following day. He was diuresed down to FV Sakkas in the low 20's and a pulmonary capillary wedge pressure of 17. On the Dobutamine he was able to be weaned. He had cardiac index of 2.1 to 2.2 and was able to be weaned off of pressors. Vancomycin was started with concern for either nosocomial pneumonia or line infection. On the Vancomycin, he defervesced. LFTs were checked to see if there was any hidden source of infection that we might be missing. His LFTs, amylase and lipase were increased and abdominal CT was obtained which showed no signs of pancreatic inflammation or liver or gallbladder pathology. After his pressors were weaned off, he was also weaned off the Dobutamine. His Swan was removed and he was successfully extubated again five days after his second intubation. He did well initially but was approximately 1?????? liters positive by the next morning and had an episode where he desatted with an increase in his respiratory rate. He did not respond to a 60 mg shot of IV Lasix and his sats continued to drop into the 80's. He was reintubated a third time. At this point his blood pressure once again dropped and he was restarted on Dopamine. After this he spiked again. Over the next three days he was continued to be diuresed and he was kept on minimal sedation to try to avoid any medicine that would lower his blood pressure. Frequent family meetings were held during his course. Decision was made to have one last try with Milrinone to try to improve his cardiac index. On Milrinone he was able to be weaned off of pressors and he had good Swan parameters as the Swan was refloated after his third intubation. However, multiple attempts to wean him off the ventilator failed. The team addressed the possibility of trach placement in a long-term wean with the family. The family stated that he would not have wanted that kind of quality of life and so the decision was made to withdraw ventilatory support. He passed away peacefully with his family at his side on 1949-7-13 at 3:05 p.m. Latrice Starks, M.D. 08842517 Dictated By:Zachary Abdullah MEDQUIST36 D: 1923-6-11 21:22 T: 1953-12-15 16:36 JOB#: Curtis, Harris and Williams-2015-054158	['Admission Date: 1980-8-5 Discharge Date: 1949-7-13\n\nDate of Birth: 1973-1-16 Sex: M\n\nService:\n\nHISTORY OF PRESENT ILLNESS: This is a 64-year-old man with a\nhistory of ischemic dilated cardiomyopathy who presents with\nfive days of shortness of breath. He developed the shortness\nof breath in the setting of cough, lethargy and subjective\nfevers. He presents to the Emergency Room where he was found\nto be significant dyspneic. Physical examination revealed\nevidence of pulmonary edema and a chest x-ray showed\nbilateral infiltrates. His oxygen saturation was 86% on room\nair. His ABG was 7.54, 48, 27. He was given supplemental\noxygen and 60 mg of IV Lasix with a good response and his\noxygen saturation increased to 90% on three liters. He was\nadmitted to the cardiac floor with a diagnosis of a CHF\nexacerbation.', "\n\nAbout one hour after arriving on the floor, about five hours\nafter presentation, he was found to be acutely hypoxic with\nan oxygen saturation in the low 80's despite being on 100%\nnon rebreather. EKG showed possible inferior ST elevations\nin the setting of a paced left bundle branch block. He\ncontinued to be hypoxic despite an additional 200 mg IV of\nLasix, Heparin and a Nitro drip. For this reason he was\nemergently intubated and transferred to the CCU.\n\nOn arrival to the CCU he was noted to have a temperature of\n103.5. His heart rate was increased and his blood pressure\nwas low. His urine output dropped off. He was started on\nDopamine and his Nitro drip was stopped. He was also started\non Vanco, Levo and Flagyl. As he defervesced, his vital\nsigns stabilized and he began to have normal urine output\nagain.", '\n\nPAST MEDICAL HISTORY: 1) Coronary artery disease status post\nanterior MI times two in 1973, in 1973 with an IMI in 1973.\nCath in 2004-10-29 revealed two vessel coronary artery\ndisease with a left ventricular apical aneurysm. 2)\nCongestive heart failure with an EF of 20%. 3) Status post\nAICD placement for monomorphic ventricular tachycardia\nupgraded in 1986-1-6. 4) Atrial fibrillation, status post\nablation in 1986-1-6, currently on Amiodarone. 5)\nHypertension. 6) Hypercholesterolemia. 7) Chronic\nobstructive pulmonary disease. 8) Obstructive sleep apnea on\nbi-pap of 15 and 10 at home.\n\nMEDICATIONS: Amiodarone 400 mg q day, Lasix 120 mg q a.m.,\nLipitor 20 mg q day, Aspirin 81 mg q day, Potassium Chloride\n16 mEq q day, Captopril 12.5 mg tid, recently decreased from\n25 mg tid, Coreg 18.', '75 mg Johnson-Fleming Hospital, Xanax 0.25 mg tid,\nMultivitamin, Vitamin E, Coumadin 2.5 mg q day except for 5\nmg on Tuesday and Saturday, Zaroxolyn 2.5 mg po q week,\nMirapex 0.125 mg q day.\n\nALLERGIES: No known drug allergies.\n\nSOCIAL HISTORY: Works as a private investigator. Is\nseparated from his wife. Uma Son a 55 pack year history of\nsmoking and quit in 1973. Uses alcohol socially. Has no\nhistory of drug abuse.\n\nPHYSICAL EXAMINATION: This is a 65-year-old man who was\nintubated and sedated with a blood pressure of 93/42 on 5 of\nDopamine. Heart rate is 60 and he is satting 100% on 100%\nFIO2. His HEENT exam is unremarkable. His neck is supple\nwith bounding carotid pulses. His chest is clear\nanterolaterally. His heart is regular with no murmurs, rubs\nor gallops. His abdomen is benign.', ' His extremities are\nwithout edema with 2+ distal pulses. His neuro exam is non\nfocal.\n\nLABORATORY DATA: He has a white count of 18.8, hematocrit\n26.6 and platelet count 286,000. His dip shows 96% polys, 2%\nlymphs and 2% monos. His Chem 7 is remarkable for a sodium\nof 130 and a creatinine of 2.2, up from his baseline of 2.0.\nHis INR is 3.6 on Coumadin. His fibrinogen is 519 and\nd-dimer is less than 500. His reticulocyte count is 1.6.\nHis EKG showed a paced left bundle branch block with a rate\nof about 70.\n\nHOSPITAL COURSE: Mr. Johnson was admitted to the coronary\ncare unit and started on antibiotics for presumed pneumonia\ngiven his presentation with cough and fever. He was\nintubated for hypoxic respiratory distress. He was\nmaintained on pressors for his hypotension. He was continued\non the Levofloxacin of his antibiotics an defervesced after\nabout 24 hours.', " He was diuresed about 3 liters and his\npressors were able to be weaned off. He was successfully\nextubated two days after intubation. The next day his\nCaptopril was restarted at 6.25 mg. He tolerated his first\ndose. With his second dose, his blood pressure dropped into\nthe 70's/30's. He was started on Dopamine and Levophed. At\nthis point he spiked a fever. Fluid boluses were given to\ntry to augment his pressure. However, he again began to\nsuffer from hypoxic respiratory arrest with a gas of 7.4, 32\nand 47. A PA catheter was placed to better assess his\nhemodynamics. His CVP was 8, wedge pressure was 35, cardiac\nindex was 2.0. At this point Dobutamine was started in\naddition to the Dopamine and Levophed. He was reintubated.\nHis PA pressures were in the 70's/40's. His systolic blood\npressure was in the 70's and diastolic blood pressure was in\nthe 50's.", " He received Lasix and Morphine overnight. He\nspiked again the following day. He was diuresed down to FV\nSakkas in the low 20's and a pulmonary capillary wedge pressure\nof 17. On the Dobutamine he was able to be weaned. He had\ncardiac index of 2.1 to 2.2 and was able to be weaned off of\npressors. Vancomycin was started with concern for either\nnosocomial pneumonia or line infection. On the Vancomycin,\nhe defervesced.\n\nLFTs were checked to see if there was any hidden source of\ninfection that we might be missing. His LFTs, amylase and\nlipase were increased and abdominal CT was obtained which\nshowed no signs of pancreatic inflammation or liver or\ngallbladder pathology.\n\nAfter his pressors were weaned off, he was also weaned off\nthe Dobutamine. His Swan was removed and he was successfully\nextubated again five days after his second intubation.", " He\ndid well initially but was approximately 1?????? liters positive\nby the next morning and had an episode where he desatted with\nan increase in his respiratory rate. He did not respond to a\n60 mg shot of IV Lasix and his sats continued to drop into\nthe 80's. He was reintubated a third time. At this point\nhis blood pressure once again dropped and he was restarted on\nDopamine. After this he spiked again. Over the next three\ndays he was continued to be diuresed and he was kept on\nminimal sedation to try to avoid any medicine that would\nlower his blood pressure. Frequent family meetings were held\nduring his course. Decision was made to have one last try\nwith Milrinone to try to improve his cardiac index. On\nMilrinone he was able to be weaned off of pressors and he had\ngood Swan parameters as the Swan was refloated after his\nthird intubation.", ' However, multiple attempts to wean him off\nthe ventilator failed.\n\nThe team addressed the possibility of trach placement in a\nlong-term wean with the family. The family stated that he\nwould not have wanted that kind of quality of life and so the\ndecision was made to withdraw ventilatory support. He passed\naway peacefully with his family at his side on 1949-7-13 at\n3:05 p.m.\n\n\n\n\n Latrice Starks, M.D. 08842517\n\nDictated By:Zachary Abdullah\n\nMEDQUIST36\n\nD: 1923-6-11 21:22\nT: 1953-12-15 16:36\nJOB#: Curtis, Harris and Williams-2015-054158\n']
148	25539	195992.0	2130-08-21	Discharge summary	Report	Admission Date: [2130-8-17] Discharge Date: [2130-8-21] Date of Birth: [2079-11-23] Sex: F Service: [Doctor First Name 147] Allergies: Penicillins / Bactrim Attending:[First Name3 (LF) 1556] Chief Complaint: Morbid obesity Major Surgical or Invasive Procedure: 1. Laparoscopic Roux en Y gastric bypass. ([8-17]) 2. Laparoscopic cholecystectomy. ([8-17]) 3. Takeback for Laparoscopic abdominal exploration. ([8-18]) History of Present Illness: Mrs. [Known lastname 1557] is a 50 year old woman, with longstanding morbid obesity, refractory to non operative attempts at weight loss. She has a preoperative weight of 230.7 pounds, a height of 63 inches and a body mass index of 40.9. She was evaluated by a multi-disciplinary bariatric team and deemed a suitable candidate for gastric bypass in accordance with the National Institute of Health Consensus Statement. Past Medical History: She suffers from associated comorbidities including hypertension, non insulin dependent diabetes mellitus, dyslipidemia, cardiac disease consisting of diastolic dysfunction, gastroesophageal reflux, non alcoholic hepatitis, cholelithiasis, urinary stress incontinence, osteoarthritis of the lower extremities and low back pain. Social History: Socially, she does not smoke although she has a 10-pack-year history. She does not use drugs or drink excessive amounts of alcohol. She is a nurse with a doctor at education and employed at the [State 1558] in [Hospital1 1559]. She is married and lives with her husband and two children. Family History: Her family history is noteworthy for heart disease, arthritis, obesity, and diabetes. Physical Exam: On examination, her recorded blood pressure is 142/82 with a pulse of 82. She is alert and oriented and in no acute distress. Pupils are equal, round, and reactive to light. Sclerae are anicteric. Oropharynx is without lesions. There are no loose teeth. Neck is supple without jugular venous distention, bruits, lymphadenopathy, thyromegaly, or nodules. Trachea is in midline. Lungs are clear to auscultation bilaterally. Heart is regular with no murmurs, rubs, or gallops. Abdomen is obese, soft, nontender, and nondistended. There is no organomegaly or masses. There are no hernias. Extremities have trace edema bilaterally with no evidence of venous stasis or varices. There is no spine or flank tenderness. Neurologically, cranial nerves II through XII are intact and otherwise nonfocal. Pertinent Results: [2130-8-17] 10:14PM WBC-11.2# RBC-4.18 HGB-11.7* HCT-35.0* MCV-84 MCH-27.9 MCHC-33.4 RDW-13.4 [2130-8-17] 10:14PM NEUTS-86.5* BANDS-0 LYMPHS-10.2* MONOS-2.9 EOS-0.3 BASOS-0.1 [2130-8-17] 10:14PM GLUCOSE-167* UREA N-10 CREAT-0.6 SODIUM-139 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13 Brief Hospital Course: Patient tolerated lap RYGBP and CCY and was transferred to PACU. On night of POD0, patient was nauseous refractory to Zofran, Compazine, and Phenergan. Subsequently her PCA was changed from MSO4 to Dilaudid and she was provided a Scopolamine patch. Later in the night, patient desat'ed to 79% on RA with continued nausea. In AM of POD1, patient was transferred to T-SICU for hypoxia. CTA of chest was done and demonstrated no PE, but evidence of bilateral consolidation. CT abdomen demonstrated no obvious leak. She was started on IV antibiotics for question aspiration pneumonia. After being seen by Dr. [Last Name (STitle) ] in SICU, team decided to take patient back to OR for laparoscopic exploration to rule out leak. No leak was found in OR. Patient tolerated procedure well and was back in PACU. She was transferred to floor without incident. Post-op course was unremarkable thereafter. On [8-19], she was started on Stage I and transitioned to Stage II later in the day. On day of discharge, patient did well on Stage III with good pain control on oral Roxicet. Patient was sent home with oral antibiotics for 10 days. Discharge Medications: 1. Roxicet 5-325 mg/5 mL Solution Sig: [1-20] teaspoons PO every 4-6 hours as needed for pain. Disp:250 ml Refills:0 2. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day for 1 months. Disp:qs Refills:0 3. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Disp:60 Tablet, Chewable(s) Refills:2 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days: Needs 10 total days of levo & flagyl. Disp:10 Tablet(s) Refills:0 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days: Needs 10 total days of levo & flagyl. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Morbid obesity s/p laparoscopic roux-en-y gastric bypass Cholethiasis Hypertension Non-insulin-dependent diabetes mellitus Dyslipidemia Discharge Condition: Good Discharge Instructions: Please stay on stage 3 diet until follow-up. Do not self-advance diet, drink from a straw, or chew gum. No heavy lifting (>10lbs) for 6 weeks. You may shower (no tub bathing or swimming for 6 weeks) as long as no drainage from wound sites. If there is clear drainage, cover wound and stop showering. Please [Name8 (MD) 138] MD for temp >101.5, persistent nausea/vomiting or pain, or drainage from wound. Please crush all pills. Followup Instructions: In 3 weeks at [Hospital 1560] clinic. Please call [Telephone/Fax (1) 305] for appointment. Completed by:[2130-9-11]	Admission Date: <Date>1984-1-7</Date> Discharge Date: <Date>2009-3-8</Date> Date of Birth: <Date>1960-3-7</Date> Sex: F Service: <Name>Marvin</Name> Allergies: Penicillins / Bactrim Attending:<Name>Haydee</Name> Chief Complaint: Morbid obesity Major Surgical or Invasive Procedure: 1. Laparoscopic Roux en Y gastric bypass. (<Date>7-11</Date>) 2. Laparoscopic cholecystectomy. (<Date>7-11</Date>) 3. Takeback for Laparoscopic abdominal exploration. (<Date>3-5</Date>) History of Present Illness: Mrs. <Name>Tamaro</Name> is a 50 year old woman, with longstanding morbid obesity, refractory to non operative attempts at weight loss. She has a preoperative weight of 230.7 pounds, a height of 63 inches and a body mass index of 40.9. She was evaluated by a multi-disciplinary bariatric team and deemed a suitable candidate for gastric bypass in accordance with the National Institute of Health Consensus Statement. Past Medical History: She suffers from associated comorbidities including hypertension, non insulin dependent diabetes mellitus, dyslipidemia, cardiac disease consisting of diastolic dysfunction, gastroesophageal reflux, non alcoholic hepatitis, cholelithiasis, urinary stress incontinence, osteoarthritis of the lower extremities and low back pain. Social History: Socially, she does not smoke although she has a 10-pack-year history. She does not use drugs or drink excessive amounts of alcohol. She is a nurse with a doctor at education and employed at the <State>Texas</State> in <Hospital>Green Inc Health System</Hospital>. She is married and lives with her husband and two children. Family History: Her family history is noteworthy for heart disease, arthritis, obesity, and diabetes. Physical Exam: On examination, her recorded blood pressure is 142/82 with a pulse of 82. She is alert and oriented and in no acute distress. Pupils are equal, round, and reactive to light. Sclerae are anicteric. Oropharynx is without lesions. There are no loose teeth. Neck is supple without jugular venous distention, bruits, lymphadenopathy, thyromegaly, or nodules. Trachea is in midline. Lungs are clear to auscultation bilaterally. Heart is regular with no murmurs, rubs, or gallops. Abdomen is obese, soft, nontender, and nondistended. There is no organomegaly or masses. There are no hernias. Extremities have trace edema bilaterally with no evidence of venous stasis or varices. There is no spine or flank tenderness. Neurologically, cranial nerves II through XII are intact and otherwise nonfocal. Pertinent Results: <Date>1984-1-7</Date> 10:14PM WBC-11.2# RBC-4.18 HGB-11.7* HCT-35.0* MCV-84 MCH-27.9 MCHC-33.4 RDW-13.4 <Date>1984-1-7</Date> 10:14PM NEUTS-86.5* BANDS-0 LYMPHS-10.2* MONOS-2.9 EOS-0.3 BASOS-0.1 <Date>1984-1-7</Date> 10:14PM GLUCOSE-167* UREA N-10 CREAT-0.6 SODIUM-139 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13 Brief Hospital Course: Patient tolerated lap RYGBP and CCY and was transferred to PACU. On night of POD0, patient was nauseous refractory to Zofran, Compazine, and Phenergan. Subsequently her PCA was changed from MSO4 to Dilaudid and she was provided a Scopolamine patch. Later in the night, patient desat'ed to 79% on RA with continued nausea. In AM of POD1, patient was transferred to T-SICU for hypoxia. CTA of chest was done and demonstrated no PE, but evidence of bilateral consolidation. CT abdomen demonstrated no obvious leak. She was started on IV antibiotics for question aspiration pneumonia. After being seen by Dr. <Name>Clark</Name> in SICU, team decided to take patient back to OR for laparoscopic exploration to rule out leak. No leak was found in OR. Patient tolerated procedure well and was back in PACU. She was transferred to floor without incident. Post-op course was unremarkable thereafter. On <Date>1-1</Date>, she was started on Stage I and transitioned to Stage II later in the day. On day of discharge, patient did well on Stage III with good pain control on oral Roxicet. Patient was sent home with oral antibiotics for 10 days. Discharge Medications: 1. Roxicet 5-325 mg/5 mL Solution Sig: <Date>6-25</Date> teaspoons PO every 4-6 hours as needed for pain. Disp:250 ml Refills:0 2. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day for 1 months. Disp:qs Refills:0 3. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Disp:60 Tablet, Chewable(s) Refills:2 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days: Needs 10 total days of levo & flagyl. Disp:10 Tablet(s) Refills:0 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days: Needs 10 total days of levo & flagyl. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Morbid obesity s/p laparoscopic roux-en-y gastric bypass Cholethiasis Hypertension Non-insulin-dependent diabetes mellitus Dyslipidemia Discharge Condition: Good Discharge Instructions: Please stay on stage 3 diet until follow-up. Do not self-advance diet, drink from a straw, or chew gum. No heavy lifting (>10lbs) for 6 weeks. You may shower (no tub bathing or swimming for 6 weeks) as long as no drainage from wound sites. If there is clear drainage, cover wound and stop showering. Please <Name>Franklin Anderson</Name> MD for temp >101.5, persistent nausea/vomiting or pain, or drainage from wound. Please crush all pills. Followup Instructions: In 3 weeks at <Hospital>Choi, Nelson and Smith Medical Center</Hospital> clinic. Please call <Telephone>224-425-7647</Telephone> for appointment. Completed by:<Date>1901-6-31</Date>	0000000000000000011111111000000000000000000000000000000001111111100000000000000000011111111000000000000000000000000000000001111110000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000011100000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000011111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111110000000000000>0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111111111111100000000000000000000001111111111110000000000000000000000000000000000111111111	Admission Date: 1984-1-7 Discharge Date: 2009-3-8 Date of Birth: 1960-3-7 Sex: F Service: Marvin Allergies: Penicillins / Bactrim Attending:Haydee Chief Complaint: Morbid obesity Major Surgical or Invasive Procedure: 1. Laparoscopic Roux en Y gastric bypass. (7-11) 2. Laparoscopic cholecystectomy. (7-11) 3. Takeback for Laparoscopic abdominal exploration. (3-5) History of Present Illness: Mrs. Tamaro is a 50 year old woman, with longstanding morbid obesity, refractory to non operative attempts at weight loss. She has a preoperative weight of 230.7 pounds, a height of 63 inches and a body mass index of 40.9. She was evaluated by a multi-disciplinary bariatric team and deemed a suitable candidate for gastric bypass in accordance with the National Institute of Health Consensus Statement. Past Medical History: She suffers from associated comorbidities including hypertension, non insulin dependent diabetes mellitus, dyslipidemia, cardiac disease consisting of diastolic dysfunction, gastroesophageal reflux, non alcoholic hepatitis, cholelithiasis, urinary stress incontinence, osteoarthritis of the lower extremities and low back pain. Social History: Socially, she does not smoke although she has a 10-pack-year history. She does not use drugs or drink excessive amounts of alcohol. She is a nurse with a doctor at education and employed at the Texas in Green Inc Health System. She is married and lives with her husband and two children. Family History: Her family history is noteworthy for heart disease, arthritis, obesity, and diabetes. Physical Exam: On examination, her recorded blood pressure is 142/82 with a pulse of 82. She is alert and oriented and in no acute distress. Pupils are equal, round, and reactive to light. Sclerae are anicteric. Oropharynx is without lesions. There are no loose teeth. Neck is supple without jugular venous distention, bruits, lymphadenopathy, thyromegaly, or nodules. Trachea is in midline. Lungs are clear to auscultation bilaterally. Heart is regular with no murmurs, rubs, or gallops. Abdomen is obese, soft, nontender, and nondistended. There is no organomegaly or masses. There are no hernias. Extremities have trace edema bilaterally with no evidence of venous stasis or varices. There is no spine or flank tenderness. Neurologically, cranial nerves II through XII are intact and otherwise nonfocal. Pertinent Results: 1984-1-7 10:14PM WBC-11.2# RBC-4.18 HGB-11.7* HCT-35.0* MCV-84 MCH-27.9 MCHC-33.4 RDW-13.4 1984-1-7 10:14PM NEUTS-86.5* BANDS-0 LYMPHS-10.2* MONOS-2.9 EOS-0.3 BASOS-0.1 1984-1-7 10:14PM GLUCOSE-167* UREA N-10 CREAT-0.6 SODIUM-139 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13 Brief Hospital Course: Patient tolerated lap RYGBP and CCY and was transferred to PACU. On night of POD0, patient was nauseous refractory to Zofran, Compazine, and Phenergan. Subsequently her PCA was changed from MSO4 to Dilaudid and she was provided a Scopolamine patch. Later in the night, patient desat'ed to 79% on RA with continued nausea. In AM of POD1, patient was transferred to T-SICU for hypoxia. CTA of chest was done and demonstrated no PE, but evidence of bilateral consolidation. CT abdomen demonstrated no obvious leak. She was started on IV antibiotics for question aspiration pneumonia. After being seen by Dr. Clark in SICU, team decided to take patient back to OR for laparoscopic exploration to rule out leak. No leak was found in OR. Patient tolerated procedure well and was back in PACU. She was transferred to floor without incident. Post-op course was unremarkable thereafter. On 1-1, she was started on Stage I and transitioned to Stage II later in the day. On day of discharge, patient did well on Stage III with good pain control on oral Roxicet. Patient was sent home with oral antibiotics for 10 days. Discharge Medications: 1. Roxicet 5-325 mg/5 mL Solution Sig: 6-25 teaspoons PO every 4-6 hours as needed for pain. Disp:250 ml Refills:0 2. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day for 1 months. Disp:qs Refills:0 3. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Disp:60 Tablet, Chewable(s) Refills:2 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days: Needs 10 total days of levo & flagyl. Disp:10 Tablet(s) Refills:0 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days: Needs 10 total days of levo & flagyl. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Morbid obesity s/p laparoscopic roux-en-y gastric bypass Cholethiasis Hypertension Non-insulin-dependent diabetes mellitus Dyslipidemia Discharge Condition: Good Discharge Instructions: Please stay on stage 3 diet until follow-up. Do not self-advance diet, drink from a straw, or chew gum. No heavy lifting (>10lbs) for 6 weeks. You may shower (no tub bathing or swimming for 6 weeks) as long as no drainage from wound sites. If there is clear drainage, cover wound and stop showering. Please Franklin Anderson MD for temp >101.5, persistent nausea/vomiting or pain, or drainage from wound. Please crush all pills. Followup Instructions: In 3 weeks at Choi, Nelson and Smith Medical Center clinic. Please call 224-425-7647 for appointment. Completed by:1901-6-31	['Admission Date: 1984-1-7 Discharge Date: 2009-3-8\n\nDate of Birth: 1960-3-7 Sex: F\n\nService: Marvin\n\nAllergies:\nPenicillins / Bactrim\n\nAttending:Haydee\nChief Complaint:\nMorbid obesity\n\nMajor Surgical or Invasive Procedure:\n1. Laparoscopic Roux en Y gastric bypass. (7-11)\n2. Laparoscopic cholecystectomy. (7-11)\n3. Takeback for Laparoscopic abdominal exploration. (3-5)\n\nHistory of Present Illness:\nMrs. Tamaro is a 50 year old\nwoman, with longstanding morbid obesity, refractory to non\noperative attempts at weight loss. She has a preoperative\nweight of 230.7 pounds, a height of 63 inches and a body mass\nindex of 40.9. She was evaluated by a multi-disciplinary\nbariatric team and\ndeemed a suitable candidate for gastric bypass in accordance\nwith the National\nInstitute of Health Consensus Statement.', '\n\n\nPast Medical History:\nShe suffers from associated comorbidities\nincluding hypertension, non insulin dependent diabetes\nmellitus, dyslipidemia, cardiac disease consisting of\ndiastolic dysfunction, gastroesophageal reflux, non alcoholic\nhepatitis, cholelithiasis, urinary stress incontinence,\nosteoarthritis of the lower extremities and low back pain.\n\n\nSocial History:\nSocially, she does not smoke although she has a 10-pack-year\nhistory. She does not use drugs or drink excessive amounts of\nalcohol. She is a nurse with a doctor at education and employed\nat the Texas in Green Inc Health System. She is married\nand lives with her husband and two children.\n\nFamily History:\nHer family history is noteworthy for heart disease, arthritis,\nobesity, and diabetes.\n\n\nPhysical Exam:\nOn examination, her recorded blood pressure is 142/82 with a\npulse of 82.', ' She is alert and oriented and in no acute distress.\n\nPupils are equal, round, and reactive to light. Sclerae are\nanicteric. Oropharynx is without lesions. There are no loose\nteeth. Neck is supple without jugular venous distention, bruits,\n\nlymphadenopathy, thyromegaly, or nodules. Trachea is in midline.\n\nLungs are clear to auscultation bilaterally. Heart is regular\nwith no murmurs, rubs, or gallops. Abdomen is obese, soft,\nnontender, and nondistended. There is no organomegaly or masses.\n\nThere are no hernias. Extremities have trace edema bilaterally\nwith no evidence of venous stasis or varices. There is no spine\nor flank tenderness. Neurologically, cranial nerves II through\nXII are intact and otherwise nonfocal.\n\n\nPertinent Results:\n1984-1-7 10:14PM WBC-11.2# RBC-4.18 HGB-11.7* HCT-35.', "0\nMCV-84 MCH-27.9 MCHC-33.4 RDW-13.4\n1984-1-7 10:14PM NEUTS-86.5 BANDS-0 LYMPHS-10.2* MONOS-2.9\nEOS-0.3 BASOS-0.1\n1984-1-7 10:14PM GLUCOSE-167* UREA N-10 CREAT-0.6 SODIUM-139\nPOTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13\n\nBrief Hospital Course:\nPatient tolerated lap RYGBP and CCY and was transferred to PACU.\nOn night of POD0, patient was nauseous refractory to Zofran,\nCompazine, and Phenergan. Subsequently her PCA was changed from\nMSO4 to Dilaudid and she was provided a Scopolamine patch. Later\nin the night, patient desat'ed to 79% on RA with continued\nnausea. In AM of POD1, patient was transferred to T-SICU for\nhypoxia. CTA of chest was done and demonstrated no PE, but\nevidence of bilateral consolidation. CT abdomen demonstrated no\nobvious leak. She was started on IV antibiotics for question\naspiration pneumonia.", ' After being seen by Dr. Clark in SICU,\nteam decided to take patient back to OR for laparoscopic\nexploration to rule out leak. No leak was found in OR. Patient\ntolerated procedure well and was back in PACU. She was\ntransferred to floor without incident. Post-op course was\nunremarkable thereafter. On 1-1, she was started on Stage I and\ntransitioned to Stage II later in the day. On day of discharge,\npatient did well on Stage III with good pain control on oral\nRoxicet. Patient was sent home with oral antibiotics for 10\ndays.\n\nDischarge Medications:\n1. Roxicet 5-325 mg/5 mL Solution Sig: 6-25 teaspoons PO every\n4-6 hours as needed for pain.\nDisp:250 ml Refills:0\n2. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day for 1\nmonths.\nDisp:qs Refills:0\n3. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1)\nTablet, Chewable PO twice a day.', '\nDisp:60 Tablet, Chewable(s) Refills:2\n4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every\n24 hours) for 10 days: Needs 10 total days of levo & flagyl.\nDisp:10 Tablet(s) Refills:0\n5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3\ntimes a day) for 10 days: Needs 10 total days of levo & flagyl.\nDisp:30 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nMorbid obesity s/p laparoscopic roux-en-y gastric bypass\nCholethiasis\nHypertension\nNon-insulin-dependent diabetes mellitus\nDyslipidemia\n\n\nDischarge Condition:\nGood\n\nDischarge Instructions:\nPlease stay on stage 3 diet until follow-up. Do not\nself-advance diet, drink from a straw, or chew gum. No heavy\nlifting (>10lbs) for 6 weeks. You may shower (no tub bathing or\nswimming for 6 weeks) as long as no drainage from wound sites.', '\nIf there is clear drainage, cover wound and stop showering.\nPlease Franklin Anderson MD for temp >101.5, persistent nausea/vomiting or\npain, or drainage from wound. Please crush all pills.\n\nFollowup Instructions:\nIn 3 weeks at Choi, Nelson and Smith Medical Center clinic. Please call 224-425-7647 for\nappointment.\n\n\n\nCompleted by:1901-6-31']
149	13268	115522.0	2163-11-20	Discharge summary	Report	Admission Date: [2163-11-11] Discharge Date: [2163-11-20] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1561] Chief Complaint: Right lung cancer Major Surgical or Invasive Procedure: Bronchoscopy x3 PleurX catheter insertion Emergent intubation History of Present Illness: This patient is an 83 year old female with small cell lung cancer who was accepted in transfer from [Hospital 1562] Hospital. Patient is with known right small cell lung cancer undergoing chemotherapy/radiation therapy at [Hospital3 1563] [Hospital3 ]. She now presents with acute respiratory falure and is status-post intubation. The reports from the outside hospital indicate extrinsic compression from right mainstem bronchus obstructing the proximal airway now with complete collapse of the right hemithorax with partial collapse of the left hemithroax. CT scans from [Hospital1 1562] indicate a large volume tumor encasing the right lung. The patient's family was advised of her dismal prognosis, and the patient was admitted for the possibility of a meaningful intervention with the goal of palliative therapy. Past Medical History: End stage small cell lung canger with known brain metastasis Now s/p chemo/radiation therapy Breast cancer X-Ray therapy pneumonitis COPD Osteoporosis Physical Exam: T 98.4 HR 86 BP 108/45 RR 22 SpO2 95% on AC 0.45/450/14/PEEP5 Intubated, sedated RRR CTA on the left, minimal breath sounds on the right Abdomen soft, NT/ND Extremeties with 1+ edema, no cyanosis Brief Hospital Course: The patient was admitted to the hospital and underwent a bronchoscopy on [2163-11-11]. This revealed a completely obstructed right upper lobe with tumor and submucosal infiltration of the proximal right mainstem bronchus. Post-bronchoscopy, a chest xray showed partial re-expansion of the right lower lobe. The patient was placed on a CPAP trial the next morning, which she passed. She was extubated for a period of a few hours. However, due to increasing respiratory effort, the patient soon fatigued, and required emergent re-intubation. The patient was fully conscious at this time, and willingly indicated a desire to be re-intubated. A repeat chest xray showed a re-accumulation of fluid in the right hemithorax with collase of the right lower lobe. The patient was kept intubated and on supportive care until [2163-11-15], when the patient underwent a repeat bronchoscopy and placement of a PleurX catheter on the right. This was done in the hopes that the patient could be extubated once the pleural effusion was cleared. However, the patient failed to properly wean off the vent. Following on-going dialogue with the patient's family, it was decided that the patient would be made comfort measures only on [2163-11-20]. The patient was extubated and expired several hours later. Medications on Admission: IV morphine Midazolam prn Hydrocortisone 25mg IV BID Azithro 500mg IV Q24h Protonix 40mg IV Q24h Zosyn 2.25g IV q6h Albuterol/atrovent nebulizer Lovenox 40qd Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Right lung cancer Obstructive pneumonitis COPD Discharge Condition: Deceased Followup Instructions: None	Admission Date: <Date>2012-4-10</Date> Discharge Date: <Date>1908-6-24</Date> Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Chau</Name> Chief Complaint: Right lung cancer Major Surgical or Invasive Procedure: Bronchoscopy x3 PleurX catheter insertion Emergent intubation History of Present Illness: This patient is an 83 year old female with small cell lung cancer who was accepted in transfer from <Hospital>Castillo Ltd Medical Center</Hospital> Hospital. Patient is with known right small cell lung cancer undergoing chemotherapy/radiation therapy at <Hospital>Webb-Maldonado Hospital</Hospital> <Hospital>Phillips, Carter and Sanchez Medical Center</Hospital>. She now presents with acute respiratory falure and is status-post intubation. The reports from the outside hospital indicate extrinsic compression from right mainstem bronchus obstructing the proximal airway now with complete collapse of the right hemithorax with partial collapse of the left hemithroax. CT scans from <Hospital>Pena, House and Taylor Medical Center</Hospital> indicate a large volume tumor encasing the right lung. The patient's family was advised of her dismal prognosis, and the patient was admitted for the possibility of a meaningful intervention with the goal of palliative therapy. Past Medical History: End stage small cell lung canger with known brain metastasis Now s/p chemo/radiation therapy Breast cancer X-Ray therapy pneumonitis COPD Osteoporosis Physical Exam: T 98.4 HR 86 BP 108/45 RR 22 SpO2 95% on AC 0.45/450/14/PEEP5 Intubated, sedated RRR CTA on the left, minimal breath sounds on the right Abdomen soft, NT/ND Extremeties with 1+ edema, no cyanosis Brief Hospital Course: The patient was admitted to the hospital and underwent a bronchoscopy on <Date>2012-4-10</Date>. This revealed a completely obstructed right upper lobe with tumor and submucosal infiltration of the proximal right mainstem bronchus. Post-bronchoscopy, a chest xray showed partial re-expansion of the right lower lobe. The patient was placed on a CPAP trial the next morning, which she passed. She was extubated for a period of a few hours. However, due to increasing respiratory effort, the patient soon fatigued, and required emergent re-intubation. The patient was fully conscious at this time, and willingly indicated a desire to be re-intubated. A repeat chest xray showed a re-accumulation of fluid in the right hemithorax with collase of the right lower lobe. The patient was kept intubated and on supportive care until <Date>1901-11-23</Date>, when the patient underwent a repeat bronchoscopy and placement of a PleurX catheter on the right. This was done in the hopes that the patient could be extubated once the pleural effusion was cleared. However, the patient failed to properly wean off the vent. Following on-going dialogue with the patient's family, it was decided that the patient would be made comfort measures only on <Date>1908-6-24</Date>. The patient was extubated and expired several hours later. Medications on Admission: IV morphine Midazolam prn Hydrocortisone 25mg IV BID Azithro 500mg IV Q24h Protonix 40mg IV Q24h Zosyn 2.25g IV q6h Albuterol/atrovent nebulizer Lovenox 40qd Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Right lung cancer Obstructive pneumonitis COPD Discharge Condition: Deceased Followup Instructions: None	0000000000000000011111111100000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111110111111111111111111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000	Admission Date: 2012-4-10 Discharge Date: 1908-6-24 Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Chau Chief Complaint: Right lung cancer Major Surgical or Invasive Procedure: Bronchoscopy x3 PleurX catheter insertion Emergent intubation History of Present Illness: This patient is an 83 year old female with small cell lung cancer who was accepted in transfer from Castillo Ltd Medical Center Hospital. Patient is with known right small cell lung cancer undergoing chemotherapy/radiation therapy at Webb-Maldonado Hospital Phillips, Carter and Sanchez Medical Center. She now presents with acute respiratory falure and is status-post intubation. The reports from the outside hospital indicate extrinsic compression from right mainstem bronchus obstructing the proximal airway now with complete collapse of the right hemithorax with partial collapse of the left hemithroax. CT scans from Pena, House and Taylor Medical Center indicate a large volume tumor encasing the right lung. The patient's family was advised of her dismal prognosis, and the patient was admitted for the possibility of a meaningful intervention with the goal of palliative therapy. Past Medical History: End stage small cell lung canger with known brain metastasis Now s/p chemo/radiation therapy Breast cancer X-Ray therapy pneumonitis COPD Osteoporosis Physical Exam: T 98.4 HR 86 BP 108/45 RR 22 SpO2 95% on AC 0.45/450/14/PEEP5 Intubated, sedated RRR CTA on the left, minimal breath sounds on the right Abdomen soft, NT/ND Extremeties with 1+ edema, no cyanosis Brief Hospital Course: The patient was admitted to the hospital and underwent a bronchoscopy on 2012-4-10. This revealed a completely obstructed right upper lobe with tumor and submucosal infiltration of the proximal right mainstem bronchus. Post-bronchoscopy, a chest xray showed partial re-expansion of the right lower lobe. The patient was placed on a CPAP trial the next morning, which she passed. She was extubated for a period of a few hours. However, due to increasing respiratory effort, the patient soon fatigued, and required emergent re-intubation. The patient was fully conscious at this time, and willingly indicated a desire to be re-intubated. A repeat chest xray showed a re-accumulation of fluid in the right hemithorax with collase of the right lower lobe. The patient was kept intubated and on supportive care until 1901-11-23, when the patient underwent a repeat bronchoscopy and placement of a PleurX catheter on the right. This was done in the hopes that the patient could be extubated once the pleural effusion was cleared. However, the patient failed to properly wean off the vent. Following on-going dialogue with the patient's family, it was decided that the patient would be made comfort measures only on 1908-6-24. The patient was extubated and expired several hours later. Medications on Admission: IV morphine Midazolam prn Hydrocortisone 25mg IV BID Azithro 500mg IV Q24h Protonix 40mg IV Q24h Zosyn 2.25g IV q6h Albuterol/atrovent nebulizer Lovenox 40qd Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Right lung cancer Obstructive pneumonitis COPD Discharge Condition: Deceased Followup Instructions: None	['Admission Date: 2012-4-10 Discharge Date: 1908-6-24\n\n\nService: CARDIOTHORACIC\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Chau\nChief Complaint:\nRight lung cancer\n\nMajor Surgical or Invasive Procedure:\nBronchoscopy x3\nPleurX catheter insertion\nEmergent intubation\n\n\nHistory of Present Illness:\nThis patient is an 83 year old female with small cell lung\ncancer who was accepted in transfer from Castillo Ltd Medical Center Hospital.\nPatient is with known right small cell lung cancer undergoing\nchemotherapy/radiation therapy at Webb-Maldonado Hospital Phillips, Carter and Sanchez Medical Center. She\nnow presents with acute respiratory falure and is status-post\nintubation. The reports from the outside hospital indicate\nextrinsic compression from right mainstem bronchus obstructing\nthe proximal airway now with complete collapse of the right\nhemithorax with partial collapse of the left hemithroax.', " CT\nscans from Pena, House and Taylor Medical Center indicate a large volume tumor encasing the\nright lung. The patient's family was advised of her dismal\nprognosis, and the patient was admitted for the possibility of a\nmeaningful intervention with the goal of palliative therapy.\n\nPast Medical History:\nEnd stage small cell lung canger with known brain metastasis\nNow s/p chemo/radiation therapy\nBreast cancer\nX-Ray therapy pneumonitis\nCOPD\nOsteoporosis\n\nPhysical Exam:\nT 98.4 HR 86 BP 108/45 RR 22 SpO2 95% on AC\n0.45/450/14/PEEP5\nIntubated, sedated\nRRR\nCTA on the left, minimal breath sounds on the right\nAbdomen soft, NT/ND\nExtremeties with 1+ edema, no cyanosis\n\nBrief Hospital Course:\nThe patient was admitted to the hospital and underwent a\nbronchoscopy on 2012-4-10. This revealed a completely obstructed\nright upper lobe with tumor and submucosal infiltration of the\nproximal right mainstem bronchus.", ' Post-bronchoscopy, a chest\nxray showed partial re-expansion of the right lower lobe. The\npatient was placed on a CPAP trial the next morning, which she\npassed. She was extubated for a period of a few hours. However,\ndue to increasing respiratory effort, the patient soon fatigued,\nand required emergent re-intubation. The patient was fully\nconscious at this time, and willingly indicated a desire to be\nre-intubated. A repeat chest xray showed a re-accumulation of\nfluid in the right hemithorax with collase of the right lower\nlobe. The patient was kept intubated and on supportive care\nuntil 1901-11-23, when the patient underwent a repeat bronchoscopy\nand placement of a PleurX catheter on the right. This was done\nin the hopes that the patient could be extubated once the\npleural effusion was cleared.', " However, the patient failed to\nproperly wean off the vent. Following on-going dialogue with the\npatient's family, it was decided that the patient would be made\ncomfort measures only on 1908-6-24. The patient was extubated and\nexpired several hours later.\n\nMedications on Admission:\nIV morphine\nMidazolam prn\nHydrocortisone 25mg IV BID\nAzithro 500mg IV Q24h\nProtonix 40mg IV Q24h\nZosyn 2.25g IV q6h\nAlbuterol/atrovent nebulizer\nLovenox 40qd\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\nRespiratory failure\nRight lung cancer\nObstructive pneumonitis\nCOPD\n\n\nDischarge Condition:\nDeceased\n\n\nFollowup Instructions:\nNone\n\n\n\n"]
150	2087	158410.0	2133-05-15	Discharge summary	Report	Admission Date: [2133-5-13] Discharge Date: [2133-5-15] Date of Birth: [2088-3-11] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[Doctor First Name 1402] Chief Complaint: palpitations Major Surgical or Invasive Procedure: s/p DC - cardioversion on [2133-5-14] History of Present Illness: In brief, 45 yo woman with history of SVT (long R-P) followed for 5 years, episodes monthly, usually lasting > 1 hr with recent ED presentation for new AFib. She was symptomatic with palpitations and shortness of breath with the AFib. She underwent DCCV last week and discharged home on ASA with outpatient Echo and EP study scheduled for [5-28] and [6-1], respectively. Given h/o SVT there is a possibility that the SVT may have triggered AF. She now presents with recurrent AFib with dyspnea and mild chest tightness. No fevers. In ED she was in AFib with HR 110-120, BP in 70's. Past Medical History: SVT AFib ? Marfan's syndrome left upper extremity radiculopathy polypectomies dilatation curettage difficulty with conceive a pregnancy Social History: Lives at home. Has three year old son. [Name (NI) ] tobacco, ivdu. Family History: mother with [Name (NI) 1564] syndrome - h/o aortic dissection Physical Exam: VS: 97.8F HR 59 BP 81/49(79-81/48-51) 24 97%RA Gen: [Last Name (un) 664], comfortable, thin, tall young female, NAD HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: irregularly irregular, nl S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, mild tenderness RLQ, no guarding or rebound, nondistended, no HSM. EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: nonfocal Pertinent Results: [2133-5-13] WBC-5.2 RBC-4.53 Hgb-14.7 Hct-42.1 MCV-93 MCH-32.3* MCHC-34.8 RDW-13.1 Plt Ct-277# Neuts-42.1* Lymphs-48.9* Monos-6.6 Eos-1.8 Baso-0.6 [2133-5-15] WBC-3.6* RBC-3.37* Hgb-10.9* Hct-31.4* MCV-93 MCH-32.3* MCHC-34.7 RDW-13.3 Plt Ct-182 . [2133-5-13] 08:00PM BLOOD PT-11.9 PTT-28.9 INR(PT)-1.0 . [2133-5-13] Glucose-99 UreaN-22* Creat-0.8 Na-140 K-3.5 Cl-106 HCO3-19* [2133-5-15] Glucose-93 UreaN-11 Creat-0.6 Na-138 K-3.8 Cl-107 HCO3-23 . [2133-5-13] 08:00PM BLOOD CK(CPK)-55 CK-MB-NotDone cTropnT-<0.01 [2133-5-14] 06:40AM BLOOD CK(CPK)-40 CK-MB-NotDone cTropnT-<0.01 . [2133-5-14] TTE Echocardiogram: The left atrium is normal in size. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are mildly myxomatous. The mitral valve leaflets are mildly elongated. There is mild mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . ELECTROCARDIOGRAM PERFORMED ON: [2133-5-14] 13:11:16 Atrial fibrillation. Compared to tracing #1 no change. . ELECTROCARDIOGRAM PERFORMED ON: [2133-5-14] 22:49:52 Normal sinus rhythm. Evidence of prior anteroseptal myocardial infarction. Compared to tracing #2 atrial fibrillation is no longer present. Brief Hospital Course: 45 yo F hx SVT, Afib p/w palpitations and dyspnea, noted to be in recurrent AFib. . # Afib - recent cardioversion for AFib, now returns with recurrence. Rate is fairly well controlled. Thyroid studies wnl. Patient underwent DC cardioversion, but had recurrent atrial fibrillation post-procedure. She was started on flecainide after attempt at cardioversion with low dose beta-blocker. She converted back into sinus rhythm that same night. She was discharged on flecainide 50mg po bid and metoprolol. She is to scheduled outpatient exercise (non-imaging) stress test in one week after discharge from the hospital. She has outpatient follow-up for possible EP study with Dr. [Last Name (STitle) ] in the next couple of weeks. She was discharged with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of hearts monitor. She had TTE Echo with mitral regurgitation and prolapse and was instructed to take pre-procedure antibiotics for any dentalwork. PCN allergy so given prescription for clindamycin. . # Dyspnea - most likely related to AFib, and resolved on admission after bring her heart rate down. No evidence of pulmonary edema or infiltrate on CXR. D-dimer negative. No JVD, and bedside echo in ED without pericardial effusion. Breathing comfortably on room air throughout hospitalization. . # Dispo - patient was discharged to home with EP follow-up, [Doctor Last Name ] of hearts monitor and stress test. Medications on Admission: ASA 325mg qday MVI Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Flecainide 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 4. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO once prior to dentalwork. Disp:6 Capsule(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation supraventricular tachycardia mitral regurgitation/mitral valve prolapse Discharge Condition: stable Discharge Instructions: Please call Dr.[Name (NI) 1565] office or 911 if you experience chest pain, shortness of breath, dizziness, palpitations, numbness, weakness or other concerning symptoms. . We have started a new medication called metoprolol 12.5mg twice daily as well as Flecainide. Please continue your aspirin as prescribed. The cardiologists want you to have an exercise stress test in one week as you have started flecainide. Please schedule this test after discharge from the hospital. . You should take clindamycin prior to any dental procedures as instructed. . You have been set up with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts monitor Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2133-11-6] 3:40 . We have ordered an exercise stress test (non-imaging). Please call [Telephone/Fax (1) 1566] to schedule this test to be done within the next week as previously instructed by the cardiologists. Completed by:[2133-5-18]	Admission Date: <Date>1941-12-20</Date> Discharge Date: <Date>1936-1-2</Date> Date of Birth: <Date>2007-7-1</Date> Sex: F Service: MEDICINE Allergies: Penicillins Attending:<Name>Haydee</Name> Chief Complaint: palpitations Major Surgical or Invasive Procedure: s/p DC - cardioversion on <Date>1922-9-22</Date> History of Present Illness: In brief, 45 yo woman with history of SVT (long R-P) followed for 5 years, episodes monthly, usually lasting > 1 hr with recent ED presentation for new AFib. She was symptomatic with palpitations and shortness of breath with the AFib. She underwent DCCV last week and discharged home on ASA with outpatient Echo and EP study scheduled for <Date>2-18</Date> and <Date>2-13</Date>, respectively. Given h/o SVT there is a possibility that the SVT may have triggered AF. She now presents with recurrent AFib with dyspnea and mild chest tightness. No fevers. In ED she was in AFib with HR 110-120, BP in 70's. Past Medical History: SVT AFib ? Marfan's syndrome left upper extremity radiculopathy polypectomies dilatation curettage difficulty with conceive a pregnancy Social History: Lives at home. Has three year old son. <Name>May Cobbs</Name> tobacco, ivdu. Family History: mother with <Name>Kamran Ignacio</Name> syndrome - h/o aortic dissection Physical Exam: VS: 97.8F HR 59 BP 81/49(79-81/48-51) 24 97%RA Gen: <Name>Atencio</Name>, comfortable, thin, tall young female, NAD HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: irregularly irregular, nl S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, mild tenderness RLQ, no guarding or rebound, nondistended, no HSM. EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: nonfocal Pertinent Results: <Date>1941-12-20</Date> WBC-5.2 RBC-4.53 Hgb-14.7 Hct-42.1 MCV-93 MCH-32.3* MCHC-34.8 RDW-13.1 Plt Ct-277# Neuts-42.1* Lymphs-48.9* Monos-6.6 Eos-1.8 Baso-0.6 <Date>1936-1-2</Date> WBC-3.6* RBC-3.37* Hgb-10.9* Hct-31.4* MCV-93 MCH-32.3* MCHC-34.7 RDW-13.3 Plt Ct-182 . <Date>1941-12-20</Date> 08:00PM BLOOD PT-11.9 PTT-28.9 INR(PT)-1.0 . <Date>1941-12-20</Date> Glucose-99 UreaN-22* Creat-0.8 Na-140 K-3.5 Cl-106 HCO3-19* <Date>1936-1-2</Date> Glucose-93 UreaN-11 Creat-0.6 Na-138 K-3.8 Cl-107 HCO3-23 . <Date>1941-12-20</Date> 08:00PM BLOOD CK(CPK)-55 CK-MB-NotDone cTropnT-<0.01 <Date>1922-9-22</Date> 06:40AM BLOOD CK(CPK)-40 CK-MB-NotDone cTropnT-<0.01 . <Date>1922-9-22</Date> TTE Echocardiogram: The left atrium is normal in size. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are mildly myxomatous. The mitral valve leaflets are mildly elongated. There is mild mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . ELECTROCARDIOGRAM PERFORMED ON: <Date>1922-9-22</Date> 13:11:16 Atrial fibrillation. Compared to tracing #1 no change. . ELECTROCARDIOGRAM PERFORMED ON: <Date>1922-9-22</Date> 22:49:52 Normal sinus rhythm. Evidence of prior anteroseptal myocardial infarction. Compared to tracing #2 atrial fibrillation is no longer present. Brief Hospital Course: 45 yo F hx SVT, Afib p/w palpitations and dyspnea, noted to be in recurrent AFib. . # Afib - recent cardioversion for AFib, now returns with recurrence. Rate is fairly well controlled. Thyroid studies wnl. Patient underwent DC cardioversion, but had recurrent atrial fibrillation post-procedure. She was started on flecainide after attempt at cardioversion with low dose beta-blocker. She converted back into sinus rhythm that same night. She was discharged on flecainide 50mg po bid and metoprolol. She is to scheduled outpatient exercise (non-imaging) stress test in one week after discharge from the hospital. She has outpatient follow-up for possible EP study with Dr. <Name>Bounds</Name> in the next couple of weeks. She was discharged with <Initial>CJ</Initial> <Name>Prieto</Name> of hearts monitor. She had TTE Echo with mitral regurgitation and prolapse and was instructed to take pre-procedure antibiotics for any dentalwork. PCN allergy so given prescription for clindamycin. . # Dyspnea - most likely related to AFib, and resolved on admission after bring her heart rate down. No evidence of pulmonary edema or infiltrate on CXR. D-dimer negative. No JVD, and bedside echo in ED without pericardial effusion. Breathing comfortably on room air throughout hospitalization. . # Dispo - patient was discharged to home with EP follow-up, <Doctor Name>Dr.Heflin</Doctor Name> of hearts monitor and stress test. Medications on Admission: ASA 325mg qday MVI Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Flecainide 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 4. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO once prior to dentalwork. Disp:6 Capsule(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation supraventricular tachycardia mitral regurgitation/mitral valve prolapse Discharge Condition: stable Discharge Instructions: Please call Dr.<Name>Emily Merino</Name> office or 911 if you experience chest pain, shortness of breath, dizziness, palpitations, numbness, weakness or other concerning symptoms. . We have started a new medication called metoprolol 12.5mg twice daily as well as Flecainide. Please continue your aspirin as prescribed. The cardiologists want you to have an exercise stress test in one week as you have started flecainide. Please schedule this test after discharge from the hospital. . You should take clindamycin prior to any dental procedures as instructed. . You have been set up with <Initial>CJ</Initial> <Name>Prieto</Name> of Hearts monitor Followup Instructions: Provider: <Name>Judith</Name> <Name>Kiel</Name>, M.D. Phone:<Telephone>944-918-5395</Telephone> Date/Time:<Date>1949-6-6</Date> 3:40 . We have ordered an exercise stress test (non-imaging). Please call <Telephone>374-137-4786</Telephone> to schedule this test to be done within the next week as previously instructed by the cardiologists. Completed 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Date: 1941-12-20 Discharge Date: 1936-1-2 Date of Birth: 2007-7-1 Sex: F Service: MEDICINE Allergies: Penicillins Attending:Haydee Chief Complaint: palpitations Major Surgical or Invasive Procedure: s/p DC - cardioversion on 1922-9-22 History of Present Illness: In brief, 45 yo woman with history of SVT (long R-P) followed for 5 years, episodes monthly, usually lasting > 1 hr with recent ED presentation for new AFib. She was symptomatic with palpitations and shortness of breath with the AFib. She underwent DCCV last week and discharged home on ASA with outpatient Echo and EP study scheduled for 2-18 and 2-13, respectively. Given h/o SVT there is a possibility that the SVT may have triggered AF. She now presents with recurrent AFib with dyspnea and mild chest tightness. No fevers. In ED she was in AFib with HR 110-120, BP in 70's. Past Medical History: SVT AFib ? Marfan's syndrome left upper extremity radiculopathy polypectomies dilatation curettage difficulty with conceive a pregnancy Social History: Lives at home. Has three year old son. May Cobbs tobacco, ivdu. Family History: mother with Kamran Ignacio syndrome - h/o aortic dissection Physical Exam: VS: 97.8F HR 59 BP 81/49(79-81/48-51) 24 97%RA Gen: Atencio, comfortable, thin, tall young female, NAD HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: irregularly irregular, nl S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, mild tenderness RLQ, no guarding or rebound, nondistended, no HSM. EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: nonfocal Pertinent Results: 1941-12-20 WBC-5.2 RBC-4.53 Hgb-14.7 Hct-42.1 MCV-93 MCH-32.3* MCHC-34.8 RDW-13.1 Plt Ct-277# Neuts-42.1* Lymphs-48.9* Monos-6.6 Eos-1.8 Baso-0.6 1936-1-2 WBC-3.6* RBC-3.37* Hgb-10.9* Hct-31.4* MCV-93 MCH-32.3* MCHC-34.7 RDW-13.3 Plt Ct-182 . 1941-12-20 08:00PM BLOOD PT-11.9 PTT-28.9 INR(PT)-1.0 . 1941-12-20 Glucose-99 UreaN-22* Creat-0.8 Na-140 K-3.5 Cl-106 HCO3-19* 1936-1-2 Glucose-93 UreaN-11 Creat-0.6 Na-138 K-3.8 Cl-107 HCO3-23 . 1941-12-20 08:00PM BLOOD CK(CPK)-55 CK-MB-NotDone cTropnT-1922-9-22 06:40AM BLOOD CK(CPK)-40 CK-MB-NotDone cTropnT-1922-9-22 TTE Echocardiogram: The left atrium is normal in size. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are mildly myxomatous. The mitral valve leaflets are mildly elongated. There is mild mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . ELECTROCARDIOGRAM PERFORMED ON: 1922-9-22 13:11:16 Atrial fibrillation. Compared to tracing #1 no change. . ELECTROCARDIOGRAM PERFORMED ON: 1922-9-22 22:49:52 Normal sinus rhythm. Evidence of prior anteroseptal myocardial infarction. Compared to tracing #2 atrial fibrillation is no longer present. Brief Hospital Course: 45 yo F hx SVT, Afib p/w palpitations and dyspnea, noted to be in recurrent AFib. . # Afib - recent cardioversion for AFib, now returns with recurrence. Rate is fairly well controlled. Thyroid studies wnl. Patient underwent DC cardioversion, but had recurrent atrial fibrillation post-procedure. She was started on flecainide after attempt at cardioversion with low dose beta-blocker. She converted back into sinus rhythm that same night. She was discharged on flecainide 50mg po bid and metoprolol. She is to scheduled outpatient exercise (non-imaging) stress test in one week after discharge from the hospital. She has outpatient follow-up for possible EP study with Dr. Bounds in the next couple of weeks. She was discharged with CJ Prieto of hearts monitor. She had TTE Echo with mitral regurgitation and prolapse and was instructed to take pre-procedure antibiotics for any dentalwork. PCN allergy so given prescription for clindamycin. . # Dyspnea - most likely related to AFib, and resolved on admission after bring her heart rate down. No evidence of pulmonary edema or infiltrate on CXR. D-dimer negative. No JVD, and bedside echo in ED without pericardial effusion. Breathing comfortably on room air throughout hospitalization. . # Dispo - patient was discharged to home with EP follow-up, Dr.Heflin of hearts monitor and stress test. Medications on Admission: ASA 325mg qday MVI Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Flecainide 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 4. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO once prior to dentalwork. Disp:6 Capsule(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation supraventricular tachycardia mitral regurgitation/mitral valve prolapse Discharge Condition: stable Discharge Instructions: Please call Dr.Emily Merino office or 911 if you experience chest pain, shortness of breath, dizziness, palpitations, numbness, weakness or other concerning symptoms. . We have started a new medication called metoprolol 12.5mg twice daily as well as Flecainide. Please continue your aspirin as prescribed. The cardiologists want you to have an exercise stress test in one week as you have started flecainide. Please schedule this test after discharge from the hospital. . You should take clindamycin prior to any dental procedures as instructed. . You have been set up with CJ Prieto of Hearts monitor Followup Instructions: Provider: Judith Kiel, M.D. Phone:944-918-5395 Date/Time:1949-6-6 3:40 . We have ordered an exercise stress test (non-imaging). Please call 374-137-4786 to schedule this test to be done within the next week as previously instructed by the cardiologists. Completed by:1998-7-8	['Admission Date: 1941-12-20 Discharge Date: 1936-1-2\n\nDate of Birth: 2007-7-1 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPenicillins\n\nAttending:Haydee\nChief Complaint:\npalpitations\n\nMajor Surgical or Invasive Procedure:\ns/p DC - cardioversion on 1922-9-22\n\n\nHistory of Present Illness:\nIn brief, 45 yo woman with history of SVT (long R-P) followed\nfor 5 years, episodes monthly, usually lasting > 1 hr with\nrecent ED presentation for new AFib. She was symptomatic with\npalpitations and shortness of breath with the AFib. She\nunderwent DCCV last week and discharged home on ASA with\noutpatient Echo and EP study scheduled for 2-18 and 2-13,\nrespectively. Given h/o SVT there is a possibility that the SVT\nmay have triggered AF. She now presents with recurrent AFib\nwith dyspnea and mild chest tightness.', " No fevers. In ED she\nwas in AFib with HR 110-120, BP in 70's.\n\nPast Medical History:\nSVT\nAFib\n? Marfan's syndrome\nleft upper extremity radiculopathy\npolypectomies\ndilatation curettage\ndifficulty with conceive a pregnancy\n\nSocial History:\nLives at home. Has three year old son. May Cobbs tobacco, ivdu.\n\nFamily History:\nmother with Kamran Ignacio syndrome - h/o aortic dissection\n\nPhysical Exam:\nVS: 97.8F HR 59 BP 81/49(79-81/48-51) 24 97%RA\nGen: Atencio, comfortable, thin, tall young female, NAD\nHEENT: Clear OP, MMM\nNECK: Supple, No LAD, No JVD\nCV: irregularly irregular, nl S1, S2. No murmurs, rubs or\ngallops\nLUNGS: CTA, BS BL, No W/R/C\nABD: Soft, mild tenderness RLQ, no guarding or rebound,\nnondistended, no HSM.\nEXT: No edema. 2+ DP pulses BL\nSKIN: No lesions\nNEURO: nonfocal\n\nPertinent Results:\n1941-12-20 WBC-5.", '2 RBC-4.53 Hgb-14.7 Hct-42.1 MCV-93 MCH-32.3\nMCHC-34.8 RDW-13.1 Plt Ct-277# Neuts-42.1 Lymphs-48.9\nMonos-6.6 Eos-1.8 Baso-0.6\n1936-1-2 WBC-3.6 RBC-3.37* Hgb-10.9* Hct-31.4* MCV-93\nMCH-32.3* MCHC-34.7 RDW-13.3 Plt Ct-182\n.\n1941-12-20 08:00PM BLOOD PT-11.9 PTT-28.9 INR(PT)-1.0\n.\n1941-12-20 Glucose-99 UreaN-22* Creat-0.8 Na-140 K-3.5 Cl-106\nHCO3-19\n1936-1-2 Glucose-93 UreaN-11 Creat-0.6 Na-138 K-3.8 Cl-107\nHCO3-23\n.\n1941-12-20 08:00PM BLOOD CK(CPK)-55 CK-MB-NotDone cTropnT-1922-9-22 06:40AM BLOOD CK(CPK)-40 CK-MB-NotDone cTropnT-1922-9-22 TTE Echocardiogram: The left atrium is normal in size.\nThe estimated right atrial pressure is 11-15mmHg. Left\nventricular wall thickness, cavity size, and systolic function\nare normal (LVEF 60%). No masses or thrombi are seen in the left\nventricle. There is no ventricular septal defect.', ' The right\nventricular cavity is dilated. Right ventricular systolic\nfunction is normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve leaflets are mildly thickened.\nThe mitral valve leaflets are mildly myxomatous. The mitral\nvalve leaflets are mildly elongated. There is mild mitral valve\nprolapse. Moderate (2+) mitral regurgitation is seen. The mitral\nregurgitation jet is eccentric. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n.\nELECTROCARDIOGRAM PERFORMED ON: 1922-9-22 13:11:16\nAtrial fibrillation. Compared to tracing #1 no change.\n.\nELECTROCARDIOGRAM PERFORMED ON: 1922-9-22 22:49:52\nNormal sinus rhythm. Evidence of prior anteroseptal myocardial\ninfarction.', '\nCompared to tracing #2 atrial fibrillation is no longer present.\n\n\n\nBrief Hospital Course:\n45 yo F hx SVT, Afib p/w palpitations and dyspnea, noted to be\nin recurrent AFib.\n.\n# Afib - recent cardioversion for AFib, now returns with\nrecurrence. Rate is fairly well controlled. Thyroid studies wnl.\n Patient underwent DC cardioversion, but had recurrent atrial\nfibrillation post-procedure. She was started on flecainide\nafter attempt at cardioversion with low dose beta-blocker. She\nconverted back into sinus rhythm that same night. She was\ndischarged on flecainide 50mg po bid and metoprolol. She is to\nscheduled outpatient exercise (non-imaging) stress test in one\nweek after discharge from the hospital. She has outpatient\nfollow-up for possible EP study with Dr. Bounds in the next\ncouple of weeks.', ' She was discharged with CJ Prieto of hearts\nmonitor. She had TTE Echo with mitral regurgitation and\nprolapse and was instructed to take pre-procedure antibiotics\nfor any dentalwork. PCN allergy so given prescription for\nclindamycin.\n.\n# Dyspnea - most likely related to AFib, and resolved on\nadmission after bring her heart rate down. No evidence of\npulmonary edema or infiltrate on CXR. D-dimer negative. No JVD,\nand bedside echo in ED without pericardial effusion. Breathing\ncomfortably on room air throughout hospitalization.\n.\n# Dispo - patient was discharged to home with EP follow-up, Dr.Heflin\nof hearts monitor and stress test.\n\n\nMedications on Admission:\nASA 325mg qday\nMVI\n\nDischarge Medications:\n1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).', '\n3. Flecainide 50 mg Tablet Sig: One (1) Tablet PO twice a day.\nDisp:60 Tablet(s)* Refills:2\n4. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO once\nprior to dentalwork.\nDisp:6 Capsule(s) Refills:2\n5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a\nday.\nDisp:30 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\natrial fibrillation\nsupraventricular tachycardia\nmitral regurgitation/mitral valve prolapse\n\n\nDischarge Condition:\nstable\n\n\nDischarge Instructions:\nPlease call Dr.Emily Merino office or 911 if you experience\nchest pain, shortness of breath, dizziness, palpitations,\nnumbness, weakness or other concerning symptoms.\n.\nWe have started a new medication called metoprolol 12.5mg twice\ndaily as well as Flecainide. Please continue your aspirin as\nprescribed.', ' The cardiologists want you to have an exercise\nstress test in one week as you have started flecainide. Please\nschedule this test after discharge from the hospital.\n.\nYou should take clindamycin prior to any dental procedures as\ninstructed.\n.\nYou have been set up with CJ Prieto of Hearts monitor\n\nFollowup Instructions:\nProvider: Judith Kiel, M.D. Phone:944-918-5395\nDate/Time:1949-6-6 3:40\n.\nWe have ordered an exercise stress test (non-imaging). Please\ncall 374-137-4786 to schedule this test to be done within the\nnext week as previously instructed by the cardiologists.\n\n\n\nCompleted by:1998-7-8']
151	28016	138584.0	2109-11-25	Discharge summary	Report	Admission Date: [2109-11-13] Discharge Date: [2109-11-25] Date of Birth: [2032-8-21] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin Attending:[Last Name (NamePattern1) 1572] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 77 yo M with h/o CHF c/o dyspnea and 23lb wt. gain in last 10 days. The patient was discharged from [Hospital1 18] 10 days ago. He has been followed closely by VNA and his cardiolgoist. His lasix doses have been progressively increased but his weight has been going up and he has been having worsening SOB. Denies CP, SOB, fevers, chills. . In the ED, initial vitals were 97.7 94 125/69 24 83%4L. O2 sat's improved to the high 90's on NRB. BNP >3000. He received a total of lasix 80mg IV x 1 and had 1900cc urine output. . In the MICU, the patient was started on Bumex IV 2mg prn dosing for goal I/O of 1-2L negative daily with good effect. He was restarted on spironolactone as well and has continued to diurese with improvement in his symptoms. His verapamil was transiently stopped on [11-16], and patient subsequently developed atrial tachycardia, thought to be MAT,(which it was not)and was started on a dilt drip and digoxin loaded. Dilt was transitioned to PO verapamil, and he has been continued on the dig. HR appears to be well controlled at this time. Additionally, he developed increased erythema of his left lower extremity at the site of his prior cellulitis, and blood cultures from that day grew coag neg staph 2 out of 2. He was initially started on Vanc IV and this was changed to tetracycline as a result of the patient's allergies. He is currently on day 3 of 7. . The patient reports he is feeling much better, though not quite to baseline. His SOB is much improved and he feels his ascites is reduced. He denies fevers, chills, night sweats, headache, chest pain, diarrhea, dysuria, melena or hematochezia. He does report abdominal distention which is improved. Has 2 pillow orthopnea at baseline and denies PND [12-21] using BiPAP at night. Additionally, denies stroke, TIA, DVT, PE, joint pains, hemoptysis or exertional buttock or calf pain. He does report a chronic dry cough which is at his baseline. . Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought [12-21] to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT -- CHF/ Cor pulmonale -- Obesity. -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 Social History: Lives at home with his wife of 49 years. Stays on the [Location (un) 453] of the house (can't climb stairs [12-21] SOB). Has 6 children and 15 grandchildren-all healthy. Quit smoking 20 yrs ago (1ppd x 35 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: Vitals - T 97.3 BP 100/55 HR 83 R 20 92% on 4L NC General - well appearing male, sitting up in chair in NAD HEENT - NCAT, PERRL, oropharynx clear, dry MM Neck - supple, JVP elevated to angle of jaw (though has 4+ TR) CV - distant heart sounds, RRR, faint [11-24] murmur at Lungs - decreased breath sounds at bases, crackles 2/3 up posteriorly on left, 1/2 up on right Abdomen - distended, nontender, soft, + BS Ext - b/l venous statsis changes/PVD, 1+ pitting edema bilaterally, well-healed scar over left shin at site of prior cellulitis, no open areas . Pertinent Results: Imaging: [2109-11-13] CXR - No significant change with persistent cardiomegaly and likely bibasilar effusions/atelectasis. No overt CHF. [2109-11-13] KUB - Gas distended stomach. No evidence of obstruction. [2109-11-13] Ct Abdomen - Slight interval increase in small right pleural effusion and intra-abdominal ascites. Otherwise, stable CT appearance of the abdomen and pelvis. [2109-11-15] Port abd - No dilated air-filled loops of bowel to suggest obstruction [2109-11-16] CXR - A single portable view of the chest is compared to prior examination dated [2109-11-13]. The cardiomediastinal silhouette is enlarged, but stable. Current examination reveals increasing patchy opacities at the bases bilaterally, right slightly greater than left. Also, blunting of the right costophrenic angle is noted, suggesting pleural effusion. Probable underlying copd. [2109-11-17] CXR - Cardiomegaly and residual CHF with small effusions. Interval improvement compared with one day earlier. . EKG [11-17]: Rhythm is sinus tachycardia with atrial premature complexes. There is borderline low voltage in both the limb leads and precordial leads. There is an RSR' pattern in lead V1 as well as right axis deviation. There are diffuse ST-T wave changes. Overall configuration suggests pulmonary disease. When compared with prior tracing of [2109-11-13] the rate has increased, though it is quite similar to tracing of [2109-10-25]. . Urine: [2109-11-15] 11:53PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.013 [2109-11-15] 11:53PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2109-11-15] 11:53PM URINE RBC-[4-29]* WBC-0 Bacteri-0 Yeast-NONE Epi-0 . Labs: [2109-11-13] 12:00PM BLOOD WBC-7.4 RBC-4.30* Hgb-13.5* Hct-39.6* MCV-92 MCH-31.5 MCHC-34.1 RDW-16.6* Plt Ct-241 [2109-11-14] 04:54AM BLOOD WBC-6.6 RBC-3.61* Hgb-11.4* Hct-32.9* MCV-91 MCH-31.5 MCHC-34.6 RDW-16.8* Plt Ct-222 [2109-11-15] 03:33AM BLOOD WBC-6.2 RBC-3.91* Hgb-11.9* Hct-36.1* MCV-93 MCH-30.5 MCHC-33.0 RDW-16.0* Plt Ct-224 [2109-11-18] 03:06AM BLOOD WBC-6.8 RBC-3.70* Hgb-11.6* Hct-35.1* MCV-95 MCH-31.5 MCHC-33.2 RDW-16.8* Plt Ct-255 [2109-11-19] 05:09AM BLOOD WBC-6.7 RBC-3.75* Hgb-11.7* Hct-35.3* MCV-94 MCH-31.1 MCHC-33.1 RDW-16.9* Plt Ct-249 [2109-11-20] 04:53AM BLOOD WBC-5.8 RBC-3.54* Hgb-11.0* Hct-32.6* MCV-92 MCH-31.1 MCHC-33.8 RDW-15.9* Plt Ct-220 [2109-11-21] 05:30AM BLOOD WBC-7.8 RBC-3.74* Hgb-11.7* Hct-34.6* MCV-92 MCH-31.2 MCHC-33.8 RDW-15.9* Plt Ct-238 [2109-11-22] 05:35AM BLOOD WBC-8.2 RBC-4.22* Hgb-12.7* Hct-39.9* MCV-95 MCH-30.1 MCHC-31.9 RDW-15.9* Plt Ct-263 [2109-11-23] 05:30AM BLOOD WBC-7.1 RBC-3.82* Hgb-11.8* Hct-35.6* MCV-93 MCH-30.9 MCHC-33.2 RDW-16.1* Plt Ct-254 [2109-11-25] 05:35AM BLOOD WBC-6.5 RBC-3.62* Hgb-10.9* Hct-32.9* MCV-91 MCH-30.2 MCHC-33.2 RDW-16.6* Plt Ct-255 [2109-11-13] 12:00PM BLOOD Neuts-78.8* Lymphs-11.2* Monos-7.5 Eos-2.1 Baso-0.3 [2109-11-15] 03:33AM BLOOD Neuts-63.6 Lymphs-19.2 Monos-11.3* Eos-5.7* Baso-0.3 [2109-11-13] 12:00PM BLOOD PT-16.2* PTT-24.7 INR(PT)-1.5* [2109-11-14] 04:54AM BLOOD PT-15.4* PTT-26.2 INR(PT)-1.4* [2109-11-15] 03:33AM BLOOD PT-16.7* PTT-27.7 INR(PT)-1.5* [2109-11-16] 04:27AM BLOOD PT-17.0* PTT-32.7 INR(PT)-1.5* [2109-11-17] 01:58AM BLOOD PT-16.4* PTT-29.3 INR(PT)-1.5* [2109-11-18] 03:06AM BLOOD PT-15.5* PTT-29.9 INR(PT)-1.4* [2109-11-21] 05:30AM BLOOD PT-15.2* PTT-30.0 INR(PT)-1.3* [2109-11-23] 05:30AM BLOOD PT-14.9* PTT-27.2 INR(PT)-1.3* [2109-11-13] 12:00PM BLOOD Glucose-137* UreaN-24* Creat-1.5* Na-136 K-3.9 Cl-98 HCO3-31 AnGap-11 [2109-11-14] 04:54AM BLOOD Glucose-97 UreaN-22* Creat-1.5* Na-135 K-3.5 Cl-98 HCO3-29 AnGap-12 [2109-11-14] 02:21PM BLOOD Glucose-123* UreaN-24* Creat-1.6* Na-137 K-3.4 Cl-98 HCO3-28 AnGap-14 [2109-11-15] 03:33AM BLOOD Glucose-92 UreaN-27* Creat-1.7* Na-138 K-4.1 Cl-102 HCO3-28 AnGap-12 [2109-11-16] 04:27AM BLOOD Glucose-127* UreaN-36* Creat-2.1* Na-140 K-4.1 Cl-101 HCO3-29 AnGap-14 [2109-11-17] 01:58AM BLOOD Glucose-138* UreaN-36* Creat-1.9* Na-139 K-3.7 Cl-102 HCO3-26 AnGap-15 [2109-11-17] 01:31PM BLOOD Glucose-128* UreaN-34* Creat-1.7* Na-138 K-3.2* Cl-100 HCO3-27 AnGap-14 [2109-11-18] 03:06AM BLOOD Glucose-127* UreaN-31* Creat-1.7* Na-138 K-4.2 Cl-101 HCO3-28 AnGap-13 [2109-11-18] 05:25PM BLOOD UreaN-29* Creat-1.6* Na-139 K-3.9 Cl-101 HCO3-29 AnGap-13 [2109-11-19] 05:09AM BLOOD Glucose-100 UreaN-27* Creat-1.6* Na-138 K-3.8 Cl-101 HCO3-29 AnGap-12 [2109-11-19] 04:17PM BLOOD Glucose-109* UreaN-29* Creat-1.7* Na-138 K-3.9 Cl-97 HCO3-30 AnGap-15 [2109-11-20] 04:53AM BLOOD Glucose-90 UreaN-28* Creat-1.6* Na-137 K-3.6 Cl-99 HCO3-31 AnGap-11 [2109-11-22] 05:35AM BLOOD Glucose-98 UreaN-26* Creat-1.8* Na-138 K-3.9 Cl-94* HCO3-32 AnGap-16 [2109-11-24] 06:03AM BLOOD Glucose-93 UreaN-28* Creat-1.9* Na-136 K-4.0 Cl-94* HCO3-31 AnGap-15 [2109-11-25] 05:35AM BLOOD Glucose-108* UreaN-27* Creat-1.9* Na-137 K-3.7 Cl-93* HCO3-31 AnGap-17 [2109-11-13] 12:00PM BLOOD ALT-28 AST-45* CK(CPK)-65 AlkPhos-197* Amylase-107* TotBili-1.1 [2109-11-13] 06:25PM BLOOD CK(CPK)-58 [2109-11-14] 04:54AM BLOOD CK(CPK)-56 [2109-11-21] 05:30AM BLOOD GGT-245* [2109-11-13] 12:00PM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-3634* [2109-11-13] 06:25PM BLOOD cTropnT-0.02* [2109-11-14] 04:54AM BLOOD CK-MB-NotDone cTropnT-0.02* [2109-11-13] 12:00PM BLOOD Albumin-3.6 Calcium-8.8 Phos-2.9 Mg-2.3 [2109-11-14] 04:54AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1 [2109-11-15] 03:33AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.3 [2109-11-16] 04:27AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.9 [2109-11-17] 01:58AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9 [2109-11-17] 01:31PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8 [2109-11-18] 03:06AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2 [2109-11-19] 05:09AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1 [2109-11-19] 04:17PM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9 [2109-11-21] 05:30AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9 [2109-11-23] 05:30AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2 [2109-11-24] 06:03AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0 [2109-11-25] 05:35AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1 [2109-11-24] 06:03AM BLOOD TSH-11* [2109-11-25] 05:35AM BLOOD Free T4-1.1 Brief Hospital Course: # CHF, acute on chronic diastolic dysfunction - Patient admitted with SOB likely [12-21] to CHF exacerbation, has severe diastolic dysfunction with pulmonary hypertension and severe TR. Difficulty balancing diuresis and renal function as an outpatient. He was initially started on Bumex IV with signficant diuresis. He was then transitioned to PO Lasix and has continued to diurese on this regimen. Appears to maintain even Is/Os on Lasix 80mg PO BID. He will be discharged on this regimen with follow up to determine the most appropriate long-term regimen for him. His baseline oxygen requirement is 4L NC satting 88-92%. Additionally, he uses BiPAP overnight. He is satting low-mid 90s on 3L NC at the time of discharge. He was continued on his Metoprolol at 12.5 [Hospital1 ], Spironolactone was added at 25mg PO daily. He was also discharged on Verapamil. His weight was 207.6 pounds on discharge. . # Atrial tachycardia: Some concern that patient was having MAT while in the MICU, however, unable to find evidence of MAT in patient's ECG. He appears to be in an atrial tachycardia. Verapamil was increased to 180mg daily, and he was continued on Metoprolol 12.5mg [Hospital1 ]. He was rate controlled with HR in the 80s on this regimen. . # COPD/Interstitial Lung Disease: Recent admission in early [Month (only) 1096], patient had workup for worsening ILD. Echo readings of severe pulmonary hypertension (not new), worsening dilated RV, and worsening TR found. Patient had a trial of sildenafil however, it was stopped secondary to side effects of hypotension, tachycardia, and dizziness. No plan for further sildenafil. He was started on prn inhalers and continued on his home oxygen regimen. He will require continued outpatient pulmonary follow-up. . # ID/Cellulitis: During his recent hospital admission (dc'd [2109-10-27]), patient completed a 7 day course of clindamycin for L shin cellulitis. During his stay in the MICU, patient developed by report increasing erythema of his L shin and spiked a fever. He was initially started on vancomycin for positive blood cultures. These subsequently grew GPC/coag neg staph. No further positive blood cultures. He was transitioned to tetracycline for his cellulitis. He received 4 days. His antibiotics were discontinued as he did not appear to have further evidence of cellulitis, remained afebrile and had no leukocytosis. Baseline erythema of PVD remained unchanged for the duration of his admission. . # CAD: Clean coronaries on cath in [7-27]. Continued on Metoprolol, Verapamil, Atorvastatin. . # Anemia: Baseline appears to be around 35. Range of 32-39 during admission with no evidence of bleed. Last iron studies in [10-26] showing iron 53, TIBC 368, Ferritin 40, TRF 283. Likely secondary to chronic kidney disease. . # Hypothyroid: Pt complaining of cold intolerance. TSH found to be 11. Free T4 1.1. Likely subclinical hypothyroidism. Started low dose thyroid supplementation on discharge. Patient should follow with PCP. . # Coagulopathy: INR elevated at 1.4 since [2109-3-19]. Unclear etiology. AST wnl, ALT slightly elevated at 45. [Month (only) 116] be nutritional though albumin is 3.6. Can be monitored as an outpatient. . # DM: On oral medications at home. On ISS during admission. Restarted on home regimen on discharge. . # CKD: Baseline creatinine is 1.6-1.7. Slight increase in creatinine to 1.9 during admission, likely a result of aggressive diuresis. Stable over several days. . Code - FULL Medications on Admission: Allopurinol 100 mg DAILY Aspirin 325 mg DAILY Atorvastatin 10 mg DAILY Hexavitamin DAILY Prilosec OTC 20 mg once a day Glimepiride 1 mg once a day. HOME o24L NC Metoprolol 12.5mg TID Verapamil 120 mg SR DAILY Lasix 40mg M-W-F; 30mg T-Th-Sat-Sun Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day. 5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:0 7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic [Hospital1 ] (2 times a day): Take as you were prior to admission. 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [11-20] Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. Disp:1 months supply Refills:0 11. Home O2 3-4L NC 12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day. Disp:30 Tablet(s) Refills:0 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day. 5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:0 7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic [Hospital1 ] (2 times a day): Take as you were prior to admission. 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [11-20] Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. Disp:1 months supply Refills:0 11. Home O2 3-4L NC 12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Acute on chronic severe right heart systolic failure Severe COPD, Pulmonary Hypertension (PA systolic 72 mm hg) Ascites secondary to right sided CHF Interstitial Pulmonary Fibrosis and emphysema Secondary diagnoses: Hypertension Hyperlipidemia Type 2 Diabetes Mellitus Sleep Apnea Hypothyroidism Discharge Condition: Stable Discharge Instructions: You were admitted with a worsening of your heart failure. A significant amount of fluid was removed, and you are now back to your baseline weight with improvement of your breathing. It is very important that you take your Lasix (furosemide) as directed. This should keep the fluid from re-accumulating. In addition, it is very important that you use your BiPAP at night as this will keep your oxygen levels up while you sleep. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Please try not to drink too much fluid after discharge. . In addition, while you were here, your thyroid hormone levels were found to be low. We have started you on a low dose of thyroid replacement hormone (levothyroxine). You should have your thyroid levels rechecked in [2-23] weeks. . Please take all your medications as directed and keep all follow up appointments. Followup Instructions: Please follow up with your cardiologist, Dr. [Last Name (STitle) ], early next week. Please follow up with your primary care doctor in the next 2 weeks as well.	Admission Date: <Date>1973-12-9</Date> Discharge Date: <Date>2017-7-23</Date> Date of Birth: <Date>1930-10-29</Date> Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin Attending:<Name>Lockett</Name> Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 77 yo M with h/o CHF c/o dyspnea and 23lb wt. gain in last 10 days. The patient was discharged from <Hospital>Burnett-Green Medical Center</Hospital> 10 days ago. He has been followed closely by VNA and his cardiolgoist. His lasix doses have been progressively increased but his weight has been going up and he has been having worsening SOB. Denies CP, SOB, fevers, chills. . In the ED, initial vitals were 97.7 94 125/69 24 83%4L. O2 sat's improved to the high 90's on NRB. BNP >3000. He received a total of lasix 80mg IV x 1 and had 1900cc urine output. . In the MICU, the patient was started on Bumex IV 2mg prn dosing for goal I/O of 1-2L negative daily with good effect. He was restarted on spironolactone as well and has continued to diurese with improvement in his symptoms. His verapamil was transiently stopped on <Date>3-13</Date>, and patient subsequently developed atrial tachycardia, thought to be MAT,(which it was not)and was started on a dilt drip and digoxin loaded. Dilt was transitioned to PO verapamil, and he has been continued on the dig. HR appears to be well controlled at this time. Additionally, he developed increased erythema of his left lower extremity at the site of his prior cellulitis, and blood cultures from that day grew coag neg staph 2 out of 2. He was initially started on Vanc IV and this was changed to tetracycline as a result of the patient's allergies. He is currently on day 3 of 7. . The patient reports he is feeling much better, though not quite to baseline. His SOB is much improved and he feels his ascites is reduced. He denies fevers, chills, night sweats, headache, chest pain, diarrhea, dysuria, melena or hematochezia. He does report abdominal distention which is improved. Has 2 pillow orthopnea at baseline and denies PND <Date>12-1</Date> using BiPAP at night. Additionally, denies stroke, TIA, DVT, PE, joint pains, hemoptysis or exertional buttock or calf pain. He does report a chronic dry cough which is at his baseline. . Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought <Date>12-1</Date> to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT -- CHF/ Cor pulmonale -- Obesity. -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 Social History: Lives at home with his wife of 49 years. Stays on the <Location>7380 Ferguson Throughway Suite 153 Bakerside, SD 74716</Location> of the house (can't climb stairs <Date>12-1</Date> SOB). Has 6 children and 15 grandchildren-all healthy. Quit smoking 20 yrs ago (1ppd x 35 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: Vitals - T 97.3 BP 100/55 HR 83 R 20 92% on 4L NC General - well appearing male, sitting up in chair in NAD HEENT - NCAT, PERRL, oropharynx clear, dry MM Neck - supple, JVP elevated to angle of jaw (though has 4+ TR) CV - distant heart sounds, RRR, faint <Date>3-26</Date> murmur at Lungs - decreased breath sounds at bases, crackles 2/3 up posteriorly on left, 1/2 up on right Abdomen - distended, nontender, soft, + BS Ext - b/l venous statsis changes/PVD, 1+ pitting edema bilaterally, well-healed scar over left shin at site of prior cellulitis, no open areas . Pertinent Results: Imaging: <Date>1973-12-9</Date> CXR - No significant change with persistent cardiomegaly and likely bibasilar effusions/atelectasis. No overt CHF. <Date>1973-12-9</Date> KUB - Gas distended stomach. No evidence of obstruction. <Date>1973-12-9</Date> Ct Abdomen - Slight interval increase in small right pleural effusion and intra-abdominal ascites. Otherwise, stable CT appearance of the abdomen and pelvis. <Date>1997-3-17</Date> Port abd - No dilated air-filled loops of bowel to suggest obstruction <Date>1991-5-29</Date> CXR - A single portable view of the chest is compared to prior examination dated <Date>1973-12-9</Date>. The cardiomediastinal silhouette is enlarged, but stable. Current examination reveals increasing patchy opacities at the bases bilaterally, right slightly greater than left. Also, blunting of the right costophrenic angle is noted, suggesting pleural effusion. Probable underlying copd. <Date>1963-10-9</Date> CXR - Cardiomegaly and residual CHF with small effusions. Interval improvement compared with one day earlier. . EKG <Date>1-8</Date>: Rhythm is sinus tachycardia with atrial premature complexes. There is borderline low voltage in both the limb leads and precordial leads. There is an RSR' pattern in lead V1 as well as right axis deviation. There are diffuse ST-T wave changes. Overall configuration suggests pulmonary disease. When compared with prior tracing of <Date>1973-12-9</Date> the rate has increased, though it is quite similar to tracing of <Date>1972-10-9</Date>. . Urine: <Date>1997-3-17</Date> 11:53PM URINE Color-Yellow Appear-Clear Sp <Name>Clapp</Name>-1.013 <Date>1997-3-17</Date> 11:53PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG <Date>1997-3-17</Date> 11:53PM URINE RBC-<Date>11-3</Date>* WBC-0 Bacteri-0 Yeast-NONE Epi-0 . Labs: <Date>1973-12-9</Date> 12:00PM BLOOD WBC-7.4 RBC-4.30* Hgb-13.5* Hct-39.6* MCV-92 MCH-31.5 MCHC-34.1 RDW-16.6* Plt Ct-241 <Date>1976-6-2</Date> 04:54AM BLOOD WBC-6.6 RBC-3.61* Hgb-11.4* Hct-32.9* MCV-91 MCH-31.5 MCHC-34.6 RDW-16.8* Plt Ct-222 <Date>1997-3-17</Date> 03:33AM BLOOD WBC-6.2 RBC-3.91* Hgb-11.9* Hct-36.1* MCV-93 MCH-30.5 MCHC-33.0 RDW-16.0* Plt Ct-224 <Date>2020-8-17</Date> 03:06AM BLOOD WBC-6.8 RBC-3.70* Hgb-11.6* Hct-35.1* MCV-95 MCH-31.5 MCHC-33.2 RDW-16.8* Plt Ct-255 <Date>1952-8-12</Date> 05:09AM BLOOD WBC-6.7 RBC-3.75* Hgb-11.7* Hct-35.3* MCV-94 MCH-31.1 MCHC-33.1 RDW-16.9* Plt Ct-249 <Date>1991-1-4</Date> 04:53AM BLOOD WBC-5.8 RBC-3.54* Hgb-11.0* Hct-32.6* MCV-92 MCH-31.1 MCHC-33.8 RDW-15.9* Plt Ct-220 <Date>1993-5-16</Date> 05:30AM BLOOD WBC-7.8 RBC-3.74* Hgb-11.7* Hct-34.6* MCV-92 MCH-31.2 MCHC-33.8 RDW-15.9* Plt Ct-238 <Date>1948-7-12</Date> 05:35AM BLOOD WBC-8.2 RBC-4.22* Hgb-12.7* Hct-39.9* MCV-95 MCH-30.1 MCHC-31.9 RDW-15.9* Plt Ct-263 <Date>1991-8-16</Date> 05:30AM BLOOD WBC-7.1 RBC-3.82* Hgb-11.8* Hct-35.6* MCV-93 MCH-30.9 MCHC-33.2 RDW-16.1* Plt Ct-254 <Date>2017-7-23</Date> 05:35AM BLOOD WBC-6.5 RBC-3.62* Hgb-10.9* Hct-32.9* MCV-91 MCH-30.2 MCHC-33.2 RDW-16.6* Plt Ct-255 <Date>1973-12-9</Date> 12:00PM BLOOD Neuts-78.8* Lymphs-11.2* Monos-7.5 Eos-2.1 Baso-0.3 <Date>1997-3-17</Date> 03:33AM BLOOD Neuts-63.6 Lymphs-19.2 Monos-11.3* Eos-5.7* Baso-0.3 <Date>1973-12-9</Date> 12:00PM BLOOD PT-16.2* PTT-24.7 INR(PT)-1.5* <Date>1976-6-2</Date> 04:54AM BLOOD PT-15.4* PTT-26.2 INR(PT)-1.4* <Date>1997-3-17</Date> 03:33AM BLOOD PT-16.7* PTT-27.7 INR(PT)-1.5* <Date>1991-5-29</Date> 04:27AM BLOOD PT-17.0* PTT-32.7 INR(PT)-1.5* <Date>1963-10-9</Date> 01:58AM BLOOD PT-16.4* PTT-29.3 INR(PT)-1.5* <Date>2020-8-17</Date> 03:06AM BLOOD PT-15.5* PTT-29.9 INR(PT)-1.4* <Date>1993-5-16</Date> 05:30AM BLOOD PT-15.2* PTT-30.0 INR(PT)-1.3* <Date>1991-8-16</Date> 05:30AM BLOOD PT-14.9* PTT-27.2 INR(PT)-1.3* <Date>1973-12-9</Date> 12:00PM BLOOD Glucose-137* UreaN-24* Creat-1.5* Na-136 K-3.9 Cl-98 HCO3-31 AnGap-11 <Date>1976-6-2</Date> 04:54AM BLOOD Glucose-97 UreaN-22* Creat-1.5* Na-135 K-3.5 Cl-98 HCO3-29 AnGap-12 <Date>1976-6-2</Date> 02:21PM BLOOD Glucose-123* UreaN-24* Creat-1.6* Na-137 K-3.4 Cl-98 HCO3-28 AnGap-14 <Date>1997-3-17</Date> 03:33AM BLOOD Glucose-92 UreaN-27* Creat-1.7* Na-138 K-4.1 Cl-102 HCO3-28 AnGap-12 <Date>1991-5-29</Date> 04:27AM BLOOD Glucose-127* UreaN-36* Creat-2.1* Na-140 K-4.1 Cl-101 HCO3-29 AnGap-14 <Date>1963-10-9</Date> 01:58AM BLOOD Glucose-138* UreaN-36* Creat-1.9* Na-139 K-3.7 Cl-102 HCO3-26 AnGap-15 <Date>1963-10-9</Date> 01:31PM BLOOD Glucose-128* UreaN-34* Creat-1.7* Na-138 K-3.2* Cl-100 HCO3-27 AnGap-14 <Date>2020-8-17</Date> 03:06AM BLOOD Glucose-127* UreaN-31* Creat-1.7* Na-138 K-4.2 Cl-101 HCO3-28 AnGap-13 <Date>2020-8-17</Date> 05:25PM BLOOD UreaN-29* Creat-1.6* Na-139 K-3.9 Cl-101 HCO3-29 AnGap-13 <Date>1952-8-12</Date> 05:09AM BLOOD Glucose-100 UreaN-27* Creat-1.6* Na-138 K-3.8 Cl-101 HCO3-29 AnGap-12 <Date>1952-8-12</Date> 04:17PM BLOOD Glucose-109* UreaN-29* Creat-1.7* Na-138 K-3.9 Cl-97 HCO3-30 AnGap-15 <Date>1991-1-4</Date> 04:53AM BLOOD Glucose-90 UreaN-28* Creat-1.6* Na-137 K-3.6 Cl-99 HCO3-31 AnGap-11 <Date>1948-7-12</Date> 05:35AM BLOOD Glucose-98 UreaN-26* Creat-1.8* Na-138 K-3.9 Cl-94* HCO3-32 AnGap-16 <Date>1925-9-30</Date> 06:03AM BLOOD Glucose-93 UreaN-28* Creat-1.9* Na-136 K-4.0 Cl-94* HCO3-31 AnGap-15 <Date>2017-7-23</Date> 05:35AM BLOOD Glucose-108* UreaN-27* Creat-1.9* Na-137 K-3.7 Cl-93* HCO3-31 AnGap-17 <Date>1973-12-9</Date> 12:00PM BLOOD ALT-28 AST-45* CK(CPK)-65 AlkPhos-197* Amylase-107* TotBili-1.1 <Date>1973-12-9</Date> 06:25PM BLOOD CK(CPK)-58 <Date>1976-6-2</Date> 04:54AM BLOOD CK(CPK)-56 <Date>1993-5-16</Date> 05:30AM BLOOD GGT-245* <Date>1973-12-9</Date> 12:00PM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-3634* <Date>1973-12-9</Date> 06:25PM BLOOD cTropnT-0.02* <Date>1976-6-2</Date> 04:54AM BLOOD CK-MB-NotDone cTropnT-0.02* <Date>1973-12-9</Date> 12:00PM BLOOD Albumin-3.6 Calcium-8.8 Phos-2.9 Mg-2.3 <Date>1976-6-2</Date> 04:54AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1 <Date>1997-3-17</Date> 03:33AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.3 <Date>1991-5-29</Date> 04:27AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.9 <Date>1963-10-9</Date> 01:58AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9 <Date>1963-10-9</Date> 01:31PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8 <Date>2020-8-17</Date> 03:06AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2 <Date>1952-8-12</Date> 05:09AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1 <Date>1952-8-12</Date> 04:17PM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9 <Date>1993-5-16</Date> 05:30AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9 <Date>1991-8-16</Date> 05:30AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2 <Date>1925-9-30</Date> 06:03AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0 <Date>2017-7-23</Date> 05:35AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1 <Date>1925-9-30</Date> 06:03AM BLOOD TSH-11* <Date>2017-7-23</Date> 05:35AM BLOOD Free T4-1.1 Brief Hospital Course: # CHF, acute on chronic diastolic dysfunction - Patient admitted with SOB likely <Date>12-1</Date> to CHF exacerbation, has severe diastolic dysfunction with pulmonary hypertension and severe TR. Difficulty balancing diuresis and renal function as an outpatient. He was initially started on Bumex IV with signficant diuresis. He was then transitioned to PO Lasix and has continued to diurese on this regimen. Appears to maintain even Is/Os on Lasix 80mg PO BID. He will be discharged on this regimen with follow up to determine the most appropriate long-term regimen for him. His baseline oxygen requirement is 4L NC satting 88-92%. Additionally, he uses BiPAP overnight. He is satting low-mid 90s on 3L NC at the time of discharge. He was continued on his Metoprolol at 12.5 <Hospital>White, Gonzalez and Martinez Medical Center</Hospital>, Spironolactone was added at 25mg PO daily. He was also discharged on Verapamil. His weight was 207.6 pounds on discharge. . # Atrial tachycardia: Some concern that patient was having MAT while in the MICU, however, unable to find evidence of MAT in patient's ECG. He appears to be in an atrial tachycardia. Verapamil was increased to 180mg daily, and he was continued on Metoprolol 12.5mg <Hospital>White, Gonzalez and Martinez Medical Center</Hospital>. He was rate controlled with HR in the 80s on this regimen. . # COPD/Interstitial Lung Disease: Recent admission in early <Month>January</Month>, patient had workup for worsening ILD. Echo readings of severe pulmonary hypertension (not new), worsening dilated RV, and worsening TR found. Patient had a trial of sildenafil however, it was stopped secondary to side effects of hypotension, tachycardia, and dizziness. No plan for further sildenafil. He was started on prn inhalers and continued on his home oxygen regimen. He will require continued outpatient pulmonary follow-up. . # ID/Cellulitis: During his recent hospital admission (dc'd <Date>1917-4-12</Date>), patient completed a 7 day course of clindamycin for L shin cellulitis. During his stay in the MICU, patient developed by report increasing erythema of his L shin and spiked a fever. He was initially started on vancomycin for positive blood cultures. These subsequently grew GPC/coag neg staph. No further positive blood cultures. He was transitioned to tetracycline for his cellulitis. He received 4 days. His antibiotics were discontinued as he did not appear to have further evidence of cellulitis, remained afebrile and had no leukocytosis. Baseline erythema of PVD remained unchanged for the duration of his admission. . # CAD: Clean coronaries on cath in <Date>4-24</Date>. Continued on Metoprolol, Verapamil, Atorvastatin. . # Anemia: Baseline appears to be around 35. Range of 32-39 during admission with no evidence of bleed. Last iron studies in <Date>11-22</Date> showing iron 53, TIBC 368, Ferritin 40, TRF 283. Likely secondary to chronic kidney disease. . # Hypothyroid: Pt complaining of cold intolerance. TSH found to be 11. Free T4 1.1. Likely subclinical hypothyroidism. Started low dose thyroid supplementation on discharge. Patient should follow with PCP. . # Coagulopathy: INR elevated at 1.4 since <Date>1977-10-10</Date>. Unclear etiology. AST wnl, ALT slightly elevated at 45. <Month>July</Month> be nutritional though albumin is 3.6. Can be monitored as an outpatient. . # DM: On oral medications at home. On ISS during admission. Restarted on home regimen on discharge. . # CKD: Baseline creatinine is 1.6-1.7. Slight increase in creatinine to 1.9 during admission, likely a result of aggressive diuresis. Stable over several days. . Code - FULL Medications on Admission: Allopurinol 100 mg DAILY Aspirin 325 mg DAILY Atorvastatin 10 mg DAILY Hexavitamin DAILY Prilosec OTC 20 mg once a day Glimepiride 1 mg once a day. HOME o24L NC Metoprolol 12.5mg TID Verapamil 120 mg SR DAILY Lasix 40mg M-W-F; 30mg T-Th-Sat-Sun Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day. 5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:0 7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic <Hospital>White, Gonzalez and Martinez Medical Center</Hospital> (2 times a day): Take as you were prior to admission. 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: <Date>3-26</Date> Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. Disp:1 months supply Refills:0 11. Home O2 3-4L NC 12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day. Disp:30 Tablet(s) Refills:0 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day. 5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:0 7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic <Hospital>White, Gonzalez and Martinez Medical Center</Hospital> (2 times a day): Take as you were prior to admission. 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: <Date>3-26</Date> Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. Disp:1 months supply Refills:0 11. Home O2 3-4L NC 12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: <Location>822 Crystal Corner Suite 322 Michellestad, VA 99374</Location> VNA Discharge Diagnosis: Acute on chronic severe right heart systolic failure Severe COPD, Pulmonary Hypertension (PA systolic 72 mm hg) Ascites secondary to right sided CHF Interstitial Pulmonary Fibrosis and emphysema Secondary diagnoses: Hypertension Hyperlipidemia Type 2 Diabetes Mellitus Sleep Apnea Hypothyroidism Discharge Condition: Stable Discharge Instructions: You were admitted with a worsening of your heart failure. A significant amount of fluid was removed, and you are now back to your baseline weight with improvement of your breathing. It is very important that you take your Lasix (furosemide) as directed. This should keep the fluid from re-accumulating. In addition, it is very important that you use your BiPAP at night as this will keep your oxygen levels up while you sleep. . Weigh yourself every morning, <Name>Jacki Atencio</Name> MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Please try not to drink too much fluid after discharge. . In addition, while you were here, your thyroid hormone levels were found to be low. We have started you on a low dose of thyroid replacement hormone (levothyroxine). You should have your thyroid levels rechecked in <Date>8-29</Date> weeks. . Please take all your medications as directed and keep all follow up appointments. Followup Instructions: Please follow up with your cardiologist, Dr. <Name>Chowdhury</Name>, early next week. Please follow up with your primary care doctor in the next 2 weeks as 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Date: 1973-12-9 Discharge Date: 2017-7-23 Date of Birth: 1930-10-29 Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin Attending:Lockett Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 77 yo M with h/o CHF c/o dyspnea and 23lb wt. gain in last 10 days. The patient was discharged from Burnett-Green Medical Center 10 days ago. He has been followed closely by VNA and his cardiolgoist. His lasix doses have been progressively increased but his weight has been going up and he has been having worsening SOB. Denies CP, SOB, fevers, chills. . In the ED, initial vitals were 97.7 94 125/69 24 83%4L. O2 sat's improved to the high 90's on NRB. BNP >3000. He received a total of lasix 80mg IV x 1 and had 1900cc urine output. . In the MICU, the patient was started on Bumex IV 2mg prn dosing for goal I/O of 1-2L negative daily with good effect. He was restarted on spironolactone as well and has continued to diurese with improvement in his symptoms. His verapamil was transiently stopped on 3-13, and patient subsequently developed atrial tachycardia, thought to be MAT,(which it was not)and was started on a dilt drip and digoxin loaded. Dilt was transitioned to PO verapamil, and he has been continued on the dig. HR appears to be well controlled at this time. Additionally, he developed increased erythema of his left lower extremity at the site of his prior cellulitis, and blood cultures from that day grew coag neg staph 2 out of 2. He was initially started on Vanc IV and this was changed to tetracycline as a result of the patient's allergies. He is currently on day 3 of 7. . The patient reports he is feeling much better, though not quite to baseline. His SOB is much improved and he feels his ascites is reduced. He denies fevers, chills, night sweats, headache, chest pain, diarrhea, dysuria, melena or hematochezia. He does report abdominal distention which is improved. Has 2 pillow orthopnea at baseline and denies PND 12-1 using BiPAP at night. Additionally, denies stroke, TIA, DVT, PE, joint pains, hemoptysis or exertional buttock or calf pain. He does report a chronic dry cough which is at his baseline. . Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought 12-1 to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT -- CHF/ Cor pulmonale -- Obesity. -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 Social History: Lives at home with his wife of 49 years. Stays on the 7380 Ferguson Throughway Suite 153 Bakerside, SD 74716 of the house (can't climb stairs 12-1 SOB). Has 6 children and 15 grandchildren-all healthy. Quit smoking 20 yrs ago (1ppd x 35 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: Vitals - T 97.3 BP 100/55 HR 83 R 20 92% on 4L NC General - well appearing male, sitting up in chair in NAD HEENT - NCAT, PERRL, oropharynx clear, dry MM Neck - supple, JVP elevated to angle of jaw (though has 4+ TR) CV - distant heart sounds, RRR, faint 3-26 murmur at Lungs - decreased breath sounds at bases, crackles 2/3 up posteriorly on left, 1/2 up on right Abdomen - distended, nontender, soft, + BS Ext - b/l venous statsis changes/PVD, 1+ pitting edema bilaterally, well-healed scar over left shin at site of prior cellulitis, no open areas . Pertinent Results: Imaging: 1973-12-9 CXR - No significant change with persistent cardiomegaly and likely bibasilar effusions/atelectasis. No overt CHF. 1973-12-9 KUB - Gas distended stomach. No evidence of obstruction. 1973-12-9 Ct Abdomen - Slight interval increase in small right pleural effusion and intra-abdominal ascites. Otherwise, stable CT appearance of the abdomen and pelvis. 1997-3-17 Port abd - No dilated air-filled loops of bowel to suggest obstruction 1991-5-29 CXR - A single portable view of the chest is compared to prior examination dated 1973-12-9. The cardiomediastinal silhouette is enlarged, but stable. Current examination reveals increasing patchy opacities at the bases bilaterally, right slightly greater than left. Also, blunting of the right costophrenic angle is noted, suggesting pleural effusion. Probable underlying copd. 1963-10-9 CXR - Cardiomegaly and residual CHF with small effusions. Interval improvement compared with one day earlier. . EKG 1-8: Rhythm is sinus tachycardia with atrial premature complexes. There is borderline low voltage in both the limb leads and precordial leads. There is an RSR' pattern in lead V1 as well as right axis deviation. There are diffuse ST-T wave changes. Overall configuration suggests pulmonary disease. When compared with prior tracing of 1973-12-9 the rate has increased, though it is quite similar to tracing of 1972-10-9. . Urine: 1997-3-17 11:53PM URINE Color-Yellow Appear-Clear Sp Clapp-1.013 1997-3-17 11:53PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG 1997-3-17 11:53PM URINE RBC-11-3* WBC-0 Bacteri-0 Yeast-NONE Epi-0 . Labs: 1973-12-9 12:00PM BLOOD WBC-7.4 RBC-4.30* Hgb-13.5* Hct-39.6* MCV-92 MCH-31.5 MCHC-34.1 RDW-16.6* Plt Ct-241 1976-6-2 04:54AM BLOOD WBC-6.6 RBC-3.61* Hgb-11.4* Hct-32.9* MCV-91 MCH-31.5 MCHC-34.6 RDW-16.8* Plt Ct-222 1997-3-17 03:33AM BLOOD WBC-6.2 RBC-3.91* Hgb-11.9* Hct-36.1* MCV-93 MCH-30.5 MCHC-33.0 RDW-16.0* Plt Ct-224 2020-8-17 03:06AM BLOOD WBC-6.8 RBC-3.70* Hgb-11.6* Hct-35.1* MCV-95 MCH-31.5 MCHC-33.2 RDW-16.8* Plt Ct-255 1952-8-12 05:09AM BLOOD WBC-6.7 RBC-3.75* Hgb-11.7* Hct-35.3* MCV-94 MCH-31.1 MCHC-33.1 RDW-16.9* Plt Ct-249 1991-1-4 04:53AM BLOOD WBC-5.8 RBC-3.54* Hgb-11.0* Hct-32.6* MCV-92 MCH-31.1 MCHC-33.8 RDW-15.9* Plt Ct-220 1993-5-16 05:30AM BLOOD WBC-7.8 RBC-3.74* Hgb-11.7* Hct-34.6* MCV-92 MCH-31.2 MCHC-33.8 RDW-15.9* Plt Ct-238 1948-7-12 05:35AM BLOOD WBC-8.2 RBC-4.22* Hgb-12.7* Hct-39.9* MCV-95 MCH-30.1 MCHC-31.9 RDW-15.9* Plt Ct-263 1991-8-16 05:30AM BLOOD WBC-7.1 RBC-3.82* Hgb-11.8* Hct-35.6* MCV-93 MCH-30.9 MCHC-33.2 RDW-16.1* Plt Ct-254 2017-7-23 05:35AM BLOOD WBC-6.5 RBC-3.62* Hgb-10.9* Hct-32.9* MCV-91 MCH-30.2 MCHC-33.2 RDW-16.6* Plt Ct-255 1973-12-9 12:00PM BLOOD Neuts-78.8* Lymphs-11.2* Monos-7.5 Eos-2.1 Baso-0.3 1997-3-17 03:33AM BLOOD Neuts-63.6 Lymphs-19.2 Monos-11.3* Eos-5.7* Baso-0.3 1973-12-9 12:00PM BLOOD PT-16.2* PTT-24.7 INR(PT)-1.5* 1976-6-2 04:54AM BLOOD PT-15.4* PTT-26.2 INR(PT)-1.4* 1997-3-17 03:33AM BLOOD PT-16.7* PTT-27.7 INR(PT)-1.5* 1991-5-29 04:27AM BLOOD PT-17.0* PTT-32.7 INR(PT)-1.5* 1963-10-9 01:58AM BLOOD PT-16.4* PTT-29.3 INR(PT)-1.5* 2020-8-17 03:06AM BLOOD PT-15.5* PTT-29.9 INR(PT)-1.4* 1993-5-16 05:30AM BLOOD PT-15.2* PTT-30.0 INR(PT)-1.3* 1991-8-16 05:30AM BLOOD PT-14.9* PTT-27.2 INR(PT)-1.3* 1973-12-9 12:00PM BLOOD Glucose-137* UreaN-24* Creat-1.5* Na-136 K-3.9 Cl-98 HCO3-31 AnGap-11 1976-6-2 04:54AM BLOOD Glucose-97 UreaN-22* Creat-1.5* Na-135 K-3.5 Cl-98 HCO3-29 AnGap-12 1976-6-2 02:21PM BLOOD Glucose-123* UreaN-24* Creat-1.6* Na-137 K-3.4 Cl-98 HCO3-28 AnGap-14 1997-3-17 03:33AM BLOOD Glucose-92 UreaN-27* Creat-1.7* Na-138 K-4.1 Cl-102 HCO3-28 AnGap-12 1991-5-29 04:27AM BLOOD Glucose-127* UreaN-36* Creat-2.1* Na-140 K-4.1 Cl-101 HCO3-29 AnGap-14 1963-10-9 01:58AM BLOOD Glucose-138* UreaN-36* Creat-1.9* Na-139 K-3.7 Cl-102 HCO3-26 AnGap-15 1963-10-9 01:31PM BLOOD Glucose-128* UreaN-34* Creat-1.7* Na-138 K-3.2* Cl-100 HCO3-27 AnGap-14 2020-8-17 03:06AM BLOOD Glucose-127* UreaN-31* Creat-1.7* Na-138 K-4.2 Cl-101 HCO3-28 AnGap-13 2020-8-17 05:25PM BLOOD UreaN-29* Creat-1.6* Na-139 K-3.9 Cl-101 HCO3-29 AnGap-13 1952-8-12 05:09AM BLOOD Glucose-100 UreaN-27* Creat-1.6* Na-138 K-3.8 Cl-101 HCO3-29 AnGap-12 1952-8-12 04:17PM BLOOD Glucose-109* UreaN-29* Creat-1.7* Na-138 K-3.9 Cl-97 HCO3-30 AnGap-15 1991-1-4 04:53AM BLOOD Glucose-90 UreaN-28* Creat-1.6* Na-137 K-3.6 Cl-99 HCO3-31 AnGap-11 1948-7-12 05:35AM BLOOD Glucose-98 UreaN-26* Creat-1.8* Na-138 K-3.9 Cl-94* HCO3-32 AnGap-16 1925-9-30 06:03AM BLOOD Glucose-93 UreaN-28* Creat-1.9* Na-136 K-4.0 Cl-94* HCO3-31 AnGap-15 2017-7-23 05:35AM BLOOD Glucose-108* UreaN-27* Creat-1.9* Na-137 K-3.7 Cl-93* HCO3-31 AnGap-17 1973-12-9 12:00PM BLOOD ALT-28 AST-45* CK(CPK)-65 AlkPhos-197* Amylase-107* TotBili-1.1 1973-12-9 06:25PM BLOOD CK(CPK)-58 1976-6-2 04:54AM BLOOD CK(CPK)-56 1993-5-16 05:30AM BLOOD GGT-245* 1973-12-9 12:00PM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-3634* 1973-12-9 06:25PM BLOOD cTropnT-0.02* 1976-6-2 04:54AM BLOOD CK-MB-NotDone cTropnT-0.02* 1973-12-9 12:00PM BLOOD Albumin-3.6 Calcium-8.8 Phos-2.9 Mg-2.3 1976-6-2 04:54AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1 1997-3-17 03:33AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.3 1991-5-29 04:27AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.9 1963-10-9 01:58AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9 1963-10-9 01:31PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8 2020-8-17 03:06AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2 1952-8-12 05:09AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1 1952-8-12 04:17PM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9 1993-5-16 05:30AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9 1991-8-16 05:30AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2 1925-9-30 06:03AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0 2017-7-23 05:35AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1 1925-9-30 06:03AM BLOOD TSH-11* 2017-7-23 05:35AM BLOOD Free T4-1.1 Brief Hospital Course: # CHF, acute on chronic diastolic dysfunction - Patient admitted with SOB likely 12-1 to CHF exacerbation, has severe diastolic dysfunction with pulmonary hypertension and severe TR. Difficulty balancing diuresis and renal function as an outpatient. He was initially started on Bumex IV with signficant diuresis. He was then transitioned to PO Lasix and has continued to diurese on this regimen. Appears to maintain even Is/Os on Lasix 80mg PO BID. He will be discharged on this regimen with follow up to determine the most appropriate long-term regimen for him. His baseline oxygen requirement is 4L NC satting 88-92%. Additionally, he uses BiPAP overnight. He is satting low-mid 90s on 3L NC at the time of discharge. He was continued on his Metoprolol at 12.5 White, Gonzalez and Martinez Medical Center, Spironolactone was added at 25mg PO daily. He was also discharged on Verapamil. His weight was 207.6 pounds on discharge. . # Atrial tachycardia: Some concern that patient was having MAT while in the MICU, however, unable to find evidence of MAT in patient's ECG. He appears to be in an atrial tachycardia. Verapamil was increased to 180mg daily, and he was continued on Metoprolol 12.5mg White, Gonzalez and Martinez Medical Center. He was rate controlled with HR in the 80s on this regimen. . # COPD/Interstitial Lung Disease: Recent admission in early January, patient had workup for worsening ILD. Echo readings of severe pulmonary hypertension (not new), worsening dilated RV, and worsening TR found. Patient had a trial of sildenafil however, it was stopped secondary to side effects of hypotension, tachycardia, and dizziness. No plan for further sildenafil. He was started on prn inhalers and continued on his home oxygen regimen. He will require continued outpatient pulmonary follow-up. . # ID/Cellulitis: During his recent hospital admission (dc'd 1917-4-12), patient completed a 7 day course of clindamycin for L shin cellulitis. During his stay in the MICU, patient developed by report increasing erythema of his L shin and spiked a fever. He was initially started on vancomycin for positive blood cultures. These subsequently grew GPC/coag neg staph. No further positive blood cultures. He was transitioned to tetracycline for his cellulitis. He received 4 days. His antibiotics were discontinued as he did not appear to have further evidence of cellulitis, remained afebrile and had no leukocytosis. Baseline erythema of PVD remained unchanged for the duration of his admission. . # CAD: Clean coronaries on cath in 4-24. Continued on Metoprolol, Verapamil, Atorvastatin. . # Anemia: Baseline appears to be around 35. Range of 32-39 during admission with no evidence of bleed. Last iron studies in 11-22 showing iron 53, TIBC 368, Ferritin 40, TRF 283. Likely secondary to chronic kidney disease. . # Hypothyroid: Pt complaining of cold intolerance. TSH found to be 11. Free T4 1.1. Likely subclinical hypothyroidism. Started low dose thyroid supplementation on discharge. Patient should follow with PCP. . # Coagulopathy: INR elevated at 1.4 since 1977-10-10. Unclear etiology. AST wnl, ALT slightly elevated at 45. July be nutritional though albumin is 3.6. Can be monitored as an outpatient. . # DM: On oral medications at home. On ISS during admission. Restarted on home regimen on discharge. . # CKD: Baseline creatinine is 1.6-1.7. Slight increase in creatinine to 1.9 during admission, likely a result of aggressive diuresis. Stable over several days. . Code - FULL Medications on Admission: Allopurinol 100 mg DAILY Aspirin 325 mg DAILY Atorvastatin 10 mg DAILY Hexavitamin DAILY Prilosec OTC 20 mg once a day Glimepiride 1 mg once a day. HOME o24L NC Metoprolol 12.5mg TID Verapamil 120 mg SR DAILY Lasix 40mg M-W-F; 30mg T-Th-Sat-Sun Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day. 5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:0 7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic White, Gonzalez and Martinez Medical Center (2 times a day): Take as you were prior to admission. 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: 3-26 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. Disp:1 months supply Refills:0 11. Home O2 3-4L NC 12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day. Disp:30 Tablet(s) Refills:0 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day. 5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:0 7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic White, Gonzalez and Martinez Medical Center (2 times a day): Take as you were prior to admission. 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: 3-26 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. Disp:1 months supply Refills:0 11. Home O2 3-4L NC 12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: 822 Crystal Corner Suite 322 Michellestad, VA 99374 VNA Discharge Diagnosis: Acute on chronic severe right heart systolic failure Severe COPD, Pulmonary Hypertension (PA systolic 72 mm hg) Ascites secondary to right sided CHF Interstitial Pulmonary Fibrosis and emphysema Secondary diagnoses: Hypertension Hyperlipidemia Type 2 Diabetes Mellitus Sleep Apnea Hypothyroidism Discharge Condition: Stable Discharge Instructions: You were admitted with a worsening of your heart failure. A significant amount of fluid was removed, and you are now back to your baseline weight with improvement of your breathing. It is very important that you take your Lasix (furosemide) as directed. This should keep the fluid from re-accumulating. In addition, it is very important that you use your BiPAP at night as this will keep your oxygen levels up while you sleep. . Weigh yourself every morning, Jacki Atencio MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Please try not to drink too much fluid after discharge. . In addition, while you were here, your thyroid hormone levels were found to be low. We have started you on a low dose of thyroid replacement hormone (levothyroxine). You should have your thyroid levels rechecked in 8-29 weeks. . Please take all your medications as directed and keep all follow up appointments. Followup Instructions: Please follow up with your cardiologist, Dr. Chowdhury, early next week. Please follow up with your primary care doctor in the next 2 weeks as well.	["Admission Date: 1973-12-9 Discharge Date: 2017-7-23\n\nDate of Birth: 1930-10-29 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPenicillins / Sulfonamides / Hytrin\n\nAttending:Lockett\nChief Complaint:\nSOB\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\nThe patient is a 77 yo M with h/o CHF c/o dyspnea and 23lb wt.\ngain in last 10 days. The patient was discharged from Burnett-Green Medical Center 10\ndays ago. He has been followed closely by VNA and his\ncardiolgoist. His lasix doses have been progressively increased\nbut his weight has been going up and he has been having\nworsening SOB. Denies CP, SOB, fevers, chills.\n.\nIn the ED, initial vitals were 97.7 94 125/69 24 83%4L. O2 sat's\nimproved to the high 90's on NRB. BNP >3000. He received a total\nof lasix 80mg IV x 1 and had 1900cc urine output.", "\n.\nIn the MICU, the patient was started on Bumex IV 2mg prn dosing\nfor goal I/O of 1-2L negative daily with good effect. He was\nrestarted on spironolactone as well and has continued to diurese\nwith improvement in his symptoms. His verapamil was transiently\nstopped on 3-13, and patient subsequently developed atrial\ntachycardia, thought to be MAT,(which it was not)and was started\non a dilt drip and digoxin loaded. Dilt was transitioned to PO\nverapamil, and he has been continued on the dig. HR appears to\nbe well controlled at this time. Additionally, he developed\nincreased erythema of his left lower extremity at the site of\nhis prior cellulitis, and blood cultures from that day grew coag\nneg staph 2 out of 2. He was initially started on Vanc IV and\nthis was changed to tetracycline as a result of the patient's\nallergies.", ' He is currently on day 3 of 7.\n.\nThe patient reports he is feeling much better, though not quite\nto baseline. His SOB is much improved and he feels his ascites\nis reduced. He denies fevers, chills, night sweats, headache,\nchest pain, diarrhea, dysuria, melena or hematochezia. He does\nreport abdominal distention which is improved. Has 2 pillow\northopnea at baseline and denies PND 12-1 using BiPAP at night.\nAdditionally, denies stroke, TIA, DVT, PE, joint pains,\nhemoptysis or exertional buttock or calf pain. He does report a\nchronic dry cough which is at his baseline.\n.\n\n\nPast Medical History:\n-- Hypertension\n-- Hyperlipidemia\n-- BPH; s/p turp x2\n-- Gout\n-- Impaired glucose tolerance\n-- Interstitial lung disease with diminished DLCO (thought 12-1\nto pulmonary fibrosis and emphysema as per Pulmonary).', " B/L\npleural thickening and honeycombing on CT\n-- CHF/ Cor pulmonale\n-- Obesity.\n-- Diabetes mellitus 2, diet controlled\n-- hiatal hernia\n-- sleep apnea\n-- R sided renal lesion\n-- CKD - baseline creatinine is 1.6-1.7\n\n\nSocial History:\nLives at home with his wife of 49 years. Stays on the 7380 Ferguson Throughway Suite 153\nBakerside, SD 74716\nof the house (can't climb stairs 12-1 SOB). Has 6 children and\n15 grandchildren-all healthy. Quit smoking 20 yrs ago (1ppd x\n35 yrs), rare ETOH, no drug use.\n\n\nFamily History:\nNon-Contributory\n\nPhysical Exam:\nVitals - T 97.3 BP 100/55 HR 83 R 20 92% on 4L NC\nGeneral - well appearing male, sitting up in chair in NAD\nHEENT - NCAT, PERRL, oropharynx clear, dry MM\nNeck - supple, JVP elevated to angle of jaw (though has 4+ TR)\nCV - distant heart sounds, RRR, faint 3-26 murmur at\nLungs - decreased breath sounds at bases, crackles 2/3 up\nposteriorly on left, 1/2 up on right\nAbdomen - distended, nontender, soft, + BS\nExt - b/l venous statsis changes/PVD, 1+ pitting edema\nbilaterally, well-healed scar over left shin at site of prior\ncellulitis, no open areas\n.", '\n\n\nPertinent Results:\nImaging:\n1973-12-9 CXR - No significant change with persistent\ncardiomegaly and likely bibasilar effusions/atelectasis. No\novert CHF.\n1973-12-9 KUB - Gas distended stomach. No evidence of\nobstruction.\n1973-12-9 Ct Abdomen - Slight interval increase in small right\npleural effusion and intra-abdominal ascites. Otherwise, stable\nCT appearance of the abdomen and pelvis.\n1997-3-17 Port abd - No dilated air-filled loops of bowel to\nsuggest obstruction\n1991-5-29 CXR - A single portable view of the chest is compared\nto prior examination dated 1973-12-9. The cardiomediastinal\nsilhouette is enlarged, but stable. Current examination reveals\nincreasing patchy opacities at the bases bilaterally, right\nslightly greater than left. Also, blunting of the right\ncostophrenic angle is noted, suggesting pleural effusion.', "\nProbable underlying copd.\n1963-10-9 CXR - Cardiomegaly and residual CHF with small\neffusions. Interval improvement compared with one day earlier.\n.\nEKG 1-8: Rhythm is sinus tachycardia with atrial premature\ncomplexes. There is borderline low voltage in both the limb\nleads and precordial leads. There is an RSR' pattern in lead V1\nas well as right axis deviation. There are diffuse ST-T wave\nchanges. Overall configuration suggests pulmonary disease. When\ncompared with prior tracing of 1973-12-9 the rate has increased,\nthough it is quite similar to tracing of 1972-10-9.\n.\nUrine:\n1997-3-17 11:53PM URINE Color-Yellow Appear-Clear Sp Clapp-1.013\n1997-3-17 11:53PM URINE Blood-LG Nitrite-NEG Protein-NEG\nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG\n1997-3-17 11:53PM URINE RBC-11-3* WBC-0 Bacteri-0 Yeast-NONE\nEpi-0\n.", '\nLabs:\n1973-12-9 12:00PM BLOOD WBC-7.4 RBC-4.30* Hgb-13.5* Hct-39.6\nMCV-92 MCH-31.5 MCHC-34.1 RDW-16.6 Plt Ct-241\n1976-6-2 04:54AM BLOOD WBC-6.6 RBC-3.61* Hgb-11.4* Hct-32.9\nMCV-91 MCH-31.5 MCHC-34.6 RDW-16.8 Plt Ct-222\n1997-3-17 03:33AM BLOOD WBC-6.2 RBC-3.91* Hgb-11.9* Hct-36.1\nMCV-93 MCH-30.5 MCHC-33.0 RDW-16.0 Plt Ct-224\n2020-8-17 03:06AM BLOOD WBC-6.8 RBC-3.70* Hgb-11.6* Hct-35.1\nMCV-95 MCH-31.5 MCHC-33.2 RDW-16.8 Plt Ct-255\n1952-8-12 05:09AM BLOOD WBC-6.7 RBC-3.75* Hgb-11.7* Hct-35.3\nMCV-94 MCH-31.1 MCHC-33.1 RDW-16.9 Plt Ct-249\n1991-1-4 04:53AM BLOOD WBC-5.8 RBC-3.54* Hgb-11.0* Hct-32.6\nMCV-92 MCH-31.1 MCHC-33.8 RDW-15.9 Plt Ct-220\n1993-5-16 05:30AM BLOOD WBC-7.8 RBC-3.74* Hgb-11.7* Hct-34.6\nMCV-92 MCH-31.2 MCHC-33.8 RDW-15.9 Plt Ct-238\n1948-7-12 05:35AM BLOOD WBC-8.2 RBC-4.', '22* Hgb-12.7* Hct-39.9\nMCV-95 MCH-30.1 MCHC-31.9 RDW-15.9 Plt Ct-263\n1991-8-16 05:30AM BLOOD WBC-7.1 RBC-3.82* Hgb-11.8* Hct-35.6\nMCV-93 MCH-30.9 MCHC-33.2 RDW-16.1 Plt Ct-254\n2017-7-23 05:35AM BLOOD WBC-6.5 RBC-3.62* Hgb-10.9* Hct-32.9\nMCV-91 MCH-30.2 MCHC-33.2 RDW-16.6 Plt Ct-255\n1973-12-9 12:00PM BLOOD Neuts-78.8* Lymphs-11.2* Monos-7.5\nEos-2.1 Baso-0.3\n1997-3-17 03:33AM BLOOD Neuts-63.6 Lymphs-19.2 Monos-11.3\nEos-5.7 Baso-0.3\n1973-12-9 12:00PM BLOOD PT-16.2* PTT-24.7 INR(PT)-1.5\n1976-6-2 04:54AM BLOOD PT-15.4 PTT-26.2 INR(PT)-1.4\n1997-3-17 03:33AM BLOOD PT-16.7 PTT-27.7 INR(PT)-1.5\n1991-5-29 04:27AM BLOOD PT-17.0 PTT-32.7 INR(PT)-1.5\n1963-10-9 01:58AM BLOOD PT-16.4 PTT-29.3 INR(PT)-1.5\n2020-8-17 03:06AM BLOOD PT-15.5 PTT-29.9 INR(PT)-1.4\n1993-5-16 05:30AM BLOOD PT-15.', '2 PTT-30.0 INR(PT)-1.3\n1991-8-16 05:30AM BLOOD PT-14.9 PTT-27.2 INR(PT)-1.3\n1973-12-9 12:00PM BLOOD Glucose-137 UreaN-24* Creat-1.5* Na-136\nK-3.9 Cl-98 HCO3-31 AnGap-11\n1976-6-2 04:54AM BLOOD Glucose-97 UreaN-22* Creat-1.5* Na-135\nK-3.5 Cl-98 HCO3-29 AnGap-12\n1976-6-2 02:21PM BLOOD Glucose-123* UreaN-24* Creat-1.6* Na-137\nK-3.4 Cl-98 HCO3-28 AnGap-14\n1997-3-17 03:33AM BLOOD Glucose-92 UreaN-27* Creat-1.7* Na-138\nK-4.1 Cl-102 HCO3-28 AnGap-12\n1991-5-29 04:27AM BLOOD Glucose-127* UreaN-36* Creat-2.1* Na-140\nK-4.1 Cl-101 HCO3-29 AnGap-14\n1963-10-9 01:58AM BLOOD Glucose-138* UreaN-36* Creat-1.9* Na-139\nK-3.7 Cl-102 HCO3-26 AnGap-15\n1963-10-9 01:31PM BLOOD Glucose-128* UreaN-34* Creat-1.7* Na-138\nK-3.2* Cl-100 HCO3-27 AnGap-14\n2020-8-17 03:06AM BLOOD Glucose-127* UreaN-31* Creat-1.7* Na-138\nK-4.', '2 Cl-101 HCO3-28 AnGap-13\n2020-8-17 05:25PM BLOOD UreaN-29* Creat-1.6* Na-139 K-3.9 Cl-101\nHCO3-29 AnGap-13\n1952-8-12 05:09AM BLOOD Glucose-100 UreaN-27* Creat-1.6* Na-138\nK-3.8 Cl-101 HCO3-29 AnGap-12\n1952-8-12 04:17PM BLOOD Glucose-109* UreaN-29* Creat-1.7* Na-138\nK-3.9 Cl-97 HCO3-30 AnGap-15\n1991-1-4 04:53AM BLOOD Glucose-90 UreaN-28* Creat-1.6* Na-137\nK-3.6 Cl-99 HCO3-31 AnGap-11\n1948-7-12 05:35AM BLOOD Glucose-98 UreaN-26* Creat-1.8* Na-138\nK-3.9 Cl-94* HCO3-32 AnGap-16\n1925-9-30 06:03AM BLOOD Glucose-93 UreaN-28* Creat-1.9* Na-136\nK-4.0 Cl-94* HCO3-31 AnGap-15\n2017-7-23 05:35AM BLOOD Glucose-108* UreaN-27* Creat-1.9* Na-137\nK-3.7 Cl-93* HCO3-31 AnGap-17\n1973-12-9 12:00PM BLOOD ALT-28 AST-45* CK(CPK)-65 AlkPhos-197\nAmylase-107 TotBili-1.1\n1973-12-9 06:25PM BLOOD CK(CPK)-58\n1976-6-2 04:54AM BLOOD CK(CPK)-56\n1993-5-16 05:30AM BLOOD GGT-245\n1973-12-9 12:00PM BLOOD CK-MB-NotDone cTropnT-0.', '02 proBNP-3634\n1973-12-9 06:25PM BLOOD cTropnT-0.02\n1976-6-2 04:54AM BLOOD CK-MB-NotDone cTropnT-0.02\n1973-12-9 12:00PM BLOOD Albumin-3.6 Calcium-8.8 Phos-2.9 Mg-2.3\n1976-6-2 04:54AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1\n1997-3-17 03:33AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.3\n1991-5-29 04:27AM BLOOD Calcium-8.3 Phos-4.8* Mg-1.9\n1963-10-9 01:58AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9\n1963-10-9 01:31PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8\n2020-8-17 03:06AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2\n1952-8-12 05:09AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1\n1952-8-12 04:17PM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9\n1993-5-16 05:30AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9\n1991-8-16 05:30AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2\n1925-9-30 06:03AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0\n2017-7-23 05:35AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1\n1925-9-30 06:03AM BLOOD TSH-11\n2017-7-23 05:35AM BLOOD Free T4-1.', '1\n\nBrief Hospital Course:\n# CHF, acute on chronic diastolic dysfunction - Patient admitted\nwith SOB likely 12-1 to CHF exacerbation, has severe diastolic\ndysfunction with pulmonary hypertension and severe TR.\nDifficulty balancing diuresis and renal function as an\noutpatient. He was initially started on Bumex IV with signficant\ndiuresis. He was then transitioned to PO Lasix and has\ncontinued to diurese on this regimen. Appears to maintain even\nIs/Os on Lasix 80mg PO BID. He will be discharged on this\nregimen with follow up to determine the most appropriate\nlong-term regimen for him. His baseline oxygen requirement is\n4L NC satting 88-92%. Additionally, he uses BiPAP overnight. He\nis satting low-mid 90s on 3L NC at the time of discharge. He was\ncontinued on his Metoprolol at 12.5 White, Gonzalez and Martinez Medical Center, Spironolactone was\nadded at 25mg PO daily.', " He was also discharged on Verapamil.\nHis weight was 207.6 pounds on discharge.\n.\n# Atrial tachycardia: Some concern that patient was having MAT\nwhile in the MICU, however, unable to find evidence of MAT in\npatient's ECG. He appears to be in an atrial tachycardia.\nVerapamil was increased to 180mg daily, and he was continued on\nMetoprolol 12.5mg White, Gonzalez and Martinez Medical Center. He was rate controlled with HR in the\n80s on this regimen.\n.\n# COPD/Interstitial Lung Disease: Recent admission in early\nJanuary, patient had workup for worsening ILD. Echo readings of\nsevere pulmonary hypertension (not new), worsening dilated RV,\nand worsening TR found. Patient had a trial of sildenafil\nhowever, it was stopped secondary to side effects of\nhypotension, tachycardia, and dizziness. No plan for further\nsildenafil.", " He was started on prn inhalers and continued on his\nhome oxygen regimen. He will require continued outpatient\npulmonary follow-up.\n.\n# ID/Cellulitis: During his recent hospital admission (dc'd\n1917-4-12), patient completed a 7 day course of clindamycin for L\nshin cellulitis. During his stay in the MICU, patient developed\nby report increasing erythema of his L shin and spiked a fever.\nHe was initially started on vancomycin for positive blood\ncultures. These subsequently grew GPC/coag neg staph. No further\npositive blood cultures. He was transitioned to tetracycline for\nhis cellulitis. He received 4 days. His antibiotics were\ndiscontinued as he did not appear to have further evidence of\ncellulitis, remained afebrile and had no leukocytosis. Baseline\nerythema of PVD remained unchanged for the duration of his\nadmission.", '\n.\n# CAD: Clean coronaries on cath in 4-24. Continued on\nMetoprolol, Verapamil, Atorvastatin.\n.\n# Anemia: Baseline appears to be around 35. Range of 32-39\nduring admission with no evidence of bleed. Last iron studies in\n11-22 showing iron 53, TIBC 368, Ferritin 40, TRF 283. Likely\nsecondary to chronic kidney disease.\n.\n# Hypothyroid: Pt complaining of cold intolerance. TSH found to\nbe 11. Free T4 1.1. Likely subclinical hypothyroidism. Started\nlow dose thyroid supplementation on discharge. Patient should\nfollow with PCP.\n.\n# Coagulopathy: INR elevated at 1.4 since 1977-10-10. Unclear\netiology. AST wnl, ALT slightly elevated at 45. July be\nnutritional though albumin is 3.6. Can be monitored as an\noutpatient.\n.\n# DM: On oral medications at home. On ISS during admission.\nRestarted on home regimen on discharge.', '\n.\n# CKD: Baseline creatinine is 1.6-1.7. Slight increase in\ncreatinine to 1.9 during admission, likely a result of\naggressive diuresis. Stable over several days.\n.\nCode - FULL\n\n\nMedications on Admission:\nAllopurinol 100 mg DAILY\nAspirin 325 mg DAILY\nAtorvastatin 10 mg DAILY\nHexavitamin DAILY\nPrilosec OTC 20 mg once a day\nGlimepiride 1 mg once a day.\nHOME o24L NC\nMetoprolol 12.5mg TID\nVerapamil 120 mg SR DAILY\nLasix 40mg M-W-F; 30mg T-Th-Sat-Sun\n\n\nDischarge Medications:\n1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.\n5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.', 'C.) PO once a day.\n6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet\nSustained Release PO Q24H (every 24 hours).\nDisp:30 Tablet Sustained Release(s)* Refills:0\n7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette\nOphthalmic White, Gonzalez and Martinez Medical Center (2 times a day): Take as you were prior to\nadmission.\n8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:0\n9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2\ntimes a day).\nDisp:30 Tablet(s) Refills:0\n10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: 3-26\nPuffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB.\nDisp:1 months supply Refills:0\n11. Home O2\n3-4L NC\n12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day.', '\n13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY\n(Daily).\nDisp:90 Tablet(s) Refills:0\n14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day.\nDisp:30 Tablet(s) Refills:0\n\n1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.\n5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO once a day.\n6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet\nSustained Release PO Q24H (every 24 hours).\nDisp:30 Tablet Sustained Release(s) Refills:0\n7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette\nOphthalmic White, Gonzalez and Martinez Medical Center (2 times a day): Take as you were prior to\nadmission.', '\n8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:0\n9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2\ntimes a day).\nDisp:30 Tablet(s) Refills:0\n10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: 3-26\nPuffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB.\nDisp:1 months supply Refills:0\n11. Home O2\n3-4L NC\n12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day.\n13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY\n(Daily).\nDisp:90 Tablet(s) Refills:0\n14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day.\nDisp:30 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n822 Crystal Corner Suite 322\nMichellestad, VA 99374 VNA\n\nDischarge Diagnosis:\nAcute on chronic severe right heart systolic failure\nSevere COPD, Pulmonary Hypertension (PA systolic 72 mm hg)\nAscites secondary to right sided CHF\nInterstitial Pulmonary Fibrosis and emphysema\nSecondary diagnoses:\nHypertension\nHyperlipidemia\nType 2 Diabetes Mellitus\nSleep Apnea\nHypothyroidism\n\n\nDischarge Condition:\nStable\n\n\nDischarge Instructions:\nYou were admitted with a worsening of your heart failure.', ' A\nsignificant amount of fluid was removed, and you are now back to\nyour baseline weight with improvement of your breathing.\n\nIt is very important that you take your Lasix (furosemide) as\ndirected. This should keep the fluid from re-accumulating. In\naddition, it is very important that you use your BiPAP at night\nas this will keep your oxygen levels up while you sleep.\n.\nWeigh yourself every morning, Jacki Atencio MD if weight > 3 lbs. Adhere\nto 2 gm sodium diet. Please try not to drink too much fluid\nafter discharge.\n.\nIn addition, while you were here, your thyroid hormone levels\nwere found to be low. We have started you on a low dose of\nthyroid replacement hormone (levothyroxine). You should have\nyour thyroid levels rechecked in 8-29 weeks.\n.\nPlease take all your medications as directed and keep all follow\nup appointments.', '\n\nFollowup Instructions:\nPlease follow up with your cardiologist, Dr. Chowdhury, early next\nweek.\n\nPlease follow up with your primary care doctor in the next 2\nweeks as well.\n\n\n\n']
152	28016	163118.0	2110-06-03	Discharge summary	Report	Admission Date: [2110-5-20] Discharge Date: [2110-6-3] Date of Birth: [2032-8-21] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin Attending:[First Name3 (LF) 898] Chief Complaint: "can't catch my breath after walking 20 feet or even button my pants!" Major Surgical or Invasive Procedure: Paracentesis x2 History of Present Illness: 77yo M w/ COPD with interstitial lung disease, pulm HTN, severe cor pulmonale, and chronic renal disease who p/w worsening SOB, increasing abdominal girth, and 20 lb wt gain for 2 weeks. Pt reports feeling exhausted and "terrible." He is becoming short of breath after walking ~20-25 feet from the bathroom to the living room, having stop and catch his breath, which is unusual for him. At the same time, he was noted to have increasing weight--a gain of 20 lbs over 2 wks (198 -> 218 lbs). Accordingly, he then developed "belly pain" and began having trouble buttoning his pants over his growing abd. Because of these increasing symptoms, he was brought to the ED for further evaluation. Of note, the pt has had a precipitous decline in his functional status since [10-26] primarily due to symptoms of end-stage cor pulmonale from his severe pulm disease. In [11-26], pt developed similar symptoms of SOB, abd distension, and wt gain and was hospitalized at [Hospital1 18] for a total of 12 days. Pt otherwise denies fever/chills, chest pain, palpitations, nausea/vomiting/diarrhea, headache/dizziness, or incontinence. Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought [12-21] to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT. pt needs 2-3L, occasionally 4L, of continuous supp O2 at baseline, pt is able to ambulate independently w/o walker, cane, or assistance. -- End-stage Cor pulmonale -- Left ventricular diastolic dysfunction/heart failure -- Obesity -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism Social History: Lives at home with his wife of 50 years. Stays on the [Location (un) 453] of the house (can't climb stairs [12-21] SOB). Has 6 children and 15 grandchildren-all healthy. Was [Initials (NamePattern4) ] [Last Name (NamePattern4) 1573] high school teacher for 7 yrs, elementary school principal for 12 yrs, and superintendent for 19 yrs. Retired in [2091] and became a lobbyist for the retirees until 1/[2109]. Quit smoking 20 yrs ago (1ppd x 20 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: Tm 98.3, Tc 96.3, HR 88 (50-80s), BP 100/67 (90-110s/40-60s), RR 20, 02 96% 4L (92-100%) Admission wt 99.3kg, I/O: Length of stay in MICU -5.5L Constitutional: Pleasant elderly man sitting up in chair waiting for transfer. HEENT: NC/AT. PERRL. Oral pharynx benign. CV: Regular rate, irregular rhythm. Loud P2. No M/R/G. PULM: B/l crackles up to mid lung fields. No wheezes. ABD: Severely distended, protuberant abd w/ significant fluid wave. Soft yet slightly taut. NT. +BS EXTREM: Mild clubbing present throughout b/l finger nails. Mild R hand tremor at rest. B/l LE 1+ pitting edema. SKIN: 2 scabs -- 1.5cm x 0.5cm and 0.5cm x 0.5cm at R inner leg. 1 broken blister w/ dried blood at L shin. L inner leg dried broken blister. Dry, scaly skin w/ hyperpigmentation below mid-leg b/l. NEURO: Alert and oriented x 3. CN II-XII intact. Motor strength full ([3-24]) throughout b/l UE and LE. Mild R hand tremor at rest. Only b/l biceps reflexes elicited, unable to elicit patellar, ankle, or triceps reflexes. Downgoing toes b/l. Proprioception intact at b/l toes. Narrow-based gait. Pertinent Results: ********LABORATORY RESULTS****** [2110-5-20*] 03:10PM BLOOD WBC-7.4 RBC-4.50 Hgb-11.8* Hct-37.6* MCV-84 MCH-Plt Ct-292 [2110-6-3] 07:10AM BLOOD WBC-5.8 RBC-3.75* Hgb-10.1* Hct-31.3* MCV-84 MCH-27.0 MCHC-32.2 RDW-21.1* Plt Ct-274 [2110-5-20] 03:10PM BLOOD PT-16.5* PTT-26.7 INR(PT)-1.5* [2110-5-20] 03:10PM BLOOD Glucose-145* UreaN-44* Creat-2.0* Na-134 K-4.7 Cl-[2110-6-3] 07:10AM BLOOD Glucose-100 UreaN-36* Creat-1.8* Na-136 K-4.1 Cl-94* HCO3-30 [2110-5-20] 03:10PM BLOOD proBNP-[Numeric Identifier 1574]* [2110-5-20] 07:26PM BLOOD Digoxin-0.6* [2110-5-20] 03:13PM BLOOD Lactate-3.1* [2110-5-20] 07:46PM BLOOD Lactate-2.7* [2110-5-21] 4:11 pm PERITONEAL FLUID. GRAM STAIN (Final [2110-5-21]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2110-5-24]): NO GROWTH. ANAEROBIC CULTURE (Final [2110-5-27]): NO GROWTH. [2110-5-20] 3:10 pm BLOOD CULTURE VENIPUNCTURE #1. Blood Culture, Routine (Final [2110-5-26]): NO GROWTH. [2110-5-20] 3:25 pm BLOOD CULTURE VENIPUNCTURE #2. Blood Culture, Routine (Final [2110-5-26]): NO GROWTH. [2110-5-28] 11:38 am URINE Source: Catheter. URINE CULTURE (Final [2110-5-30]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. _______________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S Echocardiography [2110-5-27] at 2:01:13 PM The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. Normal left ventricular systolic function. The right ventricular cavity is dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is no mass/thrombus in the right ventricle. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Severe right ventricular dilation and hypokinesis with severe tricuspid regurgitation. Right ventricular pressure/volume overload. Severe pulmonary hypertension. No evidence of intracardiac shunt. SINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST: There is a right lower lobe opacity in comparison with multiple prior studies, likely represents epicardial fat exaggerated by lordotic technique and patient rotation. With the exception of this, there are no focal consolidations. There is no pulmonary edema. There is no pleural effusion or pneumothorax. Heart size is enlarged, stable. IMPRESSION: No acute cardiopulmonary process. Study Date of [2110-5-22] 9:00 AM RIGHT UPPER QUADRANT ULTRASOUND: The liver echotexture is normal. There is no focal liver lesion or intrahepatic biliary ductal dilatation. The main portal vein is patent with the appropriate direction of flow, though flow is noted to be pulsatile. The heparic veins are also dilated. The gallbladder is normal without evidence of stones. The common duct is not dilated, measuring 2 mm. The pancreas is not visualized. The spleen is normal in size, measuring 8.5 cm. A moderate to large amount of ascites is seen in all quadrants. IMPRESSION: Probable passive hepatic congestion related to right-sided heart failure, particularly in light of relatively pulsatile blood flow in the portal vein. Normal liver echotexture and spleen size. Large amount of ascites. Brief Hospital Course: Mr. [Known lastname ] is a 77 year-old male with COPD/interstitial lung disease, pulmonary hypertension, severe cor pulmonale, and chronic kidney disease who presented with exacerbation of cor pulmonale, worsening SOB and 20 lb wt gain. In the [Name (NI) ], pt experienced hematemesis x 2. O2 sat of 80s on 4L NC and then 94-96% on NRB. Pt was placed on Bipap 10/5 and received 40 mg IV Lasix x 2. Lactate was 3.1 on admission, BNP [Numeric Identifier 1574], Trop slightly above baseline of 0.02 to 0.04. Pt was initially admitted to Medicine [Hospital1 ] for further treatment of his R-sided HF. On arrival to the medical [Hospital1 ], the patient was hypoxic w/ O2 sats in low 70s, BP 131/86, dyspneic at RR 44, tachy w/ HR of 92, as well as vomited 50cc of bloody contents upon arrival to the floor. He transferred to the MICU for further monitoring and management. In the MICU, pt was gently diuresed w/ IV Lasix. A 4L paracentesis was performed. He became hypotensive (BP into the 70s-80s systolic) following the paracentesis. For this, he received total of 75g albumin over 2 days. Once patient's vitals stabilized, he was transferred to the floor for further management. On the General Medicine floor, the following issues were managed as described below. ## Pulmonary fibrosis: Pt has severe interstitial pulmonary disease refractory to treatment. It has led to severe pulmonary hypertension and end-stage cor-pulmonale. He requires Given prior side effects of hypotension, tachycardia, and dizziness with a trial of sildenafil in the past ([11/2109]), no sildenafil was attempted during this hospital stay. Patient was maintained on prn inhalers and continued on oxygen regimen increased from home dose of 4L. Patient was also placed on CPAP overnight. Continued outpatient pulmonary follow-up with Dr. [Last Name (STitle) 575] will be needed. ## Cor pulmonale: Chronic. Echo shows severe right ventricular dilation and hypokenesis w/ severe tricuspid regurgitation, as well as right ventricular pressure/volume overload. This is thought to be secondary to severe pulmonary fibrosis/pulmonary hypertension. There is no evidence of intracardiac shunt on echo. His right ventricular failure has led to hepatic congestion -> ascites -> b/l LE edema. He was treated with aggressive diuresis as well as paracentesis x2. Net total weight/fluid loss at the end of the hospital stay was approximately 20 lbs. Discharge weight 87kg (day prior had been 92kg, before 2L paracentesis). Patient was discharged with Lasix 80 mg PO BID with increased oxygen requirement at 5L NC satting between 90-94%. He goal 02 sat is >93%. ## Hypotension: Pt is relatively hypotensive at baseline with SBP typically 90-110. However, following his first paracentesis of 4L his BP did drop into the 70s-80s. He remained asymptomatic despite this drop in blood pressure. His blood pressure responded to albumin. Of note, he underwent a 2nd therapeutic paracentesis of 2L and his blood pressure tolerated the lower volume tap. ## Chylous ascites: The fluid was chylous in nature w/ high TG's. The cause of ascites secondary to hepatic congestion related to RH failure. Abdomen remained significantly protuberant with dramatic fluid wave on exam despite paracentesis. Patient received therapeutic paracentesis x 2. ## Hematemesis: Patient had episode of hematemesis on admission, though no subsequent episodes. He was evaluated by the GI service. EGD was discussed but the patient preferred to hold on the procedure since there was no recurrence of following admission. His HCT remained relatively stable in the low to mid-30s. Given no further evidence of bleend and the patient's request to decrease the number of pills taken daily, Protonix was discontinued during the latter half of the hospitalization. ## LV diastolic HF: Echo showed 55% LV systolic function. ## Insomnia: Patient initially complained of insomnia, which was treated with home dose of 10 mg PO Ambien. ## Hypothyroidism: Clinically stable with complaints of cold intolerance but no other symptoms or signs of hypothyroidism. Patient was maintained on home dose of levothyroxine. ## CODE: DNR/DNI Medications on Admission: Allopurinol 100 mg PO qd Lipitor 10 mg PO qd BIPAP - 11cm inspiratory and 7 cm expiratory along with 4 L/min 02 Cyclosporine 0.05 % 1 Dropperette in the R eye [Hospital1 ] Fluoxetine 10 mg PO qd Lasix 80 mg PO tiw, 60 mg qiw Lactulose 10 gram qd or [Hospital1 ] PRN constipation Levothyroxine 12.5 mcg PO qd Metoprolol tartrate 12.5 mg PO bid Prilosec 20 mg PO qd PRN gastric upset Oxygen 4 Liters/min continuously (recently increased from 3L NC) Spironolactone 25 mg PO qod Digoxin 125 mcg QOD (started [5-13]) Verapamil recently discontinued ([5-13]) Discharge Medications: 1. Oximeter Please provide a pulse oximeter for use at home. Goal oxygen saturations >95%. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 4. Levothyroxine 50 mcg Tablet Sig: 0.25 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:30 Tablet(s) Refills:0 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [11-20] Puffs Inhalation Q6H (every 6 hours). 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: primary: pulmonary fibrosis, pulmonary hypertension, cor pulmonale, hypotension secondary: hypothyroidism, hematemesis, hepatic congestion, left ventricular diastolic heart failure, possible urinary tract infection, chylous ascites, insomnia Discharge Condition: Stable. Discharge weight 87kg (day prior had been 92kg, before 2L paracentesis) Discharge Instructions: You were admitted with shortness of breath, worsening edema, and weight gain of 20 lbs. This was due to your severe lung disease, which has caused heart failure. During your hospital stay, fluid was drained from your abdomen twice and you received Lasix to removed additional fluid from your body. -You should take Lasix 80 mg twice daily at home. This dose may need to be increased if you start gaining weight again. -You have also been prescribed potassium pills because your potassium levels have been low. -You should no longer take metoprolol, verapamil, spironolactone or digoxin. -You have been given a pulse oximeter. It is important that you check your oxygen levels when you are walking or exerting yourself to be sure that your oxygen level is above 90%. Otherwise, while resting, you should monitor your oxygen saturation every 6 hours. -Please keep your supplemental oxygen on at all times with a goal oxygen saturation > 93%. Please use BiPAP every night. -Weigh yourself every morning, call your primary care provider or pulmonary specialist, Dr. [Last Name (STitle) 575], if weight > 3 lbs. Please adhere to a diet of < 2 grams of sodium per day as well as fluid restriction of < 1.5 L per day. -Please take all of your medications as prescribed. If you develop any shortness of breath, weight increase, ascites, chest pain, increased abdominal girth, worsened edema, severely low blood pressure, dizziness, blood in your stool, or any other symptoms of concern, please call your primary care physician or pulmonary specialist or proceed to the nearest emergency department. Followup Instructions: Please follow-up with your physicians after discharge. The following appointments have been scheduled. PROVIDER: [First Name4 (NamePattern1) 1575] [Last Name (NamePattern1) 1576], MD on [2110-6-12] at 11:50am PHONE: ([Telephone/Fax (1) 1577] FAX: ([Telephone/Fax (1) 1578] PROVIDER: [Name10 (NameIs) 1571] FUNCTION LAB PHONE: [Telephone/Fax (1) 609] DATE/TIME: [2110-7-17] 8:40 PLACE: [Hospital Ward Name 516], [Hospital1 18] *Please arrive at 8:30am to undergo pulmonary function tests. . PROVIDER: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. PHONE: [Telephone/Fax (1) 612] DATE/TIME: [2110-7-17] 9:00 PLACE: [Hospital Ward Name 516], [Hospital1 18**]	Admission Date: <Date>2007-8-29</Date> Discharge Date: <Date>1910-7-26</Date> Date of Birth: <Date>1906-4-14</Date> Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin Attending:<Name>Adam</Name> Chief Complaint: "can't catch my breath after walking 20 feet or even button my pants!" Major Surgical or Invasive Procedure: Paracentesis x2 History of Present Illness: 77yo M w/ COPD with interstitial lung disease, pulm HTN, severe cor pulmonale, and chronic renal disease who p/w worsening SOB, increasing abdominal girth, and 20 lb wt gain for 2 weeks. Pt reports feeling exhausted and "terrible." He is becoming short of breath after walking ~20-25 feet from the bathroom to the living room, having stop and catch his breath, which is unusual for him. At the same time, he was noted to have increasing weight--a gain of 20 lbs over 2 wks (198 -> 218 lbs). Accordingly, he then developed "belly pain" and began having trouble buttoning his pants over his growing abd. Because of these increasing symptoms, he was brought to the ED for further evaluation. Of note, the pt has had a precipitous decline in his functional status since <Date>3-8</Date> primarily due to symptoms of end-stage cor pulmonale from his severe pulm disease. In <Date>8-13</Date>, pt developed similar symptoms of SOB, abd distension, and wt gain and was hospitalized at <Hospital>Mcmillan and Sons Health System</Hospital> for a total of 12 days. Pt otherwise denies fever/chills, chest pain, palpitations, nausea/vomiting/diarrhea, headache/dizziness, or incontinence. Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought <Date>3-18</Date> to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT. pt needs 2-3L, occasionally 4L, of continuous supp O2 at baseline, pt is able to ambulate independently w/o walker, cane, or assistance. -- End-stage Cor pulmonale -- Left ventricular diastolic dysfunction/heart failure -- Obesity -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism Social History: Lives at home with his wife of 50 years. Stays on the <Location>5617 Amanda Shores Wrightville, CT 22672</Location> of the house (can't climb stairs <Date>3-18</Date> SOB). Has 6 children and 15 grandchildren-all healthy. Was <Initial>ZF</Initial> <Name>Yuen</Name> high school teacher for 7 yrs, elementary school principal for 12 yrs, and superintendent for 19 yrs. Retired in <Year>1909</Year> and became a lobbyist for the retirees until 1/<Year>1909</Year>. Quit smoking 20 yrs ago (1ppd x 20 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: Tm 98.3, Tc 96.3, HR 88 (50-80s), BP 100/67 (90-110s/40-60s), RR 20, 02 96% 4L (92-100%) Admission wt 99.3kg, I/O: Length of stay in MICU -5.5L Constitutional: Pleasant elderly man sitting up in chair waiting for transfer. HEENT: NC/AT. PERRL. Oral pharynx benign. CV: Regular rate, irregular rhythm. Loud P2. No M/R/G. PULM: B/l crackles up to mid lung fields. No wheezes. ABD: Severely distended, protuberant abd w/ significant fluid wave. Soft yet slightly taut. NT. +BS EXTREM: Mild clubbing present throughout b/l finger nails. Mild R hand tremor at rest. B/l LE 1+ pitting edema. SKIN: 2 scabs -- 1.5cm x 0.5cm and 0.5cm x 0.5cm at R inner leg. 1 broken blister w/ dried blood at L shin. L inner leg dried broken blister. Dry, scaly skin w/ hyperpigmentation below mid-leg b/l. NEURO: Alert and oriented x 3. CN II-XII intact. Motor strength full (<Date>9-22</Date>) throughout b/l UE and LE. Mild R hand tremor at rest. Only b/l biceps reflexes elicited, unable to elicit patellar, ankle, or triceps reflexes. Downgoing toes b/l. Proprioception intact at b/l toes. Narrow-based gait. Pertinent Results: ********LABORATORY RESULTS******** <Date>2007-8-29</Date> 03:10PM BLOOD WBC-7.4 RBC-4.50* Hgb-11.8* Hct-37.6* MCV-84 MCH-Plt Ct-292 <Date>1910-7-26</Date> 07:10AM BLOOD WBC-5.8 RBC-3.75* Hgb-10.1* Hct-31.3* MCV-84 MCH-27.0 MCHC-32.2 RDW-21.1* Plt Ct-274 <Date>2007-8-29</Date> 03:10PM BLOOD PT-16.5* PTT-26.7 INR(PT)-1.5* <Date>2007-8-29</Date> 03:10PM BLOOD Glucose-145* UreaN-44* Creat-2.0* Na-134 K-4.7 Cl-<Date>1910-7-26</Date> 07:10AM BLOOD Glucose-100 UreaN-36* Creat-1.8* Na-136 K-4.1 Cl-94* HCO3-30 <Date>2007-8-29</Date> 03:10PM BLOOD proBNP-<Numeric Identifier>6393420</Numeric Identifier>* <Date>2007-8-29</Date> 07:26PM BLOOD Digoxin-0.6* <Date>2007-8-29</Date> 03:13PM BLOOD Lactate-3.1* <Date>2007-8-29</Date> 07:46PM BLOOD Lactate-2.7* <Date>1944-3-26</Date> 4:11 pm PERITONEAL FLUID. GRAM STAIN (Final <Date>1944-3-26</Date>): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final <Date>1960-2-23</Date>): NO GROWTH. ANAEROBIC CULTURE (Final <Date>2003-5-16</Date>): NO GROWTH. <Date>2007-8-29</Date> 3:10 pm BLOOD CULTURE VENIPUNCTURE #1. Blood Culture, Routine (Final <Date>1908-12-13</Date>): NO GROWTH. <Date>2007-8-29</Date> 3:25 pm BLOOD CULTURE VENIPUNCTURE #2. Blood Culture, Routine (Final <Date>1908-12-13</Date>): NO GROWTH. <Date>2004-10-26</Date> 11:38 am URINE Source: Catheter. URINE CULTURE (Final <Date>2017-6-14</Date>): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. _______________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S Echocardiography <Date>2003-5-16</Date> at 2:01:13 PM The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. Normal left ventricular systolic function. The right ventricular cavity is dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is no mass/thrombus in the right ventricle. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Severe right ventricular dilation and hypokinesis with severe tricuspid regurgitation. Right ventricular pressure/volume overload. Severe pulmonary hypertension. No evidence of intracardiac shunt. SINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST: There is a right lower lobe opacity in comparison with multiple prior studies, likely represents epicardial fat exaggerated by lordotic technique and patient rotation. With the exception of this, there are no focal consolidations. There is no pulmonary edema. There is no pleural effusion or pneumothorax. Heart size is enlarged, stable. IMPRESSION: No acute cardiopulmonary process. Study Date of <Date>2002-10-3</Date> 9:00 AM RIGHT UPPER QUADRANT ULTRASOUND: The liver echotexture is normal. There is no focal liver lesion or intrahepatic biliary ductal dilatation. The main portal vein is patent with the appropriate direction of flow, though flow is noted to be pulsatile. The heparic veins are also dilated. The gallbladder is normal without evidence of stones. The common duct is not dilated, measuring 2 mm. The pancreas is not visualized. The spleen is normal in size, measuring 8.5 cm. A moderate to large amount of ascites is seen in all quadrants. IMPRESSION: Probable passive hepatic congestion related to right-sided heart failure, particularly in light of relatively pulsatile blood flow in the portal vein. Normal liver echotexture and spleen size. Large amount of ascites. Brief Hospital Course: Mr. <Name>Blanks</Name> is a 77 year-old male with COPD/interstitial lung disease, pulmonary hypertension, severe cor pulmonale, and chronic kidney disease who presented with exacerbation of cor pulmonale, worsening SOB and 20 lb wt gain. In the <Name>Abigail Smith</Name>, pt experienced hematemesis x 2. O2 sat of 80s on 4L NC and then 94-96% on NRB. Pt was placed on Bipap 10/5 and received 40 mg IV Lasix x 2. Lactate was 3.1 on admission, BNP <Numeric Identifier>6393420</Numeric Identifier>, Trop slightly above baseline of 0.02 to 0.04. Pt was initially admitted to Medicine <Hospital>Cook and Sons Health System</Hospital> for further treatment of his R-sided HF. On arrival to the medical <Hospital>Cook and Sons Health System</Hospital>, the patient was hypoxic w/ O2 sats in low 70s, BP 131/86, dyspneic at RR 44, tachy w/ HR of 92, as well as vomited 50cc of bloody contents upon arrival to the floor. He transferred to the MICU for further monitoring and management. In the MICU, pt was gently diuresed w/ IV Lasix. A 4L paracentesis was performed. He became hypotensive (BP into the 70s-80s systolic) following the paracentesis. For this, he received total of 75g albumin over 2 days. Once patient's vitals stabilized, he was transferred to the floor for further management. On the General Medicine floor, the following issues were managed as described below. ## Pulmonary fibrosis: Pt has severe interstitial pulmonary disease refractory to treatment. It has led to severe pulmonary hypertension and end-stage cor-pulmonale. He requires Given prior side effects of hypotension, tachycardia, and dizziness with a trial of sildenafil in the past (<Date>5/1908</Date>), no sildenafil was attempted during this hospital stay. Patient was maintained on prn inhalers and continued on oxygen regimen increased from home dose of 4L. Patient was also placed on CPAP overnight. Continued outpatient pulmonary follow-up with Dr. <Name>Casenhiser</Name> will be needed. ## Cor pulmonale: Chronic. Echo shows severe right ventricular dilation and hypokenesis w/ severe tricuspid regurgitation, as well as right ventricular pressure/volume overload. This is thought to be secondary to severe pulmonary fibrosis/pulmonary hypertension. There is no evidence of intracardiac shunt on echo. His right ventricular failure has led to hepatic congestion -> ascites -> b/l LE edema. He was treated with aggressive diuresis as well as paracentesis x2. Net total weight/fluid loss at the end of the hospital stay was approximately 20 lbs. Discharge weight 87kg (day prior had been 92kg, before 2L paracentesis). Patient was discharged with Lasix 80 mg PO BID with increased oxygen requirement at 5L NC satting between 90-94%. He goal 02 sat is >93%. ## Hypotension: Pt is relatively hypotensive at baseline with SBP typically 90-110. However, following his first paracentesis of 4L his BP did drop into the 70s-80s. He remained asymptomatic despite this drop in blood pressure. His blood pressure responded to albumin. Of note, he underwent a 2nd therapeutic paracentesis of 2L and his blood pressure tolerated the lower volume tap. ## Chylous ascites: The fluid was chylous in nature w/ high TG's. The cause of ascites secondary to hepatic congestion related to RH failure. Abdomen remained significantly protuberant with dramatic fluid wave on exam despite paracentesis. Patient received therapeutic paracentesis x 2. ## Hematemesis: Patient had episode of hematemesis on admission, though no subsequent episodes. He was evaluated by the GI service. EGD was discussed but the patient preferred to hold on the procedure since there was no recurrence of following admission. His HCT remained relatively stable in the low to mid-30s. Given no further evidence of bleend and the patient's request to decrease the number of pills taken daily, Protonix was discontinued during the latter half of the hospitalization. ## LV diastolic HF: Echo showed 55% LV systolic function. ## Insomnia: Patient initially complained of insomnia, which was treated with home dose of 10 mg PO Ambien. ## Hypothyroidism: Clinically stable with complaints of cold intolerance but no other symptoms or signs of hypothyroidism. Patient was maintained on home dose of levothyroxine. ## CODE: DNR/DNI Medications on Admission: Allopurinol 100 mg PO qd Lipitor 10 mg PO qd BIPAP - 11cm inspiratory and 7 cm expiratory along with 4 L/min 02 Cyclosporine 0.05 % 1 Dropperette in the R eye <Hospital>Cook and Sons Health System</Hospital> Fluoxetine 10 mg PO qd Lasix 80 mg PO tiw, 60 mg qiw Lactulose 10 gram qd or <Hospital>Cook and Sons Health System</Hospital> PRN constipation Levothyroxine 12.5 mcg PO qd Metoprolol tartrate 12.5 mg PO bid Prilosec 20 mg PO qd PRN gastric upset Oxygen 4 Liters/min continuously (recently increased from 3L NC) Spironolactone 25 mg PO qod Digoxin 125 mcg QOD (started <Date>9-22</Date>) Verapamil recently discontinued (<Date>9-22</Date>) Discharge Medications: 1. Oximeter Please provide a pulse oximeter for use at home. Goal oxygen saturations >95%. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 4. Levothyroxine 50 mcg Tablet Sig: 0.25 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:30 Tablet(s) Refills:0 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: <Date>1-16</Date> Puffs Inhalation Q6H (every 6 hours). 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: <Location>34470 Davis Plains Apt. 576 New Davidbury, NV 08958</Location> VNA Discharge Diagnosis: primary: pulmonary fibrosis, pulmonary hypertension, cor pulmonale, hypotension secondary: hypothyroidism, hematemesis, hepatic congestion, left ventricular diastolic heart failure, possible urinary tract infection, chylous ascites, insomnia Discharge Condition: Stable. Discharge weight 87kg (day prior had been 92kg, before 2L paracentesis) Discharge Instructions: You were admitted with shortness of breath, worsening edema, and weight gain of 20 lbs. This was due to your severe lung disease, which has caused heart failure. During your hospital stay, fluid was drained from your abdomen twice and you received Lasix to removed additional fluid from your body. -You should take Lasix 80 mg twice daily at home. This dose may need to be increased if you start gaining weight again. -You have also been prescribed potassium pills because your potassium levels have been low. -You should no longer take metoprolol, verapamil, spironolactone or digoxin. -You have been given a pulse oximeter. It is important that you check your oxygen levels when you are walking or exerting yourself to be sure that your oxygen level is above 90%. Otherwise, while resting, you should monitor your oxygen saturation every 6 hours. -Please keep your supplemental oxygen on at all times with a goal oxygen saturation > 93%. Please use BiPAP every night. -Weigh yourself every morning, call your primary care provider or pulmonary specialist, Dr. <Name>Casenhiser</Name>, if weight > 3 lbs. Please adhere to a diet of < 2 grams of sodium per day as well as fluid restriction of < 1.5 L per day. -Please take all of your medications as prescribed. If you develop any shortness of breath, weight increase, ascites, chest pain, increased abdominal girth, worsened edema, severely low blood pressure, dizziness, blood in your stool, or any other symptoms of concern, please call your primary care physician or pulmonary specialist or proceed to the nearest emergency department. Followup Instructions: Please follow-up with your physicians after discharge. The following appointments have been scheduled. PROVIDER: <Name>Marcelino</Name> <Name>Hazelwood</Name>, MD on <Date>1980-7-21</Date> at 11:50am PHONE: (<Telephone>967-106-4829</Telephone> FAX: (<Telephone>186-799-2688</Telephone> PROVIDER: <Name>Amit Poff</Name> FUNCTION LAB PHONE: <Telephone>173-571-7683</Telephone> DATE/TIME: <Date>1917-7-1</Date> 8:40 PLACE: <Hospital>Peterson LLC Clinic</Hospital>, <Hospital>Mcmillan and Sons Health System</Hospital> ***Please arrive at 8:30am to undergo pulmonary function tests. . PROVIDER: <Name>Marti</Name> <Initial>ZF</Initial> <Name>Pichardo</Name>, M.D. PHONE: <Telephone>354-714-2267</Telephone> DATE/TIME: <Date>1917-7-1</Date> 9:00 PLACE: <Hospital>Peterson LLC Clinic</Hospital>, <Hospital>Mcmillan and Sons Health 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0000111111111000000000000000000001111111111110000000111111111111000000000000111111111000000000000000000000111111111111000000000000111111110000000000000111111111111111111100111111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000111110110111111110000000000000011111111111100000000000011111111000000000000011111111111111111110011111111111111111111111111111110000	Admission Date: 2007-8-29 Discharge Date: 1910-7-26 Date of Birth: 1906-4-14 Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin Attending:Adam Chief Complaint: "can't catch my breath after walking 20 feet or even button my pants!" Major Surgical or Invasive Procedure: Paracentesis x2 History of Present Illness: 77yo M w/ COPD with interstitial lung disease, pulm HTN, severe cor pulmonale, and chronic renal disease who p/w worsening SOB, increasing abdominal girth, and 20 lb wt gain for 2 weeks. Pt reports feeling exhausted and "terrible." He is becoming short of breath after walking ~20-25 feet from the bathroom to the living room, having stop and catch his breath, which is unusual for him. At the same time, he was noted to have increasing weight--a gain of 20 lbs over 2 wks (198 -> 218 lbs). Accordingly, he then developed "belly pain" and began having trouble buttoning his pants over his growing abd. Because of these increasing symptoms, he was brought to the ED for further evaluation. Of note, the pt has had a precipitous decline in his functional status since 3-8 primarily due to symptoms of end-stage cor pulmonale from his severe pulm disease. In 8-13, pt developed similar symptoms of SOB, abd distension, and wt gain and was hospitalized at Mcmillan and Sons Health System for a total of 12 days. Pt otherwise denies fever/chills, chest pain, palpitations, nausea/vomiting/diarrhea, headache/dizziness, or incontinence. Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought 3-18 to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT. pt needs 2-3L, occasionally 4L, of continuous supp O2 at baseline, pt is able to ambulate independently w/o walker, cane, or assistance. -- End-stage Cor pulmonale -- Left ventricular diastolic dysfunction/heart failure -- Obesity -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism Social History: Lives at home with his wife of 50 years. Stays on the 5617 Amanda Shores Wrightville, CT 22672 of the house (can't climb stairs 3-18 SOB). Has 6 children and 15 grandchildren-all healthy. Was ZF Yuen high school teacher for 7 yrs, elementary school principal for 12 yrs, and superintendent for 19 yrs. Retired in 1909 and became a lobbyist for the retirees until 1/1909. Quit smoking 20 yrs ago (1ppd x 20 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: Tm 98.3, Tc 96.3, HR 88 (50-80s), BP 100/67 (90-110s/40-60s), RR 20, 02 96% 4L (92-100%) Admission wt 99.3kg, I/O: Length of stay in MICU -5.5L Constitutional: Pleasant elderly man sitting up in chair waiting for transfer. HEENT: NC/AT. PERRL. Oral pharynx benign. CV: Regular rate, irregular rhythm. Loud P2. No M/R/G. PULM: B/l crackles up to mid lung fields. No wheezes. ABD: Severely distended, protuberant abd w/ significant fluid wave. Soft yet slightly taut. NT. +BS EXTREM: Mild clubbing present throughout b/l finger nails. Mild R hand tremor at rest. B/l LE 1+ pitting edema. SKIN: 2 scabs -- 1.5cm x 0.5cm and 0.5cm x 0.5cm at R inner leg. 1 broken blister w/ dried blood at L shin. L inner leg dried broken blister. Dry, scaly skin w/ hyperpigmentation below mid-leg b/l. NEURO: Alert and oriented x 3. CN II-XII intact. Motor strength full (9-22) throughout b/l UE and LE. Mild R hand tremor at rest. Only b/l biceps reflexes elicited, unable to elicit patellar, ankle, or triceps reflexes. Downgoing toes b/l. Proprioception intact at b/l toes. Narrow-based gait. Pertinent Results: ********LABORATORY RESULTS******** 2007-8-29 03:10PM BLOOD WBC-7.4 RBC-4.50* Hgb-11.8* Hct-37.6* MCV-84 MCH-Plt Ct-292 1910-7-26 07:10AM BLOOD WBC-5.8 RBC-3.75* Hgb-10.1* Hct-31.3* MCV-84 MCH-27.0 MCHC-32.2 RDW-21.1* Plt Ct-274 2007-8-29 03:10PM BLOOD PT-16.5* PTT-26.7 INR(PT)-1.5* 2007-8-29 03:10PM BLOOD Glucose-145* UreaN-44* Creat-2.0* Na-134 K-4.7 Cl-1910-7-26 07:10AM BLOOD Glucose-100 UreaN-36* Creat-1.8* Na-136 K-4.1 Cl-94* HCO3-30 2007-8-29 03:10PM BLOOD proBNP-6393420* 2007-8-29 07:26PM BLOOD Digoxin-0.6* 2007-8-29 03:13PM BLOOD Lactate-3.1* 2007-8-29 07:46PM BLOOD Lactate-2.7* 1944-3-26 4:11 pm PERITONEAL FLUID. GRAM STAIN (Final 1944-3-26): 1+ (1960-2-23): NO GROWTH. ANAEROBIC CULTURE (Final 2003-5-16): NO GROWTH. 2007-8-29 3:10 pm BLOOD CULTURE VENIPUNCTURE #1. Blood Culture, Routine (Final 1908-12-13): NO GROWTH. 2007-8-29 3:25 pm BLOOD CULTURE VENIPUNCTURE #2. Blood Culture, Routine (Final 1908-12-13): NO GROWTH. 2004-10-26 11:38 am URINE Source: Catheter. URINE CULTURE (Final 2017-6-14): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. _______________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ 16 R VANCOMYCIN------------ 2003-5-16 at 2:01:13 PM The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. Normal left ventricular systolic function. The right ventricular cavity is dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is no mass/thrombus in the right ventricle. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Severe right ventricular dilation and hypokinesis with severe tricuspid regurgitation. Right ventricular pressure/volume overload. Severe pulmonary hypertension. No evidence of intracardiac shunt. SINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST: There is a right lower lobe opacity in comparison with multiple prior studies, likely represents epicardial fat exaggerated by lordotic technique and patient rotation. With the exception of this, there are no focal consolidations. There is no pulmonary edema. There is no pleural effusion or pneumothorax. Heart size is enlarged, stable. IMPRESSION: No acute cardiopulmonary process. Study Date of 2002-10-3 9:00 AM RIGHT UPPER QUADRANT ULTRASOUND: The liver echotexture is normal. There is no focal liver lesion or intrahepatic biliary ductal dilatation. The main portal vein is patent with the appropriate direction of flow, though flow is noted to be pulsatile. The heparic veins are also dilated. The gallbladder is normal without evidence of stones. The common duct is not dilated, measuring 2 mm. The pancreas is not visualized. The spleen is normal in size, measuring 8.5 cm. A moderate to large amount of ascites is seen in all quadrants. IMPRESSION: Probable passive hepatic congestion related to right-sided heart failure, particularly in light of relatively pulsatile blood flow in the portal vein. Normal liver echotexture and spleen size. Large amount of ascites. Brief Hospital Course: Mr. Blanks is a 77 year-old male with COPD/interstitial lung disease, pulmonary hypertension, severe cor pulmonale, and chronic kidney disease who presented with exacerbation of cor pulmonale, worsening SOB and 20 lb wt gain. In the Abigail Smith, pt experienced hematemesis x 2. O2 sat of 80s on 4L NC and then 94-96% on NRB. Pt was placed on Bipap 10/5 and received 40 mg IV Lasix x 2. Lactate was 3.1 on admission, BNP 6393420, Trop slightly above baseline of 0.02 to 0.04. Pt was initially admitted to Medicine Cook and Sons Health System for further treatment of his R-sided HF. On arrival to the medical Cook and Sons Health System, the patient was hypoxic w/ O2 sats in low 70s, BP 131/86, dyspneic at RR 44, tachy w/ HR of 92, as well as vomited 50cc of bloody contents upon arrival to the floor. He transferred to the MICU for further monitoring and management. In the MICU, pt was gently diuresed w/ IV Lasix. A 4L paracentesis was performed. He became hypotensive (BP into the 70s-80s systolic) following the paracentesis. For this, he received total of 75g albumin over 2 days. Once patient's vitals stabilized, he was transferred to the floor for further management. On the General Medicine floor, the following issues were managed as described below. ## Pulmonary fibrosis: Pt has severe interstitial pulmonary disease refractory to treatment. It has led to severe pulmonary hypertension and end-stage cor-pulmonale. He requires Given prior side effects of hypotension, tachycardia, and dizziness with a trial of sildenafil in the past (5/1908), no sildenafil was attempted during this hospital stay. Patient was maintained on prn inhalers and continued on oxygen regimen increased from home dose of 4L. Patient was also placed on CPAP overnight. Continued outpatient pulmonary follow-up with Dr. Casenhiser will be needed. ## Cor pulmonale: Chronic. Echo shows severe right ventricular dilation and hypokenesis w/ severe tricuspid regurgitation, as well as right ventricular pressure/volume overload. This is thought to be secondary to severe pulmonary fibrosis/pulmonary hypertension. There is no evidence of intracardiac shunt on echo. His right ventricular failure has led to hepatic congestion -> ascites -> b/l LE edema. He was treated with aggressive diuresis as well as paracentesis x2. Net total weight/fluid loss at the end of the hospital stay was approximately 20 lbs. Discharge weight 87kg (day prior had been 92kg, before 2L paracentesis). Patient was discharged with Lasix 80 mg PO BID with increased oxygen requirement at 5L NC satting between 90-94%. He goal 02 sat is >93%. ## Hypotension: Pt is relatively hypotensive at baseline with SBP typically 90-110. However, following his first paracentesis of 4L his BP did drop into the 70s-80s. He remained asymptomatic despite this drop in blood pressure. His blood pressure responded to albumin. Of note, he underwent a 2nd therapeutic paracentesis of 2L and his blood pressure tolerated the lower volume tap. ## Chylous ascites: The fluid was chylous in nature w/ high TG's. The cause of ascites secondary to hepatic congestion related to RH failure. Abdomen remained significantly protuberant with dramatic fluid wave on exam despite paracentesis. Patient received therapeutic paracentesis x 2. ## Hematemesis: Patient had episode of hematemesis on admission, though no subsequent episodes. He was evaluated by the GI service. EGD was discussed but the patient preferred to hold on the procedure since there was no recurrence of following admission. His HCT remained relatively stable in the low to mid-30s. Given no further evidence of bleend and the patient's request to decrease the number of pills taken daily, Protonix was discontinued during the latter half of the hospitalization. ## LV diastolic HF: Echo showed 55% LV systolic function. ## Insomnia: Patient initially complained of insomnia, which was treated with home dose of 10 mg PO Ambien. ## Hypothyroidism: Clinically stable with complaints of cold intolerance but no other symptoms or signs of hypothyroidism. Patient was maintained on home dose of levothyroxine. ## CODE: DNR/DNI Medications on Admission: Allopurinol 100 mg PO qd Lipitor 10 mg PO qd BIPAP - 11cm inspiratory and 7 cm expiratory along with 4 L/min 02 Cyclosporine 0.05 % 1 Dropperette in the R eye Cook and Sons Health System Fluoxetine 10 mg PO qd Lasix 80 mg PO tiw, 60 mg qiw Lactulose 10 gram qd or Cook and Sons Health System PRN constipation Levothyroxine 12.5 mcg PO qd Metoprolol tartrate 12.5 mg PO bid Prilosec 20 mg PO qd PRN gastric upset Oxygen 4 Liters/min continuously (recently increased from 3L NC) Spironolactone 25 mg PO qod Digoxin 125 mcg QOD (started 9-22) Verapamil recently discontinued (9-22) Discharge Medications: 1. Oximeter Please provide a pulse oximeter for use at home. Goal oxygen saturations >95%. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 4. Levothyroxine 50 mcg Tablet Sig: 0.25 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:30 Tablet(s) Refills:0 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: 1-16 Puffs Inhalation Q6H (every 6 hours). 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: 34470 Davis Plains Apt. 576 New Davidbury, NV 08958 VNA Discharge Diagnosis: primary: pulmonary fibrosis, pulmonary hypertension, cor pulmonale, hypotension secondary: hypothyroidism, hematemesis, hepatic congestion, left ventricular diastolic heart failure, possible urinary tract infection, chylous ascites, insomnia Discharge Condition: Stable. Discharge weight 87kg (day prior had been 92kg, before 2L paracentesis) Discharge Instructions: You were admitted with shortness of breath, worsening edema, and weight gain of 20 lbs. This was due to your severe lung disease, which has caused heart failure. During your hospital stay, fluid was drained from your abdomen twice and you received Lasix to removed additional fluid from your body. -You should take Lasix 80 mg twice daily at home. This dose may need to be increased if you start gaining weight again. -You have also been prescribed potassium pills because your potassium levels have been low. -You should no longer take metoprolol, verapamil, spironolactone or digoxin. -You have been given a pulse oximeter. It is important that you check your oxygen levels when you are walking or exerting yourself to be sure that your oxygen level is above 90%. Otherwise, while resting, you should monitor your oxygen saturation every 6 hours. -Please keep your supplemental oxygen on at all times with a goal oxygen saturation > 93%. Please use BiPAP every night. -Weigh yourself every morning, call your primary care provider or pulmonary specialist, Dr. Casenhiser, if weight > 3 lbs. Please adhere to a diet of Marcelino Hazelwood, MD on 1980-7-21 at 11:50am PHONE: (967-106-4829 FAX: (186-799-2688 PROVIDER: Amit Poff FUNCTION LAB PHONE: 173-571-7683 DATE/TIME: 1917-7-1 8:40 PLACE: Peterson LLC Clinic, Mcmillan and Sons Health System ***Please arrive at 8:30am to undergo pulmonary function tests. . PROVIDER: Marti ZF Pichardo, M.D. PHONE: 354-714-2267 DATE/TIME: 1917-7-1 9:00 PLACE: Peterson LLC Clinic, Mcmillan and Sons Health System	['Admission Date: 2007-8-29 Discharge Date: 1910-7-26\n\nDate of Birth: 1906-4-14 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPenicillins / Sulfonamides / Hytrin\n\nAttending:Adam\nChief Complaint:\n"can\'t catch my breath after walking 20 feet or even button my\npants!"\n\nMajor Surgical or Invasive Procedure:\nParacentesis x2\n\n\nHistory of Present Illness:\n77yo M w/ COPD with interstitial lung disease, pulm HTN, severe\ncor pulmonale, and chronic renal disease who p/w worsening SOB,\nincreasing abdominal girth, and 20 lb wt gain for 2 weeks.\n\nPt reports feeling exhausted and "terrible." He is becoming\nshort of breath after walking ~20-25 feet from the bathroom to\nthe living room, having stop and catch his breath, which is\nunusual for him. At the same time, he was noted to have\nincreasing weight--a gain of 20 lbs over 2 wks (198 -> 218 lbs).', '\n Accordingly, he then developed "belly pain" and began having\ntrouble buttoning his pants over his growing abd.\nBecause of these increasing symptoms, he was brought to the ED\nfor further evaluation.\n\nOf note, the pt has had a precipitous decline in his functional\nstatus since 3-8 primarily due to symptoms of end-stage cor\npulmonale from his severe pulm disease. In 8-13, pt developed\nsimilar symptoms of SOB, abd distension, and wt gain and was\nhospitalized at Mcmillan and Sons Health System for a total of 12 days.\n\nPt otherwise denies fever/chills, chest pain, palpitations,\nnausea/vomiting/diarrhea, headache/dizziness, or incontinence.\n\nPast Medical History:\n-- Hypertension\n-- Hyperlipidemia\n-- BPH; s/p turp x2\n-- Gout\n-- Impaired glucose tolerance\n-- Interstitial lung disease with diminished DLCO (thought 3-18\nto pulmonary fibrosis and emphysema as per Pulmonary).', " B/L\npleural thickening and honeycombing on CT. pt needs 2-3L,\noccasionally 4L, of continuous supp O2 at baseline, pt is able\nto ambulate independently w/o walker, cane, or assistance.\n-- End-stage Cor pulmonale\n-- Left ventricular diastolic dysfunction/heart failure\n-- Obesity\n-- Diabetes mellitus 2, diet controlled\n-- hiatal hernia\n-- sleep apnea\n-- R sided renal lesion\n-- CKD - baseline creatinine is 1.6-1.7\n-- Abdominal aortic aneurysm.\n-- Constipation.\n-- Hypothyroidism\n\nSocial History:\nLives at home with his wife of 50 years. Stays on the 5617 Amanda Shores\nWrightville, CT 22672\nof the house (can't climb stairs 3-18 SOB). Has 6 children and 15\ngrandchildren-all healthy. Was ZF Yuen high school teacher for\n7 yrs, elementary school principal for 12 yrs, and\nsuperintendent for 19 yrs. Retired in 1909 and became a lobbyist\nfor the retirees until 1/1909.", ' Quit smoking 20 yrs ago (1ppd x\n20 yrs), rare ETOH, no drug use.\n\nFamily History:\nNon-Contributory\n\nPhysical Exam:\nTm 98.3, Tc 96.3, HR 88 (50-80s), BP 100/67 (90-110s/40-60s), RR\n20, 02 96% 4L (92-100%)\nAdmission wt 99.3kg, I/O: Length of stay in MICU -5.5L\nConstitutional: Pleasant elderly man sitting up in chair waiting\nfor transfer.\nHEENT: NC/AT. PERRL. Oral pharynx benign.\nCV: Regular rate, irregular rhythm. Loud P2. No M/R/G.\nPULM: B/l crackles up to mid lung fields. No wheezes.\nABD: Severely distended, protuberant abd w/ significant fluid\nwave. Soft yet slightly taut. NT. +BS\nEXTREM: Mild clubbing present throughout b/l finger nails. Mild\nR hand tremor at rest. B/l LE 1+ pitting edema.\nSKIN: 2 scabs -- 1.5cm x 0.5cm and 0.5cm x 0.5cm at R inner leg.\n1 broken blister w/ dried blood at L shin.', ' L inner leg dried\nbroken blister. Dry, scaly skin w/ hyperpigmentation below\nmid-leg b/l.\nNEURO: Alert and oriented x 3. CN II-XII intact. Motor strength\nfull (9-22) throughout b/l UE and LE. Mild R hand tremor at rest.\nOnly b/l biceps reflexes elicited, unable to elicit patellar,\nankle, or triceps reflexes. Downgoing toes b/l. Proprioception\nintact at b/l toes. Narrow-based gait.\n\nPertinent Results:\n********LABORATORY RESULTS*******\n2007-8-29 03:10PM BLOOD WBC-7.4 RBC-4.50 Hgb-11.8* Hct-37.6\nMCV-84 MCH-Plt Ct-292\n1910-7-26 07:10AM BLOOD WBC-5.8 RBC-3.75 Hgb-10.1* Hct-31.3\nMCV-84 MCH-27.0 MCHC-32.2 RDW-21.1 Plt Ct-274\n\n2007-8-29 03:10PM BLOOD PT-16.5* PTT-26.7 INR(PT)-1.5\n\n2007-8-29 03:10PM BLOOD Glucose-145 UreaN-44* Creat-2.0* Na-134\nK-4.7 Cl-1910-7-26 07:10AM BLOOD Glucose-100 UreaN-36* Creat-1.', '8\nNa-136 K-4.1 Cl-94 HCO3-30\n\n2007-8-29 03:10PM BLOOD proBNP-6393420\n\n2007-8-29 07:26PM BLOOD Digoxin-0.6\n2007-8-29 03:13PM BLOOD Lactate-3.1\n2007-8-29 07:46PM BLOOD Lactate-2.7\n\n1944-3-26 4:11 pm PERITONEAL FLUID. GRAM STAIN (Final 1944-3-26):\n1+ (1960-2-23): NO GROWTH.\nANAEROBIC CULTURE (Final 2003-5-16): NO GROWTH.\n\n2007-8-29 3:10 pm BLOOD CULTURE VENIPUNCTURE #1.\nBlood Culture, Routine (Final 1908-12-13): NO GROWTH.\n2007-8-29 3:25 pm BLOOD CULTURE VENIPUNCTURE #2.\nBlood Culture, Routine (Final 1908-12-13): NO GROWTH.\n\n2004-10-26 11:38 am URINE Source: Catheter.\n URINE CULTURE (Final 2017-6-14):\n ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..\n _______________________________________________________\n ENTEROCOCCUS SP.\n \|\nAMPICILLIN------------ 16 R\nVANCOMYCIN------------ 2003-5-16 at 2:01:13 PM\nThe right atrium is markedly dilated.', ' No atrial septal defect is\nseen by 2D or color Doppler. The estimated right atrial pressure\nis 10-20mmHg. Normal left ventricular systolic function. The\nright ventricular cavity is dilated with severe global free wall\nhypokinesis. There is abnormal septal motion/position consistent\nwith right ventricular pressure/volume overload. There is no\nmass/thrombus in the right ventricle. There are three aortic\nvalve leaflets. The aortic valve leaflets are moderately\nthickened. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve\nprolapse. There is trivial mitral regurgitation. The left\nventricular inflow pattern suggests impaired relaxation. The\ntricuspid valve leaflets are mildly thickened. The tricuspid\nvalve leaflets fail to fully coapt. Severe [4+] tricuspid\nregurgitation is seen.', ' There is severe pulmonary artery systolic\nhypertension. The pulmonic valve leaflets are thickened.\nSignificant pulmonic regurgitation is seen. There is no\npericardial effusion.\nIMPRESSION: Severe right ventricular dilation and hypokinesis\nwith severe tricuspid regurgitation. Right ventricular\npressure/volume overload. Severe pulmonary hypertension. No\nevidence of intracardiac shunt.\n\nSINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST: There is a right\nlower lobe opacity in comparison with multiple prior studies,\nlikely represents epicardial fat exaggerated by lordotic\ntechnique and patient rotation. With the exception of this,\nthere are no focal consolidations. There is no pulmonary edema.\nThere is no pleural effusion or pneumothorax. Heart size is\nenlarged, stable. IMPRESSION: No acute cardiopulmonary process.', '\n\nStudy Date of 2002-10-3 9:00 AM\nRIGHT UPPER QUADRANT ULTRASOUND: The liver echotexture is\nnormal. There is\nno focal liver lesion or intrahepatic biliary ductal dilatation.\nThe main\nportal vein is patent with the appropriate direction of flow,\nthough flow is noted to be pulsatile. The heparic veins are also\ndilated.\n\nThe gallbladder is normal without evidence of stones. The common\nduct is not dilated, measuring 2 mm. The pancreas is not\nvisualized. The spleen is normal in size, measuring 8.5 cm. A\nmoderate to large amount of ascites is seen in all quadrants.\n\nIMPRESSION: Probable passive hepatic congestion related to\nright-sided heart failure, particularly in light of relatively\npulsatile blood flow in the portal vein. Normal liver\nechotexture and spleen size. Large amount of\nascites.\n\nBrief Hospital Course:\nMr.', ' Blanks is a 77 year-old male with COPD/interstitial lung\ndisease, pulmonary hypertension, severe cor pulmonale, and\nchronic kidney disease who presented with exacerbation of cor\npulmonale, worsening SOB and 20 lb wt gain.\n\nIn the Abigail Smith, pt experienced hematemesis x 2. O2 sat of 80s on 4L\nNC and then 94-96% on NRB. Pt was placed on Bipap 10/5 and\nreceived 40 mg IV Lasix x 2. Lactate was 3.1 on admission, BNP\n6393420, Trop slightly above baseline of 0.02 to 0.04. Pt was\ninitially admitted to Medicine Cook and Sons Health System for further treatment of his\nR-sided HF. On arrival to the medical Cook and Sons Health System, the patient was\nhypoxic w/ O2 sats in low 70s, BP 131/86, dyspneic at RR 44,\ntachy w/ HR of 92, as well as vomited 50cc of bloody contents\nupon arrival to the floor.', " He transferred to the MICU for\nfurther monitoring and management.\n\nIn the MICU, pt was gently diuresed w/ IV Lasix. A 4L\nparacentesis was performed. He became hypotensive (BP into the\n70s-80s systolic) following the paracentesis. For this, he\nreceived total of 75g albumin over 2 days. Once patient's vitals\nstabilized, he was transferred to the floor for further\nmanagement.\n\nOn the General Medicine floor, the following issues were managed\nas described below.\n## Pulmonary fibrosis:\nPt has severe interstitial pulmonary disease refractory to\ntreatment. It has led to severe pulmonary hypertension and\nend-stage cor-pulmonale. He requires Given prior side effects\nof hypotension, tachycardia, and dizziness with a trial of\nsildenafil in the past (5/1908), no sildenafil was attempted\nduring this hospital stay.", ' Patient was maintained on prn\ninhalers and continued on oxygen regimen increased from home\ndose of 4L. Patient was also placed on CPAP overnight.\nContinued outpatient pulmonary follow-up with Dr. Casenhiser will\nbe needed.\n\n## Cor pulmonale:\nChronic. Echo shows severe right ventricular dilation and\nhypokenesis w/ severe tricuspid regurgitation, as well as right\nventricular pressure/volume overload. This is thought to be\nsecondary to severe pulmonary fibrosis/pulmonary hypertension.\nThere is no evidence of intracardiac shunt on echo.\nHis right ventricular failure has led to hepatic congestion ->\nascites -> b/l LE edema. He was treated with aggressive\ndiuresis as well as paracentesis x2. Net total weight/fluid\nloss at the end of the hospital stay was approximately 20 lbs.\nDischarge weight 87kg (day prior had been 92kg, before 2L\nparacentesis).', "\nPatient was discharged with Lasix 80 mg PO BID with increased\noxygen requirement at 5L NC satting between 90-94%. He goal 02\nsat is >93%.\n\n## Hypotension:\nPt is relatively hypotensive at baseline with SBP typically\n90-110. However, following his first paracentesis of 4L his BP\ndid drop into the 70s-80s. He remained asymptomatic despite\nthis drop in blood pressure. His blood pressure responded to\nalbumin. Of note, he underwent a 2nd therapeutic paracentesis\nof 2L and his blood pressure tolerated the lower volume tap.\n\n## Chylous ascites: The fluid was chylous in nature w/ high\nTG's. The cause of ascites secondary to hepatic congestion\nrelated to RH failure.\nAbdomen remained significantly protuberant with dramatic fluid\nwave on exam despite paracentesis. Patient received therapeutic\nparacentesis x 2.", "\n\n## Hematemesis:\nPatient had episode of hematemesis on admission, though no\nsubsequent episodes. He was evaluated by the GI service. EGD\nwas discussed but the patient preferred to hold on the procedure\nsince there was no recurrence of following admission. His HCT\nremained relatively stable in the low to mid-30s. Given no\nfurther evidence of bleend and the patient's request to decrease\nthe number of pills taken daily, Protonix was discontinued\nduring the latter half of the hospitalization.\n\n## LV diastolic HF: Echo showed 55% LV systolic function.\n\n## Insomnia:\nPatient initially complained of insomnia, which was treated with\nhome dose of 10 mg PO Ambien.\n\n## Hypothyroidism:\nClinically stable with complaints of cold intolerance but no\nother symptoms or signs of hypothyroidism. Patient was\nmaintained on home dose of levothyroxine.", '\n\n## CODE: DNR/DNI\n\nMedications on Admission:\nAllopurinol 100 mg PO qd\nLipitor 10 mg PO qd\nBIPAP - 11cm inspiratory and 7 cm expiratory along with 4 L/min\n02\nCyclosporine 0.05 % 1 Dropperette in the R eye Cook and Sons Health System\nFluoxetine 10 mg PO qd\nLasix 80 mg PO tiw, 60 mg qiw\nLactulose 10 gram qd or Cook and Sons Health System PRN constipation\nLevothyroxine 12.5 mcg PO qd\nMetoprolol tartrate 12.5 mg PO bid\nPrilosec 20 mg PO qd PRN gastric upset\nOxygen 4 Liters/min continuously (recently increased from 3L NC)\nSpironolactone 25 mg PO qod\nDigoxin 125 mcg QOD (started 9-22)\nVerapamil recently discontinued (9-22)\n\nDischarge Medications:\n1. Oximeter\nPlease provide a pulse oximeter for use at home. Goal oxygen\nsaturations >95%.\n2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).', '\nDisp:30 Tablet(s) Refills:0\n3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\nDisp:30 Capsule(s) Refills:0\n4. Levothyroxine 50 mcg Tablet Sig: 0.25 Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:0\n5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)\nas needed for insomnia.\nDisp:30 Tablet(s) Refills:0\n6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: 1-16\nPuffs Inhalation Q6H (every 6 hours).\n7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:\nOne (1) Tab Sust.Rel. Particle/Crystal PO once a day.\nDisp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:0\n8. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.\nDisp:60 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n34470 Davis Plains Apt. 576\nNew Davidbury, NV 08958 VNA\n\nDischarge Diagnosis:\nprimary: pulmonary fibrosis, pulmonary hypertension, cor\npulmonale, hypotension\n\nsecondary: hypothyroidism, hematemesis, hepatic congestion, left\nventricular diastolic heart failure, possible urinary tract\ninfection, chylous ascites, insomnia\n\n\nDischarge Condition:\nStable.', ' Discharge weight 87kg (day prior had been 92kg, before\n2L paracentesis)\n\n\nDischarge Instructions:\nYou were admitted with shortness of breath, worsening edema, and\nweight gain of 20 lbs. This was due to your severe lung\ndisease, which has caused heart failure.\nDuring your hospital stay, fluid was drained from your abdomen\ntwice and you received Lasix to removed additional fluid from\nyour body.\n\n-You should take Lasix 80 mg twice daily at home. This dose may\nneed to be increased if you start gaining weight again.\n-You have also been prescribed potassium pills because your\npotassium levels have been low.\n-You should no longer take metoprolol, verapamil, spironolactone\nor digoxin.\n-You have been given a pulse oximeter. It is important that you\ncheck your oxygen levels when you are walking or exerting\nyourself to be sure that your oxygen level is above 90%.', '\nOtherwise, while resting, you should monitor your oxygen\nsaturation every 6 hours.\n\n-Please keep your supplemental oxygen on at all times with a\ngoal oxygen saturation > 93%. Please use BiPAP every night.\n\n-Weigh yourself every morning, call your primary care provider\nor pulmonary specialist, Dr. Casenhiser, if weight > 3 lbs.\nPlease adhere to a diet of Marcelino Hazelwood, MD on 1980-7-21 at 11:50am\nPHONE: (967-106-4829\nFAX: (186-799-2688\n\nPROVIDER: Amit Poff FUNCTION LAB\nPHONE: 173-571-7683\nDATE/TIME: 1917-7-1 8:40\nPLACE: Peterson LLC Clinic, Mcmillan and Sons Health System\n***Please arrive at 8:30am to undergo pulmonary function tests.\n.\nPROVIDER: Marti ZF Pichardo, M.D.\nPHONE: 354-714-2267\nDATE/TIME: 1917-7-1 9:00\nPLACE: Peterson LLC Clinic, Mcmillan and Sons Health System\n\n\n\n']
153	28016	122235.0	2110-08-12	Discharge summary	Report	Admission Date: [2110-8-8] Discharge Date: [2110-8-12] Date of Birth: [2032-8-21] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin / Sildenafil Attending:[First Name3 (LF) 800] Chief Complaint: 1) leg ulcer 2) SOB 3) abdominal pain and nausea Major Surgical or Invasive Procedure: [8-10] US guided RLQ paracentesis (4L) History of Present Illness: 77 y/o man with PMH significant for severe right sided heart failure, pulmonary hypertension, COPD with interstitial lung disease, and chronic kidney disease who presents with 3 day hx of ulcer on his right leg, pt denies trauma to leg, fevers or sweats. At baseline, pt has mild pedal edema, and there was no significant swelling of the right leg. Pt has some baseline erythema of bil lower legs, but noted moderate increased erythema around ulcer and 'pus' which he described as yellow. The patient is on home 02 around the clock and has been on 4L NC for several months. Pt has had no recent changes in his breathing at home and normally sats in the low 90s, he denies new SOB or dyspnea. He has a chronic cough, which has not changed recently. He sleeps on his side on 2 pillows and denies PND. He has had no chest pain. He denies hematemesis at home. In the ED, he was satting 88% on 4L NC, and then desaturated to 70s and was placed on a NRB and satting 100%. He received Prednisone 60mg for COPD flair, lasix 40mg IV x 1, and Vanco 1g IV. He then developed some diffuse abdominal pain and nausea and received zofran 4mg IV x2 and ativan 0.5mg x1. ROS: Denies chest pain, chills, fevers, night sweats, cough, headache, vision changes, diarrhea, dysuria, melena or hematochezia. Has 2 pillow orthopnea. Uses BiPAP at night. Denies stroke, TIA, DVT, PE, joint pains, hemoptysis. He does report a chronic dry cough which is at his baseline. Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought [12-21] to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT -- dCHF/ Cor pulmonale -- Obesity. -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism . Social History: Lives at home with his wife of 50 years. Stays on the [Location (un) 453] of the house (can't climb stairs [12-21] SOB). Has 6 children and 15 grandchildren-all healthy. Was [Initials (NamePattern4) ] [Last Name (NamePattern4) 1573] high school teacher for 7 yrs, elementary school principal for 12 yrs, and superintendent for 19 yrs. Retired in [2091] and became a lobbyist for the retirees until 1/[2109]. Quit smoking 20 yrs ago (1ppd x 20 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: VSS: 97.7, 98, 141/87, 98% on 100%02NRB, changed to 4L NC, SAT90-93% GEN: Comfortable appearing, in NAD HEENT: Pupils unequal 6mmR, 4mmL, RRL, EOMI, mildly icteric sclera. NECK: supple, nontender, no LAD, JVP at jaw CV: RRR, s1, s2 wnl, 3/6 systolic murmur LSB=RSB, increase on inspiration, ? s3, s4. PULM: rales bilaterally throughout, sparse at apex, no rhonchi or wheezing. ABD: Hugely distended, with vericose veins, dull to percussion except for midline area that is tympanetic. TTP over midline/epigastric area, nontender elsewhere. EXT: DP2+, RP 2+, bilateral anterior tibial erythema, R>L, mild bilateral edema, nonpitting, equal. 3cmx4cm cicular ulcer on R ant. lower leg, w clear, yellow drainage onto bandage, mild surrounding erythema, no necrosis, no pus. TTP on medial/infeior aspect of surrounding tissue. Non tender calf or later leg or foot. NEURO: CNII-XII intact, strength 5/5 upper ext and ankles, toes downgoing bilaterally, sensation to light touch intact, no finger to nose ataxia. Pertinent Results: [2110-8-8] 03:15PM PLT COUNT-309 [2110-8-8] 03:15PM NEUTS-74.8* LYMPHS-12.4* MONOS-8.7 EOS-3.6 BASOS-0.5 [2110-8-8] 03:15PM WBC-6.0 RBC-3.97* HGB-11.1* HCT-34.4* MCV-87 MCH-28.0 MCHC-32.3 RDW-19.8* [2110-8-8] 03:15PM DIGOXIN-0.2* [2110-8-8] 03:15PM ALBUMIN-3.3* CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-2.1 [2110-8-8] 03:15PM CK-MB-NotDone proBNP-7014* [2110-8-8] 03:15PM cTropnT-0.04* [2110-8-8] 03:15PM LIPASE-58 [2110-8-8] 03:15PM ALT(SGPT)-9 AST(SGOT)-23 CK(CPK)-29* ALK PHOS-155* TOT BILI-1.1 [2110-8-8] 03:15PM estGFR-Using this [2110-8-8] 03:15PM GLUCOSE-104 UREA N-28* CREAT-1.6* SODIUM-134 POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-28 ANION GAP-15 [2110-8-8] 03:26PM GLUCOSE-101 K+-3.8 [2110-8-8] 03:26PM COMMENTS-GREEN TOP [2110-8-8] 04:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2110-8-8] 04:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.007 [2110-8-8] 06:48PM TYPE-ART PO2-88 PCO2-41 PH-7.46* TOTAL CO2-30 BASE XS-409/19/08 07:00PM PT-16.0* PTT-28.2 INR(PT)-1.4* [2110-8-8] 09:02PM PT-16.3* PTT-25.8 INR(PT)-1.5* [2110-8-8] 09:02PM PLT COUNT-293 [2110-8-8] 09:02PM NEUTS-91.1* LYMPHS-6.4* MONOS-2.2 EOS-0.2 BASOS-0.1 [2110-8-8] 09:02PM WBC-6.5 RBC-4.03* HGB-11.5* HCT-35.4* MCV-88 MCH-28.4 MCHC-32.4 RDW-18.5* [2110-8-8] 09:02PM TOT PROT-7.9 ALBUMIN-3.2* GLOBULIN-4.7* CALCIUM-9.2 PHOSPHATE-3.8 [2110-8-8] 09:02PM CK-MB-NotDone cTropnT-0.03* [2110-8-8] 09:02PM LIPASE-60 [2110-8-8] 09:02PM ALT(SGPT)-10 AST(SGOT)-23 CK(CPK)-28* ALK PHOS-161* [2110-8-8] 09:02PM GLUCOSE-157* UREA N-28* CREAT-1.6* SODIUM-134 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-27 ANION GAP-17 CXR: [8-8]: There is stable cardiomegaly. The lung volumes are preserved. There is no significant interval change in predominantly basal and subpleural interstitial abnormalities consistent with known pulmonary fibrosis. There are no acute focal consolidations. [8-10]: Increased interstitial markings are again demonstrated. The cardiac silhouette is prominent as before. Mediastinal structures are unchanged. Brief Hospital Course: Mr. [Known lastname ] is a 77 year old gentleman with a PMH significant for right-sided heart failure, pulmonary hypertension, COPD, interstital lung disease, DM 2, and CRI admitted for hypoxia and a RLE ulcer. 1. Dyspnea/Hypoxia: Most likely etiology to dyspnea and hypoxia are fluid overload in setting of severe right sided heart failure and pulmonary hypertension, as well as increasing ascites. The patient was diuresed with lasix gtt and then po lasix during admission. In addition, the patient underwent a therapeutic paracentesis with 4 liters of ascites taken off with significant improvement in symptoms. Of note, the patient was not on spironolactone, which he may benefit from in terms of managing his ascites. At discharge, the patient was at baseline on 4 liters nc supplemental O2, which is his home requirement. On discharge, he was also instructed to continue his lasix, albuterol, and home O2. 2. CHF: Patient with significant pulmonary hypertension and right-sided heart failure on last TTE with preserved EF. The patient was continued on lasix during admission. On discharge, he was instructed to continue with his lasix regimen. 3. RLE ulcer: On admission, the patient was treated empirically with vancomycin, which was converted to PO antimicrobial therapy during admission. As the patient has a significant allergy to PCN and sulfa, he was started on a 7 day course of levofloxacin. 4. COPD/Interstitial lung disease: Currently stable. Followed by Dr. [Last Name (STitle) 575] as outpatient. 5. Upper GIB: Patient with one episode of coffee ground emesis in the ED. His hematocrit has been stable and he has been guaiac negative since admission. Of note, the patient has a prior episode of coffee ground emesis during his last admission to [Hospital1 18] in [5-27]. At that time, the patient was evaluated by GI and declined an EGD. Given the the patient's significant right heart failure and congestive hepatopathy, he may likely have varices although this cannot be confirmed without EGD. He was initially started on an IV PPI for potential bleeding ulcer, which was converted to PO PPI on discharge. The patient had negative stool guaiacs and his hematocrit remained stable during admission. 6. Coagulopathy: Patient with INR of 1.5 during admission, likely secondary to malnutrition and hepatic congestion. Received 10 mg po vitamin K x2 during admission. 7. Ascites: Patient with SAAG of 1.1 with TP>2.5 suggestive of congestive hepatopathy. He does have >250 WBC (PMN 21) on ascitic fluid analysis, although this is in the setting of a traumatic tap (RBC [2101]). 8. CKD: Creatinine at baseline during admission. 9. OSA: Continued on CPAP at night during admission. 10. Prophylaxis: Patient treated with DVT prophylaxis during admission. Medications on Admission: as per OMR: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1 to 2 puffs inhaled up to four times a day as needed for shortness of breath or wheezing ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) BIPAP - (Prescribed by Other Provider) - - 11cm inspiratory and 7 cm expiratory along with 4 L/min 02 FINGERTIP OXIMETER - - use at home to monitor exertional hypoxemia FLUOXETINE - 10 mg Capsule - 1 (One) Capsule(s) by mouth once a day FUROSEMIDE [LASIX] - 80 mg Tablet - 1 Tablet(s) by mouth twice a day- Changed to TID per patient. GLIMEPIRIDE - 1 mg Tablet - [11-20] Tablet(s) by mouth once a day dm LEVOTHYROXINE - 25 mcg Tablet - 0.5 Tablet(s) by mouth once a day OXYGEN - - 4 Liters/min continuously POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. Particle/Crystal - 1 Tab Sust.Rel. Particle/Crystal(s) by mouth once a day ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth HS (at bedtime) as needed for insomnia Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet, Delayed Release (E.C.)(s) by mouth once a day prevention MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Capsule - 1 Capsule(s) by mouth once a day PSYLLIUM [METAMUCIL] - (Prescribed by Other Provider) - 0.52 gram Capsule - 1 Capsule(s) by mouth prn Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 5. Glimepiride 1 mg Tablet Sig: [11-20] tablet Tablet PO once a day. 6. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. O2 Home O2- 4 liters nasal cannula. Pulse dose for portability. 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 10. 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 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: First dose 9/24. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary 1. Dyspnea/hypoxia 2. Cellulitis Secondary -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought [12-21] to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT -- dCHF/ Cor pulmonale -- Obesity. -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- obstructive sleep apnea on CPAP -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism Discharge Condition: Patient was discharged in stable condition. Discharge Instructions: 1. You were admitted for shortness of breath. This was due to excessive fluid retention. You received lasix during your admission to reduce the amount of fluid in your body. You also received a paracentesis in order to remove the fluid from your abdomen. You will need to continue taking your lasix as prescribed. 2. You were found to have a cellulitis, or skin infection on your right leg. You received antibiotics for this during your admission that will need to be continued on discharge. The instructions for this medication are: Levofloxacin 250 mg by mouth once daily (STOP ON [2110-8-17]) 3. Unless otherwise indicated, please resume all of your home medications as taken prior to admission. It is very important that you take your medications as prescribed. 4. It is very important that you keep all of your doctor's appointments. 5. If you develop chest pain, shortness of breath, fever, or other concerning symptoms, please call your PCP or go to your local Emergency Department immediately. Followup Instructions: Provider: [First Name4 (NamePattern1) 1575] [Last Name (NamePattern1) 1576], MD Phone:[Telephone/Fax (1) 1579] Date/Time:[2110-8-18] 2:30 Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2110-10-3] 11:30 Provider: [First Name4 (NamePattern1) 1575] [Last Name (NamePattern1) 1576], MD Phone:[Telephone/Fax (1) 1579] Date/Time:[2110-11-6] 12:10 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811] Completed by:[2110-8-12]	Admission Date: <Date>1906-4-5</Date> Discharge Date: <Date>2011-3-7</Date> Date of Birth: <Date>1911-9-28</Date> Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin / Sildenafil Attending:<Name>Kaushik</Name> Chief Complaint: 1) leg ulcer 2) SOB 3) abdominal pain and nausea Major Surgical or Invasive Procedure: <Date>7-2</Date> US guided RLQ paracentesis (4L) History of Present Illness: 77 y/o man with PMH significant for severe right sided heart failure, pulmonary hypertension, COPD with interstitial lung disease, and chronic kidney disease who presents with 3 day hx of ulcer on his right leg, pt denies trauma to leg, fevers or sweats. At baseline, pt has mild pedal edema, and there was no significant swelling of the right leg. Pt has some baseline erythema of bil lower legs, but noted moderate increased erythema around ulcer and 'pus' which he described as yellow. The patient is on home 02 around the clock and has been on 4L NC for several months. Pt has had no recent changes in his breathing at home and normally sats in the low 90s, he denies new SOB or dyspnea. He has a chronic cough, which has not changed recently. He sleeps on his side on 2 pillows and denies PND. He has had no chest pain. He denies hematemesis at home. In the ED, he was satting 88% on 4L NC, and then desaturated to 70s and was placed on a NRB and satting 100%. He received Prednisone 60mg for COPD flair, lasix 40mg IV x 1, and Vanco 1g IV. He then developed some diffuse abdominal pain and nausea and received zofran 4mg IV x2 and ativan 0.5mg x1. ROS: Denies chest pain, chills, fevers, night sweats, cough, headache, vision changes, diarrhea, dysuria, melena or hematochezia. Has 2 pillow orthopnea. Uses BiPAP at night. Denies stroke, TIA, DVT, PE, joint pains, hemoptysis. He does report a chronic dry cough which is at his baseline. Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought <Date>5-17</Date> to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT -- dCHF/ Cor pulmonale -- Obesity. -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism . Social History: Lives at home with his wife of 50 years. Stays on the <Location>97197 Christopher Ports North Mark, FM 60531</Location> of the house (can't climb stairs <Date>5-17</Date> SOB). Has 6 children and 15 grandchildren-all healthy. Was <Initial>AD</Initial> <Name>Benhamou</Name> high school teacher for 7 yrs, elementary school principal for 12 yrs, and superintendent for 19 yrs. Retired in <Year>1964</Year> and became a lobbyist for the retirees until 1/<Year>1964</Year>. Quit smoking 20 yrs ago (1ppd x 20 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: VSS: 97.7, 98, 141/87, 98% on 100%02NRB, changed to 4L NC, SAT90-93% GEN: Comfortable appearing, in NAD HEENT: Pupils unequal 6mmR, 4mmL, RRL, EOMI, mildly icteric sclera. NECK: supple, nontender, no LAD, JVP at jaw CV: RRR, s1, s2 wnl, 3/6 systolic murmur LSB=RSB, increase on inspiration, ? s3, s4. PULM: rales bilaterally throughout, sparse at apex, no rhonchi or wheezing. ABD: Hugely distended, with vericose veins, dull to percussion except for midline area that is tympanetic. TTP over midline/epigastric area, nontender elsewhere. EXT: DP2+, RP 2+, bilateral anterior tibial erythema, R>L, mild bilateral edema, nonpitting, equal. 3cmx4cm cicular ulcer on R ant. lower leg, w clear, yellow drainage onto bandage, mild surrounding erythema, no necrosis, no pus. TTP on medial/infeior aspect of surrounding tissue. Non tender calf or later leg or foot. NEURO: CNII-XII intact, strength 5/5 upper ext and ankles, toes downgoing bilaterally, sensation to light touch intact, no finger to nose ataxia. Pertinent Results: <Date>1906-4-5</Date> 03:15PM PLT COUNT-309 <Date>1906-4-5</Date> 03:15PM NEUTS-74.8* LYMPHS-12.4* MONOS-8.7 EOS-3.6 BASOS-0.5 <Date>1906-4-5</Date> 03:15PM WBC-6.0 RBC-3.97* HGB-11.1* HCT-34.4* MCV-87 MCH-28.0 MCHC-32.3 RDW-19.8* <Date>1906-4-5</Date> 03:15PM DIGOXIN-0.2* <Date>1906-4-5</Date> 03:15PM ALBUMIN-3.3* CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-2.1 <Date>1906-4-5</Date> 03:15PM CK-MB-NotDone proBNP-7014* <Date>1906-4-5</Date> 03:15PM cTropnT-0.04* <Date>1906-4-5</Date> 03:15PM LIPASE-58 <Date>1906-4-5</Date> 03:15PM ALT(SGPT)-9 AST(SGOT)-23 CK(CPK)-29* ALK PHOS-155* TOT BILI-1.1 <Date>1906-4-5</Date> 03:15PM estGFR-Using this <Date>1906-4-5</Date> 03:15PM GLUCOSE-104 UREA N-28* CREAT-1.6* SODIUM-134 POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-28 ANION GAP-15 <Date>1906-4-5</Date> 03:26PM GLUCOSE-101 K+-3.8 <Date>1906-4-5</Date> 03:26PM COMMENTS-GREEN TOP <Date>1906-4-5</Date> 04:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG <Date>1906-4-5</Date> 04:15PM URINE COLOR-Yellow APPEAR-Clear SP <Name>Spikes</Name>-1.007 <Date>1906-4-5</Date> 06:48PM TYPE-ART PO2-88 PCO2-41 PH-7.46* TOTAL CO2-30 BASE XS-409/19/08 07:00PM PT-16.0* PTT-28.2 INR(PT)-1.4* <Date>1906-4-5</Date> 09:02PM PT-16.3* PTT-25.8 INR(PT)-1.5* <Date>1906-4-5</Date> 09:02PM PLT COUNT-293 <Date>1906-4-5</Date> 09:02PM NEUTS-91.1* LYMPHS-6.4* MONOS-2.2 EOS-0.2 BASOS-0.1 <Date>1906-4-5</Date> 09:02PM WBC-6.5 RBC-4.03* HGB-11.5* HCT-35.4* MCV-88 MCH-28.4 MCHC-32.4 RDW-18.5* <Date>1906-4-5</Date> 09:02PM TOT PROT-7.9 ALBUMIN-3.2* GLOBULIN-4.7* CALCIUM-9.2 PHOSPHATE-3.8 <Date>1906-4-5</Date> 09:02PM CK-MB-NotDone cTropnT-0.03* <Date>1906-4-5</Date> 09:02PM LIPASE-60 <Date>1906-4-5</Date> 09:02PM ALT(SGPT)-10 AST(SGOT)-23 CK(CPK)-28* ALK PHOS-161* <Date>1906-4-5</Date> 09:02PM GLUCOSE-157* UREA N-28* CREAT-1.6* SODIUM-134 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-27 ANION GAP-17 CXR: <Date>5-31</Date>: There is stable cardiomegaly. The lung volumes are preserved. There is no significant interval change in predominantly basal and subpleural interstitial abnormalities consistent with known pulmonary fibrosis. There are no acute focal consolidations. <Date>7-2</Date>: Increased interstitial markings are again demonstrated. The cardiac silhouette is prominent as before. Mediastinal structures are unchanged. Brief Hospital Course: Mr. <Name>Kwan</Name> is a 77 year old gentleman with a PMH significant for right-sided heart failure, pulmonary hypertension, COPD, interstital lung disease, DM 2, and CRI admitted for hypoxia and a RLE ulcer. 1. Dyspnea/Hypoxia: Most likely etiology to dyspnea and hypoxia are fluid overload in setting of severe right sided heart failure and pulmonary hypertension, as well as increasing ascites. The patient was diuresed with lasix gtt and then po lasix during admission. In addition, the patient underwent a therapeutic paracentesis with 4 liters of ascites taken off with significant improvement in symptoms. Of note, the patient was not on spironolactone, which he may benefit from in terms of managing his ascites. At discharge, the patient was at baseline on 4 liters nc supplemental O2, which is his home requirement. On discharge, he was also instructed to continue his lasix, albuterol, and home O2. 2. CHF: Patient with significant pulmonary hypertension and right-sided heart failure on last TTE with preserved EF. The patient was continued on lasix during admission. On discharge, he was instructed to continue with his lasix regimen. 3. RLE ulcer: On admission, the patient was treated empirically with vancomycin, which was converted to PO antimicrobial therapy during admission. As the patient has a significant allergy to PCN and sulfa, he was started on a 7 day course of levofloxacin. 4. COPD/Interstitial lung disease: Currently stable. Followed by Dr. <Name>Pegram</Name> as outpatient. 5. Upper GIB: Patient with one episode of coffee ground emesis in the ED. His hematocrit has been stable and he has been guaiac negative since admission. Of note, the patient has a prior episode of coffee ground emesis during his last admission to <Hospital>Bailey, Smith and Peterson Clinic</Hospital> in <Date>3-7</Date>. At that time, the patient was evaluated by GI and declined an EGD. Given the the patient's significant right heart failure and congestive hepatopathy, he may likely have varices although this cannot be confirmed without EGD. He was initially started on an IV PPI for potential bleeding ulcer, which was converted to PO PPI on discharge. The patient had negative stool guaiacs and his hematocrit remained stable during admission. 6. Coagulopathy: Patient with INR of 1.5 during admission, likely secondary to malnutrition and hepatic congestion. Received 10 mg po vitamin K x2 during admission. 7. Ascites: Patient with SAAG of 1.1 with TP>2.5 suggestive of congestive hepatopathy. He does have >250 WBC (PMN 21) on ascitic fluid analysis, although this is in the setting of a traumatic tap (RBC <Year>1964</Year>). 8. CKD: Creatinine at baseline during admission. 9. OSA: Continued on CPAP at night during admission. 10. Prophylaxis: Patient treated with DVT prophylaxis during admission. Medications on Admission: as per OMR: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1 to 2 puffs inhaled up to four times a day as needed for shortness of breath or wheezing ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) BIPAP - (Prescribed by Other Provider) - - 11cm inspiratory and 7 cm expiratory along with 4 L/min 02 FINGERTIP OXIMETER - - use at home to monitor exertional hypoxemia FLUOXETINE - 10 mg Capsule - 1 (One) Capsule(s) by mouth once a day FUROSEMIDE [LASIX] - 80 mg Tablet - 1 Tablet(s) by mouth twice a day- Changed to TID per patient. GLIMEPIRIDE - 1 mg Tablet - <Date>5-17</Date> Tablet(s) by mouth once a day dm LEVOTHYROXINE - 25 mcg Tablet - 0.5 Tablet(s) by mouth once a day OXYGEN - - 4 Liters/min continuously POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. Particle/Crystal - 1 Tab Sust.Rel. Particle/Crystal(s) by mouth once a day ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth HS (at bedtime) as needed for insomnia Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet, Delayed Release (E.C.)(s) by mouth once a day prevention MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Capsule - 1 Capsule(s) by mouth once a day PSYLLIUM [METAMUCIL] - (Prescribed by Other Provider) - 0.52 gram Capsule - 1 Capsule(s) by mouth prn Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 5. Glimepiride 1 mg Tablet Sig: <Date>5-17</Date> tablet Tablet PO once a day. 6. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. O2 Home O2- 4 liters nasal cannula. Pulse dose for portability. 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 10. 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 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: First dose 9/24. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: <Location>43037 Ware Estates Nicholsonville, NM 78312</Location> VNA Discharge Diagnosis: Primary 1. Dyspnea/hypoxia 2. Cellulitis Secondary -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought <Date>5-17</Date> to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT -- dCHF/ Cor pulmonale -- Obesity. -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- obstructive sleep apnea on CPAP -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism Discharge Condition: Patient was discharged in stable condition. Discharge Instructions: 1. You were admitted for shortness of breath. This was due to excessive fluid retention. You received lasix during your admission to reduce the amount of fluid in your body. You also received a paracentesis in order to remove the fluid from your abdomen. You will need to continue taking your lasix as prescribed. 2. You were found to have a cellulitis, or skin infection on your right leg. You received antibiotics for this during your admission that will need to be continued on discharge. The instructions for this medication are: Levofloxacin 250 mg by mouth once daily (STOP ON <Date>2018-3-4</Date>) 3. Unless otherwise indicated, please resume all of your home medications as taken prior to admission. It is very important that you take your medications as prescribed. 4. It is very important that you keep all of your doctor's appointments. 5. If you develop chest pain, shortness of breath, fever, or other concerning symptoms, please call your PCP or go to your local Emergency Department immediately. Followup Instructions: Provider: <Name>Zachary</Name> <Name>Camargo</Name>, MD Phone:<Telephone>117-838-5662</Telephone> Date/Time:<Date>1995-2-22</Date> 2:30 Provider: <Name>Dylan</Name> <Initial>AD</Initial> <Name>Booker</Name>, M.D. Phone:<Telephone>668-969-4328</Telephone> Date/Time:<Date>2009-11-2</Date> 11:30 Provider: <Name>Zachary</Name> <Name>Camargo</Name>, MD Phone:<Telephone>117-838-5662</Telephone> Date/Time:<Date>1988-12-27</Date> 12:10 <Name>Shannon</Name> <Name>Clapp</Name> MD, <MD Number>02802974</MD Number> Completed by:<Date>2011-3-7</Date>	0000000000000000011111111000000000000000000000000000000001111111100000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111111111111111000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000001101111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000111111110000000000000000000000000111111110000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000011111111000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000011111100000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000001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Date: 1906-4-5 Discharge Date: 2011-3-7 Date of Birth: 1911-9-28 Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin / Sildenafil Attending:Kaushik Chief Complaint: 1) leg ulcer 2) SOB 3) abdominal pain and nausea Major Surgical or Invasive Procedure: 7-2 US guided RLQ paracentesis (4L) History of Present Illness: 77 y/o man with PMH significant for severe right sided heart failure, pulmonary hypertension, COPD with interstitial lung disease, and chronic kidney disease who presents with 3 day hx of ulcer on his right leg, pt denies trauma to leg, fevers or sweats. At baseline, pt has mild pedal edema, and there was no significant swelling of the right leg. Pt has some baseline erythema of bil lower legs, but noted moderate increased erythema around ulcer and 'pus' which he described as yellow. The patient is on home 02 around the clock and has been on 4L NC for several months. Pt has had no recent changes in his breathing at home and normally sats in the low 90s, he denies new SOB or dyspnea. He has a chronic cough, which has not changed recently. He sleeps on his side on 2 pillows and denies PND. He has had no chest pain. He denies hematemesis at home. In the ED, he was satting 88% on 4L NC, and then desaturated to 70s and was placed on a NRB and satting 100%. He received Prednisone 60mg for COPD flair, lasix 40mg IV x 1, and Vanco 1g IV. He then developed some diffuse abdominal pain and nausea and received zofran 4mg IV x2 and ativan 0.5mg x1. ROS: Denies chest pain, chills, fevers, night sweats, cough, headache, vision changes, diarrhea, dysuria, melena or hematochezia. Has 2 pillow orthopnea. Uses BiPAP at night. Denies stroke, TIA, DVT, PE, joint pains, hemoptysis. He does report a chronic dry cough which is at his baseline. Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought 5-17 to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT -- dCHF/ Cor pulmonale -- Obesity. -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism . Social History: Lives at home with his wife of 50 years. Stays on the 97197 Christopher Ports North Mark, FM 60531 of the house (can't climb stairs 5-17 SOB). Has 6 children and 15 grandchildren-all healthy. Was AD Benhamou high school teacher for 7 yrs, elementary school principal for 12 yrs, and superintendent for 19 yrs. Retired in 1964 and became a lobbyist for the retirees until 1/1964. Quit smoking 20 yrs ago (1ppd x 20 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: VSS: 97.7, 98, 141/87, 98% on 100%02NRB, changed to 4L NC, SAT90-93% GEN: Comfortable appearing, in NAD HEENT: Pupils unequal 6mmR, 4mmL, RRL, EOMI, mildly icteric sclera. NECK: supple, nontender, no LAD, JVP at jaw CV: RRR, s1, s2 wnl, 3/6 systolic murmur LSB=RSB, increase on inspiration, ? s3, s4. PULM: rales bilaterally throughout, sparse at apex, no rhonchi or wheezing. ABD: Hugely distended, with vericose veins, dull to percussion except for midline area that is tympanetic. TTP over midline/epigastric area, nontender elsewhere. EXT: DP2+, RP 2+, bilateral anterior tibial erythema, R>L, mild bilateral edema, nonpitting, equal. 3cmx4cm cicular ulcer on R ant. lower leg, w clear, yellow drainage onto bandage, mild surrounding erythema, no necrosis, no pus. TTP on medial/infeior aspect of surrounding tissue. Non tender calf or later leg or foot. NEURO: CNII-XII intact, strength 5/5 upper ext and ankles, toes downgoing bilaterally, sensation to light touch intact, no finger to nose ataxia. Pertinent Results: 1906-4-5 03:15PM PLT COUNT-309 1906-4-5 03:15PM NEUTS-74.8* LYMPHS-12.4* MONOS-8.7 EOS-3.6 BASOS-0.5 1906-4-5 03:15PM WBC-6.0 RBC-3.97* HGB-11.1* HCT-34.4* MCV-87 MCH-28.0 MCHC-32.3 RDW-19.8* 1906-4-5 03:15PM DIGOXIN-0.2* 1906-4-5 03:15PM ALBUMIN-3.3* CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-2.1 1906-4-5 03:15PM CK-MB-NotDone proBNP-7014* 1906-4-5 03:15PM cTropnT-0.04* 1906-4-5 03:15PM LIPASE-58 1906-4-5 03:15PM ALT(SGPT)-9 AST(SGOT)-23 CK(CPK)-29* ALK PHOS-155* TOT BILI-1.1 1906-4-5 03:15PM estGFR-Using this 1906-4-5 03:15PM GLUCOSE-104 UREA N-28* CREAT-1.6* SODIUM-134 POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-28 ANION GAP-15 1906-4-5 03:26PM GLUCOSE-101 K+-3.8 1906-4-5 03:26PM COMMENTS-GREEN TOP 1906-4-5 04:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG 1906-4-5 04:15PM URINE COLOR-Yellow APPEAR-Clear SP Spikes-1.007 1906-4-5 06:48PM TYPE-ART PO2-88 PCO2-41 PH-7.46* TOTAL CO2-30 BASE XS-409/19/08 07:00PM PT-16.0* PTT-28.2 INR(PT)-1.4* 1906-4-5 09:02PM PT-16.3* PTT-25.8 INR(PT)-1.5* 1906-4-5 09:02PM PLT COUNT-293 1906-4-5 09:02PM NEUTS-91.1* LYMPHS-6.4* MONOS-2.2 EOS-0.2 BASOS-0.1 1906-4-5 09:02PM WBC-6.5 RBC-4.03* HGB-11.5* HCT-35.4* MCV-88 MCH-28.4 MCHC-32.4 RDW-18.5* 1906-4-5 09:02PM TOT PROT-7.9 ALBUMIN-3.2* GLOBULIN-4.7* CALCIUM-9.2 PHOSPHATE-3.8 1906-4-5 09:02PM CK-MB-NotDone cTropnT-0.03* 1906-4-5 09:02PM LIPASE-60 1906-4-5 09:02PM ALT(SGPT)-10 AST(SGOT)-23 CK(CPK)-28* ALK PHOS-161* 1906-4-5 09:02PM GLUCOSE-157* UREA N-28* CREAT-1.6* SODIUM-134 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-27 ANION GAP-17 CXR: 5-31: There is stable cardiomegaly. The lung volumes are preserved. There is no significant interval change in predominantly basal and subpleural interstitial abnormalities consistent with known pulmonary fibrosis. There are no acute focal consolidations. 7-2: Increased interstitial markings are again demonstrated. The cardiac silhouette is prominent as before. Mediastinal structures are unchanged. Brief Hospital Course: Mr. Kwan is a 77 year old gentleman with a PMH significant for right-sided heart failure, pulmonary hypertension, COPD, interstital lung disease, DM 2, and CRI admitted for hypoxia and a RLE ulcer. 1. Dyspnea/Hypoxia: Most likely etiology to dyspnea and hypoxia are fluid overload in setting of severe right sided heart failure and pulmonary hypertension, as well as increasing ascites. The patient was diuresed with lasix gtt and then po lasix during admission. In addition, the patient underwent a therapeutic paracentesis with 4 liters of ascites taken off with significant improvement in symptoms. Of note, the patient was not on spironolactone, which he may benefit from in terms of managing his ascites. At discharge, the patient was at baseline on 4 liters nc supplemental O2, which is his home requirement. On discharge, he was also instructed to continue his lasix, albuterol, and home O2. 2. CHF: Patient with significant pulmonary hypertension and right-sided heart failure on last TTE with preserved EF. The patient was continued on lasix during admission. On discharge, he was instructed to continue with his lasix regimen. 3. RLE ulcer: On admission, the patient was treated empirically with vancomycin, which was converted to PO antimicrobial therapy during admission. As the patient has a significant allergy to PCN and sulfa, he was started on a 7 day course of levofloxacin. 4. COPD/Interstitial lung disease: Currently stable. Followed by Dr. Pegram as outpatient. 5. Upper GIB: Patient with one episode of coffee ground emesis in the ED. His hematocrit has been stable and he has been guaiac negative since admission. Of note, the patient has a prior episode of coffee ground emesis during his last admission to Bailey, Smith and Peterson Clinic in 3-7. At that time, the patient was evaluated by GI and declined an EGD. Given the the patient's significant right heart failure and congestive hepatopathy, he may likely have varices although this cannot be confirmed without EGD. He was initially started on an IV PPI for potential bleeding ulcer, which was converted to PO PPI on discharge. The patient had negative stool guaiacs and his hematocrit remained stable during admission. 6. Coagulopathy: Patient with INR of 1.5 during admission, likely secondary to malnutrition and hepatic congestion. Received 10 mg po vitamin K x2 during admission. 7. Ascites: Patient with SAAG of 1.1 with TP>2.5 suggestive of congestive hepatopathy. He does have >250 WBC (PMN 21) on ascitic fluid analysis, although this is in the setting of a traumatic tap (RBC 1964). 8. CKD: Creatinine at baseline during admission. 9. OSA: Continued on CPAP at night during admission. 10. Prophylaxis: Patient treated with DVT prophylaxis during admission. Medications on Admission: as per OMR: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1 to 2 puffs inhaled up to four times a day as needed for shortness of breath or wheezing ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) BIPAP - (Prescribed by Other Provider) - - 11cm inspiratory and 7 cm expiratory along with 4 L/min 02 FINGERTIP OXIMETER - - use at home to monitor exertional hypoxemia FLUOXETINE - 10 mg Capsule - 1 (One) Capsule(s) by mouth once a day FUROSEMIDE [LASIX] - 80 mg Tablet - 1 Tablet(s) by mouth twice a day- Changed to TID per patient. GLIMEPIRIDE - 1 mg Tablet - 5-17 Tablet(s) by mouth once a day dm LEVOTHYROXINE - 25 mcg Tablet - 0.5 Tablet(s) by mouth once a day OXYGEN - - 4 Liters/min continuously POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. Particle/Crystal - 1 Tab Sust.Rel. Particle/Crystal(s) by mouth once a day ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth HS (at bedtime) as needed for insomnia Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet, Delayed Release (E.C.)(s) by mouth once a day prevention MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Capsule - 1 Capsule(s) by mouth once a day PSYLLIUM [METAMUCIL] - (Prescribed by Other Provider) - 0.52 gram Capsule - 1 Capsule(s) by mouth prn Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 5. Glimepiride 1 mg Tablet Sig: 5-17 tablet Tablet PO once a day. 6. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. O2 Home O2- 4 liters nasal cannula. Pulse dose for portability. 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 10. 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 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: First dose 9/24. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: 43037 Ware Estates Nicholsonville, NM 78312 VNA Discharge Diagnosis: Primary 1. Dyspnea/hypoxia 2. Cellulitis Secondary -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought 5-17 to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT -- dCHF/ Cor pulmonale -- Obesity. -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- obstructive sleep apnea on CPAP -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism Discharge Condition: Patient was discharged in stable condition. Discharge Instructions: 1. You were admitted for shortness of breath. This was due to excessive fluid retention. You received lasix during your admission to reduce the amount of fluid in your body. You also received a paracentesis in order to remove the fluid from your abdomen. You will need to continue taking your lasix as prescribed. 2. You were found to have a cellulitis, or skin infection on your right leg. You received antibiotics for this during your admission that will need to be continued on discharge. The instructions for this medication are: Levofloxacin 250 mg by mouth once daily (STOP ON 2018-3-4) 3. Unless otherwise indicated, please resume all of your home medications as taken prior to admission. It is very important that you take your medications as prescribed. 4. It is very important that you keep all of your doctor's appointments. 5. If you develop chest pain, shortness of breath, fever, or other concerning symptoms, please call your PCP or go to your local Emergency Department immediately. Followup Instructions: Provider: Zachary Camargo, MD Phone:117-838-5662 Date/Time:1995-2-22 2:30 Provider: Dylan AD Booker, M.D. Phone:668-969-4328 Date/Time:2009-11-2 11:30 Provider: Zachary Camargo, MD Phone:117-838-5662 Date/Time:1988-12-27 12:10 Shannon Clapp MD, 02802974 Completed by:2011-3-7	["Admission Date: 1906-4-5 Discharge Date: 2011-3-7\n\nDate of Birth: 1911-9-28 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPenicillins / Sulfonamides / Hytrin / Sildenafil\n\nAttending:Kaushik\nChief Complaint:\n1) leg ulcer 2) SOB 3) abdominal pain and nausea\n\nMajor Surgical or Invasive Procedure:\n7-2 US guided RLQ paracentesis (4L)\n\nHistory of Present Illness:\n77 y/o man with PMH significant for severe right sided heart\nfailure, pulmonary hypertension, COPD with interstitial lung\ndisease, and chronic kidney disease who presents with 3 day hx\nof ulcer on his right leg, pt denies trauma to leg, fevers or\nsweats. At baseline, pt has mild pedal edema, and there was no\nsignificant swelling of the right leg. Pt has some baseline\nerythema of bil lower legs, but noted moderate increased\nerythema around ulcer and 'pus' which he described as yellow.", '\n\nThe patient is on home 02 around the clock and has been on 4L NC\nfor several months. Pt has had no recent changes in his\nbreathing at home and normally sats in the low 90s, he denies\nnew SOB or dyspnea. He has a chronic cough, which has not\nchanged recently. He sleeps on his side on 2 pillows and denies\nPND. He has had no chest pain. He denies hematemesis at home.\n\nIn the ED, he was satting 88% on 4L NC, and then desaturated to\n70s and was placed on a NRB and satting 100%. He received\nPrednisone 60mg for COPD flair, lasix 40mg IV x 1, and Vanco 1g\nIV. He then developed some diffuse abdominal pain and nausea and\nreceived zofran 4mg IV x2 and ativan 0.5mg x1.\nROS: Denies chest pain, chills, fevers, night sweats, cough,\nheadache, vision changes, diarrhea, dysuria, melena or\nhematochezia. Has 2 pillow orthopnea.', " Uses BiPAP at night.\nDenies stroke, TIA, DVT, PE, joint pains, hemoptysis. He does\nreport a chronic dry cough which is at his baseline.\n\n\nPast Medical History:\n-- Hypertension\n-- Hyperlipidemia\n-- BPH; s/p turp x2\n-- Gout\n-- Impaired glucose tolerance\n-- Interstitial lung disease with diminished DLCO (thought 5-17\nto pulmonary fibrosis and emphysema as per Pulmonary). B/L\npleural thickening and honeycombing on CT\n-- dCHF/ Cor pulmonale\n-- Obesity.\n-- Diabetes mellitus 2, diet controlled\n-- hiatal hernia\n-- sleep apnea\n-- R sided renal lesion\n-- CKD - baseline creatinine is 1.6-1.7\n-- Abdominal aortic aneurysm.\n-- Constipation.\n-- Hypothyroidism\n.\n\n\nSocial History:\nLives at home with his wife of 50 years. Stays on the 97197 Christopher Ports\nNorth Mark, FM 60531\nof the house (can't climb stairs 5-17 SOB).", ' Has 6 children and 15\ngrandchildren-all healthy. Was AD Benhamou high school teacher for\n7 yrs, elementary school principal for 12 yrs, and\nsuperintendent for 19 yrs. Retired in 1964 and became a lobbyist\nfor the retirees until 1/1964. Quit smoking 20 yrs ago (1ppd x\n20 yrs), rare ETOH, no drug use.\n\nFamily History:\nNon-Contributory\n\nPhysical Exam:\nVSS: 97.7, 98, 141/87, 98% on 100%02NRB, changed to 4L NC,\nSAT90-93%\nGEN: Comfortable appearing, in NAD\nHEENT: Pupils unequal 6mmR, 4mmL, RRL, EOMI, mildly icteric\nsclera.\nNECK: supple, nontender, no LAD, JVP at jaw\nCV: RRR, s1, s2 wnl, 3/6 systolic murmur LSB=RSB, increase on\ninspiration, ? s3, s4.\nPULM: rales bilaterally throughout, sparse at apex, no rhonchi\nor wheezing.\nABD: Hugely distended, with vericose veins, dull to percussion\nexcept for midline area that is tympanetic.', ' TTP over\nmidline/epigastric area, nontender elsewhere.\nEXT: DP2+, RP 2+, bilateral anterior tibial erythema, R>L, mild\nbilateral edema, nonpitting, equal. 3cmx4cm cicular ulcer on R\nant. lower leg, w clear, yellow drainage onto bandage, mild\nsurrounding erythema, no necrosis, no pus. TTP on medial/infeior\naspect of surrounding tissue. Non tender calf or later leg or\nfoot.\nNEURO: CNII-XII intact, strength 5/5 upper ext and ankles, toes\ndowngoing bilaterally, sensation to light touch intact, no\nfinger to nose ataxia.\n\n\nPertinent Results:\n1906-4-5 03:15PM PLT COUNT-309\n1906-4-5 03:15PM NEUTS-74.8* LYMPHS-12.4* MONOS-8.7 EOS-3.6\nBASOS-0.5\n1906-4-5 03:15PM WBC-6.0 RBC-3.97* HGB-11.1* HCT-34.4* MCV-87\nMCH-28.0 MCHC-32.3 RDW-19.8\n1906-4-5 03:15PM DIGOXIN-0.2\n1906-4-5 03:15PM ALBUMIN-3.', '3* CALCIUM-8.9 PHOSPHATE-3.1\nMAGNESIUM-2.1\n1906-4-5 03:15PM CK-MB-NotDone proBNP-7014\n1906-4-5 03:15PM cTropnT-0.04\n1906-4-5 03:15PM LIPASE-58\n1906-4-5 03:15PM ALT(SGPT)-9 AST(SGOT)-23 CK(CPK)-29* ALK\nPHOS-155* TOT BILI-1.1\n1906-4-5 03:15PM estGFR-Using this\n1906-4-5 03:15PM GLUCOSE-104 UREA N-28* CREAT-1.6* SODIUM-134\nPOTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-28 ANION GAP-15\n1906-4-5 03:26PM GLUCOSE-101 K+-3.8\n1906-4-5 03:26PM COMMENTS-GREEN TOP\n1906-4-5 04:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0\nLEUK-NEG\n1906-4-5 04:15PM URINE COLOR-Yellow APPEAR-Clear SP Spikes-1.007\n1906-4-5 06:48PM TYPE-ART PO2-88 PCO2-41 PH-7.46* TOTAL CO2-30\nBASE XS-409/19/08 07:00PM PT-16.0* PTT-28.2 INR(PT)-1.4\n1906-4-5 09:02PM PT-16.', '3 PTT-25.8 INR(PT)-1.5\n1906-4-5 09:02PM PLT COUNT-293\n1906-4-5 09:02PM NEUTS-91.1 LYMPHS-6.4* MONOS-2.2 EOS-0.2\nBASOS-0.1\n1906-4-5 09:02PM WBC-6.5 RBC-4.03* HGB-11.5* HCT-35.4* MCV-88\nMCH-28.4 MCHC-32.4 RDW-18.5\n1906-4-5 09:02PM TOT PROT-7.9 ALBUMIN-3.2 GLOBULIN-4.7\nCALCIUM-9.2 PHOSPHATE-3.8\n1906-4-5 09:02PM CK-MB-NotDone cTropnT-0.03\n1906-4-5 09:02PM LIPASE-60\n1906-4-5 09:02PM ALT(SGPT)-10 AST(SGOT)-23 CK(CPK)-28* ALK\nPHOS-161\n1906-4-5 09:02PM GLUCOSE-157 UREA N-28* CREAT-1.6* SODIUM-134\nPOTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-27 ANION GAP-17\n\nCXR:\n5-31: There is stable cardiomegaly. The lung volumes are\npreserved. There is no significant interval change in\npredominantly basal and subpleural interstitial abnormalities\nconsistent with known pulmonary fibrosis. There are no acute\nfocal consolidations.', '\n\n7-2: Increased interstitial markings are again demonstrated.\nThe cardiac silhouette is prominent as before. Mediastinal\nstructures are unchanged.\n\n\nBrief Hospital Course:\nMr. Kwan is a 77 year old gentleman with a PMH significant for\nright-sided heart failure, pulmonary hypertension, COPD,\ninterstital lung disease, DM 2, and CRI admitted for hypoxia and\na RLE ulcer.\n\n1. Dyspnea/Hypoxia: Most likely etiology to dyspnea and hypoxia\nare fluid overload in setting of severe right sided heart\nfailure and pulmonary hypertension, as well as increasing\nascites. The patient was diuresed with lasix gtt and then po\nlasix during admission. In addition, the patient underwent a\ntherapeutic paracentesis with 4 liters of ascites taken off with\nsignificant improvement in symptoms. Of note, the patient was\nnot on spironolactone, which he may benefit from in terms of\nmanaging his ascites.', ' At discharge, the patient was at baseline\non 4 liters nc supplemental O2, which is his home requirement.\nOn discharge, he was also instructed to continue his lasix,\nalbuterol, and home O2.\n\n2. CHF: Patient with significant pulmonary hypertension and\nright-sided heart failure on last TTE with preserved EF. The\npatient was continued on lasix during admission. On discharge,\nhe was instructed to continue with his lasix regimen.\n\n3. RLE ulcer: On admission, the patient was treated empirically\nwith vancomycin, which was converted to PO antimicrobial therapy\nduring admission. As the patient has a significant allergy to\nPCN and sulfa, he was started on a 7 day course of levofloxacin.\n\n4. COPD/Interstitial lung disease: Currently stable. Followed by\nDr. Pegram as outpatient.\n\n5. Upper GIB: Patient with one episode of coffee ground emesis\nin the ED.', " His hematocrit has been stable and he has been guaiac\nnegative since admission. Of note, the patient has a prior\nepisode of coffee ground emesis during his last admission to\nBailey, Smith and Peterson Clinic in 3-7. At that time, the patient was evaluated by GI\nand declined an EGD. Given the the patient's significant right\nheart failure and congestive hepatopathy, he may likely have\nvarices although this cannot be confirmed without EGD. He was\ninitially started on an IV PPI for potential bleeding ulcer,\nwhich was converted to PO PPI on discharge. The patient had\nnegative stool guaiacs and his hematocrit remained stable during\nadmission.\n\n6. Coagulopathy: Patient with INR of 1.5 during admission,\nlikely secondary to malnutrition and hepatic congestion.\nReceived 10 mg po vitamin K x2 during admission.", '\n\n7. Ascites: Patient with SAAG of 1.1 with TP>2.5 suggestive of\ncongestive hepatopathy. He does have >250 WBC (PMN 21) on\nascitic fluid analysis, although this is in the setting of a\ntraumatic tap (RBC 1964).\n\n8. CKD: Creatinine at baseline during admission.\n\n9. OSA: Continued on CPAP at night during admission.\n\n10. Prophylaxis: Patient treated with DVT prophylaxis during\nadmission.\n\nMedications on Admission:\nas per OMR:\nALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1\n\nto 2 puffs inhaled up to four times a day as needed for\nshortness\nof breath or wheezing\nALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)\n\nBIPAP - (Prescribed by Other Provider) - - 11cm inspiratory\nand 7 cm expiratory along with 4 L/min 02\nFINGERTIP OXIMETER - - use at home to monitor exertional\nhypoxemia\nFLUOXETINE - 10 mg Capsule - 1 (One) Capsule(s) by mouth once a\n\nday\nFUROSEMIDE [LASIX] - 80 mg Tablet - 1 Tablet(s) by mouth twice a\n\nday- Changed to TID per patient.', '\nGLIMEPIRIDE - 1 mg Tablet - 5-17 Tablet(s) by mouth once a day dm\n\nLEVOTHYROXINE - 25 mcg Tablet - 0.5 Tablet(s) by mouth once a\nday\nOXYGEN - - 4 Liters/min continuously\nPOTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. Particle/Crystal - 1\nTab Sust.Rel. Particle/Crystal(s) by mouth once a day\nZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth HS (at bedtime) as\n\nneeded for insomnia\n\nMedications - OTC\nASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1\nTablet, Delayed Release (E.C.)(s) by mouth once a day prevention\n\nMULTIVITAMIN - (Prescribed by Other Provider; OTC) - Capsule -\n1 Capsule(s) by mouth once a day\nPSYLLIUM [METAMUCIL] - (Prescribed by Other Provider) - 0.52\ngram Capsule - 1 Capsule(s) by mouth prn\n\n\nDischarge Medications:\n1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff\nInhalation Q6H (every 6 hours).', '\n2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.\n\n3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\n4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8\nHours).\n5. Glimepiride 1 mg Tablet Sig: 5-17 tablet Tablet PO once a day.\n\n6. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).\n\n7. O2\nHome O2- 4 liters nasal cannula. Pulse dose for portability.\n8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)\nas needed.\n9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO once a day.\n10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:2\n11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H\n(every 24 hours) for 5 days: First dose 9/24.', '\nDisp:5 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n43037 Ware Estates\nNicholsonville, NM 78312 VNA\n\nDischarge Diagnosis:\nPrimary\n1. Dyspnea/hypoxia\n2. Cellulitis\n\nSecondary\n-- Hypertension\n-- Hyperlipidemia\n-- BPH; s/p turp x2\n-- Gout\n-- Impaired glucose tolerance\n-- Interstitial lung disease with diminished DLCO (thought 5-17\nto pulmonary fibrosis and emphysema as per Pulmonary). B/L\npleural thickening and honeycombing on CT\n-- dCHF/ Cor pulmonale\n-- Obesity.\n-- Diabetes mellitus 2, diet controlled\n-- hiatal hernia\n-- obstructive sleep apnea on CPAP\n-- R sided renal lesion\n-- CKD - baseline creatinine is 1.6-1.7\n-- Abdominal aortic aneurysm.\n-- Constipation.\n-- Hypothyroidism\n\n\nDischarge Condition:\nPatient was discharged in stable condition.\n\n\nDischarge Instructions:\n1.', " You were admitted for shortness of breath. This was due to\nexcessive fluid retention. You received lasix during your\nadmission to reduce the amount of fluid in your body. You also\nreceived a paracentesis in order to remove the fluid from your\nabdomen. You will need to continue taking your lasix as\nprescribed.\n\n2. You were found to have a cellulitis, or skin infection on\nyour right leg. You received antibiotics for this during your\nadmission that will need to be continued on discharge. The\ninstructions for this medication are:\nLevofloxacin 250 mg by mouth once daily (STOP ON 2018-3-4)\n\n3. Unless otherwise indicated, please resume all of your home\nmedications as taken prior to admission. It is very important\nthat you take your medications as prescribed.\n\n4. It is very important that you keep all of your doctor's\nappointments.", '\n\n5. If you develop chest pain, shortness of breath, fever, or\nother concerning symptoms, please call your PCP or go to your\nlocal Emergency Department immediately.\n\nFollowup Instructions:\nProvider: Zachary Camargo, MD Phone:117-838-5662\nDate/Time:1995-2-22 2:30\n\nProvider: Dylan AD Booker, M.D. Phone:668-969-4328\nDate/Time:2009-11-2 11:30\n\nProvider: Zachary Camargo, MD Phone:117-838-5662\nDate/Time:1988-12-27 12:10\n\n\n Shannon Clapp MD, 02802974\n\nCompleted by:2011-3-7']
154	2718	161580.0	2151-05-25	Discharge summary	Report	Admission Date: [2151-5-21] Discharge Date: [2151-5-25] Date of Birth: [2079-12-14] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 71-year-old woman with a chief complaint of hematemesis. The patient with a history of chronic obstructive pulmonary disease and peptic ulcer disease 40 years ago; who, on the morning of admission, felt nauseous upon waking up. Improved with eating breakfast; however, around noon the patient felt nauseated and weak. At 12:10 p.m. the patient suddenly vomited a large amount of bright red blood. She has had no recent illness. No chest pain. Status post vomiting, she started feeling weak and short of breath. She was brought into Emergency Department. She had melanotic stool in the Emergency Department. On arrival to the Emergency Department, her temperature was 98.1, blood pressure was 126/44, heart rate was 99, respiratory rate was 28, and oxygen saturation was 100% on room air. Nasogastric tube suctioning showed coffee-grounds emesis. She had been Prevacid orally and then given intravenous famotidine. Subsequently, several hours later, the patient was given intravenous Protonix 40 mg. PAST MEDICAL HISTORY: 1. She had peptic ulcer disease 40 years ago. 2. Chronic back pain (In [2145], she had a spinal cord stimulator placed). 3. Chronic obstructive pulmonary disease (on home oxygen at 2 liters at baseline). 4. Myocardial infarction in [2122] and [2130]; status post coronary artery bypass graft in [2140] and [2143]. 5. Hypertension. 6. Hypercholesterolemia. 7. She had an aortobifemoral bypass and a right renal artery bypass in [2147]. 8. She is status post cholecystectomy. 9. Status post appendectomy. 10. She has congestive heart failure (with an ejection fraction of 30% in [2146]). MEDICATIONS ON ADMISSION: (Her medications on admission included) 1. Azmacort 4 puffs inhaled twice per day. 2. Aspirin 81 mg p.o. once per day. 3. Norvasc. 4. Albuterol 2 puffs inhaled twice per day. 5. [Doctor First Name ] 60 mg p.o. once per day. 6. Lisinopril 5 mg p.o. once per day. 7. Soma 350 mg p.o. four times per day as needed (for pain). 8. Darvocet one tablet p.o. four times per day as needed. 9. Colace. 10. Famotidine 20 mg p.o. q.h.s. 11. Prozac 20 mg p.o. once per day. 12. Lasix 20 mg p.o. once per day. 13. Atrovent 2 puffs inhaled four times per day. 14. Sublingual nitroglycerin as needed. ALLERGIES: Allergy to ATIVAN (she gets anaphylaxis) and MORPHINE (she gets nausea). She also has an allergy to VALIUM, HALDOL, TAPE, SULFA, and CODEINE. SOCIAL HISTORY: She lives alone. Her nephew [Name (NI) ] (telephone number [Telephone/Fax (1) 1585]) is her health care proxy. She is a 100-pack-year smoker; one quarter of a pack per day currently. She is do not resuscitate/do not intubate. REVIEW OF SYSTEMS: On review of systems, she was fully independent at baseline. She drives and goes grocery shopping by herself without difficulty. She gets chest pressure once every few months and takes sublingual nitroglycerin as needed. PHYSICAL EXAMINATION ON PRESENTATION: On examination, her temperature was 98.1, blood pressure was 126/44, and heart rate was in the 80s. In general, she was a thin elderly woman in no apparent distress. She appeared slightly uncomfortable and anxious. Head, eyes, ears, nose, and throat examination revealed the oropharynx was dry. No blood was visible. Chest examination revealed breath sounds were distant. She had no wheezes, rhonchi, or rales. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Extremities were warm and well perfused. No edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed her white blood cell count was 8.3, hematocrit was 27.1 (repeat hematocrit was 25.7 three hours later), and platelets were 250. Differential with 71% neutrophils, 24% lymphocytes, and 4% monocytes. Her Chemistry-7 was unremarkable other than an elevated blood urea nitrogen of 61 and a creatinine of 0.9. Creatine kinase was 79. Troponin was less than 0.3. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no infiltrates. No pneumothorax. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Medical Intensive Care Unit from [5-21] to [5-24]. 1. GASTROINTESTINAL ISSUES: On the evening of admission, she had emergent esophagogastroduodenoscopy which showed an active pumping arterial bleeding vessel in the fundus 5 cm distal to the gastroesophageal junction. Epinephrine and electrocautery were attempted to stop the bleed, but this failed. She was then subsequently sent to Interventional Radiology who injected the celiac axis to localize the bleed, but no bleed was found. They attempted to embolize the left gastric artery but failed secondary to its tortuosity. The bleed appeared to have stopped. In the Medical Intensive Care Unit she received 48 hours of octreotide, given intravenous Protonix 40 mg twice per day (which was changed to 40 mg p.o. twice per day), and her diet was advanced to clears. She had received 4 units of packed red blood cells and one bag of platelets while on the Unit. The platelets were given because the patient had been on aspirin, but she was not thrombocytopenic. She was then transferred out to the floor after her hematocrit had been stable on [2151-5-24]. Her hematocrit was 36 status post transfusion and remained at this level over a 72-hour period. Her diet was continually advanced, and she had brown stools by the time she left the hospital. She was to follow up with Dr. [First Name8 (NamePattern2) 1586] [Name (STitle) ] on [2151-7-5] for a repeat esophagogastroduodenoscopy. 2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES: She was stable on home oxygen. She was continued on her inhalers. 3. CORONARY ARTERY DISEASE ISSUES: The patient was ruled out for a myocardial infarction given her dyspnea. Her antihypertensives were held given the possibility of becoming hypotensive, and her aspirin was also discontinued given her risk of bleeding. She was to follow up with her primary care physician; at which point he will decide on restarting her antihypertensives. She also has congestive heart failure which was stable. Previously on Lasix 20 mg p.o. once per day; but this has also been held and was to be restarted by her primary care physician. 4. BACK PAIN ISSUES: She has chronic back pain. She was to continue on her home medications including her Soma and Darvocet. 5. ANEMIA ISSUES: The patient was worked up as an outpatient including a bone marrow biopsy which was normal. Her hematocrit was stable for 72 hours status post transfusion on [5-21]. 6. CODE STATUS: Her code status is do not resuscitate/do not intubate. DISCHARGE STATUS: The patient was discharged to home with [Hospital6 407] for blood pressure monitoring. DISCHARGE DIAGNOSES: (Her discharge diagnoses included) 1. Upper gastrointestinal bleed. 2. Status post transfusion of four units of packed red blood cells and one bag of platelets. 3. Gastric ulcer with arterial bleed. 4. Hypertension. 5. Coronary artery disease. 6. Peptic ulcer disease. 7. Chronic obstructive pulmonary disease. 8. Hypercholesterolemia. 9. Congestive heart failure (which is stable). 10. Anemia. MAJOR SURGICAL/INVASIVE PROCEDURES: 1. Esophagogastroduodenoscopy with electrocautery. 2. Epinephrine injection. 3. Interventional Radiology embolectomy attempt. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was discharged to home with [Hospital6 1587] to continue blood pressure monitoring. 2. The patient was advised to return to the hospital right away with any signs of bleeding; including bright red blood per rectum, vomiting, coffee-grounds emesis, black stools, red stools, lightheadedness, chest pain, shortness of breath, or dizziness. 3. The patient was to stop aspirin and all nonsteroidal antiinflammatory drugs. 4. The patient was to hold her blood pressure medications for now including her Norvasc and lisinopril and to be restarted by Dr. [Last Name (STitle) 1588]. The patient was also to hold her Lasix; also to be restarted by Dr. [Last Name (STitle) 1588]. 5. The patient had a follow-up appointment with Dr. [Last Name (STitle) 1588] on [2151-6-26] at 12 noon. 6. The patient had a follow-up appointment with Dr. [First Name8 (NamePattern2) 1586] [Name (STitle) ] in Gastroenterology for a repeat esophagogastroduodenoscopy to follow up her gastric ulcer on [2151-6-5]. 7. Helicobacter pylori was added to her laboratories on the day of discharge; which were still pending. MEDICATIONS ON DISCHARGE: (Her discharge medications included) 1. Atrovent 2 puffs inhaled twice per day. 2. Azmacort 4 puffs inhaled twice per day. 3. Albuterol 2 puffs inhaled twice per day and q.4-6h. as needed. 4. Protonix 40 mg p.o. q.12h. 5. Soma 350 mg p.o. four times per day as needed. 6. Fluoxetine 20 mg p.o. once per day. 7. Nitroglycerin 0.4-mg tablet p.o. as needed. 8. Colace 100 mg p.o. twice per day. 9. [Doctor First Name ] 60 mg p.o. once per day. 10. Darvocet one tablet p.o. four times per day as needed (for pain). [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1589], M.D. [MD Number(1) 1590] Dictated By:[Name8 (MD) 1020] MEDQUIST36 D: [2151-5-25] 14:25 T: [2151-5-29] 02:37 JOB#: [Job Number 1591]	Admission Date: <Date>1968-12-29</Date> Discharge Date: <Date>1922-6-27</Date> Date of Birth: <Date>1927-9-28</Date> Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 71-year-old woman with a chief complaint of hematemesis. The patient with a history of chronic obstructive pulmonary disease and peptic ulcer disease 40 years ago; who, on the morning of admission, felt nauseous upon waking up. Improved with eating breakfast; however, around noon the patient felt nauseated and weak. At 12:10 p.m. the patient suddenly vomited a large amount of bright red blood. She has had no recent illness. No chest pain. Status post vomiting, she started feeling weak and short of breath. She was brought into Emergency Department. She had melanotic stool in the Emergency Department. On arrival to the Emergency Department, her temperature was 98.1, blood pressure was 126/44, heart rate was 99, respiratory rate was 28, and oxygen saturation was 100% on room air. Nasogastric tube suctioning showed coffee-grounds emesis. She had been Prevacid orally and then given intravenous famotidine. Subsequently, several hours later, the patient was given intravenous Protonix 40 mg. PAST MEDICAL HISTORY: 1. She had peptic ulcer disease 40 years ago. 2. Chronic back pain (In <Year>1919</Year>, she had a spinal cord stimulator placed). 3. Chronic obstructive pulmonary disease (on home oxygen at 2 liters at baseline). 4. Myocardial infarction in <Year>1919</Year> and <Year>1919</Year>; status post coronary artery bypass graft in <Year>1919</Year> and <Year>1919</Year>. 5. Hypertension. 6. Hypercholesterolemia. 7. She had an aortobifemoral bypass and a right renal artery bypass in <Year>1919</Year>. 8. She is status post cholecystectomy. 9. Status post appendectomy. 10. She has congestive heart failure (with an ejection fraction of 30% in <Year>1919</Year>). MEDICATIONS ON ADMISSION: (Her medications on admission included) 1. Azmacort 4 puffs inhaled twice per day. 2. Aspirin 81 mg p.o. once per day. 3. Norvasc. 4. Albuterol 2 puffs inhaled twice per day. 5. <Name>Nicki</Name> 60 mg p.o. once per day. 6. Lisinopril 5 mg p.o. once per day. 7. Soma 350 mg p.o. four times per day as needed (for pain). 8. Darvocet one tablet p.o. four times per day as needed. 9. Colace. 10. Famotidine 20 mg p.o. q.h.s. 11. Prozac 20 mg p.o. once per day. 12. Lasix 20 mg p.o. once per day. 13. Atrovent 2 puffs inhaled four times per day. 14. Sublingual nitroglycerin as needed. ALLERGIES: Allergy to ATIVAN (she gets anaphylaxis) and MORPHINE (she gets nausea). She also has an allergy to VALIUM, HALDOL, TAPE, SULFA, and CODEINE. SOCIAL HISTORY: She lives alone. Her nephew <Name>Reza Ceja</Name> (telephone number <Telephone>858-213-9557</Telephone>) is her health care proxy. She is a 100-pack-year smoker; one quarter of a pack per day currently. She is do not resuscitate/do not intubate. REVIEW OF SYSTEMS: On review of systems, she was fully independent at baseline. She drives and goes grocery shopping by herself without difficulty. She gets chest pressure once every few months and takes sublingual nitroglycerin as needed. PHYSICAL EXAMINATION ON PRESENTATION: On examination, her temperature was 98.1, blood pressure was 126/44, and heart rate was in the 80s. In general, she was a thin elderly woman in no apparent distress. She appeared slightly uncomfortable and anxious. Head, eyes, ears, nose, and throat examination revealed the oropharynx was dry. No blood was visible. Chest examination revealed breath sounds were distant. She had no wheezes, rhonchi, or rales. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Extremities were warm and well perfused. No edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed her white blood cell count was 8.3, hematocrit was 27.1 (repeat hematocrit was 25.7 three hours later), and platelets were 250. Differential with 71% neutrophils, 24% lymphocytes, and 4% monocytes. Her Chemistry-7 was unremarkable other than an elevated blood urea nitrogen of 61 and a creatinine of 0.9. Creatine kinase was 79. Troponin was less than 0.3. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no infiltrates. No pneumothorax. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Medical Intensive Care Unit from <Date>1-24</Date> to <Date>3-12</Date>. 1. GASTROINTESTINAL ISSUES: On the evening of admission, she had emergent esophagogastroduodenoscopy which showed an active pumping arterial bleeding vessel in the fundus 5 cm distal to the gastroesophageal junction. Epinephrine and electrocautery were attempted to stop the bleed, but this failed. She was then subsequently sent to Interventional Radiology who injected the celiac axis to localize the bleed, but no bleed was found. They attempted to embolize the left gastric artery but failed secondary to its tortuosity. The bleed appeared to have stopped. In the Medical Intensive Care Unit she received 48 hours of octreotide, given intravenous Protonix 40 mg twice per day (which was changed to 40 mg p.o. twice per day), and her diet was advanced to clears. She had received 4 units of packed red blood cells and one bag of platelets while on the Unit. The platelets were given because the patient had been on aspirin, but she was not thrombocytopenic. She was then transferred out to the floor after her hematocrit had been stable on <Date>1967-2-8</Date>. Her hematocrit was 36 status post transfusion and remained at this level over a 72-hour period. Her diet was continually advanced, and she had brown stools by the time she left the hospital. She was to follow up with Dr. <Name>Christian</Name> <Name>Sandhya Kaur</Name> on <Date>1922-10-9</Date> for a repeat esophagogastroduodenoscopy. 2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES: She was stable on home oxygen. She was continued on her inhalers. 3. CORONARY ARTERY DISEASE ISSUES: The patient was ruled out for a myocardial infarction given her dyspnea. Her antihypertensives were held given the possibility of becoming hypotensive, and her aspirin was also discontinued given her risk of bleeding. She was to follow up with her primary care physician; at which point he will decide on restarting her antihypertensives. She also has congestive heart failure which was stable. Previously on Lasix 20 mg p.o. once per day; but this has also been held and was to be restarted by her primary care physician. 4. BACK PAIN ISSUES: She has chronic back pain. She was to continue on her home medications including her Soma and Darvocet. 5. ANEMIA ISSUES: The patient was worked up as an outpatient including a bone marrow biopsy which was normal. Her hematocrit was stable for 72 hours status post transfusion on <Date>1-24</Date>. 6. CODE STATUS: Her code status is do not resuscitate/do not intubate. DISCHARGE STATUS: The patient was discharged to home with <Hospital>Holmes, Hartman and Chan Health System</Hospital> for blood pressure monitoring. DISCHARGE DIAGNOSES: (Her discharge diagnoses included) 1. Upper gastrointestinal bleed. 2. Status post transfusion of four units of packed red blood cells and one bag of platelets. 3. Gastric ulcer with arterial bleed. 4. Hypertension. 5. Coronary artery disease. 6. Peptic ulcer disease. 7. Chronic obstructive pulmonary disease. 8. Hypercholesterolemia. 9. Congestive heart failure (which is stable). 10. Anemia. MAJOR SURGICAL/INVASIVE PROCEDURES: 1. Esophagogastroduodenoscopy with electrocautery. 2. Epinephrine injection. 3. Interventional Radiology embolectomy attempt. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was discharged to home with <Hospital>Smith and Sons Hospital</Hospital> to continue blood pressure monitoring. 2. The patient was advised to return to the hospital right away with any signs of bleeding; including bright red blood per rectum, vomiting, coffee-grounds emesis, black stools, red stools, lightheadedness, chest pain, shortness of breath, or dizziness. 3. The patient was to stop aspirin and all nonsteroidal antiinflammatory drugs. 4. The patient was to hold her blood pressure medications for now including her Norvasc and lisinopril and to be restarted by Dr. <Name>Jain</Name>. The patient was also to hold her Lasix; also to be restarted by Dr. <Name>Jain</Name>. 5. The patient had a follow-up appointment with Dr. <Name>Jain</Name> on <Date>1974-6-28</Date> at 12 noon. 6. The patient had a follow-up appointment with Dr. <Name>Christian</Name> <Name>Sandhya Kaur</Name> in Gastroenterology for a repeat esophagogastroduodenoscopy to follow up her gastric ulcer on <Date>2007-4-10</Date>. 7. Helicobacter pylori was added to her laboratories on the day of discharge; which were still pending. MEDICATIONS ON DISCHARGE: (Her discharge medications included) 1. Atrovent 2 puffs inhaled twice per day. 2. Azmacort 4 puffs inhaled twice per day. 3. Albuterol 2 puffs inhaled twice per day and q.4-6h. as needed. 4. Protonix 40 mg p.o. q.12h. 5. Soma 350 mg p.o. four times per day as needed. 6. Fluoxetine 20 mg p.o. once per day. 7. Nitroglycerin 0.4-mg tablet p.o. as needed. 8. Colace 100 mg p.o. twice per day. 9. <Name>Nicki</Name> 60 mg p.o. once per day. 10. Darvocet one tablet p.o. four times per day as needed (for pain). <Name>Judith</Name> <Name>Kuykendall</Name>, M.D. <MD Number>31176601</MD Number> Dictated By:<Name>Evan Salgado</Name> MEDQUIST36 D: <Date>1922-6-27</Date> 14:25 T: <Date>1968-9-11</Date> 02:37 JOB#: <Job Number>Steele-Brown-2016-645343</Job 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Date: 1968-12-29 Discharge Date: 1922-6-27 Date of Birth: 1927-9-28 Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 71-year-old woman with a chief complaint of hematemesis. The patient with a history of chronic obstructive pulmonary disease and peptic ulcer disease 40 years ago; who, on the morning of admission, felt nauseous upon waking up. Improved with eating breakfast; however, around noon the patient felt nauseated and weak. At 12:10 p.m. the patient suddenly vomited a large amount of bright red blood. She has had no recent illness. No chest pain. Status post vomiting, she started feeling weak and short of breath. She was brought into Emergency Department. She had melanotic stool in the Emergency Department. On arrival to the Emergency Department, her temperature was 98.1, blood pressure was 126/44, heart rate was 99, respiratory rate was 28, and oxygen saturation was 100% on room air. Nasogastric tube suctioning showed coffee-grounds emesis. She had been Prevacid orally and then given intravenous famotidine. Subsequently, several hours later, the patient was given intravenous Protonix 40 mg. PAST MEDICAL HISTORY: 1. She had peptic ulcer disease 40 years ago. 2. Chronic back pain (In 1919, she had a spinal cord stimulator placed). 3. Chronic obstructive pulmonary disease (on home oxygen at 2 liters at baseline). 4. Myocardial infarction in 1919 and 1919; status post coronary artery bypass graft in 1919 and 1919. 5. Hypertension. 6. Hypercholesterolemia. 7. She had an aortobifemoral bypass and a right renal artery bypass in 1919. 8. She is status post cholecystectomy. 9. Status post appendectomy. 10. She has congestive heart failure (with an ejection fraction of 30% in 1919). MEDICATIONS ON ADMISSION: (Her medications on admission included) 1. Azmacort 4 puffs inhaled twice per day. 2. Aspirin 81 mg p.o. once per day. 3. Norvasc. 4. Albuterol 2 puffs inhaled twice per day. 5. Nicki 60 mg p.o. once per day. 6. Lisinopril 5 mg p.o. once per day. 7. Soma 350 mg p.o. four times per day as needed (for pain). 8. Darvocet one tablet p.o. four times per day as needed. 9. Colace. 10. Famotidine 20 mg p.o. q.h.s. 11. Prozac 20 mg p.o. once per day. 12. Lasix 20 mg p.o. once per day. 13. Atrovent 2 puffs inhaled four times per day. 14. Sublingual nitroglycerin as needed. ALLERGIES: Allergy to ATIVAN (she gets anaphylaxis) and MORPHINE (she gets nausea). She also has an allergy to VALIUM, HALDOL, TAPE, SULFA, and CODEINE. SOCIAL HISTORY: She lives alone. Her nephew Reza Ceja (telephone number 858-213-9557) is her health care proxy. She is a 100-pack-year smoker; one quarter of a pack per day currently. She is do not resuscitate/do not intubate. REVIEW OF SYSTEMS: On review of systems, she was fully independent at baseline. She drives and goes grocery shopping by herself without difficulty. She gets chest pressure once every few months and takes sublingual nitroglycerin as needed. PHYSICAL EXAMINATION ON PRESENTATION: On examination, her temperature was 98.1, blood pressure was 126/44, and heart rate was in the 80s. In general, she was a thin elderly woman in no apparent distress. She appeared slightly uncomfortable and anxious. Head, eyes, ears, nose, and throat examination revealed the oropharynx was dry. No blood was visible. Chest examination revealed breath sounds were distant. She had no wheezes, rhonchi, or rales. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Extremities were warm and well perfused. No edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed her white blood cell count was 8.3, hematocrit was 27.1 (repeat hematocrit was 25.7 three hours later), and platelets were 250. Differential with 71% neutrophils, 24% lymphocytes, and 4% monocytes. Her Chemistry-7 was unremarkable other than an elevated blood urea nitrogen of 61 and a creatinine of 0.9. Creatine kinase was 79. Troponin was less than 0.3. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no infiltrates. No pneumothorax. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Medical Intensive Care Unit from 1-24 to 3-12. 1. GASTROINTESTINAL ISSUES: On the evening of admission, she had emergent esophagogastroduodenoscopy which showed an active pumping arterial bleeding vessel in the fundus 5 cm distal to the gastroesophageal junction. Epinephrine and electrocautery were attempted to stop the bleed, but this failed. She was then subsequently sent to Interventional Radiology who injected the celiac axis to localize the bleed, but no bleed was found. They attempted to embolize the left gastric artery but failed secondary to its tortuosity. The bleed appeared to have stopped. In the Medical Intensive Care Unit she received 48 hours of octreotide, given intravenous Protonix 40 mg twice per day (which was changed to 40 mg p.o. twice per day), and her diet was advanced to clears. She had received 4 units of packed red blood cells and one bag of platelets while on the Unit. The platelets were given because the patient had been on aspirin, but she was not thrombocytopenic. She was then transferred out to the floor after her hematocrit had been stable on 1967-2-8. Her hematocrit was 36 status post transfusion and remained at this level over a 72-hour period. Her diet was continually advanced, and she had brown stools by the time she left the hospital. She was to follow up with Dr. Christian Sandhya Kaur on 1922-10-9 for a repeat esophagogastroduodenoscopy. 2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES: She was stable on home oxygen. She was continued on her inhalers. 3. CORONARY ARTERY DISEASE ISSUES: The patient was ruled out for a myocardial infarction given her dyspnea. Her antihypertensives were held given the possibility of becoming hypotensive, and her aspirin was also discontinued given her risk of bleeding. She was to follow up with her primary care physician; at which point he will decide on restarting her antihypertensives. She also has congestive heart failure which was stable. Previously on Lasix 20 mg p.o. once per day; but this has also been held and was to be restarted by her primary care physician. 4. BACK PAIN ISSUES: She has chronic back pain. She was to continue on her home medications including her Soma and Darvocet. 5. ANEMIA ISSUES: The patient was worked up as an outpatient including a bone marrow biopsy which was normal. Her hematocrit was stable for 72 hours status post transfusion on 1-24. 6. CODE STATUS: Her code status is do not resuscitate/do not intubate. DISCHARGE STATUS: The patient was discharged to home with Holmes, Hartman and Chan Health System for blood pressure monitoring. DISCHARGE DIAGNOSES: (Her discharge diagnoses included) 1. Upper gastrointestinal bleed. 2. Status post transfusion of four units of packed red blood cells and one bag of platelets. 3. Gastric ulcer with arterial bleed. 4. Hypertension. 5. Coronary artery disease. 6. Peptic ulcer disease. 7. Chronic obstructive pulmonary disease. 8. Hypercholesterolemia. 9. Congestive heart failure (which is stable). 10. Anemia. MAJOR SURGICAL/INVASIVE PROCEDURES: 1. Esophagogastroduodenoscopy with electrocautery. 2. Epinephrine injection. 3. Interventional Radiology embolectomy attempt. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was discharged to home with Smith and Sons Hospital to continue blood pressure monitoring. 2. The patient was advised to return to the hospital right away with any signs of bleeding; including bright red blood per rectum, vomiting, coffee-grounds emesis, black stools, red stools, lightheadedness, chest pain, shortness of breath, or dizziness. 3. The patient was to stop aspirin and all nonsteroidal antiinflammatory drugs. 4. The patient was to hold her blood pressure medications for now including her Norvasc and lisinopril and to be restarted by Dr. Jain. The patient was also to hold her Lasix; also to be restarted by Dr. Jain. 5. The patient had a follow-up appointment with Dr. Jain on 1974-6-28 at 12 noon. 6. The patient had a follow-up appointment with Dr. Christian Sandhya Kaur in Gastroenterology for a repeat esophagogastroduodenoscopy to follow up her gastric ulcer on 2007-4-10. 7. Helicobacter pylori was added to her laboratories on the day of discharge; which were still pending. MEDICATIONS ON DISCHARGE: (Her discharge medications included) 1. Atrovent 2 puffs inhaled twice per day. 2. Azmacort 4 puffs inhaled twice per day. 3. Albuterol 2 puffs inhaled twice per day and q.4-6h. as needed. 4. Protonix 40 mg p.o. q.12h. 5. Soma 350 mg p.o. four times per day as needed. 6. Fluoxetine 20 mg p.o. once per day. 7. Nitroglycerin 0.4-mg tablet p.o. as needed. 8. Colace 100 mg p.o. twice per day. 9. Nicki 60 mg p.o. once per day. 10. Darvocet one tablet p.o. four times per day as needed (for pain). Judith Kuykendall, M.D. 31176601 Dictated By:Evan Salgado MEDQUIST36 D: 1922-6-27 14:25 T: 1968-9-11 02:37 JOB#: Steele-Brown-2016-645343	['Admission Date: 1968-12-29 Discharge Date: 1922-6-27\n\nDate of Birth: 1927-9-28 Sex: F\n\nService: Medicine\n\nHISTORY OF PRESENT ILLNESS: This is a 71-year-old woman with\na chief complaint of hematemesis.\n\nThe patient with a history of chronic obstructive pulmonary\ndisease and peptic ulcer disease 40 years ago; who, on the\nmorning of admission, felt nauseous upon waking up. Improved\nwith eating breakfast; however, around noon the patient felt\nnauseated and weak. At 12:10 p.m. the patient suddenly\nvomited a large amount of bright red blood.\n\nShe has had no recent illness. No chest pain. Status post\nvomiting, she started feeling weak and short of breath. She\nwas brought into Emergency Department. She had melanotic\nstool in the Emergency Department.\n\nOn arrival to the Emergency Department, her temperature was\n98.', '1, blood pressure was 126/44, heart rate was 99,\nrespiratory rate was 28, and oxygen saturation was 100% on\nroom air. Nasogastric tube suctioning showed coffee-grounds\nemesis. She had been Prevacid orally and then given\nintravenous famotidine. Subsequently, several hours later,\nthe patient was given intravenous Protonix 40 mg.\n\nPAST MEDICAL HISTORY:\n 1. She had peptic ulcer disease 40 years ago.\n 2. Chronic back pain (In 1919, she had a spinal cord\nstimulator placed).\n 3. Chronic obstructive pulmonary disease (on home oxygen at\n2 liters at baseline).\n 4. Myocardial infarction in 1919 and 1919; status post\ncoronary artery bypass graft in 1919 and 1919.\n 5. Hypertension.\n 6. Hypercholesterolemia.\n 7. She had an aortobifemoral bypass and a right renal\nartery bypass in 1919.\n 8. She is status post cholecystectomy.', '\n 9. Status post appendectomy.\n10. She has congestive heart failure (with an ejection\nfraction of 30% in 1919).\n\nMEDICATIONS ON ADMISSION: (Her medications on admission\nincluded)\n 1. Azmacort 4 puffs inhaled twice per day.\n 2. Aspirin 81 mg p.o. once per day.\n 3. Norvasc.\n 4. Albuterol 2 puffs inhaled twice per day.\n 5. Nicki 60 mg p.o. once per day.\n 6. Lisinopril 5 mg p.o. once per day.\n 7. Soma 350 mg p.o. four times per day as needed (for\npain).\n 8. Darvocet one tablet p.o. four times per day as needed.\n 9. Colace.\n10. Famotidine 20 mg p.o. q.h.s.\n11. Prozac 20 mg p.o. once per day.\n12. Lasix 20 mg p.o. once per day.\n13. Atrovent 2 puffs inhaled four times per day.\n14. Sublingual nitroglycerin as needed.\n\nALLERGIES: Allergy to ATIVAN (she gets anaphylaxis) and\nMORPHINE (she gets nausea).', ' She also has an allergy to\nVALIUM, HALDOL, TAPE, SULFA, and CODEINE.\n\nSOCIAL HISTORY: She lives alone. Her nephew Reza Ceja\n(telephone number 858-213-9557) is her health care proxy.\nShe is a 100-pack-year smoker; one quarter of a pack per day\ncurrently. She is do not resuscitate/do not intubate.\n\nREVIEW OF SYSTEMS: On review of systems, she was fully\nindependent at baseline. She drives and goes grocery\nshopping by herself without difficulty. She gets chest\npressure once every few months and takes sublingual\nnitroglycerin as needed.\n\nPHYSICAL EXAMINATION ON PRESENTATION: On examination, her\ntemperature was 98.1, blood pressure was 126/44, and heart\nrate was in the 80s. In general, she was a thin elderly\nwoman in no apparent distress. She appeared slightly\nuncomfortable and anxious.', ' Head, eyes, ears, nose, and\nthroat examination revealed the oropharynx was dry. No blood\nwas visible. Chest examination revealed breath sounds were\ndistant. She had no wheezes, rhonchi, or rales.\nCardiovascular examination revealed a regular rate and\nrhythm. Normal first heart sounds and second heart sounds.\nNo murmurs. The abdomen was soft, nontender, and\nnondistended. Positive bowel sounds. Extremities were warm\nand well perfused. No edema.\n\nPERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on\nadmission revealed her white blood cell count was 8.3,\nhematocrit was 27.1 (repeat hematocrit was 25.7 three hours\nlater), and platelets were 250. Differential with 71%\nneutrophils, 24% lymphocytes, and 4% monocytes. Her\nChemistry-7 was unremarkable other than an elevated blood\nurea nitrogen of 61 and a creatinine of 0.', '9. Creatine kinase\nwas 79. Troponin was less than 0.3.\n\nPERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no\ninfiltrates. No pneumothorax.\n\nHOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted\nto the Medical Intensive Care Unit from 1-24 to 3-12.\n\n1. GASTROINTESTINAL ISSUES: On the evening of admission,\nshe had emergent esophagogastroduodenoscopy which showed an\nactive pumping arterial bleeding vessel in the fundus 5 cm\ndistal to the gastroesophageal junction. Epinephrine and\nelectrocautery were attempted to stop the bleed, but this\nfailed.\n\nShe was then subsequently sent to Interventional Radiology\nwho injected the celiac axis to localize the bleed, but no\nbleed was found. They attempted to embolize the left gastric\nartery but failed secondary to its tortuosity. The bleed\nappeared to have stopped.', '\n\nIn the Medical Intensive Care Unit she received 48 hours of\noctreotide, given intravenous Protonix 40 mg twice per day\n(which was changed to 40 mg p.o. twice per day), and her diet\nwas advanced to clears. She had received 4 units of packed\nred blood cells and one bag of platelets while on the Unit.\nThe platelets were given because the patient had been on\naspirin, but she was not thrombocytopenic.\n\nShe was then transferred out to the floor after her\nhematocrit had been stable on 1967-2-8. Her hematocrit\nwas 36 status post transfusion and remained at this level\nover a 72-hour period.\n\nHer diet was continually advanced, and she had brown stools\nby the time she left the hospital. She was to follow up with\nDr. Christian Sandhya Kaur on 1922-10-9 for a repeat\nesophagogastroduodenoscopy.\n\n2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES: She was\nstable on home oxygen.', ' She was continued on her inhalers.\n\n3. CORONARY ARTERY DISEASE ISSUES: The patient was ruled\nout for a myocardial infarction given her dyspnea. Her\nantihypertensives were held given the possibility of becoming\nhypotensive, and her aspirin was also discontinued given her\nrisk of bleeding. She was to follow up with her primary care\nphysician; at which point he will decide on restarting her\nantihypertensives.\n\nShe also has congestive heart failure which was stable.\nPreviously on Lasix 20 mg p.o. once per day; but this has\nalso been held and was to be restarted by her primary care\nphysician.\n\n4. BACK PAIN ISSUES: She has chronic back pain. She was to\ncontinue on her home medications including her Soma and\nDarvocet.\n\n5. ANEMIA ISSUES: The patient was worked up as an\noutpatient including a bone marrow biopsy which was normal.', '\nHer hematocrit was stable for 72 hours status post\ntransfusion on 1-24.\n\n6. CODE STATUS: Her code status is do not resuscitate/do\nnot intubate.\n\nDISCHARGE STATUS: The patient was discharged to home with\nHolmes, Hartman and Chan Health System for blood pressure monitoring.\n\nDISCHARGE DIAGNOSES: (Her discharge diagnoses included)\n 1. Upper gastrointestinal bleed.\n 2. Status post transfusion of four units of packed red\nblood cells and one bag of platelets.\n 3. Gastric ulcer with arterial bleed.\n 4. Hypertension.\n 5. Coronary artery disease.\n 6. Peptic ulcer disease.\n 7. Chronic obstructive pulmonary disease.\n 8. Hypercholesterolemia.\n 9. Congestive heart failure (which is stable).\n10. Anemia.\n\nMAJOR SURGICAL/INVASIVE PROCEDURES:\n1. Esophagogastroduodenoscopy with electrocautery.', '\n2. Epinephrine injection.\n3. Interventional Radiology embolectomy attempt.\n\nDISCHARGE INSTRUCTIONS/FOLLOWUP:\n1. The patient was discharged to home with Smith and Sons Hospital to continue blood pressure monitoring.\n2. The patient was advised to return to the hospital right\naway with any signs of bleeding; including bright red blood\nper rectum, vomiting, coffee-grounds emesis, black stools,\nred stools, lightheadedness, chest pain, shortness of breath,\nor dizziness.\n3. The patient was to stop aspirin and all nonsteroidal\nantiinflammatory drugs.\n4. The patient was to hold her blood pressure medications\nfor now including her Norvasc and lisinopril and to be\nrestarted by Dr. Jain. The patient was also to hold her\nLasix; also to be restarted by Dr. Jain.\n5. The patient had a follow-up appointment with Dr.', ' Jain\non 1974-6-28 at 12 noon.\n6. The patient had a follow-up appointment with Dr. Christian\nSandhya Kaur in Gastroenterology for a repeat\nesophagogastroduodenoscopy to follow up her gastric ulcer on\n2007-4-10.\n7. Helicobacter pylori was added to her laboratories on the\nday of discharge; which were still pending.\n\nMEDICATIONS ON DISCHARGE: (Her discharge medications\nincluded)\n 1. Atrovent 2 puffs inhaled twice per day.\n 2. Azmacort 4 puffs inhaled twice per day.\n 3. Albuterol 2 puffs inhaled twice per day and q.4-6h. as\nneeded.\n 4. Protonix 40 mg p.o. q.12h.\n 5. Soma 350 mg p.o. four times per day as needed.\n 6. Fluoxetine 20 mg p.o. once per day.\n 7. Nitroglycerin 0.4-mg tablet p.o. as needed.\n 8. Colace 100 mg p.o. twice per day.\n 9. Nicki 60 mg p.o. once per day.\n10. Darvocet one tablet p.', 'o. four times per day as needed\n(for pain).\n\n\n\n\n\n\n Judith Kuykendall, M.D. 31176601\n\nDictated By:Evan Salgado\n\nMEDQUIST36\n\nD: 1922-6-27 14:25\nT: 1968-9-11 02:37\nJOB#: Steele-Brown-2016-645343\n']
155	2718	148278.0	2158-05-06	Discharge summary	Report	Admission Date: [2158-5-3] Discharge Date: [2158-5-6] Date of Birth: [2079-12-14] Sex: F Service: MEDICINE Allergies: Ativan / Valium / Haldol / Adhesive Tape / Sulfonamides / Codeine / Morphine / Erythromycin/Sulfisoxazole / Amoxicillin Attending:[First Name3 (LF) 1650] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 78 yo f with h/o COPD with home O2 3L requirement, CAD s/p CABG in [2140], CHF with EF 30%, PVD s/p aortofemoral bypass, RLL granuloma, HL, and h/o dementia who presents to the ED in respitatory distress. Pt and son gave history in the [Name (NI) ] that that she became more SOB with increased o2 requirement (unknown how much she increased it to). She came in to the hospital tonight for SOB and reported some increase in her allergies but no fever. In the ED her vitals soon after arrival were HR 110s BP 194/79 RR30 o2 sat 94% on 8L face mask. She was found to be in obvious respiratory distress using accessory muscles, tachypnic, poor air flow, and speaking in one word sentences. She became diaphoretic with CP and got 0.4mg of SL nitro with resolution of chest pain. She became tachy to 123 with RR 37 and BP 200/90 then was started on a nitro gtt at 2mg/kg/hr which was increased to 3mg/kg/hr. At some point dropped her sats to 85%. She was started on BiPAP with obvious improvement. Her CXR showed pulm vascular congestion. She was given 2mg IV magnesium, solumedrol 125 IV x1, azithromycin 500mg for COPD exacerbation. Her EKG showed sinus tach with prominent p waves and LVH as well as ST elevation in v1 & v2 which was similar to prior. Cardiology was consulted and said this is likely strain in the setting of respiratory distress. Exam notable for wheezes, poor air movement, and rhonci throughout. She received 20 IV lasix prior to leaving the ED. Vitals at time of transfer were HR 101 BP 159/64 RR30 02 sat 100% on BiPap. On the floor, VS were BiPAP 8/8 Fio2 100 with afebrile RR 25, HR 99 BP 149/55. She was wearing the BiPAP but able to answer yes and no to questions. Able to confirm history that last few days had increased SOB, non productive cough, wheezing, weakness, and increased allergies including nasal congestion, runny nose, and sinus pressure. Review of systems: (+) for increased frequency of urination (-) Denies fever, chills tions, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria or urgency. Denies arthralgias or myalgias. Past Medical History: -COPD with home O2 -coronary artery disease s/p CABG '[40]; cath in [2150] showed severe native 2VD, patent LIMA->LAD, SVG->OM. -ejection fraction 30% in [2156] -peripheral vascular disease, status post aortofemoral bypass -depression -right lower lobe granuloma -hypercholesterolemia -dementia and history of psychosis with psychotic episodes -severe spinal cord stenosis s/p spinal cord stimulator yrs ago Social History: - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: not obtained at this time Physical Exam: Vitals: BiPAP 8/8 Fio2 100 with afebrile RR 25, HR 99 BP 149/55 General: A & O x3, increased WOB HEENT: Sclera anicteric, unable to access MM Neck: difficult to access JCD given so much accessory muscle use Lungs:poor air movement throughout, diffuse rhonchi and mild wheezes CV: tachycardic, nl S1/S2 Abdomen: soft, non-tender, non-distended, + bowel sounds present, no rebound tenderness or guarding, no organomegaly GU:foley with good clear UOP Ext: warm, well perfused, 1+ pulses, tenderness to big toe, ? stage 1 ulcer between big and second toe Pertinent Results: Labs on Admission: [2158-5-3] 04:50AM WBC-10.6# RBC-4.11* HGB-11.7* HCT-36.9 MCV-90 MCH-28.5 MCHC-31.7 RDW-15.1 [2158-5-3] 04:50AM NEUTS-81* BANDS-0 LYMPHS-6* MONOS-11 EOS-0 BASOS-1 ATYPS-0 METAS-1* MYELOS-0 [2158-5-3] 04:50AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [2158-5-3] 04:50AM PLT SMR-NORMAL PLT COUNT-191 [2158-5-3] 04:50AM PT-12.5 PTT-26.1 INR(PT)-1.1 [2158-5-3] 04:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2158-5-3] 04:50AM URINE RBC-[2-17]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [2158-5-3] 04:50AM URINE HYALINE-0-2 [2158-5-3] 04:50AM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-1.7 [2158-5-3] 05:02AM LACTATE-1.2 [2158-5-3] 07:32AM LACTATE-0.7 [2158-5-3] 10:28AM CK-MB-NotDone cTropnT-<0.01 proBNP-9443* [2158-5-3] 10:28AM CK(CPK)-65 [2158-5-3] 03:01PM OSMOLAL-268* [2158-5-3] 03:01PM CK-MB-NotDone cTropnT-<0.01 [2158-5-3] 03:01PM CK(CPK)-66 [2158-5-3] 06:21PM URINE OSMOLAL-281 [2158-5-3] 06:21PM URINE HOURS-RANDOM SODIUM-91 . ECHO: [2158-5-3] The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with septal, anterior and apical akinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-17]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . Compared with the report of the prior study (images unavailable for review) of [2157-9-21], the LVEF is slightly lower and the estimated PA pressure has increased. . CHEST X-RAY [2158-5-4] 1. Interval improvement in congestive heart failure. 2. Mild interval increase in bilateral pleural effusions and retrocardiac left lung base opacity likely representing atelectasis. 3. COPD, with no new evidence of pneumonia. . SHOULDER X-RAY [2158-5-5] THREE VIEWS OF THE RIGHT SHOULDER: There is mild glenohumeral joint degenerative change, with spurring at the inferior glenoid. There is minimal acromioclavicular joint degenerative change. There has been prior midline sternotomy, with intact sternal wires partially visualized, as is a left brachiocephalic venous stent. Soft tissues appear unremarkable, as does the visualized right lung apex. IMPRESSION: Mild glenohumeral joint degenerative change. Brief Hospital Course: 78 yo f with h/o COPD with home O2 3L requirement, CAD s/p CABG in [2140], CHF with EF 30%, PVD s/p aortofemoral bypass, RLL granuloma, HL, and h/o dementia who presents to the ED in respitatory distress with likely component of COPD, systolic CHF, and ? LLL pneumonia. She was initially admitted to the MICU and was transferred to the floor on [2158-5-4]. Hospital course by problem list: . # COPD: Pt arrived from [Location ] with BiPAP 8/8 and was able to quickly wean off. She did not require noninvasive ventilatory support for the duration of her ICU stay. Initially received solumedrol 125 IV q8 hrs then transitioned to po prednisone daily. Levoquin was used in place of azithro for COPD exacerbation due to allergy to erythomycin. She tolerated well and was able to be weaned down to 3L which is her home dose. She was discharged on a 5 day course of Levofloxacin (to end on [2158-5-7]) and a Prednisone taper as follows: 40mg on [2158-5-6], change to 20mg on [2158-5-7] for 3 days, then 10mg on [2158-5-10] for 3 days, then stop. . # Acute on chronic CHF exacerbation: BNP elevated to 9000. Echo on HD1 showed severe regional LV systolic dysfunction with septal, anterior, and apical akinesis (EF 25-30%); no aortic stenosis; mild-mod mitral regurg, mod tricuspid regurg; severe pulm artery systolic hypertension; very small pericardial effusion - no signs of tamponade; compared to [9-/2157], the LVEF is slightly lower and the estimated PA pressure has increased. The patient received a dose of IV lasix on arrival to the ICU and was maintained on a nitro gtt. Respiratory status improved rapidly and the nitro drip was weaned off. She was started on a Captopril for her heart failure. Blood pressure should be controlled below 140/90. . # Shoulder Pain: She reported increased shoulder pain during her echocardiogram. Shoulder x-ray did not show fracture. She was seen by the Chronic Pain Service who performed a cortisone injection on [2158-5-5]. She should follow-up with her pain specialist, Dr. [Last Name (STitle) 1651]. . # Foot pain: continued gabapentin, tramadol, carisoprodol. . # GI: continued home loperamide [Hospital1 ]. . # Dementia: continued home aricept & zyprexa & chlordiazepoxide & tylenol. . # CODE STATUS: DNR/DNI Medications on Admission: Tylenol extra strength 1 tab PO TID Clindamycin for dental procedures Chlordiazepoxide 1-2 tabs QHS Gabapentin 300mg PO TID Loperamide 2mg PO BID Albuterol Advair 500/50 [Hospital1 ] Tramadol 100mg PO BID Furosemide 20mg PO daily Aricept 10mg PO daily Pantoprazole 40mg PO daily Zyprexa 2.5mg PO daily [Doctor First Name ] PO daily Carisoprodol 350mg PO TID Discharge Disposition: Extended Care Facility: [Hospital 745] Health Care Center Discharge Diagnosis: Foot/shoulder pain COPD exacerbation Acute on chronic CHF exacerbation transient leukopenia dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital with elevated blood pressure, increased shortness of breath, and congestive heart failure. We were able to control your blood pressure and control the exacerbation of COPD and heart failure. You had pain in your shoulder and feet, we performed Xray and determined that you did not have a fracture. You had a cortisone injection on [2158-5-5] by the pain team. You improved with treatment and was discharged in stable condition. Please follow up with your primary care doctor. The following changes were made to your medications: START Levofloxacin to finish on [2158-5-7] START Prednisone with the following doses: 40mg on [2158-5-6] 20 mg on [2158-5-7], [2158-5-8], [2158-5-9] 10mg on [2158-5-10], [2158-5-11], [2158-5-12] START Captopril 12.5mg by mouth three times per day. It was a pleasure taking care of you. We wish you the best on your road to recovery. Followup Instructions: Department: GERONTOLOGY When: THURSDAY [2158-5-11] at 10:30 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 719] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: PAIN MANAGEMENT CENTER When: FRIDAY [2158-5-12] at 9:50 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [Telephone/Fax (1) 1652] Building: One [Location (un) ] Place ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Parking on Site [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 1653]	Admission Date: <Date>1979-11-23</Date> Discharge Date: <Date>1935-3-30</Date> Date of Birth: <Date>1977-2-26</Date> Sex: F Service: MEDICINE Allergies: Ativan / Valium / Haldol / Adhesive Tape / Sulfonamides / Codeine / Morphine / Erythromycin/Sulfisoxazole / Amoxicillin Attending:<Name>Billy</Name> Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 78 yo f with h/o COPD with home O2 3L requirement, CAD s/p CABG in <Year>1904</Year>, CHF with EF 30%, PVD s/p aortofemoral bypass, RLL granuloma, HL, and h/o dementia who presents to the ED in respitatory distress. Pt and son gave history in the <Name>Neha Bounds</Name> that that she became more SOB with increased o2 requirement (unknown how much she increased it to). She came in to the hospital tonight for SOB and reported some increase in her allergies but no fever. In the ED her vitals soon after arrival were HR 110s BP 194/79 RR30 o2 sat 94% on 8L face mask. She was found to be in obvious respiratory distress using accessory muscles, tachypnic, poor air flow, and speaking in one word sentences. She became diaphoretic with CP and got 0.4mg of SL nitro with resolution of chest pain. She became tachy to 123 with RR 37 and BP 200/90 then was started on a nitro gtt at 2mg/kg/hr which was increased to 3mg/kg/hr. At some point dropped her sats to 85%. She was started on BiPAP with obvious improvement. Her CXR showed pulm vascular congestion. She was given 2mg IV magnesium, solumedrol 125 IV x1, azithromycin 500mg for COPD exacerbation. Her EKG showed sinus tach with prominent p waves and LVH as well as ST elevation in v1 & v2 which was similar to prior. Cardiology was consulted and said this is likely strain in the setting of respiratory distress. Exam notable for wheezes, poor air movement, and rhonci throughout. She received 20 IV lasix prior to leaving the ED. Vitals at time of transfer were HR 101 BP 159/64 RR30 02 sat 100% on BiPap. On the floor, VS were BiPAP 8/8 Fio2 100 with afebrile RR 25, HR 99 BP 149/55. She was wearing the BiPAP but able to answer yes and no to questions. Able to confirm history that last few days had increased SOB, non productive cough, wheezing, weakness, and increased allergies including nasal congestion, runny nose, and sinus pressure. Review of systems: (+) for increased frequency of urination (-) Denies fever, chills tions, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria or urgency. Denies arthralgias or myalgias. Past Medical History: -COPD with home O2 -coronary artery disease s/p CABG '<Digit>73</Digit>; cath in <Year>1904</Year> showed severe native 2VD, patent LIMA->LAD, SVG->OM. -ejection fraction 30% in <Year>1904</Year> -peripheral vascular disease, status post aortofemoral bypass -depression -right lower lobe granuloma -hypercholesterolemia -dementia and history of psychosis with psychotic episodes -severe spinal cord stenosis s/p spinal cord stimulator yrs ago Social History: - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: not obtained at this time Physical Exam: Vitals: BiPAP 8/8 Fio2 100 with afebrile RR 25, HR 99 BP 149/55 General: A & O x3, increased WOB HEENT: Sclera anicteric, unable to access MM Neck: difficult to access JCD given so much accessory muscle use Lungs:poor air movement throughout, diffuse rhonchi and mild wheezes CV: tachycardic, nl S1/S2 Abdomen: soft, non-tender, non-distended, + bowel sounds present, no rebound tenderness or guarding, no organomegaly GU:foley with good clear UOP Ext: warm, well perfused, 1+ pulses, tenderness to big toe, ? stage 1 ulcer between big and second toe Pertinent Results: Labs on Admission: <Date>1979-11-23</Date> 04:50AM WBC-10.6# RBC-4.11* HGB-11.7* HCT-36.9 MCV-90 MCH-28.5 MCHC-31.7 RDW-15.1 <Date>1979-11-23</Date> 04:50AM NEUTS-81* BANDS-0 LYMPHS-6* MONOS-11 EOS-0 BASOS-1 ATYPS-0 METAS-1* MYELOS-0 <Date>1979-11-23</Date> 04:50AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ <Date>1979-11-23</Date> 04:50AM PLT SMR-NORMAL PLT COUNT-191 <Date>1979-11-23</Date> 04:50AM PT-12.5 PTT-26.1 INR(PT)-1.1 <Date>1979-11-23</Date> 04:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG <Date>1979-11-23</Date> 04:50AM URINE RBC-<Date>1-1</Date>* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 <Date>1979-11-23</Date> 04:50AM URINE HYALINE-0-2 <Date>1979-11-23</Date> 04:50AM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-1.7 <Date>1979-11-23</Date> 05:02AM LACTATE-1.2 <Date>1979-11-23</Date> 07:32AM LACTATE-0.7 <Date>1979-11-23</Date> 10:28AM CK-MB-NotDone cTropnT-<0.01 proBNP-9443* <Date>1979-11-23</Date> 10:28AM CK(CPK)-65 <Date>1979-11-23</Date> 03:01PM OSMOLAL-268* <Date>1979-11-23</Date> 03:01PM CK-MB-NotDone cTropnT-<0.01 <Date>1979-11-23</Date> 03:01PM CK(CPK)-66 <Date>1979-11-23</Date> 06:21PM URINE OSMOLAL-281 <Date>1979-11-23</Date> 06:21PM URINE HOURS-RANDOM SODIUM-91 . ECHO: <Date>1979-11-23</Date> The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with septal, anterior and apical akinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate (<Date>2-24</Date>+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . Compared with the report of the prior study (images unavailable for review) of <Date>1925-10-13</Date>, the LVEF is slightly lower and the estimated PA pressure has increased. . CHEST X-RAY <Date>2013-12-18</Date> 1. Interval improvement in congestive heart failure. 2. Mild interval increase in bilateral pleural effusions and retrocardiac left lung base opacity likely representing atelectasis. 3. COPD, with no new evidence of pneumonia. . SHOULDER X-RAY <Date>2008-11-11</Date> THREE VIEWS OF THE RIGHT SHOULDER: There is mild glenohumeral joint degenerative change, with spurring at the inferior glenoid. There is minimal acromioclavicular joint degenerative change. There has been prior midline sternotomy, with intact sternal wires partially visualized, as is a left brachiocephalic venous stent. Soft tissues appear unremarkable, as does the visualized right lung apex. IMPRESSION: Mild glenohumeral joint degenerative change. Brief Hospital Course: 78 yo f with h/o COPD with home O2 3L requirement, CAD s/p CABG in <Year>1904</Year>, CHF with EF 30%, PVD s/p aortofemoral bypass, RLL granuloma, HL, and h/o dementia who presents to the ED in respitatory distress with likely component of COPD, systolic CHF, and ? LLL pneumonia. She was initially admitted to the MICU and was transferred to the floor on <Date>2013-12-18</Date>. Hospital course by problem list: . # COPD: Pt arrived from <Location>722 Taylor Turnpike Apt. 417 Mcguireburgh, GU 98173</Location> with BiPAP 8/8 and was able to quickly wean off. She did not require noninvasive ventilatory support for the duration of her ICU stay. Initially received solumedrol 125 IV q8 hrs then transitioned to po prednisone daily. Levoquin was used in place of azithro for COPD exacerbation due to allergy to erythomycin. She tolerated well and was able to be weaned down to 3L which is her home dose. She was discharged on a 5 day course of Levofloxacin (to end on <Date>1996-6-8</Date>) and a Prednisone taper as follows: 40mg on <Date>1935-3-30</Date>, change to 20mg on <Date>1996-6-8</Date> for 3 days, then 10mg on <Date>1980-5-3</Date> for 3 days, then stop. . # Acute on chronic CHF exacerbation: BNP elevated to 9000. Echo on HD1 showed severe regional LV systolic dysfunction with septal, anterior, and apical akinesis (EF 25-30%); no aortic stenosis; mild-mod mitral regurg, mod tricuspid regurg; severe pulm artery systolic hypertension; very small pericardial effusion - no signs of tamponade; compared to <Date>12-1986</Date>, the LVEF is slightly lower and the estimated PA pressure has increased. The patient received a dose of IV lasix on arrival to the ICU and was maintained on a nitro gtt. Respiratory status improved rapidly and the nitro drip was weaned off. She was started on a Captopril for her heart failure. Blood pressure should be controlled below 140/90. . # Shoulder Pain: She reported increased shoulder pain during her echocardiogram. Shoulder x-ray did not show fracture. She was seen by the Chronic Pain Service who performed a cortisone injection on <Date>2008-11-11</Date>. She should follow-up with her pain specialist, Dr. <Name>Islam</Name>. . # Foot pain: continued gabapentin, tramadol, carisoprodol. . # GI: continued home loperamide <Hospital>Hill, Carpenter and Camacho Clinic</Hospital>. . # Dementia: continued home aricept & zyprexa & chlordiazepoxide & tylenol. . # CODE STATUS: DNR/DNI Medications on Admission: Tylenol extra strength 1 tab PO TID Clindamycin for dental procedures Chlordiazepoxide 1-2 tabs QHS Gabapentin 300mg PO TID Loperamide 2mg PO BID Albuterol Advair 500/50 <Hospital>Hill, Carpenter and Camacho Clinic</Hospital> Tramadol 100mg PO BID Furosemide 20mg PO daily Aricept 10mg PO daily Pantoprazole 40mg PO daily Zyprexa 2.5mg PO daily <Name>Ava</Name> PO daily Carisoprodol 350mg PO TID Discharge Disposition: Extended Care Facility: <Hospital>Ortiz-Coleman Clinic</Hospital> Health Care Center Discharge Diagnosis: Foot/shoulder pain COPD exacerbation Acute on chronic CHF exacerbation transient leukopenia dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital with elevated blood pressure, increased shortness of breath, and congestive heart failure. We were able to control your blood pressure and control the exacerbation of COPD and heart failure. You had pain in your shoulder and feet, we performed Xray and determined that you did not have a fracture. You had a cortisone injection on <Date>2008-11-11</Date> by the pain team. You improved with treatment and was discharged in stable condition. Please follow up with your primary care doctor. The following changes were made to your medications: START Levofloxacin to finish on <Date>1996-6-8</Date> START Prednisone with the following doses: 40mg on <Date>1935-3-30</Date> 20 mg on <Date>1996-6-8</Date>, <Date>1936-8-24</Date>, <Date>1914-2-5</Date> 10mg on <Date>1980-5-3</Date>, <Date>1989-7-26</Date>, <Date>1911-8-20</Date> START Captopril 12.5mg by mouth three times per day. It was a pleasure taking care of you. We wish you the best on your road to recovery. Followup Instructions: Department: GERONTOLOGY When: THURSDAY <Date>1989-7-26</Date> at 10:30 AM With: <Name>Eric</Name> <Name>Eleanor Thompkins</Name>, MD <Telephone>157-256-3986</Telephone> Building: LM <Hospital>Sanders, Krueger and Williams Clinic</Hospital> <Location>4346 Lisa Curve Apt. 515 Lukemouth, AK 07558</Location> Campus: WEST Best Parking: <Hospital>Martinez-Walter Medical Center</Hospital> Garage Department: PAIN MANAGEMENT CENTER When: FRIDAY <Date>1911-8-20</Date> at 9:50 AM With: <Name>Helen</Name> <Name>Archie</Name>, MD <Telephone>198-930-6239</Telephone> Building: One <Location>4346 Lisa Curve Apt. 515 Lukemouth, AK 07558</Location> Place (<Location>4346 Lisa Curve Apt. 515 Lukemouth, AK 07558</Location>, MA) <Location>4346 Lisa Curve Apt. 515 Lukemouth, AK 07558</Location> Campus: OFF CAMPUS Best Parking: Parking on Site <Name>Ethan Feudner</Name> <Name>Eleanor Thompkins</Name> MD <MD Number>49950760</MD 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Date: 1979-11-23 Discharge Date: 1935-3-30 Date of Birth: 1977-2-26 Sex: F Service: MEDICINE Allergies: Ativan / Valium / Haldol / Adhesive Tape / Sulfonamides / Codeine / Morphine / Erythromycin/Sulfisoxazole / Amoxicillin Attending:Billy Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 78 yo f with h/o COPD with home O2 3L requirement, CAD s/p CABG in 1904, CHF with EF 30%, PVD s/p aortofemoral bypass, RLL granuloma, HL, and h/o dementia who presents to the ED in respitatory distress. Pt and son gave history in the Neha Bounds that that she became more SOB with increased o2 requirement (unknown how much she increased it to). She came in to the hospital tonight for SOB and reported some increase in her allergies but no fever. In the ED her vitals soon after arrival were HR 110s BP 194/79 RR30 o2 sat 94% on 8L face mask. She was found to be in obvious respiratory distress using accessory muscles, tachypnic, poor air flow, and speaking in one word sentences. She became diaphoretic with CP and got 0.4mg of SL nitro with resolution of chest pain. She became tachy to 123 with RR 37 and BP 200/90 then was started on a nitro gtt at 2mg/kg/hr which was increased to 3mg/kg/hr. At some point dropped her sats to 85%. She was started on BiPAP with obvious improvement. Her CXR showed pulm vascular congestion. She was given 2mg IV magnesium, solumedrol 125 IV x1, azithromycin 500mg for COPD exacerbation. Her EKG showed sinus tach with prominent p waves and LVH as well as ST elevation in v1 & v2 which was similar to prior. Cardiology was consulted and said this is likely strain in the setting of respiratory distress. Exam notable for wheezes, poor air movement, and rhonci throughout. She received 20 IV lasix prior to leaving the ED. Vitals at time of transfer were HR 101 BP 159/64 RR30 02 sat 100% on BiPap. On the floor, VS were BiPAP 8/8 Fio2 100 with afebrile RR 25, HR 99 BP 149/55. She was wearing the BiPAP but able to answer yes and no to questions. Able to confirm history that last few days had increased SOB, non productive cough, wheezing, weakness, and increased allergies including nasal congestion, runny nose, and sinus pressure. Review of systems: (+) for increased frequency of urination (-) Denies fever, chills tions, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria or urgency. Denies arthralgias or myalgias. Past Medical History: -COPD with home O2 -coronary artery disease s/p CABG '73; cath in 1904 showed severe native 2VD, patent LIMA->LAD, SVG->OM. -ejection fraction 30% in 1904 -peripheral vascular disease, status post aortofemoral bypass -depression -right lower lobe granuloma -hypercholesterolemia -dementia and history of psychosis with psychotic episodes -severe spinal cord stenosis s/p spinal cord stimulator yrs ago Social History: - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: not obtained at this time Physical Exam: Vitals: BiPAP 8/8 Fio2 100 with afebrile RR 25, HR 99 BP 149/55 General: A & O x3, increased WOB HEENT: Sclera anicteric, unable to access MM Neck: difficult to access JCD given so much accessory muscle use Lungs:poor air movement throughout, diffuse rhonchi and mild wheezes CV: tachycardic, nl S1/S2 Abdomen: soft, non-tender, non-distended, + bowel sounds present, no rebound tenderness or guarding, no organomegaly GU:foley with good clear UOP Ext: warm, well perfused, 1+ pulses, tenderness to big toe, ? stage 1 ulcer between big and second toe Pertinent Results: Labs on Admission: 1979-11-23 04:50AM WBC-10.6# RBC-4.11* HGB-11.7* HCT-36.9 MCV-90 MCH-28.5 MCHC-31.7 RDW-15.1 1979-11-23 04:50AM NEUTS-81* BANDS-0 LYMPHS-6* MONOS-11 EOS-0 BASOS-1 ATYPS-0 METAS-1* MYELOS-0 1979-11-23 04:50AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ 1979-11-23 04:50AM PLT SMR-NORMAL PLT COUNT-191 1979-11-23 04:50AM PT-12.5 PTT-26.1 INR(PT)-1.1 1979-11-23 04:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG 1979-11-23 04:50AM URINE RBC-1-1* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 1979-11-23 04:50AM URINE HYALINE-0-2 1979-11-23 04:50AM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-1.7 1979-11-23 05:02AM LACTATE-1.2 1979-11-23 07:32AM LACTATE-0.7 1979-11-23 10:28AM CK-MB-NotDone cTropnT-1979-11-23 10:28AM CK(CPK)-65 1979-11-23 03:01PM OSMOLAL-268* 1979-11-23 03:01PM CK-MB-NotDone cTropnT-1979-11-23 03:01PM CK(CPK)-66 1979-11-23 06:21PM URINE OSMOLAL-281 1979-11-23 06:21PM URINE HOURS-RANDOM SODIUM-91 . ECHO: 1979-11-23 The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with septal, anterior and apical akinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate (2-24+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . Compared with the report of the prior study (images unavailable for review) of 1925-10-13, the LVEF is slightly lower and the estimated PA pressure has increased. . CHEST X-RAY 2013-12-18 1. Interval improvement in congestive heart failure. 2. Mild interval increase in bilateral pleural effusions and retrocardiac left lung base opacity likely representing atelectasis. 3. COPD, with no new evidence of pneumonia. . SHOULDER X-RAY 2008-11-11 THREE VIEWS OF THE RIGHT SHOULDER: There is mild glenohumeral joint degenerative change, with spurring at the inferior glenoid. There is minimal acromioclavicular joint degenerative change. There has been prior midline sternotomy, with intact sternal wires partially visualized, as is a left brachiocephalic venous stent. Soft tissues appear unremarkable, as does the visualized right lung apex. IMPRESSION: Mild glenohumeral joint degenerative change. Brief Hospital Course: 78 yo f with h/o COPD with home O2 3L requirement, CAD s/p CABG in 1904, CHF with EF 30%, PVD s/p aortofemoral bypass, RLL granuloma, HL, and h/o dementia who presents to the ED in respitatory distress with likely component of COPD, systolic CHF, and ? LLL pneumonia. She was initially admitted to the MICU and was transferred to the floor on 2013-12-18. Hospital course by problem list: . # COPD: Pt arrived from 722 Taylor Turnpike Apt. 417 Mcguireburgh, GU 98173 with BiPAP 8/8 and was able to quickly wean off. She did not require noninvasive ventilatory support for the duration of her ICU stay. Initially received solumedrol 125 IV q8 hrs then transitioned to po prednisone daily. Levoquin was used in place of azithro for COPD exacerbation due to allergy to erythomycin. She tolerated well and was able to be weaned down to 3L which is her home dose. She was discharged on a 5 day course of Levofloxacin (to end on 1996-6-8) and a Prednisone taper as follows: 40mg on 1935-3-30, change to 20mg on 1996-6-8 for 3 days, then 10mg on 1980-5-3 for 3 days, then stop. . # Acute on chronic CHF exacerbation: BNP elevated to 9000. Echo on HD1 showed severe regional LV systolic dysfunction with septal, anterior, and apical akinesis (EF 25-30%); no aortic stenosis; mild-mod mitral regurg, mod tricuspid regurg; severe pulm artery systolic hypertension; very small pericardial effusion - no signs of tamponade; compared to 12-1986, the LVEF is slightly lower and the estimated PA pressure has increased. The patient received a dose of IV lasix on arrival to the ICU and was maintained on a nitro gtt. Respiratory status improved rapidly and the nitro drip was weaned off. She was started on a Captopril for her heart failure. Blood pressure should be controlled below 140/90. . # Shoulder Pain: She reported increased shoulder pain during her echocardiogram. Shoulder x-ray did not show fracture. She was seen by the Chronic Pain Service who performed a cortisone injection on 2008-11-11. She should follow-up with her pain specialist, Dr. Islam. . # Foot pain: continued gabapentin, tramadol, carisoprodol. . # GI: continued home loperamide Hill, Carpenter and Camacho Clinic. . # Dementia: continued home aricept & zyprexa & chlordiazepoxide & tylenol. . # CODE STATUS: DNR/DNI Medications on Admission: Tylenol extra strength 1 tab PO TID Clindamycin for dental procedures Chlordiazepoxide 1-2 tabs QHS Gabapentin 300mg PO TID Loperamide 2mg PO BID Albuterol Advair 500/50 Hill, Carpenter and Camacho Clinic Tramadol 100mg PO BID Furosemide 20mg PO daily Aricept 10mg PO daily Pantoprazole 40mg PO daily Zyprexa 2.5mg PO daily Ava PO daily Carisoprodol 350mg PO TID Discharge Disposition: Extended Care Facility: Ortiz-Coleman Clinic Health Care Center Discharge Diagnosis: Foot/shoulder pain COPD exacerbation Acute on chronic CHF exacerbation transient leukopenia dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital with elevated blood pressure, increased shortness of breath, and congestive heart failure. We were able to control your blood pressure and control the exacerbation of COPD and heart failure. You had pain in your shoulder and feet, we performed Xray and determined that you did not have a fracture. You had a cortisone injection on 2008-11-11 by the pain team. You improved with treatment and was discharged in stable condition. Please follow up with your primary care doctor. The following changes were made to your medications: START Levofloxacin to finish on 1996-6-8 START Prednisone with the following doses: 40mg on 1935-3-30 20 mg on 1996-6-8, 1936-8-24, 1914-2-5 10mg on 1980-5-3, 1989-7-26, 1911-8-20 START Captopril 12.5mg by mouth three times per day. It was a pleasure taking care of you. We wish you the best on your road to recovery. Followup Instructions: Department: GERONTOLOGY When: THURSDAY 1989-7-26 at 10:30 AM With: Eric Eleanor Thompkins, MD 157-256-3986 Building: LM Sanders, Krueger and Williams Clinic 4346 Lisa Curve Apt. 515 Lukemouth, AK 07558 Campus: WEST Best Parking: Martinez-Walter Medical Center Garage Department: PAIN MANAGEMENT CENTER When: FRIDAY 1911-8-20 at 9:50 AM With: Helen Archie, MD 198-930-6239 Building: One 4346 Lisa Curve Apt. 515 Lukemouth, AK 07558 Place (4346 Lisa Curve Apt. 515 Lukemouth, AK 07558, MA) 4346 Lisa Curve Apt. 515 Lukemouth, AK 07558 Campus: OFF CAMPUS Best Parking: Parking on Site Ethan Feudner Eleanor Thompkins MD 49950760	['Admission Date: 1979-11-23 Discharge Date: 1935-3-30\n\nDate of Birth: 1977-2-26 Sex: F\n\nService: MEDICINE\n\nAllergies:\nAtivan / Valium / Haldol / Adhesive Tape / Sulfonamides /\nCodeine / Morphine / Erythromycin/Sulfisoxazole / Amoxicillin\n\nAttending:Billy\nChief Complaint:\ndyspnea\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\nPt is a 78 yo f with h/o COPD with home O2 3L requirement, CAD\ns/p CABG in 1904, CHF with EF 30%, PVD s/p aortofemoral bypass,\nRLL granuloma, HL, and h/o dementia who presents to the ED in\nrespitatory distress. Pt and son gave history in the Neha Bounds that\nthat she became more SOB with increased o2 requirement (unknown\nhow much she increased it to). She came in to the hospital\ntonight for SOB and reported some increase in her allergies but\nno fever.', '\n\nIn the ED her vitals soon after arrival were HR 110s BP 194/79\nRR30 o2 sat 94% on 8L face mask. She was found to be in obvious\nrespiratory distress using accessory muscles, tachypnic, poor\nair flow, and speaking in one word sentences. She became\ndiaphoretic with CP and got 0.4mg of SL nitro with resolution of\nchest pain. She became tachy to 123 with RR 37 and BP 200/90\nthen was started on a nitro gtt at 2mg/kg/hr which was increased\nto 3mg/kg/hr. At some point dropped her sats to 85%. She was\nstarted on BiPAP with obvious improvement. Her CXR showed pulm\nvascular congestion. She was given 2mg IV magnesium, solumedrol\n125 IV x1, azithromycin 500mg for COPD exacerbation. Her EKG\nshowed sinus tach with prominent p waves and LVH as well as ST\nelevation in v1 & v2 which was similar to prior. Cardiology was\nconsulted and said this is likely strain in the setting of\nrespiratory distress.', " Exam notable for wheezes, poor air\nmovement, and rhonci throughout. She received 20 IV lasix prior\nto leaving the ED. Vitals at time of transfer were HR 101 BP\n159/64 RR30 02 sat 100% on BiPap.\n\nOn the floor, VS were BiPAP 8/8 Fio2 100 with afebrile RR 25, HR\n99 BP 149/55. She was wearing the BiPAP but able to answer yes\nand no to questions. Able to confirm history that last few days\nhad increased SOB, non productive cough, wheezing, weakness, and\nincreased allergies including nasal congestion, runny nose, and\nsinus pressure.\n\nReview of systems:\n(+) for increased frequency of urination\n(-) Denies fever, chills tions, or weakness. Denies nausea,\nvomiting, diarrhea, constipation, abdominal pain, or changes in\nbowel habits. Denies dysuria or urgency. Denies arthralgias or\nmyalgias.\n\n\nPast Medical History:\n-COPD with home O2\n-coronary artery disease s/p CABG '73; cath in 1904 showed\nsevere native 2VD, patent LIMA->LAD, SVG->OM.", '\n-ejection fraction 30% in 1904\n-peripheral vascular disease, status post aortofemoral bypass\n-depression\n-right lower lobe granuloma\n-hypercholesterolemia\n-dementia and history of psychosis with psychotic episodes\n-severe spinal cord stenosis s/p spinal cord stimulator yrs ago\n\n\n\nSocial History:\n- Tobacco: Denies\n- Alcohol: Denies\n- Illicits: Denies\n\n\nFamily History:\nnot obtained at this time\n\nPhysical Exam:\nVitals: BiPAP 8/8 Fio2 100 with afebrile RR 25, HR 99 BP 149/55\n\nGeneral: A & O x3, increased WOB\nHEENT: Sclera anicteric, unable to access MM\nNeck: difficult to access JCD given so much accessory muscle use\n\nLungs:poor air movement throughout, diffuse rhonchi and mild\nwheezes\nCV: tachycardic, nl S1/S2\nAbdomen: soft, non-tender, non-distended, + bowel sounds\npresent, no rebound tenderness or guarding, no organomegaly\nGU:foley with good clear UOP\nExt: warm, well perfused, 1+ pulses, tenderness to big toe, ?\nstage 1 ulcer between big and second toe\n\n\nPertinent Results:\nLabs on Admission:\n1979-11-23 04:50AM WBC-10.', '6# RBC-4.11* HGB-11.7* HCT-36.9 MCV-90\nMCH-28.5 MCHC-31.7 RDW-15.1\n1979-11-23 04:50AM NEUTS-81* BANDS-0 LYMPHS-6* MONOS-11 EOS-0\nBASOS-1 ATYPS-0 METAS-1* MYELOS-0\n1979-11-23 04:50AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+\nMACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+\n1979-11-23 04:50AM PLT SMR-NORMAL PLT COUNT-191\n1979-11-23 04:50AM PT-12.5 PTT-26.1 INR(PT)-1.1\n1979-11-23 04:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500\nGLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5\nLEUK-NEG\n1979-11-23 04:50AM URINE RBC-1-1* WBC-0-2 BACTERIA-NONE\nYEAST-NONE EPI-0-2\n1979-11-23 04:50AM URINE HYALINE-0-2\n1979-11-23 04:50AM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-1.7\n1979-11-23 05:02AM LACTATE-1.2\n1979-11-23 07:32AM LACTATE-0.7\n1979-11-23 10:28AM CK-MB-NotDone cTropnT-1979-11-23 10:28AM CK(CPK)-65\n1979-11-23 03:01PM OSMOLAL-268*\n1979-11-23 03:01PM CK-MB-NotDone cTropnT-1979-11-23 03:01PM CK(CPK)-66\n1979-11-23 06:21PM URINE OSMOLAL-281\n1979-11-23 06:21PM URINE HOURS-RANDOM SODIUM-91\n.', '\nECHO: 1979-11-23\nThe left atrium is moderately dilated. No atrial septal defect\nis seen by 2D or color Doppler. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is\nmoderately dilated. There is severe regional left ventricular\nsystolic dysfunction with septal, anterior and apical akinesis.\nNo masses or thrombi are seen in the left ventricle. Right\nventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Mild to moderate (2-24+) mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened.\nModerate [2+] tricuspid regurgitation is seen. There is severe\npulmonary artery systolic hypertension.', ' There is a very small\npericardial effusion. There are no echocardiographic signs of\ntamponade.\n.\nCompared with the report of the prior study (images unavailable\nfor review) of 1925-10-13, the LVEF is slightly lower and the\nestimated PA pressure has increased.\n.\nCHEST X-RAY 2013-12-18\n1. Interval improvement in congestive heart failure.\n2. Mild interval increase in bilateral pleural effusions and\nretrocardiac\nleft lung base opacity likely representing atelectasis.\n3. COPD, with no new evidence of pneumonia.\n.\nSHOULDER X-RAY 2008-11-11\nTHREE VIEWS OF THE RIGHT SHOULDER: There is mild glenohumeral\njoint\ndegenerative change, with spurring at the inferior glenoid.\nThere is minimal acromioclavicular joint degenerative change.\nThere has been prior midline sternotomy, with intact sternal\nwires partially visualized, as is a left brachiocephalic venous\nstent.', ' Soft tissues appear unremarkable, as does the visualized\nright lung apex.\nIMPRESSION: Mild glenohumeral joint degenerative change.\n\n\nBrief Hospital Course:\n78 yo f with h/o COPD with home O2 3L requirement, CAD s/p CABG\nin 1904, CHF with EF 30%, PVD s/p aortofemoral bypass, RLL\ngranuloma, HL, and h/o dementia who presents to the ED in\nrespitatory distress with likely component of COPD, systolic\nCHF, and ? LLL pneumonia. She was initially admitted to the\nMICU and was transferred to the floor on 2013-12-18. Hospital\ncourse by problem list:\n.\n# COPD: Pt arrived from 722 Taylor Turnpike Apt. 417\nMcguireburgh, GU 98173 with BiPAP 8/8 and was able to\nquickly wean off. She did not require noninvasive ventilatory\nsupport for the duration of her ICU stay. Initially received\nsolumedrol 125 IV q8 hrs then transitioned to po prednisone\ndaily.', ' Levoquin was used in place of azithro for COPD\nexacerbation due to allergy to erythomycin. She tolerated well\nand was able to be weaned down to 3L which is her home dose.\nShe was discharged on a 5 day course of Levofloxacin (to end on\n1996-6-8) and a Prednisone taper as follows: 40mg on 1935-3-30,\nchange to 20mg on 1996-6-8 for 3 days, then 10mg on 1980-5-3 for 3\ndays, then stop.\n.\n# Acute on chronic CHF exacerbation: BNP elevated to 9000. Echo\non HD1 showed severe regional LV systolic dysfunction with\nseptal, anterior, and apical akinesis (EF 25-30%); no aortic\nstenosis; mild-mod mitral regurg, mod tricuspid regurg; severe\npulm artery systolic hypertension; very small pericardial\neffusion - no signs of tamponade; compared to 12-1986, the LVEF\nis slightly lower and the estimated PA pressure has increased.', '\nThe patient received a dose of IV lasix on arrival to the ICU\nand was maintained on a nitro gtt. Respiratory status improved\nrapidly and the nitro drip was weaned off. She was started on a\nCaptopril for her heart failure. Blood pressure should be\ncontrolled below 140/90.\n.\n# Shoulder Pain: She reported increased shoulder pain during her\nechocardiogram. Shoulder x-ray did not show fracture. She was\nseen by the Chronic Pain Service who performed a cortisone\ninjection on 2008-11-11. She should follow-up with her pain\nspecialist, Dr. Islam.\n.\n# Foot pain: continued gabapentin, tramadol, carisoprodol.\n.\n# GI: continued home loperamide Hill, Carpenter and Camacho Clinic.\n.\n# Dementia: continued home aricept & zyprexa & chlordiazepoxide\n& tylenol.\n.\n# CODE STATUS: DNR/DNI\n\nMedications on Admission:\nTylenol extra strength 1 tab PO TID\nClindamycin for dental procedures\nChlordiazepoxide 1-2 tabs QHS\nGabapentin 300mg PO TID\nLoperamide 2mg PO BID\nAlbuterol\nAdvair 500/50 Hill, Carpenter and Camacho Clinic\nTramadol 100mg PO BID\nFurosemide 20mg PO daily\nAricept 10mg PO daily\nPantoprazole 40mg PO daily\nZyprexa 2.', '5mg PO daily\nAva PO daily\nCarisoprodol 350mg PO TID\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nOrtiz-Coleman Clinic Health Care Center\n\nDischarge Diagnosis:\nFoot/shoulder pain\nCOPD exacerbation\nAcute on chronic CHF exacerbation\ntransient leukopenia\ndementia\n\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker\nor cane).\n\n\nDischarge Instructions:\nYou came to the hospital with elevated blood pressure, increased\nshortness of breath, and congestive heart failure. We were able\nto control your blood pressure and control the exacerbation of\nCOPD and heart failure. You had pain in your shoulder and feet,\nwe performed Xray and determined that you did not have a\nfracture. You had a cortisone injection on 2008-11-11 by the pain\nteam.', ' You improved with treatment and was discharged in stable\ncondition.\n\nPlease follow up with your primary care doctor.\n\nThe following changes were made to your medications:\nSTART Levofloxacin to finish on 1996-6-8\nSTART Prednisone with the following doses:\n40mg on 1935-3-30\n20 mg on 1996-6-8, 1936-8-24, 1914-2-5\n10mg on 1980-5-3, 1989-7-26, 1911-8-20\nSTART Captopril 12.5mg by mouth three times per day.\n\nIt was a pleasure taking care of you. We wish you the best on\nyour road to recovery.\n\nFollowup Instructions:\nDepartment: GERONTOLOGY\nWhen: THURSDAY 1989-7-26 at 10:30 AM\nWith: Eric Eleanor Thompkins, MD 157-256-3986\nBuilding: LM Sanders, Krueger and Williams Clinic 4346 Lisa Curve Apt. 515\nLukemouth, AK 07558\nCampus: WEST Best Parking: Martinez-Walter Medical Center Garage\n\nDepartment: PAIN MANAGEMENT CENTER\nWhen: FRIDAY 1911-8-20 at 9:50 AM\nWith: Helen Archie, MD 198-930-6239\nBuilding: One 4346 Lisa Curve Apt.', ' 515\nLukemouth, AK 07558 Place (4346 Lisa Curve Apt. 515\nLukemouth, AK 07558, MA) 4346 Lisa Curve Apt. 515\nLukemouth, AK 07558\nCampus: OFF CAMPUS Best Parking: Parking on Site\n\n\n Ethan Feudner Eleanor Thompkins MD 49950760\n\n']
156	12935	161822.0	2148-02-16	Discharge summary	Report	Admission Date: [2148-1-22] Discharge Date: [2148-2-16] Date of Birth: [2089-6-30] Sex: M Service: HEPATOBILIARY SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 58 year old male with a past medical history remarkable for pericarditis, diverticulosis, status post colostomy and take-down, obstructive sleep apnea, who was evaluated for painless jaundice in [2147-12-6]. The patient's CT scan revealed 1.6 by 2.0 centimeter Klatskin tumor with no evidence of liver mass nor encasement of vessels. The patient underwent an endoscopic retrograde cholangiopancreatography which showed normal pancreatic duct but biliary stricture, consistent with cholangiocarcinoma. A stent was placed in the upper third of the common bile duct. An MRCT in [2147-12-6], revealed a 2 centimeter mass in the porta hepatis consistent with cholangiocarcinoma, with extensive periportal lymphadenopathy. After a long discussion with the patient and family members, the patient was taken to the Operating Room on [2148-1-22]. PAST MEDICAL HISTORY: As noted above. MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Positive tobacco smoker for 25 years. PHYSICAL EXAMINATION: At the time of discharge the patient was well developed and well nourished in no apparent distress. HEENT: Sclerae was icteric with evidence of jaundice. Cranial nerves II through XII intact. Mucous membranes were moist; no evidence or oral ulcers. no cervical lymphadenopathy noted. Chest was clear to auscultation bilaterally. Cardiac is regular rhythm and rate. No murmurs. Abdomen is soft, nondistended, nontender, with lateral [Location (un) 1661]-[Location (un) 1662] intact and T-tube capped. Extremities had two plus edema, significantly decreased since discharge from the Surgical Intensive Care Unit; no evidence of rash noted. LABORATORY: On [2148-2-15], white blood cell count 8.0, hematocrit 29.9, platelets 204. PT 14.6, PTT 51.7, INR 1.4. Sodium 135, potassium 3.5, chloride 101, bicarbonate 24, BUN 14, creatinine 1.0 and glucose 78. AST 102, alkaline phosphatase 213, amylase 144/168. Total bilirubin 7.9, albumin 2.5, calcium 8.0, magnesium 1.8 and phosphate 3.2. Bio-cultures from [2-5], Enterococcus species in yeast and [Location (un) 1661]-[Location (un) 1662] cultures revealed Vancomycin sensitive enterococcus. Blood cultures from [2-5] showed no growth. IMAGING: [2-5], cholangiogram: Patent anastomosis with irregular left hepatic duct with multi-filling defects. Leakage of contrast material from left hepatic duct leading to a 5 centimeter fluid collection. [2-6] fistulogram: Drainage of right subhepatic collection after manual suction of 45 cc. fluid. [2-6] CT scan of abdomen: Complete resolution of right subhepatic collection. SUMMARY OF HOSPITAL COURSE: The patient is a 58 year old male who underwent an uncomplicated right hepatic lobectomy, common bile duct excision, cholecystectomy, Roux-en-Y hepaticojejunostomy for a Klatskin's tumor. The patient was admitted to the Surgical Intensive Care Unit intubated for close observation following surgery due to prolonged surgical time and estimated blood loss of 1200 cc.. The patient was extubated the following morning without difficulty and the epidural was discontinued secondary to induction of hypertension. The patient was placed on p.r.n. morphine with stable blood pressure achieved after additional fluid boluses. However, later on during the day, the patient's hypoxemia worsened secondary to fluid overload and required re-intubation. During this period, the patient's white blood cell count began to rise to 12.8, although the patient remained afebrile. Vancomycin and Zosyn were restarted. A [1-24] culture revealed coagulase negative Staphylococcus from blood, one out of four bottles and enterococcus fro peritoneal drain culture. On [1-27], the patient's peritoneal culture revealed [Female First Name (un) 564] and Fluconazole was added. By [1-31], the patient was doing well and the patient was extubated. With signs of bowel function, the patient's nasogastric tube was removed and he started on clears. By [2-2], the patient was transferred to the floor on Vancomycin after having discontinued Zosyn and Fluconazole. The patient had multiple fluid boluses from the Surgical Intensive Care Unit stay resulting in three plus peripheral edea. Net fluid gain was noted to be greater than ten liters at the time of transfer to the floor. A Lasix regimen was therefore added to target daily fluid losses to two liters. Interestingly, the patient's total bilirubin began to rise along with white blood cell counts. Zosyn and Fluconazole were added after consulting with Infectious Disease Service. A cholangiogram was also performed on [2-5] and because of the 5 centimeter fluid collection noted, Interventional Radiology was consulted to remove the collection for culture. With drain directly in proximity to the collection, aggressive suctioning lead to complete evacuation of this collection. No additional drain was required for removal of this collection. White blood cell count began to decrease the following day along with total bilirubin. By post-op day number 24, the patient was doing well, tolerating a regular diet and weaned off of total parenteral nutrition. The decision was made to discharge the patient on [2-16]. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with Visiting Nurse Service for help administering Zosyn. DISCHARGE INSTRUCTIONS: 1. The patient was reminded to continue on the twice a day Lasix regimen until Dr.[Name (NI) 1369] office visit in one week. At that time, the patient was to be re-evaluated on whether the Lasix should be continued. 2. The patient was also reminded to discontinue Zosyn and Fluconazole on [3-15]. 3. The patient at that time was instructed to start taking Ciprofloxacin 500 mg twice daily for prophylaxis. DISCHARGE MEDICATIONS: 1. Percocet 5/325, one to two tablets p.o. q. four to six hours p.r.n. pain. 2. Colace 100 mg p.o. three times a day. 3. Diphenhydramine 25 mg q. h.s. p.r.n. insomnia. 4. Reglan 10 mg, two tablets q. six hours. 5. Lasix 40 mg p.o. twice a day. 6. Metoprazole 40 mg p.o. q. day. 7. Fluconazole 400 mg two tablets p.o. q. day. 8. Zosyn 4.5 grams q. eight hours for 28 days. 9. Ciprofloxacin 500 mg p.o. twice a day starting [3-15]. FOLLOW-UP INSTRUCTIONS: 1. The patient was instructed to follow-up with Dr. [Last Name (STitle) ] in seven days. 2. The patient was also instructed to call Infectious Disease Clinic for follow-up with Dr. [First Name4 (NamePattern1) 1663] [Last Name (NamePattern1) 1005]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Name8 (MD) 1664] MEDQUIST36 D: [2148-2-25] 14:58 T: [2148-2-25] 16:30 JOB#: [Job Number 1665]	Admission Date: <Date>1969-9-16</Date> Discharge Date: <Date>1984-4-17</Date> Date of Birth: <Date>1986-1-14</Date> Sex: M Service: HEPATOBILIARY SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 58 year old male with a past medical history remarkable for pericarditis, diverticulosis, status post colostomy and take-down, obstructive sleep apnea, who was evaluated for painless jaundice in <Date>1911-1-2</Date>. The patient's CT scan revealed 1.6 by 2.0 centimeter Klatskin tumor with no evidence of liver mass nor encasement of vessels. The patient underwent an endoscopic retrograde cholangiopancreatography which showed normal pancreatic duct but biliary stricture, consistent with cholangiocarcinoma. A stent was placed in the upper third of the common bile duct. An MRCT in <Date>1911-1-2</Date>, revealed a 2 centimeter mass in the porta hepatis consistent with cholangiocarcinoma, with extensive periportal lymphadenopathy. After a long discussion with the patient and family members, the patient was taken to the Operating Room on <Date>1969-9-16</Date>. PAST MEDICAL HISTORY: As noted above. MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Positive tobacco smoker for 25 years. PHYSICAL EXAMINATION: At the time of discharge the patient was well developed and well nourished in no apparent distress. HEENT: Sclerae was icteric with evidence of jaundice. Cranial nerves II through XII intact. Mucous membranes were moist; no evidence or oral ulcers. no cervical lymphadenopathy noted. Chest was clear to auscultation bilaterally. Cardiac is regular rhythm and rate. No murmurs. Abdomen is soft, nondistended, nontender, with lateral <Location>36117 Cook Manors Pricetown, KY 27273</Location>-<Location>72428 Ferguson Key Lake Susantown, DC 53084</Location> intact and T-tube capped. Extremities had two plus edema, significantly decreased since discharge from the Surgical Intensive Care Unit; no evidence of rash noted. LABORATORY: On <Date>1959-11-17</Date>, white blood cell count 8.0, hematocrit 29.9, platelets 204. PT 14.6, PTT 51.7, INR 1.4. Sodium 135, potassium 3.5, chloride 101, bicarbonate 24, BUN 14, creatinine 1.0 and glucose 78. AST 102, alkaline phosphatase 213, amylase 144/168. Total bilirubin 7.9, albumin 2.5, calcium 8.0, magnesium 1.8 and phosphate 3.2. Bio-cultures from <Date>10-7</Date>, Enterococcus species in yeast and <Location>36117 Cook Manors Pricetown, KY 27273</Location>-<Location>72428 Ferguson Key Lake Susantown, DC 53084</Location> cultures revealed Vancomycin sensitive enterococcus. Blood cultures from <Date>10-7</Date> showed no growth. IMAGING: <Date>10-7</Date>, cholangiogram: Patent anastomosis with irregular left hepatic duct with multi-filling defects. Leakage of contrast material from left hepatic duct leading to a 5 centimeter fluid collection. <Date>6-23</Date> fistulogram: Drainage of right subhepatic collection after manual suction of 45 cc. fluid. <Date>6-23</Date> CT scan of abdomen: Complete resolution of right subhepatic collection. SUMMARY OF HOSPITAL COURSE: The patient is a 58 year old male who underwent an uncomplicated right hepatic lobectomy, common bile duct excision, cholecystectomy, Roux-en-Y hepaticojejunostomy for a Klatskin's tumor. The patient was admitted to the Surgical Intensive Care Unit intubated for close observation following surgery due to prolonged surgical time and estimated blood loss of 1200 cc.. The patient was extubated the following morning without difficulty and the epidural was discontinued secondary to induction of hypertension. The patient was placed on p.r.n. morphine with stable blood pressure achieved after additional fluid boluses. However, later on during the day, the patient's hypoxemia worsened secondary to fluid overload and required re-intubation. During this period, the patient's white blood cell count began to rise to 12.8, although the patient remained afebrile. Vancomycin and Zosyn were restarted. A <Date>5-17</Date> culture revealed coagulase negative Staphylococcus from blood, one out of four bottles and enterococcus fro peritoneal drain culture. On <Date>11-22</Date>, the patient's peritoneal culture revealed <Name>Jermaine</Name> and Fluconazole was added. By <Date>5-23</Date>, the patient was doing well and the patient was extubated. With signs of bowel function, the patient's nasogastric tube was removed and he started on clears. By <Date>8-6</Date>, the patient was transferred to the floor on Vancomycin after having discontinued Zosyn and Fluconazole. The patient had multiple fluid boluses from the Surgical Intensive Care Unit stay resulting in three plus peripheral edea. Net fluid gain was noted to be greater than ten liters at the time of transfer to the floor. A Lasix regimen was therefore added to target daily fluid losses to two liters. Interestingly, the patient's total bilirubin began to rise along with white blood cell counts. Zosyn and Fluconazole were added after consulting with Infectious Disease Service. A cholangiogram was also performed on <Date>10-7</Date> and because of the 5 centimeter fluid collection noted, Interventional Radiology was consulted to remove the collection for culture. With drain directly in proximity to the collection, aggressive suctioning lead to complete evacuation of this collection. No additional drain was required for removal of this collection. White blood cell count began to decrease the following day along with total bilirubin. By post-op day number 24, the patient was doing well, tolerating a regular diet and weaned off of total parenteral nutrition. The decision was made to discharge the patient on <Date>12-21</Date>. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with Visiting Nurse Service for help administering Zosyn. DISCHARGE INSTRUCTIONS: 1. The patient was reminded to continue on the twice a day Lasix regimen until Dr.<Name>Allison Beamon</Name> office visit in one week. At that time, the patient was to be re-evaluated on whether the Lasix should be continued. 2. The patient was also reminded to discontinue Zosyn and Fluconazole on <Date>10-1</Date>. 3. The patient at that time was instructed to start taking Ciprofloxacin 500 mg twice daily for prophylaxis. DISCHARGE MEDICATIONS: 1. Percocet 5/325, one to two tablets p.o. q. four to six hours p.r.n. pain. 2. Colace 100 mg p.o. three times a day. 3. Diphenhydramine 25 mg q. h.s. p.r.n. insomnia. 4. Reglan 10 mg, two tablets q. six hours. 5. Lasix 40 mg p.o. twice a day. 6. Metoprazole 40 mg p.o. q. day. 7. Fluconazole 400 mg two tablets p.o. q. day. 8. Zosyn 4.5 grams q. eight hours for 28 days. 9. Ciprofloxacin 500 mg p.o. twice a day starting <Date>10-1</Date>. FOLLOW-UP INSTRUCTIONS: 1. The patient was instructed to follow-up with Dr. <Name>Belle</Name> in seven days. 2. The patient was also instructed to call Infectious Disease Clinic for follow-up with Dr. <Name>Susana</Name> <Name>Dortch</Name>. <Name>An</Name> <Name>Broadnax</Name>, M.D.,Ph.D. 02-366 Dictated By:<Name>Emory Thompkins</Name> MEDQUIST36 D: <Date>2008-12-29</Date> 14:58 T: <Date>2008-12-29</Date> 16:30 JOB#: <Job Number>Proctor PLC-1975-346164</Job 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Date: 1969-9-16 Discharge Date: 1984-4-17 Date of Birth: 1986-1-14 Sex: M Service: HEPATOBILIARY SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 58 year old male with a past medical history remarkable for pericarditis, diverticulosis, status post colostomy and take-down, obstructive sleep apnea, who was evaluated for painless jaundice in 1911-1-2. The patient's CT scan revealed 1.6 by 2.0 centimeter Klatskin tumor with no evidence of liver mass nor encasement of vessels. The patient underwent an endoscopic retrograde cholangiopancreatography which showed normal pancreatic duct but biliary stricture, consistent with cholangiocarcinoma. A stent was placed in the upper third of the common bile duct. An MRCT in 1911-1-2, revealed a 2 centimeter mass in the porta hepatis consistent with cholangiocarcinoma, with extensive periportal lymphadenopathy. After a long discussion with the patient and family members, the patient was taken to the Operating Room on 1969-9-16. PAST MEDICAL HISTORY: As noted above. MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Positive tobacco smoker for 25 years. PHYSICAL EXAMINATION: At the time of discharge the patient was well developed and well nourished in no apparent distress. HEENT: Sclerae was icteric with evidence of jaundice. Cranial nerves II through XII intact. Mucous membranes were moist; no evidence or oral ulcers. no cervical lymphadenopathy noted. Chest was clear to auscultation bilaterally. Cardiac is regular rhythm and rate. No murmurs. Abdomen is soft, nondistended, nontender, with lateral 36117 Cook Manors Pricetown, KY 27273-72428 Ferguson Key Lake Susantown, DC 53084 intact and T-tube capped. Extremities had two plus edema, significantly decreased since discharge from the Surgical Intensive Care Unit; no evidence of rash noted. LABORATORY: On 1959-11-17, white blood cell count 8.0, hematocrit 29.9, platelets 204. PT 14.6, PTT 51.7, INR 1.4. Sodium 135, potassium 3.5, chloride 101, bicarbonate 24, BUN 14, creatinine 1.0 and glucose 78. AST 102, alkaline phosphatase 213, amylase 144/168. Total bilirubin 7.9, albumin 2.5, calcium 8.0, magnesium 1.8 and phosphate 3.2. Bio-cultures from 10-7, Enterococcus species in yeast and 36117 Cook Manors Pricetown, KY 27273-72428 Ferguson Key Lake Susantown, DC 53084 cultures revealed Vancomycin sensitive enterococcus. Blood cultures from 10-7 showed no growth. IMAGING: 10-7, cholangiogram: Patent anastomosis with irregular left hepatic duct with multi-filling defects. Leakage of contrast material from left hepatic duct leading to a 5 centimeter fluid collection. 6-23 fistulogram: Drainage of right subhepatic collection after manual suction of 45 cc. fluid. 6-23 CT scan of abdomen: Complete resolution of right subhepatic collection. SUMMARY OF HOSPITAL COURSE: The patient is a 58 year old male who underwent an uncomplicated right hepatic lobectomy, common bile duct excision, cholecystectomy, Roux-en-Y hepaticojejunostomy for a Klatskin's tumor. The patient was admitted to the Surgical Intensive Care Unit intubated for close observation following surgery due to prolonged surgical time and estimated blood loss of 1200 cc.. The patient was extubated the following morning without difficulty and the epidural was discontinued secondary to induction of hypertension. The patient was placed on p.r.n. morphine with stable blood pressure achieved after additional fluid boluses. However, later on during the day, the patient's hypoxemia worsened secondary to fluid overload and required re-intubation. During this period, the patient's white blood cell count began to rise to 12.8, although the patient remained afebrile. Vancomycin and Zosyn were restarted. A 5-17 culture revealed coagulase negative Staphylococcus from blood, one out of four bottles and enterococcus fro peritoneal drain culture. On 11-22, the patient's peritoneal culture revealed Jermaine and Fluconazole was added. By 5-23, the patient was doing well and the patient was extubated. With signs of bowel function, the patient's nasogastric tube was removed and he started on clears. By 8-6, the patient was transferred to the floor on Vancomycin after having discontinued Zosyn and Fluconazole. The patient had multiple fluid boluses from the Surgical Intensive Care Unit stay resulting in three plus peripheral edea. Net fluid gain was noted to be greater than ten liters at the time of transfer to the floor. A Lasix regimen was therefore added to target daily fluid losses to two liters. Interestingly, the patient's total bilirubin began to rise along with white blood cell counts. Zosyn and Fluconazole were added after consulting with Infectious Disease Service. A cholangiogram was also performed on 10-7 and because of the 5 centimeter fluid collection noted, Interventional Radiology was consulted to remove the collection for culture. With drain directly in proximity to the collection, aggressive suctioning lead to complete evacuation of this collection. No additional drain was required for removal of this collection. White blood cell count began to decrease the following day along with total bilirubin. By post-op day number 24, the patient was doing well, tolerating a regular diet and weaned off of total parenteral nutrition. The decision was made to discharge the patient on 12-21. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with Visiting Nurse Service for help administering Zosyn. DISCHARGE INSTRUCTIONS: 1. The patient was reminded to continue on the twice a day Lasix regimen until Dr.Allison Beamon office visit in one week. At that time, the patient was to be re-evaluated on whether the Lasix should be continued. 2. The patient was also reminded to discontinue Zosyn and Fluconazole on 10-1. 3. The patient at that time was instructed to start taking Ciprofloxacin 500 mg twice daily for prophylaxis. DISCHARGE MEDICATIONS: 1. Percocet 5/325, one to two tablets p.o. q. four to six hours p.r.n. pain. 2. Colace 100 mg p.o. three times a day. 3. Diphenhydramine 25 mg q. h.s. p.r.n. insomnia. 4. Reglan 10 mg, two tablets q. six hours. 5. Lasix 40 mg p.o. twice a day. 6. Metoprazole 40 mg p.o. q. day. 7. Fluconazole 400 mg two tablets p.o. q. day. 8. Zosyn 4.5 grams q. eight hours for 28 days. 9. Ciprofloxacin 500 mg p.o. twice a day starting 10-1. FOLLOW-UP INSTRUCTIONS: 1. The patient was instructed to follow-up with Dr. Belle in seven days. 2. The patient was also instructed to call Infectious Disease Clinic for follow-up with Dr. Susana Dortch. An Broadnax, M.D.,Ph.D. 02-366 Dictated By:Emory Thompkins MEDQUIST36 D: 2008-12-29 14:58 T: 2008-12-29 16:30 JOB#: Proctor PLC-1975-346164	["Admission Date: 1969-9-16 Discharge Date: 1984-4-17\n\nDate of Birth: 1986-1-14 Sex: M\n\nService: HEPATOBILIARY SURGERY\n\nHISTORY OF PRESENT ILLNESS: The patient is a 58 year old\nmale with a past medical history remarkable for pericarditis,\ndiverticulosis, status post colostomy and take-down,\nobstructive sleep apnea, who was evaluated for painless\njaundice in 1911-1-2. The patient's CT scan revealed\n1.6 by 2.0 centimeter Klatskin tumor with no evidence of\nliver mass nor encasement of vessels. The patient underwent\nan endoscopic retrograde cholangiopancreatography which\nshowed normal pancreatic duct but biliary stricture,\nconsistent with cholangiocarcinoma. A stent was placed in\nthe upper third of the common bile duct. An MRCT in 1911-1-2, revealed a 2 centimeter mass in the porta hepatis\nconsistent with cholangiocarcinoma, with extensive periportal\nlymphadenopathy.", '\n\nAfter a long discussion with the patient and family members,\nthe patient was taken to the Operating Room on 1969-9-16.\n\nPAST MEDICAL HISTORY: As noted above.\n\nMEDICATIONS: None.\n\nALLERGIES: No known drug allergies.\n\nSOCIAL HISTORY: Positive tobacco smoker for 25 years.\n\nPHYSICAL EXAMINATION: At the time of discharge the patient\nwas well developed and well nourished in no apparent\ndistress. HEENT: Sclerae was icteric with evidence of\njaundice. Cranial nerves II through XII intact. Mucous\nmembranes were moist; no evidence or oral ulcers. no\ncervical lymphadenopathy noted. Chest was clear to\nauscultation bilaterally. Cardiac is regular rhythm and\nrate. No murmurs. Abdomen is soft, nondistended, nontender,\nwith lateral 36117 Cook Manors\nPricetown, KY 27273-72428 Ferguson Key\nLake Susantown, DC 53084 intact and T-tube capped.', '\nExtremities had two plus edema, significantly decreased since\ndischarge from the Surgical Intensive Care Unit; no evidence\nof rash noted.\n\nLABORATORY: On 1959-11-17, white blood cell count 8.0,\nhematocrit 29.9, platelets 204. PT 14.6, PTT 51.7, INR 1.4.\nSodium 135, potassium 3.5, chloride 101, bicarbonate 24, BUN\n14, creatinine 1.0 and glucose 78. AST 102, alkaline\nphosphatase 213, amylase 144/168. Total bilirubin 7.9,\nalbumin 2.5, calcium 8.0, magnesium 1.8 and phosphate 3.2.\n\nBio-cultures from 10-7, Enterococcus species in yeast and\n36117 Cook Manors\nPricetown, KY 27273-72428 Ferguson Key\nLake Susantown, DC 53084 cultures revealed Vancomycin sensitive\nenterococcus. Blood cultures from 10-7 showed no growth.\n\nIMAGING: 10-7, cholangiogram: Patent anastomosis with\nirregular left hepatic duct with multi-filling defects.', "\nLeakage of contrast material from left hepatic duct leading\nto a 5 centimeter fluid collection.\n\n6-23 fistulogram: Drainage of right subhepatic\ncollection after manual suction of 45 cc. fluid.\n\n6-23 CT scan of abdomen: Complete resolution of right\nsubhepatic collection.\n\nSUMMARY OF HOSPITAL COURSE: The patient is a 58 year old\nmale who underwent an uncomplicated right hepatic lobectomy,\ncommon bile duct excision, cholecystectomy, Roux-en-Y\nhepaticojejunostomy for a Klatskin's tumor. The patient was\nadmitted to the Surgical Intensive Care Unit intubated for\nclose observation following surgery due to prolonged surgical\ntime and estimated blood loss of 1200 cc.. The patient was\nextubated the following morning without difficulty and the\nepidural was discontinued secondary to induction of\nhypertension.", "\n\nThe patient was placed on p.r.n. morphine with stable blood\npressure achieved after additional fluid boluses. However,\nlater on during the day, the patient's hypoxemia worsened\nsecondary to fluid overload and required re-intubation.\n\nDuring this period, the patient's white blood cell count\nbegan to rise to 12.8, although the patient remained\nafebrile. Vancomycin and Zosyn were restarted. A 5-17 culture revealed coagulase negative Staphylococcus from\nblood, one out of four bottles and enterococcus fro\nperitoneal drain culture.\n\nOn 11-22, the patient's peritoneal culture revealed\nJermaine and Fluconazole was added. By 5-23, the\npatient was doing well and the patient was extubated. With\nsigns of bowel function, the patient's nasogastric tube was\nremoved and he started on clears. By 8-6, the\npatient was transferred to the floor on Vancomycin after\nhaving discontinued Zosyn and Fluconazole.", "\n\nThe patient had multiple fluid boluses from the Surgical\nIntensive Care Unit stay resulting in three plus peripheral\nedea. Net fluid gain was noted to be greater than ten liters\nat the time of transfer to the floor. A Lasix regimen was\ntherefore added to target daily fluid losses to two liters.\n\nInterestingly, the patient's total bilirubin began to rise\nalong with white blood cell counts. Zosyn and Fluconazole\nwere added after consulting with Infectious Disease Service.\nA cholangiogram was also performed on 10-7 and because of\nthe 5 centimeter fluid collection noted, Interventional\nRadiology was consulted to remove the collection for culture.\nWith drain directly in proximity to the collection,\naggressive suctioning lead to complete evacuation of this\ncollection.\n\nNo additional drain was required for removal of this\ncollection.", ' White blood cell count began to decrease the\nfollowing day along with total bilirubin. By post-op day\nnumber 24, the patient was doing well, tolerating a regular\ndiet and weaned off of total parenteral nutrition. The\ndecision was made to discharge the patient on 12-21.\n\nCONDITION ON DISCHARGE: Good.\n\nDISCHARGE STATUS: To home with Visiting Nurse Service for\nhelp administering Zosyn.\n\nDISCHARGE INSTRUCTIONS:\n1. The patient was reminded to continue on the twice a day\nLasix regimen until Dr.Allison Beamon office visit in one week. At\nthat time, the patient was to be re-evaluated on whether the\nLasix should be continued.\n2. The patient was also reminded to discontinue Zosyn and\nFluconazole on 10-1.\n3. The patient at that time was instructed to start taking\nCiprofloxacin 500 mg twice daily for prophylaxis.', '\n\nDISCHARGE MEDICATIONS:\n1. Percocet 5/325, one to two tablets p.o. q. four to six\nhours p.r.n. pain.\n2. Colace 100 mg p.o. three times a day.\n3. Diphenhydramine 25 mg q. h.s. p.r.n. insomnia.\n4. Reglan 10 mg, two tablets q. six hours.\n5. Lasix 40 mg p.o. twice a day.\n6. Metoprazole 40 mg p.o. q. day.\n7. Fluconazole 400 mg two tablets p.o. q. day.\n8. Zosyn 4.5 grams q. eight hours for 28 days.\n9. Ciprofloxacin 500 mg p.o. twice a day starting 10-1.\n\nFOLLOW-UP INSTRUCTIONS:\n1. The patient was instructed to follow-up with Dr. Belle in\nseven days.\n2. The patient was also instructed to call Infectious\nDisease Clinic for follow-up with Dr. Susana Dortch.\n\n\n An Broadnax, M.D.,Ph.D. 02-366\n\nDictated By:Emory Thompkins\nMEDQUIST36\n\nD: 2008-12-29 14:58\nT: 2008-12-29 16:30\nJOB#: Proctor PLC-1975-346164\n']
157	30565	146707.0	2157-07-28	Discharge summary	Report	Admission Date: [2157-7-25] Discharge Date: [2157-7-28] Date of Birth: [2110-12-29] Sex: F Service: MEDICINE Allergies: Codeine / Compazine / Zofran Attending:[First Name3 (LF) 1674] Chief Complaint: suicidal attempt Major Surgical or Invasive Procedure: none History of Present Illness: 46 yo F with a history of depression admitted after intentional overdose of benzodiazepines, fluoxetine and phenytoin. . By verbal report, at 8AM the patient ingested (based upon pill bottles) an estimated 30 lorazepam, 30 prozac, 35 clonazepam, 3 unisom and 4 dilantin. She was reportedly suicidal and her husband had to break down the door to get to her. The patient reports that she had depressed mood for several months. She recalls taking 'like a handful' of clonazepam, fluoxetine and phenytoin. She states that she has a great deal of stress at home related to her children and husband and the only way to deal with this difficulty is to 'leave this world.' She denies ongoing thoughts of wanting to hurt herself. . In the ED, 98.6 72 138/64 14 99% RA. She developed hypotension with a single bp measurement of 80/50 pulse 62. She received 1.5L NS with improvement in the blood pressure back to >100/60. There was verbal report of the patient being responsive only to sternal rub at some point in her ED stay however on arrive to the ICU, the patient is alert and oriented. . ROS: Denies headaches, blurry vision, neck stiffness, chest pain, shortness of breath, abd pain, nausea, vomiting, diarrhea, dysuria, hematuria, rashes, arthralgias. . Past Medical History: -elective arachnoid cyst fenestration with right craniotomy [2157-2-22] -seizures due to recent operation on Dilantin -glaucoma -depression -GERD -asthma Social History: married, lives with husband and children denies tobacco and drug use; occasional social EtOh Family History: no hx breast, ovarian, or colon Ca Physical Exam: Gen: NAD. Comfortable. Sedated. Answering appropriate to questions. HEENT: Pupils mildly dilated, equal, round and reactive to light. Pink, moist oral mucosa without lesions. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Soft, nontender, no organomegaly. Ext: No edema. Neuro: A&Ox3. Slightly delayed in response to questioning. CN's II-XII intact. Brief, rapidly distinguishing horizontal nystagmus. Strength 5/5 in the deltoids, triceps, wrist and finger extensors. 4+/5 in the proximal left lower extremity flexion, [6-13] in the right proximal and bilateral lower extremities. Sensation intact in all fields. Reflexes 2+ in the patellas bilaterally. No clonus. Brief Hospital Course: 1)Suicidal attempt: Will require inpt psychiatric admission, no anti-depressants at this time per psych 2)Benzodiazepine dependence: CIWA with benzo for evidence of withdrawal 3)Dilantin overdose: Pt reports overdosing, levels not toxic, tele without arrhythmia 4)H/o seizure: Dilantin restarted, with correction for low albumin, dilantin therapuetic on [7-27] 5)Hepatitis: Likely due to low level ischemia in setting of hypotension on arrival to ER. Will need recheck of ast/alt/alk phos on [8-2]. If higher than [7-28] results would consult medicine. 6)Palpitations: EKG and tele without arrythmias, tsh and lytes normal. No further follow up needed. Medications on Admission: Albuterol 90 mcg 2puffs inh four times daily as needed Clonzaepam 0.5mg twice daily Fluoxetine 20-40mg Daily Fluticasone furoate 27.5mcg inh daily in AM Latanoprost 0.005% 2 drops in each eye daily Omeprazole 20mg Twice Daily Phenytoin 200mg in AM, 300mg in PM Cyanocobalamin 500mcg daily Lysine 500mg daily Magnesium Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1675] [Last Name (NamePattern1) ] 4 Discharge Diagnosis: benzodiazapine overdose Discharge Condition: stable Discharge Instructions: [Name8 (MD) ] MD [First Name (Titles) 151] [Last Name (Titles) 1676] pain, seizure, or other concerning symptoms. Followup Instructions: follow up at inpt psychiatric treatment [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677] Completed by:[2157-7-28]	Admission Date: <Date>1980-10-23</Date> Discharge Date: <Date>1927-8-15</Date> Date of Birth: <Date>1946-10-21</Date> Sex: F Service: MEDICINE Allergies: Codeine / Compazine / Zofran Attending:<Name>Norine</Name> Chief Complaint: suicidal attempt Major Surgical or Invasive Procedure: none History of Present Illness: 46 yo F with a history of depression admitted after intentional overdose of benzodiazepines, fluoxetine and phenytoin. . By verbal report, at 8AM the patient ingested (based upon pill bottles) an estimated 30 lorazepam, 30 prozac, 35 clonazepam, 3 unisom and 4 dilantin. She was reportedly suicidal and her husband had to break down the door to get to her. The patient reports that she had depressed mood for several months. She recalls taking 'like a handful' of clonazepam, fluoxetine and phenytoin. She states that she has a great deal of stress at home related to her children and husband and the only way to deal with this difficulty is to 'leave this world.' She denies ongoing thoughts of wanting to hurt herself. . In the ED, 98.6 72 138/64 14 99% RA. She developed hypotension with a single bp measurement of 80/50 pulse 62. She received 1.5L NS with improvement in the blood pressure back to >100/60. There was verbal report of the patient being responsive only to sternal rub at some point in her ED stay however on arrive to the ICU, the patient is alert and oriented. . ROS: Denies headaches, blurry vision, neck stiffness, chest pain, shortness of breath, abd pain, nausea, vomiting, diarrhea, dysuria, hematuria, rashes, arthralgias. . Past Medical History: -elective arachnoid cyst fenestration with right craniotomy <Date>1952-4-31</Date> -seizures due to recent operation on Dilantin -glaucoma -depression -GERD -asthma Social History: married, lives with husband and children denies tobacco and drug use; occasional social EtOh Family History: no hx breast, ovarian, or colon Ca Physical Exam: Gen: NAD. Comfortable. Sedated. Answering appropriate to questions. HEENT: Pupils mildly dilated, equal, round and reactive to light. Pink, moist oral mucosa without lesions. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Soft, nontender, no organomegaly. Ext: No edema. Neuro: A&Ox3. Slightly delayed in response to questioning. CN's II-XII intact. Brief, rapidly distinguishing horizontal nystagmus. Strength 5/5 in the deltoids, triceps, wrist and finger extensors. 4+/5 in the proximal left lower extremity flexion, <Date>5-18</Date> in the right proximal and bilateral lower extremities. Sensation intact in all fields. Reflexes 2+ in the patellas bilaterally. No clonus. Brief Hospital Course: 1)Suicidal attempt: Will require inpt psychiatric admission, no anti-depressants at this time per psych 2)Benzodiazepine dependence: CIWA with benzo for evidence of withdrawal 3)Dilantin overdose: Pt reports overdosing, levels not toxic, tele without arrhythmia 4)H/o seizure: Dilantin restarted, with correction for low albumin, dilantin therapuetic on <Date>9-27</Date> 5)Hepatitis: Likely due to low level ischemia in setting of hypotension on arrival to ER. Will need recheck of ast/alt/alk phos on <Date>3-15</Date>. If higher than <Date>2-30</Date> results would consult medicine. 6)Palpitations: EKG and tele without arrythmias, tsh and lytes normal. No further follow up needed. Medications on Admission: Albuterol 90 mcg 2puffs inh four times daily as needed Clonzaepam 0.5mg twice daily Fluoxetine 20-40mg Daily Fluticasone furoate 27.5mcg inh daily in AM Latanoprost 0.005% 2 drops in each eye daily Omeprazole 20mg Twice Daily Phenytoin 200mg in AM, 300mg in PM Cyanocobalamin 500mcg daily Lysine 500mg daily Magnesium Discharge Disposition: Extended Care Facility: <Name>Christina</Name> <Name>Camargo</Name> <Name>Hall</Name> 4 Discharge Diagnosis: benzodiazapine overdose Discharge Condition: stable Discharge Instructions: <Name>Marti Moore</Name> MD <Name>Chad</Name> <Name>Ngo</Name> pain, seizure, or other concerning symptoms. Followup Instructions: follow up at inpt psychiatric treatment <Name>Christina</Name> <Name>Hall</Name> MD <MD Number>26643971</MD Number> Completed by:<Date>1927-8-15</Date>	00000000000000000111111111100000000000000000000000000000000111111111000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111101111111011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111100001111011100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111101111000011111111000000000000000111111111	Admission Date: 1980-10-23 Discharge Date: 1927-8-15 Date of Birth: 1946-10-21 Sex: F Service: MEDICINE Allergies: Codeine / Compazine / Zofran Attending:Norine Chief Complaint: suicidal attempt Major Surgical or Invasive Procedure: none History of Present Illness: 46 yo F with a history of depression admitted after intentional overdose of benzodiazepines, fluoxetine and phenytoin. . By verbal report, at 8AM the patient ingested (based upon pill bottles) an estimated 30 lorazepam, 30 prozac, 35 clonazepam, 3 unisom and 4 dilantin. She was reportedly suicidal and her husband had to break down the door to get to her. The patient reports that she had depressed mood for several months. She recalls taking 'like a handful' of clonazepam, fluoxetine and phenytoin. She states that she has a great deal of stress at home related to her children and husband and the only way to deal with this difficulty is to 'leave this world.' She denies ongoing thoughts of wanting to hurt herself. . In the ED, 98.6 72 138/64 14 99% RA. She developed hypotension with a single bp measurement of 80/50 pulse 62. She received 1.5L NS with improvement in the blood pressure back to >100/60. There was verbal report of the patient being responsive only to sternal rub at some point in her ED stay however on arrive to the ICU, the patient is alert and oriented. . ROS: Denies headaches, blurry vision, neck stiffness, chest pain, shortness of breath, abd pain, nausea, vomiting, diarrhea, dysuria, hematuria, rashes, arthralgias. . Past Medical History: -elective arachnoid cyst fenestration with right craniotomy 1952-4-31 -seizures due to recent operation on Dilantin -glaucoma -depression -GERD -asthma Social History: married, lives with husband and children denies tobacco and drug use; occasional social EtOh Family History: no hx breast, ovarian, or colon Ca Physical Exam: Gen: NAD. Comfortable. Sedated. Answering appropriate to questions. HEENT: Pupils mildly dilated, equal, round and reactive to light. Pink, moist oral mucosa without lesions. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Soft, nontender, no organomegaly. Ext: No edema. Neuro: A&Ox3. Slightly delayed in response to questioning. CN's II-XII intact. Brief, rapidly distinguishing horizontal nystagmus. Strength 5/5 in the deltoids, triceps, wrist and finger extensors. 4+/5 in the proximal left lower extremity flexion, 5-18 in the right proximal and bilateral lower extremities. Sensation intact in all fields. Reflexes 2+ in the patellas bilaterally. No clonus. Brief Hospital Course: 1)Suicidal attempt: Will require inpt psychiatric admission, no anti-depressants at this time per psych 2)Benzodiazepine dependence: CIWA with benzo for evidence of withdrawal 3)Dilantin overdose: Pt reports overdosing, levels not toxic, tele without arrhythmia 4)H/o seizure: Dilantin restarted, with correction for low albumin, dilantin therapuetic on 9-27 5)Hepatitis: Likely due to low level ischemia in setting of hypotension on arrival to ER. Will need recheck of ast/alt/alk phos on 3-15. If higher than 2-30 results would consult medicine. 6)Palpitations: EKG and tele without arrythmias, tsh and lytes normal. No further follow up needed. Medications on Admission: Albuterol 90 mcg 2puffs inh four times daily as needed Clonzaepam 0.5mg twice daily Fluoxetine 20-40mg Daily Fluticasone furoate 27.5mcg inh daily in AM Latanoprost 0.005% 2 drops in each eye daily Omeprazole 20mg Twice Daily Phenytoin 200mg in AM, 300mg in PM Cyanocobalamin 500mcg daily Lysine 500mg daily Magnesium Discharge Disposition: Extended Care Facility: Christina Camargo Hall 4 Discharge Diagnosis: benzodiazapine overdose Discharge Condition: stable Discharge Instructions: Marti Moore MD Chad Ngo pain, seizure, or other concerning symptoms. Followup Instructions: follow up at inpt psychiatric treatment Christina Hall MD 26643971 Completed by:1927-8-15	["Admission Date: 1980-10-23 Discharge Date: 1927-8-15\n\nDate of Birth: 1946-10-21 Sex: F\n\nService: MEDICINE\n\nAllergies:\nCodeine / Compazine / Zofran\n\nAttending:Norine\nChief Complaint:\nsuicidal attempt\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\n46 yo F with a history of depression admitted after intentional\noverdose of benzodiazepines, fluoxetine and phenytoin.\n.\nBy verbal report, at 8AM the patient ingested (based upon pill\nbottles) an estimated 30 lorazepam, 30 prozac, 35 clonazepam, 3\nunisom and 4 dilantin. She was reportedly suicidal and her\nhusband had to break down the door to get to her. The patient\nreports that she had depressed mood for several months. She\nrecalls taking 'like a handful' of clonazepam, fluoxetine and\nphenytoin.", " She states that she has a great deal of stress at\nhome related to her children and husband and the only way to\ndeal with this difficulty is to 'leave this world.' She denies\nongoing thoughts of wanting to hurt herself.\n.\nIn the ED, 98.6 72 138/64 14 99% RA. She developed hypotension\nwith a single bp measurement of 80/50 pulse 62. She received\n1.5L NS with improvement in the blood pressure back to >100/60.\nThere was verbal report of the patient being responsive only to\nsternal rub at some point in her ED stay however on arrive to\nthe ICU, the patient is alert and oriented.\n.\nROS: Denies headaches, blurry vision, neck stiffness, chest\npain, shortness of breath, abd pain, nausea, vomiting, diarrhea,\ndysuria, hematuria, rashes, arthralgias.\n.\n\n\nPast Medical History:\n-elective arachnoid cyst fenestration with right craniotomy\n1952-4-31\n-seizures due to recent operation on Dilantin\n-glaucoma\n-depression\n-GERD\n-asthma\n\n\nSocial History:\nmarried, lives with husband and children\ndenies tobacco and drug use; occasional social EtOh\n\n\nFamily History:\nno hx breast, ovarian, or colon Ca\n\nPhysical Exam:\nGen: NAD.", " Comfortable. Sedated. Answering appropriate to\nquestions.\nHEENT: Pupils mildly dilated, equal, round and reactive to\nlight. Pink, moist oral mucosa without lesions.\nCV: RRR. Normal S1 and S2. No M/R/G.\nPulm: CTA bilaterally.\nAbd: Soft, nontender, no organomegaly.\nExt: No edema.\nNeuro: A&Ox3. Slightly delayed in response to questioning. CN's\nII-XII intact. Brief, rapidly distinguishing horizontal\nnystagmus. Strength 5/5 in the deltoids, triceps, wrist and\nfinger extensors. 4+/5 in the proximal left lower extremity\nflexion, 5-18 in the right proximal and bilateral lower\nextremities. Sensation intact in all fields. Reflexes 2+ in the\npatellas bilaterally. No clonus.\n\n\nBrief Hospital Course:\n1)Suicidal attempt: Will require inpt psychiatric admission, no\nanti-depressants at this time per psych\n\n2)Benzodiazepine dependence: CIWA with benzo for evidence of\nwithdrawal\n\n3)Dilantin overdose: Pt reports overdosing, levels not toxic,\ntele without arrhythmia\n\n4)H/o seizure: Dilantin restarted, with correction for low\nalbumin, dilantin therapuetic on 9-27\n\n5)Hepatitis: Likely due to low level ischemia in setting of\nhypotension on arrival to ER.", ' Will need recheck of ast/alt/alk\nphos on 3-15. If higher than 2-30 results would consult\nmedicine.\n\n6)Palpitations: EKG and tele without arrythmias, tsh and lytes\nnormal. No further follow up needed.\n\nMedications on Admission:\nAlbuterol 90 mcg 2puffs inh four times daily as needed\nClonzaepam 0.5mg twice daily\nFluoxetine 20-40mg Daily\nFluticasone furoate 27.5mcg inh daily in AM\nLatanoprost 0.005% 2 drops in each eye daily\nOmeprazole 20mg Twice Daily\nPhenytoin 200mg in AM, 300mg in PM\nCyanocobalamin 500mcg daily\nLysine 500mg daily\nMagnesium\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nChristina Camargo Hall 4\n\nDischarge Diagnosis:\nbenzodiazapine overdose\n\n\nDischarge Condition:\nstable\n\n\nDischarge Instructions:\nMarti Moore MD Chad Ngo pain, seizure, or other concerning\nsymptoms.\n\nFollowup Instructions:\nfollow up at inpt psychiatric treatment\n\n\n Christina Hall MD 26643971\n\nCompleted by:1927-8-15']
158	30565	105393.0	2161-08-07	Discharge summary	Report	Admission Date: [2161-8-4] Discharge Date: [2161-8-7] Date of Birth: [2110-12-29] Sex: F Service: SURGERY Allergies: Codeine / Compazine / Vicodin Attending:[First Name3 (LF) 1390] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 50 y.o. F w/ h/o sucharachnoid cyst & psychiatric history who presented s/p fall down a flight of stairs. She has a questionable seizure history and she is also on multiple psychiatric medications at home. In the ED, she had altered mental status and was intubated for airway protection. Past Medical History: Chronic hemorrhoids, Hematuria, Anemia of chronic disease, GERD, Arachnoid cyst fenestration w/ right craniotomy [2157-2-22], Seizures secondary to above, Glaucoma, Asthma PSHx: subarachnoid cyst excision ([2157]), right cystoperitoneal shunt ([2161-6-9]) Social History: negative for tobacco or EtOH Family History: NC Physical Exam: ICU physical exam: Gen: somnolent, minimally responsive CV: tachycardic, regular rhythm Pulm: CTAB Abd: soft, nontender, nondistended Ext: WWP, no edema Exam on discharge: VS: 98.3 73 126/65 20 94%RA GEN: A&OX3, NAD CHEST: CTAB, RRR ABD: Soft, nontender, nondistended EXTR: L thigh with lg echymosis, soft. LE warm, pink and well perfused. No edema. +distal pulses. Pertinent Results: [2161-8-4] 12:45AM BLOOD WBC-11.1* RBC-4.17* Hgb-12.3 Hct-36.7 MCV-88 MCH-29.6 MCHC-33.6 RDW-13.1 Plt Ct-251 [2161-8-4] 06:21AM BLOOD WBC-7.9 RBC-4.01* Hgb-12.0 Hct-35.9* MCV-90 MCH-29.9 MCHC-33.3 RDW-13.2 Plt Ct-221 [2161-8-4] 12:45AM BLOOD Glucose-117* UreaN-11 Creat-0.7 Na-138 K-3.3 Cl-99 HCO3-27 AnGap-15 [2161-8-4] 06:21AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-141 K-4.3 Cl-103 HCO3-28 AnGap-14 [2161-8-5] 02:51AM BLOOD ALT-37 AST-32 AlkPhos-65 TotBili-0.3 [2161-8-4] 12:45AM BLOOD Valproa-30* [2161-8-4] 06:21AM BLOOD Valproa-41* CT Torso [2161-8-4]: Impression: 1. Endotracheal tube terminates in the bronchus intermedius, leading to left right upper lobe atelectasis. Left lower lobe atelectasis is also present. 2. Fatty infiltration of the liver CT C-spine [2161-8-3]: 1. No fracture or malalignment. 2. Multilevel degenerative disease. 3. Small right upper lobe consolidation and ground-glass opacities in the imaged left lung are better assessed on the concurrent CT torso. CT Head [2161-8-3]: Stable appearance of the intracranial structures compared to [2161-7-22], without evidence of acute intracranial injuries. Brief Hospital Course: Ms. [Known lastname 1679] was admitted to the TSICU after her fall. She was intubated overnight and successfully extubated on HD 1. Her O2 sats remained stable and she was breathing on her own without difficulty. She was very somnolent and remained obtunded on HD 1. Neurology was consulted due to her history of questional seizures but they did not feel that her fall was related to her seizures. Psychiatry was consulted given her multiple psychiatric medications and the possibility of an overdose prior to the fall. The patient denied current suicidal ideation and psych determined there to be no contraindication to discharge home once medically cleared. Her mental status improved slightly throughout the day and when awakened, she would respond appropriately. She was put back to a regular diet. She was transferred to the floor on HD 2 in stable condition. She remained slightly lethargic and her depakote dosing was changed to 500 mg [Hospital1 ] from 250mg am 1000mg qhs. She become more alert as time progressed and by HD 4 she was alert and oriented X 3 to her baseline mental status. Occupational therapy was consulted for cognitive evaluation who recommended outpatient cogntive neurology follow up after discharge. The patient was given this information. On [8-7] (HD 4) she is alert and oriented at her baseline mental status. She denies suicidal ideation and has been cleared by psych with plans for outpatient follow up with her primary psychiatrist. Her vital signs and respiratory status are stable. She is tolerating a regular diet. She is out of bed ambulating independently. She is being discharged home with PCP and [Name9 (PRE) 1697] neurology follow up. Medications on Admission: olanzapine 5mg qam, 15mg qpm divalproex 250mg am 1000mg qhs aripiprazole 10 mg daily ativan 0.5mg daily prn trazodone 100mg qhs omeprazole 20mg before first meal clobetasol 0.05% cream prn eczema flare vit D 50, 000unit cap- 1cab weekly Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 2. Divalproex (DELayed Release) 500 mg PO BID RX divalproex 500 mg 1 Tablet(s) by mouth twice a day Disp #60 Tablet Refills:1 3. Fluoxetine 40 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: s/p Fall Concussion Discharge Condition: Alert with intermittent drowsiness Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a fall. You underwent CT scan imaging and no acute injuries were identified. You were seen by Psychiatry and Neurology during your hospital stay and some adjustments to your Depakote were made. You were also evaluated by the Occupational therapists for assessing your mental status and you have symptoms consistent with a mild concussion. It is being recommended that you follow up with the Cognitive Neurologist (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]) in the next couple of weeks for ongoing evaluation of your memory and over all mental status. If you expereince any increased headaches, dizziness, changes in your vision, nausea, vomiting and/or any other concerning symptoms please return to the Emergency room for further evaluation. Followup Instructions: Department: Primary Care Name: Dr. [First Name (STitle) 1698] [Name (STitle) 1699] When: Wednesday [2161-8-19] at 11:40 AM Location: [Hospital1 641] Address: 291 INDEPENDENCE DR, [Location ],[Numeric Identifier 1700] Phone: [Telephone/Fax (1) 1701] Department: [Hospital1 18] - Cognitive Neurology Unit Name: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] When: Dr. [Last Name (STitle) 1702] office is working on a follow up appointment within a month to follow up on your head injury. You will be called with the appointment date and time. If you have not heard from the office or have questions please call the office number listed below. Phone: ([Telephone/Fax (1) 1703] Completed by:[2161-8-7*]	Admission Date: <Date>2013-6-20</Date> Discharge Date: <Date>1949-5-26</Date> Date of Birth: <Date>1960-7-1</Date> Sex: F Service: SURGERY Allergies: Codeine / Compazine / Vicodin Attending:<Name>Meena</Name> Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 50 y.o. F w/ h/o sucharachnoid cyst & psychiatric history who presented s/p fall down a flight of stairs. She has a questionable seizure history and she is also on multiple psychiatric medications at home. In the ED, she had altered mental status and was intubated for airway protection. Past Medical History: Chronic hemorrhoids, Hematuria, Anemia of chronic disease, GERD, Arachnoid cyst fenestration w/ right craniotomy <Date>1963-7-14</Date>, Seizures secondary to above, Glaucoma, Asthma PSHx: subarachnoid cyst excision (<Year>2020</Year>), right cystoperitoneal shunt (<Date>2018-9-27</Date>) Social History: negative for tobacco or EtOH Family History: NC Physical Exam: ICU physical exam: Gen: somnolent, minimally responsive CV: tachycardic, regular rhythm Pulm: CTAB Abd: soft, nontender, nondistended Ext: WWP, no edema Exam on discharge: VS: 98.3 73 126/65 20 94%RA GEN: A&OX3, NAD CHEST: CTAB, RRR ABD: Soft, nontender, nondistended EXTR: L thigh with lg echymosis, soft. LE warm, pink and well perfused. No edema. +distal pulses. Pertinent Results: <Date>2013-6-20</Date> 12:45AM BLOOD WBC-11.1* RBC-4.17* Hgb-12.3 Hct-36.7 MCV-88 MCH-29.6 MCHC-33.6 RDW-13.1 Plt Ct-251 <Date>2013-6-20</Date> 06:21AM BLOOD WBC-7.9 RBC-4.01* Hgb-12.0 Hct-35.9* MCV-90 MCH-29.9 MCHC-33.3 RDW-13.2 Plt Ct-221 <Date>2013-6-20</Date> 12:45AM BLOOD Glucose-117* UreaN-11 Creat-0.7 Na-138 K-3.3 Cl-99 HCO3-27 AnGap-15 <Date>2013-6-20</Date> 06:21AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-141 K-4.3 Cl-103 HCO3-28 AnGap-14 <Date>1923-5-11</Date> 02:51AM BLOOD ALT-37 AST-32 AlkPhos-65 TotBili-0.3 <Date>2013-6-20</Date> 12:45AM BLOOD Valproa-30* <Date>2013-6-20</Date> 06:21AM BLOOD Valproa-41* CT Torso <Date>2013-6-20</Date>: Impression: 1. Endotracheal tube terminates in the bronchus intermedius, leading to left right upper lobe atelectasis. Left lower lobe atelectasis is also present. 2. Fatty infiltration of the liver CT C-spine <Date>1992-8-14</Date>: 1. No fracture or malalignment. 2. Multilevel degenerative disease. 3. Small right upper lobe consolidation and ground-glass opacities in the imaged left lung are better assessed on the concurrent CT torso. CT Head <Date>1992-8-14</Date>: Stable appearance of the intracranial structures compared to <Date>1983-12-2</Date>, without evidence of acute intracranial injuries. Brief Hospital Course: Ms. <Name>Mao</Name> was admitted to the TSICU after her fall. She was intubated overnight and successfully extubated on HD 1. Her O2 sats remained stable and she was breathing on her own without difficulty. She was very somnolent and remained obtunded on HD 1. Neurology was consulted due to her history of questional seizures but they did not feel that her fall was related to her seizures. Psychiatry was consulted given her multiple psychiatric medications and the possibility of an overdose prior to the fall. The patient denied current suicidal ideation and psych determined there to be no contraindication to discharge home once medically cleared. Her mental status improved slightly throughout the day and when awakened, she would respond appropriately. She was put back to a regular diet. She was transferred to the floor on HD 2 in stable condition. She remained slightly lethargic and her depakote dosing was changed to 500 mg <Hospital>Mcmahon-Lewis Clinic</Hospital> from 250mg am 1000mg qhs. She become more alert as time progressed and by HD 4 she was alert and oriented X 3 to her baseline mental status. Occupational therapy was consulted for cognitive evaluation who recommended outpatient cogntive neurology follow up after discharge. The patient was given this information. On <Date>4-22</Date> (HD 4) she is alert and oriented at her baseline mental status. She denies suicidal ideation and has been cleared by psych with plans for outpatient follow up with her primary psychiatrist. Her vital signs and respiratory status are stable. She is tolerating a regular diet. She is out of bed ambulating independently. She is being discharged home with PCP and <Name>Kraig Kenner</Name> neurology follow up. Medications on Admission: olanzapine 5mg qam, 15mg qpm divalproex 250mg am 1000mg qhs aripiprazole 10 mg daily ativan 0.5mg daily prn trazodone 100mg qhs omeprazole 20mg before first meal clobetasol 0.05% cream prn eczema flare vit D 50, 000unit cap- 1cab weekly Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 2. Divalproex (DELayed Release) 500 mg PO BID RX divalproex 500 mg 1 Tablet(s) by mouth twice a day Disp #60 Tablet Refills:*1 3. Fluoxetine 40 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: s/p Fall Concussion Discharge Condition: Alert with intermittent drowsiness Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a fall. You underwent CT scan imaging and no acute injuries were identified. You were seen by Psychiatry and Neurology during your hospital stay and some adjustments to your Depakote were made. You were also evaluated by the Occupational therapists for assessing your mental status and you have symptoms consistent with a mild concussion. It is being recommended that you follow up with the Cognitive Neurologist (Dr. <Name>Reba</Name> <Name>Booker</Name>) in the next couple of weeks for ongoing evaluation of your memory and over all mental status. If you expereince any increased headaches, dizziness, changes in your vision, nausea, vomiting and/or any other concerning symptoms please return to the Emergency room for further evaluation. Followup Instructions: Department: Primary Care Name: Dr. <Name>Cornell</Name> <Name>Jeremy Ngo</Name> When: Wednesday <Date>1941-9-31</Date> at 11:40 AM Location: <Hospital>Palmer PLC Clinic</Hospital> Address: 291 INDEPENDENCE DR, <Location>1094 Lopez Haven Suite 490 West Laura, WI 02532</Location>,<Numeric Identifier>4275417</Numeric Identifier> Phone: <Telephone>717-593-1607</Telephone> Department: <Hospital>Little Group Health System</Hospital> - Cognitive Neurology Unit Name: Dr. <Name>Reba</Name> <Name>Booker</Name> When: Dr. <Name>Booker</Name> office is working on a follow up appointment within a month to follow up on your head injury. You will be called with the appointment date and time. If you have not heard from the office or have questions please call the office number listed below. Phone: (<Telephone>934-809-4412</Telephone> Completed by:<Date>1949-5-26</Date>	000000000000000001111111110000000000000000000000000000000011111111100000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000001111111110000000000000000000000000001111111110000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000011100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 2013-6-20 Discharge Date: 1949-5-26 Date of Birth: 1960-7-1 Sex: F Service: SURGERY Allergies: Codeine / Compazine / Vicodin Attending:Meena Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 50 y.o. F w/ h/o sucharachnoid cyst & psychiatric history who presented s/p fall down a flight of stairs. She has a questionable seizure history and she is also on multiple psychiatric medications at home. In the ED, she had altered mental status and was intubated for airway protection. Past Medical History: Chronic hemorrhoids, Hematuria, Anemia of chronic disease, GERD, Arachnoid cyst fenestration w/ right craniotomy 1963-7-14, Seizures secondary to above, Glaucoma, Asthma PSHx: subarachnoid cyst excision (2020), right cystoperitoneal shunt (2018-9-27) Social History: negative for tobacco or EtOH Family History: NC Physical Exam: ICU physical exam: Gen: somnolent, minimally responsive CV: tachycardic, regular rhythm Pulm: CTAB Abd: soft, nontender, nondistended Ext: WWP, no edema Exam on discharge: VS: 98.3 73 126/65 20 94%RA GEN: A&OX3, NAD CHEST: CTAB, RRR ABD: Soft, nontender, nondistended EXTR: L thigh with lg echymosis, soft. LE warm, pink and well perfused. No edema. +distal pulses. Pertinent Results: 2013-6-20 12:45AM BLOOD WBC-11.1* RBC-4.17* Hgb-12.3 Hct-36.7 MCV-88 MCH-29.6 MCHC-33.6 RDW-13.1 Plt Ct-251 2013-6-20 06:21AM BLOOD WBC-7.9 RBC-4.01* Hgb-12.0 Hct-35.9* MCV-90 MCH-29.9 MCHC-33.3 RDW-13.2 Plt Ct-221 2013-6-20 12:45AM BLOOD Glucose-117* UreaN-11 Creat-0.7 Na-138 K-3.3 Cl-99 HCO3-27 AnGap-15 2013-6-20 06:21AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-141 K-4.3 Cl-103 HCO3-28 AnGap-14 1923-5-11 02:51AM BLOOD ALT-37 AST-32 AlkPhos-65 TotBili-0.3 2013-6-20 12:45AM BLOOD Valproa-30* 2013-6-20 06:21AM BLOOD Valproa-41* CT Torso 2013-6-20: Impression: 1. Endotracheal tube terminates in the bronchus intermedius, leading to left right upper lobe atelectasis. Left lower lobe atelectasis is also present. 2. Fatty infiltration of the liver CT C-spine 1992-8-14: 1. No fracture or malalignment. 2. Multilevel degenerative disease. 3. Small right upper lobe consolidation and ground-glass opacities in the imaged left lung are better assessed on the concurrent CT torso. CT Head 1992-8-14: Stable appearance of the intracranial structures compared to 1983-12-2, without evidence of acute intracranial injuries. Brief Hospital Course: Ms. Mao was admitted to the TSICU after her fall. She was intubated overnight and successfully extubated on HD 1. Her O2 sats remained stable and she was breathing on her own without difficulty. She was very somnolent and remained obtunded on HD 1. Neurology was consulted due to her history of questional seizures but they did not feel that her fall was related to her seizures. Psychiatry was consulted given her multiple psychiatric medications and the possibility of an overdose prior to the fall. The patient denied current suicidal ideation and psych determined there to be no contraindication to discharge home once medically cleared. Her mental status improved slightly throughout the day and when awakened, she would respond appropriately. She was put back to a regular diet. She was transferred to the floor on HD 2 in stable condition. She remained slightly lethargic and her depakote dosing was changed to 500 mg Mcmahon-Lewis Clinic from 250mg am 1000mg qhs. She become more alert as time progressed and by HD 4 she was alert and oriented X 3 to her baseline mental status. Occupational therapy was consulted for cognitive evaluation who recommended outpatient cogntive neurology follow up after discharge. The patient was given this information. On 4-22 (HD 4) she is alert and oriented at her baseline mental status. She denies suicidal ideation and has been cleared by psych with plans for outpatient follow up with her primary psychiatrist. Her vital signs and respiratory status are stable. She is tolerating a regular diet. She is out of bed ambulating independently. She is being discharged home with PCP and Kraig Kenner neurology follow up. Medications on Admission: olanzapine 5mg qam, 15mg qpm divalproex 250mg am 1000mg qhs aripiprazole 10 mg daily ativan 0.5mg daily prn trazodone 100mg qhs omeprazole 20mg before first meal clobetasol 0.05% cream prn eczema flare vit D 50, 000unit cap- 1cab weekly Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 2. Divalproex (DELayed Release) 500 mg PO BID RX divalproex 500 mg 1 Tablet(s) by mouth twice a day Disp #60 Tablet Refills:*1 3. Fluoxetine 40 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: s/p Fall Concussion Discharge Condition: Alert with intermittent drowsiness Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a fall. You underwent CT scan imaging and no acute injuries were identified. You were seen by Psychiatry and Neurology during your hospital stay and some adjustments to your Depakote were made. You were also evaluated by the Occupational therapists for assessing your mental status and you have symptoms consistent with a mild concussion. It is being recommended that you follow up with the Cognitive Neurologist (Dr. Reba Booker) in the next couple of weeks for ongoing evaluation of your memory and over all mental status. If you expereince any increased headaches, dizziness, changes in your vision, nausea, vomiting and/or any other concerning symptoms please return to the Emergency room for further evaluation. Followup Instructions: Department: Primary Care Name: Dr. Cornell Jeremy Ngo When: Wednesday 1941-9-31 at 11:40 AM Location: Palmer PLC Clinic Address: 291 INDEPENDENCE DR, 1094 Lopez Haven Suite 490 West Laura, WI 02532,4275417 Phone: 717-593-1607 Department: Little Group Health System - Cognitive Neurology Unit Name: Dr. Reba Booker When: Dr. Booker office is working on a follow up appointment within a month to follow up on your head injury. You will be called with the appointment date and time. If you have not heard from the office or have questions please call the office number listed below. Phone: (934-809-4412 Completed by:1949-5-26	['Admission Date: 2013-6-20 Discharge Date: 1949-5-26\n\nDate of Birth: 1960-7-1 Sex: F\n\nService: SURGERY\n\nAllergies:\nCodeine / Compazine / Vicodin\n\nAttending:Meena\nChief Complaint:\ns/p fall\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\n50 y.o. F w/ h/o sucharachnoid cyst & psychiatric history who\npresented s/p fall down a flight of stairs. She has a\nquestionable seizure history and she is also on multiple\npsychiatric medications at home. In the ED, she had altered\nmental status and was intubated for airway protection.\n\nPast Medical History:\nChronic hemorrhoids, Hematuria, Anemia of chronic disease, GERD,\nArachnoid cyst fenestration w/ right craniotomy 1963-7-14,\nSeizures secondary to above, Glaucoma, Asthma\n\nPSHx: subarachnoid cyst excision (2020), right cystoperitoneal\nshunt (2018-9-27)\n\n\nSocial History:\nnegative for tobacco or EtOH\n\nFamily History:\nNC\n\nPhysical Exam:\nICU physical exam:\n\nGen: somnolent, minimally responsive\nCV: tachycardic, regular rhythm\nPulm: CTAB\nAbd: soft, nontender, nondistended\nExt: WWP, no edema\n\nExam on discharge:\n\nVS: 98.', '3 73 126/65 20 94%RA\nGEN: A&OX3, NAD\nCHEST: CTAB, RRR\nABD: Soft, nontender, nondistended\nEXTR: L thigh with lg echymosis, soft. LE warm, pink and well\nperfused. No edema. +distal pulses.\n\nPertinent Results:\n2013-6-20 12:45AM BLOOD WBC-11.1* RBC-4.17* Hgb-12.3 Hct-36.7\nMCV-88 MCH-29.6 MCHC-33.6 RDW-13.1 Plt Ct-251\n2013-6-20 06:21AM BLOOD WBC-7.9 RBC-4.01* Hgb-12.0 Hct-35.9\nMCV-90 MCH-29.9 MCHC-33.3 RDW-13.2 Plt Ct-221\n2013-6-20 12:45AM BLOOD Glucose-117 UreaN-11 Creat-0.7 Na-138\nK-3.3 Cl-99 HCO3-27 AnGap-15\n2013-6-20 06:21AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-141\nK-4.3 Cl-103 HCO3-28 AnGap-14\n1923-5-11 02:51AM BLOOD ALT-37 AST-32 AlkPhos-65 TotBili-0.3\n2013-6-20 12:45AM BLOOD Valproa-30\n2013-6-20 06:21AM BLOOD Valproa-41\n\nCT Torso 2013-6-20:\nImpression: 1. Endotracheal tube terminates in the bronchus\nintermedius, leading to left right upper lobe atelectasis.', ' Left\nlower lobe atelectasis is also present. 2. Fatty infiltration\nof the liver\n\nCT C-spine 1992-8-14:\n1. No fracture or malalignment. 2. Multilevel degenerative\ndisease. 3. Small right upper lobe consolidation and\nground-glass opacities in the\nimaged left lung are better assessed on the concurrent CT torso.\n\n\nCT Head 1992-8-14: Stable appearance of the intracranial\nstructures compared to 1983-12-2, without evidence of acute\nintracranial injuries.\n\n\nBrief Hospital Course:\nMs. Mao was admitted to the TSICU after her fall. She was\nintubated overnight and successfully extubated on HD 1. Her O2\nsats remained stable and she was breathing on her own without\ndifficulty. She was very somnolent and remained obtunded on HD\n1. Neurology was consulted due to her history of questional\nseizures but they did not feel that her fall was related to her\nseizures.', ' Psychiatry was consulted given her multiple\npsychiatric medications and the possibility of an overdose prior\nto the fall. The patient denied current suicidal ideation and\npsych determined there to be no contraindication to discharge\nhome once medically cleared. Her mental status improved slightly\nthroughout the day and when awakened, she would respond\nappropriately. She was put back to a regular diet. She was\ntransferred to the floor on HD 2 in stable condition. She\nremained slightly lethargic and her depakote dosing was changed\nto 500 mg Mcmahon-Lewis Clinic from 250mg am 1000mg qhs. She become more alert as\ntime progressed and by HD 4 she was alert and oriented X 3 to\nher baseline mental status.\n\nOccupational therapy was consulted for cognitive evaluation who\nrecommended outpatient cogntive neurology follow up after\ndischarge.', ' The patient was given this information.\n\nOn 4-22 (HD 4) she is alert and oriented at her baseline mental\nstatus. She denies suicidal ideation and has been cleared by\npsych with plans for outpatient follow up with her primary\npsychiatrist. Her vital signs and respiratory status are stable.\nShe is tolerating a regular diet. She is out of bed ambulating\nindependently. She is being discharged home with PCP and\nKraig Kenner neurology follow up.\n\nMedications on Admission:\nolanzapine 5mg qam, 15mg qpm\ndivalproex 250mg am 1000mg qhs\naripiprazole 10 mg daily\nativan 0.5mg daily prn\ntrazodone 100mg qhs\nomeprazole 20mg before first meal\nclobetasol 0.05% cream prn eczema flare\nvit D 50, 000unit cap- 1cab weekly\n\n\nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever\n2. Divalproex (DELayed Release) 500 mg PO BID\nRX divalproex 500 mg 1 Tablet(s) by mouth twice a day Disp #60\nTablet Refills:*1\n3.', ' Fluoxetine 40 mg PO DAILY\n4. Omeprazole 20 mg PO DAILY\n5. Ferrous Sulfate 325 mg PO DAILY\n6. Multivitamins 1 TAB PO DAILY\n7. Vitamin D 800 UNIT PO DAILY\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\ns/p Fall\nConcussion\n\n\nDischarge Condition:\nAlert with intermittent drowsiness\nActivity Status: Ambulatory - Independent.\n\n\nDischarge Instructions:\nYou were admitted to the hospital after a fall. You underwent CT\nscan imaging and no acute injuries were identified. You were\nseen by Psychiatry and Neurology during your hospital stay and\nsome adjustments to your Depakote were made.\n\nYou were also evaluated by the Occupational therapists for\nassessing your mental status and you have symptoms consistent\nwith a mild concussion. It is being recommended that you follow\nup with the Cognitive Neurologist (Dr.', ' Reba Booker) in the\nnext couple of weeks for ongoing evaluation of your memory and\nover all mental status.\n\nIf you expereince any increased headaches, dizziness, changes in\nyour vision, nausea, vomiting and/or any other concerning\nsymptoms please return to the Emergency room for further\nevaluation.\n\nFollowup Instructions:\nDepartment: Primary Care\nName: Dr. Cornell Jeremy Ngo\nWhen: Wednesday 1941-9-31 at 11:40 AM\nLocation: Palmer PLC Clinic\nAddress: 291 INDEPENDENCE DR, 1094 Lopez Haven Suite 490\nWest Laura, WI 02532,4275417\nPhone: 717-593-1607\n\nDepartment: Little Group Health System - Cognitive Neurology Unit\nName: Dr. Reba Booker\nWhen: Dr. Booker office is working on a follow up\nappointment within a month to follow up on your head injury. You\nwill be called with the appointment date and time.', ' If you have\nnot heard from the office or have questions please call the\noffice number listed below.\nPhone: (934-809-4412\n\n\n\nCompleted by:1949-5-26']
159	9170	122085.0	2141-11-13	Discharge summary	Report	Admission Date: [2141-11-7] Discharge Date: [2141-11-13] Date of Birth: [2091-11-1] Sex: M Service: GU Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1232] Chief Complaint: Sharp abdominal pain after cough, gross hematuria Major Surgical or Invasive Procedure: s/p right partial nephrectomy on [2141-10-24] History of Present Illness: Pt is a 50 year old male who underwent a right partial nephrectomy on [2141-10-24] and was discharged and presented to the ER on [2141-10-30] after an MVA with complaint of serosanguinous discharge from old chest tube site. Chest xray and ultrasound at the time were negative. The patient then returned to hospital on [2141-11-7] with a complaint of severe abdominal pain and one episode of gross hematuria after a cough. The patient presented to an outside hospital with a hematocrit of 27 and a BP of 70/40. The patient was given IV fluids and 1 unit of PRBC's (post-transfusion hematocrit was 29), was stabilized, and then med flighted to [Hospital1 18]. Past Medical History: IgA nephropathy Hypertension Gout Psoriasis Social History: Patient has a significant alcohol history of [7-11] drinks/day Family History: Non-contributory Physical Exam: Gen: A+Ox3 CV: RRR Lungs: Crackles at right base Abd: Soft, distended, very mild tenderness to palpation diffusely, incision clean/dry/intact Ext: No cyanosis or edema Pertinent Results: [2141-11-7] 07:30PM BLOOD WBC-24.0# RBC-3.22 Hgb-9.6* Hct-28.5* MCV-89 MCH-29.8 MCHC-33.6 RDW-13.1 Plt Ct-404# [2141-11-8] 04:20AM BLOOD WBC-18.0* RBC-2.84* Hgb-8.1* Hct-24.7* MCV-87 MCH-28.6 MCHC-32.9 RDW-13.3 Plt Ct-345 [2141-11-8] 10:30AM BLOOD WBC-19.8* RBC-3.45* Hgb-10.0* Hct-29.4* MCV-85 MCH-29.0 MCHC-34.0 RDW-14.0 Plt Ct-272 [2141-11-8] 01:56PM BLOOD WBC-15.7* RBC-3.25* Hgb-9.3* Hct-27.8* MCV-85 MCH-28.6 MCHC-33.5 RDW-14.0 Plt Ct-259 [2141-11-8] 05:48PM BLOOD Hct-30.2* [2141-11-9] 06:35AM BLOOD Hct-28.3* [2141-11-9] 04:45PM BLOOD Hct-30.6* [2141-11-10] 07:35AM BLOOD WBC-12.2* RBC-3.33* Hgb-9.6* Hct-28.7* MCV-86 MCH-28.9 MCHC-33.4 RDW-13.9 Plt Ct-326 [2141-11-7] 07:30PM BLOOD Glucose-142* UreaN-44* Creat-2.5* Na-140 K-5.8* Cl-107 HCO3-21* AnGap-18 [2141-11-8] 04:20AM BLOOD Glucose-137* UreaN-47* Creat-2.9* Na-140 K-6.6* Cl-110* HCO3-21* AnGap-16 [2141-11-8] 10:30AM BLOOD Glucose-129* UreaN-42* Creat-2.5* Na-141 K-4.9 Cl-107 HCO3-20* AnGap-19 [2141-11-8] 01:56PM BLOOD Glucose-118* UreaN-38* Creat-2.3* Na-141 K-4.9 Cl-107 HCO3-22 AnGap-17 [2141-11-8] 05:48PM BLOOD Glucose-120* UreaN-35* Creat-2.2* Na-141 K-4.8 Cl-105 HCO3-22 AnGap-19 [2141-11-9] 06:35AM BLOOD Glucose-126* UreaN-25* Creat-1.8* Na-137 K-4.3 Cl-105 HCO3-23 AnGap-13 [2141-11-8] 10:30AM BLOOD Lipase-616* [2141-11-8] 01:56PM BLOOD Lipase-390* [2141-11-9] 06:35AM BLOOD Lipase-111* [2141-11-8] 10:30AM BLOOD ALT-24 AST-21 LD(LDH)-296* AlkPhos-95 Amylase-436* TotBili-0.9 [2141-11-9] 06:35AM BLOOD ALT-16 AST-16 AlkPhos-87 Amylase-165* TotBili-0.7 Brief Hospital Course: The patient was admitted to the MICU and was transfused 2 units of PRBS's. Post-transfusion hematocrit remained stable around 30. A CT scan was obtained on hospital day #2, which showed a small-to-moderate amount of high density fluid which most likely represented blood around the liver and the spleen and the right kidney, with adjacent perinephric fluid/hematoma. The origin of bleeding was not definitively identified, but bleeding could potentially have been arising in the kidney given the history of recent renal surgery and history of hematuria. No active extravasation was identified. The patient was hemodynamically stable throughout his stay in the MICU, and was transferred to the floor on HD#2. A repeat CT on hospital day #3 showed no active changes from the previous scan. On HD#4, the patient appeared more distended, though he continued to pass flatus. A KUB was obtained, which showed no signs of obstruction. An MRI urogram was also obtained, which showed stable blood around the right kidney, extending into the peritoneum and a blood clot within the right renal pelvis. The patient continued to remain stable with a hematocrit holing steady around 30 and a creatinine holding steady at 2.1. The patient was discharged on HD#7 in stable condition. Medications on Admission: Atenolol 50 mg PO QDaily Lisinopril 20 mg PO QDaily Norvasc 5 mg PO QDaily Lipitor 10 mg PO QDaily Allopurinol 100 mg PO QDaily Protonix 25 mg PO QDaily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): please take while taking pain medications. Stop if loose bowel movements. Disp:30 Capsule(s) Refills:2 2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p right partial nephrectomy, readmitted for question of postoperative bleed Discharge Condition: stable Discharge Instructions: Call Dr.[Name (NI) 1233] office for follow up Followup Instructions: as above	Admission Date: <Date>1932-8-10</Date> Discharge Date: <Date>1974-7-13</Date> Date of Birth: <Date>1908-3-10</Date> Sex: M Service: GU Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Carl</Name> Chief Complaint: Sharp abdominal pain after cough, gross hematuria Major Surgical or Invasive Procedure: s/p right partial nephrectomy on <Date>1962-3-12</Date> History of Present Illness: Pt is a 50 year old male who underwent a right partial nephrectomy on <Date>1962-3-12</Date> and was discharged and presented to the ER on <Date>2020-3-20</Date> after an MVA with complaint of serosanguinous discharge from old chest tube site. Chest xray and ultrasound at the time were negative. The patient then returned to hospital on <Date>1932-8-10</Date> with a complaint of severe abdominal pain and one episode of gross hematuria after a cough. The patient presented to an outside hospital with a hematocrit of 27 and a BP of 70/40. The patient was given IV fluids and 1 unit of PRBC's (post-transfusion hematocrit was 29), was stabilized, and then med flighted to <Hospital>Whitaker Ltd Health System</Hospital>. Past Medical History: IgA nephropathy Hypertension Gout Psoriasis Social History: Patient has a significant alcohol history of <Date>3-27</Date> drinks/day Family History: Non-contributory Physical Exam: Gen: A+Ox3 CV: RRR Lungs: Crackles at right base Abd: Soft, distended, very mild tenderness to palpation diffusely, incision clean/dry/intact Ext: No cyanosis or edema Pertinent Results: <Date>1932-8-10</Date> 07:30PM BLOOD WBC-24.0# RBC-3.22 Hgb-9.6* Hct-28.5* MCV-89 MCH-29.8 MCHC-33.6 RDW-13.1 Plt Ct-404# <Date>1989-3-29</Date> 04:20AM BLOOD WBC-18.0* RBC-2.84* Hgb-8.1* Hct-24.7* MCV-87 MCH-28.6 MCHC-32.9 RDW-13.3 Plt Ct-345 <Date>1989-3-29</Date> 10:30AM BLOOD WBC-19.8* RBC-3.45* Hgb-10.0* Hct-29.4* MCV-85 MCH-29.0 MCHC-34.0 RDW-14.0 Plt Ct-272 <Date>1989-3-29</Date> 01:56PM BLOOD WBC-15.7* RBC-3.25* Hgb-9.3* Hct-27.8* MCV-85 MCH-28.6 MCHC-33.5 RDW-14.0 Plt Ct-259 <Date>1989-3-29</Date> 05:48PM BLOOD Hct-30.2* <Date>1940-9-20</Date> 06:35AM BLOOD Hct-28.3* <Date>1940-9-20</Date> 04:45PM BLOOD Hct-30.6* <Date>2012-5-15</Date> 07:35AM BLOOD WBC-12.2* RBC-3.33* Hgb-9.6* Hct-28.7* MCV-86 MCH-28.9 MCHC-33.4 RDW-13.9 Plt Ct-326 <Date>1932-8-10</Date> 07:30PM BLOOD Glucose-142* UreaN-44* Creat-2.5* Na-140 K-5.8* Cl-107 HCO3-21* AnGap-18 <Date>1989-3-29</Date> 04:20AM BLOOD Glucose-137* UreaN-47* Creat-2.9* Na-140 K-6.6* Cl-110* HCO3-21* AnGap-16 <Date>1989-3-29</Date> 10:30AM BLOOD Glucose-129* UreaN-42* Creat-2.5* Na-141 K-4.9 Cl-107 HCO3-20* AnGap-19 <Date>1989-3-29</Date> 01:56PM BLOOD Glucose-118* UreaN-38* Creat-2.3* Na-141 K-4.9 Cl-107 HCO3-22 AnGap-17 <Date>1989-3-29</Date> 05:48PM BLOOD Glucose-120* UreaN-35* Creat-2.2* Na-141 K-4.8 Cl-105 HCO3-22 AnGap-19 <Date>1940-9-20</Date> 06:35AM BLOOD Glucose-126* UreaN-25* Creat-1.8* Na-137 K-4.3 Cl-105 HCO3-23 AnGap-13 <Date>1989-3-29</Date> 10:30AM BLOOD Lipase-616* <Date>1989-3-29</Date> 01:56PM BLOOD Lipase-390* <Date>1940-9-20</Date> 06:35AM BLOOD Lipase-111* <Date>1989-3-29</Date> 10:30AM BLOOD ALT-24 AST-21 LD(LDH)-296* AlkPhos-95 Amylase-436* TotBili-0.9 <Date>1940-9-20</Date> 06:35AM BLOOD ALT-16 AST-16 AlkPhos-87 Amylase-165* TotBili-0.7 Brief Hospital Course: The patient was admitted to the MICU and was transfused 2 units of PRBS's. Post-transfusion hematocrit remained stable around 30. A CT scan was obtained on hospital day #2, which showed a small-to-moderate amount of high density fluid which most likely represented blood around the liver and the spleen and the right kidney, with adjacent perinephric fluid/hematoma. The origin of bleeding was not definitively identified, but bleeding could potentially have been arising in the kidney given the history of recent renal surgery and history of hematuria. No active extravasation was identified. The patient was hemodynamically stable throughout his stay in the MICU, and was transferred to the floor on HD#2. A repeat CT on hospital day #3 showed no active changes from the previous scan. On HD#4, the patient appeared more distended, though he continued to pass flatus. A KUB was obtained, which showed no signs of obstruction. An MRI urogram was also obtained, which showed stable blood around the right kidney, extending into the peritoneum and a blood clot within the right renal pelvis. The patient continued to remain stable with a hematocrit holing steady around 30 and a creatinine holding steady at 2.1. The patient was discharged on HD#7 in stable condition. Medications on Admission: Atenolol 50 mg PO QDaily Lisinopril 20 mg PO QDaily Norvasc 5 mg PO QDaily Lipitor 10 mg PO QDaily Allopurinol 100 mg PO QDaily Protonix 25 mg PO QDaily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): please take while taking pain medications. Stop if loose bowel movements. Disp:30 Capsule(s) Refills:2 2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p right partial nephrectomy, readmitted for question of postoperative bleed Discharge Condition: stable Discharge Instructions: Call Dr.<Name>Gaspar Dizon</Name> office for follow up Followup Instructions: as 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000000000	Admission Date: 1932-8-10 Discharge Date: 1974-7-13 Date of Birth: 1908-3-10 Sex: M Service: GU Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Carl Chief Complaint: Sharp abdominal pain after cough, gross hematuria Major Surgical or Invasive Procedure: s/p right partial nephrectomy on 1962-3-12 History of Present Illness: Pt is a 50 year old male who underwent a right partial nephrectomy on 1962-3-12 and was discharged and presented to the ER on 2020-3-20 after an MVA with complaint of serosanguinous discharge from old chest tube site. Chest xray and ultrasound at the time were negative. The patient then returned to hospital on 1932-8-10 with a complaint of severe abdominal pain and one episode of gross hematuria after a cough. The patient presented to an outside hospital with a hematocrit of 27 and a BP of 70/40. The patient was given IV fluids and 1 unit of PRBC's (post-transfusion hematocrit was 29), was stabilized, and then med flighted to Whitaker Ltd Health System. Past Medical History: IgA nephropathy Hypertension Gout Psoriasis Social History: Patient has a significant alcohol history of 3-27 drinks/day Family History: Non-contributory Physical Exam: Gen: A+Ox3 CV: RRR Lungs: Crackles at right base Abd: Soft, distended, very mild tenderness to palpation diffusely, incision clean/dry/intact Ext: No cyanosis or edema Pertinent Results: 1932-8-10 07:30PM BLOOD WBC-24.0# RBC-3.22 Hgb-9.6* Hct-28.5* MCV-89 MCH-29.8 MCHC-33.6 RDW-13.1 Plt Ct-404# 1989-3-29 04:20AM BLOOD WBC-18.0* RBC-2.84* Hgb-8.1* Hct-24.7* MCV-87 MCH-28.6 MCHC-32.9 RDW-13.3 Plt Ct-345 1989-3-29 10:30AM BLOOD WBC-19.8* RBC-3.45* Hgb-10.0* Hct-29.4* MCV-85 MCH-29.0 MCHC-34.0 RDW-14.0 Plt Ct-272 1989-3-29 01:56PM BLOOD WBC-15.7* RBC-3.25* Hgb-9.3* Hct-27.8* MCV-85 MCH-28.6 MCHC-33.5 RDW-14.0 Plt Ct-259 1989-3-29 05:48PM BLOOD Hct-30.2* 1940-9-20 06:35AM BLOOD Hct-28.3* 1940-9-20 04:45PM BLOOD Hct-30.6* 2012-5-15 07:35AM BLOOD WBC-12.2* RBC-3.33* Hgb-9.6* Hct-28.7* MCV-86 MCH-28.9 MCHC-33.4 RDW-13.9 Plt Ct-326 1932-8-10 07:30PM BLOOD Glucose-142* UreaN-44* Creat-2.5* Na-140 K-5.8* Cl-107 HCO3-21* AnGap-18 1989-3-29 04:20AM BLOOD Glucose-137* UreaN-47* Creat-2.9* Na-140 K-6.6* Cl-110* HCO3-21* AnGap-16 1989-3-29 10:30AM BLOOD Glucose-129* UreaN-42* Creat-2.5* Na-141 K-4.9 Cl-107 HCO3-20* AnGap-19 1989-3-29 01:56PM BLOOD Glucose-118* UreaN-38* Creat-2.3* Na-141 K-4.9 Cl-107 HCO3-22 AnGap-17 1989-3-29 05:48PM BLOOD Glucose-120* UreaN-35* Creat-2.2* Na-141 K-4.8 Cl-105 HCO3-22 AnGap-19 1940-9-20 06:35AM BLOOD Glucose-126* UreaN-25* Creat-1.8* Na-137 K-4.3 Cl-105 HCO3-23 AnGap-13 1989-3-29 10:30AM BLOOD Lipase-616* 1989-3-29 01:56PM BLOOD Lipase-390* 1940-9-20 06:35AM BLOOD Lipase-111* 1989-3-29 10:30AM BLOOD ALT-24 AST-21 LD(LDH)-296* AlkPhos-95 Amylase-436* TotBili-0.9 1940-9-20 06:35AM BLOOD ALT-16 AST-16 AlkPhos-87 Amylase-165* TotBili-0.7 Brief Hospital Course: The patient was admitted to the MICU and was transfused 2 units of PRBS's. Post-transfusion hematocrit remained stable around 30. A CT scan was obtained on hospital day #2, which showed a small-to-moderate amount of high density fluid which most likely represented blood around the liver and the spleen and the right kidney, with adjacent perinephric fluid/hematoma. The origin of bleeding was not definitively identified, but bleeding could potentially have been arising in the kidney given the history of recent renal surgery and history of hematuria. No active extravasation was identified. The patient was hemodynamically stable throughout his stay in the MICU, and was transferred to the floor on HD#2. A repeat CT on hospital day #3 showed no active changes from the previous scan. On HD#4, the patient appeared more distended, though he continued to pass flatus. A KUB was obtained, which showed no signs of obstruction. An MRI urogram was also obtained, which showed stable blood around the right kidney, extending into the peritoneum and a blood clot within the right renal pelvis. The patient continued to remain stable with a hematocrit holing steady around 30 and a creatinine holding steady at 2.1. The patient was discharged on HD#7 in stable condition. Medications on Admission: Atenolol 50 mg PO QDaily Lisinopril 20 mg PO QDaily Norvasc 5 mg PO QDaily Lipitor 10 mg PO QDaily Allopurinol 100 mg PO QDaily Protonix 25 mg PO QDaily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): please take while taking pain medications. Stop if loose bowel movements. Disp:30 Capsule(s) Refills:2 2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p right partial nephrectomy, readmitted for question of postoperative bleed Discharge Condition: stable Discharge Instructions: Call Dr.Gaspar Dizon office for follow up Followup Instructions: as above	['Admission Date: 1932-8-10 Discharge Date: 1974-7-13\n\nDate of Birth: 1908-3-10 Sex: M\n\nService: GU\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Carl\nChief Complaint:\nSharp abdominal pain after cough, gross hematuria\n\nMajor Surgical or Invasive Procedure:\ns/p right partial nephrectomy on 1962-3-12\n\nHistory of Present Illness:\nPt is a 50 year old male who underwent a right partial\nnephrectomy on 1962-3-12 and was discharged and presented to the\nER on 2020-3-20 after an MVA with complaint of serosanguinous\ndischarge from old chest tube site. Chest xray and ultrasound at\nthe time were negative. The patient then returned to hospital on\n1932-8-10 with a complaint of severe abdominal pain and one\nepisode of gross hematuria after a cough.', " The patient presented\nto an outside hospital with a hematocrit of 27 and a BP of\n70/40. The patient was given IV fluids and 1 unit of PRBC's\n(post-transfusion hematocrit was 29), was stabilized, and then\nmed flighted to Whitaker Ltd Health System.\n\nPast Medical History:\nIgA nephropathy\nHypertension\nGout\nPsoriasis\n\n\nSocial History:\nPatient has a significant alcohol history of 3-27 drinks/day\n\nFamily History:\nNon-contributory\n\nPhysical Exam:\nGen: A+Ox3\nCV: RRR\nLungs: Crackles at right base\nAbd: Soft, distended, very mild tenderness to palpation\ndiffusely, incision clean/dry/intact\nExt: No cyanosis or edema\n\nPertinent Results:\n1932-8-10 07:30PM BLOOD WBC-24.0# RBC-3.22 Hgb-9.6* Hct-28.5\nMCV-89 MCH-29.8 MCHC-33.6 RDW-13.1 Plt Ct-404#\n1989-3-29 04:20AM BLOOD WBC-18.0 RBC-2.84* Hgb-8.1* Hct-24.", '7\nMCV-87 MCH-28.6 MCHC-32.9 RDW-13.3 Plt Ct-345\n1989-3-29 10:30AM BLOOD WBC-19.8 RBC-3.45* Hgb-10.0* Hct-29.4\nMCV-85 MCH-29.0 MCHC-34.0 RDW-14.0 Plt Ct-272\n1989-3-29 01:56PM BLOOD WBC-15.7 RBC-3.25* Hgb-9.3* Hct-27.8\nMCV-85 MCH-28.6 MCHC-33.5 RDW-14.0 Plt Ct-259\n1989-3-29 05:48PM BLOOD Hct-30.2\n1940-9-20 06:35AM BLOOD Hct-28.3\n1940-9-20 04:45PM BLOOD Hct-30.6\n2012-5-15 07:35AM BLOOD WBC-12.2* RBC-3.33* Hgb-9.6* Hct-28.7\nMCV-86 MCH-28.9 MCHC-33.4 RDW-13.9 Plt Ct-326\n1932-8-10 07:30PM BLOOD Glucose-142 UreaN-44* Creat-2.5* Na-140\nK-5.8* Cl-107 HCO3-21* AnGap-18\n1989-3-29 04:20AM BLOOD Glucose-137* UreaN-47* Creat-2.9* Na-140\nK-6.6* Cl-110* HCO3-21* AnGap-16\n1989-3-29 10:30AM BLOOD Glucose-129* UreaN-42* Creat-2.5* Na-141\nK-4.9 Cl-107 HCO3-20* AnGap-19\n1989-3-29 01:56PM BLOOD Glucose-118* UreaN-38* Creat-2.', "3* Na-141\nK-4.9 Cl-107 HCO3-22 AnGap-17\n1989-3-29 05:48PM BLOOD Glucose-120* UreaN-35* Creat-2.2* Na-141\nK-4.8 Cl-105 HCO3-22 AnGap-19\n1940-9-20 06:35AM BLOOD Glucose-126* UreaN-25* Creat-1.8* Na-137\nK-4.3 Cl-105 HCO3-23 AnGap-13\n1989-3-29 10:30AM BLOOD Lipase-616\n1989-3-29 01:56PM BLOOD Lipase-390\n1940-9-20 06:35AM BLOOD Lipase-111\n1989-3-29 10:30AM BLOOD ALT-24 AST-21 LD(LDH)-296 AlkPhos-95\nAmylase-436* TotBili-0.9\n1940-9-20 06:35AM BLOOD ALT-16 AST-16 AlkPhos-87 Amylase-165\nTotBili-0.7\n\nBrief Hospital Course:\nThe patient was admitted to the MICU and was transfused 2 units\nof PRBS's. Post-transfusion hematocrit remained stable around\n30. A CT scan was obtained on hospital day #2, which showed a\nsmall-to-moderate amount of high density fluid which most likely\nrepresented blood around the liver and the spleen and the right\nkidney, with\nadjacent perinephric fluid/hematoma.", ' The origin of bleeding was\nnot definitively identified, but bleeding could potentially have\nbeen arising in the kidney given the history of recent renal\nsurgery and history of hematuria. No active extravasation was\nidentified. The patient was hemodynamically stable throughout\nhis stay in the MICU, and was transferred to the floor on HD#2.\nA repeat CT on hospital day #3 showed no active changes from the\nprevious scan. On HD#4, the patient appeared more distended,\nthough he continued to pass flatus. A KUB was obtained, which\nshowed no signs of obstruction. An MRI urogram was also\nobtained, which showed stable blood around the right kidney,\nextending into the peritoneum and a blood clot within the right\nrenal pelvis. The patient continued to remain stable with a\nhematocrit holing steady around 30 and a creatinine holding\nsteady at 2.', '1. The patient was discharged on HD#7 in stable\ncondition.\n\n\nMedications on Admission:\nAtenolol 50 mg PO QDaily\nLisinopril 20 mg PO QDaily\nNorvasc 5 mg PO QDaily\nLipitor 10 mg PO QDaily\nAllopurinol 100 mg PO QDaily\nProtonix 25 mg PO QDaily\n\nDischarge Medications:\n1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day): please take while taking pain medications. Stop\nif loose bowel movements.\nDisp:30 Capsule(s)* Refills:2\n2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every\n4 hours) as needed for pain.\nDisp:50 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\ns/p right partial nephrectomy, readmitted for question of\npostoperative bleed\n\n\nDischarge Condition:\nstable\n\nDischarge Instructions:\nCall Dr.Gaspar Dizon office for follow up\n\nFollowup Instructions:\nas above\n\n\n\n']
160	26883	149002.0	2189-02-15	Discharge summary	Report	Admission Date: [2189-2-5] Discharge Date: [2189-2-15] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1711] Chief Complaint: s/p collapse Major Surgical or Invasive Procedure: Intubation Central venous line placement History of Present Illness: [Age over 90 ] yo F hx IDDM, HTN who presented after she collapsed in the lobby of her building while awaiting her son to pick her up for appointment to see her PCP. [Name10 (NameIs) ] was reportedly feeling well recently according to son, no infectious symptoms. She came down to the lobby and sat in a chair while waiting and then collapsed. Pt had CPR initiated from bystanders (RN and aide in lobby), per report EMS on presentation noted VFib, was defibrillated 200J x1. Review of provided strip appears to demonsrate a NSR with artifact followed by shock and resumption of NSR. FS was 188, unresponsive, intubated in the field. Pt hypotensive to 60's on arrival to ED, rec'd 1.5 L NS, started on levophed transiently. Pt had head, chest/abd CTs performed which were unrevealing. Past Medical History: IDDM c/b retinopathy, neuropathy HTN H/O FRONTAL LOBE MENINGIOMA - RESECTED IN [2124] S/P HEMORROIDECTOMY S/P T AND A Social History: lives by herself, independently, no prior hx of tobacco. Family History: NC Physical Exam: VS: T 93.4, BP 156/60, HR 58 , RR 16, O2 % on Gen: elderly female, sedated, intubated, unresponsive. HEENT: Pupils 2mm, nonreactive. CV: RRR nl S1, S2, no m/r/g Chest: breath sound b/l Abd: soft, ND, no HSM Ext: 2+ R pedal edema, palpable DP and PT pulses b/l Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2189-2-5] 02:46PM BLOOD WBC-7.4 RBC-3.00* Hgb-9.6* Hct-28.7* MCV-96 MCH-32.2* MCHC-33.6 RDW-15.1 Plt Ct-265 [2189-2-5] 02:46PM BLOOD PT-12.2 PTT-25.8 INR(PT)-1.0 [2189-2-5] 07:15PM BLOOD Glucose-216* UreaN-27* Creat-0.9 Na-141 K-4.1 Cl-108 HCO3-22 AnGap-15 [2189-2-5] 07:15PM BLOOD CK-MB-10 MB Indx-5.2 cTropnT-<0.01 [2189-2-6] 06:00AM BLOOD CK-MB-9 cTropnT-0.02* [2189-2-5] 07:15PM BLOOD CK(CPK)-192* [2189-2-6] 06:00AM BLOOD CK(CPK)-131 [2189-2-6] 04:10PM BLOOD ALT-12 AST-13 AlkPhos-41 TotBili-0.5 [2189-2-7] 02:34AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.6 [2189-2-5] 09:55PM BLOOD calTIBC-226* VitB12-325 Ferritn-158* TRF-174* [2189-2-6] 04:10PM BLOOD TSH-0.80 [2189-2-6] 04:10PM BLOOD Free T4-1.0 [2189-2-6] 04:10PM BLOOD Cortsol-42.3* [2189-2-5] 02:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.5 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2189-2-7] 02:48AM BLOOD Type-ART pO2-88 pCO2-35 pH-7.34* calTCO2-20* Base XS--5 CXR: No priors available for comparison. Today's examination is markedly limited by low lung volumes causing crowding of the bronchovascular structures. The right hemidiaphragm is asymmetrically elevated in comparison to the left hemidiaphragm. There is marked distention of the stomach and abdominal bowel likely related to resuscitative effort. Slightly increased spacing between the gastric bubble and the left hemidiaphragm may suggest a component of subpulmonic effusion. There is an ill-defined retrocardiac opacity which may reflect atelectasis and/or sequelae of aspiration. Endotracheal tube terminates 4.7 cm from the carina. The aorta is slightly ectatic and calcified and there is multilevel degenerative changes of the spine. No pneumothorax or large effusions are identified. IMPRESSION: 1) Appropriately positioned endotracheal tube. Gaseous distention of stomach and bowel likely related to resuscitative efforts. NGT may be of benefit. 2) Ill-defined retrocardiac opacity may represent atelectasis and/or sequelae from aspiration. CTA Torso: 1. No etiology for acute arrest identified. No PE or aortic dissection. Mild dilatation of the right main pulmonary artery may suggest underlying pulmonary arterial hypertension. 2. Moderate amount of secretions distal to the endotracheal tube within the trachea proximal to the carina may place the patient at risk for aspiration. 3. Non-obstructive left renal calculi and simple left renal cyst. 4. Incompletely characterized right adrenal lesion, likely benign on patient of this age. Hypoattenuating right thyroid lesion also likely benign in a patient's age. 5. Cholelithiasis without evidence of acute cholecystitis. 6. Extensive vasculopathy. Is there a history of diabetes? TTE: The left atrium is elongated. The interatrial septum is aneurysmal. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF 70-80%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. EEG: This is an abnormal EEG due to the existence of an active area of epileptogenesis in the left posterior frontal to anterior temporal region. Though this activity did not meet criteria for focal status epilepticus, there were periods of apparent electrographic seizures without evident clinical correlate. The presence of a slow and disorganized background is consistent with a moderate encephalopathy of toxic, metabolic, or anoxic etiology. CT C-SPINE W/O CONTRAST [2189-2-9] 9:17 PM 1. No fracture or malalignment is detected. 2. Diffuse calcification of the transverse ligament adjacent to the dens causes severe canal narrowing and cord impingement. The thecal sac measures approximately 5 mm at this area. 3. Hyperdense focus within the lower pole of pons and upper medulla, might represent intraparenchymal hemorrhage or cavernoma. 4. Bilateral thyroid nodules which can be further evaluated on nonemergent basis. CT HEAD W/O CONTRAST [2189-2-9] 9:15 PM SMALL INTRAVENTRICULAR HEMOORHAGE IN THE OCCIPITAL HORNS AND SMALL FOCUS OF HEMORRHAGE IN THE UPPER MEDULLA. HOWEVER, THE CAUSE OF THIS IS UNCERTAIN FROM THE PRESENT STUDY. A CLOSE FOLLOW-UP EXAMINATION OR MR HEAD WITHOUT AND WITH IV CONTRAST, WOULD BE HELPFUL. MRI HEAD/CSPINE [2189-2-11] 1-cm hemorrhagic non-enhancing lesion of the caudal medulla with expansion and edema. This finding may represent a hemorrhagic infarct versus a cavernoma. Given the findings on the concurrent MR cervical spine, a hemorrhagic infarct is favored. Hemorrhagic neoplasm is thought to be less likely given the lack of contrast enhancement and no prior history of cancer. Multiple extra-axial partially calcified enhancing masses as described above consistent with meningiomas. Intraventricular blood as before. Brief Hospital Course: The patient presented with syncope of unknown etiology, but likely secondary to ischemia/hemorrhage in her caudal medulla and also found to have cervical lesion and edema causing canal stenosis and compression. She was initially treated with cooling protocol due to possible cardiac arrest, but found to be in sinus rhythm. Patient was intubated and not breathing spontaneously. Initially, patient evaluated by CT head on [2-5] that showed no intracranial hemorrhage or mass. Unable to do MRI as patient with staples from prior meningioma surgery from [2120]. We did daily neurologic assessments to follow recovery s/p cooling protocol, showing patient was awake, sometimes tracking with her eyes, with some facial movements, but not moving any extremities. Repeat CT head/spine on [2-9] showing multiple hemorrhages including a lesion in her caudal medulla and edema/mass around her cervical spine. Neurology was following and after speaking to neuroradiology, patient was deemed safe to have MRI evaluation. On [2-10], patient evaluated by MRI which showed same findings. Read of MRI showing two hemorrhagic/ischemic lesions of the caudal medulla and cervical cord with severe cord compression. No indication for any surgical intervention per neurosurg and neurology.Patient trialed twice on PSV with no spontaneous respirations. One week after insult, family meeting arranged to discuss poor prognosis given lack of recovery and goals of care. Family made decision not to remove care but to place patient on spontaneous breathing trial without reinstating intubation. The patient failed the the SBT and expired 8 minutes afterwards. Medications on Admission: Klonopin Insulin Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2189-2-17]	Admission Date: <Date>1902-9-2</Date> Discharge Date: <Date>1970-5-1</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Shirley</Name> Chief Complaint: s/p collapse Major Surgical or Invasive Procedure: Intubation Central venous line placement History of Present Illness: <Age>35</Age> yo F hx IDDM, HTN who presented after she collapsed in the lobby of her building while awaiting her son to pick her up for appointment to see her PCP. <Name>Sean Benhamou</Name> was reportedly feeling well recently according to son, no infectious symptoms. She came down to the lobby and sat in a chair while waiting and then collapsed. Pt had CPR initiated from bystanders (RN and aide in lobby), per report EMS on presentation noted VFib, was defibrillated 200J x1. Review of provided strip appears to demonsrate a NSR with artifact followed by shock and resumption of NSR. FS was 188, unresponsive, intubated in the field. Pt hypotensive to 60's on arrival to ED, rec'd 1.5 L NS, started on levophed transiently. Pt had head, chest/abd CTs performed which were unrevealing. Past Medical History: IDDM c/b retinopathy, neuropathy HTN H/O FRONTAL LOBE MENINGIOMA - RESECTED IN <Year>1953</Year> S/P HEMORROIDECTOMY S/P T AND A Social History: lives by herself, independently, no prior hx of tobacco. Family History: NC Physical Exam: VS: T 93.4, BP 156/60, HR 58 , RR 16, O2 % on Gen: elderly female, sedated, intubated, unresponsive. HEENT: Pupils 2mm, nonreactive. CV: RRR nl S1, S2, no m/r/g Chest: breath sound b/l Abd: soft, ND, no HSM Ext: 2+ R pedal edema, palpable DP and PT pulses b/l Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: <Date>1902-9-2</Date> 02:46PM BLOOD WBC-7.4 RBC-3.00* Hgb-9.6* Hct-28.7* MCV-96 MCH-32.2* MCHC-33.6 RDW-15.1 Plt Ct-265 <Date>1902-9-2</Date> 02:46PM BLOOD PT-12.2 PTT-25.8 INR(PT)-1.0 <Date>1902-9-2</Date> 07:15PM BLOOD Glucose-216* UreaN-27* Creat-0.9 Na-141 K-4.1 Cl-108 HCO3-22 AnGap-15 <Date>1902-9-2</Date> 07:15PM BLOOD CK-MB-10 MB Indx-5.2 cTropnT-<0.01 <Date>1921-9-4</Date> 06:00AM BLOOD CK-MB-9 cTropnT-0.02* <Date>1902-9-2</Date> 07:15PM BLOOD CK(CPK)-192* <Date>1921-9-4</Date> 06:00AM BLOOD CK(CPK)-131 <Date>1921-9-4</Date> 04:10PM BLOOD ALT-12 AST-13 AlkPhos-41 TotBili-0.5 <Date>2007-11-29</Date> 02:34AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.6 <Date>1902-9-2</Date> 09:55PM BLOOD calTIBC-226* VitB12-325 Ferritn-158* TRF-174* <Date>1921-9-4</Date> 04:10PM BLOOD TSH-0.80 <Date>1921-9-4</Date> 04:10PM BLOOD Free T4-1.0 <Date>1921-9-4</Date> 04:10PM BLOOD Cortsol-42.3* <Date>1902-9-2</Date> 02:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.5 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG <Date>2007-11-29</Date> 02:48AM BLOOD Type-ART pO2-88 pCO2-35 pH-7.34* calTCO2-20* Base XS--5 CXR: No priors available for comparison. Today's examination is markedly limited by low lung volumes causing crowding of the bronchovascular structures. The right hemidiaphragm is asymmetrically elevated in comparison to the left hemidiaphragm. There is marked distention of the stomach and abdominal bowel likely related to resuscitative effort. Slightly increased spacing between the gastric bubble and the left hemidiaphragm may suggest a component of subpulmonic effusion. There is an ill-defined retrocardiac opacity which may reflect atelectasis and/or sequelae of aspiration. Endotracheal tube terminates 4.7 cm from the carina. The aorta is slightly ectatic and calcified and there is multilevel degenerative changes of the spine. No pneumothorax or large effusions are identified. IMPRESSION: 1) Appropriately positioned endotracheal tube. Gaseous distention of stomach and bowel likely related to resuscitative efforts. NGT may be of benefit. 2) Ill-defined retrocardiac opacity may represent atelectasis and/or sequelae from aspiration. CTA Torso: 1. No etiology for acute arrest identified. No PE or aortic dissection. Mild dilatation of the right main pulmonary artery may suggest underlying pulmonary arterial hypertension. 2. Moderate amount of secretions distal to the endotracheal tube within the trachea proximal to the carina may place the patient at risk for aspiration. 3. Non-obstructive left renal calculi and simple left renal cyst. 4. Incompletely characterized right adrenal lesion, likely benign on patient of this age. Hypoattenuating right thyroid lesion also likely benign in a patient's age. 5. Cholelithiasis without evidence of acute cholecystitis. 6. Extensive vasculopathy. Is there a history of diabetes? TTE: The left atrium is elongated. The interatrial septum is aneurysmal. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF 70-80%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. EEG: This is an abnormal EEG due to the existence of an active area of epileptogenesis in the left posterior frontal to anterior temporal region. Though this activity did not meet criteria for focal status epilepticus, there were periods of apparent electrographic seizures without evident clinical correlate. The presence of a slow and disorganized background is consistent with a moderate encephalopathy of toxic, metabolic, or anoxic etiology. CT C-SPINE W/O CONTRAST <Date>1943-7-9</Date> 9:17 PM 1. No fracture or malalignment is detected. 2. Diffuse calcification of the transverse ligament adjacent to the dens causes severe canal narrowing and cord impingement. The thecal sac measures approximately 5 mm at this area. 3. Hyperdense focus within the lower pole of pons and upper medulla, might represent intraparenchymal hemorrhage or cavernoma. 4. Bilateral thyroid nodules which can be further evaluated on nonemergent basis. CT HEAD W/O CONTRAST <Date>1943-7-9</Date> 9:15 PM SMALL INTRAVENTRICULAR HEMOORHAGE IN THE OCCIPITAL HORNS AND SMALL FOCUS OF HEMORRHAGE IN THE UPPER MEDULLA. HOWEVER, THE CAUSE OF THIS IS UNCERTAIN FROM THE PRESENT STUDY. A CLOSE FOLLOW-UP EXAMINATION OR MR HEAD WITHOUT AND WITH IV CONTRAST, WOULD BE HELPFUL. MRI HEAD/CSPINE <Date>1905-10-7</Date> 1-cm hemorrhagic non-enhancing lesion of the caudal medulla with expansion and edema. This finding may represent a hemorrhagic infarct versus a cavernoma. Given the findings on the concurrent MR cervical spine, a hemorrhagic infarct is favored. Hemorrhagic neoplasm is thought to be less likely given the lack of contrast enhancement and no prior history of cancer. Multiple extra-axial partially calcified enhancing masses as described above consistent with meningiomas. Intraventricular blood as before. Brief Hospital Course: The patient presented with syncope of unknown etiology, but likely secondary to ischemia/hemorrhage in her caudal medulla and also found to have cervical lesion and edema causing canal stenosis and compression. She was initially treated with cooling protocol due to possible cardiac arrest, but found to be in sinus rhythm. Patient was intubated and not breathing spontaneously. Initially, patient evaluated by CT head on <Date>4-10</Date> that showed no intracranial hemorrhage or mass. Unable to do MRI as patient with staples from prior meningioma surgery from <Year>1953</Year>. We did daily neurologic assessments to follow recovery s/p cooling protocol, showing patient was awake, sometimes tracking with her eyes, with some facial movements, but not moving any extremities. Repeat CT head/spine on <Date>3-15</Date> showing multiple hemorrhages including a lesion in her caudal medulla and edema/mass around her cervical spine. Neurology was following and after speaking to neuroradiology, patient was deemed safe to have MRI evaluation. On <Date>11-15</Date>, patient evaluated by MRI which showed same findings. Read of MRI showing two hemorrhagic/ischemic lesions of the caudal medulla and cervical cord with severe cord compression. No indication for any surgical intervention per neurosurg and neurology.Patient trialed twice on PSV with no spontaneous respirations. One week after insult, family meeting arranged to discuss poor prognosis given lack of recovery and goals of care. Family made decision not to remove care but to place patient on spontaneous breathing trial without reinstating intubation. The patient failed the the SBT and expired 8 minutes afterwards. Medications on Admission: Klonopin Insulin Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed 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Date: 1902-9-2 Discharge Date: 1970-5-1 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Shirley Chief Complaint: s/p collapse Major Surgical or Invasive Procedure: Intubation Central venous line placement History of Present Illness: 35 yo F hx IDDM, HTN who presented after she collapsed in the lobby of her building while awaiting her son to pick her up for appointment to see her PCP. Sean Benhamou was reportedly feeling well recently according to son, no infectious symptoms. She came down to the lobby and sat in a chair while waiting and then collapsed. Pt had CPR initiated from bystanders (RN and aide in lobby), per report EMS on presentation noted VFib, was defibrillated 200J x1. Review of provided strip appears to demonsrate a NSR with artifact followed by shock and resumption of NSR. FS was 188, unresponsive, intubated in the field. Pt hypotensive to 60's on arrival to ED, rec'd 1.5 L NS, started on levophed transiently. Pt had head, chest/abd CTs performed which were unrevealing. Past Medical History: IDDM c/b retinopathy, neuropathy HTN H/O FRONTAL LOBE MENINGIOMA - RESECTED IN 1953 S/P HEMORROIDECTOMY S/P T AND A Social History: lives by herself, independently, no prior hx of tobacco. Family History: NC Physical Exam: VS: T 93.4, BP 156/60, HR 58 , RR 16, O2 % on Gen: elderly female, sedated, intubated, unresponsive. HEENT: Pupils 2mm, nonreactive. CV: RRR nl S1, S2, no m/r/g Chest: breath sound b/l Abd: soft, ND, no HSM Ext: 2+ R pedal edema, palpable DP and PT pulses b/l Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: 1902-9-2 02:46PM BLOOD WBC-7.4 RBC-3.00* Hgb-9.6* Hct-28.7* MCV-96 MCH-32.2* MCHC-33.6 RDW-15.1 Plt Ct-265 1902-9-2 02:46PM BLOOD PT-12.2 PTT-25.8 INR(PT)-1.0 1902-9-2 07:15PM BLOOD Glucose-216* UreaN-27* Creat-0.9 Na-141 K-4.1 Cl-108 HCO3-22 AnGap-15 1902-9-2 07:15PM BLOOD CK-MB-10 MB Indx-5.2 cTropnT-1921-9-4 06:00AM BLOOD CK-MB-9 cTropnT-0.02* 1902-9-2 07:15PM BLOOD CK(CPK)-192* 1921-9-4 06:00AM BLOOD CK(CPK)-131 1921-9-4 04:10PM BLOOD ALT-12 AST-13 AlkPhos-41 TotBili-0.5 2007-11-29 02:34AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.6 1902-9-2 09:55PM BLOOD calTIBC-226* VitB12-325 Ferritn-158* TRF-174* 1921-9-4 04:10PM BLOOD TSH-0.80 1921-9-4 04:10PM BLOOD Free T4-1.0 1921-9-4 04:10PM BLOOD Cortsol-42.3* 1902-9-2 02:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.5 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG 2007-11-29 02:48AM BLOOD Type-ART pO2-88 pCO2-35 pH-7.34* calTCO2-20* Base XS--5 CXR: No priors available for comparison. Today's examination is markedly limited by low lung volumes causing crowding of the bronchovascular structures. The right hemidiaphragm is asymmetrically elevated in comparison to the left hemidiaphragm. There is marked distention of the stomach and abdominal bowel likely related to resuscitative effort. Slightly increased spacing between the gastric bubble and the left hemidiaphragm may suggest a component of subpulmonic effusion. There is an ill-defined retrocardiac opacity which may reflect atelectasis and/or sequelae of aspiration. Endotracheal tube terminates 4.7 cm from the carina. The aorta is slightly ectatic and calcified and there is multilevel degenerative changes of the spine. No pneumothorax or large effusions are identified. IMPRESSION: 1) Appropriately positioned endotracheal tube. Gaseous distention of stomach and bowel likely related to resuscitative efforts. NGT may be of benefit. 2) Ill-defined retrocardiac opacity may represent atelectasis and/or sequelae from aspiration. CTA Torso: 1. No etiology for acute arrest identified. No PE or aortic dissection. Mild dilatation of the right main pulmonary artery may suggest underlying pulmonary arterial hypertension. 2. Moderate amount of secretions distal to the endotracheal tube within the trachea proximal to the carina may place the patient at risk for aspiration. 3. Non-obstructive left renal calculi and simple left renal cyst. 4. Incompletely characterized right adrenal lesion, likely benign on patient of this age. Hypoattenuating right thyroid lesion also likely benign in a patient's age. 5. Cholelithiasis without evidence of acute cholecystitis. 6. Extensive vasculopathy. Is there a history of diabetes? TTE: The left atrium is elongated. The interatrial septum is aneurysmal. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF 70-80%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. EEG: This is an abnormal EEG due to the existence of an active area of epileptogenesis in the left posterior frontal to anterior temporal region. Though this activity did not meet criteria for focal status epilepticus, there were periods of apparent electrographic seizures without evident clinical correlate. The presence of a slow and disorganized background is consistent with a moderate encephalopathy of toxic, metabolic, or anoxic etiology. CT C-SPINE W/O CONTRAST 1943-7-9 9:17 PM 1. No fracture or malalignment is detected. 2. Diffuse calcification of the transverse ligament adjacent to the dens causes severe canal narrowing and cord impingement. The thecal sac measures approximately 5 mm at this area. 3. Hyperdense focus within the lower pole of pons and upper medulla, might represent intraparenchymal hemorrhage or cavernoma. 4. Bilateral thyroid nodules which can be further evaluated on nonemergent basis. CT HEAD W/O CONTRAST 1943-7-9 9:15 PM SMALL INTRAVENTRICULAR HEMOORHAGE IN THE OCCIPITAL HORNS AND SMALL FOCUS OF HEMORRHAGE IN THE UPPER MEDULLA. HOWEVER, THE CAUSE OF THIS IS UNCERTAIN FROM THE PRESENT STUDY. A CLOSE FOLLOW-UP EXAMINATION OR MR HEAD WITHOUT AND WITH IV CONTRAST, WOULD BE HELPFUL. MRI HEAD/CSPINE 1905-10-7 1-cm hemorrhagic non-enhancing lesion of the caudal medulla with expansion and edema. This finding may represent a hemorrhagic infarct versus a cavernoma. Given the findings on the concurrent MR cervical spine, a hemorrhagic infarct is favored. Hemorrhagic neoplasm is thought to be less likely given the lack of contrast enhancement and no prior history of cancer. Multiple extra-axial partially calcified enhancing masses as described above consistent with meningiomas. Intraventricular blood as before. Brief Hospital Course: The patient presented with syncope of unknown etiology, but likely secondary to ischemia/hemorrhage in her caudal medulla and also found to have cervical lesion and edema causing canal stenosis and compression. She was initially treated with cooling protocol due to possible cardiac arrest, but found to be in sinus rhythm. Patient was intubated and not breathing spontaneously. Initially, patient evaluated by CT head on 4-10 that showed no intracranial hemorrhage or mass. Unable to do MRI as patient with staples from prior meningioma surgery from 1953. We did daily neurologic assessments to follow recovery s/p cooling protocol, showing patient was awake, sometimes tracking with her eyes, with some facial movements, but not moving any extremities. Repeat CT head/spine on 3-15 showing multiple hemorrhages including a lesion in her caudal medulla and edema/mass around her cervical spine. Neurology was following and after speaking to neuroradiology, patient was deemed safe to have MRI evaluation. On 11-15, patient evaluated by MRI which showed same findings. Read of MRI showing two hemorrhagic/ischemic lesions of the caudal medulla and cervical cord with severe cord compression. No indication for any surgical intervention per neurosurg and neurology.Patient trialed twice on PSV with no spontaneous respirations. One week after insult, family meeting arranged to discuss poor prognosis given lack of recovery and goals of care. Family made decision not to remove care but to place patient on spontaneous breathing trial without reinstating intubation. The patient failed the the SBT and expired 8 minutes afterwards. Medications on Admission: Klonopin Insulin Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:1973-1-12	['Admission Date: 1902-9-2 Discharge Date: 1970-5-1\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Shirley\nChief Complaint:\ns/p collapse\n\nMajor Surgical or Invasive Procedure:\nIntubation\nCentral venous line placement\n\nHistory of Present Illness:\n35 yo F hx IDDM, HTN who presented after she collapsed in the\nlobby of her building while awaiting her son to pick her up for\nappointment to see her PCP. Sean Benhamou was reportedly feeling well\nrecently according to son, no infectious symptoms. She came\ndown to the lobby and sat in a chair while waiting and then\ncollapsed. Pt had CPR initiated from bystanders (RN and aide in\nlobby), per report EMS on presentation noted VFib, was\ndefibrillated 200J x1. Review of provided strip appears to\ndemonsrate a NSR with artifact followed by shock and resumption\nof NSR.', " FS was 188, unresponsive, intubated in the field. Pt\nhypotensive to 60's on arrival to ED, rec'd 1.5 L NS, started on\nlevophed transiently. Pt had head, chest/abd CTs performed\nwhich were unrevealing.\n\n\nPast Medical History:\nIDDM c/b retinopathy, neuropathy\nHTN\nH/O FRONTAL LOBE MENINGIOMA - RESECTED IN 1953\nS/P HEMORROIDECTOMY\nS/P T AND A\n\n\nSocial History:\nlives by herself, independently, no prior hx of tobacco.\n\n\nFamily History:\nNC\n\nPhysical Exam:\nVS: T 93.4, BP 156/60, HR 58 , RR 16, O2 % on\nGen: elderly female, sedated, intubated, unresponsive.\nHEENT: Pupils 2mm, nonreactive.\nCV: RRR nl S1, S2, no m/r/g\nChest: breath sound b/l\nAbd: soft, ND, no HSM\nExt: 2+ R pedal edema, palpable DP and PT pulses b/l\nSkin: No stasis dermatitis, ulcers, scars, or xanthomas.\n\nPertinent Results:\n1902-9-2 02:46PM BLOOD WBC-7.", '4 RBC-3.00* Hgb-9.6* Hct-28.7\nMCV-96 MCH-32.2 MCHC-33.6 RDW-15.1 Plt Ct-265\n1902-9-2 02:46PM BLOOD PT-12.2 PTT-25.8 INR(PT)-1.0\n1902-9-2 07:15PM BLOOD Glucose-216* UreaN-27* Creat-0.9 Na-141\nK-4.1 Cl-108 HCO3-22 AnGap-15\n1902-9-2 07:15PM BLOOD CK-MB-10 MB Indx-5.2 cTropnT-1921-9-4 06:00AM BLOOD CK-MB-9 cTropnT-0.02\n1902-9-2 07:15PM BLOOD CK(CPK)-192\n1921-9-4 06:00AM BLOOD CK(CPK)-131\n1921-9-4 04:10PM BLOOD ALT-12 AST-13 AlkPhos-41 TotBili-0.5\n2007-11-29 02:34AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.6\n1902-9-2 09:55PM BLOOD calTIBC-226* VitB12-325 Ferritn-158\nTRF-174\n1921-9-4 04:10PM BLOOD TSH-0.80\n1921-9-4 04:10PM BLOOD Free T4-1.0\n1921-9-4 04:10PM BLOOD Cortsol-42.3\n1902-9-2 02:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.5\nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n2007-11-29 02:48AM BLOOD Type-ART pO2-88 pCO2-35 pH-7.', "34\ncalTCO2-20* Base XS--5\n\nCXR:\nNo priors available for comparison. Today's examination is\nmarkedly limited by low lung volumes causing crowding of the\nbronchovascular structures. The right hemidiaphragm is\nasymmetrically elevated in comparison to the left hemidiaphragm.\nThere is marked distention of the stomach and abdominal bowel\nlikely related to resuscitative effort. Slightly increased\nspacing between the gastric bubble and the left hemidiaphragm\nmay suggest a component of subpulmonic effusion. There is an\nill-defined retrocardiac opacity which may reflect atelectasis\nand/or sequelae of aspiration. Endotracheal tube terminates 4.7\ncm from the carina. The aorta is slightly ectatic and calcified\nand there is multilevel degenerative changes of the spine. No\npneumothorax or large effusions are identified.", "\n\nIMPRESSION:\n\n1) Appropriately positioned endotracheal tube. Gaseous\ndistention of stomach and bowel likely related to resuscitative\nefforts. NGT may be of benefit.\n\n2) Ill-defined retrocardiac opacity may represent atelectasis\nand/or sequelae from aspiration.\n\nCTA Torso:\n1. No etiology for acute arrest identified. No PE or aortic\ndissection. Mild dilatation of the right main pulmonary artery\nmay suggest underlying pulmonary arterial hypertension.\n\n2. Moderate amount of secretions distal to the endotracheal tube\nwithin the trachea proximal to the carina may place the patient\nat risk for aspiration.\n\n3. Non-obstructive left renal calculi and simple left renal\ncyst.\n\n4. Incompletely characterized right adrenal lesion, likely\nbenign on patient of this age. Hypoattenuating right thyroid\nlesion also likely benign in a patient's age.", '\n\n5. Cholelithiasis without evidence of acute cholecystitis.\n\n6. Extensive vasculopathy. Is there a history of diabetes?\n\nTTE:\nThe left atrium is elongated. The interatrial septum is\naneurysmal. Left ventricular wall thicknesses are normal. The\nleft ventricular cavity is small. Left ventricular systolic\nfunction is hyperdynamic (EF 70-80%). Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure\n(PCWP>18mmHg). There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Trivial mitral regurgitation is seen. [Due to\nacoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.', '] The left ventricular inflow\npattern suggests impaired relaxation. The tricuspid valve\nleaflets are mildly thickened. The supporting structures of the\ntricuspid valve are thickened/fibrotic. The pulmonary artery\nsystolic pressure could not be determined. There is no\npericardial effusion.\n\nEEG:\n This is an abnormal EEG due to the existence of an active\narea of epileptogenesis in the left posterior frontal to\nanterior\ntemporal region. Though this activity did not meet criteria for\nfocal\nstatus epilepticus, there were periods of apparent\nelectrographic\nseizures without evident clinical correlate. The presence of a\nslow and\ndisorganized background is consistent with a moderate\nencephalopathy of\ntoxic, metabolic, or anoxic etiology.\n\nCT C-SPINE W/O CONTRAST 1943-7-9 9:17 PM\n1. No fracture or malalignment is detected.', '\n2. Diffuse calcification of the transverse ligament adjacent to\nthe dens causes severe canal narrowing and cord impingement. The\nthecal sac measures approximately 5 mm at this area.\n3. Hyperdense focus within the lower pole of pons and upper\nmedulla, might represent intraparenchymal hemorrhage or\ncavernoma.\n4. Bilateral thyroid nodules which can be further evaluated on\nnonemergent basis.\n\nCT HEAD W/O CONTRAST 1943-7-9 9:15 PM\nSMALL INTRAVENTRICULAR HEMOORHAGE IN THE OCCIPITAL HORNS AND\nSMALL FOCUS OF HEMORRHAGE IN THE UPPER MEDULLA. HOWEVER, THE\nCAUSE OF THIS IS UNCERTAIN FROM THE PRESENT STUDY. A CLOSE\nFOLLOW-UP EXAMINATION OR MR HEAD WITHOUT AND WITH IV CONTRAST,\nWOULD BE HELPFUL.\n\nMRI HEAD/CSPINE 1905-10-7\n1-cm hemorrhagic non-enhancing lesion of the caudal medulla with\nexpansion and edema.', ' This finding may represent a hemorrhagic\ninfarct versus a cavernoma. Given the findings on the concurrent\nMR cervical spine, a hemorrhagic infarct is favored. Hemorrhagic\nneoplasm is thought to be less likely given the lack of contrast\nenhancement and no prior history of cancer.\nMultiple extra-axial partially calcified enhancing masses as\ndescribed above consistent with meningiomas.\nIntraventricular blood as before.\n\n\nBrief Hospital Course:\nThe patient presented with syncope of unknown etiology, but\nlikely secondary to ischemia/hemorrhage in her caudal medulla\nand also found to have cervical lesion and edema causing canal\nstenosis and compression. She was initially treated with cooling\nprotocol due to possible cardiac arrest, but found to be in\nsinus rhythm. Patient was intubated and not breathing\nspontaneously.', ' Initially, patient evaluated by CT head on 4-10\nthat showed no intracranial hemorrhage or mass. Unable to do MRI\nas patient with staples from prior meningioma surgery from\n1953. We did daily neurologic assessments to follow recovery\ns/p cooling protocol, showing patient was awake, sometimes\ntracking with her eyes, with some facial movements, but not\nmoving any extremities. Repeat CT head/spine on 3-15 showing\nmultiple hemorrhages including a lesion in her caudal medulla\nand edema/mass around her cervical spine. Neurology was\nfollowing and after speaking to neuroradiology, patient was\ndeemed safe to have MRI evaluation. On 11-15, patient evaluated\nby MRI which showed same findings. Read of MRI showing two\nhemorrhagic/ischemic lesions of the caudal medulla and cervical\ncord with severe cord compression.', ' No indication for any\nsurgical intervention per neurosurg and neurology.Patient\ntrialed twice on PSV with no spontaneous respirations. One week\nafter insult, family meeting arranged to discuss poor prognosis\ngiven lack of recovery and goals of care. Family made decision\nnot to remove care but to place patient on spontaneous breathing\ntrial without reinstating intubation. The patient failed the\nthe SBT and expired 8 minutes afterwards.\n\n\nMedications on Admission:\nKlonopin\nInsulin\n\n\nDischarge Medications:\nexpired\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\nexpired\n\nDischarge Condition:\nexpired\n\nDischarge Instructions:\nexpired\n\nFollowup Instructions:\nexpired\n\n\nCompleted by:1973-1-12']
161	17061	123364.0	2131-09-13	Discharge summary	Report	Admission Date: [2131-9-6] Discharge Date: [2131-9-13] Date of Birth: [2062-7-11] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Please note this is from Cardiology's dictated pre catheterization admission note as there was no history and physical examination from his preoperative visit in the chart. This is a 69-year-old male patient of Dr. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] with a longstanding history of exertional angina and abnormal stress test now with worsening symptoms who was referred for outpatient catheterization to [Hospital1 188]. He reports that for the past five to six years he has been experiencing exertional back pain until recently. It occurred with activity such as walking and was resolved with rest. Over the past two to three weeks, he feels that his symptoms have gotten worse. The pain is now radiating to his chest and seems to last for a longer period of time, requiring nitroglycerin for relief. He also reports having dyspnea after climbing hills. He does report occasionally having symptoms at rest over the past few weeks, for which he takes nitroglycerin with relief. He states this occurs one to two times per week on average. PAST MEDICAL HISTORY: 1. Positive exercise tolerance test. 2. Hypertension. 3. Hyperlipidemia. 4. Occasional lightheadedness upon waking in the morning. 5. Duodenal ulcer with melena in [2119]. 6. Thrombocytosis. 7. Prostate cancer; status post prostatectomy. 8. Left tibial fracture. 9. Status post polypectomy. 10. Non-insulin-dependent diabetes mellitus. ALLERGIES: He has no known drug allergies; although he does say he an allergy to SOME FISH (TUNA, STEAK, and BLUE FISH) which cause a drop in his blood pressure. He no longer eats fish. MEDICATIONS AT CATHETERIZATION TIME: Lisinopril 20 mg by mouth daily, Agrylin 0.5 mg by mouth daily three days a week and Agrylin 1 mg by mouth twice daily four days a week (per his hematologist Dr. [Last Name (STitle) 1712], Lipitor 5 mg by mouth daily, atenolol 25 mg by mouth daily, aspirin 325 mg by mouth daily, and Niferex 150 mg by mouth daily. FAMILY HISTORY: He has a positive family history. His son had a myocardial infarction at the age of 42. SOCIAL HISTORY: He is married and retired. He had no history of transient ischemic attack or cerebrovascular accident, but did have a positive history of melena and gastrointestinal bleed in [2119]. PHYSICAL EXAMINATION ON PRESENTATION: His height was 5 feet 9 inches and weight was 186 pounds. No preoperative recorded examination was noted. LABORATORY DATA ON PRESENTATION: Laboratories prior to procedure were as follows. White blood cell count was 4.9, hematocrit was 36.3, and platelet count was 235,000. Prothrombin time was 13.7, partial thromboplastin time was 29, with an INR of 1.2. Urinalysis was negative. Glucose was 201, blood urea nitrogen was 15, creatinine was 0.8, sodium was 139, potassium of 4.1, chloride was 105, and bicarbonate was 27. Anion gap was 11. Alanine- aminotransferase was 23, aspartate aminotransferase was 17, CK was 25, alkaline phosphatase was 58, amylase was 56, total bilirubin was 0.7, direct bilirubin was 0.2, indirect bilirubin was 0.5. Albumin was 3.5. Calcium was 9. Vitamin B12 was 228. Hemoglobin A1C was 6.1 percent. RADIOLOGY: A preoperative chest x-ray showed no acute cardiopulmonary process. A preoperative electrocardiogram showed a sinus rhythm at 92 with no significant change from his prior report. Cardiac catheterization showed a right-dominant system with a 50 percent left main stenosis, 80 percent ostial and mid left anterior descending lesions, a diffusely circumflex diseased circumflex with 80 percent stenosis before a large second obtuse marginal, and a ramus intermedius with a 90 percent proximal lesion, and large right coronary artery vessel with an 80 percent stenosis. Ejection fraction was 63 percent. Please refer to the official cardiac catheterization report dated [2131-8-24]. SUMMARY OF HOSPITAL COURSE: On [9-6] - the day of admission - the patient underwent coronary artery bypass grafting times four by Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] with a left internal mammary artery to the left anterior descending, a vein graft to the ramus, a vein graft to the obtuse marginal, and a vein graft to the right coronary artery. The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition on a Levophed drip at 0.15 mcg/kilogram per minute and a propofol drip at 10 mcg/kilogram per minute. Early that morning, the patient had been extubated overnight and was on an epinephrine drip for tone. On postoperative day one, he had received 1 amp of bicarbonate and 5 units of packed red blood cells for a hematocrit that was low, and his hematocrit rose to 34. In that first 24 hour postoperative period, his heart was regular in rate and rhythm. His chest tubes were in place. He had decreased breath sounds bilaterally. His abdomen was soft. He had 1 plus trace edema peripherally. His Lopressor was held for a heart rate of 89 in a sinus rhythm, but his blood pressure was only 98/46. At that time, he began Lasix diuresis. A cortisol level was checked. Levophed remained at 0.2 mcg/kilogram per minute. On postoperative day two, a right femoral line was placed for problem with the right arterial line. He was on Levophed 0.01, sinus rhythm at 89, blood pressure was 106/42. His heart was regular in rate and rhythm. He had decreased breath sounds at the bases. The incisions were clean, dry, and intact at that time. He was encouraged to work with nurses on aggressive pulmonary toilet. He was afebrile with a white blood cell count of 8.1, and he continued to be weaned from his pressors. His potassium was 4.7, with a blood urea nitrogen of 28, and a creatinine of 0.9. He was also on a Pitressin drip at 0.04. He was seen by Case Management. On postoperative day three, he was weaned from his drips and transferred out to the floor to begin working with Physical Therapy more aggressively. His chest tubes were discontinued. His vasopressin was weaned. He was in a sinus rhythm at 100, with a blood pressure of 126/59, and saturating 94 percent on room air. His potassium was 4.4, blood urea nitrogen was 31, creatinine was 0.8. He had decreased breath sounds at the bases with 2 plus peripheral edema. His hematocrit dropped to 26.8, and this was rechecked. Beta blockade was begun later in the day, and his intravenous Lasix was increased to 40 twice daily. A repeat chest x-ray was ordered. The patient was evaluated again by Physical Therapy. On postoperative day four, he had some premature atrial contractions in the morning and some rapid atrial fibrillation late in the day prior. His beta blockade was increased to 12.5 twice daily. He was off all of his pressors at this time. He was alert and oriented with a nonfocal examination. His heart was regular in rate and rhythm. His lungs were clear bilaterally. His edema had decreased to 1 plus bilaterally. The incisions were clean, dry, and intact. He was started on amiodarone by mouth, and his pacing wires were discontinued. His hematocrit remained stable at 27.8, with a potassium of 4.4, with a blood urea nitrogen and creatinine of 29 and 0.8; respectively. Blood sugar management continued to be an issue for which the patient received additional conversations with his health care providers. On postoperative day five, the patient had another episode of rapid atrial fibrillation in the 170s the evening prior which was treated with intravenous Lopressor, magnesium, and amiodarone. He converted to a normal sinus rhythm at a rate of 100 with a blood pressure of 114/58. His creatinine remained stable at 0.7. His hematocrit rose slightly to 28.4. He continued with his diuresis. He was continued on amiodarone at 400 mg by mouth three times per day. His examination was otherwise unremarkable. His Lopressor was increased to 25 mg twice daily, and he continued his diuresis. On postoperative day six, the patient remained stable. There were no events overnight. His hematocrit dropped slightly to 26.7. He was started on Coumadin. His Lopressor was increased to 50 twice daily for a blood pressure of 130/58 and a heart rate of 86. He continued on his oral amiodarone. He received 2 mg of Coumadin that evening with discharge planning begun. His wounds were unremarkable as was the rest of his examination. He continued to be on sliding-scale insulin for persistent elevated blood sugars. On postoperative day seven, the date of discharge, his blood pressure was 106/57, with a pulse of 70, saturating 95 percent on room air. His blood urea nitrogen and creatinine were 22 and 0.8. His hematocrit was 28.3. His examination was unremarkable with trace peripheral edema. His incisions were clean, dry, and intact. He was doing very well. He was ambulating well. His amiodarone was decreased to twice daily with plans to discharge him for home and to continue his Coumadin therapy. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting times four. 2. Non-insulin-dependent diabetes mellitus. 3. Hypertension. 4. Hyperlipidemia. 5. Duodenal ulcer with gastrointestinal bleed and melena in [2119]. 6. Thrombocytosis. 7. Status post prostate cancer with prostatectomy. 8. Left tibial fracture. 9. Status post polypectomy. MEDICATIONS ON DISCHARGE: 1. Potassium chloride 20 mEq by mouth daily (for seven days). 2. Colace 100 mg by mouth twice daily. 3. Zantac 150 mg by mouth twice daily (for four weeks). 4. Enteric coated aspirin 325 mg by mouth daily. 5. Percocet 5/325 one to two tablets by mouth q.4-6h. as needed (for pain). 6. Ibuprofen 600 mg by mouth q.8h. as needed (take with food). 7. Lipitor 5 mg by mouth daily. 8. Amiodarone 400 mg by mouth twice daily for seven days and then decrease to 400 mg by mouth daily for a week and then decrease 200 mg by mouth daily. 9. Metoprolol Tartrate 50 mg by mouth twice daily. 10. Lasix 40 mg by mouth twice daily (for 10 days). 11. Coumadin 2-mg tablet by mouth on the night of discharge only and take as directed by Dr. [First Name8 (NamePattern2) 324] [Last Name (NamePattern1) 311] (telephone number [Telephone/Fax (1) 1713]) - the patient's primary care physician [Name Initial (PRE) ] [Name10 (NameIs) ] monitoring of his Coumadin dosing and INR. DISCHARGE INSTRUCTIONS: 1. Not to drive for four weeks. 2. Not to lift more than 10 pounds for three months. 3. Take a shower only let water flow over his wounds and pack dry. DISCHARGE FOLLOWUP: 1. Recommended to follow up Dr. [First Name8 (NamePattern2) 324] [Last Name (NamePattern1) 311] in one to two weeks. 2. Recommended to follow up Dr. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] - his cardiologist - in two to three weeks. 3. Recommended to see Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] in the office for his postoperative surgical visit in four weeks. CONDITION ON DISCHARGE: The patient was discharged in stable condition on [2131-9-13]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1714], [MD Number(1) 1715] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2131-10-12] 13:09:15 T: [2131-10-12] 14:07:22 Job#: [Job Number 1716]	Admission Date: <Date>1981-8-8</Date> Discharge Date: <Date>1990-10-21</Date> Date of Birth: <Date>1906-9-3</Date> Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Please note this is from Cardiology's dictated pre catheterization admission note as there was no history and physical examination from his preoperative visit in the chart. This is a 69-year-old male patient of Dr. <Name>Lisa</Name> <Name>Lisa</Name> <Name>Edward</Name> with a longstanding history of exertional angina and abnormal stress test now with worsening symptoms who was referred for outpatient catheterization to <Hospital>Robinson-Anthony Hospital</Hospital>. He reports that for the past five to six years he has been experiencing exertional back pain until recently. It occurred with activity such as walking and was resolved with rest. Over the past two to three weeks, he feels that his symptoms have gotten worse. The pain is now radiating to his chest and seems to last for a longer period of time, requiring nitroglycerin for relief. He also reports having dyspnea after climbing hills. He does report occasionally having symptoms at rest over the past few weeks, for which he takes nitroglycerin with relief. He states this occurs one to two times per week on average. PAST MEDICAL HISTORY: 1. Positive exercise tolerance test. 2. Hypertension. 3. Hyperlipidemia. 4. Occasional lightheadedness upon waking in the morning. 5. Duodenal ulcer with melena in <Year>1963</Year>. 6. Thrombocytosis. 7. Prostate cancer; status post prostatectomy. 8. Left tibial fracture. 9. Status post polypectomy. 10. Non-insulin-dependent diabetes mellitus. ALLERGIES: He has no known drug allergies; although he does say he an allergy to SOME FISH (TUNA, STEAK, and BLUE FISH) which cause a drop in his blood pressure. He no longer eats fish. MEDICATIONS AT CATHETERIZATION TIME: Lisinopril 20 mg by mouth daily, Agrylin 0.5 mg by mouth daily three days a week and Agrylin 1 mg by mouth twice daily four days a week (per his hematologist Dr. <Name>Pettway</Name>, Lipitor 5 mg by mouth daily, atenolol 25 mg by mouth daily, aspirin 325 mg by mouth daily, and Niferex 150 mg by mouth daily. FAMILY HISTORY: He has a positive family history. His son had a myocardial infarction at the age of 42. SOCIAL HISTORY: He is married and retired. He had no history of transient ischemic attack or cerebrovascular accident, but did have a positive history of melena and gastrointestinal bleed in <Year>1963</Year>. PHYSICAL EXAMINATION ON PRESENTATION: His height was 5 feet 9 inches and weight was 186 pounds. No preoperative recorded examination was noted. LABORATORY DATA ON PRESENTATION: Laboratories prior to procedure were as follows. White blood cell count was 4.9, hematocrit was 36.3, and platelet count was 235,000. Prothrombin time was 13.7, partial thromboplastin time was 29, with an INR of 1.2. Urinalysis was negative. Glucose was 201, blood urea nitrogen was 15, creatinine was 0.8, sodium was 139, potassium of 4.1, chloride was 105, and bicarbonate was 27. Anion gap was 11. Alanine- aminotransferase was 23, aspartate aminotransferase was 17, CK was 25, alkaline phosphatase was 58, amylase was 56, total bilirubin was 0.7, direct bilirubin was 0.2, indirect bilirubin was 0.5. Albumin was 3.5. Calcium was 9. Vitamin B12 was 228. Hemoglobin A1C was 6.1 percent. RADIOLOGY: A preoperative chest x-ray showed no acute cardiopulmonary process. A preoperative electrocardiogram showed a sinus rhythm at 92 with no significant change from his prior report. Cardiac catheterization showed a right-dominant system with a 50 percent left main stenosis, 80 percent ostial and mid left anterior descending lesions, a diffusely circumflex diseased circumflex with 80 percent stenosis before a large second obtuse marginal, and a ramus intermedius with a 90 percent proximal lesion, and large right coronary artery vessel with an 80 percent stenosis. Ejection fraction was 63 percent. Please refer to the official cardiac catheterization report dated <Date>1962-2-3</Date>. SUMMARY OF HOSPITAL COURSE: On <Date>5-3</Date> - the day of admission - the patient underwent coronary artery bypass grafting times four by Dr. <Name>Xin</Name> <Initial>AV</Initial>. <Name>Edward</Name> with a left internal mammary artery to the left anterior descending, a vein graft to the ramus, a vein graft to the obtuse marginal, and a vein graft to the right coronary artery. The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition on a Levophed drip at 0.15 mcg/kilogram per minute and a propofol drip at 10 mcg/kilogram per minute. Early that morning, the patient had been extubated overnight and was on an epinephrine drip for tone. On postoperative day one, he had received 1 amp of bicarbonate and 5 units of packed red blood cells for a hematocrit that was low, and his hematocrit rose to 34. In that first 24 hour postoperative period, his heart was regular in rate and rhythm. His chest tubes were in place. He had decreased breath sounds bilaterally. His abdomen was soft. He had 1 plus trace edema peripherally. His Lopressor was held for a heart rate of 89 in a sinus rhythm, but his blood pressure was only 98/46. At that time, he began Lasix diuresis. A cortisol level was checked. Levophed remained at 0.2 mcg/kilogram per minute. On postoperative day two, a right femoral line was placed for problem with the right arterial line. He was on Levophed 0.01, sinus rhythm at 89, blood pressure was 106/42. His heart was regular in rate and rhythm. He had decreased breath sounds at the bases. The incisions were clean, dry, and intact at that time. He was encouraged to work with nurses on aggressive pulmonary toilet. He was afebrile with a white blood cell count of 8.1, and he continued to be weaned from his pressors. His potassium was 4.7, with a blood urea nitrogen of 28, and a creatinine of 0.9. He was also on a Pitressin drip at 0.04. He was seen by Case Management. On postoperative day three, he was weaned from his drips and transferred out to the floor to begin working with Physical Therapy more aggressively. His chest tubes were discontinued. His vasopressin was weaned. He was in a sinus rhythm at 100, with a blood pressure of 126/59, and saturating 94 percent on room air. His potassium was 4.4, blood urea nitrogen was 31, creatinine was 0.8. He had decreased breath sounds at the bases with 2 plus peripheral edema. His hematocrit dropped to 26.8, and this was rechecked. Beta blockade was begun later in the day, and his intravenous Lasix was increased to 40 twice daily. A repeat chest x-ray was ordered. The patient was evaluated again by Physical Therapy. On postoperative day four, he had some premature atrial contractions in the morning and some rapid atrial fibrillation late in the day prior. His beta blockade was increased to 12.5 twice daily. He was off all of his pressors at this time. He was alert and oriented with a nonfocal examination. His heart was regular in rate and rhythm. His lungs were clear bilaterally. His edema had decreased to 1 plus bilaterally. The incisions were clean, dry, and intact. He was started on amiodarone by mouth, and his pacing wires were discontinued. His hematocrit remained stable at 27.8, with a potassium of 4.4, with a blood urea nitrogen and creatinine of 29 and 0.8; respectively. Blood sugar management continued to be an issue for which the patient received additional conversations with his health care providers. On postoperative day five, the patient had another episode of rapid atrial fibrillation in the 170s the evening prior which was treated with intravenous Lopressor, magnesium, and amiodarone. He converted to a normal sinus rhythm at a rate of 100 with a blood pressure of 114/58. His creatinine remained stable at 0.7. His hematocrit rose slightly to 28.4. He continued with his diuresis. He was continued on amiodarone at 400 mg by mouth three times per day. His examination was otherwise unremarkable. His Lopressor was increased to 25 mg twice daily, and he continued his diuresis. On postoperative day six, the patient remained stable. There were no events overnight. His hematocrit dropped slightly to 26.7. He was started on Coumadin. His Lopressor was increased to 50 twice daily for a blood pressure of 130/58 and a heart rate of 86. He continued on his oral amiodarone. He received 2 mg of Coumadin that evening with discharge planning begun. His wounds were unremarkable as was the rest of his examination. He continued to be on sliding-scale insulin for persistent elevated blood sugars. On postoperative day seven, the date of discharge, his blood pressure was 106/57, with a pulse of 70, saturating 95 percent on room air. His blood urea nitrogen and creatinine were 22 and 0.8. His hematocrit was 28.3. His examination was unremarkable with trace peripheral edema. His incisions were clean, dry, and intact. He was doing very well. He was ambulating well. His amiodarone was decreased to twice daily with plans to discharge him for home and to continue his Coumadin therapy. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting times four. 2. Non-insulin-dependent diabetes mellitus. 3. Hypertension. 4. Hyperlipidemia. 5. Duodenal ulcer with gastrointestinal bleed and melena in <Year>1963</Year>. 6. Thrombocytosis. 7. Status post prostate cancer with prostatectomy. 8. Left tibial fracture. 9. Status post polypectomy. MEDICATIONS ON DISCHARGE: 1. Potassium chloride 20 mEq by mouth daily (for seven days). 2. Colace 100 mg by mouth twice daily. 3. Zantac 150 mg by mouth twice daily (for four weeks). 4. Enteric coated aspirin 325 mg by mouth daily. 5. Percocet 5/325 one to two tablets by mouth q.4-6h. as needed (for pain). 6. Ibuprofen 600 mg by mouth q.8h. as needed (take with food). 7. Lipitor 5 mg by mouth daily. 8. Amiodarone 400 mg by mouth twice daily for seven days and then decrease to 400 mg by mouth daily for a week and then decrease 200 mg by mouth daily. 9. Metoprolol Tartrate 50 mg by mouth twice daily. 10. Lasix 40 mg by mouth twice daily (for 10 days). 11. Coumadin 2-mg tablet by mouth on the night of discharge only and take as directed by Dr. <Name>Nickolas</Name> <Name>Lewis</Name> (telephone number <Telephone>210-968-6046</Telephone>) - the patient's primary care physician <Name>Dylan Finateri</Name> <Name>Austin Olles</Name> monitoring of his Coumadin dosing and INR. DISCHARGE INSTRUCTIONS: 1. Not to drive for four weeks. 2. Not to lift more than 10 pounds for three months. 3. Take a shower only let water flow over his wounds and pack dry. DISCHARGE FOLLOWUP: 1. Recommended to follow up Dr. <Name>Nickolas</Name> <Name>Lewis</Name> in one to two weeks. 2. Recommended to follow up Dr. <Name>Lisa</Name> <Name>Lisa</Name> <Name>Edward</Name> - his cardiologist - in two to three weeks. 3. Recommended to see Dr. <Name>Xin</Name> <Initial>AV</Initial>. <Name>Edward</Name> in the office for his postoperative surgical visit in four weeks. CONDITION ON DISCHARGE: The patient was discharged in stable condition on <Date>1990-10-21</Date>. <Name>Xin</Name> <Name>Pichardo</Name>, <MD Number>53588472</MD Number> Dictated By:<Name>Edward</Name> MEDQUIST36 D: <Date>1981-5-26</Date> 13:09:15 T: <Date>1981-5-26</Date> 14:07:22 Job#: <Job Number>Ramsey Group-1947-889973</Job 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Date: 1981-8-8 Discharge Date: 1990-10-21 Date of Birth: 1906-9-3 Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Please note this is from Cardiology's dictated pre catheterization admission note as there was no history and physical examination from his preoperative visit in the chart. This is a 69-year-old male patient of Dr. Lisa Lisa Edward with a longstanding history of exertional angina and abnormal stress test now with worsening symptoms who was referred for outpatient catheterization to Robinson-Anthony Hospital. He reports that for the past five to six years he has been experiencing exertional back pain until recently. It occurred with activity such as walking and was resolved with rest. Over the past two to three weeks, he feels that his symptoms have gotten worse. The pain is now radiating to his chest and seems to last for a longer period of time, requiring nitroglycerin for relief. He also reports having dyspnea after climbing hills. He does report occasionally having symptoms at rest over the past few weeks, for which he takes nitroglycerin with relief. He states this occurs one to two times per week on average. PAST MEDICAL HISTORY: 1. Positive exercise tolerance test. 2. Hypertension. 3. Hyperlipidemia. 4. Occasional lightheadedness upon waking in the morning. 5. Duodenal ulcer with melena in 1963. 6. Thrombocytosis. 7. Prostate cancer; status post prostatectomy. 8. Left tibial fracture. 9. Status post polypectomy. 10. Non-insulin-dependent diabetes mellitus. ALLERGIES: He has no known drug allergies; although he does say he an allergy to SOME FISH (TUNA, STEAK, and BLUE FISH) which cause a drop in his blood pressure. He no longer eats fish. MEDICATIONS AT CATHETERIZATION TIME: Lisinopril 20 mg by mouth daily, Agrylin 0.5 mg by mouth daily three days a week and Agrylin 1 mg by mouth twice daily four days a week (per his hematologist Dr. Pettway, Lipitor 5 mg by mouth daily, atenolol 25 mg by mouth daily, aspirin 325 mg by mouth daily, and Niferex 150 mg by mouth daily. FAMILY HISTORY: He has a positive family history. His son had a myocardial infarction at the age of 42. SOCIAL HISTORY: He is married and retired. He had no history of transient ischemic attack or cerebrovascular accident, but did have a positive history of melena and gastrointestinal bleed in 1963. PHYSICAL EXAMINATION ON PRESENTATION: His height was 5 feet 9 inches and weight was 186 pounds. No preoperative recorded examination was noted. LABORATORY DATA ON PRESENTATION: Laboratories prior to procedure were as follows. White blood cell count was 4.9, hematocrit was 36.3, and platelet count was 235,000. Prothrombin time was 13.7, partial thromboplastin time was 29, with an INR of 1.2. Urinalysis was negative. Glucose was 201, blood urea nitrogen was 15, creatinine was 0.8, sodium was 139, potassium of 4.1, chloride was 105, and bicarbonate was 27. Anion gap was 11. Alanine- aminotransferase was 23, aspartate aminotransferase was 17, CK was 25, alkaline phosphatase was 58, amylase was 56, total bilirubin was 0.7, direct bilirubin was 0.2, indirect bilirubin was 0.5. Albumin was 3.5. Calcium was 9. Vitamin B12 was 228. Hemoglobin A1C was 6.1 percent. RADIOLOGY: A preoperative chest x-ray showed no acute cardiopulmonary process. A preoperative electrocardiogram showed a sinus rhythm at 92 with no significant change from his prior report. Cardiac catheterization showed a right-dominant system with a 50 percent left main stenosis, 80 percent ostial and mid left anterior descending lesions, a diffusely circumflex diseased circumflex with 80 percent stenosis before a large second obtuse marginal, and a ramus intermedius with a 90 percent proximal lesion, and large right coronary artery vessel with an 80 percent stenosis. Ejection fraction was 63 percent. Please refer to the official cardiac catheterization report dated 1962-2-3. SUMMARY OF HOSPITAL COURSE: On 5-3 - the day of admission - the patient underwent coronary artery bypass grafting times four by Dr. Xin AV. Edward with a left internal mammary artery to the left anterior descending, a vein graft to the ramus, a vein graft to the obtuse marginal, and a vein graft to the right coronary artery. The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition on a Levophed drip at 0.15 mcg/kilogram per minute and a propofol drip at 10 mcg/kilogram per minute. Early that morning, the patient had been extubated overnight and was on an epinephrine drip for tone. On postoperative day one, he had received 1 amp of bicarbonate and 5 units of packed red blood cells for a hematocrit that was low, and his hematocrit rose to 34. In that first 24 hour postoperative period, his heart was regular in rate and rhythm. His chest tubes were in place. He had decreased breath sounds bilaterally. His abdomen was soft. He had 1 plus trace edema peripherally. His Lopressor was held for a heart rate of 89 in a sinus rhythm, but his blood pressure was only 98/46. At that time, he began Lasix diuresis. A cortisol level was checked. Levophed remained at 0.2 mcg/kilogram per minute. On postoperative day two, a right femoral line was placed for problem with the right arterial line. He was on Levophed 0.01, sinus rhythm at 89, blood pressure was 106/42. His heart was regular in rate and rhythm. He had decreased breath sounds at the bases. The incisions were clean, dry, and intact at that time. He was encouraged to work with nurses on aggressive pulmonary toilet. He was afebrile with a white blood cell count of 8.1, and he continued to be weaned from his pressors. His potassium was 4.7, with a blood urea nitrogen of 28, and a creatinine of 0.9. He was also on a Pitressin drip at 0.04. He was seen by Case Management. On postoperative day three, he was weaned from his drips and transferred out to the floor to begin working with Physical Therapy more aggressively. His chest tubes were discontinued. His vasopressin was weaned. He was in a sinus rhythm at 100, with a blood pressure of 126/59, and saturating 94 percent on room air. His potassium was 4.4, blood urea nitrogen was 31, creatinine was 0.8. He had decreased breath sounds at the bases with 2 plus peripheral edema. His hematocrit dropped to 26.8, and this was rechecked. Beta blockade was begun later in the day, and his intravenous Lasix was increased to 40 twice daily. A repeat chest x-ray was ordered. The patient was evaluated again by Physical Therapy. On postoperative day four, he had some premature atrial contractions in the morning and some rapid atrial fibrillation late in the day prior. His beta blockade was increased to 12.5 twice daily. He was off all of his pressors at this time. He was alert and oriented with a nonfocal examination. His heart was regular in rate and rhythm. His lungs were clear bilaterally. His edema had decreased to 1 plus bilaterally. The incisions were clean, dry, and intact. He was started on amiodarone by mouth, and his pacing wires were discontinued. His hematocrit remained stable at 27.8, with a potassium of 4.4, with a blood urea nitrogen and creatinine of 29 and 0.8; respectively. Blood sugar management continued to be an issue for which the patient received additional conversations with his health care providers. On postoperative day five, the patient had another episode of rapid atrial fibrillation in the 170s the evening prior which was treated with intravenous Lopressor, magnesium, and amiodarone. He converted to a normal sinus rhythm at a rate of 100 with a blood pressure of 114/58. His creatinine remained stable at 0.7. His hematocrit rose slightly to 28.4. He continued with his diuresis. He was continued on amiodarone at 400 mg by mouth three times per day. His examination was otherwise unremarkable. His Lopressor was increased to 25 mg twice daily, and he continued his diuresis. On postoperative day six, the patient remained stable. There were no events overnight. His hematocrit dropped slightly to 26.7. He was started on Coumadin. His Lopressor was increased to 50 twice daily for a blood pressure of 130/58 and a heart rate of 86. He continued on his oral amiodarone. He received 2 mg of Coumadin that evening with discharge planning begun. His wounds were unremarkable as was the rest of his examination. He continued to be on sliding-scale insulin for persistent elevated blood sugars. On postoperative day seven, the date of discharge, his blood pressure was 106/57, with a pulse of 70, saturating 95 percent on room air. His blood urea nitrogen and creatinine were 22 and 0.8. His hematocrit was 28.3. His examination was unremarkable with trace peripheral edema. His incisions were clean, dry, and intact. He was doing very well. He was ambulating well. His amiodarone was decreased to twice daily with plans to discharge him for home and to continue his Coumadin therapy. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting times four. 2. Non-insulin-dependent diabetes mellitus. 3. Hypertension. 4. Hyperlipidemia. 5. Duodenal ulcer with gastrointestinal bleed and melena in 1963. 6. Thrombocytosis. 7. Status post prostate cancer with prostatectomy. 8. Left tibial fracture. 9. Status post polypectomy. MEDICATIONS ON DISCHARGE: 1. Potassium chloride 20 mEq by mouth daily (for seven days). 2. Colace 100 mg by mouth twice daily. 3. Zantac 150 mg by mouth twice daily (for four weeks). 4. Enteric coated aspirin 325 mg by mouth daily. 5. Percocet 5/325 one to two tablets by mouth q.4-6h. as needed (for pain). 6. Ibuprofen 600 mg by mouth q.8h. as needed (take with food). 7. Lipitor 5 mg by mouth daily. 8. Amiodarone 400 mg by mouth twice daily for seven days and then decrease to 400 mg by mouth daily for a week and then decrease 200 mg by mouth daily. 9. Metoprolol Tartrate 50 mg by mouth twice daily. 10. Lasix 40 mg by mouth twice daily (for 10 days). 11. Coumadin 2-mg tablet by mouth on the night of discharge only and take as directed by Dr. Nickolas Lewis (telephone number 210-968-6046) - the patient's primary care physician Dylan Finateri Austin Olles monitoring of his Coumadin dosing and INR. DISCHARGE INSTRUCTIONS: 1. Not to drive for four weeks. 2. Not to lift more than 10 pounds for three months. 3. Take a shower only let water flow over his wounds and pack dry. DISCHARGE FOLLOWUP: 1. Recommended to follow up Dr. Nickolas Lewis in one to two weeks. 2. Recommended to follow up Dr. Lisa Lisa Edward - his cardiologist - in two to three weeks. 3. Recommended to see Dr. Xin AV. Edward in the office for his postoperative surgical visit in four weeks. CONDITION ON DISCHARGE: The patient was discharged in stable condition on 1990-10-21. Xin Pichardo, 53588472 Dictated By:Edward MEDQUIST36 D: 1981-5-26 13:09:15 T: 1981-5-26 14:07:22 Job#: Ramsey Group-1947-889973	["Admission Date: 1981-8-8 Discharge Date: 1990-10-21\n\nDate of Birth: 1906-9-3 Sex: M\n\nService: CSU\n\n\nHISTORY OF PRESENT ILLNESS: Please note this is from\nCardiology's dictated pre catheterization admission note as\nthere was no history and physical examination from his\npreoperative visit in the chart.\n\nThis is a 69-year-old male patient of Dr. Lisa Lisa Edward\nwith a longstanding history of exertional angina and abnormal\nstress test now with worsening symptoms who was referred for\noutpatient catheterization to Robinson-Anthony Hospital. He reports that for the past five to six years he\nhas been experiencing exertional back pain until recently.\nIt occurred with activity such as walking and was resolved\nwith rest. Over the past two to three weeks, he feels that\nhis symptoms have gotten worse.", ' The pain is now radiating to\nhis chest and seems to last for a longer period of time,\nrequiring nitroglycerin for relief. He also reports having\ndyspnea after climbing hills. He does report occasionally\nhaving symptoms at rest over the past few weeks, for which he\ntakes nitroglycerin with relief. He states this occurs one\nto two times per week on average.\n\nPAST MEDICAL HISTORY:\n1. Positive exercise tolerance test.\n2. Hypertension.\n3. Hyperlipidemia.\n4. Occasional lightheadedness upon waking in the morning.\n5. Duodenal ulcer with melena in 1963.\n6. Thrombocytosis.\n7. Prostate cancer; status post prostatectomy.\n8. Left tibial fracture.\n9. Status post polypectomy.\n10. Non-insulin-dependent diabetes mellitus.\n\n\nALLERGIES: He has no known drug allergies; although he does\nsay he an allergy to SOME FISH (TUNA, STEAK, and BLUE FISH)\nwhich cause a drop in his blood pressure.', ' He no longer eats\nfish.\n\nMEDICATIONS AT CATHETERIZATION TIME: Lisinopril 20 mg by\nmouth daily, Agrylin 0.5 mg by mouth daily three days a week\nand Agrylin 1 mg by mouth twice daily four days a week (per\nhis hematologist Dr. Pettway, Lipitor 5 mg by mouth daily,\natenolol 25 mg by mouth daily, aspirin 325 mg by mouth daily,\nand Niferex 150 mg by mouth daily.\n\nFAMILY HISTORY: He has a positive family history. His son\nhad a myocardial infarction at the age of 42.\n\nSOCIAL HISTORY: He is married and retired. He had no\nhistory of transient ischemic attack or cerebrovascular\naccident, but did have a positive history of melena and\ngastrointestinal bleed in 1963.\n\nPHYSICAL EXAMINATION ON PRESENTATION: His height was 5 feet\n9 inches and weight was 186 pounds. No preoperative recorded\nexamination was noted.', '\n\nLABORATORY DATA ON PRESENTATION: Laboratories prior to\nprocedure were as follows. White blood cell count was 4.9,\nhematocrit was 36.3, and platelet count was 235,000.\nProthrombin time was 13.7, partial thromboplastin time was\n29, with an INR of 1.2. Urinalysis was negative. Glucose\nwas 201, blood urea nitrogen was 15, creatinine was 0.8,\nsodium was 139, potassium of 4.1, chloride was 105, and\nbicarbonate was 27. Anion gap was 11. Alanine-\naminotransferase was 23, aspartate aminotransferase was 17,\nCK was 25, alkaline phosphatase was 58, amylase was 56, total\nbilirubin was 0.7, direct bilirubin was 0.2, indirect\nbilirubin was 0.5. Albumin was 3.5. Calcium was 9. Vitamin\nB12 was 228. Hemoglobin A1C was 6.1 percent.\n\nRADIOLOGY: A preoperative chest x-ray showed no acute\ncardiopulmonary process.', '\n\nA preoperative electrocardiogram showed a sinus rhythm at 92\nwith no significant change from his prior report.\n\nCardiac catheterization showed a right-dominant system with a\n50 percent left main stenosis, 80 percent ostial and mid left\nanterior descending lesions, a diffusely circumflex diseased\ncircumflex with 80 percent stenosis before a large second\nobtuse marginal, and a ramus intermedius with a 90 percent\nproximal lesion, and large right coronary artery vessel with\nan 80 percent stenosis. Ejection fraction was 63 percent.\nPlease refer to the official cardiac catheterization report\ndated 1962-2-3.\n\nSUMMARY OF HOSPITAL COURSE: On 5-3 - the day of\nadmission - the patient underwent coronary artery bypass\ngrafting times four by Dr. Xin AV. Edward with a left\ninternal mammary artery to the left anterior descending, a\nvein graft to the ramus, a vein graft to the obtuse marginal,\nand a vein graft to the right coronary artery.', '\n\nThe patient was transferred to the Cardiothoracic Intensive\nCare Unit in stable condition on a Levophed drip at 0.15\nmcg/kilogram per minute and a propofol drip at 10\nmcg/kilogram per minute. Early that morning, the patient had\nbeen extubated overnight and was on an epinephrine drip for\ntone.\n\nOn postoperative day one, he had received 1 amp of\nbicarbonate and 5 units of packed red blood cells for a\nhematocrit that was low, and his hematocrit rose to 34. In\nthat first 24 hour postoperative period, his heart was\nregular in rate and rhythm. His chest tubes were in place.\nHe had decreased breath sounds bilaterally. His abdomen was\nsoft. He had 1 plus trace edema peripherally. His Lopressor\nwas held for a heart rate of 89 in a sinus rhythm, but his\nblood pressure was only 98/46. At that time, he began Lasix\ndiuresis.', ' A cortisol level was checked. Levophed remained\nat 0.2 mcg/kilogram per minute.\n\nOn postoperative day two, a right femoral line was placed for\nproblem with the right arterial line. He was on Levophed\n0.01, sinus rhythm at 89, blood pressure was 106/42. His\nheart was regular in rate and rhythm. He had decreased\nbreath sounds at the bases. The incisions were clean, dry,\nand intact at that time. He was encouraged to work with\nnurses on aggressive pulmonary toilet. He was afebrile with\na white blood cell count of 8.1, and he continued to be\nweaned from his pressors. His potassium was 4.7, with a\nblood urea nitrogen of 28, and a creatinine of 0.9. He was\nalso on a Pitressin drip at 0.04. He was seen by Case\nManagement.\n\nOn postoperative day three, he was weaned from his drips and\ntransferred out to the floor to begin working with Physical\nTherapy more aggressively.', ' His chest tubes were\ndiscontinued. His vasopressin was weaned. He was in a sinus\nrhythm at 100, with a blood pressure of 126/59, and\nsaturating 94 percent on room air. His potassium was 4.4,\nblood urea nitrogen was 31, creatinine was 0.8. He had\ndecreased breath sounds at the bases with 2 plus peripheral\nedema. His hematocrit dropped to 26.8, and this was\nrechecked. Beta blockade was begun later in the day, and his\nintravenous Lasix was increased to 40 twice daily. A repeat\nchest x-ray was ordered. The patient was evaluated again by\nPhysical Therapy.\n\nOn postoperative day four, he had some premature atrial\ncontractions in the morning and some rapid atrial\nfibrillation late in the day prior. His beta blockade was\nincreased to 12.5 twice daily. He was off all of his\npressors at this time.', ' He was alert and oriented with a\nnonfocal examination. His heart was regular in rate and\nrhythm. His lungs were clear bilaterally. His edema had\ndecreased to 1 plus bilaterally. The incisions were clean,\ndry, and intact. He was started on amiodarone by mouth, and\nhis pacing wires were discontinued. His hematocrit remained\nstable at 27.8, with a potassium of 4.4, with a blood urea\nnitrogen and creatinine of 29 and 0.8; respectively. Blood\nsugar management continued to be an issue for which the\npatient received additional conversations with his health\ncare providers.\n\nOn postoperative day five, the patient had another episode of\nrapid atrial fibrillation in the 170s the evening prior which\nwas treated with intravenous Lopressor, magnesium, and\namiodarone. He converted to a normal sinus rhythm at a rate\nof 100 with a blood pressure of 114/58.', ' His creatinine\nremained stable at 0.7. His hematocrit rose slightly to\n28.4. He continued with his diuresis. He was continued on\namiodarone at 400 mg by mouth three times per day. His\nexamination was otherwise unremarkable. His Lopressor was\nincreased to 25 mg twice daily, and he continued his\ndiuresis.\n\nOn postoperative day six, the patient remained stable. There\nwere no events overnight. His hematocrit dropped slightly to\n26.7. He was started on Coumadin. His Lopressor was\nincreased to 50 twice daily for a blood pressure of 130/58\nand a heart rate of 86. He continued on his oral amiodarone.\nHe received 2 mg of Coumadin that evening with discharge\nplanning begun. His wounds were unremarkable as was the rest\nof his examination. He continued to be on sliding-scale\ninsulin for persistent elevated blood sugars.', '\n\nOn postoperative day seven, the date of discharge, his blood\npressure was 106/57, with a pulse of 70, saturating 95\npercent on room air. His blood urea nitrogen and creatinine\nwere 22 and 0.8. His hematocrit was 28.3. His examination\nwas unremarkable with trace peripheral edema. His incisions\nwere clean, dry, and intact. He was doing very well. He was\nambulating well. His amiodarone was decreased to twice daily\nwith plans to discharge him for home and to continue his\nCoumadin therapy.\n\nDISCHARGE DIAGNOSES:\n1. Status post coronary artery bypass grafting times four.\n2. Non-insulin-dependent diabetes mellitus.\n3. Hypertension.\n4. Hyperlipidemia.\n5. Duodenal ulcer with gastrointestinal bleed and melena in\n 1963.\n6. Thrombocytosis.\n7. Status post prostate cancer with prostatectomy.\n8.', ' Left tibial fracture.\n9. Status post polypectomy.\n\n\nMEDICATIONS ON DISCHARGE:\n1. Potassium chloride 20 mEq by mouth daily (for seven days).\n2. Colace 100 mg by mouth twice daily.\n3. Zantac 150 mg by mouth twice daily (for four weeks).\n4. Enteric coated aspirin 325 mg by mouth daily.\n5. Percocet 5/325 one to two tablets by mouth q.4-6h. as\n needed (for pain).\n6. Ibuprofen 600 mg by mouth q.8h. as needed (take with\n food).\n7. Lipitor 5 mg by mouth daily.\n8. Amiodarone 400 mg by mouth twice daily for seven days and\n then decrease to 400 mg by mouth daily for a week and then\n decrease 200 mg by mouth daily.\n9. Metoprolol Tartrate 50 mg by mouth twice daily.\n10. Lasix 40 mg by mouth twice daily (for 10 days).\n11. Coumadin 2-mg tablet by mouth on the night of\n discharge only and take as directed by Dr.', " Nickolas Lewis\n (telephone number 210-968-6046) - the patient's primary\n care physician Dylan Finateri Austin Olles monitoring of his Coumadin dosing and\n INR.\n\n\nDISCHARGE INSTRUCTIONS:\n1. Not to drive for four weeks.\n2. Not to lift more than 10 pounds for three months.\n3. Take a shower only let water flow over his wounds and pack\n dry.\n\n\nDISCHARGE FOLLOWUP:\n1. Recommended to follow up Dr. Nickolas Lewis in one to two\n weeks.\n2. Recommended to follow up Dr. Lisa Lisa Edward - his\n cardiologist - in two to three weeks.\n3. Recommended to see Dr. Xin AV. Edward in the office for\n his postoperative surgical visit in four weeks.\n\n\nCONDITION ON DISCHARGE: The patient was discharged in stable\ncondition on 1990-10-21.\n\n\n\n Xin Pichardo, 53588472\n\nDictated By:Edward\nMEDQUIST36\nD: 1981-5-26 13:09:15\nT: 1981-5-26 14:07:22\nJob#: Ramsey Group-1947-889973\n"]
162	30977	183457.0	2192-08-21	Discharge summary	Report	Admission Date: [2192-8-7] Discharge Date: [2192-8-21] Date of Birth: [2130-11-19] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1234] Chief Complaint: left lower leg extremity ischemia Major Surgical or Invasive Procedure: s/p Left femoral-below knee popliteal bypass History of Present Illness: This is a 61-year-old female who has a history of a left femoral to above-knee popliteal bypass with prosthetic due to a previous harvesting for CABG of her saphenous vein. The patient also has a history of stenting and angioplasty of the distal popliteal artery. The patient presented to the hospital with increasing left foot pain and was found on angiography to have a completely thrombosed prosthetic graft. She had suitable runoff from the below-knee popliteal artery and the decision was made to perform a redo bypass operation. Past Medical History: PVD (Fem stent [6-12]), B CEA, IDDM, RAS, HTN, CAD (MI '[70], CABGx3 '[71]), CRI, Breast implants, Depression Social History: 80 pack year history, quit in [2170] no alcohol Family History: non contrib Physical Exam: On day of discharge, patient was feeling well without complaints, vital signs stable. T 98.3, Pulse 74, BP 140/40, RR 18, O2 sats 96% RA The patient was not in any acute distress, alert and oriented x 3 and not in any pain. CVS- regular rate and rhythm Pulm- clear to auscultation, bilaterally Abd- non distended, soft, non tender Wound- left leg- clean, dry and intact Pulses palpable bilaterally fem, [Doctor Last Name ], dp, pt Pertinent Results: [2192-8-17] 03:40AM BLOOD WBC-15.0* RBC-3.22* Hgb-9.9* Hct-29.8* MCV-93 MCH-30.6 MCHC-33.1 RDW-14.4 Plt Ct-495* [2192-8-7] 07:45PM BLOOD Neuts-63 Bands-0 Lymphs-27 Monos-5 Eos-4 Baso-1 Atyps-0 Metas-0 Myelos-0 [2192-8-17] 03:40AM BLOOD Plt Ct-495* [2192-8-17] 03:40AM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.2* [2192-8-19] 06:10AM BLOOD Glucose-118* UreaN-54* Creat-1.5* Na-136 K-4.0 Cl-100 HCO3-28 AnGap-12 [2192-8-19] 06:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.5 Blood culture all negative Brief Hospital Course: The patient was admitted on [2192-8-7] for a left lower extremity bypass on [2192-8-8]. The patient underwent a left fem-bk [Doctor Last Name ] with right arm vein (cephalic + basilic) and venovenostomy. Intraop fluids- 5.6 L crystalloid, 4 units RBC, urine output 475cc, estimated blood loss 600 cc. The patient remained intubated to the PACU with a palpable L DP, dopplerable L PT. The patient remained intubated on [2192-8-9], sedated in the PACU. She was then extubated and transferred to the VICU on [8-9]. Her vital signs were continually monitored throughout. [2192-8-10]-patient began a regular diet and treated with nebulizers, had nausea and dry heaving. The patient transferred from chair to bed, had difficulty maintaining O2 sats >90% and was transferred to the CSRU. [2192-8-11] Patient treated in CSRU for pulmonary edema secondary to CHF. Patient was intubated due to increasing shortness of breath. Transfused one unit of red blood cells and diuresed. The patient continued to be monitored in the CRSU through [8-17]. She was shortly extubated on [8-13] but intubated later that night for pulmonary edema. Tube feeds were started on [2192-8-13]. [2192-8-14]- CPAP as tolerated, nebs, wean PS as tolerated, extubated and chest PT. [8-15]- Swallow evaluation performed-cleared [8-16]-diuresis held, dispo to VICU. [8-17]- transferred to the floor, regular diet, ambulating, nebs. Seen by PT- recommend 2-4x/wk and rehab disposition. 8/11,[8-19]- continued pulm toilet, diuresis, PO home meds. [Last Name (un) ] consult for sugars >400. Patient started on standing insulin dose + sliding scale. OT consulted to help with right arm function. [8-20]- d/c central line, peripheral line inserted, PT eval, oral home meds, lasix 40 po. [8-21] VSS, no events. [Last Name (un) ] in to evaluate- will continue current BS medications. Staples removed prior to discharge. F/U Dr. [Last Name (STitle) ] 3-4 weeks with duplex Medications on Admission: [Last Name (un) 1724]: ASA 81', Lipitor 5', Citolapram 20', Metoprolol 50", Norvasc 10', Lasix 40', Humalog, Lantus 18 U HS, Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Humalog SLiding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-60 mg/dL [1-10] amp D50 61-80 mg/dL 0 Units 0 Units 0 Units 0 Units 81-120 mg/dL 3 Units 3 Units 4 Units 0 Units 121-160 mg/dL 6 Units 6 Units 7 Units 1 Units 161-200 mg/dL 9 Units 9 Units 10 Units 3 Units 201-240 mg/dL 11 Units 11 Units 11 Units 5 Units 241-280 mg/dL 13 Units 13 Units 13 Units 7 Units 281-320 mg/dL 15 Units 15 Units 15 Units 8 Units > 320 mg/dL Notify M.D. 12. Lantus 100 unit/mL Solution Sig: 20 units QHS Subcutaneous at bedtime: Continue Humalog SS. Discharge Disposition: Extended Care Facility: [Location (un) 1725] Nursing Center Discharge Diagnosis: Left lower leg ischemia- occluded femoral to above knee popliteal bypass graft PMH: PVD (Fem stent [6-12]), B CEA, IDDM, RAS, HTN, CAD (MI '[70], CABGx3 '[71]), CRI, Breast implants, Depression Discharge Condition: patient in good condition, vital signs stable Discharge Instructions: Division of [Year (2 digits) ] and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [2-11] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2192-9-11] 1:45 Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2192-9-11] 1:00 Completed by:[2192-8-21]	Admission Date: <Date>2002-9-16</Date> Discharge Date: <Date>1910-12-13</Date> Date of Birth: <Date>2016-10-22</Date> Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Dylan</Name> Chief Complaint: left lower leg extremity ischemia Major Surgical or Invasive Procedure: s/p Left femoral-below knee popliteal bypass History of Present Illness: This is a 61-year-old female who has a history of a left femoral to above-knee popliteal bypass with prosthetic due to a previous harvesting for CABG of her saphenous vein. The patient also has a history of stenting and angioplasty of the distal popliteal artery. The patient presented to the hospital with increasing left foot pain and was found on angiography to have a completely thrombosed prosthetic graft. She had suitable runoff from the below-knee popliteal artery and the decision was made to perform a redo bypass operation. Past Medical History: PVD (Fem stent <Date>11-18</Date>), B CEA, IDDM, RAS, HTN, CAD (MI '<Digit>98</Digit>, CABGx3 '<Digit>32</Digit>), CRI, Breast implants, Depression Social History: 80 pack year history, quit in <Year>1904</Year> no alcohol Family History: non contrib Physical Exam: On day of discharge, patient was feeling well without complaints, vital signs stable. T 98.3, Pulse 74, BP 140/40, RR 18, O2 sats 96% RA The patient was not in any acute distress, alert and oriented x 3 and not in any pain. CVS- regular rate and rhythm Pulm- clear to auscultation, bilaterally Abd- non distended, soft, non tender Wound- left leg- clean, dry and intact Pulses palpable bilaterally fem, <Doctor Name>Dr.Smith</Doctor Name>, dp, pt Pertinent Results: <Date>1900-10-17</Date> 03:40AM BLOOD WBC-15.0* RBC-3.22* Hgb-9.9* Hct-29.8* MCV-93 MCH-30.6 MCHC-33.1 RDW-14.4 Plt Ct-495* <Date>2002-9-16</Date> 07:45PM BLOOD Neuts-63 Bands-0 Lymphs-27 Monos-5 Eos-4 Baso-1 Atyps-0 Metas-0 Myelos-0 <Date>1900-10-17</Date> 03:40AM BLOOD Plt Ct-495* <Date>1900-10-17</Date> 03:40AM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.2* <Date>1922-2-8</Date> 06:10AM BLOOD Glucose-118* UreaN-54* Creat-1.5* Na-136 K-4.0 Cl-100 HCO3-28 AnGap-12 <Date>1922-2-8</Date> 06:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.5 Blood culture all negative Brief Hospital Course: The patient was admitted on <Date>2002-9-16</Date> for a left lower extremity bypass on <Date>2021-3-31</Date>. The patient underwent a left fem-bk <Doctor Name>Dr.Smith</Doctor Name> with right arm vein (cephalic + basilic) and venovenostomy. Intraop fluids- 5.6 L crystalloid, 4 units RBC, urine output 475cc, estimated blood loss 600 cc. The patient remained intubated to the PACU with a palpable L DP, dopplerable L PT. The patient remained intubated on <Date>1939-12-28</Date>, sedated in the PACU. She was then extubated and transferred to the VICU on <Date>10-18</Date>. Her vital signs were continually monitored throughout. <Date>1900-7-31</Date>-patient began a regular diet and treated with nebulizers, had nausea and dry heaving. The patient transferred from chair to bed, had difficulty maintaining O2 sats >90% and was transferred to the CSRU. <Date>1928-7-15</Date> Patient treated in CSRU for pulmonary edema secondary to CHF. Patient was intubated due to increasing shortness of breath. Transfused one unit of red blood cells and diuresed. The patient continued to be monitored in the CRSU through <Date>4-20</Date>. She was shortly extubated on <Date>6-3</Date> but intubated later that night for pulmonary edema. Tube feeds were started on <Date>1947-12-28</Date>. <Date>1955-9-28</Date>- CPAP as tolerated, nebs, wean PS as tolerated, extubated and chest PT. <Date>8-9</Date>- Swallow evaluation performed-cleared <Date>3-3</Date>-diuresis held, dispo to VICU. <Date>4-20</Date>- transferred to the floor, regular diet, ambulating, nebs. Seen by PT- recommend 2-4x/wk and rehab disposition. 8/11,<Date>7-26</Date>- continued pulm toilet, diuresis, PO home meds. <Name>Prieto</Name> consult for sugars >400. Patient started on standing insulin dose + sliding scale. OT consulted to help with right arm function. <Date>5-20</Date>- d/c central line, peripheral line inserted, PT eval, oral home meds, lasix 40 po. <Date>8-17</Date> VSS, no events. <Name>Prieto</Name> in to evaluate- will continue current BS medications. Staples removed prior to discharge. F/U Dr. <Name>Spikes</Name> 3-4 weeks with duplex Medications on Admission: <Name>Porras</Name>: ASA 81', Lipitor 5', Citolapram 20', Metoprolol 50", Norvasc 10', Lasix 40', Humalog, Lantus 18 U HS, Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Humalog SLiding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-60 mg/dL <Date>10-25</Date> amp D50 61-80 mg/dL 0 Units 0 Units 0 Units 0 Units 81-120 mg/dL 3 Units 3 Units 4 Units 0 Units 121-160 mg/dL 6 Units 6 Units 7 Units 1 Units 161-200 mg/dL 9 Units 9 Units 10 Units 3 Units 201-240 mg/dL 11 Units 11 Units 11 Units 5 Units 241-280 mg/dL 13 Units 13 Units 13 Units 7 Units 281-320 mg/dL 15 Units 15 Units 15 Units 8 Units > 320 mg/dL Notify M.D. 12. Lantus 100 unit/mL Solution Sig: 20 units QHS Subcutaneous at bedtime: Continue Humalog SS. Discharge Disposition: Extended Care Facility: <Location>455 Anne Ports Suite 438 South Danielfort, PW 90855</Location> Nursing Center Discharge Diagnosis: Left lower leg ischemia- occluded femoral to above knee popliteal bypass graft PMH: PVD (Fem stent <Date>11-18</Date>), B CEA, IDDM, RAS, HTN, CAD (MI '<Digit>98</Digit>, CABGx3 '<Digit>32</Digit>), CRI, Breast implants, Depression Discharge Condition: patient in good condition, vital signs stable Discharge Instructions: Division of <Year>1981</Year> and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use <Date>12-23</Date> pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: <Name>George</Name> <Name>Mao</Name>, MD Phone:<Telephone>925-688-5135</Telephone> Date/Time:<Date>1976-8-23</Date> 1:45 Provider: <Name>May Hang</Name> LAB Phone:<Telephone>925-688-5135</Telephone> Date/Time:<Date>1976-8-23</Date> 1:00 Completed by:<Date>1910-12-13</Date>	000000000000000001111111110000000000000000000000000000000011111111110000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000110000000000110000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000001111111111000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000111111111000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000011100000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110011111111100000000000000000000000000000000000000000000000000000000000000000000000001110000000000000000000000000000000000000001110000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000011111100000000000000000000>0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000001111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111110000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 2002-9-16 Discharge Date: 1910-12-13 Date of Birth: 2016-10-22 Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Dylan Chief Complaint: left lower leg extremity ischemia Major Surgical or Invasive Procedure: s/p Left femoral-below knee popliteal bypass History of Present Illness: This is a 61-year-old female who has a history of a left femoral to above-knee popliteal bypass with prosthetic due to a previous harvesting for CABG of her saphenous vein. The patient also has a history of stenting and angioplasty of the distal popliteal artery. The patient presented to the hospital with increasing left foot pain and was found on angiography to have a completely thrombosed prosthetic graft. She had suitable runoff from the below-knee popliteal artery and the decision was made to perform a redo bypass operation. Past Medical History: PVD (Fem stent 11-18), B CEA, IDDM, RAS, HTN, CAD (MI '98, CABGx3 '32), CRI, Breast implants, Depression Social History: 80 pack year history, quit in 1904 no alcohol Family History: non contrib Physical Exam: On day of discharge, patient was feeling well without complaints, vital signs stable. T 98.3, Pulse 74, BP 140/40, RR 18, O2 sats 96% RA The patient was not in any acute distress, alert and oriented x 3 and not in any pain. CVS- regular rate and rhythm Pulm- clear to auscultation, bilaterally Abd- non distended, soft, non tender Wound- left leg- clean, dry and intact Pulses palpable bilaterally fem, Dr.Smith, dp, pt Pertinent Results: 1900-10-17 03:40AM BLOOD WBC-15.0* RBC-3.22* Hgb-9.9* Hct-29.8* MCV-93 MCH-30.6 MCHC-33.1 RDW-14.4 Plt Ct-495* 2002-9-16 07:45PM BLOOD Neuts-63 Bands-0 Lymphs-27 Monos-5 Eos-4 Baso-1 Atyps-0 Metas-0 Myelos-0 1900-10-17 03:40AM BLOOD Plt Ct-495* 1900-10-17 03:40AM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.2* 1922-2-8 06:10AM BLOOD Glucose-118* UreaN-54* Creat-1.5* Na-136 K-4.0 Cl-100 HCO3-28 AnGap-12 1922-2-8 06:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.5 Blood culture all negative Brief Hospital Course: The patient was admitted on 2002-9-16 for a left lower extremity bypass on 2021-3-31. The patient underwent a left fem-bk Dr.Smith with right arm vein (cephalic + basilic) and venovenostomy. Intraop fluids- 5.6 L crystalloid, 4 units RBC, urine output 475cc, estimated blood loss 600 cc. The patient remained intubated to the PACU with a palpable L DP, dopplerable L PT. The patient remained intubated on 1939-12-28, sedated in the PACU. She was then extubated and transferred to the VICU on 10-18. Her vital signs were continually monitored throughout. 1900-7-31-patient began a regular diet and treated with nebulizers, had nausea and dry heaving. The patient transferred from chair to bed, had difficulty maintaining O2 sats >90% and was transferred to the CSRU. 1928-7-15 Patient treated in CSRU for pulmonary edema secondary to CHF. Patient was intubated due to increasing shortness of breath. Transfused one unit of red blood cells and diuresed. The patient continued to be monitored in the CRSU through 4-20. She was shortly extubated on 6-3 but intubated later that night for pulmonary edema. Tube feeds were started on 1947-12-28. 1955-9-28- CPAP as tolerated, nebs, wean PS as tolerated, extubated and chest PT. 8-9- Swallow evaluation performed-cleared 3-3-diuresis held, dispo to VICU. 4-20- transferred to the floor, regular diet, ambulating, nebs. Seen by PT- recommend 2-4x/wk and rehab disposition. 8/11,7-26- continued pulm toilet, diuresis, PO home meds. Prieto consult for sugars >400. Patient started on standing insulin dose + sliding scale. OT consulted to help with right arm function. 5-20- d/c central line, peripheral line inserted, PT eval, oral home meds, lasix 40 po. 8-17 VSS, no events. Prieto in to evaluate- will continue current BS medications. Staples removed prior to discharge. F/U Dr. Spikes 3-4 weeks with duplex Medications on Admission: Porras: ASA 81', Lipitor 5', Citolapram 20', Metoprolol 50", Norvasc 10', Lasix 40', Humalog, Lantus 18 U HS, Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Humalog SLiding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-60 mg/dL 10-25 amp D50 61-80 mg/dL 0 Units 0 Units 0 Units 0 Units 81-120 mg/dL 3 Units 3 Units 4 Units 0 Units 121-160 mg/dL 6 Units 6 Units 7 Units 1 Units 161-200 mg/dL 9 Units 9 Units 10 Units 3 Units 201-240 mg/dL 11 Units 11 Units 11 Units 5 Units 241-280 mg/dL 13 Units 13 Units 13 Units 7 Units 281-320 mg/dL 15 Units 15 Units 15 Units 8 Units > 320 mg/dL Notify M.D. 12. Lantus 100 unit/mL Solution Sig: 20 units QHS Subcutaneous at bedtime: Continue Humalog SS. Discharge Disposition: Extended Care Facility: 455 Anne Ports Suite 438 South Danielfort, PW 90855 Nursing Center Discharge Diagnosis: Left lower leg ischemia- occluded femoral to above knee popliteal bypass graft PMH: PVD (Fem stent 11-18), B CEA, IDDM, RAS, HTN, CAD (MI '98, CABGx3 '32), CRI, Breast implants, Depression Discharge Condition: patient in good condition, vital signs stable Discharge Instructions: Division of 1981 and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use 12-23 pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: George Mao, MD Phone:925-688-5135 Date/Time:1976-8-23 1:45 Provider: May Hang LAB Phone:925-688-5135 Date/Time:1976-8-23 1:00 Completed by:1910-12-13	['Admission Date: 2002-9-16 Discharge Date: 1910-12-13\n\nDate of Birth: 2016-10-22 Sex: F\n\nService: SURGERY\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Dylan\nChief Complaint:\nleft lower leg extremity ischemia\n\nMajor Surgical or Invasive Procedure:\ns/p Left femoral-below knee popliteal bypass\n\n\nHistory of Present Illness:\nThis is a 61-year-old female who has a history\nof a left femoral to above-knee popliteal bypass with\nprosthetic due to a previous harvesting for CABG of her\nsaphenous vein. The patient also has a history of stenting\nand angioplasty of the distal popliteal artery. The patient\npresented to the hospital with increasing left foot pain and\nwas found on angiography to have a completely thrombosed\nprosthetic graft. She had suitable runoff from the below-knee\npopliteal artery and the decision was made to perform a redo\nbypass operation.', "\n\n\nPast Medical History:\nPVD (Fem stent 11-18),\nB CEA,\nIDDM,\nRAS,\nHTN,\nCAD (MI '98, CABGx3 '32),\nCRI,\nBreast implants,\nDepression\n\nSocial History:\n80 pack year history, quit in 1904\nno alcohol\n\n\nFamily History:\nnon contrib\n\nPhysical Exam:\nOn day of discharge, patient was feeling well without\ncomplaints, vital signs stable. T 98.3, Pulse 74, BP 140/40, RR\n18, O2 sats 96% RA\n\nThe patient was not in any acute distress, alert and oriented x\n3 and not in any pain.\nCVS- regular rate and rhythm\nPulm- clear to auscultation, bilaterally\nAbd- non distended, soft, non tender\nWound- left leg- clean, dry and intact\nPulses palpable bilaterally fem, Dr.Smith, dp, pt\n\nPertinent Results:\n1900-10-17 03:40AM BLOOD WBC-15.0* RBC-3.22* Hgb-9.9* Hct-29.8\nMCV-93 MCH-30.6 MCHC-33.1 RDW-14.4 Plt Ct-495\n2002-9-16 07:45PM BLOOD Neuts-63 Bands-0 Lymphs-27 Monos-5 Eos-4\nBaso-1 Atyps-0 Metas-0 Myelos-0\n1900-10-17 03:40AM BLOOD Plt Ct-495\n1900-10-17 03:40AM BLOOD PT-14.", '0 PTT-33.0 INR(PT)-1.2\n1922-2-8 06:10AM BLOOD Glucose-118 UreaN-54* Creat-1.5* Na-136\nK-4.0 Cl-100 HCO3-28 AnGap-12\n1922-2-8 06:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.5\n\nBlood culture all negative\n\nBrief Hospital Course:\nThe patient was admitted on 2002-9-16 for a left lower extremity\nbypass on 2021-3-31. The patient underwent a left fem-bk Dr.Smith with\nright arm vein (cephalic + basilic) and venovenostomy. Intraop\nfluids- 5.6 L crystalloid, 4 units RBC, urine output 475cc,\nestimated blood loss 600 cc. The patient remained intubated to\nthe PACU with a palpable L DP, dopplerable L PT. The patient\nremained intubated on 1939-12-28, sedated in the PACU. She was then\nextubated and transferred to the VICU on 10-18. Her vital signs\nwere continually monitored throughout.\n1900-7-31-patient began a regular diet and treated with nebulizers,\nhad nausea and dry heaving.', ' The patient transferred from chair\nto bed, had difficulty maintaining O2 sats >90% and was\ntransferred to the CSRU.\n1928-7-15 Patient treated in CSRU for pulmonary edema secondary to\nCHF. Patient was intubated due to increasing shortness of\nbreath. Transfused one unit of red blood cells and diuresed.\nThe patient continued to be monitored in the CRSU through 4-20.\nShe was shortly extubated on 6-3 but intubated later that night\nfor pulmonary edema. Tube feeds were started on 1947-12-28.\n1955-9-28- CPAP as tolerated, nebs, wean PS as tolerated, extubated\nand chest PT.\n8-9- Swallow evaluation performed-cleared\n3-3-diuresis held, dispo to VICU.\n4-20- transferred to the floor, regular diet, ambulating, nebs.\nSeen by PT- recommend 2-4x/wk and rehab disposition.\n8/11,7-26- continued pulm toilet, diuresis, PO home meds.', '\nPrieto consult for sugars >400. Patient started on standing\ninsulin dose + sliding scale. OT consulted to help with right\narm function.\n5-20- d/c central line, peripheral line inserted, PT eval, oral\nhome meds, lasix 40 po.\n8-17 VSS, no events. Prieto in to evaluate- will continue\ncurrent BS medications. Staples removed prior to discharge. F/U\nDr. Spikes 3-4 weeks with duplex\n\nMedications on Admission:\nPorras: ASA 81\', Lipitor 5\', Citolapram 20\', Metoprolol 50",\nNorvasc 10\', Lasix 40\', Humalog, Lantus 18 U HS,\n\n\nDischarge Medications:\n1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID\n(3 times a day).', '\n5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24\nhours).\n6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times\na day).\n7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every\n6 hours) as needed.\n9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)\nInhalation Q4H (every 4 hours) as needed.\n10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed.\n11. Humalog SLiding Scale\nInsulin SC Sliding Scale\nBreakfast Lunch Dinner Bedtime\nHumalog\nGlucose Insulin Dose\n0-60 mg/dL 10-25 amp D50\n61-80 mg/dL 0 Units 0 Units 0 Units 0 Units\n81-120 mg/dL 3 Units 3 Units 4 Units 0 Units\n121-160 mg/dL 6 Units 6 Units 7 Units 1 Units\n161-200 mg/dL 9 Units 9 Units 10 Units 3 Units\n201-240 mg/dL 11 Units 11 Units 11 Units 5 Units\n241-280 mg/dL 13 Units 13 Units 13 Units 7 Units\n281-320 mg/dL 15 Units 15 Units 15 Units 8 Units\n> 320 mg/dL Notify M.', "D.\n12. Lantus 100 unit/mL Solution Sig: 20 units QHS Subcutaneous\nat bedtime: Continue Humalog SS.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\n455 Anne Ports Suite 438\nSouth Danielfort, PW 90855 Nursing Center\n\nDischarge Diagnosis:\nLeft lower leg ischemia- occluded femoral to above knee\npopliteal bypass graft\n\nPMH: PVD (Fem stent 11-18), B CEA, IDDM, RAS, HTN, CAD (MI '98,\nCABGx3 '32), CRI, Breast implants, Depression\n\n\nDischarge Condition:\npatient in good condition, vital signs stable\n\n\nDischarge Instructions:\nDivision of 1981 and Endovascular Surgery\nLower Extremity Bypass Surgery Discharge Instructions\n\nWhat to expect when you go home:\n1. It is normal to feel tired, this will last for 4-6 weeks\n??????\tYou should get up out of bed every day and gradually increase\nyour activity each day\n??????\tUnless you were told not to bear any weight on operative foot:\nyou may walk and you may go up and down stairs\n??????\tIncrease your activities as you can tolerate- do not do too\nmuch right away!\n\n2.", ' It is normal to have swelling of the leg you were operated\non:\n??????\tElevate your leg above the level of your heart (use 12-23\npillows or a recliner) every 2-3 hours throughout the day and at\nnight\n??????\tAvoid prolonged periods of standing or sitting without your\nlegs elevated\n\n3. It is normal to have a decreased appetite, your appetite will\nreturn with time\n??????\tYou will probably lose your taste for food and lose some\nweight\n??????\tEat small frequent meals\n??????\tIt is important to eat nutritious food options (high fiber,\nlean meats, vegetables/fruits, low fat, low cholesterol) to\nmaintain your strength and assist in wound healing\n??????\tTo avoid constipation: eat a high fiber diet and use stool\nsoftener while taking pain medication\n\nWhat activities you can and cannot do:\n??????\tNo driving until post-op visit and you are no longer taking\npain medications\n??????\tUnless you were told not to bear any weight on operative foot:\n\n??????\tYou should get up every day, get dressed and walk\n??????\tYou should gradually increase your activity\n??????\tYou may up and down stairs, go outside and/or ride in a car\n??????\tIncrease your activities as you can tolerate- do not do too\nmuch right away!\n??????\tNo heavy lifting, pushing or pulling (greater than 5 pounds)\nuntil your post op visit\n??????\tYou may shower (unless you have stitches or foot incisions) no\ndirect spray on incision, let the soapy water run over incision,\nrinse and pat dry\n??????\tYour incision may be left uncovered, unless you have small\namounts of drainage from the wound, then place a dry dressing\nover the area that is draining, as needed\n??????\tTake all the medications you were taking before surgery,\nunless otherwise directed\n??????\tTake one full strength (325mg) enteric coated aspirin daily,\nunless otherwise directed\n??????\tCall and schedule an appointment to be seen in 2 weeks for\nstaple/suture removal\n\nWhat to report to office:\n??????\tRedness that extends away from your incision\n??????\tA sudden increase in pain that is not controlled with pain\nmedication\n??????\tA sudden change in the ability to move or use your leg or the\nability to feel your leg\n??????\tTemperature greater than 100.', '5F for 24 hours\n??????\tBleeding, new or increased drainage from incision or white,\nyellow or green drainage from incisions\n\nFollowup Instructions:\nProvider: George Mao, MD Phone:925-688-5135\nDate/Time:1976-8-23 1:45\nProvider: May Hang LAB Phone:925-688-5135 Date/Time:1976-8-23\n1:00\n\n\n\nCompleted by:1910-12-13']
163	17513	124736.0	2140-11-24	Discharge summary	Report	Admission Date: [2140-11-16] Discharge Date: [2140-11-24] Date of Birth: [2080-4-23] Sex: M CHIEF COMPLAINT: Cough/shortness of breath. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 1726] is a 60-year-old male with a past medical history significant for hypertension, times two, who developed a dry cough in late [Month (only) ] while fly fishing in [State 1727]. The cough persisted and he was given erythromycin times ten days times two courses by his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 1728]. The erythromycin did not improve the patient's symptoms. The patient describes the cough as dry, not worse at night, breath. He denied fevers and chills. He states that he lost about six pounds over the past two months intentionally. Over the past one to two weeks, however, he has noted increasing dyspnea with stairs, as well as fatigue. On the day prior to admission, he started a Z pack. At his primary care physician's office today, he had a chest x-ray which disclosed an enlarged heart and interstitial infiltrates. An esophagogastroduodenoscopy was done, as well as an echocardiogram which disclosed evidence of a pericardial effusion with tamponade. There was diastolic collapse of the right atrium and right ventricle. The patient was sent to the Emergency Department at [Hospital6 256] for evaluation of the pericardial effusion and drainage. His pulses paradoxes was 18. The echocardiogram performed in the Emergency Department was consistent with cardiac tamponade. The patient remained hemodynamically stable. PAST MEDICAL HISTORY: 1. Melanoma. Patient is status post removal of melanoma in [2118] and in [2138]. 2. Empyema of the left lung in [2122]. 3. Labile hypertension. 4. Overweight. 5. Hypercholesterolemia. 6. Myxomatous mitral valve prolapse with mild mitral regurgitation. 7. Non-sustained ventricular tachycardia. 8. Chronic asymptomatic VEA. 9. Peripheral vision loss. 10. History of smoking, quit in [2122]. MEDICATIONS: 1. Tenormin 150 mg q.d. 2. Lipitor 80 hs. 3. Enteric coated aspirin 325 mg po q.d. 4. Accupril 20 mg po q.d. 5. Multivitamin. 6. Folate 2 tablets b.i.d. 7. Vitamin E. 8. Vitamin B6. 9. Vitamin B12. 10. Ativan prn sleep. ALLERGIES: Penicillin. Patient has a rash. SOCIAL HISTORY: Patient does office work. He has been a widow for the past nine years. He coaches a girls basketball team. He has two children, ages 30 and 25. He lives with his 30-year-old daughter. [Name (NI) ] has a 2-year-old grandchild. He smoked cigars until [2122]. He has not had alcohol for the past nine years. FAMILY HISTORY: No heart disease and no diabetes mellitus. REVIEW OF SYSTEMS: No fevers, chills or night sweats. Patient reports a six pound intentional weight loss over the past two months. No history of positive PPD or Tuberculosis exposure. No upper respiratory infection symptoms with cough. No nausea, vomiting, diarrhea or abdominal pain, but occasionally "spits up" after his cough. Reports dyspnea with stairs and chest tightness occasionally on stairs. No rash, no joint symptoms, no melanoma, no bright red blood per rectum, no dysuria, no edema, no paroxysmal nocturnal dyspnea, no orthopnea, no palpitations, no dizziness. PHYSICAL EXAMINATION: Temperature 97 degrees. Pulse 86. Blood pressure 124/63. Respiratory rate 23. Oxygen saturation 95% on three liters nasal cannula. General: Elderly white male in no apparent distress. Head, eyes, ears, nose and throat: Anicteric, oropharynx clear, pupils equal, round and reactive to light, extraocular movements intact. Neck: Supple, no carotid bruit, no jugular venous distention. Cardiovascular: Regular rate and rhythm, soft S1, S2, no murmurs, rubs or gallops, pericardial drain in place. Chest clear to auscultation anteriorly, left lateral chest scar. Abdomen soft, nontender, nondistended with positive bowel sounds. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis pulses bilaterally. Neurological: Cranial nerves II through XII are intact. Alert and oriented times three. Exam otherwise nonfocal. Note: This physical examination was done after the patient underwent his cardiac catheterization. LABORATORY DATA ON ADMISSION: White blood cell count 7.3, hematocrit of 41, platelet count of 294,000. PT 13, PTT 23.6, INR 1.1. Echocardiogram: Normal sinus rhythm, 71 beats per minute, electrical alternans, low voltage precordial leads, prolonged PR. After the procedure, esophagogastroduodenoscopy showed a sinus rhythm at 82 beats per minute, normal axis, prolonged PR, T wave inversions I and aVL, biphasic T in V2, Qs in V1 to V2, increased voltage. HOSPITAL COURSE: The patient was admitted initially to the Coronary Care Unit. He underwent a cardiac catheterization on [11-16] for pericardiocentesis. Hemodynamics showed elevated and equal RA and pericardial pressures, 11-12 mm mercury, slightly lower than pulmonary capillary wedge pressure. There was preserved cardiac index. There is preserved blood pressure with 15-20 mm mercury pulses paradoxes. During the pericardiocentesis, 1116 ml of serosanguinous fluid was easily removed. Fluid was sent to the laboratory for analysis. Following the pericardiocentesis, the patient was admitted to the Coronary Care Unit for further management. On [11-17], the pericardial drain was removed. Repeat echocardiogram did not disclose recurrence of the pericardial effusion. Patient underwent CT of the chest which disclosed diffuse interstitial infiltrates consistent with lymphangitic spread. There was also a positive mediastinal lymphadenopathy and lytic sclerotic bone lesions. On [11-19], the patient was transferred to the [Location (un) ] Service. On the night of the 16th, he was tachycardic to the 160s. Echocardiogram disclosed atrial flutter. His blood pressure was stable. He was started on sotalol 120 mg b.i.d. The following day this was decreased to 80 mg b.i.d. While on sotalol, his QTC interval was monitored and his potassium was kept between 4.5 and 5.2. Repeat echocardiogram did not disclose re-accumulation of the pericardial effusion. While on the [Location (un) ] Service. A Pulmonary Consult was obtained for further evaluation of the diffuse infiltrates seen on the CT. Pulmonary Service recommended awaiting the final pathology from the pericardial fluid. They were willing to perform transbronchial biopsy if necessary. Patient was also seen by his Oncologist, Dr. [Last Name (STitle) 1729]. Patient underwent an MRI of his brain on [11-23]. MRI disclosed foci on the surface of the brain that appeared consistent with leptomeningeal spread of cancer. An abdominal CT was done on [11-23]. CT of the abdomen disclosed one lymphangitic spread of metastatic disease throughout the lungs was stable since the study one week before. There was an increase in the pericardial fluid since the study one week prior. There was interval development of multiple sclerotic and lytic lesions within the osseous structures since [2139]. There were stable hepatic lesions that likely represent simple cysts. There was a stable splenic lesion that likely represents a hemangioma. Although, colon appeared grossly normal, radiologist's caution that the study was not diagnostic for colon cancer. Finally, pathology results from pericardial fluid were obtained. Pathologists performed multiple stains to identify the type of cancer, the types of cells in the pericardial fluid. Pathologist's concluded that the malignant cells were from adenocarcinoma. The tumor cells are positive for CK7 and TTF1 markers. TTF1 marker is specific for lung and thyroid. The cells were focally positive for CK20. Pathologist's concluded that this immunoprofile is consistent with an adenocarcinoma arising in the lung. The patient was discharged on [11-24]. He will have outpatient work-up of his malignancy. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Patient discharged home on Monday, [2140-11-28]. DISCHARGE FOLLOW-UP: He will follow-up with his Oncologist, Dr. [Last Name (STitle) 1729], at 2 p.m. He will be seen by Dr. [Last Name (STitle) 724] in the Brain [Hospital 341] Clinic at 4 p.m. on [2140-11-28]. He will follow-up with his Cardiologist, Dr. [Last Name (STitle) ], on Wednesday, [2140-11-30]. He was encouraged to call his primary care physician for [Initials (NamePattern4) ] [Last Name (NamePattern4) 702] appointment. Patient was given [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Heart's monitor so that his QTC interval could be monitored for an additional week while on sotalol. DISCHARGE DIAGNOSES: 1. Pericardial effusion with cardiac tamponade. 2. Non-sustained ventricular tachycardia. 3. Hypertension. 4. Atrial Fibrillation. DISCHARGE MEDICATIONS: 1. Sotalol 80 mg po b.i.d. 2. Lipitor 80 hs. 3. Enteric coated aspirin 325 mg po q.d. 4. Accupril 20 mg po q.d. 5. Multivitamin. 6. Folate 2 mg po b.i.d. 7. Vitamin E. 8. Vitamin B6. 9. Vitamin B12. 10. Ativan prn sleep. 11. Potassium chloride 30 mEq po q.d. 12. Celebrex 100 mg po b.i.d. as needed. [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern1) 1731], M.D. [MD Number(1) 1732] Dictated By:[First Name3 (LF) 1733] MEDQUIST36 D: [2140-11-25] T: [2140-11-27] 19:57 JOB#: [Job Number 1734]	Admission Date: <Date>1987-7-3</Date> Discharge Date: <Date>1934-11-22</Date> Date of Birth: <Date>1962-8-11</Date> Sex: M CHIEF COMPLAINT: Cough/shortness of breath. HISTORY OF PRESENT ILLNESS: Mr. <Name>Pegram</Name> is a 60-year-old male with a past medical history significant for hypertension, times two, who developed a dry cough in late <Month>September</Month> while fly fishing in <State>Iowa</State>. The cough persisted and he was given erythromycin times ten days times two courses by his primary care physician, <Name>Ivory</Name>. <Name>Bludsworth</Name>. The erythromycin did not improve the patient's symptoms. The patient describes the cough as dry, not worse at night, breath. He denied fevers and chills. He states that he lost about six pounds over the past two months intentionally. Over the past one to two weeks, however, he has noted increasing dyspnea with stairs, as well as fatigue. On the day prior to admission, he started a Z pack. At his primary care physician's office today, he had a chest x-ray which disclosed an enlarged heart and interstitial infiltrates. An esophagogastroduodenoscopy was done, as well as an echocardiogram which disclosed evidence of a pericardial effusion with tamponade. There was diastolic collapse of the right atrium and right ventricle. The patient was sent to the Emergency Department at <Hospital>Knight-Fox Clinic</Hospital> for evaluation of the pericardial effusion and drainage. His pulses paradoxes was 18. The echocardiogram performed in the Emergency Department was consistent with cardiac tamponade. The patient remained hemodynamically stable. PAST MEDICAL HISTORY: 1. Melanoma. Patient is status post removal of melanoma in <Year>2004</Year> and in <Year>2004</Year>. 2. Empyema of the left lung in <Year>2004</Year>. 3. Labile hypertension. 4. Overweight. 5. Hypercholesterolemia. 6. Myxomatous mitral valve prolapse with mild mitral regurgitation. 7. Non-sustained ventricular tachycardia. 8. Chronic asymptomatic VEA. 9. Peripheral vision loss. 10. History of smoking, quit in <Year>2004</Year>. MEDICATIONS: 1. Tenormin 150 mg q.d. 2. Lipitor 80 hs. 3. Enteric coated aspirin 325 mg po q.d. 4. Accupril 20 mg po q.d. 5. Multivitamin. 6. Folate 2 tablets b.i.d. 7. Vitamin E. 8. Vitamin B6. 9. Vitamin B12. 10. Ativan prn sleep. ALLERGIES: Penicillin. Patient has a rash. SOCIAL HISTORY: Patient does office work. He has been a widow for the past nine years. He coaches a girls basketball team. He has two children, ages 30 and 25. He lives with his 30-year-old daughter. <Name>Christina Ngo</Name> has a 2-year-old grandchild. He smoked cigars until <Year>2004</Year>. He has not had alcohol for the past nine years. FAMILY HISTORY: No heart disease and no diabetes mellitus. REVIEW OF SYSTEMS: No fevers, chills or night sweats. Patient reports a six pound intentional weight loss over the past two months. No history of positive PPD or Tuberculosis exposure. No upper respiratory infection symptoms with cough. No nausea, vomiting, diarrhea or abdominal pain, but occasionally "spits up" after his cough. Reports dyspnea with stairs and chest tightness occasionally on stairs. No rash, no joint symptoms, no melanoma, no bright red blood per rectum, no dysuria, no edema, no paroxysmal nocturnal dyspnea, no orthopnea, no palpitations, no dizziness. PHYSICAL EXAMINATION: Temperature 97 degrees. Pulse 86. Blood pressure 124/63. Respiratory rate 23. Oxygen saturation 95% on three liters nasal cannula. General: Elderly white male in no apparent distress. Head, eyes, ears, nose and throat: Anicteric, oropharynx clear, pupils equal, round and reactive to light, extraocular movements intact. Neck: Supple, no carotid bruit, no jugular venous distention. Cardiovascular: Regular rate and rhythm, soft S1, S2, no murmurs, rubs or gallops, pericardial drain in place. Chest clear to auscultation anteriorly, left lateral chest scar. Abdomen soft, nontender, nondistended with positive bowel sounds. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis pulses bilaterally. Neurological: Cranial nerves II through XII are intact. Alert and oriented times three. Exam otherwise nonfocal. Note: This physical examination was done after the patient underwent his cardiac catheterization. LABORATORY DATA ON ADMISSION: White blood cell count 7.3, hematocrit of 41, platelet count of 294,000. PT 13, PTT 23.6, INR 1.1. Echocardiogram: Normal sinus rhythm, 71 beats per minute, electrical alternans, low voltage precordial leads, prolonged PR. After the procedure, esophagogastroduodenoscopy showed a sinus rhythm at 82 beats per minute, normal axis, prolonged PR, T wave inversions I and aVL, biphasic T in V2, Qs in V1 to V2, increased voltage. HOSPITAL COURSE: The patient was admitted initially to the Coronary Care Unit. He underwent a cardiac catheterization on <Date>11-11</Date> for pericardiocentesis. Hemodynamics showed elevated and equal RA and pericardial pressures, 11-12 mm mercury, slightly lower than pulmonary capillary wedge pressure. There was preserved cardiac index. There is preserved blood pressure with 15-20 mm mercury pulses paradoxes. During the pericardiocentesis, 1116 ml of serosanguinous fluid was easily removed. Fluid was sent to the laboratory for analysis. Following the pericardiocentesis, the patient was admitted to the Coronary Care Unit for further management. On <Date>11-6</Date>, the pericardial drain was removed. Repeat echocardiogram did not disclose recurrence of the pericardial effusion. Patient underwent CT of the chest which disclosed diffuse interstitial infiltrates consistent with lymphangitic spread. There was also a positive mediastinal lymphadenopathy and lytic sclerotic bone lesions. On <Date>4-27</Date>, the patient was transferred to the <Location>68762 Daniel Stream Johnsonside, KS 92297</Location> Service. On the night of the 16th, he was tachycardic to the 160s. Echocardiogram disclosed atrial flutter. His blood pressure was stable. He was started on sotalol 120 mg b.i.d. The following day this was decreased to 80 mg b.i.d. While on sotalol, his QTC interval was monitored and his potassium was kept between 4.5 and 5.2. Repeat echocardiogram did not disclose re-accumulation of the pericardial effusion. While on the <Location>68762 Daniel Stream Johnsonside, KS 92297</Location> Service. A Pulmonary Consult was obtained for further evaluation of the diffuse infiltrates seen on the CT. Pulmonary Service recommended awaiting the final pathology from the pericardial fluid. They were willing to perform transbronchial biopsy if necessary. Patient was also seen by his Oncologist, Dr. <Name>Ornelas</Name>. Patient underwent an MRI of his brain on <Date>6-9</Date>. MRI disclosed foci on the surface of the brain that appeared consistent with leptomeningeal spread of cancer. An abdominal CT was done on <Date>6-9</Date>. CT of the abdomen disclosed one lymphangitic spread of metastatic disease throughout the lungs was stable since the study one week before. There was an increase in the pericardial fluid since the study one week prior. There was interval development of multiple sclerotic and lytic lesions within the osseous structures since <Year>2004</Year>. There were stable hepatic lesions that likely represent simple cysts. There was a stable splenic lesion that likely represents a hemangioma. Although, colon appeared grossly normal, radiologist's caution that the study was not diagnostic for colon cancer. Finally, pathology results from pericardial fluid were obtained. Pathologists performed multiple stains to identify the type of cancer, the types of cells in the pericardial fluid. Pathologist's concluded that the malignant cells were from adenocarcinoma. The tumor cells are positive for CK7 and TTF1 markers. TTF1 marker is specific for lung and thyroid. The cells were focally positive for CK20. Pathologist's concluded that this immunoprofile is consistent with an adenocarcinoma arising in the lung. The patient was discharged on <Date>11-9</Date>. He will have outpatient work-up of his malignancy. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Patient discharged home on Monday, <Date>1978-9-9</Date>. DISCHARGE FOLLOW-UP: He will follow-up with his Oncologist, Dr. <Name>Ornelas</Name>, at 2 p.m. He will be seen by Dr. <Name>Finateri</Name> in the Brain <Hospital>Vargas PLC Clinic</Hospital> Clinic at 4 p.m. on <Date>1978-9-9</Date>. He will follow-up with his Cardiologist, Dr. <Name>Quinones</Name>, on Wednesday, <Date>1903-7-15</Date>. He was encouraged to call his primary care physician for <Initial>NM</Initial> <Name>Walker</Name> appointment. Patient was given <Initial>NM</Initial> <Name>Ivory</Name> of Heart's monitor so that his QTC interval could be monitored for an additional week while on sotalol. DISCHARGE DIAGNOSES: 1. Pericardial effusion with cardiac tamponade. 2. Non-sustained ventricular tachycardia. 3. Hypertension. 4. Atrial Fibrillation. DISCHARGE MEDICATIONS: 1. Sotalol 80 mg po b.i.d. 2. Lipitor 80 hs. 3. Enteric coated aspirin 325 mg po q.d. 4. Accupril 20 mg po q.d. 5. Multivitamin. 6. Folate 2 mg po b.i.d. 7. Vitamin E. 8. Vitamin B6. 9. Vitamin B12. 10. Ativan prn sleep. 11. Potassium chloride 30 mEq po q.d. 12. Celebrex 100 mg po b.i.d. as needed. <Name>Shannan</Name> <Name>Pettway</Name>, M.D. <MD Number>03835815</MD Number> Dictated By:<Name>Sachin</Name> MEDQUIST36 D: <Date>1926-3-18</Date> T: <Date>1971-11-1</Date> 19:57 JOB#: <Job Number>Johnson-Hunt-1902-242603</Job 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Date: 1987-7-3 Discharge Date: 1934-11-22 Date of Birth: 1962-8-11 Sex: M CHIEF COMPLAINT: Cough/shortness of breath. HISTORY OF PRESENT ILLNESS: Mr. Pegram is a 60-year-old male with a past medical history significant for hypertension, times two, who developed a dry cough in late September while fly fishing in Iowa. The cough persisted and he was given erythromycin times ten days times two courses by his primary care physician, Ivory. Bludsworth. The erythromycin did not improve the patient's symptoms. The patient describes the cough as dry, not worse at night, breath. He denied fevers and chills. He states that he lost about six pounds over the past two months intentionally. Over the past one to two weeks, however, he has noted increasing dyspnea with stairs, as well as fatigue. On the day prior to admission, he started a Z pack. At his primary care physician's office today, he had a chest x-ray which disclosed an enlarged heart and interstitial infiltrates. An esophagogastroduodenoscopy was done, as well as an echocardiogram which disclosed evidence of a pericardial effusion with tamponade. There was diastolic collapse of the right atrium and right ventricle. The patient was sent to the Emergency Department at Knight-Fox Clinic for evaluation of the pericardial effusion and drainage. His pulses paradoxes was 18. The echocardiogram performed in the Emergency Department was consistent with cardiac tamponade. The patient remained hemodynamically stable. PAST MEDICAL HISTORY: 1. Melanoma. Patient is status post removal of melanoma in 2004 and in 2004. 2. Empyema of the left lung in 2004. 3. Labile hypertension. 4. Overweight. 5. Hypercholesterolemia. 6. Myxomatous mitral valve prolapse with mild mitral regurgitation. 7. Non-sustained ventricular tachycardia. 8. Chronic asymptomatic VEA. 9. Peripheral vision loss. 10. History of smoking, quit in 2004. MEDICATIONS: 1. Tenormin 150 mg q.d. 2. Lipitor 80 hs. 3. Enteric coated aspirin 325 mg po q.d. 4. Accupril 20 mg po q.d. 5. Multivitamin. 6. Folate 2 tablets b.i.d. 7. Vitamin E. 8. Vitamin B6. 9. Vitamin B12. 10. Ativan prn sleep. ALLERGIES: Penicillin. Patient has a rash. SOCIAL HISTORY: Patient does office work. He has been a widow for the past nine years. He coaches a girls basketball team. He has two children, ages 30 and 25. He lives with his 30-year-old daughter. Christina Ngo has a 2-year-old grandchild. He smoked cigars until 2004. He has not had alcohol for the past nine years. FAMILY HISTORY: No heart disease and no diabetes mellitus. REVIEW OF SYSTEMS: No fevers, chills or night sweats. Patient reports a six pound intentional weight loss over the past two months. No history of positive PPD or Tuberculosis exposure. No upper respiratory infection symptoms with cough. No nausea, vomiting, diarrhea or abdominal pain, but occasionally "spits up" after his cough. Reports dyspnea with stairs and chest tightness occasionally on stairs. No rash, no joint symptoms, no melanoma, no bright red blood per rectum, no dysuria, no edema, no paroxysmal nocturnal dyspnea, no orthopnea, no palpitations, no dizziness. PHYSICAL EXAMINATION: Temperature 97 degrees. Pulse 86. Blood pressure 124/63. Respiratory rate 23. Oxygen saturation 95% on three liters nasal cannula. General: Elderly white male in no apparent distress. Head, eyes, ears, nose and throat: Anicteric, oropharynx clear, pupils equal, round and reactive to light, extraocular movements intact. Neck: Supple, no carotid bruit, no jugular venous distention. Cardiovascular: Regular rate and rhythm, soft S1, S2, no murmurs, rubs or gallops, pericardial drain in place. Chest clear to auscultation anteriorly, left lateral chest scar. Abdomen soft, nontender, nondistended with positive bowel sounds. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis pulses bilaterally. Neurological: Cranial nerves II through XII are intact. Alert and oriented times three. Exam otherwise nonfocal. Note: This physical examination was done after the patient underwent his cardiac catheterization. LABORATORY DATA ON ADMISSION: White blood cell count 7.3, hematocrit of 41, platelet count of 294,000. PT 13, PTT 23.6, INR 1.1. Echocardiogram: Normal sinus rhythm, 71 beats per minute, electrical alternans, low voltage precordial leads, prolonged PR. After the procedure, esophagogastroduodenoscopy showed a sinus rhythm at 82 beats per minute, normal axis, prolonged PR, T wave inversions I and aVL, biphasic T in V2, Qs in V1 to V2, increased voltage. HOSPITAL COURSE: The patient was admitted initially to the Coronary Care Unit. He underwent a cardiac catheterization on 11-11 for pericardiocentesis. Hemodynamics showed elevated and equal RA and pericardial pressures, 11-12 mm mercury, slightly lower than pulmonary capillary wedge pressure. There was preserved cardiac index. There is preserved blood pressure with 15-20 mm mercury pulses paradoxes. During the pericardiocentesis, 1116 ml of serosanguinous fluid was easily removed. Fluid was sent to the laboratory for analysis. Following the pericardiocentesis, the patient was admitted to the Coronary Care Unit for further management. On 11-6, the pericardial drain was removed. Repeat echocardiogram did not disclose recurrence of the pericardial effusion. Patient underwent CT of the chest which disclosed diffuse interstitial infiltrates consistent with lymphangitic spread. There was also a positive mediastinal lymphadenopathy and lytic sclerotic bone lesions. On 4-27, the patient was transferred to the 68762 Daniel Stream Johnsonside, KS 92297 Service. On the night of the 16th, he was tachycardic to the 160s. Echocardiogram disclosed atrial flutter. His blood pressure was stable. He was started on sotalol 120 mg b.i.d. The following day this was decreased to 80 mg b.i.d. While on sotalol, his QTC interval was monitored and his potassium was kept between 4.5 and 5.2. Repeat echocardiogram did not disclose re-accumulation of the pericardial effusion. While on the 68762 Daniel Stream Johnsonside, KS 92297 Service. A Pulmonary Consult was obtained for further evaluation of the diffuse infiltrates seen on the CT. Pulmonary Service recommended awaiting the final pathology from the pericardial fluid. They were willing to perform transbronchial biopsy if necessary. Patient was also seen by his Oncologist, Dr. Ornelas. Patient underwent an MRI of his brain on 6-9. MRI disclosed foci on the surface of the brain that appeared consistent with leptomeningeal spread of cancer. An abdominal CT was done on 6-9. CT of the abdomen disclosed one lymphangitic spread of metastatic disease throughout the lungs was stable since the study one week before. There was an increase in the pericardial fluid since the study one week prior. There was interval development of multiple sclerotic and lytic lesions within the osseous structures since 2004. There were stable hepatic lesions that likely represent simple cysts. There was a stable splenic lesion that likely represents a hemangioma. Although, colon appeared grossly normal, radiologist's caution that the study was not diagnostic for colon cancer. Finally, pathology results from pericardial fluid were obtained. Pathologists performed multiple stains to identify the type of cancer, the types of cells in the pericardial fluid. Pathologist's concluded that the malignant cells were from adenocarcinoma. The tumor cells are positive for CK7 and TTF1 markers. TTF1 marker is specific for lung and thyroid. The cells were focally positive for CK20. Pathologist's concluded that this immunoprofile is consistent with an adenocarcinoma arising in the lung. The patient was discharged on 11-9. He will have outpatient work-up of his malignancy. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Patient discharged home on Monday, 1978-9-9. DISCHARGE FOLLOW-UP: He will follow-up with his Oncologist, Dr. Ornelas, at 2 p.m. He will be seen by Dr. Finateri in the Brain Vargas PLC Clinic Clinic at 4 p.m. on 1978-9-9. He will follow-up with his Cardiologist, Dr. Quinones, on Wednesday, 1903-7-15. He was encouraged to call his primary care physician for NM Walker appointment. Patient was given NM Ivory of Heart's monitor so that his QTC interval could be monitored for an additional week while on sotalol. DISCHARGE DIAGNOSES: 1. Pericardial effusion with cardiac tamponade. 2. Non-sustained ventricular tachycardia. 3. Hypertension. 4. Atrial Fibrillation. DISCHARGE MEDICATIONS: 1. Sotalol 80 mg po b.i.d. 2. Lipitor 80 hs. 3. Enteric coated aspirin 325 mg po q.d. 4. Accupril 20 mg po q.d. 5. Multivitamin. 6. Folate 2 mg po b.i.d. 7. Vitamin E. 8. Vitamin B6. 9. Vitamin B12. 10. Ativan prn sleep. 11. Potassium chloride 30 mEq po q.d. 12. Celebrex 100 mg po b.i.d. as needed. Shannan Pettway, M.D. 03835815 Dictated By:Sachin MEDQUIST36 D: 1926-3-18 T: 1971-11-1 19:57 JOB#: Johnson-Hunt-1902-242603	["Admission Date: 1987-7-3 Discharge Date: 1934-11-22\n\nDate of Birth: 1962-8-11 Sex: M\n\n\nCHIEF COMPLAINT: Cough/shortness of breath.\n\nHISTORY OF PRESENT ILLNESS: Mr. Pegram is a 60-year-old male\nwith a past medical history significant for hypertension,\ntimes two, who developed a dry cough in late September while\nfly fishing in Iowa. The cough persisted and he was given\nerythromycin times ten days times two courses by his primary\ncare physician, Ivory. Bludsworth. The erythromycin did not improve\nthe patient's symptoms.\n\nThe patient describes the cough as dry, not worse at night,\nbreath. He denied fevers and chills. He states that he\nlost about six pounds over the past two months intentionally.\nOver the past one to two weeks, however, he has noted\nincreasing dyspnea with stairs, as well as fatigue.", " On the\nday prior to admission, he started a Z pack.\n\nAt his primary care physician's office today, he had a chest\nx-ray which disclosed an enlarged heart and interstitial\ninfiltrates. An esophagogastroduodenoscopy was done, as well\nas an echocardiogram which disclosed evidence of a\npericardial effusion with tamponade.\n\nThere was diastolic collapse of the right atrium and right\nventricle. The patient was sent to the Emergency Department\nat Knight-Fox Clinic for evaluation of the\npericardial effusion and drainage. His pulses paradoxes was\n18. The echocardiogram performed in the Emergency Department\nwas consistent with cardiac tamponade. The patient remained\nhemodynamically stable.\n\nPAST MEDICAL HISTORY:\n1. Melanoma. Patient is status post removal of melanoma in\n2004 and in 2004.\n2. Empyema of the left lung in 2004.", '\n3. Labile hypertension.\n4. Overweight.\n5. Hypercholesterolemia.\n6. Myxomatous mitral valve prolapse with mild mitral\nregurgitation.\n7. Non-sustained ventricular tachycardia.\n8. Chronic asymptomatic VEA.\n9. Peripheral vision loss.\n10. History of smoking, quit in 2004.\n\nMEDICATIONS:\n1. Tenormin 150 mg q.d.\n2. Lipitor 80 hs.\n3. Enteric coated aspirin 325 mg po q.d.\n4. Accupril 20 mg po q.d.\n5. Multivitamin.\n6. Folate 2 tablets b.i.d.\n7. Vitamin E.\n8. Vitamin B6.\n9. Vitamin B12.\n10. Ativan prn sleep.\n\nALLERGIES: Penicillin. Patient has a rash.\n\nSOCIAL HISTORY: Patient does office work. He has been a\nwidow for the past nine years. He coaches a girls basketball\nteam. He has two children, ages 30 and 25. He lives with\nhis 30-year-old daughter. Christina Ngo has a 2-year-old grandchild.', '\nHe smoked cigars until 2004. He has not had alcohol for the\npast nine years.\n\nFAMILY HISTORY: No heart disease and no diabetes mellitus.\n\nREVIEW OF SYSTEMS: No fevers, chills or night sweats.\nPatient reports a six pound intentional weight loss over the\npast two months. No history of positive PPD or Tuberculosis\nexposure. No upper respiratory infection symptoms with\ncough. No nausea, vomiting, diarrhea or abdominal pain, but\noccasionally "spits up" after his cough. Reports dyspnea\nwith stairs and chest tightness occasionally on stairs. No\nrash, no joint symptoms, no melanoma, no bright red blood per\nrectum, no dysuria, no edema, no paroxysmal nocturnal\ndyspnea, no orthopnea, no palpitations, no dizziness.\n\nPHYSICAL EXAMINATION: Temperature 97 degrees. Pulse 86.\nBlood pressure 124/63.', ' Respiratory rate 23. Oxygen\nsaturation 95% on three liters nasal cannula. General:\nElderly white male in no apparent distress. Head, eyes,\nears, nose and throat: Anicteric, oropharynx clear, pupils\nequal, round and reactive to light, extraocular movements\nintact. Neck: Supple, no carotid bruit, no jugular venous\ndistention. Cardiovascular: Regular rate and rhythm, soft\nS1, S2, no murmurs, rubs or gallops, pericardial drain in\nplace. Chest clear to auscultation anteriorly, left lateral\nchest scar. Abdomen soft, nontender, nondistended with\npositive bowel sounds. Extremities: No cyanosis, clubbing\nor edema, 2+ dorsalis pedis pulses bilaterally.\nNeurological: Cranial nerves II through XII are intact.\nAlert and oriented times three. Exam otherwise nonfocal.\nNote: This physical examination was done after the patient\nunderwent his cardiac catheterization.', '\n\nLABORATORY DATA ON ADMISSION: White blood cell count 7.3,\nhematocrit of 41, platelet count of 294,000. PT 13, PTT\n23.6, INR 1.1. Echocardiogram: Normal sinus rhythm, 71\nbeats per minute, electrical alternans, low voltage\nprecordial leads, prolonged PR. After the procedure,\nesophagogastroduodenoscopy showed a sinus rhythm at 82 beats\nper minute, normal axis, prolonged PR, T wave inversions I\nand aVL, biphasic T in V2, Qs in V1 to V2, increased voltage.\n\nHOSPITAL COURSE: The patient was admitted initially to the\nCoronary Care Unit. He underwent a cardiac catheterization\non 11-11 for pericardiocentesis. Hemodynamics showed\nelevated and equal RA and pericardial pressures, 11-12 mm\nmercury, slightly lower than pulmonary capillary wedge\npressure. There was preserved cardiac index. There is\npreserved blood pressure with 15-20 mm mercury pulses\nparadoxes.', ' During the pericardiocentesis, 1116 ml of\nserosanguinous fluid was easily removed. Fluid was sent to\nthe laboratory for analysis.\n\nFollowing the pericardiocentesis, the patient was admitted to\nthe Coronary Care Unit for further management. On 11-6, the pericardial drain was removed. Repeat echocardiogram\ndid not disclose recurrence of the pericardial effusion.\nPatient underwent CT of the chest which disclosed diffuse\ninterstitial infiltrates consistent with lymphangitic spread.\nThere was also a positive mediastinal lymphadenopathy and\nlytic sclerotic bone lesions.\n\nOn 4-27, the patient was transferred to the 68762 Daniel Stream\nJohnsonside, KS 92297\nService. On the night of the 16th, he was tachycardic to the\n160s. Echocardiogram disclosed atrial flutter. His blood\npressure was stable.', ' He was started on sotalol 120 mg b.i.d.\nThe following day this was decreased to 80 mg b.i.d. While\non sotalol, his QTC interval was monitored and his potassium\nwas kept between 4.5 and 5.2. Repeat echocardiogram did not\ndisclose re-accumulation of the pericardial effusion.\n\nWhile on the 68762 Daniel Stream\nJohnsonside, KS 92297 Service. A Pulmonary Consult was\nobtained for further evaluation of the diffuse infiltrates\nseen on the CT. Pulmonary Service recommended awaiting the\nfinal pathology from the pericardial fluid. They were\nwilling to perform transbronchial biopsy if necessary.\n\nPatient was also seen by his Oncologist, Dr. Ornelas. Patient\nunderwent an MRI of his brain on 6-9. MRI disclosed\nfoci on the surface of the brain that appeared consistent\nwith leptomeningeal spread of cancer.', " An abdominal CT was\ndone on 6-9. CT of the abdomen disclosed one\nlymphangitic spread of metastatic disease throughout the\nlungs was stable since the study one week before. There was\nan increase in the pericardial fluid since the study one week\nprior. There was interval development of multiple sclerotic\nand lytic lesions within the osseous structures since 2004.\nThere were stable hepatic lesions that likely represent\nsimple cysts. There was a stable splenic lesion that likely\nrepresents a hemangioma. Although, colon appeared grossly\nnormal, radiologist's caution that the study was not\ndiagnostic for colon cancer.\n\nFinally, pathology results from pericardial fluid were\nobtained. Pathologists performed multiple stains to identify\nthe type of cancer, the types of cells in the pericardial\nfluid.", " Pathologist's concluded that the malignant cells were\nfrom adenocarcinoma. The tumor cells are positive for CK7\nand TTF1 markers. TTF1 marker is specific for lung and\nthyroid. The cells were focally positive for CK20.\nPathologist's concluded that this immunoprofile is consistent\nwith an adenocarcinoma arising in the lung.\n\nThe patient was discharged on 11-9. He will have\noutpatient work-up of his malignancy.\n\nDISCHARGE CONDITION: Stable.\n\nDISCHARGE STATUS: Patient discharged home on Monday,\n1978-9-9.\n\nDISCHARGE FOLLOW-UP: He will follow-up with his Oncologist,\nDr. Ornelas, at 2 p.m. He will be seen by Dr. Finateri in the\nBrain Vargas PLC Clinic Clinic at 4 p.m. on 1978-9-9. He will\nfollow-up with his Cardiologist, Dr. Quinones, on Wednesday,\n1903-7-15. He was encouraged to call his primary\ncare physician for NM Walker appointment.", " Patient was\ngiven NM Ivory of Heart's monitor so that his QTC interval\ncould be monitored for an additional week while on sotalol.\n\nDISCHARGE DIAGNOSES:\n1. Pericardial effusion with cardiac tamponade.\n2. Non-sustained ventricular tachycardia.\n3. Hypertension.\n4. Atrial Fibrillation.\n\nDISCHARGE MEDICATIONS:\n1. Sotalol 80 mg po b.i.d.\n2. Lipitor 80 hs.\n3. Enteric coated aspirin 325 mg po q.d.\n4. Accupril 20 mg po q.d.\n5. Multivitamin.\n6. Folate 2 mg po b.i.d.\n7. Vitamin E.\n8. Vitamin B6.\n9. Vitamin B12.\n10. Ativan prn sleep.\n11. Potassium chloride 30 mEq po q.d.\n12. Celebrex 100 mg po b.i.d. as needed.\n\n\n Shannan Pettway, M.D. 03835815\n\nDictated By:Sachin\n\nMEDQUIST36\n\nD: 1926-3-18\nT: 1971-11-1 19:57\nJOB#: Johnson-Hunt-1902-242603\n\n\n\n\n\n\n\n\n"]
164	17513	119766.0	2141-01-09	Discharge summary	Report	Admission Date: [2141-1-4] Discharge Date:[2141-1-12] Date of Birth: [2080-4-23] Sex: M Service:Oncology CHIEF COMPLAINT: Short of breath times one week plus weakness. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male with a history of metastatic lung cancer to brain, failure to thrive. He had a recent diagnosis on [11-5] of lung adenocarcinoma with metastases to [Last Name (LF) 500], [First Name3 (LF) ], pericardium. He had a recent admit for malignant pericardial effusion with tamponade, status post drainage on [11-5]. Plan for chemotherapy after patient completes XRT. Had an Lumbar puncture on [11-29] with negative meningeal spread of cancer. He has noted one week prior to admission progressive increase He had a pulses paradoxus of 15 in the emergency department. No fever, chills, chest pain, cough, nausea, vomiting, diarrhea, abdominal pain. He had a normal p.o. intake but decreased ambulation secondary to weakness post XRT. Can go approximately 10 steps and then gets tired with short of breath. In the emergency department he got a dose of Levofloxacin for concern of pneumonia and bronchitis and stress dose steroids. Chest x-ray shows increased in cardiac silhouette. Electrocardiogram showed alternans. Bedside echo concerning for tamponade. Catheterization laboratory for pericardial drain placement. Got 2500 cc's removed. PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia, mitral valve prolapse, status post melanoma. Status post resection in [2118] and [2138]. Empyema left lung [2122], status post thoracotomy and supraventricular tachycardia. Lung adenocarcinoma with metastases to brain, [Year (4 digits) 500], pericardium. Now undergoing brain XRT. Atrial flutter, peripheral visual loss. An echo on [11/2134] showed EF greater than 55% MEDICATIONS ON ADMISSION: 1. Decadron 4 mg q AM, 2 mg q PM. 2. Zantac 150 mg b.i.d. 3. Sotalol 80 mg twice a day. 4. Ambien 10 mg q h.s. 5. Lipitor 80 mg q h.s. 6. Folate 1 mg q day. 7. Accupril 10 mg q day. 8. ASA 81 mg q day. ALLERGIES: Penicillin which causes a rash. SOCIAL HISTORY: Lives with a daughter at home. No tobacco in the past 20 years, no alcohol. PHYSICAL EXAMINATION: On admission in general no acute distress, pleasant, slightly tachypneic. Vital signs 97.5, heart rate 94, blood pressure 99/61. Respiratory rate 36, 99% on 100% face mask. Left pupil minimally reactive, down visual acuity. OP clear. Neck: No jugular venous distention. Pulmonary: Coronary artery disease bilaterally. Carotids: Regular rate and rhythm. No murmurs. Abdomen: Soft, nontender, no distension. Bowel sounds positive. Extremities: No cyanosis, clubbing or edema. 2+ distal pulses bilaterally. Neurological 5/5 strength bilaterally. Pupils reactive. Electrocardiogram on admission normal sinus rhythm, electrical alternans. Normal intervals, no ST changes or Q-waves, diffuse T-wave changes. LABS: White blood count 9.6, hematocrit 36.1, platelets 128. INR 1.3. NA 137, K 4.6. CL 104, CO2 20. BUN 31, creatinine 0.8. Glucose 140. Chest x-ray shows increased in cardiac size, increased pericardial effusion. Increased left pleural effusion. Lymphangitic tumor spread unchanged. A left TTX new since [2140-11-19]. The patient was taken from the Emergency Room to the CCU for close monitoring. Given large pericardial effusion and tamponade physiology. On cardiac catheterization he demonstrated low pressure tamponade with equalization of right atrium and pericardial pressures. After removal of approximately one liter of bloody fluid his right atrial and pericardial pressure decreased. Procedure was notable for pericardial preparation and partial pneumothorax given low atrial/pericardial pressures and evidence of a possible small left pneumothorax. For this reason the drain was pulled. However, subsequent review of the chest x-ray showed that the finding of pneumothorax was present prior to the procedure. Follow-up echocardiogram revealed resolution of electrical alternans. CT Surgery was consulted for possibility of placing a pericardial window for definitive treatment of recurrent pericardial effusions however, it was felt that a procedure of this degree of invasiveness would likely lead to patient's deterioration rather than improvement. The decision was made that the patient would be best served by a balloon pericardiocentesis via catheter done by Cardiology however, this would require waiting until the pericardial effusion re-accumulated. Recommended that the patient undergo q week transthoracic echocardiogram in order to assess the size of pericardial effusion and when deemed large enough the patient is to undergo balloon pericardiocentesis. The patient's cardiac status improved with this procedure however, his respiratory status remained tenuous requiring 100% non-rebreather mask to maintain O2 saturations in the mid-90% The patient had marked dyspnea on exertion throughout hospitalization. It was felt that this is a combination of intrinsic lung damage as well as lymphangitic spread and some small degree of residual cardiac dysfunction. Other than oxygen and nebulizers there is no further therapeutic option for this patient at this time. The patient remained on Sotalol 80 mg p.o. b.i.d. as he was as an outpatient for an supraventricular tachycardia and remained in a normal sinus rhythm throughout hospitalization. Hem/Onc. The patient continued XRT as well as Decadron for palliation. He will be followed by Hem/Onc as an outpatient. There were no gastrointestinal issues throughout this hospitalization. Infectious Disease. The patient was not felt to be infected and after the initial dose of Levofloxacin in the emergency department antibiotics were discontinued. The patient remained afebrile. Dictation will be completed with discharge diagnosis and discharge medications prior to discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1735] m.d. [MD Number(1) 1736] Dictated By:[Last Name (NamePattern1) 1737] MEDQUIST36 D: [2141-1-9] 18:16 T: [2141-1-9] 19:22 JOB#: [Job Number 1738]	Admission Date: <Date>1928-3-21</Date> Discharge Date:<Date>1918-2-20</Date> Date of Birth: <Date>2021-10-22</Date> Sex: M Service:Oncology CHIEF COMPLAINT: Short of breath times one week plus weakness. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male with a history of metastatic lung cancer to brain, failure to thrive. He had a recent diagnosis on <Date>5-22</Date> of lung adenocarcinoma with metastases to <Name>Heflin</Name>, <Name>Ava</Name>, pericardium. He had a recent admit for malignant pericardial effusion with tamponade, status post drainage on <Date>5-22</Date>. Plan for chemotherapy after patient completes XRT. Had an Lumbar puncture on <Date>6-2</Date> with negative meningeal spread of cancer. He has noted one week prior to admission progressive increase He had a pulses paradoxus of 15 in the emergency department. No fever, chills, chest pain, cough, nausea, vomiting, diarrhea, abdominal pain. He had a normal p.o. intake but decreased ambulation secondary to weakness post XRT. Can go approximately 10 steps and then gets tired with short of breath. In the emergency department he got a dose of Levofloxacin for concern of pneumonia and bronchitis and stress dose steroids. Chest x-ray shows increased in cardiac silhouette. Electrocardiogram showed alternans. Bedside echo concerning for tamponade. Catheterization laboratory for pericardial drain placement. Got 2500 cc's removed. PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia, mitral valve prolapse, status post melanoma. Status post resection in <Year>1968</Year> and <Year>1968</Year>. Empyema left lung <Year>1968</Year>, status post thoracotomy and supraventricular tachycardia. Lung adenocarcinoma with metastases to brain, <Year>2014</Year>, pericardium. Now undergoing brain XRT. Atrial flutter, peripheral visual loss. An echo on <Date>1/1902</Date> showed EF greater than 55% MEDICATIONS ON ADMISSION: 1. Decadron 4 mg q AM, 2 mg q PM. 2. Zantac 150 mg b.i.d. 3. Sotalol 80 mg twice a day. 4. Ambien 10 mg q h.s. 5. Lipitor 80 mg q h.s. 6. Folate 1 mg q day. 7. Accupril 10 mg q day. 8. ASA 81 mg q day. ALLERGIES: Penicillin which causes a rash. SOCIAL HISTORY: Lives with a daughter at home. No tobacco in the past 20 years, no alcohol. PHYSICAL EXAMINATION: On admission in general no acute distress, pleasant, slightly tachypneic. Vital signs 97.5, heart rate 94, blood pressure 99/61. Respiratory rate 36, 99% on 100% face mask. Left pupil minimally reactive, down visual acuity. OP clear. Neck: No jugular venous distention. Pulmonary: Coronary artery disease bilaterally. Carotids: Regular rate and rhythm. No murmurs. Abdomen: Soft, nontender, no distension. Bowel sounds positive. Extremities: No cyanosis, clubbing or edema. 2+ distal pulses bilaterally. Neurological 5/5 strength bilaterally. Pupils reactive. Electrocardiogram on admission normal sinus rhythm, electrical alternans. Normal intervals, no ST changes or Q-waves, diffuse T-wave changes. LABS: White blood count 9.6, hematocrit 36.1, platelets 128. INR 1.3. NA 137, K 4.6. CL 104, CO2 20. BUN 31, creatinine 0.8. Glucose 140. Chest x-ray shows increased in cardiac size, increased pericardial effusion. Increased left pleural effusion. Lymphangitic tumor spread unchanged. A left TTX new since <Date>1921-3-5</Date>. The patient was taken from the Emergency Room to the CCU for close monitoring. Given large pericardial effusion and tamponade physiology. On cardiac catheterization he demonstrated low pressure tamponade with equalization of right atrium and pericardial pressures. After removal of approximately one liter of bloody fluid his right atrial and pericardial pressure decreased. Procedure was notable for pericardial preparation and partial pneumothorax given low atrial/pericardial pressures and evidence of a possible small left pneumothorax. For this reason the drain was pulled. However, subsequent review of the chest x-ray showed that the finding of pneumothorax was present prior to the procedure. Follow-up echocardiogram revealed resolution of electrical alternans. CT Surgery was consulted for possibility of placing a pericardial window for definitive treatment of recurrent pericardial effusions however, it was felt that a procedure of this degree of invasiveness would likely lead to patient's deterioration rather than improvement. The decision was made that the patient would be best served by a balloon pericardiocentesis via catheter done by Cardiology however, this would require waiting until the pericardial effusion re-accumulated. Recommended that the patient undergo q week transthoracic echocardiogram in order to assess the size of pericardial effusion and when deemed large enough the patient is to undergo balloon pericardiocentesis. The patient's cardiac status improved with this procedure however, his respiratory status remained tenuous requiring 100% non-rebreather mask to maintain O2 saturations in the mid-90% The patient had marked dyspnea on exertion throughout hospitalization. It was felt that this is a combination of intrinsic lung damage as well as lymphangitic spread and some small degree of residual cardiac dysfunction. Other than oxygen and nebulizers there is no further therapeutic option for this patient at this time. The patient remained on Sotalol 80 mg p.o. b.i.d. as he was as an outpatient for an supraventricular tachycardia and remained in a normal sinus rhythm throughout hospitalization. Hem/Onc. The patient continued XRT as well as Decadron for palliation. He will be followed by Hem/Onc as an outpatient. There were no gastrointestinal issues throughout this hospitalization. Infectious Disease. The patient was not felt to be infected and after the initial dose of Levofloxacin in the emergency department antibiotics were discontinued. The patient remained afebrile. Dictation will be completed with discharge diagnosis and discharge medications prior to discharge. <Name>Kala</Name> <Name>Walker</Name> m.d. <MD Number>96233129</MD Number> Dictated By:<Name>Islam</Name> MEDQUIST36 D: <Date>2022-11-25</Date> 18:16 T: <Date>2022-11-25</Date> 19:22 JOB#: <Job Number>Grant, Rasmussen and Harris-1960-623870</Job 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0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111011111100000011111111000000000000001111100000000000000000111111111100000000000011111111110000000000000001111111111111111111111111111111111111110	Admission Date: 1928-3-21 Discharge Date:1918-2-20 Date of Birth: 2021-10-22 Sex: M Service:Oncology CHIEF COMPLAINT: Short of breath times one week plus weakness. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male with a history of metastatic lung cancer to brain, failure to thrive. He had a recent diagnosis on 5-22 of lung adenocarcinoma with metastases to Heflin, Ava, pericardium. He had a recent admit for malignant pericardial effusion with tamponade, status post drainage on 5-22. Plan for chemotherapy after patient completes XRT. Had an Lumbar puncture on 6-2 with negative meningeal spread of cancer. He has noted one week prior to admission progressive increase He had a pulses paradoxus of 15 in the emergency department. No fever, chills, chest pain, cough, nausea, vomiting, diarrhea, abdominal pain. He had a normal p.o. intake but decreased ambulation secondary to weakness post XRT. Can go approximately 10 steps and then gets tired with short of breath. In the emergency department he got a dose of Levofloxacin for concern of pneumonia and bronchitis and stress dose steroids. Chest x-ray shows increased in cardiac silhouette. Electrocardiogram showed alternans. Bedside echo concerning for tamponade. Catheterization laboratory for pericardial drain placement. Got 2500 cc's removed. PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia, mitral valve prolapse, status post melanoma. Status post resection in 1968 and 1968. Empyema left lung 1968, status post thoracotomy and supraventricular tachycardia. Lung adenocarcinoma with metastases to brain, 2014, pericardium. Now undergoing brain XRT. Atrial flutter, peripheral visual loss. An echo on 1/1902 showed EF greater than 55% MEDICATIONS ON ADMISSION: 1. Decadron 4 mg q AM, 2 mg q PM. 2. Zantac 150 mg b.i.d. 3. Sotalol 80 mg twice a day. 4. Ambien 10 mg q h.s. 5. Lipitor 80 mg q h.s. 6. Folate 1 mg q day. 7. Accupril 10 mg q day. 8. ASA 81 mg q day. ALLERGIES: Penicillin which causes a rash. SOCIAL HISTORY: Lives with a daughter at home. No tobacco in the past 20 years, no alcohol. PHYSICAL EXAMINATION: On admission in general no acute distress, pleasant, slightly tachypneic. Vital signs 97.5, heart rate 94, blood pressure 99/61. Respiratory rate 36, 99% on 100% face mask. Left pupil minimally reactive, down visual acuity. OP clear. Neck: No jugular venous distention. Pulmonary: Coronary artery disease bilaterally. Carotids: Regular rate and rhythm. No murmurs. Abdomen: Soft, nontender, no distension. Bowel sounds positive. Extremities: No cyanosis, clubbing or edema. 2+ distal pulses bilaterally. Neurological 5/5 strength bilaterally. Pupils reactive. Electrocardiogram on admission normal sinus rhythm, electrical alternans. Normal intervals, no ST changes or Q-waves, diffuse T-wave changes. LABS: White blood count 9.6, hematocrit 36.1, platelets 128. INR 1.3. NA 137, K 4.6. CL 104, CO2 20. BUN 31, creatinine 0.8. Glucose 140. Chest x-ray shows increased in cardiac size, increased pericardial effusion. Increased left pleural effusion. Lymphangitic tumor spread unchanged. A left TTX new since 1921-3-5. The patient was taken from the Emergency Room to the CCU for close monitoring. Given large pericardial effusion and tamponade physiology. On cardiac catheterization he demonstrated low pressure tamponade with equalization of right atrium and pericardial pressures. After removal of approximately one liter of bloody fluid his right atrial and pericardial pressure decreased. Procedure was notable for pericardial preparation and partial pneumothorax given low atrial/pericardial pressures and evidence of a possible small left pneumothorax. For this reason the drain was pulled. However, subsequent review of the chest x-ray showed that the finding of pneumothorax was present prior to the procedure. Follow-up echocardiogram revealed resolution of electrical alternans. CT Surgery was consulted for possibility of placing a pericardial window for definitive treatment of recurrent pericardial effusions however, it was felt that a procedure of this degree of invasiveness would likely lead to patient's deterioration rather than improvement. The decision was made that the patient would be best served by a balloon pericardiocentesis via catheter done by Cardiology however, this would require waiting until the pericardial effusion re-accumulated. Recommended that the patient undergo q week transthoracic echocardiogram in order to assess the size of pericardial effusion and when deemed large enough the patient is to undergo balloon pericardiocentesis. The patient's cardiac status improved with this procedure however, his respiratory status remained tenuous requiring 100% non-rebreather mask to maintain O2 saturations in the mid-90% The patient had marked dyspnea on exertion throughout hospitalization. It was felt that this is a combination of intrinsic lung damage as well as lymphangitic spread and some small degree of residual cardiac dysfunction. Other than oxygen and nebulizers there is no further therapeutic option for this patient at this time. The patient remained on Sotalol 80 mg p.o. b.i.d. as he was as an outpatient for an supraventricular tachycardia and remained in a normal sinus rhythm throughout hospitalization. Hem/Onc. The patient continued XRT as well as Decadron for palliation. He will be followed by Hem/Onc as an outpatient. There were no gastrointestinal issues throughout this hospitalization. Infectious Disease. The patient was not felt to be infected and after the initial dose of Levofloxacin in the emergency department antibiotics were discontinued. The patient remained afebrile. Dictation will be completed with discharge diagnosis and discharge medications prior to discharge. Kala Walker m.d. 96233129 Dictated By:Islam MEDQUIST36 D: 2022-11-25 18:16 T: 2022-11-25 19:22 JOB#: Grant, Rasmussen and Harris-1960-623870	['Admission Date: 1928-3-21 Discharge Date:1918-2-20\n\nDate of Birth: 2021-10-22 Sex: M\n\nService:Oncology\nCHIEF COMPLAINT: Short of breath times one week plus\nweakness.\n\nHISTORY OF PRESENT ILLNESS: The patient is a 60-year-old\nmale with a history of metastatic lung cancer to brain,\nfailure to thrive. He had a recent diagnosis on 5-22 of\nlung adenocarcinoma with metastases to Heflin, Ava,\npericardium. He had a recent admit for malignant pericardial\neffusion with tamponade, status post drainage on 5-22. Plan\nfor chemotherapy after patient completes XRT. Had an Lumbar\npuncture on 6-2 with negative meningeal spread of cancer.\nHe has noted one week prior to admission progressive increase\nHe had a pulses paradoxus of 15 in the emergency department.\nNo fever, chills, chest pain, cough, nausea, vomiting,\ndiarrhea, abdominal pain.', " He had a normal p.o. intake but\ndecreased ambulation secondary to weakness post XRT. Can go\napproximately 10 steps and then gets tired with short of\nbreath.\n\nIn the emergency department he got a dose of Levofloxacin for\nconcern of pneumonia and bronchitis and stress dose steroids.\n\nChest x-ray shows increased in cardiac silhouette.\nElectrocardiogram showed alternans. Bedside echo concerning\nfor tamponade. Catheterization laboratory for pericardial\ndrain placement. Got 2500 cc's removed.\n\nPAST MEDICAL HISTORY: Significant for hypertension,\nhypercholesterolemia, mitral valve prolapse, status post\nmelanoma. Status post resection in 1968 and 1968. Empyema\nleft lung 1968, status post thoracotomy and supraventricular\ntachycardia. Lung adenocarcinoma with metastases to brain,\n2014, pericardium.", ' Now undergoing brain XRT. Atrial\nflutter, peripheral visual loss.\n\nAn echo on 1/1902 showed EF greater than 55%\n\nMEDICATIONS ON ADMISSION:\n1. Decadron 4 mg q AM, 2 mg q PM.\n2. Zantac 150 mg b.i.d.\n3. Sotalol 80 mg twice a day.\n4. Ambien 10 mg q h.s.\n5. Lipitor 80 mg q h.s.\n6. Folate 1 mg q day.\n7. Accupril 10 mg q day.\n8. ASA 81 mg q day.\n\nALLERGIES: Penicillin which causes a rash.\n\nSOCIAL HISTORY: Lives with a daughter at home. No tobacco\nin the past 20 years, no alcohol.\n\nPHYSICAL EXAMINATION: On admission in general no acute\ndistress, pleasant, slightly tachypneic. Vital signs 97.5,\nheart rate 94, blood pressure 99/61. Respiratory rate 36,\n99% on 100% face mask. Left pupil minimally reactive, down\nvisual acuity. OP clear. Neck: No jugular venous\ndistention. Pulmonary: Coronary artery disease bilaterally.', '\nCarotids: Regular rate and rhythm. No murmurs. Abdomen:\nSoft, nontender, no distension. Bowel sounds positive.\nExtremities: No cyanosis, clubbing or edema. 2+ distal\npulses bilaterally. Neurological 5/5 strength bilaterally.\nPupils reactive.\n\nElectrocardiogram on admission normal sinus rhythm,\nelectrical alternans. Normal intervals, no ST changes or\nQ-waves, diffuse T-wave changes.\n\nLABS: White blood count 9.6, hematocrit 36.1, platelets 128.\nINR 1.3. NA 137, K 4.6. CL 104, CO2 20. BUN 31, creatinine\n0.8. Glucose 140.\n\nChest x-ray shows increased in cardiac size, increased\npericardial effusion. Increased left pleural effusion.\nLymphangitic tumor spread unchanged. A left TTX new since\n1921-3-5.\n\nThe patient was taken from the Emergency Room to the CCU for\nclose monitoring. Given large pericardial effusion and\ntamponade physiology.', " On cardiac catheterization he\ndemonstrated low pressure tamponade with equalization of\nright atrium and pericardial pressures. After removal of\napproximately one liter of bloody fluid his right atrial and\npericardial pressure decreased. Procedure was notable for\npericardial preparation and partial pneumothorax given low\natrial/pericardial pressures and evidence of a possible small\nleft pneumothorax. For this reason the drain was pulled.\nHowever, subsequent review of the chest x-ray showed that the\nfinding of pneumothorax was present prior to the procedure.\nFollow-up echocardiogram revealed resolution of electrical\nalternans. CT Surgery was consulted for possibility of\nplacing a pericardial window for definitive treatment of\nrecurrent pericardial effusions however, it was felt that a\nprocedure of this degree of invasiveness would likely lead to\npatient's deterioration rather than improvement.", "\n\nThe decision was made that the patient would be best served\nby a balloon pericardiocentesis via catheter done by\nCardiology however, this would require waiting until the\npericardial effusion re-accumulated. Recommended that the\npatient undergo q week transthoracic echocardiogram in order\nto assess the size of pericardial effusion and when deemed\nlarge enough the patient is to undergo balloon\npericardiocentesis.\n\nThe patient's cardiac status improved with this procedure\nhowever, his respiratory status remained tenuous requiring\n100% non-rebreather mask to maintain O2 saturations in the\nmid-90% The patient had marked dyspnea on exertion\nthroughout hospitalization. It was felt that this is a\ncombination of intrinsic lung damage as well as lymphangitic\nspread and some small degree of residual cardiac dysfunction.", '\nOther than oxygen and nebulizers there is no further\ntherapeutic option for this patient at this time. The\npatient remained on Sotalol 80 mg p.o. b.i.d. as he was as an\noutpatient for an supraventricular tachycardia and remained\nin a normal sinus rhythm throughout hospitalization.\n\nHem/Onc. The patient continued XRT as well as Decadron for\npalliation. He will be followed by Hem/Onc as an outpatient.\nThere were no gastrointestinal issues throughout this\nhospitalization.\n\nInfectious Disease. The patient was not felt to be infected\nand after the initial dose of Levofloxacin in the emergency\ndepartment antibiotics were discontinued. The patient\nremained afebrile.\n\nDictation will be completed with discharge diagnosis and\ndischarge medications prior to discharge.\n\n\n\n\n\n\n Kala Walker m.', 'd. 96233129\n\nDictated By:Islam\nMEDQUIST36\n\nD: 2022-11-25 18:16\nT: 2022-11-25 19:22\nJOB#: Grant, Rasmussen and Harris-1960-623870\n']
165	17513	119766.0	2141-01-12	Discharge summary	Report	Admission Date: [2141-1-4] Discharge Date: [2141-1-12] Date of Birth: [2080-4-23] Sex: M Service:Oncology DISCHARGE DIAGNOSES: 1. Non-small cell lung carcinoma metastatic to [Last Name (LF) 500], [First Name3 (LF) ] and pericardium. 2. Pericardial tamponade requiring pericardiocentesis. 3. Hypoxia due to multifactorial lung disease. DISCHARGE MEDICATIONS: 1. Ambien 10 mg p.o. q.h.s. 2. Sotalol 80 mg p.o. b.i.d. 3. Multivitamin one p.o. q.d. 4. Tylenol 225 to 650 mg p.o. q. four to six hours p.r.n. 5. Colace 100 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 8. Morphine Sulfate 1 to 5 mg IV q. four to six hours p.r.n. 9. Dibutoline one application TP q.i.d. p.r.n. 10. Methylprednisone 80 mg p.o. b.i.d.. 11. Albuterol nebs q. four to six hours. 12. Atrovent nebs q. four to six hours. 13. Levofloxacin 500 mg p.o. q.d. till [2141-1-19]. 13. Bactrim Double Strength tabs one p.o. b.i.d. till [2141-1-19]. 14. Percocet one to two tabs p.o. q. four to six hours p.r.n. He was discharged to [Hospital 1739] Hospice in stable condition. He is DNI, DNR and moving towards comfort care only. [Known firstname ] [Last Name (NamePattern4) 1735] m.d. [MD Number(1) 1736] Dictated By:[Last Name (NamePattern1) 1737] MEDQUIST36 D: [2141-1-11] 10:20 T: [2141-1-11] 10:15 JOB#: [Job Number 1740]	Admission Date: <Date>1975-10-23</Date> Discharge Date: <Date>1985-11-24</Date> Date of Birth: <Date>1937-6-31</Date> Sex: M Service:Oncology DISCHARGE DIAGNOSES: 1. Non-small cell lung carcinoma metastatic to <Name>Casenhiser</Name>, <Name>Alexis</Name> and pericardium. 2. Pericardial tamponade requiring pericardiocentesis. 3. Hypoxia due to multifactorial lung disease. DISCHARGE MEDICATIONS: 1. Ambien 10 mg p.o. q.h.s. 2. Sotalol 80 mg p.o. b.i.d. 3. Multivitamin one p.o. q.d. 4. Tylenol 225 to 650 mg p.o. q. four to six hours p.r.n. 5. Colace 100 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 8. Morphine Sulfate 1 to 5 mg IV q. four to six hours p.r.n. 9. Dibutoline one application TP q.i.d. p.r.n. 10. Methylprednisone 80 mg p.o. b.i.d.. 11. Albuterol nebs q. four to six hours. 12. Atrovent nebs q. four to six hours. 13. Levofloxacin 500 mg p.o. q.d. till <Date>1925-10-10</Date>. 13. Bactrim Double Strength tabs one p.o. b.i.d. till <Date>1925-10-10</Date>. 14. Percocet one to two tabs p.o. q. four to six hours p.r.n. He was discharged to <Hospital>Smith-Carey Health System</Hospital> Hospice in stable condition. He is DNI, DNR and moving towards comfort care only. <Name>Taryn</Name> <Name>Sakkas</Name> m.d. <MD Number>06682163</MD Number> Dictated By:<Name>Lockett</Name> MEDQUIST36 D: <Date>1968-11-15</Date> 10:20 T: <Date>1968-11-15</Date> 10:15 JOB#: <Job Number>Todd, Moon and Griffin-1947-531587</Job Number>	00000000000000000111111111100000000000000000000000011111111110000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111011111100000011111111000000000000001111111000000000000000001111111111000000000000111111111100000000000000011111111111111111111111111111111110	Admission Date: 1975-10-23 Discharge Date: 1985-11-24 Date of Birth: 1937-6-31 Sex: M Service:Oncology DISCHARGE DIAGNOSES: 1. Non-small cell lung carcinoma metastatic to Casenhiser, Alexis and pericardium. 2. Pericardial tamponade requiring pericardiocentesis. 3. Hypoxia due to multifactorial lung disease. DISCHARGE MEDICATIONS: 1. Ambien 10 mg p.o. q.h.s. 2. Sotalol 80 mg p.o. b.i.d. 3. Multivitamin one p.o. q.d. 4. Tylenol 225 to 650 mg p.o. q. four to six hours p.r.n. 5. Colace 100 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 8. Morphine Sulfate 1 to 5 mg IV q. four to six hours p.r.n. 9. Dibutoline one application TP q.i.d. p.r.n. 10. Methylprednisone 80 mg p.o. b.i.d.. 11. Albuterol nebs q. four to six hours. 12. Atrovent nebs q. four to six hours. 13. Levofloxacin 500 mg p.o. q.d. till 1925-10-10. 13. Bactrim Double Strength tabs one p.o. b.i.d. till 1925-10-10. 14. Percocet one to two tabs p.o. q. four to six hours p.r.n. He was discharged to Smith-Carey Health System Hospice in stable condition. He is DNI, DNR and moving towards comfort care only. Taryn Sakkas m.d. 06682163 Dictated By:Lockett MEDQUIST36 D: 1968-11-15 10:20 T: 1968-11-15 10:15 JOB#: Todd, Moon and Griffin-1947-531587	['Admission Date: 1975-10-23 Discharge Date: 1985-11-24\n\nDate of Birth: 1937-6-31 Sex: M\n\nService:Oncology\nDISCHARGE DIAGNOSES:\n1. Non-small cell lung carcinoma metastatic to Casenhiser, Alexis\nand pericardium.\n2. Pericardial tamponade requiring pericardiocentesis.\n3. Hypoxia due to multifactorial lung disease.\nDISCHARGE MEDICATIONS:\n1. Ambien 10 mg p.o. q.h.s.\n2. Sotalol 80 mg p.o. b.i.d.\n3. Multivitamin one p.o. q.d.\n4. Tylenol 225 to 650 mg p.o. q. four to six hours p.r.n.\n5. Colace 100 mg p.o. b.i.d.\n6. Protonix 40 mg p.o. q.d.\n8. Morphine Sulfate 1 to 5 mg IV q. four to six hours p.r.n.\n9. Dibutoline one application TP q.i.d. p.r.n.\n10. Methylprednisone 80 mg p.o. b.i.d..\n11. Albuterol nebs q. four to six hours.\n12. Atrovent nebs q. four to six hours.\n13. Levofloxacin 500 mg p.', 'o. q.d. till 1925-10-10.\n13. Bactrim Double Strength tabs one p.o. b.i.d. till\n1925-10-10.\n14. Percocet one to two tabs p.o. q. four to six hours p.r.n.\n\nHe was discharged to Smith-Carey Health System Hospice in stable condition.\nHe is DNI, DNR and moving towards comfort care only.\n\n\n\n\n Taryn Sakkas m.d. 06682163\n\nDictated By:Lockett\nMEDQUIST36\n\nD: 1968-11-15 10:20\nT: 1968-11-15 10:15\nJOB#: Todd, Moon and Griffin-1947-531587\n']
166	9801	146305.0	2181-09-15	Discharge summary	Report	Admission Date: [2181-9-5] Discharge Date: [2181-9-14] Service: CARDIAC HISTORY OF THE PRESENT ILLNESS: The patient is an 82-year-old female with hypercholesterolemia, chronic renal insufficiency, hypertension, and long history of atypical chest pain, as well as possibly asymptomatic myocardial infarction a long time ago. Prior to admission, the last cardiac evaluation was in [Month (only) 956], when a stress MIBI showed an ejection fraction of 67% without evidence of ischemia, although the patient only tolerated three minutes. The patient was in the usual state of health until several months ago, when she began to complain of increased shortness of breath and pedal edema. The symptoms specifically, shortness of breath and chest pain, increased in intensity about two weeks prior to admission. On [2181-9-3], the patient presented to her primary care physician and stress tests were performed. On the night, prior to admission, the patient presented with left sided substernal chest pain radiating to the scapula that had lasted for 10 to 12 hours. The patient lasted all night prior to admission without significant relief from sublingual nitroglycerin. The patient complained of nausea, shortness of breath. The patient was not diaphoretic. EKG performed at the time showed ST elevations in leads V1 through V3 and loss of R wave. The patient was given Morphine nitropaste and aspirin according to protocol. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Gout. 4. Arthritis. 5. Multinodular goiter. 6. History of appendectomy. 7. Possible history of myocardial infarction in distant past. ALLERGIES: The patient is allergic to AMIODARONE, WHICH CAUSES FACIAL EDEMA. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg PO q.d. 2. Diltiazem CD 180 PO q.d. 3. Hydrochlorothiazide 25 q.d. 4. Lipitor 10 mg PO q.d. 5. Lopressor 25 mg PO b.i.d. 6. Nitroglycerin patch 10 mg PO q.d. 7. Vasotec 75 mg PO b.i.d. 8. Allopurinol 100 mg q.d. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Examination revealed the following: Vital signs afebrile. Heart rate: "geminy." Blood pressure: 110/60. Respiratory rate: 16. 100% on room air. The patient appeared to be mild distress. HEENT: JVP distention of about 10 cm. No carotid bruits. CARDIOVASCULAR: Regular rate and rhythm, S3 sound, no murmurs. PULMONARY: Examination showed diffuse crackles anteriorly and laterally without wheezes. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Extremities showed trace edema. Right dorsalis pedis pulse palpable. Left dorsalis pedis and posterior tibial pulses were Dopplerable. NEUROLOGICAL: The patient was alert and oriented times three. Cranial nerves: Grossly intact with full range of motion of lower and upper extremities. LABORATORY DATA: Laboratory data revealed the following: Hematocrit 32.4, white blood cell count 10.7, platelet count 260, sodium 143, potassium 5.0, BUN 33, creatinine 1.1. Creatinine kinase 350, MB 55, troponin 24.1. Chest x-ray performed on [2181-9-5] showed enlarged cardiac silhouette, diffuse interstitial opacifications and small bilateral pleural effusions. EKG showed sinus rhythm. There was also left atrial abnormality, slow R wave progression consistent with underlying anterior myocardial infarction, nondiagnostic Q waves seen in lead #3. Anterolateral ST and T wave changes consistent with ischemia. There was also loss of R wave progression in leads V1 through V3 with ST segment elevations. HOSPITAL COURSE: The patient was admitted to the coronary care unit. The patient ruled in for a myocardial infarction by enzymes and EKG changes. Cardiac catheterization procedure was performed on [2181-9-5], showed three-vessel coronary artery disease. It also showed severe systolic left ventricular dysfunction, severe biventricular diastolic dysfunction. There was also severe pulmonary hypertension. IABP device was inserted. On [2181-9-6] the patient was taken back to the cardiac catheterization laboratory. Successful stenting of the proximal LAD was performed. At the same time limited angiography of the right dominant system showed a severely diseased ALD with a 90% ulcerated lesion and a long segment of 80% to 90% disease in the mid-distal LAD. Cardiac catheterization also revealed 50% diffuse disease in the mid segment and 90% disease in the distal segment of the LAD. Left circumflex artery had up to 90% disease. RI had 50% lesion. RCA was diffusely diseased up to 80% in the proximal segment and subtotally occluded approximately 99% in the mid vessel. The patient was started on IV heparin, nitroglycerin drip, Lasix p.r.n., Protonix, Lipitor, and Lopressor, as well as aspirin. On [2181-9-7] the patient underwent coronary artery bypass grafting times three with left internal mammary artery to left anterior descending coronary artery, reverse saphenous vein graft from the aorta to the right posterior descending coronary artery and reverse saphenous vein graft from the aorta to the obtuse marginal coronary artery. The procedure was without complications. Please see the full operative report for further details. The patient was transferred to the Intensive Care Unit in satisfactory condition. Postoperative course was complicated by upper GI bleed. Hematocrit at the time was 27 with platelet count of 125,000. The patient was treated with FFP and packed red blood cells. At that time urgent EGD was performed. Upper GI studies showed a deep ulcer in the GE junction, which was thought to be the cause of the bleeding. Epinephrine injection was performed to stop the bleeding of the ulcer. The patient continued to well in the Intensive Care Unit. Diet was advanced. She was in sinus rhythm with blood pressures maintained without pressors on postoperative day #3. The patient was successfully extubated. On [2181-9-12] the patient was transferred to the regular cardiac floor for further care. She was showing adequate oxygenation at 96% on two liter nasal cannula. She was noted to be unwilling to get out of bed. Regarding physical therapy: The patient's Foley catheter was discontinued on [2181-9-12]. Maximum temperature was 100.0. She had intensive treatment program with physical therapy. On examination, the patient continued to have significant upper extremity swelling bilaterally. The swelling slowly subsided, although on the day of discharge she was still edematous. The patient was maintained on Lopressor and Lasix throughout the hospitalization. On [2181-9-14], the patient was discharged to the rehabilitation center in stable condition. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Rehabilitation Center. DISCHARGE DIAGNOSES: 1. Coronary artery bypass graft times three. 2. Myocardial infarction. 3. Congestive heart failure. 4. Upper GI bleed. 5. Hypertension. 6. Hypercholesterolemia. 7. Gout. 8. Arthritis. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg PO b.i.d. 2. Allopurinol 100 mg PO q.d. 3. Protonix 40 mg PO q.d. 4. Lipitor 10 mg PO q.d. 5. Milk of Magnesia 30 mg PO h.s. 6. Tylenol 650 mg PO q.4h.p.r.n. 7. Percocet one tablet to two tablets PO q.4h. to 6h.p.r.n. pain. 8. Lasix 20 mg PO b.i.d. times 10 days. 9. Potassium chloride 20 mg PO q.12h. times ten days. 10. Aspirin 325 mg PO q.d. 11. Colace 100 mg PO b.i.d. DISCHARGE INSTRUCTIONS: The patient is to see her surgeon, Dr. [Last Name (STitle) 70] in six weeks. The patient is to see her cardiologist in approximately three to four weeks. The patient is to see her primary care physician within the next week. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 1741] MEDQUIST36 D: [2181-9-13] 13:16 T: [2181-9-13] 13:30 JOB#: [Job Number 1742]	Admission Date: <Date>1911-3-10</Date> Discharge Date: <Date>1913-2-17</Date> Service: CARDIAC HISTORY OF THE PRESENT ILLNESS: The patient is an 82-year-old female with hypercholesterolemia, chronic renal insufficiency, hypertension, and long history of atypical chest pain, as well as possibly asymptomatic myocardial infarction a long time ago. Prior to admission, the last cardiac evaluation was in <Month>July</Month>, when a stress MIBI showed an ejection fraction of 67% without evidence of ischemia, although the patient only tolerated three minutes. The patient was in the usual state of health until several months ago, when she began to complain of increased shortness of breath and pedal edema. The symptoms specifically, shortness of breath and chest pain, increased in intensity about two weeks prior to admission. On <Date>2014-10-20</Date>, the patient presented to her primary care physician and stress tests were performed. On the night, prior to admission, the patient presented with left sided substernal chest pain radiating to the scapula that had lasted for 10 to 12 hours. The patient lasted all night prior to admission without significant relief from sublingual nitroglycerin. The patient complained of nausea, shortness of breath. The patient was not diaphoretic. EKG performed at the time showed ST elevations in leads V1 through V3 and loss of R wave. The patient was given Morphine nitropaste and aspirin according to protocol. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Gout. 4. Arthritis. 5. Multinodular goiter. 6. History of appendectomy. 7. Possible history of myocardial infarction in distant past. ALLERGIES: The patient is allergic to AMIODARONE, WHICH CAUSES FACIAL EDEMA. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg PO q.d. 2. Diltiazem CD 180 PO q.d. 3. Hydrochlorothiazide 25 q.d. 4. Lipitor 10 mg PO q.d. 5. Lopressor 25 mg PO b.i.d. 6. Nitroglycerin patch 10 mg PO q.d. 7. Vasotec 75 mg PO b.i.d. 8. Allopurinol 100 mg q.d. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Examination revealed the following: Vital signs afebrile. Heart rate: "geminy." Blood pressure: 110/60. Respiratory rate: 16. 100% on room air. The patient appeared to be mild distress. HEENT: JVP distention of about 10 cm. No carotid bruits. CARDIOVASCULAR: Regular rate and rhythm, S3 sound, no murmurs. PULMONARY: Examination showed diffuse crackles anteriorly and laterally without wheezes. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Extremities showed trace edema. Right dorsalis pedis pulse palpable. Left dorsalis pedis and posterior tibial pulses were Dopplerable. NEUROLOGICAL: The patient was alert and oriented times three. Cranial nerves: Grossly intact with full range of motion of lower and upper extremities. LABORATORY DATA: Laboratory data revealed the following: Hematocrit 32.4, white blood cell count 10.7, platelet count 260, sodium 143, potassium 5.0, BUN 33, creatinine 1.1. Creatinine kinase 350, MB 55, troponin 24.1. Chest x-ray performed on <Date>1911-3-10</Date> showed enlarged cardiac silhouette, diffuse interstitial opacifications and small bilateral pleural effusions. EKG showed sinus rhythm. There was also left atrial abnormality, slow R wave progression consistent with underlying anterior myocardial infarction, nondiagnostic Q waves seen in lead #3. Anterolateral ST and T wave changes consistent with ischemia. There was also loss of R wave progression in leads V1 through V3 with ST segment elevations. HOSPITAL COURSE: The patient was admitted to the coronary care unit. The patient ruled in for a myocardial infarction by enzymes and EKG changes. Cardiac catheterization procedure was performed on <Date>1911-3-10</Date>, showed three-vessel coronary artery disease. It also showed severe systolic left ventricular dysfunction, severe biventricular diastolic dysfunction. There was also severe pulmonary hypertension. IABP device was inserted. On <Date>1918-10-31</Date> the patient was taken back to the cardiac catheterization laboratory. Successful stenting of the proximal LAD was performed. At the same time limited angiography of the right dominant system showed a severely diseased ALD with a 90% ulcerated lesion and a long segment of 80% to 90% disease in the mid-distal LAD. Cardiac catheterization also revealed 50% diffuse disease in the mid segment and 90% disease in the distal segment of the LAD. Left circumflex artery had up to 90% disease. RI had 50% lesion. RCA was diffusely diseased up to 80% in the proximal segment and subtotally occluded approximately 99% in the mid vessel. The patient was started on IV heparin, nitroglycerin drip, Lasix p.r.n., Protonix, Lipitor, and Lopressor, as well as aspirin. On <Date>1905-11-10</Date> the patient underwent coronary artery bypass grafting times three with left internal mammary artery to left anterior descending coronary artery, reverse saphenous vein graft from the aorta to the right posterior descending coronary artery and reverse saphenous vein graft from the aorta to the obtuse marginal coronary artery. The procedure was without complications. Please see the full operative report for further details. The patient was transferred to the Intensive Care Unit in satisfactory condition. Postoperative course was complicated by upper GI bleed. Hematocrit at the time was 27 with platelet count of 125,000. The patient was treated with FFP and packed red blood cells. At that time urgent EGD was performed. Upper GI studies showed a deep ulcer in the GE junction, which was thought to be the cause of the bleeding. Epinephrine injection was performed to stop the bleeding of the ulcer. The patient continued to well in the Intensive Care Unit. Diet was advanced. She was in sinus rhythm with blood pressures maintained without pressors on postoperative day #3. The patient was successfully extubated. On <Date>2014-10-5</Date> the patient was transferred to the regular cardiac floor for further care. She was showing adequate oxygenation at 96% on two liter nasal cannula. She was noted to be unwilling to get out of bed. Regarding physical therapy: The patient's Foley catheter was discontinued on <Date>2014-10-5</Date>. Maximum temperature was 100.0. She had intensive treatment program with physical therapy. On examination, the patient continued to have significant upper extremity swelling bilaterally. The swelling slowly subsided, although on the day of discharge she was still edematous. The patient was maintained on Lopressor and Lasix throughout the hospitalization. On <Date>1913-2-17</Date>, the patient was discharged to the rehabilitation center in stable condition. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Rehabilitation Center. DISCHARGE DIAGNOSES: 1. Coronary artery bypass graft times three. 2. Myocardial infarction. 3. Congestive heart failure. 4. Upper GI bleed. 5. Hypertension. 6. Hypercholesterolemia. 7. Gout. 8. Arthritis. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg PO b.i.d. 2. Allopurinol 100 mg PO q.d. 3. Protonix 40 mg PO q.d. 4. Lipitor 10 mg PO q.d. 5. Milk of Magnesia 30 mg PO h.s. 6. Tylenol 650 mg PO q.4h.p.r.n. 7. Percocet one tablet to two tablets PO q.4h. to 6h.p.r.n. pain. 8. Lasix 20 mg PO b.i.d. times 10 days. 9. Potassium chloride 20 mg PO q.12h. times ten days. 10. Aspirin 325 mg PO q.d. 11. Colace 100 mg PO b.i.d. DISCHARGE INSTRUCTIONS: The patient is to see her surgeon, Dr. <Name>Kenner</Name> in six weeks. The patient is to see her cardiologist in approximately three to four weeks. The patient is to see her primary care physician within the next week. <Name>Janice</Name> <Initial>PG</Initial> <Name>Edward</Name>, M.D. <MD Number>53832734</MD Number> Dictated By:<Name>Spikes</Name> MEDQUIST36 D: <Date>1971-6-17</Date> 13:16 T: <Date>1971-6-17</Date> 13:30 JOB#: <Job Number>Cook, Hendrix and Perkins-2021-110474</Job 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Date: 1911-3-10 Discharge Date: 1913-2-17 Service: CARDIAC HISTORY OF THE PRESENT ILLNESS: The patient is an 82-year-old female with hypercholesterolemia, chronic renal insufficiency, hypertension, and long history of atypical chest pain, as well as possibly asymptomatic myocardial infarction a long time ago. Prior to admission, the last cardiac evaluation was in July, when a stress MIBI showed an ejection fraction of 67% without evidence of ischemia, although the patient only tolerated three minutes. The patient was in the usual state of health until several months ago, when she began to complain of increased shortness of breath and pedal edema. The symptoms specifically, shortness of breath and chest pain, increased in intensity about two weeks prior to admission. On 2014-10-20, the patient presented to her primary care physician and stress tests were performed. On the night, prior to admission, the patient presented with left sided substernal chest pain radiating to the scapula that had lasted for 10 to 12 hours. The patient lasted all night prior to admission without significant relief from sublingual nitroglycerin. The patient complained of nausea, shortness of breath. The patient was not diaphoretic. EKG performed at the time showed ST elevations in leads V1 through V3 and loss of R wave. The patient was given Morphine nitropaste and aspirin according to protocol. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Gout. 4. Arthritis. 5. Multinodular goiter. 6. History of appendectomy. 7. Possible history of myocardial infarction in distant past. ALLERGIES: The patient is allergic to AMIODARONE, WHICH CAUSES FACIAL EDEMA. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg PO q.d. 2. Diltiazem CD 180 PO q.d. 3. Hydrochlorothiazide 25 q.d. 4. Lipitor 10 mg PO q.d. 5. Lopressor 25 mg PO b.i.d. 6. Nitroglycerin patch 10 mg PO q.d. 7. Vasotec 75 mg PO b.i.d. 8. Allopurinol 100 mg q.d. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Examination revealed the following: Vital signs afebrile. Heart rate: "geminy." Blood pressure: 110/60. Respiratory rate: 16. 100% on room air. The patient appeared to be mild distress. HEENT: JVP distention of about 10 cm. No carotid bruits. CARDIOVASCULAR: Regular rate and rhythm, S3 sound, no murmurs. PULMONARY: Examination showed diffuse crackles anteriorly and laterally without wheezes. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Extremities showed trace edema. Right dorsalis pedis pulse palpable. Left dorsalis pedis and posterior tibial pulses were Dopplerable. NEUROLOGICAL: The patient was alert and oriented times three. Cranial nerves: Grossly intact with full range of motion of lower and upper extremities. LABORATORY DATA: Laboratory data revealed the following: Hematocrit 32.4, white blood cell count 10.7, platelet count 260, sodium 143, potassium 5.0, BUN 33, creatinine 1.1. Creatinine kinase 350, MB 55, troponin 24.1. Chest x-ray performed on 1911-3-10 showed enlarged cardiac silhouette, diffuse interstitial opacifications and small bilateral pleural effusions. EKG showed sinus rhythm. There was also left atrial abnormality, slow R wave progression consistent with underlying anterior myocardial infarction, nondiagnostic Q waves seen in lead #3. Anterolateral ST and T wave changes consistent with ischemia. There was also loss of R wave progression in leads V1 through V3 with ST segment elevations. HOSPITAL COURSE: The patient was admitted to the coronary care unit. The patient ruled in for a myocardial infarction by enzymes and EKG changes. Cardiac catheterization procedure was performed on 1911-3-10, showed three-vessel coronary artery disease. It also showed severe systolic left ventricular dysfunction, severe biventricular diastolic dysfunction. There was also severe pulmonary hypertension. IABP device was inserted. On 1918-10-31 the patient was taken back to the cardiac catheterization laboratory. Successful stenting of the proximal LAD was performed. At the same time limited angiography of the right dominant system showed a severely diseased ALD with a 90% ulcerated lesion and a long segment of 80% to 90% disease in the mid-distal LAD. Cardiac catheterization also revealed 50% diffuse disease in the mid segment and 90% disease in the distal segment of the LAD. Left circumflex artery had up to 90% disease. RI had 50% lesion. RCA was diffusely diseased up to 80% in the proximal segment and subtotally occluded approximately 99% in the mid vessel. The patient was started on IV heparin, nitroglycerin drip, Lasix p.r.n., Protonix, Lipitor, and Lopressor, as well as aspirin. On 1905-11-10 the patient underwent coronary artery bypass grafting times three with left internal mammary artery to left anterior descending coronary artery, reverse saphenous vein graft from the aorta to the right posterior descending coronary artery and reverse saphenous vein graft from the aorta to the obtuse marginal coronary artery. The procedure was without complications. Please see the full operative report for further details. The patient was transferred to the Intensive Care Unit in satisfactory condition. Postoperative course was complicated by upper GI bleed. Hematocrit at the time was 27 with platelet count of 125,000. The patient was treated with FFP and packed red blood cells. At that time urgent EGD was performed. Upper GI studies showed a deep ulcer in the GE junction, which was thought to be the cause of the bleeding. Epinephrine injection was performed to stop the bleeding of the ulcer. The patient continued to well in the Intensive Care Unit. Diet was advanced. She was in sinus rhythm with blood pressures maintained without pressors on postoperative day #3. The patient was successfully extubated. On 2014-10-5 the patient was transferred to the regular cardiac floor for further care. She was showing adequate oxygenation at 96% on two liter nasal cannula. She was noted to be unwilling to get out of bed. Regarding physical therapy: The patient's Foley catheter was discontinued on 2014-10-5. Maximum temperature was 100.0. She had intensive treatment program with physical therapy. On examination, the patient continued to have significant upper extremity swelling bilaterally. The swelling slowly subsided, although on the day of discharge she was still edematous. The patient was maintained on Lopressor and Lasix throughout the hospitalization. On 1913-2-17, the patient was discharged to the rehabilitation center in stable condition. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Rehabilitation Center. DISCHARGE DIAGNOSES: 1. Coronary artery bypass graft times three. 2. Myocardial infarction. 3. Congestive heart failure. 4. Upper GI bleed. 5. Hypertension. 6. Hypercholesterolemia. 7. Gout. 8. Arthritis. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg PO b.i.d. 2. Allopurinol 100 mg PO q.d. 3. Protonix 40 mg PO q.d. 4. Lipitor 10 mg PO q.d. 5. Milk of Magnesia 30 mg PO h.s. 6. Tylenol 650 mg PO q.4h.p.r.n. 7. Percocet one tablet to two tablets PO q.4h. to 6h.p.r.n. pain. 8. Lasix 20 mg PO b.i.d. times 10 days. 9. Potassium chloride 20 mg PO q.12h. times ten days. 10. Aspirin 325 mg PO q.d. 11. Colace 100 mg PO b.i.d. DISCHARGE INSTRUCTIONS: The patient is to see her surgeon, Dr. Kenner in six weeks. The patient is to see her cardiologist in approximately three to four weeks. The patient is to see her primary care physician within the next week. Janice PG Edward, M.D. 53832734 Dictated By:Spikes MEDQUIST36 D: 1971-6-17 13:16 T: 1971-6-17 13:30 JOB#: Cook, Hendrix and Perkins-2021-110474	['Admission Date: 1911-3-10 Discharge Date: 1913-2-17\n\n\nService: CARDIAC\n\nHISTORY OF THE PRESENT ILLNESS: The patient is an\n82-year-old female with hypercholesterolemia, chronic renal\ninsufficiency, hypertension, and long history of atypical\nchest pain, as well as possibly asymptomatic myocardial\ninfarction a long time ago. Prior to admission, the last\ncardiac evaluation was in July, when a stress MIBI showed\nan ejection fraction of 67% without evidence of ischemia,\nalthough the patient only tolerated three minutes.\n\nThe patient was in the usual state of health until several\nmonths ago, when she began to complain of increased shortness\nof breath and pedal edema. The symptoms specifically,\nshortness of breath and chest pain, increased in intensity\nabout two weeks prior to admission.', ' On 2014-10-20, the\npatient presented to her primary care physician and stress\ntests were performed. On the night, prior to admission, the\npatient presented with left sided substernal chest pain\nradiating to the scapula that had lasted for 10 to 12 hours.\nThe patient lasted all night prior to admission without\nsignificant relief from sublingual nitroglycerin. The\npatient complained of nausea, shortness of breath. The\npatient was not diaphoretic. EKG performed at the time\nshowed ST elevations in leads V1 through V3 and loss of R\nwave. The patient was given Morphine nitropaste and aspirin\naccording to protocol.\n\nPAST MEDICAL HISTORY:\n1. Hypertension.\n2. Hypercholesterolemia.\n3. Gout.\n4. Arthritis.\n5. Multinodular goiter.\n6. History of appendectomy.\n7. Possible history of myocardial infarction in distant\npast.', '\n\nALLERGIES: The patient is allergic to AMIODARONE, WHICH\nCAUSES FACIAL EDEMA.\n\nMEDICATIONS ON ADMISSION:\n1. Aspirin 325 mg PO q.d.\n2. Diltiazem CD 180 PO q.d.\n3. Hydrochlorothiazide 25 q.d.\n4. Lipitor 10 mg PO q.d.\n5. Lopressor 25 mg PO b.i.d.\n6. Nitroglycerin patch 10 mg PO q.d.\n7. Vasotec 75 mg PO b.i.d.\n8. Allopurinol 100 mg q.d.\n\nFAMILY HISTORY: Noncontributory.\n\nPHYSICAL EXAMINATION: Examination revealed the following:\nVital signs afebrile. Heart rate: "geminy." Blood\npressure: 110/60. Respiratory rate: 16. 100% on room air.\n The patient appeared to be mild distress. HEENT: JVP\ndistention of about 10 cm. No carotid bruits.\nCARDIOVASCULAR: Regular rate and rhythm, S3 sound, no\nmurmurs. PULMONARY: Examination showed diffuse crackles\nanteriorly and laterally without wheezes.', ' ABDOMEN: Soft,\nnontender, nondistended. EXTREMITIES: Extremities showed\ntrace edema. Right dorsalis pedis pulse palpable. Left\ndorsalis pedis and posterior tibial pulses were Dopplerable.\nNEUROLOGICAL: The patient was alert and oriented times\nthree. Cranial nerves: Grossly intact with full range of\nmotion of lower and upper extremities.\n\nLABORATORY DATA: Laboratory data revealed the following:\nHematocrit 32.4, white blood cell count 10.7, platelet count\n260, sodium 143, potassium 5.0, BUN 33, creatinine 1.1.\nCreatinine kinase 350, MB 55, troponin 24.1. Chest x-ray\nperformed on 1911-3-10 showed enlarged cardiac silhouette,\ndiffuse interstitial opacifications and small bilateral\npleural effusions. EKG showed sinus rhythm. There was also\nleft atrial abnormality, slow R wave progression consistent\nwith underlying anterior myocardial infarction, nondiagnostic\nQ waves seen in lead #3.', ' Anterolateral ST and T wave changes\nconsistent with ischemia. There was also loss of R wave\nprogression in leads V1 through V3 with ST segment\nelevations.\n\nHOSPITAL COURSE: The patient was admitted to the coronary\ncare unit. The patient ruled in for a myocardial infarction\nby enzymes and EKG changes. Cardiac catheterization\nprocedure was performed on 1911-3-10, showed three-vessel\ncoronary artery disease. It also showed severe systolic left\nventricular dysfunction, severe biventricular diastolic\ndysfunction. There was also severe pulmonary hypertension.\nIABP device was inserted.\n\nOn 1918-10-31 the patient was taken back to the cardiac\ncatheterization laboratory. Successful stenting of the\nproximal LAD was performed. At the same time limited\nangiography of the right dominant system showed a severely\ndiseased ALD with a 90% ulcerated lesion and a long segment\nof 80% to 90% disease in the mid-distal LAD.', ' Cardiac\ncatheterization also revealed 50% diffuse disease in the mid\nsegment and 90% disease in the distal segment of the LAD.\nLeft circumflex artery had up to 90% disease. RI had 50%\nlesion. RCA was diffusely diseased up to 80% in the proximal\nsegment and subtotally occluded approximately 99% in the mid\nvessel.\n\nThe patient was started on IV heparin, nitroglycerin drip,\nLasix p.r.n., Protonix, Lipitor, and Lopressor, as well as\naspirin.\n\nOn 1905-11-10 the patient underwent coronary artery bypass\ngrafting times three with left internal mammary artery to\nleft anterior descending coronary artery, reverse saphenous\nvein graft from the aorta to the right posterior descending\ncoronary artery and reverse saphenous vein graft from the\naorta to the obtuse marginal coronary artery. The procedure\nwas without complications.', ' Please see the full operative\nreport for further details.\n\nThe patient was transferred to the Intensive Care Unit in\nsatisfactory condition.\n\nPostoperative course was complicated by upper GI bleed.\nHematocrit at the time was 27 with platelet count of 125,000.\nThe patient was treated with FFP and packed red blood cells.\nAt that time urgent EGD was performed. Upper GI studies\nshowed a deep ulcer in the GE junction, which was thought to\nbe the cause of the bleeding. Epinephrine injection was\nperformed to stop the bleeding of the ulcer.\n\nThe patient continued to well in the Intensive Care Unit.\nDiet was advanced. She was in sinus rhythm with blood\npressures maintained without pressors on postoperative day\n#3. The patient was successfully extubated.\n\nOn 2014-10-5 the patient was transferred to the regular\ncardiac floor for further care.', " She was showing adequate\noxygenation at 96% on two liter nasal cannula. She was noted\nto be unwilling to get out of bed. Regarding physical\ntherapy: The patient's Foley catheter was discontinued on\n2014-10-5. Maximum temperature was 100.0. She had intensive\ntreatment program with physical therapy.\n\nOn examination, the patient continued to have significant\nupper extremity swelling bilaterally. The swelling slowly\nsubsided, although on the day of discharge she was still\nedematous. The patient was maintained on Lopressor and Lasix\nthroughout the hospitalization. On 1913-2-17, the patient\nwas discharged to the rehabilitation center in stable\ncondition.\n\nCONDITION ON DISCHARGE: Good.\n\nDISCHARGE DISPOSITION: Rehabilitation Center.\n\nDISCHARGE DIAGNOSES:\n1. Coronary artery bypass graft times three.", '\n2. Myocardial infarction.\n3. Congestive heart failure.\n4. Upper GI bleed.\n5. Hypertension.\n6. Hypercholesterolemia.\n7. Gout.\n8. Arthritis.\n\nDISCHARGE MEDICATIONS:\n1. Lopressor 50 mg PO b.i.d.\n2. Allopurinol 100 mg PO q.d.\n3. Protonix 40 mg PO q.d.\n4. Lipitor 10 mg PO q.d.\n5. Milk of Magnesia 30 mg PO h.s.\n6. Tylenol 650 mg PO q.4h.p.r.n.\n7. Percocet one tablet to two tablets PO q.4h. to 6h.p.r.n.\npain.\n8. Lasix 20 mg PO b.i.d. times 10 days.\n9. Potassium chloride 20 mg PO q.12h. times ten days.\n10. Aspirin 325 mg PO q.d.\n11. Colace 100 mg PO b.i.d.\n\nDISCHARGE INSTRUCTIONS: The patient is to see her surgeon,\nDr. Kenner in six weeks. The patient is to see her\ncardiologist in approximately three to four weeks. The\npatient is to see her primary care physician within the next\nweek.', '\n\n\n\n\n Janice PG Edward, M.D. 53832734\n\nDictated By:Spikes\nMEDQUIST36\n\nD: 1971-6-17 13:16\nT: 1971-6-17 13:30\nJOB#: Cook, Hendrix and Perkins-2021-110474\n']
167	784	187825.0	2200-07-08	Discharge summary	Report	Admission Date: [2200-6-2] Discharge Date:[2200-7-8] Date of Birth: [2131-8-1] Sex: F Service: DATE OF DISCHARGE: Pending. AGE: 68. HISTORY OF THE PRESENT ILLNESS: [Known firstname 1743] [Last Name (NamePattern1) 1744] is a 68-year-old female who was at acute rehabilitation at [Location (un) 38] after having a right-sided knee replacement on [2200-5-6]. The patient had been on antibiotics following her knee replacement and had developed abdominal pain two weeks prior to admission with diarrhea. The patient was presumed to have C. difficile and had been started on Flagyl. She was taken to the [Hospital1 69] Emergency Department and on presentation she had a white blood cell count of 25,000, large amounts of nausea, and fevers up to 101.0 degrees. Of note, the patient had been on Flagyl since [5-21], until the patient's presentation on [2200-6-2]. REVIEW OF SYSTEMS: Review of systems was negative for dysuria. PAST MEDICAL HISTORY: History was notable for the following: 1. Osteoarthritis. 2. Left sided breast cancer. 3. Diverticulitis. 4. Gastrointestinal bleed. 5. Fibromyalgia. MEDICATIONS ON ADMISSION: 1. Coumadin. 2. Vistaril. 3. .................... 4. Tamoxifen. 5. Zoloft. 6. Protonix. 7. Ditropan. 8. [Doctor First Name ]. 9. Lasix. ALLERGIES: The patient is allergic to SULFA AND IBUPROFEN. SOCIAL HISTORY: The patient has no history of alcohol, drugs, or smoking. PHYSICAL EXAMINATION: On presentation, the patient's physical examination revealed the following: Temperature 100.3, heart rate 109, blood pressure 149/74, respiratory rate 18, oxygen saturation 97%. She was ill-appearing on presentation with a diffusely tender abdomen with positive rebound and no guarding. Stool was guaiac negative. HOSPITAL COURSE: The patient was then admitted medical service initially for management of her presumed C. difficile colitis. The patient was admitted to the medical service postoperatively and then was noted to have pleural effusion and then underwent a thoracocentesis of her effusion. On the 14th, the patient continued to have poor hospital course and on [2200-6-5] due to difficult medical management of the disease, surgical consultation was obtained and the patient underwent a subtotal colectomy with ileostomy. Regarding the patient's operation, please referred to Dr. [Name (NI) 1745] operative note on [2200-6-5]. Postoperatively, the patient was taken to the Medical Intensive Care Unit for further management of her disease. She underwent numerous transfusion of fresh-frozen plasma. The patient was continued to be intubated. The patient was managed in the Medical Intensive Care Unit with bilateral chest tubes placed while the patient was in the Medical Intensive Care Unit. The patient continued to have high fevers. Sputum culture from [2200-6-21] demonstrated Methicillin-resistant Staphylococcus aureus and transthoracic cardiac echocardiogram demonstrated no pericardial effusion or no obvious vegetations, while the patient continued to have these fevers. The patient was continued on Vancomycin and continued to be intubated for a long period of time until [2200-6-25] when the patient was extubated successfully. Post extubation, the patient had difficulty with her voice and swallowing, and she was deemed an aspiration risk, so Dobbhoff was placed. She was then transferred to the floor and she continued to do well. Chest tubes were removed, and she stopped having fevers. Physical therapy consultation was obtained and the patient began to improved dramatically while on the floor. She remained afebrile with stable vital signs with reasonable respiratory parameters, and she was continued on tube feeds or Promote with fiber at a goal rate of 70 cc per hour. The patient will be discharged to a rehabilitation facility on the following regimen: 1. Lopressor 50 mg PO t.i.d. 2. Ambien 10 mg PO q.h.s. 3. Vancomycin 1 gram q.d. 4. Heparin 5000 units subcutaneously b.i.d. 5. Regular insulin sliding scale. 6. Protonix 40 mg IV q.d. 7. The patient will continue on her tube feeds, Promote with fiber at 70 cc an hour. FOLLOW-UP CARE: The patient will followup with Dr. [Last Name (STitle) 519] in one to two weeks. The patient will followup with her primary care physician at the time deemed appropriate by their office. OF NOTE: Portions of this chart were not available during this dictation. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Name8 (MD) 522] MEDQUIST36 D: [2200-7-7] 13:37 T: [2200-7-7] 13:57 JOB#: [Job Number 1746]	Admission Date: <Date>1933-3-14</Date> Discharge Date:<Date>1920-7-19</Date> Date of Birth: <Date>1918-10-23</Date> Sex: F Service: DATE OF DISCHARGE: Pending. AGE: 68. HISTORY OF THE PRESENT ILLNESS: <Name>Tracy</Name> <Name>Anderson</Name> is a 68-year-old female who was at acute rehabilitation at <Location>00045 Sandra Manor Suite 900 Lake Matthew, SD 42646</Location> after having a right-sided knee replacement on <Date>1939-8-2</Date>. The patient had been on antibiotics following her knee replacement and had developed abdominal pain two weeks prior to admission with diarrhea. The patient was presumed to have C. difficile and had been started on Flagyl. She was taken to the <Hospital>Daniels Inc Health System</Hospital> Emergency Department and on presentation she had a white blood cell count of 25,000, large amounts of nausea, and fevers up to 101.0 degrees. Of note, the patient had been on Flagyl since <Date>12-8</Date>, until the patient's presentation on <Date>1933-3-14</Date>. REVIEW OF SYSTEMS: Review of systems was negative for dysuria. PAST MEDICAL HISTORY: History was notable for the following: 1. Osteoarthritis. 2. Left sided breast cancer. 3. Diverticulitis. 4. Gastrointestinal bleed. 5. Fibromyalgia. MEDICATIONS ON ADMISSION: 1. Coumadin. 2. Vistaril. 3. .................... 4. Tamoxifen. 5. Zoloft. 6. Protonix. 7. Ditropan. 8. <Name>Eldon</Name>. 9. Lasix. ALLERGIES: The patient is allergic to SULFA AND IBUPROFEN. SOCIAL HISTORY: The patient has no history of alcohol, drugs, or smoking. PHYSICAL EXAMINATION: On presentation, the patient's physical examination revealed the following: Temperature 100.3, heart rate 109, blood pressure 149/74, respiratory rate 18, oxygen saturation 97%. She was ill-appearing on presentation with a diffusely tender abdomen with positive rebound and no guarding. Stool was guaiac negative. HOSPITAL COURSE: The patient was then admitted medical service initially for management of her presumed C. difficile colitis. The patient was admitted to the medical service postoperatively and then was noted to have pleural effusion and then underwent a thoracocentesis of her effusion. On the 14th, the patient continued to have poor hospital course and on <Date>1928-7-13</Date> due to difficult medical management of the disease, surgical consultation was obtained and the patient underwent a subtotal colectomy with ileostomy. Regarding the patient's operation, please referred to Dr. <Name>Jai Booker</Name> operative note on <Date>1928-7-13</Date>. Postoperatively, the patient was taken to the Medical Intensive Care Unit for further management of her disease. She underwent numerous transfusion of fresh-frozen plasma. The patient was continued to be intubated. The patient was managed in the Medical Intensive Care Unit with bilateral chest tubes placed while the patient was in the Medical Intensive Care Unit. The patient continued to have high fevers. Sputum culture from <Date>1921-10-30</Date> demonstrated Methicillin-resistant Staphylococcus aureus and transthoracic cardiac echocardiogram demonstrated no pericardial effusion or no obvious vegetations, while the patient continued to have these fevers. The patient was continued on Vancomycin and continued to be intubated for a long period of time until <Date>1965-5-19</Date> when the patient was extubated successfully. Post extubation, the patient had difficulty with her voice and swallowing, and she was deemed an aspiration risk, so Dobbhoff was placed. She was then transferred to the floor and she continued to do well. Chest tubes were removed, and she stopped having fevers. Physical therapy consultation was obtained and the patient began to improved dramatically while on the floor. She remained afebrile with stable vital signs with reasonable respiratory parameters, and she was continued on tube feeds or Promote with fiber at a goal rate of 70 cc per hour. The patient will be discharged to a rehabilitation facility on the following regimen: 1. Lopressor 50 mg PO t.i.d. 2. Ambien 10 mg PO q.h.s. 3. Vancomycin 1 gram q.d. 4. Heparin 5000 units subcutaneously b.i.d. 5. Regular insulin sliding scale. 6. Protonix 40 mg IV q.d. 7. The patient will continue on her tube feeds, Promote with fiber at 70 cc an hour. FOLLOW-UP CARE: The patient will followup with Dr. <Name>Prieto</Name> in one to two weeks. The patient will followup with her primary care physician at the time deemed appropriate by their office. OF NOTE: Portions of this chart were not available during this dictation. <Name>Shannan</Name> <Name>Camargo</Name>, M.D. <MD Number>19097315</MD Number> Dictated By:<Name>Ivory Tamaro</Name> MEDQUIST36 D: <Date>2003-11-26</Date> 13:37 T: <Date>2003-11-26</Date> 13:57 JOB#: <Job Number>Waters Ltd-1957-614644</Job Number>	00000000000000000111111111000000000000000000000011111111100000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111011111111000000000000000000000000000000000000000000000000000000000000111111111111111111111111111111111111111111111111111000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111101111111000000001111111100000000000000111111111111000000000000000001111111111000000000000111111111100000000000000011111111111111111111110	Admission Date: 1933-3-14 Discharge Date:1920-7-19 Date of Birth: 1918-10-23 Sex: F Service: DATE OF DISCHARGE: Pending. AGE: 68. HISTORY OF THE PRESENT ILLNESS: Tracy Anderson is a 68-year-old female who was at acute rehabilitation at 00045 Sandra Manor Suite 900 Lake Matthew, SD 42646 after having a right-sided knee replacement on 1939-8-2. The patient had been on antibiotics following her knee replacement and had developed abdominal pain two weeks prior to admission with diarrhea. The patient was presumed to have C. difficile and had been started on Flagyl. She was taken to the Daniels Inc Health System Emergency Department and on presentation she had a white blood cell count of 25,000, large amounts of nausea, and fevers up to 101.0 degrees. Of note, the patient had been on Flagyl since 12-8, until the patient's presentation on 1933-3-14. REVIEW OF SYSTEMS: Review of systems was negative for dysuria. PAST MEDICAL HISTORY: History was notable for the following: 1. Osteoarthritis. 2. Left sided breast cancer. 3. Diverticulitis. 4. Gastrointestinal bleed. 5. Fibromyalgia. MEDICATIONS ON ADMISSION: 1. Coumadin. 2. Vistaril. 3. .................... 4. Tamoxifen. 5. Zoloft. 6. Protonix. 7. Ditropan. 8. Eldon. 9. Lasix. ALLERGIES: The patient is allergic to SULFA AND IBUPROFEN. SOCIAL HISTORY: The patient has no history of alcohol, drugs, or smoking. PHYSICAL EXAMINATION: On presentation, the patient's physical examination revealed the following: Temperature 100.3, heart rate 109, blood pressure 149/74, respiratory rate 18, oxygen saturation 97%. She was ill-appearing on presentation with a diffusely tender abdomen with positive rebound and no guarding. Stool was guaiac negative. HOSPITAL COURSE: The patient was then admitted medical service initially for management of her presumed C. difficile colitis. The patient was admitted to the medical service postoperatively and then was noted to have pleural effusion and then underwent a thoracocentesis of her effusion. On the 14th, the patient continued to have poor hospital course and on 1928-7-13 due to difficult medical management of the disease, surgical consultation was obtained and the patient underwent a subtotal colectomy with ileostomy. Regarding the patient's operation, please referred to Dr. Jai Booker operative note on 1928-7-13. Postoperatively, the patient was taken to the Medical Intensive Care Unit for further management of her disease. She underwent numerous transfusion of fresh-frozen plasma. The patient was continued to be intubated. The patient was managed in the Medical Intensive Care Unit with bilateral chest tubes placed while the patient was in the Medical Intensive Care Unit. The patient continued to have high fevers. Sputum culture from 1921-10-30 demonstrated Methicillin-resistant Staphylococcus aureus and transthoracic cardiac echocardiogram demonstrated no pericardial effusion or no obvious vegetations, while the patient continued to have these fevers. The patient was continued on Vancomycin and continued to be intubated for a long period of time until 1965-5-19 when the patient was extubated successfully. Post extubation, the patient had difficulty with her voice and swallowing, and she was deemed an aspiration risk, so Dobbhoff was placed. She was then transferred to the floor and she continued to do well. Chest tubes were removed, and she stopped having fevers. Physical therapy consultation was obtained and the patient began to improved dramatically while on the floor. She remained afebrile with stable vital signs with reasonable respiratory parameters, and she was continued on tube feeds or Promote with fiber at a goal rate of 70 cc per hour. The patient will be discharged to a rehabilitation facility on the following regimen: 1. Lopressor 50 mg PO t.i.d. 2. Ambien 10 mg PO q.h.s. 3. Vancomycin 1 gram q.d. 4. Heparin 5000 units subcutaneously b.i.d. 5. Regular insulin sliding scale. 6. Protonix 40 mg IV q.d. 7. The patient will continue on her tube feeds, Promote with fiber at 70 cc an hour. FOLLOW-UP CARE: The patient will followup with Dr. Prieto in one to two weeks. The patient will followup with her primary care physician at the time deemed appropriate by their office. OF NOTE: Portions of this chart were not available during this dictation. Shannan Camargo, M.D. 19097315 Dictated By:Ivory Tamaro MEDQUIST36 D: 2003-11-26 13:37 T: 2003-11-26 13:57 JOB#: Waters Ltd-1957-614644	["Admission Date: 1933-3-14 Discharge Date:1920-7-19\n\nDate of Birth: 1918-10-23 Sex: F\n\nService:\n\nDATE OF DISCHARGE: Pending.\n\nAGE: 68.\n\nHISTORY OF THE PRESENT ILLNESS: Tracy Anderson is a\n68-year-old female who was at acute rehabilitation at\n00045 Sandra Manor Suite 900\nLake Matthew, SD 42646 after having a right-sided knee replacement on\n1939-8-2. The patient had been on antibiotics following her\nknee replacement and had developed abdominal pain two weeks\nprior to admission with diarrhea. The patient was presumed\nto have C. difficile and had been started on Flagyl. She was\ntaken to the Daniels Inc Health System Emergency\nDepartment and on presentation she had a white blood cell\ncount of 25,000, large amounts of nausea, and fevers up to\n101.0 degrees. Of note, the patient had been on Flagyl since\n12-8, until the patient's presentation on 1933-3-14.", "\n\nREVIEW OF SYSTEMS: Review of systems was negative for\ndysuria.\n\nPAST MEDICAL HISTORY: History was notable for the following:\n1. Osteoarthritis.\n2. Left sided breast cancer.\n3. Diverticulitis.\n4. Gastrointestinal bleed.\n5. Fibromyalgia.\n\nMEDICATIONS ON ADMISSION:\n1. Coumadin.\n2. Vistaril.\n3. ....................\n4. Tamoxifen.\n5. Zoloft.\n6. Protonix.\n7. Ditropan.\n8. Eldon.\n9. Lasix.\n\nALLERGIES: The patient is allergic to SULFA AND IBUPROFEN.\n\nSOCIAL HISTORY: The patient has no history of alcohol,\ndrugs, or smoking.\n\nPHYSICAL EXAMINATION: On presentation, the patient's\nphysical examination revealed the following: Temperature\n100.3, heart rate 109, blood pressure 149/74, respiratory\nrate 18, oxygen saturation 97%. She was ill-appearing on\npresentation with a diffusely tender abdomen with positive\nrebound and no guarding.", " Stool was guaiac negative.\n\nHOSPITAL COURSE: The patient was then admitted medical\nservice initially for management of her presumed C. difficile\ncolitis.\n\nThe patient was admitted to the medical service\npostoperatively and then was noted to have pleural effusion\nand then underwent a thoracocentesis of her effusion. On the\n14th, the patient continued to have poor hospital course and\non 1928-7-13 due to difficult medical management of the\ndisease, surgical consultation was obtained and the patient\nunderwent a subtotal colectomy with ileostomy.\n\nRegarding the patient's operation, please referred to\nDr. Jai Booker operative note on 1928-7-13. Postoperatively,\nthe patient was taken to the Medical Intensive Care Unit for\nfurther management of her disease. She underwent numerous\ntransfusion of fresh-frozen plasma.", ' The patient was\ncontinued to be intubated. The patient was managed in the\nMedical Intensive Care Unit with bilateral chest tubes placed\nwhile the patient was in the Medical Intensive Care Unit.\nThe patient continued to have high fevers. Sputum culture\nfrom 1921-10-30 demonstrated Methicillin-resistant\nStaphylococcus aureus and transthoracic cardiac\nechocardiogram demonstrated no pericardial effusion or no\nobvious vegetations, while the patient continued to have\nthese fevers. The patient was continued on Vancomycin and\ncontinued to be intubated for a long period of time until\n1965-5-19 when the patient was extubated successfully.\n\nPost extubation, the patient had difficulty with her voice\nand swallowing, and she was deemed an aspiration risk, so\nDobbhoff was placed. She was then transferred to the floor\nand she continued to do well.', ' Chest tubes were removed, and\nshe stopped having fevers. Physical therapy consultation was\nobtained and the patient began to improved dramatically while\non the floor. She remained afebrile with stable vital signs\nwith reasonable respiratory parameters, and she was continued\non tube feeds or Promote with fiber at a goal rate of 70 cc\nper hour.\n\nThe patient will be discharged to a rehabilitation facility\non the following regimen:\n1. Lopressor 50 mg PO t.i.d.\n2. Ambien 10 mg PO q.h.s.\n3. Vancomycin 1 gram q.d.\n4. Heparin 5000 units subcutaneously b.i.d.\n5. Regular insulin sliding scale.\n6. Protonix 40 mg IV q.d.\n7. The patient will continue on her tube feeds, Promote with\nfiber at 70 cc an hour.\n\nFOLLOW-UP CARE: The patient will followup with Dr. Prieto in\none to two weeks. The patient will followup with her primary\ncare physician at the time deemed appropriate by their\noffice.', '\n\nOF NOTE: Portions of this chart were not available during\nthis dictation.\n\n\n\n\n Shannan Camargo, M.D. 19097315\n\nDictated By:Ivory Tamaro\nMEDQUIST36\n\nD: 2003-11-26 13:37\nT: 2003-11-26 13:57\nJOB#: Waters Ltd-1957-614644\n']
168	24711	155303.0	2174-08-17	Discharge summary	Report	Admission Date: [2174-8-8] Discharge Date: [2174-8-17] Service: [Location (un) 259] MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman, a resident of [Hospital3 ] Facility, with end-stage dementia, diabetes mellitus, and multiple other medical problems, who presented to [Hospital6 649] with a history of lethargy, cough, fever, and shortness of breath. According to the [Hospital 228] [Hospital3 ] chart, the patient had several recurrent temperatures to 101?????? and 102?????? over the two weeks prior to admission which were attributed to her stage 3 sacral decubitus ulcers; the patient had been treated with Levofloxacin and Flagyl for some time. On the day prior to admission, the patient's Flagyl was changed to Clindamycin. Over the few days prior to admission, the patient exhibited increased lethargy, as well as increased shortness of breath. The patient was transferred to [Hospital6 256] for further management. PAST MEDICAL HISTORY: 1. Dementia. 2. Arthritis. 3. Hypertension. 4. Coronary artery disease; status post myocardial infarction times two; recent echocardiogram revealed an ejection fraction of 55%. 5. Glaucoma. 6. History of Clostridium difficile colitis. 7. Paroxysmal atrial fibrillation. 8. Bilateral pleural effusions. 9. Anemia of chronic disease. 10. Diabetes mellitus type 2. 11. Chronic sacral decubiti. 12. Recurrent urinary tract infections. 13. Recurrent aspiration pneumonia. 14. Question of chronic obstructive pulmonary disease. ALLERGIES: CEFTRIAXONE WHICH CAUSES A RASH. MEDICATIONS ON ADMISSION: Clindamycin 150 mg q.i.d., Motrin 400 mg p.o. q.8 hours, Apap 650 mg p.r. q.4 hours, Multivitamin q.d., Nizatidine 150 mg q.d., Risperidone 0.5 mg b.i.d., Zinc Sulfate 220 mcg q.d., Humulin NPH Insulin 3 U subcue q.12 hours, Ultracal tube feeds 65 cc/hr continuous, Amiodarone 400 mg b.i.d., Ascorbic Acid 500 mg q.d., Aspirin 325 mg q.d., Lasix 20 mg p.o. q.d., Hyoscyamine Sulfate 0.125 mg sublingual b.i.d., Levofloxacin 250 mg q.d., Bisacodyl suppository 10 mg per rectum q.d., Ibuprofen 400 mg q.8 hours for knee pain, Lorazepam 0.5 mg q.6 hours p.r.n. for agitation, Magnesium Hydroxide suspension 30 ml p.r.n., Morphine Sulfate 2 mg sublingual q.4 hours p.r.n. PHYSICAL EXAMINATION: Vital signs: On presentation temperature was 104??????, heart rate 71, blood pressure 100/60, respirations 44/min, oxygen saturation 80% on room air and subsequently 100% after intubation on the ventilator. General: The patient was an ill-appearing, elderly woman. HEENT: Mucous membranes slightly dry. Pupils equal and reactive to light. Neck: No lymphadenopathy. No jugular venous distention. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2, though distant heart sounds. Pulmonary: Diffuse rhonchi breath sounds bilaterally. Abdomen: Soft, nontender, nondistended. Positive normoactive bowel sounds. PEG tube in place. Extremities: No edema. Wasted extremities. Vascular: Good capillary refill. Dermatology: Large stage 3-4 sacral decubitus ulcers with some granulation tissue present. LABORATORY DATA: On presentation CBC revealed a white count of 24.8, a hematocrit of 33.5, platelet count 417,000; CHEM7 revealed a sodium of 139, potassium 5.5, chloride 100, bicarb 25, BUN 45, creatinine 1.0, glucose 527; coag studies revealed PT 14.1, PTT 24, INR 1.3; urinalysis revealed large blood and nitrite positive, 22 red blood cells, 6 white blood cells, occasional bacteria; blood cultures were sent with 1 out of 2 bottles coming back positive for diphtheroids, this was presumed to be contaminant, although it would have been covered by subsequent antibiotic treatment; ABG revealed a pH of 7.53, pCO2 38, pO2 52. Electrocardiogram revealed sinus rhythm in the 80s with a normal axis, normal [Doctor Last Name 1754], normal intervals, U-wave, early transition, 0.[Street Address(2) 1755] depression in leads II, III, and AVF. Chest x-ray revealed right lower lobe and left lower lobe infiltrates. Other studies of note were a recent echocardiogram from [2174-6-30], which revealed an ejection fraction of 60%, 2+ mitral regurgitation noted, as was a small to moderately sized pericardial effusion, there were no echocardiographic signs of tamponade, there was no significant change from a prior echocardiogram of [2174-6-27]. Urine culture taken on admission later revealed growth of Proteus mirabilis. Wound culture from the patient's decubitus ulcer grew out MRSA. Sputum culture from [2174-8-8], grew out Proteus mirabilis and MRSA. Stool studies from [2174-8-8], revealed positive Clostridium difficile. Blood cultures from [2174-8-8], were negative for any growth. HOSPITAL COURSE: In the Emergency Department, the patient was noted to be in respiratory distress (please above noted arterial blood gas), and the patient was also found to be hypotensive with a systolic blood pressure running in the 60s. The patient was intubated emergently and started on Dopamine after which her systolic blood pressure rose to the 90s and 100s. The patient was admitted directly into the Medical Intensive Care Unit. The [Hospital 228] medical Intensive Care Unit course is notable for the following events: The patient was started on Vancomycin 750 mg IV q.24 hours, as well as Flagyl 500 mg per PEG tube q.8 hours on the evening [8-7] and the morning of [8-8]. [8-7] through [8-8], a left IJ was placed. The patient was weaned off pressors. The patient spiked a temperature to 103??????. [8-8] through [8-9], the patient's systolic blood pressure dipped again down into the 70s, and thus she was restarted on pressors. [8-9] through [8-10], the patient was again weaned off pressors. She was also ruled out for myocardial infarction by serial enzymes. A hematocrit drop over the previous several days from 33.5 to 27.8 to 25.9 prompted a transfusion of 2 U of packed red blood cells with an appropriately elevated hematocrit thereafter. The patient also spiked a temperature to 101??????. The patient was found to be C-diff colitis positive and was continued on Flagyl. [8-10] through [8-11], the patient was found to have MRSA from her decubitus ulcer culture. Sputum grew out Proteus mirabilis and MRSA. The patient was started on Ampicillin 2 g IV q.12 hours on [8-11]. [8-11] through [8-12], the patient had a brief episode of hypotension with systolic blood pressure running in the 80s. On [8-13], the patient was extubated. On [8-14], the patient had an oxygen saturation of 99% on shovel mask and was subsequently transferred to the Medicine floor. While on the Medicine floor, the patient's above noted antibiotics were continued. Also, a PICC line was placed on the evening of [2174-8-16]. Subsequently the patient's left IJ was pulled. During the patient's course on the Medical floor, she remained afebrile, and her white count remained in the normal range. She was noted to have some hyponatremia to 131. Otherwise, her course was stable, and she continued to do well on oxygenation by mask. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Sepsis. 2. Pneumonia. 3. Urinary tract infection. 4. Clostridium difficile colitis. 5. Dementia. 6. Hypertension. 7. Diabetes mellitus type 2. 8. Coronary artery disease. 9. Methicillin resistant Staphylococcus aureus positive decubitus ulcer. DISCHARGE MEDICATIONS: Multivitamin 1 per PEG q.d., Heparin 5000 U subcue b.i.d., Aspirin 81 mg per PEG q.d., Zinc Sulfate 220 mcg per PEG q.d., Ampicillin 2 g IV q.12 hours to finish on [2174-8-25], Vancomycin 750 mg IV q.24 hours to finish on [2174-8-20], Flagyl 500 mg per PEG q.8 hours to finish on [2174-8-20], Ascorbic acid 500 mg per PEG q.d., Amiodarone 200 mg per PEG q.d., hold for systolic blood pressure less than 90, NPH Insulin 10 U subcue q.a.m., 6 U subcue q.p.m., regular Insulin sliding scale, for fingerstick 0-60 give 1 amp D50, call physician, 61-150 give nothing, 151-180 give 2 U subcue, 181-210 give 4 U subcue, 211-240 give 6 U subcue, 241-270 give 8 U subcue, 271-300 give 10 U subcue, greater than 300 give 12 U subcue and call physician, [Name Initial (NameIs) 1756] 5 mg per PEG q.6 hours, Risperidone 0.5 mg per PEG b.i.d., Morphine 1-2 mg IV q.2 hours p.r.n., Prevacid 30 mg per PEG q.d., Neutra-Phos 1 packet per PEG q.i.d. FOLLOW-UP: The patient is to be discharged back to her residence at [Hospital3 ] and subsequently follow-up with her primary care physician within the following week. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 1757], M.D. [MD Number(1) 1758] Dictated By:[Last Name (NamePattern1) 1550] MEDQUIST36 D: [2174-8-16] 19:35 T: [2174-8-16] 19:33 JOB#: [Job Number 1759]	Admission Date: <Date>1907-11-6</Date> Discharge Date: <Date>2017-6-2</Date> Service: <Location>9425 David Falls Milesfurt, MT 44402</Location> MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman, a resident of <Hospital>Randall-Cameron Clinic</Hospital> Facility, with end-stage dementia, diabetes mellitus, and multiple other medical problems, who presented to <Hospital>Turner, Hutchinson and Coleman Clinic</Hospital> with a history of lethargy, cough, fever, and shortness of breath. According to the <Hospital>Heath and Sons Clinic</Hospital> <Hospital>Randall-Cameron Clinic</Hospital> chart, the patient had several recurrent temperatures to 101?????? and 102?????? over the two weeks prior to admission which were attributed to her stage 3 sacral decubitus ulcers; the patient had been treated with Levofloxacin and Flagyl for some time. On the day prior to admission, the patient's Flagyl was changed to Clindamycin. Over the few days prior to admission, the patient exhibited increased lethargy, as well as increased shortness of breath. The patient was transferred to <Hospital>Mcgee Group Clinic</Hospital> for further management. PAST MEDICAL HISTORY: 1. Dementia. 2. Arthritis. 3. Hypertension. 4. Coronary artery disease; status post myocardial infarction times two; recent echocardiogram revealed an ejection fraction of 55%. 5. Glaucoma. 6. History of Clostridium difficile colitis. 7. Paroxysmal atrial fibrillation. 8. Bilateral pleural effusions. 9. Anemia of chronic disease. 10. Diabetes mellitus type 2. 11. Chronic sacral decubiti. 12. Recurrent urinary tract infections. 13. Recurrent aspiration pneumonia. 14. Question of chronic obstructive pulmonary disease. ALLERGIES: CEFTRIAXONE WHICH CAUSES A RASH. MEDICATIONS ON ADMISSION: Clindamycin 150 mg q.i.d., Motrin 400 mg p.o. q.8 hours, Apap 650 mg p.r. q.4 hours, Multivitamin q.d., Nizatidine 150 mg q.d., Risperidone 0.5 mg b.i.d., Zinc Sulfate 220 mcg q.d., Humulin NPH Insulin 3 U subcue q.12 hours, Ultracal tube feeds 65 cc/hr continuous, Amiodarone 400 mg b.i.d., Ascorbic Acid 500 mg q.d., Aspirin 325 mg q.d., Lasix 20 mg p.o. q.d., Hyoscyamine Sulfate 0.125 mg sublingual b.i.d., Levofloxacin 250 mg q.d., Bisacodyl suppository 10 mg per rectum q.d., Ibuprofen 400 mg q.8 hours for knee pain, Lorazepam 0.5 mg q.6 hours p.r.n. for agitation, Magnesium Hydroxide suspension 30 ml p.r.n., Morphine Sulfate 2 mg sublingual q.4 hours p.r.n. PHYSICAL EXAMINATION: Vital signs: On presentation temperature was 104??????, heart rate 71, blood pressure 100/60, respirations 44/min, oxygen saturation 80% on room air and subsequently 100% after intubation on the ventilator. General: The patient was an ill-appearing, elderly woman. HEENT: Mucous membranes slightly dry. Pupils equal and reactive to light. Neck: No lymphadenopathy. No jugular venous distention. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2, though distant heart sounds. Pulmonary: Diffuse rhonchi breath sounds bilaterally. Abdomen: Soft, nontender, nondistended. Positive normoactive bowel sounds. PEG tube in place. Extremities: No edema. Wasted extremities. Vascular: Good capillary refill. Dermatology: Large stage 3-4 sacral decubitus ulcers with some granulation tissue present. LABORATORY DATA: On presentation CBC revealed a white count of 24.8, a hematocrit of 33.5, platelet count 417,000; CHEM7 revealed a sodium of 139, potassium 5.5, chloride 100, bicarb 25, BUN 45, creatinine 1.0, glucose 527; coag studies revealed PT 14.1, PTT 24, INR 1.3; urinalysis revealed large blood and nitrite positive, 22 red blood cells, 6 white blood cells, occasional bacteria; blood cultures were sent with 1 out of 2 bottles coming back positive for diphtheroids, this was presumed to be contaminant, although it would have been covered by subsequent antibiotic treatment; ABG revealed a pH of 7.53, pCO2 38, pO2 52. Electrocardiogram revealed sinus rhythm in the 80s with a normal axis, normal <Doctor Name>Dr.Walker</Doctor Name>, normal intervals, U-wave, early transition, 0.<Location>6994 Amy Port Suite 172 East Andrewside, OH 43919</Location> depression in leads II, III, and AVF. Chest x-ray revealed right lower lobe and left lower lobe infiltrates. Other studies of note were a recent echocardiogram from <Date>1966-9-7</Date>, which revealed an ejection fraction of 60%, 2+ mitral regurgitation noted, as was a small to moderately sized pericardial effusion, there were no echocardiographic signs of tamponade, there was no significant change from a prior echocardiogram of <Date>2010-11-14</Date>. Urine culture taken on admission later revealed growth of Proteus mirabilis. Wound culture from the patient's decubitus ulcer grew out MRSA. Sputum culture from <Date>1907-11-6</Date>, grew out Proteus mirabilis and MRSA. Stool studies from <Date>1907-11-6</Date>, revealed positive Clostridium difficile. Blood cultures from <Date>1907-11-6</Date>, were negative for any growth. HOSPITAL COURSE: In the Emergency Department, the patient was noted to be in respiratory distress (please above noted arterial blood gas), and the patient was also found to be hypotensive with a systolic blood pressure running in the 60s. The patient was intubated emergently and started on Dopamine after which her systolic blood pressure rose to the 90s and 100s. The patient was admitted directly into the Medical Intensive Care Unit. The <Hospital>Heath and Sons Clinic</Hospital> medical Intensive Care Unit course is notable for the following events: The patient was started on Vancomycin 750 mg IV q.24 hours, as well as Flagyl 500 mg per PEG tube q.8 hours on the evening <Date>10-6</Date> and the morning of <Date>5-19</Date>. <Date>10-6</Date> through <Date>5-19</Date>, a left IJ was placed. The patient was weaned off pressors. The patient spiked a temperature to 103??????. <Date>5-19</Date> through <Date>4-28</Date>, the patient's systolic blood pressure dipped again down into the 70s, and thus she was restarted on pressors. <Date>4-28</Date> through <Date>12-22</Date>, the patient was again weaned off pressors. She was also ruled out for myocardial infarction by serial enzymes. A hematocrit drop over the previous several days from 33.5 to 27.8 to 25.9 prompted a transfusion of 2 U of packed red blood cells with an appropriately elevated hematocrit thereafter. The patient also spiked a temperature to 101??????. The patient was found to be C-diff colitis positive and was continued on Flagyl. <Date>12-22</Date> through <Date>3-29</Date>, the patient was found to have MRSA from her decubitus ulcer culture. Sputum grew out Proteus mirabilis and MRSA. The patient was started on Ampicillin 2 g IV q.12 hours on <Date>3-29</Date>. <Date>3-29</Date> through <Date>10-3</Date>, the patient had a brief episode of hypotension with systolic blood pressure running in the 80s. On <Date>11-9</Date>, the patient was extubated. On <Date>11-8</Date>, the patient had an oxygen saturation of 99% on shovel mask and was subsequently transferred to the Medicine floor. While on the Medicine floor, the patient's above noted antibiotics were continued. Also, a PICC line was placed on the evening of <Date>1941-11-21</Date>. Subsequently the patient's left IJ was pulled. During the patient's course on the Medical floor, she remained afebrile, and her white count remained in the normal range. She was noted to have some hyponatremia to 131. Otherwise, her course was stable, and she continued to do well on oxygenation by mask. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Sepsis. 2. Pneumonia. 3. Urinary tract infection. 4. Clostridium difficile colitis. 5. Dementia. 6. Hypertension. 7. Diabetes mellitus type 2. 8. Coronary artery disease. 9. Methicillin resistant Staphylococcus aureus positive decubitus ulcer. DISCHARGE MEDICATIONS: Multivitamin 1 per PEG q.d., Heparin 5000 U subcue b.i.d., Aspirin 81 mg per PEG q.d., Zinc Sulfate 220 mcg per PEG q.d., Ampicillin 2 g IV q.12 hours to finish on <Date>1904-1-10</Date>, Vancomycin 750 mg IV q.24 hours to finish on <Date>1994-1-14</Date>, Flagyl 500 mg per PEG q.8 hours to finish on <Date>1994-1-14</Date>, Ascorbic acid 500 mg per PEG q.d., Amiodarone 200 mg per PEG q.d., hold for systolic blood pressure less than 90, NPH Insulin 10 U subcue q.a.m., 6 U subcue q.p.m., regular Insulin sliding scale, for fingerstick 0-60 give 1 amp D50, call physician, 61-150 give nothing, 151-180 give 2 U subcue, 181-210 give 4 U subcue, 211-240 give 6 U subcue, 241-270 give 8 U subcue, 271-300 give 10 U subcue, greater than 300 give 12 U subcue and call physician, <Name>Alyssa Chau</Name> 5 mg per PEG q.6 hours, Risperidone 0.5 mg per PEG b.i.d., Morphine 1-2 mg IV q.2 hours p.r.n., Prevacid 30 mg per PEG q.d., Neutra-Phos 1 packet per PEG q.i.d. FOLLOW-UP: The patient is to be discharged back to her residence at <Hospital>Randall-Cameron Clinic</Hospital> and subsequently follow-up with her primary care physician within the following week. <Name>Athanasios</Name> <Initial>GX</Initial> <Name>Ahmed</Name>, M.D. <MD Number>84031723</MD Number> Dictated By:<Name>Tamaro</Name> MEDQUIST36 D: <Date>1941-11-21</Date> 19:35 T: <Date>1941-11-21</Date> 19:33 JOB#: <Job Number>Parker Group-1915-947305</Job 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Date: 1907-11-6 Discharge Date: 2017-6-2 Service: 9425 David Falls Milesfurt, MT 44402 MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman, a resident of Randall-Cameron Clinic Facility, with end-stage dementia, diabetes mellitus, and multiple other medical problems, who presented to Turner, Hutchinson and Coleman Clinic with a history of lethargy, cough, fever, and shortness of breath. According to the Heath and Sons Clinic Randall-Cameron Clinic chart, the patient had several recurrent temperatures to 101?????? and 102?????? over the two weeks prior to admission which were attributed to her stage 3 sacral decubitus ulcers; the patient had been treated with Levofloxacin and Flagyl for some time. On the day prior to admission, the patient's Flagyl was changed to Clindamycin. Over the few days prior to admission, the patient exhibited increased lethargy, as well as increased shortness of breath. The patient was transferred to Mcgee Group Clinic for further management. PAST MEDICAL HISTORY: 1. Dementia. 2. Arthritis. 3. Hypertension. 4. Coronary artery disease; status post myocardial infarction times two; recent echocardiogram revealed an ejection fraction of 55%. 5. Glaucoma. 6. History of Clostridium difficile colitis. 7. Paroxysmal atrial fibrillation. 8. Bilateral pleural effusions. 9. Anemia of chronic disease. 10. Diabetes mellitus type 2. 11. Chronic sacral decubiti. 12. Recurrent urinary tract infections. 13. Recurrent aspiration pneumonia. 14. Question of chronic obstructive pulmonary disease. ALLERGIES: CEFTRIAXONE WHICH CAUSES A RASH. MEDICATIONS ON ADMISSION: Clindamycin 150 mg q.i.d., Motrin 400 mg p.o. q.8 hours, Apap 650 mg p.r. q.4 hours, Multivitamin q.d., Nizatidine 150 mg q.d., Risperidone 0.5 mg b.i.d., Zinc Sulfate 220 mcg q.d., Humulin NPH Insulin 3 U subcue q.12 hours, Ultracal tube feeds 65 cc/hr continuous, Amiodarone 400 mg b.i.d., Ascorbic Acid 500 mg q.d., Aspirin 325 mg q.d., Lasix 20 mg p.o. q.d., Hyoscyamine Sulfate 0.125 mg sublingual b.i.d., Levofloxacin 250 mg q.d., Bisacodyl suppository 10 mg per rectum q.d., Ibuprofen 400 mg q.8 hours for knee pain, Lorazepam 0.5 mg q.6 hours p.r.n. for agitation, Magnesium Hydroxide suspension 30 ml p.r.n., Morphine Sulfate 2 mg sublingual q.4 hours p.r.n. PHYSICAL EXAMINATION: Vital signs: On presentation temperature was 104??????, heart rate 71, blood pressure 100/60, respirations 44/min, oxygen saturation 80% on room air and subsequently 100% after intubation on the ventilator. General: The patient was an ill-appearing, elderly woman. HEENT: Mucous membranes slightly dry. Pupils equal and reactive to light. Neck: No lymphadenopathy. No jugular venous distention. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2, though distant heart sounds. Pulmonary: Diffuse rhonchi breath sounds bilaterally. Abdomen: Soft, nontender, nondistended. Positive normoactive bowel sounds. PEG tube in place. Extremities: No edema. Wasted extremities. Vascular: Good capillary refill. Dermatology: Large stage 3-4 sacral decubitus ulcers with some granulation tissue present. LABORATORY DATA: On presentation CBC revealed a white count of 24.8, a hematocrit of 33.5, platelet count 417,000; CHEM7 revealed a sodium of 139, potassium 5.5, chloride 100, bicarb 25, BUN 45, creatinine 1.0, glucose 527; coag studies revealed PT 14.1, PTT 24, INR 1.3; urinalysis revealed large blood and nitrite positive, 22 red blood cells, 6 white blood cells, occasional bacteria; blood cultures were sent with 1 out of 2 bottles coming back positive for diphtheroids, this was presumed to be contaminant, although it would have been covered by subsequent antibiotic treatment; ABG revealed a pH of 7.53, pCO2 38, pO2 52. Electrocardiogram revealed sinus rhythm in the 80s with a normal axis, normal Dr.Walker, normal intervals, U-wave, early transition, 0.6994 Amy Port Suite 172 East Andrewside, OH 43919 depression in leads II, III, and AVF. Chest x-ray revealed right lower lobe and left lower lobe infiltrates. Other studies of note were a recent echocardiogram from 1966-9-7, which revealed an ejection fraction of 60%, 2+ mitral regurgitation noted, as was a small to moderately sized pericardial effusion, there were no echocardiographic signs of tamponade, there was no significant change from a prior echocardiogram of 2010-11-14. Urine culture taken on admission later revealed growth of Proteus mirabilis. Wound culture from the patient's decubitus ulcer grew out MRSA. Sputum culture from 1907-11-6, grew out Proteus mirabilis and MRSA. Stool studies from 1907-11-6, revealed positive Clostridium difficile. Blood cultures from 1907-11-6, were negative for any growth. HOSPITAL COURSE: In the Emergency Department, the patient was noted to be in respiratory distress (please above noted arterial blood gas), and the patient was also found to be hypotensive with a systolic blood pressure running in the 60s. The patient was intubated emergently and started on Dopamine after which her systolic blood pressure rose to the 90s and 100s. The patient was admitted directly into the Medical Intensive Care Unit. The Heath and Sons Clinic medical Intensive Care Unit course is notable for the following events: The patient was started on Vancomycin 750 mg IV q.24 hours, as well as Flagyl 500 mg per PEG tube q.8 hours on the evening 10-6 and the morning of 5-19. 10-6 through 5-19, a left IJ was placed. The patient was weaned off pressors. The patient spiked a temperature to 103??????. 5-19 through 4-28, the patient's systolic blood pressure dipped again down into the 70s, and thus she was restarted on pressors. 4-28 through 12-22, the patient was again weaned off pressors. She was also ruled out for myocardial infarction by serial enzymes. A hematocrit drop over the previous several days from 33.5 to 27.8 to 25.9 prompted a transfusion of 2 U of packed red blood cells with an appropriately elevated hematocrit thereafter. The patient also spiked a temperature to 101??????. The patient was found to be C-diff colitis positive and was continued on Flagyl. 12-22 through 3-29, the patient was found to have MRSA from her decubitus ulcer culture. Sputum grew out Proteus mirabilis and MRSA. The patient was started on Ampicillin 2 g IV q.12 hours on 3-29. 3-29 through 10-3, the patient had a brief episode of hypotension with systolic blood pressure running in the 80s. On 11-9, the patient was extubated. On 11-8, the patient had an oxygen saturation of 99% on shovel mask and was subsequently transferred to the Medicine floor. While on the Medicine floor, the patient's above noted antibiotics were continued. Also, a PICC line was placed on the evening of 1941-11-21. Subsequently the patient's left IJ was pulled. During the patient's course on the Medical floor, she remained afebrile, and her white count remained in the normal range. She was noted to have some hyponatremia to 131. Otherwise, her course was stable, and she continued to do well on oxygenation by mask. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Sepsis. 2. Pneumonia. 3. Urinary tract infection. 4. Clostridium difficile colitis. 5. Dementia. 6. Hypertension. 7. Diabetes mellitus type 2. 8. Coronary artery disease. 9. Methicillin resistant Staphylococcus aureus positive decubitus ulcer. DISCHARGE MEDICATIONS: Multivitamin 1 per PEG q.d., Heparin 5000 U subcue b.i.d., Aspirin 81 mg per PEG q.d., Zinc Sulfate 220 mcg per PEG q.d., Ampicillin 2 g IV q.12 hours to finish on 1904-1-10, Vancomycin 750 mg IV q.24 hours to finish on 1994-1-14, Flagyl 500 mg per PEG q.8 hours to finish on 1994-1-14, Ascorbic acid 500 mg per PEG q.d., Amiodarone 200 mg per PEG q.d., hold for systolic blood pressure less than 90, NPH Insulin 10 U subcue q.a.m., 6 U subcue q.p.m., regular Insulin sliding scale, for fingerstick 0-60 give 1 amp D50, call physician, 61-150 give nothing, 151-180 give 2 U subcue, 181-210 give 4 U subcue, 211-240 give 6 U subcue, 241-270 give 8 U subcue, 271-300 give 10 U subcue, greater than 300 give 12 U subcue and call physician, Alyssa Chau 5 mg per PEG q.6 hours, Risperidone 0.5 mg per PEG b.i.d., Morphine 1-2 mg IV q.2 hours p.r.n., Prevacid 30 mg per PEG q.d., Neutra-Phos 1 packet per PEG q.i.d. FOLLOW-UP: The patient is to be discharged back to her residence at Randall-Cameron Clinic and subsequently follow-up with her primary care physician within the following week. Athanasios GX Ahmed, M.D. 84031723 Dictated By:Tamaro MEDQUIST36 D: 1941-11-21 19:35 T: 1941-11-21 19:33 JOB#: Parker Group-1915-947305	["Admission Date: 1907-11-6 Discharge Date: 2017-6-2\n\n\nService: 9425 David Falls\nMilesfurt, MT 44402 MEDICINE\n\nHISTORY OF PRESENT ILLNESS: The patient is a 79-year-old\nwoman, a resident of Randall-Cameron Clinic Facility, with\nend-stage dementia, diabetes mellitus, and multiple other\nmedical problems, who presented to Turner, Hutchinson and Coleman Clinic with a history of lethargy, cough, fever, and\nshortness of breath.\n\nAccording to the Heath and Sons Clinic Randall-Cameron Clinic chart, the\npatient had several recurrent temperatures to 101?????? and 102??????\nover the two weeks prior to admission which were attributed\nto her stage 3 sacral decubitus ulcers; the patient had been\ntreated with Levofloxacin and Flagyl for some time.\n\nOn the day prior to admission, the patient's Flagyl was\nchanged to Clindamycin.", ' Over the few days prior to\nadmission, the patient exhibited increased lethargy, as well\nas increased shortness of breath. The patient was\ntransferred to Mcgee Group Clinic for\nfurther management.\n\nPAST MEDICAL HISTORY: 1. Dementia. 2. Arthritis. 3.\nHypertension. 4. Coronary artery disease; status post\nmyocardial infarction times two; recent echocardiogram\nrevealed an ejection fraction of 55%. 5. Glaucoma. 6.\nHistory of Clostridium difficile colitis. 7. Paroxysmal\natrial fibrillation. 8. Bilateral pleural effusions. 9.\nAnemia of chronic disease. 10. Diabetes mellitus type 2.\n11. Chronic sacral decubiti. 12. Recurrent urinary tract\ninfections. 13. Recurrent aspiration pneumonia. 14.\nQuestion of chronic obstructive pulmonary disease.\n\nALLERGIES: CEFTRIAXONE WHICH CAUSES A RASH.', '\n\nMEDICATIONS ON ADMISSION: Clindamycin 150 mg q.i.d., Motrin\n400 mg p.o. q.8 hours, Apap 650 mg p.r. q.4 hours,\nMultivitamin q.d., Nizatidine 150 mg q.d., Risperidone 0.5 mg\nb.i.d., Zinc Sulfate 220 mcg q.d., Humulin NPH Insulin 3 U\nsubcue q.12 hours, Ultracal tube feeds 65 cc/hr continuous,\nAmiodarone 400 mg b.i.d., Ascorbic Acid 500 mg q.d., Aspirin\n325 mg q.d., Lasix 20 mg p.o. q.d., Hyoscyamine Sulfate 0.125\nmg sublingual b.i.d., Levofloxacin 250 mg q.d., Bisacodyl\nsuppository 10 mg per rectum q.d., Ibuprofen 400 mg q.8 hours\nfor knee pain, Lorazepam 0.5 mg q.6 hours p.r.n. for\nagitation, Magnesium Hydroxide suspension 30 ml p.r.n.,\nMorphine Sulfate 2 mg sublingual q.4 hours p.r.n.\nPHYSICAL EXAMINATION: Vital signs: On presentation\ntemperature was 104??????, heart rate 71, blood pressure 100/60,\nrespirations 44/min, oxygen saturation 80% on room air and\nsubsequently 100% after intubation on the ventilator.', '\nGeneral: The patient was an ill-appearing, elderly woman.\nHEENT: Mucous membranes slightly dry. Pupils equal and\nreactive to light. Neck: No lymphadenopathy. No jugular\nvenous distention. Cardiovascular: Regular, rate and\nrhythm. Normal S1 and S2, though distant heart sounds.\nPulmonary: Diffuse rhonchi breath sounds bilaterally.\nAbdomen: Soft, nontender, nondistended. Positive\nnormoactive bowel sounds. PEG tube in place. Extremities:\nNo edema. Wasted extremities. Vascular: Good capillary\nrefill. Dermatology: Large stage 3-4 sacral decubitus\nulcers with some granulation tissue present.\n\nLABORATORY DATA: On presentation CBC revealed a white count\nof 24.8, a hematocrit of 33.5, platelet count 417,000; CHEM7\nrevealed a sodium of 139, potassium 5.5, chloride 100, bicarb\n25, BUN 45, creatinine 1.', '0, glucose 527; coag studies\nrevealed PT 14.1, PTT 24, INR 1.3; urinalysis revealed large\nblood and nitrite positive, 22 red blood cells, 6 white blood\ncells, occasional bacteria; blood cultures were sent with 1\nout of 2 bottles coming back positive for diphtheroids, this\nwas presumed to be contaminant, although it would have been\ncovered by subsequent antibiotic treatment; ABG revealed a pH\nof 7.53, pCO2 38, pO2 52.\n\nElectrocardiogram revealed sinus rhythm in the 80s with a\nnormal axis, normal Dr.Walker, normal intervals, U-wave, early\ntransition, 0.6994 Amy Port Suite 172\nEast Andrewside, OH 43919 depression in leads II, III, and AVF.\n\nChest x-ray revealed right lower lobe and left lower lobe\ninfiltrates.\n\nOther studies of note were a recent echocardiogram from\n1966-9-7, which revealed an ejection fraction of 60%,\n2+ mitral regurgitation noted, as was a small to moderately\nsized pericardial effusion, there were no echocardiographic\nsigns of tamponade, there was no significant change from a\nprior echocardiogram of 2010-11-14.', "\n\nUrine culture taken on admission later revealed growth of\nProteus mirabilis.\n\nWound culture from the patient's decubitus ulcer grew out\nMRSA. Sputum culture from 1907-11-6, grew out\nProteus mirabilis and MRSA.\n\nStool studies from 1907-11-6, revealed positive\nClostridium difficile.\n\n\nBlood cultures from 1907-11-6, were negative for any\ngrowth.\n\nHOSPITAL COURSE: In the Emergency Department, the patient\nwas noted to be in respiratory distress (please above noted\narterial blood gas), and the patient was also found to be\nhypotensive with a systolic blood pressure running in the\n60s. The patient was intubated emergently and started on\nDopamine after which her systolic blood pressure rose to the\n90s and 100s. The patient was admitted directly into the\nMedical Intensive Care Unit.\n\nThe Heath and Sons Clinic medical Intensive Care Unit course is notable\nfor the following events:\n\nThe patient was started on Vancomycin 750 mg IV q.", "24 hours,\nas well as Flagyl 500 mg per PEG tube q.8 hours on the\nevening 10-6 and the morning of 5-19.\n\n10-6 through 5-19, a left IJ was placed. The\npatient was weaned off pressors. The patient spiked a\ntemperature to 103??????.\n\n5-19 through 4-28, the patient's systolic\nblood pressure dipped again down into the 70s, and thus she\nwas restarted on pressors.\n\n4-28 through 12-22, the patient was again\nweaned off pressors. She was also ruled out for myocardial\ninfarction by serial enzymes. A hematocrit drop over the\nprevious several days from 33.5 to 27.8 to 25.9 prompted a\ntransfusion of 2 U of packed red blood cells with an\nappropriately elevated hematocrit thereafter. The patient\nalso spiked a temperature to 101??????. The patient was found to\nbe C-diff colitis positive and was continued on Flagyl.", "\n\n12-22 through 3-29, the patient was found to\nhave MRSA from her decubitus ulcer culture. Sputum grew out\nProteus mirabilis and MRSA. The patient was started on\nAmpicillin 2 g IV q.12 hours on 3-29.\n\n3-29 through 10-3, the patient had a brief\nepisode of hypotension with systolic blood pressure running\nin the 80s.\n\nOn 11-9, the patient was extubated.\n\nOn 11-8, the patient had an oxygen saturation of 99%\non shovel mask and was subsequently transferred to the\nMedicine floor.\n\nWhile on the Medicine floor, the patient's above noted\nantibiotics were continued. Also, a PICC line was placed on\nthe evening of 1941-11-21. Subsequently the\npatient's left IJ was pulled. During the patient's course on\nthe Medical floor, she remained afebrile, and her white count\nremained in the normal range. She was noted to have some\nhyponatremia to 131.", ' Otherwise, her course was stable, and\nshe continued to do well on oxygenation by mask.\n\nCONDITION ON DISCHARGE: Stable.\n\nDISCHARGE DIAGNOSIS:\n1. Sepsis.\n2. Pneumonia.\n3. Urinary tract infection.\n4. Clostridium difficile colitis.\n5. Dementia.\n6. Hypertension.\n7. Diabetes mellitus type 2.\n8. Coronary artery disease.\n9. Methicillin resistant Staphylococcus aureus positive\ndecubitus ulcer.\n\nDISCHARGE MEDICATIONS: Multivitamin 1 per PEG q.d., Heparin\n5000 U subcue b.i.d., Aspirin 81 mg per PEG q.d., Zinc\nSulfate 220 mcg per PEG q.d., Ampicillin 2 g IV q.12 hours to\nfinish on 1904-1-10, Vancomycin 750 mg IV q.24 hours to\nfinish on 1994-1-14, Flagyl 500 mg per PEG q.8 hours\nto finish on 1994-1-14, Ascorbic acid 500 mg per PEG\nq.d., Amiodarone 200 mg per PEG q.d., hold for systolic blood\npressure less than 90, NPH Insulin 10 U subcue q.', 'a.m., 6 U\nsubcue q.p.m., regular Insulin sliding scale, for fingerstick\n0-60 give 1 amp D50, call physician, 61-150 give nothing,\n151-180 give 2 U subcue, 181-210 give 4 U subcue, 211-240\ngive 6 U subcue, 241-270 give 8 U subcue, 271-300 give 10 U\nsubcue, greater than 300 give 12 U subcue and call physician,\nAlyssa Chau 5 mg per PEG q.6 hours, Risperidone 0.5 mg per PEG\nb.i.d., Morphine 1-2 mg IV q.2 hours p.r.n., Prevacid 30 mg\nper PEG q.d., Neutra-Phos 1 packet per PEG q.i.d.\n\nFOLLOW-UP: The patient is to be discharged back to her\nresidence at Randall-Cameron Clinic and subsequently follow-up\nwith her primary care physician within the following week.\n\n\n\n\n\n Athanasios GX Ahmed, M.D. 84031723\n\nDictated By:Tamaro\nMEDQUIST36\n\nD: 1941-11-21 19:35\nT: 1941-11-21 19:33\nJOB#: Parker Group-1915-947305\n']
169	24711	143442.0	2175-05-23	Discharge summary	Report	Admission Date: [2175-5-3] Discharge Date: [2175-5-23] Service: MEDICAL ICU HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 1764] is an 80 year-old female with a past medical history significant for dementia presents as a transfer from HCRA with fevers and hypotension. Per available information the patient was in her usual state of health until 9:30 in the morning of [2175-5-3] when she spiked a temperature to 104. She was seen by [Name6 (MD) 1765] cover MD and found to be bradycardic. A few hours later the patient was found to be hypotensive with a systolic blood pressure in the 50s. She was unresponsive. She was bolused 500 cc of normal saline without a change in blood pressure and was transferred to the [Hospital1 69] Emergency Department at that point. Initial vital signs in the Emergency Room were temperature 100.8. Blood pressure 54/27 with a pulse of 88. Respirations 28 with an O2 saturation of 91% on room air increasing to 99% on 10 liters. She received 4 liters of intravenous fluids, antibiotics were started Ampicillin, Gentamycin and Flagyl and a left subclavian triple lumen catheter was placed. Physical examination was noncontributory initially. Initial laboratories were notable for a white blood cell count of 10.9 with a bandemia. Urinalysis was very concentrated and multiple white blood cells. Despite intravenous fluids systolic blood pressure remained low and she was started on a dopamine drip titrated to 15 mcs per minute and systolic blood pressure was maintained in the low 100s. At that point the patient was transferred to the MICU for further evaluation. PAST MEDICAL HISTORY: 1. Dementia. 2. Hypertension. 3. Glaucoma. 4. Coronary artery disease. 5. Ischemic cardiomyopathy with EF of 40%. 6. PEG tube. 7. Paroxysmal atrial fibrillation on Amiodarone. 8. Type 2 diabetes. MEDICATIONS ON TRANSFER: Sorbitol 30 mg po q day, Amiodarone 200 mg po q day, vitamin C 500 units po q day, aspirin 81 mg po q day, multivitamin q day, Axid 150 mg po q day, Risperdal 10 mg po b.i.d. and zinc 220 mg po q day. PHYSICAL EXAMINATION: Afebrile 97.9. Heart rate 99. Blood pressure 84/43. O2 sat 99% on nonrebreather. Generally, was unresponsive to oral stimuli or to sternal rub. Of note,the patient is Russian speaking only. HEENT pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. Neck was supple without lymphadenopathy. Neck veins were flat. Chest was clear to auscultation bilaterally. Heart was tachycardic with distant heart sounds, 2/6 systolic murmur at the left lower sternal border. Abdomen soft, nontender, nondistended. Normoactive bowel sounds. Extremities mild pedal edema. LABORATORY: White blood cell count 10.9, hematocrit 34.4, platelet count of 214, INR 2.0, sodium 147, creatinine 2.0, anion gap of 14. Her differential showed 62 polys and 20 bands. Urinalysis was cloudy, specific gravity of 1.015, pH of 8.5, large blood, positive nitrite, greater then 300 protein, large leukocyte esterase, greater then 50 white blood cells and red blood cells with many bacteria. Chest x-ray showed diffuse left sided infiltrates. Electrocardiogram was sinus at 100 with normal axis and intervals, ___________________ voltage with nonspecific T diffuse T wave inversions and 1 to [Street Address(2) 1766] depressions, T wave inversions in V2 to V5. Blood and urine cultures were sent at that point. HOSPITAL COURSE: The patient was presumed to have urosepsis initially managed on Dopamine and Levophed drips. She had intermittent runs of rapid atrial fibrillation on Amiodarone requiring at one point Diltiazem drip. She was successfully weaned from her Dopamine and Levophed drips on hospital day four. She was presumed to have aspiration pneumonitis versus pneumonia and acute lung injury. During intubation and was initially managed with Levofloxacin, Vancomycin and Ceftazidime. Her antibiotics regimen were switched around several times when she would intermittently spike temperatures with no obvious source. She was extremely slow to wean from the vent despite the aggressive pulmonary toilet, chest physical therapy and broad spectrum antibiotics. Of note, the patient's urine initially grew Providencia stuartii E and proteus mirabilis and she grew proteus mirabilis as well in her blood. On [2175-5-3] also had coag negative staph in her blood, which was the rational for the Ceptaz and Vancomycin and Levofloxacin initially. Subsequent blood cultures were negative on [5-5] and [5-6]. She completed a course for her urinary tract infection. Ceftazidime was subsequently stopped. However, she was febrile on [5-10]. Sputum showed Pseudomonas aeruginosa again. The patient was subsequently restarted on Ceftazidime, which was later switched to Piperacillin and Tazobactam. At the time of discharge the patient had completed nineteen days of Levofloxacin and was on day eight of her third round of her Vancomycin and Zosyn. Her central lines were changed on multiple occasions. She had a PICC line placed on [5-19]. Given her slow wean off of pressors and intermittent hypotensive episodes the patient had [Last Name (un) 104] stem test on [5-20], which was performed according to regular protocol and it showed an inappropriate Cortisol response to ACTH infusion. Her baseline Cortisol was 18 and a one hour Cortisol level was measured at 18. She was therefore started on Prednisone 5 mg po q day as replacement therapy. She may at some point require mineral corticoid supplementation. However, elected not to add Florinef at this time. The patient was very slow to wean from the vent given her continued diffuse pulmonary infiltrates and adult respiratory distress syndrome type picture. She was trached on [5-18] without complications. She was maintained on assist control ventilation, however, her PEEP was successfully weaned from 15 to 5 and her FIO2 was weaned from 0.6 to 0.4. The patient tolerated that with O2 saturations in the high 90s. The patient did continue to spike low grade temperatures. Her line sites looked clean and had a PICC line placed on [5-19]. She did have twelve hours of increased stool output while on broad spectrum antibiotics, therefore C-diff was sent. The first C-diff was pending at the time of discharge. Her active issues upon discharge include: 1. Pulmonary, the patient continues to have diffuse bilateral infiltrates presumed noncardiogenic pulmonary edema and resolving acute lung injury/pneumonia. She will be discharged on Vancomycin day eight of fourteen, Piperacillin and Tazobactam day eight of fourteen and Levofloxacin day nineteen. She will require aggressive pulmonary toilet and is currently being suctioned more overnight, but generally every two to three hours. She currently is on assist control 450 by 20 breathing at 26 with a PEEP of 5 and an FIO2 of 0.4 maintaining O2 sats in the high 90s. She continues to auto diurese and generally is more awake and interactive. She will most likely be a very slow wean and may not be possible to decannulate her trach 2. Infectious disease: The patient continues to hve intermittent low grade temperature spikes with no obvious source. Her cultures remain negative at this point. She should receive two more C-diff toxins upon reaching the rehab facility and po Flagyl should be added to her nasogastric tube should she come back positive. At this point her stool output has decreased and she has been afebrile for greater then 24 hours at the time of discharge. She should complete a fourteen day course of Vancomycin and Piperacillin and Tazobactam. Dosages are listed at the end of this dictation. I would continue the Levofloxacin for the remaining six days and stop all antibiotics at that point. Should she spike she should be recultured for sources, although I feel that her intermittent temperature spike was likely related to her pulmonary disease. 3. Cardiovascular/atrial fibrillation: The patient has intermittent atrial fibrillation currently in normal sinus rhythm. She responds very well to Diltiazem should she have recurrent atrial fibrillation. There is no plan to anticoagulate the patient at this time despite her risk of stroke given her multiple comorbidities. 4. FEN: Our goal ins and outs at this point are even to slightly negative. The patient continues to auto diurese and generally line status is euvolemic to slightly positive. Continue to follow her electrolytes and replete. She is currently on tube feeds and at goal with minimal residuals. She has a PICC line, which was placed on [5-19], which is functioning well and the site looks clean. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Acquired Immunodeficiency Syndrome. 3. Urinary tract infection. 4. Atrial fibrillation with rapid ventricular response. 5. Dementia. 6. Respiratory failure requiring tracheostomy placement. DISPOSITION: [Hospital3 1767]. DISCHARGE MEDICATIONS: Vancomycin 750 mg intravenous q 18 hours day eight of fourteen, stop on [2175-5-29], Piperacillin Tazobactam of 2.25 grams intravenous q 6 hours day eight of fourteen stop [2175-5-29]. Levofloxacin 500 mg po q day eighteen of twenty four stop [2175-5-29]. Reglan 10 mg intravenous q.i.d., Prevacid 50 mg po q day, Amiodarone 200 mg po q day, aspirin 325 mg po q day, ProMod with fiber tube feeds 55 cc per hour, check residuals q 4 hours. Regular insulin sliding scale, specific listed on page one. Neutrophos one tab po b.i.d. times one day stop [2175-5-24]. SubQ heparin 5000 units subQ b.i.d., Prednisone 5 mg po q day, Ativan 0.5 mg per G tube q 4 to 6 hours prn. Morphine sulfate 1 to 2 mg intravenous q 2 to 3 hours prn. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ], M.D. [MD Number(1) 292] Dictated By:[Last Name (NamePattern1) 1768] MEDQUIST36 D: [2175-5-23] 08:40 T: [2175-5-23] 08:54 JOB#: [Job Number 1769]	Admission Date: <Date>1947-8-19</Date> Discharge Date: <Date>1914-1-2</Date> Service: MEDICAL ICU HISTORY OF PRESENT ILLNESS: Ms. <Name>Broadnax</Name> is an 80 year-old female with a past medical history significant for dementia presents as a transfer from HCRA with fevers and hypotension. Per available information the patient was in her usual state of health until 9:30 in the morning of <Date>1947-8-19</Date> when she spiked a temperature to 104. She was seen by <Name>Shawn Martin</Name> cover MD and found to be bradycardic. A few hours later the patient was found to be hypotensive with a systolic blood pressure in the 50s. She was unresponsive. She was bolused 500 cc of normal saline without a change in blood pressure and was transferred to the <Hospital>Hernandez-Rojas Hospital</Hospital> Emergency Department at that point. Initial vital signs in the Emergency Room were temperature 100.8. Blood pressure 54/27 with a pulse of 88. Respirations 28 with an O2 saturation of 91% on room air increasing to 99% on 10 liters. She received 4 liters of intravenous fluids, antibiotics were started Ampicillin, Gentamycin and Flagyl and a left subclavian triple lumen catheter was placed. Physical examination was noncontributory initially. Initial laboratories were notable for a white blood cell count of 10.9 with a bandemia. Urinalysis was very concentrated and multiple white blood cells. Despite intravenous fluids systolic blood pressure remained low and she was started on a dopamine drip titrated to 15 mcs per minute and systolic blood pressure was maintained in the low 100s. At that point the patient was transferred to the MICU for further evaluation. PAST MEDICAL HISTORY: 1. Dementia. 2. Hypertension. 3. Glaucoma. 4. Coronary artery disease. 5. Ischemic cardiomyopathy with EF of 40%. 6. PEG tube. 7. Paroxysmal atrial fibrillation on Amiodarone. 8. Type 2 diabetes. MEDICATIONS ON TRANSFER: Sorbitol 30 mg po q day, Amiodarone 200 mg po q day, vitamin C 500 units po q day, aspirin 81 mg po q day, multivitamin q day, Axid 150 mg po q day, Risperdal 10 mg po b.i.d. and zinc 220 mg po q day. PHYSICAL EXAMINATION: Afebrile 97.9. Heart rate 99. Blood pressure 84/43. O2 sat 99% on nonrebreather. Generally, was unresponsive to oral stimuli or to sternal rub. Of note,the patient is Russian speaking only. HEENT pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. Neck was supple without lymphadenopathy. Neck veins were flat. Chest was clear to auscultation bilaterally. Heart was tachycardic with distant heart sounds, 2/6 systolic murmur at the left lower sternal border. Abdomen soft, nontender, nondistended. Normoactive bowel sounds. Extremities mild pedal edema. LABORATORY: White blood cell count 10.9, hematocrit 34.4, platelet count of 214, INR 2.0, sodium 147, creatinine 2.0, anion gap of 14. Her differential showed 62 polys and 20 bands. Urinalysis was cloudy, specific gravity of 1.015, pH of 8.5, large blood, positive nitrite, greater then 300 protein, large leukocyte esterase, greater then 50 white blood cells and red blood cells with many bacteria. Chest x-ray showed diffuse left sided infiltrates. Electrocardiogram was sinus at 100 with normal axis and intervals, ___________________ voltage with nonspecific T diffuse T wave inversions and 1 to <Location>186 David Causeway Apt. 045 Sarahstad, GA 47371</Location> depressions, T wave inversions in V2 to V5. Blood and urine cultures were sent at that point. HOSPITAL COURSE: The patient was presumed to have urosepsis initially managed on Dopamine and Levophed drips. She had intermittent runs of rapid atrial fibrillation on Amiodarone requiring at one point Diltiazem drip. She was successfully weaned from her Dopamine and Levophed drips on hospital day four. She was presumed to have aspiration pneumonitis versus pneumonia and acute lung injury. During intubation and was initially managed with Levofloxacin, Vancomycin and Ceftazidime. Her antibiotics regimen were switched around several times when she would intermittently spike temperatures with no obvious source. She was extremely slow to wean from the vent despite the aggressive pulmonary toilet, chest physical therapy and broad spectrum antibiotics. Of note, the patient's urine initially grew Providencia stuartii E and proteus mirabilis and she grew proteus mirabilis as well in her blood. On <Date>1947-8-19</Date> also had coag negative staph in her blood, which was the rational for the Ceptaz and Vancomycin and Levofloxacin initially. Subsequent blood cultures were negative on <Date>4-14</Date> and <Date>2-20</Date>. She completed a course for her urinary tract infection. Ceftazidime was subsequently stopped. However, she was febrile on <Date>12-7</Date>. Sputum showed Pseudomonas aeruginosa again. The patient was subsequently restarted on Ceftazidime, which was later switched to Piperacillin and Tazobactam. At the time of discharge the patient had completed nineteen days of Levofloxacin and was on day eight of her third round of her Vancomycin and Zosyn. Her central lines were changed on multiple occasions. She had a PICC line placed on <Date>5-13</Date>. Given her slow wean off of pressors and intermittent hypotensive episodes the patient had <Name>Islam</Name> stem test on <Date>12-16</Date>, which was performed according to regular protocol and it showed an inappropriate Cortisol response to ACTH infusion. Her baseline Cortisol was 18 and a one hour Cortisol level was measured at 18. She was therefore started on Prednisone 5 mg po q day as replacement therapy. She may at some point require mineral corticoid supplementation. However, elected not to add Florinef at this time. The patient was very slow to wean from the vent given her continued diffuse pulmonary infiltrates and adult respiratory distress syndrome type picture. She was trached on <Date>9-11</Date> without complications. She was maintained on assist control ventilation, however, her PEEP was successfully weaned from 15 to 5 and her FIO2 was weaned from 0.6 to 0.4. The patient tolerated that with O2 saturations in the high 90s. The patient did continue to spike low grade temperatures. Her line sites looked clean and had a PICC line placed on <Date>5-13</Date>. She did have twelve hours of increased stool output while on broad spectrum antibiotics, therefore C-diff was sent. The first C-diff was pending at the time of discharge. Her active issues upon discharge include: 1. Pulmonary, the patient continues to have diffuse bilateral infiltrates presumed noncardiogenic pulmonary edema and resolving acute lung injury/pneumonia. She will be discharged on Vancomycin day eight of fourteen, Piperacillin and Tazobactam day eight of fourteen and Levofloxacin day nineteen. She will require aggressive pulmonary toilet and is currently being suctioned more overnight, but generally every two to three hours. She currently is on assist control 450 by 20 breathing at 26 with a PEEP of 5 and an FIO2 of 0.4 maintaining O2 sats in the high 90s. She continues to auto diurese and generally is more awake and interactive. She will most likely be a very slow wean and may not be possible to decannulate her trach 2. Infectious disease: The patient continues to hve intermittent low grade temperature spikes with no obvious source. Her cultures remain negative at this point. She should receive two more C-diff toxins upon reaching the rehab facility and po Flagyl should be added to her nasogastric tube should she come back positive. At this point her stool output has decreased and she has been afebrile for greater then 24 hours at the time of discharge. She should complete a fourteen day course of Vancomycin and Piperacillin and Tazobactam. Dosages are listed at the end of this dictation. I would continue the Levofloxacin for the remaining six days and stop all antibiotics at that point. Should she spike she should be recultured for sources, although I feel that her intermittent temperature spike was likely related to her pulmonary disease. 3. Cardiovascular/atrial fibrillation: The patient has intermittent atrial fibrillation currently in normal sinus rhythm. She responds very well to Diltiazem should she have recurrent atrial fibrillation. There is no plan to anticoagulate the patient at this time despite her risk of stroke given her multiple comorbidities. 4. FEN: Our goal ins and outs at this point are even to slightly negative. The patient continues to auto diurese and generally line status is euvolemic to slightly positive. Continue to follow her electrolytes and replete. She is currently on tube feeds and at goal with minimal residuals. She has a PICC line, which was placed on <Date>5-13</Date>, which is functioning well and the site looks clean. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Acquired Immunodeficiency Syndrome. 3. Urinary tract infection. 4. Atrial fibrillation with rapid ventricular response. 5. Dementia. 6. Respiratory failure requiring tracheostomy placement. DISPOSITION: <Hospital>Miller-Lee Clinic</Hospital>. DISCHARGE MEDICATIONS: Vancomycin 750 mg intravenous q 18 hours day eight of fourteen, stop on <Date>2007-10-13</Date>, Piperacillin Tazobactam of 2.25 grams intravenous q 6 hours day eight of fourteen stop <Date>2007-10-13</Date>. Levofloxacin 500 mg po q day eighteen of twenty four stop <Date>2007-10-13</Date>. Reglan 10 mg intravenous q.i.d., Prevacid 50 mg po q day, Amiodarone 200 mg po q day, aspirin 325 mg po q day, ProMod with fiber tube feeds 55 cc per hour, check residuals q 4 hours. Regular insulin sliding scale, specific listed on page one. Neutrophos one tab po b.i.d. times one day stop <Date>1914-11-3</Date>. SubQ heparin 5000 units subQ b.i.d., Prednisone 5 mg po q day, Ativan 0.5 mg per G tube q 4 to 6 hours prn. Morphine sulfate 1 to 2 mg intravenous q 2 to 3 hours prn. <Name>Lisa</Name> <Name>Kibler</Name> <Name>Cleveland Bogle</Name>, M.D. <MD Number>11145110</MD Number> Dictated By:<Name>Pegram</Name> MEDQUIST36 D: <Date>1914-1-2</Date> 08:40 T: <Date>1914-1-2</Date> 08:54 JOB#: <Job Number>Gonzalez, Smith and Lewis-1901-745310</Job 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Date: 1947-8-19 Discharge Date: 1914-1-2 Service: MEDICAL ICU HISTORY OF PRESENT ILLNESS: Ms. Broadnax is an 80 year-old female with a past medical history significant for dementia presents as a transfer from HCRA with fevers and hypotension. Per available information the patient was in her usual state of health until 9:30 in the morning of 1947-8-19 when she spiked a temperature to 104. She was seen by Shawn Martin cover MD and found to be bradycardic. A few hours later the patient was found to be hypotensive with a systolic blood pressure in the 50s. She was unresponsive. She was bolused 500 cc of normal saline without a change in blood pressure and was transferred to the Hernandez-Rojas Hospital Emergency Department at that point. Initial vital signs in the Emergency Room were temperature 100.8. Blood pressure 54/27 with a pulse of 88. Respirations 28 with an O2 saturation of 91% on room air increasing to 99% on 10 liters. She received 4 liters of intravenous fluids, antibiotics were started Ampicillin, Gentamycin and Flagyl and a left subclavian triple lumen catheter was placed. Physical examination was noncontributory initially. Initial laboratories were notable for a white blood cell count of 10.9 with a bandemia. Urinalysis was very concentrated and multiple white blood cells. Despite intravenous fluids systolic blood pressure remained low and she was started on a dopamine drip titrated to 15 mcs per minute and systolic blood pressure was maintained in the low 100s. At that point the patient was transferred to the MICU for further evaluation. PAST MEDICAL HISTORY: 1. Dementia. 2. Hypertension. 3. Glaucoma. 4. Coronary artery disease. 5. Ischemic cardiomyopathy with EF of 40%. 6. PEG tube. 7. Paroxysmal atrial fibrillation on Amiodarone. 8. Type 2 diabetes. MEDICATIONS ON TRANSFER: Sorbitol 30 mg po q day, Amiodarone 200 mg po q day, vitamin C 500 units po q day, aspirin 81 mg po q day, multivitamin q day, Axid 150 mg po q day, Risperdal 10 mg po b.i.d. and zinc 220 mg po q day. PHYSICAL EXAMINATION: Afebrile 97.9. Heart rate 99. Blood pressure 84/43. O2 sat 99% on nonrebreather. Generally, was unresponsive to oral stimuli or to sternal rub. Of note,the patient is Russian speaking only. HEENT pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. Neck was supple without lymphadenopathy. Neck veins were flat. Chest was clear to auscultation bilaterally. Heart was tachycardic with distant heart sounds, 2/6 systolic murmur at the left lower sternal border. Abdomen soft, nontender, nondistended. Normoactive bowel sounds. Extremities mild pedal edema. LABORATORY: White blood cell count 10.9, hematocrit 34.4, platelet count of 214, INR 2.0, sodium 147, creatinine 2.0, anion gap of 14. Her differential showed 62 polys and 20 bands. Urinalysis was cloudy, specific gravity of 1.015, pH of 8.5, large blood, positive nitrite, greater then 300 protein, large leukocyte esterase, greater then 50 white blood cells and red blood cells with many bacteria. Chest x-ray showed diffuse left sided infiltrates. Electrocardiogram was sinus at 100 with normal axis and intervals, ___________________ voltage with nonspecific T diffuse T wave inversions and 1 to 186 David Causeway Apt. 045 Sarahstad, GA 47371 depressions, T wave inversions in V2 to V5. Blood and urine cultures were sent at that point. HOSPITAL COURSE: The patient was presumed to have urosepsis initially managed on Dopamine and Levophed drips. She had intermittent runs of rapid atrial fibrillation on Amiodarone requiring at one point Diltiazem drip. She was successfully weaned from her Dopamine and Levophed drips on hospital day four. She was presumed to have aspiration pneumonitis versus pneumonia and acute lung injury. During intubation and was initially managed with Levofloxacin, Vancomycin and Ceftazidime. Her antibiotics regimen were switched around several times when she would intermittently spike temperatures with no obvious source. She was extremely slow to wean from the vent despite the aggressive pulmonary toilet, chest physical therapy and broad spectrum antibiotics. Of note, the patient's urine initially grew Providencia stuartii E and proteus mirabilis and she grew proteus mirabilis as well in her blood. On 1947-8-19 also had coag negative staph in her blood, which was the rational for the Ceptaz and Vancomycin and Levofloxacin initially. Subsequent blood cultures were negative on 4-14 and 2-20. She completed a course for her urinary tract infection. Ceftazidime was subsequently stopped. However, she was febrile on 12-7. Sputum showed Pseudomonas aeruginosa again. The patient was subsequently restarted on Ceftazidime, which was later switched to Piperacillin and Tazobactam. At the time of discharge the patient had completed nineteen days of Levofloxacin and was on day eight of her third round of her Vancomycin and Zosyn. Her central lines were changed on multiple occasions. She had a PICC line placed on 5-13. Given her slow wean off of pressors and intermittent hypotensive episodes the patient had Islam stem test on 12-16, which was performed according to regular protocol and it showed an inappropriate Cortisol response to ACTH infusion. Her baseline Cortisol was 18 and a one hour Cortisol level was measured at 18. She was therefore started on Prednisone 5 mg po q day as replacement therapy. She may at some point require mineral corticoid supplementation. However, elected not to add Florinef at this time. The patient was very slow to wean from the vent given her continued diffuse pulmonary infiltrates and adult respiratory distress syndrome type picture. She was trached on 9-11 without complications. She was maintained on assist control ventilation, however, her PEEP was successfully weaned from 15 to 5 and her FIO2 was weaned from 0.6 to 0.4. The patient tolerated that with O2 saturations in the high 90s. The patient did continue to spike low grade temperatures. Her line sites looked clean and had a PICC line placed on 5-13. She did have twelve hours of increased stool output while on broad spectrum antibiotics, therefore C-diff was sent. The first C-diff was pending at the time of discharge. Her active issues upon discharge include: 1. Pulmonary, the patient continues to have diffuse bilateral infiltrates presumed noncardiogenic pulmonary edema and resolving acute lung injury/pneumonia. She will be discharged on Vancomycin day eight of fourteen, Piperacillin and Tazobactam day eight of fourteen and Levofloxacin day nineteen. She will require aggressive pulmonary toilet and is currently being suctioned more overnight, but generally every two to three hours. She currently is on assist control 450 by 20 breathing at 26 with a PEEP of 5 and an FIO2 of 0.4 maintaining O2 sats in the high 90s. She continues to auto diurese and generally is more awake and interactive. She will most likely be a very slow wean and may not be possible to decannulate her trach 2. Infectious disease: The patient continues to hve intermittent low grade temperature spikes with no obvious source. Her cultures remain negative at this point. She should receive two more C-diff toxins upon reaching the rehab facility and po Flagyl should be added to her nasogastric tube should she come back positive. At this point her stool output has decreased and she has been afebrile for greater then 24 hours at the time of discharge. She should complete a fourteen day course of Vancomycin and Piperacillin and Tazobactam. Dosages are listed at the end of this dictation. I would continue the Levofloxacin for the remaining six days and stop all antibiotics at that point. Should she spike she should be recultured for sources, although I feel that her intermittent temperature spike was likely related to her pulmonary disease. 3. Cardiovascular/atrial fibrillation: The patient has intermittent atrial fibrillation currently in normal sinus rhythm. She responds very well to Diltiazem should she have recurrent atrial fibrillation. There is no plan to anticoagulate the patient at this time despite her risk of stroke given her multiple comorbidities. 4. FEN: Our goal ins and outs at this point are even to slightly negative. The patient continues to auto diurese and generally line status is euvolemic to slightly positive. Continue to follow her electrolytes and replete. She is currently on tube feeds and at goal with minimal residuals. She has a PICC line, which was placed on 5-13, which is functioning well and the site looks clean. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Acquired Immunodeficiency Syndrome. 3. Urinary tract infection. 4. Atrial fibrillation with rapid ventricular response. 5. Dementia. 6. Respiratory failure requiring tracheostomy placement. DISPOSITION: Miller-Lee Clinic. DISCHARGE MEDICATIONS: Vancomycin 750 mg intravenous q 18 hours day eight of fourteen, stop on 2007-10-13, Piperacillin Tazobactam of 2.25 grams intravenous q 6 hours day eight of fourteen stop 2007-10-13. Levofloxacin 500 mg po q day eighteen of twenty four stop 2007-10-13. Reglan 10 mg intravenous q.i.d., Prevacid 50 mg po q day, Amiodarone 200 mg po q day, aspirin 325 mg po q day, ProMod with fiber tube feeds 55 cc per hour, check residuals q 4 hours. Regular insulin sliding scale, specific listed on page one. Neutrophos one tab po b.i.d. times one day stop 1914-11-3. SubQ heparin 5000 units subQ b.i.d., Prednisone 5 mg po q day, Ativan 0.5 mg per G tube q 4 to 6 hours prn. Morphine sulfate 1 to 2 mg intravenous q 2 to 3 hours prn. Lisa Kibler Cleveland Bogle, M.D. 11145110 Dictated By:Pegram MEDQUIST36 D: 1914-1-2 08:40 T: 1914-1-2 08:54 JOB#: Gonzalez, Smith and Lewis-1901-745310	['Admission Date: 1947-8-19 Discharge Date: 1914-1-2\n\n\nService: MEDICAL ICU\n\nHISTORY OF PRESENT ILLNESS: Ms. Broadnax is an 80 year-old\nfemale with a past medical history significant for dementia\npresents as a transfer from HCRA with fevers and hypotension.\nPer available information the patient was in her usual state\nof health until 9:30 in the morning of 1947-8-19 when she\nspiked a temperature to 104. She was seen by Shawn Martin cover MD\nand found to be bradycardic. A few hours later the patient\nwas found to be hypotensive with a systolic blood pressure in\nthe 50s. She was unresponsive. She was bolused 500 cc of\nnormal saline without a change in blood pressure and was\ntransferred to the Hernandez-Rojas Hospital\nEmergency Department at that point.\n\nInitial vital signs in the Emergency Room were temperature\n100.', '8. Blood pressure 54/27 with a pulse of 88.\nRespirations 28 with an O2 saturation of 91% on room air\nincreasing to 99% on 10 liters. She received 4 liters of\nintravenous fluids, antibiotics were started Ampicillin,\nGentamycin and Flagyl and a left subclavian triple lumen\ncatheter was placed. Physical examination was\nnoncontributory initially. Initial laboratories were notable\nfor a white blood cell count of 10.9 with a bandemia.\nUrinalysis was very concentrated and multiple white blood\ncells. Despite intravenous fluids systolic blood pressure\nremained low and she was started on a dopamine drip titrated\nto 15 mcs per minute and systolic blood pressure was\nmaintained in the low 100s. At that point the patient was\ntransferred to the MICU for further evaluation.\n\nPAST MEDICAL HISTORY: 1.', ' Dementia. 2. Hypertension. 3.\nGlaucoma. 4. Coronary artery disease. 5. Ischemic\ncardiomyopathy with EF of 40%. 6. PEG tube. 7. Paroxysmal\natrial fibrillation on Amiodarone. 8. Type 2 diabetes.\n\nMEDICATIONS ON TRANSFER: Sorbitol 30 mg po q day, Amiodarone\n200 mg po q day, vitamin C 500 units po q day, aspirin 81 mg\npo q day, multivitamin q day, Axid 150 mg po q day, Risperdal\n10 mg po b.i.d. and zinc 220 mg po q day.\n\nPHYSICAL EXAMINATION: Afebrile 97.9. Heart rate 99. Blood\npressure 84/43. O2 sat 99% on nonrebreather. Generally, was\nunresponsive to oral stimuli or to sternal rub. Of note,the\npatient is Russian speaking only. HEENT pupils are equal,\nround and reactive to light and accommodation. Extraocular\nmovements intact. Neck was supple without lymphadenopathy.\nNeck veins were flat.', ' Chest was clear to auscultation\nbilaterally. Heart was tachycardic with distant heart\nsounds, 2/6 systolic murmur at the left lower sternal border.\nAbdomen soft, nontender, nondistended. Normoactive bowel\nsounds. Extremities mild pedal edema.\n\nLABORATORY: White blood cell count 10.9, hematocrit 34.4,\nplatelet count of 214, INR 2.0, sodium 147, creatinine 2.0,\nanion gap of 14. Her differential showed 62 polys and 20\nbands. Urinalysis was cloudy, specific gravity of 1.015, pH\nof 8.5, large blood, positive nitrite, greater then 300\nprotein, large leukocyte esterase, greater then 50 white\nblood cells and red blood cells with many bacteria. Chest\nx-ray showed diffuse left sided infiltrates.\nElectrocardiogram was sinus at 100 with normal axis and\nintervals, ___________________ voltage with nonspecific T\ndiffuse T wave inversions and 1 to 186 David Causeway Apt.', ' 045\nSarahstad, GA 47371 depressions, T\nwave inversions in V2 to V5. Blood and urine cultures were\nsent at that point.\n\nHOSPITAL COURSE: The patient was presumed to have urosepsis\ninitially managed on Dopamine and Levophed drips. She had\nintermittent runs of rapid atrial fibrillation on Amiodarone\nrequiring at one point Diltiazem drip. She was successfully\nweaned from her Dopamine and Levophed drips on hospital day\nfour. She was presumed to have aspiration pneumonitis versus\npneumonia and acute lung injury. During intubation and was\ninitially managed with Levofloxacin, Vancomycin and\nCeftazidime. Her antibiotics regimen were switched around\nseveral times when she would intermittently spike\ntemperatures with no obvious source. She was extremely slow\nto wean from the vent despite the aggressive pulmonary\ntoilet, chest physical therapy and broad spectrum\nantibiotics.', " Of note, the patient's urine initially grew\nProvidencia stuartii E and proteus mirabilis and she grew\nproteus mirabilis as well in her blood. On 1947-8-19 also had\ncoag negative staph in her blood, which was the rational for\nthe Ceptaz and Vancomycin and Levofloxacin initially.\nSubsequent blood cultures were negative on 4-14 and 2-20.\nShe completed a course for her urinary tract infection.\nCeftazidime was subsequently stopped. However, she was\nfebrile on 12-7. Sputum showed Pseudomonas aeruginosa again.\nThe patient was subsequently restarted on Ceftazidime, which\nwas later switched to Piperacillin and Tazobactam.\n\nAt the time of discharge the patient had completed nineteen\ndays of Levofloxacin and was on day eight of her third round\nof her Vancomycin and Zosyn. Her central lines were changed\non multiple occasions.", ' She had a PICC line placed on 5-13.\nGiven her slow wean off of pressors and intermittent\nhypotensive episodes the patient had Islam stem test on 12-16,\nwhich was performed according to regular protocol and it\nshowed an inappropriate Cortisol response to ACTH infusion.\nHer baseline Cortisol was 18 and a one hour Cortisol level\nwas measured at 18. She was therefore started on Prednisone\n5 mg po q day as replacement therapy. She may at some point\nrequire mineral corticoid supplementation. However, elected\nnot to add Florinef at this time.\n\nThe patient was very slow to wean from the vent given her\ncontinued diffuse pulmonary infiltrates and adult respiratory\ndistress syndrome type picture. She was trached on 9-11\nwithout complications. She was maintained on assist control\nventilation, however, her PEEP was successfully weaned from\n15 to 5 and her FIO2 was weaned from 0.', '6 to 0.4. The patient\ntolerated that with O2 saturations in the high 90s. The\npatient did continue to spike low grade temperatures. Her\nline sites looked clean and had a PICC line placed on 5-13.\nShe did have twelve hours of increased stool output while on\nbroad spectrum antibiotics, therefore C-diff was sent. The\nfirst C-diff was pending at the time of discharge. Her\nactive issues upon discharge include:\n\n1. Pulmonary, the patient continues to have diffuse\nbilateral infiltrates presumed noncardiogenic pulmonary edema\nand resolving acute lung injury/pneumonia. She will be\ndischarged on Vancomycin day eight of fourteen, Piperacillin\nand Tazobactam day eight of fourteen and Levofloxacin day\nnineteen. She will require aggressive pulmonary toilet and\nis currently being suctioned more overnight, but generally\nevery two to three hours.', ' She currently is on assist control\n450 by 20 breathing at 26 with a PEEP of 5 and an FIO2 of 0.4\nmaintaining O2 sats in the high 90s. She continues to\nauto diurese and generally is more awake and interactive.\nShe will most likely be a very slow wean and may not be\npossible to decannulate her trach\n\n2. Infectious disease: The patient continues to hve\nintermittent low grade temperature spikes with no obvious\nsource. Her cultures remain negative at this point. She\nshould receive two more C-diff toxins upon reaching the rehab\nfacility and po Flagyl should be added to her nasogastric\ntube should she come back positive. At this point her stool\noutput has decreased and she has been afebrile for greater\nthen 24 hours at the time of discharge. She should complete\na fourteen day course of Vancomycin and Piperacillin and\nTazobactam.', ' Dosages are listed at the end of this dictation.\nI would continue the Levofloxacin for the remaining six days\nand stop all antibiotics at that point. Should she spike she\nshould be recultured for sources, although I feel that her\nintermittent temperature spike was likely related to her\npulmonary disease.\n\n3. Cardiovascular/atrial fibrillation: The patient has\nintermittent atrial fibrillation currently in normal sinus\nrhythm. She responds very well to Diltiazem should she have\nrecurrent atrial fibrillation. There is no plan to\nanticoagulate the patient at this time despite her risk of\nstroke given her multiple comorbidities.\n\n4. FEN: Our goal ins and outs at this point are even to\nslightly negative. The patient continues to auto diurese and\ngenerally line status is euvolemic to slightly positive.', '\nContinue to follow her electrolytes and replete. She is\ncurrently on tube feeds and at goal with minimal residuals.\nShe has a PICC line, which was placed on 5-13, which is\nfunctioning well and the site looks clean.\n\nDISCHARGE DIAGNOSES:\n1. Pneumonia.\n2. Acquired Immunodeficiency Syndrome.\n3. Urinary tract infection.\n4. Atrial fibrillation with rapid ventricular response.\n5. Dementia.\n6. Respiratory failure requiring tracheostomy placement.\n\nDISPOSITION: Miller-Lee Clinic.\n\nDISCHARGE MEDICATIONS: Vancomycin 750 mg intravenous q 18\nhours day eight of fourteen, stop on 2007-10-13, Piperacillin\nTazobactam of 2.25 grams intravenous q 6 hours day eight of\nfourteen stop 2007-10-13. Levofloxacin 500 mg po q day eighteen\nof twenty four stop 2007-10-13. Reglan 10 mg intravenous q.i.d.,\nPrevacid 50 mg po q day, Amiodarone 200 mg po q day, aspirin\n325 mg po q day, ProMod with fiber tube feeds 55 cc per hour,\ncheck residuals q 4 hours.', ' Regular insulin sliding scale,\nspecific listed on page one. Neutrophos one tab po b.i.d.\ntimes one day stop 1914-11-3. SubQ heparin 5000 units subQ\nb.i.d., Prednisone 5 mg po q day, Ativan 0.5 mg per G tube q\n4 to 6 hours prn. Morphine sulfate 1 to 2 mg intravenous q 2\nto 3 hours prn.\n\n\n\n\n\n\n Lisa Kibler Cleveland Bogle, M.D. 11145110\n\nDictated By:Pegram\nMEDQUIST36\n\nD: 1914-1-2 08:40\nT: 1914-1-2 08:54\nJOB#: Gonzalez, Smith and Lewis-1901-745310\n']
170	22532	167853.0	2151-08-04	Discharge summary	Report	Admission Date: [2151-7-16] Discharge Date: [2151-8-4] HISTORY OF PRESENT ILLNESS: The patient is an 86 year old African American female who on the morning of [7-16], was found on the floor of her unair-conditioned home by a relative during the heat wave. She was conscious but The family reports she had not been drinking much and had not been feeling well one day prior to admission. The family also reports a productive cough, 30 lb weight loss in the last three months, shortness of breath over the last few months, worsened by exertion and increasing edema. The patient was taken to the Emergency Department and rectal and irregular. Blood pressure was 137/76, respiratory rate 27. Cooling measures were started in the Emergency Department. She was placed on a 100% oxygen nonrebreather mask. The patient gradually became alert and oriented times two. In the Emergency Department she subsequently became hypotensive with blood pressure of 80/49, heart rate 87 and irregular. More aggressive fluid resuscitation was started. She was briefly placed on a Norepinephrine drip for hemodynamic instability which was later changed to a Levophed drip. A central line was placed. The patient's temperature gradually came down to 98.6 over several hours. Laboratory studies and blood cultures were drawn. Chest x-ray was done. Electrocardiogram, urinalysis, arterial blood gases were doneand the patient was started on broad spectrum antibiotics. PAST MEDICAL HISTORY: Cardiomyopathy- idiopathic, echocardiogram in [2141] showed an ejection fraction of 20%. Hypertension. Pulmonary hypertension. Chronic atrial fibrillation. Intermittent left bundle branch block. History of anemia and heme positive stools (previously refused colonoscopy). History of previous pulmonary embolism in [2141]. History of previous stroke in [2141]. History of previous myocardial infarction, (undocumented in [2144]). Chronic right-sided pleural effusion, first found in [2150-11-12]. History of multiple episodes of cellulitis. Claustrophobia. MEDICATIONS ON ADMISSION: Coumadin 6 mg alternating 4 mg q.d., Lasix 20 mg q.d., Lisinopril 10 mg q.d., Diltiazem 300 mg q.d., Digoxin 0.125 mg q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is an African American female who lived alone. Family checks on her often and lives nearby. FAMILY HISTORY: There is a family history of colon cancer. PHYSICAL EXAMINATION: On physical examination (as noted in Emergency Department/Medicine Intensive Care Unit notes). General, a thin malnourished African American female, disoriented. Head, eyes, ears, nose and throat, pupils are equal, round, and reactive to light, extraocular movements intact. Dry mucous membranes. Oropharynx clear. Neck supple. Jugulovenous distension noted to be 6 cm. Lungs, bibasilar crackles, denies cough. Rhonchi throughout. No wheezes. Cardiovascular, irregularly, irregular rhythm, II/VI systolic murmur. Abdominal, positive bowel sounds, soft, nontender, nondistended, no rebound or guarding. No masses. Guaiac positive, rectal examination. Extremities, no edema, severe chronic venous insufficiency/stasis dermatitis in the lower extremities, 1+ pulses bilaterally. Neurological, no photophobia. The patient waxes and wanes with her disorientation. LABORATORY DATA: Complete blood count showed white count 7.2, hematocrit 34.2, platelets 285, differential 96 neutrophils, 3 lymphocytes, 1 monocyte. Chem-7, sodium 140, potassium 4.8, chloride 100, bicarbonate 27, BUN 38, creatinine 1.4, glucose 157. PT 25.4, INR 4.5, PTT 40. Lactate 1.8, calcium 9, magnesium 1.7, prostate 3. CK was 53, alkaline phosphatase 137, total bilirubin 0.3, ALT 15, AST 18. Electrocardiogram showed atrial fibrillation at a rate of 144 with left bundle branch block. Chest x-ray showed possible interstitial edema, persistent right basilar opacity which could represent pleural thickening or effusion, possible infection process in the right lung. Infection could not be excluded. New opacities in the left lung apex which were concerning for acute infection. INTENSIVE CARE UNIT COURSE: In the Medicine Intensive Care Unit pressors were discontinued a few hours after admission secondary to improved hemodynamic instability. Repeat chest x-ray showed possible pneumonia in the lower lobes with a cavitary lesion in the left upper lobe concerning for tuberculosis. The patient was subsequently placed in negative pressure room with respiratory precautions started. The patient also had three cycles of induced sputums for acid fast bacillus, smear and culture. Antibiotics were continued. On hospital day #2 the patient began taking p.o. She remained afebrile throughout her hospital course. On hospital day #4 the patient was transferred to the Medicine Service and acid fast bacillus smear from hospital day #2 came back as moderately positive for acid fast bacilli. HOSPITAL COURSE: Infectious disease - As noted above, repeat chest x-ray showed cavitary lesions in the left apex. On hospital day #2 the patient was placed on isolation/respiratory precautions with negative pressure isolation room. Acid fast sputums times three were taken for acid fast bacilli. On hospital day #4 sputum [Doctor Last Name 1770] from hospital day #2 showed positive acid fast bacilli. Infectious Disease consult was called. On hospital day #5 ( [7-20]), the patient was started on Isoniazid, Rifampin, Pyrazinamide for pulmonary TB, Ethambutol was started on hospital day #6, Infectious Control and the Department of Public Health were notified and got in touch with the family members and hospital staff. The patient completed a seven day course of Ceftriaxone and Azithromycin for five days for question of aspiration pneumonia. All of the patient's blood cultures and sputum and urine cultures were. She was Clostridium difficile negative and RPR negative. There were three attempts, one fluoroscopy guided, at lumbar puncture to evaluate for meningeal tuberculosis but were unsuccessful due to severe degenerative joint disease of the spine. Ultimately it was decided there was a low suspicion for CNS TB given the patients improvement in mental status. Final recommendations for duration of antituberculosis regimen will be given at a later date by Infectious Disease Service. Sensitivities are pending for tuberculosis. Tuberculosis was confirmed by PCR, gene probe. The patient remained throughout the rest of the hospital day #2, throughout hospital course and isolation in negative pressure room with respiratory precautions. She will remain so until she has negative acid fast bacillus cultures by three sputums. Sputum on hospital day #15 was positive for acid fast bacilli and she thus remamined in isolation. Pulmonary - The patient's initial acute respiratory acidosis was corrected with resolution of hypoventilation secondary to carbon dioxide retention and dehydration. In the Medicine Intensive Care Unit she was followed by repeated arterial blood gases. The patient denied shortness of breath throughout. She was positive for productive cough. The patient did have an episode of somnolence when supplemental oxygen was turned up secondary to carbon dioxide retention. Somnolence resolved with supplemental oxygen being decreased. She was kept on oxygen approximately .5 to 1 liter to keep saturations between 90 and 95%. On hospital day #7 her thoracentesis was performed on a new left effusion with no complications, showed white blood cells of 50,l red blood cells 2,500, differential of 16 neutrophils, 33 lymphocytes, and 4 monocytes with 3 eosinophils. Protein was 1.7, glucose 157, LDH 73, PH 7.8. Gram stain negative. [Doctor First Name ] was negative. Smear was negative. Effusion consistent with a transudative process. On hospital day #12 thoracentesis was performed on her right pleural effusion, red blood cells 50, red blood cells of 3,200, protein 1.2, glucose 92, LDH 106, PH 7.26, gram stain negative. At the time of discharge [Doctor First Name ] was still pending, smears were negative. Cultures were at this time still pending and both pleural effusions were negative for malignant cells. Cardiovascular - As noted above, the patient was in rapid atrial fibrillation initially. By hospital day #2 and throughout course the patient remained in rate control atrial fibrillation. Digoxin, Lasix and Metoprolol were started. Lisinopril was also restarted. Diltiazem was discontinued. The patient was found to have a troponin leak. Troponin peak was noted to be 14.6, CK MB ranged between 12 and 3. CKs ranged between 124 and 129. It is thought that the high troponin and CKs were secondary to myocardial damage suffered through heat stroke. Echocardiogram on hospital day #4 showed right atrium markedly dilated, mild symmetric left ventricular hypertrophy, severe global ventricular hypokinesis, severely depressed left ventricular systolic function and pulmonary hypertension. There was a question of a marantic endocarditis versus degenerative changes on the aortic valve. There was no significant aortic valve stenosis, no aortic regurgitation. Prior to previous report of [2141-8-12], there was no significant change in regards to left ventricular function. On hospital day #2 the patient underwent repeat echocardiogram which again showed left atrium moderately dilated, right atrium markedly dilated with left ventricular wall thickness normal. The overall left ventricular systolic function at this time was considered normal, greater than 55%. There was mild to moderate mitral regurgitation, severe tricuspid regurgitation and again this could not rule out marantic endocarditis though echogenic density is noted on aortic cusps and were consistent with degenerative changes. The patient was subsequently evaluated for infective endocarditis by blood cultures times three and computerized tomography scan of the head looking for signs of emboli. Computerized tomography scan of the head results are subsequently pending at the time of this dictation. Digoxin level at discharge was 0.6. It is the recommendation of the Medicine Staff to restart Coumadin at 5 mg approximately two days after discharge at the rehabilitation hospital and then to follow INRs every day until therapeutic range is met. We have very low suspicion for infective endocarditis. Heme - Coumadin was held secondary to supertherapeutic INR. INR peaked at 7.7. Vitamin K times one was given. INR had normalized by hospital day #6. Hematocrit was stable at 29.9 to 34 until hospital day #15 when hematocrit was found to be 27.5 secondary to occult gastrointestinal bleed. The patient was transfused 1 unit which was well tolerated. Follow up hematocrit was 32.2. Hematocrit remained stable for the rest of the hospital course. Renal - Baseline creatinine is 1 to 1.4. She arrived with mild prerenal azotemia, diuretics were held. During the hospital course she required several boluses for low urine output. The patient started mobilizing fluids approximately hospital day #12. Urine outpatient remained good thereafter. Fluids, electrolytes and nutrition - Initial dehydration was treated with intravenous fluids. She tolerated p.o. throughout her placement and was placed on a thin pureed diet with supplemental Boost at breakfast, lunch and dinner. This was following swallow and nutrition evaluations for malnutrition. She was also placed on thiamine, folate and multivitamin supplements. Asymptomatic hypercalcemia was noted, because of the low setting of albumin 2.4. Free calcium was noted to be 1.4, free calcium on discharge was noted to be 1.9. During hospital stay her potassium rose to 5.5 secondary to increased dosage of ACE inhibitor, subsequently Lisinopril was decreased to 5 mg at which time her potassium normalized. Other laboratory studies were as follows, B12 7.9, folate 7.5, PTH 15, 25 hydroxy vitamin D, less than 7. Neurological - Change in mental status secondary to heat stroke/malnutrition. Throughout the hospital course the patient's mental status was alert, awake and oriented to two, sometimes to three. On discharge she is awake, alert and oriented times three. Head computerized tomography scan on hospital day #20 was performed, results are pending at the time of this dictation. Gastrointestinal - The patient has a history of heme positive stools with refusal of colonoscopy. She had intermittent guaiac positive stools while in-house. She was seen by Gastrointestinal Service for possible occult malignancy versus tuberculosis colitis. Colonoscopy was performed on hospital day #20 which showed diverticulosis and two polyps in the right colon that were subsequently removed and biopsied. Liver function tests were followed q. two weeks secondary to antituberculosis medications. Liver function tests after tuberculosis medications were started were within normal limits. ALT was 22, ALT 23, LDH 342, alkaline phosphatase 158, bilirubin 0.5. Our medical team recommended rehabilitation hospital follow liver function tests q. two weeks. Endomysal antibody was 3, this was within normal limits. Endocrine - Free cortisol was noted to be 22. The hyperclcemia was likely due to granulomatous disease (TB) and improved with treatment of the TB. Musculoskeletal - The patient complained early on of hip soreness. X-ray of the pelvis showed no fractures. The patient was followed by physical therapy. This improved over time. Prophylaxis - The with Zantac for stomach, heparin for deep vein thrombosis and fall and aspiration precautions were maintained throughout the hospital stay. CONDITION ON DISCHARGE: Stable to [Hospital3 7] for rehabilitation.. DISCHARGE INSTRUCTIONS: Maintain respiratory precautions while keeping patient in isolation/negative pressure room. The patient will continue to need physical therapy. Her diet should be regular plus Boost t.i.d. DISCHARGE MEDICATIONS: 1. Isoniazid 300 mg p.o. q.d. 2. Rifampin 600 mg p.o. q.d. 3. Pyrazinamide [2149] mg q.d. 4. Ethambutol 1600 mg p.o. q.d. 5. Pyridoxine 50 mg q.d. - Note that tuberculosis medications should be given on an empty stomach 6. Lisinopril 5 mg q.d. 7. Digoxin 0.25 mg p.o. q.d. 8. Metoprolol 25 mg b.i.d. 9. Lasix 20 mg p.o. q.d. 10. Aspirin 325 mg p.o. q.d. 11. Heparin 5000 units subcutaneously q. 12 hours 12. Ranitidine 150 mg p.o. b.i.d. 13. Nitroglycerin sublingual 0.4 mg q. 5 minutes, maximum three doses 14. Colace 100 mg p.o. b.i.d. prn constipation 15. Folic 1 mg p.o. q.d. 16. Thiamine 100 mg p.o. q.d. 17. Multivitamin p.o. q.d. 18. Tylenol #3 one to two tablets p.o. q. 6 hours prn pain 19. Tylenol 325 mg to 650 mg p.o. q. 4-6 hours prn fever/pain It is recommended that Coumadin be restarted on [8-6] at 5 mg p.o. q.d. with following INR daily, until therapeutic dose is set. The patient will also require liver function tests checked q. two weeks. She is due for her next liver function tests next week. The patient's Digoxin level should be followed q. one to two weeks. Goal digoxon level is 1.0-1.2 FOLLOW UP: 1. Follow up appointment with her primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1771] [8-25] 3 PM at [Hospital Ward Name 23] Center on [Location (un) 1772]. 2. Pulmonary Dr. [Last Name (STitle) ] on [8-19] at 9 AM in the [Hospital1 ] Building [Location (un) 1773]. 3. Infectious Disease, Dr. [Last Name (STitle) 1774] [2159-9-9] AM in the [Doctor Last Name 780] Building, [Location (un) ]. 4. Fall precautions to be maintained, the patient can not bear her weight. DISCHARGE DIAGNOSIS: 1. Pulmonary tuberculosis, reactivated 2. Bilateral pleural effusions 3. atrial fibrillation 4. Cardiomyopathy 5. Left bundle branch block 6. hypercalcemia- resolved 7. h/o CVA 8. h/o PE [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1775] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1776] Dictated By:[Last Name (NamePattern1) 1777] MEDQUIST36 D: [2151-8-4] 15:52 T: [2151-8-4] 16:10 JOB#: [Job Number 1778]	Admission Date: <Date>1936-5-9</Date> Discharge Date: <Date>2003-3-24</Date> HISTORY OF PRESENT ILLNESS: The patient is an 86 year old African American female who on the morning of <Date>11-18</Date>, was found on the floor of her unair-conditioned home by a relative during the heat wave. She was conscious but The family reports she had not been drinking much and had not been feeling well one day prior to admission. The family also reports a productive cough, 30 lb weight loss in the last three months, shortness of breath over the last few months, worsened by exertion and increasing edema. The patient was taken to the Emergency Department and rectal and irregular. Blood pressure was 137/76, respiratory rate 27. Cooling measures were started in the Emergency Department. She was placed on a 100% oxygen nonrebreather mask. The patient gradually became alert and oriented times two. In the Emergency Department she subsequently became hypotensive with blood pressure of 80/49, heart rate 87 and irregular. More aggressive fluid resuscitation was started. She was briefly placed on a Norepinephrine drip for hemodynamic instability which was later changed to a Levophed drip. A central line was placed. The patient's temperature gradually came down to 98.6 over several hours. Laboratory studies and blood cultures were drawn. Chest x-ray was done. Electrocardiogram, urinalysis, arterial blood gases were doneand the patient was started on broad spectrum antibiotics. PAST MEDICAL HISTORY: Cardiomyopathy- idiopathic, echocardiogram in <Year>1997</Year> showed an ejection fraction of 20%. Hypertension. Pulmonary hypertension. Chronic atrial fibrillation. Intermittent left bundle branch block. History of anemia and heme positive stools (previously refused colonoscopy). History of previous pulmonary embolism in <Year>1997</Year>. History of previous stroke in <Year>1997</Year>. History of previous myocardial infarction, (undocumented in <Year>1997</Year>). Chronic right-sided pleural effusion, first found in <Date>1987-1-6</Date>. History of multiple episodes of cellulitis. Claustrophobia. MEDICATIONS ON ADMISSION: Coumadin 6 mg alternating 4 mg q.d., Lasix 20 mg q.d., Lisinopril 10 mg q.d., Diltiazem 300 mg q.d., Digoxin 0.125 mg q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is an African American female who lived alone. Family checks on her often and lives nearby. FAMILY HISTORY: There is a family history of colon cancer. PHYSICAL EXAMINATION: On physical examination (as noted in Emergency Department/Medicine Intensive Care Unit notes). General, a thin malnourished African American female, disoriented. Head, eyes, ears, nose and throat, pupils are equal, round, and reactive to light, extraocular movements intact. Dry mucous membranes. Oropharynx clear. Neck supple. Jugulovenous distension noted to be 6 cm. Lungs, bibasilar crackles, denies cough. Rhonchi throughout. No wheezes. Cardiovascular, irregularly, irregular rhythm, II/VI systolic murmur. Abdominal, positive bowel sounds, soft, nontender, nondistended, no rebound or guarding. No masses. Guaiac positive, rectal examination. Extremities, no edema, severe chronic venous insufficiency/stasis dermatitis in the lower extremities, 1+ pulses bilaterally. Neurological, no photophobia. The patient waxes and wanes with her disorientation. LABORATORY DATA: Complete blood count showed white count 7.2, hematocrit 34.2, platelets 285, differential 96 neutrophils, 3 lymphocytes, 1 monocyte. Chem-7, sodium 140, potassium 4.8, chloride 100, bicarbonate 27, BUN 38, creatinine 1.4, glucose 157. PT 25.4, INR 4.5, PTT 40. Lactate 1.8, calcium 9, magnesium 1.7, prostate 3. CK was 53, alkaline phosphatase 137, total bilirubin 0.3, ALT 15, AST 18. Electrocardiogram showed atrial fibrillation at a rate of 144 with left bundle branch block. Chest x-ray showed possible interstitial edema, persistent right basilar opacity which could represent pleural thickening or effusion, possible infection process in the right lung. Infection could not be excluded. New opacities in the left lung apex which were concerning for acute infection. INTENSIVE CARE UNIT COURSE: In the Medicine Intensive Care Unit pressors were discontinued a few hours after admission secondary to improved hemodynamic instability. Repeat chest x-ray showed possible pneumonia in the lower lobes with a cavitary lesion in the left upper lobe concerning for tuberculosis. The patient was subsequently placed in negative pressure room with respiratory precautions started. The patient also had three cycles of induced sputums for acid fast bacillus, smear and culture. Antibiotics were continued. On hospital day #2 the patient began taking p.o. She remained afebrile throughout her hospital course. On hospital day #4 the patient was transferred to the Medicine Service and acid fast bacillus smear from hospital day #2 came back as moderately positive for acid fast bacilli. HOSPITAL COURSE: Infectious disease - As noted above, repeat chest x-ray showed cavitary lesions in the left apex. On hospital day #2 the patient was placed on isolation/respiratory precautions with negative pressure isolation room. Acid fast sputums times three were taken for acid fast bacilli. On hospital day #4 sputum <Doctor Name>Dr.Kwan</Doctor Name> from hospital day #2 showed positive acid fast bacilli. Infectious Disease consult was called. On hospital day #5 ( <Date>7-8</Date>), the patient was started on Isoniazid, Rifampin, Pyrazinamide for pulmonary TB, Ethambutol was started on hospital day #6, Infectious Control and the Department of Public Health were notified and got in touch with the family members and hospital staff. The patient completed a seven day course of Ceftriaxone and Azithromycin for five days for question of aspiration pneumonia. All of the patient's blood cultures and sputum and urine cultures were. She was Clostridium difficile negative and RPR negative. There were three attempts, one fluoroscopy guided, at lumbar puncture to evaluate for meningeal tuberculosis but were unsuccessful due to severe degenerative joint disease of the spine. Ultimately it was decided there was a low suspicion for CNS TB given the patients improvement in mental status. Final recommendations for duration of antituberculosis regimen will be given at a later date by Infectious Disease Service. Sensitivities are pending for tuberculosis. Tuberculosis was confirmed by PCR, gene probe. The patient remained throughout the rest of the hospital day #2, throughout hospital course and isolation in negative pressure room with respiratory precautions. She will remain so until she has negative acid fast bacillus cultures by three sputums. Sputum on hospital day #15 was positive for acid fast bacilli and she thus remamined in isolation. Pulmonary - The patient's initial acute respiratory acidosis was corrected with resolution of hypoventilation secondary to carbon dioxide retention and dehydration. In the Medicine Intensive Care Unit she was followed by repeated arterial blood gases. The patient denied shortness of breath throughout. She was positive for productive cough. The patient did have an episode of somnolence when supplemental oxygen was turned up secondary to carbon dioxide retention. Somnolence resolved with supplemental oxygen being decreased. She was kept on oxygen approximately .5 to 1 liter to keep saturations between 90 and 95%. On hospital day #7 her thoracentesis was performed on a new left effusion with no complications, showed white blood cells of 50,l red blood cells 2,500, differential of 16 neutrophils, 33 lymphocytes, and 4 monocytes with 3 eosinophils. Protein was 1.7, glucose 157, LDH 73, PH 7.8. Gram stain negative. <Name>Carl</Name> was negative. Smear was negative. Effusion consistent with a transudative process. On hospital day #12 thoracentesis was performed on her right pleural effusion, red blood cells 50, red blood cells of 3,200, protein 1.2, glucose 92, LDH 106, PH 7.26, gram stain negative. At the time of discharge <Name>Carl</Name> was still pending, smears were negative. Cultures were at this time still pending and both pleural effusions were negative for malignant cells. Cardiovascular - As noted above, the patient was in rapid atrial fibrillation initially. By hospital day #2 and throughout course the patient remained in rate control atrial fibrillation. Digoxin, Lasix and Metoprolol were started. Lisinopril was also restarted. Diltiazem was discontinued. The patient was found to have a troponin leak. Troponin peak was noted to be 14.6, CK MB ranged between 12 and 3. CKs ranged between 124 and 129. It is thought that the high troponin and CKs were secondary to myocardial damage suffered through heat stroke. Echocardiogram on hospital day #4 showed right atrium markedly dilated, mild symmetric left ventricular hypertrophy, severe global ventricular hypokinesis, severely depressed left ventricular systolic function and pulmonary hypertension. There was a question of a marantic endocarditis versus degenerative changes on the aortic valve. There was no significant aortic valve stenosis, no aortic regurgitation. Prior to previous report of <Date>1916-9-15</Date>, there was no significant change in regards to left ventricular function. On hospital day #2 the patient underwent repeat echocardiogram which again showed left atrium moderately dilated, right atrium markedly dilated with left ventricular wall thickness normal. The overall left ventricular systolic function at this time was considered normal, greater than 55%. There was mild to moderate mitral regurgitation, severe tricuspid regurgitation and again this could not rule out marantic endocarditis though echogenic density is noted on aortic cusps and were consistent with degenerative changes. The patient was subsequently evaluated for infective endocarditis by blood cultures times three and computerized tomography scan of the head looking for signs of emboli. Computerized tomography scan of the head results are subsequently pending at the time of this dictation. Digoxin level at discharge was 0.6. It is the recommendation of the Medicine Staff to restart Coumadin at 5 mg approximately two days after discharge at the rehabilitation hospital and then to follow INRs every day until therapeutic range is met. We have very low suspicion for infective endocarditis. Heme - Coumadin was held secondary to supertherapeutic INR. INR peaked at 7.7. Vitamin K times one was given. INR had normalized by hospital day #6. Hematocrit was stable at 29.9 to 34 until hospital day #15 when hematocrit was found to be 27.5 secondary to occult gastrointestinal bleed. The patient was transfused 1 unit which was well tolerated. Follow up hematocrit was 32.2. Hematocrit remained stable for the rest of the hospital course. Renal - Baseline creatinine is 1 to 1.4. She arrived with mild prerenal azotemia, diuretics were held. During the hospital course she required several boluses for low urine output. The patient started mobilizing fluids approximately hospital day #12. Urine outpatient remained good thereafter. Fluids, electrolytes and nutrition - Initial dehydration was treated with intravenous fluids. She tolerated p.o. throughout her placement and was placed on a thin pureed diet with supplemental Boost at breakfast, lunch and dinner. This was following swallow and nutrition evaluations for malnutrition. She was also placed on thiamine, folate and multivitamin supplements. Asymptomatic hypercalcemia was noted, because of the low setting of albumin 2.4. Free calcium was noted to be 1.4, free calcium on discharge was noted to be 1.9. During hospital stay her potassium rose to 5.5 secondary to increased dosage of ACE inhibitor, subsequently Lisinopril was decreased to 5 mg at which time her potassium normalized. Other laboratory studies were as follows, B12 7.9, folate 7.5, PTH 15, 25 hydroxy vitamin D, less than 7. Neurological - Change in mental status secondary to heat stroke/malnutrition. Throughout the hospital course the patient's mental status was alert, awake and oriented to two, sometimes to three. On discharge she is awake, alert and oriented times three. Head computerized tomography scan on hospital day #20 was performed, results are pending at the time of this dictation. Gastrointestinal - The patient has a history of heme positive stools with refusal of colonoscopy. She had intermittent guaiac positive stools while in-house. She was seen by Gastrointestinal Service for possible occult malignancy versus tuberculosis colitis. Colonoscopy was performed on hospital day #20 which showed diverticulosis and two polyps in the right colon that were subsequently removed and biopsied. Liver function tests were followed q. two weeks secondary to antituberculosis medications. Liver function tests after tuberculosis medications were started were within normal limits. ALT was 22, ALT 23, LDH 342, alkaline phosphatase 158, bilirubin 0.5. Our medical team recommended rehabilitation hospital follow liver function tests q. two weeks. Endomysal antibody was 3, this was within normal limits. Endocrine - Free cortisol was noted to be 22. The hyperclcemia was likely due to granulomatous disease (TB) and improved with treatment of the TB. Musculoskeletal - The patient complained early on of hip soreness. X-ray of the pelvis showed no fractures. The patient was followed by physical therapy. This improved over time. Prophylaxis - The with Zantac for stomach, heparin for deep vein thrombosis and fall and aspiration precautions were maintained throughout the hospital stay. CONDITION ON DISCHARGE: Stable to <Hospital>Ball-Hanna Clinic</Hospital> for rehabilitation.. DISCHARGE INSTRUCTIONS: Maintain respiratory precautions while keeping patient in isolation/negative pressure room. The patient will continue to need physical therapy. Her diet should be regular plus Boost t.i.d. DISCHARGE MEDICATIONS: 1. Isoniazid 300 mg p.o. q.d. 2. Rifampin 600 mg p.o. q.d. 3. Pyrazinamide <Year>1997</Year> mg q.d. 4. Ethambutol 1600 mg p.o. q.d. 5. Pyridoxine 50 mg q.d. - Note that tuberculosis medications should be given on an empty stomach 6. Lisinopril 5 mg q.d. 7. Digoxin 0.25 mg p.o. q.d. 8. Metoprolol 25 mg b.i.d. 9. Lasix 20 mg p.o. q.d. 10. Aspirin 325 mg p.o. q.d. 11. Heparin 5000 units subcutaneously q. 12 hours 12. Ranitidine 150 mg p.o. b.i.d. 13. Nitroglycerin sublingual 0.4 mg q. 5 minutes, maximum three doses 14. Colace 100 mg p.o. b.i.d. prn constipation 15. Folic 1 mg p.o. q.d. 16. Thiamine 100 mg p.o. q.d. 17. Multivitamin p.o. q.d. 18. Tylenol #3 one to two tablets p.o. q. 6 hours prn pain 19. Tylenol 325 mg to 650 mg p.o. q. 4-6 hours prn fever/pain It is recommended that Coumadin be restarted on <Date>8-22</Date> at 5 mg p.o. q.d. with following INR daily, until therapeutic dose is set. The patient will also require liver function tests checked q. two weeks. She is due for her next liver function tests next week. The patient's Digoxin level should be followed q. one to two weeks. Goal digoxon level is 1.0-1.2 FOLLOW UP: 1. Follow up appointment with her primary care physician, <Name>Bounds</Name>. <Name>Nicki</Name> <Name>Chowdhury</Name> <Date>8-30</Date> 3 PM at <Hospital>Washington, Newman and Schultz Medical Center</Hospital> Center on <Location>USCGC Garcia FPO AE 96192</Location>. 2. Pulmonary Dr. <Name>Kenner</Name> on <Date>1-3</Date> at 9 AM in the <Hospital>Anderson-Hawkins Clinic</Hospital> Building <Location>5472 April Stravenue Suite 539 East Cody, GU 74326</Location>. 3. Infectious Disease, Dr. <Name>Negrete</Name> <Date>1998-1-10</Date> AM in the <Doctor Name>Dr.Debelius</Doctor Name> Building, <Location>4358 Knox Mount West Chelseabury, AK 74303</Location>. 4. Fall precautions to be maintained, the patient can not bear her weight. DISCHARGE DIAGNOSIS: 1. Pulmonary tuberculosis, reactivated 2. Bilateral pleural effusions 3. atrial fibrillation 4. Cardiomyopathy 5. Left bundle branch block 6. hypercalcemia- resolved 7. h/o CVA 8. h/o PE <Name>Quincy</Name> <Name>Kamran</Name> <Name>Quinones</Name>, M.D. <MD Number>14195261</MD Number> Dictated By:<Name>Yuen</Name> MEDQUIST36 D: <Date>2003-3-24</Date> 15:52 T: <Date>2003-3-24</Date> 16:10 JOB#: <Job Number>Swanson-Allison-1960-048235</Job 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Date: 1936-5-9 Discharge Date: 2003-3-24 HISTORY OF PRESENT ILLNESS: The patient is an 86 year old African American female who on the morning of 11-18, was found on the floor of her unair-conditioned home by a relative during the heat wave. She was conscious but The family reports she had not been drinking much and had not been feeling well one day prior to admission. The family also reports a productive cough, 30 lb weight loss in the last three months, shortness of breath over the last few months, worsened by exertion and increasing edema. The patient was taken to the Emergency Department and rectal and irregular. Blood pressure was 137/76, respiratory rate 27. Cooling measures were started in the Emergency Department. She was placed on a 100% oxygen nonrebreather mask. The patient gradually became alert and oriented times two. In the Emergency Department she subsequently became hypotensive with blood pressure of 80/49, heart rate 87 and irregular. More aggressive fluid resuscitation was started. She was briefly placed on a Norepinephrine drip for hemodynamic instability which was later changed to a Levophed drip. A central line was placed. The patient's temperature gradually came down to 98.6 over several hours. Laboratory studies and blood cultures were drawn. Chest x-ray was done. Electrocardiogram, urinalysis, arterial blood gases were doneand the patient was started on broad spectrum antibiotics. PAST MEDICAL HISTORY: Cardiomyopathy- idiopathic, echocardiogram in 1997 showed an ejection fraction of 20%. Hypertension. Pulmonary hypertension. Chronic atrial fibrillation. Intermittent left bundle branch block. History of anemia and heme positive stools (previously refused colonoscopy). History of previous pulmonary embolism in 1997. History of previous stroke in 1997. History of previous myocardial infarction, (undocumented in 1997). Chronic right-sided pleural effusion, first found in 1987-1-6. History of multiple episodes of cellulitis. Claustrophobia. MEDICATIONS ON ADMISSION: Coumadin 6 mg alternating 4 mg q.d., Lasix 20 mg q.d., Lisinopril 10 mg q.d., Diltiazem 300 mg q.d., Digoxin 0.125 mg q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is an African American female who lived alone. Family checks on her often and lives nearby. FAMILY HISTORY: There is a family history of colon cancer. PHYSICAL EXAMINATION: On physical examination (as noted in Emergency Department/Medicine Intensive Care Unit notes). General, a thin malnourished African American female, disoriented. Head, eyes, ears, nose and throat, pupils are equal, round, and reactive to light, extraocular movements intact. Dry mucous membranes. Oropharynx clear. Neck supple. Jugulovenous distension noted to be 6 cm. Lungs, bibasilar crackles, denies cough. Rhonchi throughout. No wheezes. Cardiovascular, irregularly, irregular rhythm, II/VI systolic murmur. Abdominal, positive bowel sounds, soft, nontender, nondistended, no rebound or guarding. No masses. Guaiac positive, rectal examination. Extremities, no edema, severe chronic venous insufficiency/stasis dermatitis in the lower extremities, 1+ pulses bilaterally. Neurological, no photophobia. The patient waxes and wanes with her disorientation. LABORATORY DATA: Complete blood count showed white count 7.2, hematocrit 34.2, platelets 285, differential 96 neutrophils, 3 lymphocytes, 1 monocyte. Chem-7, sodium 140, potassium 4.8, chloride 100, bicarbonate 27, BUN 38, creatinine 1.4, glucose 157. PT 25.4, INR 4.5, PTT 40. Lactate 1.8, calcium 9, magnesium 1.7, prostate 3. CK was 53, alkaline phosphatase 137, total bilirubin 0.3, ALT 15, AST 18. Electrocardiogram showed atrial fibrillation at a rate of 144 with left bundle branch block. Chest x-ray showed possible interstitial edema, persistent right basilar opacity which could represent pleural thickening or effusion, possible infection process in the right lung. Infection could not be excluded. New opacities in the left lung apex which were concerning for acute infection. INTENSIVE CARE UNIT COURSE: In the Medicine Intensive Care Unit pressors were discontinued a few hours after admission secondary to improved hemodynamic instability. Repeat chest x-ray showed possible pneumonia in the lower lobes with a cavitary lesion in the left upper lobe concerning for tuberculosis. The patient was subsequently placed in negative pressure room with respiratory precautions started. The patient also had three cycles of induced sputums for acid fast bacillus, smear and culture. Antibiotics were continued. On hospital day #2 the patient began taking p.o. She remained afebrile throughout her hospital course. On hospital day #4 the patient was transferred to the Medicine Service and acid fast bacillus smear from hospital day #2 came back as moderately positive for acid fast bacilli. HOSPITAL COURSE: Infectious disease - As noted above, repeat chest x-ray showed cavitary lesions in the left apex. On hospital day #2 the patient was placed on isolation/respiratory precautions with negative pressure isolation room. Acid fast sputums times three were taken for acid fast bacilli. On hospital day #4 sputum Dr.Kwan from hospital day #2 showed positive acid fast bacilli. Infectious Disease consult was called. On hospital day #5 ( 7-8), the patient was started on Isoniazid, Rifampin, Pyrazinamide for pulmonary TB, Ethambutol was started on hospital day #6, Infectious Control and the Department of Public Health were notified and got in touch with the family members and hospital staff. The patient completed a seven day course of Ceftriaxone and Azithromycin for five days for question of aspiration pneumonia. All of the patient's blood cultures and sputum and urine cultures were. She was Clostridium difficile negative and RPR negative. There were three attempts, one fluoroscopy guided, at lumbar puncture to evaluate for meningeal tuberculosis but were unsuccessful due to severe degenerative joint disease of the spine. Ultimately it was decided there was a low suspicion for CNS TB given the patients improvement in mental status. Final recommendations for duration of antituberculosis regimen will be given at a later date by Infectious Disease Service. Sensitivities are pending for tuberculosis. Tuberculosis was confirmed by PCR, gene probe. The patient remained throughout the rest of the hospital day #2, throughout hospital course and isolation in negative pressure room with respiratory precautions. She will remain so until she has negative acid fast bacillus cultures by three sputums. Sputum on hospital day #15 was positive for acid fast bacilli and she thus remamined in isolation. Pulmonary - The patient's initial acute respiratory acidosis was corrected with resolution of hypoventilation secondary to carbon dioxide retention and dehydration. In the Medicine Intensive Care Unit she was followed by repeated arterial blood gases. The patient denied shortness of breath throughout. She was positive for productive cough. The patient did have an episode of somnolence when supplemental oxygen was turned up secondary to carbon dioxide retention. Somnolence resolved with supplemental oxygen being decreased. She was kept on oxygen approximately .5 to 1 liter to keep saturations between 90 and 95%. On hospital day #7 her thoracentesis was performed on a new left effusion with no complications, showed white blood cells of 50,l red blood cells 2,500, differential of 16 neutrophils, 33 lymphocytes, and 4 monocytes with 3 eosinophils. Protein was 1.7, glucose 157, LDH 73, PH 7.8. Gram stain negative. Carl was negative. Smear was negative. Effusion consistent with a transudative process. On hospital day #12 thoracentesis was performed on her right pleural effusion, red blood cells 50, red blood cells of 3,200, protein 1.2, glucose 92, LDH 106, PH 7.26, gram stain negative. At the time of discharge Carl was still pending, smears were negative. Cultures were at this time still pending and both pleural effusions were negative for malignant cells. Cardiovascular - As noted above, the patient was in rapid atrial fibrillation initially. By hospital day #2 and throughout course the patient remained in rate control atrial fibrillation. Digoxin, Lasix and Metoprolol were started. Lisinopril was also restarted. Diltiazem was discontinued. The patient was found to have a troponin leak. Troponin peak was noted to be 14.6, CK MB ranged between 12 and 3. CKs ranged between 124 and 129. It is thought that the high troponin and CKs were secondary to myocardial damage suffered through heat stroke. Echocardiogram on hospital day #4 showed right atrium markedly dilated, mild symmetric left ventricular hypertrophy, severe global ventricular hypokinesis, severely depressed left ventricular systolic function and pulmonary hypertension. There was a question of a marantic endocarditis versus degenerative changes on the aortic valve. There was no significant aortic valve stenosis, no aortic regurgitation. Prior to previous report of 1916-9-15, there was no significant change in regards to left ventricular function. On hospital day #2 the patient underwent repeat echocardiogram which again showed left atrium moderately dilated, right atrium markedly dilated with left ventricular wall thickness normal. The overall left ventricular systolic function at this time was considered normal, greater than 55%. There was mild to moderate mitral regurgitation, severe tricuspid regurgitation and again this could not rule out marantic endocarditis though echogenic density is noted on aortic cusps and were consistent with degenerative changes. The patient was subsequently evaluated for infective endocarditis by blood cultures times three and computerized tomography scan of the head looking for signs of emboli. Computerized tomography scan of the head results are subsequently pending at the time of this dictation. Digoxin level at discharge was 0.6. It is the recommendation of the Medicine Staff to restart Coumadin at 5 mg approximately two days after discharge at the rehabilitation hospital and then to follow INRs every day until therapeutic range is met. We have very low suspicion for infective endocarditis. Heme - Coumadin was held secondary to supertherapeutic INR. INR peaked at 7.7. Vitamin K times one was given. INR had normalized by hospital day #6. Hematocrit was stable at 29.9 to 34 until hospital day #15 when hematocrit was found to be 27.5 secondary to occult gastrointestinal bleed. The patient was transfused 1 unit which was well tolerated. Follow up hematocrit was 32.2. Hematocrit remained stable for the rest of the hospital course. Renal - Baseline creatinine is 1 to 1.4. She arrived with mild prerenal azotemia, diuretics were held. During the hospital course she required several boluses for low urine output. The patient started mobilizing fluids approximately hospital day #12. Urine outpatient remained good thereafter. Fluids, electrolytes and nutrition - Initial dehydration was treated with intravenous fluids. She tolerated p.o. throughout her placement and was placed on a thin pureed diet with supplemental Boost at breakfast, lunch and dinner. This was following swallow and nutrition evaluations for malnutrition. She was also placed on thiamine, folate and multivitamin supplements. Asymptomatic hypercalcemia was noted, because of the low setting of albumin 2.4. Free calcium was noted to be 1.4, free calcium on discharge was noted to be 1.9. During hospital stay her potassium rose to 5.5 secondary to increased dosage of ACE inhibitor, subsequently Lisinopril was decreased to 5 mg at which time her potassium normalized. Other laboratory studies were as follows, B12 7.9, folate 7.5, PTH 15, 25 hydroxy vitamin D, less than 7. Neurological - Change in mental status secondary to heat stroke/malnutrition. Throughout the hospital course the patient's mental status was alert, awake and oriented to two, sometimes to three. On discharge she is awake, alert and oriented times three. Head computerized tomography scan on hospital day #20 was performed, results are pending at the time of this dictation. Gastrointestinal - The patient has a history of heme positive stools with refusal of colonoscopy. She had intermittent guaiac positive stools while in-house. She was seen by Gastrointestinal Service for possible occult malignancy versus tuberculosis colitis. Colonoscopy was performed on hospital day #20 which showed diverticulosis and two polyps in the right colon that were subsequently removed and biopsied. Liver function tests were followed q. two weeks secondary to antituberculosis medications. Liver function tests after tuberculosis medications were started were within normal limits. ALT was 22, ALT 23, LDH 342, alkaline phosphatase 158, bilirubin 0.5. Our medical team recommended rehabilitation hospital follow liver function tests q. two weeks. Endomysal antibody was 3, this was within normal limits. Endocrine - Free cortisol was noted to be 22. The hyperclcemia was likely due to granulomatous disease (TB) and improved with treatment of the TB. Musculoskeletal - The patient complained early on of hip soreness. X-ray of the pelvis showed no fractures. The patient was followed by physical therapy. This improved over time. Prophylaxis - The with Zantac for stomach, heparin for deep vein thrombosis and fall and aspiration precautions were maintained throughout the hospital stay. CONDITION ON DISCHARGE: Stable to Ball-Hanna Clinic for rehabilitation.. DISCHARGE INSTRUCTIONS: Maintain respiratory precautions while keeping patient in isolation/negative pressure room. The patient will continue to need physical therapy. Her diet should be regular plus Boost t.i.d. DISCHARGE MEDICATIONS: 1. Isoniazid 300 mg p.o. q.d. 2. Rifampin 600 mg p.o. q.d. 3. Pyrazinamide 1997 mg q.d. 4. Ethambutol 1600 mg p.o. q.d. 5. Pyridoxine 50 mg q.d. - Note that tuberculosis medications should be given on an empty stomach 6. Lisinopril 5 mg q.d. 7. Digoxin 0.25 mg p.o. q.d. 8. Metoprolol 25 mg b.i.d. 9. Lasix 20 mg p.o. q.d. 10. Aspirin 325 mg p.o. q.d. 11. Heparin 5000 units subcutaneously q. 12 hours 12. Ranitidine 150 mg p.o. b.i.d. 13. Nitroglycerin sublingual 0.4 mg q. 5 minutes, maximum three doses 14. Colace 100 mg p.o. b.i.d. prn constipation 15. Folic 1 mg p.o. q.d. 16. Thiamine 100 mg p.o. q.d. 17. Multivitamin p.o. q.d. 18. Tylenol #3 one to two tablets p.o. q. 6 hours prn pain 19. Tylenol 325 mg to 650 mg p.o. q. 4-6 hours prn fever/pain It is recommended that Coumadin be restarted on 8-22 at 5 mg p.o. q.d. with following INR daily, until therapeutic dose is set. The patient will also require liver function tests checked q. two weeks. She is due for her next liver function tests next week. The patient's Digoxin level should be followed q. one to two weeks. Goal digoxon level is 1.0-1.2 FOLLOW UP: 1. Follow up appointment with her primary care physician, Bounds. Nicki Chowdhury 8-30 3 PM at Washington, Newman and Schultz Medical Center Center on USCGC Garcia FPO AE 96192. 2. Pulmonary Dr. Kenner on 1-3 at 9 AM in the Anderson-Hawkins Clinic Building 5472 April Stravenue Suite 539 East Cody, GU 74326. 3. Infectious Disease, Dr. Negrete 1998-1-10 AM in the Dr.Debelius Building, 4358 Knox Mount West Chelseabury, AK 74303. 4. Fall precautions to be maintained, the patient can not bear her weight. DISCHARGE DIAGNOSIS: 1. Pulmonary tuberculosis, reactivated 2. Bilateral pleural effusions 3. atrial fibrillation 4. Cardiomyopathy 5. Left bundle branch block 6. hypercalcemia- resolved 7. h/o CVA 8. h/o PE Quincy Kamran Quinones, M.D. 14195261 Dictated By:Yuen MEDQUIST36 D: 2003-3-24 15:52 T: 2003-3-24 16:10 JOB#: Swanson-Allison-1960-048235	['Admission Date: 1936-5-9 Discharge Date: 2003-3-24\n\n\n\nHISTORY OF PRESENT ILLNESS: The patient is an 86 year old\nAfrican American female who on the morning of 11-18, was\nfound on the floor of her unair-conditioned home by a\nrelative during the heat wave. She was conscious but\nThe family reports she had not been drinking much and had not\nbeen feeling well one day prior to admission. The family\nalso reports a productive cough, 30 lb weight loss in the\nlast three months, shortness of breath over the last few\nmonths, worsened by exertion and increasing edema.\n\nThe patient was taken to the Emergency Department and rectal\nand irregular. Blood pressure was 137/76, respiratory rate 27.\nCooling measures were started in the Emergency Department.\nShe was placed on a 100% oxygen nonrebreather mask.', " The\npatient gradually became alert and oriented times two. In\nthe Emergency Department she subsequently became hypotensive\nwith blood pressure of 80/49, heart rate 87 and irregular.\nMore aggressive fluid resuscitation was started. She was\nbriefly placed on a Norepinephrine drip for hemodynamic\ninstability which was later changed to a Levophed drip. A\ncentral line was placed. The patient's temperature gradually\ncame down to 98.6 over several hours. Laboratory studies and\nblood cultures were drawn. Chest x-ray was done.\nElectrocardiogram, urinalysis, arterial blood gases were doneand\nthe patient was started on broad spectrum antibiotics.\n\nPAST MEDICAL HISTORY: Cardiomyopathy- idiopathic, echocardiogram\nin 1997 showed an ejection fraction of 20%. Hypertension.\nPulmonary hypertension.", ' Chronic atrial fibrillation. Intermittent\nleft bundle branch block. History of anemia and heme positive\nstools (previously refused colonoscopy). History of previous\npulmonary embolism in 1997. History of previous stroke in 1997.\nHistory of previous myocardial infarction, (undocumented in\n1997). Chronic right-sided pleural effusion, first found in\n1987-1-6. History of multiple episodes of cellulitis.\nClaustrophobia.\n\nMEDICATIONS ON ADMISSION: Coumadin 6 mg alternating 4 mg\nq.d., Lasix 20 mg q.d., Lisinopril 10 mg q.d., Diltiazem 300\nmg q.d., Digoxin 0.125 mg q.d.\n\nALLERGIES: No known drug allergies.\n\nSOCIAL HISTORY: The patient is an African American female\nwho lived alone. Family checks on her often and lives\nnearby.\n\nFAMILY HISTORY: There is a family history of colon cancer.\n\nPHYSICAL EXAMINATION: On physical examination (as noted in\nEmergency Department/Medicine Intensive Care Unit notes).', '\nGeneral, a thin malnourished African American female,\ndisoriented. Head, eyes, ears, nose and throat, pupils are\nequal, round, and reactive to light, extraocular movements\nintact. Dry mucous membranes. Oropharynx clear. Neck\nsupple. Jugulovenous distension noted to be 6 cm. Lungs,\nbibasilar crackles, denies cough. Rhonchi throughout. No\nwheezes. Cardiovascular, irregularly, irregular rhythm,\nII/VI systolic murmur. Abdominal, positive bowel sounds,\nsoft, nontender, nondistended, no rebound or guarding. No\nmasses. Guaiac positive, rectal examination. Extremities,\nno edema, severe chronic venous insufficiency/stasis\ndermatitis in the lower extremities, 1+ pulses bilaterally.\nNeurological, no photophobia. The patient waxes and wanes\nwith her disorientation.\n\nLABORATORY DATA: Complete blood count showed white count\n7.', '2, hematocrit 34.2, platelets 285, differential 96\nneutrophils, 3 lymphocytes, 1 monocyte. Chem-7, sodium 140,\npotassium 4.8, chloride 100, bicarbonate 27, BUN 38,\ncreatinine 1.4, glucose 157. PT 25.4, INR 4.5, PTT 40.\nLactate 1.8, calcium 9, magnesium 1.7, prostate 3. CK was\n53, alkaline phosphatase 137, total bilirubin 0.3, ALT 15,\nAST 18. Electrocardiogram showed atrial fibrillation at a\nrate of 144 with left bundle branch block. Chest\nx-ray showed possible interstitial edema, persistent right\nbasilar opacity which could represent pleural thickening or\neffusion, possible infection process in the right lung.\nInfection could not be excluded. New opacities in the left lung\napex which were concerning for acute infection.\n\nINTENSIVE CARE UNIT COURSE: In the Medicine Intensive Care\nUnit pressors were discontinued a few hours after admission\nsecondary to improved hemodynamic instability.', ' Repeat chest\nx-ray showed possible pneumonia in the lower lobes with a\ncavitary lesion in the left upper lobe concerning for\ntuberculosis. The patient was subsequently placed in\nnegative pressure room with respiratory precautions started.\nThe patient also had three cycles of induced sputums for acid\nfast bacillus, smear and culture. Antibiotics were\ncontinued. On hospital day #2 the patient began taking p.o.\nShe remained afebrile throughout her hospital course. On\nhospital day #4 the patient was transferred to the Medicine\nService and acid fast bacillus smear from hospital day #2\ncame back as moderately positive for acid fast bacilli.\n\nHOSPITAL COURSE: Infectious disease - As noted above, repeat\nchest x-ray showed cavitary lesions in the left apex. On\nhospital day #2 the patient was placed on\nisolation/respiratory precautions with negative pressure\nisolation room.', " Acid fast sputums times three were taken for\nacid fast bacilli. On hospital day #4 sputum Dr.Kwan from\nhospital day #2 showed positive acid fast bacilli.\nInfectious Disease consult was called. On hospital day #5 (\n7-8), the patient was started on Isoniazid, Rifampin,\nPyrazinamide for pulmonary TB, Ethambutol was started on hospital\nday #6, Infectious Control and the Department of Public Health\nwere notified and got in touch with the family members and\nhospital staff. The patient completed a seven day course of\nCeftriaxone and Azithromycin for five days for question of\naspiration pneumonia. All of the patient's blood cultures\nand sputum and urine cultures were. She was Clostridium\ndifficile negative and RPR negative. There were three\nattempts, one fluoroscopy guided, at lumbar puncture to evaluate\nfor meningeal tuberculosis but were unsuccessful due to\nsevere degenerative joint disease of the spine.", " Ultimately it was\ndecided there was a low suspicion for CNS TB given the\npatients improvement in mental status. Final recommendations for\nduration of antituberculosis regimen will be given at a later\ndate by Infectious Disease Service. Sensitivities are pending for\ntuberculosis. Tuberculosis was confirmed by PCR, gene probe. The\npatient remained throughout the rest of the hospital day #2,\nthroughout hospital course and isolation in negative pressure\nroom with respiratory precautions. She will remain so until she\nhas negative acid fast bacillus cultures by three sputums.\nSputum on hospital day #15 was positive for acid fast\nbacilli and she thus remamined in isolation.\n\nPulmonary - The patient's initial acute respiratory acidosis\nwas corrected with resolution of hypoventilation secondary to\ncarbon dioxide retention and dehydration.", ' In the Medicine\nIntensive Care Unit she was followed by repeated arterial\nblood gases. The patient denied shortness of breath\nthroughout. She was positive for productive cough. The\npatient did have an episode of somnolence when supplemental\noxygen was turned up secondary to carbon dioxide retention.\nSomnolence resolved with supplemental oxygen being decreased.\nShe was kept on oxygen approximately .5 to 1 liter to keep\nsaturations between 90 and 95%. On hospital day #7 her\nthoracentesis was performed on a new left effusion with no\ncomplications, showed white blood cells of 50,l red blood\ncells 2,500, differential of 16 neutrophils, 33 lymphocytes,\nand 4 monocytes with 3 eosinophils. Protein was 1.7, glucose\n157, LDH 73, PH 7.8. Gram stain negative. Carl was negative.\nSmear was negative.', ' Effusion consistent with a transudative\nprocess. On hospital day #12 thoracentesis was performed on\nher right pleural effusion, red blood cells 50, red blood\ncells of 3,200, protein 1.2, glucose 92, LDH 106, PH 7.26,\ngram stain negative. At the time of discharge Carl was still\npending, smears were negative. Cultures were at this time\nstill pending and both pleural effusions were negative for\nmalignant cells.\n\nCardiovascular - As noted above, the patient was in rapid\natrial fibrillation initially. By hospital day #2 and\nthroughout course the patient remained in rate control atrial\nfibrillation. Digoxin, Lasix and Metoprolol were started.\nLisinopril was also restarted. Diltiazem was discontinued. The\npatient was found to have a troponin leak. Troponin peak was\nnoted to be 14.6, CK MB ranged between 12 and 3.', ' CKs ranged\nbetween 124 and 129. It is thought that the high troponin\nand CKs were secondary to myocardial damage suffered through\nheat stroke. Echocardiogram on hospital day #4 showed right\natrium markedly dilated, mild symmetric left ventricular\nhypertrophy, severe global ventricular hypokinesis, severely\ndepressed left ventricular systolic function and pulmonary\nhypertension. There was a question of a marantic endocarditis\nversus degenerative changes on the aortic valve. There was no\nsignificant aortic valve stenosis, no aortic regurgitation. Prior\nto previous report of 1916-9-15, there was no significant\nchange in regards to left ventricular function. On hospital day\n#2 the patient underwent repeat echocardiogram which again showed\nleft atrium moderately dilated, right atrium markedly dilated\nwith left ventricular wall thickness normal.', ' The overall\nleft ventricular systolic function at this time was\nconsidered normal, greater than 55%. There was mild to\nmoderate mitral regurgitation, severe tricuspid regurgitation\nand again this could not rule out marantic endocarditis\nthough echogenic density is noted on aortic cusps and were\nconsistent with degenerative changes. The patient was\nsubsequently evaluated for infective endocarditis by blood\ncultures times three and computerized tomography scan of the\nhead looking for signs of emboli. Computerized tomography\nscan of the head results are subsequently pending at the time\nof this dictation. Digoxin level at discharge was 0.6. It\nis the recommendation of the Medicine Staff to restart\nCoumadin at 5 mg approximately two days after discharge at\nthe rehabilitation hospital and then to follow INRs every day\nuntil therapeutic range is met.', ' We have very low suspicion for\ninfective endocarditis.\n\nHeme - Coumadin was held secondary to supertherapeutic INR.\nINR peaked at 7.7. Vitamin K times one was given. INR had\nnormalized by hospital day #6. Hematocrit was stable at 29.9\nto 34 until hospital day #15 when hematocrit was found to be\n27.5 secondary to occult gastrointestinal bleed. The patient\nwas transfused 1 unit which was well tolerated. Follow up\nhematocrit was 32.2. Hematocrit remained stable for the rest\nof the hospital course.\n\nRenal - Baseline creatinine is 1 to 1.4. She arrived with\nmild prerenal azotemia, diuretics were held. During the\nhospital course she required several boluses for low urine\noutput. The patient started mobilizing fluids approximately\nhospital day #12. Urine outpatient remained good thereafter.', '\n\nFluids, electrolytes and nutrition - Initial dehydration was\ntreated with intravenous fluids. She tolerated p.o.\nthroughout her placement and was placed on a thin pureed diet\nwith supplemental Boost at breakfast, lunch and dinner. This\nwas following swallow and nutrition evaluations for\nmalnutrition. She was also placed on thiamine, folate and\nmultivitamin supplements. Asymptomatic hypercalcemia was\nnoted, because of the low setting of albumin 2.4. Free\ncalcium was noted to be 1.4, free calcium on discharge was\nnoted to be 1.9. During hospital stay her potassium rose to\n5.5 secondary to increased dosage of ACE inhibitor,\nsubsequently Lisinopril was decreased to 5 mg at which time\nher potassium normalized. Other laboratory studies were as\nfollows, B12 7.9, folate 7.5, PTH 15, 25 hydroxy vitamin D,\nless than 7.', "\n\nNeurological - Change in mental status secondary to heat\nstroke/malnutrition. Throughout the hospital course the\npatient's mental status was alert, awake and oriented to two,\nsometimes to three. On discharge she is awake, alert and\noriented times three. Head computerized tomography scan on\nhospital day #20 was performed, results are pending at the\ntime of this dictation.\n\nGastrointestinal - The patient has a history of heme positive\nstools with refusal of colonoscopy. She had intermittent\nguaiac positive stools while in-house. She was seen by\nGastrointestinal Service for possible occult malignancy\nversus tuberculosis colitis. Colonoscopy was performed on\nhospital day #20 which showed diverticulosis and two polyps\nin the right colon that were subsequently removed and\nbiopsied. Liver function tests were followed q.", ' two weeks\nsecondary to antituberculosis medications. Liver function\ntests after tuberculosis medications were started were within\nnormal limits. ALT was 22, ALT 23, LDH 342, alkaline\nphosphatase 158, bilirubin 0.5. Our medical team recommended\nrehabilitation hospital follow liver function tests q. two\nweeks. Endomysal antibody was 3, this was within normal\nlimits.\n\nEndocrine - Free cortisol was noted to be 22. The hyperclcemia\nwas likely due to granulomatous disease (TB) and improved with\ntreatment of the TB.\n\nMusculoskeletal - The patient complained early on of hip\nsoreness. X-ray of the pelvis showed no fractures. The\npatient was followed by physical therapy. This improved over\ntime.\n\nProphylaxis - The with Zantac for stomach, heparin for deep\nvein thrombosis and fall and aspiration precautions were\nmaintained throughout the hospital stay.', '\n\nCONDITION ON DISCHARGE: Stable to Ball-Hanna Clinic for\nrehabilitation..\n\nDISCHARGE INSTRUCTIONS: Maintain respiratory precautions\nwhile keeping patient in isolation/negative pressure room.\nThe patient will continue to need physical therapy. Her diet\nshould be regular plus Boost t.i.d.\n\n\nDISCHARGE MEDICATIONS:\n1. Isoniazid 300 mg p.o. q.d.\n2. Rifampin 600 mg p.o. q.d.\n3. Pyrazinamide 1997 mg q.d.\n4. Ethambutol 1600 mg p.o. q.d.\n5. Pyridoxine 50 mg q.d. - Note that tuberculosis\nmedications should be given on an empty stomach\n6. Lisinopril 5 mg q.d.\n7. Digoxin 0.25 mg p.o. q.d.\n8. Metoprolol 25 mg b.i.d.\n9. Lasix 20 mg p.o. q.d.\n10. Aspirin 325 mg p.o. q.d.\n11. Heparin 5000 units subcutaneously q. 12 hours\n12. Ranitidine 150 mg p.o. b.i.d.\n13. Nitroglycerin sublingual 0.4 mg q. 5 minutes, maximum\nthree doses\n14.', " Colace 100 mg p.o. b.i.d. prn constipation\n15. Folic 1 mg p.o. q.d.\n16. Thiamine 100 mg p.o. q.d.\n17. Multivitamin p.o. q.d.\n18. Tylenol #3 one to two tablets p.o. q. 6 hours prn pain\n19. Tylenol 325 mg to 650 mg p.o. q. 4-6 hours prn fever/pain\n\nIt is recommended that Coumadin be restarted on 8-22 at 5\nmg p.o. q.d. with following INR daily, until therapeutic dose\nis set. The patient will also require liver function tests\nchecked q. two weeks. She is due for her next liver function\ntests next week. The patient's Digoxin level should be\nfollowed q. one to two weeks. Goal digoxon level is 1.0-1.2\n\nFOLLOW UP:\n1. Follow up appointment with her primary care physician,\nBounds. Nicki Chowdhury 8-30 3 PM at Washington, Newman and Schultz Medical Center Center on USCGC Garcia\nFPO AE 96192.\n2. Pulmonary Dr.", ' Kenner on 1-3 at 9 AM in the Anderson-Hawkins Clinic\nBuilding 5472 April Stravenue Suite 539\nEast Cody, GU 74326.\n3. Infectious Disease, Dr. Negrete 1998-1-10 AM in the\nDr.Debelius Building, 4358 Knox Mount\nWest Chelseabury, AK 74303.\n4. Fall precautions to be maintained, the patient can not\nbear her weight.\n\nDISCHARGE DIAGNOSIS:\n1. Pulmonary tuberculosis, reactivated\n2. Bilateral pleural effusions\n3. atrial fibrillation\n4. Cardiomyopathy\n5. Left bundle branch block\n6. hypercalcemia- resolved\n7. h/o CVA\n8. h/o PE\n Quincy Kamran Quinones, M.D. 14195261\n\nDictated By:Yuen\nMEDQUIST36\n\nD: 2003-3-24 15:52\nT: 2003-3-24 16:10\nJOB#: Swanson-Allison-1960-048235\n\n']
171	10634	165525.0	2169-04-09	Discharge summary	Report	Admission Date: [2169-3-26] Discharge Date: [2169-4-9] Date of Birth: [2090-12-5] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1781] Chief Complaint: Right foot pain s/p stenting of right superficial femoral artery Major Surgical or Invasive Procedure: [2169-3-30] stenting of right superficial femoral artery History of Present Illness: 78 y.o female s/p angio of the SFA with stent on [2169-3-14] presents with RLE foot pain Past Medical History: Adrenal insufficiency hx hypercaoguable state - but no clear h/o DVT/PE hypercholestremia ? hx Dm2 - recent dx in setting of recent MTA asthma s/p cholecystectomy PVD: on coumadin, s/p left metatarsal amputation '[62] bilateral adrenal masses cath [4-18]: clean coronary arteries ECHO [5-21]: EF > 60% Social History: Lived alone prior to d/c [3-25] when she was d/c to rehabiltation ([First Name4 (NamePattern1) 1785] [Last Name (NamePattern1) ])Denies tobacco and ETOH useWorked as greenhouse worker and babys[Name (NI) 1786] in the past6 kids (2 deceased), divorced, her daughter [Name (NI) 1787] has been very involved w/ this hospitalization and visits w/ patient daily Family History: no h/o PUD, pancreatic cancer or pancreatitis + h/o DM Physical Exam: Vital signs: 99.1-74-18 110/80 oxygen saturation 98% room air. General: alert and oriented HEENT: EOMI no caroitd bruits Lungs: clear to ausculation Heart: regular rate rythmn, no mumur, gallop or rubs ABD: begnin Pulses: femorals 2+ bilaterally, popliteals 1+ bilaterally, pedal pulses monophasic dopperable signal bilaterally. Pertinent Results: [2169-4-9] WBC-8.6 RBC-3.53* Hgb-9.5* Hct-30.4* MCV-86 MCH-26.9* MCHC-31.2 RDW-14.5 Plt Ct-119* [2169-4-9] PT-17.5* PTT-32.1 INR(PT)-1.9 [2169-4-9] Glucose-102 UreaN-15 Creat-0.9 Na-137 K-4.7 Cl-99 HCO3-32* AnGap-11 [2169-4-9] Calcium-8.9 Phos-3.5 Mg-2.0 [2169-4-5] 2:26 PM ART DUP LOW EXT RIGHT FINDINGS: Duplex evaluation of the right lower extremity arterial system was performed which demonstrates a patent right common femoral, superficial femoral, and popliteal artery. Velocity in the right common femoral artery is 112 cm/sec, with velocities ranging between 70 to 87 cm/sec between the common femoral, and the trifurcation. IMPRESSION: No stenosis seen in common femoral, superficial femoral and popliteal arteries on the right. [2169-3-11]. CHEST, TWO VIEWS: The heart size is within normal limits. Mediastinal and hilar contours unchanged in the interval. The aorta is slightly tortuous, unchanged. No focal consolidations are seen. Again, seen is linear scarring at the left base, unchanged. There is eventration of the posterior hemidiaphragms unchanged. There is DISH again seen. IMPRESSION: No CHF or pneumonia. [2169-3-29] Sinus rhythm Short PR interval ST-T changes are nonspecific Since previous tracing, T waves more upright in leads V5-V6 Intervals Axes Rate PR QRS QT/QTc P QRS T 80 108 88 370/405.71 67 40 80 GENERAL URINE INFORMATION Type Color Appear Sp [Last Name (un) ] Cath Straw Clear 1.015 Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks LG NEG NEG NEG NEG NEG NEG 7.0 NEG MOD NEG NEG NEG NEG RBC WBC Bacteri Yeast Epi Brief Hospital Course: Pt admitted on [2169-3-26] [2169-3-26] - [2169-3-29] Pt pre -oped for procedure on the [2169-3-30]. Pt was started on heparin for anti-coagulation. A pre - op note was done on [2169-3-29]. All results evxamined. Pt cleared for procedue on the [2169-3-30]. [2169-3-30] Pt underwent a right lower extremity arteriogram via left common femoral artery approach, with angioplasty and stent placement in the distal right SFA, for peripheral vascular disease with right lower extremity rest pain and hypercoagulable state. Pt tolerated the procedure well. There were no complications. After the procedure pt was transfered to the recovery room in stable condition. When here ACT was around 180 her sheath was pulled without complications. She remained on bedrest for 6 hour after the sheath was pulled. After she recovered from anesthesia she was transfered to the VICU in stable condition. A post procedure check was done. It was found that the pt had a hematome from the last admission. The pt was watched over the next day. [2169-3-31] Pt still c/o foot pain post procedure. This coupled with the hematoma an US was ordered. The results as were a atent right superficial femoral artery through popliteal artery angioplasty/stent. There is a large left groin hematoma with no pseudoaneurysm or AV fistula. Pt coumadin was started. [2169-4-1] Pt transfered from the VICU to the floor. Pt recieved a PICC becaouse of poor access. [2169-4-2] - [2169-4-3] Pt anticoagulate with heparin and coumadin. She was mobilized, her diet was advanced, her foley was removed. Pt responded with good UO. [2169-4-4] Pt PLT count decreased from 200 to 89. Her heparin was DC'd a HIT panel was sent. Pt still c/o toe pain. Because of the above another ultrasound was done. [2169-4-5] The US revealed no stenosis seen in common femoral, superficial femoral and popliteal arteries on the right. A pain consult was obtained for the toe pain. The pain service recommended nuerontin. Pt responded to the medication. A hematology consult was obtained for her decrease PLTS. [2169-4-6] Hematolgy saw the pt. [2169-4-7] - [2169-4-8] Pt PLT improved, foot pain improved with nuerontin. Case mangement and PT were consulted. Recommended that the pt go home with no sevices needed. [2169-4-9] Pt [Name (NI) 1788] home. PLT stable, toe pain much improved, pt taking PO, urinating with BM, ambulating well, INR 2-3 range. Medications on Admission: albutrol protonix tylenol oxycodone predisone coumadin fludrocortizone nuerontin Discharge Medications: 1. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:80 Tablet(s) Refills:0 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 4. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:2 5. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO once a day: You should have your INR checked on [3-19], and [4-14] at the clinic of Dr. [Last Name (STitle) 1789] and coumadin dosed accordingly for goal [3-23]. . Disp:30 Tablet(s) Refills:2 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Outpatient Lab Work Check INR (coags) and CBC on [2169-4-10], [2169-4-12], and [2169-4-14] Discharge Disposition: Home Discharge Diagnosis: Primary: Peripheral Vascular Disease with stenosis of Right superficial femoral artery Secondary: Hypercoagulability, Asthma, Hyperlipidemia, status-post Left transmetatarsal amputation Discharge Condition: Good Discharge Instructions: Please contact the office or come to the emergency with any worsening bleeding from your groin or worsening coldness/pain in your legs not improved with pain medications, or any questions. You should follow-up with Dr. [First Name4 (NamePattern1) 1790] [Last Name (NamePattern1) 1789] in the clinic on [2169-4-10] between 8am and 2 pm to have your INR checked and Coumadin dosed (as discussed with your daughter, [Name (NI) 1791], on [2169-4-9]). Please call with any questions. You may address questions related to adjusting your narcotic medications with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 1789]. Followup Instructions: You should follow-up with Dr. [First Name4 (NamePattern1) 1790] [Last Name (NamePattern1) 1789] ([Telephone/Fax (1) 1792]) in the clinic on [2169-4-10], [2169-4-12], [2169-4-14] to have your INR checked and Coumadin dosed (as discussed with your daughter, [Name (NI) 1791], on [2169-4-9]). Please contact the office of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (vascular surgery) to set-up a follow-up appointment at a time of your convenience within the next 2 weeks. [Telephone/Fax (1) 1784] Completed by:[2169-7-18]	Admission Date: <Date>1915-12-16</Date> Discharge Date: <Date>1901-10-31</Date> Date of Birth: <Date>1977-11-6</Date> Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Ollie</Name> Chief Complaint: Right foot pain s/p stenting of right superficial femoral artery Major Surgical or Invasive Procedure: <Date>1990-4-6</Date> stenting of right superficial femoral artery History of Present Illness: 78 y.o female s/p angio of the SFA with stent on <Date>1961-9-2</Date> presents with RLE foot pain Past Medical History: Adrenal insufficiency hx hypercaoguable state - but no clear h/o DVT/PE hypercholestremia ? hx Dm2 - recent dx in setting of recent MTA asthma s/p cholecystectomy PVD: on coumadin, s/p left metatarsal amputation '<Digit>36</Digit> bilateral adrenal masses cath <Date>1-23</Date>: clean coronary arteries ECHO <Date>10-17</Date>: EF > 60% Social History: Lived alone prior to d/c <Date>6-13</Date> when she was d/c to rehabiltation (<Name>Odell</Name> <Name>Camargo</Name>)Denies tobacco and ETOH useWorked as greenhouse worker and babys<Name>Alexander Merino</Name> in the past6 kids (2 deceased), divorced, her daughter <Name>Norine Benavidez</Name> has been very involved w/ this hospitalization and visits w/ patient daily Family History: no h/o PUD, pancreatic cancer or pancreatitis + h/o DM Physical Exam: Vital signs: 99.1-74-18 110/80 oxygen saturation 98% room air. General: alert and oriented HEENT: EOMI no caroitd bruits Lungs: clear to ausculation Heart: regular rate rythmn, no mumur, gallop or rubs ABD: begnin Pulses: femorals 2+ bilaterally, popliteals 1+ bilaterally, pedal pulses monophasic dopperable signal bilaterally. Pertinent Results: <Date>1901-10-31</Date> WBC-8.6 RBC-3.53* Hgb-9.5* Hct-30.4* MCV-86 MCH-26.9* MCHC-31.2 RDW-14.5 Plt Ct-119* <Date>1901-10-31</Date> PT-17.5* PTT-32.1 INR(PT)-1.9 <Date>1901-10-31</Date> Glucose-102 UreaN-15 Creat-0.9 Na-137 K-4.7 Cl-99 HCO3-32* AnGap-11 <Date>1901-10-31</Date> Calcium-8.9 Phos-3.5 Mg-2.0 <Date>1943-8-15</Date> 2:26 PM ART DUP LOW EXT RIGHT FINDINGS: Duplex evaluation of the right lower extremity arterial system was performed which demonstrates a patent right common femoral, superficial femoral, and popliteal artery. Velocity in the right common femoral artery is 112 cm/sec, with velocities ranging between 70 to 87 cm/sec between the common femoral, and the trifurcation. IMPRESSION: No stenosis seen in common femoral, superficial femoral and popliteal arteries on the right. <Date>1939-5-2</Date>. CHEST, TWO VIEWS: The heart size is within normal limits. Mediastinal and hilar contours unchanged in the interval. The aorta is slightly tortuous, unchanged. No focal consolidations are seen. Again, seen is linear scarring at the left base, unchanged. There is eventration of the posterior hemidiaphragms unchanged. There is DISH again seen. IMPRESSION: No CHF or pneumonia. <Date>1966-7-7</Date> Sinus rhythm Short PR interval ST-T changes are nonspecific Since previous tracing, T waves more upright in leads V5-V6 Intervals Axes Rate PR QRS QT/QTc P QRS T 80 108 88 370/405.71 67 40 80 GENERAL URINE INFORMATION Type Color Appear Sp <Name>Wilson</Name> Cath Straw Clear 1.015 Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks LG NEG NEG NEG NEG NEG NEG 7.0 NEG MOD NEG NEG NEG NEG RBC WBC Bacteri Yeast Epi Brief Hospital Course: Pt admitted on <Date>1915-12-16</Date> <Date>1915-12-16</Date> - <Date>1966-7-7</Date> Pt pre -oped for procedure on the <Date>1990-4-6</Date>. Pt was started on heparin for anti-coagulation. A pre - op note was done on <Date>1966-7-7</Date>. All results evxamined. Pt cleared for procedue on the <Date>1990-4-6</Date>. <Date>1990-4-6</Date> Pt underwent a right lower extremity arteriogram via left common femoral artery approach, with angioplasty and stent placement in the distal right SFA, for peripheral vascular disease with right lower extremity rest pain and hypercoagulable state. Pt tolerated the procedure well. There were no complications. After the procedure pt was transfered to the recovery room in stable condition. When here ACT was around 180 her sheath was pulled without complications. She remained on bedrest for 6 hour after the sheath was pulled. After she recovered from anesthesia she was transfered to the VICU in stable condition. A post procedure check was done. It was found that the pt had a hematome from the last admission. The pt was watched over the next day. <Date>1942-4-23</Date> Pt still c/o foot pain post procedure. This coupled with the hematoma an US was ordered. The results as were a atent right superficial femoral artery through popliteal artery angioplasty/stent. There is a large left groin hematoma with no pseudoaneurysm or AV fistula. Pt coumadin was started. <Date>1992-10-3</Date> Pt transfered from the VICU to the floor. Pt recieved a PICC becaouse of poor access. <Date>1958-11-1</Date> - <Date>1951-12-19</Date> Pt anticoagulate with heparin and coumadin. She was mobilized, her diet was advanced, her foley was removed. Pt responded with good UO. <Date>1979-8-8</Date> Pt PLT count decreased from 200 to 89. Her heparin was DC'd a HIT panel was sent. Pt still c/o toe pain. Because of the above another ultrasound was done. <Date>1943-8-15</Date> The US revealed no stenosis seen in common femoral, superficial femoral and popliteal arteries on the right. A pain consult was obtained for the toe pain. The pain service recommended nuerontin. Pt responded to the medication. A hematology consult was obtained for her decrease PLTS. <Date>2015-8-5</Date> Hematolgy saw the pt. <Date>1914-5-31</Date> - <Date>1918-2-8</Date> Pt PLT improved, foot pain improved with nuerontin. Case mangement and PT were consulted. Recommended that the pt go home with no sevices needed. <Date>1901-10-31</Date> Pt <Name>Shirley Blanks</Name> home. PLT stable, toe pain much improved, pt taking PO, urinating with BM, ambulating well, INR 2-3 range. Medications on Admission: albutrol protonix tylenol oxycodone predisone coumadin fludrocortizone nuerontin Discharge Medications: 1. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:80 Tablet(s) Refills:0 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 4. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:2 5. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO once a day: You should have your INR checked on <Date>2-18</Date>, and <Date>4-13</Date> at the clinic of Dr. <Name>Meraz</Name> and coumadin dosed accordingly for goal <Date>1-24</Date>. . Disp:30 Tablet(s) Refills:2 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Outpatient Lab Work Check INR (coags) and CBC on <Date>1904-7-22</Date>, <Date>1994-7-24</Date>, and <Date>1949-6-7</Date> Discharge Disposition: Home Discharge Diagnosis: Primary: Peripheral Vascular Disease with stenosis of Right superficial femoral artery Secondary: Hypercoagulability, Asthma, Hyperlipidemia, status-post Left transmetatarsal amputation Discharge Condition: Good Discharge Instructions: Please contact the office or come to the emergency with any worsening bleeding from your groin or worsening coldness/pain in your legs not improved with pain medications, or any questions. You should follow-up with Dr. <Name>Iliana</Name> <Name>Thompkins</Name> in the clinic on <Date>1904-7-22</Date> between 8am and 2 pm to have your INR checked and Coumadin dosed (as discussed with your daughter, <Name>Fannie Abdullah</Name>, on <Date>1901-10-31</Date>). Please call with any questions. You may address questions related to adjusting your narcotic medications with your primary care physician, <Name>Chau</Name>. <Name>Meraz</Name>. Followup Instructions: You should follow-up with Dr. <Name>Iliana</Name> <Name>Thompkins</Name> (<Telephone>491-386-5004</Telephone>) in the clinic on <Date>1904-7-22</Date>, <Date>1994-7-24</Date>, <Date>1949-6-7</Date> to have your INR checked and Coumadin dosed (as discussed with your daughter, <Name>Fannie Abdullah</Name>, on <Date>1901-10-31</Date>). Please contact the office of Dr. <Name>Kala</Name> <Name>Camargo</Name> (vascular surgery) to set-up a follow-up appointment at a time of your convenience within the next 2 weeks. <Telephone>301-821-4964</Telephone> Completed by:<Date>1909-11-2</Date>	00000000000000000111111111100000000000000000000000000000000111111111100000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000110000000000000000000000000000000111100000000000000000000000000000001111100000>000000000000000000000000000000000000000000000000111100000000000000000000000000000000000011111011111110000000000000000000000000000000000000000000000000000000000000000011111111111111110000000000000000000000000000000000000000000000000000000011111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111001111111111000111111110000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000001111111100011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1915-12-16 Discharge Date: 1901-10-31 Date of Birth: 1977-11-6 Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Ollie Chief Complaint: Right foot pain s/p stenting of right superficial femoral artery Major Surgical or Invasive Procedure: 1990-4-6 stenting of right superficial femoral artery History of Present Illness: 78 y.o female s/p angio of the SFA with stent on 1961-9-2 presents with RLE foot pain Past Medical History: Adrenal insufficiency hx hypercaoguable state - but no clear h/o DVT/PE hypercholestremia ? hx Dm2 - recent dx in setting of recent MTA asthma s/p cholecystectomy PVD: on coumadin, s/p left metatarsal amputation '36 bilateral adrenal masses cath 1-23: clean coronary arteries ECHO 10-17: EF > 60% Social History: Lived alone prior to d/c 6-13 when she was d/c to rehabiltation (Odell Camargo)Denies tobacco and ETOH useWorked as greenhouse worker and babysAlexander Merino in the past6 kids (2 deceased), divorced, her daughter Norine Benavidez has been very involved w/ this hospitalization and visits w/ patient daily Family History: no h/o PUD, pancreatic cancer or pancreatitis + h/o DM Physical Exam: Vital signs: 99.1-74-18 110/80 oxygen saturation 98% room air. General: alert and oriented HEENT: EOMI no caroitd bruits Lungs: clear to ausculation Heart: regular rate rythmn, no mumur, gallop or rubs ABD: begnin Pulses: femorals 2+ bilaterally, popliteals 1+ bilaterally, pedal pulses monophasic dopperable signal bilaterally. Pertinent Results: 1901-10-31 WBC-8.6 RBC-3.53* Hgb-9.5* Hct-30.4* MCV-86 MCH-26.9* MCHC-31.2 RDW-14.5 Plt Ct-119* 1901-10-31 PT-17.5* PTT-32.1 INR(PT)-1.9 1901-10-31 Glucose-102 UreaN-15 Creat-0.9 Na-137 K-4.7 Cl-99 HCO3-32* AnGap-11 1901-10-31 Calcium-8.9 Phos-3.5 Mg-2.0 1943-8-15 2:26 PM ART DUP LOW EXT RIGHT FINDINGS: Duplex evaluation of the right lower extremity arterial system was performed which demonstrates a patent right common femoral, superficial femoral, and popliteal artery. Velocity in the right common femoral artery is 112 cm/sec, with velocities ranging between 70 to 87 cm/sec between the common femoral, and the trifurcation. IMPRESSION: No stenosis seen in common femoral, superficial femoral and popliteal arteries on the right. 1939-5-2. CHEST, TWO VIEWS: The heart size is within normal limits. Mediastinal and hilar contours unchanged in the interval. The aorta is slightly tortuous, unchanged. No focal consolidations are seen. Again, seen is linear scarring at the left base, unchanged. There is eventration of the posterior hemidiaphragms unchanged. There is DISH again seen. IMPRESSION: No CHF or pneumonia. 1966-7-7 Sinus rhythm Short PR interval ST-T changes are nonspecific Since previous tracing, T waves more upright in leads V5-V6 Intervals Axes Rate PR QRS QT/QTc P QRS T 80 108 88 370/405.71 67 40 80 GENERAL URINE INFORMATION Type Color Appear Sp Wilson Cath Straw Clear 1.015 Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks LG NEG NEG NEG NEG NEG NEG 7.0 NEG MOD NEG NEG NEG NEG RBC WBC Bacteri Yeast Epi Brief Hospital Course: Pt admitted on 1915-12-16 1915-12-16 - 1966-7-7 Pt pre -oped for procedure on the 1990-4-6. Pt was started on heparin for anti-coagulation. A pre - op note was done on 1966-7-7. All results evxamined. Pt cleared for procedue on the 1990-4-6. 1990-4-6 Pt underwent a right lower extremity arteriogram via left common femoral artery approach, with angioplasty and stent placement in the distal right SFA, for peripheral vascular disease with right lower extremity rest pain and hypercoagulable state. Pt tolerated the procedure well. There were no complications. After the procedure pt was transfered to the recovery room in stable condition. When here ACT was around 180 her sheath was pulled without complications. She remained on bedrest for 6 hour after the sheath was pulled. After she recovered from anesthesia she was transfered to the VICU in stable condition. A post procedure check was done. It was found that the pt had a hematome from the last admission. The pt was watched over the next day. 1942-4-23 Pt still c/o foot pain post procedure. This coupled with the hematoma an US was ordered. The results as were a atent right superficial femoral artery through popliteal artery angioplasty/stent. There is a large left groin hematoma with no pseudoaneurysm or AV fistula. Pt coumadin was started. 1992-10-3 Pt transfered from the VICU to the floor. Pt recieved a PICC becaouse of poor access. 1958-11-1 - 1951-12-19 Pt anticoagulate with heparin and coumadin. She was mobilized, her diet was advanced, her foley was removed. Pt responded with good UO. 1979-8-8 Pt PLT count decreased from 200 to 89. Her heparin was DC'd a HIT panel was sent. Pt still c/o toe pain. Because of the above another ultrasound was done. 1943-8-15 The US revealed no stenosis seen in common femoral, superficial femoral and popliteal arteries on the right. A pain consult was obtained for the toe pain. The pain service recommended nuerontin. Pt responded to the medication. A hematology consult was obtained for her decrease PLTS. 2015-8-5 Hematolgy saw the pt. 1914-5-31 - 1918-2-8 Pt PLT improved, foot pain improved with nuerontin. Case mangement and PT were consulted. Recommended that the pt go home with no sevices needed. 1901-10-31 Pt Shirley Blanks home. PLT stable, toe pain much improved, pt taking PO, urinating with BM, ambulating well, INR 2-3 range. Medications on Admission: albutrol protonix tylenol oxycodone predisone coumadin fludrocortizone nuerontin Discharge Medications: 1. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:80 Tablet(s) Refills:0 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 4. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:2 5. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO once a day: You should have your INR checked on 2-18, and 4-13 at the clinic of Dr. Meraz and coumadin dosed accordingly for goal 1-24. . Disp:30 Tablet(s) Refills:2 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Outpatient Lab Work Check INR (coags) and CBC on 1904-7-22, 1994-7-24, and 1949-6-7 Discharge Disposition: Home Discharge Diagnosis: Primary: Peripheral Vascular Disease with stenosis of Right superficial femoral artery Secondary: Hypercoagulability, Asthma, Hyperlipidemia, status-post Left transmetatarsal amputation Discharge Condition: Good Discharge Instructions: Please contact the office or come to the emergency with any worsening bleeding from your groin or worsening coldness/pain in your legs not improved with pain medications, or any questions. You should follow-up with Dr. Iliana Thompkins in the clinic on 1904-7-22 between 8am and 2 pm to have your INR checked and Coumadin dosed (as discussed with your daughter, Fannie Abdullah, on 1901-10-31). Please call with any questions. You may address questions related to adjusting your narcotic medications with your primary care physician, Chau. Meraz. Followup Instructions: You should follow-up with Dr. Iliana Thompkins (491-386-5004) in the clinic on 1904-7-22, 1994-7-24, 1949-6-7 to have your INR checked and Coumadin dosed (as discussed with your daughter, Fannie Abdullah, on 1901-10-31). Please contact the office of Dr. Kala Camargo (vascular surgery) to set-up a follow-up appointment at a time of your convenience within the next 2 weeks. 301-821-4964 Completed by:1909-11-2	["Admission Date: 1915-12-16 Discharge Date: 1901-10-31\n\nDate of Birth: 1977-11-6 Sex: F\n\nService: SURGERY\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Ollie\nChief Complaint:\nRight foot pain s/p stenting of right superficial femoral artery\n\n\nMajor Surgical or Invasive Procedure:\n1990-4-6 stenting of right superficial femoral artery\n\n\nHistory of Present Illness:\n78 y.o female s/p angio of the SFA with stent on 1961-9-2\npresents with RLE foot pain\n\nPast Medical History:\nAdrenal insufficiency\nhx hypercaoguable state - but no clear h/o DVT/PE\nhypercholestremia\n? hx Dm2 - recent dx in setting of recent MTA\nasthma\ns/p cholecystectomy\nPVD: on coumadin, s/p left metatarsal amputation '36\nbilateral adrenal masses\ncath 1-23: clean coronary arteries\nECHO 10-17: EF > 60%\n\n\nSocial History:\nLived alone prior to d/c 6-13 when she was d/c to rehabiltation\n(Odell Camargo)Denies tobacco and ETOH useWorked as greenhouse\nworker and babysAlexander Merino in the past6 kids (2 deceased), divorced,\nher daughter Norine Benavidez has been very involved w/ this\nhospitalization and visits w/ patient daily\n\n\nFamily History:\nno h/o PUD, pancreatic cancer or pancreatitis\n+ h/o DM\n\nPhysical Exam:\nVital signs: 99.", '1-74-18 110/80 oxygen saturation 98% room air.\nGeneral: alert and oriented\nHEENT: EOMI no caroitd bruits\nLungs: clear to ausculation\nHeart: regular rate rythmn, no mumur, gallop or rubs\nABD: begnin\nPulses: femorals 2+ bilaterally, popliteals 1+ bilaterally,\npedal pulses monophasic dopperable signal bilaterally.\n\nPertinent Results:\n1901-10-31\n\nWBC-8.6 RBC-3.53* Hgb-9.5* Hct-30.4* MCV-86 MCH-26.9* MCHC-31.2\nRDW-14.5 Plt Ct-119\n\n1901-10-31\n\nPT-17.5 PTT-32.1 INR(PT)-1.9\n\n1901-10-31\n\nGlucose-102 UreaN-15 Creat-0.9 Na-137 K-4.7 Cl-99 HCO3-32\nAnGap-11\n\n1901-10-31\n\nCalcium-8.9 Phos-3.5 Mg-2.0\n\n1943-8-15 2:26 PM\n\nART DUP LOW EXT RIGHT\n\nFINDINGS:\n\nDuplex evaluation of the right lower extremity arterial system\nwas performed which demonstrates a patent right common femoral,\nsuperficial femoral, and popliteal artery.', ' Velocity in the right\ncommon femoral artery is 112 cm/sec, with velocities ranging\nbetween 70 to 87 cm/sec between the common femoral, and the\ntrifurcation.\n\nIMPRESSION:\n\nNo stenosis seen in common femoral, superficial femoral and\npopliteal arteries on the right.\n\n1939-5-2.\n\nCHEST, TWO VIEWS: The heart size is within normal limits.\nMediastinal and hilar contours unchanged in the interval. The\naorta is slightly tortuous, unchanged. No focal consolidations\nare seen. Again, seen is linear scarring at the left base,\nunchanged. There is eventration of the posterior hemidiaphragms\nunchanged. There is DISH again seen.\n\nIMPRESSION: No CHF or pneumonia.\n\n1966-7-7\n\nSinus rhythm\nShort PR interval\nST-T changes are nonspecific\nSince previous tracing, T waves more upright in leads V5-V6\n\nIntervals Axes\nRate PR QRS QT/QTc P QRS T\n80 108 88 370/405.', '71 67 40 80\n\nGENERAL URINE INFORMATION\n\nType Color Appear Sp Wilson\nCath Straw Clear 1.015\nBlood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks\nLG NEG NEG NEG NEG NEG NEG 7.0 NEG\n\nMOD NEG NEG NEG NEG\nRBC WBC Bacteri Yeast Epi\n\n\n\n\nBrief Hospital Course:\nPt admitted on 1915-12-16\n\n1915-12-16 - 1966-7-7\n\nPt pre -oped for procedure on the 1990-4-6. Pt was started on\nheparin for anti-coagulation. A pre - op note was done on\n1966-7-7. All results evxamined. Pt cleared for procedue on the\n1990-4-6.\n\n1990-4-6\n\nPt underwent a right lower extremity arteriogram via left common\nfemoral artery approach, with angioplasty and stent placement in\nthe distal right SFA, for\nperipheral vascular disease with right lower extremity rest pain\nand hypercoagulable state.\n\nPt tolerated the procedure well.', ' There were no complications.\nAfter the procedure pt was transfered to the recovery room in\nstable condition. When here ACT was around 180 her sheath was\npulled without complications. She remained on bedrest for 6 hour\nafter the sheath was pulled. After she recovered from anesthesia\nshe was transfered to the VICU in stable condition.\n\nA post procedure check was done. It was found that the pt had a\nhematome from the last admission. The pt was watched over the\nnext day.\n\n1942-4-23\n\nPt still c/o foot pain post procedure. This coupled with the\nhematoma an US was ordered. The results as were a atent right\nsuperficial femoral artery through popliteal artery\nangioplasty/stent. There is a large left groin hematoma with no\npseudoaneurysm or AV fistula.\n\nPt coumadin was started.\n\n1992-10-3\n\nPt transfered from the VICU to the floor.', " Pt recieved a PICC\nbecaouse of poor access.\n\n1958-11-1 - 1951-12-19\n\nPt anticoagulate with heparin and coumadin. She was mobilized,\nher diet was advanced, her foley was removed. Pt responded with\ngood UO.\n\n1979-8-8\n\nPt PLT count decreased from 200 to 89. Her heparin was DC'd a\nHIT panel was sent. Pt still c/o toe pain. Because of the above\nanother ultrasound was done.\n\n1943-8-15\n\nThe US revealed no stenosis seen in common femoral, superficial\nfemoral and popliteal arteries on the right.\n\nA pain consult was obtained for the toe pain. The pain service\nrecommended nuerontin.\nPt responded to the medication.\n\nA hematology consult was obtained for her decrease PLTS.\n\n2015-8-5\n\nHematolgy saw the pt.\n\n1914-5-31 - 1918-2-8\n\nPt PLT improved, foot pain improved with nuerontin.\n\nCase mangement and PT were consulted.", ' Recommended that the pt go\nhome with no sevices needed.\n\n1901-10-31\n\nPt Shirley Blanks home. PLT stable, toe pain much improved, pt taking PO,\nurinating with BM, ambulating well, INR 2-3 range.\n\n\nMedications on Admission:\nalbutrol\nprotonix\ntylenol\noxycodone\npredisone\ncoumadin\nfludrocortizone\nnuerontin\n\nDischarge Medications:\n1. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every\n4 hours) as needed for pain.\nDisp:80 Tablet(s)* Refills:0\n2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation\nQ6H (every 6 hours) as needed.\n3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day) as needed for constipation.\nDisp:60 Capsule(s) Refills:0\n4. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1)\nTablet Sustained Release PO Q12H (every 12 hours).', '\nDisp:60 Tablet Sustained Release(s) Refills:2\n5. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO once a\nday: You should have your INR checked on 2-18, and 4-13 at\nthe clinic of Dr. Meraz and coumadin dosed accordingly for goal\n1-24. .\nDisp:30 Tablet(s) Refills:2\n6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3\ntimes a day).\nDisp:90 Capsule(s) Refills:2\n7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.\n8. Outpatient Lab Work\nCheck INR (coags) and CBC on 1904-7-22, 1994-7-24, and 1949-6-7\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPrimary: Peripheral Vascular Disease with stenosis of Right\nsuperficial femoral artery\nSecondary: Hypercoagulability, Asthma, Hyperlipidemia,\nstatus-post Left transmetatarsal amputation\n\n\nDischarge Condition:\nGood\n\nDischarge Instructions:\nPlease contact the office or come to the emergency with any\nworsening bleeding from your groin or worsening coldness/pain in\nyour legs not improved with pain medications, or any questions.', '\nYou should follow-up with Dr. Iliana Thompkins in the clinic on\n1904-7-22 between 8am and 2 pm to have your INR checked and\nCoumadin dosed (as discussed with your daughter, Fannie Abdullah, on\n1901-10-31). Please call with any questions. You may address\nquestions related to adjusting your narcotic medications with\nyour primary care physician, Chau. Meraz.\n\nFollowup Instructions:\nYou should follow-up with Dr. Iliana Thompkins (491-386-5004)\nin the clinic on 1904-7-22, 1994-7-24, 1949-6-7 to have your INR\nchecked and Coumadin dosed (as discussed with your daughter,\nFannie Abdullah, on 1901-10-31).\n\nPlease contact the office of Dr. Kala Camargo (vascular\nsurgery) to set-up a follow-up appointment at a time of your\nconvenience within the next 2 weeks. 301-821-4964\n\n\n\nCompleted by:1909-11-2']
172	10634	104315.0	2169-04-24	Discharge summary	Report	Admission Date: [2169-4-16] Discharge Date: [2169-4-25] Date of Birth: [2090-12-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: 78 yo F w/ abd pain Major Surgical or Invasive Procedure: right femoral line right upper extremity PICC transient levophed History of Present Illness: 78 yo F w/ h/o hyperchol, IDDM, asthma, and s/p CCY several years ago who presents from rehab w/ c/o RUQ abd pain x 3 days. Patient d/c from [Hospital1 18] [2169-4-14] following a right transmetatarsal amputation for gangrenous right foot. Patient's admission was uncomplicated other than a fever spike on POD #1 o/n but CXR negative and patient defervesced. She required 1 U PRBC intraoperatively for hct 26.8. Per daughter, patient is somewhat confused and currently an unreliable historian, thus I relied on her daughter for hx. Her daughter states that her mom first started c/o diffuse abdominal pain but particularly subxiphoidal abdominal pain on Friday. Her mother states that the pain was occasionally worse w/ eating but her daughter states that her mom was eating a full liquid diet. She has been vomiting, however. Occasionally it is the food she just ate and other times she will vomit up her pills. However, she had soup and jello this am w/o vomiting. Her mom has also been c/o back pain but as far as her daughter can tell this is just her chronic LBP. She doesn't seem to relate the pain to her abdominal pain. Patient's daughter thinks her mom's last BM was on Friday but she is really not sure. Per notes, patient spiked temp of 101 at rehab. Patient's daughter is not aware of any h/o PUD or CAD in her mother. [Name (NI) ] mom did have a gall bladder attack severeal years ago leading to CCY, but o/w no abdominal surgeries/issues. + h/o BRBPR. Daughter not sure if she's had a c-scope in the past. Daughter is not aware of any urinary complaints On further ROS: Patient has been having hallucinations which started in the hospital, attributed to pain medications. + SOB which is worse if she lies flat since her last admission to [Hospital1 18] Per notes, her mother also reported some chest tightness. Past Medical History: # hx hypercaoguable state - but no clear h/o DVT/PE # hypercholestremia # ? hx Dm2 - recent dx in setting of recent MTA # asthma # s/p cholecystectomy # PVD: on coumadin, s/p left metatarsal amputation '[62], right metatarsal amputation [2169-4-11] - cath [4-18]: clean coronary arteries - ECHO [5-21]: EF > 60% Social History: Lived alone prior to d/c [3-25] when she was d/c to rehabiltation (Scherrill House) Denies tobacco and ETOH use Worked as greenhouse worker and babys[Name (NI) 1786] in the past 6 kids (2 deceased), divorced, her daughter [Name (NI) 1787] has been very involved w/ this hospitalization Family History: no h/o PUD, pancreatic cancer or pancreatitis + h/o DM Physical Exam: T 99.5 bp 147/53 hr 78 rr 21 O2 97% RA genrl: lethargic but when aroused seems very awake but then quickly falls back to sleep, in nad at any time during my exam heent: pinpoint pupils but reactive (3mm->2mm), no photophobia, eomi, sclera anicteric, op clear but limited exam due to poor patient cooperation neck: supple cv: rrr, no m/r/g pulm: minimal expiratory wheeze, o/w CTA bilaterally, moves air well back: no cva tenderness, localizes back pain to L4/5 w/o spinous process tenderness abd: nabs, RUQ oblique scar (6" long, c/d/i), soft, mildly tender to palpation of RUQ w/o rebound/guarding, no masses/hsm extr: no c/c/e, s/p right metatarsal amputation - c/d/i w/o skin changes, left metatarsal amputation site appears somewhat cyanotic but warm bilaterally, slight underlying erythema but does not appear infected, no fluctuance and no d/c from surgical incision Pertinent Results: CK: 106 MB: 3 Trop-T: <0.01 x 2 Lactate:1.1 133 95 10 91 3.9 30 0.7 Ca: Pnd Mg: Pnd P: Pnd ALT: 86 AP: 165 Tbili: 0.6 Alb: 3.3 AST: 77 [Doctor First Name ]: 60 Lip: 16 PT: 19.9 PTT: 31.6 INR: 2.5 [2169-4-16] 12:30PM WBC-12.2* RBC-3.68* HGB-10.0* HCT-30.4* MCV-83 MCH-27.1 MCHC-32.8 RDW-14.0 N:77.8 L:15.6 M:5.2 E:1.2 Bas:0.2 Hypochr: 1+ Poiklo: 1+ [2169-4-16] 07:42PM calTIBC-256* VIT B12-678 FOLATE-12.7 FERRITIN-568* TRF-197* RETIC 2.3% [2169-4-16] 07:42PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE Hep A IgG pos, IgM neg [2169-4-16] 07:42PM HCV Ab-NEGATIVE random cortisol 1.1 HGB A1C: pending TSH: 1.8 RPR: NR c diff neg x 3 Unit admission: FDP 10-40, fibrinogen 672 CT abd/pelvis [4-16]: 1. Mild dilatation of the distal common duct with no choledocholithiasis, unchanged from the prior ultrasound. 2. Status post cholecystectomy. 3. Likely left renal cyst, although too small to characterize. 4. Sigmoid diverticulosis. 5. Calcified fibroids. 6. Bilateral 2 cm adrenal masses, which cannot be characterized further on this study. 7. Fluid collection in the left groin, presumably related to recent catheterization. 6.0 x 3.0 cm RUQ U/S [2169-4-18]: IMPRESSION: Diffusely prominent common duct, as described above, unchanged in appearance from the patient's previous ultrasound exam of [2167-6-9]. This finding is likely related to the remote history of cholecystectomy. Otherwise, an unremarkable right upper quadrant ultrasound. CXR [4-16]: Right hilar fullness on the AP view without a definite abnormality on the lateral view. A repeat good technique AP and lateral may be performed to see whether this should be further evaluated with CT. EKG: sinus at 82 bpm, old QIII, no STTW changes urine cx [4-13]: > 100K GP bacteria - lactobacillus or alphastrep, neg nit/LE on UA at the time [Last Name (un) ] cx [2169-4-17]: > 100K enterococcus sensitive to vanc, ampicillin, levo bld cx [4-16], [4-17]: no growth Brief Hospital Course: 78 yo F w/ h/o hyperchol, ? T2DM, asthma, and h/o PVD s/p bilateral MTA, most recently on the right ([2169-4-11]) who presents from rehab w/ c/o RUQ abd pain x 3 days. # Abdominal pain/vomiting CT abd/pelvis did not show anything that might explain this patient's presenting complaint. Her LFTs were slightly elevated on presentation concerning for possible cholestasis postop but they essentially normalized. Her statin was held prophylactically. Hepatitis panel was unremarkable, positive for hep A IgG but negative for hep A IgM. Her h/o vomiting was concerning for pancreatitis but her lipase/amylase WNL. Given ? h/o BM, we considered constipation as a cause of her abdominal pain and tx w/ aggressive bowel regimen. Consideration was made for a RP bleed or leaking AAA given h/o left groin hematoma following cath [3-30] but her presenting pain was in the RUQ, in addition to c/o her chronic L4/5 back pain. In addition her hct remained stable and her CT was unremarkable. Ms. [Known lastname 1794] had no h/o PUD but did report h/o BRBPR years ago so we considered a possible stress ulcer and tx her accordingly w/ PPI, guiacing all her stools. There was no lactic acisosis to suggest ischemic gut and her lytes were WNL. She ultimately ended up being dx w/ urosepsis. Her urine cx showed > 100K colonies/ml of enterococcus sensitive to amp/levo/vanc. Plan to tx w/ vanc x 10 days (long duration of antibx for concurrent MTA cellulitis). Patient currently has no further c/o abdominal pain. # Decreased MS [First Name (Titles) ] [Last Name (Titles) 1795] on initial presentation given pinpoint pupils, h/o hallucinations, and being tx w/ dilaudid, MS contin, and neurontin at rehab. However, her MS [First Name (Titles) 1796] [Last Name (Titles) 1797] despite holding pain medications, at which time patient was found to be hypotensive (70/palp w/ doppler assist). She was transiently started on pressors, aggressively hydrated, and MS returned to [Location 213] w/in 24 hours. She was thus also dx w/ urosepsis. Of note, blood cultures were negative for any growth. Folate/B12/TSH/RPR were all unremarkable. CXR was w/o infiltrate. # Fever/leukocytosis Patient ultimately dx w/ enterococcal UTI and right stump cellulitis. Plan to tx w/ a total of 10 days of vancomycin + zosyn. Of note, CXR w/o overt infiltrate. She did have loose stools this admission but was c diff neg x 3. Blood cx were no growth. # Hypocortisolism Patient w/ cortisol 1.1 on transfer to ICU. She was noted to have bilateral adrenal masses which will need to be w/u as outpatient as potential cause of adrenal insufficiency. Due to patient's hypotn, she was tx w/ stress dosed steroids which will be tapered to off as an outpatient. # right MTA cellulitis Patient p/w mild cellulitis of her right MTA stump. This improved on antibx. Vascular was consulted and recommended, ultimately BKA. However, given patient is s/p urosepsis and on stress dose steroids, plan for d/c to rehab w/ plan to return for BKA in the future. She will undergo persantine MIBI prior to d/c for cardiac risk stratification preop. She will need to be on ASA and BB perioperatively. Her home BB was restarted on the day of d/c. Dr. [Last Name (STitle) ] is her vascular surgeon and is adamant that patient remain anticoagulated for dx hypercoagulable state. Her coumadin was held prior to d/c given supratherapeutic INR while on antibx. Today her INR is 1.9 so we will start lovenox and restart her coumadin w/ goal INR 2-2.5, at which time lovenox can be d/c. # CV - CAD: cath [4-18] w/ clean coronaries, EF > 60%, no CP this admission - Pump: bp well controlled, no failure on CXR - sinus rhythm # h/o asthma: Patient was tx w/ scheduled atrovent w/ albuterol prn given somewhat wheezy on exam. # Chronic anemia: Hct stable. Checking iron studies/folate/b12. # IDDM: RSSI. DM diet. Checking hgb A1c to further characterize. # PPX: PPI, on coumadin, bowel regimen, aspiration/fall precxs # FEN: Patient initially p/w mild hyponatremia (Na 133, down from 135-138 on last admission). Patient did not appear severely dry on exam but given h/o decreased MS, I suspected hypovolemic hyponatremia. However, after 1 L NS, patient's Na was down to 127. Patient's daughter had given h/o ? orthopnea at rehab and given patient's response to NS, patient was postulated to be hypervolemic. Thus, attempt was made for diuresis w/ lasix. This also did not improve patient's sodium and bp decreased to 85/palp. Patient subsequently responded to 1L NS bolus and was kept on maintenance NS o/n but in the AM was hypotn to 70/palp w/ sodium back up to 136. After aggressive rehydration in the ICU, her sodium improved further to 142. Her sodium has been stable since. Patient maintained on DM/cardiac diet. She underwent swallow evaluation which showed no evidence of aspiration. # Access: Patient has difficult access. Thus, a right UE PICC placed. # Full code # Dispo: to rehab, return for BKA in future Medications on Admission: hydromorphone 2 mg po q4h prn albuterol prn colace 100 mg po bid ms contin 15 mg po bid neurontin 100 mg po tid lipitor 20 mg po qd metoprolol 25 mg po bid tylenol prn coumadin 2 mg po qhs lactulose prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every 4-6 hours as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection four times a day: Please follow attached RSSI. 6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days: [4-25]. 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: [4-26], [4-27]. 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: [4-28], [4-29]. 11. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams Intravenous Q6H (every 6 hours) for 4 days: through [2169-4-27]. 12. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours) for 4 days: through [2169-4-27]. 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift until PICC d/c. 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day: hold for sbp < 110 or hr < 60. 16. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous twice a day: until INR > 2 on 2 consecutive days. 17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: goal INR 2-2.5. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: urosepsis right stump cellulitis Discharge Condition: good: bp stable, awake, alert, afebrile Discharge Instructions: Please call Dr. [First Name4 (NamePattern1) 1790] [Last Name (NamePattern1) 1789] at [Telephone/Fax (1) 1792] for temperature > 101, decreased mental status, redness/swelling of right stump, or any other concerning symptoms. Followup Instructions: 1. Please follow-up with Dr. [Last Name (STitle) ] on [2169-5-3] at 11:15 to discuss your need for further surgery on your right leg. Phone: ([Telephone/Fax (1) 1798] 2. Please follow-up with Dr. [Last Name (STitle) 1789] in 1 week to	Admission Date: <Date>1925-9-17</Date> Discharge Date: <Date>1960-10-8</Date> Date of Birth: <Date>1994-2-25</Date> Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Kamran</Name> Chief Complaint: 78 yo F w/ abd pain Major Surgical or Invasive Procedure: right femoral line right upper extremity PICC transient levophed History of Present Illness: 78 yo F w/ h/o hyperchol, IDDM, asthma, and s/p CCY several years ago who presents from rehab w/ c/o RUQ abd pain x 3 days. Patient d/c from <Hospital>Howell Ltd Hospital</Hospital> <Date>2011-3-5</Date> following a right transmetatarsal amputation for gangrenous right foot. Patient's admission was uncomplicated other than a fever spike on POD #1 o/n but CXR negative and patient defervesced. She required 1 U PRBC intraoperatively for hct 26.8. Per daughter, patient is somewhat confused and currently an unreliable historian, thus I relied on her daughter for hx. Her daughter states that her mom first started c/o diffuse abdominal pain but particularly subxiphoidal abdominal pain on Friday. Her mother states that the pain was occasionally worse w/ eating but her daughter states that her mom was eating a full liquid diet. She has been vomiting, however. Occasionally it is the food she just ate and other times she will vomit up her pills. However, she had soup and jello this am w/o vomiting. Her mom has also been c/o back pain but as far as her daughter can tell this is just her chronic LBP. She doesn't seem to relate the pain to her abdominal pain. Patient's daughter thinks her mom's last BM was on Friday but she is really not sure. Per notes, patient spiked temp of 101 at rehab. Patient's daughter is not aware of any h/o PUD or CAD in her mother. <Name>Heath Chin</Name> mom did have a gall bladder attack severeal years ago leading to CCY, but o/w no abdominal surgeries/issues. + h/o BRBPR. Daughter not sure if she's had a c-scope in the past. Daughter is not aware of any urinary complaints On further ROS: Patient has been having hallucinations which started in the hospital, attributed to pain medications. + SOB which is worse if she lies flat since her last admission to <Hospital>Howell Ltd Hospital</Hospital> Per notes, her mother also reported some chest tightness. Past Medical History: # hx hypercaoguable state - but no clear h/o DVT/PE # hypercholestremia # ? hx Dm2 - recent dx in setting of recent MTA # asthma # s/p cholecystectomy # PVD: on coumadin, s/p left metatarsal amputation '<Digit>33</Digit>, right metatarsal amputation <Date>2005-4-19</Date> - cath <Date>7-2</Date>: clean coronary arteries - ECHO <Date>4-18</Date>: EF > 60% Social History: Lived alone prior to d/c <Date>1-2</Date> when she was d/c to rehabiltation (Scherrill House) Denies tobacco and ETOH use Worked as greenhouse worker and babys<Name>Eleanor Feguson</Name> in the past 6 kids (2 deceased), divorced, her daughter <Name>Ubaldo Blanks</Name> has been very involved w/ this hospitalization Family History: no h/o PUD, pancreatic cancer or pancreatitis + h/o DM Physical Exam: T 99.5 bp 147/53 hr 78 rr 21 O2 97% RA genrl: lethargic but when aroused seems very awake but then quickly falls back to sleep, in nad at any time during my exam heent: pinpoint pupils but reactive (3mm->2mm), no photophobia, eomi, sclera anicteric, op clear but limited exam due to poor patient cooperation neck: supple cv: rrr, no m/r/g pulm: minimal expiratory wheeze, o/w CTA bilaterally, moves air well back: no cva tenderness, localizes back pain to L4/5 w/o spinous process tenderness abd: nabs, RUQ oblique scar (6" long, c/d/i), soft, mildly tender to palpation of RUQ w/o rebound/guarding, no masses/hsm extr: no c/c/e, s/p right metatarsal amputation - c/d/i w/o skin changes, left metatarsal amputation site appears somewhat cyanotic but warm bilaterally, slight underlying erythema but does not appear infected, no fluctuance and no d/c from surgical incision Pertinent Results: CK: 106 MB: 3 Trop-T: <0.01 x 2 Lactate:1.1 133 95 10 91 3.9 30 0.7 Ca: Pnd Mg: Pnd P: Pnd ALT: 86 AP: 165 Tbili: 0.6 Alb: 3.3 AST: 77 <Name>Juvenal</Name>: 60 Lip: 16 PT: 19.9 PTT: 31.6 INR: 2.5 <Date>1925-9-17</Date> 12:30PM WBC-12.2* RBC-3.68* HGB-10.0* HCT-30.4* MCV-83 MCH-27.1 MCHC-32.8 RDW-14.0 N:77.8 L:15.6 M:5.2 E:1.2 Bas:0.2 Hypochr: 1+ Poiklo: 1+ <Date>1925-9-17</Date> 07:42PM calTIBC-256* VIT B12-678 FOLATE-12.7 FERRITIN-568* TRF-197* RETIC 2.3% <Date>1925-9-17</Date> 07:42PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE Hep A IgG pos, IgM neg <Date>1925-9-17</Date> 07:42PM HCV Ab-NEGATIVE random cortisol 1.1 HGB A1C: pending TSH: 1.8 RPR: NR c diff neg x 3 Unit admission: FDP 10-40, fibrinogen 672 CT abd/pelvis <Date>10-5</Date>: 1. Mild dilatation of the distal common duct with no choledocholithiasis, unchanged from the prior ultrasound. 2. Status post cholecystectomy. 3. Likely left renal cyst, although too small to characterize. 4. Sigmoid diverticulosis. 5. Calcified fibroids. 6. Bilateral 2 cm adrenal masses, which cannot be characterized further on this study. 7. Fluid collection in the left groin, presumably related to recent catheterization. 6.0 x 3.0 cm RUQ U/S <Date>1940-12-29</Date>: IMPRESSION: Diffusely prominent common duct, as described above, unchanged in appearance from the patient's previous ultrasound exam of <Date>1915-10-23</Date>. This finding is likely related to the remote history of cholecystectomy. Otherwise, an unremarkable right upper quadrant ultrasound. CXR <Date>10-5</Date>: Right hilar fullness on the AP view without a definite abnormality on the lateral view. A repeat good technique AP and lateral may be performed to see whether this should be further evaluated with CT. EKG: sinus at 82 bpm, old QIII, no STTW changes urine cx <Date>4-3</Date>: > 100K GP bacteria - lactobacillus or alphastrep, neg nit/LE on UA at the time <Name>Shipley</Name> cx <Date>2003-9-13</Date>: > 100K enterococcus sensitive to vanc, ampicillin, levo bld cx <Date>10-5</Date>, <Date>9-23</Date>: no growth Brief Hospital Course: 78 yo F w/ h/o hyperchol, ? T2DM, asthma, and h/o PVD s/p bilateral MTA, most recently on the right (<Date>2005-4-19</Date>) who presents from rehab w/ c/o RUQ abd pain x 3 days. # Abdominal pain/vomiting CT abd/pelvis did not show anything that might explain this patient's presenting complaint. Her LFTs were slightly elevated on presentation concerning for possible cholestasis postop but they essentially normalized. Her statin was held prophylactically. Hepatitis panel was unremarkable, positive for hep A IgG but negative for hep A IgM. Her h/o vomiting was concerning for pancreatitis but her lipase/amylase WNL. Given ? h/o BM, we considered constipation as a cause of her abdominal pain and tx w/ aggressive bowel regimen. Consideration was made for a RP bleed or leaking AAA given h/o left groin hematoma following cath <Date>1-16</Date> but her presenting pain was in the RUQ, in addition to c/o her chronic L4/5 back pain. In addition her hct remained stable and her CT was unremarkable. Ms. <Name>Jones</Name> had no h/o PUD but did report h/o BRBPR years ago so we considered a possible stress ulcer and tx her accordingly w/ PPI, guiacing all her stools. There was no lactic acisosis to suggest ischemic gut and her lytes were WNL. She ultimately ended up being dx w/ urosepsis. Her urine cx showed > 100K colonies/ml of enterococcus sensitive to amp/levo/vanc. Plan to tx w/ vanc x 10 days (long duration of antibx for concurrent MTA cellulitis). Patient currently has no further c/o abdominal pain. # Decreased MS <Name>Pascual</Name> <Name>Brown</Name> on initial presentation given pinpoint pupils, h/o hallucinations, and being tx w/ dilaudid, MS contin, and neurontin at rehab. However, her MS <Name>Manu</Name> <Name>Moore</Name> despite holding pain medications, at which time patient was found to be hypotensive (70/palp w/ doppler assist). She was transiently started on pressors, aggressively hydrated, and MS returned to <Location>5480 Eric Ford Apt. 737 South Amandamouth, NJ 22097</Location> w/in 24 hours. She was thus also dx w/ urosepsis. Of note, blood cultures were negative for any growth. Folate/B12/TSH/RPR were all unremarkable. CXR was w/o infiltrate. # Fever/leukocytosis Patient ultimately dx w/ enterococcal UTI and right stump cellulitis. Plan to tx w/ a total of 10 days of vancomycin + zosyn. Of note, CXR w/o overt infiltrate. She did have loose stools this admission but was c diff neg x 3. Blood cx were no growth. # Hypocortisolism Patient w/ cortisol 1.1 on transfer to ICU. She was noted to have bilateral adrenal masses which will need to be w/u as outpatient as potential cause of adrenal insufficiency. Due to patient's hypotn, she was tx w/ stress dosed steroids which will be tapered to off as an outpatient. # right MTA cellulitis Patient p/w mild cellulitis of her right MTA stump. This improved on antibx. Vascular was consulted and recommended, ultimately BKA. However, given patient is s/p urosepsis and on stress dose steroids, plan for d/c to rehab w/ plan to return for BKA in the future. She will undergo persantine MIBI prior to d/c for cardiac risk stratification preop. She will need to be on ASA and BB perioperatively. Her home BB was restarted on the day of d/c. Dr. <Name>Sakkas</Name> is her vascular surgeon and is adamant that patient remain anticoagulated for dx hypercoagulable state. Her coumadin was held prior to d/c given supratherapeutic INR while on antibx. Today her INR is 1.9 so we will start lovenox and restart her coumadin w/ goal INR 2-2.5, at which time lovenox can be d/c. # CV - CAD: cath <Date>7-2</Date> w/ clean coronaries, EF > 60%, no CP this admission - Pump: bp well controlled, no failure on CXR - sinus rhythm # h/o asthma: Patient was tx w/ scheduled atrovent w/ albuterol prn given somewhat wheezy on exam. # Chronic anemia: Hct stable. Checking iron studies/folate/b12. # IDDM: RSSI. DM diet. Checking hgb A1c to further characterize. # PPX: PPI, on coumadin, bowel regimen, aspiration/fall precxs # FEN: Patient initially p/w mild hyponatremia (Na 133, down from 135-138 on last admission). Patient did not appear severely dry on exam but given h/o decreased MS, I suspected hypovolemic hyponatremia. However, after 1 L NS, patient's Na was down to 127. Patient's daughter had given h/o ? orthopnea at rehab and given patient's response to NS, patient was postulated to be hypervolemic. Thus, attempt was made for diuresis w/ lasix. This also did not improve patient's sodium and bp decreased to 85/palp. Patient subsequently responded to 1L NS bolus and was kept on maintenance NS o/n but in the AM was hypotn to 70/palp w/ sodium back up to 136. After aggressive rehydration in the ICU, her sodium improved further to 142. Her sodium has been stable since. Patient maintained on DM/cardiac diet. She underwent swallow evaluation which showed no evidence of aspiration. # Access: Patient has difficult access. Thus, a right UE PICC placed. # Full code # Dispo: to rehab, return for BKA in future Medications on Admission: hydromorphone 2 mg po q4h prn albuterol prn colace 100 mg po bid ms contin 15 mg po bid neurontin 100 mg po tid lipitor 20 mg po qd metoprolol 25 mg po bid tylenol prn coumadin 2 mg po qhs lactulose prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every 4-6 hours as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection four times a day: Please follow attached RSSI. 6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days: <Date>9-8</Date>. 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: <Date>12-1</Date>, <Date>3-29</Date>. 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: <Date>2-5</Date>, <Date>1-20</Date>. 11. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams Intravenous Q6H (every 6 hours) for 4 days: through <Date>1991-11-29</Date>. 12. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours) for 4 days: through <Date>1991-11-29</Date>. 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift until PICC d/c. 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day: hold for sbp < 110 or hr < 60. 16. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous twice a day: until INR > 2 on 2 consecutive days. 17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: goal INR 2-2.5. Discharge Disposition: Extended Care Facility: <Hospital>Salas PLC Health System</Hospital> - <Location>7223 Elliott Vista Suite 170 Lake Katherine, MD 85402</Location> Discharge Diagnosis: urosepsis right stump cellulitis Discharge Condition: good: bp stable, awake, alert, afebrile Discharge Instructions: Please call Dr. <Name>Cameron</Name> <Name>Deluna</Name> at <Telephone>955-176-3059</Telephone> for temperature > 101, decreased mental status, redness/swelling of right stump, or any other concerning symptoms. Followup Instructions: 1. Please follow-up with Dr. <Name>Sakkas</Name> on <Date>2010-10-27</Date> at 11:15 to discuss your need for further surgery on your right leg. Phone: (<Telephone>698-249-7155</Telephone> 2. Please follow-up with Dr. <Name>Meraz</Name> in 1 week 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Date: 1925-9-17 Discharge Date: 1960-10-8 Date of Birth: 1994-2-25 Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Kamran Chief Complaint: 78 yo F w/ abd pain Major Surgical or Invasive Procedure: right femoral line right upper extremity PICC transient levophed History of Present Illness: 78 yo F w/ h/o hyperchol, IDDM, asthma, and s/p CCY several years ago who presents from rehab w/ c/o RUQ abd pain x 3 days. Patient d/c from Howell Ltd Hospital 2011-3-5 following a right transmetatarsal amputation for gangrenous right foot. Patient's admission was uncomplicated other than a fever spike on POD #1 o/n but CXR negative and patient defervesced. She required 1 U PRBC intraoperatively for hct 26.8. Per daughter, patient is somewhat confused and currently an unreliable historian, thus I relied on her daughter for hx. Her daughter states that her mom first started c/o diffuse abdominal pain but particularly subxiphoidal abdominal pain on Friday. Her mother states that the pain was occasionally worse w/ eating but her daughter states that her mom was eating a full liquid diet. She has been vomiting, however. Occasionally it is the food she just ate and other times she will vomit up her pills. However, she had soup and jello this am w/o vomiting. Her mom has also been c/o back pain but as far as her daughter can tell this is just her chronic LBP. She doesn't seem to relate the pain to her abdominal pain. Patient's daughter thinks her mom's last BM was on Friday but she is really not sure. Per notes, patient spiked temp of 101 at rehab. Patient's daughter is not aware of any h/o PUD or CAD in her mother. Heath Chin mom did have a gall bladder attack severeal years ago leading to CCY, but o/w no abdominal surgeries/issues. + h/o BRBPR. Daughter not sure if she's had a c-scope in the past. Daughter is not aware of any urinary complaints On further ROS: Patient has been having hallucinations which started in the hospital, attributed to pain medications. + SOB which is worse if she lies flat since her last admission to Howell Ltd Hospital Per notes, her mother also reported some chest tightness. Past Medical History: # hx hypercaoguable state - but no clear h/o DVT/PE # hypercholestremia # ? hx Dm2 - recent dx in setting of recent MTA # asthma # s/p cholecystectomy # PVD: on coumadin, s/p left metatarsal amputation '33, right metatarsal amputation 2005-4-19 - cath 7-2: clean coronary arteries - ECHO 4-18: EF > 60% Social History: Lived alone prior to d/c 1-2 when she was d/c to rehabiltation (Scherrill House) Denies tobacco and ETOH use Worked as greenhouse worker and babysEleanor Feguson in the past 6 kids (2 deceased), divorced, her daughter Ubaldo Blanks has been very involved w/ this hospitalization Family History: no h/o PUD, pancreatic cancer or pancreatitis + h/o DM Physical Exam: T 99.5 bp 147/53 hr 78 rr 21 O2 97% RA genrl: lethargic but when aroused seems very awake but then quickly falls back to sleep, in nad at any time during my exam heent: pinpoint pupils but reactive (3mm->2mm), no photophobia, eomi, sclera anicteric, op clear but limited exam due to poor patient cooperation neck: supple cv: rrr, no m/r/g pulm: minimal expiratory wheeze, o/w CTA bilaterally, moves air well back: no cva tenderness, localizes back pain to L4/5 w/o spinous process tenderness abd: nabs, RUQ oblique scar (6" long, c/d/i), soft, mildly tender to palpation of RUQ w/o rebound/guarding, no masses/hsm extr: no c/c/e, s/p right metatarsal amputation - c/d/i w/o skin changes, left metatarsal amputation site appears somewhat cyanotic but warm bilaterally, slight underlying erythema but does not appear infected, no fluctuance and no d/c from surgical incision Pertinent Results: CK: 106 MB: 3 Trop-T: Juvenal: 60 Lip: 16 PT: 19.9 PTT: 31.6 INR: 2.5 1925-9-17 12:30PM WBC-12.2* RBC-3.68* HGB-10.0* HCT-30.4* MCV-83 MCH-27.1 MCHC-32.8 RDW-14.0 N:77.8 L:15.6 M:5.2 E:1.2 Bas:0.2 Hypochr: 1+ Poiklo: 1+ 1925-9-17 07:42PM calTIBC-256* VIT B12-678 FOLATE-12.7 FERRITIN-568* TRF-197* RETIC 2.3% 1925-9-17 07:42PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE Hep A IgG pos, IgM neg 1925-9-17 07:42PM HCV Ab-NEGATIVE random cortisol 1.1 HGB A1C: pending TSH: 1.8 RPR: NR c diff neg x 3 Unit admission: FDP 10-40, fibrinogen 672 CT abd/pelvis 10-5: 1. Mild dilatation of the distal common duct with no choledocholithiasis, unchanged from the prior ultrasound. 2. Status post cholecystectomy. 3. Likely left renal cyst, although too small to characterize. 4. Sigmoid diverticulosis. 5. Calcified fibroids. 6. Bilateral 2 cm adrenal masses, which cannot be characterized further on this study. 7. Fluid collection in the left groin, presumably related to recent catheterization. 6.0 x 3.0 cm RUQ U/S 1940-12-29: IMPRESSION: Diffusely prominent common duct, as described above, unchanged in appearance from the patient's previous ultrasound exam of 1915-10-23. This finding is likely related to the remote history of cholecystectomy. Otherwise, an unremarkable right upper quadrant ultrasound. CXR 10-5: Right hilar fullness on the AP view without a definite abnormality on the lateral view. A repeat good technique AP and lateral may be performed to see whether this should be further evaluated with CT. EKG: sinus at 82 bpm, old QIII, no STTW changes urine cx 4-3: > 100K GP bacteria - lactobacillus or alphastrep, neg nit/LE on UA at the time Shipley cx 2003-9-13: > 100K enterococcus sensitive to vanc, ampicillin, levo bld cx 10-5, 9-23: no growth Brief Hospital Course: 78 yo F w/ h/o hyperchol, ? T2DM, asthma, and h/o PVD s/p bilateral MTA, most recently on the right (2005-4-19) who presents from rehab w/ c/o RUQ abd pain x 3 days. # Abdominal pain/vomiting CT abd/pelvis did not show anything that might explain this patient's presenting complaint. Her LFTs were slightly elevated on presentation concerning for possible cholestasis postop but they essentially normalized. Her statin was held prophylactically. Hepatitis panel was unremarkable, positive for hep A IgG but negative for hep A IgM. Her h/o vomiting was concerning for pancreatitis but her lipase/amylase WNL. Given ? h/o BM, we considered constipation as a cause of her abdominal pain and tx w/ aggressive bowel regimen. Consideration was made for a RP bleed or leaking AAA given h/o left groin hematoma following cath 1-16 but her presenting pain was in the RUQ, in addition to c/o her chronic L4/5 back pain. In addition her hct remained stable and her CT was unremarkable. Ms. Jones had no h/o PUD but did report h/o BRBPR years ago so we considered a possible stress ulcer and tx her accordingly w/ PPI, guiacing all her stools. There was no lactic acisosis to suggest ischemic gut and her lytes were WNL. She ultimately ended up being dx w/ urosepsis. Her urine cx showed > 100K colonies/ml of enterococcus sensitive to amp/levo/vanc. Plan to tx w/ vanc x 10 days (long duration of antibx for concurrent MTA cellulitis). Patient currently has no further c/o abdominal pain. # Decreased MS Pascual Brown on initial presentation given pinpoint pupils, h/o hallucinations, and being tx w/ dilaudid, MS contin, and neurontin at rehab. However, her MS Manu Moore despite holding pain medications, at which time patient was found to be hypotensive (70/palp w/ doppler assist). She was transiently started on pressors, aggressively hydrated, and MS returned to 5480 Eric Ford Apt. 737 South Amandamouth, NJ 22097 w/in 24 hours. She was thus also dx w/ urosepsis. Of note, blood cultures were negative for any growth. Folate/B12/TSH/RPR were all unremarkable. CXR was w/o infiltrate. # Fever/leukocytosis Patient ultimately dx w/ enterococcal UTI and right stump cellulitis. Plan to tx w/ a total of 10 days of vancomycin + zosyn. Of note, CXR w/o overt infiltrate. She did have loose stools this admission but was c diff neg x 3. Blood cx were no growth. # Hypocortisolism Patient w/ cortisol 1.1 on transfer to ICU. She was noted to have bilateral adrenal masses which will need to be w/u as outpatient as potential cause of adrenal insufficiency. Due to patient's hypotn, she was tx w/ stress dosed steroids which will be tapered to off as an outpatient. # right MTA cellulitis Patient p/w mild cellulitis of her right MTA stump. This improved on antibx. Vascular was consulted and recommended, ultimately BKA. However, given patient is s/p urosepsis and on stress dose steroids, plan for d/c to rehab w/ plan to return for BKA in the future. She will undergo persantine MIBI prior to d/c for cardiac risk stratification preop. She will need to be on ASA and BB perioperatively. Her home BB was restarted on the day of d/c. Dr. Sakkas is her vascular surgeon and is adamant that patient remain anticoagulated for dx hypercoagulable state. Her coumadin was held prior to d/c given supratherapeutic INR while on antibx. Today her INR is 1.9 so we will start lovenox and restart her coumadin w/ goal INR 2-2.5, at which time lovenox can be d/c. # CV - CAD: cath 7-2 w/ clean coronaries, EF > 60%, no CP this admission - Pump: bp well controlled, no failure on CXR - sinus rhythm # h/o asthma: Patient was tx w/ scheduled atrovent w/ albuterol prn given somewhat wheezy on exam. # Chronic anemia: Hct stable. Checking iron studies/folate/b12. # IDDM: RSSI. DM diet. Checking hgb A1c to further characterize. # PPX: PPI, on coumadin, bowel regimen, aspiration/fall precxs # FEN: Patient initially p/w mild hyponatremia (Na 133, down from 135-138 on last admission). Patient did not appear severely dry on exam but given h/o decreased MS, I suspected hypovolemic hyponatremia. However, after 1 L NS, patient's Na was down to 127. Patient's daughter had given h/o ? orthopnea at rehab and given patient's response to NS, patient was postulated to be hypervolemic. Thus, attempt was made for diuresis w/ lasix. This also did not improve patient's sodium and bp decreased to 85/palp. Patient subsequently responded to 1L NS bolus and was kept on maintenance NS o/n but in the AM was hypotn to 70/palp w/ sodium back up to 136. After aggressive rehydration in the ICU, her sodium improved further to 142. Her sodium has been stable since. Patient maintained on DM/cardiac diet. She underwent swallow evaluation which showed no evidence of aspiration. # Access: Patient has difficult access. Thus, a right UE PICC placed. # Full code # Dispo: to rehab, return for BKA in future Medications on Admission: hydromorphone 2 mg po q4h prn albuterol prn colace 100 mg po bid ms contin 15 mg po bid neurontin 100 mg po tid lipitor 20 mg po qd metoprolol 25 mg po bid tylenol prn coumadin 2 mg po qhs lactulose prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every 4-6 hours as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection four times a day: Please follow attached RSSI. 6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days: 9-8. 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: 12-1, 3-29. 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: 2-5, 1-20. 11. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams Intravenous Q6H (every 6 hours) for 4 days: through 1991-11-29. 12. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours) for 4 days: through 1991-11-29. 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift until PICC d/c. 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day: hold for sbp 2 on 2 consecutive days. 17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: goal INR 2-2.5. Discharge Disposition: Extended Care Facility: Salas PLC Health System - 7223 Elliott Vista Suite 170 Lake Katherine, MD 85402 Discharge Diagnosis: urosepsis right stump cellulitis Discharge Condition: good: bp stable, awake, alert, afebrile Discharge Instructions: Please call Dr. Cameron Deluna at 955-176-3059 for temperature > 101, decreased mental status, redness/swelling of right stump, or any other concerning symptoms. Followup Instructions: 1. Please follow-up with Dr. Sakkas on 2010-10-27 at 11:15 to discuss your need for further surgery on your right leg. Phone: (698-249-7155 2. Please follow-up with Dr. Meraz in 1 week to	["Admission Date: 1925-9-17 Discharge Date: 1960-10-8\n\nDate of Birth: 1994-2-25 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Kamran\nChief Complaint:\n78 yo F w/ abd pain\n\nMajor Surgical or Invasive Procedure:\nright femoral line\nright upper extremity PICC\ntransient levophed\n\n\nHistory of Present Illness:\n78 yo F w/ h/o hyperchol, IDDM, asthma, and s/p CCY several\nyears ago who presents from rehab w/ c/o RUQ abd pain x 3 days.\nPatient d/c from Howell Ltd Hospital 2011-3-5 following a right transmetatarsal\namputation for gangrenous right foot. Patient's admission was\nuncomplicated other than a fever spike on POD #1 o/n but CXR\nnegative and patient defervesced. She required 1 U PRBC\nintraoperatively for hct 26.", "8. Per daughter, patient is somewhat\nconfused and currently an unreliable historian, thus I relied on\nher daughter for hx. Her daughter states that her mom first\nstarted c/o diffuse abdominal pain but particularly subxiphoidal\nabdominal pain on Friday. Her mother states that the pain was\noccasionally worse w/ eating but her daughter states that her\nmom was eating a full liquid diet. She has been vomiting,\nhowever. Occasionally it is the food she just ate and other\ntimes she will vomit up her pills. However, she had soup and\njello this am w/o vomiting. Her mom has also been c/o back pain\nbut as far as her daughter can tell this is just her chronic\nLBP. She doesn't seem to relate the pain to her abdominal pain.\nPatient's daughter thinks her mom's last BM was on Friday but\nshe is really not sure.", " Per notes, patient spiked temp of 101 at\nrehab. Patient's daughter is not aware of any h/o PUD or CAD in\nher mother. Heath Chin mom did have a gall bladder attack severeal\nyears ago leading to CCY, but o/w no abdominal surgeries/issues.\n+ h/o BRBPR. Daughter not sure if she's had a c-scope in the\npast. Daughter is not aware of any urinary complaints\n\nOn further ROS:\nPatient has been having hallucinations which started in the\nhospital, attributed to pain medications.\n\n+ SOB which is worse if she lies flat since her last admission\nto Howell Ltd Hospital\n\nPer notes, her mother also reported some chest tightness.\n\nPast Medical History:\n# hx hypercaoguable state - but no clear h/o DVT/PE\n# hypercholestremia\n# ? hx Dm2 - recent dx in setting of recent MTA\n# asthma\n# s/p cholecystectomy\n# PVD: on coumadin, s/p left metatarsal amputation '33, right\nmetatarsal amputation 2005-4-19\n\n- cath 7-2: clean coronary arteries\n- ECHO 4-18: EF > 60%\n\n\nSocial History:\nLived alone prior to d/c 1-2 when she was d/c to rehabiltation\n(Scherrill House)\nDenies tobacco and ETOH use\nWorked as greenhouse worker and babysEleanor Feguson in the past\n6 kids (2 deceased), divorced, her daughter Ubaldo Blanks has been very\ninvolved w/ this hospitalization\n\nFamily History:\nno h/o PUD, pancreatic cancer or pancreatitis\n+ h/o DM\n\nPhysical Exam:\nT 99.", '5 bp 147/53 hr 78 rr 21 O2 97% RA\ngenrl: lethargic but when aroused seems very awake but then\nquickly falls back to sleep, in nad at any time during my exam\nheent: pinpoint pupils but reactive (3mm->2mm), no photophobia,\neomi, sclera anicteric, op clear but limited exam due to poor\npatient cooperation\nneck: supple\ncv: rrr, no m/r/g\npulm: minimal expiratory wheeze, o/w CTA bilaterally, moves air\nwell\nback: no cva tenderness, localizes back pain to L4/5 w/o spinous\nprocess tenderness\nabd: nabs, RUQ oblique scar (6" long, c/d/i), soft, mildly\ntender to palpation of RUQ w/o rebound/guarding, no masses/hsm\nextr: no c/c/e, s/p right metatarsal amputation - c/d/i w/o skin\nchanges, left metatarsal amputation site appears somewhat\ncyanotic but warm bilaterally, slight underlying erythema but\ndoes not appear infected, no fluctuance and no d/c from surgical\nincision\n\n\nPertinent Results:\nCK: 106 MB: 3 Trop-T: Juvenal: 60 Lip: 16\n\nPT: 19.', '9 PTT: 31.6 INR: 2.5\n\n1925-9-17 12:30PM WBC-12.2* RBC-3.68* HGB-10.0* HCT-30.4\nMCV-83 MCH-27.1 MCHC-32.8 RDW-14.0\n\nN:77.8 L:15.6 M:5.2 E:1.2 Bas:0.2\nHypochr: 1+ Poiklo: 1+\n\n1925-9-17 07:42PM calTIBC-256 VIT B12-678 FOLATE-12.7\nFERRITIN-568* TRF-197* RETIC 2.3%\n1925-9-17 07:42PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc\nAb-NEGATIVE\nHep A IgG pos, IgM neg\n1925-9-17 07:42PM HCV Ab-NEGATIVE\n\nrandom cortisol 1.1\nHGB A1C: pending\nTSH: 1.8\nRPR: NR\n\nc diff neg x 3\n\nUnit admission:\nFDP 10-40, fibrinogen 672\n\nCT abd/pelvis 10-5:\n1. Mild dilatation of the distal common duct with no\ncholedocholithiasis, unchanged from the prior ultrasound.\n2. Status post cholecystectomy.\n3. Likely left renal cyst, although too small to characterize.\n4. Sigmoid diverticulosis.\n5. Calcified fibroids.\n6. Bilateral 2 cm adrenal masses, which cannot be characterized\nfurther on this study.', "\n7. Fluid collection in the left groin, presumably related to\nrecent\ncatheterization. 6.0 x 3.0 cm\n\nRUQ U/S 1940-12-29:\nIMPRESSION: Diffusely prominent common duct, as described above,\nunchanged in appearance from the patient's previous ultrasound\nexam of 1915-10-23. This\nfinding is likely related to the remote history of\ncholecystectomy. Otherwise, an unremarkable right upper quadrant\nultrasound.\n\nCXR 10-5:\nRight hilar fullness on the AP view without a definite\nabnormality\non the lateral view. A repeat good technique AP and lateral may\nbe performed to see whether this should be further evaluated\nwith CT.\n\nEKG: sinus at 82 bpm, old QIII, no STTW changes\n\nurine cx 4-3: > 100K GP bacteria - lactobacillus or alphastrep,\nneg nit/LE on UA at the time\n\nShipley cx 2003-9-13: > 100K enterococcus sensitive to vanc,\nampicillin, levo\n\nbld cx 10-5, 9-23: no growth\n\n\nBrief Hospital Course:\n78 yo F w/ h/o hyperchol, ? T2DM, asthma, and h/o PVD s/p\nbilateral MTA, most recently on the right (2005-4-19) who presents\nfrom rehab w/ c/o RUQ abd pain x 3 days.", "\n\n# Abdominal pain/vomiting\nCT abd/pelvis did not show anything that might explain this\npatient's presenting complaint. Her LFTs were slightly elevated\non presentation concerning for possible cholestasis postop but\nthey essentially normalized. Her statin was held\nprophylactically. Hepatitis panel was unremarkable, positive for\nhep A IgG but negative for hep A IgM. Her h/o vomiting was\nconcerning for pancreatitis but her lipase/amylase WNL. Given ?\nh/o BM, we considered constipation as a cause of her abdominal\npain and tx w/ aggressive bowel regimen. Consideration was made\nfor a RP bleed or leaking AAA given h/o left groin hematoma\nfollowing cath 1-16 but her presenting pain was in the RUQ, in\naddition to c/o her chronic L4/5 back pain. In addition her hct\nremained stable and her CT was unremarkable.", ' Ms. Jones had no\nh/o PUD but did report h/o BRBPR years ago so we considered a\npossible stress ulcer and tx her accordingly w/ PPI, guiacing\nall her stools. There was no lactic acisosis to suggest ischemic\ngut and her lytes were WNL. She ultimately ended up being dx w/\nurosepsis. Her urine cx showed > 100K colonies/ml of\nenterococcus sensitive to amp/levo/vanc. Plan to tx w/ vanc x 10\ndays (long duration of antibx for concurrent MTA cellulitis).\nPatient currently has no further c/o abdominal pain.\n\n# Decreased MS\nPascual Brown on initial presentation given pinpoint pupils,\nh/o hallucinations, and being tx w/ dilaudid, MS contin, and\nneurontin at rehab. However, her MS Manu Moore despite\nholding pain medications, at which time patient was found to be\nhypotensive (70/palp w/ doppler assist).', " She was transiently\nstarted on pressors, aggressively hydrated, and MS returned to\n5480 Eric Ford Apt. 737\nSouth Amandamouth, NJ 22097 w/in 24 hours. She was thus also dx w/ urosepsis. Of\nnote, blood cultures were negative for any growth.\nFolate/B12/TSH/RPR were all unremarkable. CXR was w/o\ninfiltrate.\n\n# Fever/leukocytosis\nPatient ultimately dx w/ enterococcal UTI and right stump\ncellulitis. Plan to tx w/ a total of 10 days of vancomycin +\nzosyn. Of note, CXR w/o overt infiltrate. She did have loose\nstools this admission but was c diff neg x 3. Blood cx were no\ngrowth.\n\n# Hypocortisolism\nPatient w/ cortisol 1.1 on transfer to ICU. She was noted to\nhave bilateral adrenal masses which will need to be w/u as\noutpatient as potential cause of adrenal insufficiency. Due to\npatient's hypotn, she was tx w/ stress dosed steroids which will\nbe tapered to off as an outpatient.", '\n\n# right MTA cellulitis\nPatient p/w mild cellulitis of her right MTA stump. This\nimproved on antibx. Vascular was consulted and recommended,\nultimately BKA. However, given patient is s/p urosepsis and on\nstress dose steroids, plan for d/c to rehab w/ plan to return\nfor BKA in the future. She will undergo persantine MIBI prior to\nd/c for cardiac risk stratification preop. She will need to be\non ASA and BB perioperatively. Her home BB was restarted on the\nday of d/c. Dr. Sakkas is her vascular surgeon and is adamant\nthat patient remain anticoagulated for dx hypercoagulable state.\nHer coumadin was held prior to d/c given supratherapeutic INR\nwhile on antibx. Today her INR is 1.9 so we will start lovenox\nand restart her coumadin w/ goal INR 2-2.5, at which time\nlovenox can be d/c.\n\n# CV\n- CAD: cath 7-2 w/ clean coronaries, EF > 60%, no CP this\nadmission\n- Pump: bp well controlled, no failure on CXR\n- sinus rhythm\n\n# h/o asthma: Patient was tx w/ scheduled atrovent w/ albuterol\nprn given somewhat wheezy on exam.', "\n\n# Chronic anemia: Hct stable. Checking iron studies/folate/b12.\n\n# IDDM: RSSI. DM diet. Checking hgb A1c to further characterize.\n\n# PPX: PPI, on coumadin, bowel regimen, aspiration/fall precxs\n\n# FEN:\nPatient initially p/w mild hyponatremia (Na 133, down from\n135-138 on last admission). Patient did not appear severely dry\non exam but given h/o decreased MS, I suspected hypovolemic\nhyponatremia. However, after 1 L NS, patient's Na was down to\n127. Patient's daughter had given h/o ? orthopnea at rehab and\ngiven patient's response to NS, patient was postulated to be\nhypervolemic. Thus, attempt was made for diuresis w/ lasix. This\nalso did not improve patient's sodium and bp decreased to\n85/palp. Patient subsequently responded to 1L NS bolus and was\nkept on maintenance NS o/n but in the AM was hypotn to 70/palp\nw/ sodium back up to 136.", ' After aggressive rehydration in the\nICU, her sodium improved further to 142. Her sodium has been\nstable since.\n\nPatient maintained on DM/cardiac diet. She underwent swallow\nevaluation which showed no evidence of aspiration.\n\n# Access: Patient has difficult access. Thus, a right UE PICC\nplaced.\n# Full code\n# Dispo: to rehab, return for BKA in future\n\nMedications on Admission:\nhydromorphone 2 mg po q4h prn\nalbuterol prn\ncolace 100 mg po bid\nms contin 15 mg po bid\nneurontin 100 mg po tid\nlipitor 20 mg po qd\nmetoprolol 25 mg po bid\ntylenol prn\ncoumadin 2 mg po qhs\nlactulose prn\n\n\nDischarge Medications:\n1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb\nInhalation every 4-6 hours as needed.\n2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed.', '\n4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.\n5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)\ninjection Injection four times a day: Please follow attached\nRSSI.\n6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\nhours) as needed for pain.\n7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3\ntimes a day).\n8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)\nfor 1 days: 9-8.\n9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for\n2 days: 12-1, 3-29.\n10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for\n2 days: 2-5, 1-20.\n11. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams\nIntravenous Q6H (every 6 hours) for 4 days: through 1991-11-29.\n12. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous\n Q24H (every 24 hours) for 4 days: through 1991-11-29.', '\n13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One\n(1) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by\n1ml of 100 units/ml heparin (100 units heparin) each lumen QD\nand PRN. Inspect site every shift until PICC d/c.\n14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO once a day.\n15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO\ntwice a day: hold for sbp 2 on 2 consecutive days.\n17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: goal\nINR 2-2.5.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nSalas PLC Health System - 7223 Elliott Vista Suite 170\nLake Katherine, MD 85402\n\nDischarge Diagnosis:\nurosepsis\nright stump cellulitis\n\n\nDischarge Condition:\ngood: bp stable, awake, alert, afebrile\n\nDischarge Instructions:\nPlease call Dr.', ' Cameron Deluna at 955-176-3059 for temperature\n> 101, decreased mental status, redness/swelling of right stump,\nor any other concerning symptoms.\n\nFollowup Instructions:\n1. Please follow-up with Dr. Sakkas on 2010-10-27 at 11:15 to\ndiscuss your need for further surgery on your right leg. Phone:\n(698-249-7155\n\n2. Please follow-up with Dr. Meraz in 1 week to\n\n\n\n']
173	10634	188945.0	2169-05-10	Discharge summary	Report	Admission Date: [2169-5-2] Discharge Date: [2169-5-10] Date of Birth: [2090-12-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: pt is a 78 yo Spanish-speaking lady who presents w/ fevers and lethargy. She is s/p was admit at [Hospital1 18] [Date range (2) 1799] c/b adrenal insufficiency (cortisol 1.1), bilateral adrenal masses, urosepsis. She was briefly on pressors and was noted to have a R MTA cellulitis as well. She is s/p right transmetatarsal amputation [3-25] by [Month/Year (2) 1106] surgery and is planned for elective R BKA once her medical condition stabalizes. On day of this admission, pt was noted to have fevers and lethargy at her rehab, was "quiet." Patient herself denies CP/sob/abd pain/headaches/dysuria/diarrhea. In the ED, she was found to be febrile to 103, sbp's 70's, HR 132, sat 91% RA, and she was admitted to the MICU w/ sepsis protocol. She was treated initially with stress dose steroids, empiric abx, fluids, levophed. Past Medical History: # hx hypercaoguable state - but no clear h/o DVT/PE # hypercholestremia # ? hx Dm2 - recent dx in setting of recent MTA # asthma # s/p cholecystectomy # PVD: on coumadin, s/p left metatarsal amputation '[62], right metatarsal amputation [2169-4-11] - cath [4-18]: clean coronary arteries - ECHO [5-21]: EF > 60% Social History: Lived alone prior to d/c [3-25] when she was d/c to rehabiltation ([First Name4 (NamePattern1) 1785] [Last Name (NamePattern1) ])Denies tobacco and ETOH useWorked as greenhouse worker and babys[Name (NI) 1786] in the past6 kids (2 deceased), divorced, her daughter [Name (NI) 1787] has been very involved w/ this hospitalization and visits w/ patient daily Family History: no h/o PUD, pancreatic cancer or pancreatitis + h/o DM Physical Exam: T 103 BP 110/62 (sbp's 70's-110) P 132 RR 24 sat 91% RA Gen: resting comfortable, NAD HEENT: anicteric, MMM, RIJ line in place Neck: supple, No LAD Chest: BCTA CV: tachy, regular, no murmurs ABD: obese, NABS, soft, NT, ND EXTRM: No LE edema, Right LE stump w/ mild erythema, sutures in place w/o drainage, pus, minimal tenderness, no palpable pulses or RLE; PICC in right forearm w/o warmth/tenderness Neuro: intact Pertinent Results: [2169-5-2] 12:40PM PT-17.6* PTT-44.4* INR(PT)-2.0 [2169-5-2] 12:40PM PLT COUNT-132* [2169-5-2] 12:40PM NEUTS-76.2* LYMPHS-17.9* MONOS-3.9 EOS-1.7 BASOS-0.3 [2169-5-2] 12:40PM WBC-19.7* RBC-4.88 HGB-13.3 HCT-41.8 MCV-86 MCH-27.3 MCHC-31.8 RDW-15.7* [2169-5-2] 12:40PM GLUCOSE-115* UREA N-16 CREAT-1.2* SODIUM-135 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12 [2169-5-2] 12:45PM GLUCOSE-124* LACTATE-0.9 [2169-5-2] 03:41PM URINE RBC-0-2 WBC-[4-22] BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-0-2 [2169-5-2] 03:41PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2169-5-2] 03:41PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.018 [2169-5-2] 05:24PM TYPE-MIX RATES-/20 O2 FLOW-4 PO2-62* PCO2-59* PH-7.24* TOTAL CO2-27 BASE XS--3 INTUBATED-NOT INTUBA CXR: persistent L effusion,?consolidation EKG: sinus tachy, rate 127, no other changes (per MICU report)- EKG not in chart at time of discharge Brief Hospital Course: 78 yo lady w/ recent urosepsis, recent right transmetatarsal ampuatation, adrenal insufficiency, temp, here w/ likely sepsis. 1. Sepsis/fever: patient was initially admitted to the MICU for sepsis protocol. She was started on empiric antibiotic therapy w/ vanco/levoflox/flagyl. She was pancultured and her PICC line was removed, central line placed. Her cultures (urine, blood, PICC line tip) are negative to date. She was given fluid resussitation w/ good response in her BP. She was on pressors for a short time in the intensive care unit as well but was quickly weaned. She was given stress dose steroids for her recent diagnosis of adrenal insufficiency. She stabalized, was afebrile after admission, and was transferred to the medical floor in stable condition. Her vancomycin and flagyl were stopped secondary to lack of culture data and stable, afebrile course. Levoflox was continued for 7 day course to tx for ?UTI. [Month/Day/Year ] surgery service followed patient closely and felt her RLE warranted elective BKA but there was no active site of infection. Exam consistent w/ dry gangrene. ?RLE cellulits noted on admission H+P resolved quickly and was not thought to be source for sepsis. Upon d/c, she will be on no further antibiotic therapy. 2. Adrenal insufficiency/hemorrhage: patient had adrenal insufficiency during admission, was given stress dose steroids. Endocrine was consulted and requested dedicated ABD CT to adrenal glands. Bilateral adrenal hemorrhage was noted on the scan. She was at risk for this, given her recent surgery, coumadin use, hospitalization. Her hematocrits remained stable. Her steroids were rapidly weaned to prednisone 5 mg/day and fludricortisone was added on [5-6] as well. An early morning cortisytropin stim test was done during admission (previous to her daily prednisone 5 mg dose given). This showed cortisol 1.3 w/ stim to 1.5 and 1.6 at 30 min and 60 min, respectively. This indicates that the patient remains adrenally insufficient and should continue on her prednisone. ACTH and aldosterone are pending at the time of this dictation and will be followed up as outpatient. Patient is scheduled for follow up with [Hospital 1800] clinic. BP's remained stable after ICU course. 3. Hyperglycemia: not diabetic but kept on insulin scale while on high dose steroids. D/c'd this during her admission when steroids tapered down. 4. hypercoagulable state: has h/o of this-- is on coumadin. Details unclear. Goal INR [3-23]. Coumadin transiently stopped during admit for line placement, etc. Restarted and will need dose adjustments after discharge. 5. PVD: s/p Right transmetatarsal amputation last month. [Month/Day (3) ] followed patient during admission. On coumadin as above. Plans for right BKA discussed at length. Dr. [Last Name (STitle) ] from [Last Name (STitle) 1106] surgery wished to do this electively in 2 weeks, but not on this admission. Follow up scheduled. 6. thromocytopenia: stable and chronically low. No clear med-related decrease. Stable counts on admission. Peripheral smear w/o abnormality. 7. full code 8. dispo: daughter [Name (NI) 1801] wanted to take patient home w/ services, but then decided pt best suited for rehab stay. Medications on Admission: albuterol nebs colace/senna sliding scale insulin? oxycodone 5 mg q6 hr prn neurontin 100 mg tid prednisone taper (now d/c'd) zosyn/vanco (d/c'd [2169-4-27]) protonix metoprolol 25 mg [Hospital1 ] lovenox--->coumadin Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q3-4H () as needed. 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Outpatient Lab Work INR daily until [3-23], then weekly 9. Fludrocortisone Acetate 0.1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): please adjust once INR [3-23] (note: was on 1 mg qhs as outpatient). 11. dry dressing changes qd to right lower extremity Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Sepsis Adrenal insufficiency Bilateral adrenal hemorrhage severe PVD ?dry gangrene RLE Discharge Condition: stable Discharge Instructions: Take all medications as below. please follow up with your doctors, as below. If you develop dizziness, lightheadedness, confusion, fevers, chills, please call your doctor and/or return to the emergency room for evaluation. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1802], MD Where: [Hospital6 29] MEDICAL SPECIALTIES (endocrinology) Phone:[Telephone/Fax (1) 1803] Date/Time:[2169-6-16] 1:30. [Hospital Ward Name 23] bldg, [Location (un) 436]. Booked w/ spanish interpreter. Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY Where: [Last Name (NamePattern4) ] SURGERY Date/Time:[2169-5-17] with interpreter at 1 pm ([Telephone/Fax (1) 1804] Please follow up with Dr [Last Name (STitle) 1789] as well, within 1-2 weeks of discharge. Completed by:[2169-5-10]	Admission Date: <Date>1958-8-4</Date> Discharge Date: <Date>1996-6-17</Date> Date of Birth: <Date>1926-8-9</Date> Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Austin</Name> Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: pt is a 78 yo Spanish-speaking lady who presents w/ fevers and lethargy. She is s/p was admit at <Hospital>Hutchinson-Finley Clinic</Hospital> <Date Range>1918-7-29 to 2019-7-4</Date Range> c/b adrenal insufficiency (cortisol 1.1), bilateral adrenal masses, urosepsis. She was briefly on pressors and was noted to have a R MTA cellulitis as well. She is s/p right transmetatarsal amputation <Date>7-26</Date> by <Month>April</Month> surgery and is planned for elective R BKA once her medical condition stabalizes. On day of this admission, pt was noted to have fevers and lethargy at her rehab, was "quiet." Patient herself denies CP/sob/abd pain/headaches/dysuria/diarrhea. In the ED, she was found to be febrile to 103, sbp's 70's, HR 132, sat 91% RA, and she was admitted to the MICU w/ sepsis protocol. She was treated initially with stress dose steroids, empiric abx, fluids, levophed. Past Medical History: # hx hypercaoguable state - but no clear h/o DVT/PE # hypercholestremia # ? hx Dm2 - recent dx in setting of recent MTA # asthma # s/p cholecystectomy # PVD: on coumadin, s/p left metatarsal amputation '<Digit>31</Digit>, right metatarsal amputation <Date>1974-1-10</Date> - cath <Date>7-11</Date>: clean coronary arteries - ECHO <Date>1-31</Date>: EF > 60% Social History: Lived alone prior to d/c <Date>7-26</Date> when she was d/c to rehabiltation (<Name>Eliseo</Name> <Name>Debelius</Name>)Denies tobacco and ETOH useWorked as greenhouse worker and babys<Name>Keisha Yuen</Name> in the past6 kids (2 deceased), divorced, her daughter <Name>Zachary Hui</Name> has been very involved w/ this hospitalization and visits w/ patient daily Family History: no h/o PUD, pancreatic cancer or pancreatitis + h/o DM Physical Exam: T 103 BP 110/62 (sbp's 70's-110) P 132 RR 24 sat 91% RA Gen: resting comfortable, NAD HEENT: anicteric, MMM, RIJ line in place Neck: supple, No LAD Chest: BCTA CV: tachy, regular, no murmurs ABD: obese, NABS, soft, NT, ND EXTRM: No LE edema, Right LE stump w/ mild erythema, sutures in place w/o drainage, pus, minimal tenderness, no palpable pulses or RLE; PICC in right forearm w/o warmth/tenderness Neuro: intact Pertinent Results: <Date>1958-8-4</Date> 12:40PM PT-17.6* PTT-44.4* INR(PT)-2.0 <Date>1958-8-4</Date> 12:40PM PLT COUNT-132* <Date>1958-8-4</Date> 12:40PM NEUTS-76.2* LYMPHS-17.9* MONOS-3.9 EOS-1.7 BASOS-0.3 <Date>1958-8-4</Date> 12:40PM WBC-19.7* RBC-4.88 HGB-13.3 HCT-41.8 MCV-86 MCH-27.3 MCHC-31.8 RDW-15.7* <Date>1958-8-4</Date> 12:40PM GLUCOSE-115* UREA N-16 CREAT-1.2* SODIUM-135 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12 <Date>1958-8-4</Date> 12:45PM GLUCOSE-124* LACTATE-0.9 <Date>1958-8-4</Date> 03:41PM URINE RBC-0-2 WBC-<Date>11-22</Date> BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-0-2 <Date>1958-8-4</Date> 03:41PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG <Date>1958-8-4</Date> 03:41PM URINE COLOR-Yellow APPEAR-Clear SP <Name>William</Name>-1.018 <Date>1958-8-4</Date> 05:24PM TYPE-MIX RATES-/20 O2 FLOW-4 PO2-62* PCO2-59* PH-7.24* TOTAL CO2-27 BASE XS--3 INTUBATED-NOT INTUBA CXR: persistent L effusion,?consolidation EKG: sinus tachy, rate 127, no other changes (per MICU report)- EKG not in chart at time of discharge Brief Hospital Course: 78 yo lady w/ recent urosepsis, recent right transmetatarsal ampuatation, adrenal insufficiency, temp, here w/ likely sepsis. 1. Sepsis/fever: patient was initially admitted to the MICU for sepsis protocol. She was started on empiric antibiotic therapy w/ vanco/levoflox/flagyl. She was pancultured and her PICC line was removed, central line placed. Her cultures (urine, blood, PICC line tip) are negative to date. She was given fluid resussitation w/ good response in her BP. She was on pressors for a short time in the intensive care unit as well but was quickly weaned. She was given stress dose steroids for her recent diagnosis of adrenal insufficiency. She stabalized, was afebrile after admission, and was transferred to the medical floor in stable condition. Her vancomycin and flagyl were stopped secondary to lack of culture data and stable, afebrile course. Levoflox was continued for 7 day course to tx for ?UTI. <Month>June</Month> surgery service followed patient closely and felt her RLE warranted elective BKA but there was no active site of infection. Exam consistent w/ dry gangrene. ?RLE cellulits noted on admission H+P resolved quickly and was not thought to be source for sepsis. Upon d/c, she will be on no further antibiotic therapy. 2. Adrenal insufficiency/hemorrhage: patient had adrenal insufficiency during admission, was given stress dose steroids. Endocrine was consulted and requested dedicated ABD CT to adrenal glands. Bilateral adrenal hemorrhage was noted on the scan. She was at risk for this, given her recent surgery, coumadin use, hospitalization. Her hematocrits remained stable. Her steroids were rapidly weaned to prednisone 5 mg/day and fludricortisone was added on <Date>7-22</Date> as well. An early morning cortisytropin stim test was done during admission (previous to her daily prednisone 5 mg dose given). This showed cortisol 1.3 w/ stim to 1.5 and 1.6 at 30 min and 60 min, respectively. This indicates that the patient remains adrenally insufficient and should continue on her prednisone. ACTH and aldosterone are pending at the time of this dictation and will be followed up as outpatient. Patient is scheduled for follow up with <Hospital>White-Ponce Clinic</Hospital> clinic. BP's remained stable after ICU course. 3. Hyperglycemia: not diabetic but kept on insulin scale while on high dose steroids. D/c'd this during her admission when steroids tapered down. 4. hypercoagulable state: has h/o of this-- is on coumadin. Details unclear. Goal INR <Date>10-20</Date>. Coumadin transiently stopped during admit for line placement, etc. Restarted and will need dose adjustments after discharge. 5. PVD: s/p Right transmetatarsal amputation last month. <Month>July</Month> followed patient during admission. On coumadin as above. Plans for right BKA discussed at length. Dr. <Name>Dizon</Name> from <Name>Waldon</Name> surgery wished to do this electively in 2 weeks, but not on this admission. Follow up scheduled. 6. thromocytopenia: stable and chronically low. No clear med-related decrease. Stable counts on admission. Peripheral smear w/o abnormality. 7. full code 8. dispo: daughter <Name>Lauren Smith</Name> wanted to take patient home w/ services, but then decided pt best suited for rehab stay. Medications on Admission: albuterol nebs colace/senna sliding scale insulin? oxycodone 5 mg q6 hr prn neurontin 100 mg tid prednisone taper (now d/c'd) zosyn/vanco (d/c'd <Date>2017-12-1</Date>) protonix metoprolol 25 mg <Hospital>Stewart-Ray Medical Center</Hospital> lovenox--->coumadin Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q3-4H () as needed. 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Outpatient Lab Work INR daily until <Date>10-20</Date>, then weekly 9. Fludrocortisone Acetate 0.1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): please adjust once INR <Date>10-20</Date> (note: was on 1 mg qhs as outpatient). 11. dry dressing changes qd to right lower extremity Discharge Disposition: Extended Care Facility: <Hospital>Mitchell-Patterson Clinic</Hospital> for the Aged - <Location>06479 Johnson Turnpike Adamtown, HI 91338</Location> Discharge Diagnosis: Sepsis Adrenal insufficiency Bilateral adrenal hemorrhage severe PVD ?dry gangrene RLE Discharge Condition: stable Discharge Instructions: Take all medications as below. please follow up with your doctors, as below. If you develop dizziness, lightheadedness, confusion, fevers, chills, please call your doctor and/or return to the emergency room for evaluation. Followup Instructions: Provider: <Name>Celeste</Name> <Name>Johnson</Name>, MD Where: <Hospital>Vaughan Inc Hospital</Hospital> MEDICAL SPECIALTIES (endocrinology) Phone:<Telephone>416-619-2638</Telephone> Date/Time:<Date>2020-3-25</Date> 1:30. <Hospital>Martinez-Stevenson Health System</Hospital> bldg, <Location>469 Stephanie Mount Suite 184 West Lindsayton, MH 29657</Location>. Booked w/ spanish interpreter. Provider: <Name>Ava Finateri</Name>,<Name>Dylan</Name> <Initial>OI</Initial> <Name>Lockett</Name> SURGERY Where: <Name>Lockett</Name> SURGERY Date/Time:<Date>1923-12-4</Date> with interpreter at 1 pm (<Telephone>417-783-8505</Telephone> Please follow up with Dr <Name>Turcios</Name> as well, within 1-2 weeks of discharge. Completed 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Date: 1958-8-4 Discharge Date: 1996-6-17 Date of Birth: 1926-8-9 Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Austin Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: pt is a 78 yo Spanish-speaking lady who presents w/ fevers and lethargy. She is s/p was admit at Hutchinson-Finley Clinic 1918-7-29 to 2019-7-4 c/b adrenal insufficiency (cortisol 1.1), bilateral adrenal masses, urosepsis. She was briefly on pressors and was noted to have a R MTA cellulitis as well. She is s/p right transmetatarsal amputation 7-26 by April surgery and is planned for elective R BKA once her medical condition stabalizes. On day of this admission, pt was noted to have fevers and lethargy at her rehab, was "quiet." Patient herself denies CP/sob/abd pain/headaches/dysuria/diarrhea. In the ED, she was found to be febrile to 103, sbp's 70's, HR 132, sat 91% RA, and she was admitted to the MICU w/ sepsis protocol. She was treated initially with stress dose steroids, empiric abx, fluids, levophed. Past Medical History: # hx hypercaoguable state - but no clear h/o DVT/PE # hypercholestremia # ? hx Dm2 - recent dx in setting of recent MTA # asthma # s/p cholecystectomy # PVD: on coumadin, s/p left metatarsal amputation '31, right metatarsal amputation 1974-1-10 - cath 7-11: clean coronary arteries - ECHO 1-31: EF > 60% Social History: Lived alone prior to d/c 7-26 when she was d/c to rehabiltation (Eliseo Debelius)Denies tobacco and ETOH useWorked as greenhouse worker and babysKeisha Yuen in the past6 kids (2 deceased), divorced, her daughter Zachary Hui has been very involved w/ this hospitalization and visits w/ patient daily Family History: no h/o PUD, pancreatic cancer or pancreatitis + h/o DM Physical Exam: T 103 BP 110/62 (sbp's 70's-110) P 132 RR 24 sat 91% RA Gen: resting comfortable, NAD HEENT: anicteric, MMM, RIJ line in place Neck: supple, No LAD Chest: BCTA CV: tachy, regular, no murmurs ABD: obese, NABS, soft, NT, ND EXTRM: No LE edema, Right LE stump w/ mild erythema, sutures in place w/o drainage, pus, minimal tenderness, no palpable pulses or RLE; PICC in right forearm w/o warmth/tenderness Neuro: intact Pertinent Results: 1958-8-4 12:40PM PT-17.6* PTT-44.4* INR(PT)-2.0 1958-8-4 12:40PM PLT COUNT-132* 1958-8-4 12:40PM NEUTS-76.2* LYMPHS-17.9* MONOS-3.9 EOS-1.7 BASOS-0.3 1958-8-4 12:40PM WBC-19.7* RBC-4.88 HGB-13.3 HCT-41.8 MCV-86 MCH-27.3 MCHC-31.8 RDW-15.7* 1958-8-4 12:40PM GLUCOSE-115* UREA N-16 CREAT-1.2* SODIUM-135 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12 1958-8-4 12:45PM GLUCOSE-124* LACTATE-0.9 1958-8-4 03:41PM URINE RBC-0-2 WBC-11-22 BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-0-2 1958-8-4 03:41PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 1958-8-4 03:41PM URINE COLOR-Yellow APPEAR-Clear SP William-1.018 1958-8-4 05:24PM TYPE-MIX RATES-/20 O2 FLOW-4 PO2-62* PCO2-59* PH-7.24* TOTAL CO2-27 BASE XS--3 INTUBATED-NOT INTUBA CXR: persistent L effusion,?consolidation EKG: sinus tachy, rate 127, no other changes (per MICU report)- EKG not in chart at time of discharge Brief Hospital Course: 78 yo lady w/ recent urosepsis, recent right transmetatarsal ampuatation, adrenal insufficiency, temp, here w/ likely sepsis. 1. Sepsis/fever: patient was initially admitted to the MICU for sepsis protocol. She was started on empiric antibiotic therapy w/ vanco/levoflox/flagyl. She was pancultured and her PICC line was removed, central line placed. Her cultures (urine, blood, PICC line tip) are negative to date. She was given fluid resussitation w/ good response in her BP. She was on pressors for a short time in the intensive care unit as well but was quickly weaned. She was given stress dose steroids for her recent diagnosis of adrenal insufficiency. She stabalized, was afebrile after admission, and was transferred to the medical floor in stable condition. Her vancomycin and flagyl were stopped secondary to lack of culture data and stable, afebrile course. Levoflox was continued for 7 day course to tx for ?UTI. June surgery service followed patient closely and felt her RLE warranted elective BKA but there was no active site of infection. Exam consistent w/ dry gangrene. ?RLE cellulits noted on admission H+P resolved quickly and was not thought to be source for sepsis. Upon d/c, she will be on no further antibiotic therapy. 2. Adrenal insufficiency/hemorrhage: patient had adrenal insufficiency during admission, was given stress dose steroids. Endocrine was consulted and requested dedicated ABD CT to adrenal glands. Bilateral adrenal hemorrhage was noted on the scan. She was at risk for this, given her recent surgery, coumadin use, hospitalization. Her hematocrits remained stable. Her steroids were rapidly weaned to prednisone 5 mg/day and fludricortisone was added on 7-22 as well. An early morning cortisytropin stim test was done during admission (previous to her daily prednisone 5 mg dose given). This showed cortisol 1.3 w/ stim to 1.5 and 1.6 at 30 min and 60 min, respectively. This indicates that the patient remains adrenally insufficient and should continue on her prednisone. ACTH and aldosterone are pending at the time of this dictation and will be followed up as outpatient. Patient is scheduled for follow up with White-Ponce Clinic clinic. BP's remained stable after ICU course. 3. Hyperglycemia: not diabetic but kept on insulin scale while on high dose steroids. D/c'd this during her admission when steroids tapered down. 4. hypercoagulable state: has h/o of this-- is on coumadin. Details unclear. Goal INR 10-20. Coumadin transiently stopped during admit for line placement, etc. Restarted and will need dose adjustments after discharge. 5. PVD: s/p Right transmetatarsal amputation last month. July followed patient during admission. On coumadin as above. Plans for right BKA discussed at length. Dr. Dizon from Waldon surgery wished to do this electively in 2 weeks, but not on this admission. Follow up scheduled. 6. thromocytopenia: stable and chronically low. No clear med-related decrease. Stable counts on admission. Peripheral smear w/o abnormality. 7. full code 8. dispo: daughter Lauren Smith wanted to take patient home w/ services, but then decided pt best suited for rehab stay. Medications on Admission: albuterol nebs colace/senna sliding scale insulin? oxycodone 5 mg q6 hr prn neurontin 100 mg tid prednisone taper (now d/c'd) zosyn/vanco (d/c'd 2017-12-1) protonix metoprolol 25 mg Stewart-Ray Medical Center lovenox--->coumadin Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q3-4H () as needed. 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Outpatient Lab Work INR daily until 10-20, then weekly 9. Fludrocortisone Acetate 0.1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): please adjust once INR 10-20 (note: was on 1 mg qhs as outpatient). 11. dry dressing changes qd to right lower extremity Discharge Disposition: Extended Care Facility: Mitchell-Patterson Clinic for the Aged - 06479 Johnson Turnpike Adamtown, HI 91338 Discharge Diagnosis: Sepsis Adrenal insufficiency Bilateral adrenal hemorrhage severe PVD ?dry gangrene RLE Discharge Condition: stable Discharge Instructions: Take all medications as below. please follow up with your doctors, as below. If you develop dizziness, lightheadedness, confusion, fevers, chills, please call your doctor and/or return to the emergency room for evaluation. Followup Instructions: Provider: Celeste Johnson, MD Where: Vaughan Inc Hospital MEDICAL SPECIALTIES (endocrinology) Phone:416-619-2638 Date/Time:2020-3-25 1:30. Martinez-Stevenson Health System bldg, 469 Stephanie Mount Suite 184 West Lindsayton, MH 29657. Booked w/ spanish interpreter. Provider: Ava Finateri,Dylan OI Lockett SURGERY Where: Lockett SURGERY Date/Time:1923-12-4 with interpreter at 1 pm (417-783-8505 Please follow up with Dr Turcios as well, within 1-2 weeks of discharge. Completed by:1996-6-17	['Admission Date: 1958-8-4 Discharge Date: 1996-6-17\n\nDate of Birth: 1926-8-9 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Austin\nChief Complaint:\nfever\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\npt is a 78 yo Spanish-speaking lady who presents w/ fevers and\nlethargy. She is s/p was admit at Hutchinson-Finley Clinic 1918-7-29 to 2019-7-4 c/b\nadrenal insufficiency (cortisol 1.1), bilateral adrenal masses,\nurosepsis. She was briefly on pressors and was noted to have a R\nMTA cellulitis as well. She is s/p right transmetatarsal\namputation 7-26 by April surgery and is planned for elective\nR BKA once her medical condition stabalizes. On day of this\nadmission, pt was noted to have fevers and lethargy at her\nrehab, was "quiet.', '" Patient herself denies CP/sob/abd\npain/headaches/dysuria/diarrhea. In the ED, she was found to be\nfebrile to 103, sbp\'s 70\'s, HR 132, sat 91% RA, and she was\nadmitted to the MICU w/ sepsis protocol. She was treated\ninitially with stress dose steroids, empiric abx, fluids,\nlevophed.\n\nPast Medical History:\n# hx hypercaoguable state - but no clear h/o DVT/PE\n# hypercholestremia\n# ? hx Dm2 - recent dx in setting of recent MTA\n# asthma\n# s/p cholecystectomy\n# PVD: on coumadin, s/p left metatarsal amputation \'31, right\nmetatarsal amputation 1974-1-10\n\n- cath 7-11: clean coronary arteries\n- ECHO 1-31: EF > 60%\n\n\nSocial History:\nLived alone prior to d/c 7-26 when she was d/c to rehabiltation\n(Eliseo Debelius)Denies tobacco and ETOH useWorked as greenhouse\nworker and babysKeisha Yuen in the past6 kids (2 deceased), divorced,\nher daughter Zachary Hui has been very involved w/ this\nhospitalization and visits w/ patient daily\n\nFamily History:\nno h/o PUD, pancreatic cancer or pancreatitis\n+ h/o DM\n\nPhysical Exam:\nT 103 BP 110/62 (sbp\'s 70\'s-110) P 132 RR 24 sat 91% RA\nGen: resting comfortable, NAD\nHEENT: anicteric, MMM, RIJ line in place\nNeck: supple, No LAD\nChest: BCTA\nCV: tachy, regular, no murmurs\nABD: obese, NABS, soft, NT, ND\nEXTRM: No LE edema, Right LE stump w/ mild erythema, sutures in\nplace w/o drainage, pus, minimal tenderness, no palpable pulses\nor RLE; PICC in right forearm w/o warmth/tenderness\nNeuro: intact\n\nPertinent Results:\n1958-8-4 12:40PM PT-17.', '6* PTT-44.4* INR(PT)-2.0\n1958-8-4 12:40PM PLT COUNT-132\n1958-8-4 12:40PM NEUTS-76.2 LYMPHS-17.9* MONOS-3.9 EOS-1.7\nBASOS-0.3\n1958-8-4 12:40PM WBC-19.7* RBC-4.88 HGB-13.3 HCT-41.8 MCV-86\nMCH-27.3 MCHC-31.8 RDW-15.7\n1958-8-4 12:40PM GLUCOSE-115 UREA N-16 CREAT-1.2* SODIUM-135\nPOTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12\n1958-8-4 12:45PM GLUCOSE-124* LACTATE-0.9\n1958-8-4 03:41PM URINE RBC-0-2 WBC-11-22 BACTERIA-RARE YEAST-NONE\nEPI-0-2 TRANS EPI-0-2\n1958-8-4 03:41PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0\nLEUK-NEG\n1958-8-4 03:41PM URINE COLOR-Yellow APPEAR-Clear SP William-1.018\n\n1958-8-4 05:24PM TYPE-MIX RATES-/20 O2 FLOW-4 PO2-62* PCO2-59\nPH-7.24 TOTAL CO2-27 BASE XS--3 INTUBATED-NOT INTUBA\n\nCXR: persistent L effusion,?consolidation\n\nEKG: sinus tachy, rate 127, no other changes (per MICU report)-\nEKG not in chart at time of discharge\n\n\nBrief Hospital Course:\n78 yo lady w/ recent urosepsis, recent right transmetatarsal\nampuatation, adrenal insufficiency, temp, here w/ likely sepsis.', '\n\n1. Sepsis/fever: patient was initially admitted to the MICU for\nsepsis protocol. She was started on empiric antibiotic therapy\nw/ vanco/levoflox/flagyl. She was pancultured and her PICC line\nwas removed, central line placed. Her cultures (urine, blood,\nPICC line tip) are negative to date. She was given fluid\nresussitation w/ good response in her BP. She was on pressors\nfor a short time in the intensive care unit as well but was\nquickly weaned. She was given stress dose steroids for her\nrecent diagnosis of adrenal insufficiency. She stabalized, was\nafebrile after admission, and was transferred to the medical\nfloor in stable condition. Her vancomycin and flagyl were\nstopped secondary to lack of culture data and stable, afebrile\ncourse. Levoflox was continued for 7 day course to tx for ?UTI.', '\nJune surgery service followed patient closely and felt her\nRLE warranted elective BKA but there was no active site of\ninfection. Exam consistent w/ dry gangrene. ?RLE cellulits noted\non admission H+P resolved quickly and was not thought to be\nsource for sepsis. Upon d/c, she will be on no further\nantibiotic therapy.\n\n2. Adrenal insufficiency/hemorrhage: patient had adrenal\ninsufficiency during admission, was given stress dose steroids.\nEndocrine was consulted and requested dedicated ABD CT to\nadrenal glands. Bilateral adrenal hemorrhage was noted on the\nscan. She was at risk for this, given her recent surgery,\ncoumadin use, hospitalization. Her hematocrits remained stable.\nHer steroids were rapidly weaned to prednisone 5 mg/day and\nfludricortisone was added on 7-22 as well. An early morning\ncortisytropin stim test was done during admission (previous to\nher daily prednisone 5 mg dose given).', " This showed cortisol 1.3\nw/ stim to 1.5 and 1.6 at 30 min and 60 min, respectively. This\nindicates that the patient remains adrenally insufficient and\nshould continue on her prednisone. ACTH and aldosterone are\npending at the time of this dictation and will be followed up as\noutpatient. Patient is scheduled for follow up with White-Ponce Clinic\nclinic. BP's remained stable after ICU course.\n\n3. Hyperglycemia: not diabetic but kept on insulin scale while\non high dose steroids. D/c'd this during her admission when\nsteroids tapered down.\n\n4. hypercoagulable state: has h/o of this-- is on coumadin.\nDetails unclear. Goal INR 10-20. Coumadin transiently stopped\nduring admit for line placement, etc. Restarted and will need\ndose adjustments after discharge.\n\n5. PVD: s/p Right transmetatarsal amputation last month.", "\nJuly followed patient during admission. On coumadin as\nabove. Plans for right BKA discussed at length. Dr. Dizon from\nWaldon surgery wished to do this electively in 2 weeks, but\nnot on this admission. Follow up scheduled.\n\n6. thromocytopenia: stable and chronically low. No clear\nmed-related decrease. Stable counts on admission. Peripheral\nsmear w/o abnormality.\n\n7. full code\n\n8. dispo: daughter Lauren Smith wanted to take patient home w/\nservices, but then decided pt best suited for rehab stay.\n\n\nMedications on Admission:\nalbuterol nebs\ncolace/senna\nsliding scale insulin?\noxycodone 5 mg q6 hr prn\nneurontin 100 mg tid\nprednisone taper (now d/c'd)\nzosyn/vanco (d/c'd 2017-12-1)\nprotonix\nmetoprolol 25 mg Stewart-Ray Medical Center\nlovenox--->coumadin\n\nDischarge Medications:\n1. Albuterol Sulfate 0.", '083 % Solution Sig: One (1) neb\nInhalation Q3-4H () as needed.\n2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3\ntimes a day).\n3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:\nOne (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n\n4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every\n4 to 6 hours) as needed.\n5. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\nhours) as needed for pain.\n6. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime).\n7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n8. Outpatient Lab Work\nINR daily until 10-20, then weekly\n9. Fludrocortisone Acetate 0.1 mg Tablet Sig: 0.5 Tablet PO\nDAILY (Daily).\n10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime): please adjust once INR 10-20 (note: was on 1 mg qhs as\noutpatient).', '\n11. dry dressing changes qd to right lower extremity\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nMitchell-Patterson Clinic for the Aged - 06479 Johnson Turnpike\nAdamtown, HI 91338\n\nDischarge Diagnosis:\nSepsis\nAdrenal insufficiency\nBilateral adrenal hemorrhage\nsevere PVD\n?dry gangrene RLE\n\n\nDischarge Condition:\nstable\n\nDischarge Instructions:\nTake all medications as below. please follow up with your\ndoctors, as below. If you develop dizziness, lightheadedness,\nconfusion, fevers, chills, please call your doctor and/or return\nto the emergency room for evaluation.\n\nFollowup Instructions:\nProvider: Celeste Johnson, MD Where: Vaughan Inc Hospital MEDICAL\nSPECIALTIES (endocrinology) Phone:416-619-2638\nDate/Time:2020-3-25 1:30. Martinez-Stevenson Health System bldg, 469 Stephanie Mount Suite 184\nWest Lindsayton, MH 29657.', ' Booked w/\nspanish interpreter.\n\nProvider: Ava Finateri,Dylan OI Lockett SURGERY Where: Lockett\nSURGERY Date/Time:1923-12-4 with interpreter at 1 pm (417-783-8505\n\nPlease follow up with Dr Turcios as well, within 1-2 weeks of\ndischarge.\n\n\n\nCompleted by:1996-6-17']
440	13728	171866.0	2149-06-05	Discharge summary	Report	Admission Date: [2149-6-2] Discharge Date: [2149-6-5] Date of Birth: [2081-3-23] Sex: M Service: CHIEF COMPLAINT: Left lower lobe pneumococcal pneumonia, congestive heart failure. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 1968] is a 68-year-old white male with a history of CAD status post three vessel CABG, EF less than 20%, mild COPD, hypertension, history of head and neck cancer, history of Hodgkin's disease, status post resection in [2144], in remission, who presents with left sided chest pain, worsening dyspnea on exertion, shortness of breath and cough. Roughly two months ago the patient was still able to walk about one mile without problems, however, in the last month he has started to notice increasing fatigue and dyspnea on exertion. Three weeks ago he began coughing with fevers up to 101 and mild chills intermittently. In the last two weeks he has also noted increased sneezing and severe non productive cough. Two days ago he developed [2158-1-26] constant stabbing chest pain under the left breast, pleuritic in nature, worse with cough and unresponsive to Nitroglycerin. It was also worse with walking. His episodes of pain occur approximately one hour at a time and he does experience shortness of breath but no nausea, vomiting, diaphoresis or radiation. The patient denies headaches, neck stiffness, sore throat, abdominal pain, myalgias, arthralgias and dysuria. He has never been intubated. He does not have a history of pneumonia. In the Emergency Room he was tachypneic into the 30's, initially satting 77%. He was then placed on a partial non rebreather mask at 15 liters and was noted to sat in the low 90's. He was given 40 mg of IV Lasix and diuresed about 150 cc of urine. Chest x-ray obtained in the AW showed mild failure and a retrocardiac opacity. He received 325 mg of Aspirin. Blood cultures times two were obtained and he was given one dose of Levofloxacin. His initial ABG was as follows: 7.49/32/38. PHYSICAL EXAMINATION: On admission, vital signs, temperature 103.0 (rectal), pulse 109, blood pressure 98/44, respiratory rate 26, O2 saturation 96% on 15 liters partial non rebreather mask. General, alert and oriented times three, pleasant, in mild respiratory distress with face mask on but talking in full sentences. HEENT: Pupils were equal, round and reactive to light, extraocular movements intact, oropharynx was dry. There is fullness of the neck but no lymphadenopathy. Heart, normal S1 and normal S2, no S3, no murmurs or rubs. PMI non displaced. Lungs, bronchial breath sounds bibasilarly left greater than right. No rales. Abdominal, obese, soft, nontender, non distended, normoactive bowel sounds, no CVA tenderness. Extremities, 1+ DP and PT pulses bilaterally, trace bilateral pitting edema up to the knees. LABORATORY DATA: White blood cell count 21.5, hematocrit 41.2, platelet count 311,000, neutrophils 92%, bands 7%, lymphs 0%, basos 1%, sodium 137, potassium 4.5, chloride 100, CO2 20, BUN 33, creatinine 1.7, glucose 100. PT 20.7, PTT 41.5, INR 2.8. Urinalysis, yellow, clear, specific gravity 1.014, no nitrites, no red blood cells, no white blood cells, no bacteria, no yeast. Chest x-ray #1 perihilar edema bilaterally, #2 left retrocardiac opacity, effusion vs infiltrate. EKG, sinus tachycardia with rate 108, normal axis, normal intervals, no acute ST-T wave abnormalities. PROBLEM LIST: 1. Possible pneumonia. 2. Possible CHF exacerbation. 3. Increased creatinine. 4. Chest pain. HOSPITAL COURSE: The patient was brought to the MICU on a partial 15 liters of oxygen flowing through partial non rebreather mask. His oxygen saturations were in the mid to high 90's on this and his tachypnea began resolving quickly. The patient was ruled out for an MI by cardiac enzymes and serial EKG's and he was started on 500 mg IV q d of Levofloxacin. His blood pressure in the MICU was initially 80/40 and there was concern that central access would need to be placed to evaluate the etiology of his hypotension. However, his blood pressure responded well to normal saline boluses of 250 cc each. He did not experience further hypotension for the rest of his admission. All of his home medications were continued except for Carvedilol which was held as we were concerned for possible CHF exacerbation. On day #2 of his admission he began to diurese well on his home regimen of Lasix and his oxygen requirement was quickly weaned from 15 liters partial non rebreather mask to 4 liters of nasal cannula oxygen. On day #2 of his admission the blood cultures came back 4/4 bottles positive for pneumococcus which was pansensitive. Theory then to explain his acute and severe hypoxia was that his gas exchange was impaired by pneumococcal pneumonia and a transient bacteremia which may have dropped his SVR and caused him to temporarily decompensate from a cardiac standpoint. In order to further evaluate his cardiac function, a transthoracic echocardiogram was obtained which was most notable for a normal LV wall thickness and cavity size and an ejection fraction of 30-40%. This is in contrast to an echocardiogram done in [2146] which showed an anteroapical aneurysm in the LV and an ejection fraction of less than 20%. His initial AP chest x-ray was followed up with PA and lateral to further evaluate this retrocardiac opacity and the lateral appeared more consistent with an infiltrate than an effusion. On day #3 of his admission the sensitivities came back on the blood cultures, strain of strep pneumonia was sensitive to Penicillin and so the patient's regimen was switched to 2,000,000 units q 4 hours of Penicillin G. The patient tolerated this well, showing no acute allergic reactions. Since being admitted to the MICU, Mr. [Known lastname 1968] has been stable from a hemodynamic standpoint and a gas exchange standpoint. On day #3 of his admission a PT consult was obtained and Mr. [Known lastname 1968] was able to walk around the [Hospital1 ] without any difficulty or desaturation. MEDICAL ISSUES: 1. Congestive heart failure. 2. Resolving pneumococcal pneumonia. 3. Coronary artery disease, status post three vessel CABG and silent MI. 4. Mild Chronic obstructive pulmonary disease. 5. Crohn's disease. 6. Head and neck squamous cell carcinoma. 7. Advanced Hodgkin's disease status post resection in [2144]. 8. Nephrolithiasis. DISCHARGE MEDICATIONS: Penicillin VK 2,000,000 units qid, Lipitor 10 mg po q d, Lasix 40 mg po q d, K-Dur 20 mEq po bid, Coumadin 2.5 mg po q d, Synthroid 300 mcg po q d, Carvedilol 6.25 mg po q d, Cozaar 50 mg po q d, Amiodarone 200 mg po bid, Theophylline 24 hours 300 mg po q d, Dipentum 250 mg po bid. CONDITION ON DISCHARGE: Stable. Discharged to home. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3090], M.D. [MD Number(1) 3091] Dictated By:[Doctor Last Name 3769] MEDQUIST36 D: [2149-6-4] 18:09 T: [2149-6-4] 18:31 JOB#: [Job Number 3770]	Admission Date: <Date>2015-4-26</Date> Discharge Date: <Date>1948-6-28</Date> Date of Birth: <Date>1992-4-19</Date> Sex: M Service: CHIEF COMPLAINT: Left lower lobe pneumococcal pneumonia, congestive heart failure. HISTORY OF PRESENT ILLNESS: Mr. <Name>Thompson</Name> is a 68-year-old white male with a history of CAD status post three vessel CABG, EF less than 20%, mild COPD, hypertension, history of head and neck cancer, history of Hodgkin's disease, status post resection in <Year>1983</Year>, in remission, who presents with left sided chest pain, worsening dyspnea on exertion, shortness of breath and cough. Roughly two months ago the patient was still able to walk about one mile without problems, however, in the last month he has started to notice increasing fatigue and dyspnea on exertion. Three weeks ago he began coughing with fevers up to 101 and mild chills intermittently. In the last two weeks he has also noted increased sneezing and severe non productive cough. Two days ago he developed <Date>1998-1-3</Date> constant stabbing chest pain under the left breast, pleuritic in nature, worse with cough and unresponsive to Nitroglycerin. It was also worse with walking. His episodes of pain occur approximately one hour at a time and he does experience shortness of breath but no nausea, vomiting, diaphoresis or radiation. The patient denies headaches, neck stiffness, sore throat, abdominal pain, myalgias, arthralgias and dysuria. He has never been intubated. He does not have a history of pneumonia. In the Emergency Room he was tachypneic into the 30's, initially satting 77%. He was then placed on a partial non rebreather mask at 15 liters and was noted to sat in the low 90's. He was given 40 mg of IV Lasix and diuresed about 150 cc of urine. Chest x-ray obtained in the AW showed mild failure and a retrocardiac opacity. He received 325 mg of Aspirin. Blood cultures times two were obtained and he was given one dose of Levofloxacin. His initial ABG was as follows: 7.49/32/38. PHYSICAL EXAMINATION: On admission, vital signs, temperature 103.0 (rectal), pulse 109, blood pressure 98/44, respiratory rate 26, O2 saturation 96% on 15 liters partial non rebreather mask. General, alert and oriented times three, pleasant, in mild respiratory distress with face mask on but talking in full sentences. HEENT: Pupils were equal, round and reactive to light, extraocular movements intact, oropharynx was dry. There is fullness of the neck but no lymphadenopathy. Heart, normal S1 and normal S2, no S3, no murmurs or rubs. PMI non displaced. Lungs, bronchial breath sounds bibasilarly left greater than right. No rales. Abdominal, obese, soft, nontender, non distended, normoactive bowel sounds, no CVA tenderness. Extremities, 1+ DP and PT pulses bilaterally, trace bilateral pitting edema up to the knees. LABORATORY DATA: White blood cell count 21.5, hematocrit 41.2, platelet count 311,000, neutrophils 92%, bands 7%, lymphs 0%, basos 1%, sodium 137, potassium 4.5, chloride 100, CO2 20, BUN 33, creatinine 1.7, glucose 100. PT 20.7, PTT 41.5, INR 2.8. Urinalysis, yellow, clear, specific gravity 1.014, no nitrites, no red blood cells, no white blood cells, no bacteria, no yeast. Chest x-ray #1 perihilar edema bilaterally, #2 left retrocardiac opacity, effusion vs infiltrate. EKG, sinus tachycardia with rate 108, normal axis, normal intervals, no acute ST-T wave abnormalities. PROBLEM LIST: 1. Possible pneumonia. 2. Possible CHF exacerbation. 3. Increased creatinine. 4. Chest pain. HOSPITAL COURSE: The patient was brought to the MICU on a partial 15 liters of oxygen flowing through partial non rebreather mask. His oxygen saturations were in the mid to high 90's on this and his tachypnea began resolving quickly. The patient was ruled out for an MI by cardiac enzymes and serial EKG's and he was started on 500 mg IV q d of Levofloxacin. His blood pressure in the MICU was initially 80/40 and there was concern that central access would need to be placed to evaluate the etiology of his hypotension. However, his blood pressure responded well to normal saline boluses of 250 cc each. He did not experience further hypotension for the rest of his admission. All of his home medications were continued except for Carvedilol which was held as we were concerned for possible CHF exacerbation. On day #2 of his admission he began to diurese well on his home regimen of Lasix and his oxygen requirement was quickly weaned from 15 liters partial non rebreather mask to 4 liters of nasal cannula oxygen. On day #2 of his admission the blood cultures came back 4/4 bottles positive for pneumococcus which was pansensitive. Theory then to explain his acute and severe hypoxia was that his gas exchange was impaired by pneumococcal pneumonia and a transient bacteremia which may have dropped his SVR and caused him to temporarily decompensate from a cardiac standpoint. In order to further evaluate his cardiac function, a transthoracic echocardiogram was obtained which was most notable for a normal LV wall thickness and cavity size and an ejection fraction of 30-40%. This is in contrast to an echocardiogram done in <Year>1983</Year> which showed an anteroapical aneurysm in the LV and an ejection fraction of less than 20%. His initial AP chest x-ray was followed up with PA and lateral to further evaluate this retrocardiac opacity and the lateral appeared more consistent with an infiltrate than an effusion. On day #3 of his admission the sensitivities came back on the blood cultures, strain of strep pneumonia was sensitive to Penicillin and so the patient's regimen was switched to 2,000,000 units q 4 hours of Penicillin G. The patient tolerated this well, showing no acute allergic reactions. Since being admitted to the MICU, Mr. <Name>Thompson</Name> has been stable from a hemodynamic standpoint and a gas exchange standpoint. On day #3 of his admission a PT consult was obtained and Mr. <Name>Thompson</Name> was able to walk around the <Hospital>Avila-Summers Hospital</Hospital> without any difficulty or desaturation. MEDICAL ISSUES: 1. Congestive heart failure. 2. Resolving pneumococcal pneumonia. 3. Coronary artery disease, status post three vessel CABG and silent MI. 4. Mild Chronic obstructive pulmonary disease. 5. Crohn's disease. 6. Head and neck squamous cell carcinoma. 7. Advanced Hodgkin's disease status post resection in <Year>1983</Year>. 8. Nephrolithiasis. DISCHARGE MEDICATIONS: Penicillin VK 2,000,000 units qid, Lipitor 10 mg po q d, Lasix 40 mg po q d, K-Dur 20 mEq po bid, Coumadin 2.5 mg po q d, Synthroid 300 mcg po q d, Carvedilol 6.25 mg po q d, Cozaar 50 mg po q d, Amiodarone 200 mg po bid, Theophylline 24 hours 300 mg po q d, Dipentum 250 mg po bid. CONDITION ON DISCHARGE: Stable. Discharged to home. <Name>Raymundo</Name> <Name>Deluna</Name>, M.D. <MD Number>50561007</MD Number> Dictated By:<Doctor Name>Dr.Chowdhury</Doctor Name> MEDQUIST36 D: <Date>2006-7-26</Date> 18:09 T: <Date>2006-7-26</Date> 18:31 JOB#: <Job Number>Wong LLC-1907-258129</Job 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00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000011111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111011111100000000111111110000000000000011111111111100000000000000000111111111000000000000111111111000000000000000111111111111111111110	Admission Date: 2015-4-26 Discharge Date: 1948-6-28 Date of Birth: 1992-4-19 Sex: M Service: CHIEF COMPLAINT: Left lower lobe pneumococcal pneumonia, congestive heart failure. HISTORY OF PRESENT ILLNESS: Mr. Thompson is a 68-year-old white male with a history of CAD status post three vessel CABG, EF less than 20%, mild COPD, hypertension, history of head and neck cancer, history of Hodgkin's disease, status post resection in 1983, in remission, who presents with left sided chest pain, worsening dyspnea on exertion, shortness of breath and cough. Roughly two months ago the patient was still able to walk about one mile without problems, however, in the last month he has started to notice increasing fatigue and dyspnea on exertion. Three weeks ago he began coughing with fevers up to 101 and mild chills intermittently. In the last two weeks he has also noted increased sneezing and severe non productive cough. Two days ago he developed 1998-1-3 constant stabbing chest pain under the left breast, pleuritic in nature, worse with cough and unresponsive to Nitroglycerin. It was also worse with walking. His episodes of pain occur approximately one hour at a time and he does experience shortness of breath but no nausea, vomiting, diaphoresis or radiation. The patient denies headaches, neck stiffness, sore throat, abdominal pain, myalgias, arthralgias and dysuria. He has never been intubated. He does not have a history of pneumonia. In the Emergency Room he was tachypneic into the 30's, initially satting 77%. He was then placed on a partial non rebreather mask at 15 liters and was noted to sat in the low 90's. He was given 40 mg of IV Lasix and diuresed about 150 cc of urine. Chest x-ray obtained in the AW showed mild failure and a retrocardiac opacity. He received 325 mg of Aspirin. Blood cultures times two were obtained and he was given one dose of Levofloxacin. His initial ABG was as follows: 7.49/32/38. PHYSICAL EXAMINATION: On admission, vital signs, temperature 103.0 (rectal), pulse 109, blood pressure 98/44, respiratory rate 26, O2 saturation 96% on 15 liters partial non rebreather mask. General, alert and oriented times three, pleasant, in mild respiratory distress with face mask on but talking in full sentences. HEENT: Pupils were equal, round and reactive to light, extraocular movements intact, oropharynx was dry. There is fullness of the neck but no lymphadenopathy. Heart, normal S1 and normal S2, no S3, no murmurs or rubs. PMI non displaced. Lungs, bronchial breath sounds bibasilarly left greater than right. No rales. Abdominal, obese, soft, nontender, non distended, normoactive bowel sounds, no CVA tenderness. Extremities, 1+ DP and PT pulses bilaterally, trace bilateral pitting edema up to the knees. LABORATORY DATA: White blood cell count 21.5, hematocrit 41.2, platelet count 311,000, neutrophils 92%, bands 7%, lymphs 0%, basos 1%, sodium 137, potassium 4.5, chloride 100, CO2 20, BUN 33, creatinine 1.7, glucose 100. PT 20.7, PTT 41.5, INR 2.8. Urinalysis, yellow, clear, specific gravity 1.014, no nitrites, no red blood cells, no white blood cells, no bacteria, no yeast. Chest x-ray #1 perihilar edema bilaterally, #2 left retrocardiac opacity, effusion vs infiltrate. EKG, sinus tachycardia with rate 108, normal axis, normal intervals, no acute ST-T wave abnormalities. PROBLEM LIST: 1. Possible pneumonia. 2. Possible CHF exacerbation. 3. Increased creatinine. 4. Chest pain. HOSPITAL COURSE: The patient was brought to the MICU on a partial 15 liters of oxygen flowing through partial non rebreather mask. His oxygen saturations were in the mid to high 90's on this and his tachypnea began resolving quickly. The patient was ruled out for an MI by cardiac enzymes and serial EKG's and he was started on 500 mg IV q d of Levofloxacin. His blood pressure in the MICU was initially 80/40 and there was concern that central access would need to be placed to evaluate the etiology of his hypotension. However, his blood pressure responded well to normal saline boluses of 250 cc each. He did not experience further hypotension for the rest of his admission. All of his home medications were continued except for Carvedilol which was held as we were concerned for possible CHF exacerbation. On day #2 of his admission he began to diurese well on his home regimen of Lasix and his oxygen requirement was quickly weaned from 15 liters partial non rebreather mask to 4 liters of nasal cannula oxygen. On day #2 of his admission the blood cultures came back 4/4 bottles positive for pneumococcus which was pansensitive. Theory then to explain his acute and severe hypoxia was that his gas exchange was impaired by pneumococcal pneumonia and a transient bacteremia which may have dropped his SVR and caused him to temporarily decompensate from a cardiac standpoint. In order to further evaluate his cardiac function, a transthoracic echocardiogram was obtained which was most notable for a normal LV wall thickness and cavity size and an ejection fraction of 30-40%. This is in contrast to an echocardiogram done in 1983 which showed an anteroapical aneurysm in the LV and an ejection fraction of less than 20%. His initial AP chest x-ray was followed up with PA and lateral to further evaluate this retrocardiac opacity and the lateral appeared more consistent with an infiltrate than an effusion. On day #3 of his admission the sensitivities came back on the blood cultures, strain of strep pneumonia was sensitive to Penicillin and so the patient's regimen was switched to 2,000,000 units q 4 hours of Penicillin G. The patient tolerated this well, showing no acute allergic reactions. Since being admitted to the MICU, Mr. Thompson has been stable from a hemodynamic standpoint and a gas exchange standpoint. On day #3 of his admission a PT consult was obtained and Mr. Thompson was able to walk around the Avila-Summers Hospital without any difficulty or desaturation. MEDICAL ISSUES: 1. Congestive heart failure. 2. Resolving pneumococcal pneumonia. 3. Coronary artery disease, status post three vessel CABG and silent MI. 4. Mild Chronic obstructive pulmonary disease. 5. Crohn's disease. 6. Head and neck squamous cell carcinoma. 7. Advanced Hodgkin's disease status post resection in 1983. 8. Nephrolithiasis. DISCHARGE MEDICATIONS: Penicillin VK 2,000,000 units qid, Lipitor 10 mg po q d, Lasix 40 mg po q d, K-Dur 20 mEq po bid, Coumadin 2.5 mg po q d, Synthroid 300 mcg po q d, Carvedilol 6.25 mg po q d, Cozaar 50 mg po q d, Amiodarone 200 mg po bid, Theophylline 24 hours 300 mg po q d, Dipentum 250 mg po bid. CONDITION ON DISCHARGE: Stable. Discharged to home. Raymundo Deluna, M.D. 50561007 Dictated By:Dr.Chowdhury MEDQUIST36 D: 2006-7-26 18:09 T: 2006-7-26 18:31 JOB#: Wong LLC-1907-258129	["Admission Date: 2015-4-26 Discharge Date: 1948-6-28\n\nDate of Birth: 1992-4-19 Sex: M\n\nService:\n\nCHIEF COMPLAINT: Left lower lobe pneumococcal pneumonia,\ncongestive heart failure.\n\nHISTORY OF PRESENT ILLNESS: Mr. Thompson is a 68-year-old white\nmale with a history of CAD status post three vessel CABG, EF\nless than 20%, mild COPD, hypertension, history of head and\nneck cancer, history of Hodgkin's disease, status post\nresection in 1983, in remission, who presents with left sided\nchest pain, worsening dyspnea on exertion, shortness of\nbreath and cough. Roughly two months ago the patient was\nstill able to walk about one mile without problems, however,\nin the last month he has started to notice increasing fatigue\nand dyspnea on exertion. Three weeks ago he began coughing\nwith fevers up to 101 and mild chills intermittently.", " In the\nlast two weeks he has also noted increased sneezing and\nsevere non productive cough. Two days ago he developed\n1998-1-3 constant stabbing chest pain under the left breast,\npleuritic in nature, worse with cough and unresponsive to\nNitroglycerin. It was also worse with walking. His episodes\nof pain occur approximately one hour at a time and he does\nexperience shortness of breath but no nausea, vomiting,\ndiaphoresis or radiation. The patient denies headaches, neck\nstiffness, sore throat, abdominal pain, myalgias, arthralgias\nand dysuria. He has never been intubated. He does not have\na history of pneumonia. In the Emergency Room he was\ntachypneic into the 30's, initially satting 77%. He was then\nplaced on a partial non rebreather mask at 15 liters and was\nnoted to sat in the low 90's.", ' He was given 40 mg of IV Lasix\nand diuresed about 150 cc of urine. Chest x-ray obtained in\nthe AW showed mild failure and a retrocardiac opacity. He\nreceived 325 mg of Aspirin. Blood cultures times two were\nobtained and he was given one dose of Levofloxacin. His\ninitial ABG was as follows: 7.49/32/38.\n\nPHYSICAL EXAMINATION: On admission, vital signs, temperature\n103.0 (rectal), pulse 109, blood pressure 98/44, respiratory\nrate 26, O2 saturation 96% on 15 liters partial non\nrebreather mask. General, alert and oriented times three,\npleasant, in mild respiratory distress with face mask on but\ntalking in full sentences. HEENT: Pupils were equal, round\nand reactive to light, extraocular movements intact,\noropharynx was dry. There is fullness of the neck but no\nlymphadenopathy. Heart, normal S1 and normal S2, no S3, no\nmurmurs or rubs.', ' PMI non displaced. Lungs, bronchial breath\nsounds bibasilarly left greater than right. No rales.\nAbdominal, obese, soft, nontender, non distended, normoactive\nbowel sounds, no CVA tenderness. Extremities, 1+ DP and PT\npulses bilaterally, trace bilateral pitting edema up to the\nknees.\n\nLABORATORY DATA: White blood cell count 21.5, hematocrit\n41.2, platelet count 311,000, neutrophils 92%, bands 7%,\nlymphs 0%, basos 1%, sodium 137, potassium 4.5, chloride 100,\nCO2 20, BUN 33, creatinine 1.7, glucose 100. PT 20.7, PTT\n41.5, INR 2.8. Urinalysis, yellow, clear, specific gravity\n1.014, no nitrites, no red blood cells, no white blood cells,\nno bacteria, no yeast. Chest x-ray #1 perihilar edema\nbilaterally, #2 left retrocardiac opacity, effusion vs\ninfiltrate. EKG, sinus tachycardia with rate 108, normal\naxis, normal intervals, no acute ST-T wave abnormalities.', "\n\nPROBLEM LIST:\n1. Possible pneumonia.\n2. Possible CHF exacerbation.\n3. Increased creatinine.\n4. Chest pain.\n\nHOSPITAL COURSE: The patient was brought to the MICU on a\npartial 15 liters of oxygen flowing through partial non\nrebreather mask. His oxygen saturations were in the mid to\nhigh 90's on this and his tachypnea began resolving quickly.\nThe patient was ruled out for an MI by cardiac enzymes and\nserial EKG's and he was started on 500 mg IV q d of\nLevofloxacin. His blood pressure in the MICU was initially\n80/40 and there was concern that central access would need to\nbe placed to evaluate the etiology of his hypotension.\nHowever, his blood pressure responded well to normal saline\nboluses of 250 cc each. He did not experience further\nhypotension for the rest of his admission. All of his home\nmedications were continued except for Carvedilol which was\nheld as we were concerned for possible CHF exacerbation.", ' On\nday #2 of his admission he began to diurese well on his home\nregimen of Lasix and his oxygen requirement was quickly\nweaned from 15 liters partial non rebreather mask to 4 liters\nof nasal cannula oxygen. On day #2 of his admission the\nblood cultures came back 4/4 bottles positive for\npneumococcus which was pansensitive. Theory then to explain\nhis acute and severe hypoxia was that his gas exchange was\nimpaired by pneumococcal pneumonia and a transient bacteremia\nwhich may have dropped his SVR and caused him to temporarily\ndecompensate from a cardiac standpoint. In order to further\nevaluate his cardiac function, a transthoracic echocardiogram\nwas obtained which was most notable for a normal LV wall\nthickness and cavity size and an ejection fraction of 30-40%.\nThis is in contrast to an echocardiogram done in 1983 which\nshowed an anteroapical aneurysm in the LV and an ejection\nfraction of less than 20%.', " His initial AP chest x-ray was\nfollowed up with PA and lateral to further evaluate this\nretrocardiac opacity and the lateral appeared more consistent\nwith an infiltrate than an effusion. On day #3 of his\nadmission the sensitivities came back on the blood cultures,\nstrain of strep pneumonia was sensitive to Penicillin and so\nthe patient's regimen was switched to 2,000,000 units q 4\nhours of Penicillin G. The patient tolerated this well,\nshowing no acute allergic reactions.\n\nSince being admitted to the MICU, Mr. Thompson has been stable\nfrom a hemodynamic standpoint and a gas exchange standpoint.\nOn day #3 of his admission a PT consult was obtained and Mr.\nThompson was able to walk around the Avila-Summers Hospital without any difficulty\nor desaturation.\n\nMEDICAL ISSUES:\n1. Congestive heart failure.", "\n2. Resolving pneumococcal pneumonia.\n3. Coronary artery disease, status post three vessel CABG\nand silent MI.\n4. Mild Chronic obstructive pulmonary disease.\n5. Crohn's disease.\n6. Head and neck squamous cell carcinoma.\n7. Advanced Hodgkin's disease status post resection in 1983.\n8. Nephrolithiasis.\n\nDISCHARGE MEDICATIONS: Penicillin VK 2,000,000 units qid,\nLipitor 10 mg po q d, Lasix 40 mg po q d, K-Dur 20 mEq po\nbid, Coumadin 2.5 mg po q d, Synthroid 300 mcg po q d,\nCarvedilol 6.25 mg po q d, Cozaar 50 mg po q d, Amiodarone\n200 mg po bid, Theophylline 24 hours 300 mg po q d, Dipentum\n250 mg po bid.\n\nCONDITION ON DISCHARGE: Stable.\n\nDischarged to home.\n\n\n\n\n Raymundo Deluna, M.D. 50561007\n\nDictated By:Dr.Chowdhury\nMEDQUIST36\n\nD: 2006-7-26 18:09\nT: 2006-7-26 18:31\nJOB#: Wong LLC-1907-258129\n"]
441	13728	147900.0	2149-09-08	Discharge summary	Report	Admission Date: [2149-9-2] Discharge Date: Date of Birth: [2081-3-23] Sex: M Service: CHIEF COMPLAINT: Shortness of breath, cough, increased dyspnea on exertion. HISTORY OF PRESENT ILLNESS: This is a 68 year old male with a history of congestive heart failure and an ejection fraction of 30 to 40%, status post three vessel coronary artery bypass graft, likely chronic obstructive pulmonary disease, and a [2149-5-25] admission for pansensitive Streptococcus pneumococcal pneumonia who presented yesterday with shortness of breath for two days, a cough productive of white sputum, chills, and increased dyspnea on exertion. The patient was in his usual state of health, able to walk ?????? mile before becoming winded until three to four days ago when he developed rhinorrhea and congestion. Then one day later he developed shortness of breath, cough, chills and increased dyspnea on exertion. He also commenced sharp, substernal nonradiating chest pain which he rated 4 out of 10 in intensity. This pain was relieved with rest and worsened with cough. He did have one episode of dry heaves. He denied green or yellow sputum, hemoptysis or fevers. Of note, the patient has had poor dietary compliance of late, eating a large Chinese food dinner three to four nights prior to arrival. He does deny paroxysmal nocturnal dyspnea and new orthopnea, although at baseline he sleeps on four pillows. He does note one day of bilateral lower extremity edema. He has had good urine output by report and no changes in medicine. PAST MEDICAL/SURGICAL HISTORY: 1. Coronary artery disease; 2. Status post coronary artery bypass graft in [2146-8-25] (left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal of circumflex, saphenous vein graft to the right coronary artery); 3. Congestive heart failure, [2149-5-25] ejection fraction of 30 to 40% with moderate mitral regurgitation, [2146] ejection fraction of less than 20%; 4. Anteroapical aneurysm; 5. Silent myocardial infarction; 6. Mild chronic obstructive pulmonary disease; 7. Left pneumothorax with chest tube placement; 8. Atrial fibrillation/atrial flutter; 9. Hypertension; 10. Head and neck cancer, status post resection; 11. Hodgkin's disease, Stage 4B with bone marrow infiltration in [2143], underwent six cycles of ABVD, [2144] torso computerized tomography scan and gallium scan were negative as were bone marrow biopsy times two; 12. Question of Crohn's; 13. Nephrolithiasis; 14. Mild chronic renal insufficiency with a baseline creatinine of 1.3; 15. Left lower lobe pneumococcal pneumonia in [2149-5-25]; 16. Hypothyroidism; 17. Status post hernia repair 40 years ago. MEDICATIONS: 1. Lipitor 10 mg p.o. q.d. 2. Lasix 40 mg p.o. q.d. 3. K-Dur 20 mEq p.o. b.i.d. 4. Coumadin 3 mg p.o. Tuesday, Thursday, Saturday and Sunday, 2 mg p.o. Monday, Wednesday and Friday 5. Synthroid 300 mcg p.o. q.d. 6. Carvedilol 6.25 mg p.o. b.i.d. 7. Cozaar 50 mg p.o. q.d. 8. Amiodarone 200 mg p.o. q.d. 9. Theophylline 300 mg p.o. q.h.s. 10. Dipentum 750 mg p.o. b.i.d. The patient reports compliance with medications and no recent change in medications. SOCIAL HISTORY: 160 pack year history of smoking, quit 12 years ago, no alcohol use, no recreational drug use. The patient lives with his wife [Name (NI) 3771] in [Name (NI) 3772]. He owned a travel agency company. PHYSICAL EXAMINATION: Temperature 97.2, heartrate 85, blood pressure 111/66, oxygen saturation 92 to 96% on 5 liters by face mask. General: Obese male in no acute distress on face mask. Head, eyes, ears, nose and throat: Pupils are equal, round, and reactive to light. Mucous membranes dry. No oral lesions. Neck: Supple, full range of motion, no jugulovenous distension appreciated. Chest: Bilateral crackles at the bases, right greater than left. Cardiac: Distant heartsounds, regular rate and rhythm. Normal S1 and S2, no murmurs, rubs or gallops appreciated. Abdomen: Distended, soft, nontender, some shifting dullness. Extremities, trace pedal edema, no calf tenderness. Other: Foley catheter in place. Two antecubital intravenous lines in place. LABORATORY DATA: Admission labs revealed sodium 136, hemolyzed potassium 6.5, repeated 6.0, chloride 98, bicarbonate 25, BUN 33, creatinine 2.0, glucose 108. White blood cell count 16.3, hematocrit 43.8, platelets 457, MCV 78, RDW 15.5. Differential: Neutrophils 59, bands 35, lymphocytes 3, atypicals 2, PT 29.8, PTT 47.7, INR 5.9. Cardiac enzymes, CK 110, CK MB 3, troponin I 3.2. Sputum culture: Reddish brown in appearance. Chest x-ray: Right middle lobe infiltrate, cardiomegaly. Electrocardiogram, no ST segment changes, no Q waves, rate 99, normal axis, normal intervals. HOSPITAL COURSE: When the patient presented to the Emergency Department he received an aspirin and because he was thought to be in congestive heart failure he also received 100 mg of Lasix intravenously spread out over two doses. He also received sublingual nitroglycerin paste. This brought his blood pressure in to the 90s, at which time the patient was removed. In the Emergency Department the patient also received Ceftriaxone, 1 gm intravenously times one. He was subsequently admitted to the Medical Intensive Care Unit. 1. Pulmonary - Because the patient was presumed to have community-acquired pneumonia, by clinical presentation and chest x-ray he was started on Levofloxacin 500 mg p.o. q. day. He continued this regimen for the remainder of his hospital stay and after discharge, such that he would complete a 14 day course. The patient was given Atrovent metered dose inhalers initially q. 4 hours and then q. 6 hours and this appeared to help with his oxygen saturation and dyspnea. In addition he was placed on Albuterol prn nebulizers and then metered dose inhalers. His initial oxygen requirement in the Intensive Care Unit was 12 liters by face mask with an FIO2 of .5 and was subsequently weaned from the face mask to a nasal cannula once on the floor. His oxygen requirement slowly improved while in-house, however, his saturations frequently dropped while ambulating. 2. Cardiovascular - For the patient's hypotension, he received a 500 cc normal saline bolus over night long in the Intensive Care Unit. His systolic blood pressure improved to the 100s, subsequently. His Cozaar and Carvedilol were held at that time but returned gradually over the next few days as his pressures continued to rise to an appropriate level. He was also gently diuresed on Lasix approximately 20 mg intravenously q.o.d. His blood pressure was monitored for the remainder of his inpatient stay and remains approximately in the 1-teens/70s. The patient was diuresed approximately 500 to 1000 cc per day. For his atrial fibrillation/atrial flutter, he was continued on Amiodarone 200 mg p.o. b.i.d. In terms of septicemia the patient was negative CK times three. His initial troponin I was 3.2 and the following troponin I was 1.7. There were no electrocardiogram changes and he experienced no chest pain while in the hospital. 3. Infectious disease - The Gram stain of the patient's sputum showed multiple organisms consistent with oral pharyngeal Flora. The sputum culture grew out oropharyngeal organisms as well as moderate coagulase positive Staphylococcus growth. He remained afebrile for the remainder of his inpatient stay and he was continued on his 14 day regimen of Levofloxacin 500 mg. 4. Heme - As the patient's INR and PT were initially elevated, his Coumadin was held until the INR began to drop. As the INR began to normalize, the Coumadin was slowly returned. Of note, his PTT was elevated as were his fibrinogen and haptoglobin. His FDT and D-dimer were also mildly elevated. It was unclear how much of this was due to mild DIC, how much due to acute phase reaction and how much due to underproduction of coagulation factors by the liver. 5. Oncology - Because the patient's PTT remained elevated without explanation while in-house and because he had not received regular follow up after his Hodgkin's disease an oncology consultation was obtained. At the consults recommendation we suggested that the patient follow up with his previous oncologist in [State 108] while he is visiting there next month. He should undergo a surveillance computerized tomography scan as well as a possible gallium scan, PET scan and/or bone marrow biopsy. 6. Renal - The patient initially appeared to have some degree of acute and chronic renal failure, given his elevated BUN and creatinine. His creatinine decreased to 1.7 after the 500 cc bolus and continued to trend down thereafter. BUN and creatinine were monitored throughout the remainder of the stay. 7. Gastrointestinal - For his history of Crohn's disease with chronic diarrhea, the patient was maintained on Asacol 800 mg p.o. t.i.d. He also received Protonix and Colace prn. 8. Endocrine - Because of a history of hypothyroidism, the patient was maintained on his Synthroid. 9. Fluids, electrolytes and nutrition - The patient was maintained on a cardiac diet as tolerated. Fluids were not given after the patient was transferred from the Intensive Care Unit to the floor because of his likely congestive heart failure. 10. Code - The patient was full code. 11. Prophylaxis - The patient was kept on Protonix. His INR was therapeutic or supertherapeutic throughout the hospital stay and so no further deep vein thrombosis prophylaxis was required. DISPOSITION: The patient was discharged home to [Hospital 3773] Rehabilitation once he was able to ambulate without dropping his saturations into the 80s. DISCHARGE DIAGNOSIS: 1. Community acquired pneumonia 2. Congestive heart failure DISCHARGE MEDICATIONS: 1. Cozaar 50 mg p.o. q.d. 2. Carvedilol 6.25 mg p.o. b.i.d. 3. Amiodarone 200 mg p.o. q.d. 4. Levofloxacin 500 mg p.o. q.d. times nine days 5. Lipitor 10 mg p.o. q.d. 6. Asacol 800 mg p.o. t.i.d. 7. Colace 100 mg p.o. b.i.d. prn 8. Synthroid 300 mcg p.o. q.d. 9. Tylenol 325 mg p.o. q. 4 to 6 hours prn 10. Atrovent metered dose inhalers 2 to 3 puffs q.i.d. 11. Albuterol metered dose inhaler 2 to 4 puffs q.i.d. prn 12. Protonix 40 mg p.o. q.d. 13. Lasix 40 mg p.o. q.d. 14. Coumadin p.o. 3 mg on Tuesday, Thursday, Saturday and Sunday, 2 mg Monday, Wednesday and Friday 15. K-dur 20 mEq p.o. b.i.d. FOLLOW UP: 1. The patient should follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 410] 2. The patient should follow up with his oncologist in [State 108], regarding surveillance for his Hodgkin's disease [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Last Name (NamePattern1) 3774] MEDQUIST36 D: [2149-9-5] 16:24 T: [2149-9-6] 17:22 JOB#: [Job Number 3775]	Admission Date: <Date>1927-2-13</Date> Discharge Date: Date of Birth: <Date>2010-1-14</Date> Sex: M Service: CHIEF COMPLAINT: Shortness of breath, cough, increased dyspnea on exertion. HISTORY OF PRESENT ILLNESS: This is a 68 year old male with a history of congestive heart failure and an ejection fraction of 30 to 40%, status post three vessel coronary artery bypass graft, likely chronic obstructive pulmonary disease, and a <Date>1921-4-17</Date> admission for pansensitive Streptococcus pneumococcal pneumonia who presented yesterday with shortness of breath for two days, a cough productive of white sputum, chills, and increased dyspnea on exertion. The patient was in his usual state of health, able to walk ?????? mile before becoming winded until three to four days ago when he developed rhinorrhea and congestion. Then one day later he developed shortness of breath, cough, chills and increased dyspnea on exertion. He also commenced sharp, substernal nonradiating chest pain which he rated 4 out of 10 in intensity. This pain was relieved with rest and worsened with cough. He did have one episode of dry heaves. He denied green or yellow sputum, hemoptysis or fevers. Of note, the patient has had poor dietary compliance of late, eating a large Chinese food dinner three to four nights prior to arrival. He does deny paroxysmal nocturnal dyspnea and new orthopnea, although at baseline he sleeps on four pillows. He does note one day of bilateral lower extremity edema. He has had good urine output by report and no changes in medicine. PAST MEDICAL/SURGICAL HISTORY: 1. Coronary artery disease; 2. Status post coronary artery bypass graft in <Date>1944-6-13</Date> (left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal of circumflex, saphenous vein graft to the right coronary artery); 3. Congestive heart failure, <Date>1921-4-17</Date> ejection fraction of 30 to 40% with moderate mitral regurgitation, <Year>1918</Year> ejection fraction of less than 20%; 4. Anteroapical aneurysm; 5. Silent myocardial infarction; 6. Mild chronic obstructive pulmonary disease; 7. Left pneumothorax with chest tube placement; 8. Atrial fibrillation/atrial flutter; 9. Hypertension; 10. Head and neck cancer, status post resection; 11. Hodgkin's disease, Stage 4B with bone marrow infiltration in <Year>1918</Year>, underwent six cycles of ABVD, <Year>1918</Year> torso computerized tomography scan and gallium scan were negative as were bone marrow biopsy times two; 12. Question of Crohn's; 13. Nephrolithiasis; 14. Mild chronic renal insufficiency with a baseline creatinine of 1.3; 15. Left lower lobe pneumococcal pneumonia in <Date>1921-4-17</Date>; 16. Hypothyroidism; 17. Status post hernia repair 40 years ago. MEDICATIONS: 1. Lipitor 10 mg p.o. q.d. 2. Lasix 40 mg p.o. q.d. 3. K-Dur 20 mEq p.o. b.i.d. 4. Coumadin 3 mg p.o. Tuesday, Thursday, Saturday and Sunday, 2 mg p.o. Monday, Wednesday and Friday 5. Synthroid 300 mcg p.o. q.d. 6. Carvedilol 6.25 mg p.o. b.i.d. 7. Cozaar 50 mg p.o. q.d. 8. Amiodarone 200 mg p.o. q.d. 9. Theophylline 300 mg p.o. q.h.s. 10. Dipentum 750 mg p.o. b.i.d. The patient reports compliance with medications and no recent change in medications. SOCIAL HISTORY: 160 pack year history of smoking, quit 12 years ago, no alcohol use, no recreational drug use. The patient lives with his wife <Name>Scott Tennity</Name> in <Name>Carl Feudner</Name>. He owned a travel agency company. PHYSICAL EXAMINATION: Temperature 97.2, heartrate 85, blood pressure 111/66, oxygen saturation 92 to 96% on 5 liters by face mask. General: Obese male in no acute distress on face mask. Head, eyes, ears, nose and throat: Pupils are equal, round, and reactive to light. Mucous membranes dry. No oral lesions. Neck: Supple, full range of motion, no jugulovenous distension appreciated. Chest: Bilateral crackles at the bases, right greater than left. Cardiac: Distant heartsounds, regular rate and rhythm. Normal S1 and S2, no murmurs, rubs or gallops appreciated. Abdomen: Distended, soft, nontender, some shifting dullness. Extremities, trace pedal edema, no calf tenderness. Other: Foley catheter in place. Two antecubital intravenous lines in place. LABORATORY DATA: Admission labs revealed sodium 136, hemolyzed potassium 6.5, repeated 6.0, chloride 98, bicarbonate 25, BUN 33, creatinine 2.0, glucose 108. White blood cell count 16.3, hematocrit 43.8, platelets 457, MCV 78, RDW 15.5. Differential: Neutrophils 59, bands 35, lymphocytes 3, atypicals 2, PT 29.8, PTT 47.7, INR 5.9. Cardiac enzymes, CK 110, CK MB 3, troponin I 3.2. Sputum culture: Reddish brown in appearance. Chest x-ray: Right middle lobe infiltrate, cardiomegaly. Electrocardiogram, no ST segment changes, no Q waves, rate 99, normal axis, normal intervals. HOSPITAL COURSE: When the patient presented to the Emergency Department he received an aspirin and because he was thought to be in congestive heart failure he also received 100 mg of Lasix intravenously spread out over two doses. He also received sublingual nitroglycerin paste. This brought his blood pressure in to the 90s, at which time the patient was removed. In the Emergency Department the patient also received Ceftriaxone, 1 gm intravenously times one. He was subsequently admitted to the Medical Intensive Care Unit. 1. Pulmonary - Because the patient was presumed to have community-acquired pneumonia, by clinical presentation and chest x-ray he was started on Levofloxacin 500 mg p.o. q. day. He continued this regimen for the remainder of his hospital stay and after discharge, such that he would complete a 14 day course. The patient was given Atrovent metered dose inhalers initially q. 4 hours and then q. 6 hours and this appeared to help with his oxygen saturation and dyspnea. In addition he was placed on Albuterol prn nebulizers and then metered dose inhalers. His initial oxygen requirement in the Intensive Care Unit was 12 liters by face mask with an FIO2 of .5 and was subsequently weaned from the face mask to a nasal cannula once on the floor. His oxygen requirement slowly improved while in-house, however, his saturations frequently dropped while ambulating. 2. Cardiovascular - For the patient's hypotension, he received a 500 cc normal saline bolus over night long in the Intensive Care Unit. His systolic blood pressure improved to the 100s, subsequently. His Cozaar and Carvedilol were held at that time but returned gradually over the next few days as his pressures continued to rise to an appropriate level. He was also gently diuresed on Lasix approximately 20 mg intravenously q.o.d. His blood pressure was monitored for the remainder of his inpatient stay and remains approximately in the 1-teens/70s. The patient was diuresed approximately 500 to 1000 cc per day. For his atrial fibrillation/atrial flutter, he was continued on Amiodarone 200 mg p.o. b.i.d. In terms of septicemia the patient was negative CK times three. His initial troponin I was 3.2 and the following troponin I was 1.7. There were no electrocardiogram changes and he experienced no chest pain while in the hospital. 3. Infectious disease - The Gram stain of the patient's sputum showed multiple organisms consistent with oral pharyngeal Flora. The sputum culture grew out oropharyngeal organisms as well as moderate coagulase positive Staphylococcus growth. He remained afebrile for the remainder of his inpatient stay and he was continued on his 14 day regimen of Levofloxacin 500 mg. 4. Heme - As the patient's INR and PT were initially elevated, his Coumadin was held until the INR began to drop. As the INR began to normalize, the Coumadin was slowly returned. Of note, his PTT was elevated as were his fibrinogen and haptoglobin. His FDT and D-dimer were also mildly elevated. It was unclear how much of this was due to mild DIC, how much due to acute phase reaction and how much due to underproduction of coagulation factors by the liver. 5. Oncology - Because the patient's PTT remained elevated without explanation while in-house and because he had not received regular follow up after his Hodgkin's disease an oncology consultation was obtained. At the consults recommendation we suggested that the patient follow up with his previous oncologist in <State>Florida</State> while he is visiting there next month. He should undergo a surveillance computerized tomography scan as well as a possible gallium scan, PET scan and/or bone marrow biopsy. 6. Renal - The patient initially appeared to have some degree of acute and chronic renal failure, given his elevated BUN and creatinine. His creatinine decreased to 1.7 after the 500 cc bolus and continued to trend down thereafter. BUN and creatinine were monitored throughout the remainder of the stay. 7. Gastrointestinal - For his history of Crohn's disease with chronic diarrhea, the patient was maintained on Asacol 800 mg p.o. t.i.d. He also received Protonix and Colace prn. 8. Endocrine - Because of a history of hypothyroidism, the patient was maintained on his Synthroid. 9. Fluids, electrolytes and nutrition - The patient was maintained on a cardiac diet as tolerated. Fluids were not given after the patient was transferred from the Intensive Care Unit to the floor because of his likely congestive heart failure. 10. Code - The patient was full code. 11. Prophylaxis - The patient was kept on Protonix. His INR was therapeutic or supertherapeutic throughout the hospital stay and so no further deep vein thrombosis prophylaxis was required. DISPOSITION: The patient was discharged home to <Hospital>Rodriguez Inc Health System</Hospital> Rehabilitation once he was able to ambulate without dropping his saturations into the 80s. DISCHARGE DIAGNOSIS: 1. Community acquired pneumonia 2. Congestive heart failure DISCHARGE MEDICATIONS: 1. Cozaar 50 mg p.o. q.d. 2. Carvedilol 6.25 mg p.o. b.i.d. 3. Amiodarone 200 mg p.o. q.d. 4. Levofloxacin 500 mg p.o. q.d. times nine days 5. Lipitor 10 mg p.o. q.d. 6. Asacol 800 mg p.o. t.i.d. 7. Colace 100 mg p.o. b.i.d. prn 8. Synthroid 300 mcg p.o. q.d. 9. Tylenol 325 mg p.o. q. 4 to 6 hours prn 10. Atrovent metered dose inhalers 2 to 3 puffs q.i.d. 11. Albuterol metered dose inhaler 2 to 4 puffs q.i.d. prn 12. Protonix 40 mg p.o. q.d. 13. Lasix 40 mg p.o. q.d. 14. Coumadin p.o. 3 mg on Tuesday, Thursday, Saturday and Sunday, 2 mg Monday, Wednesday and Friday 15. K-dur 20 mEq p.o. b.i.d. FOLLOW UP: 1. The patient should follow up with his primary care physician, <Name>Pleasant</Name>. <Name>Kraig</Name> <Name>Amaro</Name> 2. The patient should follow up with his oncologist in <State>Florida</State>, regarding surveillance for his Hodgkin's disease <Name>Darnell</Name> <Initial>ME</Initial> <Name>Lees</Name>, M.D. <MD Number>71092658</MD Number> Dictated By:<Name>Tamaro</Name> MEDQUIST36 D: <Date>1969-10-15</Date> 16:24 T: <Date>2022-7-24</Date> 17:22 JOB#: <Job Number>Jones-Spears-2004-291982</Job 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Date: 1927-2-13 Discharge Date: Date of Birth: 2010-1-14 Sex: M Service: CHIEF COMPLAINT: Shortness of breath, cough, increased dyspnea on exertion. HISTORY OF PRESENT ILLNESS: This is a 68 year old male with a history of congestive heart failure and an ejection fraction of 30 to 40%, status post three vessel coronary artery bypass graft, likely chronic obstructive pulmonary disease, and a 1921-4-17 admission for pansensitive Streptococcus pneumococcal pneumonia who presented yesterday with shortness of breath for two days, a cough productive of white sputum, chills, and increased dyspnea on exertion. The patient was in his usual state of health, able to walk ?????? mile before becoming winded until three to four days ago when he developed rhinorrhea and congestion. Then one day later he developed shortness of breath, cough, chills and increased dyspnea on exertion. He also commenced sharp, substernal nonradiating chest pain which he rated 4 out of 10 in intensity. This pain was relieved with rest and worsened with cough. He did have one episode of dry heaves. He denied green or yellow sputum, hemoptysis or fevers. Of note, the patient has had poor dietary compliance of late, eating a large Chinese food dinner three to four nights prior to arrival. He does deny paroxysmal nocturnal dyspnea and new orthopnea, although at baseline he sleeps on four pillows. He does note one day of bilateral lower extremity edema. He has had good urine output by report and no changes in medicine. PAST MEDICAL/SURGICAL HISTORY: 1. Coronary artery disease; 2. Status post coronary artery bypass graft in 1944-6-13 (left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal of circumflex, saphenous vein graft to the right coronary artery); 3. Congestive heart failure, 1921-4-17 ejection fraction of 30 to 40% with moderate mitral regurgitation, 1918 ejection fraction of less than 20%; 4. Anteroapical aneurysm; 5. Silent myocardial infarction; 6. Mild chronic obstructive pulmonary disease; 7. Left pneumothorax with chest tube placement; 8. Atrial fibrillation/atrial flutter; 9. Hypertension; 10. Head and neck cancer, status post resection; 11. Hodgkin's disease, Stage 4B with bone marrow infiltration in 1918, underwent six cycles of ABVD, 1918 torso computerized tomography scan and gallium scan were negative as were bone marrow biopsy times two; 12. Question of Crohn's; 13. Nephrolithiasis; 14. Mild chronic renal insufficiency with a baseline creatinine of 1.3; 15. Left lower lobe pneumococcal pneumonia in 1921-4-17; 16. Hypothyroidism; 17. Status post hernia repair 40 years ago. MEDICATIONS: 1. Lipitor 10 mg p.o. q.d. 2. Lasix 40 mg p.o. q.d. 3. K-Dur 20 mEq p.o. b.i.d. 4. Coumadin 3 mg p.o. Tuesday, Thursday, Saturday and Sunday, 2 mg p.o. Monday, Wednesday and Friday 5. Synthroid 300 mcg p.o. q.d. 6. Carvedilol 6.25 mg p.o. b.i.d. 7. Cozaar 50 mg p.o. q.d. 8. Amiodarone 200 mg p.o. q.d. 9. Theophylline 300 mg p.o. q.h.s. 10. Dipentum 750 mg p.o. b.i.d. The patient reports compliance with medications and no recent change in medications. SOCIAL HISTORY: 160 pack year history of smoking, quit 12 years ago, no alcohol use, no recreational drug use. The patient lives with his wife Scott Tennity in Carl Feudner. He owned a travel agency company. PHYSICAL EXAMINATION: Temperature 97.2, heartrate 85, blood pressure 111/66, oxygen saturation 92 to 96% on 5 liters by face mask. General: Obese male in no acute distress on face mask. Head, eyes, ears, nose and throat: Pupils are equal, round, and reactive to light. Mucous membranes dry. No oral lesions. Neck: Supple, full range of motion, no jugulovenous distension appreciated. Chest: Bilateral crackles at the bases, right greater than left. Cardiac: Distant heartsounds, regular rate and rhythm. Normal S1 and S2, no murmurs, rubs or gallops appreciated. Abdomen: Distended, soft, nontender, some shifting dullness. Extremities, trace pedal edema, no calf tenderness. Other: Foley catheter in place. Two antecubital intravenous lines in place. LABORATORY DATA: Admission labs revealed sodium 136, hemolyzed potassium 6.5, repeated 6.0, chloride 98, bicarbonate 25, BUN 33, creatinine 2.0, glucose 108. White blood cell count 16.3, hematocrit 43.8, platelets 457, MCV 78, RDW 15.5. Differential: Neutrophils 59, bands 35, lymphocytes 3, atypicals 2, PT 29.8, PTT 47.7, INR 5.9. Cardiac enzymes, CK 110, CK MB 3, troponin I 3.2. Sputum culture: Reddish brown in appearance. Chest x-ray: Right middle lobe infiltrate, cardiomegaly. Electrocardiogram, no ST segment changes, no Q waves, rate 99, normal axis, normal intervals. HOSPITAL COURSE: When the patient presented to the Emergency Department he received an aspirin and because he was thought to be in congestive heart failure he also received 100 mg of Lasix intravenously spread out over two doses. He also received sublingual nitroglycerin paste. This brought his blood pressure in to the 90s, at which time the patient was removed. In the Emergency Department the patient also received Ceftriaxone, 1 gm intravenously times one. He was subsequently admitted to the Medical Intensive Care Unit. 1. Pulmonary - Because the patient was presumed to have community-acquired pneumonia, by clinical presentation and chest x-ray he was started on Levofloxacin 500 mg p.o. q. day. He continued this regimen for the remainder of his hospital stay and after discharge, such that he would complete a 14 day course. The patient was given Atrovent metered dose inhalers initially q. 4 hours and then q. 6 hours and this appeared to help with his oxygen saturation and dyspnea. In addition he was placed on Albuterol prn nebulizers and then metered dose inhalers. His initial oxygen requirement in the Intensive Care Unit was 12 liters by face mask with an FIO2 of .5 and was subsequently weaned from the face mask to a nasal cannula once on the floor. His oxygen requirement slowly improved while in-house, however, his saturations frequently dropped while ambulating. 2. Cardiovascular - For the patient's hypotension, he received a 500 cc normal saline bolus over night long in the Intensive Care Unit. His systolic blood pressure improved to the 100s, subsequently. His Cozaar and Carvedilol were held at that time but returned gradually over the next few days as his pressures continued to rise to an appropriate level. He was also gently diuresed on Lasix approximately 20 mg intravenously q.o.d. His blood pressure was monitored for the remainder of his inpatient stay and remains approximately in the 1-teens/70s. The patient was diuresed approximately 500 to 1000 cc per day. For his atrial fibrillation/atrial flutter, he was continued on Amiodarone 200 mg p.o. b.i.d. In terms of septicemia the patient was negative CK times three. His initial troponin I was 3.2 and the following troponin I was 1.7. There were no electrocardiogram changes and he experienced no chest pain while in the hospital. 3. Infectious disease - The Gram stain of the patient's sputum showed multiple organisms consistent with oral pharyngeal Flora. The sputum culture grew out oropharyngeal organisms as well as moderate coagulase positive Staphylococcus growth. He remained afebrile for the remainder of his inpatient stay and he was continued on his 14 day regimen of Levofloxacin 500 mg. 4. Heme - As the patient's INR and PT were initially elevated, his Coumadin was held until the INR began to drop. As the INR began to normalize, the Coumadin was slowly returned. Of note, his PTT was elevated as were his fibrinogen and haptoglobin. His FDT and D-dimer were also mildly elevated. It was unclear how much of this was due to mild DIC, how much due to acute phase reaction and how much due to underproduction of coagulation factors by the liver. 5. Oncology - Because the patient's PTT remained elevated without explanation while in-house and because he had not received regular follow up after his Hodgkin's disease an oncology consultation was obtained. At the consults recommendation we suggested that the patient follow up with his previous oncologist in Florida while he is visiting there next month. He should undergo a surveillance computerized tomography scan as well as a possible gallium scan, PET scan and/or bone marrow biopsy. 6. Renal - The patient initially appeared to have some degree of acute and chronic renal failure, given his elevated BUN and creatinine. His creatinine decreased to 1.7 after the 500 cc bolus and continued to trend down thereafter. BUN and creatinine were monitored throughout the remainder of the stay. 7. Gastrointestinal - For his history of Crohn's disease with chronic diarrhea, the patient was maintained on Asacol 800 mg p.o. t.i.d. He also received Protonix and Colace prn. 8. Endocrine - Because of a history of hypothyroidism, the patient was maintained on his Synthroid. 9. Fluids, electrolytes and nutrition - The patient was maintained on a cardiac diet as tolerated. Fluids were not given after the patient was transferred from the Intensive Care Unit to the floor because of his likely congestive heart failure. 10. Code - The patient was full code. 11. Prophylaxis - The patient was kept on Protonix. His INR was therapeutic or supertherapeutic throughout the hospital stay and so no further deep vein thrombosis prophylaxis was required. DISPOSITION: The patient was discharged home to Rodriguez Inc Health System Rehabilitation once he was able to ambulate without dropping his saturations into the 80s. DISCHARGE DIAGNOSIS: 1. Community acquired pneumonia 2. Congestive heart failure DISCHARGE MEDICATIONS: 1. Cozaar 50 mg p.o. q.d. 2. Carvedilol 6.25 mg p.o. b.i.d. 3. Amiodarone 200 mg p.o. q.d. 4. Levofloxacin 500 mg p.o. q.d. times nine days 5. Lipitor 10 mg p.o. q.d. 6. Asacol 800 mg p.o. t.i.d. 7. Colace 100 mg p.o. b.i.d. prn 8. Synthroid 300 mcg p.o. q.d. 9. Tylenol 325 mg p.o. q. 4 to 6 hours prn 10. Atrovent metered dose inhalers 2 to 3 puffs q.i.d. 11. Albuterol metered dose inhaler 2 to 4 puffs q.i.d. prn 12. Protonix 40 mg p.o. q.d. 13. Lasix 40 mg p.o. q.d. 14. Coumadin p.o. 3 mg on Tuesday, Thursday, Saturday and Sunday, 2 mg Monday, Wednesday and Friday 15. K-dur 20 mEq p.o. b.i.d. FOLLOW UP: 1. The patient should follow up with his primary care physician, Pleasant. Kraig Amaro 2. The patient should follow up with his oncologist in Florida, regarding surveillance for his Hodgkin's disease Darnell ME Lees, M.D. 71092658 Dictated By:Tamaro MEDQUIST36 D: 1969-10-15 16:24 T: 2022-7-24 17:22 JOB#: Jones-Spears-2004-291982	['Admission Date: 1927-2-13 Discharge Date:\n\nDate of Birth: 2010-1-14 Sex: M\n\nService:\n\nCHIEF COMPLAINT: Shortness of breath, cough, increased\ndyspnea on exertion.\n\nHISTORY OF PRESENT ILLNESS: This is a 68 year old male with\na history of congestive heart failure and an ejection\nfraction of 30 to 40%, status post three vessel coronary\nartery bypass graft, likely chronic obstructive pulmonary\ndisease, and a 1921-4-17 admission for pansensitive\nStreptococcus pneumococcal pneumonia who presented yesterday\nwith shortness of breath for two days, a cough productive of\nwhite sputum, chills, and increased dyspnea on exertion. The\npatient was in his usual state of health, able to walk ?????? mile\nbefore becoming winded until three to four days ago when he\ndeveloped rhinorrhea and congestion.', ' Then one day later he\ndeveloped shortness of breath, cough, chills and increased\ndyspnea on exertion. He also commenced sharp, substernal\nnonradiating chest pain which he rated 4 out of 10 in\nintensity. This pain was relieved with rest and worsened\nwith cough. He did have one episode of dry heaves. He\ndenied green or yellow sputum, hemoptysis or fevers. Of\nnote, the patient has had poor dietary compliance of late,\neating a large Chinese food dinner three to four nights prior\nto arrival. He does deny paroxysmal nocturnal dyspnea and\nnew orthopnea, although at baseline he sleeps on four\npillows. He does note one day of bilateral lower extremity\nedema. He has had good urine output by report and no changes\nin medicine.\n\nPAST MEDICAL/SURGICAL HISTORY: 1. Coronary artery disease;\n2. Status post coronary artery bypass graft in 1944-6-13\n(left internal mammary artery to left anterior descending,\nsaphenous vein graft to obtuse marginal of circumflex,\nsaphenous vein graft to the right coronary artery); 3.', "\nCongestive heart failure, 1921-4-17 ejection fraction of 30\nto 40% with moderate mitral regurgitation, 1918 ejection\nfraction of less than 20%; 4. Anteroapical aneurysm; 5.\nSilent myocardial infarction; 6. Mild chronic obstructive\npulmonary disease; 7. Left pneumothorax with chest tube\nplacement; 8. Atrial fibrillation/atrial flutter; 9.\nHypertension; 10. Head and neck cancer, status post\nresection; 11. Hodgkin's disease, Stage 4B with bone marrow\ninfiltration in 1918, underwent six cycles of ABVD, 1918\ntorso computerized tomography scan and gallium scan were\nnegative as were bone marrow biopsy times two; 12. Question\nof Crohn's; 13. Nephrolithiasis; 14. Mild chronic renal\ninsufficiency with a baseline creatinine of 1.3; 15. Left\nlower lobe pneumococcal pneumonia in 1921-4-17; 16.\nHypothyroidism; 17.", ' Status post hernia repair 40 years ago.\n\nMEDICATIONS:\n1. Lipitor 10 mg p.o. q.d.\n2. Lasix 40 mg p.o. q.d.\n3. K-Dur 20 mEq p.o. b.i.d.\n4. Coumadin 3 mg p.o. Tuesday, Thursday, Saturday and\nSunday, 2 mg p.o. Monday, Wednesday and Friday\n5. Synthroid 300 mcg p.o. q.d.\n6. Carvedilol 6.25 mg p.o. b.i.d.\n7. Cozaar 50 mg p.o. q.d.\n8. Amiodarone 200 mg p.o. q.d.\n9. Theophylline 300 mg p.o. q.h.s.\n10. Dipentum 750 mg p.o. b.i.d.\n\nThe patient reports compliance with medications and no recent\nchange in medications.\n\nSOCIAL HISTORY: 160 pack year history of smoking, quit 12\nyears ago, no alcohol use, no recreational drug use. The\npatient lives with his wife Scott Tennity in Carl Feudner. He owned a\ntravel agency company.\n\nPHYSICAL EXAMINATION: Temperature 97.2, heartrate 85, blood\npressure 111/66, oxygen saturation 92 to 96% on 5 liters by\nface mask.', ' General: Obese male in no acute distress on face\nmask. Head, eyes, ears, nose and throat: Pupils are equal,\nround, and reactive to light. Mucous membranes dry. No oral\nlesions. Neck: Supple, full range of motion, no\njugulovenous distension appreciated. Chest: Bilateral\ncrackles at the bases, right greater than left. Cardiac:\nDistant heartsounds, regular rate and rhythm. Normal S1 and\nS2, no murmurs, rubs or gallops appreciated. Abdomen:\nDistended, soft, nontender, some shifting dullness.\nExtremities, trace pedal edema, no calf tenderness. Other:\nFoley catheter in place. Two antecubital intravenous lines\nin place.\n\nLABORATORY DATA: Admission labs revealed sodium 136,\nhemolyzed potassium 6.5, repeated 6.0, chloride 98,\nbicarbonate 25, BUN 33, creatinine 2.0, glucose 108. White\nblood cell count 16.', '3, hematocrit 43.8, platelets 457, MCV\n78, RDW 15.5. Differential: Neutrophils 59, bands 35,\nlymphocytes 3, atypicals 2, PT 29.8, PTT 47.7, INR 5.9.\nCardiac enzymes, CK 110, CK MB 3, troponin I 3.2. Sputum\nculture: Reddish brown in appearance. Chest x-ray: Right\nmiddle lobe infiltrate, cardiomegaly. Electrocardiogram, no\nST segment changes, no Q waves, rate 99, normal axis, normal\nintervals.\n\nHOSPITAL COURSE: When the patient presented to the Emergency\nDepartment he received an aspirin and because he was thought\nto be in congestive heart failure he also received 100 mg of\nLasix intravenously spread out over two doses. He also\nreceived sublingual nitroglycerin paste. This brought his\nblood pressure in to the 90s, at which time the patient was\nremoved. In the Emergency Department the patient also\nreceived Ceftriaxone, 1 gm intravenously times one.', ' He was\nsubsequently admitted to the Medical Intensive Care Unit.\n\n1. Pulmonary - Because the patient was presumed to have\ncommunity-acquired pneumonia, by clinical presentation and\nchest x-ray he was started on Levofloxacin 500 mg p.o. q.\nday. He continued this regimen for the remainder of his\nhospital stay and after discharge, such that he would\ncomplete a 14 day course. The patient was given Atrovent\nmetered dose inhalers initially q. 4 hours and then q. 6\nhours and this appeared to help with his oxygen saturation\nand dyspnea. In addition he was placed on Albuterol prn\nnebulizers and then metered dose inhalers. His initial\noxygen requirement in the Intensive Care Unit was 12 liters\nby face mask with an FIO2 of .5 and was subsequently weaned\nfrom the face mask to a nasal cannula once on the floor.', " His\noxygen requirement slowly improved while in-house, however,\nhis saturations frequently dropped while ambulating.\n\n2. Cardiovascular - For the patient's hypotension, he\nreceived a 500 cc normal saline bolus over night long in the\nIntensive Care Unit. His systolic blood pressure improved to\nthe 100s, subsequently. His Cozaar and Carvedilol were held\nat that time but returned gradually over the next few days as\nhis pressures continued to rise to an appropriate level. He\nwas also gently diuresed on Lasix approximately 20 mg\nintravenously q.o.d. His blood pressure was monitored for\nthe remainder of his inpatient stay and remains approximately\nin the 1-teens/70s. The patient was diuresed approximately\n500 to 1000 cc per day. For his atrial fibrillation/atrial\nflutter, he was continued on Amiodarone 200 mg p.", "o. b.i.d.\nIn terms of septicemia the patient was negative CK times\nthree. His initial troponin I was 3.2 and the following\ntroponin I was 1.7. There were no electrocardiogram changes\nand he experienced no chest pain while in the hospital.\n\n3. Infectious disease - The Gram stain of the patient's\nsputum showed multiple organisms consistent with oral\npharyngeal Flora. The sputum culture grew out oropharyngeal\norganisms as well as moderate coagulase positive\nStaphylococcus growth. He remained afebrile for the\nremainder of his inpatient stay and he was continued on his\n14 day regimen of Levofloxacin 500 mg.\n\n4. Heme - As the patient's INR and PT were initially\nelevated, his Coumadin was held until the INR began to drop.\nAs the INR began to normalize, the Coumadin was slowly\nreturned. Of note, his PTT was elevated as were his\nfibrinogen and haptoglobin.", " His FDT and D-dimer were also\nmildly elevated. It was unclear how much of this was due to\nmild DIC, how much due to acute phase reaction and how much\ndue to underproduction of coagulation factors by the liver.\n\n5. Oncology - Because the patient's PTT remained elevated\nwithout explanation while in-house and because he had not\nreceived regular follow up after his Hodgkin's disease an\noncology consultation was obtained. At the consults\nrecommendation we suggested that the patient follow up with\nhis previous oncologist in Florida while he is visiting there\nnext month. He should undergo a surveillance computerized\ntomography scan as well as a possible gallium scan, PET scan\nand/or bone marrow biopsy.\n\n6. Renal - The patient initially appeared to have some\ndegree of acute and chronic renal failure, given his elevated\nBUN and creatinine.", " His creatinine decreased to 1.7 after\nthe 500 cc bolus and continued to trend down thereafter. BUN\nand creatinine were monitored throughout the remainder of the\nstay.\n\n7. Gastrointestinal - For his history of Crohn's disease\nwith chronic diarrhea, the patient was maintained on Asacol\n800 mg p.o. t.i.d. He also received Protonix and Colace prn.\n\n\n8. Endocrine - Because of a history of hypothyroidism, the\npatient was maintained on his Synthroid.\n\n9. Fluids, electrolytes and nutrition - The patient was\nmaintained on a cardiac diet as tolerated. Fluids were not\ngiven after the patient was transferred from the Intensive\nCare Unit to the floor because of his likely congestive heart\nfailure.\n\n10. Code - The patient was full code.\n\n11. Prophylaxis - The patient was kept on Protonix. His INR\nwas therapeutic or supertherapeutic throughout the hospital\nstay and so no further deep vein thrombosis prophylaxis was\nrequired.", '\n\nDISPOSITION: The patient was discharged home to\nRodriguez Inc Health System Rehabilitation once he was able to ambulate\nwithout dropping his saturations into the 80s.\n\nDISCHARGE DIAGNOSIS:\n1. Community acquired pneumonia\n2. Congestive heart failure\n\nDISCHARGE MEDICATIONS:\n1. Cozaar 50 mg p.o. q.d.\n2. Carvedilol 6.25 mg p.o. b.i.d.\n3. Amiodarone 200 mg p.o. q.d.\n4. Levofloxacin 500 mg p.o. q.d. times nine days\n5. Lipitor 10 mg p.o. q.d.\n6. Asacol 800 mg p.o. t.i.d.\n7. Colace 100 mg p.o. b.i.d. prn\n8. Synthroid 300 mcg p.o. q.d.\n9. Tylenol 325 mg p.o. q. 4 to 6 hours prn\n10. Atrovent metered dose inhalers 2 to 3 puffs q.i.d.\n11. Albuterol metered dose inhaler 2 to 4 puffs q.i.d. prn\n12. Protonix 40 mg p.o. q.d.\n13. Lasix 40 mg p.o. q.d.\n14. Coumadin p.o. 3 mg on Tuesday, Thursday, Saturday and\nSunday, 2 mg Monday, Wednesday and Friday\n15.', " K-dur 20 mEq p.o. b.i.d.\n\nFOLLOW UP:\n1. The patient should follow up with his primary care\nphysician, Pleasant. Kraig Amaro\n2. The patient should follow up with his oncologist in\nFlorida, regarding surveillance for his Hodgkin's disease\n\n\n\n Darnell ME Lees, M.D. 71092658\n\nDictated By:Tamaro\nMEDQUIST36\n\nD: 1969-10-15 16:24\nT: 2022-7-24 17:22\nJOB#: Jones-Spears-2004-291982\n"]
442	94982	139806.0	2193-01-18	Discharge summary	Report	Admission Date: [2193-1-8] Discharge Date: [2193-1-18] Date of Birth: [2141-12-5] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 602] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [1-8] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [Name (NI) ] for evaluation. . In the ED, initial VS were: 97.8 70 158/90 18 96RA . He was evaluated by psychiatry who felt his symptoms were due to aquired catatonia in the setting of a mood disorder and weaning off abilify. They noted that in the ED he exhibited mutism, hypokinetic behavior, echolalia/echopraxia, posturing and decreased eye blink. He was placed on section 12 and bed search was initiated. However he became agitated yesterday afternoon when he was ready to be transferred to an outside facility. He was given ativan but eventurally required 4 point restraints. Restraints were kept in place overnight, removed this morning, but then replaced due to concern for fall risk as he would not remain in his bed. His CK was noted to be trending upward, and the ED requested that he be admitted to the MICU given possible need for ativan drip, rising CK, and high risk for NMS. . Last vitals in ED: 97.8 70 158/90 18 96%RA. Just prior to admission he was noted to be drowsy, with his last benzo dose of ativan 2mg, midazolam 5mg at 1130hrs, and total of 20mg ativan given during ED course. ED records noted his head CT was negative for hemorrhage, mediastinum appeared widened on AP CXR, and initial ECG showed sinus tachycardia with normal QTc interval. . On arrival to the MICU patient was conversant, but remained mildly agitated. . Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [2180], stent placed in [2188] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [Name (NI) 3264]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [Name (NI) 3494] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [2193-1-8] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [2193-1-8] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [2193-1-8] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [2193-1-8] 02:20PM BLOOD CK(CPK)-565* [2193-1-10] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [2193-1-10] 02:40AM BLOOD Lipase-29 [2193-1-8] 02:20PM BLOOD cTropnT-<0.01 [2193-1-10] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [2193-1-10] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [2193-1-10] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [2193-1-10] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [2193-1-11] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [2193-1-10] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [2193-1-8] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2193-1-12] 07:56PM BLOOD Type-[Last Name (un) ] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [2193-1-12] 07:56PM BLOOD freeCa-0.94* [2193-1-12] 07:56PM BLOOD Lactate-1.1 . MICRO: [2193-1-11] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. . IMAGING: [1-10] CT HEAD TECHNIQUE: Contiguous axial images were obtained through the brain. No contrast was administered. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. The mastoid air cells, and middle ear cavities are clear. There is mild mucosal thickening in the ethmoid air cells. Sphenoid sinus septations insert anterior to the carotid grooves. IMPRESSION: No evidence of hemorrhage, mass effect. Correlate clinically to decide on the need for further workup. . [1-13] CXR HISTORY: Catatonia and worsening rhonchi. Suspect pneumonia. IMPRESSION: AP chest compared to [2194-1-12]:11 p.m. There may be a new consolidation at the base of the left lung denoted by the appearance of air bronchograms, pneumonia until proved otherwise. Top normal heart size, unchanged. Pulmonary vascular engorgement is present, but there is no clear edema or appreciable pleural effusion. Mediastinal widening due to fat deposition is longstanding. Discharge Labs: [2193-1-18] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [2193-1-18] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [2193-1-18] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [2193-1-18] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [2193-1-14] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2193-1-16] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [Known lastname 3776] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [Doctor Last Name 688] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [Hospital1 ], with ativan 1mg [Hospital1 ]). Unfortunately, although his catatonia improved, Mr. [Known lastname 3777] psychosis did not continue to improve with haloperidol from [Date range (1) 3778], and ECT was deemed necessary. He was scheduled to begin ECT on [1-18], and medical clearance was obtained, but unfortunately Mr. [Known lastname 3776] could not be consented for the procedure and health care proxy authority for his mother was not formalized. Mr. [Name14 (STitle) 3779] remained in [4-6] point restraints during his floor stay. # Leukocytosis/Fever/Pneumonia: Mr. [Name14 (STitle) 3779] was noted to have difficulty with secretions on [1-12] after recieving ativan for agitation. CXR on [1-13] [Month/Year (2) 3780] a left lower lobe infiltrate and rhonchi on exam. Mr. [Known lastname 3776] also was noted to have low grade fevers (100.5-101), and leukocytosis to 14. He was therefore felt to have pneumonia and symptoms with levofloxacin for a 7 day course. # Elevated creatine kinase (CK): Psychiatry was concerned his elevated CK represented neuroleptic malignant syndrome (NMS). He was admitted to the MICU but did not exhibit any signs or symptoms of NMS including no fevers and had progressively downtrending CK. Ultimately, the elevated CK was likely due to thrashing in the ED. #Transaminitis: Mr. [First Name (Titles) 3779] [Last Name (Titles) 3780] low-grade transaminitis 40-60s which is consistent with prior levels. This may be secondary to known fatty liver disease or toxic effects of CK. It persisted during admission without evidence of synthetic dysfunction and should be followed as an outpatient. LFTs should be monitored periodically as elevated aminotransferases may also represent mild hepatotoxicity from the high doses of antipsychotic medications he has been receiving. Viral hepatitis serologies were within normal limits. Of note, his hepatitis B surface antibody was negative, and future vaccination should be considered. # Groin pustule: Noted by nurse in the MICU, was unroofed and sent for culture, growing MSSA. This was sensitive to levofloxacin which he recieved for his pneumonia. # Coronary artery disease (CAD): History of acute myocardial infarction in [2178], stent placed in [2188]. ECG showed sinus rhythm with no acute ischemic changes. He has a baseline widened mediastinum found on prior CT to be fat deposits and lymphadenopathy. We initially held his simvastatin and zetia given elevated LFTs. We continued his aspirin given his LAD stent. #Poor PO intake: Mr. [Known lastname 3776] [Last Name (Titles) 3781] refused to take PO intake while on the floor. We continued IV fluids with D5 1/2 NS at 125 cc/hr during his stay, but his hematocrit increased from 41 to 49 indicating hemoconcentration. We increased his IVF to 150 cc/hr on [1-17], but his hct continued to rise from [1-17] to [1-18] from 47.6 to 49.6. We suggest increasing his IVF to D5 [2-5] NS at 200 cc/hr if he continues to refuse oral intake. # Asthma: Continued home albuterol and ipratropium PRN. # Communication: mother, [Name (NI) 3782] psychiatrist Dr. [Last Name (STitle) 3783] ([Telephone/Fax (1) 3784]) TRANSITIONAL ISSUES: - Please determine if luvox and lamictal are to be restarted. These were held upon admission for unclear reasons, and were not restarted upon transfer to the floor as they had been held for 8 days. Medications on Admission: - diazepam 5-10mg qhs prn insomnia - luvox cr 300mg qhs - lamictal 300mg qhs - simvastatin 40mg daily - aspirin 325mg daily - atrovent Q6hrs prn - zetia 10mg daily - acebutolol 200mg [Hospital1 ] Discharge Medications: 1. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000 unit injection 5,000 unit injection Injection TID (3 times a day). 4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Last day of course will be [2193-1-20]. 9. haloperidol 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY DIAGNOSIS Depression with psychotic features Asthma Obesity Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. [Known lastname 3776], . It was a pleasure taking care of you at [Hospital1 18]. You were admitted to the hospital because you were having a manifestation of your depression called catatonia. There was concern that your muscles were ungoing breakdown because of the catatonia so we monitored you closely in the ICU, but your muscles turned out to be recovering well. . Your catatonia was treated with medications called haldol and lorazepam. Your depression and psychosis will need further treatment with a procedure known as electroconvulsive therapy. It is very important that you keep all of the appointments with your doctors listed below. You will be transfered to the psychiatric [Hospital1 ] to continue to treat your depression and psychosis. Your psychiatric medications will be adjusted further during your psychiatric hospitalization. . It is also very important that you take your medications everyday. The following changes were made to your medications: 1. Your Luvox and lamictal (treatments for depression and other mood disorders) have been stopped, please consult with your psychiatrists regarding whether to restart these. START haloperidol (for your confusion) START levofloxacin (for pneumonia), you will have 2 more days START ativan for agitation STOP simvastatin and START atorvastatin because we need to treat your lipids, but the simvastatin may have been harming your liver Followup Instructions: Please follow up with your PCP after you are discharged from deaconness 4.	Admission Date: <Date>1987-1-12</Date> Discharge Date: <Date>1915-3-2</Date> Date of Birth: <Date>2006-4-13</Date> Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Trent</Name> Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on <Date>10-14</Date> with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the <Name>Shannon Bludsworth</Name> for evaluation. . In the ED, initial VS were: 97.8 70 158/90 18 96RA . He was evaluated by psychiatry who felt his symptoms were due to aquired catatonia in the setting of a mood disorder and weaning off abilify. They noted that in the ED he exhibited mutism, hypokinetic behavior, echolalia/echopraxia, posturing and decreased eye blink. He was placed on section 12 and bed search was initiated. However he became agitated yesterday afternoon when he was ready to be transferred to an outside facility. He was given ativan but eventurally required 4 point restraints. Restraints were kept in place overnight, removed this morning, but then replaced due to concern for fall risk as he would not remain in his bed. His CK was noted to be trending upward, and the ED requested that he be admitted to the MICU given possible need for ativan drip, rising CK, and high risk for NMS. . Last vitals in ED: 97.8 70 158/90 18 96%RA. Just prior to admission he was noted to be drowsy, with his last benzo dose of ativan 2mg, midazolam 5mg at 1130hrs, and total of 20mg ativan given during ED course. ED records noted his head CT was negative for hemorrhage, mediastinum appeared widened on AP CXR, and initial ECG showed sinus tachycardia with normal QTc interval. . On arrival to the MICU patient was conversant, but remained mildly agitated. . Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI <Year>2016</Year>, stent placed in <Year>2016</Year> - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - <Name>Guadalupe Blanchar</Name>: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in <Name>Estrella Merino</Name> Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: <Date>1987-1-12</Date> 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 <Date>1987-1-12</Date> 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 <Date>1987-1-12</Date> 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 <Date>1987-1-12</Date> 02:20PM BLOOD CK(CPK)-565* <Date>1905-9-21</Date> 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 <Date>1905-9-21</Date> 02:40AM BLOOD Lipase-29 <Date>1987-1-12</Date> 02:20PM BLOOD cTropnT-<0.01 <Date>1905-9-21</Date> 02:40AM BLOOD CK-MB-14* MB Indx-1.0 <Date>1905-9-21</Date> 02:40AM BLOOD CK-MB-14* MB Indx-1.0 <Date>1905-9-21</Date> 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 <Date>1905-9-21</Date> 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 <Date>1955-2-2</Date> 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 <Date>1905-9-21</Date> 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 <Date>1987-1-12</Date> 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG <Date>1991-12-11</Date> 07:56PM BLOOD Type-<Name>Pettway</Name> Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP <Date>1991-12-11</Date> 07:56PM BLOOD freeCa-0.94* <Date>1991-12-11</Date> 07:56PM BLOOD Lactate-1.1 . MICRO: <Date>1955-2-2</Date> 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. . IMAGING: <Date>12-18</Date> CT HEAD TECHNIQUE: Contiguous axial images were obtained through the brain. No contrast was administered. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. The mastoid air cells, and middle ear cavities are clear. There is mild mucosal thickening in the ethmoid air cells. Sphenoid sinus septations insert anterior to the carotid grooves. IMPRESSION: No evidence of hemorrhage, mass effect. Correlate clinically to decide on the need for further workup. . <Date>12-18</Date> CXR HISTORY: Catatonia and worsening rhonchi. Suspect pneumonia. IMPRESSION: AP chest compared to <Date>1912-3-28</Date>:11 p.m. There may be a new consolidation at the base of the left lung denoted by the appearance of air bronchograms, pneumonia until proved otherwise. Top normal heart size, unchanged. Pulmonary vascular engorgement is present, but there is no clear edema or appreciable pleural effusion. Mediastinal widening due to fat deposition is longstanding. Discharge Labs: <Date>1915-3-2</Date> 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 <Date>1915-3-2</Date> 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 <Date>1915-3-2</Date> 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 <Date>1915-3-2</Date> 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 <Date>1964-6-29</Date> 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE <Date>1919-2-14</Date> 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. <Name>Booker</Name> is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and <Doctor Name>Dr.Braswell</Doctor Name> catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg <Hospital>Dawson PLC Hospital</Hospital>, with ativan 1mg <Hospital>Dawson PLC Hospital</Hospital>). Unfortunately, although his catatonia improved, Mr. <Name>Smith</Name> psychosis did not continue to improve with haloperidol from <Date Range>1977-8-13 to 1999-10-4</Date Range>, and ECT was deemed necessary. He was scheduled to begin ECT on <Date>8-25</Date>, and medical clearance was obtained, but unfortunately Mr. <Name>Booker</Name> could not be consented for the procedure and health care proxy authority for his mother was not formalized. Mr. <Name>Ollie Scheet</Name> remained in <Date>8-30</Date> point restraints during his floor stay. # Leukocytosis/Fever/Pneumonia: Mr. <Name>Ollie Scheet</Name> was noted to have difficulty with secretions on <Date>10-11</Date> after recieving ativan for agitation. CXR on <Date>12-18</Date> <Month>October</Month> a left lower lobe infiltrate and rhonchi on exam. Mr. <Name>Booker</Name> also was noted to have low grade fevers (100.5-101), and leukocytosis to 14. He was therefore felt to have pneumonia and symptoms with levofloxacin for a 7 day course. # Elevated creatine kinase (CK): Psychiatry was concerned his elevated CK represented neuroleptic malignant syndrome (NMS). He was admitted to the MICU but did not exhibit any signs or symptoms of NMS including no fevers and had progressively downtrending CK. Ultimately, the elevated CK was likely due to thrashing in the ED. #Transaminitis: Mr. <Name>Kelly</Name> <Name>Atencio</Name> low-grade transaminitis 40-60s which is consistent with prior levels. This may be secondary to known fatty liver disease or toxic effects of CK. It persisted during admission without evidence of synthetic dysfunction and should be followed as an outpatient. LFTs should be monitored periodically as elevated aminotransferases may also represent mild hepatotoxicity from the high doses of antipsychotic medications he has been receiving. Viral hepatitis serologies were within normal limits. Of note, his hepatitis B surface antibody was negative, and future vaccination should be considered. # Groin pustule: Noted by nurse in the MICU, was unroofed and sent for culture, growing MSSA. This was sensitive to levofloxacin which he recieved for his pneumonia. # Coronary artery disease (CAD): History of acute myocardial infarction in <Year>2016</Year>, stent placed in <Year>2016</Year>. ECG showed sinus rhythm with no acute ischemic changes. He has a baseline widened mediastinum found on prior CT to be fat deposits and lymphadenopathy. We initially held his simvastatin and zetia given elevated LFTs. We continued his aspirin given his LAD stent. #Poor PO intake: Mr. <Name>Booker</Name> <Name>Anderson</Name> refused to take PO intake while on the floor. We continued IV fluids with D5 1/2 NS at 125 cc/hr during his stay, but his hematocrit increased from 41 to 49 indicating hemoconcentration. We increased his IVF to 150 cc/hr on <Date>5-26</Date>, but his hct continued to rise from <Date>5-26</Date> to <Date>8-25</Date> from 47.6 to 49.6. We suggest increasing his IVF to D5 <Date>3-23</Date> NS at 200 cc/hr if he continues to refuse oral intake. # Asthma: Continued home albuterol and ipratropium PRN. # Communication: mother, <Name>Cedric Post</Name> psychiatrist Dr. <Name>White</Name> (<Telephone>724-591-7529</Telephone>) TRANSITIONAL ISSUES: - Please determine if luvox and lamictal are to be restarted. These were held upon admission for unclear reasons, and were not restarted upon transfer to the floor as they had been held for 8 days. Medications on Admission: - diazepam 5-10mg qhs prn insomnia - luvox cr 300mg qhs - lamictal 300mg qhs - simvastatin 40mg daily - aspirin 325mg daily - atrovent Q6hrs prn - zetia 10mg daily - acebutolol 200mg <Hospital>Dawson PLC Hospital</Hospital> Discharge Medications: 1. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000 unit injection 5,000 unit injection Injection TID (3 times a day). 4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Last day of course will be <Date>1942-1-4</Date>. 9. haloperidol 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY DIAGNOSIS Depression with psychotic features Asthma Obesity Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. <Name>Booker</Name>, . It was a pleasure taking care of you at <Hospital>Martinez, Love and Buckley Clinic</Hospital>. You were admitted to the hospital because you were having a manifestation of your depression called catatonia. There was concern that your muscles were ungoing breakdown because of the catatonia so we monitored you closely in the ICU, but your muscles turned out to be recovering well. . Your catatonia was treated with medications called haldol and lorazepam. Your depression and psychosis will need further treatment with a procedure known as electroconvulsive therapy. It is very important that you keep all of the appointments with your doctors listed below. You will be transfered to the psychiatric <Hospital>Dawson PLC Hospital</Hospital> to continue to treat your depression and psychosis. Your psychiatric medications will be adjusted further during your psychiatric hospitalization. . It is also very important that you take your medications everyday. The following changes were made to your medications: 1. Your Luvox and lamictal (treatments for depression and other mood disorders) have been stopped, please consult with your psychiatrists regarding whether to restart these. START haloperidol (for your confusion) START levofloxacin (for pneumonia), you will have 2 more days START ativan for agitation STOP simvastatin and START atorvastatin because we need to treat your lipids, but the simvastatin may have been harming your liver Followup Instructions: Please follow up with your PCP after you are discharged from deaconness 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Date: 1987-1-12 Discharge Date: 1915-3-2 Date of Birth: 2006-4-13 Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Trent Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on 10-14 with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the Shannon Bludsworth for evaluation. . In the ED, initial VS were: 97.8 70 158/90 18 96RA . He was evaluated by psychiatry who felt his symptoms were due to aquired catatonia in the setting of a mood disorder and weaning off abilify. They noted that in the ED he exhibited mutism, hypokinetic behavior, echolalia/echopraxia, posturing and decreased eye blink. He was placed on section 12 and bed search was initiated. However he became agitated yesterday afternoon when he was ready to be transferred to an outside facility. He was given ativan but eventurally required 4 point restraints. Restraints were kept in place overnight, removed this morning, but then replaced due to concern for fall risk as he would not remain in his bed. His CK was noted to be trending upward, and the ED requested that he be admitted to the MICU given possible need for ativan drip, rising CK, and high risk for NMS. . Last vitals in ED: 97.8 70 158/90 18 96%RA. Just prior to admission he was noted to be drowsy, with his last benzo dose of ativan 2mg, midazolam 5mg at 1130hrs, and total of 20mg ativan given during ED course. ED records noted his head CT was negative for hemorrhage, mediastinum appeared widened on AP CXR, and initial ECG showed sinus tachycardia with normal QTc interval. . On arrival to the MICU patient was conversant, but remained mildly agitated. . Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI 2016, stent placed in 2016 - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - Guadalupe Blanchar: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in Estrella Merino Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: 1987-1-12 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 1987-1-12 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 1987-1-12 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 1987-1-12 02:20PM BLOOD CK(CPK)-565* 1905-9-21 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 1905-9-21 02:40AM BLOOD Lipase-29 1987-1-12 02:20PM BLOOD cTropnT-1905-9-21 02:40AM BLOOD CK-MB-14* MB Indx-1.0 1905-9-21 02:40AM BLOOD CK-MB-14* MB Indx-1.0 1905-9-21 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-1905-9-21 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-1955-2-2 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-1905-9-21 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 1987-1-12 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG 1991-12-11 07:56PM BLOOD Type-Pettway Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP 1991-12-11 07:56PM BLOOD freeCa-0.94* 1991-12-11 07:56PM BLOOD Lactate-1.1 . MICRO: 1955-2-2 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. . IMAGING: 12-18 CT HEAD TECHNIQUE: Contiguous axial images were obtained through the brain. No contrast was administered. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. The mastoid air cells, and middle ear cavities are clear. There is mild mucosal thickening in the ethmoid air cells. Sphenoid sinus septations insert anterior to the carotid grooves. IMPRESSION: No evidence of hemorrhage, mass effect. Correlate clinically to decide on the need for further workup. . 12-18 CXR HISTORY: Catatonia and worsening rhonchi. Suspect pneumonia. IMPRESSION: AP chest compared to 1912-3-28:11 p.m. There may be a new consolidation at the base of the left lung denoted by the appearance of air bronchograms, pneumonia until proved otherwise. Top normal heart size, unchanged. Pulmonary vascular engorgement is present, but there is no clear edema or appreciable pleural effusion. Mediastinal widening due to fat deposition is longstanding. Discharge Labs: 1915-3-2 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 1915-3-2 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 1915-3-2 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 1915-3-2 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 1964-6-29 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE 1919-2-14 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. Booker is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and Dr.Braswell catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg Dawson PLC Hospital, with ativan 1mg Dawson PLC Hospital). Unfortunately, although his catatonia improved, Mr. Smith psychosis did not continue to improve with haloperidol from 1977-8-13 to 1999-10-4, and ECT was deemed necessary. He was scheduled to begin ECT on 8-25, and medical clearance was obtained, but unfortunately Mr. Booker could not be consented for the procedure and health care proxy authority for his mother was not formalized. Mr. Ollie Scheet remained in 8-30 point restraints during his floor stay. # Leukocytosis/Fever/Pneumonia: Mr. Ollie Scheet was noted to have difficulty with secretions on 10-11 after recieving ativan for agitation. CXR on 12-18 October a left lower lobe infiltrate and rhonchi on exam. Mr. Booker also was noted to have low grade fevers (100.5-101), and leukocytosis to 14. He was therefore felt to have pneumonia and symptoms with levofloxacin for a 7 day course. # Elevated creatine kinase (CK): Psychiatry was concerned his elevated CK represented neuroleptic malignant syndrome (NMS). He was admitted to the MICU but did not exhibit any signs or symptoms of NMS including no fevers and had progressively downtrending CK. Ultimately, the elevated CK was likely due to thrashing in the ED. #Transaminitis: Mr. Kelly Atencio low-grade transaminitis 40-60s which is consistent with prior levels. This may be secondary to known fatty liver disease or toxic effects of CK. It persisted during admission without evidence of synthetic dysfunction and should be followed as an outpatient. LFTs should be monitored periodically as elevated aminotransferases may also represent mild hepatotoxicity from the high doses of antipsychotic medications he has been receiving. Viral hepatitis serologies were within normal limits. Of note, his hepatitis B surface antibody was negative, and future vaccination should be considered. # Groin pustule: Noted by nurse in the MICU, was unroofed and sent for culture, growing MSSA. This was sensitive to levofloxacin which he recieved for his pneumonia. # Coronary artery disease (CAD): History of acute myocardial infarction in 2016, stent placed in 2016. ECG showed sinus rhythm with no acute ischemic changes. He has a baseline widened mediastinum found on prior CT to be fat deposits and lymphadenopathy. We initially held his simvastatin and zetia given elevated LFTs. We continued his aspirin given his LAD stent. #Poor PO intake: Mr. Booker Anderson refused to take PO intake while on the floor. We continued IV fluids with D5 1/2 NS at 125 cc/hr during his stay, but his hematocrit increased from 41 to 49 indicating hemoconcentration. We increased his IVF to 150 cc/hr on 5-26, but his hct continued to rise from 5-26 to 8-25 from 47.6 to 49.6. We suggest increasing his IVF to D5 3-23 NS at 200 cc/hr if he continues to refuse oral intake. # Asthma: Continued home albuterol and ipratropium PRN. # Communication: mother, Cedric Post psychiatrist Dr. White (724-591-7529) TRANSITIONAL ISSUES: - Please determine if luvox and lamictal are to be restarted. These were held upon admission for unclear reasons, and were not restarted upon transfer to the floor as they had been held for 8 days. Medications on Admission: - diazepam 5-10mg qhs prn insomnia - luvox cr 300mg qhs - lamictal 300mg qhs - simvastatin 40mg daily - aspirin 325mg daily - atrovent Q6hrs prn - zetia 10mg daily - acebutolol 200mg Dawson PLC Hospital Discharge Medications: 1. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000 unit injection 5,000 unit injection Injection TID (3 times a day). 4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Last day of course will be 1942-1-4. 9. haloperidol 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY DIAGNOSIS Depression with psychotic features Asthma Obesity Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. Booker, . It was a pleasure taking care of you at Martinez, Love and Buckley Clinic. You were admitted to the hospital because you were having a manifestation of your depression called catatonia. There was concern that your muscles were ungoing breakdown because of the catatonia so we monitored you closely in the ICU, but your muscles turned out to be recovering well. . Your catatonia was treated with medications called haldol and lorazepam. Your depression and psychosis will need further treatment with a procedure known as electroconvulsive therapy. It is very important that you keep all of the appointments with your doctors listed below. You will be transfered to the psychiatric Dawson PLC Hospital to continue to treat your depression and psychosis. Your psychiatric medications will be adjusted further during your psychiatric hospitalization. . It is also very important that you take your medications everyday. The following changes were made to your medications: 1. Your Luvox and lamictal (treatments for depression and other mood disorders) have been stopped, please consult with your psychiatrists regarding whether to restart these. START haloperidol (for your confusion) START levofloxacin (for pneumonia), you will have 2 more days START ativan for agitation STOP simvastatin and START atorvastatin because we need to treat your lipids, but the simvastatin may have been harming your liver Followup Instructions: Please follow up with your PCP after you are discharged from deaconness 4.	['Admission Date: 1987-1-12 Discharge Date: 1915-3-2\n\nDate of Birth: 2006-4-13 Sex: M\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Trent\nChief Complaint:\ncatatonia\n\n\nMajor Surgical or Invasive Procedure:\nnone\n\n\nHistory of Present Illness:\n51M w/ hx of depression, remote suicide attempts and OCD\npresented to ED on 10-14 with c/o being nonconversant. He was\nbeing weaned off abilify over the past 3 weeks due to\n"drowsiness", and 3 days ago the patient\'s mother, with whom he\nlives, noticed that he was pacing the floor, a behavior that is\nunusual for him, but otherwise was at his baseline which is\nfully functional and independent in ADLs. The next morning\nhowever he became nonconversant and minimally responsive to\nverbal commands.', ' After contacting his psychiatrist, his mother\nbrought the patient to the Shannon Bludsworth for evaluation.\n.\nIn the ED, initial VS were: 97.8 70 158/90 18 96RA\n.\nHe was evaluated by psychiatry who felt his symptoms were due to\naquired catatonia in the setting of a mood disorder and weaning\noff abilify. They noted that in the ED he exhibited mutism,\nhypokinetic behavior, echolalia/echopraxia, posturing and\ndecreased eye blink. He was placed on section 12 and bed search\nwas initiated. However he became agitated yesterday afternoon\nwhen he was ready to be transferred to an outside facility. He\nwas given ativan but eventurally required 4 point restraints.\nRestraints were kept in place overnight, removed this morning,\nbut then replaced due to concern for fall risk as he would not\nremain in his bed.', ' His CK was noted to be trending upward, and\nthe ED requested that he be admitted to the MICU given possible\nneed for ativan drip, rising CK, and high risk for NMS.\n.\nLast vitals in ED: 97.8 70 158/90 18 96%RA. Just prior to\nadmission he was noted to be drowsy, with his last benzo dose of\nativan 2mg, midazolam 5mg at 1130hrs, and total of 20mg ativan\ngiven during ED course. ED records noted his head CT was\nnegative for hemorrhage, mediastinum appeared widened on AP CXR,\nand initial ECG showed sinus tachycardia with normal QTc\ninterval.\n.\nOn arrival to the MICU patient was conversant, but remained\nmildly agitated.\n.\nReview of systems:\n- Reviewed and negative except per HPI\n\nPast Medical History:\n- depression w/ psychotic feactures, s/p ECT, hx of suicide\nattempts\n- Obsessive-compulsive traits\n- CAD s/p AMI 2016, stent placed in 2016\n- chronic low back pain\n- asthma\n- obesity\n\n\nSocial History:\n- Tobacco: smokes 1-1.', '5ppd x 30yrs\n- Alcohol: none per mother\n- Guadalupe Blanchar: hx of cocaine and marijuana abuse, none for past\n20yrs\n- Divorced 20yrs ago, has 2 adult children, lives with mother in\nEstrella Merino\n\n\nFamily History:\n- sister: post-partum depression, suicide\n- grandfather: OCD\n\n\nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA\nGeneral: A/Ox2, answers basic questions\nHEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL\nNeck: supple, no LAD\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops\nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nronchi\nAbdomen: Obese, protuberant abdomen, nontender, bowel sounds\nGU: foley in place\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema\nNeuro: CNII-XII intact, 5/5 strength upper/lower extremities,\ngrossly normal sensation, 2+ reflexes bilaterally, gait\ndeferred, unable to complete finger-to-nose d/t restraints\n\n\nPertinent Results:\nADMISSION LABS:\n1987-1-12 02:20PM BLOOD WBC-12.', '7* RBC-5.61 Hgb-17.0 Hct-50.7\nMCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269\n1987-1-12 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8\nEos-1.0 Baso-0.4\n1987-1-12 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139\nK-4.7 Cl-100 HCO3-29 AnGap-15\n1987-1-12 02:20PM BLOOD CK(CPK)-565\n1905-9-21 02:40AM BLOOD ALT-27 AST-53 LD(LDH)-223 CK(CPK)-1354\nAlkPhos-111 TotBili-0.4\n1905-9-21 02:40AM BLOOD Lipase-29\n1987-1-12 02:20PM BLOOD cTropnT-1905-9-21 02:40AM BLOOD CK-MB-14 MB Indx-1.0\n1905-9-21 02:40AM BLOOD CK-MB-14* MB Indx-1.0\n1905-9-21 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-1905-9-21 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-1955-2-2 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-1905-9-21 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0\n1987-1-12 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS\nBarbitr-NEG Tricycl-NEG\n1991-12-11 07:56PM BLOOD Type-Pettway Temp-37.', '9 pO2-100 pCO2-26\npH-7.56 calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN\nTOP\n1991-12-11 07:56PM BLOOD freeCa-0.94\n1991-12-11 07:56PM BLOOD Lactate-1.1\n.\nMICRO:\n1955-2-2 8:02 pm SWAB Source: left groin.\n\n WOUND CULTURE (Preliminary):\n STAPH AUREUS COAG +. MODERATE GROWTH.\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.\n.\nIMAGING:\n12-18 CT HEAD TECHNIQUE: Contiguous axial images were obtained\nthrough the brain. No contrast was administered.\nFINDINGS: There is no evidence of hemorrhage, edema, mass\neffect, or\ninfarction. The ventricles and sulci are normal in size and\nconfiguration. The mastoid air cells, and middle ear cavities\nare clear. There is mild mucosal thickening in the ethmoid air\ncells. Sphenoid sinus septations insert anterior to the carotid\ngrooves.', '\nIMPRESSION: No evidence of hemorrhage, mass effect. Correlate\nclinically to decide on the need for further workup.\n.\n12-18 CXR HISTORY: Catatonia and worsening rhonchi. Suspect\npneumonia.\nIMPRESSION: AP chest compared to 1912-3-28:11 p.m.\nThere may be a new consolidation at the base of the left lung\ndenoted by the appearance of air bronchograms, pneumonia until\nproved otherwise. Top normal heart size, unchanged. Pulmonary\nvascular engorgement is present, but there is no clear edema or\nappreciable pleural effusion. Mediastinal widening due to fat\ndeposition is longstanding.\n\nDischarge Labs:\n1915-3-2 06:10AM BLOOD WBC-12.7 RBC-5.51 Hgb-16.5 Hct-49.6\nMCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352\n1915-3-2 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139\nK-3.9 Cl-101 HCO3-25 AnGap-17\n1915-3-2 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213\nAlkPhos-109 TotBili-0.', '3\n1915-3-2 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1\n1964-6-29 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE\nHBcAb-NEGATIVE HAV Ab-NEGATIVE\n1919-2-14 05:50AM BLOOD %HbA1c-5.5 eAG-111\n\nStudies pending at Discharge:\nNone\n\n\nBrief Hospital Course:\nMr. Booker is a 51 year old male with history of depression,\nobsessive compulsive disorder (OCD), and coronary artery disease\n(CAD) who was admitted for catatonia and course was notable for\nwaxing and Dr.Braswell catatonia and agitation.\n\nACTIVE PROBLEMS BY ISSUES:\n# Catatonia: He was seen by psychiatry and they felt that his\ncatatonia was most likely due to recent weaning from abilify\nwith exacerbation of underlying mood disorder (depression with\npsychosis). In ED, patient exhibited agitation requiring 4 point\nrestraints for prolonged course, and 20mg lorazepman total.', ' ECT\nwas entertained as a possible intervention for catatonia, and\nwas initially deferred as his catatonia resolved with standing\nantipsychotics (haloperidol 10mg Dawson PLC Hospital, with ativan 1mg Dawson PLC Hospital).\nUnfortunately, although his catatonia improved, Mr. Smith\npsychosis did not continue to improve with haloperidol from\n1977-8-13 to 1999-10-4, and ECT was deemed necessary. He was scheduled to\nbegin ECT on 8-25, and medical clearance was obtained, but\nunfortunately Mr. Booker could not be consented for the\nprocedure and health care proxy authority for his mother was not\nformalized. Mr. Ollie Scheet remained in 8-30 point restraints during\nhis floor stay.\n\n# Leukocytosis/Fever/Pneumonia: Mr. Ollie Scheet was noted to have\ndifficulty with secretions on 10-11 after recieving ativan for\nagitation.', ' CXR on 12-18 October a left lower lobe\ninfiltrate and rhonchi on exam. Mr. Booker also was noted to\nhave low grade fevers (100.5-101), and leukocytosis to 14. He\nwas therefore felt to have pneumonia and symptoms with\nlevofloxacin for a 7 day course.\n\n# Elevated creatine kinase (CK): Psychiatry was concerned his\nelevated CK represented neuroleptic malignant syndrome (NMS).\nHe was admitted to the MICU but did not exhibit any signs or\nsymptoms of NMS including no fevers and had progressively\ndowntrending CK. Ultimately, the elevated CK was likely due to\nthrashing in the ED.\n\n#Transaminitis: Mr. Kelly Atencio low-grade transaminitis\n40-60s which is consistent with prior levels. This may be\nsecondary to known fatty liver disease or toxic effects of CK.\nIt persisted during admission without evidence of synthetic\ndysfunction and should be followed as an outpatient.', ' LFTs should\nbe monitored periodically as elevated aminotransferases may also\nrepresent mild hepatotoxicity from the high doses of\nantipsychotic medications he has been receiving. Viral hepatitis\nserologies were within normal limits. Of note, his hepatitis B\nsurface antibody was negative, and future vaccination should be\nconsidered.\n\n# Groin pustule: Noted by nurse in the MICU, was unroofed and\nsent for culture, growing MSSA. This was sensitive to\nlevofloxacin which he recieved for his pneumonia.\n\n# Coronary artery disease (CAD): History of acute myocardial\ninfarction in 2016, stent placed in 2016. ECG showed sinus\nrhythm with no acute ischemic changes. He has a baseline widened\nmediastinum found on prior CT to be fat deposits and\nlymphadenopathy. We initially held his simvastatin and zetia\ngiven elevated LFTs.', ' We continued his aspirin given his LAD\nstent.\n\n#Poor PO intake: Mr. Booker Anderson refused to take PO\nintake while on the floor. We continued IV fluids with D5 1/2 NS\nat 125 cc/hr during his stay, but his hematocrit increased from\n41 to 49 indicating hemoconcentration. We increased his IVF to\n150 cc/hr on 5-26, but his hct continued to rise from 5-26 to\n8-25 from 47.6 to 49.6. We suggest increasing his IVF to D5 3-23\nNS at 200 cc/hr if he continues to refuse oral intake.\n\n# Asthma: Continued home albuterol and ipratropium PRN.\n\n# Communication: mother, Cedric Post psychiatrist Dr. White\n(724-591-7529)\n\nTRANSITIONAL ISSUES:\n- Please determine if luvox and lamictal are to be restarted.\nThese were held upon admission for unclear reasons, and were not\nrestarted upon transfer to the floor as they had been held for 8\ndays.', '\n\nMedications on Admission:\n- diazepam 5-10mg qhs prn insomnia\n- luvox cr 300mg qhs\n- lamictal 300mg qhs\n- simvastatin 40mg daily\n- aspirin 325mg daily\n- atrovent Q6hrs prn\n- zetia 10mg daily\n- acebutolol 200mg Dawson PLC Hospital\n\n\nDischarge Medications:\n1. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.\n2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000\nunit injection\n5,000 unit injection Injection TID (3 times a day).\n4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr\nTransdermal DAILY (Daily).\n5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed for shortness of breath or\nwheezing.\n7. albuterol sulfate 2.', '5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) Inhalation Q6H (every 6 hours) as\nneeded for shortness of breath or wheezing.\n8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every\n24 hours) for 2 days: Last day of course will be 1942-1-4.\n9. haloperidol 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a\nday).\n10. acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n\n\nDischarge Disposition:\nExtended Care\n\nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\nDepression with psychotic features\nAsthma\nObesity\nCoronary Artery Disease\n\n\nDischarge Condition:\nMental Status: Clear and coherent.\n\n\nDischarge Instructions:\nDear Mr. Booker,\n.\nIt was a pleasure taking care of you at Martinez, Love and Buckley Clinic.', ' You were admitted\nto the hospital because you were having a manifestation of your\ndepression called catatonia. There was concern that your\nmuscles were ungoing breakdown because of the catatonia so we\nmonitored you closely in the ICU, but your muscles turned out to\nbe recovering well.\n.\nYour catatonia was treated with medications called haldol and\nlorazepam. Your depression and psychosis will need further\ntreatment with a procedure known as electroconvulsive therapy.\nIt is very important that you keep all of the appointments with\nyour doctors listed below. You will be transfered to the\npsychiatric Dawson PLC Hospital to continue to treat your depression and\npsychosis.\n\nYour psychiatric medications will be adjusted further during\nyour psychiatric hospitalization.\n.\nIt is also very important that you take your medications\neveryday.', ' The following changes were made to your medications:\n\n1. Your Luvox and lamictal (treatments for depression and other\nmood disorders) have been stopped, please consult with your\npsychiatrists regarding whether to restart these.\nSTART haloperidol (for your confusion)\nSTART levofloxacin (for pneumonia), you will have 2 more days\nSTART ativan for agitation\nSTOP simvastatin and START atorvastatin because we need to treat\nyour lipids, but the simvastatin may have been harming your\nliver\n\n\nFollowup Instructions:\nPlease follow up with your PCP after you are discharged from\ndeaconness 4.\n\n\n\n']
443	636	142160.0	2133-09-13	Discharge summary	Report	Admission Date: [2133-9-3] Discharge Date: [2133-9-13] Service: MEDICINE Allergies: Codeine / Penicillins Attending:[First Name3 (LF) 1974] Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: Bone biopsy--left humerus History of Present Illness: 82M with h/o prostate CA who p/w increasing pain of left arm. Sveral months PTA, pt hit his arm. He went to local ER and was told he had a mild fracture, treated with sling and pain control. however, the pain worsened over the last few months. Pt came in to [Hospital1 18] for further evaluation. In [Name (NI) ], pt noted to have displaced left humerus fracture, likely pathologic. ROS of notable for increased LE edema. Past Medical History: Prostate CA s/p resection, unknown status CAD s/p CABG x 4 in [2123] with no further caths per family Vfib arrest, s/p ICD placement with 2 subsequent firings CHF, unknown EF%, followed by Dr. [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) 3236] at [Hospital1 3793] Hospital (cards) Afib s/p pacemaker hypercholesterolemia glaucoma Social History: Lives at home with son and daughter heavily involved in care. Tob: 1 ppd x many years, quit 6y ago Etoh: none Illicits: none Family History: non contributory Physical Exam: T=99.0, BP=100/70, HR=82 irreg, RR=20, O2=98% 3LNC, 88% RA elderly man lying in bed, in NAD PERRL <EOMI, MMM, OP clear JVP 10cm, no LAD irreg irreg, no m/r/g lungs rales lower [12-8] b/l Abd benign EXT: LUE with limited ROM, 2+ radial pulses b/l Pertinent Results: [2133-9-3] 07:00PM WBC-9.8 RBC-3.98* HGB-13.7* HCT-40.7 MCV-102* MCH-34.4* MCHC-33.6 RDW-13.4 [2133-9-3] 07:00PM NEUTS-79.8* LYMPHS-11.7* MONOS-6.3 EOS-0.1 BASOS-2.1* [2133-9-3] 07:00PM PLT COUNT-240 [2133-9-3] 07:00PM PT-19.3* PTT-29.5 INR(PT)-1.8* [2133-9-3] 07:00PM CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-2.1 [2133-9-3] 07:00PM CRP-191.6* PSA-<0.1 LEFT ARM FILM: Pathologic fracture of the proximal humerus as described above. A large lytic lesion is present involving the humeral head and proximal humerus. This is concerning for metastatic disease. Taking into account the recent chest x-ray that did not demonstrate evidence of malignancy, this is concerning for metastasis from a renal cell carcinoma and abdominal CT is recommended for further evaluation. CHEST CT: 1. 2.6 x 2.4 cm left lower lobe lesion, likely lung carcinoma. This lesion would be amenable to a CT-guided biopsy if clinically desired. 2. Extensive pleural thickening and calcification likely from asbestos exposure. 3. Rounded pulmonary nodule in the right upper lobe, suspicious for metastasis. 4. Bony destruction of T9 and T10 vertebrae with tumor extension into the bony spinal canal. There is a high risk for compression fracture in the future given the extent of these lesions. 5. Two suspicious enhancing areas within the right lobe of the liver raise the question of metastases, though the appearance is not typical. 6. Likely bilateral renal cysts, incompletely characterized. 7. Mild aneurysmal dilatation of the distal aspect of the abdominal aorta. Left common iliac artery aneurysm. Roughly 50% stenosis of the right superficial femoral artery. Bilateral atrial enlargement. Brief Hospital Course: 1) RESP: Initially, pt admitted to floor for workup of malignancy. However, on day#1, he developed increasing agitation. He was not clearing secretions and was intubated for airway protection. He was then transferred to [Hospital Unit Name 153]. Pt was in ICU for about 6 days. As his agitation and myoclonuse improved, he was extubated, and then transferred back to floor. . 2) HUMERUS FRACTURE: AS this represented likely pathologic fracture, a needle biopsy was done. Pt also had malignancy w/u with torso CT. This showed lung masses and abdominal mets. The pathology from humerus revealed likely metastatic lung carcinoma. Pt was seen by ortho onc but was not a surgical candidate. . 3) ONC: Pt was seen by onc, rad onc, neurosurg, and ortho onc regarding likely lung CA with mets to bone including spine. However, based on discussions with family, pt was made CMO given very poor prognosis. A few days after this change, on [9-13], the pt was found unresponsive and pronounced dead at 7:15AM. The family was called and declined autopsy. . 4) CV: His CAD, CHF, afib were not active issues during this hospitalization. EP service was consulted to turn off ICD given pt made CMO, however, this was not completed as there was concern that the family did not want to tell pt this was to be done. Medications on Admission: Coumadin 1.25mg per day, 6d/week; 2.5mg per day, 1d/week Colace 100mg [Hospital1 ] Toprol XL 25mg per day Lasix 120mg po qday (recent increase from 80mg per day) Lescol XL (statin) 80mg qd Losartan 25mg qd Xalatan 1 drop OU QHS Tylenol 1000mg tid prn Morphine elixir 10mg/5ml, [12-10] teaspoon q3h prn:pain in LUE Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Metastatic lung cancer Pathologic left humurous fracture Discharge Condition: Expired Discharge Instructions: none. Followup Instructions: none.	Admission Date: <Date>1997-8-15</Date> Discharge Date: <Date>1926-7-22</Date> Service: MEDICINE Allergies: Codeine / Penicillins Attending:<Name>Coral</Name> Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: Bone biopsy--left humerus History of Present Illness: 82M with h/o prostate CA who p/w increasing pain of left arm. Sveral months PTA, pt hit his arm. He went to local ER and was told he had a mild fracture, treated with sling and pain control. however, the pain worsened over the last few months. Pt came in to <Hospital>Ellis-Grant Hospital</Hospital> for further evaluation. In <Name>Henry Kaur</Name>, pt noted to have displaced left humerus fracture, likely pathologic. ROS of notable for increased LE edema. Past Medical History: Prostate CA s/p resection, unknown status CAD s/p CABG x 4 in <Year>1995</Year> with no further caths per family Vfib arrest, s/p ICD placement with 2 subsequent firings CHF, unknown EF%, followed by Dr. <Name>Samuel</Name> <Name>Archie</Name> at <Hospital>Hudson, Ibarra and Cook Clinic</Hospital> Hospital (cards) Afib s/p pacemaker hypercholesterolemia glaucoma Social History: Lives at home with son and daughter heavily involved in care. Tob: 1 ppd x many years, quit 6y ago Etoh: none Illicits: none Family History: non contributory Physical Exam: T=99.0, BP=100/70, HR=82 irreg, RR=20, O2=98% 3LNC, 88% RA elderly man lying in bed, in NAD PERRL <EOMI, MMM, OP clear JVP 10cm, no LAD irreg irreg, no m/r/g lungs rales lower <Date>3-30</Date> b/l Abd benign EXT: LUE with limited ROM, 2+ radial pulses b/l Pertinent Results: <Date>1997-8-15</Date> 07:00PM WBC-9.8 RBC-3.98* HGB-13.7* HCT-40.7 MCV-102* MCH-34.4* MCHC-33.6 RDW-13.4 <Date>1997-8-15</Date> 07:00PM NEUTS-79.8* LYMPHS-11.7* MONOS-6.3 EOS-0.1 BASOS-2.1* <Date>1997-8-15</Date> 07:00PM PLT COUNT-240 <Date>1997-8-15</Date> 07:00PM PT-19.3* PTT-29.5 INR(PT)-1.8* <Date>1997-8-15</Date> 07:00PM CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-2.1 <Date>1997-8-15</Date> 07:00PM CRP-191.6* PSA-<0.1 LEFT ARM FILM: Pathologic fracture of the proximal humerus as described above. A large lytic lesion is present involving the humeral head and proximal humerus. This is concerning for metastatic disease. Taking into account the recent chest x-ray that did not demonstrate evidence of malignancy, this is concerning for metastasis from a renal cell carcinoma and abdominal CT is recommended for further evaluation. CHEST CT: 1. 2.6 x 2.4 cm left lower lobe lesion, likely lung carcinoma. This lesion would be amenable to a CT-guided biopsy if clinically desired. 2. Extensive pleural thickening and calcification likely from asbestos exposure. 3. Rounded pulmonary nodule in the right upper lobe, suspicious for metastasis. 4. Bony destruction of T9 and T10 vertebrae with tumor extension into the bony spinal canal. There is a high risk for compression fracture in the future given the extent of these lesions. 5. Two suspicious enhancing areas within the right lobe of the liver raise the question of metastases, though the appearance is not typical. 6. Likely bilateral renal cysts, incompletely characterized. 7. Mild aneurysmal dilatation of the distal aspect of the abdominal aorta. Left common iliac artery aneurysm. Roughly 50% stenosis of the right superficial femoral artery. Bilateral atrial enlargement. Brief Hospital Course: 1) RESP: Initially, pt admitted to floor for workup of malignancy. However, on day#1, he developed increasing agitation. He was not clearing secretions and was intubated for airway protection. He was then transferred to <Hospital>Banks-Wilson Hospital</Hospital>. Pt was in ICU for about 6 days. As his agitation and myoclonuse improved, he was extubated, and then transferred back to floor. . 2) HUMERUS FRACTURE: AS this represented likely pathologic fracture, a needle biopsy was done. Pt also had malignancy w/u with torso CT. This showed lung masses and abdominal mets. The pathology from humerus revealed likely metastatic lung carcinoma. Pt was seen by ortho onc but was not a surgical candidate. . 3) ONC: Pt was seen by onc, rad onc, neurosurg, and ortho onc regarding likely lung CA with mets to bone including spine. However, based on discussions with family, pt was made CMO given very poor prognosis. A few days after this change, on <Date>8-5</Date>, the pt was found unresponsive and pronounced dead at 7:15AM. The family was called and declined autopsy. . 4) CV: His CAD, CHF, afib were not active issues during this hospitalization. EP service was consulted to turn off ICD given pt made CMO, however, this was not completed as there was concern that the family did not want to tell pt this was to be done. Medications on Admission: Coumadin 1.25mg per day, 6d/week; 2.5mg per day, 1d/week Colace 100mg <Hospital>Collins-Vega Hospital</Hospital> Toprol XL 25mg per day Lasix 120mg po qday (recent increase from 80mg per day) Lescol XL (statin) 80mg qd Losartan 25mg qd Xalatan 1 drop OU QHS Tylenol 1000mg tid prn Morphine elixir 10mg/5ml, <Date>5-8</Date> teaspoon q3h prn:pain in LUE Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Metastatic lung cancer Pathologic left humurous fracture Discharge Condition: Expired Discharge Instructions: none. Followup Instructions: none.	00000000000000000111111111000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111110000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111011111100001111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000111111111000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000	Admission Date: 1997-8-15 Discharge Date: 1926-7-22 Service: MEDICINE Allergies: Codeine / Penicillins Attending:Coral Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: Bone biopsy--left humerus History of Present Illness: 82M with h/o prostate CA who p/w increasing pain of left arm. Sveral months PTA, pt hit his arm. He went to local ER and was told he had a mild fracture, treated with sling and pain control. however, the pain worsened over the last few months. Pt came in to Ellis-Grant Hospital for further evaluation. In Henry Kaur, pt noted to have displaced left humerus fracture, likely pathologic. ROS of notable for increased LE edema. Past Medical History: Prostate CA s/p resection, unknown status CAD s/p CABG x 4 in 1995 with no further caths per family Vfib arrest, s/p ICD placement with 2 subsequent firings CHF, unknown EF%, followed by Dr. Samuel Archie at Hudson, Ibarra and Cook Clinic Hospital (cards) Afib s/p pacemaker hypercholesterolemia glaucoma Social History: Lives at home with son and daughter heavily involved in care. Tob: 1 ppd x many years, quit 6y ago Etoh: none Illicits: none Family History: non contributory Physical Exam: T=99.0, BP=100/70, HR=82 irreg, RR=20, O2=98% 3LNC, 88% RA elderly man lying in bed, in NAD PERRL 3-30 b/l Abd benign EXT: LUE with limited ROM, 2+ radial pulses b/l Pertinent Results: 1997-8-15 07:00PM WBC-9.8 RBC-3.98* HGB-13.7* HCT-40.7 MCV-102* MCH-34.4* MCHC-33.6 RDW-13.4 1997-8-15 07:00PM NEUTS-79.8* LYMPHS-11.7* MONOS-6.3 EOS-0.1 BASOS-2.1* 1997-8-15 07:00PM PLT COUNT-240 1997-8-15 07:00PM PT-19.3* PTT-29.5 INR(PT)-1.8* 1997-8-15 07:00PM CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-2.1 1997-8-15 07:00PM CRP-191.6* PSA-Banks-Wilson Hospital. Pt was in ICU for about 6 days. As his agitation and myoclonuse improved, he was extubated, and then transferred back to floor. . 2) HUMERUS FRACTURE: AS this represented likely pathologic fracture, a needle biopsy was done. Pt also had malignancy w/u with torso CT. This showed lung masses and abdominal mets. The pathology from humerus revealed likely metastatic lung carcinoma. Pt was seen by ortho onc but was not a surgical candidate. . 3) ONC: Pt was seen by onc, rad onc, neurosurg, and ortho onc regarding likely lung CA with mets to bone including spine. However, based on discussions with family, pt was made CMO given very poor prognosis. A few days after this change, on 8-5, the pt was found unresponsive and pronounced dead at 7:15AM. The family was called and declined autopsy. . 4) CV: His CAD, CHF, afib were not active issues during this hospitalization. EP service was consulted to turn off ICD given pt made CMO, however, this was not completed as there was concern that the family did not want to tell pt this was to be done. Medications on Admission: Coumadin 1.25mg per day, 6d/week; 2.5mg per day, 1d/week Colace 100mg Collins-Vega Hospital Toprol XL 25mg per day Lasix 120mg po qday (recent increase from 80mg per day) Lescol XL (statin) 80mg qd Losartan 25mg qd Xalatan 1 drop OU QHS Tylenol 1000mg tid prn Morphine elixir 10mg/5ml, 5-8 teaspoon q3h prn:pain in LUE Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Metastatic lung cancer Pathologic left humurous fracture Discharge Condition: Expired Discharge Instructions: none. Followup Instructions: none.	['Admission Date: 1997-8-15 Discharge Date: 1926-7-22\n\n\nService: MEDICINE\n\nAllergies:\nCodeine / Penicillins\n\nAttending:Coral\nChief Complaint:\nLeft arm pain\n\nMajor Surgical or Invasive Procedure:\nBone biopsy--left humerus\n\nHistory of Present Illness:\n82M with h/o prostate CA who p/w increasing pain of left arm.\nSveral months PTA, pt hit his arm. He went to local ER and was\ntold he had a mild fracture, treated with sling and pain\ncontrol. however, the pain worsened over the last few months.\nPt came in to Ellis-Grant Hospital for further evaluation. In Henry Kaur, pt noted to\nhave displaced left humerus fracture, likely pathologic. ROS of\nnotable for increased LE edema.\n\nPast Medical History:\nProstate CA s/p resection, unknown status\nCAD s/p CABG x 4 in 1995 with no further caths per family\nVfib arrest, s/p ICD placement with 2 subsequent firings\nCHF, unknown EF%, followed by Dr.', ' Samuel Archie at Hudson, Ibarra and Cook Clinic Hospital (cards)\n Afib s/p pacemaker\nhypercholesterolemia\nglaucoma\n\n\nSocial History:\nLives at home with son and daughter heavily involved in care.\nTob: 1 ppd x many years, quit 6y ago\nEtoh: none\nIllicits: none\n\n\nFamily History:\nnon contributory\n\nPhysical Exam:\nT=99.0, BP=100/70, HR=82 irreg, RR=20, O2=98% 3LNC, 88% RA\nelderly man lying in bed, in NAD\nPERRL 3-30 b/l\nAbd benign\nEXT: LUE with limited ROM, 2+ radial pulses b/l\n\n\nPertinent Results:\n1997-8-15 07:00PM WBC-9.8 RBC-3.98* HGB-13.7* HCT-40.7 MCV-102\nMCH-34.4 MCHC-33.6 RDW-13.4\n1997-8-15 07:00PM NEUTS-79.8* LYMPHS-11.7* MONOS-6.3 EOS-0.1\nBASOS-2.1\n1997-8-15 07:00PM PLT COUNT-240\n1997-8-15 07:00PM PT-19.3 PTT-29.5 INR(PT)-1.8\n1997-8-15 07:00PM CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-2.', '1\n1997-8-15 07:00PM CRP-191.6 PSA-Banks-Wilson Hospital. Pt was in\nICU for about 6 days. As his agitation and myoclonuse improved,\nhe was extubated, and then transferred back to floor.\n.\n2) HUMERUS FRACTURE: AS this represented likely pathologic\nfracture, a needle biopsy was done. Pt also had malignancy w/u\nwith torso CT. This showed lung masses and abdominal mets. The\npathology from humerus revealed likely metastatic lung\ncarcinoma. Pt was seen by ortho onc but was not a surgical\ncandidate.\n.\n3) ONC: Pt was seen by onc, rad onc, neurosurg, and ortho onc\nregarding likely lung CA with mets to bone including spine.\nHowever, based on discussions with family, pt was made CMO given\nvery poor prognosis. A few days after this change, on 8-5, the\npt was found unresponsive and pronounced dead at 7:15AM.', ' The\nfamily was called and declined autopsy.\n.\n4) CV: His CAD, CHF, afib were not active issues during this\nhospitalization. EP service was consulted to turn off ICD given\npt made CMO, however, this was not completed as there was\nconcern that the family did not want to tell pt this was to be\ndone.\n\n\nMedications on Admission:\nCoumadin 1.25mg per day, 6d/week; 2.5mg per day, 1d/week\nColace 100mg Collins-Vega Hospital\nToprol XL 25mg per day\nLasix 120mg po qday (recent increase from 80mg per day)\nLescol XL (statin) 80mg qd\nLosartan 25mg qd\nXalatan 1 drop OU QHS\nTylenol 1000mg tid prn\nMorphine elixir 10mg/5ml, 5-8 teaspoon q3h prn:pain in LUE\n\n\nDischarge Medications:\nnone\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\nMetastatic lung cancer\nPathologic left humurous fracture\n\n\nDischarge Condition:\nExpired\n\nDischarge Instructions:\nnone.', '\n\nFollowup Instructions:\nnone.\n\n\n']
444	15159	187095.0	2103-08-19	Discharge summary	Report	Admission Date: [2103-8-16] Discharge Date: [2103-8-19] Date of Birth: [2070-11-24] Sex: M Service: CHIEF COMPLAINT: Cough and shortness of breath. HISTORY OF PRESENT ILLNESS: This is a 32 year-old male with a history of Down Syndrome, autism and [2097] pneumonia complicated with ARDS who presents with one day of productive cough and low grade fever as well as yellowish nasal discharge for the past few days. The patient was prescribed Doxycycline outpatient and took only two tablets before refusing to take anymore. He then became short of breath. The patient has had some fatigue and anorexia for the past couple of days. REVIEW OF SYSTEMS: No nausea, vomiting, abdominal pain or diarrhea. The patient generally gets an infection once every two to three months especially infection of the sinuses, which is treated with Amoxicillin. He is hospitalized back in [10-3] to [2098-11-4] for similar symptoms, which progressed to ARDS. At that time he was treated with Cefuroxime, Clindamycin and Erythromycin. He was intubated at that time for 27 days. In the Emergency Room his saturation was low to mid 90s on 80% on room air and 94 to 95% on a nonrebreather. ALLERGIES: Haldol, prolonged QT, benzodiazepines and narcotics, positive to severe hypertension. MEDICATIONS AT HOME: None. PAST MEDICAL HISTORY: Cataracts bilaterally status post surgery. Downs and autism with mental age level of 4 years old, recurrent sinusitis. History of pneumonia in [2097] complicated by ARDS. [2099] tetanus and pneumovax vaccination with a negative PPD at that time. SOCIAL HISTORY: He does not smoke or drink. He lives with his parents. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Pulse 119. Blood pressure 113/61. Respiratory rate 24. Temperature 103. 94% on a nonrebreather. Generally, this is an agitated male who is breathing with much effort. HEENT pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Mucous membranes are dry. Oropharynx is difficult to examine. There is no sinus tenderness. Neck is supple. Chest there are rhonchi bilaterally. No wheezes or crackles noted. There is some nasal flaring and use of abdominal muscles to breath. Cardiovascular regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. Abdomen is soft, obese, which is nontender with decreased bowel sounds. Extremities no clubbing, cyanosis or edema. LABORATORIES ON ADMISSION: White blood cell count 5.7, 79.3% neutrophils, 10.6% lymphocytes, 7.5% monocytes, 0.6% eosinophils and 2% basophils. Hemoglobin is 14.3, hematocrit 42.1, platelet 208, sodium 144, potassium 4.7, chloride 103, bicarb 31, BUN 17, creatinine 1.4, glucose 128, INR 1.3, PTT 28.8. Chest x-ray on [8-15] shows no signs of pneumonia and chest x-ray on [8-16] showed prominent pulmonary vasculature. Blood cultures are pending. Arterial blood gas, which is polyvenous had a pH of 7.33, PCO2 60, PO2 48% and this is done while on 85% on room air. HOSPITAL COURSE: 1. Respiratory: The patient had hypoxia and probable hypercarbic respiratory failure secondary to tracheal bronchitis and mucous plugging. The patient was treated with antibiotics and given Albuterol Atrovent nebulizer to improve the breathing. He was given a nonrebreather, but could not tolerate it. The patient was switched over to 8 liters of oxygen on nasal cannula. The patient then was able tolerate the nonrebreather for a couple of hours before needing to switch over to a simple mask. The patient began to have low oxygen saturations and required intubation. However, the patient's family decided to have his code status switched from full code to DNR/DNI so the patient was not intubated. The patient became progressively more hypoxic until he expired. On the second day of hospitalization the patient's respiratory distress was further complicated with mucous plugging that caused right upper lobe collapse. 2. Cardiovascular: The patient was tachycardic upon admission secondary to dehydration so he was given 125 cc an hour of D5 half normal saline. His tachycardia did resolve transiently until he became quite anxious in the Intensive Care Unit. He then became tachycardic secondary to anxiety. 3. Renal: He had some prerenal azotemia due to dehydration with a creatinine of 1.4. We did hydrate him with D5 half normal saline. 4. Infectious disease: In regards to tracheal bronchitis, he was given empiric treatment with Levaquin 500 mg intravenous q.d. and Ceftriaxone 1 gram intravenous q.d. However, his right middle lobe opacity did not improve. The patient also had sinusitis, which was treated with the antibiotics, saline nasal spray and a 45 degree bed position. On [2103-8-19] Mr. [Known firstname ] [Known lastname 3794] expired at 9:05 a.m. due to respiratory arrest secondary to pneumonia and lung collapse that is secondary to mucous plugging. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Last Name (NamePattern1) 3796] MEDQUIST36 D: [2103-8-21] 16:57 T: [2103-8-27] 10:25 JOB#: [Job Number 3797]	Admission Date: <Date>1988-4-29</Date> Discharge Date: <Date>1912-11-12</Date> Date of Birth: <Date>2001-11-18</Date> Sex: M Service: CHIEF COMPLAINT: Cough and shortness of breath. HISTORY OF PRESENT ILLNESS: This is a 32 year-old male with a history of Down Syndrome, autism and <Year>1966</Year> pneumonia complicated with ARDS who presents with one day of productive cough and low grade fever as well as yellowish nasal discharge for the past few days. The patient was prescribed Doxycycline outpatient and took only two tablets before refusing to take anymore. He then became short of breath. The patient has had some fatigue and anorexia for the past couple of days. REVIEW OF SYSTEMS: No nausea, vomiting, abdominal pain or diarrhea. The patient generally gets an infection once every two to three months especially infection of the sinuses, which is treated with Amoxicillin. He is hospitalized back in <Date>5-30</Date> to <Date>1914-4-3</Date> for similar symptoms, which progressed to ARDS. At that time he was treated with Cefuroxime, Clindamycin and Erythromycin. He was intubated at that time for 27 days. In the Emergency Room his saturation was low to mid 90s on 80% on room air and 94 to 95% on a nonrebreather. ALLERGIES: Haldol, prolonged QT, benzodiazepines and narcotics, positive to severe hypertension. MEDICATIONS AT HOME: None. PAST MEDICAL HISTORY: Cataracts bilaterally status post surgery. Downs and autism with mental age level of 4 years old, recurrent sinusitis. History of pneumonia in <Year>1966</Year> complicated by ARDS. <Year>1966</Year> tetanus and pneumovax vaccination with a negative PPD at that time. SOCIAL HISTORY: He does not smoke or drink. He lives with his parents. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Pulse 119. Blood pressure 113/61. Respiratory rate 24. Temperature 103. 94% on a nonrebreather. Generally, this is an agitated male who is breathing with much effort. HEENT pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Mucous membranes are dry. Oropharynx is difficult to examine. There is no sinus tenderness. Neck is supple. Chest there are rhonchi bilaterally. No wheezes or crackles noted. There is some nasal flaring and use of abdominal muscles to breath. Cardiovascular regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. Abdomen is soft, obese, which is nontender with decreased bowel sounds. Extremities no clubbing, cyanosis or edema. LABORATORIES ON ADMISSION: White blood cell count 5.7, 79.3% neutrophils, 10.6% lymphocytes, 7.5% monocytes, 0.6% eosinophils and 2% basophils. Hemoglobin is 14.3, hematocrit 42.1, platelet 208, sodium 144, potassium 4.7, chloride 103, bicarb 31, BUN 17, creatinine 1.4, glucose 128, INR 1.3, PTT 28.8. Chest x-ray on <Date>5-23</Date> shows no signs of pneumonia and chest x-ray on <Date>1-1</Date> showed prominent pulmonary vasculature. Blood cultures are pending. Arterial blood gas, which is polyvenous had a pH of 7.33, PCO2 60, PO2 48% and this is done while on 85% on room air. HOSPITAL COURSE: 1. Respiratory: The patient had hypoxia and probable hypercarbic respiratory failure secondary to tracheal bronchitis and mucous plugging. The patient was treated with antibiotics and given Albuterol Atrovent nebulizer to improve the breathing. He was given a nonrebreather, but could not tolerate it. The patient was switched over to 8 liters of oxygen on nasal cannula. The patient then was able tolerate the nonrebreather for a couple of hours before needing to switch over to a simple mask. The patient began to have low oxygen saturations and required intubation. However, the patient's family decided to have his code status switched from full code to DNR/DNI so the patient was not intubated. The patient became progressively more hypoxic until he expired. On the second day of hospitalization the patient's respiratory distress was further complicated with mucous plugging that caused right upper lobe collapse. 2. Cardiovascular: The patient was tachycardic upon admission secondary to dehydration so he was given 125 cc an hour of D5 half normal saline. His tachycardia did resolve transiently until he became quite anxious in the Intensive Care Unit. He then became tachycardic secondary to anxiety. 3. Renal: He had some prerenal azotemia due to dehydration with a creatinine of 1.4. We did hydrate him with D5 half normal saline. 4. Infectious disease: In regards to tracheal bronchitis, he was given empiric treatment with Levaquin 500 mg intravenous q.d. and Ceftriaxone 1 gram intravenous q.d. However, his right middle lobe opacity did not improve. The patient also had sinusitis, which was treated with the antibiotics, saline nasal spray and a 45 degree bed position. On <Date>1912-11-12</Date> Mr. <Name>Leslee</Name> <Name>Booker</Name> expired at 9:05 a.m. due to respiratory arrest secondary to pneumonia and lung collapse that is secondary to mucous plugging. <Name>Susana</Name> <Name>Turcios</Name>, M.D. <MD Number>76175216</MD Number> Dictated By:<Name>Whitehead</Name> MEDQUIST36 D: <Date>1935-10-17</Date> 16:57 T: <Date>1949-3-27</Date> 10:25 JOB#: <Job Number>Larsen, Smith and Stevens-1946-039038</Job 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1000000000000000000111111111100000000000011111111100000000000000011111111111111111111111111111111111110	Admission Date: 1988-4-29 Discharge Date: 1912-11-12 Date of Birth: 2001-11-18 Sex: M Service: CHIEF COMPLAINT: Cough and shortness of breath. HISTORY OF PRESENT ILLNESS: This is a 32 year-old male with a history of Down Syndrome, autism and 1966 pneumonia complicated with ARDS who presents with one day of productive cough and low grade fever as well as yellowish nasal discharge for the past few days. The patient was prescribed Doxycycline outpatient and took only two tablets before refusing to take anymore. He then became short of breath. The patient has had some fatigue and anorexia for the past couple of days. REVIEW OF SYSTEMS: No nausea, vomiting, abdominal pain or diarrhea. The patient generally gets an infection once every two to three months especially infection of the sinuses, which is treated with Amoxicillin. He is hospitalized back in 5-30 to 1914-4-3 for similar symptoms, which progressed to ARDS. At that time he was treated with Cefuroxime, Clindamycin and Erythromycin. He was intubated at that time for 27 days. In the Emergency Room his saturation was low to mid 90s on 80% on room air and 94 to 95% on a nonrebreather. ALLERGIES: Haldol, prolonged QT, benzodiazepines and narcotics, positive to severe hypertension. MEDICATIONS AT HOME: None. PAST MEDICAL HISTORY: Cataracts bilaterally status post surgery. Downs and autism with mental age level of 4 years old, recurrent sinusitis. History of pneumonia in 1966 complicated by ARDS. 1966 tetanus and pneumovax vaccination with a negative PPD at that time. SOCIAL HISTORY: He does not smoke or drink. He lives with his parents. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Pulse 119. Blood pressure 113/61. Respiratory rate 24. Temperature 103. 94% on a nonrebreather. Generally, this is an agitated male who is breathing with much effort. HEENT pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Mucous membranes are dry. Oropharynx is difficult to examine. There is no sinus tenderness. Neck is supple. Chest there are rhonchi bilaterally. No wheezes or crackles noted. There is some nasal flaring and use of abdominal muscles to breath. Cardiovascular regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. Abdomen is soft, obese, which is nontender with decreased bowel sounds. Extremities no clubbing, cyanosis or edema. LABORATORIES ON ADMISSION: White blood cell count 5.7, 79.3% neutrophils, 10.6% lymphocytes, 7.5% monocytes, 0.6% eosinophils and 2% basophils. Hemoglobin is 14.3, hematocrit 42.1, platelet 208, sodium 144, potassium 4.7, chloride 103, bicarb 31, BUN 17, creatinine 1.4, glucose 128, INR 1.3, PTT 28.8. Chest x-ray on 5-23 shows no signs of pneumonia and chest x-ray on 1-1 showed prominent pulmonary vasculature. Blood cultures are pending. Arterial blood gas, which is polyvenous had a pH of 7.33, PCO2 60, PO2 48% and this is done while on 85% on room air. HOSPITAL COURSE: 1. Respiratory: The patient had hypoxia and probable hypercarbic respiratory failure secondary to tracheal bronchitis and mucous plugging. The patient was treated with antibiotics and given Albuterol Atrovent nebulizer to improve the breathing. He was given a nonrebreather, but could not tolerate it. The patient was switched over to 8 liters of oxygen on nasal cannula. The patient then was able tolerate the nonrebreather for a couple of hours before needing to switch over to a simple mask. The patient began to have low oxygen saturations and required intubation. However, the patient's family decided to have his code status switched from full code to DNR/DNI so the patient was not intubated. The patient became progressively more hypoxic until he expired. On the second day of hospitalization the patient's respiratory distress was further complicated with mucous plugging that caused right upper lobe collapse. 2. Cardiovascular: The patient was tachycardic upon admission secondary to dehydration so he was given 125 cc an hour of D5 half normal saline. His tachycardia did resolve transiently until he became quite anxious in the Intensive Care Unit. He then became tachycardic secondary to anxiety. 3. Renal: He had some prerenal azotemia due to dehydration with a creatinine of 1.4. We did hydrate him with D5 half normal saline. 4. Infectious disease: In regards to tracheal bronchitis, he was given empiric treatment with Levaquin 500 mg intravenous q.d. and Ceftriaxone 1 gram intravenous q.d. However, his right middle lobe opacity did not improve. The patient also had sinusitis, which was treated with the antibiotics, saline nasal spray and a 45 degree bed position. On 1912-11-12 Mr. Leslee Booker expired at 9:05 a.m. due to respiratory arrest secondary to pneumonia and lung collapse that is secondary to mucous plugging. Susana Turcios, M.D. 76175216 Dictated By:Whitehead MEDQUIST36 D: 1935-10-17 16:57 T: 1949-3-27 10:25 JOB#: Larsen, Smith and Stevens-1946-039038	['Admission Date: 1988-4-29 Discharge Date: 1912-11-12\n\nDate of Birth: 2001-11-18 Sex: M\n\nService:\n\nCHIEF COMPLAINT: Cough and shortness of breath.\n\nHISTORY OF PRESENT ILLNESS: This is a 32 year-old male with\na history of Down Syndrome, autism and 1966 pneumonia\ncomplicated with ARDS who presents with one day of productive\ncough and low grade fever as well as yellowish nasal\ndischarge for the past few days. The patient was prescribed\nDoxycycline outpatient and took only two tablets before\nrefusing to take anymore. He then became short of breath.\nThe patient has had some fatigue and anorexia for the past\ncouple of days.\n\nREVIEW OF SYSTEMS: No nausea, vomiting, abdominal pain or\ndiarrhea. The patient generally gets an infection once every\ntwo to three months especially infection of the sinuses,\nwhich is treated with Amoxicillin.', ' He is hospitalized back\nin 5-30 to 1914-4-3 for similar symptoms, which progressed\nto ARDS. At that time he was treated with Cefuroxime,\nClindamycin and Erythromycin. He was intubated at that time\nfor 27 days. In the Emergency Room his saturation was low to\nmid 90s on 80% on room air and 94 to 95% on a nonrebreather.\n\nALLERGIES: Haldol, prolonged QT, benzodiazepines and\nnarcotics, positive to severe hypertension.\n\nMEDICATIONS AT HOME: None.\n\nPAST MEDICAL HISTORY: Cataracts bilaterally status post\nsurgery. Downs and autism with mental age level of 4 years\nold, recurrent sinusitis. History of pneumonia in 1966\ncomplicated by ARDS. 1966 tetanus and pneumovax vaccination\nwith a negative PPD at that time.\n\nSOCIAL HISTORY: He does not smoke or drink. He lives with\nhis parents.\n\nFAMILY HISTORY: Noncontributory.', '\n\nPHYSICAL EXAMINATION ON ADMISSION: Pulse 119. Blood\npressure 113/61. Respiratory rate 24. Temperature 103. 94%\non a nonrebreather. Generally, this is an agitated male who\nis breathing with much effort. HEENT pupils are equal,\nround, and reactive to light and accommodation. Extraocular\nmovements intact. Mucous membranes are dry. Oropharynx is\ndifficult to examine. There is no sinus tenderness. Neck is\nsupple. Chest there are rhonchi bilaterally. No wheezes or\ncrackles noted. There is some nasal flaring and use of\nabdominal muscles to breath. Cardiovascular regular rate and\nrhythm. Normal S1 and S2. No murmurs, rubs or gallops.\nAbdomen is soft, obese, which is nontender with decreased\nbowel sounds. Extremities no clubbing, cyanosis or edema.\n\nLABORATORIES ON ADMISSION: White blood cell count 5.', '7, 79.3%\nneutrophils, 10.6% lymphocytes, 7.5% monocytes, 0.6%\neosinophils and 2% basophils. Hemoglobin is 14.3, hematocrit\n42.1, platelet 208, sodium 144, potassium 4.7, chloride 103,\nbicarb 31, BUN 17, creatinine 1.4, glucose 128, INR 1.3, PTT\n28.8. Chest x-ray on 5-23 shows no signs of pneumonia and\nchest x-ray on 1-1 showed prominent pulmonary vasculature.\nBlood cultures are pending. Arterial blood gas, which is\npolyvenous had a pH of 7.33, PCO2 60, PO2 48% and this is\ndone while on 85% on room air.\n\nHOSPITAL COURSE: 1. Respiratory: The patient had hypoxia\nand probable hypercarbic respiratory failure secondary to\ntracheal bronchitis and mucous plugging. The patient was\ntreated with antibiotics and given Albuterol Atrovent\nnebulizer to improve the breathing. He was given a\nnonrebreather, but could not tolerate it.', " The patient was\nswitched over to 8 liters of oxygen on nasal cannula. The\npatient then was able tolerate the nonrebreather for a couple\nof hours before needing to switch over to a simple mask. The\npatient began to have low oxygen saturations and required\nintubation. However, the patient's family decided to have\nhis code status switched from full code to DNR/DNI so the\npatient was not intubated. The patient became progressively\nmore hypoxic until he expired. On the second day of\nhospitalization the patient's respiratory distress was\nfurther complicated with mucous plugging that caused right\nupper lobe collapse.\n\n2. Cardiovascular: The patient was tachycardic upon\nadmission secondary to dehydration so he was given 125 cc an\nhour of D5 half normal saline. His tachycardia did resolve\ntransiently until he became quite anxious in the Intensive\nCare Unit.", ' He then became tachycardic secondary to anxiety.\n\n3. Renal: He had some prerenal azotemia due to dehydration\nwith a creatinine of 1.4. We did hydrate him with D5 half\nnormal saline.\n\n4. Infectious disease: In regards to tracheal bronchitis,\nhe was given empiric treatment with Levaquin 500 mg\nintravenous q.d. and Ceftriaxone 1 gram intravenous q.d.\nHowever, his right middle lobe opacity did not improve. The\npatient also had sinusitis, which was treated with the\nantibiotics, saline nasal spray and a 45 degree bed position.\n\nOn 1912-11-12 Mr. Leslee Booker expired at 9:05 a.m. due to\nrespiratory arrest secondary to pneumonia and lung collapse\nthat is secondary to mucous plugging.\n\n\n\n\n\n\n Susana Turcios, M.D. 76175216\n\nDictated By:Whitehead\n\nMEDQUIST36\n\nD: 1935-10-17 16:57\nT: 1949-3-27 10:25\nJOB#: Larsen, Smith and Stevens-1946-039038\n']
445	27973	105962.0	2157-10-03	Discharge summary	Report	Admission Date: [2157-9-26] Discharge Date: [2157-10-3] Date of Birth: [2092-5-20] Sex: M Service: CARDIOTHORACIC Allergies: Thiopental Sodium Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2157-9-26] Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to Diag, SVG to OM1 to OM2, SVG to PDA) History of Present Illness: 65 y/o male with PMH of CAD s/p MI in [2147] and [2152]. Recently c/o DOE and underwent an ETT which showed a perfusion defect. Underwent Cardiac cath which revealed severe three vessel disease and referred for surgical intervention. Past Medical History: Myocardial Infarction [2147]/[2152], Hypertension, Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder cancer Social History: Active smoker with approx. 1.5ppd x 40yrs. Denies ETOH use. Family History: Father with MI in 80's, Brother with MI at 67. Physical Exam: VS: 58 14 160/90 Gen: WDWN male in NAD Skin: w/d, mult. nevi on torso HEENT: NCAT, EOMI, PERRL, OP benign with poor dentitian Neck: Supple, FROM, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, trace edema Neuro: A&O x 3, MAE, non-focal Pertinent Results: [2157-9-26] Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with thinning and dyskinesis of the basilar inferrior and inferolateral walls.. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%). The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen. POSTBYPASS: LV systolic function is marginally improved (LVEF-45-50%) Previous wall motion abnormalities persist. RV systolic function remains normal. Study is otehrwise unchanged from prebypass. [2157-9-26] 12:24PM BLOOD WBC-15.5# RBC-3.46# Hgb-11.0# Hct-30.7# MCV-89 MCH-31.7 MCHC-35.7* RDW-13.9 Plt Ct-144* [2157-9-28] 06:35AM BLOOD WBC-11.9* RBC-3.36* Hgb-10.1* Hct-29.0* MCV-86 MCH-30.0 MCHC-34.7 RDW-14.1 Plt Ct-111* [2157-9-26] 12:24PM BLOOD PT-13.6* PTT-25.1 INR(PT)-1.2* [2157-9-27] 03:09AM BLOOD PT-12.3 PTT-27.7 INR(PT)-1.1 [2157-9-26] 01:48PM BLOOD UreaN-15 Creat-1.2 Cl-108 HCO3-28 [2157-9-29] 11:30AM BLOOD Glucose-211* UreaN-17 Creat-1.0 Na-135 K-4.4 Cl-97 HCO3-33* AnGap-9 Brief Hospital Course: Mr. [Known lastname ] was a same day admit after undergoing all pre-operative work-up as an outpatient. On the day of admission he was brought directly to the operating room where he underwent coronary artery bypass grafting to five vessels. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on operative day one, he was weaned from sedation, awoke neurologically intact and extubated. He was then transferred to the step down unit for further recovery. Mr. [Known lastname ] was gently diuresed towards his preoperative weight. He remained stable post-operatively and worked with physical therapy for assistance with his postoperative strength and mobility. Beta blockers were increased for heart rate and blood pressure control. He developed atrial fibrillation which was treated with an increase in his beta blockade. He progressed well and was discharged home with VNA services on [2157-10-3]. He will follow-up with Dr. [Last Name (STitle) 1290], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Aspirin 325mg qd, Lisinopril 20mg qd, Metformin 500mg [Hospital1 ], Toprol XL 100mg qd, Lipitor 80mg qd Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:1 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:1 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:60 Capsule, Sustained Release(s) Refills:2 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 PMH: Myocardial Infarction [2147]/[2152], Hypertension, Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder cancer Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not lift more than 10 lbs. for 2 months. Do not drive for 4 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office with sternal drainage, temps.>101.5 [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) ] [Last Name (STitle) ] [2-12] weeks Dr. [Last Name (STitle) 3314] in [1-11] weeks Completed by:[2157-10-4]	Admission Date: <Date>2010-3-21</Date> Discharge Date: <Date>1974-12-13</Date> Date of Birth: <Date>1904-2-4</Date> Sex: M Service: CARDIOTHORACIC Allergies: Thiopental Sodium Attending:<Name>Keith</Name> Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: <Date>2010-3-21</Date> Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to Diag, SVG to OM1 to OM2, SVG to PDA) History of Present Illness: 65 y/o male with PMH of CAD s/p MI in <Year>1927</Year> and <Year>1927</Year>. Recently c/o DOE and underwent an ETT which showed a perfusion defect. Underwent Cardiac cath which revealed severe three vessel disease and referred for surgical intervention. Past Medical History: Myocardial Infarction <Year>1927</Year>/<Year>1927</Year>, Hypertension, Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder cancer Social History: Active smoker with approx. 1.5ppd x 40yrs. Denies ETOH use. Family History: Father with MI in 80's, Brother with MI at 67. Physical Exam: VS: 58 14 160/90 Gen: WDWN male in NAD Skin: w/d, mult. nevi on torso HEENT: NCAT, EOMI, PERRL, OP benign with poor dentitian Neck: Supple, FROM, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, trace edema Neuro: A&O x 3, MAE, non-focal Pertinent Results: <Date>2010-3-21</Date> Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with thinning and dyskinesis of the basilar inferrior and inferolateral walls.. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%). The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen. POSTBYPASS: LV systolic function is marginally improved (LVEF-45-50%) Previous wall motion abnormalities persist. RV systolic function remains normal. Study is otehrwise unchanged from prebypass. <Date>2010-3-21</Date> 12:24PM BLOOD WBC-15.5# RBC-3.46# Hgb-11.0# Hct-30.7# MCV-89 MCH-31.7 MCHC-35.7* RDW-13.9 Plt Ct-144* <Date>1997-4-18</Date> 06:35AM BLOOD WBC-11.9* RBC-3.36* Hgb-10.1* Hct-29.0* MCV-86 MCH-30.0 MCHC-34.7 RDW-14.1 Plt Ct-111* <Date>2010-3-21</Date> 12:24PM BLOOD PT-13.6* PTT-25.1 INR(PT)-1.2* <Date>1968-1-7</Date> 03:09AM BLOOD PT-12.3 PTT-27.7 INR(PT)-1.1 <Date>2010-3-21</Date> 01:48PM BLOOD UreaN-15 Creat-1.2 Cl-108 HCO3-28 <Date>2020-7-25</Date> 11:30AM BLOOD Glucose-211* UreaN-17 Creat-1.0 Na-135 K-4.4 Cl-97 HCO3-33* AnGap-9 Brief Hospital Course: Mr. <Name>Deluna</Name> was a same day admit after undergoing all pre-operative work-up as an outpatient. On the day of admission he was brought directly to the operating room where he underwent coronary artery bypass grafting to five vessels. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on operative day one, he was weaned from sedation, awoke neurologically intact and extubated. He was then transferred to the step down unit for further recovery. Mr. <Name>Deluna</Name> was gently diuresed towards his preoperative weight. He remained stable post-operatively and worked with physical therapy for assistance with his postoperative strength and mobility. Beta blockers were increased for heart rate and blood pressure control. He developed atrial fibrillation which was treated with an increase in his beta blockade. He progressed well and was discharged home with VNA services on <Date>1974-12-13</Date>. He will follow-up with Dr. <Name>Post</Name>, his cardiologist and his primary care physician as an outpatient. Medications on Admission: Aspirin 325mg qd, Lisinopril 20mg qd, Metformin 500mg <Hospital>Goodwin-Vincent Hospital</Hospital>, Toprol XL 100mg qd, Lipitor 80mg qd Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:1 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:1 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:60 Capsule, Sustained Release(s) Refills:2 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 PMH: Myocardial Infarction <Year>1927</Year>/<Year>1927</Year>, Hypertension, Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder cancer Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not lift more than 10 lbs. for 2 months. Do not drive for 4 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office with sternal drainage, temps.>101.5 <Name>Tejada</Name>p Instructions: Dr. <Name>Hazelwood</Name> in 4 weeks Dr. <Name>Waldon</Name> <Name>Waldon</Name> <Date>8-29</Date> weeks Dr. <Name>Kobayashi</Name> in <Date>6-4</Date> weeks Completed by:<Date>1997-7-1</Date>	0000000000000000011111111100000000000000000000000000000000111111111100000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 2010-3-21 Discharge Date: 1974-12-13 Date of Birth: 1904-2-4 Sex: M Service: CARDIOTHORACIC Allergies: Thiopental Sodium Attending:Keith Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: 2010-3-21 Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to Diag, SVG to OM1 to OM2, SVG to PDA) History of Present Illness: 65 y/o male with PMH of CAD s/p MI in 1927 and 1927. Recently c/o DOE and underwent an ETT which showed a perfusion defect. Underwent Cardiac cath which revealed severe three vessel disease and referred for surgical intervention. Past Medical History: Myocardial Infarction 1927/1927, Hypertension, Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder cancer Social History: Active smoker with approx. 1.5ppd x 40yrs. Denies ETOH use. Family History: Father with MI in 80's, Brother with MI at 67. Physical Exam: VS: 58 14 160/90 Gen: WDWN male in NAD Skin: w/d, mult. nevi on torso HEENT: NCAT, EOMI, PERRL, OP benign with poor dentitian Neck: Supple, FROM, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, trace edema Neuro: A&O x 3, MAE, non-focal Pertinent Results: 2010-3-21 Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with thinning and dyskinesis of the basilar inferrior and inferolateral walls.. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%). The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen. POSTBYPASS: LV systolic function is marginally improved (LVEF-45-50%) Previous wall motion abnormalities persist. RV systolic function remains normal. Study is otehrwise unchanged from prebypass. 2010-3-21 12:24PM BLOOD WBC-15.5# RBC-3.46# Hgb-11.0# Hct-30.7# MCV-89 MCH-31.7 MCHC-35.7* RDW-13.9 Plt Ct-144* 1997-4-18 06:35AM BLOOD WBC-11.9* RBC-3.36* Hgb-10.1* Hct-29.0* MCV-86 MCH-30.0 MCHC-34.7 RDW-14.1 Plt Ct-111* 2010-3-21 12:24PM BLOOD PT-13.6* PTT-25.1 INR(PT)-1.2* 1968-1-7 03:09AM BLOOD PT-12.3 PTT-27.7 INR(PT)-1.1 2010-3-21 01:48PM BLOOD UreaN-15 Creat-1.2 Cl-108 HCO3-28 2020-7-25 11:30AM BLOOD Glucose-211* UreaN-17 Creat-1.0 Na-135 K-4.4 Cl-97 HCO3-33* AnGap-9 Brief Hospital Course: Mr. Deluna was a same day admit after undergoing all pre-operative work-up as an outpatient. On the day of admission he was brought directly to the operating room where he underwent coronary artery bypass grafting to five vessels. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on operative day one, he was weaned from sedation, awoke neurologically intact and extubated. He was then transferred to the step down unit for further recovery. Mr. Deluna was gently diuresed towards his preoperative weight. He remained stable post-operatively and worked with physical therapy for assistance with his postoperative strength and mobility. Beta blockers were increased for heart rate and blood pressure control. He developed atrial fibrillation which was treated with an increase in his beta blockade. He progressed well and was discharged home with VNA services on 1974-12-13. He will follow-up with Dr. Post, his cardiologist and his primary care physician as an outpatient. Medications on Admission: Aspirin 325mg qd, Lisinopril 20mg qd, Metformin 500mg Goodwin-Vincent Hospital, Toprol XL 100mg qd, Lipitor 80mg qd Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:1 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:1 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:60 Capsule, Sustained Release(s) Refills:2 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 PMH: Myocardial Infarction 1927/1927, Hypertension, Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder cancer Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not lift more than 10 lbs. for 2 months. Do not drive for 4 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office with sternal drainage, temps.>101.5 Tejadap Instructions: Dr. Hazelwood in 4 weeks Dr. Waldon Waldon 8-29 weeks Dr. Kobayashi in 6-4 weeks Completed by:1997-7-1	['Admission Date: 2010-3-21 Discharge Date: 1974-12-13\n\nDate of Birth: 1904-2-4 Sex: M\n\nService: CARDIOTHORACIC\n\nAllergies:\nThiopental Sodium\n\nAttending:Keith\nChief Complaint:\nDyspnea on exertion\n\nMajor Surgical or Invasive Procedure:\n2010-3-21 Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to\nDiag, SVG to OM1 to OM2, SVG to PDA)\n\nHistory of Present Illness:\n65 y/o male with PMH of CAD s/p MI in 1927 and 1927. Recently\nc/o DOE and underwent an ETT which showed a perfusion defect.\nUnderwent Cardiac cath which revealed severe three vessel\ndisease and referred for surgical intervention.\n\nPast Medical History:\nMyocardial Infarction 1927/1927, Hypertension,\nHypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder\ncancer\n\nSocial History:\nActive smoker with approx.', " 1.5ppd x 40yrs. Denies ETOH use.\n\nFamily History:\nFather with MI in 80's, Brother with MI at 67.\n\nPhysical Exam:\nVS: 58 14 160/90\nGen: WDWN male in NAD\nSkin: w/d, mult. nevi on torso\nHEENT: NCAT, EOMI, PERRL, OP benign with poor dentitian\nNeck: Supple, FROM, -carotid bruit\nChest: CTAB -w/r/r\nHeart: RRR -c/r/m/g\nAbd: Soft, NT/ND +BS\nExt: Warm, well-perfused, trace edema\nNeuro: A&O x 3, MAE, non-focal\n\nPertinent Results:\n2010-3-21 Echo: PREBYPASS: No atrial septal defect is seen by 2D\nor color Doppler. Left ventricular wall thicknesses and cavity\nsize are normal. There is mild regional left ventricular\nsystolic dysfunction with thinning and dyskinesis of the basilar\ninferrior and inferolateral walls.. Overall left ventricular\nsystolic function is mildly depressed (LVEF= 40-45%). The\nremaining left ventricular segments contract normally.", ' Right\nventricular chamber size and free wall motion are normal. There\nare complex (>4mm) atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly\nthickened. An eccentric, posteriorly directed jet of Mild (1+)\nmitral regurgitation is seen. POSTBYPASS: LV systolic function\nis marginally improved (LVEF-45-50%) Previous wall motion\nabnormalities persist. RV systolic function remains normal.\nStudy is otehrwise unchanged from prebypass.\n\n2010-3-21 12:24PM BLOOD WBC-15.5# RBC-3.46# Hgb-11.0#\nHct-30.7# MCV-89 MCH-31.7 MCHC-35.7* RDW-13.9 Plt Ct-144\n1997-4-18 06:35AM BLOOD WBC-11.9 RBC-3.36* Hgb-10.1* Hct-29.0\nMCV-86 MCH-30.0 MCHC-34.7 RDW-14.1 Plt Ct-111\n2010-3-21 12:24PM BLOOD PT-13.', '6* PTT-25.1 INR(PT)-1.2\n1968-1-7 03:09AM BLOOD PT-12.3 PTT-27.7 INR(PT)-1.1\n2010-3-21 01:48PM BLOOD UreaN-15 Creat-1.2 Cl-108 HCO3-28\n2020-7-25 11:30AM BLOOD Glucose-211 UreaN-17 Creat-1.0 Na-135\nK-4.4 Cl-97 HCO3-33* AnGap-9\n\nBrief Hospital Course:\nMr. Deluna was a same day admit after undergoing all\npre-operative work-up as an outpatient. On the day of admission\nhe was brought directly to the operating room where he underwent\ncoronary artery bypass grafting to five vessels. Please see\noperative report for surgical details. Following surgery he was\ntransferred to the CSRU for invasive monitoring in stable\ncondition. Later on operative day one, he was weaned from\nsedation, awoke neurologically intact and extubated. He was then\ntransferred to the step down unit for further recovery. Mr.\nDeluna was gently diuresed towards his preoperative weight.', ' He\nremained stable post-operatively and worked with physical\ntherapy for assistance with his postoperative strength and\nmobility. Beta blockers were increased for heart rate and blood\npressure control. He developed atrial fibrillation which was\ntreated with an increase in his beta blockade. He progressed\nwell and was discharged home with VNA services on 1974-12-13. He\nwill follow-up with Dr. Post, his cardiologist and his\nprimary care physician as an outpatient.\n\nMedications on Admission:\nAspirin 325mg qd, Lisinopril 20mg qd, Metformin 500mg Goodwin-Vincent Hospital,\nToprol XL 100mg qd, Lipitor 80mg qd\n\nDischarge Medications:\n1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:1\n2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.', 'C.) PO DAILY (Daily).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:1\n3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\nDisp:60 Capsule(s) Refills:1\n4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO\nQ4H (every 4 hours) as needed for pain.\nDisp:40 Tablet(s) Refills:0\n5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)\nCapsule, Sust. Release 24 hr PO HS (at bedtime).\nDisp:30 Capsule, Sust. Release 24 hr(s) Refills:1\n6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\nDisp:60 Tablet(s) Refills:1\n7. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID\n(3 times a day).\nDisp:180 Tablet(s) Refills:1\n8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two\n(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2\nweeks.', '\nDisp:60 Capsule, Sustained Release(s) Refills:2\n9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day).\nDisp:60 Tablet(s) Refills:2\n10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 2\nweeks.\nDisp:28 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\ntba\n\nDischarge Diagnosis:\nCoronary Artery Disease s/p Coronary Artery Bypass Graft x 5\nPMH: Myocardial Infarction 1927/1927, Hypertension,\nHypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder\ncancer\n\nDischarge Condition:\nGood\n\nDischarge Instructions:\nFollow medications on discharge instructions.\nDo not lift more than 10 lbs. for 2 months.\nDo not drive for 4 weeks.\nShower daily, let water flow over wounds, pat dry with a towel.\nDo not use creams, lotions, or powders on wounds.', '\nCall our office with sternal drainage, temps.>101.5\n\nTejadap Instructions:\nDr. Hazelwood in 4 weeks\nDr. Waldon Waldon 8-29 weeks\nDr. Kobayashi in 6-4 weeks\n\n\nCompleted by:1997-7-1']
446	9138	148309.0	2196-05-01	Discharge summary	Report	Admission Date: [2196-4-27] Discharge Date: [2196-5-1] Date of Birth: [2136-3-15] Sex: F Service: General Surgery HISTORY OF PRESENT ILLNESS: This is a 60-year-old woman with class III morbid obesity with a body mass index of 66.9 who has tried and failed numerous weight loss programs. She presents now to the Gastric [Hospital 3798] Clinic for the evaluation of gastric restrictive surgery. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea. 2. Hypertension. 3. Dyslipidemia. 4. Gastroesophageal reflux disease. 5. Cholelithiasis. 6. Osteoarthritis. 7. Chronic low back pain. 8. Fibromyalgia. 9. Diverticulosis. 10. Hemorrhoids. 11. Recurrent panniculitis. PAST SURGICAL HISTORY: Past surgical history is significant for exploratory laparotomy, hysterectomy, and bilateral salpingo-oophorectomy in [2183] for benign disease. She is status post supraclavicular node biopsy in [2181]. She is status post paniculectomy in [2189] complicated by development of a seroma. MEDICATIONS ON ADMISSION: Medications include Zestril, Cardizem, hydrochlorothiazide, potassium, Zoloft, Premarin, Celebrex, albuterol inhaler, multivitamin, and aspirin. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted to the General Surgery Service on [4-27] and underwent an uncomplicated open gastric bypass surgery with open cholecystectomy. The patient's postoperative course was notable for persistent hypotension with stout pressure in the 80s requiring fluid boluses in order to maintain appropriate pressure and urine output. An electrocardiogram was obtained, and the was ruled out for a myocardial infarction. She spent the following day in the Intensive Care Unit where she was closely hemodynamically monitored. She subsequently came out of the unit on postoperative day three and had a relatively benign remainder of her hospital stay. On postoperative day two, she underwent a transesophageal echocardiogram that demonstrated decreased left atrial velocities, but no other abnormalities. She remained afebrile, and on postoperative three was restarted on her hydrochlorothiazide. Her intravenous fluids were hep-locked, and her diet was advanced to a stage II. Her patient-controlled analgesia was discontinued, and she was initiated on oral pain medications which controlled her pain adequately. By postoperative four, the patient was tolerating a stage II diet, was passing gas, and was advanced to a stage III diet. Her Foley had been discontinued midnight the night before, and she was voiding without difficulty. Per the recommendations of the Electrophysiology fellow, the patient was initiated on Coumadin for her new onset of atrial fibrillation. DISCHARGE STATUS: The patient was subsequently discharged to home. CONDITION AT DISCHARGE: In stable condition. DISCHARGE FOLLOWUP: Instructions to follow up with her primary care physician to manage her outpatient Coumadin dosing. MEDICATIONS ON DISCHARGE: (Medications at the time of discharge included) 1. Coumadin 2.5 mg p.o. q.d. 2. Atenolol 25 mg p.o. q.d. 3. Zestril 20 mg p.o. b.i.d. 4. Premarin 0.625 mg p.o. q.d. 5. Celebrex. 6. Hydrochlorothiazide 25 mg p.o. q.d. 7. Potassium chloride 10 mEq p.o. q.d. 8. Procardia. 9. Roxicet elixir 5 cc to 10 cc p.o. q.4-6h. p.r.n. for pain. 10. Zantac elixir 150 mg p.o. q.d. 11. Multivitamin. 12. Vitamin B12. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3799], M.D. [MD Number(1) 3800] Dictated By:[Last Name (NamePattern1) 3801] MEDQUIST36 D: [2196-5-17] 15:14 T: [2196-5-18] 08:42 JOB#: [Job Number 3802]	Admission Date: <Date>1998-4-3</Date> Discharge Date: <Date>1920-12-15</Date> Date of Birth: <Date>1925-4-11</Date> Sex: F Service: General Surgery HISTORY OF PRESENT ILLNESS: This is a 60-year-old woman with class III morbid obesity with a body mass index of 66.9 who has tried and failed numerous weight loss programs. She presents now to the Gastric <Hospital>Washington-Jones Hospital</Hospital> Clinic for the evaluation of gastric restrictive surgery. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea. 2. Hypertension. 3. Dyslipidemia. 4. Gastroesophageal reflux disease. 5. Cholelithiasis. 6. Osteoarthritis. 7. Chronic low back pain. 8. Fibromyalgia. 9. Diverticulosis. 10. Hemorrhoids. 11. Recurrent panniculitis. PAST SURGICAL HISTORY: Past surgical history is significant for exploratory laparotomy, hysterectomy, and bilateral salpingo-oophorectomy in <Year>1956</Year> for benign disease. She is status post supraclavicular node biopsy in <Year>1956</Year>. She is status post paniculectomy in <Year>1956</Year> complicated by development of a seroma. MEDICATIONS ON ADMISSION: Medications include Zestril, Cardizem, hydrochlorothiazide, potassium, Zoloft, Premarin, Celebrex, albuterol inhaler, multivitamin, and aspirin. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted to the General Surgery Service on <Date>7-21</Date> and underwent an uncomplicated open gastric bypass surgery with open cholecystectomy. The patient's postoperative course was notable for persistent hypotension with stout pressure in the 80s requiring fluid boluses in order to maintain appropriate pressure and urine output. An electrocardiogram was obtained, and the was ruled out for a myocardial infarction. She spent the following day in the Intensive Care Unit where she was closely hemodynamically monitored. She subsequently came out of the unit on postoperative day three and had a relatively benign remainder of her hospital stay. On postoperative day two, she underwent a transesophageal echocardiogram that demonstrated decreased left atrial velocities, but no other abnormalities. She remained afebrile, and on postoperative three was restarted on her hydrochlorothiazide. Her intravenous fluids were hep-locked, and her diet was advanced to a stage II. Her patient-controlled analgesia was discontinued, and she was initiated on oral pain medications which controlled her pain adequately. By postoperative four, the patient was tolerating a stage II diet, was passing gas, and was advanced to a stage III diet. Her Foley had been discontinued midnight the night before, and she was voiding without difficulty. Per the recommendations of the Electrophysiology fellow, the patient was initiated on Coumadin for her new onset of atrial fibrillation. DISCHARGE STATUS: The patient was subsequently discharged to home. CONDITION AT DISCHARGE: In stable condition. DISCHARGE FOLLOWUP: Instructions to follow up with her primary care physician to manage her outpatient Coumadin dosing. MEDICATIONS ON DISCHARGE: (Medications at the time of discharge included) 1. Coumadin 2.5 mg p.o. q.d. 2. Atenolol 25 mg p.o. q.d. 3. Zestril 20 mg p.o. b.i.d. 4. Premarin 0.625 mg p.o. q.d. 5. Celebrex. 6. Hydrochlorothiazide 25 mg p.o. q.d. 7. Potassium chloride 10 mEq p.o. q.d. 8. Procardia. 9. Roxicet elixir 5 cc to 10 cc p.o. q.4-6h. p.r.n. for pain. 10. Zantac elixir 150 mg p.o. q.d. 11. Multivitamin. 12. Vitamin B12. <Name>Isabella</Name> <Name>Mao</Name>, M.D. <MD Number>61201396</MD Number> Dictated By:<Name>Son</Name> MEDQUIST36 D: <Date>1996-6-22</Date> 15:14 T: <Date>1956-10-18</Date> 08:42 JOB#: <Job Number>Fisher Group-1982-478843</Job Number>	000000000000000001111111100000000000000000000001111111111000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111011100000000111111110000000000000011100000000000000000011111111100000000000011111111110000000000000001111111111111111111111110	Admission Date: 1998-4-3 Discharge Date: 1920-12-15 Date of Birth: 1925-4-11 Sex: F Service: General Surgery HISTORY OF PRESENT ILLNESS: This is a 60-year-old woman with class III morbid obesity with a body mass index of 66.9 who has tried and failed numerous weight loss programs. She presents now to the Gastric Washington-Jones Hospital Clinic for the evaluation of gastric restrictive surgery. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea. 2. Hypertension. 3. Dyslipidemia. 4. Gastroesophageal reflux disease. 5. Cholelithiasis. 6. Osteoarthritis. 7. Chronic low back pain. 8. Fibromyalgia. 9. Diverticulosis. 10. Hemorrhoids. 11. Recurrent panniculitis. PAST SURGICAL HISTORY: Past surgical history is significant for exploratory laparotomy, hysterectomy, and bilateral salpingo-oophorectomy in 1956 for benign disease. She is status post supraclavicular node biopsy in 1956. She is status post paniculectomy in 1956 complicated by development of a seroma. MEDICATIONS ON ADMISSION: Medications include Zestril, Cardizem, hydrochlorothiazide, potassium, Zoloft, Premarin, Celebrex, albuterol inhaler, multivitamin, and aspirin. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted to the General Surgery Service on 7-21 and underwent an uncomplicated open gastric bypass surgery with open cholecystectomy. The patient's postoperative course was notable for persistent hypotension with stout pressure in the 80s requiring fluid boluses in order to maintain appropriate pressure and urine output. An electrocardiogram was obtained, and the was ruled out for a myocardial infarction. She spent the following day in the Intensive Care Unit where she was closely hemodynamically monitored. She subsequently came out of the unit on postoperative day three and had a relatively benign remainder of her hospital stay. On postoperative day two, she underwent a transesophageal echocardiogram that demonstrated decreased left atrial velocities, but no other abnormalities. She remained afebrile, and on postoperative three was restarted on her hydrochlorothiazide. Her intravenous fluids were hep-locked, and her diet was advanced to a stage II. Her patient-controlled analgesia was discontinued, and she was initiated on oral pain medications which controlled her pain adequately. By postoperative four, the patient was tolerating a stage II diet, was passing gas, and was advanced to a stage III diet. Her Foley had been discontinued midnight the night before, and she was voiding without difficulty. Per the recommendations of the Electrophysiology fellow, the patient was initiated on Coumadin for her new onset of atrial fibrillation. DISCHARGE STATUS: The patient was subsequently discharged to home. CONDITION AT DISCHARGE: In stable condition. DISCHARGE FOLLOWUP: Instructions to follow up with her primary care physician to manage her outpatient Coumadin dosing. MEDICATIONS ON DISCHARGE: (Medications at the time of discharge included) 1. Coumadin 2.5 mg p.o. q.d. 2. Atenolol 25 mg p.o. q.d. 3. Zestril 20 mg p.o. b.i.d. 4. Premarin 0.625 mg p.o. q.d. 5. Celebrex. 6. Hydrochlorothiazide 25 mg p.o. q.d. 7. Potassium chloride 10 mEq p.o. q.d. 8. Procardia. 9. Roxicet elixir 5 cc to 10 cc p.o. q.4-6h. p.r.n. for pain. 10. Zantac elixir 150 mg p.o. q.d. 11. Multivitamin. 12. Vitamin B12. Isabella Mao, M.D. 61201396 Dictated By:Son MEDQUIST36 D: 1996-6-22 15:14 T: 1956-10-18 08:42 JOB#: Fisher Group-1982-478843	['Admission Date: 1998-4-3 Discharge Date: 1920-12-15\n\nDate of Birth: 1925-4-11 Sex: F\n\nService: General Surgery\n\nHISTORY OF PRESENT ILLNESS: This is a 60-year-old woman with\nclass III morbid obesity with a body mass index of 66.9 who\nhas tried and failed numerous weight loss programs. She\npresents now to the Gastric Washington-Jones Hospital Clinic for the evaluation\nof gastric restrictive surgery.\n\nPAST MEDICAL HISTORY:\n 1. Obstructive sleep apnea.\n 2. Hypertension.\n 3. Dyslipidemia.\n 4. Gastroesophageal reflux disease.\n 5. Cholelithiasis.\n 6. Osteoarthritis.\n 7. Chronic low back pain.\n 8. Fibromyalgia.\n 9. Diverticulosis.\n10. Hemorrhoids.\n11. Recurrent panniculitis.\n\nPAST SURGICAL HISTORY: Past surgical history is significant\nfor exploratory laparotomy, hysterectomy, and bilateral\nsalpingo-oophorectomy in 1956 for benign disease.', " She is\nstatus post supraclavicular node biopsy in 1956. She is\nstatus post paniculectomy in 1956 complicated by development\nof a seroma.\n\nMEDICATIONS ON ADMISSION: Medications include Zestril,\nCardizem, hydrochlorothiazide, potassium, Zoloft, Premarin,\nCelebrex, albuterol inhaler, multivitamin, and aspirin.\n\nALLERGIES: No known drug allergies.\n\nHOSPITAL COURSE: The patient was admitted to the General\nSurgery Service on 7-21 and underwent an uncomplicated\nopen gastric bypass surgery with open cholecystectomy.\n\nThe patient's postoperative course was notable for persistent\nhypotension with stout pressure in the 80s requiring fluid\nboluses in order to maintain appropriate pressure and urine\noutput. An electrocardiogram was obtained, and the was ruled\nout for a myocardial infarction.\n\nShe spent the following day in the Intensive Care Unit where\nshe was closely hemodynamically monitored.", ' She subsequently\ncame out of the unit on postoperative day three and had a\nrelatively benign remainder of her hospital stay.\n\nOn postoperative day two, she underwent a transesophageal\nechocardiogram that demonstrated decreased left atrial\nvelocities, but no other abnormalities.\n\nShe remained afebrile, and on postoperative three was\nrestarted on her hydrochlorothiazide. Her intravenous fluids\nwere hep-locked, and her diet was advanced to a stage II.\nHer patient-controlled analgesia was discontinued, and she\nwas initiated on oral pain medications which controlled her\npain adequately.\n\nBy postoperative four, the patient was tolerating a stage II\ndiet, was passing gas, and was advanced to a stage III diet.\nHer Foley had been discontinued midnight the night before,\nand she was voiding without difficulty.', ' Per the\nrecommendations of the Electrophysiology fellow, the patient\nwas initiated on Coumadin for her new onset of atrial\nfibrillation.\n\nDISCHARGE STATUS: The patient was subsequently discharged to\nhome.\n\nCONDITION AT DISCHARGE: In stable condition.\n\nDISCHARGE FOLLOWUP: Instructions to follow up with her\nprimary care physician to manage her outpatient Coumadin\ndosing.\n\nMEDICATIONS ON DISCHARGE: (Medications at the time of\ndischarge included)\n 1. Coumadin 2.5 mg p.o. q.d.\n 2. Atenolol 25 mg p.o. q.d.\n 3. Zestril 20 mg p.o. b.i.d.\n 4. Premarin 0.625 mg p.o. q.d.\n 5. Celebrex.\n 6. Hydrochlorothiazide 25 mg p.o. q.d.\n 7. Potassium chloride 10 mEq p.o. q.d.\n 8. Procardia.\n 9. Roxicet elixir 5 cc to 10 cc p.o. q.4-6h. p.r.n. for\npain.\n10. Zantac elixir 150 mg p.o. q.d.\n11. Multivitamin.', '\n12. Vitamin B12.\n\n\n\n\n Isabella Mao, M.D. 61201396\n\nDictated By:Son\n\nMEDQUIST36\n\nD: 1996-6-22 15:14\nT: 1956-10-18 08:42\nJOB#: Fisher Group-1982-478843\n']
447	6475	154622.0	2113-05-14	Discharge summary	Report	Admission Date: [2113-5-10] Discharge Date: [2113-5-14] Date of Birth: [2035-11-8] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 77 year old gentleman with past medical history of asthma, recent Group A Streptococcus, non-necrotizing fasciitis, Dr. [Last Name (STitle) ] for his recent infection the day of admission. At the appointment, Dr. [Last Name (STitle) ] noted that the patient had a significant cardiac rub. A chest x-ray was ordered which documented that there was significant cardiomegaly compared to his previous chest x-ray one week prior to admission. Dr. [Last Name (STitle) ] referred the patient to the [Hospital6 256] Emergency Department for echocardiogram to evaluate for a possible pericardial effusion. In the Emergency Department the patient was noted to have significant accumulation of pericardial fluid and physiological evidence of cardiac tamponade. The patient was admitted from the Emergency Department to the Cardiac Intensive Care Unit for hemodynamic monitoring. The cardiology fellow was consulted regarding the need for pericardiocentesis. Given the patient's blood pressure was stable, the decision was made to hold off on pericardiocentesis until the morning following admission, so the patient could have the full attention of all members of the Cardiac Catheterization Laboratory. PAST MEDICAL HISTORY: 1. Asthma. 2. Gout. 3. Gastroesophageal reflux disease. 4. Mild anemia. MEDICATIONS ON ADMISSION: 1. Amoxicillin 500 q. 8 hours. 2. Singulair. 3. Albuterol. 4. Salmeterol. 5. Fosamax 70 q. Tuesday. 6. Calcium with Vitamin D. 7. Fluticasone. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.1, heart rate 55, blood pressure 151/56, respiratory rate 22, oxygen saturation 98% on room air. In general, she was a well-appearing elderly male in no apparent distress. Head, eyes, ears, nose and throat was anicteric. Facial muscles were symmetric. Mucous membranes were moist. Cardiovascular, borderline tachycardia, notable soft, vocal-like rub at the left lower sternal border. The patient had a pulsus paradoxus at 22. Pulmonary, the patient was noted to have basilar crackles, no wheezes or rhonchi. The abdomen with active bowel sounds, soft, nontender. The patient had mild mid epigastric tenderness as well as right upper quadrant tenderness. There was no apparent guarding, no rebound, no evidence of acute abdomen. Extremities, he had mild 1+ peripheral edema, isolated only to his feet bilaterally. Feet were warm. He has had some notable conjunctival pallor. HOSPITAL COURSE: 1. Cardiac - The patient was noted to have tamponade physiology on his transesophageal echocardiogram in the setting of recent pericarditis. The patient was taken to the Cardiac Catheterization Laboratory on [2113-5-11] for pericardiocentesis. The procedure drained approximately 550 cc of bloody fluid. On post procedure the patient's pulsus paradoxus decreased to less than 10. The patient did have some pain post procedure, for which she was treated with Toradol and Morphine with good effect. The drain was removed after 24 hours. The patient was followed with serial echocardiograms which did not reveal reaccumulation of the fluid. He had three separate echocardiograms performed. There was some notation of increased density on the perimeter of his pericardium which could be possible. Dr. [Last Name (STitle) 284] discussed with the patient that this may place him at risk for developing a constrictive etiology in the future. The patient was informed that if he develops worsening shortness of breath or lower extremity edema, he should call Dr. [Last Name (STitle) ] or Dr. [Last Name (STitle) 284] for further evaluation immediately. 2. Rhythm - The patient was in normal sinus rhythm on admission. Initially he was noted to have short runs of nonsustained ventricular tachycardia no greater than 5 beats in a row. This resolved with drainage of the pericardial fluid. 3. Ischemia - The patient had his cardiac enzymes cycled. There was no evidence of coronary artery disease by cardiac enzymes. The patient had no history of coronary artery disease. 4. Heme/infectious disease - The patient had a recent Group A Streptococcus non-necrotizing fasciitis for which he had been treated with Amoxicillin for a ten day course. The patient completed a ten day course during this hospitalization with the last day being [2113-5-14]. In addition, the patient was noted to have a history of chronic anemia which had been described as sideroblast anemia by Dr. [Last Name (STitle) 2148]. The patient also was noted to have Vitamin B12 deficiency during the hospital stay. He was started on B12 supplementations during his hospital stay and will be started on Vitamin B12 p.o. 100 q.d. 5. Pulmonary - The patient has a history of asthma, which appears well controlled. He was continued on his home asthma medications which include Fluticasone, Salmeterol, Albuterol and Montelukast without any exacerbations during his hospital stay. In addition, the patient had some history of lung nodules and has been recommended to have a repeat computerized tomography scan which had not been done. During this hospital stay, the patient did have a repeat chest computerized tomography scan which showed moderate pericardial effusion, moderate bilateral pleural effusions left greater than right and bibasilar atelectasis. Computerized tomography scan was able to comment on the tiny nodule in the lingula which was unchanged as well as the 2 mm left upper lobe nodule which appeared unstable. They were unable to comment on the previous 6 mm nodule in the left lower lobe given this was obscured by pleural fluid. Based on the chest computerized tomography scan though, it appears that none of the nodules have changed in size. If there is concern, then a repeat chest computerized tomography scan can be performed as an outpatient in the future. 6. Fluids, electrolytes and nutrition - The patient was noted to have the bilateral pleural effusions and had been given a significant amount of hydration prior to having the pericardiocentesis to maintain adequate preload. The patient was diuresed with Lasix with good effect prior to discharge. DISCHARGE CONDITION: Stable. The patient's pain with deep inspiration has resolved. The patient is tolerating a full p.o. diet. The patient is ambulating without difficulty. DISCHARGE DIAGNOSIS: 1. Cardiac tamponade. 2. Idiopathic pericarditis. 3. Pericardial effusion. 4. Asthma, mild. 5. Anemia of chronic disease. 6. B12 deficiency. DISCHARGE FOLLOW UP: The patient should follow up with Dr. [Last Name (STitle) ] within one to two weeks of discharge. In addition he was informed he should call Dr.[Name (NI) 3811] office the day following discharge to make an appointment. He was advised to schedule an echocardiogram approximately one week prior to his next appointment with Dr. [Last Name (STitle) 284]. DISCHARGE MEDICATIONS: 1. Salmeterol 1 puffs b.i.d. 2. Montelukast 1 tablet p.o. q.d. 3. Fluticasone 2 puffs b.i.d. 4. Nexium 40 mg p.o. q.d. 5. Albuterol 1 to 2 puffs q. 6 hours prn. 6. Tylenol prn. 7. Calcium carbonate with Vitamin D. 8. Fosamax 70 q. Tuesday. 9. Vitamin B12 100 mcg p.o. q.d. 10. Multivitamin one tablet p.o. q.d. 11. Amoxicillin 500 mg p.o. q. 8 hours, today is the last day. 12. Ibuprofen 200 mg tablet, three tablets p.o. t.i.d. prn arthritic pain. [First Name4 (NamePattern1) 610] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3812] Dictated By:[Name8 (MD) 3482] MEDQUIST36 D: [2113-5-14] 12:45 T: [2113-5-14] 19:12 JOB#: [Job Number 3813]	Admission Date: <Date>1935-10-20</Date> Discharge Date: <Date>1994-1-18</Date> Date of Birth: <Date>1992-12-11</Date> Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 77 year old gentleman with past medical history of asthma, recent Group A Streptococcus, non-necrotizing fasciitis, Dr. <Name>Beamon</Name> for his recent infection the day of admission. At the appointment, Dr. <Name>Beamon</Name> noted that the patient had a significant cardiac rub. A chest x-ray was ordered which documented that there was significant cardiomegaly compared to his previous chest x-ray one week prior to admission. Dr. <Name>Beamon</Name> referred the patient to the <Hospital>Arias Group Hospital</Hospital> Emergency Department for echocardiogram to evaluate for a possible pericardial effusion. In the Emergency Department the patient was noted to have significant accumulation of pericardial fluid and physiological evidence of cardiac tamponade. The patient was admitted from the Emergency Department to the Cardiac Intensive Care Unit for hemodynamic monitoring. The cardiology fellow was consulted regarding the need for pericardiocentesis. Given the patient's blood pressure was stable, the decision was made to hold off on pericardiocentesis until the morning following admission, so the patient could have the full attention of all members of the Cardiac Catheterization Laboratory. PAST MEDICAL HISTORY: 1. Asthma. 2. Gout. 3. Gastroesophageal reflux disease. 4. Mild anemia. MEDICATIONS ON ADMISSION: 1. Amoxicillin 500 q. 8 hours. 2. Singulair. 3. Albuterol. 4. Salmeterol. 5. Fosamax 70 q. Tuesday. 6. Calcium with Vitamin D. 7. Fluticasone. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.1, heart rate 55, blood pressure 151/56, respiratory rate 22, oxygen saturation 98% on room air. In general, she was a well-appearing elderly male in no apparent distress. Head, eyes, ears, nose and throat was anicteric. Facial muscles were symmetric. Mucous membranes were moist. Cardiovascular, borderline tachycardia, notable soft, vocal-like rub at the left lower sternal border. The patient had a pulsus paradoxus at 22. Pulmonary, the patient was noted to have basilar crackles, no wheezes or rhonchi. The abdomen with active bowel sounds, soft, nontender. The patient had mild mid epigastric tenderness as well as right upper quadrant tenderness. There was no apparent guarding, no rebound, no evidence of acute abdomen. Extremities, he had mild 1+ peripheral edema, isolated only to his feet bilaterally. Feet were warm. He has had some notable conjunctival pallor. HOSPITAL COURSE: 1. Cardiac - The patient was noted to have tamponade physiology on his transesophageal echocardiogram in the setting of recent pericarditis. The patient was taken to the Cardiac Catheterization Laboratory on <Date>1977-10-23</Date> for pericardiocentesis. The procedure drained approximately 550 cc of bloody fluid. On post procedure the patient's pulsus paradoxus decreased to less than 10. The patient did have some pain post procedure, for which she was treated with Toradol and Morphine with good effect. The drain was removed after 24 hours. The patient was followed with serial echocardiograms which did not reveal reaccumulation of the fluid. He had three separate echocardiograms performed. There was some notation of increased density on the perimeter of his pericardium which could be possible. Dr. <Name>Pegram</Name> discussed with the patient that this may place him at risk for developing a constrictive etiology in the future. The patient was informed that if he develops worsening shortness of breath or lower extremity edema, he should call Dr. <Name>Beamon</Name> or Dr. <Name>Pegram</Name> for further evaluation immediately. 2. Rhythm - The patient was in normal sinus rhythm on admission. Initially he was noted to have short runs of nonsustained ventricular tachycardia no greater than 5 beats in a row. This resolved with drainage of the pericardial fluid. 3. Ischemia - The patient had his cardiac enzymes cycled. There was no evidence of coronary artery disease by cardiac enzymes. The patient had no history of coronary artery disease. 4. Heme/infectious disease - The patient had a recent Group A Streptococcus non-necrotizing fasciitis for which he had been treated with Amoxicillin for a ten day course. The patient completed a ten day course during this hospitalization with the last day being <Date>1994-1-18</Date>. In addition, the patient was noted to have a history of chronic anemia which had been described as sideroblast anemia by Dr. <Name>Kibler</Name>. The patient also was noted to have Vitamin B12 deficiency during the hospital stay. He was started on B12 supplementations during his hospital stay and will be started on Vitamin B12 p.o. 100 q.d. 5. Pulmonary - The patient has a history of asthma, which appears well controlled. He was continued on his home asthma medications which include Fluticasone, Salmeterol, Albuterol and Montelukast without any exacerbations during his hospital stay. In addition, the patient had some history of lung nodules and has been recommended to have a repeat computerized tomography scan which had not been done. During this hospital stay, the patient did have a repeat chest computerized tomography scan which showed moderate pericardial effusion, moderate bilateral pleural effusions left greater than right and bibasilar atelectasis. Computerized tomography scan was able to comment on the tiny nodule in the lingula which was unchanged as well as the 2 mm left upper lobe nodule which appeared unstable. They were unable to comment on the previous 6 mm nodule in the left lower lobe given this was obscured by pleural fluid. Based on the chest computerized tomography scan though, it appears that none of the nodules have changed in size. If there is concern, then a repeat chest computerized tomography scan can be performed as an outpatient in the future. 6. Fluids, electrolytes and nutrition - The patient was noted to have the bilateral pleural effusions and had been given a significant amount of hydration prior to having the pericardiocentesis to maintain adequate preload. The patient was diuresed with Lasix with good effect prior to discharge. DISCHARGE CONDITION: Stable. The patient's pain with deep inspiration has resolved. The patient is tolerating a full p.o. diet. The patient is ambulating without difficulty. DISCHARGE DIAGNOSIS: 1. Cardiac tamponade. 2. Idiopathic pericarditis. 3. Pericardial effusion. 4. Asthma, mild. 5. Anemia of chronic disease. 6. B12 deficiency. DISCHARGE FOLLOW UP: The patient should follow up with Dr. <Name>Beamon</Name> within one to two weeks of discharge. In addition he was informed he should call Dr.<Name>Logan Pleasant</Name> office the day following discharge to make an appointment. He was advised to schedule an echocardiogram approximately one week prior to his next appointment with Dr. <Name>Pegram</Name>. DISCHARGE MEDICATIONS: 1. Salmeterol 1 puffs b.i.d. 2. Montelukast 1 tablet p.o. q.d. 3. Fluticasone 2 puffs b.i.d. 4. Nexium 40 mg p.o. q.d. 5. Albuterol 1 to 2 puffs q. 6 hours prn. 6. Tylenol prn. 7. Calcium carbonate with Vitamin D. 8. Fosamax 70 q. Tuesday. 9. Vitamin B12 100 mcg p.o. q.d. 10. Multivitamin one tablet p.o. q.d. 11. Amoxicillin 500 mg p.o. q. 8 hours, today is the last day. 12. Ibuprofen 200 mg tablet, three tablets p.o. t.i.d. prn arthritic pain. <Name>Hattie</Name> <Name>Kiel</Name>, M.D. <MD Number>34313046</MD Number> Dictated By:<Name>Betty Thompson</Name> MEDQUIST36 D: <Date>1994-1-18</Date> 12:45 T: <Date>1994-1-18</Date> 19:12 JOB#: <Job Number>May Group-1975-957840</Job Number>	000000000000000001111111111000000000000000000000011111111100000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111110000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1935-10-20 Discharge Date: 1994-1-18 Date of Birth: 1992-12-11 Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 77 year old gentleman with past medical history of asthma, recent Group A Streptococcus, non-necrotizing fasciitis, Dr. Beamon for his recent infection the day of admission. At the appointment, Dr. Beamon noted that the patient had a significant cardiac rub. A chest x-ray was ordered which documented that there was significant cardiomegaly compared to his previous chest x-ray one week prior to admission. Dr. Beamon referred the patient to the Arias Group Hospital Emergency Department for echocardiogram to evaluate for a possible pericardial effusion. In the Emergency Department the patient was noted to have significant accumulation of pericardial fluid and physiological evidence of cardiac tamponade. The patient was admitted from the Emergency Department to the Cardiac Intensive Care Unit for hemodynamic monitoring. The cardiology fellow was consulted regarding the need for pericardiocentesis. Given the patient's blood pressure was stable, the decision was made to hold off on pericardiocentesis until the morning following admission, so the patient could have the full attention of all members of the Cardiac Catheterization Laboratory. PAST MEDICAL HISTORY: 1. Asthma. 2. Gout. 3. Gastroesophageal reflux disease. 4. Mild anemia. MEDICATIONS ON ADMISSION: 1. Amoxicillin 500 q. 8 hours. 2. Singulair. 3. Albuterol. 4. Salmeterol. 5. Fosamax 70 q. Tuesday. 6. Calcium with Vitamin D. 7. Fluticasone. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.1, heart rate 55, blood pressure 151/56, respiratory rate 22, oxygen saturation 98% on room air. In general, she was a well-appearing elderly male in no apparent distress. Head, eyes, ears, nose and throat was anicteric. Facial muscles were symmetric. Mucous membranes were moist. Cardiovascular, borderline tachycardia, notable soft, vocal-like rub at the left lower sternal border. The patient had a pulsus paradoxus at 22. Pulmonary, the patient was noted to have basilar crackles, no wheezes or rhonchi. The abdomen with active bowel sounds, soft, nontender. The patient had mild mid epigastric tenderness as well as right upper quadrant tenderness. There was no apparent guarding, no rebound, no evidence of acute abdomen. Extremities, he had mild 1+ peripheral edema, isolated only to his feet bilaterally. Feet were warm. He has had some notable conjunctival pallor. HOSPITAL COURSE: 1. Cardiac - The patient was noted to have tamponade physiology on his transesophageal echocardiogram in the setting of recent pericarditis. The patient was taken to the Cardiac Catheterization Laboratory on 1977-10-23 for pericardiocentesis. The procedure drained approximately 550 cc of bloody fluid. On post procedure the patient's pulsus paradoxus decreased to less than 10. The patient did have some pain post procedure, for which she was treated with Toradol and Morphine with good effect. The drain was removed after 24 hours. The patient was followed with serial echocardiograms which did not reveal reaccumulation of the fluid. He had three separate echocardiograms performed. There was some notation of increased density on the perimeter of his pericardium which could be possible. Dr. Pegram discussed with the patient that this may place him at risk for developing a constrictive etiology in the future. The patient was informed that if he develops worsening shortness of breath or lower extremity edema, he should call Dr. Beamon or Dr. Pegram for further evaluation immediately. 2. Rhythm - The patient was in normal sinus rhythm on admission. Initially he was noted to have short runs of nonsustained ventricular tachycardia no greater than 5 beats in a row. This resolved with drainage of the pericardial fluid. 3. Ischemia - The patient had his cardiac enzymes cycled. There was no evidence of coronary artery disease by cardiac enzymes. The patient had no history of coronary artery disease. 4. Heme/infectious disease - The patient had a recent Group A Streptococcus non-necrotizing fasciitis for which he had been treated with Amoxicillin for a ten day course. The patient completed a ten day course during this hospitalization with the last day being 1994-1-18. In addition, the patient was noted to have a history of chronic anemia which had been described as sideroblast anemia by Dr. Kibler. The patient also was noted to have Vitamin B12 deficiency during the hospital stay. He was started on B12 supplementations during his hospital stay and will be started on Vitamin B12 p.o. 100 q.d. 5. Pulmonary - The patient has a history of asthma, which appears well controlled. He was continued on his home asthma medications which include Fluticasone, Salmeterol, Albuterol and Montelukast without any exacerbations during his hospital stay. In addition, the patient had some history of lung nodules and has been recommended to have a repeat computerized tomography scan which had not been done. During this hospital stay, the patient did have a repeat chest computerized tomography scan which showed moderate pericardial effusion, moderate bilateral pleural effusions left greater than right and bibasilar atelectasis. Computerized tomography scan was able to comment on the tiny nodule in the lingula which was unchanged as well as the 2 mm left upper lobe nodule which appeared unstable. They were unable to comment on the previous 6 mm nodule in the left lower lobe given this was obscured by pleural fluid. Based on the chest computerized tomography scan though, it appears that none of the nodules have changed in size. If there is concern, then a repeat chest computerized tomography scan can be performed as an outpatient in the future. 6. Fluids, electrolytes and nutrition - The patient was noted to have the bilateral pleural effusions and had been given a significant amount of hydration prior to having the pericardiocentesis to maintain adequate preload. The patient was diuresed with Lasix with good effect prior to discharge. DISCHARGE CONDITION: Stable. The patient's pain with deep inspiration has resolved. The patient is tolerating a full p.o. diet. The patient is ambulating without difficulty. DISCHARGE DIAGNOSIS: 1. Cardiac tamponade. 2. Idiopathic pericarditis. 3. Pericardial effusion. 4. Asthma, mild. 5. Anemia of chronic disease. 6. B12 deficiency. DISCHARGE FOLLOW UP: The patient should follow up with Dr. Beamon within one to two weeks of discharge. In addition he was informed he should call Dr.Logan Pleasant office the day following discharge to make an appointment. He was advised to schedule an echocardiogram approximately one week prior to his next appointment with Dr. Pegram. DISCHARGE MEDICATIONS: 1. Salmeterol 1 puffs b.i.d. 2. Montelukast 1 tablet p.o. q.d. 3. Fluticasone 2 puffs b.i.d. 4. Nexium 40 mg p.o. q.d. 5. Albuterol 1 to 2 puffs q. 6 hours prn. 6. Tylenol prn. 7. Calcium carbonate with Vitamin D. 8. Fosamax 70 q. Tuesday. 9. Vitamin B12 100 mcg p.o. q.d. 10. Multivitamin one tablet p.o. q.d. 11. Amoxicillin 500 mg p.o. q. 8 hours, today is the last day. 12. Ibuprofen 200 mg tablet, three tablets p.o. t.i.d. prn arthritic pain. Hattie Kiel, M.D. 34313046 Dictated By:Betty Thompson MEDQUIST36 D: 1994-1-18 12:45 T: 1994-1-18 19:12 JOB#: May Group-1975-957840	['Admission Date: 1935-10-20 Discharge Date: 1994-1-18\n\nDate of Birth: 1992-12-11 Sex: M\n\nService:\n\nHISTORY OF PRESENT ILLNESS: This is a 77 year old gentleman\nwith past medical history of asthma, recent Group A\nStreptococcus, non-necrotizing fasciitis, Dr. Beamon for his\nrecent infection the day of admission. At the appointment, Dr.\nBeamon noted that the patient had a significant cardiac rub. A\nchest x-ray was ordered which documented that there was\nsignificant cardiomegaly compared to his previous chest x-ray one\nweek prior to admission. Dr. Beamon referred the patient to\nthe Arias Group Hospital Emergency Department for\nechocardiogram to evaluate for a possible pericardial effusion.\nIn the Emergency Department the patient was noted to have\nsignificant accumulation of pericardial fluid and\nphysiological evidence of cardiac tamponade.', " The patient was\nadmitted from the Emergency Department to the Cardiac\nIntensive Care Unit for hemodynamic monitoring. The\ncardiology fellow was consulted regarding the need for\npericardiocentesis. Given the patient's blood pressure was\nstable, the decision was made to hold off on pericardiocentesis\nuntil the morning following admission, so the patient could have\nthe full attention of all members of the Cardiac Catheterization\nLaboratory.\n\nPAST MEDICAL HISTORY:\n1. Asthma.\n2. Gout.\n3. Gastroesophageal reflux disease.\n4. Mild anemia.\n\nMEDICATIONS ON ADMISSION:\n1. Amoxicillin 500 q. 8 hours.\n2. Singulair.\n3. Albuterol.\n4. Salmeterol.\n5. Fosamax 70 q. Tuesday.\n6. Calcium with Vitamin D.\n7. Fluticasone.\n\nPHYSICAL EXAMINATION ON ADMISSION: Temperature 98.1, heart\nrate 55, blood pressure 151/56, respiratory rate 22, oxygen\nsaturation 98% on room air.", ' In general, she was a\nwell-appearing elderly male in no apparent distress. Head,\neyes, ears, nose and throat was anicteric. Facial muscles\nwere symmetric. Mucous membranes were moist.\nCardiovascular, borderline tachycardia, notable soft,\nvocal-like rub at the left lower sternal border. The patient\nhad a pulsus paradoxus at 22. Pulmonary, the patient was\nnoted to have basilar crackles, no wheezes or rhonchi. The\nabdomen with active bowel sounds, soft, nontender. The\npatient had mild mid epigastric tenderness as well as right\nupper quadrant tenderness. There was no apparent guarding,\nno rebound, no evidence of acute abdomen. Extremities, he\nhad mild 1+ peripheral edema, isolated only to his feet\nbilaterally. Feet were warm. He has had some notable\nconjunctival pallor.\n\nHOSPITAL COURSE: 1.', " Cardiac - The patient was noted to have\ntamponade physiology on his transesophageal echocardiogram in\nthe setting of recent pericarditis. The patient was taken to\nthe Cardiac Catheterization Laboratory on 1977-10-23 for\npericardiocentesis. The procedure drained approximately 550\ncc of bloody fluid. On post procedure the patient's\npulsus paradoxus decreased to less than 10. The patient\ndid have some pain post procedure, for which she was treated\nwith Toradol and Morphine with good effect. The drain was\nremoved after 24 hours. The patient was followed with serial\nechocardiograms which did not reveal reaccumulation of the\nfluid. He had three separate echocardiograms performed.\nThere was some notation of increased density on the perimeter\nof his pericardium which could be possible. Dr.", ' Pegram\ndiscussed with the patient that this may place him at risk\nfor developing a constrictive etiology in the future. The\npatient was informed that if he develops worsening shortness\nof breath or lower extremity edema, he should call Dr.\nBeamon or Dr. Pegram for further evaluation\nimmediately.\n\n2. Rhythm - The patient was in normal sinus rhythm on\nadmission. Initially he was noted to have short runs of\nnonsustained ventricular tachycardia no greater than 5 beats\nin a row. This resolved with drainage of the pericardial\nfluid.\n\n3. Ischemia - The patient had his cardiac enzymes cycled.\nThere was no evidence of coronary artery disease by cardiac\nenzymes. The patient had no history of coronary artery\ndisease.\n\n4. Heme/infectious disease - The patient had a recent Group\nA Streptococcus non-necrotizing fasciitis for which he had\nbeen treated with Amoxicillin for a ten day course.', ' The\npatient completed a ten day course during this\nhospitalization with the last day being 1994-1-18. In\naddition, the patient was noted to have a history of chronic\nanemia which had been described as sideroblast anemia by Dr.\nKibler. The patient also was noted to have Vitamin B12\ndeficiency during the hospital stay. He was started on B12\nsupplementations during his hospital stay and will be started\non Vitamin B12 p.o. 100 q.d.\n\n5. Pulmonary - The patient has a history of asthma, which\nappears well controlled. He was continued on his home asthma\nmedications which include Fluticasone, Salmeterol, Albuterol\nand Montelukast without any exacerbations during his hospital\nstay. In addition, the patient had some history of lung\nnodules and has been recommended to have a repeat\ncomputerized tomography scan which had not been done.', ' During\nthis hospital stay, the patient did have a repeat chest\ncomputerized tomography scan which showed moderate\npericardial effusion, moderate bilateral pleural effusions\nleft greater than right and bibasilar atelectasis.\nComputerized tomography scan was able to comment on the tiny\nnodule in the lingula which was unchanged as well as the 2 mm\nleft upper lobe nodule which appeared unstable. They were\nunable to comment on the previous 6 mm nodule in the left\nlower lobe given this was obscured by pleural fluid. Based\non the chest computerized tomography scan though, it appears\nthat none of the nodules have changed in size. If there is\nconcern, then a repeat chest computerized tomography scan can\nbe performed as an outpatient in the future.\n\n6. Fluids, electrolytes and nutrition - The patient was\nnoted to have the bilateral pleural effusions and had been\ngiven a significant amount of hydration prior to having the\npericardiocentesis to maintain adequate preload.', " The patient\nwas diuresed with Lasix with good effect prior to discharge.\n\nDISCHARGE CONDITION: Stable. The patient's pain with deep\ninspiration has resolved. The patient is tolerating a full\np.o. diet. The patient is ambulating without difficulty.\n\nDISCHARGE DIAGNOSIS:\n1. Cardiac tamponade.\n2. Idiopathic pericarditis.\n3. Pericardial effusion.\n4. Asthma, mild.\n5. Anemia of chronic disease.\n6. B12 deficiency.\n\nDISCHARGE FOLLOW UP: The patient should follow up with Dr.\nBeamon within one to two weeks of discharge. In addition\nhe was informed he should call Dr.Logan Pleasant office the\nday following discharge to make an appointment. He was\nadvised to schedule an echocardiogram approximately one week\nprior to his next appointment with Dr. Pegram.\n\nDISCHARGE MEDICATIONS:\n1. Salmeterol 1 puffs b.", 'i.d.\n2. Montelukast 1 tablet p.o. q.d.\n3. Fluticasone 2 puffs b.i.d.\n4. Nexium 40 mg p.o. q.d.\n5. Albuterol 1 to 2 puffs q. 6 hours prn.\n6. Tylenol prn.\n7. Calcium carbonate with Vitamin D.\n8. Fosamax 70 q. Tuesday.\n9. Vitamin B12 100 mcg p.o. q.d.\n10. Multivitamin one tablet p.o. q.d.\n11. Amoxicillin 500 mg p.o. q. 8 hours, today is the last\nday.\n12. Ibuprofen 200 mg tablet, three tablets p.o. t.i.d. prn\narthritic pain.\n\n\n Hattie Kiel, M.D. 34313046\n\nDictated By:Betty Thompson\n\nMEDQUIST36\n\nD: 1994-1-18 12:45\nT: 1994-1-18 19:12\nJOB#: May Group-1975-957840\n\n\n\n\n\n\n\n\n']
448	11178	169254.0	2158-01-09	Discharge summary	Report	Admission Date: [2158-1-5] Discharge Date: [2158-1-9] Date of Birth: [2105-1-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3814] Chief Complaint: DKA/Uremia Major Surgical or Invasive Procedure: EGD History of Present Illness: 52 yo man with DM 1 and triopathy as well as PVD and CRI (followed by transplant) p/w 3 days of hyperglycemia, and N/V of coffee-ground emesis this am. Patient denies infectious symptoms or cardiac symptoms. Of note, had a stress test 3 days ago read as normal. EKG in ED with lateral ST depressions and + troponin (trending down). Past Medical History: 1. Diabetes mellitus type 2 x 35 years. 2. Triopathy. 3. Chronic renal insufficiency. 4. Chronic anemia. 5. Hypertension. 6. Hypercholesterolemia. 7. Depression Family History: non-contributory Brief Hospital Course: A/P: 52 yo male w/ DM 1, depression admitted for DKA, developed ARF, gastritis, r/o for MI, now stable. . DKA - The pt was placed in an insulin dip and was transferred to MICU. In the MICU his sugars came under control and the patient was eventually transitioned to fixed doses of insulin with a Humalog SS with [Last Name (un) ] consult input. His sugars were well controlled. It remained unclear as to what caused the pt's DKA; it was felt that he may not have been compliant with his home regimen [1-11] to depression. . Acute on CRI - The patient was found to have an acute increase in his baseline creatinine thought to arise from dehydration. His serum creatinine began to decrease with aggressive fluid hydration. Nephrology followed the patient. The pt stayed in the hospital for venous mapping, to help initiate the process of moving towards HD. He was set up for an appointment with renal transplant on discharge. . CAD/HTN - The pt was found to have EKG changes in the ED with elevated serum troponin but in the setting of renal failure. He ruled out for MI with negative cardiac enzymes x 3. He had an echo that shows a depressed EF from prior echo, but this was in the setting of an acidosis. Metoprolol was increased to 50mg [Hospital1 ] for better BP control. . Depression - Pt appears obviously depressed and expressed little confidence in medical and psychotherapy. This may have contributed to his current presentation. He has tried medication in the past but did not find them to be helpful. A psychiatry consult was called who urged the pt to seek o/p psychiatric help. . Coffee Ground Emesis - The pt was found to have gastritis on EGD but no source of active large bleed. He was started on a high dose PPI. He was transfused one unit PRBCs in MICU. . Anemia - Per renal, will start procrit [Numeric Identifier 961] units 3x/week . Proph - Hep SC, PPI . FEN - con't to replete Mg and K. Diabetic diet. . Code - Full. HCP is wife. . Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units Injection QMOWEFR (Monday -Wednesday-Friday). Disp:qs units Refills:2 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous twice a day: QAM and QHS. Humalog sliding scale as attached. Discharge Disposition: Home Discharge Diagnosis: DKA GIB Acute on chronic renal failure NSTEMI in setting of likely demand ischemia Depression Discharge Condition: Stable and improved Discharge Instructions: Please call your doctor or return to the ER if you have any fevers or chills, any difficulty breathing, any chest pain, abdominal pain, or if your depression worsens in any way. Please maintain good foot care. . Please take all your medications as directed. Bring your medication list to your appointments. . MEDICATION CHANGES: 1. Stop taking: Zestril. 2. New med: Protonix 40mg twice a day. 3. New med: Metoprolol 50mg twice a day. 4. Increase in med dose: Procrit 10,000U three times a week 5. Increase in med dose: Lipitor 40mg once a day 6. Change in insulin schedule: a. Take 10mg NPH every morning and every night before bed b. Follow a new Novalog insulin sliding scale, attached. Bring this sliding scale to your [Last Name (un) ] follow up appointment. . Do not take aspirin or NSAIDS for now, given your GI bleed. You can discuss this, as well as when to stop taking Pantoprazole, with Dr. [Last Name (STitle) 3815] (GI doctor). Followup Instructions: 1. PCP [Name Initial (PRE) ] [Name10 (NameIs) 3816], [1-17] at 11:20 with [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) 3817] at Dr.[Name (NI) 2989] office, [Company 191], Atrium Suite, [Location (un) 453]. [Telephone/Fax (1) 250] . 2. [Last Name (un) ] - Dr. [Last Name (STitle) 3818] - [Last Name (STitle) 3816], [1-24] at 12pm. [Hospital ] Clinic [Location (un) ]. [Telephone/Fax (1) 2384] . 3. Dr. [Last Name (STitle) ] - Thursday, [1-26] at 9:30am with Dr. [Last Name (STitle) ], [Hospital Ward Name 121] Building, [Location (un) 470]. [Telephone/Fax (1) 543] . 4. GI - [Telephone/Fax (1) 3816], [1-24] at 2:20pm with Dr. [Last Name (STitle) 3815]. [Hospital Ward Name 23] Building, [Location (un) 436]. [Telephone/Fax (1) 1954] . 5. Transplant: [Name6 (MD) 1344] [Last Name (NamePattern4) 3125], MD. Where: LM [Hospital Unit Name 3126] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2158-1-12] 2:00 [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 3819] MD, [MD Number(3) 3820]	Admission Date: <Date>1963-2-18</Date> Discharge Date: <Date>1924-5-27</Date> Date of Birth: <Date>1949-5-16</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Prince</Name> Chief Complaint: DKA/Uremia Major Surgical or Invasive Procedure: EGD History of Present Illness: 52 yo man with DM 1 and triopathy as well as PVD and CRI (followed by transplant) p/w 3 days of hyperglycemia, and N/V of coffee-ground emesis this am. Patient denies infectious symptoms or cardiac symptoms. Of note, had a stress test 3 days ago read as normal. EKG in ED with lateral ST depressions and + troponin (trending down). Past Medical History: 1. Diabetes mellitus type 2 x 35 years. 2. Triopathy. 3. Chronic renal insufficiency. 4. Chronic anemia. 5. Hypertension. 6. Hypercholesterolemia. 7. Depression Family History: non-contributory Brief Hospital Course: A/P: 52 yo male w/ DM 1, depression admitted for DKA, developed ARF, gastritis, r/o for MI, now stable. . DKA - The pt was placed in an insulin dip and was transferred to MICU. In the MICU his sugars came under control and the patient was eventually transitioned to fixed doses of insulin with a Humalog SS with <Name>Son</Name> consult input. His sugars were well controlled. It remained unclear as to what caused the pt's DKA; it was felt that he may not have been compliant with his home regimen <Date>6-20</Date> to depression. . Acute on CRI - The patient was found to have an acute increase in his baseline creatinine thought to arise from dehydration. His serum creatinine began to decrease with aggressive fluid hydration. Nephrology followed the patient. The pt stayed in the hospital for venous mapping, to help initiate the process of moving towards HD. He was set up for an appointment with renal transplant on discharge. . CAD/HTN - The pt was found to have EKG changes in the ED with elevated serum troponin but in the setting of renal failure. He ruled out for MI with negative cardiac enzymes x 3. He had an echo that shows a depressed EF from prior echo, but this was in the setting of an acidosis. Metoprolol was increased to 50mg <Hospital>Martin, Mullins and Spencer Health System</Hospital> for better BP control. . Depression - Pt appears obviously depressed and expressed little confidence in medical and psychotherapy. This may have contributed to his current presentation. He has tried medication in the past but did not find them to be helpful. A psychiatry consult was called who urged the pt to seek o/p psychiatric help. . Coffee Ground Emesis - The pt was found to have gastritis on EGD but no source of active large bleed. He was started on a high dose PPI. He was transfused one unit PRBCs in MICU. . Anemia - Per renal, will start procrit <Numeric Identifier>0599339</Numeric Identifier> units 3x/week . Proph - Hep SC, PPI . FEN - con't to replete Mg and K. Diabetic diet. . Code - Full. HCP is wife. . Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units Injection QMOWEFR (Monday -Wednesday-Friday). Disp:qs units Refills:2 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous twice a day: QAM and QHS. Humalog sliding scale as attached. Discharge Disposition: Home Discharge Diagnosis: DKA GIB Acute on chronic renal failure NSTEMI in setting of likely demand ischemia Depression Discharge Condition: Stable and improved Discharge Instructions: Please call your doctor or return to the ER if you have any fevers or chills, any difficulty breathing, any chest pain, abdominal pain, or if your depression worsens in any way. Please maintain good foot care. . Please take all your medications as directed. Bring your medication list to your appointments. . MEDICATION CHANGES: 1. Stop taking: Zestril. 2. New med: Protonix 40mg twice a day. 3. New med: Metoprolol 50mg twice a day. 4. Increase in med dose: Procrit 10,000U three times a week 5. Increase in med dose: Lipitor 40mg once a day 6. Change in insulin schedule: a. Take 10mg NPH every morning and every night before bed b. Follow a new Novalog insulin sliding scale, attached. Bring this sliding scale to your <Name>Son</Name> follow up appointment. . Do not take aspirin or NSAIDS for now, given your GI bleed. You can discuss this, as well as when to stop taking Pantoprazole, with Dr. <Name>Davis</Name> (GI doctor). Followup Instructions: 1. PCP <Name>Alesha Dortch</Name> <Name>Pascual Salgado</Name>, <Date>12-5</Date> at 11:20 with <Name>Kaushik</Name> <Name>Abdullah</Name> at Dr.<Name>Danilo Shipley</Name> office, <Company>Randolph LLC</Company>, Atrium Suite, <Location>935 Ariana Oval Suite 561 Careyside, NY 84179</Location>. <Telephone>276-763-5103</Telephone> . 2. <Name>Son</Name> - Dr. <Name>Pichardo</Name> - <Name>Brown</Name>, <Date>9-11</Date> at 12pm. <Hospital>Garrett, Price and Jones Medical Center</Hospital> Clinic <Location>63691 Katherine Knolls Suite 990 Lake Shaneport, FL 77538</Location>. <Telephone>528-780-6265</Telephone> . 3. Dr. <Name>Davis</Name> - Thursday, <Date>10-16</Date> at 9:30am with Dr. <Name>Davis</Name>, <Hospital>Larson, Moran and Anderson Medical Center</Hospital> Building, <Location>6325 Kent Square Suite 701 Sarahview, WY 87024</Location>. <Telephone>163-726-3693</Telephone> . 4. GI - <Telephone>945-677-9613</Telephone>, <Date>9-11</Date> at 2:20pm with Dr. <Name>Davis</Name>. <Hospital>Phillips-Obrien Hospital</Hospital> Building, <Location>533 Christopher Island Apt. 265 West Kathleenborough, MT 52956</Location>. <Telephone>994-538-9044</Telephone> . 5. Transplant: <Name>Gaspar Hasan</Name> <Name>Sakkas</Name>, MD. Where: LM <Hospital>Blake-Vaughn Clinic</Hospital> CENTER Phone:<Telephone>417-584-9779</Telephone> Date/Time:<Date>2022-10-27</Date> 2:00 <Name>Chloe</Name> <Name>Amaro</Name> MD, <MD Number>31134757</MD 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Date: 1963-2-18 Discharge Date: 1924-5-27 Date of Birth: 1949-5-16 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Prince Chief Complaint: DKA/Uremia Major Surgical or Invasive Procedure: EGD History of Present Illness: 52 yo man with DM 1 and triopathy as well as PVD and CRI (followed by transplant) p/w 3 days of hyperglycemia, and N/V of coffee-ground emesis this am. Patient denies infectious symptoms or cardiac symptoms. Of note, had a stress test 3 days ago read as normal. EKG in ED with lateral ST depressions and + troponin (trending down). Past Medical History: 1. Diabetes mellitus type 2 x 35 years. 2. Triopathy. 3. Chronic renal insufficiency. 4. Chronic anemia. 5. Hypertension. 6. Hypercholesterolemia. 7. Depression Family History: non-contributory Brief Hospital Course: A/P: 52 yo male w/ DM 1, depression admitted for DKA, developed ARF, gastritis, r/o for MI, now stable. . DKA - The pt was placed in an insulin dip and was transferred to MICU. In the MICU his sugars came under control and the patient was eventually transitioned to fixed doses of insulin with a Humalog SS with Son consult input. His sugars were well controlled. It remained unclear as to what caused the pt's DKA; it was felt that he may not have been compliant with his home regimen 6-20 to depression. . Acute on CRI - The patient was found to have an acute increase in his baseline creatinine thought to arise from dehydration. His serum creatinine began to decrease with aggressive fluid hydration. Nephrology followed the patient. The pt stayed in the hospital for venous mapping, to help initiate the process of moving towards HD. He was set up for an appointment with renal transplant on discharge. . CAD/HTN - The pt was found to have EKG changes in the ED with elevated serum troponin but in the setting of renal failure. He ruled out for MI with negative cardiac enzymes x 3. He had an echo that shows a depressed EF from prior echo, but this was in the setting of an acidosis. Metoprolol was increased to 50mg Martin, Mullins and Spencer Health System for better BP control. . Depression - Pt appears obviously depressed and expressed little confidence in medical and psychotherapy. This may have contributed to his current presentation. He has tried medication in the past but did not find them to be helpful. A psychiatry consult was called who urged the pt to seek o/p psychiatric help. . Coffee Ground Emesis - The pt was found to have gastritis on EGD but no source of active large bleed. He was started on a high dose PPI. He was transfused one unit PRBCs in MICU. . Anemia - Per renal, will start procrit 0599339 units 3x/week . Proph - Hep SC, PPI . FEN - con't to replete Mg and K. Diabetic diet. . Code - Full. HCP is wife. . Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units Injection QMOWEFR (Monday -Wednesday-Friday). Disp:qs units Refills:2 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous twice a day: QAM and QHS. Humalog sliding scale as attached. Discharge Disposition: Home Discharge Diagnosis: DKA GIB Acute on chronic renal failure NSTEMI in setting of likely demand ischemia Depression Discharge Condition: Stable and improved Discharge Instructions: Please call your doctor or return to the ER if you have any fevers or chills, any difficulty breathing, any chest pain, abdominal pain, or if your depression worsens in any way. Please maintain good foot care. . Please take all your medications as directed. Bring your medication list to your appointments. . MEDICATION CHANGES: 1. Stop taking: Zestril. 2. New med: Protonix 40mg twice a day. 3. New med: Metoprolol 50mg twice a day. 4. Increase in med dose: Procrit 10,000U three times a week 5. Increase in med dose: Lipitor 40mg once a day 6. Change in insulin schedule: a. Take 10mg NPH every morning and every night before bed b. Follow a new Novalog insulin sliding scale, attached. Bring this sliding scale to your Son follow up appointment. . Do not take aspirin or NSAIDS for now, given your GI bleed. You can discuss this, as well as when to stop taking Pantoprazole, with Dr. Davis (GI doctor). Followup Instructions: 1. PCP Alesha Dortch Pascual Salgado, 12-5 at 11:20 with Kaushik Abdullah at Dr.Danilo Shipley office, Randolph LLC, Atrium Suite, 935 Ariana Oval Suite 561 Careyside, NY 84179. 276-763-5103 . 2. Son - Dr. Pichardo - Brown, 9-11 at 12pm. Garrett, Price and Jones Medical Center Clinic 63691 Katherine Knolls Suite 990 Lake Shaneport, FL 77538. 528-780-6265 . 3. Dr. Davis - Thursday, 10-16 at 9:30am with Dr. Davis, Larson, Moran and Anderson Medical Center Building, 6325 Kent Square Suite 701 Sarahview, WY 87024. 163-726-3693 . 4. GI - 945-677-9613, 9-11 at 2:20pm with Dr. Davis. Phillips-Obrien Hospital Building, 533 Christopher Island Apt. 265 West Kathleenborough, MT 52956. 994-538-9044 . 5. Transplant: Gaspar Hasan Sakkas, MD. Where: LM Blake-Vaughn Clinic CENTER Phone:417-584-9779 Date/Time:2022-10-27 2:00 Chloe Amaro MD, 31134757	['Admission Date: 1963-2-18 Discharge Date: 1924-5-27\n\nDate of Birth: 1949-5-16 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Prince\nChief Complaint:\nDKA/Uremia\n\nMajor Surgical or Invasive Procedure:\nEGD\n\nHistory of Present Illness:\n52 yo man with DM 1 and triopathy as well as PVD and CRI\n(followed by transplant) p/w 3 days of hyperglycemia, and N/V of\ncoffee-ground emesis this am. Patient denies infectious symptoms\nor cardiac symptoms. Of note, had a stress test 3 days ago read\nas normal. EKG in ED with lateral ST depressions and + troponin\n(trending down).\n\nPast Medical History:\n1. Diabetes mellitus type 2 x 35 years.\n2. Triopathy.\n3. Chronic renal insufficiency.\n4. Chronic anemia.\n5. Hypertension.\n6. Hypercholesterolemia.', "\n7. Depression\n\n\nFamily History:\nnon-contributory\n\nBrief Hospital Course:\nA/P: 52 yo male w/ DM 1, depression admitted for DKA, developed\nARF, gastritis, r/o for MI, now stable.\n.\nDKA - The pt was placed in an insulin dip and was transferred to\nMICU. In the MICU his sugars came under control and the patient\nwas eventually transitioned to fixed doses of insulin with a\nHumalog SS with Son consult input. His sugars were well\ncontrolled. It remained unclear as to what caused the pt's DKA;\nit was felt that he may not have been compliant with his home\nregimen 6-20 to depression.\n.\nAcute on CRI - The patient was found to have an acute increase\nin his baseline creatinine thought to arise from dehydration.\nHis serum creatinine began to decrease with aggressive fluid\nhydration. Nephrology followed the patient.", ' The pt stayed in\nthe hospital for venous mapping, to help initiate the process of\nmoving towards HD. He was set up for an appointment with renal\ntransplant on discharge.\n.\nCAD/HTN - The pt was found to have EKG changes in the ED with\nelevated serum troponin but in the setting of renal failure. He\nruled out for MI with negative cardiac enzymes x 3. He had an\necho that shows a depressed EF from prior echo, but this was in\nthe setting of an acidosis. Metoprolol was increased to 50mg Martin, Mullins and Spencer Health System\nfor better BP control.\n.\nDepression - Pt appears obviously depressed and expressed little\nconfidence in medical and psychotherapy. This may have\ncontributed to his current presentation. He has tried\nmedication in the past but did not find them to be helpful. A\npsychiatry consult was called who urged the pt to seek o/p\npsychiatric help.', "\n.\nCoffee Ground Emesis - The pt was found to have gastritis on EGD\nbut no source of active large bleed. He was started on a high\ndose PPI. He was transfused one unit PRBCs in MICU.\n.\nAnemia - Per renal, will start procrit 0599339 units 3x/week\n.\nProph - Hep SC, PPI\n.\nFEN - con't to replete Mg and K. Diabetic diet.\n.\nCode - Full. HCP is wife.\n.\n\nDischarge Medications:\n1. Calcitriol 0.25 mcg Capsule Sig: Three (3) Capsule PO DAILY\n(Daily).\n2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID\nW/MEALS (3 TIMES A DAY WITH MEALS).\n3. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units\nInjection QMOWEFR (Monday -Wednesday-Friday).\nDisp:qs units Refills:2\n4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID\n(3 times a day).\nDisp:90 Tablet(s) Refills:2\n5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.", 'C.) Sig:\nOne (1) Tablet, Delayed Release (E.C.) PO twice a day.\nDisp:60 Tablet, Delayed Release (E.C.)(s) Refills:2\n6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\nDisp:30 Tablet(s) Refills:2\n7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Ten (10)\nunits Subcutaneous twice a day: QAM and QHS.\nHumalog sliding scale as attached.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nDKA\nGIB\nAcute on chronic renal failure\nNSTEMI in setting of likely demand ischemia\nDepression\n\n\nDischarge Condition:\nStable and improved\n\nDischarge Instructions:\nPlease call your doctor or return to the ER if you have any\nfevers or chills, any difficulty breathing, any chest pain,\nabdominal pain, or if your depression worsens in any way. Please\nmaintain good foot care.\n.\nPlease take all your medications as directed.', ' Bring your\nmedication list to your appointments.\n.\nMEDICATION CHANGES:\n1. Stop taking: Zestril.\n2. New med: Protonix 40mg twice a day.\n3. New med: Metoprolol 50mg twice a day.\n4. Increase in med dose: Procrit 10,000U three times a week\n5. Increase in med dose: Lipitor 40mg once a day\n6. Change in insulin schedule:\na. Take 10mg NPH every morning and every night before bed\nb. Follow a new Novalog insulin sliding scale, attached. Bring\nthis sliding scale to your Son follow up appointment.\n.\nDo not take aspirin or NSAIDS for now, given your GI bleed. You\ncan discuss this, as well as when to stop taking Pantoprazole,\nwith Dr. Davis (GI doctor).\n\nFollowup Instructions:\n1. PCP Alesha Dortch Pascual Salgado, 12-5 at 11:20 with Kaushik Abdullah at\nDr.Danilo Shipley office, Randolph LLC, Atrium Suite, 935 Ariana Oval Suite 561\nCareyside, NY 84179.', ' 276-763-5103\n\n.\n\n2. Son - Dr. Pichardo - Brown, 9-11 at 12pm. Garrett, Price and Jones Medical Center\nClinic 63691 Katherine Knolls Suite 990\nLake Shaneport, FL 77538. 528-780-6265\n\n.\n\n3. Dr. Davis - Thursday, 10-16 at 9:30am with Dr.\nDavis, Larson, Moran and Anderson Medical Center Building, 6325 Kent Square Suite 701\nSarahview, WY 87024. 163-726-3693\n\n.\n\n4. GI - 945-677-9613, 9-11 at 2:20pm with Dr. Davis.\nPhillips-Obrien Hospital Building, 533 Christopher Island Apt. 265\nWest Kathleenborough, MT 52956. 994-538-9044\n\n.\n\n5. Transplant: Gaspar Hasan Sakkas, MD. Where: LM Blake-Vaughn Clinic CENTER Phone:417-584-9779 Date/Time:2022-10-27 2:00\n\n\n Chloe Amaro MD, 31134757\n\n']
449	17074	147313.0	2137-04-29	Discharge summary	Report	Admission Date: [2137-4-23] Discharge Date: [2137-4-29] Date of Birth: [2090-12-9] Sex: M Service: CARDIOTHOR CHIEF COMPLAINT: Aortic regurgitation. HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male with a history of coronary artery disease, status post stent to left anterior descending. Subsequent to this procedure, patient developed aortic regurgitation. He was evaluated by Cardiology and he underwent a catheterization on [2137-4-9], which showed aortic regurgitation 4+, normal coronary arteries with the stent being open, and a normal ejection fraction of 45%. The patient was then referred to Dr. [Last Name (STitle) ] for aortic valve replacement. Patient denies any chest pain, nausea, vomiting, shortness of breath or dyspnea on exertion. PAST MEDICAL HISTORY: Significant for coronary artery disease, IJ nephropathy, stent to left anterior descending, hypertension. PAST SURGICAL HISTORY: Significant for a left calf reconstruction. MEDICATIONS ON ADMISSION: Zestril 10 mg po q.d., Atenolol 25 mg po q.d., aspirin 325 mg po q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient has rare ETOH use and no tobacco use. PHYSICAL EXAMINATION: Patient's in no acute distress. Temperature 98.6. Pulse 65. Blood pressure 160/73. O2 saturation 98% on room air. Patient has no carotid bruits, no lymphadenopathy. Chest is clear bilaterally. Patient is regular rate and rhythm with a 2/6 systolic ejection murmur. Abdomen soft, nontender with normal abdominal bowel sounds. Patient has no extremity edema. LABORATORY ON ADMISSION: White blood cell count 6.8, hematocrit of 43.7, platelets 186,000. Sodium of 137, potassium 4.3, chloride of 99, bicarbonate of 27, BUN 19, creatinine 1.0, INR of 1.1. Stress test done on [2137-3-8] was significant for 8.5 minute [Doctor First Name ] protocol, stopped secondary to 20 mmHg drop in systolic blood pressure. Asymptomatic with a ejection fraction of 30-35%. Cardiac catheterization significant for an ejection fraction of 45%, hypokinetic wall motion, aortic regurgitation, which is rated at 4+ with normal coronaries. Electrocardiogram was significant for sinus rhythm with a rate of 71 with left anterior fascicular block. No ischemic changes. HOSPITAL COURSE: The patient on the day of admission went to the Operating Room where he underwent an aortic valve replacement with a #27 [First Name8 (NamePattern2) 1495] [Male First Name (un) 923] mechanical valve. Patient tolerated this procedure well and was transferred to the Cardiothoracic Intensive Care Unit in stable condition. Patient was extubated without incident. Patient remained hemodynamically stable and was weaned off all drips. Patient's hematocrit remained stable at 29. On postoperative day number one, patient continued to remain hemodynamically stable. Patient continued to be weaned off all drips. Chest tubes were discontinued without incident. The patient was started on his Coumadin for anticoagulation for his mechanical valve. Patient on postoperative day number two was transferred to the floor. Patient has remained hemodynamically stable. Patient's INR has risen appropriately to latest INR being 1.9. Patient has remained afebrile. On postoperative day number six, patient developed tachycardia on the monitor. Upon further evaluation, it was found that patient has tachycardia with frequent atrial premature contractions, but not to be in atrial fibrillation. Patient's blood pressure remained stable. Patient's electrocardiogram demonstrated an elevated PR interval of 300 milliseconds. Patient was continued on his beta-blockade and was restarted on his ACE inhibitor. Patient will follow-up with his primary care physician for electrocardiogram in one week and to evaluate the PR interval at that time. There will be no further intervention done by the Electrophysiologic Service at this time. Patient has now been tolerating a regular diet and has been ambulating at an activity level of 5 with Physical Therapy. Patient is stable and ready for discharge to home. DISCHARGE DIAGNOSES: 1. Aortic insufficiency, status post aortic valve replacement #27 [First Name8 (NamePattern2) 1495] [Male First Name (un) 923] valve. 2. Hypertension. 3. Hypercholesterolemia. 4. IJ nephropathy. MEDICATIONS ON DISCHARGE: 1. Atenolol 25 mg po q.d. 2. Lasix 20 mg po b.i.d. times seven days. 3. KCL 20 mEq po b.i.d. times seven days. 4. Colace 100 mg po b.i.d. 5. Enteric coated aspirin 81 mg po q.d. 6. Coumadin 10 mg po q.d. Does [Name8 (MD) ] M.D. 7. Percocet 5/325 [1-2] po q. 4 hours prn. 8. Zestril 10 mg po q.d. FOLLOW-UP: Patient will follow-up with coagulation draws at [Hospital3 3834] to be called into his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) ]. Patient to follow-up with Dr. [Last Name (STitle) ] in four weeks. CONDITION AT DISCHARGE: Stable. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 3835] MEDQUIST36 D: [2137-4-30] 14:01 T: [2137-4-30] 14:01 JOB#: [Job Number 3836]	Admission Date: <Date>1946-2-8</Date> Discharge Date: <Date>1937-1-27</Date> Date of Birth: <Date>1929-12-3</Date> Sex: M Service: CARDIOTHOR CHIEF COMPLAINT: Aortic regurgitation. HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male with a history of coronary artery disease, status post stent to left anterior descending. Subsequent to this procedure, patient developed aortic regurgitation. He was evaluated by Cardiology and he underwent a catheterization on <Date>1952-11-27</Date>, which showed aortic regurgitation 4+, normal coronary arteries with the stent being open, and a normal ejection fraction of 45%. The patient was then referred to Dr. <Name>Pleasant</Name> for aortic valve replacement. Patient denies any chest pain, nausea, vomiting, shortness of breath or dyspnea on exertion. PAST MEDICAL HISTORY: Significant for coronary artery disease, IJ nephropathy, stent to left anterior descending, hypertension. PAST SURGICAL HISTORY: Significant for a left calf reconstruction. MEDICATIONS ON ADMISSION: Zestril 10 mg po q.d., Atenolol 25 mg po q.d., aspirin 325 mg po q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient has rare ETOH use and no tobacco use. PHYSICAL EXAMINATION: Patient's in no acute distress. Temperature 98.6. Pulse 65. Blood pressure 160/73. O2 saturation 98% on room air. Patient has no carotid bruits, no lymphadenopathy. Chest is clear bilaterally. Patient is regular rate and rhythm with a 2/6 systolic ejection murmur. Abdomen soft, nontender with normal abdominal bowel sounds. Patient has no extremity edema. LABORATORY ON ADMISSION: White blood cell count 6.8, hematocrit of 43.7, platelets 186,000. Sodium of 137, potassium 4.3, chloride of 99, bicarbonate of 27, BUN 19, creatinine 1.0, INR of 1.1. Stress test done on <Date>2019-11-30</Date> was significant for 8.5 minute <Name>Kelly</Name> protocol, stopped secondary to 20 mmHg drop in systolic blood pressure. Asymptomatic with a ejection fraction of 30-35%. Cardiac catheterization significant for an ejection fraction of 45%, hypokinetic wall motion, aortic regurgitation, which is rated at 4+ with normal coronaries. Electrocardiogram was significant for sinus rhythm with a rate of 71 with left anterior fascicular block. No ischemic changes. HOSPITAL COURSE: The patient on the day of admission went to the Operating Room where he underwent an aortic valve replacement with a #27 <Name>Coral</Name> <Name>Johnathon</Name> mechanical valve. Patient tolerated this procedure well and was transferred to the Cardiothoracic Intensive Care Unit in stable condition. Patient was extubated without incident. Patient remained hemodynamically stable and was weaned off all drips. Patient's hematocrit remained stable at 29. On postoperative day number one, patient continued to remain hemodynamically stable. Patient continued to be weaned off all drips. Chest tubes were discontinued without incident. The patient was started on his Coumadin for anticoagulation for his mechanical valve. Patient on postoperative day number two was transferred to the floor. Patient has remained hemodynamically stable. Patient's INR has risen appropriately to latest INR being 1.9. Patient has remained afebrile. On postoperative day number six, patient developed tachycardia on the monitor. Upon further evaluation, it was found that patient has tachycardia with frequent atrial premature contractions, but not to be in atrial fibrillation. Patient's blood pressure remained stable. Patient's electrocardiogram demonstrated an elevated PR interval of 300 milliseconds. Patient was continued on his beta-blockade and was restarted on his ACE inhibitor. Patient will follow-up with his primary care physician for electrocardiogram in one week and to evaluate the PR interval at that time. There will be no further intervention done by the Electrophysiologic Service at this time. Patient has now been tolerating a regular diet and has been ambulating at an activity level of 5 with Physical Therapy. Patient is stable and ready for discharge to home. DISCHARGE DIAGNOSES: 1. Aortic insufficiency, status post aortic valve replacement #27 <Name>Coral</Name> <Name>Johnathon</Name> valve. 2. Hypertension. 3. Hypercholesterolemia. 4. IJ nephropathy. MEDICATIONS ON DISCHARGE: 1. Atenolol 25 mg po q.d. 2. Lasix 20 mg po b.i.d. times seven days. 3. KCL 20 mEq po b.i.d. times seven days. 4. Colace 100 mg po b.i.d. 5. Enteric coated aspirin 81 mg po q.d. 6. Coumadin 10 mg po q.d. Does <Name>Arnaldo Camargo</Name> M.D. 7. Percocet 5/325 <Date>4-24</Date> po q. 4 hours prn. 8. Zestril 10 mg po q.d. FOLLOW-UP: Patient will follow-up with coagulation draws at <Hospital>Kelly, Carr and Cruz Clinic</Hospital> to be called into his primary care physician, <Name>Cobbs</Name>. <Name>Rafaela</Name> <Name>Juvenal Thomas</Name>. Patient to follow-up with Dr. <Name>Pleasant</Name> in four weeks. CONDITION AT DISCHARGE: Stable. <Name>Taryn</Name> <Name>Lyna</Name>, M.D. <MD Number>47382330</MD Number> Dictated By:<Name>Braswell</Name> MEDQUIST36 D: <Date>1937-4-1</Date> 14:01 T: <Date>1937-4-1</Date> 14:01 JOB#: <Job Number>Mcdaniel Inc-1991-438447</Job 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Date: 1946-2-8 Discharge Date: 1937-1-27 Date of Birth: 1929-12-3 Sex: M Service: CARDIOTHOR CHIEF COMPLAINT: Aortic regurgitation. HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male with a history of coronary artery disease, status post stent to left anterior descending. Subsequent to this procedure, patient developed aortic regurgitation. He was evaluated by Cardiology and he underwent a catheterization on 1952-11-27, which showed aortic regurgitation 4+, normal coronary arteries with the stent being open, and a normal ejection fraction of 45%. The patient was then referred to Dr. Pleasant for aortic valve replacement. Patient denies any chest pain, nausea, vomiting, shortness of breath or dyspnea on exertion. PAST MEDICAL HISTORY: Significant for coronary artery disease, IJ nephropathy, stent to left anterior descending, hypertension. PAST SURGICAL HISTORY: Significant for a left calf reconstruction. MEDICATIONS ON ADMISSION: Zestril 10 mg po q.d., Atenolol 25 mg po q.d., aspirin 325 mg po q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient has rare ETOH use and no tobacco use. PHYSICAL EXAMINATION: Patient's in no acute distress. Temperature 98.6. Pulse 65. Blood pressure 160/73. O2 saturation 98% on room air. Patient has no carotid bruits, no lymphadenopathy. Chest is clear bilaterally. Patient is regular rate and rhythm with a 2/6 systolic ejection murmur. Abdomen soft, nontender with normal abdominal bowel sounds. Patient has no extremity edema. LABORATORY ON ADMISSION: White blood cell count 6.8, hematocrit of 43.7, platelets 186,000. Sodium of 137, potassium 4.3, chloride of 99, bicarbonate of 27, BUN 19, creatinine 1.0, INR of 1.1. Stress test done on 2019-11-30 was significant for 8.5 minute Kelly protocol, stopped secondary to 20 mmHg drop in systolic blood pressure. Asymptomatic with a ejection fraction of 30-35%. Cardiac catheterization significant for an ejection fraction of 45%, hypokinetic wall motion, aortic regurgitation, which is rated at 4+ with normal coronaries. Electrocardiogram was significant for sinus rhythm with a rate of 71 with left anterior fascicular block. No ischemic changes. HOSPITAL COURSE: The patient on the day of admission went to the Operating Room where he underwent an aortic valve replacement with a #27 Coral Johnathon mechanical valve. Patient tolerated this procedure well and was transferred to the Cardiothoracic Intensive Care Unit in stable condition. Patient was extubated without incident. Patient remained hemodynamically stable and was weaned off all drips. Patient's hematocrit remained stable at 29. On postoperative day number one, patient continued to remain hemodynamically stable. Patient continued to be weaned off all drips. Chest tubes were discontinued without incident. The patient was started on his Coumadin for anticoagulation for his mechanical valve. Patient on postoperative day number two was transferred to the floor. Patient has remained hemodynamically stable. Patient's INR has risen appropriately to latest INR being 1.9. Patient has remained afebrile. On postoperative day number six, patient developed tachycardia on the monitor. Upon further evaluation, it was found that patient has tachycardia with frequent atrial premature contractions, but not to be in atrial fibrillation. Patient's blood pressure remained stable. Patient's electrocardiogram demonstrated an elevated PR interval of 300 milliseconds. Patient was continued on his beta-blockade and was restarted on his ACE inhibitor. Patient will follow-up with his primary care physician for electrocardiogram in one week and to evaluate the PR interval at that time. There will be no further intervention done by the Electrophysiologic Service at this time. Patient has now been tolerating a regular diet and has been ambulating at an activity level of 5 with Physical Therapy. Patient is stable and ready for discharge to home. DISCHARGE DIAGNOSES: 1. Aortic insufficiency, status post aortic valve replacement #27 Coral Johnathon valve. 2. Hypertension. 3. Hypercholesterolemia. 4. IJ nephropathy. MEDICATIONS ON DISCHARGE: 1. Atenolol 25 mg po q.d. 2. Lasix 20 mg po b.i.d. times seven days. 3. KCL 20 mEq po b.i.d. times seven days. 4. Colace 100 mg po b.i.d. 5. Enteric coated aspirin 81 mg po q.d. 6. Coumadin 10 mg po q.d. Does Arnaldo Camargo M.D. 7. Percocet 5/325 4-24 po q. 4 hours prn. 8. Zestril 10 mg po q.d. FOLLOW-UP: Patient will follow-up with coagulation draws at Kelly, Carr and Cruz Clinic to be called into his primary care physician, Cobbs. Rafaela Juvenal Thomas. Patient to follow-up with Dr. Pleasant in four weeks. CONDITION AT DISCHARGE: Stable. Taryn Lyna, M.D. 47382330 Dictated By:Braswell MEDQUIST36 D: 1937-4-1 14:01 T: 1937-4-1 14:01 JOB#: Mcdaniel Inc-1991-438447	['Admission Date: 1946-2-8 Discharge Date: 1937-1-27\n\nDate of Birth: 1929-12-3 Sex: M\n\nService: CARDIOTHOR\n\nCHIEF COMPLAINT: Aortic regurgitation.\n\nHISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male\nwith a history of coronary artery disease, status post stent\nto left anterior descending. Subsequent to this procedure,\npatient developed aortic regurgitation. He was evaluated by\nCardiology and he underwent a catheterization on 1952-11-27, which showed aortic regurgitation 4+, normal coronary\narteries with the stent being open, and a normal ejection\nfraction of 45%. The patient was then referred to Dr. Pleasant\nfor aortic valve replacement.\n\nPatient denies any chest pain, nausea, vomiting, shortness of\nbreath or dyspnea on exertion.\n\nPAST MEDICAL HISTORY: Significant for coronary artery\ndisease, IJ nephropathy, stent to left anterior descending,\nhypertension.', "\n\nPAST SURGICAL HISTORY: Significant for a left calf\nreconstruction.\n\nMEDICATIONS ON ADMISSION: Zestril 10 mg po q.d., Atenolol 25\nmg po q.d., aspirin 325 mg po q.d.\n\nALLERGIES: No known drug allergies.\n\nSOCIAL HISTORY: Patient has rare ETOH use and no tobacco\nuse.\n\nPHYSICAL EXAMINATION: Patient's in no acute distress.\nTemperature 98.6. Pulse 65. Blood pressure 160/73. O2\nsaturation 98% on room air. Patient has no carotid bruits,\nno lymphadenopathy. Chest is clear bilaterally. Patient is\nregular rate and rhythm with a 2/6 systolic ejection murmur.\nAbdomen soft, nontender with normal abdominal bowel sounds.\nPatient has no extremity edema.\n\nLABORATORY ON ADMISSION: White blood cell count 6.8,\nhematocrit of 43.7, platelets 186,000. Sodium of 137,\npotassium 4.3, chloride of 99, bicarbonate of 27, BUN 19,\ncreatinine 1.", '0, INR of 1.1.\n\nStress test done on 2019-11-30 was significant for 8.5\nminute Kelly protocol, stopped secondary to 20 mmHg drop in\nsystolic blood pressure. Asymptomatic with a ejection\nfraction of 30-35%.\n\nCardiac catheterization significant for an ejection fraction\nof 45%, hypokinetic wall motion, aortic regurgitation, which\nis rated at 4+ with normal coronaries.\n\nElectrocardiogram was significant for sinus rhythm with a\nrate of 71 with left anterior fascicular block. No ischemic\nchanges.\n\nHOSPITAL COURSE: The patient on the day of admission went to\nthe Operating Room where he underwent an aortic valve\nreplacement with a #27 Coral Johnathon mechanical valve. Patient\ntolerated this procedure well and was transferred to the\nCardiothoracic Intensive Care Unit in stable condition.\nPatient was extubated without incident.', " Patient remained\nhemodynamically stable and was weaned off all drips.\nPatient's hematocrit remained stable at 29.\n\nOn postoperative day number one, patient continued to remain\nhemodynamically stable. Patient continued to be weaned off\nall drips. Chest tubes were discontinued without incident.\nThe patient was started on his Coumadin for anticoagulation\nfor his mechanical valve. Patient on postoperative day\nnumber two was transferred to the floor. Patient has\nremained hemodynamically stable. Patient's INR has risen\nappropriately to latest INR being 1.9. Patient has remained\nafebrile.\n\nOn postoperative day number six, patient developed\ntachycardia on the monitor. Upon further evaluation, it was\nfound that patient has tachycardia with frequent atrial\npremature contractions, but not to be in atrial fibrillation.", "\nPatient's blood pressure remained stable. Patient's\nelectrocardiogram demonstrated an elevated PR interval of 300\nmilliseconds. Patient was continued on his beta-blockade and\nwas restarted on his ACE inhibitor. Patient will follow-up\nwith his primary care physician for electrocardiogram in one\nweek and to evaluate the PR interval at that time. There\nwill be no further intervention done by the\nElectrophysiologic Service at this time.\n\nPatient has now been tolerating a regular diet and has been\nambulating at an activity level of 5 with Physical Therapy.\nPatient is stable and ready for discharge to home.\n\nDISCHARGE DIAGNOSES:\n1. Aortic insufficiency, status post aortic valve\nreplacement #27 Coral Johnathon valve.\n2. Hypertension.\n3. Hypercholesterolemia.\n4. IJ nephropathy.\n\nMEDICATIONS ON DISCHARGE:\n1.", ' Atenolol 25 mg po q.d.\n2. Lasix 20 mg po b.i.d. times seven days.\n3. KCL 20 mEq po b.i.d. times seven days.\n4. Colace 100 mg po b.i.d.\n5. Enteric coated aspirin 81 mg po q.d.\n6. Coumadin 10 mg po q.d. Does Arnaldo Camargo M.D.\n7. Percocet 5/325 4-24 po q. 4 hours prn.\n8. Zestril 10 mg po q.d.\n\nFOLLOW-UP: Patient will follow-up with coagulation draws at\nKelly, Carr and Cruz Clinic to be called into his primary care\nphysician, Cobbs. Rafaela Juvenal Thomas. Patient to follow-up with Dr.\nPleasant in four weeks.\n\nCONDITION AT DISCHARGE: Stable.\n\n\n\n\n\n\n\n Taryn Lyna, M.D. 47382330\n\nDictated By:Braswell\n\nMEDQUIST36\n\nD: 1937-4-1 14:01\nT: 1937-4-1 14:01\nJOB#: Mcdaniel Inc-1991-438447\n']
450	15008	109252.0	2110-01-10	Discharge summary	Report	Admission Date: [2110-1-6] Discharge Date: [2110-1-10] Date of Birth: [2046-5-20] Sex: F Service: ADMISSION DIAGNOSES: 1. Rheumatic heart disease. 2. Aortic and mitral valve disease. DISCHARGE DIAGNOSES: 1. Aortic valve stenosis. 2. Mitral valve regurgitation. 3. Status post aortic valve replacement with 21 mm pericardial valve, mitral valve repair with 28 mm [Doctor Last Name 405] annuloplasty band. HISTORY OF PRESENT ILLNESS: The patient is a 63 year old woman with a history of rheumatic heart disease. She has known aortic and mitral valve disease. Her last echocardiogram was done on [2109-12-12] which revealed an ejection fraction of 60%. Moderately severe MR [First Name (Titles) 151] [Last Name (Titles) 3841] enlarged LA were demonstrated as well as moderate to severe aortic stenosis with an estimated valve area of 0.9 cm squared. There was also significant pulmonary hypertension with PA pressures estimated at 64 mmHg. Most recent ETT was negative in [2105] and performed for brief complaints of chest discomfort. Clinically patient reports that she is very active. She walks several miles a day, cross country skiis and is able to cut and stack wood for her fireplace. Over the past three weeks, however, she has noticed decrease in activity tolerance along with chest pain and mild shortness of breath that occurs with vigorous exertion. She reports that this discomfort can take up to several hours to resolve. She has never taken nitroglycerin. She is now referred for cardiac catheterization. Patient denies claudication, orthopnea, edema, PND, lightheadedness. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Smoking history, quit 20 years ago. Insulin dependent diabetes mellitus. Rheumatic heart disease. Autoimmune iron disease. Hypothyroidism. Osteoporosis. Bilateral carotid bruit without significant carotid disease. Breast cancer status post chemotherapy and surgery. PAST SURGICAL HISTORY: Status post left mastectomy in [2086]. Cholecystectomy in [2079]. MEDICATIONS ON ADMISSION: Miacalcin nasal spray, Levoxyl 200 mcg q.d., Lipitor 10 mg q.d., enalapril 5 mg q.d., Celebrex 200 mg b.i.d., Protonix 40 mg q.d., folate 1 mg q.d., NPH 15 units q.h.s., regular and Humalog insulin sliding scale. PHYSICAL EXAMINATION: In general, the patient was an elderly woman who appeared younger than her stated age and was in no acute distress. Vital signs were stable, afebrile. Height was 5'2", weight 122 pounds. HEENT was normocephalic, atraumatic, EOMI, PERRL, anicteric. Throat was clear. Neck was supple, midline, without masses or lymphadenopathy. Chest was clear to auscultation bilaterally. Cardiovascular was regular rate and rhythm with a [12-26] to 3/6 systolic ejection murmur. Abdomen was soft, nondistended, nontender without masses or organomegaly. Extremities were warm, not cyanotic, not edematous times four. Neuro was grossly intact. LABORATORY DATA: On admission CBC was 12/11.6/35.4/336. Chemistries 138/4.1/104/27/13/0.7. INR was 1.1. HOSPITAL COURSE: The patient had cardiac catheterization performed on [2109-12-20] which revealed 3+ mitral valve regurgitation, calcification of the aortic valve, ejection fraction of 61%, severe aortic stenosis, normal coronary arteries. Patient now presents for elective valve repair. On [2110-1-6] patient was taken to the operating room and had aortic valve placement with a 21 mm pericardial valve and mitral valve repair with a 28 mm [Doctor Last Name 405] annuloplasty band. Patient was subsequently taken to the CSRU for close monitoring. Patient did well and was initially A-paced for blood pressure support. Drips, chest tubes and pacing wires were discontinued as her clinical condition allowed. The patient had a largely unremarkable postoperative course and was subsequently transferred to the floor on postoperative day two. On the floor her status was again unremarkable and patient was ambulating well on her own without physical therapy. Patient did test her own blood sugar glucoses and maintained her own blood sugars with her own sliding scale. She is very aggressive about this and took her finger sticks at least eight times a day. Ultimately, patient was discharged on postoperative day four, tolerating a regular diet, had adequate pain control on p.o. pain meds and had been cleared for home by physical therapy. The patient was placed on a 10 day course of Levaquin for an elevated white count of 50 and x-ray finding of some right lower lobe atelectasis as well as increased clinical sputum production. Patient remained afebrile. Physical examination on discharge, in general, in no acute distress. Vital signs temperature 98.0, heart rate 68, blood pressure 119/57, respirations 18, 95% in room air. Chest was clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. There was no sternal click or sternal wound drainage. Patient did have 1+ peripheral edema. Labs on discharge included CBC with white count of 25.4 down from 26.2, hematocrit 24.1, platelets 235. Chemistries 131/4.9/99/25/30/1.1/65. Magnesium 1.7. CONDITION ON DISCHARGE: Good. DISPOSITION: To home. DISCHARGE DIET: Diabetic. DISCHARGE MEDICATIONS: 1. Lasix 20 mg b.i.d. times seven days. 2. Potassium chloride 20 mEq b.i.d. times seven days. 3. Aspirin 325 mg q.d. 4. Lopressor 12.5 b.i.d. 5. Levaquin 500 mg q.d. times eight days for a 10 day course. 6. Lipitor 10 mg q.d. 7. Levothyroxine 200 mcg q.d. 8. NPH 15 units q.p.m. 9. Percocet 5/325 one to two q.four hours p.r.n. 10. Colace 100 mg b.i.d. DI[Last Name (STitle) 408]E INSTRUCTIONS: The patient is to continue her tight blood sugar control as well as a diabetic diet. She should follow up with her cardiologist in one to two weeks to address the need for continued diuresis as well as adjustment of cardiac medications at that time. Patient should follow up with Dr. [Last Name (Prefixes) ] in four weeks' time. Patient was instructed to continue Levaquin as well as encourage incentive spirometry for possible mild respiratory infection. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Dictator Info ] MEDQUIST36 D: [2110-1-10] 04:02 T: [2110-1-10] 16:08 JOB#: [Job Number 3842]	Admission Date: <Date>1904-6-5</Date> Discharge Date: <Date>1967-9-26</Date> Date of Birth: <Date>1909-9-22</Date> Sex: F Service: ADMISSION DIAGNOSES: 1. Rheumatic heart disease. 2. Aortic and mitral valve disease. DISCHARGE DIAGNOSES: 1. Aortic valve stenosis. 2. Mitral valve regurgitation. 3. Status post aortic valve replacement with 21 mm pericardial valve, mitral valve repair with 28 mm <Doctor Name>Dr.Hang</Doctor Name> annuloplasty band. HISTORY OF PRESENT ILLNESS: The patient is a 63 year old woman with a history of rheumatic heart disease. She has known aortic and mitral valve disease. Her last echocardiogram was done on <Date>2008-7-16</Date> which revealed an ejection fraction of 60%. Moderately severe MR <Name>Eleanor</Name> <Name>Post</Name> enlarged LA were demonstrated as well as moderate to severe aortic stenosis with an estimated valve area of 0.9 cm squared. There was also significant pulmonary hypertension with PA pressures estimated at 64 mmHg. Most recent ETT was negative in <Year>1971</Year> and performed for brief complaints of chest discomfort. Clinically patient reports that she is very active. She walks several miles a day, cross country skiis and is able to cut and stack wood for her fireplace. Over the past three weeks, however, she has noticed decrease in activity tolerance along with chest pain and mild shortness of breath that occurs with vigorous exertion. She reports that this discomfort can take up to several hours to resolve. She has never taken nitroglycerin. She is now referred for cardiac catheterization. Patient denies claudication, orthopnea, edema, PND, lightheadedness. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Smoking history, quit 20 years ago. Insulin dependent diabetes mellitus. Rheumatic heart disease. Autoimmune iron disease. Hypothyroidism. Osteoporosis. Bilateral carotid bruit without significant carotid disease. Breast cancer status post chemotherapy and surgery. PAST SURGICAL HISTORY: Status post left mastectomy in <Year>1971</Year>. Cholecystectomy in <Year>1971</Year>. MEDICATIONS ON ADMISSION: Miacalcin nasal spray, Levoxyl 200 mcg q.d., Lipitor 10 mg q.d., enalapril 5 mg q.d., Celebrex 200 mg b.i.d., Protonix 40 mg q.d., folate 1 mg q.d., NPH 15 units q.h.s., regular and Humalog insulin sliding scale. PHYSICAL EXAMINATION: In general, the patient was an elderly woman who appeared younger than her stated age and was in no acute distress. Vital signs were stable, afebrile. Height was 5'2", weight 122 pounds. HEENT was normocephalic, atraumatic, EOMI, PERRL, anicteric. Throat was clear. Neck was supple, midline, without masses or lymphadenopathy. Chest was clear to auscultation bilaterally. Cardiovascular was regular rate and rhythm with a <Date>5-29</Date> to 3/6 systolic ejection murmur. Abdomen was soft, nondistended, nontender without masses or organomegaly. Extremities were warm, not cyanotic, not edematous times four. Neuro was grossly intact. LABORATORY DATA: On admission CBC was 12/11.6/35.4/336. Chemistries 138/4.1/104/27/13/0.7. INR was 1.1. HOSPITAL COURSE: The patient had cardiac catheterization performed on <Date>1913-12-17</Date> which revealed 3+ mitral valve regurgitation, calcification of the aortic valve, ejection fraction of 61%, severe aortic stenosis, normal coronary arteries. Patient now presents for elective valve repair. On <Date>1904-6-5</Date> patient was taken to the operating room and had aortic valve placement with a 21 mm pericardial valve and mitral valve repair with a 28 mm <Doctor Name>Dr.Hang</Doctor Name> annuloplasty band. Patient was subsequently taken to the CSRU for close monitoring. Patient did well and was initially A-paced for blood pressure support. Drips, chest tubes and pacing wires were discontinued as her clinical condition allowed. The patient had a largely unremarkable postoperative course and was subsequently transferred to the floor on postoperative day two. On the floor her status was again unremarkable and patient was ambulating well on her own without physical therapy. Patient did test her own blood sugar glucoses and maintained her own blood sugars with her own sliding scale. She is very aggressive about this and took her finger sticks at least eight times a day. Ultimately, patient was discharged on postoperative day four, tolerating a regular diet, had adequate pain control on p.o. pain meds and had been cleared for home by physical therapy. The patient was placed on a 10 day course of Levaquin for an elevated white count of 50 and x-ray finding of some right lower lobe atelectasis as well as increased clinical sputum production. Patient remained afebrile. Physical examination on discharge, in general, in no acute distress. Vital signs temperature 98.0, heart rate 68, blood pressure 119/57, respirations 18, 95% in room air. Chest was clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. There was no sternal click or sternal wound drainage. Patient did have 1+ peripheral edema. Labs on discharge included CBC with white count of 25.4 down from 26.2, hematocrit 24.1, platelets 235. Chemistries 131/4.9/99/25/30/1.1/65. Magnesium 1.7. CONDITION ON DISCHARGE: Good. DISPOSITION: To home. DISCHARGE DIET: Diabetic. DISCHARGE MEDICATIONS: 1. Lasix 20 mg b.i.d. times seven days. 2. Potassium chloride 20 mEq b.i.d. times seven days. 3. Aspirin 325 mg q.d. 4. Lopressor 12.5 b.i.d. 5. Levaquin 500 mg q.d. times eight days for a 10 day course. 6. Lipitor 10 mg q.d. 7. Levothyroxine 200 mcg q.d. 8. NPH 15 units q.p.m. 9. Percocet 5/325 one to two q.four hours p.r.n. 10. Colace 100 mg b.i.d. DI<Name>Benhamou</Name>E INSTRUCTIONS: The patient is to continue her tight blood sugar control as well as a diabetic diet. She should follow up with her cardiologist in one to two weeks to address the need for continued diuresis as well as adjustment of cardiac medications at that time. Patient should follow up with Dr. <Name>Meraz</Name> in four weeks' time. Patient was instructed to continue Levaquin as well as encourage incentive spirometry for possible mild respiratory infection. <Doctor Name>Dr.Londrie</Doctor Name> <Name>Brown</Name>, M.D. <MD Number>23156909</MD Number> Dictated By:<Dictator Info>Physician Assistant in Surgery</Dictator Info> MEDQUIST36 D: <Date>1967-9-26</Date> 04:02 T: <Date>1967-9-26</Date> 16:08 JOB#: <Job Number>Choi-Smith-1912-870288</Job 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Date: 1904-6-5 Discharge Date: 1967-9-26 Date of Birth: 1909-9-22 Sex: F Service: ADMISSION DIAGNOSES: 1. Rheumatic heart disease. 2. Aortic and mitral valve disease. DISCHARGE DIAGNOSES: 1. Aortic valve stenosis. 2. Mitral valve regurgitation. 3. Status post aortic valve replacement with 21 mm pericardial valve, mitral valve repair with 28 mm Dr.Hang annuloplasty band. HISTORY OF PRESENT ILLNESS: The patient is a 63 year old woman with a history of rheumatic heart disease. She has known aortic and mitral valve disease. Her last echocardiogram was done on 2008-7-16 which revealed an ejection fraction of 60%. Moderately severe MR Eleanor Post enlarged LA were demonstrated as well as moderate to severe aortic stenosis with an estimated valve area of 0.9 cm squared. There was also significant pulmonary hypertension with PA pressures estimated at 64 mmHg. Most recent ETT was negative in 1971 and performed for brief complaints of chest discomfort. Clinically patient reports that she is very active. She walks several miles a day, cross country skiis and is able to cut and stack wood for her fireplace. Over the past three weeks, however, she has noticed decrease in activity tolerance along with chest pain and mild shortness of breath that occurs with vigorous exertion. She reports that this discomfort can take up to several hours to resolve. She has never taken nitroglycerin. She is now referred for cardiac catheterization. Patient denies claudication, orthopnea, edema, PND, lightheadedness. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Smoking history, quit 20 years ago. Insulin dependent diabetes mellitus. Rheumatic heart disease. Autoimmune iron disease. Hypothyroidism. Osteoporosis. Bilateral carotid bruit without significant carotid disease. Breast cancer status post chemotherapy and surgery. PAST SURGICAL HISTORY: Status post left mastectomy in 1971. Cholecystectomy in 1971. MEDICATIONS ON ADMISSION: Miacalcin nasal spray, Levoxyl 200 mcg q.d., Lipitor 10 mg q.d., enalapril 5 mg q.d., Celebrex 200 mg b.i.d., Protonix 40 mg q.d., folate 1 mg q.d., NPH 15 units q.h.s., regular and Humalog insulin sliding scale. PHYSICAL EXAMINATION: In general, the patient was an elderly woman who appeared younger than her stated age and was in no acute distress. Vital signs were stable, afebrile. Height was 5'2", weight 122 pounds. HEENT was normocephalic, atraumatic, EOMI, PERRL, anicteric. Throat was clear. Neck was supple, midline, without masses or lymphadenopathy. Chest was clear to auscultation bilaterally. Cardiovascular was regular rate and rhythm with a 5-29 to 3/6 systolic ejection murmur. Abdomen was soft, nondistended, nontender without masses or organomegaly. Extremities were warm, not cyanotic, not edematous times four. Neuro was grossly intact. LABORATORY DATA: On admission CBC was 12/11.6/35.4/336. Chemistries 138/4.1/104/27/13/0.7. INR was 1.1. HOSPITAL COURSE: The patient had cardiac catheterization performed on 1913-12-17 which revealed 3+ mitral valve regurgitation, calcification of the aortic valve, ejection fraction of 61%, severe aortic stenosis, normal coronary arteries. Patient now presents for elective valve repair. On 1904-6-5 patient was taken to the operating room and had aortic valve placement with a 21 mm pericardial valve and mitral valve repair with a 28 mm Dr.Hang annuloplasty band. Patient was subsequently taken to the CSRU for close monitoring. Patient did well and was initially A-paced for blood pressure support. Drips, chest tubes and pacing wires were discontinued as her clinical condition allowed. The patient had a largely unremarkable postoperative course and was subsequently transferred to the floor on postoperative day two. On the floor her status was again unremarkable and patient was ambulating well on her own without physical therapy. Patient did test her own blood sugar glucoses and maintained her own blood sugars with her own sliding scale. She is very aggressive about this and took her finger sticks at least eight times a day. Ultimately, patient was discharged on postoperative day four, tolerating a regular diet, had adequate pain control on p.o. pain meds and had been cleared for home by physical therapy. The patient was placed on a 10 day course of Levaquin for an elevated white count of 50 and x-ray finding of some right lower lobe atelectasis as well as increased clinical sputum production. Patient remained afebrile. Physical examination on discharge, in general, in no acute distress. Vital signs temperature 98.0, heart rate 68, blood pressure 119/57, respirations 18, 95% in room air. Chest was clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. There was no sternal click or sternal wound drainage. Patient did have 1+ peripheral edema. Labs on discharge included CBC with white count of 25.4 down from 26.2, hematocrit 24.1, platelets 235. Chemistries 131/4.9/99/25/30/1.1/65. Magnesium 1.7. CONDITION ON DISCHARGE: Good. DISPOSITION: To home. DISCHARGE DIET: Diabetic. DISCHARGE MEDICATIONS: 1. Lasix 20 mg b.i.d. times seven days. 2. Potassium chloride 20 mEq b.i.d. times seven days. 3. Aspirin 325 mg q.d. 4. Lopressor 12.5 b.i.d. 5. Levaquin 500 mg q.d. times eight days for a 10 day course. 6. Lipitor 10 mg q.d. 7. Levothyroxine 200 mcg q.d. 8. NPH 15 units q.p.m. 9. Percocet 5/325 one to two q.four hours p.r.n. 10. Colace 100 mg b.i.d. DIBenhamouE INSTRUCTIONS: The patient is to continue her tight blood sugar control as well as a diabetic diet. She should follow up with her cardiologist in one to two weeks to address the need for continued diuresis as well as adjustment of cardiac medications at that time. Patient should follow up with Dr. Meraz in four weeks' time. Patient was instructed to continue Levaquin as well as encourage incentive spirometry for possible mild respiratory infection. Dr.Londrie Brown, M.D. 23156909 Dictated By:Physician Assistant in Surgery MEDQUIST36 D: 1967-9-26 04:02 T: 1967-9-26 16:08 JOB#: Choi-Smith-1912-870288	['Admission Date: 1904-6-5 Discharge Date: 1967-9-26\n\nDate of Birth: 1909-9-22 Sex: F\n\nService:\n\nADMISSION DIAGNOSES:\n1. Rheumatic heart disease.\n2. Aortic and mitral valve disease.\n\nDISCHARGE DIAGNOSES:\n1. Aortic valve stenosis.\n2. Mitral valve regurgitation.\n3. Status post aortic valve replacement with 21 mm\npericardial valve, mitral valve repair with 28 mm Dr.Hang\nannuloplasty band.\n\nHISTORY OF PRESENT ILLNESS: The patient is a 63 year old\nwoman with a history of rheumatic heart disease. She has\nknown aortic and mitral valve disease. Her last\nechocardiogram was done on 2008-7-16 which revealed an ejection\nfraction of 60%. Moderately severe MR Eleanor Post enlarged\nLA were demonstrated as well as moderate to severe aortic\nstenosis with an estimated valve area of 0.', '9 cm squared.\nThere was also significant pulmonary hypertension with PA\npressures estimated at 64 mmHg. Most recent ETT was negative\nin 1971 and performed for brief complaints of chest\ndiscomfort. Clinically patient reports that she is very\nactive. She walks several miles a day, cross country skiis\nand is able to cut and stack wood for her fireplace. Over\nthe past three weeks, however, she has noticed decrease in\nactivity tolerance along with chest pain and mild shortness\nof breath that occurs with vigorous exertion. She reports\nthat this discomfort can take up to several hours to resolve.\nShe has never taken nitroglycerin. She is now referred for\ncardiac catheterization. Patient denies claudication,\northopnea, edema, PND, lightheadedness.\n\nPAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia.', '\nSmoking history, quit 20 years ago. Insulin dependent\ndiabetes mellitus. Rheumatic heart disease. Autoimmune iron\ndisease. Hypothyroidism. Osteoporosis. Bilateral carotid\nbruit without significant carotid disease. Breast cancer\nstatus post chemotherapy and surgery.\n\nPAST SURGICAL HISTORY: Status post left mastectomy in 1971.\nCholecystectomy in 1971.\n\nMEDICATIONS ON ADMISSION: Miacalcin nasal spray, Levoxyl 200\nmcg q.d., Lipitor 10 mg q.d., enalapril 5 mg q.d., Celebrex\n200 mg b.i.d., Protonix 40 mg q.d., folate 1 mg q.d., NPH 15\nunits q.h.s., regular and Humalog insulin sliding scale.\n\nPHYSICAL EXAMINATION: In general, the patient was an elderly\nwoman who appeared younger than her stated age and was in no\nacute distress. Vital signs were stable, afebrile. Height\nwas 5\'2", weight 122 pounds.', ' HEENT was normocephalic,\natraumatic, EOMI, PERRL, anicteric. Throat was clear. Neck\nwas supple, midline, without masses or lymphadenopathy.\nChest was clear to auscultation bilaterally. Cardiovascular\nwas regular rate and rhythm with a 5-29 to 3/6 systolic\nejection murmur. Abdomen was soft, nondistended, nontender\nwithout masses or organomegaly. Extremities were warm, not\ncyanotic, not edematous times four. Neuro was grossly\nintact.\n\nLABORATORY DATA: On admission CBC was 12/11.6/35.4/336.\nChemistries 138/4.1/104/27/13/0.7. INR was 1.1.\n\nHOSPITAL COURSE: The patient had cardiac catheterization\nperformed on 1913-12-17 which revealed 3+ mitral valve\nregurgitation, calcification of the aortic valve, ejection\nfraction of 61%, severe aortic stenosis, normal coronary\narteries. Patient now presents for elective valve repair.', '\nOn 1904-6-5 patient was taken to the operating room and had\naortic valve placement with a 21 mm pericardial valve and\nmitral valve repair with a 28 mm Dr.Hang annuloplasty band.\nPatient was subsequently taken to the CSRU for close\nmonitoring. Patient did well and was initially A-paced for\nblood pressure support. Drips, chest tubes and pacing wires\nwere discontinued as her clinical condition allowed.\n\nThe patient had a largely unremarkable postoperative course\nand was subsequently transferred to the floor on\npostoperative day two. On the floor her status was again\nunremarkable and patient was ambulating well on her own\nwithout physical therapy. Patient did test her own blood\nsugar glucoses and maintained her own blood sugars with her\nown sliding scale. She is very aggressive about this and\ntook her finger sticks at least eight times a day.', '\nUltimately, patient was discharged on postoperative day four,\ntolerating a regular diet, had adequate pain control on p.o.\npain meds and had been cleared for home by physical therapy.\n\nThe patient was placed on a 10 day course of Levaquin for an\nelevated white count of 50 and x-ray finding of some right\nlower lobe atelectasis as well as increased clinical sputum\nproduction. Patient remained afebrile.\n\nPhysical examination on discharge, in general, in no acute\ndistress. Vital signs temperature 98.0, heart rate 68, blood\npressure 119/57, respirations 18, 95% in room air. Chest was\nclear to auscultation bilaterally. Cardiovascular regular\nrate and rhythm. There was no sternal click or sternal wound\ndrainage. Patient did have 1+ peripheral edema.\n\nLabs on discharge included CBC with white count of 25.', '4 down\nfrom 26.2, hematocrit 24.1, platelets 235. Chemistries\n131/4.9/99/25/30/1.1/65. Magnesium 1.7.\n\nCONDITION ON DISCHARGE: Good.\n\nDISPOSITION: To home.\n\nDISCHARGE DIET: Diabetic.\n\nDISCHARGE MEDICATIONS:\n1. Lasix 20 mg b.i.d. times seven days.\n2. Potassium chloride 20 mEq b.i.d. times seven days.\n3. Aspirin 325 mg q.d.\n4. Lopressor 12.5 b.i.d.\n5. Levaquin 500 mg q.d. times eight days for a 10 day\ncourse.\n6. Lipitor 10 mg q.d.\n7. Levothyroxine 200 mcg q.d.\n8. NPH 15 units q.p.m.\n9. Percocet 5/325 one to two q.four hours p.r.n.\n10. Colace 100 mg b.i.d.\n\nDIBenhamouE INSTRUCTIONS: The patient is to continue her tight\nblood sugar control as well as a diabetic diet. She should\nfollow up with her cardiologist in one to two weeks to\naddress the need for continued diuresis as well as adjustment\nof cardiac medications at that time.', " Patient should follow\nup with Dr. Meraz in four weeks' time. Patient was\ninstructed to continue Levaquin as well as encourage\nincentive spirometry for possible mild respiratory infection.\n\n\n\n\n\n\n Dr.Londrie Brown, M.D. 23156909\n\nDictated By:Physician Assistant in Surgery\nMEDQUIST36\n\nD: 1967-9-26 04:02\nT: 1967-9-26 16:08\nJOB#: Choi-Smith-1912-870288\n"]
451	19535	182834.0	2191-04-22	Discharge summary	Report	Admission Date: [2191-4-8] Discharge Date: [2191-4-22] Service: MICU HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old African-American male with a known history of prostate cancer, carcinoid syndrome and interstitial lung disease secondary to asbestos exposure with an admitted in [2190-2-21] for pneumonia. At baseline, the patient has shortness of breath and dyspnea on exertion. Two days prior to admission, the patient believes that he acquired a cold because he subsequently developed a cough that was nonproductive. The patient had mild wheezing and a temperature as high as 100.1 degrees one day prior to admission. The patient's shortness of breath increased with exertion and when lying flat. The patient stated that walking him "really short of breath," and that this was relieved by rest. The patient denied nausea or vomiting, diaphoresis, paroxysmal nocturnal dyspnea, chest pain, and palpitations. No recent history of recent myocardial infarction. No history of syncope. No history of lightheadedness. No history of lower extremity edema. No history of weight gain. No anxiety. No leg pain. The patient admitted to a good appetite and oral intake. PAST MEDICAL HISTORY: 1. Prostate cancer diagnosed in [2181], status post radiation therapy with radiation proctitis evidenced by bright red blood per rectum. 2. Asbestosis. 3. Gout. 4. Gastroesophageal reflux disease. 5. Hypertension. 6. Chronic renal failure with a bowel sounds creatinine of 2.2 to 2.6. 7. Duodenal carcinoid tumor. 8. Retropharyngeal abscess. 9. History of gastrointestinal bleed. 10. Iron deficiency anemia. 11. Gallstones. MEDICATIONS ON ADMISSION: Actigall 300 mg p.o. b.i.d., allopurinol 300 mg p.o. q.d., Prilosec 20 mg p.o. b.i.d., Celebrex 200 mg p.o. q.d., Norvasc 10 mg p.o. q.d., albuterol and Azmacort meter-dosed inhaler, vitamin C, iron, folic acid. ALLERGIES: SULFONAMIDES. SOCIAL HISTORY: The patient is married and lives in [Hospital1 8]. FAMILY HISTORY: Family history was deferred. REVIEW OF SYSTEMS: Review of systems as in History of Present Illness. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed a temperature of 98.7, heart rate of 110, blood pressure of 110/70, respiratory rate of 20, oxygen saturation of 96% on 2 liters. In general, the patient is an elderly African-American male with oxygen by nasal cannula, breathing with effort. Head and neck examination revealed normocephalic and atraumatic. The oropharynx was clear. No lymphadenopathy. No thyromegaly. Respiratory revealed the patient was audibly grunting, dense crackles at bases with egophony. Cardiovascular revealed a regular rate and rhythm. Extremities revealed no clubbing, cyanosis or edema. Neurologic examination revealed cranial nerves II through XII were intact. Sensory and motor examinations were intact. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory examination on admission revealed a white blood cell count of 7.2, hematocrit of 29.8 (which is decrease from baseline hematocrit of 35.8), platelets of 202. Sodium of 141, potassium of 5.1, chloride of 111, bicarbonate of 18, blood urea nitrogen of 141, creatinine of 2.5, blood glucose of 136. Differential with 58 neutrophils, 22 bands, 14 lymphocytes. RADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus rhythm at 95 beats per minute, normal axis and intervals, with no acute changes. Chest x-ray revealed no cardiopulmonary process. HOSPITAL COURSE: Impression was that this was an 82-year-old gentleman with a history of underlying lung disease presenting with increased shortness of breath and dyspnea on exertion with significant bandemia and increased oxygen requirement. The clinical impression was that the patient had acquired a community-acquired pneumonia. 1. PULMONARY: The patient was initially admitted to the general medical floor for treatment of a community-acquired pneumonia. The patient was placed on levofloxacin by mouth with the intent to finish a 2-week course in addition to intravenous Solu-Medrol. The patient initially did well, but he subsequently proceeded to experience increased shortness of breath, increasing oxygen requirement, and an increasing white blood cell count, with an increasing blood urea nitrogen and creatinine, and worsening acidosis. The Medical Intensive Care Unit team came to evaluate the patient while he was still on the general medical floor and discontinued to admit the patient to the Medical Intensive Care Unit for hypoxic respiratory failure (PO2 was 54 on a 100% nonrebreather). A CT of the chest was done on the day prior to transfer to the Medical Intensive Care Unit to evaluate the patient's worsening status and was consistent with a multilobar pneumonia with honey combing consistent with the patient's underlying interstitial lung disease. On admission to the Medical Intensive Care Unit, the patient's antibiotic coverage was broadened, and the patient was placed on intravenous Levaquin as well as intravenous vancomycin. The patient was initially placed on BiPAP with the intent of immediately broadening the patient's antibiotic coverage and giving time for the intravenous antibiotics to start working and possibly avoiding intubation with administration of BiPAP. However, the patient became persistently more hypercarbic and acidotic while on BiPAP, after which the decision was made to intubate the patient. While intubated, for the first several days, the patient's respiratory status had stabilized. The patient's sputum was continuously suctioned from the endotracheal tube. Despite broad coverage with antibiotics, the patient's white blood cell count remained very elevated (at 20) with continuous copious sputum production. At this point, a repeat chest CT was obtained one week after intubation which showed an incomplete resolution of the original infiltrate on chest CT and a new large right-sided consolidation. At this point, the patient's antibiotic coverage was broadened to include both ceftazidime as well as Flagyl to cover for a nosocomial pneumonia and for the possibility of an aspiration pneumonia. Blood cultures were obtained to work the etiology for persistent elevated white blood cell count and low-grade temperatures. A blood culture from [4-17] revealed 1/4 bottles positive for vancomycin-resistant enterococcus. At this point, vancomycin was discontinued and the patient was started on linezolid. As the patient's clinical status worsened, with worsening hypotension (which was presumed secondary to sepsis), worsening hypoxemia, worsening renal failure, and increased volume overload the ceftazidime, Flagyl, and levofloxacin were all held in order to minimize intravenous fluids input with the intent of minimizing the patient's edema, and linezolid was continued. With increased volume overload and incomplete resolution of the pneumonia, the patient became persistently hypoxic until the time of demise. 2. CARDIOVASCULAR: The patient's blood pressure was initially well maintained on admission to the Intensive Care Unit. The patient was intermittently placed on his outpatient antihypertensive regimen. However, as the patient became frankly septic and had a decreasing blood pressure, antihypertensives were discontinued. With ongoing infection and sepsis, the patient's blood pressure had continued to decline. A family meeting was held several days prior to demise where the family requested that no pressors be used, and the patient was made do not resuscitate. The patient was given intermittent fluid boluses to support blood pressure in the meantime. However, as it was evident that the patient was becoming grossly volume overloaded and that the fluid boluses were not helping to maintain blood pressure in an acceptable range, the fluid boluses were discontinued. 3. RENAL: The patient's baseline creatinine was 2.3 to 2.6. Throughout the hospital course, the patient's renal function worsened. The patient was presumed to have developed acute tubular necrosis in the setting of sepsis on admission. The patient's creatinine had increased to 3.6 to 3.8 and remained in this range for several days. However, as the patient had worsening hypotension, renal function continued to decline with creatinine increasing to 5.4 on the day of expiration. The family had stated that they did not wish for the patient to receive dialysis given his poor prognosis. 4. INFECTIOUS DISEASE: The patient's antibiotic regimen was changed several times during the hospital course in accordance with the data that was obtained and his clinical status. On admission to the general medical floor, the patient was started on p.o. Levaquin for treatment of a community-acquired pneumonia. On transfer to the Intensive Care Unit, antibiotic coverage for treatment of pneumonia was brought to Levaquin and vancomycin intravenously. As the patient developed a new pulmonary infiltrate on chest CT, ceftazidime and Flagyl were added to cover for an aspiration pneumonia. When blood cultures grew out vancomycin-resistant enterococcus, linezolid was added. As the patient's clinical status worsened, all antibiotics were discontinued except for linezolid to treat vancomycin-resistant enterococcus. The patient became increasing septic throughout the hospital course with worsening hypotension. 5. GASTROINTESTINAL: The patient was initially placed on tube feeds for nutritional support. However, on the day of expiration, it was noted that the patient's abdomen was significantly distended with no bowel sounds. The patient's tube feeds were therefore held. 6. GENITOURINARY: The patient was noted to have significant hematuria during his Intensive Care Unit stay. The nursing staff had difficulty placing a Foley, presumably secondary to the patient's history of prostate cancer and radiation proctitis. Urology came to evaluate the patient and placed a coude catheter. The patient was started on continuous Foley irrigation with initial clearing of the hematuria. However, the hematuria recurred upon stopping bladder irrigation. On the day of expiration, bladder irrigation was discontinued as the patient was noted to have increasing abdominal distention and the amount of irrigant fluid being instilled was not returning in the Foley bag. 7. HEMATOLOGY: The patient was given packed red blood cell transfusions in order to maintain his hematocrit above 30. However, one day prior to expiration, the family requested that the patient no longer receive any packed red blood cell transfusions. The patient was continued on Epogen injections for his history of chronic anemia throughout the hospital course. 8. FLUIDS/ELECTROLYTES/NUTRITION: The patient was noted to be increasing hyperphosphatemic throughout the hospital course, presumably secondary to his renal failure. The patient was started on Amphojel for hyperphosphatemia. The patient was initially given fluid boluses to maintain blood pressure in an acceptable range when the patient started becoming more septic and hypotensive. However, the patient continued to become more edematous and was exhibiting signs of extravascular volume overload. Fluid boluses were discontinued. 9. CODE STATUS: The patient was initially do not resuscitate/do not intubate on admission to the hospital. However, when questioned on admission to the Intensive Care Unit and possible intubation came up, the code status was reversed to full code. As the patient's clinical status worsened during his Intensive Care Unit stay, the family decided to change the code status to do not resuscitate with no pressors. The patient's primary care physician (Dr. [Last Name (STitle) ] was very involved throughout the [Hospital 228] hospital stay. DATE OF EXPIRATION: [2191-4-22]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3851] Dictated By:[Name8 (MD) 2692] MEDQUIST36 D: [2191-4-22] 14:32 T: [2191-4-23] 04:26 JOB#: [Job Number 3852]	Admission Date: <Date>2020-4-3</Date> Discharge Date: <Date>1973-4-2</Date> Service: MICU HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old African-American male with a known history of prostate cancer, carcinoid syndrome and interstitial lung disease secondary to asbestos exposure with an admitted in <Date>1980-6-2</Date> for pneumonia. At baseline, the patient has shortness of breath and dyspnea on exertion. Two days prior to admission, the patient believes that he acquired a cold because he subsequently developed a cough that was nonproductive. The patient had mild wheezing and a temperature as high as 100.1 degrees one day prior to admission. The patient's shortness of breath increased with exertion and when lying flat. The patient stated that walking him "really short of breath," and that this was relieved by rest. The patient denied nausea or vomiting, diaphoresis, paroxysmal nocturnal dyspnea, chest pain, and palpitations. No recent history of recent myocardial infarction. No history of syncope. No history of lightheadedness. No history of lower extremity edema. No history of weight gain. No anxiety. No leg pain. The patient admitted to a good appetite and oral intake. PAST MEDICAL HISTORY: 1. Prostate cancer diagnosed in <Year>1949</Year>, status post radiation therapy with radiation proctitis evidenced by bright red blood per rectum. 2. Asbestosis. 3. Gout. 4. Gastroesophageal reflux disease. 5. Hypertension. 6. Chronic renal failure with a bowel sounds creatinine of 2.2 to 2.6. 7. Duodenal carcinoid tumor. 8. Retropharyngeal abscess. 9. History of gastrointestinal bleed. 10. Iron deficiency anemia. 11. Gallstones. MEDICATIONS ON ADMISSION: Actigall 300 mg p.o. b.i.d., allopurinol 300 mg p.o. q.d., Prilosec 20 mg p.o. b.i.d., Celebrex 200 mg p.o. q.d., Norvasc 10 mg p.o. q.d., albuterol and Azmacort meter-dosed inhaler, vitamin C, iron, folic acid. ALLERGIES: SULFONAMIDES. SOCIAL HISTORY: The patient is married and lives in <Hospital>Quinn-Sullivan Health System</Hospital>. FAMILY HISTORY: Family history was deferred. REVIEW OF SYSTEMS: Review of systems as in History of Present Illness. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed a temperature of 98.7, heart rate of 110, blood pressure of 110/70, respiratory rate of 20, oxygen saturation of 96% on 2 liters. In general, the patient is an elderly African-American male with oxygen by nasal cannula, breathing with effort. Head and neck examination revealed normocephalic and atraumatic. The oropharynx was clear. No lymphadenopathy. No thyromegaly. Respiratory revealed the patient was audibly grunting, dense crackles at bases with egophony. Cardiovascular revealed a regular rate and rhythm. Extremities revealed no clubbing, cyanosis or edema. Neurologic examination revealed cranial nerves II through XII were intact. Sensory and motor examinations were intact. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory examination on admission revealed a white blood cell count of 7.2, hematocrit of 29.8 (which is decrease from baseline hematocrit of 35.8), platelets of 202. Sodium of 141, potassium of 5.1, chloride of 111, bicarbonate of 18, blood urea nitrogen of 141, creatinine of 2.5, blood glucose of 136. Differential with 58 neutrophils, 22 bands, 14 lymphocytes. RADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus rhythm at 95 beats per minute, normal axis and intervals, with no acute changes. Chest x-ray revealed no cardiopulmonary process. HOSPITAL COURSE: Impression was that this was an 82-year-old gentleman with a history of underlying lung disease presenting with increased shortness of breath and dyspnea on exertion with significant bandemia and increased oxygen requirement. The clinical impression was that the patient had acquired a community-acquired pneumonia. 1. PULMONARY: The patient was initially admitted to the general medical floor for treatment of a community-acquired pneumonia. The patient was placed on levofloxacin by mouth with the intent to finish a 2-week course in addition to intravenous Solu-Medrol. The patient initially did well, but he subsequently proceeded to experience increased shortness of breath, increasing oxygen requirement, and an increasing white blood cell count, with an increasing blood urea nitrogen and creatinine, and worsening acidosis. The Medical Intensive Care Unit team came to evaluate the patient while he was still on the general medical floor and discontinued to admit the patient to the Medical Intensive Care Unit for hypoxic respiratory failure (PO2 was 54 on a 100% nonrebreather). A CT of the chest was done on the day prior to transfer to the Medical Intensive Care Unit to evaluate the patient's worsening status and was consistent with a multilobar pneumonia with honey combing consistent with the patient's underlying interstitial lung disease. On admission to the Medical Intensive Care Unit, the patient's antibiotic coverage was broadened, and the patient was placed on intravenous Levaquin as well as intravenous vancomycin. The patient was initially placed on BiPAP with the intent of immediately broadening the patient's antibiotic coverage and giving time for the intravenous antibiotics to start working and possibly avoiding intubation with administration of BiPAP. However, the patient became persistently more hypercarbic and acidotic while on BiPAP, after which the decision was made to intubate the patient. While intubated, for the first several days, the patient's respiratory status had stabilized. The patient's sputum was continuously suctioned from the endotracheal tube. Despite broad coverage with antibiotics, the patient's white blood cell count remained very elevated (at 20) with continuous copious sputum production. At this point, a repeat chest CT was obtained one week after intubation which showed an incomplete resolution of the original infiltrate on chest CT and a new large right-sided consolidation. At this point, the patient's antibiotic coverage was broadened to include both ceftazidime as well as Flagyl to cover for a nosocomial pneumonia and for the possibility of an aspiration pneumonia. Blood cultures were obtained to work the etiology for persistent elevated white blood cell count and low-grade temperatures. A blood culture from <Date>2-10</Date> revealed 1/4 bottles positive for vancomycin-resistant enterococcus. At this point, vancomycin was discontinued and the patient was started on linezolid. As the patient's clinical status worsened, with worsening hypotension (which was presumed secondary to sepsis), worsening hypoxemia, worsening renal failure, and increased volume overload the ceftazidime, Flagyl, and levofloxacin were all held in order to minimize intravenous fluids input with the intent of minimizing the patient's edema, and linezolid was continued. With increased volume overload and incomplete resolution of the pneumonia, the patient became persistently hypoxic until the time of demise. 2. CARDIOVASCULAR: The patient's blood pressure was initially well maintained on admission to the Intensive Care Unit. The patient was intermittently placed on his outpatient antihypertensive regimen. However, as the patient became frankly septic and had a decreasing blood pressure, antihypertensives were discontinued. With ongoing infection and sepsis, the patient's blood pressure had continued to decline. A family meeting was held several days prior to demise where the family requested that no pressors be used, and the patient was made do not resuscitate. The patient was given intermittent fluid boluses to support blood pressure in the meantime. However, as it was evident that the patient was becoming grossly volume overloaded and that the fluid boluses were not helping to maintain blood pressure in an acceptable range, the fluid boluses were discontinued. 3. RENAL: The patient's baseline creatinine was 2.3 to 2.6. Throughout the hospital course, the patient's renal function worsened. The patient was presumed to have developed acute tubular necrosis in the setting of sepsis on admission. The patient's creatinine had increased to 3.6 to 3.8 and remained in this range for several days. However, as the patient had worsening hypotension, renal function continued to decline with creatinine increasing to 5.4 on the day of expiration. The family had stated that they did not wish for the patient to receive dialysis given his poor prognosis. 4. INFECTIOUS DISEASE: The patient's antibiotic regimen was changed several times during the hospital course in accordance with the data that was obtained and his clinical status. On admission to the general medical floor, the patient was started on p.o. Levaquin for treatment of a community-acquired pneumonia. On transfer to the Intensive Care Unit, antibiotic coverage for treatment of pneumonia was brought to Levaquin and vancomycin intravenously. As the patient developed a new pulmonary infiltrate on chest CT, ceftazidime and Flagyl were added to cover for an aspiration pneumonia. When blood cultures grew out vancomycin-resistant enterococcus, linezolid was added. As the patient's clinical status worsened, all antibiotics were discontinued except for linezolid to treat vancomycin-resistant enterococcus. The patient became increasing septic throughout the hospital course with worsening hypotension. 5. GASTROINTESTINAL: The patient was initially placed on tube feeds for nutritional support. However, on the day of expiration, it was noted that the patient's abdomen was significantly distended with no bowel sounds. The patient's tube feeds were therefore held. 6. GENITOURINARY: The patient was noted to have significant hematuria during his Intensive Care Unit stay. The nursing staff had difficulty placing a Foley, presumably secondary to the patient's history of prostate cancer and radiation proctitis. Urology came to evaluate the patient and placed a coude catheter. The patient was started on continuous Foley irrigation with initial clearing of the hematuria. However, the hematuria recurred upon stopping bladder irrigation. On the day of expiration, bladder irrigation was discontinued as the patient was noted to have increasing abdominal distention and the amount of irrigant fluid being instilled was not returning in the Foley bag. 7. HEMATOLOGY: The patient was given packed red blood cell transfusions in order to maintain his hematocrit above 30. However, one day prior to expiration, the family requested that the patient no longer receive any packed red blood cell transfusions. The patient was continued on Epogen injections for his history of chronic anemia throughout the hospital course. 8. FLUIDS/ELECTROLYTES/NUTRITION: The patient was noted to be increasing hyperphosphatemic throughout the hospital course, presumably secondary to his renal failure. The patient was started on Amphojel for hyperphosphatemia. The patient was initially given fluid boluses to maintain blood pressure in an acceptable range when the patient started becoming more septic and hypotensive. However, the patient continued to become more edematous and was exhibiting signs of extravascular volume overload. Fluid boluses were discontinued. 9. CODE STATUS: The patient was initially do not resuscitate/do not intubate on admission to the hospital. However, when questioned on admission to the Intensive Care Unit and possible intubation came up, the code status was reversed to full code. As the patient's clinical status worsened during his Intensive Care Unit stay, the family decided to change the code status to do not resuscitate with no pressors. The patient's primary care physician (Dr. <Name>Miller</Name> was very involved throughout the <Hospital>Bradshaw Inc Medical Center</Hospital> hospital stay. DATE OF EXPIRATION: <Date>1973-4-2</Date>. <Name>Abigail</Name> <Name>Hasan</Name>, M.D. <MD Number>43778654</MD Number> Dictated By:<Name>Indira Shipley</Name> MEDQUIST36 D: <Date>1973-4-2</Date> 14:32 T: <Date>2001-5-11</Date> 04:26 JOB#: <Job Number>Todd, Anthony and Bennett-1912-163026</Job 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Date: 2020-4-3 Discharge Date: 1973-4-2 Service: MICU HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old African-American male with a known history of prostate cancer, carcinoid syndrome and interstitial lung disease secondary to asbestos exposure with an admitted in 1980-6-2 for pneumonia. At baseline, the patient has shortness of breath and dyspnea on exertion. Two days prior to admission, the patient believes that he acquired a cold because he subsequently developed a cough that was nonproductive. The patient had mild wheezing and a temperature as high as 100.1 degrees one day prior to admission. The patient's shortness of breath increased with exertion and when lying flat. The patient stated that walking him "really short of breath," and that this was relieved by rest. The patient denied nausea or vomiting, diaphoresis, paroxysmal nocturnal dyspnea, chest pain, and palpitations. No recent history of recent myocardial infarction. No history of syncope. No history of lightheadedness. No history of lower extremity edema. No history of weight gain. No anxiety. No leg pain. The patient admitted to a good appetite and oral intake. PAST MEDICAL HISTORY: 1. Prostate cancer diagnosed in 1949, status post radiation therapy with radiation proctitis evidenced by bright red blood per rectum. 2. Asbestosis. 3. Gout. 4. Gastroesophageal reflux disease. 5. Hypertension. 6. Chronic renal failure with a bowel sounds creatinine of 2.2 to 2.6. 7. Duodenal carcinoid tumor. 8. Retropharyngeal abscess. 9. History of gastrointestinal bleed. 10. Iron deficiency anemia. 11. Gallstones. MEDICATIONS ON ADMISSION: Actigall 300 mg p.o. b.i.d., allopurinol 300 mg p.o. q.d., Prilosec 20 mg p.o. b.i.d., Celebrex 200 mg p.o. q.d., Norvasc 10 mg p.o. q.d., albuterol and Azmacort meter-dosed inhaler, vitamin C, iron, folic acid. ALLERGIES: SULFONAMIDES. SOCIAL HISTORY: The patient is married and lives in Quinn-Sullivan Health System. FAMILY HISTORY: Family history was deferred. REVIEW OF SYSTEMS: Review of systems as in History of Present Illness. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed a temperature of 98.7, heart rate of 110, blood pressure of 110/70, respiratory rate of 20, oxygen saturation of 96% on 2 liters. In general, the patient is an elderly African-American male with oxygen by nasal cannula, breathing with effort. Head and neck examination revealed normocephalic and atraumatic. The oropharynx was clear. No lymphadenopathy. No thyromegaly. Respiratory revealed the patient was audibly grunting, dense crackles at bases with egophony. Cardiovascular revealed a regular rate and rhythm. Extremities revealed no clubbing, cyanosis or edema. Neurologic examination revealed cranial nerves II through XII were intact. Sensory and motor examinations were intact. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory examination on admission revealed a white blood cell count of 7.2, hematocrit of 29.8 (which is decrease from baseline hematocrit of 35.8), platelets of 202. Sodium of 141, potassium of 5.1, chloride of 111, bicarbonate of 18, blood urea nitrogen of 141, creatinine of 2.5, blood glucose of 136. Differential with 58 neutrophils, 22 bands, 14 lymphocytes. RADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus rhythm at 95 beats per minute, normal axis and intervals, with no acute changes. Chest x-ray revealed no cardiopulmonary process. HOSPITAL COURSE: Impression was that this was an 82-year-old gentleman with a history of underlying lung disease presenting with increased shortness of breath and dyspnea on exertion with significant bandemia and increased oxygen requirement. The clinical impression was that the patient had acquired a community-acquired pneumonia. 1. PULMONARY: The patient was initially admitted to the general medical floor for treatment of a community-acquired pneumonia. The patient was placed on levofloxacin by mouth with the intent to finish a 2-week course in addition to intravenous Solu-Medrol. The patient initially did well, but he subsequently proceeded to experience increased shortness of breath, increasing oxygen requirement, and an increasing white blood cell count, with an increasing blood urea nitrogen and creatinine, and worsening acidosis. The Medical Intensive Care Unit team came to evaluate the patient while he was still on the general medical floor and discontinued to admit the patient to the Medical Intensive Care Unit for hypoxic respiratory failure (PO2 was 54 on a 100% nonrebreather). A CT of the chest was done on the day prior to transfer to the Medical Intensive Care Unit to evaluate the patient's worsening status and was consistent with a multilobar pneumonia with honey combing consistent with the patient's underlying interstitial lung disease. On admission to the Medical Intensive Care Unit, the patient's antibiotic coverage was broadened, and the patient was placed on intravenous Levaquin as well as intravenous vancomycin. The patient was initially placed on BiPAP with the intent of immediately broadening the patient's antibiotic coverage and giving time for the intravenous antibiotics to start working and possibly avoiding intubation with administration of BiPAP. However, the patient became persistently more hypercarbic and acidotic while on BiPAP, after which the decision was made to intubate the patient. While intubated, for the first several days, the patient's respiratory status had stabilized. The patient's sputum was continuously suctioned from the endotracheal tube. Despite broad coverage with antibiotics, the patient's white blood cell count remained very elevated (at 20) with continuous copious sputum production. At this point, a repeat chest CT was obtained one week after intubation which showed an incomplete resolution of the original infiltrate on chest CT and a new large right-sided consolidation. At this point, the patient's antibiotic coverage was broadened to include both ceftazidime as well as Flagyl to cover for a nosocomial pneumonia and for the possibility of an aspiration pneumonia. Blood cultures were obtained to work the etiology for persistent elevated white blood cell count and low-grade temperatures. A blood culture from 2-10 revealed 1/4 bottles positive for vancomycin-resistant enterococcus. At this point, vancomycin was discontinued and the patient was started on linezolid. As the patient's clinical status worsened, with worsening hypotension (which was presumed secondary to sepsis), worsening hypoxemia, worsening renal failure, and increased volume overload the ceftazidime, Flagyl, and levofloxacin were all held in order to minimize intravenous fluids input with the intent of minimizing the patient's edema, and linezolid was continued. With increased volume overload and incomplete resolution of the pneumonia, the patient became persistently hypoxic until the time of demise. 2. CARDIOVASCULAR: The patient's blood pressure was initially well maintained on admission to the Intensive Care Unit. The patient was intermittently placed on his outpatient antihypertensive regimen. However, as the patient became frankly septic and had a decreasing blood pressure, antihypertensives were discontinued. With ongoing infection and sepsis, the patient's blood pressure had continued to decline. A family meeting was held several days prior to demise where the family requested that no pressors be used, and the patient was made do not resuscitate. The patient was given intermittent fluid boluses to support blood pressure in the meantime. However, as it was evident that the patient was becoming grossly volume overloaded and that the fluid boluses were not helping to maintain blood pressure in an acceptable range, the fluid boluses were discontinued. 3. RENAL: The patient's baseline creatinine was 2.3 to 2.6. Throughout the hospital course, the patient's renal function worsened. The patient was presumed to have developed acute tubular necrosis in the setting of sepsis on admission. The patient's creatinine had increased to 3.6 to 3.8 and remained in this range for several days. However, as the patient had worsening hypotension, renal function continued to decline with creatinine increasing to 5.4 on the day of expiration. The family had stated that they did not wish for the patient to receive dialysis given his poor prognosis. 4. INFECTIOUS DISEASE: The patient's antibiotic regimen was changed several times during the hospital course in accordance with the data that was obtained and his clinical status. On admission to the general medical floor, the patient was started on p.o. Levaquin for treatment of a community-acquired pneumonia. On transfer to the Intensive Care Unit, antibiotic coverage for treatment of pneumonia was brought to Levaquin and vancomycin intravenously. As the patient developed a new pulmonary infiltrate on chest CT, ceftazidime and Flagyl were added to cover for an aspiration pneumonia. When blood cultures grew out vancomycin-resistant enterococcus, linezolid was added. As the patient's clinical status worsened, all antibiotics were discontinued except for linezolid to treat vancomycin-resistant enterococcus. The patient became increasing septic throughout the hospital course with worsening hypotension. 5. GASTROINTESTINAL: The patient was initially placed on tube feeds for nutritional support. However, on the day of expiration, it was noted that the patient's abdomen was significantly distended with no bowel sounds. The patient's tube feeds were therefore held. 6. GENITOURINARY: The patient was noted to have significant hematuria during his Intensive Care Unit stay. The nursing staff had difficulty placing a Foley, presumably secondary to the patient's history of prostate cancer and radiation proctitis. Urology came to evaluate the patient and placed a coude catheter. The patient was started on continuous Foley irrigation with initial clearing of the hematuria. However, the hematuria recurred upon stopping bladder irrigation. On the day of expiration, bladder irrigation was discontinued as the patient was noted to have increasing abdominal distention and the amount of irrigant fluid being instilled was not returning in the Foley bag. 7. HEMATOLOGY: The patient was given packed red blood cell transfusions in order to maintain his hematocrit above 30. However, one day prior to expiration, the family requested that the patient no longer receive any packed red blood cell transfusions. The patient was continued on Epogen injections for his history of chronic anemia throughout the hospital course. 8. FLUIDS/ELECTROLYTES/NUTRITION: The patient was noted to be increasing hyperphosphatemic throughout the hospital course, presumably secondary to his renal failure. The patient was started on Amphojel for hyperphosphatemia. The patient was initially given fluid boluses to maintain blood pressure in an acceptable range when the patient started becoming more septic and hypotensive. However, the patient continued to become more edematous and was exhibiting signs of extravascular volume overload. Fluid boluses were discontinued. 9. CODE STATUS: The patient was initially do not resuscitate/do not intubate on admission to the hospital. However, when questioned on admission to the Intensive Care Unit and possible intubation came up, the code status was reversed to full code. As the patient's clinical status worsened during his Intensive Care Unit stay, the family decided to change the code status to do not resuscitate with no pressors. The patient's primary care physician (Dr. Miller was very involved throughout the Bradshaw Inc Medical Center hospital stay. DATE OF EXPIRATION: 1973-4-2. Abigail Hasan, M.D. 43778654 Dictated By:Indira Shipley MEDQUIST36 D: 1973-4-2 14:32 T: 2001-5-11 04:26 JOB#: Todd, Anthony and Bennett-1912-163026	['Admission Date: 2020-4-3 Discharge Date: 1973-4-2\n\n\nService: MICU\n\nHISTORY OF PRESENT ILLNESS: The patient is an 82-year-old\nAfrican-American male with a known history of prostate\ncancer, carcinoid syndrome and interstitial lung disease\nsecondary to asbestos exposure with an admitted in 1980-6-2 for pneumonia.\n\nAt baseline, the patient has shortness of breath and dyspnea\non exertion. Two days prior to admission, the patient\nbelieves that he acquired a cold because he subsequently\ndeveloped a cough that was nonproductive. The patient had\nmild wheezing and a temperature as high as 100.1 degrees one\nday prior to admission. The patient\'s shortness of breath\nincreased with exertion and when lying flat. The patient\nstated that walking him "really short of breath," and that\nthis was relieved by rest.', ' The patient denied nausea or\nvomiting, diaphoresis, paroxysmal nocturnal dyspnea, chest\npain, and palpitations. No recent history of recent\nmyocardial infarction. No history of syncope. No history of\nlightheadedness. No history of lower extremity edema. No\nhistory of weight gain. No anxiety. No leg pain. The\npatient admitted to a good appetite and oral intake.\n\nPAST MEDICAL HISTORY:\n 1. Prostate cancer diagnosed in 1949, status post radiation\ntherapy with radiation proctitis evidenced by bright red\nblood per rectum.\n 2. Asbestosis.\n 3. Gout.\n 4. Gastroesophageal reflux disease.\n 5. Hypertension.\n 6. Chronic renal failure with a bowel sounds creatinine\nof 2.2 to 2.6.\n 7. Duodenal carcinoid tumor.\n 8. Retropharyngeal abscess.\n 9. History of gastrointestinal bleed.\n10. Iron deficiency anemia.', '\n11. Gallstones.\n\nMEDICATIONS ON ADMISSION: Actigall 300 mg p.o. b.i.d.,\nallopurinol 300 mg p.o. q.d., Prilosec 20 mg p.o. b.i.d.,\nCelebrex 200 mg p.o. q.d., Norvasc 10 mg p.o. q.d., albuterol\nand Azmacort meter-dosed inhaler, vitamin C, iron, folic\nacid.\n\nALLERGIES: SULFONAMIDES.\n\nSOCIAL HISTORY: The patient is married and lives in\nQuinn-Sullivan Health System.\n\nFAMILY HISTORY: Family history was deferred.\n\nREVIEW OF SYSTEMS: Review of systems as in History of\nPresent Illness.\n\nPHYSICAL EXAMINATION ON PRESENTATION: Physical examination\non admission revealed a temperature of 98.7, heart rate\nof 110, blood pressure of 110/70, respiratory rate of 20,\noxygen saturation of 96% on 2 liters. In general, the\npatient is an elderly African-American male with oxygen by\nnasal cannula, breathing with effort.', ' Head and neck\nexamination revealed normocephalic and atraumatic. The\noropharynx was clear. No lymphadenopathy. No thyromegaly.\nRespiratory revealed the patient was audibly grunting, dense\ncrackles at bases with egophony. Cardiovascular revealed a\nregular rate and rhythm. Extremities revealed no clubbing,\ncyanosis or edema. Neurologic examination revealed cranial\nnerves II through XII were intact. Sensory and motor\nexaminations were intact.\n\nPERTINENT LABORATORY DATA ON PRESENTATION: Laboratory\nexamination on admission revealed a white blood cell count\nof 7.2, hematocrit of 29.8 (which is decrease from baseline\nhematocrit of 35.8), platelets of 202. Sodium of 141,\npotassium of 5.1, chloride of 111, bicarbonate of 18, blood\nurea nitrogen of 141, creatinine of 2.5, blood glucose\nof 136.', ' Differential with 58 neutrophils, 22 bands,\n14 lymphocytes.\n\nRADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus\nrhythm at 95 beats per minute, normal axis and intervals,\nwith no acute changes.\n\nChest x-ray revealed no cardiopulmonary process.\n\nHOSPITAL COURSE: Impression was that this was an 82-year-old\ngentleman with a history of underlying lung disease\npresenting with increased shortness of breath and dyspnea on\nexertion with significant bandemia and increased oxygen\nrequirement. The clinical impression was that the patient\nhad acquired a community-acquired pneumonia.\n\n1. PULMONARY: The patient was initially admitted to the\ngeneral medical floor for treatment of a community-acquired\npneumonia. The patient was placed on levofloxacin by mouth\nwith the intent to finish a 2-week course in addition to\nintravenous Solu-Medrol.', "\n\nThe patient initially did well, but he subsequently proceeded\nto experience increased shortness of breath, increasing\noxygen requirement, and an increasing white blood cell count,\nwith an increasing blood urea nitrogen and creatinine, and\nworsening acidosis.\n\nThe Medical Intensive Care Unit team came to evaluate the\npatient while he was still on the general medical floor and\ndiscontinued to admit the patient to the Medical Intensive\nCare Unit for hypoxic respiratory failure (PO2 was 54 on a\n100% nonrebreather).\n\nA CT of the chest was done on the day prior to transfer to\nthe Medical Intensive Care Unit to evaluate the patient's\nworsening status and was consistent with a multilobar\npneumonia with honey combing consistent with the patient's\nunderlying interstitial lung disease.\n\nOn admission to the Medical Intensive Care Unit, the\npatient's antibiotic coverage was broadened, and the patient\nwas placed on intravenous Levaquin as well as intravenous\nvancomycin.", " The patient was initially placed on BiPAP with\nthe intent of immediately broadening the patient's antibiotic\ncoverage and giving time for the intravenous antibiotics to\nstart working and possibly avoiding intubation with\nadministration of BiPAP. However, the patient became\npersistently more hypercarbic and acidotic while on BiPAP,\nafter which the decision was made to intubate the patient.\nWhile intubated, for the first several days, the patient's\nrespiratory status had stabilized. The patient's sputum was\ncontinuously suctioned from the endotracheal tube.\n\nDespite broad coverage with antibiotics, the patient's white\nblood cell count remained very elevated (at 20) with\ncontinuous copious sputum production. At this point, a\nrepeat chest CT was obtained one week after intubation which\nshowed an incomplete resolution of the original infiltrate on\nchest CT and a new large right-sided consolidation.", " At this\npoint, the patient's antibiotic coverage was broadened to\ninclude both ceftazidime as well as Flagyl to cover for a\nnosocomial pneumonia and for the possibility of an aspiration\npneumonia.\n\nBlood cultures were obtained to work the etiology for\npersistent elevated white blood cell count and low-grade\ntemperatures. A blood culture from 2-10 revealed 1/4\nbottles positive for vancomycin-resistant enterococcus. At\nthis point, vancomycin was discontinued and the patient was\nstarted on linezolid.\n\nAs the patient's clinical status worsened, with worsening\nhypotension (which was presumed secondary to sepsis),\nworsening hypoxemia, worsening renal failure, and increased\nvolume overload the ceftazidime, Flagyl, and levofloxacin\nwere all held in order to minimize intravenous fluids input\nwith the intent of minimizing the patient's edema, and\nlinezolid was continued.", "\n\nWith increased volume overload and incomplete resolution of\nthe pneumonia, the patient became persistently hypoxic until\nthe time of demise.\n\n2. CARDIOVASCULAR: The patient's blood pressure was\ninitially well maintained on admission to the Intensive Care\nUnit. The patient was intermittently placed on his\noutpatient antihypertensive regimen. However, as the patient\nbecame frankly septic and had a decreasing blood pressure,\nantihypertensives were discontinued. With ongoing infection\nand sepsis, the patient's blood pressure had continued to\ndecline.\n\nA family meeting was held several days prior to demise where\nthe family requested that no pressors be used, and the\npatient was made do not resuscitate.\n\nThe patient was given intermittent fluid boluses to support\nblood pressure in the meantime.", " However, as it was evident\nthat the patient was becoming grossly volume overloaded and\nthat the fluid boluses were not helping to maintain blood\npressure in an acceptable range, the fluid boluses were\ndiscontinued.\n\n3. RENAL: The patient's baseline creatinine was 2.3 to 2.6.\nThroughout the hospital course, the patient's renal function\nworsened. The patient was presumed to have developed acute\ntubular necrosis in the setting of sepsis on admission.\n\nThe patient's creatinine had increased to 3.6 to 3.8 and\nremained in this range for several days. However, as the\npatient had worsening hypotension, renal function continued\nto decline with creatinine increasing to 5.4 on the day of\nexpiration.\n\nThe family had stated that they did not wish for the patient\nto receive dialysis given his poor prognosis.", "\n\n4. INFECTIOUS DISEASE: The patient's antibiotic regimen was\nchanged several times during the hospital course in\naccordance with the data that was obtained and his clinical\nstatus.\n\nOn admission to the general medical floor, the patient was\nstarted on p.o. Levaquin for treatment of a\ncommunity-acquired pneumonia.\n\nOn transfer to the Intensive Care Unit, antibiotic coverage\nfor treatment of pneumonia was brought to Levaquin and\nvancomycin intravenously. As the patient developed a new\npulmonary infiltrate on chest CT, ceftazidime and Flagyl were\nadded to cover for an aspiration pneumonia. When blood\ncultures grew out vancomycin-resistant enterococcus,\nlinezolid was added. As the patient's clinical status\nworsened, all antibiotics were discontinued except for\nlinezolid to treat vancomycin-resistant enterococcus.", "\n\nThe patient became increasing septic throughout the hospital\ncourse with worsening hypotension.\n\n5. GASTROINTESTINAL: The patient was initially placed on\ntube feeds for nutritional support. However, on the day of\nexpiration, it was noted that the patient's abdomen was\nsignificantly distended with no bowel sounds. The patient's\ntube feeds were therefore held.\n\n6. GENITOURINARY: The patient was noted to have significant\nhematuria during his Intensive Care Unit stay. The nursing\nstaff had difficulty placing a Foley, presumably secondary to\nthe patient's history of prostate cancer and radiation\nproctitis. Urology came to evaluate the patient and placed a\ncoude catheter. The patient was started on continuous Foley\nirrigation with initial clearing of the hematuria. However,\nthe hematuria recurred upon stopping bladder irrigation.", '\n\nOn the day of expiration, bladder irrigation was discontinued\nas the patient was noted to have increasing abdominal\ndistention and the amount of irrigant fluid being instilled\nwas not returning in the Foley bag.\n\n7. HEMATOLOGY: The patient was given packed red blood cell\ntransfusions in order to maintain his hematocrit above 30.\nHowever, one day prior to expiration, the family requested\nthat the patient no longer receive any packed red blood cell\ntransfusions.\n\nThe patient was continued on Epogen injections for his\nhistory of chronic anemia throughout the hospital course.\n\n8. FLUIDS/ELECTROLYTES/NUTRITION: The patient was noted to\nbe increasing hyperphosphatemic throughout the hospital\ncourse, presumably secondary to his renal failure. The\npatient was started on Amphojel for hyperphosphatemia.', " The\npatient was initially given fluid boluses to maintain blood\npressure in an acceptable range when the patient started\nbecoming more septic and hypotensive. However, the patient\ncontinued to become more edematous and was exhibiting signs\nof extravascular volume overload. Fluid boluses were\ndiscontinued.\n\n9. CODE STATUS: The patient was initially do not\nresuscitate/do not intubate on admission to the hospital.\nHowever, when questioned on admission to the Intensive Care\nUnit and possible intubation came up, the code status was\nreversed to full code. As the patient's clinical status\nworsened during his Intensive Care Unit stay, the family\ndecided to change the code status to do not resuscitate with\nno pressors.\n\nThe patient's primary care physician (Dr. Miller was\nvery involved throughout the Bradshaw Inc Medical Center hospital stay.", '\n\nDATE OF EXPIRATION: 1973-4-2.\n\n\n\n\n Abigail Hasan, M.D. 43778654\n\nDictated By:Indira Shipley\n\nMEDQUIST36\n\nD: 1973-4-2 14:32\nT: 2001-5-11 04:26\nJOB#: Todd, Anthony and Bennett-1912-163026\n']
452	88064	107776.0	2100-08-12	Discharge summary	Report	Admission Date: [2100-8-8] Discharge Date: [2100-8-12] Date of Birth: [2015-2-6] Sex: M Service: [Year (4 digits) 662] Allergies: Procainamide Attending:[First Name3 (LF) 3853] Chief Complaint: Altered mental status, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 85 yo M w/ PMH of bladder ca, CAD, HTN who is transferred from OSH for concern for urosepsis. Pt presented to OSH day prior to admission here with shaking chills and altered mental status. Pt reports he has had urinary incontinece over the past few days which is abnormal for him, denies any dysuria. He reports awaking in the middle of the night with shaking chills and does not recall what else happed but that his girlfriend must have taken him to the [Name (NI) ]. ON arrival to the OSH he was febrile to 103.3 and given 1 dose of tylenol. UA at the OSH was positive for UTI. His BP dropped to 86/46 and he was given 3-4L of fluids with improvement in BP to 101/48. They did a head CT for concern of his altered mental status in the setting of anticoagulation which was per report negative. He was transferred here for further care given that this is where he has all of his providers. On arrival to the [Hospital1 18] ED he was febrile at 102.5 rectally and was given 650mg of tylenol. He was initially hemodyanmially stable, however his BP did drop down transiently into the 70s and he was given 2L bolus of fluid with good response in his BP and was stable in the 110s prior to transfer to the floor. Repeat blood and urine cultures were performed and he was admitted for possible urosepsis. On arrival to the MICU the patient is sleepy and complains of some chronic left sided pain. He denies any recent suprapubic pain, nausea, vomiting, flank pain. He has not had a UTI since [2091] and he denies any hematuria, or changes in his urine color. 10 point ros is negative except per above Past Medical History: -Recurrent bladder tumors- followed by Dr. [Last Name (STitle) 3854] recent urine cytology from cystoscopy on [3-/2100] showed clusters of highly atypical urothelial cells,suspicious for urothelial carcinoma. -history of prostatitis dx at [Hospital1 2025] -ATRIAL FIBRILLATION - amiodarone /warfarin -CARPAL TUNNEL SYNDROME -CHOLELITHIASIS -CORONARY ARTERY DISEASE CABG in [2070]: SVG to LAD, SVG to OM, SVG to PDA, cath in [2086], severe native disease, occluded SVG to RCA and OM, patent SVG to LAD, redo CABG -HYPERTENSION -INGUINAL HERNIA -RENAL INSUFFICIENCY Social History: Social History: lives alone in an apartment and has a service that he pays for were people can come help him if needed. Has a son and is in a long term relationship. 40pack year former smoker, quit years ago. Denies alcohol. Sings in acapella at [Hospital ] rehab Family History: Noncontributory Physical Exam: Admission Physical Exam: Vitals: 97.8, 115/64, 52, 100% 2L General: Alert, oriented, no acute distress , sleepy in bed HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Bradycardic, diastolic murmur at the LUSB not radiating, Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Protuberant, soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: yellow urine in foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . Discharge PE VSS CV: systolic murmur [12-28], brisk carotid upstroke Lungs: CTAB, no wrr Abdomen/Back: NTND, active BS, no CVA tenderness -otherwise unchanged Pertinent Results: Admission Labs: [2100-8-8] 07:24AM URINE RBC-155* WBC->182* BACTERIA-MANY YEAST-NONE EPI-<1 TRANS EPI-1 [2100-8-8] 07:24AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [2100-8-8] 07:24AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.017 [2100-8-8] 07:24AM PLT COUNT-324 [2100-8-8] 07:24AM NEUTS-81.8* LYMPHS-10.7* MONOS-6.5 EOS-0.5 BASOS-0.6 [2100-8-8] 07:24AM WBC-16.6# RBC-3.72 HGB-11.4* HCT-34.4* MCV-93 MCH-30.7 MCHC-33.2 RDW-14.4 [2100-8-8] 07:24AM GLUCOSE-115* UREA N-23* CREAT-1.4* SODIUM-144 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13 [2100-8-8] 07:33AM LACTATE-1.2 [2100-8-8] 12:48PM PT-17.0* PTT-31.6 INR(PT)-1.6* . [2100-8-10] IMPRESSION: 1. No evidence of pyelonephritis or perinephric focal fluid collections. Note that ultrasound has a relatively low sensitivity for detection of pyelonephritis (in the absence of significant phlegmon or abscess). 2. 0.7 x 0.7 x 0.8 cm anechoic structure, likely representing a small renal cyst within the lower pole of the left kidney. 3. Enlarged prostate. . [2100-8-8] 7:24 am URINE FINAL REPORT [2100-8-10] URINE CULTURE (Final [2100-8-10]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . BC pending from [8-9] and [8-10] . Brief Hospital Course: 85 yo M w/ PMHx of bladder tumors, prior episode of bacterial prostatitis, CAD s/p CABG X2, AF, CKD, HTN who was transferred from OSH with urosepsis and found to have GNR bacteremia who was stabilized in the MICU with fluid resucitation and antibiotics and continued to do well on floor after switching to oral antibiotics . #Urosepsis likely secondary to prostatitis with altered mental status Patient has known bladder tumors and noted increased urinary urgency and incontinence in the few days prior to admission. He met sepsis criteria at the OSH with fever, tachypnea, leukocytosis and positive UA which ultimately grew out EColi and GNR bacteremia. He was started on zosyn at the OSH and this was switched to cefepime initially in the MICU. His cultures at the [Hospital3 1280] ([First Name4 (NamePattern1) 3075] [Last Name (NamePattern1) 3549] Hospital) were pending at the time of discharge and despite multiple calls (including after discharge on [2100-8-14])they were never faxed to [Hospital1 18]. I will send a note to the patients PCP alerting her of the situation. At [Hospital1 18] the patient grew out pan sensitive e. coli in his urine. Surveillance blood cultures were no growth to date, his WBC normalized and he was afebrile. His mental status was back to baseline on the medical floors. In addition, his PSA was checked which was elevated. After conversations with Dr. [Last Name (STitle) 79] (the patients Urologist) and negative renal US, bacterial prostatitis was thought to be the ultimate source of the patients infection. The patient will be sent home on 3 weeks of cipro for this. An interaction with Coumadin was noted, but this was thought to be the best drug that concentrates in the prostate and covers the patients e. coli. . # left leg pain The patient describes about a 1 month history of left leg pain in a radicular pattern radiating from his back down his leg. His pain is improved with unloading of the spine (bending forward) and is somewhat consistent with spinal stenosis. We also considered sciatic nerve pain as a possibility. PT worked with the patient and they indicated he was safe to go home with a wheeled walker, a home safety evaluation and consideration of home vs. outpatient PT. The patient was sent home with low dose oxycodone (tolerated this in house with good relief) and a bowel regimen. He was advised to consider follow up with a Orthopedist for consideration of further management with injection vs. surgery. . #Afib: Patient is rhythm controlled with amiodarone. This was continued while he was inpatient and his Coumadin was increased to 3 mg QD. Further titration as an outpatient will likely be necessary given that he will be on cipro for 3 weeks. His PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 3855] will follow his INR and he was given a prescription to have this re-checked in the next several days. . # Transitional Issues: -please follow up with the patient blood cultures from [Hospital 3856]/[First Name4 (NamePattern1) 3075] [Last Name (NamePattern1) 3549] in [Location (un) 47] which were not yet speciated but grew GNR -please also note that the patient has pending blood cultures from [Hospital1 18] on [8-9] and [8-10] which are pending that the time of the discharge summary and they need follow up -Follow up with PCP [Last Name (NamePattern4) ] [11-23] weeks and have INR checked prior to visit . Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Amiodarone 200 mg PO DAILY 2. Amlodipine 5 mg PO DAILY hold for sbp<100 or hr<55 3. Losartan Potassium 100 mg PO DAILY hold for sbp<100 or hr<60 4. Finasteride 5 mg PO DAILY 5. fish oil-dha-epa NF (om-3-dha-epa-fish oil-vit D3) 1,200-144-216 mg Oral daily 6. Aspirin 81 mg PO DAILY 7. Warfarin 2 mg PO EVERY OTHER DAY 8. Warfarin 3 mg PO EVERY OTHER DAY 9. Oxazepam 15 mg PO HS:PRN anxiety 10. Cetirizine NF 10 mg Oral qday prn allergies 11. Vitamin D 1000 UNIT PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Metamucil NF (psyllium;<br>psyllium husk;<br>psyllium husk (with sugar);<br>psyllium seed (sugar)) 0.52 gram Oral qday 14. Ranitidine 150 mg PO BID:PRN reflux 15. Cialis NF (tadalafil) 20 mg Oral prn 16. Terbinafine 1% Cream 1 Appl TP [Hospital1 ] Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY hold for sbp<100 or hr<60 5. Multivitamins 1 TAB PO DAILY 6. Terbinafine 1% Cream 1 Appl TP [Hospital1 ] 7. Vitamin D 1000 UNIT PO DAILY 8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 21 Days RX ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #42 Tablet Refills:0 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN severe pain RX oxycodone 5 mg one half to one tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:0 10. Amlodipine 5 mg PO DAILY hold for sbp<100 or hr<55 11. Cetirizine NF 10 mg Oral qday prn allergies 12. Cialis NF (tadalafil) 20 mg Oral prn 13. fish oil-dha-epa NF (om-3-dha-epa-fish oil-vit D3) 1,200-144-216 mg Oral daily 14. Metamucil NF (psyllium;<br>psyllium husk;<br>psyllium husk (with sugar);<br>psyllium seed (sugar)) 0.52 gram Oral qday 15. Oxazepam 15 mg PO HS:PRN anxiety 16. Ranitidine 150 mg PO BID:PRN reflux 17. Warfarin 3 mg PO DAILY16 18. Outpatient Lab Work please draw an inr on [2100-8-13] and fax to the office of the patient pcp, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 3857] [Last Name (NamePattern1) 3855] Phone: [Telephone/Fax (1) 3858] Fax: [Telephone/Fax (1) 3859] atrial fibrillation (427.31) Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: acute bacterial prostatitis e. coli bacteremia with sepsis and hypotension coronary artery disease hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to [Hospital1 18] from an outside hospital because you had low blood pressure and bacteria in your blood. You were in the ICU here and on antibiotics and your condition improved. The bacteria from your blood likely came from an infected prostate. Please take your antibitoics for a total of 3 additional weeks. You will also be sent home with home PT. Please follow up with your doctors as below. . Medication changes 1) cipro 500 mg Q12H for 3 weeks, last dose is [2100-9-2]-*please do not take cipro within 2 hours of taking milk, iron or calcium* 2) coumadin 3 mg QD 3) tylenol 650 Q6H prn for mild to moderate pain (over the counter) 4) oxycodone 2.5-5 mg Q6H prn for severe pain 5) docusate 100 [Hospital1 ], for constipation while on narcotics (over the counter) Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] T. Location: [Hospital1 ] [First Name (Titles) 3860] [Last Name (Titles) 662] CENTER Address: [Street Address(2) 3861], [Location (un) ],[Numeric Identifier 3862] Phone: [Telephone/Fax (1) 3858] Appointment: Thursday [2100-8-19] 12:00pm Department: RADIOLOGY When: TUESDAY [2100-9-7] at 10:35 AM With: RADIOLOGY MRI [Telephone/Fax (1) 590] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SURGICAL SPECIALTIES When: TUESDAY [2100-9-7] at 1 PM With: [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 276], M.D. [Telephone/Fax (1) 277] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	Admission Date: <Date>1991-6-5</Date> Discharge Date: <Date>1935-11-7</Date> Date of Birth: <Date>2001-4-16</Date> Sex: M Service: <Year>1990</Year> Allergies: Procainamide Attending:<Name>Rocio</Name> Chief Complaint: Altered mental status, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 85 yo M w/ PMH of bladder ca, CAD, HTN who is transferred from OSH for concern for urosepsis. Pt presented to OSH day prior to admission here with shaking chills and altered mental status. Pt reports he has had urinary incontinece over the past few days which is abnormal for him, denies any dysuria. He reports awaking in the middle of the night with shaking chills and does not recall what else happed but that his girlfriend must have taken him to the <Name>Samuel Moore</Name>. ON arrival to the OSH he was febrile to 103.3 and given 1 dose of tylenol. UA at the OSH was positive for UTI. His BP dropped to 86/46 and he was given 3-4L of fluids with improvement in BP to 101/48. They did a head CT for concern of his altered mental status in the setting of anticoagulation which was per report negative. He was transferred here for further care given that this is where he has all of his providers. On arrival to the <Hospital>Shelton, Contreras and Walker Health System</Hospital> ED he was febrile at 102.5 rectally and was given 650mg of tylenol. He was initially hemodyanmially stable, however his BP did drop down transiently into the 70s and he was given 2L bolus of fluid with good response in his BP and was stable in the 110s prior to transfer to the floor. Repeat blood and urine cultures were performed and he was admitted for possible urosepsis. On arrival to the MICU the patient is sleepy and complains of some chronic left sided pain. He denies any recent suprapubic pain, nausea, vomiting, flank pain. He has not had a UTI since <Year>1980</Year> and he denies any hematuria, or changes in his urine color. 10 point ros is negative except per above Past Medical History: -Recurrent bladder tumors- followed by Dr. <Name>Lockett</Name> recent urine cytology from cystoscopy on <Date>7-1974</Date> showed clusters of highly atypical urothelial cells,suspicious for urothelial carcinoma. -history of prostatitis dx at <Hospital>Orr Ltd Hospital</Hospital> -ATRIAL FIBRILLATION - amiodarone /warfarin -CARPAL TUNNEL SYNDROME -CHOLELITHIASIS -CORONARY ARTERY DISEASE CABG in <Year>1980</Year>: SVG to LAD, SVG to OM, SVG to PDA, cath in <Year>1980</Year>, severe native disease, occluded SVG to RCA and OM, patent SVG to LAD, redo CABG -HYPERTENSION -INGUINAL HERNIA -RENAL INSUFFICIENCY Social History: Social History: lives alone in an apartment and has a service that he pays for were people can come help him if needed. Has a son and is in a long term relationship. 40pack year former smoker, quit years ago. Denies alcohol. Sings in acapella at <Hospital>Landry, Stuart and Hart Clinic</Hospital> rehab Family History: Noncontributory Physical Exam: Admission Physical Exam: Vitals: 97.8, 115/64, 52, 100% 2L General: Alert, oriented, no acute distress , sleepy in bed HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Bradycardic, diastolic murmur at the LUSB not radiating, Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Protuberant, soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: yellow urine in foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . Discharge PE VSS CV: systolic murmur <Date>10-22</Date>, brisk carotid upstroke Lungs: CTAB, no wrr Abdomen/Back: NTND, active BS, no CVA tenderness -otherwise unchanged Pertinent Results: Admission Labs: <Date>1991-6-5</Date> 07:24AM URINE RBC-155* WBC->182* BACTERIA-MANY YEAST-NONE EPI-<1 TRANS EPI-1 <Date>1991-6-5</Date> 07:24AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG <Date>1991-6-5</Date> 07:24AM URINE COLOR-Yellow APPEAR-Hazy SP <Name>Hui</Name>-1.017 <Date>1991-6-5</Date> 07:24AM PLT COUNT-324 <Date>1991-6-5</Date> 07:24AM NEUTS-81.8* LYMPHS-10.7* MONOS-6.5 EOS-0.5 BASOS-0.6 <Date>1991-6-5</Date> 07:24AM WBC-16.6# RBC-3.72 HGB-11.4* HCT-34.4* MCV-93 MCH-30.7 MCHC-33.2 RDW-14.4 <Date>1991-6-5</Date> 07:24AM GLUCOSE-115* UREA N-23* CREAT-1.4* SODIUM-144 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13 <Date>1991-6-5</Date> 07:33AM LACTATE-1.2 <Date>1991-6-5</Date> 12:48PM PT-17.0* PTT-31.6 INR(PT)-1.6* . <Date>1983-12-9</Date> IMPRESSION: 1. No evidence of pyelonephritis or perinephric focal fluid collections. Note that ultrasound has a relatively low sensitivity for detection of pyelonephritis (in the absence of significant phlegmon or abscess). 2. 0.7 x 0.7 x 0.8 cm anechoic structure, likely representing a small renal cyst within the lower pole of the left kidney. 3. Enlarged prostate. . <Date>1991-6-5</Date> 7:24 am URINE FINAL REPORT <Date>1983-12-9</Date> URINE CULTURE (Final <Date>1983-12-9</Date>): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . BC pending from <Date>2-25</Date> and <Date>9-27</Date> . Brief Hospital Course: 85 yo M w/ PMHx of bladder tumors, prior episode of bacterial prostatitis, CAD s/p CABG X2, AF, CKD, HTN who was transferred from OSH with urosepsis and found to have GNR bacteremia who was stabilized in the MICU with fluid resucitation and antibiotics and continued to do well on floor after switching to oral antibiotics . #Urosepsis likely secondary to prostatitis with altered mental status Patient has known bladder tumors and noted increased urinary urgency and incontinence in the few days prior to admission. He met sepsis criteria at the OSH with fever, tachypnea, leukocytosis and positive UA which ultimately grew out EColi and GNR bacteremia. He was started on zosyn at the OSH and this was switched to cefepime initially in the MICU. His cultures at the <Hospital>Green-Morales Medical Center</Hospital> (<Name>Eleanor</Name> <Name>Bogle</Name> Hospital) were pending at the time of discharge and despite multiple calls (including after discharge on <Date>1991-10-23</Date>)they were never faxed to <Hospital>Shelton, Contreras and Walker Health System</Hospital>. I will send a note to the patients PCP alerting her of the situation. At <Hospital>Shelton, Contreras and Walker Health System</Hospital> the patient grew out pan sensitive e. coli in his urine. Surveillance blood cultures were no growth to date, his WBC normalized and he was afebrile. His mental status was back to baseline on the medical floors. In addition, his PSA was checked which was elevated. After conversations with Dr. <Name>Cobbs</Name> (the patients Urologist) and negative renal US, bacterial prostatitis was thought to be the ultimate source of the patients infection. The patient will be sent home on 3 weeks of cipro for this. An interaction with Coumadin was noted, but this was thought to be the best drug that concentrates in the prostate and covers the patients e. coli. . # left leg pain The patient describes about a 1 month history of left leg pain in a radicular pattern radiating from his back down his leg. His pain is improved with unloading of the spine (bending forward) and is somewhat consistent with spinal stenosis. We also considered sciatic nerve pain as a possibility. PT worked with the patient and they indicated he was safe to go home with a wheeled walker, a home safety evaluation and consideration of home vs. outpatient PT. The patient was sent home with low dose oxycodone (tolerated this in house with good relief) and a bowel regimen. He was advised to consider follow up with a Orthopedist for consideration of further management with injection vs. surgery. . #Afib: Patient is rhythm controlled with amiodarone. This was continued while he was inpatient and his Coumadin was increased to 3 mg QD. Further titration as an outpatient will likely be necessary given that he will be on cipro for 3 weeks. His PCP <Name>Cobbs</Name>. <Name>Ivory</Name> will follow his INR and he was given a prescription to have this re-checked in the next several days. . # Transitional Issues: -please follow up with the patient blood cultures from <Hospital>Bentley Group Hospital</Hospital>/<Name>Eleanor</Name> <Name>Bogle</Name> in <Location>882 Brian Lakes Apt. 125 North Katherinemouth, MS 02124</Location> which were not yet speciated but grew GNR -please also note that the patient has pending blood cultures from <Hospital>Shelton, Contreras and Walker Health System</Hospital> on <Date>2-25</Date> and <Date>9-27</Date> which are pending that the time of the discharge summary and they need follow up -Follow up with PCP <Name>Cobbs</Name> <Date>9-16</Date> weeks and have INR checked prior to visit . Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Amiodarone 200 mg PO DAILY 2. Amlodipine 5 mg PO DAILY hold for sbp<100 or hr<55 3. Losartan Potassium 100 mg PO DAILY hold for sbp<100 or hr<60 4. Finasteride 5 mg PO DAILY 5. fish oil-dha-epa NF (om-3-dha-epa-fish oil-vit D3) 1,200-144-216 mg Oral daily 6. Aspirin 81 mg PO DAILY 7. Warfarin 2 mg PO EVERY OTHER DAY 8. Warfarin 3 mg PO EVERY OTHER DAY 9. Oxazepam 15 mg PO HS:PRN anxiety 10. Cetirizine NF 10 mg Oral qday prn allergies 11. Vitamin D 1000 UNIT PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Metamucil NF (psyllium;<br>psyllium husk;<br>psyllium husk (with sugar);<br>psyllium seed (sugar)) 0.52 gram Oral qday 14. Ranitidine 150 mg PO BID:PRN reflux 15. Cialis NF (tadalafil) 20 mg Oral prn 16. Terbinafine 1% Cream 1 Appl TP <Hospital>Ruiz and Sons Health System</Hospital> Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY hold for sbp<100 or hr<60 5. Multivitamins 1 TAB PO DAILY 6. Terbinafine 1% Cream 1 Appl TP <Hospital>Ruiz and Sons Health System</Hospital> 7. Vitamin D 1000 UNIT PO DAILY 8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 21 Days RX ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #42 Tablet Refills:0 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN severe pain RX oxycodone 5 mg one half to one tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:0 10. Amlodipine 5 mg PO DAILY hold for sbp<100 or hr<55 11. Cetirizine NF 10 mg Oral qday prn allergies 12. Cialis NF (tadalafil) 20 mg Oral prn 13. fish oil-dha-epa NF (om-3-dha-epa-fish oil-vit D3) 1,200-144-216 mg Oral daily 14. Metamucil NF (psyllium;<br>psyllium husk;<br>psyllium husk (with sugar);<br>psyllium seed (sugar)) 0.52 gram Oral qday 15. Oxazepam 15 mg PO HS:PRN anxiety 16. Ranitidine 150 mg PO BID:PRN reflux 17. Warfarin 3 mg PO DAILY16 18. Outpatient Lab Work please draw an inr on <Date>1988-8-14</Date> and fax to the office of the patient pcp, <Name>Cobbs</Name>. <Name>Felecia</Name> <Name>Pegram</Name> Phone: <Telephone>217-746-9949</Telephone> Fax: <Telephone>828-489-6440</Telephone> atrial fibrillation (427.31) Discharge Disposition: Home With Service Facility: <Location>9735 Coleman Route Port Williamview, CA 89215</Location> VNA Discharge Diagnosis: acute bacterial prostatitis e. coli bacteremia with sepsis and hypotension coronary artery disease hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to <Hospital>Shelton, Contreras and Walker Health System</Hospital> from an outside hospital because you had low blood pressure and bacteria in your blood. You were in the ICU here and on antibiotics and your condition improved. The bacteria from your blood likely came from an infected prostate. Please take your antibitoics for a total of 3 additional weeks. You will also be sent home with home PT. Please follow up with your doctors as below. . Medication changes 1) cipro 500 mg Q12H for 3 weeks, last dose is <Date>1962-4-18</Date>-*please do not take cipro within 2 hours of taking milk, iron or calcium* 2) coumadin 3 mg QD 3) tylenol 650 Q6H prn for mild to moderate pain (over the counter) 4) oxycodone 2.5-5 mg Q6H prn for severe pain 5) docusate 100 <Hospital>Ruiz and Sons Health System</Hospital>, for constipation while on narcotics (over the counter) Followup Instructions: Name: <Name>Heflin</Name>,<Name>Octavia</Name> T. Location: <Hospital>Ruiz and Sons Health System</Hospital> <Name>Michelle</Name> <Name>Negrete</Name> CENTER Address: <Location>01371 Lisa Hills Suite 950 Antonioborough, OH 62302</Location>, <Location>PSC 1696, Box 0443 APO AA 27458</Location>,<Numeric Identifier>0774131</Numeric Identifier> Phone: <Telephone>217-746-9949</Telephone> Appointment: Thursday <Date>1931-2-23</Date> 12:00pm Department: RADIOLOGY When: TUESDAY <Date>1909-4-2</Date> at 10:35 AM With: RADIOLOGY MRI <Telephone>750-800-5191</Telephone> Building: SC <Hospital>Hardy, David and Burke Hospital</Hospital> Clinical Ctr <Location>5877 Timothy Crest Suite 922 Moodymouth, RI 88542</Location> Campus: EAST Best Parking: <Hospital>Hardy, David and Burke Hospital</Hospital> Garage Department: SURGICAL SPECIALTIES When: TUESDAY <Date>1909-4-2</Date> at 1 PM With: <Name>Zhi</Name> <Name>Salgado</Name>, M.D. <Telephone>570-865-7350</Telephone> Building: <Hospital>Munoz, Aguilar and Lee Medical Center</Hospital> <Location>PSC 1696, Box 0443 APO AA 27458</Location> Campus: EAST Best Parking: <Hospital>Hardy, David and Burke Hospital</Hospital> 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Date: 1991-6-5 Discharge Date: 1935-11-7 Date of Birth: 2001-4-16 Sex: M Service: 1990 Allergies: Procainamide Attending:Rocio Chief Complaint: Altered mental status, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 85 yo M w/ PMH of bladder ca, CAD, HTN who is transferred from OSH for concern for urosepsis. Pt presented to OSH day prior to admission here with shaking chills and altered mental status. Pt reports he has had urinary incontinece over the past few days which is abnormal for him, denies any dysuria. He reports awaking in the middle of the night with shaking chills and does not recall what else happed but that his girlfriend must have taken him to the Samuel Moore. ON arrival to the OSH he was febrile to 103.3 and given 1 dose of tylenol. UA at the OSH was positive for UTI. His BP dropped to 86/46 and he was given 3-4L of fluids with improvement in BP to 101/48. They did a head CT for concern of his altered mental status in the setting of anticoagulation which was per report negative. He was transferred here for further care given that this is where he has all of his providers. On arrival to the Shelton, Contreras and Walker Health System ED he was febrile at 102.5 rectally and was given 650mg of tylenol. He was initially hemodyanmially stable, however his BP did drop down transiently into the 70s and he was given 2L bolus of fluid with good response in his BP and was stable in the 110s prior to transfer to the floor. Repeat blood and urine cultures were performed and he was admitted for possible urosepsis. On arrival to the MICU the patient is sleepy and complains of some chronic left sided pain. He denies any recent suprapubic pain, nausea, vomiting, flank pain. He has not had a UTI since 1980 and he denies any hematuria, or changes in his urine color. 10 point ros is negative except per above Past Medical History: -Recurrent bladder tumors- followed by Dr. Lockett recent urine cytology from cystoscopy on 7-1974 showed clusters of highly atypical urothelial cells,suspicious for urothelial carcinoma. -history of prostatitis dx at Orr Ltd Hospital -ATRIAL FIBRILLATION - amiodarone /warfarin -CARPAL TUNNEL SYNDROME -CHOLELITHIASIS -CORONARY ARTERY DISEASE CABG in 1980: SVG to LAD, SVG to OM, SVG to PDA, cath in 1980, severe native disease, occluded SVG to RCA and OM, patent SVG to LAD, redo CABG -HYPERTENSION -INGUINAL HERNIA -RENAL INSUFFICIENCY Social History: Social History: lives alone in an apartment and has a service that he pays for were people can come help him if needed. Has a son and is in a long term relationship. 40pack year former smoker, quit years ago. Denies alcohol. Sings in acapella at Landry, Stuart and Hart Clinic rehab Family History: Noncontributory Physical Exam: Admission Physical Exam: Vitals: 97.8, 115/64, 52, 100% 2L General: Alert, oriented, no acute distress , sleepy in bed HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Bradycardic, diastolic murmur at the LUSB not radiating, Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Protuberant, soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: yellow urine in foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . Discharge PE VSS CV: systolic murmur 10-22, brisk carotid upstroke Lungs: CTAB, no wrr Abdomen/Back: NTND, active BS, no CVA tenderness -otherwise unchanged Pertinent Results: Admission Labs: 1991-6-5 07:24AM URINE RBC-155* WBC->182* BACTERIA-MANY YEAST-NONE EPI-1991-6-5 07:24AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG 1991-6-5 07:24AM URINE COLOR-Yellow APPEAR-Hazy SP Hui-1.017 1991-6-5 07:24AM PLT COUNT-324 1991-6-5 07:24AM NEUTS-81.8* LYMPHS-10.7* MONOS-6.5 EOS-0.5 BASOS-0.6 1991-6-5 07:24AM WBC-16.6# RBC-3.72 HGB-11.4* HCT-34.4* MCV-93 MCH-30.7 MCHC-33.2 RDW-14.4 1991-6-5 07:24AM GLUCOSE-115* UREA N-23* CREAT-1.4* SODIUM-144 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13 1991-6-5 07:33AM LACTATE-1.2 1991-6-5 12:48PM PT-17.0* PTT-31.6 INR(PT)-1.6* . 1983-12-9 IMPRESSION: 1. No evidence of pyelonephritis or perinephric focal fluid collections. Note that ultrasound has a relatively low sensitivity for detection of pyelonephritis (in the absence of significant phlegmon or abscess). 2. 0.7 x 0.7 x 0.8 cm anechoic structure, likely representing a small renal cyst within the lower pole of the left kidney. 3. Enlarged prostate. . 1991-6-5 7:24 am URINE FINAL REPORT 1983-12-9 URINE CULTURE (Final 1983-12-9): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- 2-25 and 9-27 . Brief Hospital Course: 85 yo M w/ PMHx of bladder tumors, prior episode of bacterial prostatitis, CAD s/p CABG X2, AF, CKD, HTN who was transferred from OSH with urosepsis and found to have GNR bacteremia who was stabilized in the MICU with fluid resucitation and antibiotics and continued to do well on floor after switching to oral antibiotics . #Urosepsis likely secondary to prostatitis with altered mental status Patient has known bladder tumors and noted increased urinary urgency and incontinence in the few days prior to admission. He met sepsis criteria at the OSH with fever, tachypnea, leukocytosis and positive UA which ultimately grew out EColi and GNR bacteremia. He was started on zosyn at the OSH and this was switched to cefepime initially in the MICU. His cultures at the Green-Morales Medical Center (Eleanor Bogle Hospital) were pending at the time of discharge and despite multiple calls (including after discharge on 1991-10-23)they were never faxed to Shelton, Contreras and Walker Health System. I will send a note to the patients PCP alerting her of the situation. At Shelton, Contreras and Walker Health System the patient grew out pan sensitive e. coli in his urine. Surveillance blood cultures were no growth to date, his WBC normalized and he was afebrile. His mental status was back to baseline on the medical floors. In addition, his PSA was checked which was elevated. After conversations with Dr. Cobbs (the patients Urologist) and negative renal US, bacterial prostatitis was thought to be the ultimate source of the patients infection. The patient will be sent home on 3 weeks of cipro for this. An interaction with Coumadin was noted, but this was thought to be the best drug that concentrates in the prostate and covers the patients e. coli. . # left leg pain The patient describes about a 1 month history of left leg pain in a radicular pattern radiating from his back down his leg. His pain is improved with unloading of the spine (bending forward) and is somewhat consistent with spinal stenosis. We also considered sciatic nerve pain as a possibility. PT worked with the patient and they indicated he was safe to go home with a wheeled walker, a home safety evaluation and consideration of home vs. outpatient PT. The patient was sent home with low dose oxycodone (tolerated this in house with good relief) and a bowel regimen. He was advised to consider follow up with a Orthopedist for consideration of further management with injection vs. surgery. . #Afib: Patient is rhythm controlled with amiodarone. This was continued while he was inpatient and his Coumadin was increased to 3 mg QD. Further titration as an outpatient will likely be necessary given that he will be on cipro for 3 weeks. His PCP Cobbs. Ivory will follow his INR and he was given a prescription to have this re-checked in the next several days. . # Transitional Issues: -please follow up with the patient blood cultures from Bentley Group Hospital/Eleanor Bogle in 882 Brian Lakes Apt. 125 North Katherinemouth, MS 02124 which were not yet speciated but grew GNR -please also note that the patient has pending blood cultures from Shelton, Contreras and Walker Health System on 2-25 and 9-27 which are pending that the time of the discharge summary and they need follow up -Follow up with PCP Cobbs 9-16 weeks and have INR checked prior to visit . Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Amiodarone 200 mg PO DAILY 2. Amlodipine 5 mg PO DAILY hold for sbppsyllium husk;psyllium husk (with sugar);psyllium seed (sugar)) 0.52 gram Oral qday 14. Ranitidine 150 mg PO BID:PRN reflux 15. Cialis NF (tadalafil) 20 mg Oral prn 16. Terbinafine 1% Cream 1 Appl TP Ruiz and Sons Health System Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY hold for sbpRuiz and Sons Health System 7. Vitamin D 1000 UNIT PO DAILY 8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 21 Days RX ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #42 Tablet Refills:0 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN severe pain RX oxycodone 5 mg one half to one tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:0 10. Amlodipine 5 mg PO DAILY hold for sbppsyllium husk;psyllium husk (with sugar);psyllium seed (sugar)) 0.52 gram Oral qday 15. Oxazepam 15 mg PO HS:PRN anxiety 16. Ranitidine 150 mg PO BID:PRN reflux 17. Warfarin 3 mg PO DAILY16 18. Outpatient Lab Work please draw an inr on 1988-8-14 and fax to the office of the patient pcp, Cobbs. Felecia Pegram Phone: 217-746-9949 Fax: 828-489-6440 atrial fibrillation (427.31) Discharge Disposition: Home With Service Facility: 9735 Coleman Route Port Williamview, CA 89215 VNA Discharge Diagnosis: acute bacterial prostatitis e. coli bacteremia with sepsis and hypotension coronary artery disease hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to Shelton, Contreras and Walker Health System from an outside hospital because you had low blood pressure and bacteria in your blood. You were in the ICU here and on antibiotics and your condition improved. The bacteria from your blood likely came from an infected prostate. Please take your antibitoics for a total of 3 additional weeks. You will also be sent home with home PT. Please follow up with your doctors as below. . Medication changes 1) cipro 500 mg Q12H for 3 weeks, last dose is 1962-4-18-*please do not take cipro within 2 hours of taking milk, iron or calcium* 2) coumadin 3 mg QD 3) tylenol 650 Q6H prn for mild to moderate pain (over the counter) 4) oxycodone 2.5-5 mg Q6H prn for severe pain 5) docusate 100 Ruiz and Sons Health System, for constipation while on narcotics (over the counter) Followup Instructions: Name: Heflin,Octavia T. Location: Ruiz and Sons Health System Michelle Negrete CENTER Address: 01371 Lisa Hills Suite 950 Antonioborough, OH 62302, PSC 1696, Box 0443 APO AA 27458,0774131 Phone: 217-746-9949 Appointment: Thursday 1931-2-23 12:00pm Department: RADIOLOGY When: TUESDAY 1909-4-2 at 10:35 AM With: RADIOLOGY MRI 750-800-5191 Building: SC Hardy, David and Burke Hospital Clinical Ctr 5877 Timothy Crest Suite 922 Moodymouth, RI 88542 Campus: EAST Best Parking: Hardy, David and Burke Hospital Garage Department: SURGICAL SPECIALTIES When: TUESDAY 1909-4-2 at 1 PM With: Zhi Salgado, M.D. 570-865-7350 Building: Munoz, Aguilar and Lee Medical Center PSC 1696, Box 0443 APO AA 27458 Campus: EAST Best Parking: Hardy, David and Burke Hospital Garage	['Admission Date: 1991-6-5 Discharge Date: 1935-11-7\n\nDate of Birth: 2001-4-16 Sex: M\n\nService: 1990\n\nAllergies:\nProcainamide\n\nAttending:Rocio\nChief Complaint:\nAltered mental status, hypotension\n\nMajor Surgical or Invasive Procedure:\nnone\n\n\nHistory of Present Illness:\n85 yo M w/ PMH of bladder ca, CAD, HTN who is transferred from\nOSH for concern for urosepsis. Pt presented to OSH day prior to\nadmission here with shaking chills and altered mental status. Pt\nreports he has had urinary incontinece over the past few days\nwhich is abnormal for him, denies any dysuria. He reports\nawaking in the middle of the night with shaking chills and does\nnot recall what else happed but that his girlfriend must have\ntaken him to the Samuel Moore. ON arrival to the OSH he was febrile to\n103.', '3 and given 1 dose of tylenol. UA at the OSH was positive\nfor UTI. His BP dropped to 86/46 and he was given 3-4L of fluids\nwith improvement in BP to 101/48. They did a head CT for\nconcern of his altered mental status in the setting of\nanticoagulation which was per report negative. He was\ntransferred here for further care given that this is where he\nhas all of his providers.\n\nOn arrival to the Shelton, Contreras and Walker Health System ED he was febrile at 102.5 rectally and\nwas given 650mg of tylenol. He was initially hemodyanmially\nstable, however his BP did drop down transiently into the 70s\nand he was given 2L bolus of fluid with good response in his BP\nand was stable in the 110s prior to transfer to the floor.\nRepeat blood and urine cultures were performed and he was\nadmitted for possible urosepsis.', '\n\nOn arrival to the MICU the patient is sleepy and complains of\nsome chronic left sided pain. He denies any recent suprapubic\npain, nausea, vomiting, flank pain. He has not had a UTI since\n1980 and he denies any hematuria, or changes in his urine color.\n\n\n10 point ros is negative except per above\n\n\nPast Medical History:\n-Recurrent bladder tumors- followed by Dr. Lockett recent urine\ncytology from cystoscopy on 7-1974 showed clusters of highly\natypical urothelial cells,suspicious for urothelial carcinoma.\n-history of prostatitis dx at Orr Ltd Hospital\n-ATRIAL FIBRILLATION - amiodarone /warfarin\n-CARPAL TUNNEL SYNDROME\n-CHOLELITHIASIS\n-CORONARY ARTERY DISEASE\n CABG in 1980: SVG to LAD, SVG to OM, SVG to PDA, cath in\n1980, severe native disease, occluded SVG to RCA and OM, patent\nSVG to LAD, redo CABG\n-HYPERTENSION\n-INGUINAL HERNIA\n-RENAL INSUFFICIENCY\n\nSocial History:\nSocial History: lives alone in an apartment and has a service\nthat he pays for were people can come help him if needed.', ' Has a\nson and is in a long term relationship. 40pack year former\nsmoker, quit years ago. Denies alcohol. Sings in acapella at\nLandry, Stuart and Hart Clinic rehab\n\n\n\n\nFamily History:\nNoncontributory\n\nPhysical Exam:\nAdmission Physical Exam:\nVitals: 97.8, 115/64, 52, 100% 2L\nGeneral: Alert, oriented, no acute distress , sleepy in bed\nHEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL\nNeck: supple, JVP not elevated, no LAD\nCV: Bradycardic, diastolic murmur at the LUSB not radiating,\nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi\nAbdomen: Protuberant, soft, non-tender, non-distended, bowel\nsounds present, no organomegaly, no rebound or guarding\nGU: yellow urine in foley\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema\nNeuro: CNII-XII intact, 5/5 strength upper/lower extremities,\ngrossly normal sensation, 2+ reflexes bilaterally, gait\ndeferred.', '\n.\nDischarge PE\nVSS\nCV: systolic murmur 10-22, brisk carotid upstroke\nLungs: CTAB, no wrr\nAbdomen/Back: NTND, active BS, no CVA tenderness\n-otherwise unchanged\n\nPertinent Results:\nAdmission Labs:\n\n1991-6-5 07:24AM URINE RBC-155* WBC->182* BACTERIA-MANY\nYEAST-NONE EPI-1991-6-5 07:24AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5\nLEUK-LG\n1991-6-5 07:24AM URINE COLOR-Yellow APPEAR-Hazy SP Hui-1.017\n1991-6-5 07:24AM PLT COUNT-324\n1991-6-5 07:24AM NEUTS-81.8* LYMPHS-10.7* MONOS-6.5 EOS-0.5\nBASOS-0.6\n1991-6-5 07:24AM WBC-16.6# RBC-3.72 HGB-11.4* HCT-34.4\nMCV-93 MCH-30.7 MCHC-33.2 RDW-14.4\n1991-6-5 07:24AM GLUCOSE-115 UREA N-23* CREAT-1.4* SODIUM-144\nPOTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13\n1991-6-5 07:33AM LACTATE-1.', '2\n1991-6-5 12:48PM PT-17.0* PTT-31.6 INR(PT)-1.6\n.\n1983-12-9\nIMPRESSION:\n\n1. No evidence of pyelonephritis or perinephric focal fluid\ncollections. Note\nthat ultrasound has a relatively low sensitivity for detection\nof\npyelonephritis (in the absence of significant phlegmon or\nabscess).\n2. 0.7 x 0.7 x 0.8 cm anechoic structure, likely representing a\nsmall renal\ncyst within the lower pole of the left kidney.\n3. Enlarged prostate.\n.\n1991-6-5 7:24 am URINE\n\n FINAL REPORT 1983-12-9\n\n URINE CULTURE (Final 1983-12-9):\n ESCHERICHIA COLI. >100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n Cefazolin interpretative criteria are based on a dosage\nregimen of\n 2g every 8h.\n Piperacillin/tazobactam sensitivity testing available\non request.', '\n\n SENSITIVITIES: MIC expressed in\nMCG/ML\n\n_________________________________________________________\n ESCHERICHIA COLI\n \|\nAMPICILLIN------------ 8 S\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- 2-25 and 9-27\n.\n\n\nBrief Hospital Course:\n85 yo M w/ PMHx of bladder tumors, prior episode of bacterial\nprostatitis, CAD s/p CABG X2, AF, CKD, HTN who was transferred\nfrom OSH with urosepsis and found to have GNR bacteremia who was\nstabilized in the MICU with fluid resucitation and antibiotics\nand continued to do well on floor after switching to oral\nantibiotics\n.\n#Urosepsis likely secondary to prostatitis with altered mental\nstatus\nPatient has known bladder tumors and noted increased urinary\nurgency and incontinence in the few days prior to admission.', ' He\nmet sepsis criteria at the OSH with fever, tachypnea,\nleukocytosis and positive UA which ultimately grew out EColi and\nGNR bacteremia. He was started on zosyn at the OSH and this was\nswitched to cefepime initially in the MICU. His cultures at the\nGreen-Morales Medical Center (Eleanor Bogle Hospital) were pending at the time of\ndischarge and despite multiple calls (including after discharge\non 1991-10-23)they were never faxed to Shelton, Contreras and Walker Health System. I will send a note\nto the patients PCP alerting her of the situation. At Shelton, Contreras and Walker Health System the\npatient grew out pan sensitive e. coli in his urine.\nSurveillance blood cultures were no growth to date, his WBC\nnormalized and he was afebrile. His mental status was back to\nbaseline on the medical floors.', ' In addition, his PSA was\nchecked which was elevated. After conversations with Dr. Cobbs\n(the patients Urologist) and negative renal US, bacterial\nprostatitis was thought to be the ultimate source of the\npatients infection. The patient will be sent home on 3 weeks of\ncipro for this. An interaction with Coumadin was noted, but\nthis was thought to be the best drug that concentrates in the\nprostate and covers the patients e. coli.\n.\n# left leg pain\nThe patient describes about a 1 month history of left leg pain\nin a radicular pattern radiating from his back down his leg.\nHis pain is improved with unloading of the spine (bending\nforward) and is somewhat consistent with spinal stenosis. We\nalso considered sciatic nerve pain as a possibility. PT worked\nwith the patient and they indicated he was safe to go home with\na wheeled walker, a home safety evaluation and consideration of\nhome vs.', ' outpatient PT. The patient was sent home with low dose\noxycodone (tolerated this in house with good relief) and a bowel\nregimen. He was advised to consider follow up with a\nOrthopedist for consideration of further management with\ninjection vs. surgery.\n.\n#Afib:\nPatient is rhythm controlled with amiodarone. This was continued\nwhile he was inpatient and his Coumadin was increased to 3 mg\nQD. Further titration as an outpatient will likely be necessary\ngiven that he will be on cipro for 3 weeks. His PCP Cobbs. Ivory\nwill follow his INR and he was given a prescription to have this\nre-checked in the next several days.\n.\n# Transitional Issues:\n-please follow up with the patient blood cultures from Bentley Group Hospital/Eleanor Bogle in 882 Brian Lakes Apt. 125\nNorth Katherinemouth, MS 02124 which were not yet speciated\nbut grew GNR\n-please also note that the patient has pending blood cultures\nfrom Shelton, Contreras and Walker Health System on 2-25 and 9-27 which are pending that the time of\nthe discharge summary and they need follow up\n-Follow up with PCP Cobbs 9-16 weeks and have INR checked prior to\nvisit\n.', '\n\nMedications on Admission:\nPreadmission medications listed are correct and complete.\nInformation was obtained from PatientwebOMR.\n1. Amiodarone 200 mg PO DAILY\n2. Amlodipine 5 mg PO DAILY\nhold for sbppsyllium husk;psyllium husk\n(with sugar);psyllium seed (sugar)) 0.52 gram Oral qday\n14. Ranitidine 150 mg PO BID:PRN reflux\n15. Cialis NF* (tadalafil) 20 mg Oral prn\n16. Terbinafine 1% Cream 1 Appl TP Ruiz and Sons Health System\n\n\nDischarge Medications:\n1. Amiodarone 200 mg PO DAILY\n2. Aspirin 81 mg PO DAILY\n3. Finasteride 5 mg PO DAILY\n4. Losartan Potassium 100 mg PO DAILY\nhold for sbpRuiz and Sons Health System\n7. Vitamin D 1000 UNIT PO DAILY\n8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 21 Days\nRX ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)\nhours Disp #42 Tablet Refills:0\n9.', ' OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN severe\npain\nRX oxycodone 5 mg one half to one tablet(s) by mouth every six\n(6) hours Disp #20 Tablet Refills:0\n10. Amlodipine 5 mg PO DAILY\nhold for sbppsyllium husk;psyllium husk\n(with sugar);psyllium seed (sugar)) 0.52 gram Oral qday\n15. Oxazepam 15 mg PO HS:PRN anxiety\n16. Ranitidine 150 mg PO BID:PRN reflux\n17. Warfarin 3 mg PO DAILY16\n18. Outpatient Lab Work\nplease draw an inr on 1988-8-14 and fax to the office of the\npatient pcp, Cobbs. Felecia Pegram Phone: 217-746-9949\nFax: 828-489-6440 atrial fibrillation (427.31)\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n9735 Coleman Route\nPort Williamview, CA 89215 VNA\n\nDischarge Diagnosis:\nacute bacterial prostatitis\ne. coli bacteremia with sepsis and hypotension\ncoronary artery disease\nhypertension\n\n\nDischarge Condition:\nMental Status: Clear and coherent.', '\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker\nor cane).\n\n\nDischarge Instructions:\nYou came to Shelton, Contreras and Walker Health System from an outside hospital because you had low\nblood pressure and bacteria in your blood. You were in the ICU\nhere and on antibiotics and your condition improved. The\nbacteria from your blood likely came from an infected prostate.\nPlease take your antibitoics for a total of 3 additional weeks.\nYou will also be sent home with home PT. Please follow up with\nyour doctors as below.\n.\nMedication changes\n1) cipro 500 mg Q12H for 3 weeks, last dose is 1962-4-18-*please do not take cipro within 2 hours of taking milk,\niron or calcium*\n2) coumadin 3 mg QD\n3) tylenol 650 Q6H prn for mild to moderate pain (over the\ncounter)\n4) oxycodone 2.', '5-5 mg Q6H prn for severe pain\n5) docusate 100 Ruiz and Sons Health System, for constipation while on narcotics (over\nthe counter)\n\nFollowup Instructions:\nName: Heflin,Octavia T.\nLocation: Ruiz and Sons Health System Michelle Negrete CENTER\nAddress: 01371 Lisa Hills Suite 950\nAntonioborough, OH 62302, PSC 1696, Box 0443\nAPO AA 27458,0774131\nPhone: 217-746-9949\nAppointment: Thursday 1931-2-23 12:00pm\n\nDepartment: RADIOLOGY\nWhen: TUESDAY 1909-4-2 at 10:35 AM\nWith: RADIOLOGY MRI 750-800-5191\nBuilding: SC Hardy, David and Burke Hospital Clinical Ctr 5877 Timothy Crest Suite 922\nMoodymouth, RI 88542\nCampus: EAST Best Parking: Hardy, David and Burke Hospital Garage\n\nDepartment: SURGICAL SPECIALTIES\nWhen: TUESDAY 1909-4-2 at 1 PM\nWith: Zhi Salgado, M.D. 570-865-7350\nBuilding: Munoz, Aguilar and Lee Medical Center PSC 1696, Box 0443\nAPO AA 27458\nCampus: EAST Best Parking: Hardy, David and Burke Hospital Garage\n\n\n\n']
528	2650	188655.0	2132-10-01	Discharge summary	Report	Admission Date: [2132-12-3] Discharge Date: [2132-10-1] Date of Birth: [2098-11-23] Sex: M Service: HOSPITAL COURSE: The patient is a 34 year old male, status post motor vehicle accident on [2132-7-9], status post talectomy on the right foot and bilateral ....... here for a right tibiocalcaneal fusion and a right iliac bone graft and internal hardware placement. The patient tolerated the procedure well. On postoperative day number one, he had a maximum temperature of 101.5 that spontaneously defervesced. He was maintained on intravenous antibiotics throughout the course of his stay. His incision was clean, dry and intact. The patient was seen by physical therapy and, after plain films were reviewed, it was deemed appropriate to allow the patient to have weightbearing as tolerated on the left lower extremity with a walker boot in place and nonweightbearing on the right ankle. He was discharged to rehabilitation on an AFO boot and is to follow up with Dr. [Last Name (STitle) 284] in two weeks. Dr. ...... will be following him as an outpatient regarding his sciatic nerve issues. Dictated By:[Name8 (MD) 4385] MEDQUIST36 D: [2132-12-5] 14:52 T: [2132-12-5] 15:17 JOB#: [Job Number 4386]	Admission Date: <Date>1936-5-12</Date> Discharge Date: <Date>1947-12-23</Date> Date of Birth: <Date>2000-5-1</Date> Sex: M Service: HOSPITAL COURSE: The patient is a 34 year old male, status post motor vehicle accident on <Date>1968-7-16</Date>, status post talectomy on the right foot and bilateral ....... here for a right tibiocalcaneal fusion and a right iliac bone graft and internal hardware placement. The patient tolerated the procedure well. On postoperative day number one, he had a maximum temperature of 101.5 that spontaneously defervesced. He was maintained on intravenous antibiotics throughout the course of his stay. His incision was clean, dry and intact. The patient was seen by physical therapy and, after plain films were reviewed, it was deemed appropriate to allow the patient to have weightbearing as tolerated on the left lower extremity with a walker boot in place and nonweightbearing on the right ankle. He was discharged to rehabilitation on an AFO boot and is to follow up with Dr. <Name>Porras</Name> in two weeks. Dr. ...... will be following him as an outpatient regarding his sciatic nerve issues. Dictated By:<Name>Retha Ivory</Name> MEDQUIST36 D: <Date>1935-5-31</Date> 14:52 T: <Date>1935-5-31</Date> 15:17 JOB#: <Job Number>Taylor LLC-2008-606832</Job Number>	000000000000000001111111110000000000000000000000001111111111000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111110000000000000000011111111100000000000011111111100000000000000011111111111111111111110	Admission Date: 1936-5-12 Discharge Date: 1947-12-23 Date of Birth: 2000-5-1 Sex: M Service: HOSPITAL COURSE: The patient is a 34 year old male, status post motor vehicle accident on 1968-7-16, status post talectomy on the right foot and bilateral ....... here for a right tibiocalcaneal fusion and a right iliac bone graft and internal hardware placement. The patient tolerated the procedure well. On postoperative day number one, he had a maximum temperature of 101.5 that spontaneously defervesced. He was maintained on intravenous antibiotics throughout the course of his stay. His incision was clean, dry and intact. The patient was seen by physical therapy and, after plain films were reviewed, it was deemed appropriate to allow the patient to have weightbearing as tolerated on the left lower extremity with a walker boot in place and nonweightbearing on the right ankle. He was discharged to rehabilitation on an AFO boot and is to follow up with Dr. Porras in two weeks. Dr. ...... will be following him as an outpatient regarding his sciatic nerve issues. Dictated By:Retha Ivory MEDQUIST36 D: 1935-5-31 14:52 T: 1935-5-31 15:17 JOB#: Taylor LLC-2008-606832	['Admission Date: 1936-5-12 Discharge Date: 1947-12-23\n\nDate of Birth: 2000-5-1 Sex: M\n\nService:\n\nHOSPITAL COURSE: The patient is a 34 year old male, status\npost motor vehicle accident on 1968-7-16, status post\ntalectomy on the right foot and bilateral ....... here for a\nright tibiocalcaneal fusion and a right iliac bone graft and\ninternal hardware placement.\n\nThe patient tolerated the procedure well. On postoperative\nday number one, he had a maximum temperature of 101.5 that\nspontaneously defervesced. He was maintained on intravenous\nantibiotics throughout the course of his stay. His incision\nwas clean, dry and intact.\n\nThe patient was seen by physical therapy and, after plain\nfilms were reviewed, it was deemed appropriate to allow the\npatient to have weightbearing as tolerated on the left lower\nextremity with a walker boot in place and nonweightbearing on\nthe right ankle.', ' He was discharged to rehabilitation on an\nAFO boot and is to follow up with Dr. Porras in two\nweeks. Dr. ...... will be following him as an outpatient\nregarding his sciatic nerve issues.\n\n\n\n\n\n\nDictated By:Retha Ivory\nMEDQUIST36\n\nD: 1935-5-31 14:52\nT: 1935-5-31 15:17\nJOB#: Taylor LLC-2008-606832\n']
529	29048	117238.0	2150-02-16	Discharge summary	Report	Admission Date: [2150-2-3] Discharge Date: [2150-2-16] Service: CARDIOTHORACIC Allergies: Promethazine/Codeine Attending:[First Name3 (LF) 1267] Chief Complaint: Chest pain and syncope Major Surgical or Invasive Procedure: s/p AVR(19mm Mosaic porcine valve)/Aortic endarterctomy [2-3] s/p pacer placement [2-10] History of Present Illness: This 84WF presented to [Hospital1 18] [Location (un) 620] [2150-1-19] with CP and was in AF. She was treated with Lopressor and Dilt and became asystolic. She was resuscitated and transferred to [Hospital1 18]. She was found to have aortic stenosis and is now admitted for AVR. Past Medical History: Aortic stenosis recent Afib HTN Pseudogout of R knee Hypothyroidism GERD, EGD [2144] Breast Cancer [2102] s/p left mastectomy s/p Hysterectomy Osteoporosis on Evista Aortic Stenosis DJD Hand Iron Deficiency Anemia [2146] Left Shoulder Impingement Syndrome Spinal Stenosis: MRI [10-26] showed severe stenosis of spinal canal and recesses at L4-L5 Osteoarthritis: Right lower extremity pain and lower back pain Paronychia Actinic keratosis on R face Social History: Social history is significant for the absence of current tobacco use. She previously smoked 1 ppd, but quit 40 years ago. There is no history of alcohol abuse. She lives at home with a boarder. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Elderly WF in NAD AVSS HEENT: NC/AT, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+ bilat. with rad murmur Lungs: Clear to A+P CV: RRR w/ III/VI SEM Abd: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, pulses 2+= bilat. throughout Neuro: nonfocal Pertinent Results: [2150-2-14] 07:15AM BLOOD WBC-13.2* RBC-3.61* Hgb-11.0* Hct-32.2* MCV-89 MCH-30.4 MCHC-34.0 RDW-14.0 Plt Ct-294 [2150-2-14] 09:04AM BLOOD PT-24.2* INR(PT)-2.4* [2150-2-14] 07:15AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-139 K-4.1 Cl-99 HCO3-34* AnGap-10 RADIOLOGY Preliminary Report CHEST (PA & LAT) [2150-2-13] 6:12 PM CHEST (PA & LAT) Reason: eval for pleural effusions [Hospital 93] MEDICAL CONDITION: 84 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for pleural effusions CHEST HISTORY: AVR. Two views. Comparison with the previous study done [2150-2-11]. Small bilateral pleural effusions and subsegmental atelectasis or scarring at the right base are again demonstrated. The patient is status post median sternotomy and AVR as before. A bipolar transvenous pacemaker remains in place. Aorta is mildly tortuous and calcified. Mediastinal structures are unchanged. The bony thorax is grossly intact. There are degenerative arthritic changes in the spine. IMPRESSION: Small pleural effusions. Status post AVR. No significant change. DR. [First Name (STitle) ] [Doctor Last Name 4391] DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4392] Brief Hospital Course: The pt. was admitted [2150-2-3] and underwent elective AVR(19mm Mosaic porcine valve)/Aortic endarterectomy. The cross-clamp time was 52 mins., total bypass timewas 72 mins. The pt. tolerated the procedure well and was transferred to the CVICU in stable condition on Propofol and Neo. She had a stable post op night and was extubated on POD#1. She was quite lethargic but eventually was more alert. Her chest tubes were d/c'd on POD#2 and was transferred to the floor on POD#4. She had intermittent AF and was treated with beta blockers. On POD#5 she had a 10 second pause and was paced with her temporary epicardial wires. EP was consulted and on POD#7 she underwent permanent pacer placement. She was restarted on coumadin for afib. She continued to have intermittent rapid a fib and her beta blocker was increased. Her INR became supratherapeutic and her coumadin was held. Her INR came down and she was discharged on 1 mg daily. She was discharged to rehab in stable condition on POD#11. Medications on Admission: Thyroid 15mg PO 5x/week. ASA 81 mg PO daily Ascorbic acid 500 mg PO BID Calcium carbonate 1500mg PO TID Vitamin D3 400 mg PO daily Raloxifene 60 mg PO daily Prilosec 20 mg PO daily Lopressor 12.5 mg PO daily Hexavitamin 1 PO daily Simvistatin 40 mg PO daily Lisinopril 5 mg PO daily Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. 10. Thyroid 30 mg Tablet Sig: 0.5 Tablet PO 5X/WEEK ([Doctor First Name ],MO,WE,TH,SA). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 12. CefazoLIN 1 g IV Q12H pacer Duration: 3 Days 13. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 3 days: Then decrease dose to 400 mg PO daily for 7 days, then decrease to 200 mg PO daily. 16. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Check daily PT, dose for INR goal of [2-21].5. 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Aortic stenosis HTN hypothyroidism GERD s/p breast ca, s/p L mastectomy s/p TAH osteoporosis iron deficiency anemia spinal stenosis Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs for 2 months. After pacer dressing is off (7 days), shower daily, let water flow over wounds. Do not use lotions, powders, or creams on wounds. Call our office for temp. >101.5, sternal drainage. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2150-2-17] 9:00 Make an appointment with Dr. [Last Name (STitle) 4390] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Completed by:[2150-2-14]	Admission Date: <Date>1977-9-13</Date> Discharge Date: <Date>2012-5-26</Date> Service: CARDIOTHORACIC Allergies: Promethazine/Codeine Attending:<Name>Miriam</Name> Chief Complaint: Chest pain and syncope Major Surgical or Invasive Procedure: s/p AVR(19mm Mosaic porcine valve)/Aortic endarterctomy <Date>5-18</Date> s/p pacer placement <Date>7-9</Date> History of Present Illness: This 84WF presented to <Hospital>Porter PLC Hospital</Hospital> <Location>730 Judy Rapid Apt. 491 Muellerfurt, VA 02244</Location> <Date>1984-4-7</Date> with CP and was in AF. She was treated with Lopressor and Dilt and became asystolic. She was resuscitated and transferred to <Hospital>Porter PLC Hospital</Hospital>. She was found to have aortic stenosis and is now admitted for AVR. Past Medical History: Aortic stenosis recent Afib HTN Pseudogout of R knee Hypothyroidism GERD, EGD <Year>1938</Year> Breast Cancer <Year>1938</Year> s/p left mastectomy s/p Hysterectomy Osteoporosis on Evista Aortic Stenosis DJD Hand Iron Deficiency Anemia <Year>1938</Year> Left Shoulder Impingement Syndrome Spinal Stenosis: MRI <Date>7-28</Date> showed severe stenosis of spinal canal and recesses at L4-L5 Osteoarthritis: Right lower extremity pain and lower back pain Paronychia Actinic keratosis on R face Social History: Social history is significant for the absence of current tobacco use. She previously smoked 1 ppd, but quit 40 years ago. There is no history of alcohol abuse. She lives at home with a boarder. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Elderly WF in NAD AVSS HEENT: NC/AT, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+ bilat. with rad murmur Lungs: Clear to A+P CV: RRR w/ III/VI SEM Abd: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, pulses 2+= bilat. throughout Neuro: nonfocal Pertinent Results: <Date>1907-4-7</Date> 07:15AM BLOOD WBC-13.2* RBC-3.61* Hgb-11.0* Hct-32.2* MCV-89 MCH-30.4 MCHC-34.0 RDW-14.0 Plt Ct-294 <Date>1907-4-7</Date> 09:04AM BLOOD PT-24.2* INR(PT)-2.4* <Date>1907-4-7</Date> 07:15AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-139 K-4.1 Cl-99 HCO3-34* AnGap-10 RADIOLOGY Preliminary Report CHEST (PA & LAT) <Date>1979-1-20</Date> 6:12 PM CHEST (PA & LAT) Reason: eval for pleural effusions <Hospital>Miller Inc Health System</Hospital> MEDICAL CONDITION: 84 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for pleural effusions CHEST HISTORY: AVR. Two views. Comparison with the previous study done <Date>2006-5-18</Date>. Small bilateral pleural effusions and subsegmental atelectasis or scarring at the right base are again demonstrated. The patient is status post median sternotomy and AVR as before. A bipolar transvenous pacemaker remains in place. Aorta is mildly tortuous and calcified. Mediastinal structures are unchanged. The bony thorax is grossly intact. There are degenerative arthritic changes in the spine. IMPRESSION: Small pleural effusions. Status post AVR. No significant change. DR. <Name>Isaias</Name> <Doctor Name>Dr.Bogle</Doctor Name> DR. <Name>Aparna</Name> <Name>Kwan</Name> Brief Hospital Course: The pt. was admitted <Date>1977-9-13</Date> and underwent elective AVR(19mm Mosaic porcine valve)/Aortic endarterectomy. The cross-clamp time was 52 mins., total bypass timewas 72 mins. The pt. tolerated the procedure well and was transferred to the CVICU in stable condition on Propofol and Neo. She had a stable post op night and was extubated on POD#1. She was quite lethargic but eventually was more alert. Her chest tubes were d/c'd on POD#2 and was transferred to the floor on POD#4. She had intermittent AF and was treated with beta blockers. On POD#5 she had a 10 second pause and was paced with her temporary epicardial wires. EP was consulted and on POD#7 she underwent permanent pacer placement. She was restarted on coumadin for afib. She continued to have intermittent rapid a fib and her beta blocker was increased. Her INR became supratherapeutic and her coumadin was held. Her INR came down and she was discharged on 1 mg daily. She was discharged to rehab in stable condition on POD#11. Medications on Admission: Thyroid 15mg PO 5x/week. ASA 81 mg PO daily Ascorbic acid 500 mg PO BID Calcium carbonate 1500mg PO TID Vitamin D3 400 mg PO daily Raloxifene 60 mg PO daily Prilosec 20 mg PO daily Lopressor 12.5 mg PO daily Hexavitamin 1 PO daily Simvistatin 40 mg PO daily Lisinopril 5 mg PO daily Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. 10. Thyroid 30 mg Tablet Sig: 0.5 Tablet PO 5X/WEEK (<Name>Heath</Name>,MO,WE,TH,SA). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 12. CefazoLIN 1 g IV Q12H pacer Duration: 3 Days 13. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 3 days: Then decrease dose to 400 mg PO daily for 7 days, then decrease to 200 mg PO daily. 16. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Check daily PT, dose for INR goal of <Date>1-30</Date>.5. 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: <Hospital>Jones, May and Miller Clinic</Hospital> & Rehab Center - <Hospital>Montes, Moore and Lewis Clinic</Hospital> Discharge Diagnosis: Aortic stenosis HTN hypothyroidism GERD s/p breast ca, s/p L mastectomy s/p TAH osteoporosis iron deficiency anemia spinal stenosis Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs for 2 months. After pacer dressing is off (7 days), shower daily, let water flow over wounds. Do not use lotions, powders, or creams on wounds. Call our office for temp. >101.5, sternal drainage. Followup Instructions: Provider: <Name>Meena Prieto</Name> CLINIC Phone:<Telephone>481-904-3119</Telephone> Date/Time:<Date>1997-1-24</Date> 9:00 Make an appointment with Dr. <Name>Johnson</Name> for 1-2 weeks. Make an appointment with Dr. <Name>Harris</Name> for 4 weeks. Completed 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Date: 1977-9-13 Discharge Date: 2012-5-26 Service: CARDIOTHORACIC Allergies: Promethazine/Codeine Attending:Miriam Chief Complaint: Chest pain and syncope Major Surgical or Invasive Procedure: s/p AVR(19mm Mosaic porcine valve)/Aortic endarterctomy 5-18 s/p pacer placement 7-9 History of Present Illness: This 84WF presented to Porter PLC Hospital 730 Judy Rapid Apt. 491 Muellerfurt, VA 02244 1984-4-7 with CP and was in AF. She was treated with Lopressor and Dilt and became asystolic. She was resuscitated and transferred to Porter PLC Hospital. She was found to have aortic stenosis and is now admitted for AVR. Past Medical History: Aortic stenosis recent Afib HTN Pseudogout of R knee Hypothyroidism GERD, EGD 1938 Breast Cancer 1938 s/p left mastectomy s/p Hysterectomy Osteoporosis on Evista Aortic Stenosis DJD Hand Iron Deficiency Anemia 1938 Left Shoulder Impingement Syndrome Spinal Stenosis: MRI 7-28 showed severe stenosis of spinal canal and recesses at L4-L5 Osteoarthritis: Right lower extremity pain and lower back pain Paronychia Actinic keratosis on R face Social History: Social history is significant for the absence of current tobacco use. She previously smoked 1 ppd, but quit 40 years ago. There is no history of alcohol abuse. She lives at home with a boarder. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Elderly WF in NAD AVSS HEENT: NC/AT, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+ bilat. with rad murmur Lungs: Clear to A+P CV: RRR w/ III/VI SEM Abd: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, pulses 2+= bilat. throughout Neuro: nonfocal Pertinent Results: 1907-4-7 07:15AM BLOOD WBC-13.2* RBC-3.61* Hgb-11.0* Hct-32.2* MCV-89 MCH-30.4 MCHC-34.0 RDW-14.0 Plt Ct-294 1907-4-7 09:04AM BLOOD PT-24.2* INR(PT)-2.4* 1907-4-7 07:15AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-139 K-4.1 Cl-99 HCO3-34* AnGap-10 RADIOLOGY Preliminary Report CHEST (PA & LAT) 1979-1-20 6:12 PM CHEST (PA & LAT) Reason: eval for pleural effusions Miller Inc Health System MEDICAL CONDITION: 84 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for pleural effusions CHEST HISTORY: AVR. Two views. Comparison with the previous study done 2006-5-18. Small bilateral pleural effusions and subsegmental atelectasis or scarring at the right base are again demonstrated. The patient is status post median sternotomy and AVR as before. A bipolar transvenous pacemaker remains in place. Aorta is mildly tortuous and calcified. Mediastinal structures are unchanged. The bony thorax is grossly intact. There are degenerative arthritic changes in the spine. IMPRESSION: Small pleural effusions. Status post AVR. No significant change. DR. Isaias Dr.Bogle DR. Aparna Kwan Brief Hospital Course: The pt. was admitted 1977-9-13 and underwent elective AVR(19mm Mosaic porcine valve)/Aortic endarterectomy. The cross-clamp time was 52 mins., total bypass timewas 72 mins. The pt. tolerated the procedure well and was transferred to the CVICU in stable condition on Propofol and Neo. She had a stable post op night and was extubated on POD#1. She was quite lethargic but eventually was more alert. Her chest tubes were d/c'd on POD#2 and was transferred to the floor on POD#4. She had intermittent AF and was treated with beta blockers. On POD#5 she had a 10 second pause and was paced with her temporary epicardial wires. EP was consulted and on POD#7 she underwent permanent pacer placement. She was restarted on coumadin for afib. She continued to have intermittent rapid a fib and her beta blocker was increased. Her INR became supratherapeutic and her coumadin was held. Her INR came down and she was discharged on 1 mg daily. She was discharged to rehab in stable condition on POD#11. Medications on Admission: Thyroid 15mg PO 5x/week. ASA 81 mg PO daily Ascorbic acid 500 mg PO BID Calcium carbonate 1500mg PO TID Vitamin D3 400 mg PO daily Raloxifene 60 mg PO daily Prilosec 20 mg PO daily Lopressor 12.5 mg PO daily Hexavitamin 1 PO daily Simvistatin 40 mg PO daily Lisinopril 5 mg PO daily Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. 10. Thyroid 30 mg Tablet Sig: 0.5 Tablet PO 5X/WEEK (Heath,MO,WE,TH,SA). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 12. CefazoLIN 1 g IV Q12H pacer Duration: 3 Days 13. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 3 days: Then decrease dose to 400 mg PO daily for 7 days, then decrease to 200 mg PO daily. 16. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Check daily PT, dose for INR goal of 1-30.5. 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: Jones, May and Miller Clinic & Rehab Center - Montes, Moore and Lewis Clinic Discharge Diagnosis: Aortic stenosis HTN hypothyroidism GERD s/p breast ca, s/p L mastectomy s/p TAH osteoporosis iron deficiency anemia spinal stenosis Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs for 2 months. After pacer dressing is off (7 days), shower daily, let water flow over wounds. Do not use lotions, powders, or creams on wounds. Call our office for temp. >101.5, sternal drainage. Followup Instructions: Provider: Meena Prieto CLINIC Phone:481-904-3119 Date/Time:1997-1-24 9:00 Make an appointment with Dr. Johnson for 1-2 weeks. Make an appointment with Dr. Harris for 4 weeks. Completed by:1907-4-7	['Admission Date: 1977-9-13 Discharge Date: 2012-5-26\n\n\nService: CARDIOTHORACIC\n\nAllergies:\nPromethazine/Codeine\n\nAttending:Miriam\nChief Complaint:\nChest pain and syncope\n\nMajor Surgical or Invasive Procedure:\ns/p AVR(19mm Mosaic porcine valve)/Aortic endarterctomy 5-18\ns/p pacer placement 7-9\n\n\nHistory of Present Illness:\nThis 84WF presented to Porter PLC Hospital 730 Judy Rapid Apt. 491\nMuellerfurt, VA 02244 1984-4-7 with CP and was in\nAF. She was treated with Lopressor and Dilt and became\nasystolic. She was resuscitated and transferred to Porter PLC Hospital. She\nwas found to have aortic stenosis and is now admitted for AVR.\n\nPast Medical History:\nAortic stenosis\nrecent Afib\nHTN\nPseudogout of R knee\nHypothyroidism\nGERD, EGD 1938\nBreast Cancer 1938 s/p left mastectomy\ns/p Hysterectomy\nOsteoporosis on Evista\nAortic Stenosis\nDJD Hand\nIron Deficiency Anemia 1938\nLeft Shoulder Impingement Syndrome\nSpinal Stenosis: MRI 7-28 showed severe stenosis of spinal\ncanal and recesses at L4-L5\nOsteoarthritis: Right lower extremity pain and lower back pain\nParonychia\nActinic keratosis on R face\n\nSocial History:\nSocial history is significant for the absence of current tobacco\nuse.', ' She previously smoked 1 ppd, but quit 40 years ago. There\nis no history of alcohol abuse. She lives at home with a\nboarder.\n\n\nFamily History:\nThere is no family history of premature coronary artery disease\nor sudden death.\n\nPhysical Exam:\nElderly WF in NAD\nAVSS\nHEENT: NC/AT, oropharynx benign\nNeck: supple, FROM, no lymphadenopathy or thyromegaly, carotids\n2+ bilat. with rad murmur\nLungs: Clear to A+P\nCV: RRR w/ III/VI SEM\nAbd: +BS, soft, nontender, without masses or hepatosplenomegaly\nExt: without C/C/E, pulses 2+= bilat. throughout\nNeuro: nonfocal\n\nPertinent Results:\n1907-4-7 07:15AM BLOOD WBC-13.2* RBC-3.61* Hgb-11.0* Hct-32.2\nMCV-89 MCH-30.4 MCHC-34.0 RDW-14.0 Plt Ct-294\n1907-4-7 09:04AM BLOOD PT-24.2 INR(PT)-2.4\n1907-4-7 07:15AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-139\nK-4.1 Cl-99 HCO3-34 AnGap-10\nRADIOLOGY Preliminary Report\n\nCHEST (PA & LAT) 1979-1-20 6:12 PM\n\nCHEST (PA & LAT)\n\nReason: eval for pleural effusions\n\nMiller Inc Health System MEDICAL CONDITION:\n84 year old woman s/p AVR\nREASON FOR THIS EXAMINATION:\neval for pleural effusions\nCHEST\n\nHISTORY: AVR.', '\n\nTwo views. Comparison with the previous study done 2006-5-18.\nSmall bilateral pleural effusions and subsegmental atelectasis\nor scarring at the right base are again demonstrated. The\npatient is status post median sternotomy and AVR as before. A\nbipolar transvenous pacemaker remains in place. Aorta is mildly\ntortuous and calcified. Mediastinal structures are unchanged.\nThe bony thorax is grossly intact. There are degenerative\narthritic changes in the spine.\n\nIMPRESSION: Small pleural effusions. Status post AVR. No\nsignificant change.\n\nDR. Isaias Dr.Bogle\nDR. Aparna Kwan\n\n\n\n\n\nBrief Hospital Course:\nThe pt. was admitted 1977-9-13 and underwent elective AVR(19mm\nMosaic porcine valve)/Aortic endarterectomy. The cross-clamp\ntime was 52 mins., total bypass timewas 72 mins. The pt.\ntolerated the procedure well and was transferred to the CVICU in\nstable condition on Propofol and Neo.', " She had a stable post op\nnight and was extubated on POD#1. She was quite lethargic but\neventually was more alert. Her chest tubes were d/c'd on POD#2\nand was transferred to the floor on POD#4. She had intermittent\nAF and was treated with beta blockers. On POD#5 she had a 10\nsecond pause and was paced with her temporary epicardial wires.\nEP was consulted and on POD#7 she underwent permanent pacer\nplacement. She was restarted on coumadin for afib. She\ncontinued to have intermittent rapid a fib and her beta blocker\nwas increased. Her INR became supratherapeutic and her coumadin\nwas held. Her INR came down and she was discharged on 1 mg\ndaily. She was discharged to rehab in stable condition on\nPOD#11.\n\nMedications on Admission:\nThyroid 15mg PO 5x/week.\nASA 81 mg PO daily\nAscorbic acid 500 mg PO BID\nCalcium carbonate 1500mg PO TID\nVitamin D3 400 mg PO daily\nRaloxifene 60 mg PO daily\nPrilosec 20 mg PO daily\nLopressor 12.", '5 mg PO daily\nHexavitamin 1 PO daily\nSimvistatin 40 mg PO daily\nLisinopril 5 mg PO daily\n\nDischarge Medications:\n1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:\nOne (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)\nfor 5 days.\n2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\n4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n5. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().\n6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3\ntimes a day).\n8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID\n(3 times a day).', '\n9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) for 5 days.\n10. Thyroid 30 mg Tablet Sig: 0.5 Tablet PO 5X/WEEK\n(Heath,MO,WE,TH,SA).\n11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)\nTablet, Chewable PO QID (4 times a day) as needed.\n12. CefazoLIN 1 g IV Q12H pacer Duration: 3 Days\n13. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\nhours) as needed.\n14. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3\ntimes a day).\n15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times\na day) for 3 days: Then decrease dose to 400 mg PO daily for 7\ndays, then decrease to 200 mg PO daily.\n16. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:\nCheck daily PT, dose for INR goal of 1-30.5.\n17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H\n(every 4 hours) as needed.', '\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nJones, May and Miller Clinic & Rehab Center - Montes, Moore and Lewis Clinic\n\nDischarge Diagnosis:\nAortic stenosis\nHTN\nhypothyroidism\nGERD\ns/p breast ca, s/p L mastectomy\ns/p TAH\nosteoporosis\niron deficiency anemia\nspinal stenosis\n\n\nDischarge Condition:\nGood.\n\n\nDischarge Instructions:\nFollow medications on discharge instructions.\nDo not drive for 4 weeks.\nDo not lift more than 10 lbs for 2 months.\nAfter pacer dressing is off (7 days), shower daily, let water\nflow over wounds.\nDo not use lotions, powders, or creams on wounds.\nCall our office for temp. >101.5, sternal drainage.\n\nFollowup Instructions:\nProvider: Meena Prieto CLINIC Phone:481-904-3119 Date/Time:1997-1-24\n9:00\nMake an appointment with Dr. Johnson for 1-2 weeks.\nMake an appointment with Dr.', ' Harris for 4 weeks.\n\n\n\nCompleted by:1907-4-7']
530	54589	131896.0	2165-10-16	Discharge summary	Report	Admission Date: [2165-10-10] Discharge Date: [2165-10-16] Date of Birth: [2107-12-18] Sex: M Service: MEDICINE Allergies: Iodine Attending:[First Name3 (LF) 4393] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 57 year old male with history of EtOH and HCV cirrhosis (genotype 1, treatment-naive) complicated by ascites, hepatic encephalopathy, with most recent EGD in [2163] showing no varices, as well as seizure disorder, polysubstance abuse on methadone, with recent admission for hepatic encephalopathy, now referred from his PCP's office for hyperkalemia and acute renal failure. He admits that he is often noncompliant with her medications, and is almost completely reliant on his sister [Name (NI) ] to administer them (he can't even say which meds he's on). His last admission ([9-13] - [2165-9-19]) was notable for hyponatremia, hyperkalemia, acute kidney injury, and encephalopathy. He underwent large volume paracentesis (4.7L), from which the peritoneal fluid grew GPCs and he was treated with vancomycin for 48 hours until cultures returned showing one bottle growing peptostreptococcus (believed to be a contaminant). Antibiotics were discontinued at that time and he had no further signs of infection for the remainder of his hospital stay. His acute kidney injury was thought to be related to hypovolemia from overdiuresis, improved with IV albumin. His hyperkalemia was treated with kayexylate and the hyponatremia improved with fluid restriction (132 on discharge). His hepatic encephalopathy resolved with lactlose. He was given ciprofloxacin 250mg daily for SBP prohpylaxis (given low peritoneal fluid protein) and spironolactone was decreased from 200 to 100mg + furosemide decreased from 80 to 40mg. Since discharge, patient has had 3 weekly, large volume paracenteses ([9-24] - 5L, [10-3] - 4.75L, [10-7] - 3L). He was seen by his PCP today who checked routine labs, which showed K+ of 6.8 along with acute kidney injury (creatinine of he was referred to the ED for further management. In the ED, triage vitals were 96.7 73 109/65 20 97%. He was AAox3 and without complaints. Labs showed K 6.8, Na 121 (ranging 121-132 in past 20 days) Cr 1.9 (baseline ranging 0.9- 1.8 in past 20 days) INR 1.7, AST 47 ALT 89 tbili 1.4, Lactate 2.1. EKG reportedly had no peaked T waves, He was given calcium gluconate, dextrose + insulin, kayexelate, and 1L IV NS. His blood glucose dropped and he started having terrible muscle cramps, requiring morphine and lorazepam to calm him down. He is being admitted to the ICU after he received too much insulin and concern for hypoglycemia. On arrival to the MICU, he is awake, oriented, but sleepy. His muscle cramps are much improved and he is having lots of diarrhea. His electrolytes have started to normalize. Past Medical History: - Cirrhosis [2-21] EtOH and HCV (genotype 1, treatment naive) --- Decompensations: hepatic encephalopathy, ascites requiring weekly paracenteses, --- IV drug abuse (quit in [2151]) --- Alcohol abuse (quit in [2151]) --- Confirmed by biopsy in [2159] --- Being actively considered by transplant - Seizure disorder, not on any AEDs - Polysubstance abuse, on methadone Social History: Tobacco history: [3-24] ppd currently. 40 years total. -ETOH: None since [2151] -Illicit drugs: Previous Heroin, none since [2151] -Home: Lives with brother and sister. Does hobbies around the house. Family History: Father - unknown Mother - deceased age 71, ?cancer, hypercholesterolemia Siblings - AIDS, hypercholesterolemia Physical Exam: On admission: Vitals: T: 97.7, BP:121/62, P: 113, R 20, O2:97% RA General: alert, oriented, no acute distress, but requires re-directing to keep his attention; temporal wasting HEENT: Sclera anicteric, MMM, oropharynx clear, edentulous; EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops; chest remarkable for gynecomastia Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: markedly distended and tympanitic, non-tender, bowel sounds present, significant splenomegaly palpated with some ascites leaking from umbilicus and prior paracentesis sites GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: + asterixis, CNII-XII intact, 5/5 strength upper/lower extremities (able to sit himself up for lung exam), grossly normal sensation, gait deferred Discharge PE: Physical Exam: VS: 98.7, 109/54, 79, 18, 94% RA I/O 300 alb, 960 PO, 825 urine, 2BM General: A&Ox3; in NAD HEENT: Sclera anicteric CV: RRR, no murmurs Chest: gynecomastia Skin: scattered angiomata Lungs: CTAB with decreased BS at the bases bilaterally, no wheezes, rales, rhonchi Abdomen: distended but soft, non-tender, bowel sounds present Ext: warm, well perfused, 2+ DP pulses, trace LE edema with overlying increased skin pigmentation Neuro: minimal asterixis Pertinent Results: Labs on admission [2165-10-10] 06:05PM BLOOD WBC-9.4 RBC-3.68* Hgb-13.1* Hct-40.0 MCV-109* MCH-35.6* MCHC-32.7 RDW-13.2 Plt Ct-106* [2165-10-10] 06:05PM BLOOD Neuts-73.8* Lymphs-12.8* Monos-12.3* Eos-0.7 Baso-0.3 [2165-10-10] 06:05PM BLOOD PT-17.6* PTT-41.9* INR(PT)-1.7* [2165-10-9] 01:07PM BLOOD UreaN-41* Creat-1.8* Na-121* K-5.9* Cl-89* HCO3-27 AnGap-11 [2165-10-10] 06:05PM BLOOD ALT-47* AST-78* CK(CPK)-50 AlkPhos-95 TotBili-1.4 [2165-10-10] 06:05PM BLOOD Albumin-3.0* Calcium-8.9 Phos-4.7# Mg-2.4 [2165-10-10] 06:21PM BLOOD Lactate-2.1 MICRO: Blood cx [10-10]: pending (NGTD) Urine cx [10-11]: neg Ascites cx [10-11]: pending (NGTD) IMAGING: RUQ U/S [10-11]: 1. Cirrhosis with large volume ascites. 2. Patent hepatic vasculature. 3. Unchanged dilatation of the common bile duct to 10 mm without intrahepatic biliary duct dilatation. CXR [10-11]: Heart size is normal. Mediastinum is normal. Mild interstitial prominence is demonstrated, unchanged since the prior study. Bilateral pleural effusions are moderate, slightly decreased since prior examination but minimally. Upper lungs are essentially clear. There is no pneumothorax. [2165-10-15] 05:50AM BLOOD WBC-4.4 RBC-2.85* Hgb-10.1* Hct-30.9* MCV-108* MCH-35.5* MCHC-32.8 RDW-13.2 Plt Ct-64* [2165-10-13] 06:35AM BLOOD Neuts-54.9 Lymphs-26.9 Monos-14.7* Eos-2.7 Baso-0.8 [2165-10-15] 05:50AM BLOOD Plt Ct-64* [2165-10-15] 05:50AM BLOOD UreaN-44* Creat-1.3* Na-134 K-4.9 Cl-102 HCO3-27 AnGap-10 [2165-10-12] 04:10PM BLOOD FDP-10-40* [2165-10-15] 05:50AM BLOOD ALT-39 AST-74* AlkPhos-50 TotBili-2.5* [2165-10-15] 05:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.5 Brief Hospital Course: 57 year old male with history of EtOH and HCV cirrhosis with multiple prior hospitalizations for encephalopathy and ascites requiring weekly paracenteses, initially admitted to the ICU for stabilization of blood sugars after treatment for hyperkalemia, transferred to the Liver service for management of his ascites and encephalopathy. He was started on lactulose and rifaximin and his encephalopathy cleared. On [10-14] he underwent paracenteses with removal of 3L fluid. On this admission his creatinine peaked at 1.9 on [10-10]. Home Lasix and Aldactone were held. On the floor he was given three units of albumin and creatinine eventually trended down to 1.3. With improvement in [Last Name (un) ], potassium also trended down. On the day of discharge ([10-16]) it was noted to again be elevated at 5.6, confirmed with a value of 5.3 later in the day. He was given a dose of Kayexylate with instructions for outpatient lab draw (LFTs and basic chemistry) on [10-18] and to follow up with Dr. [Last Name (STitle) ] on [2165-10-24]. . >> Active Issues: # Hepatic encephalopathy: Presented with asterixis change in mental status relative to baseline. MS improved with lactulose. Infectious workup negative to date with neg Ucx; tap neg for SBP [10-11]. Bl cx NGTD. CXR without evidence of PNA. RUQ U/S with dopplers unremarkable. . # [Last Name (un) ]: Cr of 1.9 on adm. Cr improved with albumin but plateaued at 1.5. Baseline approx 0.9. Most likely from diuretics causing prerenal azotemia, especially since improvement after albumin but DDx also included HRS. Ulytes c/w prerenal etiology with low Una which may also suggest HRS. Pt given 2 day albumin challenge without significant improvement in Cr. Diuretics held and pt will discharged off diuretics and plan for weekly taps for ascites mgmt. After third albumin dose Creatinine trended down to 1.5 and remained stable at that level until discharge. . # Hyperkalemia: On adm, K 6.8 without EKG changes. Pt given insulin/glucose in ED as well as kayexalate and hyperK resolved. Pt initially with muscle cramping on adm, which resolved with treatment of hyperkalemia. Etiology likely from [Last Name (un) ] in combination with spironolactone and questionable compliance. On day of discharge [10-16] it was noted to be high at 5.6 and then confirmed with repeat chemistries in the afternoon. Pt was given one dose of kayexylate with instructions to go for lab draw on [10-18]. Pt is to follow up with Dr. [Last Name (STitle) ] in [Hospital 1326] clinic on [2165-10-24]. . # Leukocytosis: WBC bump to 12.8 [10-11], and quickly normalized. No clear infectious source. . # Hyponatremia: likely from decompensated cirrhosis. Na as low as 120 and improved with holding diuretics and fluid restriction. . # Thrombocytopenia: plts to 28 on [10-12], improved to 68. DIC/hemolysis labs suggestive that this is most likely related to cirrhosis vs low grade chronic DIC. . # Hypoglycemia: From insulin given in ED for hyperkalemia. Resolved. Likely has nothing to do with the degree of his liver failure, as he does not appear to be in these late stages yet. Fingersticks stable in ICU. . >> Chronic issues: # HCV and EtOH cirrhosis c/b diuretic-refractory ascites requiring weekly therapeutic taps, as well as HE: Asterixis and significant ascites on exam. Receiving transplant work-up as outpt. Continued cipro 250mg daily for now for SBP ppx. HE mgmt per above. Consider TIPS for diuretic refractory ascites. Discontinue diuretics on discharge and proceed with weekly therapeutic taps for ascites mgmt. . # Polysubstance abuse: continue methadone 100 TRANSITIONAL ISSUES # Communication: [Name (NI) 420] [Name (NI) ] (sister) [Telephone/Fax (1) 4408] # Code: Full code # Consider TIPS for diuretic-refractory ascites. # Basic chemistries and LFTs to be drawn on Friday [10-18]. Please follow up at appointment with Dr. [Last Name (STitle) ] on [2165-10-24]. # F/u: Dr. [Last Name (STitle) ] in Liver transplant clinic. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Methadone 100 mg PO DAILY Hold for sedation 2. Lactulose 30 mL PO TID 3. Rifaximin 550 mg PO BID 4. Ciprofloxacin HCl 250 mg PO Q24H 5. Furosemide 40 mg PO DAILY hold for SBP<90 6. Spironolactone 100 mg PO DAILY Hold for K>5.5 7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Discharge Medications: 1. Ciprofloxacin HCl 250 mg PO Q24H 2. Lactulose 30 mL PO TID 3. Methadone 100 mg PO DAILY Hold for sedation 4. Rifaximin 550 mg PO BID 5. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 6. Outpatient Lab Work Please draw LFTs and a basic chemistry panel on [10-18] and fax the results to Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] at ([Telephone/Fax (1) 4409] ICD-9: 571.5. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Acute kidney injury Hyperkalemia Hepatic encephalopathy Secondary diagnosis: Hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 4401], It was a pleasure taking care of you in the hospital. You were admitted because of high potassium levels in your blood and labs suggestive of decreased kidney function. Your blood sugar dropped low after you were given insulin to treat the high potassium levels. You had to be observed overnight in the ICU. You developed a bit of confusion. We did not find any infections to explain this. We gave you lactulose and you improved. Please follow-up at the appointments listed below. Please see the attached list for updates and changes to your home medications. Please make sure to take lactulose so that you have [3-24] bowel movements daily. We have stopped the two diuretics below. Please stop taking them at home: STOP: Furosemide 40 mg by mouth DAILY STOP: Spironolactone 100 mg by mouth DAILY Please have your labs drawn this Friday ([2165-11-17]) and then follow up with our liver center in 2 weeks as below. Followup Instructions: Department: TRANSPLANT When: THURSDAY [2165-10-24] at 11:00 AM With: TRANSPLANT FELLOW & [Doctor Last Name ] [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: LIVER CENTER When: THURSDAY [2165-11-7] at 12:40 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: THURSDAY [2166-2-27] at 1:30 PM With: ULTRASOUND [Telephone/Fax (1) 590] Building: CC [Location (un) 591] [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 4407] Completed by:[2165-10-16]	Admission Date: <Date>1960-3-26</Date> Discharge Date: <Date>2010-2-31</Date> Date of Birth: <Date>2009-5-24</Date> Sex: M Service: MEDICINE Allergies: Iodine Attending:<Name>Uma</Name> Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 57 year old male with history of EtOH and HCV cirrhosis (genotype 1, treatment-naive) complicated by ascites, hepatic encephalopathy, with most recent EGD in <Year>1916</Year> showing no varices, as well as seizure disorder, polysubstance abuse on methadone, with recent admission for hepatic encephalopathy, now referred from his PCP's office for hyperkalemia and acute renal failure. He admits that he is often noncompliant with her medications, and is almost completely reliant on his sister <Name>Heather Feudner</Name> to administer them (he can't even say which meds he's on). His last admission (<Date>2-14</Date> - <Date>1997-1-25</Date>) was notable for hyponatremia, hyperkalemia, acute kidney injury, and encephalopathy. He underwent large volume paracentesis (4.7L), from which the peritoneal fluid grew GPCs and he was treated with vancomycin for 48 hours until cultures returned showing one bottle growing peptostreptococcus (believed to be a contaminant). Antibiotics were discontinued at that time and he had no further signs of infection for the remainder of his hospital stay. His acute kidney injury was thought to be related to hypovolemia from overdiuresis, improved with IV albumin. His hyperkalemia was treated with kayexylate and the hyponatremia improved with fluid restriction (132 on discharge). His hepatic encephalopathy resolved with lactlose. He was given ciprofloxacin 250mg daily for SBP prohpylaxis (given low peritoneal fluid protein) and spironolactone was decreased from 200 to 100mg + furosemide decreased from 80 to 40mg. Since discharge, patient has had 3 weekly, large volume paracenteses (<Date>11-21</Date> - 5L, <Date>2-29</Date> - 4.75L, <Date>12-13</Date> - 3L). He was seen by his PCP today who checked routine labs, which showed K+ of 6.8 along with acute kidney injury (creatinine of he was referred to the ED for further management. In the ED, triage vitals were 96.7 73 109/65 20 97%. He was AAox3 and without complaints. Labs showed K 6.8, Na 121 (ranging 121-132 in past 20 days) Cr 1.9 (baseline ranging 0.9- 1.8 in past 20 days) INR 1.7, AST 47 ALT 89 tbili 1.4, Lactate 2.1. EKG reportedly had no peaked T waves, He was given calcium gluconate, dextrose + insulin, kayexelate, and 1L IV NS. His blood glucose dropped and he started having terrible muscle cramps, requiring morphine and lorazepam to calm him down. He is being admitted to the ICU after he received too much insulin and concern for hypoglycemia. On arrival to the MICU, he is awake, oriented, but sleepy. His muscle cramps are much improved and he is having lots of diarrhea. His electrolytes have started to normalize. Past Medical History: - Cirrhosis <Date>4-19</Date> EtOH and HCV (genotype 1, treatment naive) --- Decompensations: hepatic encephalopathy, ascites requiring weekly paracenteses, --- IV drug abuse (quit in <Year>1916</Year>) --- Alcohol abuse (quit in <Year>1916</Year>) --- Confirmed by biopsy in <Year>1916</Year> --- Being actively considered by transplant - Seizure disorder, not on any AEDs - Polysubstance abuse, on methadone Social History: Tobacco history: <Date>11-8</Date> ppd currently. 40 years total. -ETOH: None since <Year>1916</Year> -Illicit drugs: Previous Heroin, none since <Year>1916</Year> -Home: Lives with brother and sister. Does hobbies around the house. Family History: Father - unknown Mother - deceased age 71, ?cancer, hypercholesterolemia Siblings - AIDS, hypercholesterolemia Physical Exam: On admission: Vitals: T: 97.7, BP:121/62, P: 113, R 20, O2:97% RA General: alert, oriented, no acute distress, but requires re-directing to keep his attention; temporal wasting HEENT: Sclera anicteric, MMM, oropharynx clear, edentulous; EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops; chest remarkable for gynecomastia Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: markedly distended and tympanitic, non-tender, bowel sounds present, significant splenomegaly palpated with some ascites leaking from umbilicus and prior paracentesis sites GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: + asterixis, CNII-XII intact, 5/5 strength upper/lower extremities (able to sit himself up for lung exam), grossly normal sensation, gait deferred Discharge PE: Physical Exam: VS: 98.7, 109/54, 79, 18, 94% RA I/O 300 alb, 960 PO, 825 urine, 2BM General: A&Ox3; in NAD HEENT: Sclera anicteric CV: RRR, no murmurs Chest: gynecomastia Skin: scattered angiomata Lungs: CTAB with decreased BS at the bases bilaterally, no wheezes, rales, rhonchi Abdomen: distended but soft, non-tender, bowel sounds present Ext: warm, well perfused, 2+ DP pulses, trace LE edema with overlying increased skin pigmentation Neuro: minimal asterixis Pertinent Results: Labs on admission <Date>1960-3-26</Date> 06:05PM BLOOD WBC-9.4 RBC-3.68* Hgb-13.1* Hct-40.0 MCV-109* MCH-35.6* MCHC-32.7 RDW-13.2 Plt Ct-106* <Date>1960-3-26</Date> 06:05PM BLOOD Neuts-73.8* Lymphs-12.8* Monos-12.3* Eos-0.7 Baso-0.3 <Date>1960-3-26</Date> 06:05PM BLOOD PT-17.6* PTT-41.9* INR(PT)-1.7* <Date>1945-12-27</Date> 01:07PM BLOOD UreaN-41* Creat-1.8* Na-121* K-5.9* Cl-89* HCO3-27 AnGap-11 <Date>1960-3-26</Date> 06:05PM BLOOD ALT-47* AST-78* CK(CPK)-50 AlkPhos-95 TotBili-1.4 <Date>1960-3-26</Date> 06:05PM BLOOD Albumin-3.0* Calcium-8.9 Phos-4.7# Mg-2.4 <Date>1960-3-26</Date> 06:21PM BLOOD Lactate-2.1 MICRO: Blood cx <Date>5-26</Date>: pending (NGTD) Urine cx <Date>9-22</Date>: neg Ascites cx <Date>9-22</Date>: pending (NGTD) IMAGING: RUQ U/S <Date>9-22</Date>: 1. Cirrhosis with large volume ascites. 2. Patent hepatic vasculature. 3. Unchanged dilatation of the common bile duct to 10 mm without intrahepatic biliary duct dilatation. CXR <Date>9-22</Date>: Heart size is normal. Mediastinum is normal. Mild interstitial prominence is demonstrated, unchanged since the prior study. Bilateral pleural effusions are moderate, slightly decreased since prior examination but minimally. Upper lungs are essentially clear. There is no pneumothorax. <Date>1999-11-31</Date> 05:50AM BLOOD WBC-4.4 RBC-2.85* Hgb-10.1* Hct-30.9* MCV-108* MCH-35.5* MCHC-32.8 RDW-13.2 Plt Ct-64* <Date>1965-11-3</Date> 06:35AM BLOOD Neuts-54.9 Lymphs-26.9 Monos-14.7* Eos-2.7 Baso-0.8 <Date>1999-11-31</Date> 05:50AM BLOOD Plt Ct-64* <Date>1999-11-31</Date> 05:50AM BLOOD UreaN-44* Creat-1.3* Na-134 K-4.9 Cl-102 HCO3-27 AnGap-10 <Date>1929-5-15</Date> 04:10PM BLOOD FDP-10-40* <Date>1999-11-31</Date> 05:50AM BLOOD ALT-39 AST-74* AlkPhos-50 TotBili-2.5* <Date>1999-11-31</Date> 05:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.5 Brief Hospital Course: 57 year old male with history of EtOH and HCV cirrhosis with multiple prior hospitalizations for encephalopathy and ascites requiring weekly paracenteses, initially admitted to the ICU for stabilization of blood sugars after treatment for hyperkalemia, transferred to the Liver service for management of his ascites and encephalopathy. He was started on lactulose and rifaximin and his encephalopathy cleared. On <Date>5-26</Date> he underwent paracenteses with removal of 3L fluid. On this admission his creatinine peaked at 1.9 on <Date>5-26</Date>. Home Lasix and Aldactone were held. On the floor he was given three units of albumin and creatinine eventually trended down to 1.3. With improvement in <Name>Kuykendall</Name>, potassium also trended down. On the day of discharge (<Date>4-12</Date>) it was noted to again be elevated at 5.6, confirmed with a value of 5.3 later in the day. He was given a dose of Kayexylate with instructions for outpatient lab draw (LFTs and basic chemistry) on <Date>6-8</Date> and to follow up with Dr. <Name>Chowdhury</Name> on <Date>1989-3-1</Date>. . >> Active Issues: # Hepatic encephalopathy: Presented with asterixis change in mental status relative to baseline. MS improved with lactulose. Infectious workup negative to date with neg Ucx; tap neg for SBP <Date>9-22</Date>. Bl cx NGTD. CXR without evidence of PNA. RUQ U/S with dopplers unremarkable. . # <Name>Kuykendall</Name>: Cr of 1.9 on adm. Cr improved with albumin but plateaued at 1.5. Baseline approx 0.9. Most likely from diuretics causing prerenal azotemia, especially since improvement after albumin but DDx also included HRS. Ulytes c/w prerenal etiology with low Una which may also suggest HRS. Pt given 2 day albumin challenge without significant improvement in Cr. Diuretics held and pt will discharged off diuretics and plan for weekly taps for ascites mgmt. After third albumin dose Creatinine trended down to 1.5 and remained stable at that level until discharge. . # Hyperkalemia: On adm, K 6.8 without EKG changes. Pt given insulin/glucose in ED as well as kayexalate and hyperK resolved. Pt initially with muscle cramping on adm, which resolved with treatment of hyperkalemia. Etiology likely from <Name>Kuykendall</Name> in combination with spironolactone and questionable compliance. On day of discharge <Date>4-12</Date> it was noted to be high at 5.6 and then confirmed with repeat chemistries in the afternoon. Pt was given one dose of kayexylate with instructions to go for lab draw on <Date>6-8</Date>. Pt is to follow up with Dr. <Name>Chowdhury</Name> in <Hospital>Richards Group Health System</Hospital> clinic on <Date>1989-3-1</Date>. . # Leukocytosis: WBC bump to 12.8 <Date>9-22</Date>, and quickly normalized. No clear infectious source. . # Hyponatremia: likely from decompensated cirrhosis. Na as low as 120 and improved with holding diuretics and fluid restriction. . # Thrombocytopenia: plts to 28 on <Date>1-18</Date>, improved to 68. DIC/hemolysis labs suggestive that this is most likely related to cirrhosis vs low grade chronic DIC. . # Hypoglycemia: From insulin given in ED for hyperkalemia. Resolved. Likely has nothing to do with the degree of his liver failure, as he does not appear to be in these late stages yet. Fingersticks stable in ICU. . >> Chronic issues: # HCV and EtOH cirrhosis c/b diuretic-refractory ascites requiring weekly therapeutic taps, as well as HE: Asterixis and significant ascites on exam. Receiving transplant work-up as outpt. Continued cipro 250mg daily for now for SBP ppx. HE mgmt per above. Consider TIPS for diuretic refractory ascites. Discontinue diuretics on discharge and proceed with weekly therapeutic taps for ascites mgmt. . # Polysubstance abuse: continue methadone 100 TRANSITIONAL ISSUES # Communication: <Name>Ava Tejada</Name> <Name>Heather Feudner</Name> (sister) <Telephone>208-940-1137</Telephone> # Code: Full code # Consider TIPS for diuretic-refractory ascites. # Basic chemistries and LFTs to be drawn on Friday <Date>6-8</Date>. Please follow up at appointment with Dr. <Name>Chowdhury</Name> on <Date>1989-3-1</Date>. # F/u: Dr. <Name>Chowdhury</Name> in Liver transplant clinic. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Methadone 100 mg PO DAILY Hold for sedation 2. Lactulose 30 mL PO TID 3. Rifaximin 550 mg PO BID 4. Ciprofloxacin HCl 250 mg PO Q24H 5. Furosemide 40 mg PO DAILY hold for SBP<90 6. Spironolactone 100 mg PO DAILY Hold for K>5.5 7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Discharge Medications: 1. Ciprofloxacin HCl 250 mg PO Q24H 2. Lactulose 30 mL PO TID 3. Methadone 100 mg PO DAILY Hold for sedation 4. Rifaximin 550 mg PO BID 5. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 6. Outpatient Lab Work Please draw LFTs and a basic chemistry panel on <Date>6-8</Date> and fax the results to Dr. <Name>Leonel</Name> <Name>Kimberly White</Name> at (<Telephone>622-595-8760</Telephone> ICD-9: 571.5. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Acute kidney injury Hyperkalemia Hepatic encephalopathy Secondary diagnosis: Hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. <Name>Blanchar</Name>, It was a pleasure taking care of you in the hospital. You were admitted because of high potassium levels in your blood and labs suggestive of decreased kidney function. Your blood sugar dropped low after you were given insulin to treat the high potassium levels. You had to be observed overnight in the ICU. You developed a bit of confusion. We did not find any infections to explain this. We gave you lactulose and you improved. Please follow-up at the appointments listed below. Please see the attached list for updates and changes to your home medications. Please make sure to take lactulose so that you have <Date>11-8</Date> bowel movements daily. We have stopped the two diuretics below. Please stop taking them at home: STOP: Furosemide 40 mg by mouth DAILY STOP: Spironolactone 100 mg by mouth DAILY Please have your labs drawn this Friday (<Date>1938-2-28</Date>) and then follow up with our liver center in 2 weeks as below. Followup Instructions: Department: TRANSPLANT When: THURSDAY <Date>1989-3-1</Date> at 11:00 AM With: TRANSPLANT FELLOW & <Doctor Name>Dr.Dortch</Doctor Name> <Telephone>490-531-6305</Telephone> Building: LM <Hospital>Mitchell-Smith Clinic</Hospital> Bldg (<Name>Clapp</Name>) <Location>17918 Kimberly Ville Suite 637 Ramirezton, MI 31004</Location> Campus: WEST Best Parking: <Hospital>Mitchell-Smith Clinic</Hospital> Garage Department: LIVER CENTER When: THURSDAY <Date>1956-4-16</Date> at 12:40 PM With: <Name>Bradley Kobayashi</Name> <Name>Eleanor Blanks</Name>, MD <Telephone>786-358-2547</Telephone> Building: LM <Hospital>Mitchell-Smith Clinic</Hospital> Bldg (<Name>Clapp</Name>) <Location>591 Timothy Plains Johnland, NH 96048</Location> Campus: WEST Best Parking: <Hospital>Mitchell-Smith Clinic</Hospital> Garage Department: RADIOLOGY When: THURSDAY <Date>1968-6-19</Date> at 1:30 PM With: ULTRASOUND <Telephone>825-246-9876</Telephone> Building: CC <Location>72705 Kelly Creek Suite 212 New Chadmouth, OR 71779</Location> <Location>17918 Kimberly Ville Suite 637 Ramirezton, MI 31004</Location> Campus: WEST Best Parking: <Location>614 Anthony Cape Hensontown, WV 58982</Location> Garage <Name>Leonel</Name> <Name>Eleanor Blanks</Name> MD <MD Number>32265665</MD Number> Completed by:<Date>2010-2-31</Date>	000000000000000001111111110000000000000000000000000000000011111111100000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000111100011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000001111000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000001111000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1960-3-26 Discharge Date: 2010-2-31 Date of Birth: 2009-5-24 Sex: M Service: MEDICINE Allergies: Iodine Attending:Uma Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 57 year old male with history of EtOH and HCV cirrhosis (genotype 1, treatment-naive) complicated by ascites, hepatic encephalopathy, with most recent EGD in 1916 showing no varices, as well as seizure disorder, polysubstance abuse on methadone, with recent admission for hepatic encephalopathy, now referred from his PCP's office for hyperkalemia and acute renal failure. He admits that he is often noncompliant with her medications, and is almost completely reliant on his sister Heather Feudner to administer them (he can't even say which meds he's on). His last admission (2-14 - 1997-1-25) was notable for hyponatremia, hyperkalemia, acute kidney injury, and encephalopathy. He underwent large volume paracentesis (4.7L), from which the peritoneal fluid grew GPCs and he was treated with vancomycin for 48 hours until cultures returned showing one bottle growing peptostreptococcus (believed to be a contaminant). Antibiotics were discontinued at that time and he had no further signs of infection for the remainder of his hospital stay. His acute kidney injury was thought to be related to hypovolemia from overdiuresis, improved with IV albumin. His hyperkalemia was treated with kayexylate and the hyponatremia improved with fluid restriction (132 on discharge). His hepatic encephalopathy resolved with lactlose. He was given ciprofloxacin 250mg daily for SBP prohpylaxis (given low peritoneal fluid protein) and spironolactone was decreased from 200 to 100mg + furosemide decreased from 80 to 40mg. Since discharge, patient has had 3 weekly, large volume paracenteses (11-21 - 5L, 2-29 - 4.75L, 12-13 - 3L). He was seen by his PCP today who checked routine labs, which showed K+ of 6.8 along with acute kidney injury (creatinine of he was referred to the ED for further management. In the ED, triage vitals were 96.7 73 109/65 20 97%. He was AAox3 and without complaints. Labs showed K 6.8, Na 121 (ranging 121-132 in past 20 days) Cr 1.9 (baseline ranging 0.9- 1.8 in past 20 days) INR 1.7, AST 47 ALT 89 tbili 1.4, Lactate 2.1. EKG reportedly had no peaked T waves, He was given calcium gluconate, dextrose + insulin, kayexelate, and 1L IV NS. His blood glucose dropped and he started having terrible muscle cramps, requiring morphine and lorazepam to calm him down. He is being admitted to the ICU after he received too much insulin and concern for hypoglycemia. On arrival to the MICU, he is awake, oriented, but sleepy. His muscle cramps are much improved and he is having lots of diarrhea. His electrolytes have started to normalize. Past Medical History: - Cirrhosis 4-19 EtOH and HCV (genotype 1, treatment naive) --- Decompensations: hepatic encephalopathy, ascites requiring weekly paracenteses, --- IV drug abuse (quit in 1916) --- Alcohol abuse (quit in 1916) --- Confirmed by biopsy in 1916 --- Being actively considered by transplant - Seizure disorder, not on any AEDs - Polysubstance abuse, on methadone Social History: Tobacco history: 11-8 ppd currently. 40 years total. -ETOH: None since 1916 -Illicit drugs: Previous Heroin, none since 1916 -Home: Lives with brother and sister. Does hobbies around the house. Family History: Father - unknown Mother - deceased age 71, ?cancer, hypercholesterolemia Siblings - AIDS, hypercholesterolemia Physical Exam: On admission: Vitals: T: 97.7, BP:121/62, P: 113, R 20, O2:97% RA General: alert, oriented, no acute distress, but requires re-directing to keep his attention; temporal wasting HEENT: Sclera anicteric, MMM, oropharynx clear, edentulous; EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops; chest remarkable for gynecomastia Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: markedly distended and tympanitic, non-tender, bowel sounds present, significant splenomegaly palpated with some ascites leaking from umbilicus and prior paracentesis sites GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: + asterixis, CNII-XII intact, 5/5 strength upper/lower extremities (able to sit himself up for lung exam), grossly normal sensation, gait deferred Discharge PE: Physical Exam: VS: 98.7, 109/54, 79, 18, 94% RA I/O 300 alb, 960 PO, 825 urine, 2BM General: A&Ox3; in NAD HEENT: Sclera anicteric CV: RRR, no murmurs Chest: gynecomastia Skin: scattered angiomata Lungs: CTAB with decreased BS at the bases bilaterally, no wheezes, rales, rhonchi Abdomen: distended but soft, non-tender, bowel sounds present Ext: warm, well perfused, 2+ DP pulses, trace LE edema with overlying increased skin pigmentation Neuro: minimal asterixis Pertinent Results: Labs on admission 1960-3-26 06:05PM BLOOD WBC-9.4 RBC-3.68* Hgb-13.1* Hct-40.0 MCV-109* MCH-35.6* MCHC-32.7 RDW-13.2 Plt Ct-106* 1960-3-26 06:05PM BLOOD Neuts-73.8* Lymphs-12.8* Monos-12.3* Eos-0.7 Baso-0.3 1960-3-26 06:05PM BLOOD PT-17.6* PTT-41.9* INR(PT)-1.7* 1945-12-27 01:07PM BLOOD UreaN-41* Creat-1.8* Na-121* K-5.9* Cl-89* HCO3-27 AnGap-11 1960-3-26 06:05PM BLOOD ALT-47* AST-78* CK(CPK)-50 AlkPhos-95 TotBili-1.4 1960-3-26 06:05PM BLOOD Albumin-3.0* Calcium-8.9 Phos-4.7# Mg-2.4 1960-3-26 06:21PM BLOOD Lactate-2.1 MICRO: Blood cx 5-26: pending (NGTD) Urine cx 9-22: neg Ascites cx 9-22: pending (NGTD) IMAGING: RUQ U/S 9-22: 1. Cirrhosis with large volume ascites. 2. Patent hepatic vasculature. 3. Unchanged dilatation of the common bile duct to 10 mm without intrahepatic biliary duct dilatation. CXR 9-22: Heart size is normal. Mediastinum is normal. Mild interstitial prominence is demonstrated, unchanged since the prior study. Bilateral pleural effusions are moderate, slightly decreased since prior examination but minimally. Upper lungs are essentially clear. There is no pneumothorax. 1999-11-31 05:50AM BLOOD WBC-4.4 RBC-2.85* Hgb-10.1* Hct-30.9* MCV-108* MCH-35.5* MCHC-32.8 RDW-13.2 Plt Ct-64* 1965-11-3 06:35AM BLOOD Neuts-54.9 Lymphs-26.9 Monos-14.7* Eos-2.7 Baso-0.8 1999-11-31 05:50AM BLOOD Plt Ct-64* 1999-11-31 05:50AM BLOOD UreaN-44* Creat-1.3* Na-134 K-4.9 Cl-102 HCO3-27 AnGap-10 1929-5-15 04:10PM BLOOD FDP-10-40* 1999-11-31 05:50AM BLOOD ALT-39 AST-74* AlkPhos-50 TotBili-2.5* 1999-11-31 05:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.5 Brief Hospital Course: 57 year old male with history of EtOH and HCV cirrhosis with multiple prior hospitalizations for encephalopathy and ascites requiring weekly paracenteses, initially admitted to the ICU for stabilization of blood sugars after treatment for hyperkalemia, transferred to the Liver service for management of his ascites and encephalopathy. He was started on lactulose and rifaximin and his encephalopathy cleared. On 5-26 he underwent paracenteses with removal of 3L fluid. On this admission his creatinine peaked at 1.9 on 5-26. Home Lasix and Aldactone were held. On the floor he was given three units of albumin and creatinine eventually trended down to 1.3. With improvement in Kuykendall, potassium also trended down. On the day of discharge (4-12) it was noted to again be elevated at 5.6, confirmed with a value of 5.3 later in the day. He was given a dose of Kayexylate with instructions for outpatient lab draw (LFTs and basic chemistry) on 6-8 and to follow up with Dr. Chowdhury on 1989-3-1. . >> Active Issues: # Hepatic encephalopathy: Presented with asterixis change in mental status relative to baseline. MS improved with lactulose. Infectious workup negative to date with neg Ucx; tap neg for SBP 9-22. Bl cx NGTD. CXR without evidence of PNA. RUQ U/S with dopplers unremarkable. . # Kuykendall: Cr of 1.9 on adm. Cr improved with albumin but plateaued at 1.5. Baseline approx 0.9. Most likely from diuretics causing prerenal azotemia, especially since improvement after albumin but DDx also included HRS. Ulytes c/w prerenal etiology with low Una which may also suggest HRS. Pt given 2 day albumin challenge without significant improvement in Cr. Diuretics held and pt will discharged off diuretics and plan for weekly taps for ascites mgmt. After third albumin dose Creatinine trended down to 1.5 and remained stable at that level until discharge. . # Hyperkalemia: On adm, K 6.8 without EKG changes. Pt given insulin/glucose in ED as well as kayexalate and hyperK resolved. Pt initially with muscle cramping on adm, which resolved with treatment of hyperkalemia. Etiology likely from Kuykendall in combination with spironolactone and questionable compliance. On day of discharge 4-12 it was noted to be high at 5.6 and then confirmed with repeat chemistries in the afternoon. Pt was given one dose of kayexylate with instructions to go for lab draw on 6-8. Pt is to follow up with Dr. Chowdhury in Richards Group Health System clinic on 1989-3-1. . # Leukocytosis: WBC bump to 12.8 9-22, and quickly normalized. No clear infectious source. . # Hyponatremia: likely from decompensated cirrhosis. Na as low as 120 and improved with holding diuretics and fluid restriction. . # Thrombocytopenia: plts to 28 on 1-18, improved to 68. DIC/hemolysis labs suggestive that this is most likely related to cirrhosis vs low grade chronic DIC. . # Hypoglycemia: From insulin given in ED for hyperkalemia. Resolved. Likely has nothing to do with the degree of his liver failure, as he does not appear to be in these late stages yet. Fingersticks stable in ICU. . >> Chronic issues: # HCV and EtOH cirrhosis c/b diuretic-refractory ascites requiring weekly therapeutic taps, as well as HE: Asterixis and significant ascites on exam. Receiving transplant work-up as outpt. Continued cipro 250mg daily for now for SBP ppx. HE mgmt per above. Consider TIPS for diuretic refractory ascites. Discontinue diuretics on discharge and proceed with weekly therapeutic taps for ascites mgmt. . # Polysubstance abuse: continue methadone 100 TRANSITIONAL ISSUES # Communication: Ava Tejada Heather Feudner (sister) 208-940-1137 # Code: Full code # Consider TIPS for diuretic-refractory ascites. # Basic chemistries and LFTs to be drawn on Friday 6-8. Please follow up at appointment with Dr. Chowdhury on 1989-3-1. # F/u: Dr. Chowdhury in Liver transplant clinic. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Methadone 100 mg PO DAILY Hold for sedation 2. Lactulose 30 mL PO TID 3. Rifaximin 550 mg PO BID 4. Ciprofloxacin HCl 250 mg PO Q24H 5. Furosemide 40 mg PO DAILY hold for SBP5.5 7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Discharge Medications: 1. Ciprofloxacin HCl 250 mg PO Q24H 2. Lactulose 30 mL PO TID 3. Methadone 100 mg PO DAILY Hold for sedation 4. Rifaximin 550 mg PO BID 5. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 6. Outpatient Lab Work Please draw LFTs and a basic chemistry panel on 6-8 and fax the results to Dr. Leonel Kimberly White at (622-595-8760 ICD-9: 571.5. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Acute kidney injury Hyperkalemia Hepatic encephalopathy Secondary diagnosis: Hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. Blanchar, It was a pleasure taking care of you in the hospital. You were admitted because of high potassium levels in your blood and labs suggestive of decreased kidney function. Your blood sugar dropped low after you were given insulin to treat the high potassium levels. You had to be observed overnight in the ICU. You developed a bit of confusion. We did not find any infections to explain this. We gave you lactulose and you improved. Please follow-up at the appointments listed below. Please see the attached list for updates and changes to your home medications. Please make sure to take lactulose so that you have 11-8 bowel movements daily. We have stopped the two diuretics below. Please stop taking them at home: STOP: Furosemide 40 mg by mouth DAILY STOP: Spironolactone 100 mg by mouth DAILY Please have your labs drawn this Friday (1938-2-28) and then follow up with our liver center in 2 weeks as below. Followup Instructions: Department: TRANSPLANT When: THURSDAY 1989-3-1 at 11:00 AM With: TRANSPLANT FELLOW & Dr.Dortch 490-531-6305 Building: LM Mitchell-Smith Clinic Bldg (Clapp) 17918 Kimberly Ville Suite 637 Ramirezton, MI 31004 Campus: WEST Best Parking: Mitchell-Smith Clinic Garage Department: LIVER CENTER When: THURSDAY 1956-4-16 at 12:40 PM With: Bradley Kobayashi Eleanor Blanks, MD 786-358-2547 Building: LM Mitchell-Smith Clinic Bldg (Clapp) 591 Timothy Plains Johnland, NH 96048 Campus: WEST Best Parking: Mitchell-Smith Clinic Garage Department: RADIOLOGY When: THURSDAY 1968-6-19 at 1:30 PM With: ULTRASOUND 825-246-9876 Building: CC 72705 Kelly Creek Suite 212 New Chadmouth, OR 71779 17918 Kimberly Ville Suite 637 Ramirezton, MI 31004 Campus: WEST Best Parking: 614 Anthony Cape Hensontown, WV 58982 Garage Leonel Eleanor Blanks MD 32265665 Completed by:2010-2-31	["Admission Date: 1960-3-26 Discharge Date: 2010-2-31\n\nDate of Birth: 2009-5-24 Sex: M\n\nService: MEDICINE\n\nAllergies:\nIodine\n\nAttending:Uma\nChief Complaint:\nHyperkalemia\n\nMajor Surgical or Invasive Procedure:\nParacentesis\n\nHistory of Present Illness:\n57 year old male with history of EtOH and HCV cirrhosis\n(genotype 1, treatment-naive) complicated by ascites, hepatic\nencephalopathy, with most recent EGD in 1916 showing no varices,\nas well as seizure disorder, polysubstance abuse on methadone,\nwith recent admission for hepatic encephalopathy, now referred\nfrom his PCP's office for hyperkalemia and acute renal failure.\nHe admits that he is often noncompliant with her medications,\nand is almost completely reliant on his sister Heather Feudner to\nadminister them (he can't even say which meds he's on).", '\n\nHis last admission (2-14 - 1997-1-25) was notable for\nhyponatremia, hyperkalemia, acute kidney injury, and\nencephalopathy. He underwent large volume paracentesis (4.7L),\nfrom which the peritoneal fluid grew GPCs and he was treated\nwith vancomycin for 48 hours until cultures returned showing one\nbottle growing peptostreptococcus (believed to be a\ncontaminant). Antibiotics were discontinued at that time and he\nhad no further signs of infection for the remainder of his\nhospital stay. His acute kidney injury was thought to be related\nto hypovolemia from overdiuresis, improved with IV albumin. His\nhyperkalemia was treated with kayexylate and the hyponatremia\nimproved with fluid restriction (132 on discharge). His hepatic\nencephalopathy resolved with lactlose. He was given\nciprofloxacin 250mg daily for SBP prohpylaxis (given low\nperitoneal fluid protein) and spironolactone was decreased from\n200 to 100mg + furosemide decreased from 80 to 40mg.', '\n\nSince discharge, patient has had 3 weekly, large volume\nparacenteses (11-21 - 5L, 2-29 - 4.75L, 12-13 - 3L). He was seen by\nhis PCP today who checked routine labs, which showed K+ of 6.8\nalong with acute kidney injury (creatinine of he was referred\nto the ED for further management.\n\nIn the ED, triage vitals were 96.7 73 109/65 20 97%. He was\nAAox3 and without complaints. Labs showed K 6.8, Na 121 (ranging\n121-132 in past 20 days) Cr 1.9 (baseline ranging 0.9- 1.8 in\npast 20 days) INR 1.7, AST 47 ALT 89 tbili 1.4, Lactate 2.1. EKG\nreportedly had no peaked T waves, He was given calcium\ngluconate, dextrose + insulin, kayexelate, and 1L IV NS. His\nblood glucose dropped and he started having terrible muscle\ncramps, requiring morphine and lorazepam to calm him down. He\nis being admitted to the ICU after he received too much insulin\nand concern for hypoglycemia.', '\n\nOn arrival to the MICU, he is awake, oriented, but sleepy. His\nmuscle cramps are much improved and he is having lots of\ndiarrhea. His electrolytes have started to normalize.\n\n\nPast Medical History:\n- Cirrhosis 4-19 EtOH and HCV (genotype 1, treatment naive)\n--- Decompensations: hepatic encephalopathy, ascites requiring\nweekly paracenteses,\n--- IV drug abuse (quit in 1916)\n--- Alcohol abuse (quit in 1916)\n--- Confirmed by biopsy in 1916\n--- Being actively considered by transplant\n- Seizure disorder, not on any AEDs\n- Polysubstance abuse, on methadone\n\n\nSocial History:\nTobacco history: 11-8 ppd currently. 40 years total.\n-ETOH: None since 1916\n-Illicit drugs: Previous Heroin, none since 1916\n-Home: Lives with brother and sister. Does hobbies around the\nhouse.\n\n\nFamily History:\nFather - unknown\nMother - deceased age 71, ?cancer, hypercholesterolemia\nSiblings - AIDS, hypercholesterolemia\n\n\nPhysical Exam:\nOn admission:\nVitals: T: 97.', '7, BP:121/62, P: 113, R 20, O2:97% RA\nGeneral: alert, oriented, no acute distress, but requires\nre-directing to keep his attention; temporal wasting\nHEENT: Sclera anicteric, MMM, oropharynx clear, edentulous;\nEOMI, PERRL\nNeck: supple, JVP not elevated, no LAD\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops; chest remarkable for gynecomastia\nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi\nAbdomen: markedly distended and tympanitic, non-tender, bowel\nsounds present, significant splenomegaly palpated with some\nascites leaking from umbilicus and prior paracentesis sites\nGU: no foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema\nNeuro: + asterixis, CNII-XII intact, 5/5 strength upper/lower\nextremities (able to sit himself up for lung exam), grossly\nnormal sensation, gait deferred\n\nDischarge PE:\nPhysical Exam:\nVS: 98.', '7, 109/54, 79, 18, 94% RA\nI/O 300 alb, 960 PO, 825 urine, 2BM\nGeneral: A&Ox3; in NAD\nHEENT: Sclera anicteric\nCV: RRR, no murmurs\nChest: gynecomastia\nSkin: scattered angiomata\nLungs: CTAB with decreased BS at the bases bilaterally, no\nwheezes, rales, rhonchi\nAbdomen: distended but soft, non-tender, bowel sounds present\nExt: warm, well perfused, 2+ DP pulses, trace LE edema with\noverlying increased skin pigmentation\nNeuro: minimal asterixis\n\n\nPertinent Results:\nLabs on admission\n1960-3-26 06:05PM BLOOD WBC-9.4 RBC-3.68* Hgb-13.1* Hct-40.0\nMCV-109* MCH-35.6* MCHC-32.7 RDW-13.2 Plt Ct-106\n1960-3-26 06:05PM BLOOD Neuts-73.8 Lymphs-12.8* Monos-12.3\nEos-0.7 Baso-0.3\n1960-3-26 06:05PM BLOOD PT-17.6 PTT-41.9* INR(PT)-1.7\n1945-12-27 01:07PM BLOOD UreaN-41 Creat-1.8* Na-121* K-5.9\nCl-89 HCO3-27 AnGap-11\n1960-3-26 06:05PM BLOOD ALT-47* AST-78* CK(CPK)-50 AlkPhos-95\nTotBili-1.', '4\n1960-3-26 06:05PM BLOOD Albumin-3.0* Calcium-8.9 Phos-4.7#\nMg-2.4\n1960-3-26 06:21PM BLOOD Lactate-2.1\n\nMICRO:\nBlood cx 5-26: pending (NGTD)\nUrine cx 9-22: neg\nAscites cx 9-22: pending (NGTD)\n\nIMAGING:\nRUQ U/S 9-22:\n1. Cirrhosis with large volume ascites.\n2. Patent hepatic vasculature.\n3. Unchanged dilatation of the common bile duct to 10 mm\nwithout intrahepatic biliary duct dilatation.\n\nCXR 9-22: Heart size is normal. Mediastinum is normal. Mild\ninterstitial prominence is demonstrated, unchanged since the\nprior study. Bilateral pleural effusions are moderate, slightly\ndecreased since prior examination but minimally. Upper lungs\nare essentially clear. There is no pneumothorax.\n\n1999-11-31 05:50AM BLOOD WBC-4.4 RBC-2.85* Hgb-10.1* Hct-30.9\nMCV-108 MCH-35.5* MCHC-32.8 RDW-13.2 Plt Ct-64\n1965-11-3 06:35AM BLOOD Neuts-54.', '9 Lymphs-26.9 Monos-14.7\nEos-2.7 Baso-0.8\n1999-11-31 05:50AM BLOOD Plt Ct-64\n1999-11-31 05:50AM BLOOD UreaN-44 Creat-1.3* Na-134 K-4.9 Cl-102\nHCO3-27 AnGap-10\n1929-5-15 04:10PM BLOOD FDP-10-40\n1999-11-31 05:50AM BLOOD ALT-39 AST-74 AlkPhos-50 TotBili-2.5*\n1999-11-31 05:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.5\n\nBrief Hospital Course:\n57 year old male with history of EtOH and HCV cirrhosis with\nmultiple prior hospitalizations for encephalopathy and ascites\nrequiring weekly paracenteses, initially admitted to the ICU for\nstabilization of blood sugars after treatment for hyperkalemia,\ntransferred to the Liver service for management of his ascites\nand encephalopathy. He was started on lactulose and rifaximin\nand his encephalopathy cleared. On 5-26 he underwent\nparacenteses with removal of 3L fluid.', ' On this admission his\ncreatinine peaked at 1.9 on 5-26. Home Lasix and Aldactone were\nheld. On the floor he was given three units of albumin and\ncreatinine eventually trended down to 1.3. With improvement in\nKuykendall, potassium also trended down. On the day of discharge (4-12)\nit was noted to again be elevated at 5.6, confirmed with a value\nof 5.3 later in the day. He was given a dose of Kayexylate with\ninstructions for outpatient lab draw (LFTs and basic chemistry)\non 6-8 and to follow up with Dr. Chowdhury on 1989-3-1.\n.\n>> Active Issues:\n# Hepatic encephalopathy: Presented with asterixis change in\nmental status relative to baseline. MS improved with lactulose.\nInfectious workup negative to date with neg Ucx; tap neg for SBP\n9-22. Bl cx NGTD. CXR without evidence of PNA. RUQ U/S with\ndopplers unremarkable.', '\n.\n# Kuykendall: Cr of 1.9 on adm. Cr improved with albumin but plateaued\nat 1.5. Baseline approx 0.9. Most likely from diuretics causing\nprerenal azotemia, especially since improvement after albumin\nbut DDx also included HRS. Ulytes c/w prerenal etiology with low\nUna which may also suggest HRS. Pt given 2 day albumin challenge\nwithout significant improvement in Cr. Diuretics held and pt\nwill discharged off diuretics and plan for weekly taps for\nascites mgmt. After third albumin dose Creatinine trended down\nto 1.5 and remained stable at that level until discharge.\n.\n# Hyperkalemia: On adm, K 6.8 without EKG changes. Pt given\ninsulin/glucose in ED as well as kayexalate and hyperK resolved.\nPt initially with muscle cramping on adm, which resolved with\ntreatment of hyperkalemia. Etiology likely from Kuykendall in\ncombination with spironolactone and questionable compliance.', ' On\nday of discharge 4-12 it was noted to be high at 5.6 and then\nconfirmed with repeat chemistries in the afternoon. Pt was given\none dose of kayexylate with instructions to go for lab draw on\n6-8. Pt is to follow up with Dr. Chowdhury in Richards Group Health System clinic on\n1989-3-1.\n.\n# Leukocytosis: WBC bump to 12.8 9-22, and quickly normalized.\nNo clear infectious source.\n.\n# Hyponatremia: likely from decompensated cirrhosis. Na as low\nas 120 and improved with holding diuretics and fluid\nrestriction.\n.\n# Thrombocytopenia: plts to 28 on 1-18, improved to 68.\nDIC/hemolysis labs suggestive that this is most likely related\nto cirrhosis vs low grade chronic DIC.\n.\n# Hypoglycemia: From insulin given in ED for hyperkalemia.\nResolved. Likely has nothing to do with the degree of his liver\nfailure, as he does not appear to be in these late stages yet.', '\nFingersticks stable in ICU.\n.\n>> Chronic issues:\n# HCV and EtOH cirrhosis c/b diuretic-refractory ascites\nrequiring weekly therapeutic taps, as well as HE: Asterixis and\nsignificant ascites on exam. Receiving transplant work-up as\noutpt. Continued cipro 250mg daily for now for SBP ppx. HE mgmt\nper above. Consider TIPS for diuretic refractory ascites.\nDiscontinue diuretics on discharge and proceed with weekly\ntherapeutic taps for ascites mgmt.\n.\n# Polysubstance abuse: continue methadone 100\n\nTRANSITIONAL ISSUES\n# Communication: Ava Tejada Heather Feudner (sister) 208-940-1137\n# Code: Full code\n# Consider TIPS for diuretic-refractory ascites.\n# Basic chemistries and LFTs to be drawn on Friday 6-8. Please\nfollow up at appointment with Dr. Chowdhury on 1989-3-1.\n# F/u: Dr. Chowdhury in Liver transplant clinic.', '\n\nMedications on Admission:\nPreadmission medications listed are correct and complete.\nInformation was obtained from webOMR.\n1. Methadone 100 mg PO DAILY\nHold for sedation\n2. Lactulose 30 mL PO TID\n3. Rifaximin 550 mg PO BID\n4. Ciprofloxacin HCl 250 mg PO Q24H\n5. Furosemide 40 mg PO DAILY\nhold for SBP5.5\n7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)\n\n\nDischarge Medications:\n1. Ciprofloxacin HCl 250 mg PO Q24H\n2. Lactulose 30 mL PO TID\n3. Methadone 100 mg PO DAILY\nHold for sedation\n4. Rifaximin 550 mg PO BID\n5. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)\n6. Outpatient Lab Work\nPlease draw LFTs and a basic chemistry panel on 6-8 and fax the\nresults to Dr. Leonel Kimberly White at (622-595-8760\nICD-9: 571.5.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPrimary diagnosis:\nAcute kidney injury\nHyperkalemia\nHepatic encephalopathy\n\nSecondary diagnosis:\nHepatitis C cirrhosis\n\n\nDischarge Condition:\nMental Status: Clear and coherent.', '\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n\nDischarge Instructions:\nDear Mr. Blanchar,\n\nIt was a pleasure taking care of you in the hospital. You were\nadmitted because of high potassium levels in your blood and labs\nsuggestive of decreased kidney function. Your blood sugar\ndropped low after you were given insulin to treat the high\npotassium levels. You had to be observed overnight in the ICU.\nYou developed a bit of confusion. We did not find any infections\nto explain this. We gave you lactulose and you improved.\n\nPlease follow-up at the appointments listed below. Please see\nthe attached list for updates and changes to your home\nmedications. Please make sure to take lactulose so that you have\n11-8 bowel movements daily.\n\nWe have stopped the two diuretics below.', ' Please stop taking them\nat home:\nSTOP: Furosemide 40 mg by mouth DAILY\nSTOP: Spironolactone 100 mg by mouth DAILY\n\nPlease have your labs drawn this Friday (1938-2-28) and then\nfollow up with our liver center in 2 weeks as below.\n\nFollowup Instructions:\nDepartment: TRANSPLANT\nWhen: THURSDAY 1989-3-1 at 11:00 AM\nWith: TRANSPLANT FELLOW & Dr.Dortch 490-531-6305\nBuilding: LM Mitchell-Smith Clinic Bldg (Clapp) 17918 Kimberly Ville Suite 637\nRamirezton, MI 31004\nCampus: WEST Best Parking: Mitchell-Smith Clinic Garage\n\nDepartment: LIVER CENTER\nWhen: THURSDAY 1956-4-16 at 12:40 PM\nWith: Bradley Kobayashi Eleanor Blanks, MD 786-358-2547\nBuilding: LM Mitchell-Smith Clinic Bldg (Clapp) 591 Timothy Plains\nJohnland, NH 96048\nCampus: WEST Best Parking: Mitchell-Smith Clinic Garage\n\nDepartment: RADIOLOGY\nWhen: THURSDAY 1968-6-19 at 1:30 PM\nWith: ULTRASOUND 825-246-9876\nBuilding: CC 72705 Kelly Creek Suite 212\nNew Chadmouth, OR 71779 17918 Kimberly Ville Suite 637\nRamirezton, MI 31004\nCampus: WEST Best Parking: 614 Anthony Cape\nHensontown, WV 58982 Garage\n\n\n Leonel Eleanor Blanks MD 32265665\n\nCompleted by:2010-2-31']
531	14330	128792.0	2111-11-20	Discharge summary	Report	Admission Date: [2111-11-9] Discharge Date: Service: Medical-[Hospital1 ] ADMITTING DIAGNOSIS: Pneumonia. DISCHARGE DIAGNOSIS: MSSA line infection. CHIEF COMPLAINT: Right upper quadrant pain. HISTORY OF PRESENT ILLNESS: [Known firstname ] [Known lastname 4410] is an 82-year-old male with history of end stage renal disease on hemodialysis, atrial fibrillation, peptic ulcer disease, hypertension, SVT and triple A who presented with right upper quadrant pain, right flank pain, nausea, retching and decreased appetite. Three days prior to admission after his routine dialysis, he noted some shakes and later that day he noted some right upper quadrant pain that was intermittent. Associated symptoms included right flank pain, nausea, retching and decreased appetite with poor oral intake. The pain was not associated with eating or position. He describes no previous episodes that were similar to this. At his scheduled dialysis on the day of admission, the dialysis center was unable to access his catheter. Of note, on [2111-6-29] he was admitted to [Hospital1 2025] for line sepsis with MSSA and treated with Vanc and Gent and then switched to Nafcillin for 6 weeks, despite a TEE that was negative for vegetation. REVIEW OF SYSTEMS: Negative for headache, visual changes, chest pain, shortness of breath, PND, orthopnea, diarrhea, change in color of stool, rashes or skin changes. He does complain of chronic constipation and longstanding decreased sensation in his lower extremities. PAST MEDICAL HISTORY: Hypertension, BPH, end stage renal disease on hemodialysis, SVT, CVA, PVD with severe claudication in left leg, status post left transmetatarsal amputation, gastritis and esophagitis, atrial fibrillation, triple A 4.3 cm in 12/98, 4.6 cm in 3/00, right inguinal hernia, GI bleed [2111-6-5] while hospitalized at [Hospital1 2025] for line sepsis. ALLERGIES: No known drug allergies. MEDICATIONS: Amiodarone 200 mg q day, Nephrocaps one mg q day, Phos-Lo 667 mg, three tablets tid, TUMS 500 mg three tabs tid, Percocet 2 tabs q h.s. FAMILY HISTORY: Mother, renal failure. No diabetes, hypertension, coronary artery disease or cancer. SOCIAL HISTORY: Positive for tobacco, two packs per day for 65 years, occasional alcohol, no drugs. He is a retired iron worker. He has three children and lives alone. PHYSICAL EXAMINATION: On admission temperature 99.0, pulse 76, respirations 18, blood pressure 116/70, 88% on room air to 93% on two liters. General, lying in bed in no apparent distress. HEENT: Pupils equal, round and reactive to light, extraocular movements intact. Oropharynx clear. Moist mucus membranes. CV, quiet heart sounds, regular rate and rhythm, no murmurs. Pulmonary clear to auscultation bilaterally. Abdomen soft, non distended, mild right upper quadrant tenderness to deep palpation, no rubs or gallops, normoactive bowel sounds. Back, no CVA tenderness. Extremities, no edema, nontender, left transmetatarsal amputation, unable to palpate DP pulses bilaterally but feet were warm. Neuro, alert and oriented times three, cranial nerves II through XII grossly intact. LABORATORY DATA: White count 13.2, 83 polys, no bands, 10 lymphs, 6 monos, hematocrit 41.5, platelet count 182,000, PT 13.4, INR 1.3, PTT 30.2, sodium 141, potassium 5.2, chloride 94, CO2 27, BUN 69, creatinine 10.5, glucose 87, blood cultures were sent. Chest x-ray showed cardiomegaly and small bilateral pleural effusions, septal line consistent with mild interstitial edema. Cannot rule out left lower lobe pneumonia. CT, triple A measures 4.8 cm maximum, unchanged from [3-/2110], no appendicitis or diverticulitis, small right pleural effusion, bibasilar consolidation, gallstones right inguinal hernia without obstruction or strangulation. HOSPITAL COURSE: While in the Emergency Room the patient's symptoms greatly improved. He was tolerating po in the Emergency Room. He had eaten a hamburger and has very little pain. The patient was admitted for further evaluation of this right upper quadrant pain. Blood culture quickly grew out gram positive cocci which later were found to be MSSA. The patient was started on Vanc 1 gm IV q day. On hospital day #2 the patient began to complain of dyspnea and pleuritic chest pain. He desatted to 87% on three liters which came out to 90% on 100% non rebreather face mask. His temperature was 101.7. ABG showed PO2 of 72, PCO2 41, PH 7.9. The EKG showed atrial fibrillation. He was given 2 mg of Morphine for the pain and they attempted to wean the patient off the non rebreather. However, he became hypotensive with blood pressure 80's/50's, pulse 100-140. He began to become somnolent and did not respond to a 250 cc IV fluid bolus and was transferred to the MICU. While in the ICU the antibiotic coverage was broadened to include Ceftriaxone and Flagyl. The patient's pressures were supported with Neo and the catheter was changed to a right groin Quinton catheter. The patient was stabilized and transferred back to the floor on hospital day #4. On hospital day #5 a TTE was performed that showed a mildly dilated left atrium and a small mass or artifact seen on the aortic valve in the LV outflow tract. At this point the patient had grown out 6 bottles of Oxacillin sensitive staff. The patient's antibiotic coverage was now changed to Oxacillin and Gentamycin. The goal was Oxacillin for six weeks and Gentamycin for two weeks. Throughout the stay the patient received hemodialysis three times a week without complications. On hospital day #8 a repeat chest x-ray was done that showed an increase in the pleural effusion on the right with an appearance of loculation. After prolonged discussions with the patient, the patient declined to have the effusion tapped. The patient continued to have difficulty with access throughout his stay and MR venogram was performed and the venogram showed complete SVC occlusion above the azygous, right brachiocephalic, right subclavian and right IJ occlusion and partial clot in the left brachiocephalic. At this time it was felt that it was unlikely to be able to get a PICC line in the patient. So after discussion with ID, antibiotic coverage was now going to be changed to Oxacillin while an inpatient and Vancomycin dosed at hemodialysis as an outpatient, again for total treatment of 6 weeks. On hospital day #10 the patient developed diarrhea, the diarrhea was non bloody, had no abdominal pain, it was sent for C. diff and as of hospital day 12, one sample had come back negative. On hospital day #9, also the right groin Quinton was removed without complication and on hospital day 11 a tunneled groin cath was placed by IR. This tunneled groin cath was to be used for hemodialysis only. Discussions with transplant surgery were begun and the plan is for an AV fistula after completion of the antibiotics. Discussions were also begun as to option for central access besides groin line. On hospital day #11, it was felt that the patient was appropriate for acute rehab. He was seen by case management and referrals were placed. The total antibiotic therapy was started on [11-12] and the end date is [12-23]. He will receive Oxacillin while an inpatient which will be changed to Vancomycin dosed at hemodialysis as an outpatient. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 910] Dictated By:[Last Name (NamePattern1) 4411] MEDQUIST36 D: [2111-11-20] 09:17 T: [2111-11-20] 09:16 JOB#: [Job Number 4412]	Admission Date: <Date>1900-1-26</Date> Discharge Date: Service: Medical-<Hospital>Moore, Cook and Williams Hospital</Hospital> ADMITTING DIAGNOSIS: Pneumonia. DISCHARGE DIAGNOSIS: MSSA line infection. CHIEF COMPLAINT: Right upper quadrant pain. HISTORY OF PRESENT ILLNESS: <Name>Bernardino</Name> <Name>Amaro</Name> is an 82-year-old male with history of end stage renal disease on hemodialysis, atrial fibrillation, peptic ulcer disease, hypertension, SVT and triple A who presented with right upper quadrant pain, right flank pain, nausea, retching and decreased appetite. Three days prior to admission after his routine dialysis, he noted some shakes and later that day he noted some right upper quadrant pain that was intermittent. Associated symptoms included right flank pain, nausea, retching and decreased appetite with poor oral intake. The pain was not associated with eating or position. He describes no previous episodes that were similar to this. At his scheduled dialysis on the day of admission, the dialysis center was unable to access his catheter. Of note, on <Date>1948-3-31</Date> he was admitted to <Hospital>Young, Ford and Wong Hospital</Hospital> for line sepsis with MSSA and treated with Vanc and Gent and then switched to Nafcillin for 6 weeks, despite a TEE that was negative for vegetation. REVIEW OF SYSTEMS: Negative for headache, visual changes, chest pain, shortness of breath, PND, orthopnea, diarrhea, change in color of stool, rashes or skin changes. He does complain of chronic constipation and longstanding decreased sensation in his lower extremities. PAST MEDICAL HISTORY: Hypertension, BPH, end stage renal disease on hemodialysis, SVT, CVA, PVD with severe claudication in left leg, status post left transmetatarsal amputation, gastritis and esophagitis, atrial fibrillation, triple A 4.3 cm in 12/98, 4.6 cm in 3/00, right inguinal hernia, GI bleed <Date>1972-7-21</Date> while hospitalized at <Hospital>Young, Ford and Wong Hospital</Hospital> for line sepsis. ALLERGIES: No known drug allergies. MEDICATIONS: Amiodarone 200 mg q day, Nephrocaps one mg q day, Phos-Lo 667 mg, three tablets tid, TUMS 500 mg three tabs tid, Percocet 2 tabs q h.s. FAMILY HISTORY: Mother, renal failure. No diabetes, hypertension, coronary artery disease or cancer. SOCIAL HISTORY: Positive for tobacco, two packs per day for 65 years, occasional alcohol, no drugs. He is a retired iron worker. He has three children and lives alone. PHYSICAL EXAMINATION: On admission temperature 99.0, pulse 76, respirations 18, blood pressure 116/70, 88% on room air to 93% on two liters. General, lying in bed in no apparent distress. HEENT: Pupils equal, round and reactive to light, extraocular movements intact. Oropharynx clear. Moist mucus membranes. CV, quiet heart sounds, regular rate and rhythm, no murmurs. Pulmonary clear to auscultation bilaterally. Abdomen soft, non distended, mild right upper quadrant tenderness to deep palpation, no rubs or gallops, normoactive bowel sounds. Back, no CVA tenderness. Extremities, no edema, nontender, left transmetatarsal amputation, unable to palpate DP pulses bilaterally but feet were warm. Neuro, alert and oriented times three, cranial nerves II through XII grossly intact. LABORATORY DATA: White count 13.2, 83 polys, no bands, 10 lymphs, 6 monos, hematocrit 41.5, platelet count 182,000, PT 13.4, INR 1.3, PTT 30.2, sodium 141, potassium 5.2, chloride 94, CO2 27, BUN 69, creatinine 10.5, glucose 87, blood cultures were sent. Chest x-ray showed cardiomegaly and small bilateral pleural effusions, septal line consistent with mild interstitial edema. Cannot rule out left lower lobe pneumonia. CT, triple A measures 4.8 cm maximum, unchanged from <Date>12-1990</Date>, no appendicitis or diverticulitis, small right pleural effusion, bibasilar consolidation, gallstones right inguinal hernia without obstruction or strangulation. HOSPITAL COURSE: While in the Emergency Room the patient's symptoms greatly improved. He was tolerating po in the Emergency Room. He had eaten a hamburger and has very little pain. The patient was admitted for further evaluation of this right upper quadrant pain. Blood culture quickly grew out gram positive cocci which later were found to be MSSA. The patient was started on Vanc 1 gm IV q day. On hospital day #2 the patient began to complain of dyspnea and pleuritic chest pain. He desatted to 87% on three liters which came out to 90% on 100% non rebreather face mask. His temperature was 101.7. ABG showed PO2 of 72, PCO2 41, PH 7.9. The EKG showed atrial fibrillation. He was given 2 mg of Morphine for the pain and they attempted to wean the patient off the non rebreather. However, he became hypotensive with blood pressure 80's/50's, pulse 100-140. He began to become somnolent and did not respond to a 250 cc IV fluid bolus and was transferred to the MICU. While in the ICU the antibiotic coverage was broadened to include Ceftriaxone and Flagyl. The patient's pressures were supported with Neo and the catheter was changed to a right groin Quinton catheter. The patient was stabilized and transferred back to the floor on hospital day #4. On hospital day #5 a TTE was performed that showed a mildly dilated left atrium and a small mass or artifact seen on the aortic valve in the LV outflow tract. At this point the patient had grown out 6 bottles of Oxacillin sensitive staff. The patient's antibiotic coverage was now changed to Oxacillin and Gentamycin. The goal was Oxacillin for six weeks and Gentamycin for two weeks. Throughout the stay the patient received hemodialysis three times a week without complications. On hospital day #8 a repeat chest x-ray was done that showed an increase in the pleural effusion on the right with an appearance of loculation. After prolonged discussions with the patient, the patient declined to have the effusion tapped. The patient continued to have difficulty with access throughout his stay and MR venogram was performed and the venogram showed complete SVC occlusion above the azygous, right brachiocephalic, right subclavian and right IJ occlusion and partial clot in the left brachiocephalic. At this time it was felt that it was unlikely to be able to get a PICC line in the patient. So after discussion with ID, antibiotic coverage was now going to be changed to Oxacillin while an inpatient and Vancomycin dosed at hemodialysis as an outpatient, again for total treatment of 6 weeks. On hospital day #10 the patient developed diarrhea, the diarrhea was non bloody, had no abdominal pain, it was sent for C. diff and as of hospital day 12, one sample had come back negative. On hospital day #9, also the right groin Quinton was removed without complication and on hospital day 11 a tunneled groin cath was placed by IR. This tunneled groin cath was to be used for hemodialysis only. Discussions with transplant surgery were begun and the plan is for an AV fistula after completion of the antibiotics. Discussions were also begun as to option for central access besides groin line. On hospital day #11, it was felt that the patient was appropriate for acute rehab. He was seen by case management and referrals were placed. The total antibiotic therapy was started on <Date>10-26</Date> and the end date is <Date>3-3</Date>. He will receive Oxacillin while an inpatient which will be changed to Vancomycin dosed at hemodialysis as an outpatient. <Name>Frank Pichardo</Name> <Name>Jamila Deng</Name>, M.D. <MD Number>88719235</MD Number> Dictated By:<Name>Kwan</Name> MEDQUIST36 D: <Date>1929-6-23</Date> 09:17 T: <Date>1929-6-23</Date> 09:16 JOB#: <Job Number>Hernandez Ltd-1975-557782</Job 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Date: 1900-1-26 Discharge Date: Service: Medical-Moore, Cook and Williams Hospital ADMITTING DIAGNOSIS: Pneumonia. DISCHARGE DIAGNOSIS: MSSA line infection. CHIEF COMPLAINT: Right upper quadrant pain. HISTORY OF PRESENT ILLNESS: Bernardino Amaro is an 82-year-old male with history of end stage renal disease on hemodialysis, atrial fibrillation, peptic ulcer disease, hypertension, SVT and triple A who presented with right upper quadrant pain, right flank pain, nausea, retching and decreased appetite. Three days prior to admission after his routine dialysis, he noted some shakes and later that day he noted some right upper quadrant pain that was intermittent. Associated symptoms included right flank pain, nausea, retching and decreased appetite with poor oral intake. The pain was not associated with eating or position. He describes no previous episodes that were similar to this. At his scheduled dialysis on the day of admission, the dialysis center was unable to access his catheter. Of note, on 1948-3-31 he was admitted to Young, Ford and Wong Hospital for line sepsis with MSSA and treated with Vanc and Gent and then switched to Nafcillin for 6 weeks, despite a TEE that was negative for vegetation. REVIEW OF SYSTEMS: Negative for headache, visual changes, chest pain, shortness of breath, PND, orthopnea, diarrhea, change in color of stool, rashes or skin changes. He does complain of chronic constipation and longstanding decreased sensation in his lower extremities. PAST MEDICAL HISTORY: Hypertension, BPH, end stage renal disease on hemodialysis, SVT, CVA, PVD with severe claudication in left leg, status post left transmetatarsal amputation, gastritis and esophagitis, atrial fibrillation, triple A 4.3 cm in 12/98, 4.6 cm in 3/00, right inguinal hernia, GI bleed 1972-7-21 while hospitalized at Young, Ford and Wong Hospital for line sepsis. ALLERGIES: No known drug allergies. MEDICATIONS: Amiodarone 200 mg q day, Nephrocaps one mg q day, Phos-Lo 667 mg, three tablets tid, TUMS 500 mg three tabs tid, Percocet 2 tabs q h.s. FAMILY HISTORY: Mother, renal failure. No diabetes, hypertension, coronary artery disease or cancer. SOCIAL HISTORY: Positive for tobacco, two packs per day for 65 years, occasional alcohol, no drugs. He is a retired iron worker. He has three children and lives alone. PHYSICAL EXAMINATION: On admission temperature 99.0, pulse 76, respirations 18, blood pressure 116/70, 88% on room air to 93% on two liters. General, lying in bed in no apparent distress. HEENT: Pupils equal, round and reactive to light, extraocular movements intact. Oropharynx clear. Moist mucus membranes. CV, quiet heart sounds, regular rate and rhythm, no murmurs. Pulmonary clear to auscultation bilaterally. Abdomen soft, non distended, mild right upper quadrant tenderness to deep palpation, no rubs or gallops, normoactive bowel sounds. Back, no CVA tenderness. Extremities, no edema, nontender, left transmetatarsal amputation, unable to palpate DP pulses bilaterally but feet were warm. Neuro, alert and oriented times three, cranial nerves II through XII grossly intact. LABORATORY DATA: White count 13.2, 83 polys, no bands, 10 lymphs, 6 monos, hematocrit 41.5, platelet count 182,000, PT 13.4, INR 1.3, PTT 30.2, sodium 141, potassium 5.2, chloride 94, CO2 27, BUN 69, creatinine 10.5, glucose 87, blood cultures were sent. Chest x-ray showed cardiomegaly and small bilateral pleural effusions, septal line consistent with mild interstitial edema. Cannot rule out left lower lobe pneumonia. CT, triple A measures 4.8 cm maximum, unchanged from 12-1990, no appendicitis or diverticulitis, small right pleural effusion, bibasilar consolidation, gallstones right inguinal hernia without obstruction or strangulation. HOSPITAL COURSE: While in the Emergency Room the patient's symptoms greatly improved. He was tolerating po in the Emergency Room. He had eaten a hamburger and has very little pain. The patient was admitted for further evaluation of this right upper quadrant pain. Blood culture quickly grew out gram positive cocci which later were found to be MSSA. The patient was started on Vanc 1 gm IV q day. On hospital day #2 the patient began to complain of dyspnea and pleuritic chest pain. He desatted to 87% on three liters which came out to 90% on 100% non rebreather face mask. His temperature was 101.7. ABG showed PO2 of 72, PCO2 41, PH 7.9. The EKG showed atrial fibrillation. He was given 2 mg of Morphine for the pain and they attempted to wean the patient off the non rebreather. However, he became hypotensive with blood pressure 80's/50's, pulse 100-140. He began to become somnolent and did not respond to a 250 cc IV fluid bolus and was transferred to the MICU. While in the ICU the antibiotic coverage was broadened to include Ceftriaxone and Flagyl. The patient's pressures were supported with Neo and the catheter was changed to a right groin Quinton catheter. The patient was stabilized and transferred back to the floor on hospital day #4. On hospital day #5 a TTE was performed that showed a mildly dilated left atrium and a small mass or artifact seen on the aortic valve in the LV outflow tract. At this point the patient had grown out 6 bottles of Oxacillin sensitive staff. The patient's antibiotic coverage was now changed to Oxacillin and Gentamycin. The goal was Oxacillin for six weeks and Gentamycin for two weeks. Throughout the stay the patient received hemodialysis three times a week without complications. On hospital day #8 a repeat chest x-ray was done that showed an increase in the pleural effusion on the right with an appearance of loculation. After prolonged discussions with the patient, the patient declined to have the effusion tapped. The patient continued to have difficulty with access throughout his stay and MR venogram was performed and the venogram showed complete SVC occlusion above the azygous, right brachiocephalic, right subclavian and right IJ occlusion and partial clot in the left brachiocephalic. At this time it was felt that it was unlikely to be able to get a PICC line in the patient. So after discussion with ID, antibiotic coverage was now going to be changed to Oxacillin while an inpatient and Vancomycin dosed at hemodialysis as an outpatient, again for total treatment of 6 weeks. On hospital day #10 the patient developed diarrhea, the diarrhea was non bloody, had no abdominal pain, it was sent for C. diff and as of hospital day 12, one sample had come back negative. On hospital day #9, also the right groin Quinton was removed without complication and on hospital day 11 a tunneled groin cath was placed by IR. This tunneled groin cath was to be used for hemodialysis only. Discussions with transplant surgery were begun and the plan is for an AV fistula after completion of the antibiotics. Discussions were also begun as to option for central access besides groin line. On hospital day #11, it was felt that the patient was appropriate for acute rehab. He was seen by case management and referrals were placed. The total antibiotic therapy was started on 10-26 and the end date is 3-3. He will receive Oxacillin while an inpatient which will be changed to Vancomycin dosed at hemodialysis as an outpatient. Frank Pichardo Jamila Deng, M.D. 88719235 Dictated By:Kwan MEDQUIST36 D: 1929-6-23 09:17 T: 1929-6-23 09:16 JOB#: Hernandez Ltd-1975-557782	['Admission Date: 1900-1-26 Discharge Date:\n\n\nService: Medical-Moore, Cook and Williams Hospital\n\nADMITTING DIAGNOSIS: Pneumonia.\n\nDISCHARGE DIAGNOSIS: MSSA line infection.\n\nCHIEF COMPLAINT: Right upper quadrant pain.\n\nHISTORY OF PRESENT ILLNESS: Bernardino Amaro is an 82-year-old\nmale with history of end stage renal disease on hemodialysis,\natrial fibrillation, peptic ulcer disease, hypertension, SVT\nand triple A who presented with right upper quadrant pain,\nright flank pain, nausea, retching and decreased appetite.\nThree days prior to admission after his routine dialysis, he\nnoted some shakes and later that day he noted some right\nupper quadrant pain that was intermittent. Associated\nsymptoms included right flank pain, nausea, retching and\ndecreased appetite with poor oral intake.', ' The pain was not\nassociated with eating or position. He describes no previous\nepisodes that were similar to this. At his scheduled\ndialysis on the day of admission, the dialysis center was\nunable to access his catheter. Of note, on 1948-3-31 he was\nadmitted to Young, Ford and Wong Hospital for line sepsis with MSSA and treated with\nVanc and Gent and then switched to Nafcillin for 6 weeks,\ndespite a TEE that was negative for vegetation.\n\nREVIEW OF SYSTEMS: Negative for headache, visual changes,\nchest pain, shortness of breath, PND, orthopnea, diarrhea,\nchange in color of stool, rashes or skin changes. He does\ncomplain of chronic constipation and longstanding decreased\nsensation in his lower extremities.\n\nPAST MEDICAL HISTORY: Hypertension, BPH, end stage renal\ndisease on hemodialysis, SVT, CVA, PVD with severe\nclaudication in left leg, status post left transmetatarsal\namputation, gastritis and esophagitis, atrial fibrillation,\ntriple A 4.', '3 cm in 12/98, 4.6 cm in 3/00, right inguinal\nhernia, GI bleed 1972-7-21 while hospitalized at Young, Ford and Wong Hospital for line\nsepsis.\n\nALLERGIES: No known drug allergies.\n\nMEDICATIONS: Amiodarone 200 mg q day, Nephrocaps one mg q\nday, Phos-Lo 667 mg, three tablets tid, TUMS 500 mg three\ntabs tid, Percocet 2 tabs q h.s.\n\nFAMILY HISTORY: Mother, renal failure. No diabetes,\nhypertension, coronary artery disease or cancer.\n\nSOCIAL HISTORY: Positive for tobacco, two packs per day for\n65 years, occasional alcohol, no drugs. He is a retired iron\nworker. He has three children and lives alone.\n\nPHYSICAL EXAMINATION: On admission temperature 99.0, pulse\n76, respirations 18, blood pressure 116/70, 88% on room air\nto 93% on two liters. General, lying in bed in no apparent\ndistress. HEENT: Pupils equal, round and reactive to light,\nextraocular movements intact.', ' Oropharynx clear. Moist mucus\nmembranes. CV, quiet heart sounds, regular rate and rhythm,\nno murmurs. Pulmonary clear to auscultation bilaterally.\nAbdomen soft, non distended, mild right upper quadrant\ntenderness to deep palpation, no rubs or gallops, normoactive\nbowel sounds. Back, no CVA tenderness. Extremities, no\nedema, nontender, left transmetatarsal amputation, unable to\npalpate DP pulses bilaterally but feet were warm. Neuro,\nalert and oriented times three, cranial nerves II through XII\ngrossly intact.\n\nLABORATORY DATA: White count 13.2, 83 polys, no bands, 10\nlymphs, 6 monos, hematocrit 41.5, platelet count 182,000, PT\n13.4, INR 1.3, PTT 30.2, sodium 141, potassium 5.2, chloride\n94, CO2 27, BUN 69, creatinine 10.5, glucose 87, blood\ncultures were sent. Chest x-ray showed cardiomegaly and\nsmall bilateral pleural effusions, septal line consistent\nwith mild interstitial edema.', " Cannot rule out left lower\nlobe pneumonia. CT, triple A measures 4.8 cm maximum,\nunchanged from 12-1990, no appendicitis or diverticulitis, small\nright pleural effusion, bibasilar consolidation, gallstones\nright inguinal hernia without obstruction or strangulation.\n\nHOSPITAL COURSE: While in the Emergency Room the patient's\nsymptoms greatly improved. He was tolerating po in the\nEmergency Room. He had eaten a hamburger and has very little\npain. The patient was admitted for further evaluation of\nthis right upper quadrant pain. Blood culture quickly grew\nout gram positive cocci which later were found to be MSSA.\nThe patient was started on Vanc 1 gm IV q day. On hospital\nday #2 the patient began to complain of dyspnea and pleuritic\nchest pain. He desatted to 87% on three liters which came\nout to 90% on 100% non rebreather face mask.", " His temperature\nwas 101.7. ABG showed PO2 of 72, PCO2 41, PH 7.9. The EKG\nshowed atrial fibrillation. He was given 2 mg of Morphine\nfor the pain and they attempted to wean the patient off the\nnon rebreather. However, he became hypotensive with blood\npressure 80's/50's, pulse 100-140. He began to become\nsomnolent and did not respond to a 250 cc IV fluid bolus and\nwas transferred to the MICU. While in the ICU the antibiotic\ncoverage was broadened to include Ceftriaxone and Flagyl.\nThe patient's pressures were supported with Neo and the\ncatheter was changed to a right groin Quinton catheter. The\npatient was stabilized and transferred back to the floor on\nhospital day #4. On hospital day #5 a TTE was performed that\nshowed a mildly dilated left atrium and a small mass or\nartifact seen on the aortic valve in the LV outflow tract.", "\nAt this point the patient had grown out 6 bottles of\nOxacillin sensitive staff. The patient's antibiotic coverage\nwas now changed to Oxacillin and Gentamycin. The goal was\nOxacillin for six weeks and Gentamycin for two weeks.\nThroughout the stay the patient received hemodialysis three\ntimes a week without complications. On hospital day #8 a\nrepeat chest x-ray was done that showed an increase in the\npleural effusion on the right with an appearance of\nloculation. After prolonged discussions with the patient,\nthe patient declined to have the effusion tapped. The\npatient continued to have difficulty with access throughout\nhis stay and MR venogram was performed and the venogram\nshowed complete SVC occlusion above the azygous, right\nbrachiocephalic, right subclavian and right IJ occlusion and\npartial clot in the left brachiocephalic.", ' At this time it\nwas felt that it was unlikely to be able to get a PICC line\nin the patient. So after discussion with ID, antibiotic\ncoverage was now going to be changed to Oxacillin while an\ninpatient and Vancomycin dosed at hemodialysis as an\noutpatient, again for total treatment of 6 weeks. On\nhospital day #10 the patient developed diarrhea, the diarrhea\nwas non bloody, had no abdominal pain, it was sent for C.\ndiff and as of hospital day 12, one sample had come back\nnegative. On hospital day #9, also the right groin Quinton\nwas removed without complication and on hospital day 11 a\ntunneled groin cath was placed by IR. This tunneled groin\ncath was to be used for hemodialysis only. Discussions with\ntransplant surgery were begun and the plan is for an AV\nfistula after completion of the antibiotics.', ' Discussions\nwere also begun as to option for central access besides groin\nline. On hospital day #11, it was felt that the patient was\nappropriate for acute rehab. He was seen by case management\nand referrals were placed. The total antibiotic therapy was\nstarted on 10-26 and the end date is 3-3. He will receive\nOxacillin while an inpatient which will be changed to\nVancomycin dosed at hemodialysis as an outpatient.\n\n\n\n\n Frank Pichardo Jamila Deng, M.D. 88719235\n\nDictated By:Kwan\n\nMEDQUIST36\n\nD: 1929-6-23 09:17\nT: 1929-6-23 09:16\nJOB#: Hernandez Ltd-1975-557782\n']
532	14330	188415.0	2112-05-27	Discharge summary	Report	Admission Date: [2112-5-23] Discharge Date: [2112-5-27] Service: ACOVE HISTORY OF PRESENT ILLNESS: This is an 83 year old male with multiple medical problems including end-stage renal disease on hemodialysis who had initially presented on [5-23] at Hemodialysis with decreased p.o. intake and one week of cough productive of clear sputum. In Hemodialysis, the patient was also noted to be rigoring, at which time blood cultures were drawn and the patient was subsequently sent home. At home, the patient experienced generalized weakness and so presented to the Emergency Department. In the Emergency Department, initial vital signs were a temperature of 103.0 F.; heart rate 88; blood pressure 94/68; respiratory rate 20; pulse oximetry 96% on room air. Emergency Department work-up revealed a slight left shift without elevated white blood cell count and a left lower lobe infiltrate on chest x-ray. The patient was treated in the Emergency Department with Vancomycin 1 gram and Gentamicin 100 mg given his history of prior Methicillin sensitive Staphylococcus aureus line sepsis. The patient experienced an episode of hypotension to 64/40 in the Emergency Department, which was asymptomatic (normal mentation). The patient was bolused one liter of normal saline and systolic blood pressure increased appropriately to 107. Per the patient, his baseline blood pressure is 90 to 100 systolic, and generally 85 systolic following hemodialysis. The patient was admitted to the Medical Intensive Care Unit from the Emergency Department for relative hypotension and concern for sepsis. On arrival to the Medical Intensive Care Unit, temperature was 99.2 F.; heart rate 66; blood pressure 94/36; respirations 15; pulse oximetry 95% on room air and the patient was asymptomatic. The Medical Intensive Care Unit course was notable for the addition of Levofloxacin to the patient's antibiotic regimen for atypical organism coverage in the setting of community acquired pneumonia. The patient did not receive any further doses of Vancomycin or Gentamicin following the Emergency Department visit. Levofloxacin was dosed q.o.d. given the patient's renal failure and at the time of discharge, the patient had received a total of 3 doses. By report, culture data from hemodialysis on [5-23] showed no growth from blood cultures. Admission blood cultures at [Hospital1 69] have shown no growth to date. The patient remained hemodynamically stable in the Medical Intensive Care Unit without further hypotensive episodes. He was continued on amiodarone for his atrial fibrillation and Coumadin for anti-coagulation in the setting of atrial fibrillation. His INR was noted to be subtherapeutic at 1.5 on admission. A Renal consultation was obtained and the patient was dialyzed on hospital day number three. Also on hospital day number three, the patient was transferred to the ACOVE Service for continued care. REVIEW OF SYSTEMS: On review of systems, the patient noted a minimally productive cough. The patient had a good appetite. No shortness of breath, chest pain, back pain, fevers, chills, nausea, vomiting diarrhea, black or bloody stools, dysuria, headache. The patient was feeling his baseline on transfer to the ACOVE Service. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis. 2. Atrial fibrillation. 3. Peptic ulcer disease. 4. Hypertension. 5. Back pain. 6. Supraventricular tachycardia. 7. Abdominal aortic aneurysm (4.3 centimeters in [2108]). 8. Benign prostatic hypertrophy. 9. History of cerebrovascular accident. 10. Peripheral vascular disease with left leg claudication. 11. Left transmetatarsal amputation. 12. Gastritis and esophagitis. 13. Right inguinal hernia. 14. History of gastrointestinal bleed in [2111-6-5]. 15. History of Methicillin sensitive Staphylococcus aureus arterial line sepsis. 16. Pneumonia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Coumadin 1 mg p.o. q. day. 2. Nephrocaps one p.o. q. day. 3. Amiodarone 200 mg p.o. q. day. 4. Remegel 800 mg p.o. three times a day. 5. Protonix 40 mg p.o. q. day. 6. Tylenol 650 mg p.o. p.r.n. PHYSICAL EXAMINATION: On admission to MICU, temperature 99.2 F.; heart rate 66; blood pressure 94/36; respirations 15; 95% on room air. In general, an alert, pleasant comfortable appearing male in no acute distress. HEENT: Anicteric sclerae. Pupils are equal, round and reactive to light. Oropharynx clear. Mucous membranes were moist. Neck: Supple, no lymphadenopathy, no elevated jugular venous distention. Chest: Rhonchi at the left base, otherwise clear to auscultation bilaterally. Cardiovascular: Distant heart sounds, apparent regular rate and rhythm without murmur. Abdomen soft and nondistended, nontender. Bowel sounds present. No hepatosplenomegaly. Extremities with no cyanosis, clubbing or edema. Left foot notable for transmetatarsal amputation. Right foot notable for toenail thickening and heavy scale of the distal foot. ADMISSION LABORATORY DATA: White blood cell count 7.2, hematocrit 41.3, platelets 167, 83% neutrophils, 10% lymphocytes, 5% monocytes. PT 14.6, INR 1.5, PTT 42.2. Sodium 146, potassium 4.6, chloride 98, bicarbonate 33, creatinine 6.0, BUN 24, glucose 98. EKG normal sinus rhythm at 83. Left axis deviation (old). Q waves in III and F (old). No ST or T wave changes. Chest x-ray: Left lower lobe pneumonia. HOSPITAL COURSE: The initial hospital course is as outlined in the History of Present Illness. The patient was transferred to the ACOVE Service on [5-25]. The patient had a temperature spike on [5-25] to 101.5 F., at which time blood cultures were drawn; to date blood cultures have shown no growth. Levofloxacin was continued for community acquired pneumonia. The patient was feeling his normal self and was afebrile on the day of discharge. He received in-house dialysis prior to discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE INSTRUCTIONS: 1. Diet renal and cardiac. 2. Activity as tolerated. 3. The patient is to continue Levofloxacin 250 mg p.o. q.o.d. to end [2112-6-2], for community acquired pneumonia. 4. The patient to continue outpatient hemodialysis as directed. 5. The patient to continue Coumadin 1 mg p.o. q. day until hemodialysis on [5-30], at which time a repeat INR will be checked. The patient refused a blood draw prior to discharge to assess INR. Given that he is on Levofloxacin he has been advised at discharge to continue his current Coumadin dose until the INR recheck. DISCHARGE DIAGNOSES: 1. End-stage renal disease on hemodialysis. 2. Atrial fibrillation. 3. Peptic ulcer disease. 4. Hypertension. 5. Back pain. 6. Supraventricular tachycardia. 7. Abdominal aortic aneurysm (4.3 centimeters in [2108]). 8. Benign prostatic hypertrophy. 9. History of cerebrovascular accident. 10. Peripheral vascular disease with left leg claudication. 11. Left transmetatarsal amputation. 12. Gastritis and esophagitis. 13. Right inguinal hernia. 14. History of gastrointestinal bleed in [2111-6-5]. 15. History of Methicillin sensitive Staphylococcus aureus arterial line sepsis. 16. Left lower lobe pneumonia. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. q. day. 2. Nephrocaps one p.o. q. day. 3. Protonix 40 mg p.o. q. day. 4. Remegel 800 mg p.o. three times a day. 5. Coumadin 1 mg p.o. q. day or as directed. 6. Levofloxacin 250 mg p.o. q.o.d. to end [2112-6-2]. 7. Tylenol as needed. FOLLOW-UP INSTRUCTIONS: 1. The patient to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], phone number [Telephone/Fax (1) 1144]. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Last Name (NamePattern1) 737] MEDQUIST36 D: [2112-5-27] 14:30 T: [2112-5-30] 17:02 JOB#: [Job Number 4413]	Admission Date: <Date>1989-9-26</Date> Discharge Date: <Date>1973-5-26</Date> Service: ACOVE HISTORY OF PRESENT ILLNESS: This is an 83 year old male with multiple medical problems including end-stage renal disease on hemodialysis who had initially presented on <Date>4-14</Date> at Hemodialysis with decreased p.o. intake and one week of cough productive of clear sputum. In Hemodialysis, the patient was also noted to be rigoring, at which time blood cultures were drawn and the patient was subsequently sent home. At home, the patient experienced generalized weakness and so presented to the Emergency Department. In the Emergency Department, initial vital signs were a temperature of 103.0 F.; heart rate 88; blood pressure 94/68; respiratory rate 20; pulse oximetry 96% on room air. Emergency Department work-up revealed a slight left shift without elevated white blood cell count and a left lower lobe infiltrate on chest x-ray. The patient was treated in the Emergency Department with Vancomycin 1 gram and Gentamicin 100 mg given his history of prior Methicillin sensitive Staphylococcus aureus line sepsis. The patient experienced an episode of hypotension to 64/40 in the Emergency Department, which was asymptomatic (normal mentation). The patient was bolused one liter of normal saline and systolic blood pressure increased appropriately to 107. Per the patient, his baseline blood pressure is 90 to 100 systolic, and generally 85 systolic following hemodialysis. The patient was admitted to the Medical Intensive Care Unit from the Emergency Department for relative hypotension and concern for sepsis. On arrival to the Medical Intensive Care Unit, temperature was 99.2 F.; heart rate 66; blood pressure 94/36; respirations 15; pulse oximetry 95% on room air and the patient was asymptomatic. The Medical Intensive Care Unit course was notable for the addition of Levofloxacin to the patient's antibiotic regimen for atypical organism coverage in the setting of community acquired pneumonia. The patient did not receive any further doses of Vancomycin or Gentamicin following the Emergency Department visit. Levofloxacin was dosed q.o.d. given the patient's renal failure and at the time of discharge, the patient had received a total of 3 doses. By report, culture data from hemodialysis on <Date>4-14</Date> showed no growth from blood cultures. Admission blood cultures at <Hospital>Walker, Harrison and Houston Clinic</Hospital> have shown no growth to date. The patient remained hemodynamically stable in the Medical Intensive Care Unit without further hypotensive episodes. He was continued on amiodarone for his atrial fibrillation and Coumadin for anti-coagulation in the setting of atrial fibrillation. His INR was noted to be subtherapeutic at 1.5 on admission. A Renal consultation was obtained and the patient was dialyzed on hospital day number three. Also on hospital day number three, the patient was transferred to the ACOVE Service for continued care. REVIEW OF SYSTEMS: On review of systems, the patient noted a minimally productive cough. The patient had a good appetite. No shortness of breath, chest pain, back pain, fevers, chills, nausea, vomiting diarrhea, black or bloody stools, dysuria, headache. The patient was feeling his baseline on transfer to the ACOVE Service. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis. 2. Atrial fibrillation. 3. Peptic ulcer disease. 4. Hypertension. 5. Back pain. 6. Supraventricular tachycardia. 7. Abdominal aortic aneurysm (4.3 centimeters in <Year>1928</Year>). 8. Benign prostatic hypertrophy. 9. History of cerebrovascular accident. 10. Peripheral vascular disease with left leg claudication. 11. Left transmetatarsal amputation. 12. Gastritis and esophagitis. 13. Right inguinal hernia. 14. History of gastrointestinal bleed in <Date>1900-1-22</Date>. 15. History of Methicillin sensitive Staphylococcus aureus arterial line sepsis. 16. Pneumonia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Coumadin 1 mg p.o. q. day. 2. Nephrocaps one p.o. q. day. 3. Amiodarone 200 mg p.o. q. day. 4. Remegel 800 mg p.o. three times a day. 5. Protonix 40 mg p.o. q. day. 6. Tylenol 650 mg p.o. p.r.n. PHYSICAL EXAMINATION: On admission to MICU, temperature 99.2 F.; heart rate 66; blood pressure 94/36; respirations 15; 95% on room air. In general, an alert, pleasant comfortable appearing male in no acute distress. HEENT: Anicteric sclerae. Pupils are equal, round and reactive to light. Oropharynx clear. Mucous membranes were moist. Neck: Supple, no lymphadenopathy, no elevated jugular venous distention. Chest: Rhonchi at the left base, otherwise clear to auscultation bilaterally. Cardiovascular: Distant heart sounds, apparent regular rate and rhythm without murmur. Abdomen soft and nondistended, nontender. Bowel sounds present. No hepatosplenomegaly. Extremities with no cyanosis, clubbing or edema. Left foot notable for transmetatarsal amputation. Right foot notable for toenail thickening and heavy scale of the distal foot. ADMISSION LABORATORY DATA: White blood cell count 7.2, hematocrit 41.3, platelets 167, 83% neutrophils, 10% lymphocytes, 5% monocytes. PT 14.6, INR 1.5, PTT 42.2. Sodium 146, potassium 4.6, chloride 98, bicarbonate 33, creatinine 6.0, BUN 24, glucose 98. EKG normal sinus rhythm at 83. Left axis deviation (old). Q waves in III and F (old). No ST or T wave changes. Chest x-ray: Left lower lobe pneumonia. HOSPITAL COURSE: The initial hospital course is as outlined in the History of Present Illness. The patient was transferred to the ACOVE Service on <Date>10-24</Date>. The patient had a temperature spike on <Date>10-24</Date> to 101.5 F., at which time blood cultures were drawn; to date blood cultures have shown no growth. Levofloxacin was continued for community acquired pneumonia. The patient was feeling his normal self and was afebrile on the day of discharge. He received in-house dialysis prior to discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE INSTRUCTIONS: 1. Diet renal and cardiac. 2. Activity as tolerated. 3. The patient is to continue Levofloxacin 250 mg p.o. q.o.d. to end <Date>1905-12-18</Date>, for community acquired pneumonia. 4. The patient to continue outpatient hemodialysis as directed. 5. The patient to continue Coumadin 1 mg p.o. q. day until hemodialysis on <Date>5-25</Date>, at which time a repeat INR will be checked. The patient refused a blood draw prior to discharge to assess INR. Given that he is on Levofloxacin he has been advised at discharge to continue his current Coumadin dose until the INR recheck. DISCHARGE DIAGNOSES: 1. End-stage renal disease on hemodialysis. 2. Atrial fibrillation. 3. Peptic ulcer disease. 4. Hypertension. 5. Back pain. 6. Supraventricular tachycardia. 7. Abdominal aortic aneurysm (4.3 centimeters in <Year>1928</Year>). 8. Benign prostatic hypertrophy. 9. History of cerebrovascular accident. 10. Peripheral vascular disease with left leg claudication. 11. Left transmetatarsal amputation. 12. Gastritis and esophagitis. 13. Right inguinal hernia. 14. History of gastrointestinal bleed in <Date>1900-1-22</Date>. 15. History of Methicillin sensitive Staphylococcus aureus arterial line sepsis. 16. Left lower lobe pneumonia. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. q. day. 2. Nephrocaps one p.o. q. day. 3. Protonix 40 mg p.o. q. day. 4. Remegel 800 mg p.o. three times a day. 5. Coumadin 1 mg p.o. q. day or as directed. 6. Levofloxacin 250 mg p.o. q.o.d. to end <Date>1905-12-18</Date>. 7. Tylenol as needed. FOLLOW-UP INSTRUCTIONS: 1. The patient to follow-up with Dr. <Name>Isabella</Name> <Name>Abdullah</Name>, phone number <Telephone>170-866-6970</Telephone>. <Name>Dawn William</Name> <Name>Xochitl Lenling</Name>, M.D. <MD Number>34584379</MD Number> Dictated By:<Name>Mao</Name> MEDQUIST36 D: <Date>1973-5-26</Date> 14:30 T: <Date>1934-5-21</Date> 17:02 JOB#: <Job Number>Kirk-Carroll-1942-702487</Job 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Date: 1989-9-26 Discharge Date: 1973-5-26 Service: ACOVE HISTORY OF PRESENT ILLNESS: This is an 83 year old male with multiple medical problems including end-stage renal disease on hemodialysis who had initially presented on 4-14 at Hemodialysis with decreased p.o. intake and one week of cough productive of clear sputum. In Hemodialysis, the patient was also noted to be rigoring, at which time blood cultures were drawn and the patient was subsequently sent home. At home, the patient experienced generalized weakness and so presented to the Emergency Department. In the Emergency Department, initial vital signs were a temperature of 103.0 F.; heart rate 88; blood pressure 94/68; respiratory rate 20; pulse oximetry 96% on room air. Emergency Department work-up revealed a slight left shift without elevated white blood cell count and a left lower lobe infiltrate on chest x-ray. The patient was treated in the Emergency Department with Vancomycin 1 gram and Gentamicin 100 mg given his history of prior Methicillin sensitive Staphylococcus aureus line sepsis. The patient experienced an episode of hypotension to 64/40 in the Emergency Department, which was asymptomatic (normal mentation). The patient was bolused one liter of normal saline and systolic blood pressure increased appropriately to 107. Per the patient, his baseline blood pressure is 90 to 100 systolic, and generally 85 systolic following hemodialysis. The patient was admitted to the Medical Intensive Care Unit from the Emergency Department for relative hypotension and concern for sepsis. On arrival to the Medical Intensive Care Unit, temperature was 99.2 F.; heart rate 66; blood pressure 94/36; respirations 15; pulse oximetry 95% on room air and the patient was asymptomatic. The Medical Intensive Care Unit course was notable for the addition of Levofloxacin to the patient's antibiotic regimen for atypical organism coverage in the setting of community acquired pneumonia. The patient did not receive any further doses of Vancomycin or Gentamicin following the Emergency Department visit. Levofloxacin was dosed q.o.d. given the patient's renal failure and at the time of discharge, the patient had received a total of 3 doses. By report, culture data from hemodialysis on 4-14 showed no growth from blood cultures. Admission blood cultures at Walker, Harrison and Houston Clinic have shown no growth to date. The patient remained hemodynamically stable in the Medical Intensive Care Unit without further hypotensive episodes. He was continued on amiodarone for his atrial fibrillation and Coumadin for anti-coagulation in the setting of atrial fibrillation. His INR was noted to be subtherapeutic at 1.5 on admission. A Renal consultation was obtained and the patient was dialyzed on hospital day number three. Also on hospital day number three, the patient was transferred to the ACOVE Service for continued care. REVIEW OF SYSTEMS: On review of systems, the patient noted a minimally productive cough. The patient had a good appetite. No shortness of breath, chest pain, back pain, fevers, chills, nausea, vomiting diarrhea, black or bloody stools, dysuria, headache. The patient was feeling his baseline on transfer to the ACOVE Service. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis. 2. Atrial fibrillation. 3. Peptic ulcer disease. 4. Hypertension. 5. Back pain. 6. Supraventricular tachycardia. 7. Abdominal aortic aneurysm (4.3 centimeters in 1928). 8. Benign prostatic hypertrophy. 9. History of cerebrovascular accident. 10. Peripheral vascular disease with left leg claudication. 11. Left transmetatarsal amputation. 12. Gastritis and esophagitis. 13. Right inguinal hernia. 14. History of gastrointestinal bleed in 1900-1-22. 15. History of Methicillin sensitive Staphylococcus aureus arterial line sepsis. 16. Pneumonia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Coumadin 1 mg p.o. q. day. 2. Nephrocaps one p.o. q. day. 3. Amiodarone 200 mg p.o. q. day. 4. Remegel 800 mg p.o. three times a day. 5. Protonix 40 mg p.o. q. day. 6. Tylenol 650 mg p.o. p.r.n. PHYSICAL EXAMINATION: On admission to MICU, temperature 99.2 F.; heart rate 66; blood pressure 94/36; respirations 15; 95% on room air. In general, an alert, pleasant comfortable appearing male in no acute distress. HEENT: Anicteric sclerae. Pupils are equal, round and reactive to light. Oropharynx clear. Mucous membranes were moist. Neck: Supple, no lymphadenopathy, no elevated jugular venous distention. Chest: Rhonchi at the left base, otherwise clear to auscultation bilaterally. Cardiovascular: Distant heart sounds, apparent regular rate and rhythm without murmur. Abdomen soft and nondistended, nontender. Bowel sounds present. No hepatosplenomegaly. Extremities with no cyanosis, clubbing or edema. Left foot notable for transmetatarsal amputation. Right foot notable for toenail thickening and heavy scale of the distal foot. ADMISSION LABORATORY DATA: White blood cell count 7.2, hematocrit 41.3, platelets 167, 83% neutrophils, 10% lymphocytes, 5% monocytes. PT 14.6, INR 1.5, PTT 42.2. Sodium 146, potassium 4.6, chloride 98, bicarbonate 33, creatinine 6.0, BUN 24, glucose 98. EKG normal sinus rhythm at 83. Left axis deviation (old). Q waves in III and F (old). No ST or T wave changes. Chest x-ray: Left lower lobe pneumonia. HOSPITAL COURSE: The initial hospital course is as outlined in the History of Present Illness. The patient was transferred to the ACOVE Service on 10-24. The patient had a temperature spike on 10-24 to 101.5 F., at which time blood cultures were drawn; to date blood cultures have shown no growth. Levofloxacin was continued for community acquired pneumonia. The patient was feeling his normal self and was afebrile on the day of discharge. He received in-house dialysis prior to discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE INSTRUCTIONS: 1. Diet renal and cardiac. 2. Activity as tolerated. 3. The patient is to continue Levofloxacin 250 mg p.o. q.o.d. to end 1905-12-18, for community acquired pneumonia. 4. The patient to continue outpatient hemodialysis as directed. 5. The patient to continue Coumadin 1 mg p.o. q. day until hemodialysis on 5-25, at which time a repeat INR will be checked. The patient refused a blood draw prior to discharge to assess INR. Given that he is on Levofloxacin he has been advised at discharge to continue his current Coumadin dose until the INR recheck. DISCHARGE DIAGNOSES: 1. End-stage renal disease on hemodialysis. 2. Atrial fibrillation. 3. Peptic ulcer disease. 4. Hypertension. 5. Back pain. 6. Supraventricular tachycardia. 7. Abdominal aortic aneurysm (4.3 centimeters in 1928). 8. Benign prostatic hypertrophy. 9. History of cerebrovascular accident. 10. Peripheral vascular disease with left leg claudication. 11. Left transmetatarsal amputation. 12. Gastritis and esophagitis. 13. Right inguinal hernia. 14. History of gastrointestinal bleed in 1900-1-22. 15. History of Methicillin sensitive Staphylococcus aureus arterial line sepsis. 16. Left lower lobe pneumonia. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. q. day. 2. Nephrocaps one p.o. q. day. 3. Protonix 40 mg p.o. q. day. 4. Remegel 800 mg p.o. three times a day. 5. Coumadin 1 mg p.o. q. day or as directed. 6. Levofloxacin 250 mg p.o. q.o.d. to end 1905-12-18. 7. Tylenol as needed. FOLLOW-UP INSTRUCTIONS: 1. The patient to follow-up with Dr. Isabella Abdullah, phone number 170-866-6970. Dawn William Xochitl Lenling, M.D. 34584379 Dictated By:Mao MEDQUIST36 D: 1973-5-26 14:30 T: 1934-5-21 17:02 JOB#: Kirk-Carroll-1942-702487	['Admission Date: 1989-9-26 Discharge Date: 1973-5-26\n\n\nService: ACOVE\n\nHISTORY OF PRESENT ILLNESS: This is an 83 year old male\nwith multiple medical problems including end-stage renal\ndisease on hemodialysis who had initially presented on 4-14\nat Hemodialysis with decreased p.o. intake and one week of\ncough productive of clear sputum. In Hemodialysis, the\npatient was also noted to be rigoring, at which time blood\ncultures were drawn and the patient was subsequently sent\nhome. At home, the patient experienced generalized weakness\nand so presented to the Emergency Department.\n\nIn the Emergency Department, initial vital signs were a\ntemperature of 103.0 F.; heart rate 88; blood pressure 94/68;\nrespiratory rate 20; pulse oximetry 96% on room air.\nEmergency Department work-up revealed a slight left shift\nwithout elevated white blood cell count and a left lower lobe\ninfiltrate on chest x-ray.', ' The patient was treated in the\nEmergency Department with Vancomycin 1 gram and Gentamicin\n100 mg given his history of prior Methicillin sensitive\nStaphylococcus aureus line sepsis.\n\nThe patient experienced an episode of hypotension to 64/40 in\nthe Emergency Department, which was asymptomatic (normal\nmentation). The patient was bolused one liter of normal\nsaline and systolic blood pressure increased appropriately to\n107. Per the patient, his baseline blood pressure is 90 to\n100 systolic, and generally 85 systolic following\nhemodialysis.\n\nThe patient was admitted to the Medical Intensive Care Unit\nfrom the Emergency Department for relative hypotension and\nconcern for sepsis. On arrival to the Medical Intensive Care\nUnit, temperature was 99.2 F.; heart rate 66; blood pressure\n94/36; respirations 15; pulse oximetry 95% on room air and\nthe patient was asymptomatic.', "\n\nThe Medical Intensive Care Unit course was notable for the\naddition of Levofloxacin to the patient's antibiotic regimen\nfor atypical organism coverage in the setting of community\nacquired pneumonia. The patient did not receive any further\ndoses of Vancomycin or Gentamicin following the Emergency\nDepartment visit. Levofloxacin was dosed q.o.d. given the\npatient's renal failure and at the time of discharge, the\npatient had received a total of 3 doses.\n\nBy report, culture data from hemodialysis on 4-14 showed\nno growth from blood cultures. Admission blood cultures at\nWalker, Harrison and Houston Clinic have shown no growth to\ndate.\n\nThe patient remained hemodynamically stable in the Medical\nIntensive Care Unit without further hypotensive episodes. He\nwas continued on amiodarone for his atrial fibrillation and\nCoumadin for anti-coagulation in the setting of atrial\nfibrillation.", ' His INR was noted to be subtherapeutic at 1.5\non admission.\n\nA Renal consultation was obtained and the patient was\ndialyzed on hospital day number three. Also on hospital day\nnumber three, the patient was transferred to the ACOVE\nService for continued care.\n\nREVIEW OF SYSTEMS: On review of systems, the patient noted a\nminimally productive cough. The patient had a good appetite.\nNo shortness of breath, chest pain, back pain, fevers,\nchills, nausea, vomiting diarrhea, black or bloody stools,\ndysuria, headache. The patient was feeling his baseline on\ntransfer to the ACOVE Service.\n\nPAST MEDICAL HISTORY:\n1. End-stage renal disease on hemodialysis.\n2. Atrial fibrillation.\n3. Peptic ulcer disease.\n4. Hypertension.\n5. Back pain.\n6. Supraventricular tachycardia.\n7. Abdominal aortic aneurysm (4.', '3 centimeters in 1928).\n8. Benign prostatic hypertrophy.\n9. History of cerebrovascular accident.\n10. Peripheral vascular disease with left leg claudication.\n11. Left transmetatarsal amputation.\n12. Gastritis and esophagitis.\n13. Right inguinal hernia.\n14. History of gastrointestinal bleed in 1900-1-22.\n15. History of Methicillin sensitive Staphylococcus aureus\narterial line sepsis.\n16. Pneumonia.\n\nALLERGIES: No known drug allergies.\n\nMEDICATIONS ON ADMISSION:\n1. Coumadin 1 mg p.o. q. day.\n2. Nephrocaps one p.o. q. day.\n3. Amiodarone 200 mg p.o. q. day.\n4. Remegel 800 mg p.o. three times a day.\n5. Protonix 40 mg p.o. q. day.\n6. Tylenol 650 mg p.o. p.r.n.\n\nPHYSICAL EXAMINATION: On admission to MICU, temperature\n99.2 F.; heart rate 66; blood pressure 94/36; respirations\n15; 95% on room air.', ' In general, an alert, pleasant\ncomfortable appearing male in no acute distress. HEENT:\nAnicteric sclerae. Pupils are equal, round and reactive to\nlight. Oropharynx clear. Mucous membranes were moist.\nNeck: Supple, no lymphadenopathy, no elevated jugular venous\ndistention. Chest: Rhonchi at the left base, otherwise\nclear to auscultation bilaterally. Cardiovascular: Distant\nheart sounds, apparent regular rate and rhythm without\nmurmur. Abdomen soft and nondistended, nontender. Bowel\nsounds present. No hepatosplenomegaly. Extremities with no\ncyanosis, clubbing or edema. Left foot notable for\ntransmetatarsal amputation. Right foot notable for toenail\nthickening and heavy scale of the distal foot.\n\nADMISSION LABORATORY DATA: White blood cell count 7.2,\nhematocrit 41.3, platelets 167, 83% neutrophils, 10%\nlymphocytes, 5% monocytes.', ' PT 14.6, INR 1.5, PTT 42.2.\nSodium 146, potassium 4.6, chloride 98, bicarbonate 33,\ncreatinine 6.0, BUN 24, glucose 98.\n\nEKG normal sinus rhythm at 83. Left axis deviation (old). Q\nwaves in III and F (old). No ST or T wave changes.\n\nChest x-ray: Left lower lobe pneumonia.\n\nHOSPITAL COURSE: The initial hospital course is as outlined\nin the History of Present Illness. The patient was\ntransferred to the ACOVE Service on 10-24. The patient had\na temperature spike on 10-24 to 101.5 F., at which time\nblood cultures were drawn; to date blood cultures have shown\nno growth. Levofloxacin was continued for community acquired\npneumonia. The patient was feeling his normal self and was\nafebrile on the day of discharge.\n\nHe received in-house dialysis prior to discharge.\n\nCONDITION ON DISCHARGE: Stable.', '\n\nDISCHARGE STATUS: To home.\n\nDISCHARGE INSTRUCTIONS:\n1. Diet renal and cardiac.\n2. Activity as tolerated.\n3. The patient is to continue Levofloxacin 250 mg p.o.\nq.o.d. to end 1905-12-18, for community acquired pneumonia.\n4. The patient to continue outpatient hemodialysis as\ndirected.\n5. The patient to continue Coumadin 1 mg p.o. q. day until\nhemodialysis on 5-25, at which time a repeat INR will be\nchecked. The patient refused a blood draw prior to discharge\nto assess INR. Given that he is on Levofloxacin he has been\nadvised at discharge to continue his current Coumadin dose\nuntil the INR recheck.\n\nDISCHARGE DIAGNOSES:\n1. End-stage renal disease on hemodialysis.\n2. Atrial fibrillation.\n3. Peptic ulcer disease.\n4. Hypertension.\n5. Back pain.\n6. Supraventricular tachycardia.\n7. Abdominal aortic aneurysm (4.', '3 centimeters in 1928).\n8. Benign prostatic hypertrophy.\n9. History of cerebrovascular accident.\n10. Peripheral vascular disease with left leg claudication.\n11. Left transmetatarsal amputation.\n12. Gastritis and esophagitis.\n13. Right inguinal hernia.\n14. History of gastrointestinal bleed in 1900-1-22.\n15. History of Methicillin sensitive Staphylococcus aureus\narterial line sepsis.\n16. Left lower lobe pneumonia.\n\nDISCHARGE MEDICATIONS:\n1. Amiodarone 200 mg p.o. q. day.\n2. Nephrocaps one p.o. q. day.\n3. Protonix 40 mg p.o. q. day.\n4. Remegel 800 mg p.o. three times a day.\n5. Coumadin 1 mg p.o. q. day or as directed.\n6. Levofloxacin 250 mg p.o. q.o.d. to end 1905-12-18.\n7. Tylenol as needed.\n\nFOLLOW-UP INSTRUCTIONS:\n1. The patient to follow-up with Dr. Isabella Abdullah, phone\nnumber 170-866-6970.', '\n\n\n\n Dawn William Xochitl Lenling, M.D. 34584379\n\nDictated By:Mao\n\nMEDQUIST36\n\nD: 1973-5-26 14:30\nT: 1934-5-21 17:02\nJOB#: Kirk-Carroll-1942-702487\n']
533	14330	162631.0	2113-05-01	Discharge summary	Report	Admission Date: [2113-4-18] Discharge Date: [2113-5-2] Service: MEDICAL/VASCULAR CHIEF COMPLAINT: Left foot cellulitis. HISTORY OF PRESENT ILLNESS: This is an 83 year-old male with extensive past medical history sent from dialysis for evaluation and treatment who has been unable to walk or the past eight months. He de orthopnea, paroxysmal nocturnal dyspnea, fevers or chills, nausea or vomiting. PAST MEDICAL HISTORY: End stage renal disease on hemodialysis, hypertension, MSSA sepsis treated, chronic atrial fibrillation, history of peptic ulcer disease, history of abdominal aortic aneurysm, history of benign prostatic hypertrophy, history of cerebrovascular accident, history of peripheral vascular disease, history of gastrointestinal bleed, history of prostate carcinoma. Left lower lobe pneumonia in [2112-5-4]. History of gastritis and esophagitis. History of right inguinal hernia without repair. PAST SURGICAL HISTORY: Hemorrhoidectomy remote, amputation of right first toe remote, left TMA in [2110-5-5]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Levofloxacin 250 mg po q 48 hours. 2. Flagyl 500 t.i.d. 3. Colace. 4. Senna tabs. 5. Protonix. 6. Zolpidem 5 mg q.d. 7. Sevelamer 800 mg t.i.d. 8. Nephrocaps one q.d. 9. Amiodarone 200 mg po q.d. 10. Coumadin 1 mg q.d. ADMISSION LABORATORIES: CBC with a white blood cell count of 6.9, poly 72, lymphocytes 18, hematocrit 33, platelets 255, BUN 9, creatinine 3.4, K 3.5. Echocardiogram done in [Month (only) 956] showed normal ejection fraction with mitral regurgitation and aortic regurgitation noted. The patient was begun on Vanco, Levo and Flagyl antibiotics. Coumadin was continued. Protonix was continued and vascular was consulted regarding management. Vascular examination showed a pleasant male in no acute distress. HEENT examination was unremarkable. carotids were without bruits. Heart was a regular rate and rhythm. The lungs were diminished at the right base and abdominal examination had a palpable aortic aneurysm. The foot examination showed a left foot cold with ischemic appearing black ulceration on the left medial heel and ankle with no erythema, fluctuance or drainage. The pulse examination showed palpable femorals on the right, dopplerable on the left. Popliteal was dopplerable on the right, absent on the left. The dorsalis pedis pulses were absent bilaterally. The patient PT was dopplerable on the right and absent on the left. The foot x-ray showed no evidence of osteomyelitis. Arteriogram on [2113-3-30] showed a abdominal aortic aneurysm with a left common iliac aneurysm with plaque. The distal superficial femoral artery, popliteal and BK [Doctor Last Name ] diseased, the single vessel run off via the peroneal was reconstituted to the dorsalis pedis pulse. There was no posterior tibial pulse. Recommendations were to hold his Coumadin, normalize his INR, begin heparinization for goal PTT between 40 and 60, obtain MRI/MRA of the left leg and the aorta to evaluate the aorta and in flow disease, consider cardiac workup with echocardiogram and PMIBI, continue antibiotics broad spectrum, follow culture results and tailor as necessary. Multipodus splint to the right foot to prevent heel ulcerations. Echocardiogram was obtained, which demonstrated symmetric left ventricular hypertrophy. This was a suboptimal technical quality study, so focal wall motion could not be excluded. The overall ventricular function EF was greater then 55%. There was a mild aortic stenosis and mitral leaflets appeared thickened, but they were unable to adequately assess the mitral regurgitation. There was mild pulmonary hypertension. Compared to previous study on [2113-1-18] there is probably a similar aortic gradient that is slightly higher. The patient underwent a PMIBI. There were no anginal or ischemic changes, but the patient did have premature ventricular contractions and premature atrial contractions. His nuclear portion showed an abnormal study with severe fixed defect involving the basilar portion of the inferior wall. The ejection fraction was calculated at 54% and on visual inspection it is in the range of 65 to 70. Medical attending evaluated the patient and a moderate cardiac risk for surgery. The patient had a CTA of the abdomen and pelvis to determine abdominal aortic aneurysm. Findings demonstrated intrarenal abdominal aortic aneurysm of 4.9 by 5.2 cm. There is an aneurysm of the right proximal common iliac artery, which measures 4.1 by 2.9 cm. There is an aneurysm of the left common iliac, which measures 1.7 by 2.5 cm. There is an aneurysm in the proximal right internal iliac artery, which measures 1.4 to 2.0. There is dense vascular calcification and multiple venous collaterals seen along the anterior subcutaneous tissues of the abdomen with collateral flow to the right common femoral vein. There is moderate stenosis of the right external iliac artery. The celiac superior mesenteric arteries are patent. There is dense calcification involving the ostium of the left renal artery and dense calcifications at the origin of the right renal artery. There are extensive venous intercostal collaterals along the anterior abdominal wall. These findings are consistent with severe vena cava occlusion. The right inguinal hernia contains small bowel. There is no evidence of obstruction. Incidentally there was gallstones in the gallbladder. Bilateral adrenal enlargement may represent adrenal hyperplasia. Diverticulosis without evidence of diverticulitis. The patient underwent an abdominal aortic angio with left leg run off. There showed significant infrarenal aortic atherosclerotic changes with aneurysmal dilatation extending to the common iliac. There is diffuse atherosclerotic ulcerative plaque of the bilateral external and internal iliac arteries. There is severe disease of the left superficial femoral artery, which occluded at the adductor canal. The left PFA is occluded and above and below knee popliteal arteries are occluded. There is reconstruction of a diffusely diseased attenuated peroneal, which reconstitutes the dorsalis pedis. After careful review of the arteriogram and CTA a long discussion with the patient's daughter and the patient was determined being as a high risk and his comorbidities and recommendations were a left below the knee amputation. The patient consented to that and underwent on [2113-4-27] a left below the knee amputation. He tolerated the procedure well and he was transferred to the PAC in stable condition. He remained hemodynamically stable. He was transferred to the VICU for continued monitoring and care. Initial dressing was removed on postoperative day number two. The wound was clean, dry and intact. The skin edges were intact with no ecchymosis and no drainage. Physical therapy and occupational therapy began to work with the patient. renal continued to follow the patient for hemodialysis needs. Percocet caused the patient to be confused so he was started on Tylenol #3. Renal recommended that the patient only receive narcotics a single dose q 24 hours supplement the patient's break through pain with extra strength Tylenol tablets two q 4 to 6 hours prn for pain. The remaining hospitalization was unremarkable. The patient was discharged to rehab. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg po q.d. 2. Nephrocaps one q.d. 3. Sevelamer 800 mg t.i.d. 4. Protonix 40 mg po q.d. 5. Acetaminophen 325 to 650 mg po q 4 to 6 hours prn for pain. 6. Colace 100 mg b.i.d. 7. Senna tablets one b.i.d. 8. Metoprolol 25 mg b.i.d. hold for systolic blood pressure less then 100, heart rate less then 60. 9. Albuterol Ipratropium multi dose inhaler one to two puffs q 6 hours. 10. Coumadin 1 mg q.h.s. DISCHARGE DIAGNOSES: 1. Severe peripheral vascular disease with left leg ischemia status post below the knee amputation. 2. End stage renal disease on hemodialysis. 3. PMIBI with fixed inferior basilar wall defect, ejection fraction greater then 55%. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4417] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2113-5-1] 10:13 T: [2113-5-1] 10:23 JOB#: [Job Number 4418]	Admission Date: <Date>1917-10-28</Date> Discharge Date: <Date>1936-2-19</Date> Service: MEDICAL/VASCULAR CHIEF COMPLAINT: Left foot cellulitis. HISTORY OF PRESENT ILLNESS: This is an 83 year-old male with extensive past medical history sent from dialysis for evaluation and treatment who has been unable to walk or the past eight months. He de orthopnea, paroxysmal nocturnal dyspnea, fevers or chills, nausea or vomiting. PAST MEDICAL HISTORY: End stage renal disease on hemodialysis, hypertension, MSSA sepsis treated, chronic atrial fibrillation, history of peptic ulcer disease, history of abdominal aortic aneurysm, history of benign prostatic hypertrophy, history of cerebrovascular accident, history of peripheral vascular disease, history of gastrointestinal bleed, history of prostate carcinoma. Left lower lobe pneumonia in <Date>2006-3-3</Date>. History of gastritis and esophagitis. History of right inguinal hernia without repair. PAST SURGICAL HISTORY: Hemorrhoidectomy remote, amputation of right first toe remote, left TMA in <Date>2017-6-23</Date>. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Levofloxacin 250 mg po q 48 hours. 2. Flagyl 500 t.i.d. 3. Colace. 4. Senna tabs. 5. Protonix. 6. Zolpidem 5 mg q.d. 7. Sevelamer 800 mg t.i.d. 8. Nephrocaps one q.d. 9. Amiodarone 200 mg po q.d. 10. Coumadin 1 mg q.d. ADMISSION LABORATORIES: CBC with a white blood cell count of 6.9, poly 72, lymphocytes 18, hematocrit 33, platelets 255, BUN 9, creatinine 3.4, K 3.5. Echocardiogram done in <Month>March</Month> showed normal ejection fraction with mitral regurgitation and aortic regurgitation noted. The patient was begun on Vanco, Levo and Flagyl antibiotics. Coumadin was continued. Protonix was continued and vascular was consulted regarding management. Vascular examination showed a pleasant male in no acute distress. HEENT examination was unremarkable. carotids were without bruits. Heart was a regular rate and rhythm. The lungs were diminished at the right base and abdominal examination had a palpable aortic aneurysm. The foot examination showed a left foot cold with ischemic appearing black ulceration on the left medial heel and ankle with no erythema, fluctuance or drainage. The pulse examination showed palpable femorals on the right, dopplerable on the left. Popliteal was dopplerable on the right, absent on the left. The dorsalis pedis pulses were absent bilaterally. The patient PT was dopplerable on the right and absent on the left. The foot x-ray showed no evidence of osteomyelitis. Arteriogram on <Date>2021-2-13</Date> showed a abdominal aortic aneurysm with a left common iliac aneurysm with plaque. The distal superficial femoral artery, popliteal and BK <Doctor Name>Dr.Moore</Doctor Name> diseased, the single vessel run off via the peroneal was reconstituted to the dorsalis pedis pulse. There was no posterior tibial pulse. Recommendations were to hold his Coumadin, normalize his INR, begin heparinization for goal PTT between 40 and 60, obtain MRI/MRA of the left leg and the aorta to evaluate the aorta and in flow disease, consider cardiac workup with echocardiogram and PMIBI, continue antibiotics broad spectrum, follow culture results and tailor as necessary. Multipodus splint to the right foot to prevent heel ulcerations. Echocardiogram was obtained, which demonstrated symmetric left ventricular hypertrophy. This was a suboptimal technical quality study, so focal wall motion could not be excluded. The overall ventricular function EF was greater then 55%. There was a mild aortic stenosis and mitral leaflets appeared thickened, but they were unable to adequately assess the mitral regurgitation. There was mild pulmonary hypertension. Compared to previous study on <Date>1911-3-4</Date> there is probably a similar aortic gradient that is slightly higher. The patient underwent a PMIBI. There were no anginal or ischemic changes, but the patient did have premature ventricular contractions and premature atrial contractions. His nuclear portion showed an abnormal study with severe fixed defect involving the basilar portion of the inferior wall. The ejection fraction was calculated at 54% and on visual inspection it is in the range of 65 to 70. Medical attending evaluated the patient and a moderate cardiac risk for surgery. The patient had a CTA of the abdomen and pelvis to determine abdominal aortic aneurysm. Findings demonstrated intrarenal abdominal aortic aneurysm of 4.9 by 5.2 cm. There is an aneurysm of the right proximal common iliac artery, which measures 4.1 by 2.9 cm. There is an aneurysm of the left common iliac, which measures 1.7 by 2.5 cm. There is an aneurysm in the proximal right internal iliac artery, which measures 1.4 to 2.0. There is dense vascular calcification and multiple venous collaterals seen along the anterior subcutaneous tissues of the abdomen with collateral flow to the right common femoral vein. There is moderate stenosis of the right external iliac artery. The celiac superior mesenteric arteries are patent. There is dense calcification involving the ostium of the left renal artery and dense calcifications at the origin of the right renal artery. There are extensive venous intercostal collaterals along the anterior abdominal wall. These findings are consistent with severe vena cava occlusion. The right inguinal hernia contains small bowel. There is no evidence of obstruction. Incidentally there was gallstones in the gallbladder. Bilateral adrenal enlargement may represent adrenal hyperplasia. Diverticulosis without evidence of diverticulitis. The patient underwent an abdominal aortic angio with left leg run off. There showed significant infrarenal aortic atherosclerotic changes with aneurysmal dilatation extending to the common iliac. There is diffuse atherosclerotic ulcerative plaque of the bilateral external and internal iliac arteries. There is severe disease of the left superficial femoral artery, which occluded at the adductor canal. The left PFA is occluded and above and below knee popliteal arteries are occluded. There is reconstruction of a diffusely diseased attenuated peroneal, which reconstitutes the dorsalis pedis. After careful review of the arteriogram and CTA a long discussion with the patient's daughter and the patient was determined being as a high risk and his comorbidities and recommendations were a left below the knee amputation. The patient consented to that and underwent on <Date>1980-1-21</Date> a left below the knee amputation. He tolerated the procedure well and he was transferred to the PAC in stable condition. He remained hemodynamically stable. He was transferred to the VICU for continued monitoring and care. Initial dressing was removed on postoperative day number two. The wound was clean, dry and intact. The skin edges were intact with no ecchymosis and no drainage. Physical therapy and occupational therapy began to work with the patient. renal continued to follow the patient for hemodialysis needs. Percocet caused the patient to be confused so he was started on Tylenol #3. Renal recommended that the patient only receive narcotics a single dose q 24 hours supplement the patient's break through pain with extra strength Tylenol tablets two q 4 to 6 hours prn for pain. The remaining hospitalization was unremarkable. The patient was discharged to rehab. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg po q.d. 2. Nephrocaps one q.d. 3. Sevelamer 800 mg t.i.d. 4. Protonix 40 mg po q.d. 5. Acetaminophen 325 to 650 mg po q 4 to 6 hours prn for pain. 6. Colace 100 mg b.i.d. 7. Senna tablets one b.i.d. 8. Metoprolol 25 mg b.i.d. hold for systolic blood pressure less then 100, heart rate less then 60. 9. Albuterol Ipratropium multi dose inhaler one to two puffs q 6 hours. 10. Coumadin 1 mg q.h.s. DISCHARGE DIAGNOSES: 1. Severe peripheral vascular disease with left leg ischemia status post below the knee amputation. 2. End stage renal disease on hemodialysis. 3. PMIBI with fixed inferior basilar wall defect, ejection fraction greater then 55%. <Name>Brenda</Name> <Name>Prieto</Name>, M.D. <MD Number>53522359</MD Number> Dictated By:<Name>Kenner</Name> MEDQUIST36 D: <Date>1943-5-23</Date> 10:13 T: <Date>1943-5-23</Date> 10:23 JOB#: <Job Number>Parker, Bowers and Hardy-1971-385969</Job 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Date: 1917-10-28 Discharge Date: 1936-2-19 Service: MEDICAL/VASCULAR CHIEF COMPLAINT: Left foot cellulitis. HISTORY OF PRESENT ILLNESS: This is an 83 year-old male with extensive past medical history sent from dialysis for evaluation and treatment who has been unable to walk or the past eight months. He de orthopnea, paroxysmal nocturnal dyspnea, fevers or chills, nausea or vomiting. PAST MEDICAL HISTORY: End stage renal disease on hemodialysis, hypertension, MSSA sepsis treated, chronic atrial fibrillation, history of peptic ulcer disease, history of abdominal aortic aneurysm, history of benign prostatic hypertrophy, history of cerebrovascular accident, history of peripheral vascular disease, history of gastrointestinal bleed, history of prostate carcinoma. Left lower lobe pneumonia in 2006-3-3. History of gastritis and esophagitis. History of right inguinal hernia without repair. PAST SURGICAL HISTORY: Hemorrhoidectomy remote, amputation of right first toe remote, left TMA in 2017-6-23. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Levofloxacin 250 mg po q 48 hours. 2. Flagyl 500 t.i.d. 3. Colace. 4. Senna tabs. 5. Protonix. 6. Zolpidem 5 mg q.d. 7. Sevelamer 800 mg t.i.d. 8. Nephrocaps one q.d. 9. Amiodarone 200 mg po q.d. 10. Coumadin 1 mg q.d. ADMISSION LABORATORIES: CBC with a white blood cell count of 6.9, poly 72, lymphocytes 18, hematocrit 33, platelets 255, BUN 9, creatinine 3.4, K 3.5. Echocardiogram done in March showed normal ejection fraction with mitral regurgitation and aortic regurgitation noted. The patient was begun on Vanco, Levo and Flagyl antibiotics. Coumadin was continued. Protonix was continued and vascular was consulted regarding management. Vascular examination showed a pleasant male in no acute distress. HEENT examination was unremarkable. carotids were without bruits. Heart was a regular rate and rhythm. The lungs were diminished at the right base and abdominal examination had a palpable aortic aneurysm. The foot examination showed a left foot cold with ischemic appearing black ulceration on the left medial heel and ankle with no erythema, fluctuance or drainage. The pulse examination showed palpable femorals on the right, dopplerable on the left. Popliteal was dopplerable on the right, absent on the left. The dorsalis pedis pulses were absent bilaterally. The patient PT was dopplerable on the right and absent on the left. The foot x-ray showed no evidence of osteomyelitis. Arteriogram on 2021-2-13 showed a abdominal aortic aneurysm with a left common iliac aneurysm with plaque. The distal superficial femoral artery, popliteal and BK Dr.Moore diseased, the single vessel run off via the peroneal was reconstituted to the dorsalis pedis pulse. There was no posterior tibial pulse. Recommendations were to hold his Coumadin, normalize his INR, begin heparinization for goal PTT between 40 and 60, obtain MRI/MRA of the left leg and the aorta to evaluate the aorta and in flow disease, consider cardiac workup with echocardiogram and PMIBI, continue antibiotics broad spectrum, follow culture results and tailor as necessary. Multipodus splint to the right foot to prevent heel ulcerations. Echocardiogram was obtained, which demonstrated symmetric left ventricular hypertrophy. This was a suboptimal technical quality study, so focal wall motion could not be excluded. The overall ventricular function EF was greater then 55%. There was a mild aortic stenosis and mitral leaflets appeared thickened, but they were unable to adequately assess the mitral regurgitation. There was mild pulmonary hypertension. Compared to previous study on 1911-3-4 there is probably a similar aortic gradient that is slightly higher. The patient underwent a PMIBI. There were no anginal or ischemic changes, but the patient did have premature ventricular contractions and premature atrial contractions. His nuclear portion showed an abnormal study with severe fixed defect involving the basilar portion of the inferior wall. The ejection fraction was calculated at 54% and on visual inspection it is in the range of 65 to 70. Medical attending evaluated the patient and a moderate cardiac risk for surgery. The patient had a CTA of the abdomen and pelvis to determine abdominal aortic aneurysm. Findings demonstrated intrarenal abdominal aortic aneurysm of 4.9 by 5.2 cm. There is an aneurysm of the right proximal common iliac artery, which measures 4.1 by 2.9 cm. There is an aneurysm of the left common iliac, which measures 1.7 by 2.5 cm. There is an aneurysm in the proximal right internal iliac artery, which measures 1.4 to 2.0. There is dense vascular calcification and multiple venous collaterals seen along the anterior subcutaneous tissues of the abdomen with collateral flow to the right common femoral vein. There is moderate stenosis of the right external iliac artery. The celiac superior mesenteric arteries are patent. There is dense calcification involving the ostium of the left renal artery and dense calcifications at the origin of the right renal artery. There are extensive venous intercostal collaterals along the anterior abdominal wall. These findings are consistent with severe vena cava occlusion. The right inguinal hernia contains small bowel. There is no evidence of obstruction. Incidentally there was gallstones in the gallbladder. Bilateral adrenal enlargement may represent adrenal hyperplasia. Diverticulosis without evidence of diverticulitis. The patient underwent an abdominal aortic angio with left leg run off. There showed significant infrarenal aortic atherosclerotic changes with aneurysmal dilatation extending to the common iliac. There is diffuse atherosclerotic ulcerative plaque of the bilateral external and internal iliac arteries. There is severe disease of the left superficial femoral artery, which occluded at the adductor canal. The left PFA is occluded and above and below knee popliteal arteries are occluded. There is reconstruction of a diffusely diseased attenuated peroneal, which reconstitutes the dorsalis pedis. After careful review of the arteriogram and CTA a long discussion with the patient's daughter and the patient was determined being as a high risk and his comorbidities and recommendations were a left below the knee amputation. The patient consented to that and underwent on 1980-1-21 a left below the knee amputation. He tolerated the procedure well and he was transferred to the PAC in stable condition. He remained hemodynamically stable. He was transferred to the VICU for continued monitoring and care. Initial dressing was removed on postoperative day number two. The wound was clean, dry and intact. The skin edges were intact with no ecchymosis and no drainage. Physical therapy and occupational therapy began to work with the patient. renal continued to follow the patient for hemodialysis needs. Percocet caused the patient to be confused so he was started on Tylenol #3. Renal recommended that the patient only receive narcotics a single dose q 24 hours supplement the patient's break through pain with extra strength Tylenol tablets two q 4 to 6 hours prn for pain. The remaining hospitalization was unremarkable. The patient was discharged to rehab. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg po q.d. 2. Nephrocaps one q.d. 3. Sevelamer 800 mg t.i.d. 4. Protonix 40 mg po q.d. 5. Acetaminophen 325 to 650 mg po q 4 to 6 hours prn for pain. 6. Colace 100 mg b.i.d. 7. Senna tablets one b.i.d. 8. Metoprolol 25 mg b.i.d. hold for systolic blood pressure less then 100, heart rate less then 60. 9. Albuterol Ipratropium multi dose inhaler one to two puffs q 6 hours. 10. Coumadin 1 mg q.h.s. DISCHARGE DIAGNOSES: 1. Severe peripheral vascular disease with left leg ischemia status post below the knee amputation. 2. End stage renal disease on hemodialysis. 3. PMIBI with fixed inferior basilar wall defect, ejection fraction greater then 55%. Brenda Prieto, M.D. 53522359 Dictated By:Kenner MEDQUIST36 D: 1943-5-23 10:13 T: 1943-5-23 10:23 JOB#: Parker, Bowers and Hardy-1971-385969	['Admission Date: 1917-10-28 Discharge Date: 1936-2-19\n\n\nService: MEDICAL/VASCULAR\n\nCHIEF COMPLAINT: Left foot cellulitis.\n\nHISTORY OF PRESENT ILLNESS: This is an 83 year-old male with\nextensive past medical history sent from dialysis for\nevaluation and treatment who has been unable to walk or the\npast eight months. He de orthopnea, paroxysmal nocturnal\ndyspnea, fevers or chills, nausea or vomiting.\n\nPAST MEDICAL HISTORY: End stage renal disease on\nhemodialysis, hypertension, MSSA sepsis treated, chronic\natrial fibrillation, history of peptic ulcer disease, history\nof abdominal aortic aneurysm, history of benign prostatic\nhypertrophy, history of cerebrovascular accident, history of\nperipheral vascular disease, history of gastrointestinal\nbleed, history of prostate carcinoma. Left lower lobe\npneumonia in 2006-3-3.', ' History of gastritis and\nesophagitis. History of right inguinal hernia without\nrepair.\n\nPAST SURGICAL HISTORY: Hemorrhoidectomy remote, amputation\nof right first toe remote, left TMA in 2017-6-23.\n\nALLERGIES: No known drug allergies.\n\nMEDICATIONS ON ADMISSION:\n1. Levofloxacin 250 mg po q 48 hours.\n2. Flagyl 500 t.i.d.\n3. Colace.\n4. Senna tabs.\n5. Protonix.\n6. Zolpidem 5 mg q.d.\n7. Sevelamer 800 mg t.i.d.\n8. Nephrocaps one q.d.\n9. Amiodarone 200 mg po q.d.\n10. Coumadin 1 mg q.d.\n\nADMISSION LABORATORIES: CBC with a white blood cell count of\n6.9, poly 72, lymphocytes 18, hematocrit 33, platelets 255,\nBUN 9, creatinine 3.4, K 3.5. Echocardiogram done in\nMarch showed normal ejection fraction with mitral\nregurgitation and aortic regurgitation noted.\n\nThe patient was begun on Vanco, Levo and Flagyl antibiotics.', '\nCoumadin was continued. Protonix was continued and vascular\nwas consulted regarding management. Vascular examination\nshowed a pleasant male in no acute distress. HEENT\nexamination was unremarkable. carotids were without bruits.\nHeart was a regular rate and rhythm. The lungs were\ndiminished at the right base and abdominal examination had a\npalpable aortic aneurysm. The foot examination showed a left\nfoot cold with ischemic appearing black ulceration on the\nleft medial heel and ankle with no erythema, fluctuance or\ndrainage. The pulse examination showed palpable femorals on\nthe right, dopplerable on the left. Popliteal was\ndopplerable on the right, absent on the left. The dorsalis\npedis pulses were absent bilaterally. The patient PT was\ndopplerable on the right and absent on the left.', ' The foot\nx-ray showed no evidence of osteomyelitis. Arteriogram on\n2021-2-13 showed a abdominal aortic aneurysm with a left common\niliac aneurysm with plaque. The distal superficial femoral\nartery, popliteal and BK Dr.Moore diseased, the single vessel run\noff via the peroneal was reconstituted to the dorsalis pedis\npulse. There was no posterior tibial pulse.\n\nRecommendations were to hold his Coumadin, normalize his INR,\nbegin heparinization for goal PTT between 40 and 60, obtain\nMRI/MRA of the left leg and the aorta to evaluate the aorta\nand in flow disease, consider cardiac workup with\nechocardiogram and PMIBI, continue antibiotics broad\nspectrum, follow culture results and tailor as necessary.\nMultipodus splint to the right foot to prevent heel\nulcerations. Echocardiogram was obtained, which demonstrated\nsymmetric left ventricular hypertrophy.', ' This was a\nsuboptimal technical quality study, so focal wall motion\ncould not be excluded. The overall ventricular function EF\nwas greater then 55%. There was a mild aortic stenosis and\nmitral leaflets appeared thickened, but they were unable to\nadequately assess the mitral regurgitation. There was mild\npulmonary hypertension. Compared to previous study on\n1911-3-4 there is probably a similar aortic gradient that is\nslightly higher. The patient underwent a PMIBI. There were\nno anginal or ischemic changes, but the patient did have\npremature ventricular contractions and premature atrial\ncontractions. His nuclear portion showed an abnormal study\nwith severe fixed defect involving the basilar portion of the\ninferior wall. The ejection fraction was calculated at 54%\nand on visual inspection it is in the range of 65 to 70.', '\n\nMedical attending evaluated the patient and a moderate\ncardiac risk for surgery. The patient had a CTA of the\nabdomen and pelvis to determine abdominal aortic aneurysm.\nFindings demonstrated intrarenal abdominal aortic aneurysm of\n4.9 by 5.2 cm. There is an aneurysm of the right proximal\ncommon iliac artery, which measures 4.1 by 2.9 cm. There is\nan aneurysm of the left common iliac, which measures 1.7 by\n2.5 cm. There is an aneurysm in the proximal right internal\niliac artery, which measures 1.4 to 2.0. There is dense\nvascular calcification and multiple venous collaterals seen\nalong the anterior subcutaneous tissues of the abdomen with\ncollateral flow to the right common femoral vein. There is\nmoderate stenosis of the right external iliac artery. The\nceliac superior mesenteric arteries are patent.', ' There is\ndense calcification involving the ostium of the left renal\nartery and dense calcifications at the origin of the right\nrenal artery. There are extensive venous intercostal\ncollaterals along the anterior abdominal wall. These\nfindings are consistent with severe vena cava occlusion. The\nright inguinal hernia contains small bowel. There is no\nevidence of obstruction. Incidentally there was gallstones\nin the gallbladder. Bilateral adrenal enlargement may\nrepresent adrenal hyperplasia. Diverticulosis without\nevidence of diverticulitis. The patient underwent an\nabdominal aortic angio with left leg run off. There showed\nsignificant infrarenal aortic atherosclerotic changes with\naneurysmal dilatation extending to the common iliac. There\nis diffuse atherosclerotic ulcerative plaque of the bilateral\nexternal and internal iliac arteries.', " There is severe\ndisease of the left superficial femoral artery, which\noccluded at the adductor canal. The left PFA is occluded and\nabove and below knee popliteal arteries are occluded. There\nis reconstruction of a diffusely diseased attenuated\nperoneal, which reconstitutes the dorsalis pedis.\n\nAfter careful review of the arteriogram and CTA a long\ndiscussion with the patient's daughter and the patient was\ndetermined being as a high risk and his comorbidities and\nrecommendations were a left below the knee amputation. The\npatient consented to that and underwent on 1980-1-21 a left\nbelow the knee amputation. He tolerated the procedure well\nand he was transferred to the PAC in stable condition. He\nremained hemodynamically stable. He was transferred to the\nVICU for continued monitoring and care.", " Initial dressing was\nremoved on postoperative day number two. The wound was\nclean, dry and intact. The skin edges were intact with no\necchymosis and no drainage. Physical therapy and\noccupational therapy began to work with the patient. renal\ncontinued to follow the patient for hemodialysis needs.\nPercocet caused the patient to be confused so he was started\non Tylenol #3. Renal recommended that the patient only\nreceive narcotics a single dose q 24 hours supplement the\npatient's break through pain with extra strength Tylenol\ntablets two q 4 to 6 hours prn for pain. The remaining\nhospitalization was unremarkable. The patient was discharged\nto rehab.\n\nDISCHARGE MEDICATIONS:\n1. Amiodarone 200 mg po q.d.\n2. Nephrocaps one q.d.\n3. Sevelamer 800 mg t.i.d.\n4. Protonix 40 mg po q.d.\n5. Acetaminophen 325 to 650 mg po q 4 to 6 hours prn for\npain.", '\n6. Colace 100 mg b.i.d.\n7. Senna tablets one b.i.d.\n8. Metoprolol 25 mg b.i.d. hold for systolic blood pressure\nless then 100, heart rate less then 60.\n9. Albuterol Ipratropium multi dose inhaler one to two puffs\nq 6 hours.\n10. Coumadin 1 mg q.h.s.\n\nDISCHARGE DIAGNOSES:\n1. Severe peripheral vascular disease with left leg ischemia\nstatus post below the knee amputation.\n2. End stage renal disease on hemodialysis.\n3. PMIBI with fixed inferior basilar wall defect, ejection\nfraction greater then 55%.\n\n\n\n\n\n\n Brenda Prieto, M.D. 53522359\n\nDictated By:Kenner\nMEDQUIST36\n\nD: 1943-5-23 10:13\nT: 1943-5-23 10:23\nJOB#: Parker, Bowers and Hardy-1971-385969\n']
534	14330	162631.0	2113-05-05	Discharge summary	Report	Admission Date: [2113-5-2] Discharge Date: [2113-5-5] Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is an 84-year-old man with multiple medical problems including end-stage renal disease on hemodialysis, previous hypertension, atrial fibrillation, peptic ulcer disease, recently status post left below the knee amputation from [4-27] and discharged from [Hospital1 ] on [5-1], and was transferred to rehab. He returned to us on [5-1] because of increased shortness of breath and hypoxia, and was slightly obtunded. The patient had dialysis on [5-1] and he was initially sating 96% on 2 liters. In the Emergency Department, he was given a dose of ceftriaxone and Levaquin for a pneumonia and left pleural effusion that was drained 800 cc of fluid. Postthoracentesis, his saturations went up to 96-97%. He did have a small pneumothorax as a complication of this procedure. However, then his oxygen saturations fluctuated in the low 90s. His blood pressure transiently dropped to systolic blood pressure 75, which responded to fluid boluses. In the Emergency Department, it was discussed with Renal, there was no need to dialyze at that time. He was evaluated by Surgery for his left below the knee amputation which appeared to be healing well as per Surgery. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis, Tuesdays, Thursdays, Saturdays. 2. Hypertension. 3. Atrial fibrillation. 4. Peptic ulcer disease. 5. Abdominal aortic aneurysm which is 4.3 cm in [2108]. 6. Benign prostatic hypertrophy with prostate cancer. 7. Cerebrovascular accident. 8. Peripheral vascular disease. 9. Left below the knee amputation. 10. History of MSSA line sepsis. 11. Gastritis. 12. Esophagitis. 13. Right inguinal hernia. 14. Gastrointestinal bleed in [2111-6-5]. 15. Chronic lower back pain. 16. Previous admissions for persistent left lower lobe retrocardiac pneumonia. CT scan in the past had shown a mass. The patient on a previous admission had refused bronchoscopy, therefore the question of whether this postobstructive pneumonia was never worked up. MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg q day. 2. Nephrocaps one cap q day. 3. Renagel of 800 mg tid. 4. Protonix 40 mg q day. 5. Colace 100 mg [Hospital1 ]. 6. Coumadin 1 mg q day. 7. Lopressor 25 mg [Hospital1 ]. 8. Senna. SOCIAL HISTORY: He is a two pack per day smoker for 65 years, occasional alcohol use. He is a retired iron worker and lives alone. EXAMINATION ON ADMISSION: His temperature was 99.2, blood pressure 102/45, heart rate 83, respiratory rate 18, and sating at 91% on 4 liters. In general, he was awake. His HEENT: Pupils are equal and reactive, but were about 1 mm bilaterally. Extraocular movements are intact. Dry mucous membranes. Chest: He had decreased breath sounds on the left with coarse breath sounds on the right. Cardiac: Regular, rate, and rhythm with a systolic murmur, distant heart sounds. Abdomen: Positive bowel sounds. Soft, nontender, nondistended. Extremities: Left below the knee amputation, tender stump bandage, right leg showed no edema with poor toenail care. Neurologic: Mental status: He was awake and talks. Alert to person and [Hospital1 ], and was speaking nonsense at times. LABORATORIES ON ADMISSION: Sodium of 140, potassium 5.9, chloride 104, bicarb 21, BUN 38, creatinine 6.5, glucose 72, nonhemolyzed specimen. His white count was 9.4, hematocrit of 33.5, platelets of 200, 83% neutrophils, 13% lymphocytes. His INR was 1.5 with a PT of 14.8 and a PTT of 24.6. CK of 4,006, CK MB of 17, MBI was 0.4 and troponin of 1. His pleural fluid showed protein 2.3, glucose 92, LDH 84, albumin of 1.3. His blood cultures were drawn. Electrocardiogram showed a junctional rhythm with questionable ST depressions in V3 through V6, but appears older consistent with electrocardiogram on [2113-4-19]. Regular rate at 86 with some low voltages. Chest x-ray showed progression of a left pleural effusion, with partial layering and the right pleural effusion appeared to be stable. The patient was initially admitted to the MICU from [5-1] to [5-3]. 1. Pulmonary: The patient presented with shortness of breath and hypoxia. Chest x-ray showed a large left pleural effusion which was much increased from his previous chest x-ray. His left effusion was tapped in the Emergency Room. His sats have been maintaining in the low 90s on a nonrebreather, given that the probability of a pneumonia and intermittent hypertension. Blood cultures were sent. This was thought to be sepsis from a pneumonia. He was started on ceftriaxone and Levaquin. His antibiotics were then changed to ceftazidime and was continued on Vancomycin, since he had previously been on this for colonization by MRSA in his toes. Eventually his sputum cultures did grow out Staph coag positive species, and his ceftazidime was then switched over to levofloxacin and Flagyl po on [2113-5-4]. The possibility of pulmonary embolus was considered given his hypotension, his acute respiratory decompensation and increased left pleural effusion, however, the patient has since refused CTA. Patient's saturations over the course of the hospitalization has remained approximately 94-95% on the Medical floor when he was transferred on [2113-5-4]. 2. Cardiovascular: The patient has a history of atrial fibrillation, hypertension, and abdominal aortic aneurysm. Given his new hypotension, his blood pressure medications were held (his beta blocker was held). He was continued on amiodarone and was kept in regular rhythm. His anticoagulation he had been subtherapeutic as per records on his last admission, and had not been anticoagulated. He was refusing Heparin drip as well because he was refusing blood draws, and understood the risks and benefits of not being on Heparin and was restarted on Coumadin in hospital. His blood pressure has remained in the 85-100 range, tolerating ................ greater than 55. His last issue was his elevated CK MB and troponin. His elevated CK was thought to be secondary to his below the knee amputation since his MB index was low thought to be secondary to his renal failure. His enzymes were cycled and remained stable. His CK continued to fall. 3. Renal: Patient with end-stage renal disease on hemodialysis. He continued on hemodialysis on Tuesdays, Thursdays, and Saturdays. He had some degree of rhabdomyolysis, and the Renal team did not feel that there was any urgent need for dialysis initially. He was continued on Nephrocaps and Renagel. 4. GI: Given his history of peptic ulcer disease and gastrointestinal bleed, he was given Protonix. His hematocrit had remained stable throughout hospitalization, and his vascular surgery had been following him for his left below the knee amputation. He is stable from that standpoint and has been having dressing changes as needed. He has a multipodas boot on the right foot that should be continued given his tenderness on the right heel. His code status was changed in the hospital from full code from DNR/DNI. The patient has been refusing blood draws and understands the risks of refusing both the CTA of the chest and refusing blood draws. DISCHARGE DIAGNOSES: 1. Left lower lobe pneumonia. 2. Left pleural effusion status post thoracentesis with small pneumothorax. 3. Hypotension. 4. Sepsis. 5. Paroxysmal atrial fibrillation. 6. End-stage renal disease. MEDICATIONS AT DISCHARGE: 1. Amiodarone 200 mg po q day. 2. Aspirin 325 mg po q day. 3. Combivent 1-2 puffs q6h. 4. Renagel 800 mg po tid. 5. Nephrocaps one cap po q day. 6. Vancomycin dosed when Vancomycin level is less than 15 at hemodialysis. 7. Levofloxacin 250 mg po q48h starting on [2115-5-7]. 8. Flagyl 500 mg po tid to stop on [5-14]. 9. Coumadin 1 mg po q hs to be titrated for a goal of [2-6] INR. 10. Protonix 40 mg po q day. 11. Senna one tablet po bid prn. 12. Colace 100 mg po bid. 13. Folic acid 1 mg po q day. TREATMENTS: He is to continue on hemodialysis on Tuesdays, Thursdays, Saturdays and to be monitored for his INR on Coumadin. He is to have dressing changes to the left below the knee amputation, and to keep the left leg straight. He is to followup with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], and he should also have multipodas boot to the right foot while in bed, sheepskin, and Physical Therapy for his left below the knee amputation. He is to be discharged to [Hospital3 4419]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[Name8 (MD) 1020] MEDQUIST36 D: [2113-5-5] 08:31 T: [2113-5-5] 08:35 JOB#: [Job Number 4420]	Admission Date: <Date>2016-6-21</Date> Discharge Date: <Date>1942-5-22</Date> Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is an 84-year-old man with multiple medical problems including end-stage renal disease on hemodialysis, previous hypertension, atrial fibrillation, peptic ulcer disease, recently status post left below the knee amputation from <Date>6-25</Date> and discharged from <Hospital>Wagner, Jackson and Conner Hospital</Hospital> on <Date>11-1</Date>, and was transferred to rehab. He returned to us on <Date>11-1</Date> because of increased shortness of breath and hypoxia, and was slightly obtunded. The patient had dialysis on <Date>11-1</Date> and he was initially sating 96% on 2 liters. In the Emergency Department, he was given a dose of ceftriaxone and Levaquin for a pneumonia and left pleural effusion that was drained 800 cc of fluid. Postthoracentesis, his saturations went up to 96-97%. He did have a small pneumothorax as a complication of this procedure. However, then his oxygen saturations fluctuated in the low 90s. His blood pressure transiently dropped to systolic blood pressure 75, which responded to fluid boluses. In the Emergency Department, it was discussed with Renal, there was no need to dialyze at that time. He was evaluated by Surgery for his left below the knee amputation which appeared to be healing well as per Surgery. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis, Tuesdays, Thursdays, Saturdays. 2. Hypertension. 3. Atrial fibrillation. 4. Peptic ulcer disease. 5. Abdominal aortic aneurysm which is 4.3 cm in <Year>1965</Year>. 6. Benign prostatic hypertrophy with prostate cancer. 7. Cerebrovascular accident. 8. Peripheral vascular disease. 9. Left below the knee amputation. 10. History of MSSA line sepsis. 11. Gastritis. 12. Esophagitis. 13. Right inguinal hernia. 14. Gastrointestinal bleed in <Date>1941-8-18</Date>. 15. Chronic lower back pain. 16. Previous admissions for persistent left lower lobe retrocardiac pneumonia. CT scan in the past had shown a mass. The patient on a previous admission had refused bronchoscopy, therefore the question of whether this postobstructive pneumonia was never worked up. MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg q day. 2. Nephrocaps one cap q day. 3. Renagel of 800 mg tid. 4. Protonix 40 mg q day. 5. Colace 100 mg <Hospital>Wagner, Jackson and Conner Hospital</Hospital>. 6. Coumadin 1 mg q day. 7. Lopressor 25 mg <Hospital>Wagner, Jackson and Conner Hospital</Hospital>. 8. Senna. SOCIAL HISTORY: He is a two pack per day smoker for 65 years, occasional alcohol use. He is a retired iron worker and lives alone. EXAMINATION ON ADMISSION: His temperature was 99.2, blood pressure 102/45, heart rate 83, respiratory rate 18, and sating at 91% on 4 liters. In general, he was awake. His HEENT: Pupils are equal and reactive, but were about 1 mm bilaterally. Extraocular movements are intact. Dry mucous membranes. Chest: He had decreased breath sounds on the left with coarse breath sounds on the right. Cardiac: Regular, rate, and rhythm with a systolic murmur, distant heart sounds. Abdomen: Positive bowel sounds. Soft, nontender, nondistended. Extremities: Left below the knee amputation, tender stump bandage, right leg showed no edema with poor toenail care. Neurologic: Mental status: He was awake and talks. Alert to person and <Hospital>Wagner, Jackson and Conner Hospital</Hospital>, and was speaking nonsense at times. LABORATORIES ON ADMISSION: Sodium of 140, potassium 5.9, chloride 104, bicarb 21, BUN 38, creatinine 6.5, glucose 72, nonhemolyzed specimen. His white count was 9.4, hematocrit of 33.5, platelets of 200, 83% neutrophils, 13% lymphocytes. His INR was 1.5 with a PT of 14.8 and a PTT of 24.6. CK of 4,006, CK MB of 17, MBI was 0.4 and troponin of 1. His pleural fluid showed protein 2.3, glucose 92, LDH 84, albumin of 1.3. His blood cultures were drawn. Electrocardiogram showed a junctional rhythm with questionable ST depressions in V3 through V6, but appears older consistent with electrocardiogram on <Date>1981-8-19</Date>. Regular rate at 86 with some low voltages. Chest x-ray showed progression of a left pleural effusion, with partial layering and the right pleural effusion appeared to be stable. The patient was initially admitted to the MICU from <Date>11-1</Date> to <Date>10-25</Date>. 1. Pulmonary: The patient presented with shortness of breath and hypoxia. Chest x-ray showed a large left pleural effusion which was much increased from his previous chest x-ray. His left effusion was tapped in the Emergency Room. His sats have been maintaining in the low 90s on a nonrebreather, given that the probability of a pneumonia and intermittent hypertension. Blood cultures were sent. This was thought to be sepsis from a pneumonia. He was started on ceftriaxone and Levaquin. His antibiotics were then changed to ceftazidime and was continued on Vancomycin, since he had previously been on this for colonization by MRSA in his toes. Eventually his sputum cultures did grow out Staph coag positive species, and his ceftazidime was then switched over to levofloxacin and Flagyl po on <Date>1993-7-5</Date>. The possibility of pulmonary embolus was considered given his hypotension, his acute respiratory decompensation and increased left pleural effusion, however, the patient has since refused CTA. Patient's saturations over the course of the hospitalization has remained approximately 94-95% on the Medical floor when he was transferred on <Date>1993-7-5</Date>. 2. Cardiovascular: The patient has a history of atrial fibrillation, hypertension, and abdominal aortic aneurysm. Given his new hypotension, his blood pressure medications were held (his beta blocker was held). He was continued on amiodarone and was kept in regular rhythm. His anticoagulation he had been subtherapeutic as per records on his last admission, and had not been anticoagulated. He was refusing Heparin drip as well because he was refusing blood draws, and understood the risks and benefits of not being on Heparin and was restarted on Coumadin in hospital. His blood pressure has remained in the 85-100 range, tolerating ................ greater than 55. His last issue was his elevated CK MB and troponin. His elevated CK was thought to be secondary to his below the knee amputation since his MB index was low thought to be secondary to his renal failure. His enzymes were cycled and remained stable. His CK continued to fall. 3. Renal: Patient with end-stage renal disease on hemodialysis. He continued on hemodialysis on Tuesdays, Thursdays, and Saturdays. He had some degree of rhabdomyolysis, and the Renal team did not feel that there was any urgent need for dialysis initially. He was continued on Nephrocaps and Renagel. 4. GI: Given his history of peptic ulcer disease and gastrointestinal bleed, he was given Protonix. His hematocrit had remained stable throughout hospitalization, and his vascular surgery had been following him for his left below the knee amputation. He is stable from that standpoint and has been having dressing changes as needed. He has a multipodas boot on the right foot that should be continued given his tenderness on the right heel. His code status was changed in the hospital from full code from DNR/DNI. The patient has been refusing blood draws and understands the risks of refusing both the CTA of the chest and refusing blood draws. DISCHARGE DIAGNOSES: 1. Left lower lobe pneumonia. 2. Left pleural effusion status post thoracentesis with small pneumothorax. 3. Hypotension. 4. Sepsis. 5. Paroxysmal atrial fibrillation. 6. End-stage renal disease. MEDICATIONS AT DISCHARGE: 1. Amiodarone 200 mg po q day. 2. Aspirin 325 mg po q day. 3. Combivent 1-2 puffs q6h. 4. Renagel 800 mg po tid. 5. Nephrocaps one cap po q day. 6. Vancomycin dosed when Vancomycin level is less than 15 at hemodialysis. 7. Levofloxacin 250 mg po q48h starting on <Date>2012-10-5</Date>. 8. Flagyl 500 mg po tid to stop on <Date>4-11</Date>. 9. Coumadin 1 mg po q hs to be titrated for a goal of <Date>8-22</Date> INR. 10. Protonix 40 mg po q day. 11. Senna one tablet po bid prn. 12. Colace 100 mg po bid. 13. Folic acid 1 mg po q day. TREATMENTS: He is to continue on hemodialysis on Tuesdays, Thursdays, Saturdays and to be monitored for his INR on Coumadin. He is to have dressing changes to the left below the knee amputation, and to keep the left leg straight. He is to followup with his primary care physician, <Name>Mao</Name>. <Name>Harris</Name>, and he should also have multipodas boot to the right foot while in bed, sheepskin, and Physical Therapy for his left below the knee amputation. He is to be discharged to <Hospital>Decker, Owens and Brooks Health System</Hospital>. <Name>Marcelino</Name> <Name>Braswell</Name>, M.D. <MD Number>52451896</MD Number> Dictated By:<Name>Nancy Kibler</Name> MEDQUIST36 D: <Date>1942-5-22</Date> 08:31 T: <Date>1942-5-22</Date> 08:35 JOB#: <Job Number>Gonzales Inc-2022-035082</Job 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Date: 2016-6-21 Discharge Date: 1942-5-22 Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is an 84-year-old man with multiple medical problems including end-stage renal disease on hemodialysis, previous hypertension, atrial fibrillation, peptic ulcer disease, recently status post left below the knee amputation from 6-25 and discharged from Wagner, Jackson and Conner Hospital on 11-1, and was transferred to rehab. He returned to us on 11-1 because of increased shortness of breath and hypoxia, and was slightly obtunded. The patient had dialysis on 11-1 and he was initially sating 96% on 2 liters. In the Emergency Department, he was given a dose of ceftriaxone and Levaquin for a pneumonia and left pleural effusion that was drained 800 cc of fluid. Postthoracentesis, his saturations went up to 96-97%. He did have a small pneumothorax as a complication of this procedure. However, then his oxygen saturations fluctuated in the low 90s. His blood pressure transiently dropped to systolic blood pressure 75, which responded to fluid boluses. In the Emergency Department, it was discussed with Renal, there was no need to dialyze at that time. He was evaluated by Surgery for his left below the knee amputation which appeared to be healing well as per Surgery. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis, Tuesdays, Thursdays, Saturdays. 2. Hypertension. 3. Atrial fibrillation. 4. Peptic ulcer disease. 5. Abdominal aortic aneurysm which is 4.3 cm in 1965. 6. Benign prostatic hypertrophy with prostate cancer. 7. Cerebrovascular accident. 8. Peripheral vascular disease. 9. Left below the knee amputation. 10. History of MSSA line sepsis. 11. Gastritis. 12. Esophagitis. 13. Right inguinal hernia. 14. Gastrointestinal bleed in 1941-8-18. 15. Chronic lower back pain. 16. Previous admissions for persistent left lower lobe retrocardiac pneumonia. CT scan in the past had shown a mass. The patient on a previous admission had refused bronchoscopy, therefore the question of whether this postobstructive pneumonia was never worked up. MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg q day. 2. Nephrocaps one cap q day. 3. Renagel of 800 mg tid. 4. Protonix 40 mg q day. 5. Colace 100 mg Wagner, Jackson and Conner Hospital. 6. Coumadin 1 mg q day. 7. Lopressor 25 mg Wagner, Jackson and Conner Hospital. 8. Senna. SOCIAL HISTORY: He is a two pack per day smoker for 65 years, occasional alcohol use. He is a retired iron worker and lives alone. EXAMINATION ON ADMISSION: His temperature was 99.2, blood pressure 102/45, heart rate 83, respiratory rate 18, and sating at 91% on 4 liters. In general, he was awake. His HEENT: Pupils are equal and reactive, but were about 1 mm bilaterally. Extraocular movements are intact. Dry mucous membranes. Chest: He had decreased breath sounds on the left with coarse breath sounds on the right. Cardiac: Regular, rate, and rhythm with a systolic murmur, distant heart sounds. Abdomen: Positive bowel sounds. Soft, nontender, nondistended. Extremities: Left below the knee amputation, tender stump bandage, right leg showed no edema with poor toenail care. Neurologic: Mental status: He was awake and talks. Alert to person and Wagner, Jackson and Conner Hospital, and was speaking nonsense at times. LABORATORIES ON ADMISSION: Sodium of 140, potassium 5.9, chloride 104, bicarb 21, BUN 38, creatinine 6.5, glucose 72, nonhemolyzed specimen. His white count was 9.4, hematocrit of 33.5, platelets of 200, 83% neutrophils, 13% lymphocytes. His INR was 1.5 with a PT of 14.8 and a PTT of 24.6. CK of 4,006, CK MB of 17, MBI was 0.4 and troponin of 1. His pleural fluid showed protein 2.3, glucose 92, LDH 84, albumin of 1.3. His blood cultures were drawn. Electrocardiogram showed a junctional rhythm with questionable ST depressions in V3 through V6, but appears older consistent with electrocardiogram on 1981-8-19. Regular rate at 86 with some low voltages. Chest x-ray showed progression of a left pleural effusion, with partial layering and the right pleural effusion appeared to be stable. The patient was initially admitted to the MICU from 11-1 to 10-25. 1. Pulmonary: The patient presented with shortness of breath and hypoxia. Chest x-ray showed a large left pleural effusion which was much increased from his previous chest x-ray. His left effusion was tapped in the Emergency Room. His sats have been maintaining in the low 90s on a nonrebreather, given that the probability of a pneumonia and intermittent hypertension. Blood cultures were sent. This was thought to be sepsis from a pneumonia. He was started on ceftriaxone and Levaquin. His antibiotics were then changed to ceftazidime and was continued on Vancomycin, since he had previously been on this for colonization by MRSA in his toes. Eventually his sputum cultures did grow out Staph coag positive species, and his ceftazidime was then switched over to levofloxacin and Flagyl po on 1993-7-5. The possibility of pulmonary embolus was considered given his hypotension, his acute respiratory decompensation and increased left pleural effusion, however, the patient has since refused CTA. Patient's saturations over the course of the hospitalization has remained approximately 94-95% on the Medical floor when he was transferred on 1993-7-5. 2. Cardiovascular: The patient has a history of atrial fibrillation, hypertension, and abdominal aortic aneurysm. Given his new hypotension, his blood pressure medications were held (his beta blocker was held). He was continued on amiodarone and was kept in regular rhythm. His anticoagulation he had been subtherapeutic as per records on his last admission, and had not been anticoagulated. He was refusing Heparin drip as well because he was refusing blood draws, and understood the risks and benefits of not being on Heparin and was restarted on Coumadin in hospital. His blood pressure has remained in the 85-100 range, tolerating ................ greater than 55. His last issue was his elevated CK MB and troponin. His elevated CK was thought to be secondary to his below the knee amputation since his MB index was low thought to be secondary to his renal failure. His enzymes were cycled and remained stable. His CK continued to fall. 3. Renal: Patient with end-stage renal disease on hemodialysis. He continued on hemodialysis on Tuesdays, Thursdays, and Saturdays. He had some degree of rhabdomyolysis, and the Renal team did not feel that there was any urgent need for dialysis initially. He was continued on Nephrocaps and Renagel. 4. GI: Given his history of peptic ulcer disease and gastrointestinal bleed, he was given Protonix. His hematocrit had remained stable throughout hospitalization, and his vascular surgery had been following him for his left below the knee amputation. He is stable from that standpoint and has been having dressing changes as needed. He has a multipodas boot on the right foot that should be continued given his tenderness on the right heel. His code status was changed in the hospital from full code from DNR/DNI. The patient has been refusing blood draws and understands the risks of refusing both the CTA of the chest and refusing blood draws. DISCHARGE DIAGNOSES: 1. Left lower lobe pneumonia. 2. Left pleural effusion status post thoracentesis with small pneumothorax. 3. Hypotension. 4. Sepsis. 5. Paroxysmal atrial fibrillation. 6. End-stage renal disease. MEDICATIONS AT DISCHARGE: 1. Amiodarone 200 mg po q day. 2. Aspirin 325 mg po q day. 3. Combivent 1-2 puffs q6h. 4. Renagel 800 mg po tid. 5. Nephrocaps one cap po q day. 6. Vancomycin dosed when Vancomycin level is less than 15 at hemodialysis. 7. Levofloxacin 250 mg po q48h starting on 2012-10-5. 8. Flagyl 500 mg po tid to stop on 4-11. 9. Coumadin 1 mg po q hs to be titrated for a goal of 8-22 INR. 10. Protonix 40 mg po q day. 11. Senna one tablet po bid prn. 12. Colace 100 mg po bid. 13. Folic acid 1 mg po q day. TREATMENTS: He is to continue on hemodialysis on Tuesdays, Thursdays, Saturdays and to be monitored for his INR on Coumadin. He is to have dressing changes to the left below the knee amputation, and to keep the left leg straight. He is to followup with his primary care physician, Mao. Harris, and he should also have multipodas boot to the right foot while in bed, sheepskin, and Physical Therapy for his left below the knee amputation. He is to be discharged to Decker, Owens and Brooks Health System. Marcelino Braswell, M.D. 52451896 Dictated By:Nancy Kibler MEDQUIST36 D: 1942-5-22 08:31 T: 1942-5-22 08:35 JOB#: Gonzales Inc-2022-035082	['Admission Date: 2016-6-21 Discharge Date: 1942-5-22\n\n\nService: MEDICINE\n\nHISTORY OF PRESENT ILLNESS: This is an 84-year-old man with\nmultiple medical problems including end-stage renal disease\non hemodialysis, previous hypertension, atrial fibrillation,\npeptic ulcer disease, recently status post left below the\nknee amputation from 6-25 and discharged from Wagner, Jackson and Conner Hospital on 11-1, and was transferred to rehab.\n\nHe returned to us on 11-1 because of increased shortness of\nbreath and hypoxia, and was slightly obtunded. The patient\nhad dialysis on 11-1 and he was initially sating 96% on 2\nliters. In the Emergency Department, he was given a dose of\nceftriaxone and Levaquin for a pneumonia and left pleural\neffusion that was drained 800 cc of fluid.\nPostthoracentesis, his saturations went up to 96-97%.', ' He did\nhave a small pneumothorax as a complication of this\nprocedure. However, then his oxygen saturations fluctuated\nin the low 90s. His blood pressure transiently dropped to\nsystolic blood pressure 75, which responded to fluid boluses.\n\nIn the Emergency Department, it was discussed with Renal,\nthere was no need to dialyze at that time. He was evaluated\nby Surgery for his left below the knee amputation which\nappeared to be healing well as per Surgery.\n\nPAST MEDICAL HISTORY:\n1. End-stage renal disease on hemodialysis, Tuesdays,\nThursdays, Saturdays.\n2. Hypertension.\n3. Atrial fibrillation.\n4. Peptic ulcer disease.\n5. Abdominal aortic aneurysm which is 4.3 cm in 1965.\n6. Benign prostatic hypertrophy with prostate cancer.\n7. Cerebrovascular accident.\n8. Peripheral vascular disease.\n9. Left below the knee amputation.', '\n10. History of MSSA line sepsis.\n11. Gastritis.\n12. Esophagitis.\n13. Right inguinal hernia.\n14. Gastrointestinal bleed in 1941-8-18.\n15. Chronic lower back pain.\n16. Previous admissions for persistent left lower lobe\nretrocardiac pneumonia. CT scan in the past had shown a\nmass. The patient on a previous admission had refused\nbronchoscopy, therefore the question of whether this\npostobstructive pneumonia was never worked up.\n\nMEDICATIONS ON ADMISSION:\n1. Amiodarone 200 mg q day.\n2. Nephrocaps one cap q day.\n3. Renagel of 800 mg tid.\n4. Protonix 40 mg q day.\n5. Colace 100 mg Wagner, Jackson and Conner Hospital.\n6. Coumadin 1 mg q day.\n7. Lopressor 25 mg Wagner, Jackson and Conner Hospital.\n8. Senna.\n\nSOCIAL HISTORY: He is a two pack per day smoker for 65\nyears, occasional alcohol use. He is a retired iron worker\nand lives alone.', '\n\nEXAMINATION ON ADMISSION: His temperature was 99.2, blood\npressure 102/45, heart rate 83, respiratory rate 18, and\nsating at 91% on 4 liters. In general, he was awake. His\nHEENT: Pupils are equal and reactive, but were about 1 mm\nbilaterally. Extraocular movements are intact. Dry mucous\nmembranes. Chest: He had decreased breath sounds on the\nleft with coarse breath sounds on the right. Cardiac:\nRegular, rate, and rhythm with a systolic murmur, distant\nheart sounds. Abdomen: Positive bowel sounds. Soft,\nnontender, nondistended. Extremities: Left below the knee\namputation, tender stump bandage, right leg showed no edema\nwith poor toenail care. Neurologic: Mental status: He was\nawake and talks. Alert to person and Wagner, Jackson and Conner Hospital,\nand was speaking nonsense at times.', '\n\nLABORATORIES ON ADMISSION: Sodium of 140, potassium 5.9,\nchloride 104, bicarb 21, BUN 38, creatinine 6.5, glucose 72,\nnonhemolyzed specimen. His white count was 9.4, hematocrit\nof 33.5, platelets of 200, 83% neutrophils, 13% lymphocytes.\nHis INR was 1.5 with a PT of 14.8 and a PTT of 24.6. CK of\n4,006, CK MB of 17, MBI was 0.4 and troponin of 1. His\npleural fluid showed protein 2.3, glucose 92, LDH 84, albumin\nof 1.3. His blood cultures were drawn.\n\nElectrocardiogram showed a junctional rhythm with\nquestionable ST depressions in V3 through V6, but appears\nolder consistent with electrocardiogram on 1981-8-19. Regular\nrate at 86 with some low voltages.\n\nChest x-ray showed progression of a left pleural effusion,\nwith partial layering and the right pleural effusion appeared\nto be stable.', '\n\nThe patient was initially admitted to the MICU from 11-1 to\n10-25.\n\n1. Pulmonary: The patient presented with shortness of breath\nand hypoxia. Chest x-ray showed a large left pleural\neffusion which was much increased from his previous chest\nx-ray. His left effusion was tapped in the Emergency Room.\nHis sats have been maintaining in the low 90s on a\nnonrebreather, given that the probability of a pneumonia and\nintermittent hypertension. Blood cultures were sent. This\nwas thought to be sepsis from a pneumonia. He was started on\nceftriaxone and Levaquin.\n\nHis antibiotics were then changed to ceftazidime and was\ncontinued on Vancomycin, since he had previously been on this\nfor colonization by MRSA in his toes. Eventually his sputum\ncultures did grow out Staph coag positive species, and his\nceftazidime was then switched over to levofloxacin and Flagyl\npo on 1993-7-5.', "\n\nThe possibility of pulmonary embolus was considered given his\nhypotension, his acute respiratory decompensation and\nincreased left pleural effusion, however, the patient has\nsince refused CTA. Patient's saturations over the course of\nthe hospitalization has remained approximately 94-95% on the\nMedical floor when he was transferred on 1993-7-5.\n\n2. Cardiovascular: The patient has a history of atrial\nfibrillation, hypertension, and abdominal aortic aneurysm.\nGiven his new hypotension, his blood pressure medications\nwere held (his beta blocker was held). He was continued on\namiodarone and was kept in regular rhythm. His\nanticoagulation he had been subtherapeutic as per records on\nhis last admission, and had not been anticoagulated. He was\nrefusing Heparin drip as well because he was refusing blood\ndraws, and understood the risks and benefits of not being on\nHeparin and was restarted on Coumadin in hospital.", '\n\nHis blood pressure has remained in the 85-100 range,\ntolerating ................ greater than 55.\n\nHis last issue was his elevated CK MB and troponin. His\nelevated CK was thought to be secondary to his below the knee\namputation since his MB index was low thought to be secondary\nto his renal failure. His enzymes were cycled and remained\nstable. His CK continued to fall.\n\n3. Renal: Patient with end-stage renal disease on\nhemodialysis. He continued on hemodialysis on Tuesdays,\nThursdays, and Saturdays. He had some degree of\nrhabdomyolysis, and the Renal team did not feel that there\nwas any urgent need for dialysis initially. He was continued\non Nephrocaps and Renagel.\n\n4. GI: Given his history of peptic ulcer disease and\ngastrointestinal bleed, he was given Protonix. His\nhematocrit had remained stable throughout hospitalization,\nand his vascular surgery had been following him for his left\nbelow the knee amputation.', ' He is stable from that standpoint\nand has been having dressing changes as needed. He has a\nmultipodas boot on the right foot that should be continued\ngiven his tenderness on the right heel.\n\nHis code status was changed in the hospital from full code\nfrom DNR/DNI. The patient has been refusing blood draws and\nunderstands the risks of refusing both the CTA of the chest\nand refusing blood draws.\n\nDISCHARGE DIAGNOSES:\n1. Left lower lobe pneumonia.\n2. Left pleural effusion status post thoracentesis with small\npneumothorax.\n3. Hypotension.\n4. Sepsis.\n5. Paroxysmal atrial fibrillation.\n6. End-stage renal disease.\n\nMEDICATIONS AT DISCHARGE:\n1. Amiodarone 200 mg po q day.\n2. Aspirin 325 mg po q day.\n3. Combivent 1-2 puffs q6h.\n4. Renagel 800 mg po tid.\n5. Nephrocaps one cap po q day.\n6. Vancomycin dosed when Vancomycin level is less than 15 at\nhemodialysis.', '\n7. Levofloxacin 250 mg po q48h starting on 2012-10-5.\n8. Flagyl 500 mg po tid to stop on 4-11.\n9. Coumadin 1 mg po q hs to be titrated for a goal of 8-22\nINR.\n10. Protonix 40 mg po q day.\n11. Senna one tablet po bid prn.\n12. Colace 100 mg po bid.\n13. Folic acid 1 mg po q day.\n\nTREATMENTS: He is to continue on hemodialysis on Tuesdays,\nThursdays, Saturdays and to be monitored for his INR on\nCoumadin. He is to have dressing changes to the left below\nthe knee amputation, and to keep the left leg straight. He\nis to followup with his primary care physician, Mao. Harris,\nand he should also have multipodas boot to the right foot\nwhile in bed, sheepskin, and Physical Therapy for his left\nbelow the knee amputation. He is to be discharged to\nDecker, Owens and Brooks Health System.\n\n\n\n Marcelino Braswell, M.', 'D. 52451896\n\nDictated By:Nancy Kibler\nMEDQUIST36\n\nD: 1942-5-22 08:31\nT: 1942-5-22 08:35\nJOB#: Gonzales Inc-2022-035082\n']
535	22547	189895.0	2113-12-02	Discharge summary	Report	Admission Date: [2113-11-29] Discharge Date: [2113-12-2] Date of Birth: [2058-2-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4421] Chief Complaint: Nausea and Vomiting. Major Surgical or Invasive Procedure: None. History of Present Illness: 55 year-old female with recently diagnosed stage IIIA fallopian tube adenocarcinoma who presented to oncology clinic complaining of ongoing nausea, vomiting, and weakness. She received her first cycle of chemotherapy consisting of intravenous Taxol and carboplatin on [2113-11-1], and last week received her second cycle consisting of intravenous Taxol and intraperitoneal cisplatin, followed by aggressive antiemetics with dolasetron, Emend, and compazine. Ever since her recent chemotherapy, she has had some abdominal pain, nausea, vomiting, and was feeling tired. She has not been able to keep any food down, but has been tying to drink Boost and Ensure as tolerated. She has not had any diarrhea. She describes also intermittent fevers/chills at home, without any headache, change in vision, chest pain, SOB, excessive thirst or urination, or change in her bowel habits. In oncology clinic she was found to be dehydrated, with a serum sodium in the 108 range and potassium in the low 2 range, and is admitted for further management. . In the ED she was afebrile, with normal vital signs, and a normal mental status exam (per her husband). She was given IV normal saline, potassium replacement, and was admitted to the [Hospital Unit Name 153] for further management. The patient's sodium improved with normal saline. The etiology of her hyponatremia and hypokalemia was unclear but was possibly secondary to SIADH, exacerbated by dehydration and electrolyte loss (vomiting), or secondary to a component of Fanconi's syndrome. Hypertonic saline and democycline were not necessary. The patient's cortisol stimulation test and TSH were within normal limits. Celexa was discontinued due to its association with SIADH. The patient's IVF were discontinued at noon the day of transfer to the OMED floor with sodium improving to 128 and normalization of her potassium. Past Medical History: 1. Stage IIIA grade III left-sided fallopian tube cancer, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, left pelvic lymph node dissection, peritoneal washings and omental biopsy on [2113-10-10]. 2. Hypertension 3. Major Depression 4. History of gastrointestinal bleed Social History: She lives in [Doctor Last Name 792]with husband and two of her three sons. [Name (NI) ] husband is a cardiologist. She denies tobacco or EtOH use. Family History: NC Physical Exam: VITAL SIGNS: 98 85 160/100 20 98% RA GENERAL: Pale female with alopecia, tired-appearing, in NAD HEENT: MM dry with cracked red lips, anicteric, no sinus tenderness NECK: Supple, no LAD, JVP flat HEART: RRR with a flow murmur, no S3 or S4 CHEST: Clear to ausculatation and percussion bilaterally ABDOMEN: Soft, obese, NT, ND, palpable IP port in LUQ without erythema EXTREMITIES: No c/c/e, pale nail beds, normal cap refill NEUROLOGIC: AAO x 3, appropriate, CN intact, strength 5/5 in bilateral upper and lower extremities. No sensory defect. Did not assess gait SKIN: Flushed, erythematous apearance of neck MUSCULOSKELETAL: No joint effusions noted Pertinent Results: [2113-11-29] 12:30PM SODIUM-108* POTASSIUM-2.0* CHLORIDE-65* [2113-11-29] 03:15PM GLUCOSE-175* UREA N-22* CREAT-1.0 SODIUM-109* POTASSIUM-2.8* CHLORIDE-66* TOTAL CO2-29 ANION GAP-17 [2113-11-29] 03:25PM GLUCOSE-171* LACTATE-3.2* K+-2.6* [2113-11-29] 09:35PM URINE OSMOLAL-381 [2113-11-29] 09:35PM URINE HOURS-RANDOM UREA N-386 CREAT-27 SODIUM-60 POTASSIUM-39 PHOSPHATE-39.1 [2113-11-29] 10:25PM TSH-1.4 [2113-11-29] 10:25PM calTIBC-397 FERRITIN-391* TRF-305 [2113-11-29] 10:25PM GLUCOSE-140* UREA N-19 CREAT-0.9 SODIUM-111* POTASSIUM-2.9* CHLORIDE-73* TOTAL CO2-26 ANION GAP-15 [2113-11-29] 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111* K-2.9* Cl-73* HCO3-26 AnGap-15 [2113-11-30] 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113* K-2.7* Cl-79* HCO3-27 AnGap-10 [2113-11-29] 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111* K-2.9* Cl-73* HCO3-26 AnGap-15 [2113-11-30] 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113* K-2.7* Cl-79* HCO3-27 AnGap-10 [2113-11-30] 10:41AM BLOOD Na-114* K-3.8 [2113-11-30] 04:12PM BLOOD Na-116* K-3.4 [2113-11-30] 08:19PM BLOOD Na-122* K-3.7 [2113-12-1] 12:34AM BLOOD Na-122* K-3.9 [2113-12-1] 04:31AM BLOOD Glucose-98 Creat-1.1 Na-123* K-4.0 Cl-92* HCO3-23 AnGap-12 [2113-12-1] 09:48AM BLOOD Na-124* K-3.4 [2113-12-1] 02:02PM BLOOD Na-128* K-3.5 . [2113-11-29] CXR: IMPRESSION: No acute cardiopulmonary disease. Gas distended loops of small bowel with air-fluid levels within the upper abdomen. Unclear of the etiology of this finding; however, it may be related to her history of ovarian cancer and correlation with past imaging studies and patient history is recommended. . ECG: NSR, mild LAD, prolonged QTc, delayed RWP . Brief Hospital Course: 55 year-old female patient with history of hypertension, depression, and recent diagnosis of stage IIIA fallopian tube cancer who presents with one week of nausea, vomiting, and malaise and laboratory abnormalities of hyponatremia and hypokalemia. This was likely secondary to either SIADH or Fanconi's syndrome. 1. Hyponatremia. The patient's baseline sodium is 128 per previous records. The patient was asymptomatic on presentation. The patient was followed by the renal team throughout admission. Cortisol stimulation was performed with appropriate response. TSH was within normal limits. Her serum osmolality was low, and her urine osmolarity was high. Her urine sodium was > 60 with FENa > 2%. Citalopram was discontinued for its association with SIADH. Hydrochlorothiazide were discontinued because of hyponatremia and dehydration. The patient was initially treated with normal saline with slow correction of hyponatremia. Liberal salt intake was encouraged. Hypertonic saline and demecycline were not necessary. The patient's creatinine increased to 1.4 the day of discharge, possibly secondary to recent cisplatin treatment. The patient will have repeat labwork after discharge to monitor this. . 2. Hypokalemia. This is most likely related to GI and renal potassium. The patient will have outpatient labwork as above. . 3. Nausea/vomiting. Likely secondary to chemotherapy and hyponatremia. The patient was given anti-emetics as needed. This was improved prior to discharge. . 4. Fallopian tube cancer. The patient was followed by Dr. [Last Name (STitle) ] while she was in the intensive care unit. The patient will follow-up with Drs [Last Name (STitle) ] and [Name5 (PTitle) ]. The patient's blood counts remained stable throughout. . 5. Hypertension. The patient was continued on Diovan. The patient's hydrochlorothiazide was held because of the patient's hyponatremia and dehydration. . 6. Depression. She has a long history of major depression including one drug overdose. She denied suicidal ideation. The patient's citalopram was held due to its association with SIADH. The patient was continued on Remeron. The patient will follow-up with an outpatient psychiatrist. . 7. Hypothyroidism. The patient's TSH was within the normal range. The patient was continued on her outpatient dose of levothyroxine. . 8. Erythema of neck and back. Patient states this is related to anxiety. The patient was given atarax as needed with good effect. . 9. History of gastrointestinal bleed. No active issues. The patient was continued on Protonix. . Code: Full, discussed with patient Medications on Admission: 1. Diovan/HCTZ 320/25 2. Celexa 20mg 3. Remeron 15mg 4. Synthroid 0.1mg 5. Motrin 800mg prn 6. Vicodin 5/500 prn abdominal pain 7. Compazine prn 8. Zofran prn 9. Ativan 1mg tid prn 10. Temazepam 30mg qhs Discharge Medications: 1. Outpatient Lab Work Please obtain blood work in [Doctor Last Name 792]as instructed. Please call Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ] with results; phone number ([Telephone/Fax (1) 4422]. 2. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety, nausea. Disp:30 Tablet(s) Refills:0 7. Temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:30 Capsule(s) Refills:2 8. Hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:2 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 12. Anzemet 100 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea for 2 weeks. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Hyponatremia secondary to Fanconi's syndrome versus SIADH . Secondary: 1. Stage IIIA grade III left-sided fallopian tube cancer 2. Hypertension 3. Major Depression 4. History of gastrointestinal bleed Discharge Condition: Afebrile, vital signs stable. Electrolytes stable. Discharge Instructions: Please contact a physician if you experience fevers, chills, increased confusion, change in vision, increased nausea, or any other concerning symptoms. . Please take your medications as prescribed. - Your celexa and hydrochlorothiazide were discontinued because they can contribute to low sodium (salt) in your blood. - You can take anzemet 100 mg once daily as needed for nausea. - You can take ativan 1 mg every six hours as needed for nausea. Please contact your psychiatrist about a refill for this medication if he feels it is medically necessary. - You should take colace and senna as needed for constipation while taking pain medications. . Please increase your salt intake as much as possible; add table salt to foods, eat foods high in sodium such as [Last Name (un) 4423]. . Please have your blood checked early next week. You have a prescription written for labwork. Dr. [First Name8 (NamePattern2) 4424] [Name (STitle) ] will follow-up these results. . Please keep your follow-up appointments as below. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4425], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2113-12-20] 10:00 Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2113-12-20] 10:00 Provider: [Name Initial (NameIs) 4426] 19 Date/Time:[2113-12-20] 10:00	Admission Date: <Date>2001-1-26</Date> Discharge Date: <Date>1962-8-8</Date> Date of Birth: <Date>1909-8-8</Date> Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Bradley</Name> Chief Complaint: Nausea and Vomiting. Major Surgical or Invasive Procedure: None. History of Present Illness: 55 year-old female with recently diagnosed stage IIIA fallopian tube adenocarcinoma who presented to oncology clinic complaining of ongoing nausea, vomiting, and weakness. She received her first cycle of chemotherapy consisting of intravenous Taxol and carboplatin on <Date>1997-12-12</Date>, and last week received her second cycle consisting of intravenous Taxol and intraperitoneal cisplatin, followed by aggressive antiemetics with dolasetron, Emend, and compazine. Ever since her recent chemotherapy, she has had some abdominal pain, nausea, vomiting, and was feeling tired. She has not been able to keep any food down, but has been tying to drink Boost and Ensure as tolerated. She has not had any diarrhea. She describes also intermittent fevers/chills at home, without any headache, change in vision, chest pain, SOB, excessive thirst or urination, or change in her bowel habits. In oncology clinic she was found to be dehydrated, with a serum sodium in the 108 range and potassium in the low 2 range, and is admitted for further management. . In the ED she was afebrile, with normal vital signs, and a normal mental status exam (per her husband). She was given IV normal saline, potassium replacement, and was admitted to the <Hospital>Woods-Vargas Medical Center</Hospital> for further management. The patient's sodium improved with normal saline. The etiology of her hyponatremia and hypokalemia was unclear but was possibly secondary to SIADH, exacerbated by dehydration and electrolyte loss (vomiting), or secondary to a component of Fanconi's syndrome. Hypertonic saline and democycline were not necessary. The patient's cortisol stimulation test and TSH were within normal limits. Celexa was discontinued due to its association with SIADH. The patient's IVF were discontinued at noon the day of transfer to the OMED floor with sodium improving to 128 and normalization of her potassium. Past Medical History: 1. Stage IIIA grade III left-sided fallopian tube cancer, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, left pelvic lymph node dissection, peritoneal washings and omental biopsy on <Date>2002-2-8</Date>. 2. Hypertension 3. Major Depression 4. History of gastrointestinal bleed Social History: She lives in <Doctor Name>Dr.Ngo</Doctor Name>with husband and two of her three sons. <Name>Arnaldo William</Name> husband is a cardiologist. She denies tobacco or EtOH use. Family History: NC Physical Exam: VITAL SIGNS: 98 85 160/100 20 98% RA GENERAL: Pale female with alopecia, tired-appearing, in NAD HEENT: MM dry with cracked red lips, anicteric, no sinus tenderness NECK: Supple, no LAD, JVP flat HEART: RRR with a flow murmur, no S3 or S4 CHEST: Clear to ausculatation and percussion bilaterally ABDOMEN: Soft, obese, NT, ND, palpable IP port in LUQ without erythema EXTREMITIES: No c/c/e, pale nail beds, normal cap refill NEUROLOGIC: AAO x 3, appropriate, CN intact, strength 5/5 in bilateral upper and lower extremities. No sensory defect. Did not assess gait SKIN: Flushed, erythematous apearance of neck MUSCULOSKELETAL: No joint effusions noted Pertinent Results: <Date>2001-1-26</Date> 12:30PM SODIUM-108* POTASSIUM-2.0* CHLORIDE-65* <Date>2001-1-26</Date> 03:15PM GLUCOSE-175* UREA N-22* CREAT-1.0 SODIUM-109* POTASSIUM-2.8* CHLORIDE-66* TOTAL CO2-29 ANION GAP-17 <Date>2001-1-26</Date> 03:25PM GLUCOSE-171* LACTATE-3.2* K+-2.6* <Date>2001-1-26</Date> 09:35PM URINE OSMOLAL-381 <Date>2001-1-26</Date> 09:35PM URINE HOURS-RANDOM UREA N-386 CREAT-27 SODIUM-60 POTASSIUM-39 PHOSPHATE-39.1 <Date>2001-1-26</Date> 10:25PM TSH-1.4 <Date>2001-1-26</Date> 10:25PM calTIBC-397 FERRITIN-391* TRF-305 <Date>2001-1-26</Date> 10:25PM GLUCOSE-140* UREA N-19 CREAT-0.9 SODIUM-111* POTASSIUM-2.9* CHLORIDE-73* TOTAL CO2-26 ANION GAP-15 <Date>2001-1-26</Date> 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111* K-2.9* Cl-73* HCO3-26 AnGap-15 <Date>1989-4-15</Date> 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113* K-2.7* Cl-79* HCO3-27 AnGap-10 <Date>2001-1-26</Date> 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111* K-2.9* Cl-73* HCO3-26 AnGap-15 <Date>1989-4-15</Date> 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113* K-2.7* Cl-79* HCO3-27 AnGap-10 <Date>1989-4-15</Date> 10:41AM BLOOD Na-114* K-3.8 <Date>1989-4-15</Date> 04:12PM BLOOD Na-116* K-3.4 <Date>1989-4-15</Date> 08:19PM BLOOD Na-122* K-3.7 <Date>1939-10-6</Date> 12:34AM BLOOD Na-122* K-3.9 <Date>1939-10-6</Date> 04:31AM BLOOD Glucose-98 Creat-1.1 Na-123* K-4.0 Cl-92* HCO3-23 AnGap-12 <Date>1939-10-6</Date> 09:48AM BLOOD Na-124* K-3.4 <Date>1939-10-6</Date> 02:02PM BLOOD Na-128* K-3.5 . <Date>2001-1-26</Date> CXR: IMPRESSION: No acute cardiopulmonary disease. Gas distended loops of small bowel with air-fluid levels within the upper abdomen. Unclear of the etiology of this finding; however, it may be related to her history of ovarian cancer and correlation with past imaging studies and patient history is recommended. . ECG: NSR, mild LAD, prolonged QTc, delayed RWP . Brief Hospital Course: 55 year-old female patient with history of hypertension, depression, and recent diagnosis of stage IIIA fallopian tube cancer who presents with one week of nausea, vomiting, and malaise and laboratory abnormalities of hyponatremia and hypokalemia. This was likely secondary to either SIADH or Fanconi's syndrome. 1. Hyponatremia. The patient's baseline sodium is 128 per previous records. The patient was asymptomatic on presentation. The patient was followed by the renal team throughout admission. Cortisol stimulation was performed with appropriate response. TSH was within normal limits. Her serum osmolality was low, and her urine osmolarity was high. Her urine sodium was > 60 with FENa > 2%. Citalopram was discontinued for its association with SIADH. Hydrochlorothiazide were discontinued because of hyponatremia and dehydration. The patient was initially treated with normal saline with slow correction of hyponatremia. Liberal salt intake was encouraged. Hypertonic saline and demecycline were not necessary. The patient's creatinine increased to 1.4 the day of discharge, possibly secondary to recent cisplatin treatment. The patient will have repeat labwork after discharge to monitor this. . 2. Hypokalemia. This is most likely related to GI and renal potassium. The patient will have outpatient labwork as above. . 3. Nausea/vomiting. Likely secondary to chemotherapy and hyponatremia. The patient was given anti-emetics as needed. This was improved prior to discharge. . 4. Fallopian tube cancer. The patient was followed by Dr. <Name>Porras</Name> while she was in the intensive care unit. The patient will follow-up with Drs <Name>Porras</Name> and <Name>Allison Jain</Name>. The patient's blood counts remained stable throughout. . 5. Hypertension. The patient was continued on Diovan. The patient's hydrochlorothiazide was held because of the patient's hyponatremia and dehydration. . 6. Depression. She has a long history of major depression including one drug overdose. She denied suicidal ideation. The patient's citalopram was held due to its association with SIADH. The patient was continued on Remeron. The patient will follow-up with an outpatient psychiatrist. . 7. Hypothyroidism. The patient's TSH was within the normal range. The patient was continued on her outpatient dose of levothyroxine. . 8. Erythema of neck and back. Patient states this is related to anxiety. The patient was given atarax as needed with good effect. . 9. History of gastrointestinal bleed. No active issues. The patient was continued on Protonix. . Code: Full, discussed with patient Medications on Admission: 1. Diovan/HCTZ 320/25 2. Celexa 20mg 3. Remeron 15mg 4. Synthroid 0.1mg 5. Motrin 800mg prn 6. Vicodin 5/500 prn abdominal pain 7. Compazine prn 8. Zofran prn 9. Ativan 1mg tid prn 10. Temazepam 30mg qhs Discharge Medications: 1. Outpatient Lab Work Please obtain blood work in <Doctor Name>Dr.Ngo</Doctor Name>as instructed. Please call Dr. <Name>Ollie</Name> <Name>Scheet</Name> with results; phone number (<Telephone>606-453-7323</Telephone>. 2. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety, nausea. Disp:30 Tablet(s) Refills:0 7. Temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:30 Capsule(s) Refills:2 8. Hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:2 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 12. Anzemet 100 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea for 2 weeks. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Hyponatremia secondary to Fanconi's syndrome versus SIADH . Secondary: 1. Stage IIIA grade III left-sided fallopian tube cancer 2. Hypertension 3. Major Depression 4. History of gastrointestinal bleed Discharge Condition: Afebrile, vital signs stable. Electrolytes stable. Discharge Instructions: Please contact a physician if you experience fevers, chills, increased confusion, change in vision, increased nausea, or any other concerning symptoms. . Please take your medications as prescribed. - Your celexa and hydrochlorothiazide were discontinued because they can contribute to low sodium (salt) in your blood. - You can take anzemet 100 mg once daily as needed for nausea. - You can take ativan 1 mg every six hours as needed for nausea. Please contact your psychiatrist about a refill for this medication if he feels it is medically necessary. - You should take colace and senna as needed for constipation while taking pain medications. . Please increase your salt intake as much as possible; add table salt to foods, eat foods high in sodium such as <Name>Post</Name>. . Please have your blood checked early next week. You have a prescription written for labwork. Dr. <Name>Andreas</Name> <Name>Ethan Grier</Name> will follow-up these results. . Please keep your follow-up appointments as below. Followup Instructions: Provider: <Name>Teresita</Name> <Name>Ornelas</Name>, RN Phone:<Telephone>186-709-2703</Telephone> Date/Time:<Date>1908-5-4</Date> 10:00 Provider: <Name>Teresita</Name> <Name>Teresita</Name> <Name>Scheet</Name>, MD Phone:<Telephone>186-709-2703</Telephone> Date/Time:<Date>1908-5-4</Date> 10:00 Provider: <Name>Kenna Ngo</Name> 19 Date/Time:<Date>1908-5-4</Date> 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Date: 2001-1-26 Discharge Date: 1962-8-8 Date of Birth: 1909-8-8 Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Bradley Chief Complaint: Nausea and Vomiting. Major Surgical or Invasive Procedure: None. History of Present Illness: 55 year-old female with recently diagnosed stage IIIA fallopian tube adenocarcinoma who presented to oncology clinic complaining of ongoing nausea, vomiting, and weakness. She received her first cycle of chemotherapy consisting of intravenous Taxol and carboplatin on 1997-12-12, and last week received her second cycle consisting of intravenous Taxol and intraperitoneal cisplatin, followed by aggressive antiemetics with dolasetron, Emend, and compazine. Ever since her recent chemotherapy, she has had some abdominal pain, nausea, vomiting, and was feeling tired. She has not been able to keep any food down, but has been tying to drink Boost and Ensure as tolerated. She has not had any diarrhea. She describes also intermittent fevers/chills at home, without any headache, change in vision, chest pain, SOB, excessive thirst or urination, or change in her bowel habits. In oncology clinic she was found to be dehydrated, with a serum sodium in the 108 range and potassium in the low 2 range, and is admitted for further management. . In the ED she was afebrile, with normal vital signs, and a normal mental status exam (per her husband). She was given IV normal saline, potassium replacement, and was admitted to the Woods-Vargas Medical Center for further management. The patient's sodium improved with normal saline. The etiology of her hyponatremia and hypokalemia was unclear but was possibly secondary to SIADH, exacerbated by dehydration and electrolyte loss (vomiting), or secondary to a component of Fanconi's syndrome. Hypertonic saline and democycline were not necessary. The patient's cortisol stimulation test and TSH were within normal limits. Celexa was discontinued due to its association with SIADH. The patient's IVF were discontinued at noon the day of transfer to the OMED floor with sodium improving to 128 and normalization of her potassium. Past Medical History: 1. Stage IIIA grade III left-sided fallopian tube cancer, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, left pelvic lymph node dissection, peritoneal washings and omental biopsy on 2002-2-8. 2. Hypertension 3. Major Depression 4. History of gastrointestinal bleed Social History: She lives in Dr.Ngowith husband and two of her three sons. Arnaldo William husband is a cardiologist. She denies tobacco or EtOH use. Family History: NC Physical Exam: VITAL SIGNS: 98 85 160/100 20 98% RA GENERAL: Pale female with alopecia, tired-appearing, in NAD HEENT: MM dry with cracked red lips, anicteric, no sinus tenderness NECK: Supple, no LAD, JVP flat HEART: RRR with a flow murmur, no S3 or S4 CHEST: Clear to ausculatation and percussion bilaterally ABDOMEN: Soft, obese, NT, ND, palpable IP port in LUQ without erythema EXTREMITIES: No c/c/e, pale nail beds, normal cap refill NEUROLOGIC: AAO x 3, appropriate, CN intact, strength 5/5 in bilateral upper and lower extremities. No sensory defect. Did not assess gait SKIN: Flushed, erythematous apearance of neck MUSCULOSKELETAL: No joint effusions noted Pertinent Results: 2001-1-26 12:30PM SODIUM-108* POTASSIUM-2.0* CHLORIDE-65* 2001-1-26 03:15PM GLUCOSE-175* UREA N-22* CREAT-1.0 SODIUM-109* POTASSIUM-2.8* CHLORIDE-66* TOTAL CO2-29 ANION GAP-17 2001-1-26 03:25PM GLUCOSE-171* LACTATE-3.2* K+-2.6* 2001-1-26 09:35PM URINE OSMOLAL-381 2001-1-26 09:35PM URINE HOURS-RANDOM UREA N-386 CREAT-27 SODIUM-60 POTASSIUM-39 PHOSPHATE-39.1 2001-1-26 10:25PM TSH-1.4 2001-1-26 10:25PM calTIBC-397 FERRITIN-391* TRF-305 2001-1-26 10:25PM GLUCOSE-140* UREA N-19 CREAT-0.9 SODIUM-111* POTASSIUM-2.9* CHLORIDE-73* TOTAL CO2-26 ANION GAP-15 2001-1-26 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111* K-2.9* Cl-73* HCO3-26 AnGap-15 1989-4-15 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113* K-2.7* Cl-79* HCO3-27 AnGap-10 2001-1-26 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111* K-2.9* Cl-73* HCO3-26 AnGap-15 1989-4-15 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113* K-2.7* Cl-79* HCO3-27 AnGap-10 1989-4-15 10:41AM BLOOD Na-114* K-3.8 1989-4-15 04:12PM BLOOD Na-116* K-3.4 1989-4-15 08:19PM BLOOD Na-122* K-3.7 1939-10-6 12:34AM BLOOD Na-122* K-3.9 1939-10-6 04:31AM BLOOD Glucose-98 Creat-1.1 Na-123* K-4.0 Cl-92* HCO3-23 AnGap-12 1939-10-6 09:48AM BLOOD Na-124* K-3.4 1939-10-6 02:02PM BLOOD Na-128* K-3.5 . 2001-1-26 CXR: IMPRESSION: No acute cardiopulmonary disease. Gas distended loops of small bowel with air-fluid levels within the upper abdomen. Unclear of the etiology of this finding; however, it may be related to her history of ovarian cancer and correlation with past imaging studies and patient history is recommended. . ECG: NSR, mild LAD, prolonged QTc, delayed RWP . Brief Hospital Course: 55 year-old female patient with history of hypertension, depression, and recent diagnosis of stage IIIA fallopian tube cancer who presents with one week of nausea, vomiting, and malaise and laboratory abnormalities of hyponatremia and hypokalemia. This was likely secondary to either SIADH or Fanconi's syndrome. 1. Hyponatremia. The patient's baseline sodium is 128 per previous records. The patient was asymptomatic on presentation. The patient was followed by the renal team throughout admission. Cortisol stimulation was performed with appropriate response. TSH was within normal limits. Her serum osmolality was low, and her urine osmolarity was high. Her urine sodium was > 60 with FENa > 2%. Citalopram was discontinued for its association with SIADH. Hydrochlorothiazide were discontinued because of hyponatremia and dehydration. The patient was initially treated with normal saline with slow correction of hyponatremia. Liberal salt intake was encouraged. Hypertonic saline and demecycline were not necessary. The patient's creatinine increased to 1.4 the day of discharge, possibly secondary to recent cisplatin treatment. The patient will have repeat labwork after discharge to monitor this. . 2. Hypokalemia. This is most likely related to GI and renal potassium. The patient will have outpatient labwork as above. . 3. Nausea/vomiting. Likely secondary to chemotherapy and hyponatremia. The patient was given anti-emetics as needed. This was improved prior to discharge. . 4. Fallopian tube cancer. The patient was followed by Dr. Porras while she was in the intensive care unit. The patient will follow-up with Drs Porras and Allison Jain. The patient's blood counts remained stable throughout. . 5. Hypertension. The patient was continued on Diovan. The patient's hydrochlorothiazide was held because of the patient's hyponatremia and dehydration. . 6. Depression. She has a long history of major depression including one drug overdose. She denied suicidal ideation. The patient's citalopram was held due to its association with SIADH. The patient was continued on Remeron. The patient will follow-up with an outpatient psychiatrist. . 7. Hypothyroidism. The patient's TSH was within the normal range. The patient was continued on her outpatient dose of levothyroxine. . 8. Erythema of neck and back. Patient states this is related to anxiety. The patient was given atarax as needed with good effect. . 9. History of gastrointestinal bleed. No active issues. The patient was continued on Protonix. . Code: Full, discussed with patient Medications on Admission: 1. Diovan/HCTZ 320/25 2. Celexa 20mg 3. Remeron 15mg 4. Synthroid 0.1mg 5. Motrin 800mg prn 6. Vicodin 5/500 prn abdominal pain 7. Compazine prn 8. Zofran prn 9. Ativan 1mg tid prn 10. Temazepam 30mg qhs Discharge Medications: 1. Outpatient Lab Work Please obtain blood work in Dr.Ngoas instructed. Please call Dr. Ollie Scheet with results; phone number (606-453-7323. 2. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety, nausea. Disp:30 Tablet(s) Refills:0 7. Temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:30 Capsule(s) Refills:2 8. Hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:2 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 12. Anzemet 100 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea for 2 weeks. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Hyponatremia secondary to Fanconi's syndrome versus SIADH . Secondary: 1. Stage IIIA grade III left-sided fallopian tube cancer 2. Hypertension 3. Major Depression 4. History of gastrointestinal bleed Discharge Condition: Afebrile, vital signs stable. Electrolytes stable. Discharge Instructions: Please contact a physician if you experience fevers, chills, increased confusion, change in vision, increased nausea, or any other concerning symptoms. . Please take your medications as prescribed. - Your celexa and hydrochlorothiazide were discontinued because they can contribute to low sodium (salt) in your blood. - You can take anzemet 100 mg once daily as needed for nausea. - You can take ativan 1 mg every six hours as needed for nausea. Please contact your psychiatrist about a refill for this medication if he feels it is medically necessary. - You should take colace and senna as needed for constipation while taking pain medications. . Please increase your salt intake as much as possible; add table salt to foods, eat foods high in sodium such as Post. . Please have your blood checked early next week. You have a prescription written for labwork. Dr. Andreas Ethan Grier will follow-up these results. . Please keep your follow-up appointments as below. Followup Instructions: Provider: Teresita Ornelas, RN Phone:186-709-2703 Date/Time:1908-5-4 10:00 Provider: Teresita Teresita Scheet, MD Phone:186-709-2703 Date/Time:1908-5-4 10:00 Provider: Kenna Ngo 19 Date/Time:1908-5-4 10:00	['Admission Date: 2001-1-26 Discharge Date: 1962-8-8\n\nDate of Birth: 1909-8-8 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Bradley\nChief Complaint:\nNausea and Vomiting.\n\nMajor Surgical or Invasive Procedure:\nNone.\n\nHistory of Present Illness:\n55 year-old female with recently diagnosed stage IIIA fallopian\ntube adenocarcinoma who presented to oncology clinic complaining\nof ongoing nausea, vomiting, and weakness. She received her\nfirst cycle of chemotherapy consisting of intravenous Taxol and\ncarboplatin on 1997-12-12, and last week received her second cycle\nconsisting of intravenous Taxol and intraperitoneal cisplatin,\nfollowed by aggressive antiemetics with dolasetron, Emend, and\ncompazine. Ever since her recent chemotherapy, she has had some\nabdominal pain, nausea, vomiting, and was feeling tired.', " She\nhas not been able to keep any food down, but has been tying to\ndrink Boost and Ensure as tolerated. She has not had any\ndiarrhea. She describes also intermittent fevers/chills at\nhome, without any headache, change in vision, chest pain, SOB,\nexcessive thirst or urination, or change in her bowel habits.\nIn oncology clinic she was found to be dehydrated, with a serum\nsodium in the 108 range and potassium in the low 2 range, and is\nadmitted for further management.\n.\nIn the ED she was afebrile, with normal vital signs, and a\nnormal mental status exam (per her husband). She was given IV\nnormal saline, potassium replacement, and was admitted to the\nWoods-Vargas Medical Center for further management. The patient's sodium improved with\nnormal saline. The etiology of her hyponatremia and hypokalemia\nwas unclear but was possibly secondary to SIADH, exacerbated by\ndehydration and electrolyte loss (vomiting), or secondary to a\ncomponent of Fanconi's syndrome.", " Hypertonic saline and\ndemocycline were not necessary. The patient's cortisol\nstimulation test and TSH were within normal limits. Celexa was\ndiscontinued due to its association with SIADH. The patient's\nIVF were discontinued at noon the day of transfer to the OMED\nfloor with sodium improving to 128 and normalization of her\npotassium.\n\nPast Medical History:\n1. Stage IIIA grade III left-sided fallopian tube cancer, status\npost total abdominal hysterectomy, bilateral\nsalpingo-oophorectomy, left pelvic lymph node dissection,\nperitoneal washings and omental biopsy on 2002-2-8.\n2. Hypertension\n3. Major Depression\n4. History of gastrointestinal bleed\n\nSocial History:\nShe lives in Dr.Ngowith husband and two of her three\nsons. Arnaldo William husband is a cardiologist. She denies tobacco or\nEtOH use.", '\n\n\nFamily History:\nNC\n\nPhysical Exam:\nVITAL SIGNS: 98 85 160/100 20 98% RA\nGENERAL: Pale female with alopecia, tired-appearing, in NAD\nHEENT: MM dry with cracked red lips, anicteric, no sinus\ntenderness\nNECK: Supple, no LAD, JVP flat\nHEART: RRR with a flow murmur, no S3 or S4\nCHEST: Clear to ausculatation and percussion bilaterally\nABDOMEN: Soft, obese, NT, ND, palpable IP port in LUQ without\nerythema\nEXTREMITIES: No c/c/e, pale nail beds, normal cap refill\nNEUROLOGIC: AAO x 3, appropriate, CN intact, strength 5/5 in\nbilateral upper and lower extremities. No sensory defect. Did\nnot assess gait\nSKIN: Flushed, erythematous apearance of neck\nMUSCULOSKELETAL: No joint effusions noted\n\nPertinent Results:\n2001-1-26 12:30PM SODIUM-108* POTASSIUM-2.0* CHLORIDE-65\n2001-1-26 03:15PM GLUCOSE-175 UREA N-22* CREAT-1.', '0 SODIUM-109\nPOTASSIUM-2.8 CHLORIDE-66* TOTAL CO2-29 ANION GAP-17\n2001-1-26 03:25PM GLUCOSE-171* LACTATE-3.2* K+-2.6\n2001-1-26 09:35PM URINE OSMOLAL-381\n2001-1-26 09:35PM URINE HOURS-RANDOM UREA N-386 CREAT-27\nSODIUM-60 POTASSIUM-39 PHOSPHATE-39.1\n2001-1-26 10:25PM TSH-1.4\n2001-1-26 10:25PM calTIBC-397 FERRITIN-391 TRF-305\n2001-1-26 10:25PM GLUCOSE-140* UREA N-19 CREAT-0.9 SODIUM-111\nPOTASSIUM-2.9 CHLORIDE-73* TOTAL CO2-26 ANION GAP-15\n2001-1-26 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111\nK-2.9 Cl-73* HCO3-26 AnGap-15\n1989-4-15 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113\nK-2.7 Cl-79* HCO3-27 AnGap-10\n\n2001-1-26 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111\nK-2.9 Cl-73* HCO3-26 AnGap-15\n1989-4-15 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113\nK-2.', '7 Cl-79* HCO3-27 AnGap-10\n1989-4-15 10:41AM BLOOD Na-114* K-3.8\n1989-4-15 04:12PM BLOOD Na-116* K-3.4\n1989-4-15 08:19PM BLOOD Na-122* K-3.7\n1939-10-6 12:34AM BLOOD Na-122* K-3.9\n1939-10-6 04:31AM BLOOD Glucose-98 Creat-1.1 Na-123* K-4.0 Cl-92\nHCO3-23 AnGap-12\n1939-10-6 09:48AM BLOOD Na-124 K-3.4\n1939-10-6 02:02PM BLOOD Na-128* K-3.5\n.\n2001-1-26 CXR: IMPRESSION: No acute cardiopulmonary disease.\nGas distended loops of small bowel with air-fluid levels within\nthe upper abdomen. Unclear of the etiology of this finding;\nhowever, it may be related to her history of ovarian cancer and\ncorrelation with past imaging studies and patient history is\nrecommended.\n.\nECG: NSR, mild LAD, prolonged QTc, delayed RWP\n.\n\nBrief Hospital Course:\n55 year-old female patient with history of hypertension,\ndepression, and recent diagnosis of stage IIIA fallopian tube\ncancer who presents with one week of nausea, vomiting, and\nmalaise and laboratory abnormalities of hyponatremia and\nhypokalemia.', " This was likely secondary to either SIADH or\nFanconi's syndrome.\n\n1. Hyponatremia. The patient's baseline sodium is 128 per\nprevious records. The patient was asymptomatic on presentation.\nThe patient was followed by the renal team throughout admission.\nCortisol stimulation was performed with appropriate response.\nTSH was within normal limits. Her serum osmolality was low, and\nher urine osmolarity was high. Her urine sodium was > 60 with\nFENa > 2%. Citalopram was discontinued for its association with\nSIADH. Hydrochlorothiazide were discontinued because of\nhyponatremia and dehydration. The patient was initially treated\nwith normal saline with slow correction of hyponatremia. Liberal\nsalt intake was encouraged. Hypertonic saline and demecycline\nwere not necessary. The patient's creatinine increased to 1.", "4\nthe day of discharge, possibly secondary to recent cisplatin\ntreatment. The patient will have repeat labwork after discharge\nto monitor this.\n.\n2. Hypokalemia. This is most likely related to GI and renal\npotassium. The patient will have outpatient labwork as above.\n.\n3. Nausea/vomiting. Likely secondary to chemotherapy and\nhyponatremia. The patient was given anti-emetics as needed. This\nwas improved prior to discharge.\n.\n4. Fallopian tube cancer. The patient was followed by Dr.\nPorras while she was in the intensive care unit. The patient\nwill follow-up with Drs Porras and Allison Jain. The patient's\nblood counts remained stable throughout.\n.\n5. Hypertension. The patient was continued on Diovan. The\npatient's hydrochlorothiazide was held because of the patient's\nhyponatremia and dehydration.", "\n.\n6. Depression. She has a long history of major depression\nincluding one drug overdose. She denied suicidal ideation. The\npatient's citalopram was held due to its association with SIADH.\nThe patient was continued on Remeron. The patient will follow-up\nwith an outpatient psychiatrist.\n.\n7. Hypothyroidism. The patient's TSH was within the normal\nrange. The patient was continued on her outpatient dose of\nlevothyroxine.\n.\n8. Erythema of neck and back. Patient states this is related to\nanxiety. The patient was given atarax as needed with good\neffect.\n.\n9. History of gastrointestinal bleed. No active issues. The\npatient was continued on Protonix.\n.\nCode: Full, discussed with patient\n\nMedications on Admission:\n1. Diovan/HCTZ 320/25\n2. Celexa 20mg\n3. Remeron 15mg\n4. Synthroid 0.1mg\n5. Motrin 800mg prn\n6.", ' Vicodin 5/500 prn abdominal pain\n7. Compazine prn\n8. Zofran prn\n9. Ativan 1mg tid prn\n10. Temazepam 30mg qhs\n\n\nDischarge Medications:\n1. Outpatient Lab Work\nPlease obtain blood work in Dr.Ngoas instructed. Please\ncall Dr. Ollie Scheet with results; phone number (606-453-7323.\n2. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\nDisp:60 Tablet(s) Refills:2\n3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime).\nDisp:30 Tablet(s) Refills:2\n4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:2\n5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO\nQ4-6H (every 4 to 6 hours) as needed.\n6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8\nhours) as needed for anxiety, nausea.\nDisp:30 Tablet(s) Refills:0\n7.', " Temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime.\nDisp:30 Capsule(s) Refills:2\n8. Hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\nhours) as needed for anxiety.\n9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for constipation.\nDisp:60 Tablet(s) Refills:2\n10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID\n(2 times a day) as needed for constipation.\nDisp:60 Capsule(s) Refills:2\n11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:2\n12. Anzemet 100 mg Tablet Sig: One (1) Tablet PO once a day as\nneeded for nausea for 2 weeks.\nDisp:14 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPrimary:\nHyponatremia secondary to Fanconi's syndrome versus SIADH\n.", '\nSecondary:\n1. Stage IIIA grade III left-sided fallopian tube cancer\n2. Hypertension\n3. Major Depression\n4. History of gastrointestinal bleed\n\nDischarge Condition:\nAfebrile, vital signs stable. Electrolytes stable.\n\n\nDischarge Instructions:\nPlease contact a physician if you experience fevers, chills,\nincreased confusion, change in vision, increased nausea, or any\nother concerning symptoms.\n.\nPlease take your medications as prescribed.\n- Your celexa and hydrochlorothiazide were discontinued because\nthey can contribute to low sodium (salt) in your blood.\n- You can take anzemet 100 mg once daily as needed for nausea.\n- You can take ativan 1 mg every six hours as needed for nausea.\nPlease contact your psychiatrist about a refill for this\nmedication if he feels it is medically necessary.\n- You should take colace and senna as needed for constipation\nwhile taking pain medications.', '\n.\nPlease increase your salt intake as much as possible; add table\nsalt to foods, eat foods high in sodium such as Post.\n.\nPlease have your blood checked early next week. You have a\nprescription written for labwork. Dr. Andreas Ethan Grier will\nfollow-up these results.\n.\nPlease keep your follow-up appointments as below.\n\nFollowup Instructions:\nProvider: Teresita Ornelas, RN Phone:186-709-2703 Date/Time:1908-5-4\n10:00\nProvider: Teresita Teresita Scheet, MD Phone:186-709-2703\nDate/Time:1908-5-4 10:00\nProvider: Kenna Ngo 19 Date/Time:1908-5-4 10:00\n\n\n\n']
536	6962	147360.0	2178-12-03	Discharge summary	Report	Admission Date: [2178-11-12] Discharge Date: [2178-12-3] Date of Birth: [2112-4-25] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old female who was initially admitted on [2178-11-12], complaining of increased weakness and groin pain since nine days prior to admission when she had a fall. Since the fall, the patient had been basically confined to her bedroom, did not drink or eat, and lived on some water, coffee, cigarettes and occasional beer. According to her family, the patient had been not very mobile for some time prior to admission, mostly because of severe exertional dyspnea. However, despite her dyspnea, she continued to smoke two packs of cigarettes per day. On admission, the patient denied any fevers, chills, nausea, vomiting, dizziness, chest pain. PAST MEDICAL HISTORY: Significant for chronic obstructive pulmonary disease, hypertension, history of vitamin B12 deficiency. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Tiazac 240 per day, Premarin 0.625 mg per day, Provera 2.5 mg per day, clonazepam 1 mg three times a day, Atrovent two puffs four times a day, albuterol four puffs four times a day, Ventolin as needed. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives alone, lifelong smoker, at least two packs per day. Drinks ethanol on a regular basis. PHYSICAL EXAMINATION: On admission, vital signs 97.7, blood pressure 90/60, heart rate 101, respiratory rate 29, oxygen saturation 90% on 2 liters. In general, she was alert and oriented x 3, very cachectic, in no apparent distress. Her pupils were equal, reactive, responsive to light and accommodation, extraocular muscles were intact, oropharynx was clear. The skin was without rashes. The neck showed no jugular venous distention, no bruits. The lungs showed decreased air movement and were wheezy. Heart regular rate and rhythm plus murmur. The abdomen was soft, nontender, with normal active bowel sounds. Extremities were clear, no clubbing, cyanosis or edema, good pulses distally. Neurological examination was nonfocal. LABORATORY DATA: On admission, significant for a white blood cell count of 23.7, hematocrit 43.5, platelets 651. Liver function tests were normal. Chemistries were normal. Creatinine 0.5. Chest x-ray showed a right upper lobe infiltrate. Hip films were suspicious for a left femoral neck fracture. Electrocardiogram showed sinus tachycardia. HOSPITAL COURSE: This is a 66-year-old female with severe chronic obstructive pulmonary disease, hypertension, who presented with right upper lobe pneumonia and a possible left hip fracture and generalized weakness. She is a long-time smoker, and has also had ethanol abuse on a regular basis. She was given intravenous fluids, antibiotics, levofloxacin intravenously, nebulizer therapy, inhalers and oxygen. She was put on ethanol and nicotine withdrawal precautions, given deep venous thrombosis prophylaxis, and was seen by Orthopaedic Surgery consult. Orthopaedic service decided to treat her left hip fracture nonoperatively because it was stable and impacted in an acceptable but not ideal position. Pinning the hip in that position would have been technically difficult and has drawbacks and, because of her severe chronic obstructive pulmonary disease and pneumonia, it was decided to avoid surgery. She was discontinued from her Premarin because this increases the risk of deep venous thrombosis. She would need to walk with a walker for four to six more weeks, for which she would need a rehabilitation hospital or home care with services. On [11-15], the patient was found to have oxygen saturations as low as 53%. She was placed on 100% non-rebreather, which improved her saturations to 100%. The patient was noted to have a weak cough. Oral/nasal suctioning was started, and the patient was breathing better. Changed to 4 liters of nasal cannula oxygen, saturating 95%. However, she continued to be more somnolent and difficult to arouse. An arterial blood gas showed a pH of 7.3, PCO2 89, PO2 200 on 100% non-rebreather. Chest x-ray showed worsening right upper lobe pneumonia. The patient was transferred to the Medical Intensive Care Unit for further airway management. She did not tolerate BiPAP secondary to depressed mental status and secretions, and therefore was intubated for pulmonary toilet and more adequate respiration to protect mental status. Later that day, after a lengthy discussion with the son, [Name (NI) 1704], and daughter, [Name (NI) ], it was learned that the patient had been completely noncompliant with medical care prior to admission. Her oldest daughter, [Name (NI) ], is her health care proxy, but feels that [Name (NI) 1704] should be making the medical decision, as Mrs. [Known lastname 4427] lives with him and is close to him. Mrs. [Known lastname 4427] had previously expressed to her primary care physician that she wanted to have all medical interventions, but no be on a breathing machine for a prolonged period of time. Given her acute decompensation and pneumonia, there was reversible component to her situation, however, it was explained to them the severity of the underlying lung disease and the chance of prolonged intubation. [Doctor First Name ] expressed that her mother has been severely depressed for the past 15 years, since her husband and two children died, and has been committing slow suicide by abusing her body with tobacco, ethanol and caffeine. She has refused interventional therapy or medication. It was decided at that point that she would be made Do Not Resuscitate, but would continue on the ventilator. The patient continued to be treated with Levaquin and Flagyl for possible aspiration pneumonia, and was continued on the respirator, but had a difficult time being weaned from the ventilator. Chest x-ray showed emphysematous blebs in her left lower lobe, and continuing right pleural effusion that layered. By [11-19], her pressure support on the ventilator was decreased to 10, although she failed a spontaneous breathing trial. Pleural effusion was stable, acid fast bacilli negative x 3. She was evaluated by Nutrition, and started on tube feeds, Impact with fiber at 40 cc/hour. On [11-20], she had to be placed back on pressure support of 12 and 5 because of failure to tolerate the lower pressures. Plans were made on that day for percutaneous tracheostomy if she continued to fail her wean. She was treated for eight out of 21 days with levofloxacin and eight of 14 days with Flagyl. She continued to demonstrate difficulties in weaning from the ventilator. Atrovent was added on [11-22], and she was continued on her antibiotics. On [11-21], it was discussed with the family and it was decided that it would be attempted to avoid tracheostomy and attempt ventilatory wean because the wishes of the patient and the family were to not have long-term intubation on a tracheostomy, and that she would not want to be reintubated. However, a short trial of pressure support [3-28] with increased respiration, decreased tidal volume, subsequent arterial blood gas of 7.31/84/54, and the patient had to be put back on pressure support of 15 with 5 of PEEP. She spiked to 101 and was cultured, grew 4+ gram-positive cocci, and the patient was started on vancomycin over concern for methicillin resistant staphylococcus aureus. She continued to fail spontaneous breathing trial on [11-23]. The trach issue was discussed with her primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], and the family. On [11-24], she tolerated a spontaneous breathing trial for two hours, but the required increased ventilation assist control overnight. This was day ten of intubation, on [11-24]. She was continued on antibiotics, continued on tube feeds, prophylaxis for deep venous thrombosis. On [11-24], later in the day, Mrs. [Known lastname 4427] was able to communicate her wishes to proceed with a trach and a percutaneous endoscopic gastrostomy tube, and her son consented for the procedures. Later that day, a PICC line and an arterial line were placed, and on [11-25], day number 11 of intubation, a tracheostomy was placed at the bedside. The patient tolerated the procedure well, but with some chest pain at the tracheostomy site. Chest pain was without electrocardiogram changes, and with stable vital signs. She was ruled out for myocardial infarction by enzymes. During this time, she was also treated with prednisone for a chronic obstructive pulmonary disease flare, as well as antibiotics. On [11-28], the percutaneous endoscopic gastrostomy tube was placed. The procedure was tolerated well, and the patient was continued on a weaning protocol from the ventilator, with slowly decreasing pressure support. On that day, all antibiotics were discontinued because she had completed her course, and she was tapered from her steroids. The patient remained afebrile throughout her hospital course, was continued on tube feeds with intravenous fluids as necessary, was seen by Physical Therapy services, was found to be requiring daily mobility and exercise for two to three weeks to regain her strength. On [12-1], the patient was evaluated by Speech and Swallow for a ________________ valve. This was fitted on her trach mask as tolerated. The patient was able to tolerate five hours off of the ventilator without events. On [12-2], she was screened for discharge to a rehabilitation hospital for continued strengthening and weaning from ventilator. Her prognosis for removal of her tracheostomy was thought to be good. An addendum to this discharge summary is to follow. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4428], M.D. [MD Number(1) 4429] Dictated By:[Name8 (MD) 4430] MEDQUIST36 D: [2178-12-2] 20:59 T: [2178-12-3] 00:00 JOB#: [Job Number 4431]	Admission Date: <Date>1901-4-5</Date> Discharge Date: <Date>1917-8-26</Date> Date of Birth: <Date>1963-6-12</Date> Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old female who was initially admitted on <Date>1901-4-5</Date>, complaining of increased weakness and groin pain since nine days prior to admission when she had a fall. Since the fall, the patient had been basically confined to her bedroom, did not drink or eat, and lived on some water, coffee, cigarettes and occasional beer. According to her family, the patient had been not very mobile for some time prior to admission, mostly because of severe exertional dyspnea. However, despite her dyspnea, she continued to smoke two packs of cigarettes per day. On admission, the patient denied any fevers, chills, nausea, vomiting, dizziness, chest pain. PAST MEDICAL HISTORY: Significant for chronic obstructive pulmonary disease, hypertension, history of vitamin B12 deficiency. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Tiazac 240 per day, Premarin 0.625 mg per day, Provera 2.5 mg per day, clonazepam 1 mg three times a day, Atrovent two puffs four times a day, albuterol four puffs four times a day, Ventolin as needed. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives alone, lifelong smoker, at least two packs per day. Drinks ethanol on a regular basis. PHYSICAL EXAMINATION: On admission, vital signs 97.7, blood pressure 90/60, heart rate 101, respiratory rate 29, oxygen saturation 90% on 2 liters. In general, she was alert and oriented x 3, very cachectic, in no apparent distress. Her pupils were equal, reactive, responsive to light and accommodation, extraocular muscles were intact, oropharynx was clear. The skin was without rashes. The neck showed no jugular venous distention, no bruits. The lungs showed decreased air movement and were wheezy. Heart regular rate and rhythm plus murmur. The abdomen was soft, nontender, with normal active bowel sounds. Extremities were clear, no clubbing, cyanosis or edema, good pulses distally. Neurological examination was nonfocal. LABORATORY DATA: On admission, significant for a white blood cell count of 23.7, hematocrit 43.5, platelets 651. Liver function tests were normal. Chemistries were normal. Creatinine 0.5. Chest x-ray showed a right upper lobe infiltrate. Hip films were suspicious for a left femoral neck fracture. Electrocardiogram showed sinus tachycardia. HOSPITAL COURSE: This is a 66-year-old female with severe chronic obstructive pulmonary disease, hypertension, who presented with right upper lobe pneumonia and a possible left hip fracture and generalized weakness. She is a long-time smoker, and has also had ethanol abuse on a regular basis. She was given intravenous fluids, antibiotics, levofloxacin intravenously, nebulizer therapy, inhalers and oxygen. She was put on ethanol and nicotine withdrawal precautions, given deep venous thrombosis prophylaxis, and was seen by Orthopaedic Surgery consult. Orthopaedic service decided to treat her left hip fracture nonoperatively because it was stable and impacted in an acceptable but not ideal position. Pinning the hip in that position would have been technically difficult and has drawbacks and, because of her severe chronic obstructive pulmonary disease and pneumonia, it was decided to avoid surgery. She was discontinued from her Premarin because this increases the risk of deep venous thrombosis. She would need to walk with a walker for four to six more weeks, for which she would need a rehabilitation hospital or home care with services. On <Date>1-20</Date>, the patient was found to have oxygen saturations as low as 53%. She was placed on 100% non-rebreather, which improved her saturations to 100%. The patient was noted to have a weak cough. Oral/nasal suctioning was started, and the patient was breathing better. Changed to 4 liters of nasal cannula oxygen, saturating 95%. However, she continued to be more somnolent and difficult to arouse. An arterial blood gas showed a pH of 7.3, PCO2 89, PO2 200 on 100% non-rebreather. Chest x-ray showed worsening right upper lobe pneumonia. The patient was transferred to the Medical Intensive Care Unit for further airway management. She did not tolerate BiPAP secondary to depressed mental status and secretions, and therefore was intubated for pulmonary toilet and more adequate respiration to protect mental status. Later that day, after a lengthy discussion with the son, <Name>Juvenal Pichardo</Name>, and daughter, <Name>Meena Blanchar</Name>, it was learned that the patient had been completely noncompliant with medical care prior to admission. Her oldest daughter, <Name>Meena Blanchar</Name>, is her health care proxy, but feels that <Name>Juvenal Pichardo</Name> should be making the medical decision, as Mrs. <Name>Post</Name> lives with him and is close to him. Mrs. <Name>Post</Name> had previously expressed to her primary care physician that she wanted to have all medical interventions, but no be on a breathing machine for a prolonged period of time. Given her acute decompensation and pneumonia, there was reversible component to her situation, however, it was explained to them the severity of the underlying lung disease and the chance of prolonged intubation. <Name>Isidro</Name> expressed that her mother has been severely depressed for the past 15 years, since her husband and two children died, and has been committing slow suicide by abusing her body with tobacco, ethanol and caffeine. She has refused interventional therapy or medication. It was decided at that point that she would be made Do Not Resuscitate, but would continue on the ventilator. The patient continued to be treated with Levaquin and Flagyl for possible aspiration pneumonia, and was continued on the respirator, but had a difficult time being weaned from the ventilator. Chest x-ray showed emphysematous blebs in her left lower lobe, and continuing right pleural effusion that layered. By <Date>12-15</Date>, her pressure support on the ventilator was decreased to 10, although she failed a spontaneous breathing trial. Pleural effusion was stable, acid fast bacilli negative x 3. She was evaluated by Nutrition, and started on tube feeds, Impact with fiber at 40 cc/hour. On <Date>8-19</Date>, she had to be placed back on pressure support of 12 and 5 because of failure to tolerate the lower pressures. Plans were made on that day for percutaneous tracheostomy if she continued to fail her wean. She was treated for eight out of 21 days with levofloxacin and eight of 14 days with Flagyl. She continued to demonstrate difficulties in weaning from the ventilator. Atrovent was added on <Date>8-12</Date>, and she was continued on her antibiotics. On <Date>7-22</Date>, it was discussed with the family and it was decided that it would be attempted to avoid tracheostomy and attempt ventilatory wean because the wishes of the patient and the family were to not have long-term intubation on a tracheostomy, and that she would not want to be reintubated. However, a short trial of pressure support <Date>12-24</Date> with increased respiration, decreased tidal volume, subsequent arterial blood gas of 7.31/84/54, and the patient had to be put back on pressure support of 15 with 5 of PEEP. She spiked to 101 and was cultured, grew 4+ gram-positive cocci, and the patient was started on vancomycin over concern for methicillin resistant staphylococcus aureus. She continued to fail spontaneous breathing trial on <Date>7-29</Date>. The trach issue was discussed with her primary care physician, <Name>Negrete</Name>. <Name>Gauthier</Name>, and the family. On <Date>4-19</Date>, she tolerated a spontaneous breathing trial for two hours, but the required increased ventilation assist control overnight. This was day ten of intubation, on <Date>4-19</Date>. She was continued on antibiotics, continued on tube feeds, prophylaxis for deep venous thrombosis. On <Date>4-19</Date>, later in the day, Mrs. <Name>Post</Name> was able to communicate her wishes to proceed with a trach and a percutaneous endoscopic gastrostomy tube, and her son consented for the procedures. Later that day, a PICC line and an arterial line were placed, and on <Date>10-25</Date>, day number 11 of intubation, a tracheostomy was placed at the bedside. The patient tolerated the procedure well, but with some chest pain at the tracheostomy site. Chest pain was without electrocardiogram changes, and with stable vital signs. She was ruled out for myocardial infarction by enzymes. During this time, she was also treated with prednisone for a chronic obstructive pulmonary disease flare, as well as antibiotics. On <Date>7-23</Date>, the percutaneous endoscopic gastrostomy tube was placed. The procedure was tolerated well, and the patient was continued on a weaning protocol from the ventilator, with slowly decreasing pressure support. On that day, all antibiotics were discontinued because she had completed her course, and she was tapered from her steroids. The patient remained afebrile throughout her hospital course, was continued on tube feeds with intravenous fluids as necessary, was seen by Physical Therapy services, was found to be requiring daily mobility and exercise for two to three weeks to regain her strength. On <Date>8-4</Date>, the patient was evaluated by Speech and Swallow for a ________________ valve. This was fitted on her trach mask as tolerated. The patient was able to tolerate five hours off of the ventilator without events. On <Date>11-19</Date>, she was screened for discharge to a rehabilitation hospital for continued strengthening and weaning from ventilator. Her prognosis for removal of her tracheostomy was thought to be good. An addendum to this discharge summary is to follow. <Name>Delfina</Name> <Name>Harris</Name>, M.D. <MD Number>84057682</MD Number> Dictated By:<Name>Walter Tejada</Name> MEDQUIST36 D: <Date>1994-3-11</Date> 20:59 T: <Date>1917-8-26</Date> 00:00 JOB#: <Job Number>Richardson, Payne and Knox-1906-757688</Job 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Date: 1901-4-5 Discharge Date: 1917-8-26 Date of Birth: 1963-6-12 Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old female who was initially admitted on 1901-4-5, complaining of increased weakness and groin pain since nine days prior to admission when she had a fall. Since the fall, the patient had been basically confined to her bedroom, did not drink or eat, and lived on some water, coffee, cigarettes and occasional beer. According to her family, the patient had been not very mobile for some time prior to admission, mostly because of severe exertional dyspnea. However, despite her dyspnea, she continued to smoke two packs of cigarettes per day. On admission, the patient denied any fevers, chills, nausea, vomiting, dizziness, chest pain. PAST MEDICAL HISTORY: Significant for chronic obstructive pulmonary disease, hypertension, history of vitamin B12 deficiency. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Tiazac 240 per day, Premarin 0.625 mg per day, Provera 2.5 mg per day, clonazepam 1 mg three times a day, Atrovent two puffs four times a day, albuterol four puffs four times a day, Ventolin as needed. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives alone, lifelong smoker, at least two packs per day. Drinks ethanol on a regular basis. PHYSICAL EXAMINATION: On admission, vital signs 97.7, blood pressure 90/60, heart rate 101, respiratory rate 29, oxygen saturation 90% on 2 liters. In general, she was alert and oriented x 3, very cachectic, in no apparent distress. Her pupils were equal, reactive, responsive to light and accommodation, extraocular muscles were intact, oropharynx was clear. The skin was without rashes. The neck showed no jugular venous distention, no bruits. The lungs showed decreased air movement and were wheezy. Heart regular rate and rhythm plus murmur. The abdomen was soft, nontender, with normal active bowel sounds. Extremities were clear, no clubbing, cyanosis or edema, good pulses distally. Neurological examination was nonfocal. LABORATORY DATA: On admission, significant for a white blood cell count of 23.7, hematocrit 43.5, platelets 651. Liver function tests were normal. Chemistries were normal. Creatinine 0.5. Chest x-ray showed a right upper lobe infiltrate. Hip films were suspicious for a left femoral neck fracture. Electrocardiogram showed sinus tachycardia. HOSPITAL COURSE: This is a 66-year-old female with severe chronic obstructive pulmonary disease, hypertension, who presented with right upper lobe pneumonia and a possible left hip fracture and generalized weakness. She is a long-time smoker, and has also had ethanol abuse on a regular basis. She was given intravenous fluids, antibiotics, levofloxacin intravenously, nebulizer therapy, inhalers and oxygen. She was put on ethanol and nicotine withdrawal precautions, given deep venous thrombosis prophylaxis, and was seen by Orthopaedic Surgery consult. Orthopaedic service decided to treat her left hip fracture nonoperatively because it was stable and impacted in an acceptable but not ideal position. Pinning the hip in that position would have been technically difficult and has drawbacks and, because of her severe chronic obstructive pulmonary disease and pneumonia, it was decided to avoid surgery. She was discontinued from her Premarin because this increases the risk of deep venous thrombosis. She would need to walk with a walker for four to six more weeks, for which she would need a rehabilitation hospital or home care with services. On 1-20, the patient was found to have oxygen saturations as low as 53%. She was placed on 100% non-rebreather, which improved her saturations to 100%. The patient was noted to have a weak cough. Oral/nasal suctioning was started, and the patient was breathing better. Changed to 4 liters of nasal cannula oxygen, saturating 95%. However, she continued to be more somnolent and difficult to arouse. An arterial blood gas showed a pH of 7.3, PCO2 89, PO2 200 on 100% non-rebreather. Chest x-ray showed worsening right upper lobe pneumonia. The patient was transferred to the Medical Intensive Care Unit for further airway management. She did not tolerate BiPAP secondary to depressed mental status and secretions, and therefore was intubated for pulmonary toilet and more adequate respiration to protect mental status. Later that day, after a lengthy discussion with the son, Juvenal Pichardo, and daughter, Meena Blanchar, it was learned that the patient had been completely noncompliant with medical care prior to admission. Her oldest daughter, Meena Blanchar, is her health care proxy, but feels that Juvenal Pichardo should be making the medical decision, as Mrs. Post lives with him and is close to him. Mrs. Post had previously expressed to her primary care physician that she wanted to have all medical interventions, but no be on a breathing machine for a prolonged period of time. Given her acute decompensation and pneumonia, there was reversible component to her situation, however, it was explained to them the severity of the underlying lung disease and the chance of prolonged intubation. Isidro expressed that her mother has been severely depressed for the past 15 years, since her husband and two children died, and has been committing slow suicide by abusing her body with tobacco, ethanol and caffeine. She has refused interventional therapy or medication. It was decided at that point that she would be made Do Not Resuscitate, but would continue on the ventilator. The patient continued to be treated with Levaquin and Flagyl for possible aspiration pneumonia, and was continued on the respirator, but had a difficult time being weaned from the ventilator. Chest x-ray showed emphysematous blebs in her left lower lobe, and continuing right pleural effusion that layered. By 12-15, her pressure support on the ventilator was decreased to 10, although she failed a spontaneous breathing trial. Pleural effusion was stable, acid fast bacilli negative x 3. She was evaluated by Nutrition, and started on tube feeds, Impact with fiber at 40 cc/hour. On 8-19, she had to be placed back on pressure support of 12 and 5 because of failure to tolerate the lower pressures. Plans were made on that day for percutaneous tracheostomy if she continued to fail her wean. She was treated for eight out of 21 days with levofloxacin and eight of 14 days with Flagyl. She continued to demonstrate difficulties in weaning from the ventilator. Atrovent was added on 8-12, and she was continued on her antibiotics. On 7-22, it was discussed with the family and it was decided that it would be attempted to avoid tracheostomy and attempt ventilatory wean because the wishes of the patient and the family were to not have long-term intubation on a tracheostomy, and that she would not want to be reintubated. However, a short trial of pressure support 12-24 with increased respiration, decreased tidal volume, subsequent arterial blood gas of 7.31/84/54, and the patient had to be put back on pressure support of 15 with 5 of PEEP. She spiked to 101 and was cultured, grew 4+ gram-positive cocci, and the patient was started on vancomycin over concern for methicillin resistant staphylococcus aureus. She continued to fail spontaneous breathing trial on 7-29. The trach issue was discussed with her primary care physician, Negrete. Gauthier, and the family. On 4-19, she tolerated a spontaneous breathing trial for two hours, but the required increased ventilation assist control overnight. This was day ten of intubation, on 4-19. She was continued on antibiotics, continued on tube feeds, prophylaxis for deep venous thrombosis. On 4-19, later in the day, Mrs. Post was able to communicate her wishes to proceed with a trach and a percutaneous endoscopic gastrostomy tube, and her son consented for the procedures. Later that day, a PICC line and an arterial line were placed, and on 10-25, day number 11 of intubation, a tracheostomy was placed at the bedside. The patient tolerated the procedure well, but with some chest pain at the tracheostomy site. Chest pain was without electrocardiogram changes, and with stable vital signs. She was ruled out for myocardial infarction by enzymes. During this time, she was also treated with prednisone for a chronic obstructive pulmonary disease flare, as well as antibiotics. On 7-23, the percutaneous endoscopic gastrostomy tube was placed. The procedure was tolerated well, and the patient was continued on a weaning protocol from the ventilator, with slowly decreasing pressure support. On that day, all antibiotics were discontinued because she had completed her course, and she was tapered from her steroids. The patient remained afebrile throughout her hospital course, was continued on tube feeds with intravenous fluids as necessary, was seen by Physical Therapy services, was found to be requiring daily mobility and exercise for two to three weeks to regain her strength. On 8-4, the patient was evaluated by Speech and Swallow for a ________________ valve. This was fitted on her trach mask as tolerated. The patient was able to tolerate five hours off of the ventilator without events. On 11-19, she was screened for discharge to a rehabilitation hospital for continued strengthening and weaning from ventilator. Her prognosis for removal of her tracheostomy was thought to be good. An addendum to this discharge summary is to follow. Delfina Harris, M.D. 84057682 Dictated By:Walter Tejada MEDQUIST36 D: 1994-3-11 20:59 T: 1917-8-26 00:00 JOB#: Richardson, Payne and Knox-1906-757688	['Admission Date: 1901-4-5 Discharge Date: 1917-8-26\n\nDate of Birth: 1963-6-12 Sex: F\n\nService: MEDICINE\n\nHISTORY OF PRESENT ILLNESS: The patient is a 66-year-old\nfemale who was initially admitted on 1901-4-5,\ncomplaining of increased weakness and groin pain since nine\ndays prior to admission when she had a fall. Since the fall,\nthe patient had been basically confined to her bedroom, did\nnot drink or eat, and lived on some water, coffee, cigarettes\nand occasional beer. According to her family, the patient\nhad been not very mobile for some time prior to admission,\nmostly because of severe exertional dyspnea. However,\ndespite her dyspnea, she continued to smoke two packs of\ncigarettes per day.\n\nOn admission, the patient denied any fevers, chills, nausea,\nvomiting, dizziness, chest pain.', '\n\nPAST MEDICAL HISTORY: Significant for chronic obstructive\npulmonary disease, hypertension, history of vitamin B12\ndeficiency.\n\nALLERGIES: No known drug allergies.\n\nMEDICATIONS ON ADMISSION: Tiazac 240 per day, Premarin\n0.625 mg per day, Provera 2.5 mg per day, clonazepam 1 mg\nthree times a day, Atrovent two puffs four times a day,\nalbuterol four puffs four times a day, Ventolin as needed.\n\nFAMILY HISTORY: Noncontributory.\n\nSOCIAL HISTORY: Lives alone, lifelong smoker, at least two\npacks per day. Drinks ethanol on a regular basis.\n\nPHYSICAL EXAMINATION: On admission, vital signs 97.7, blood\npressure 90/60, heart rate 101, respiratory rate 29, oxygen\nsaturation 90% on 2 liters. In general, she was alert and\noriented x 3, very cachectic, in no apparent distress. Her\npupils were equal, reactive, responsive to light and\naccommodation, extraocular muscles were intact, oropharynx\nwas clear.', ' The skin was without rashes. The neck showed no\njugular venous distention, no bruits. The lungs showed\ndecreased air movement and were wheezy. Heart regular rate\nand rhythm plus murmur. The abdomen was soft, nontender,\nwith normal active bowel sounds. Extremities were clear, no\nclubbing, cyanosis or edema, good pulses distally.\nNeurological examination was nonfocal.\n\nLABORATORY DATA: On admission, significant for a white\nblood cell count of 23.7, hematocrit 43.5, platelets 651.\nLiver function tests were normal. Chemistries were normal.\nCreatinine 0.5. Chest x-ray showed a right upper lobe\ninfiltrate. Hip films were suspicious for a left femoral\nneck fracture. Electrocardiogram showed sinus tachycardia.\n\nHOSPITAL COURSE: This is a 66-year-old female with severe\nchronic obstructive pulmonary disease, hypertension, who\npresented with right upper lobe pneumonia and a possible left\nhip fracture and generalized weakness.', ' She is a long-time\nsmoker, and has also had ethanol abuse on a regular basis.\n\nShe was given intravenous fluids, antibiotics, levofloxacin\nintravenously, nebulizer therapy, inhalers and oxygen. She\nwas put on ethanol and nicotine withdrawal precautions, given\ndeep venous thrombosis prophylaxis, and was seen by\nOrthopaedic Surgery consult. Orthopaedic service decided to\ntreat her left hip fracture nonoperatively because it was\nstable and impacted in an acceptable but not ideal position.\nPinning the hip in that position would have been technically\ndifficult and has drawbacks and, because of her severe\nchronic obstructive pulmonary disease and pneumonia, it was\ndecided to avoid surgery. She was discontinued from her\nPremarin because this increases the risk of deep venous\nthrombosis. She would need to walk with a walker for four to\nsix more weeks, for which she would need a rehabilitation\nhospital or home care with services.', '\n\nOn 1-20, the patient was found to have oxygen saturations as\nlow as 53%. She was placed on 100% non-rebreather, which\nimproved her saturations to 100%. The patient was noted to\nhave a weak cough. Oral/nasal suctioning was started, and\nthe patient was breathing better. Changed to 4 liters of\nnasal cannula oxygen, saturating 95%. However, she continued\nto be more somnolent and difficult to arouse. An arterial\nblood gas showed a pH of 7.3, PCO2 89, PO2 200 on 100%\nnon-rebreather. Chest x-ray showed worsening right upper\nlobe pneumonia.\n\nThe patient was transferred to the Medical Intensive Care\nUnit for further airway management. She did not tolerate\nBiPAP secondary to depressed mental status and secretions,\nand therefore was intubated for pulmonary toilet and more\nadequate respiration to protect mental status.', '\n\nLater that day, after a lengthy discussion with the son,\nJuvenal Pichardo, and daughter, Meena Blanchar, it was learned that the patient\nhad been completely noncompliant with medical care prior to\nadmission. Her oldest daughter, Meena Blanchar, is her health care\nproxy, but feels that Juvenal Pichardo should be making the medical\ndecision, as Mrs. Post lives with him and is close to him.\nMrs. Post had previously expressed to her primary care\nphysician that she wanted to have all medical interventions,\nbut no be on a breathing machine for a prolonged period of\ntime. Given her acute decompensation and pneumonia, there\nwas reversible component to her situation, however, it was\nexplained to them the severity of the underlying lung disease\nand the chance of prolonged intubation. Isidro expressed that\nher mother has been severely depressed for the past 15 years,\nsince her husband and two children died, and has been\ncommitting slow suicide by abusing her body with tobacco,\nethanol and caffeine.', ' She has refused interventional therapy\nor medication. It was decided at that point that she would\nbe made Do Not Resuscitate, but would continue on the\nventilator.\n\nThe patient continued to be treated with Levaquin and Flagyl\nfor possible aspiration pneumonia, and was continued on the\nrespirator, but had a difficult time being weaned from the\nventilator. Chest x-ray showed emphysematous blebs in her\nleft lower lobe, and continuing right pleural effusion that\nlayered.\n\nBy 12-15, her pressure support on the ventilator was\ndecreased to 10, although she failed a spontaneous breathing\ntrial. Pleural effusion was stable, acid fast bacilli\nnegative x 3. She was evaluated by Nutrition, and started on\ntube feeds, Impact with fiber at 40 cc/hour.\n\nOn 8-19, she had to be placed back on pressure support of 12\nand 5 because of failure to tolerate the lower pressures.', '\nPlans were made on that day for percutaneous tracheostomy if\nshe continued to fail her wean. She was treated for eight\nout of 21 days with levofloxacin and eight of 14 days with\nFlagyl.\n\nShe continued to demonstrate difficulties in weaning from the\nventilator. Atrovent was added on 8-12, and she was\ncontinued on her antibiotics.\n\nOn 7-22, it was discussed with the family and it was decided\nthat it would be attempted to avoid tracheostomy and attempt\nventilatory wean because the wishes of the patient and the\nfamily were to not have long-term intubation on a\ntracheostomy, and that she would not want to be reintubated.\nHowever, a short trial of pressure support 12-24 with increased\nrespiration, decreased tidal volume, subsequent arterial\nblood gas of 7.31/84/54, and the patient had to be put back\non pressure support of 15 with 5 of PEEP.', ' She spiked to 101\nand was cultured, grew 4+ gram-positive cocci, and the\npatient was started on vancomycin over concern for\nmethicillin resistant staphylococcus aureus.\n\nShe continued to fail spontaneous breathing trial on 7-29.\nThe trach issue was discussed with her primary care\nphysician, Negrete. Gauthier, and the family. On 4-19, she\ntolerated a spontaneous breathing trial for two hours, but\nthe required increased ventilation assist control overnight.\nThis was day ten of intubation, on 4-19. She was\ncontinued on antibiotics, continued on tube feeds,\nprophylaxis for deep venous thrombosis.\n\nOn 4-19, later in the day, Mrs. Post was able to\ncommunicate her wishes to proceed with a trach and a\npercutaneous endoscopic gastrostomy tube, and her son\nconsented for the procedures. Later that day, a PICC line\nand an arterial line were placed, and on 10-25, day\nnumber 11 of intubation, a tracheostomy was placed at the\nbedside.', ' The patient tolerated the procedure well, but with\nsome chest pain at the tracheostomy site. Chest pain was\nwithout electrocardiogram changes, and with stable vital\nsigns. She was ruled out for myocardial infarction by\nenzymes. During this time, she was also treated with\nprednisone for a chronic obstructive pulmonary disease flare,\nas well as antibiotics.\n\nOn 7-23, the percutaneous endoscopic gastrostomy tube\nwas placed. The procedure was tolerated well, and the\npatient was continued on a weaning protocol from the\nventilator, with slowly decreasing pressure support. On that\nday, all antibiotics were discontinued because she had\ncompleted her course, and she was tapered from her steroids.\nThe patient remained afebrile throughout her hospital course,\nwas continued on tube feeds with intravenous fluids as\nnecessary, was seen by Physical Therapy services, was found\nto be requiring daily mobility and exercise for two to three\nweeks to regain her strength.', '\n\nOn 8-4, the patient was evaluated by Speech and Swallow\nfor a ________________ valve. This was fitted on her trach\nmask as tolerated. The patient was able to tolerate five\nhours off of the ventilator without events.\n\nOn 11-19, she was screened for discharge to a\nrehabilitation hospital for continued strengthening and\nweaning from ventilator. Her prognosis for removal of her\ntracheostomy was thought to be good. An addendum to this\ndischarge summary is to follow.\n\n\n\n\n Delfina Harris, M.D. 84057682\n\nDictated By:Walter Tejada\nMEDQUIST36\n\nD: 1994-3-11 20:59\nT: 1917-8-26 00:00\nJOB#: Richardson, Payne and Knox-1906-757688\n']
537	6962	185719.0	2180-06-02	Discharge summary	Report	Admission Date: [2180-5-24] Discharge Date: [2180-6-2] Date of Birth: [2112-4-25] Sex: F Service: FENARD INTENSIVE CARE UNIT CHIEF COMPLAINT: Hypoxia. HISTORY OF PRESENT ILLNESS: This is a 68-year-old woman with a history of chronic obstructive pulmonary disease, history of right upper lobe pneumonia, status post prolonged intubation with trache and PEG placements from [2177-11-24] to [2178-12-25], full exercise tolerance at baseline, chronic productive cough with thick-clear sputum, but otherwise not on home O2 or po prednisone, who has been in her usual state of health until about a week prior to admission when she started to experience increased fatigue, and shortness of breath, and productive cough. But otherwise no fevers, chills, no overt upper respiratory infection, urinary tract infection, or abdominal symptoms. Two days prior to admission, her family noticed a dramatic worsening of shortness of breath and increased sputum production, but otherwise no change in the color or blood in the sputum. She also had significant worsening of appetite for two days. She fell at home the day prior to admission due to extreme weakness. She was on the floor for about 15 minutes, but no loss of consciousness. She was brought into the Emergency Room by her family. Her head CT scan was negative for hemorrhage. Her shortness of breath was much better with nebulizers and IV steroids. However, the next day while she was still in the Emergency Room, she was noticed to have increased lethargy, and was electively intubated for an arterial blood gas of pH 7.24, pCO2 84, and pO2 of 73. She became significantly hypotensive after intubation and required 10 liter normal saline resuscitation. She was started on Neo-Synephrine for blood pressure support. She was given a dose of levofloxacin and Vancomycin for empiric coverage of possible sepsis. Her chest x-ray and chest CT scan in the Emergency Department suggested right upper lobe pneumonia or other processes. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Severe emphysema and bronchitis. Pulmonary function tests in [2178-6-24] showed a FVC of 1.85 liters, FEV1 0.73 liters, and a FEV1/FVC ratio 39%. 3. Hypertension. 4. Vitamin B12 deficiency. 5. Alcohol and benzodiazepine dependency. 6. History of tuberculosis exposure versus infection. 7. Osteoporosis. 8. Status post right upper lobe pneumonia in [2178-10-24] to [2178-12-25] with prolonged intubation with trache and PEG placement. ALLERGIES: 1. Bactrim with nausea. 2. Orajel with benzocaine with dermatitis. MEDICATIONS ON ADMISSION: 1. Combivent two puffs [Hospital1 ]. 2. Serevent two puffs [Hospital1 ]. 3. Vitamin B12 250 mcg po q day. 4. Flovent two puffs [Hospital1 ]. 5. Klonopin 1 mg po bid. 6. Atrovent. 7. Remeron 30 mg q hs. 8. Diltiazem 120 mg po bid. 9. Multivitamins one tablet po q day. 10. Stool softeners. 11. Oxycodone 5 mg prn for pain. SOCIAL HISTORY: Two packs per day until last year after the pneumonia. Still smokes now and then. Regular alcohol use. Lives with her son and grandson. EXAM ON ADMISSION: Temperature 97.0, heart rate 74, blood pressure 85/35, respiratory rate 16, O2 saturation 100% on FIO2 100% with vent setting of tidal volume 350, rate of 16, PEEP of 5, FIO2 1.0. General: She is intubated, but easily arousable, thin, chronically sick appearing, but otherwise in no acute distress. Head and neck examination is anicteric. Oropharynx is clear. Cardiovascular: Regular, rate, and rhythm. Lungs: Equal breath sounds bilaterally, significantly prolonged expiratory phases. Abdomen is soft, normal bowel sounds. Extremities no edema. Neurologic: Moves all extremities. Lines with Foley and ET tube. LABORATORIES UPON ADMISSION: Arterial blood gas 7.24, 84, 73 preintubation. After intubation, 7.07, 25, 459. Complete blood count: White count of 34.3, hematocrit of 43.5, platelets 474. PT of 16.0, PTT 53.4, INR of 1.7. Sodium 135, potassium 4.6, chloride 96, bicarb 31, BUN 9, creatinine 0.5, glucose of 133. Urinalysis is negative. Chest x-ray showed increased capacity and pleural thickening at the right upper lobe concerning for infection, TB versus aspergillosis, versus actinomycosis, versus mucomycosis, and also need to rule out neoplasts. Chest CT scan: Diffuse emphysematous changes with bullae, right apical thick walled cavity suggesting semi-invasive aspergillus, versus TB, versus actinomycosis, versus mucomycosis, versus neoplasts, multilobular pneumonia, versus aspiration, multiple liver lesions. Head CT scan: No evidence of intracranial hemorrhage. Sputum Gram stain showed [11-25]+ gram-positive cocci. Culture was essentially negative. Had some oral flora. Urine culture negative. Blood cultures were negative. HOSPITAL COURSE: Patient had remained relatively stable through her hospital stay. She finished a 10 day course of Vancomycin for a possible MRSA pneumonia. She continued to have low grade temperatures, but her white counts came down significantly to her baseline around 16. Since her initial hypertension was thought most likely secondary to intubation instead of sepsis, she was aggressively diuresed through her hospital stay, and she received 10 liters normal saline initially in the Emergency Room. Although her respiratory status continued to improve significantly, she was not able to be weaned off vent at this time. She had a trache and PEG placed so she can be discharged to rehab for slow weaning of ventilation. Decision was made to discharge her to rehab with Lasix drip in order to diurese her about 1 liter negative everyday until her weight is down back to her baseline or her BUN or creatinine start to increase. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: [Hospital ] Rehab. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. Right upper lobe pneumonia. 3. Chronic obstructive pulmonary disease. 4. Possible aspergillosis. 5. Hypertension. DISCHARGE MEDICATIONS: 1. Vitamin B12 250 mcg po q day. 2. Flovent two puffs [Hospital1 ]. 3. Klonopin 1 mg po bid. 4. Senna one tablet po bid. 5. SubQ Heparin 5,000 units subQ [Hospital1 ]. 6. Atrovent four puffs qid. 7. Albuterol four puffs qid. 8. Prevacid 30 mg po q day. 9. Multivitamins 5 cc po q day. 10. Colace 150 mg po bid. 11. Nystatin swish and swallow qid prn. 12. Ritalin 2.5 mg po q am. 13. Remeron 30 mg po q hs. 14. Dulcolax 10 mg po q day prn. 15. Milk of magnesia 30 cc po qid prn. 16. Lactulose 30 cc po qid prn. 17. Tylenol prn. 18. Lasix drip 0.25 mg/hour titrate to in and out's negative a liter per day until BUN and creatinine start to increase for weight back to baseline. 19. Insulin NPH 6 units [Hospital1 ]. 20. Regular insulin-sliding scale qid. DISCHARGE FOLLOWUP: The patient will continue her outpatient followup with her primary care physician. [Name10 (NameIs) ] will also need to be seen in the Pulmonary Clinic to followup the right upper lobe lesion. CT-guided aspiration versus biopsy might be considered. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ], M.D. [MD Number(1) 292] Dictated By:[Last Name (NamePattern1) 4432] MEDQUIST36 D: [2180-6-2] 13:03 T: [2180-6-2] 13:19 JOB#: [Job Number 4433]	Admission Date: <Date>1911-12-22</Date> Discharge Date: <Date>1933-11-4</Date> Date of Birth: <Date>1904-5-12</Date> Sex: F Service: FENARD INTENSIVE CARE UNIT CHIEF COMPLAINT: Hypoxia. HISTORY OF PRESENT ILLNESS: This is a 68-year-old woman with a history of chronic obstructive pulmonary disease, history of right upper lobe pneumonia, status post prolonged intubation with trache and PEG placements from <Date>1967-1-12</Date> to <Date>2004-9-5</Date>, full exercise tolerance at baseline, chronic productive cough with thick-clear sputum, but otherwise not on home O2 or po prednisone, who has been in her usual state of health until about a week prior to admission when she started to experience increased fatigue, and shortness of breath, and productive cough. But otherwise no fevers, chills, no overt upper respiratory infection, urinary tract infection, or abdominal symptoms. Two days prior to admission, her family noticed a dramatic worsening of shortness of breath and increased sputum production, but otherwise no change in the color or blood in the sputum. She also had significant worsening of appetite for two days. She fell at home the day prior to admission due to extreme weakness. She was on the floor for about 15 minutes, but no loss of consciousness. She was brought into the Emergency Room by her family. Her head CT scan was negative for hemorrhage. Her shortness of breath was much better with nebulizers and IV steroids. However, the next day while she was still in the Emergency Room, she was noticed to have increased lethargy, and was electively intubated for an arterial blood gas of pH 7.24, pCO2 84, and pO2 of 73. She became significantly hypotensive after intubation and required 10 liter normal saline resuscitation. She was started on Neo-Synephrine for blood pressure support. She was given a dose of levofloxacin and Vancomycin for empiric coverage of possible sepsis. Her chest x-ray and chest CT scan in the Emergency Department suggested right upper lobe pneumonia or other processes. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Severe emphysema and bronchitis. Pulmonary function tests in <Date>2014-4-3</Date> showed a FVC of 1.85 liters, FEV1 0.73 liters, and a FEV1/FVC ratio 39%. 3. Hypertension. 4. Vitamin B12 deficiency. 5. Alcohol and benzodiazepine dependency. 6. History of tuberculosis exposure versus infection. 7. Osteoporosis. 8. Status post right upper lobe pneumonia in <Date>1962-3-1</Date> to <Date>2004-9-5</Date> with prolonged intubation with trache and PEG placement. ALLERGIES: 1. Bactrim with nausea. 2. Orajel with benzocaine with dermatitis. MEDICATIONS ON ADMISSION: 1. Combivent two puffs <Hospital>Russell Ltd Health System</Hospital>. 2. Serevent two puffs <Hospital>Russell Ltd Health System</Hospital>. 3. Vitamin B12 250 mcg po q day. 4. Flovent two puffs <Hospital>Russell Ltd Health System</Hospital>. 5. Klonopin 1 mg po bid. 6. Atrovent. 7. Remeron 30 mg q hs. 8. Diltiazem 120 mg po bid. 9. Multivitamins one tablet po q day. 10. Stool softeners. 11. Oxycodone 5 mg prn for pain. SOCIAL HISTORY: Two packs per day until last year after the pneumonia. Still smokes now and then. Regular alcohol use. Lives with her son and grandson. EXAM ON ADMISSION: Temperature 97.0, heart rate 74, blood pressure 85/35, respiratory rate 16, O2 saturation 100% on FIO2 100% with vent setting of tidal volume 350, rate of 16, PEEP of 5, FIO2 1.0. General: She is intubated, but easily arousable, thin, chronically sick appearing, but otherwise in no acute distress. Head and neck examination is anicteric. Oropharynx is clear. Cardiovascular: Regular, rate, and rhythm. Lungs: Equal breath sounds bilaterally, significantly prolonged expiratory phases. Abdomen is soft, normal bowel sounds. Extremities no edema. Neurologic: Moves all extremities. Lines with Foley and ET tube. LABORATORIES UPON ADMISSION: Arterial blood gas 7.24, 84, 73 preintubation. After intubation, 7.07, 25, 459. Complete blood count: White count of 34.3, hematocrit of 43.5, platelets 474. PT of 16.0, PTT 53.4, INR of 1.7. Sodium 135, potassium 4.6, chloride 96, bicarb 31, BUN 9, creatinine 0.5, glucose of 133. Urinalysis is negative. Chest x-ray showed increased capacity and pleural thickening at the right upper lobe concerning for infection, TB versus aspergillosis, versus actinomycosis, versus mucomycosis, and also need to rule out neoplasts. Chest CT scan: Diffuse emphysematous changes with bullae, right apical thick walled cavity suggesting semi-invasive aspergillus, versus TB, versus actinomycosis, versus mucomycosis, versus neoplasts, multilobular pneumonia, versus aspiration, multiple liver lesions. Head CT scan: No evidence of intracranial hemorrhage. Sputum Gram stain showed <Date>11-12</Date>+ gram-positive cocci. Culture was essentially negative. Had some oral flora. Urine culture negative. Blood cultures were negative. HOSPITAL COURSE: Patient had remained relatively stable through her hospital stay. She finished a 10 day course of Vancomycin for a possible MRSA pneumonia. She continued to have low grade temperatures, but her white counts came down significantly to her baseline around 16. Since her initial hypertension was thought most likely secondary to intubation instead of sepsis, she was aggressively diuresed through her hospital stay, and she received 10 liters normal saline initially in the Emergency Room. Although her respiratory status continued to improve significantly, she was not able to be weaned off vent at this time. She had a trache and PEG placed so she can be discharged to rehab for slow weaning of ventilation. Decision was made to discharge her to rehab with Lasix drip in order to diurese her about 1 liter negative everyday until her weight is down back to her baseline or her BUN or creatinine start to increase. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: <Hospital>Huff LLC Hospital</Hospital> Rehab. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. Right upper lobe pneumonia. 3. Chronic obstructive pulmonary disease. 4. Possible aspergillosis. 5. Hypertension. DISCHARGE MEDICATIONS: 1. Vitamin B12 250 mcg po q day. 2. Flovent two puffs <Hospital>Russell Ltd Health System</Hospital>. 3. Klonopin 1 mg po bid. 4. Senna one tablet po bid. 5. SubQ Heparin 5,000 units subQ <Hospital>Russell Ltd Health System</Hospital>. 6. Atrovent four puffs qid. 7. Albuterol four puffs qid. 8. Prevacid 30 mg po q day. 9. Multivitamins 5 cc po q day. 10. Colace 150 mg po bid. 11. Nystatin swish and swallow qid prn. 12. Ritalin 2.5 mg po q am. 13. Remeron 30 mg po q hs. 14. Dulcolax 10 mg po q day prn. 15. Milk of magnesia 30 cc po qid prn. 16. Lactulose 30 cc po qid prn. 17. Tylenol prn. 18. Lasix drip 0.25 mg/hour titrate to in and out's negative a liter per day until BUN and creatinine start to increase for weight back to baseline. 19. Insulin NPH 6 units <Hospital>Russell Ltd Health System</Hospital>. 20. Regular insulin-sliding scale qid. DISCHARGE FOLLOWUP: The patient will continue her outpatient followup with her primary care physician. <Name>Amy Merino</Name> will also need to be seen in the Pulmonary Clinic to followup the right upper lobe lesion. CT-guided aspiration versus biopsy might be considered. <Name>Rocio</Name> <Name>Medrano</Name> <Name>Joyce Chowdhury</Name>, M.D. <MD Number>83078810</MD Number> Dictated By:<Name>Harris</Name> MEDQUIST36 D: <Date>1933-11-4</Date> 13:03 T: <Date>1933-11-4</Date> 13:19 JOB#: <Job Number>Steele-Strong-1923-132014</Job Number>	000000000000000001111111111000000000000000000000000111111111000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111110000000000000000000000001111111111111111111111111000000000000000000000000000000000000000000000000000000001111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1911-12-22 Discharge Date: 1933-11-4 Date of Birth: 1904-5-12 Sex: F Service: FENARD INTENSIVE CARE UNIT CHIEF COMPLAINT: Hypoxia. HISTORY OF PRESENT ILLNESS: This is a 68-year-old woman with a history of chronic obstructive pulmonary disease, history of right upper lobe pneumonia, status post prolonged intubation with trache and PEG placements from 1967-1-12 to 2004-9-5, full exercise tolerance at baseline, chronic productive cough with thick-clear sputum, but otherwise not on home O2 or po prednisone, who has been in her usual state of health until about a week prior to admission when she started to experience increased fatigue, and shortness of breath, and productive cough. But otherwise no fevers, chills, no overt upper respiratory infection, urinary tract infection, or abdominal symptoms. Two days prior to admission, her family noticed a dramatic worsening of shortness of breath and increased sputum production, but otherwise no change in the color or blood in the sputum. She also had significant worsening of appetite for two days. She fell at home the day prior to admission due to extreme weakness. She was on the floor for about 15 minutes, but no loss of consciousness. She was brought into the Emergency Room by her family. Her head CT scan was negative for hemorrhage. Her shortness of breath was much better with nebulizers and IV steroids. However, the next day while she was still in the Emergency Room, she was noticed to have increased lethargy, and was electively intubated for an arterial blood gas of pH 7.24, pCO2 84, and pO2 of 73. She became significantly hypotensive after intubation and required 10 liter normal saline resuscitation. She was started on Neo-Synephrine for blood pressure support. She was given a dose of levofloxacin and Vancomycin for empiric coverage of possible sepsis. Her chest x-ray and chest CT scan in the Emergency Department suggested right upper lobe pneumonia or other processes. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Severe emphysema and bronchitis. Pulmonary function tests in 2014-4-3 showed a FVC of 1.85 liters, FEV1 0.73 liters, and a FEV1/FVC ratio 39%. 3. Hypertension. 4. Vitamin B12 deficiency. 5. Alcohol and benzodiazepine dependency. 6. History of tuberculosis exposure versus infection. 7. Osteoporosis. 8. Status post right upper lobe pneumonia in 1962-3-1 to 2004-9-5 with prolonged intubation with trache and PEG placement. ALLERGIES: 1. Bactrim with nausea. 2. Orajel with benzocaine with dermatitis. MEDICATIONS ON ADMISSION: 1. Combivent two puffs Russell Ltd Health System. 2. Serevent two puffs Russell Ltd Health System. 3. Vitamin B12 250 mcg po q day. 4. Flovent two puffs Russell Ltd Health System. 5. Klonopin 1 mg po bid. 6. Atrovent. 7. Remeron 30 mg q hs. 8. Diltiazem 120 mg po bid. 9. Multivitamins one tablet po q day. 10. Stool softeners. 11. Oxycodone 5 mg prn for pain. SOCIAL HISTORY: Two packs per day until last year after the pneumonia. Still smokes now and then. Regular alcohol use. Lives with her son and grandson. EXAM ON ADMISSION: Temperature 97.0, heart rate 74, blood pressure 85/35, respiratory rate 16, O2 saturation 100% on FIO2 100% with vent setting of tidal volume 350, rate of 16, PEEP of 5, FIO2 1.0. General: She is intubated, but easily arousable, thin, chronically sick appearing, but otherwise in no acute distress. Head and neck examination is anicteric. Oropharynx is clear. Cardiovascular: Regular, rate, and rhythm. Lungs: Equal breath sounds bilaterally, significantly prolonged expiratory phases. Abdomen is soft, normal bowel sounds. Extremities no edema. Neurologic: Moves all extremities. Lines with Foley and ET tube. LABORATORIES UPON ADMISSION: Arterial blood gas 7.24, 84, 73 preintubation. After intubation, 7.07, 25, 459. Complete blood count: White count of 34.3, hematocrit of 43.5, platelets 474. PT of 16.0, PTT 53.4, INR of 1.7. Sodium 135, potassium 4.6, chloride 96, bicarb 31, BUN 9, creatinine 0.5, glucose of 133. Urinalysis is negative. Chest x-ray showed increased capacity and pleural thickening at the right upper lobe concerning for infection, TB versus aspergillosis, versus actinomycosis, versus mucomycosis, and also need to rule out neoplasts. Chest CT scan: Diffuse emphysematous changes with bullae, right apical thick walled cavity suggesting semi-invasive aspergillus, versus TB, versus actinomycosis, versus mucomycosis, versus neoplasts, multilobular pneumonia, versus aspiration, multiple liver lesions. Head CT scan: No evidence of intracranial hemorrhage. Sputum Gram stain showed 11-12+ gram-positive cocci. Culture was essentially negative. Had some oral flora. Urine culture negative. Blood cultures were negative. HOSPITAL COURSE: Patient had remained relatively stable through her hospital stay. She finished a 10 day course of Vancomycin for a possible MRSA pneumonia. She continued to have low grade temperatures, but her white counts came down significantly to her baseline around 16. Since her initial hypertension was thought most likely secondary to intubation instead of sepsis, she was aggressively diuresed through her hospital stay, and she received 10 liters normal saline initially in the Emergency Room. Although her respiratory status continued to improve significantly, she was not able to be weaned off vent at this time. She had a trache and PEG placed so she can be discharged to rehab for slow weaning of ventilation. Decision was made to discharge her to rehab with Lasix drip in order to diurese her about 1 liter negative everyday until her weight is down back to her baseline or her BUN or creatinine start to increase. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Huff LLC Hospital Rehab. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. Right upper lobe pneumonia. 3. Chronic obstructive pulmonary disease. 4. Possible aspergillosis. 5. Hypertension. DISCHARGE MEDICATIONS: 1. Vitamin B12 250 mcg po q day. 2. Flovent two puffs Russell Ltd Health System. 3. Klonopin 1 mg po bid. 4. Senna one tablet po bid. 5. SubQ Heparin 5,000 units subQ Russell Ltd Health System. 6. Atrovent four puffs qid. 7. Albuterol four puffs qid. 8. Prevacid 30 mg po q day. 9. Multivitamins 5 cc po q day. 10. Colace 150 mg po bid. 11. Nystatin swish and swallow qid prn. 12. Ritalin 2.5 mg po q am. 13. Remeron 30 mg po q hs. 14. Dulcolax 10 mg po q day prn. 15. Milk of magnesia 30 cc po qid prn. 16. Lactulose 30 cc po qid prn. 17. Tylenol prn. 18. Lasix drip 0.25 mg/hour titrate to in and out's negative a liter per day until BUN and creatinine start to increase for weight back to baseline. 19. Insulin NPH 6 units Russell Ltd Health System. 20. Regular insulin-sliding scale qid. DISCHARGE FOLLOWUP: The patient will continue her outpatient followup with her primary care physician. Amy Merino will also need to be seen in the Pulmonary Clinic to followup the right upper lobe lesion. CT-guided aspiration versus biopsy might be considered. Rocio Medrano Joyce Chowdhury, M.D. 83078810 Dictated By:Harris MEDQUIST36 D: 1933-11-4 13:03 T: 1933-11-4 13:19 JOB#: Steele-Strong-1923-132014	['Admission Date: 1911-12-22 Discharge Date: 1933-11-4\n\nDate of Birth: 1904-5-12 Sex: F\n\nService: FENARD INTENSIVE CARE UNIT\n\nCHIEF COMPLAINT: Hypoxia.\n\nHISTORY OF PRESENT ILLNESS: This is a 68-year-old woman with\na history of chronic obstructive pulmonary disease, history\nof right upper lobe pneumonia, status post prolonged\nintubation with trache and PEG placements from 1967-1-12 to 2004-9-5, full exercise tolerance at\nbaseline, chronic productive cough with thick-clear sputum,\nbut otherwise not on home O2 or po prednisone, who has been\nin her usual state of health until about a week prior to\nadmission when she started to experience increased fatigue,\nand shortness of breath, and productive cough. But otherwise\nno fevers, chills, no overt upper respiratory infection,\nurinary tract infection, or abdominal symptoms.', '\n\nTwo days prior to admission, her family noticed a dramatic\nworsening of shortness of breath and increased sputum\nproduction, but otherwise no change in the color or blood in\nthe sputum. She also had significant worsening of appetite\nfor two days. She fell at home the day prior to admission\ndue to extreme weakness. She was on the floor for about 15\nminutes, but no loss of consciousness. She was brought into\nthe Emergency Room by her family.\n\nHer head CT scan was negative for hemorrhage. Her shortness\nof breath was much better with nebulizers and IV steroids.\nHowever, the next day while she was still in the Emergency\nRoom, she was noticed to have increased lethargy, and was\nelectively intubated for an arterial blood gas of pH 7.24,\npCO2 84, and pO2 of 73. She became significantly hypotensive\nafter intubation and required 10 liter normal saline\nresuscitation.', ' She was started on Neo-Synephrine for blood\npressure support. She was given a dose of levofloxacin and\nVancomycin for empiric coverage of possible sepsis. Her\nchest x-ray and chest CT scan in the Emergency Department\nsuggested right upper lobe pneumonia or other processes.\n\nPAST MEDICAL HISTORY:\n1. Chronic obstructive pulmonary disease.\n2. Severe emphysema and bronchitis. Pulmonary function tests\nin 2014-4-3 showed a FVC of 1.85 liters, FEV1 0.73\nliters, and a FEV1/FVC ratio 39%.\n3. Hypertension.\n4. Vitamin B12 deficiency.\n5. Alcohol and benzodiazepine dependency.\n6. History of tuberculosis exposure versus infection.\n7. Osteoporosis.\n8. Status post right upper lobe pneumonia in 1962-3-1\nto 2004-9-5 with prolonged intubation with trache and\nPEG placement.\n\nALLERGIES:\n1. Bactrim with nausea.', '\n2. Orajel with benzocaine with dermatitis.\n\nMEDICATIONS ON ADMISSION:\n1. Combivent two puffs Russell Ltd Health System.\n2. Serevent two puffs Russell Ltd Health System.\n3. Vitamin B12 250 mcg po q day.\n4. Flovent two puffs Russell Ltd Health System.\n5. Klonopin 1 mg po bid.\n6. Atrovent.\n7. Remeron 30 mg q hs.\n8. Diltiazem 120 mg po bid.\n9. Multivitamins one tablet po q day.\n10. Stool softeners.\n11. Oxycodone 5 mg prn for pain.\n\nSOCIAL HISTORY: Two packs per day until last year after the\npneumonia. Still smokes now and then. Regular alcohol use.\nLives with her son and grandson.\n\nEXAM ON ADMISSION: Temperature 97.0, heart rate 74, blood\npressure 85/35, respiratory rate 16, O2 saturation 100% on\nFIO2 100% with vent setting of tidal volume 350, rate of 16,\nPEEP of 5, FIO2 1.0. General: She is intubated, but easily\narousable, thin, chronically sick appearing, but otherwise in\nno acute distress.', ' Head and neck examination is anicteric.\nOropharynx is clear. Cardiovascular: Regular, rate, and\nrhythm. Lungs: Equal breath sounds bilaterally,\nsignificantly prolonged expiratory phases. Abdomen is soft,\nnormal bowel sounds. Extremities no edema. Neurologic:\nMoves all extremities. Lines with Foley and ET tube.\n\nLABORATORIES UPON ADMISSION: Arterial blood gas 7.24, 84, 73\npreintubation. After intubation, 7.07, 25, 459.\n\nComplete blood count: White count of 34.3, hematocrit of\n43.5, platelets 474. PT of 16.0, PTT 53.4, INR of 1.7.\nSodium 135, potassium 4.6, chloride 96, bicarb 31, BUN 9,\ncreatinine 0.5, glucose of 133. Urinalysis is negative.\n\nChest x-ray showed increased capacity and pleural thickening\nat the right upper lobe concerning for infection, TB versus\naspergillosis, versus actinomycosis, versus mucomycosis, and\nalso need to rule out neoplasts.', '\n\nChest CT scan: Diffuse emphysematous changes with bullae,\nright apical thick walled cavity suggesting semi-invasive\naspergillus, versus TB, versus actinomycosis, versus\nmucomycosis, versus neoplasts, multilobular pneumonia, versus\naspiration, multiple liver lesions.\n\nHead CT scan: No evidence of intracranial hemorrhage.\n\nSputum Gram stain showed 11-12+ gram-positive cocci. Culture\nwas essentially negative. Had some oral flora. Urine\nculture negative. Blood cultures were negative.\n\nHOSPITAL COURSE: Patient had remained relatively stable\nthrough her hospital stay. She finished a 10 day course of\nVancomycin for a possible MRSA pneumonia. She continued to\nhave low grade temperatures, but her white counts came down\nsignificantly to her baseline around 16. Since her initial\nhypertension was thought most likely secondary to intubation\ninstead of sepsis, she was aggressively diuresed through her\nhospital stay, and she received 10 liters normal saline\ninitially in the Emergency Room.', '\n\nAlthough her respiratory status continued to improve\nsignificantly, she was not able to be weaned off vent at this\ntime. She had a trache and PEG placed so she can be\ndischarged to rehab for slow weaning of ventilation.\nDecision was made to discharge her to rehab with Lasix drip\nin order to diurese her about 1 liter negative everyday until\nher weight is down back to her baseline or her BUN or\ncreatinine start to increase.\n\nDISCHARGE CONDITION: Stable.\n\nDISCHARGE STATUS: Huff LLC Hospital Rehab.\n\nDISCHARGE DIAGNOSES:\n1. Respiratory failure.\n2. Right upper lobe pneumonia.\n3. Chronic obstructive pulmonary disease.\n4. Possible aspergillosis.\n5. Hypertension.\n\nDISCHARGE MEDICATIONS:\n1. Vitamin B12 250 mcg po q day.\n2. Flovent two puffs Russell Ltd Health System.\n3. Klonopin 1 mg po bid.\n4. Senna one tablet po bid.', "\n5. SubQ Heparin 5,000 units subQ Russell Ltd Health System.\n6. Atrovent four puffs qid.\n7. Albuterol four puffs qid.\n8. Prevacid 30 mg po q day.\n9. Multivitamins 5 cc po q day.\n10. Colace 150 mg po bid.\n11. Nystatin swish and swallow qid prn.\n12. Ritalin 2.5 mg po q am.\n13. Remeron 30 mg po q hs.\n14. Dulcolax 10 mg po q day prn.\n15. Milk of magnesia 30 cc po qid prn.\n16. Lactulose 30 cc po qid prn.\n17. Tylenol prn.\n18. Lasix drip 0.25 mg/hour titrate to in and out's negative\na liter per day until BUN and creatinine start to increase\nfor weight back to baseline.\n19. Insulin NPH 6 units Russell Ltd Health System.\n20. Regular insulin-sliding scale qid.\n\nDISCHARGE FOLLOWUP: The patient will continue her outpatient\nfollowup with her primary care physician. Amy Merino will also need\nto be seen in the Pulmonary Clinic to followup the right\nupper lobe lesion.", ' CT-guided aspiration versus biopsy might\nbe considered.\n\n\n\n Rocio Medrano Joyce Chowdhury, M.D. 83078810\n\nDictated By:Harris\nMEDQUIST36\n\nD: 1933-11-4 13:03\nT: 1933-11-4 13:19\nJOB#: Steele-Strong-1923-132014\n']
538	3734	154629.0	2110-08-30	Discharge summary	Report	Admission Date: [2110-8-26] Discharge Date: [2110-8-30] Date of Birth: [2053-7-14] Sex: F Service: VASCULAR HISTORY OF PRESENT ILLNESS: The patient is a 57 year old female with multiple medical problems who presented with gangrene of the right lower extremity, required admission for pain control, intravenous antibiotics and ultimately for right below the knee amputation. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft, complicated by sternal wound infection. 2. History of Methicillin resistant Staphylococcus aureus bacteremia in [2109-8-3]. 3. Diet controlled diabetes mellitus. 4. Hypertension. 5. Hypercholesterolemia. 6. Significant tobacco use. 7. History of wound abscess in the right lower extremity which grew out Methicillin resistant Staphylococcus aureus. 8. Status post AV fistula in [2105]. 9. Status post coronary artery bypass graft times three that was complicated by the sternal wound infection, [8-3], by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537]. 10. Status post right femoral to below knee popliteal bypass with PTFE done in [3-4], followed by a right first toe amputation completed in [3-4]. 11. History of cesarean section. 12. Questionable history of Penicillin allergy, but she does state otherwise that she has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Nephrocaps one tablet p.o. once daily. 2. Norvasc 5 mg twice a day. 3. Gabapentin 300 mg q Monday, Wednesday and Friday after hemodialysis. 4. Tramadol 50 mg p.o. twice a day p.r.n. 5. Trazodone 100 mg q.h.s. 6. Medroxyprogesterone 2.5 mg once daily. 7. Albuterol MDI. 8. Pantoprazole 40 mg p.o. once daily. 9. Calcitriol 0.25 mcg once daily. 10. Aspirin 81 mg p.o. once daily. 11. Epogen 20,000 units q Monday, Wednesday and Friday with hemodialysis as well as using MSIR 50 mg q12hours. The patient was admitted with increasing right lower extremity pain and low grade temperature. Her admission white count was noted to be 10.4 with a left shift, hematocrit 40.0 with a platelet count of 244,000. Prothrombin time was 13.7 and INR was 1.3 with a partial thromboplastin time of 28.0. She was on dialysis with a blood urea nitrogen and creatinine of 74 and 6.9, respectively. She had an admission potassium of 7.6 which was repeated in the Emergency Department and shown to be 8.0. Hyperkalemia was emergently treated with calcium chloride, bicarbonate, dextrose, insulin, Lasix as she does make some urine, as well as emergent hemodialysis and Kayexalate. Upon the day of admission, she went to dialysis and received her hemodialysis. Her potassium postdialysis was 4.1. She was otherwise feeling OK except complaining of persistent right lower extremity pain. PHYSICAL EXAMINATION: Her admission examination was notable for a temperature of 100.1, pulse 90, blood pressure 158/60, respiratory rate 18, oxygen saturation 94% in room air. She was a cachectic female who appeared older than her stated age. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The sclera were anicteric. She had no jugular venous distention and no carotid bruit. The heart was regular with no gallop. The lungs were clear but decreased throughout. The abdomen was soft, nontender, scaphoid, no hepatosplenomegaly, no pulsatile masses and no bruit. She had palpable femoral pulses bilaterally. Popliteal pulses were not palpable. Distal pulses in the right lower extremity were absent. She had some dry and wet gangrene involving the right forefoot with a failed right first toe amputation site that clearly had some purulent exudate. She was admitted for intravenous antibiotics and started on Vancomycin, Levofloxacin and Flagyl for her hemodialysis. Over the next couple days, she was resuscitated adequately and ultimately on [2110-8-26], she went to the operating room and received a right below the knee amputation. Postoperatively she did well. She was ruled out by enzymes and kept on telemetry times 24 hours and was uneventful. Her postoperative white blood cell count was 9.6 and hematocrit was 41.8. Platelet count was 157,000. Blood urea nitrogen and creatinine were 58 and 6.3 with a potassium of 5.3. Her phosphate was noted to be elevated at 11.8. Therefore, in hospital medications, she had her Calcitriol stopped and she was started on Amphojel and PhosLo. The Amphojel was continued for a total of three days of therapy, starting on [2110-8-28], and to end on [2110-8-31]. Over the next couple days, her pain was appropriately controlled with Dilaudid PCA although the patient demanded that the Dilaudid did not work for her. Therefore, she was requesting Morphine. This was given concomitantly and resulted in some mental status changes and confusion which quickly resolved upon removal of her narcotic. She had a foot culture from [2110-8-25], that grew out Methicillin resistant Staphylococcus aureus. Blood cultures from [2110-8-24], were negative. By postoperative day number four, she continued on triple antibiotics. Her temperature maximum was 100.1, but a current of 97.4, pulse 82, blood pressure 130/70, respiratory rate 18, 96% oxygen saturation in room air. Her fingerstick was mildly elevated but she was noncompliant and was not taking a diabetic or renal diet. She was taking adequate p.o. Her white blood cell count at discharge was 9.4. Her blood urea nitrogen and creatinine were 52 and 6.3 with a potassium of 4.8 and bicarbonate of 21. At this time, her stump which had been resected back to the level of the proximal one third of the right lower extremity was clean, dry and intact with staples in place, no erythema, no exudate, no evidence of hematoma and the flaps were warm. She was deemed stable and appropriate for discharge by Dr.[Name (NI) 4436] service. MEDICATIONS ON DISCHARGE: 1. Nephrocaps one tablet p.o. once daily. 2. Vancomycin to be dosed at time of dialysis times two weeks, dose for trough values less than 15.0. 3. Norvasc 5 mg p.o. twice a day. 4. Gabapentin 300 mg q Monday, Wednesday and Friday after hemodialysis. 5. Tramadol 50 mg p.o. twice a day p.r.n. 6. Trazodone 100 mg p.o. q.h.s. 7. Medroxyprogesterone 2.5 mg p.o. once daily. 8. Albuterol MDI q4hours p.r.n. 9. Pantoprazole 40 mg p.o. once daily. 10. Calcitriol 0.25 mcg p.o. once daily to be on hold until followed up by her nephrologist. 11. Aspirin 81 mg p.o. once daily. 12. Folic Acid 1 mg p.o. once daily. 13. Epogen 20,000 units q Monday, Wednesday and Friday with hemodialysis. 14. MSIR 50 mg p.o. q12hours. 15. Dilaudid 2 to 4 mg p.o. q3-4hours p.r.n. breakthrough pain. 16. Colace and Pericolace for stool softening agents. FOLLOW-UP: The patient should follow-up with Dr. [Last Name (STitle) 1391] in approximately two to three weeks for skin clip removal. She will have right lower extremity remain in knee immobilizer with a dry dressing and ace wrap to above knee region to help immobilize and straighten her leg. She should take part in aggressive physical therapy and learn how to do transfers and so forth. Ultimately she will require outpatient sitting for prosthesis, however, the stump cannot be used until designated by Dr. [Last Name (STitle) 1391]. Typically this occurs within six to eight weeks postoperatively. The patient is deemed appropriate and stable for discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4417] Dictated By:[Last Name (NamePattern4) 4437] MEDQUIST36 D: [2110-8-30] 10:13 T: [2110-8-30] 10:32 JOB#: [Job Number 4438] cc:[Last Name (NamePattern1) 4439]	Admission Date: <Date>1933-6-3</Date> Discharge Date: <Date>1946-6-29</Date> Date of Birth: <Date>1943-11-29</Date> Sex: F Service: VASCULAR HISTORY OF PRESENT ILLNESS: The patient is a 57 year old female with multiple medical problems who presented with gangrene of the right lower extremity, required admission for pain control, intravenous antibiotics and ultimately for right below the knee amputation. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft, complicated by sternal wound infection. 2. History of Methicillin resistant Staphylococcus aureus bacteremia in <Date>1955-9-24</Date>. 3. Diet controlled diabetes mellitus. 4. Hypertension. 5. Hypercholesterolemia. 6. Significant tobacco use. 7. History of wound abscess in the right lower extremity which grew out Methicillin resistant Staphylococcus aureus. 8. Status post AV fistula in <Year>2004</Year>. 9. Status post coronary artery bypass graft times three that was complicated by the sternal wound infection, <Date>1-18</Date>, by Dr. <Name>Carolyn</Name> <Name>Kenner</Name>. 10. Status post right femoral to below knee popliteal bypass with PTFE done in <Date>1-7</Date>, followed by a right first toe amputation completed in <Date>1-7</Date>. 11. History of cesarean section. 12. Questionable history of Penicillin allergy, but she does state otherwise that she has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Nephrocaps one tablet p.o. once daily. 2. Norvasc 5 mg twice a day. 3. Gabapentin 300 mg q Monday, Wednesday and Friday after hemodialysis. 4. Tramadol 50 mg p.o. twice a day p.r.n. 5. Trazodone 100 mg q.h.s. 6. Medroxyprogesterone 2.5 mg once daily. 7. Albuterol MDI. 8. Pantoprazole 40 mg p.o. once daily. 9. Calcitriol 0.25 mcg once daily. 10. Aspirin 81 mg p.o. once daily. 11. Epogen 20,000 units q Monday, Wednesday and Friday with hemodialysis as well as using MSIR 50 mg q12hours. The patient was admitted with increasing right lower extremity pain and low grade temperature. Her admission white count was noted to be 10.4 with a left shift, hematocrit 40.0 with a platelet count of 244,000. Prothrombin time was 13.7 and INR was 1.3 with a partial thromboplastin time of 28.0. She was on dialysis with a blood urea nitrogen and creatinine of 74 and 6.9, respectively. She had an admission potassium of 7.6 which was repeated in the Emergency Department and shown to be 8.0. Hyperkalemia was emergently treated with calcium chloride, bicarbonate, dextrose, insulin, Lasix as she does make some urine, as well as emergent hemodialysis and Kayexalate. Upon the day of admission, she went to dialysis and received her hemodialysis. Her potassium postdialysis was 4.1. She was otherwise feeling OK except complaining of persistent right lower extremity pain. PHYSICAL EXAMINATION: Her admission examination was notable for a temperature of 100.1, pulse 90, blood pressure 158/60, respiratory rate 18, oxygen saturation 94% in room air. She was a cachectic female who appeared older than her stated age. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The sclera were anicteric. She had no jugular venous distention and no carotid bruit. The heart was regular with no gallop. The lungs were clear but decreased throughout. The abdomen was soft, nontender, scaphoid, no hepatosplenomegaly, no pulsatile masses and no bruit. She had palpable femoral pulses bilaterally. Popliteal pulses were not palpable. Distal pulses in the right lower extremity were absent. She had some dry and wet gangrene involving the right forefoot with a failed right first toe amputation site that clearly had some purulent exudate. She was admitted for intravenous antibiotics and started on Vancomycin, Levofloxacin and Flagyl for her hemodialysis. Over the next couple days, she was resuscitated adequately and ultimately on <Date>1933-6-3</Date>, she went to the operating room and received a right below the knee amputation. Postoperatively she did well. She was ruled out by enzymes and kept on telemetry times 24 hours and was uneventful. Her postoperative white blood cell count was 9.6 and hematocrit was 41.8. Platelet count was 157,000. Blood urea nitrogen and creatinine were 58 and 6.3 with a potassium of 5.3. Her phosphate was noted to be elevated at 11.8. Therefore, in hospital medications, she had her Calcitriol stopped and she was started on Amphojel and PhosLo. The Amphojel was continued for a total of three days of therapy, starting on <Date>1990-4-2</Date>, and to end on <Date>1923-8-10</Date>. Over the next couple days, her pain was appropriately controlled with Dilaudid PCA although the patient demanded that the Dilaudid did not work for her. Therefore, she was requesting Morphine. This was given concomitantly and resulted in some mental status changes and confusion which quickly resolved upon removal of her narcotic. She had a foot culture from <Date>1931-5-12</Date>, that grew out Methicillin resistant Staphylococcus aureus. Blood cultures from <Date>1934-7-8</Date>, were negative. By postoperative day number four, she continued on triple antibiotics. Her temperature maximum was 100.1, but a current of 97.4, pulse 82, blood pressure 130/70, respiratory rate 18, 96% oxygen saturation in room air. Her fingerstick was mildly elevated but she was noncompliant and was not taking a diabetic or renal diet. She was taking adequate p.o. Her white blood cell count at discharge was 9.4. Her blood urea nitrogen and creatinine were 52 and 6.3 with a potassium of 4.8 and bicarbonate of 21. At this time, her stump which had been resected back to the level of the proximal one third of the right lower extremity was clean, dry and intact with staples in place, no erythema, no exudate, no evidence of hematoma and the flaps were warm. She was deemed stable and appropriate for discharge by Dr.<Name>Cindy Edward</Name> service. MEDICATIONS ON DISCHARGE: 1. Nephrocaps one tablet p.o. once daily. 2. Vancomycin to be dosed at time of dialysis times two weeks, dose for trough values less than 15.0. 3. Norvasc 5 mg p.o. twice a day. 4. Gabapentin 300 mg q Monday, Wednesday and Friday after hemodialysis. 5. Tramadol 50 mg p.o. twice a day p.r.n. 6. Trazodone 100 mg p.o. q.h.s. 7. Medroxyprogesterone 2.5 mg p.o. once daily. 8. Albuterol MDI q4hours p.r.n. 9. Pantoprazole 40 mg p.o. once daily. 10. Calcitriol 0.25 mcg p.o. once daily to be on hold until followed up by her nephrologist. 11. Aspirin 81 mg p.o. once daily. 12. Folic Acid 1 mg p.o. once daily. 13. Epogen 20,000 units q Monday, Wednesday and Friday with hemodialysis. 14. MSIR 50 mg p.o. q12hours. 15. Dilaudid 2 to 4 mg p.o. q3-4hours p.r.n. breakthrough pain. 16. Colace and Pericolace for stool softening agents. FOLLOW-UP: The patient should follow-up with Dr. <Name>Quinones</Name> in approximately two to three weeks for skin clip removal. She will have right lower extremity remain in knee immobilizer with a dry dressing and ace wrap to above knee region to help immobilize and straighten her leg. She should take part in aggressive physical therapy and learn how to do transfers and so forth. Ultimately she will require outpatient sitting for prosthesis, however, the stump cannot be used until designated by Dr. <Name>Quinones</Name>. Typically this occurs within six to eight weeks postoperatively. The patient is deemed appropriate and stable for discharge. <Name>Nicholas</Name> <Name>Post</Name>, M.D. <MD Number>74106888</MD Number> Dictated By:<Name>Thomas</Name> MEDQUIST36 D: <Date>1946-6-29</Date> 10:13 T: <Date>1946-6-29</Date> 10:32 JOB#: <Job Number>Garcia, Brennan and Taylor-1913-770282</Job Number> 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Date: 1933-6-3 Discharge Date: 1946-6-29 Date of Birth: 1943-11-29 Sex: F Service: VASCULAR HISTORY OF PRESENT ILLNESS: The patient is a 57 year old female with multiple medical problems who presented with gangrene of the right lower extremity, required admission for pain control, intravenous antibiotics and ultimately for right below the knee amputation. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft, complicated by sternal wound infection. 2. History of Methicillin resistant Staphylococcus aureus bacteremia in 1955-9-24. 3. Diet controlled diabetes mellitus. 4. Hypertension. 5. Hypercholesterolemia. 6. Significant tobacco use. 7. History of wound abscess in the right lower extremity which grew out Methicillin resistant Staphylococcus aureus. 8. Status post AV fistula in 2004. 9. Status post coronary artery bypass graft times three that was complicated by the sternal wound infection, 1-18, by Dr. Carolyn Kenner. 10. Status post right femoral to below knee popliteal bypass with PTFE done in 1-7, followed by a right first toe amputation completed in 1-7. 11. History of cesarean section. 12. Questionable history of Penicillin allergy, but she does state otherwise that she has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Nephrocaps one tablet p.o. once daily. 2. Norvasc 5 mg twice a day. 3. Gabapentin 300 mg q Monday, Wednesday and Friday after hemodialysis. 4. Tramadol 50 mg p.o. twice a day p.r.n. 5. Trazodone 100 mg q.h.s. 6. Medroxyprogesterone 2.5 mg once daily. 7. Albuterol MDI. 8. Pantoprazole 40 mg p.o. once daily. 9. Calcitriol 0.25 mcg once daily. 10. Aspirin 81 mg p.o. once daily. 11. Epogen 20,000 units q Monday, Wednesday and Friday with hemodialysis as well as using MSIR 50 mg q12hours. The patient was admitted with increasing right lower extremity pain and low grade temperature. Her admission white count was noted to be 10.4 with a left shift, hematocrit 40.0 with a platelet count of 244,000. Prothrombin time was 13.7 and INR was 1.3 with a partial thromboplastin time of 28.0. She was on dialysis with a blood urea nitrogen and creatinine of 74 and 6.9, respectively. She had an admission potassium of 7.6 which was repeated in the Emergency Department and shown to be 8.0. Hyperkalemia was emergently treated with calcium chloride, bicarbonate, dextrose, insulin, Lasix as she does make some urine, as well as emergent hemodialysis and Kayexalate. Upon the day of admission, she went to dialysis and received her hemodialysis. Her potassium postdialysis was 4.1. She was otherwise feeling OK except complaining of persistent right lower extremity pain. PHYSICAL EXAMINATION: Her admission examination was notable for a temperature of 100.1, pulse 90, blood pressure 158/60, respiratory rate 18, oxygen saturation 94% in room air. She was a cachectic female who appeared older than her stated age. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The sclera were anicteric. She had no jugular venous distention and no carotid bruit. The heart was regular with no gallop. The lungs were clear but decreased throughout. The abdomen was soft, nontender, scaphoid, no hepatosplenomegaly, no pulsatile masses and no bruit. She had palpable femoral pulses bilaterally. Popliteal pulses were not palpable. Distal pulses in the right lower extremity were absent. She had some dry and wet gangrene involving the right forefoot with a failed right first toe amputation site that clearly had some purulent exudate. She was admitted for intravenous antibiotics and started on Vancomycin, Levofloxacin and Flagyl for her hemodialysis. Over the next couple days, she was resuscitated adequately and ultimately on 1933-6-3, she went to the operating room and received a right below the knee amputation. Postoperatively she did well. She was ruled out by enzymes and kept on telemetry times 24 hours and was uneventful. Her postoperative white blood cell count was 9.6 and hematocrit was 41.8. Platelet count was 157,000. Blood urea nitrogen and creatinine were 58 and 6.3 with a potassium of 5.3. Her phosphate was noted to be elevated at 11.8. Therefore, in hospital medications, she had her Calcitriol stopped and she was started on Amphojel and PhosLo. The Amphojel was continued for a total of three days of therapy, starting on 1990-4-2, and to end on 1923-8-10. Over the next couple days, her pain was appropriately controlled with Dilaudid PCA although the patient demanded that the Dilaudid did not work for her. Therefore, she was requesting Morphine. This was given concomitantly and resulted in some mental status changes and confusion which quickly resolved upon removal of her narcotic. She had a foot culture from 1931-5-12, that grew out Methicillin resistant Staphylococcus aureus. Blood cultures from 1934-7-8, were negative. By postoperative day number four, she continued on triple antibiotics. Her temperature maximum was 100.1, but a current of 97.4, pulse 82, blood pressure 130/70, respiratory rate 18, 96% oxygen saturation in room air. Her fingerstick was mildly elevated but she was noncompliant and was not taking a diabetic or renal diet. She was taking adequate p.o. Her white blood cell count at discharge was 9.4. Her blood urea nitrogen and creatinine were 52 and 6.3 with a potassium of 4.8 and bicarbonate of 21. At this time, her stump which had been resected back to the level of the proximal one third of the right lower extremity was clean, dry and intact with staples in place, no erythema, no exudate, no evidence of hematoma and the flaps were warm. She was deemed stable and appropriate for discharge by Dr.Cindy Edward service. MEDICATIONS ON DISCHARGE: 1. Nephrocaps one tablet p.o. once daily. 2. Vancomycin to be dosed at time of dialysis times two weeks, dose for trough values less than 15.0. 3. Norvasc 5 mg p.o. twice a day. 4. Gabapentin 300 mg q Monday, Wednesday and Friday after hemodialysis. 5. Tramadol 50 mg p.o. twice a day p.r.n. 6. Trazodone 100 mg p.o. q.h.s. 7. Medroxyprogesterone 2.5 mg p.o. once daily. 8. Albuterol MDI q4hours p.r.n. 9. Pantoprazole 40 mg p.o. once daily. 10. Calcitriol 0.25 mcg p.o. once daily to be on hold until followed up by her nephrologist. 11. Aspirin 81 mg p.o. once daily. 12. Folic Acid 1 mg p.o. once daily. 13. Epogen 20,000 units q Monday, Wednesday and Friday with hemodialysis. 14. MSIR 50 mg p.o. q12hours. 15. Dilaudid 2 to 4 mg p.o. q3-4hours p.r.n. breakthrough pain. 16. Colace and Pericolace for stool softening agents. FOLLOW-UP: The patient should follow-up with Dr. Quinones in approximately two to three weeks for skin clip removal. She will have right lower extremity remain in knee immobilizer with a dry dressing and ace wrap to above knee region to help immobilize and straighten her leg. She should take part in aggressive physical therapy and learn how to do transfers and so forth. Ultimately she will require outpatient sitting for prosthesis, however, the stump cannot be used until designated by Dr. Quinones. Typically this occurs within six to eight weeks postoperatively. The patient is deemed appropriate and stable for discharge. Nicholas Post, M.D. 74106888 Dictated By:Thomas MEDQUIST36 D: 1946-6-29 10:13 T: 1946-6-29 10:32 JOB#: Garcia, Brennan and Taylor-1913-770282 cc:Lofft	['Admission Date: 1933-6-3 Discharge Date: 1946-6-29\n\nDate of Birth: 1943-11-29 Sex: F\n\nService: VASCULAR\n\nHISTORY OF PRESENT ILLNESS: The patient is a 57 year old\nfemale with multiple medical problems who presented with\ngangrene of the right lower extremity, required admission for\npain control, intravenous antibiotics and ultimately for\nright below the knee amputation.\n\nPAST MEDICAL HISTORY:\n1. Coronary artery disease, status post coronary artery\nbypass graft, complicated by sternal wound infection.\n2. History of Methicillin resistant Staphylococcus aureus\nbacteremia in 1955-9-24.\n3. Diet controlled diabetes mellitus.\n4. Hypertension.\n5. Hypercholesterolemia.\n6. Significant tobacco use.\n7. History of wound abscess in the right lower extremity\nwhich grew out Methicillin resistant Staphylococcus aureus.', '\n8. Status post AV fistula in 2004.\n9. Status post coronary artery bypass graft times three that\nwas complicated by the sternal wound infection, 1-18, by Dr.\nCarolyn Kenner.\n10. Status post right femoral to below knee popliteal bypass\nwith PTFE done in 1-7, followed by a right first toe\namputation completed in 1-7.\n11. History of cesarean section.\n12. Questionable history of Penicillin allergy, but she does\nstate otherwise that she has no known drug allergies.\n\nMEDICATIONS ON ADMISSION:\n1. Nephrocaps one tablet p.o. once daily.\n2. Norvasc 5 mg twice a day.\n3. Gabapentin 300 mg q Monday, Wednesday and Friday after\nhemodialysis.\n4. Tramadol 50 mg p.o. twice a day p.r.n.\n5. Trazodone 100 mg q.h.s.\n6. Medroxyprogesterone 2.5 mg once daily.\n7. Albuterol MDI.\n8. Pantoprazole 40 mg p.o. once daily.', '\n9. Calcitriol 0.25 mcg once daily.\n10. Aspirin 81 mg p.o. once daily.\n11. Epogen 20,000 units q Monday, Wednesday and Friday with\nhemodialysis as well as using MSIR 50 mg q12hours.\n\nThe patient was admitted with increasing right lower\nextremity pain and low grade temperature. Her admission\nwhite count was noted to be 10.4 with a left shift,\nhematocrit 40.0 with a platelet count of 244,000.\nProthrombin time was 13.7 and INR was 1.3 with a partial\nthromboplastin time of 28.0. She was on dialysis with a\nblood urea nitrogen and creatinine of 74 and 6.9,\nrespectively. She had an admission potassium of 7.6 which\nwas repeated in the Emergency Department and shown to be 8.0.\nHyperkalemia was emergently treated with calcium chloride,\nbicarbonate, dextrose, insulin, Lasix as she does make some\nurine, as well as emergent hemodialysis and Kayexalate.', '\n\nUpon the day of admission, she went to dialysis and received\nher hemodialysis. Her potassium postdialysis was 4.1. She\nwas otherwise feeling OK except complaining of persistent\nright lower extremity pain.\n\nPHYSICAL EXAMINATION: Her admission examination was notable\nfor a temperature of 100.1, pulse 90, blood pressure 158/60,\nrespiratory rate 18, oxygen saturation 94% in room air. She\nwas a cachectic female who appeared older than her stated\nage. The pupils are equal, round, and reactive to light and\naccommodation. Extraocular movements are intact. The sclera\nwere anicteric. She had no jugular venous distention and no\ncarotid bruit. The heart was regular with no gallop. The\nlungs were clear but decreased throughout. The abdomen was\nsoft, nontender, scaphoid, no hepatosplenomegaly, no\npulsatile masses and no bruit.', ' She had palpable femoral\npulses bilaterally. Popliteal pulses were not palpable.\nDistal pulses in the right lower extremity were absent. She\nhad some dry and wet gangrene involving the right forefoot\nwith a failed right first toe amputation site that clearly\nhad some purulent exudate.\n\nShe was admitted for intravenous antibiotics and started on\nVancomycin, Levofloxacin and Flagyl for her hemodialysis.\nOver the next couple days, she was resuscitated adequately\nand ultimately on 1933-6-3, she went to the operating room\nand received a right below the knee amputation.\nPostoperatively she did well. She was ruled out by enzymes\nand kept on telemetry times 24 hours and was uneventful. Her\npostoperative white blood cell count was 9.6 and hematocrit\nwas 41.8. Platelet count was 157,000. Blood urea nitrogen\nand creatinine were 58 and 6.', '3 with a potassium of 5.3. Her\nphosphate was noted to be elevated at 11.8. Therefore, in\nhospital medications, she had her Calcitriol stopped and she\nwas started on Amphojel and PhosLo. The Amphojel was\ncontinued for a total of three days of therapy, starting on\n1990-4-2, and to end on 1923-8-10. Over the next couple days,\nher pain was appropriately controlled with Dilaudid PCA\nalthough the patient demanded that the Dilaudid did not work\nfor her. Therefore, she was requesting Morphine. This was\ngiven concomitantly and resulted in some mental status\nchanges and confusion which quickly resolved upon removal of\nher narcotic. She had a foot culture from 1931-5-12, that\ngrew out Methicillin resistant Staphylococcus aureus. Blood\ncultures from 1934-7-8, were negative. By postoperative day\nnumber four, she continued on triple antibiotics.', ' Her\ntemperature maximum was 100.1, but a current of 97.4, pulse\n82, blood pressure 130/70, respiratory rate 18, 96% oxygen\nsaturation in room air. Her fingerstick was mildly elevated\nbut she was noncompliant and was not taking a diabetic or\nrenal diet. She was taking adequate p.o. Her white blood\ncell count at discharge was 9.4. Her blood urea nitrogen and\ncreatinine were 52 and 6.3 with a potassium of 4.8 and\nbicarbonate of 21.\n\nAt this time, her stump which had been resected back to the\nlevel of the proximal one third of the right lower extremity\nwas clean, dry and intact with staples in place, no erythema,\nno exudate, no evidence of hematoma and the flaps were warm.\nShe was deemed stable and appropriate for discharge by Dr.Cindy Edward service.\n\nMEDICATIONS ON DISCHARGE:\n1. Nephrocaps one tablet p.', 'o. once daily.\n2. Vancomycin to be dosed at time of dialysis times two\nweeks, dose for trough values less than 15.0.\n3. Norvasc 5 mg p.o. twice a day.\n4. Gabapentin 300 mg q Monday, Wednesday and Friday after\nhemodialysis.\n5. Tramadol 50 mg p.o. twice a day p.r.n.\n6. Trazodone 100 mg p.o. q.h.s.\n7. Medroxyprogesterone 2.5 mg p.o. once daily.\n8. Albuterol MDI q4hours p.r.n.\n9. Pantoprazole 40 mg p.o. once daily.\n10. Calcitriol 0.25 mcg p.o. once daily to be on hold until\nfollowed up by her nephrologist.\n11. Aspirin 81 mg p.o. once daily.\n12. Folic Acid 1 mg p.o. once daily.\n13. Epogen 20,000 units q Monday, Wednesday and Friday with\nhemodialysis.\n14. MSIR 50 mg p.o. q12hours.\n15. Dilaudid 2 to 4 mg p.o. q3-4hours p.r.n. breakthrough\npain.\n16. Colace and Pericolace for stool softening agents.', '\n\nFOLLOW-UP: The patient should follow-up with Dr. Quinones in\napproximately two to three weeks for skin clip removal. She\nwill have right lower extremity remain in knee immobilizer\nwith a dry dressing and ace wrap to above knee region to help\nimmobilize and straighten her leg. She should take part in\naggressive physical therapy and learn how to do transfers and\nso forth. Ultimately she will require outpatient sitting for\nprosthesis, however, the stump cannot be used until\ndesignated by Dr. Quinones. Typically this occurs within six\nto eight weeks postoperatively. The patient is deemed\nappropriate and stable for discharge.\n\n\n\n\n Nicholas Post, M.D. 74106888\n\nDictated By:Thomas\nMEDQUIST36\n\nD: 1946-6-29 10:13\nT: 1946-6-29 10:32\nJOB#: Garcia, Brennan and Taylor-1913-770282\n\ncc:Lofft']
539	1174	111717.0	2152-10-05	Discharge summary	Report	Admission Date: [2152-9-23] Discharge Date: [2152-10-5] Date of Birth: [2075-7-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2186] Chief Complaint: Respiratory distress/hypoxia Major Surgical or Invasive Procedure: elective intubation [2152-9-26] History of Present Illness: 77 YO old male with PMH significant for DM, HTN, high chol, CAD s/p stents [2150], CHF, Afib s/p PPM [2150], CKD who presents to ED because of weakness and collapse at home. Patient was found on admission to be febrile, tachypneic with RUL pneumonia on chest film. Patient complained of chronic cough with increasing sputum production. He denies fevers, chills, shortness of breath, chest pain. He denies any loss of consciousness or head trauma with falls. Denies bowel or bladder incontinence or changes in function. Denies any weight loss or changes in eating habits. No abd pain/n/v/d. No choking on food reported. Patient was admitted and started on ceftriaxone and azithromycin for CAP which was then changed to Levoflox and Flagyl as CXR showed ? evidence for aspiration PNA. The patient since admission has remained tachypneic and hypoxic requiring O2 today. He needed a non-rebreather for some time but has since been titrated down. As the patient additionally has a history of CHF, a repeat chest film was performed to evaluate for any component of congestion. Although the film did not appear to be all that congested, the patient's pneumonia appeared to worsen, now a multilobar pneumonia involving the right upper and middle/lower lung fields. ABG 7.43/37/54 at time of transfer to ICU, he received 80 mg of Lasix with minimal urinary output after 20 mg caused 250 cc of urine output earlier in the day. Albuterol nebs with minimal improvement in O2 sat. Pt was x-ferred to ICU and started on BiPAP. See additional course below. Past Medical History: PAST MEDICAL HISTORY: 1. Congestive heart failure; ejection fraction of 55% in 02/[2148]. 2. Diabetes mellitus, insulin dependent, complicated by nephropathy and retinopathy. 3. Hypertension. 4. History of bradycardia. 5. Hypercholesterolemia. 6. Chronic renal insufficiency with baseline creatinine 1.9 to 2.1. 7. Anemia thought secondary to chronic disease. 8. CAD s/p stent of LCx and RCA in [2150] 9. A fib s/p [Year (4 digits) 4448] in [2150] Social History: Lives with wife and 1 daughter. [Name (NI) ] 5 daughters. Quit smoking 25 years ago, but 10 year smoking history. No Etoh or IVDA. Family History: NC Physical Exam: Physical Exam: 101.7 Tm, 65 BP118/93 RR21 O2sat 91% on RA --> 100% 3L NAD, +Diaphoretic. MMM, JVD elevated around angle of jaw at 45 deg neck FROM, no LAD RRR with 3/6 SEM at RUSB bronchial breath sounds at RUL, RLL obese, paradoxical abdominal movements with abdominal grunting, umbilical hernia- no erythema, easy to reduce, +BS Trace LE edema, no cyanosis. Moves all 4 extremeities, 2+ DTRs Pertinent Results: EKG: paced at 60bpm, no changes from prior . CXR: Cardiac, mediastinal, and hilar contours are not significantly changed. There is a right upper lobe opacity. There are mildly increased pulmonary vascular markings indicating mild failure. . CT head: No evidence of acute intracranial hemorrhage. Findings consistent with old lacunes. [2152-9-23] 09:09PM LACTATE-2.1* [2152-9-23] 09:05PM GLUCOSE-130* UREA N-30* CREAT-2.8* SODIUM-144 POTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-28 ANION GAP-17 [2152-9-23] 09:05PM WBC-13.2# RBC-4.12 HGB-12.4* HCT-36.9* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.3 [2152-9-23] 09:05PM NEUTS-86.0* LYMPHS-8.4* MONOS-5.1 EOS-0.3 BASOS-0.2 [2152-9-23] 09:05PM PT-14.5* PTT-27.4 INR(PT)-1.4 [2152-9-23] 09:05PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2152-9-29] 4:10 am SPUTUM Site: ENDOTRACHEAL FINAL REPORT [2152-10-1] GRAM STAIN (Final [2152-9-29]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2152-10-1]): SPARSE GROWTH OROPHARYNGEAL FLORA. [2152-9-28] 12:30 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE TEST. GRAM STAIN (Final [2152-9-28]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2152-9-30]): ~1000/ML OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [2152-9-29]): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2152-9-29]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): VIRAL CULTURE (Final [2152-9-29]): SPECIMEN NOT PROCESSED DUE TO:. DUPLICATE ORDER. REFER TO [Numeric Identifier 4449] FOR RESULTS [2152-9-28]. PATIENT CREDITED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [2152-9-29]): SPECIMEN NOT PROCESSED DUE TO:. DUPLICATE ORDER. REFER TO [Numeric Identifier 4449] FOR RESULTS [2152-9-28]. PATIENT CREDITED. Brief Hospital Course: A/P: 77 year old male with hx of HTN, high chol, CAD, afib s/p pacer here with lobar PNA. . 1. Respiratory Distress: Initially, the patient was started on ceftriaxone and azithro for CAP but Abx were adjusted to levoflox/flagyl based on patient's continued hypoxia and CXR [Location (un) 1131] concerning for aspiration event. The patient became more distressed with his respiratory state over the first 3 days of his hospitalization. It was felt that the most likely source of his resp distress was thought to be his RUL pneumonia, perhaps with contribution from his diastolic CHF. PE was considered but felt to be very low suspicion given XRAY findings, febrile state. Although the film did not appear to be all that congested, the patient's pneumonia appeared to worsen to a multilobar pneumonia involving the right upper and middle/lower lung fields. The patient was found to be dangerously hypoxic on [2152-9-25] with increasing work of breathing. ABG 7.43/37/54 at that time, patient received 80 mg of IV Lasix with minimal urinary output. Albuterol nebs resulted in minimal improvement in O2 sat. Pt was x-ferred to ICU and started on BiPAP. He was intubated [2152-9-26] due to continued respiratory distress (it was a difficult intubation). His Abx was adjusted again to include Vancomycin and levofloxacin to cover MRSA and CAP. Despite no cx data, it was felt the patient most likely had strep pneum. pneumonia due to clinical course. The pateint was liberated from ventilator slowly due to difficult airway issues and he was extubated on [10-2]. His sputum culture from BAL on [9-28] showed 1000 oropharyngeal flora; all other cultures were negative. Serial CXRs showed clearing of pneumonia. He was transferred to the floor on 4L NC on [2152-10-3]. He maintained excellent O2 sats and he was weaned to 2L upon discharge. He has been intermittently diuresed with Lasix (20mg IV), but his CXRs have not shown congestion and the course of his respiratory status has closely followed that of his pneumonia. He has also received albuterol and atrovent nebs with improvement in his wheeze and dyspena. He has completed 12 days of Vancomycin and levofloxacin, and they were continued upon discharge to finish a 14 day course for ? pneumococcal vs staph aureus pneumonia. The patient was given pneumococcal vaccine prior to discharge. No blood cx were positive. . 2. CAD: His EKG showed a paced rhythm and old LBBB. He was without chest pain and had no signs of ischemia throughout his stay. Cardiac enzymes were cycled to rule out the possibility of silent ischemia, and were negative. He was maintained on his ASA, BB, and statin. An outpatient echocardiogram may be considered for future management. . 3. HTN: Mr. [Known lastname ] was maintained on metoprolol, [Last Name (un) ] and amlodopine and imdur. He will titrate up his HTN management with his PCP. [Name10 (NameIs) ] BP upon discharge was slightly above goal (SBPs 140s). . 4. Afib/AVNRT: Mr. [Known lastname ] has a [Known lastname 4448] for tachy-brady syndrome in the past. He has also had ablation for SVT with aberrancy in [2150]. At that time he was started on amiodarone. He has a ? history of atrial fibrillation/flutter, but is not on anticoagulation as the history is unclear. [Name2 (NI) ] was in NSR throughout his stay. He has an appointment in EP Device Clinic later this month and is also set up for a Cardiology appointment in [Month (only) ]. . 5. DMII: Mr. [Known lastname ] was put on half of his outpatient dose of NPH 75/25 and sliding scale insulin during his hospitalization. He maintained good glucose control (FSBG < 150). He was discharged on the half-dose NPH 75/25, and should follow up with his PCP/[Last Name (un) ] to adjust as needed. . 6. FEN: He was maintained on a cardiac/diabetic diet and 2L fluid restriction. The patient needed prn Lasix dosing for volume overload (he responded well to 20-40mg IV lasix). . 7. CKD: Baseline Creatinine 1.9-2.2. He had some variations in creat throughout stay (likely due to varying volume status and diuresis) but was back to baseline prior to discharge (1.9). His medications were all renally dosed (Vancomycin by levels < 15). His kidney disease is related to lond standing diabetes and he is followed at the [Hospital ] clinic by Dr. [First Name8 (NamePattern2) ] [Name (STitle) 805] for this issue. 8. Anemia: patient's baseline Hct 27-31 with Fe studies consistent with anemia of chronic disease. His hct remained in the range (27-32) throughout his stay and the patient did not receive any pRBCs. He would likely benefit from erythropoetin as an outpt as his epo-deficient state from CKD is the likely etiology of his anemia. Medications on Admission: MEDICATIONS: 1. Atenolol 50 mg p.o. q.d. 2. Amiodarone 400mg q.d. 3. Norvasc 10 mg p.o. q.d. 4. Doxazosin 2 mg p.o. q.d. 5. Cozaar 50 mg p.o. b.i.d 6. Niferex 150 mg p.o. b.i.d. 7. Plavix 75mg qd 8. Aspirin 325 mg p.o. q.d. 9. Humalog 75/25, 12U qam, 10U qpm 10. Furosemide 40mg qam, 20mg qpm 11. Atorvastatin 10 mg p.o. q.d. 12. Imdur 90mg q.d 13. Laxatives 14. Meclizine 25mg qhs Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebs Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 13. Meclizine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous once a day for 2 days: finish [2152-10-7]. 16. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Six (6) units Subcutaneous qAM: adjust as needed for glycemic control (FSBG 80-120). 17. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Five (5) units Subcutaneous qPM: adjust as needed for goal FSBG 80-120. 18. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: Primary: 1. multilobar PNA (community-acquired) 2. diastolic CHF Secondary: 3. HTN 4. ? AVNRT/aflutter s/p ablation/pacer 5. anemia of chronic disease 6. CKD Discharge Condition: stable, on 2L NC and improving daily. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500mL If you experience any fevers > 101.5, chills, chest pain, Followup Instructions: 1. Provider: [Name10 (NameIs) ] CALL Phone:[Telephone/Fax (1) 59] Date/Time:[2152-10-24] 10:15 . 2. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4450], M.D. Phone:[Telephone/Fax (1) 4451] Date/Time:[2152-11-29] 9:00 (please consider outpt echocardiogram). . 3. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2153-1-22] 10:30 Completed by:[2152-10-5]	Admission Date: <Date>1945-6-16</Date> Discharge Date: <Date>1979-6-16</Date> Date of Birth: <Date>1960-11-3</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Lisa</Name> Chief Complaint: Respiratory distress/hypoxia Major Surgical or Invasive Procedure: elective intubation <Date>1915-6-23</Date> History of Present Illness: 77 YO old male with PMH significant for DM, HTN, high chol, CAD s/p stents <Year>2014</Year>, CHF, Afib s/p PPM <Year>2014</Year>, CKD who presents to ED because of weakness and collapse at home. Patient was found on admission to be febrile, tachypneic with RUL pneumonia on chest film. Patient complained of chronic cough with increasing sputum production. He denies fevers, chills, shortness of breath, chest pain. He denies any loss of consciousness or head trauma with falls. Denies bowel or bladder incontinence or changes in function. Denies any weight loss or changes in eating habits. No abd pain/n/v/d. No choking on food reported. Patient was admitted and started on ceftriaxone and azithromycin for CAP which was then changed to Levoflox and Flagyl as CXR showed ? evidence for aspiration PNA. The patient since admission has remained tachypneic and hypoxic requiring O2 today. He needed a non-rebreather for some time but has since been titrated down. As the patient additionally has a history of CHF, a repeat chest film was performed to evaluate for any component of congestion. Although the film did not appear to be all that congested, the patient's pneumonia appeared to worsen, now a multilobar pneumonia involving the right upper and middle/lower lung fields. ABG 7.43/37/54 at time of transfer to ICU, he received 80 mg of Lasix with minimal urinary output after 20 mg caused 250 cc of urine output earlier in the day. Albuterol nebs with minimal improvement in O2 sat. Pt was x-ferred to ICU and started on BiPAP. See additional course below. Past Medical History: PAST MEDICAL HISTORY: 1. Congestive heart failure; ejection fraction of 55% in 02/<Year>2014</Year>. 2. Diabetes mellitus, insulin dependent, complicated by nephropathy and retinopathy. 3. Hypertension. 4. History of bradycardia. 5. Hypercholesterolemia. 6. Chronic renal insufficiency with baseline creatinine 1.9 to 2.1. 7. Anemia thought secondary to chronic disease. 8. CAD s/p stent of LCx and RCA in <Year>2014</Year> 9. A fib s/p <Year>1909</Year> in <Year>2014</Year> Social History: Lives with wife and 1 daughter. <Name>Kenna Kobayashi</Name> 5 daughters. Quit smoking 25 years ago, but 10 year smoking history. No Etoh or IVDA. Family History: NC Physical Exam: Physical Exam: 101.7 Tm, 65 BP118/93 RR21 O2sat 91% on RA --> 100% 3L NAD, +Diaphoretic. MMM, JVD elevated around angle of jaw at 45 deg neck FROM, no LAD RRR with 3/6 SEM at RUSB bronchial breath sounds at RUL, RLL obese, paradoxical abdominal movements with abdominal grunting, umbilical hernia- no erythema, easy to reduce, +BS Trace LE edema, no cyanosis. Moves all 4 extremeities, 2+ DTRs Pertinent Results: EKG: paced at 60bpm, no changes from prior . CXR: Cardiac, mediastinal, and hilar contours are not significantly changed. There is a right upper lobe opacity. There are mildly increased pulmonary vascular markings indicating mild failure. . CT head: No evidence of acute intracranial hemorrhage. Findings consistent with old lacunes. <Date>1945-6-16</Date> 09:09PM LACTATE-2.1* <Date>1945-6-16</Date> 09:05PM GLUCOSE-130* UREA N-30* CREAT-2.8* SODIUM-144 POTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-28 ANION GAP-17 <Date>1945-6-16</Date> 09:05PM WBC-13.2# RBC-4.12 HGB-12.4* HCT-36.9* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.3 <Date>1945-6-16</Date> 09:05PM NEUTS-86.0* LYMPHS-8.4* MONOS-5.1 EOS-0.3 BASOS-0.2 <Date>1945-6-16</Date> 09:05PM PT-14.5* PTT-27.4 INR(PT)-1.4 <Date>1945-6-16</Date> 09:05PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG <Date>1990-12-29</Date> 4:10 am SPUTUM Site: ENDOTRACHEAL FINAL REPORT <Date>1910-1-3</Date> GRAM STAIN (Final <Date>1990-12-29</Date>): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final <Date>1910-1-3</Date>): SPARSE GROWTH OROPHARYNGEAL FLORA. <Date>1962-6-23</Date> 12:30 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE TEST. GRAM STAIN (Final <Date>1962-6-23</Date>): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final <Date>2021-9-11</Date>): ~1000/ML OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final <Date>1990-12-29</Date>): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final <Date>1990-12-29</Date>): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): VIRAL CULTURE (Final <Date>1990-12-29</Date>): SPECIMEN NOT PROCESSED DUE TO:. DUPLICATE ORDER. REFER TO <Numeric Identifier>6385448</Numeric Identifier> FOR RESULTS <Date>1962-6-23</Date>. PATIENT CREDITED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final <Date>1990-12-29</Date>): SPECIMEN NOT PROCESSED DUE TO:. DUPLICATE ORDER. REFER TO <Numeric Identifier>6385448</Numeric Identifier> FOR RESULTS <Date>1962-6-23</Date>. PATIENT CREDITED. Brief Hospital Course: A/P: 77 year old male with hx of HTN, high chol, CAD, afib s/p pacer here with lobar PNA. . 1. Respiratory Distress: Initially, the patient was started on ceftriaxone and azithro for CAP but Abx were adjusted to levoflox/flagyl based on patient's continued hypoxia and CXR <Location>7085 James Loop West Kimberlyberg, OH 13040</Location> concerning for aspiration event. The patient became more distressed with his respiratory state over the first 3 days of his hospitalization. It was felt that the most likely source of his resp distress was thought to be his RUL pneumonia, perhaps with contribution from his diastolic CHF. PE was considered but felt to be very low suspicion given XRAY findings, febrile state. Although the film did not appear to be all that congested, the patient's pneumonia appeared to worsen to a multilobar pneumonia involving the right upper and middle/lower lung fields. The patient was found to be dangerously hypoxic on <Date>1976-8-17</Date> with increasing work of breathing. ABG 7.43/37/54 at that time, patient received 80 mg of IV Lasix with minimal urinary output. Albuterol nebs resulted in minimal improvement in O2 sat. Pt was x-ferred to ICU and started on BiPAP. He was intubated <Date>1915-6-23</Date> due to continued respiratory distress (it was a difficult intubation). His Abx was adjusted again to include Vancomycin and levofloxacin to cover MRSA and CAP. Despite no cx data, it was felt the patient most likely had strep pneum. pneumonia due to clinical course. The pateint was liberated from ventilator slowly due to difficult airway issues and he was extubated on <Date>3-6</Date>. His sputum culture from BAL on <Date>8-9</Date> showed 1000 oropharyngeal flora; all other cultures were negative. Serial CXRs showed clearing of pneumonia. He was transferred to the floor on 4L NC on <Date>1931-9-14</Date>. He maintained excellent O2 sats and he was weaned to 2L upon discharge. He has been intermittently diuresed with Lasix (20mg IV), but his CXRs have not shown congestion and the course of his respiratory status has closely followed that of his pneumonia. He has also received albuterol and atrovent nebs with improvement in his wheeze and dyspena. He has completed 12 days of Vancomycin and levofloxacin, and they were continued upon discharge to finish a 14 day course for ? pneumococcal vs staph aureus pneumonia. The patient was given pneumococcal vaccine prior to discharge. No blood cx were positive. . 2. CAD: His EKG showed a paced rhythm and old LBBB. He was without chest pain and had no signs of ischemia throughout his stay. Cardiac enzymes were cycled to rule out the possibility of silent ischemia, and were negative. He was maintained on his ASA, BB, and statin. An outpatient echocardiogram may be considered for future management. . 3. HTN: Mr. <Name>Olles</Name> was maintained on metoprolol, <Name>Ivory</Name> and amlodopine and imdur. He will titrate up his HTN management with his PCP. <Name>Kenna Ivory</Name> BP upon discharge was slightly above goal (SBPs 140s). . 4. Afib/AVNRT: Mr. <Name>Olles</Name> has a <Name>Kuykendall</Name> for tachy-brady syndrome in the past. He has also had ablation for SVT with aberrancy in <Year>2014</Year>. At that time he was started on amiodarone. He has a ? history of atrial fibrillation/flutter, but is not on anticoagulation as the history is unclear. <Name>Bo Bounds</Name> was in NSR throughout his stay. He has an appointment in EP Device Clinic later this month and is also set up for a Cardiology appointment in <Month>February</Month>. . 5. DMII: Mr. <Name>Olles</Name> was put on half of his outpatient dose of NPH 75/25 and sliding scale insulin during his hospitalization. He maintained good glucose control (FSBG < 150). He was discharged on the half-dose NPH 75/25, and should follow up with his PCP/<Name>Ivory</Name> to adjust as needed. . 6. FEN: He was maintained on a cardiac/diabetic diet and 2L fluid restriction. The patient needed prn Lasix dosing for volume overload (he responded well to 20-40mg IV lasix). . 7. CKD: Baseline Creatinine 1.9-2.2. He had some variations in creat throughout stay (likely due to varying volume status and diuresis) but was back to baseline prior to discharge (1.9). His medications were all renally dosed (Vancomycin by levels < 15). His kidney disease is related to lond standing diabetes and he is followed at the <Hospital>Conner-Williams Health System</Hospital> clinic by Dr. <Name>Isaias</Name> <Name>Grace Cobbs</Name> for this issue. 8. Anemia: patient's baseline Hct 27-31 with Fe studies consistent with anemia of chronic disease. His hct remained in the range (27-32) throughout his stay and the patient did not receive any pRBCs. He would likely benefit from erythropoetin as an outpt as his epo-deficient state from CKD is the likely etiology of his anemia. Medications on Admission: MEDICATIONS: 1. Atenolol 50 mg p.o. q.d. 2. Amiodarone 400mg q.d. 3. Norvasc 10 mg p.o. q.d. 4. Doxazosin 2 mg p.o. q.d. 5. Cozaar 50 mg p.o. b.i.d 6. Niferex 150 mg p.o. b.i.d. 7. Plavix 75mg qd 8. Aspirin 325 mg p.o. q.d. 9. Humalog 75/25, 12U qam, 10U qpm 10. Furosemide 40mg qam, 20mg qpm 11. Atorvastatin 10 mg p.o. q.d. 12. Imdur 90mg q.d 13. Laxatives 14. Meclizine 25mg qhs Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebs Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 13. Meclizine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous once a day for 2 days: finish <Date>1982-12-31</Date>. 16. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Six (6) units Subcutaneous qAM: adjust as needed for glycemic control (FSBG 80-120). 17. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Five (5) units Subcutaneous qPM: adjust as needed for goal FSBG 80-120. 18. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: <Hospital>Walker Group Health System</Hospital> for the Aged - Acute Rehab Discharge Diagnosis: Primary: 1. multilobar PNA (community-acquired) 2. diastolic CHF Secondary: 3. HTN 4. ? AVNRT/aflutter s/p ablation/pacer 5. anemia of chronic disease 6. CKD Discharge Condition: stable, on 2L NC and improving daily. Discharge Instructions: Weigh yourself every morning, <Name>Cruz Recinos</Name> MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500mL If you experience any fevers > 101.5, chills, chest pain, Followup Instructions: 1. Provider: <Name>Kenna Ivory</Name> CALL Phone:<Telephone>228-994-4511</Telephone> Date/Time:<Date>1917-8-11</Date> 10:15 . 2. Provider: <Name>Frank</Name> <Name>Moore</Name>, M.D. Phone:<Telephone>268-202-7209</Telephone> Date/Time:<Date>1960-8-25</Date> 9:00 (please consider outpt echocardiogram). . 3. Provider: <Name>Ethan Son</Name> CLINIC Phone:<Telephone>228-994-4511</Telephone> Date/Time:<Date>2016-10-11</Date> 10:30 Completed by:<Date>1979-6-16</Date>	000000000000000001111111110000000000000000000000000000000011111111100000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000011110000111100000000000000000000000000000000000000000000000000001111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000001111111111000000000>0000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000111111100000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000011111110000000000000111111111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Date: 1945-6-16 Discharge Date: 1979-6-16 Date of Birth: 1960-11-3 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Lisa Chief Complaint: Respiratory distress/hypoxia Major Surgical or Invasive Procedure: elective intubation 1915-6-23 History of Present Illness: 77 YO old male with PMH significant for DM, HTN, high chol, CAD s/p stents 2014, CHF, Afib s/p PPM 2014, CKD who presents to ED because of weakness and collapse at home. Patient was found on admission to be febrile, tachypneic with RUL pneumonia on chest film. Patient complained of chronic cough with increasing sputum production. He denies fevers, chills, shortness of breath, chest pain. He denies any loss of consciousness or head trauma with falls. Denies bowel or bladder incontinence or changes in function. Denies any weight loss or changes in eating habits. No abd pain/n/v/d. No choking on food reported. Patient was admitted and started on ceftriaxone and azithromycin for CAP which was then changed to Levoflox and Flagyl as CXR showed ? evidence for aspiration PNA. The patient since admission has remained tachypneic and hypoxic requiring O2 today. He needed a non-rebreather for some time but has since been titrated down. As the patient additionally has a history of CHF, a repeat chest film was performed to evaluate for any component of congestion. Although the film did not appear to be all that congested, the patient's pneumonia appeared to worsen, now a multilobar pneumonia involving the right upper and middle/lower lung fields. ABG 7.43/37/54 at time of transfer to ICU, he received 80 mg of Lasix with minimal urinary output after 20 mg caused 250 cc of urine output earlier in the day. Albuterol nebs with minimal improvement in O2 sat. Pt was x-ferred to ICU and started on BiPAP. See additional course below. Past Medical History: PAST MEDICAL HISTORY: 1. Congestive heart failure; ejection fraction of 55% in 02/2014. 2. Diabetes mellitus, insulin dependent, complicated by nephropathy and retinopathy. 3. Hypertension. 4. History of bradycardia. 5. Hypercholesterolemia. 6. Chronic renal insufficiency with baseline creatinine 1.9 to 2.1. 7. Anemia thought secondary to chronic disease. 8. CAD s/p stent of LCx and RCA in 2014 9. A fib s/p 1909 in 2014 Social History: Lives with wife and 1 daughter. Kenna Kobayashi 5 daughters. Quit smoking 25 years ago, but 10 year smoking history. No Etoh or IVDA. Family History: NC Physical Exam: Physical Exam: 101.7 Tm, 65 BP118/93 RR21 O2sat 91% on RA --> 100% 3L NAD, +Diaphoretic. MMM, JVD elevated around angle of jaw at 45 deg neck FROM, no LAD RRR with 3/6 SEM at RUSB bronchial breath sounds at RUL, RLL obese, paradoxical abdominal movements with abdominal grunting, umbilical hernia- no erythema, easy to reduce, +BS Trace LE edema, no cyanosis. Moves all 4 extremeities, 2+ DTRs Pertinent Results: EKG: paced at 60bpm, no changes from prior . CXR: Cardiac, mediastinal, and hilar contours are not significantly changed. There is a right upper lobe opacity. There are mildly increased pulmonary vascular markings indicating mild failure. . CT head: No evidence of acute intracranial hemorrhage. Findings consistent with old lacunes. 1945-6-16 09:09PM LACTATE-2.1* 1945-6-16 09:05PM GLUCOSE-130* UREA N-30* CREAT-2.8* SODIUM-144 POTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-28 ANION GAP-17 1945-6-16 09:05PM WBC-13.2# RBC-4.12 HGB-12.4* HCT-36.9* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.3 1945-6-16 09:05PM NEUTS-86.0* LYMPHS-8.4* MONOS-5.1 EOS-0.3 BASOS-0.2 1945-6-16 09:05PM PT-14.5* PTT-27.4 INR(PT)-1.4 1945-6-16 09:05PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 1990-12-29 4:10 am SPUTUM Site: ENDOTRACHEAL FINAL REPORT 1910-1-3 GRAM STAIN (Final 1990-12-29): >25 PMNs and 1910-1-3): SPARSE GROWTH OROPHARYNGEAL FLORA. 1962-6-23 12:30 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE TEST. GRAM STAIN (Final 1962-6-23): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final 2021-9-11): ~1000/ML OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final 1990-12-29): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final 1990-12-29): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): VIRAL CULTURE (Final 1990-12-29): SPECIMEN NOT PROCESSED DUE TO:. DUPLICATE ORDER. REFER TO 6385448 FOR RESULTS 1962-6-23. PATIENT CREDITED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final 1990-12-29): SPECIMEN NOT PROCESSED DUE TO:. DUPLICATE ORDER. REFER TO 6385448 FOR RESULTS 1962-6-23. PATIENT CREDITED. Brief Hospital Course: A/P: 77 year old male with hx of HTN, high chol, CAD, afib s/p pacer here with lobar PNA. . 1. Respiratory Distress: Initially, the patient was started on ceftriaxone and azithro for CAP but Abx were adjusted to levoflox/flagyl based on patient's continued hypoxia and CXR 7085 James Loop West Kimberlyberg, OH 13040 concerning for aspiration event. The patient became more distressed with his respiratory state over the first 3 days of his hospitalization. It was felt that the most likely source of his resp distress was thought to be his RUL pneumonia, perhaps with contribution from his diastolic CHF. PE was considered but felt to be very low suspicion given XRAY findings, febrile state. Although the film did not appear to be all that congested, the patient's pneumonia appeared to worsen to a multilobar pneumonia involving the right upper and middle/lower lung fields. The patient was found to be dangerously hypoxic on 1976-8-17 with increasing work of breathing. ABG 7.43/37/54 at that time, patient received 80 mg of IV Lasix with minimal urinary output. Albuterol nebs resulted in minimal improvement in O2 sat. Pt was x-ferred to ICU and started on BiPAP. He was intubated 1915-6-23 due to continued respiratory distress (it was a difficult intubation). His Abx was adjusted again to include Vancomycin and levofloxacin to cover MRSA and CAP. Despite no cx data, it was felt the patient most likely had strep pneum. pneumonia due to clinical course. The pateint was liberated from ventilator slowly due to difficult airway issues and he was extubated on 3-6. His sputum culture from BAL on 8-9 showed 1000 oropharyngeal flora; all other cultures were negative. Serial CXRs showed clearing of pneumonia. He was transferred to the floor on 4L NC on 1931-9-14. He maintained excellent O2 sats and he was weaned to 2L upon discharge. He has been intermittently diuresed with Lasix (20mg IV), but his CXRs have not shown congestion and the course of his respiratory status has closely followed that of his pneumonia. He has also received albuterol and atrovent nebs with improvement in his wheeze and dyspena. He has completed 12 days of Vancomycin and levofloxacin, and they were continued upon discharge to finish a 14 day course for ? pneumococcal vs staph aureus pneumonia. The patient was given pneumococcal vaccine prior to discharge. No blood cx were positive. . 2. CAD: His EKG showed a paced rhythm and old LBBB. He was without chest pain and had no signs of ischemia throughout his stay. Cardiac enzymes were cycled to rule out the possibility of silent ischemia, and were negative. He was maintained on his ASA, BB, and statin. An outpatient echocardiogram may be considered for future management. . 3. HTN: Mr. Olles was maintained on metoprolol, Ivory and amlodopine and imdur. He will titrate up his HTN management with his PCP. Kenna Ivory BP upon discharge was slightly above goal (SBPs 140s). . 4. Afib/AVNRT: Mr. Olles has a Kuykendall for tachy-brady syndrome in the past. He has also had ablation for SVT with aberrancy in 2014. At that time he was started on amiodarone. He has a ? history of atrial fibrillation/flutter, but is not on anticoagulation as the history is unclear. Bo Bounds was in NSR throughout his stay. He has an appointment in EP Device Clinic later this month and is also set up for a Cardiology appointment in February. . 5. DMII: Mr. Olles was put on half of his outpatient dose of NPH 75/25 and sliding scale insulin during his hospitalization. He maintained good glucose control (FSBG Ivory to adjust as needed. . 6. FEN: He was maintained on a cardiac/diabetic diet and 2L fluid restriction. The patient needed prn Lasix dosing for volume overload (he responded well to 20-40mg IV lasix). . 7. CKD: Baseline Creatinine 1.9-2.2. He had some variations in creat throughout stay (likely due to varying volume status and diuresis) but was back to baseline prior to discharge (1.9). His medications were all renally dosed (Vancomycin by levels Conner-Williams Health System clinic by Dr. Isaias Grace Cobbs for this issue. 8. Anemia: patient's baseline Hct 27-31 with Fe studies consistent with anemia of chronic disease. His hct remained in the range (27-32) throughout his stay and the patient did not receive any pRBCs. He would likely benefit from erythropoetin as an outpt as his epo-deficient state from CKD is the likely etiology of his anemia. Medications on Admission: MEDICATIONS: 1. Atenolol 50 mg p.o. q.d. 2. Amiodarone 400mg q.d. 3. Norvasc 10 mg p.o. q.d. 4. Doxazosin 2 mg p.o. q.d. 5. Cozaar 50 mg p.o. b.i.d 6. Niferex 150 mg p.o. b.i.d. 7. Plavix 75mg qd 8. Aspirin 325 mg p.o. q.d. 9. Humalog 75/25, 12U qam, 10U qpm 10. Furosemide 40mg qam, 20mg qpm 11. Atorvastatin 10 mg p.o. q.d. 12. Imdur 90mg q.d 13. Laxatives 14. Meclizine 25mg qhs Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebs Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 13. Meclizine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous once a day for 2 days: finish 1982-12-31. 16. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Six (6) units Subcutaneous qAM: adjust as needed for glycemic control (FSBG 80-120). 17. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Five (5) units Subcutaneous qPM: adjust as needed for goal FSBG 80-120. 18. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Walker Group Health System for the Aged - Acute Rehab Discharge Diagnosis: Primary: 1. multilobar PNA (community-acquired) 2. diastolic CHF Secondary: 3. HTN 4. ? AVNRT/aflutter s/p ablation/pacer 5. anemia of chronic disease 6. CKD Discharge Condition: stable, on 2L NC and improving daily. Discharge Instructions: Weigh yourself every morning, Cruz Recinos MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500mL If you experience any fevers > 101.5, chills, chest pain, Followup Instructions: 1. Provider: Kenna Ivory CALL Phone:228-994-4511 Date/Time:1917-8-11 10:15 . 2. Provider: Frank Moore, M.D. Phone:268-202-7209 Date/Time:1960-8-25 9:00 (please consider outpt echocardiogram). . 3. Provider: Ethan Son CLINIC Phone:228-994-4511 Date/Time:2016-10-11 10:30 Completed by:1979-6-16	['Admission Date: 1945-6-16 Discharge Date: 1979-6-16\n\nDate of Birth: 1960-11-3 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Lisa\nChief Complaint:\nRespiratory distress/hypoxia\n\nMajor Surgical or Invasive Procedure:\nelective intubation 1915-6-23\n\nHistory of Present Illness:\n77 YO old male with PMH significant for DM, HTN, high chol, CAD\ns/p stents 2014, CHF, Afib s/p PPM 2014, CKD who presents to ED\nbecause of weakness and collapse at home. Patient was found on\nadmission to be febrile, tachypneic with RUL pneumonia on chest\nfilm. Patient complained of chronic cough with increasing sputum\nproduction. He denies fevers, chills, shortness of breath,\nchest pain. He denies any loss of consciousness or head trauma\nwith falls.', " Denies bowel or bladder incontinence or changes in\nfunction. Denies any weight loss or changes in eating habits.\nNo abd pain/n/v/d. No choking on food reported.\n\nPatient was admitted and started on ceftriaxone and azithromycin\nfor CAP which was then changed to Levoflox and Flagyl as CXR\nshowed ? evidence for aspiration PNA. The patient since\nadmission has remained tachypneic and hypoxic requiring O2\ntoday. He needed a non-rebreather for some time but has since\nbeen titrated down. As the patient additionally has a history of\nCHF, a repeat chest film was performed to evaluate for any\ncomponent of congestion. Although the film did not appear to be\nall that congested, the patient's pneumonia appeared to worsen,\nnow a multilobar pneumonia involving the right upper and\nmiddle/lower lung fields.", ' ABG 7.43/37/54 at time of transfer to\nICU, he received 80 mg of Lasix with minimal urinary output\nafter 20 mg caused 250 cc of urine output earlier in the day.\nAlbuterol nebs with minimal improvement in O2 sat. Pt was\nx-ferred to ICU and started on BiPAP. See additional course\nbelow.\n\n\nPast Medical History:\nPAST MEDICAL HISTORY:\n1. Congestive heart failure; ejection fraction of 55% in\n02/2014.\n2. Diabetes mellitus, insulin dependent, complicated by\nnephropathy and retinopathy.\n3. Hypertension.\n4. History of bradycardia.\n5. Hypercholesterolemia.\n6. Chronic renal insufficiency with baseline creatinine 1.9 to\n2.1.\n7. Anemia thought secondary to chronic disease.\n8. CAD s/p stent of LCx and RCA in 2014\n9. A fib s/p 1909 in 2014\n\n\nSocial History:\nLives with wife and 1 daughter. Kenna Kobayashi 5 daughters.', ' Quit smoking\n25 years ago, but 10 year smoking history. No Etoh or IVDA.\n\nFamily History:\nNC\n\nPhysical Exam:\nPhysical Exam: 101.7 Tm, 65 BP118/93 RR21 O2sat 91% on RA -->\n100% 3L\nNAD, +Diaphoretic.\nMMM, JVD elevated around angle of jaw at 45 deg\nneck FROM, no LAD\nRRR with 3/6 SEM at RUSB\nbronchial breath sounds at RUL, RLL\nobese, paradoxical abdominal movements with abdominal grunting,\numbilical hernia- no erythema, easy to reduce, +BS\nTrace LE edema, no cyanosis.\nMoves all 4 extremeities, 2+ DTRs\n\nPertinent Results:\nEKG: paced at 60bpm, no changes from prior\n.\nCXR: Cardiac, mediastinal, and hilar contours are not\nsignificantly changed. There is a right upper lobe opacity.\nThere are mildly increased pulmonary vascular markings\nindicating mild failure.\n.\nCT head: No evidence of acute intracranial hemorrhage.', ' Findings\nconsistent with old lacunes.\n\n1945-6-16 09:09PM LACTATE-2.1\n1945-6-16 09:05PM GLUCOSE-130 UREA N-30* CREAT-2.8* SODIUM-144\nPOTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-28 ANION GAP-17\n1945-6-16 09:05PM WBC-13.2# RBC-4.12 HGB-12.4* HCT-36.9\nMCV-89 MCH-30.1 MCHC-33.7 RDW-15.3\n1945-6-16 09:05PM NEUTS-86.0 LYMPHS-8.4* MONOS-5.1 EOS-0.3\nBASOS-0.2\n1945-6-16 09:05PM PT-14.5* PTT-27.4 INR(PT)-1.4\n1945-6-16 09:05PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0\nLEUK-NEG\n\n1990-12-29 4:10 am SPUTUM Site: ENDOTRACHEAL\n\n FINAL REPORT 1910-1-3\n\n GRAM STAIN (Final 1990-12-29):\n >25 PMNs and 1910-1-3):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n\n1962-6-23 12:30 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE\nTEST.', '\n\n GRAM STAIN (Final 1962-6-23):\n 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR\nLEUKOCYTES.\n NO MICROORGANISMS SEEN.\n\n RESPIRATORY CULTURE (Final 2021-9-11): ~1000/ML\nOROPHARYNGEAL FLORA.\n\n LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.\n\n IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final\n1990-12-29):\n PNEUMOCYSTIS CARINII NOT SEEN.\n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n\n ACID FAST SMEAR (Final 1990-12-29):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n\n ACID FAST CULTURE (Pending):\n\n VIRAL CULTURE (Final 1990-12-29):\n SPECIMEN NOT PROCESSED DUE TO:.\n DUPLICATE ORDER.\n REFER TO 6385448 FOR RESULTS 1962-6-23.\n PATIENT CREDITED.\n\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final 1990-12-29):\n SPECIMEN NOT PROCESSED DUE TO:.', "\n DUPLICATE ORDER.\n REFER TO 6385448 FOR RESULTS 1962-6-23.\n PATIENT CREDITED.\n\n\nBrief Hospital Course:\nA/P: 77 year old male with hx of HTN, high chol, CAD, afib s/p\npacer here with lobar PNA.\n.\n1. Respiratory Distress: Initially, the patient was started on\nceftriaxone and azithro for CAP but Abx were adjusted to\nlevoflox/flagyl based on patient's continued hypoxia and CXR\n7085 James Loop\nWest Kimberlyberg, OH 13040 concerning for aspiration event. The patient became more\ndistressed with his respiratory state over the first 3 days of\nhis hospitalization. It was felt that the most likely source of\nhis resp distress was thought to be his RUL pneumonia, perhaps\nwith contribution from his diastolic CHF. PE was considered but\nfelt to be very low suspicion given XRAY findings, febrile\nstate.", " Although the film did not appear to be all that\ncongested, the patient's pneumonia appeared to worsen to a\nmultilobar pneumonia involving the right upper and middle/lower\nlung fields. The patient was found to be dangerously hypoxic on\n1976-8-17 with increasing work of breathing. ABG 7.43/37/54 at\nthat time, patient received 80 mg of IV Lasix with minimal\nurinary output. Albuterol nebs resulted in minimal improvement\nin O2 sat. Pt was x-ferred to ICU and started on BiPAP. He was\nintubated 1915-6-23 due to continued respiratory distress (it was\na difficult intubation). His Abx was adjusted again to include\nVancomycin and levofloxacin to cover MRSA and CAP. Despite no\ncx data, it was felt the patient most likely had strep pneum.\npneumonia due to clinical course. The pateint was liberated\nfrom ventilator slowly due to difficult airway issues and he was\nextubated on 3-6.", ' His sputum culture from BAL on 8-9 showed\n1000 oropharyngeal flora; all other cultures were negative.\nSerial CXRs showed clearing of pneumonia. He was transferred to\nthe floor on 4L NC on 1931-9-14. He maintained excellent O2 sats\nand he was weaned to 2L upon discharge. He has been\nintermittently diuresed with Lasix (20mg IV), but his CXRs have\nnot shown congestion and the course of his respiratory status\nhas closely followed that of his pneumonia. He has also received\nalbuterol and atrovent nebs with improvement in his wheeze and\ndyspena. He has completed 12 days of Vancomycin and\nlevofloxacin, and they were continued upon discharge to finish a\n14 day course for ? pneumococcal vs staph aureus pneumonia. The\npatient was given pneumococcal vaccine prior to discharge. No\nblood cx were positive.', '\n.\n2. CAD: His EKG showed a paced rhythm and old LBBB. He was\nwithout chest pain and had no signs of ischemia throughout his\nstay. Cardiac enzymes were cycled to rule out the possibility\nof silent ischemia, and were negative. He was maintained on his\nASA, BB, and statin. An outpatient echocardiogram may be\nconsidered for future management.\n.\n3. HTN: Mr. Olles was maintained on metoprolol, Ivory and\namlodopine and imdur. He will titrate up his HTN management\nwith his PCP. Kenna Ivory BP upon discharge was slightly above goal\n(SBPs 140s).\n.\n4. Afib/AVNRT: Mr. Olles has a Kuykendall for tachy-brady\nsyndrome in the past. He has also had ablation for SVT with\naberrancy in 2014. At that time he was started on amiodarone.\nHe has a ? history of atrial fibrillation/flutter, but is not on\nanticoagulation as the history is unclear.', ' Bo Bounds was in NSR\nthroughout his stay. He has an appointment in EP Device Clinic\nlater this month and is also set up for a Cardiology appointment\nin February.\n.\n5. DMII: Mr. Olles was put on half of his outpatient dose of\nNPH 75/25 and sliding scale insulin during his hospitalization.\nHe maintained good glucose control (FSBG Ivory to adjust as needed.\n.\n6. FEN: He was maintained on a cardiac/diabetic diet and 2L\nfluid restriction. The patient needed prn Lasix dosing for\nvolume overload (he responded well to 20-40mg IV lasix).\n.\n7. CKD: Baseline Creatinine 1.9-2.2. He had some variations in\ncreat throughout stay (likely due to varying volume status and\ndiuresis) but was back to baseline prior to discharge (1.9).\nHis medications were all renally dosed (Vancomycin by levels Conner-Williams Health System clinic by Dr.', " Isaias Grace Cobbs for\nthis issue.\n\n8. Anemia: patient's baseline Hct 27-31 with Fe studies\nconsistent with anemia of chronic disease. His hct remained in\nthe range (27-32) throughout his stay and the patient did not\nreceive any pRBCs. He would likely benefit from erythropoetin\nas an outpt as his epo-deficient state from CKD is the likely\netiology of his anemia.\n\n\nMedications on Admission:\nMEDICATIONS:\n1. Atenolol 50 mg p.o. q.d.\n2. Amiodarone 400mg q.d.\n3. Norvasc 10 mg p.o. q.d.\n4. Doxazosin 2 mg p.o. q.d.\n5. Cozaar 50 mg p.o. b.i.d\n6. Niferex 150 mg p.o. b.i.d.\n7. Plavix 75mg qd\n8. Aspirin 325 mg p.o. q.d.\n9. Humalog 75/25, 12U qam, 10U qpm\n10. Furosemide 40mg qam, 20mg qpm\n11. Atorvastatin 10 mg p.o. q.d.\n12. Imdur 90mg q.d\n13. Laxatives\n14. Meclizine 25mg qhs\n\n\nDischarge Medications:\n1.", ' Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime).\n3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every\n6 hours) as needed.\n5. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebs\nInhalation Q6H (every 6 hours) as needed.\n6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours) as needed.\n7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO\nTID (3 times a day).\n9. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).\n\n10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\n11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).', '\n12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H\n(every 24 hours) for 2 days.\n13. Meclizine 25 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime) as needed for insomnia.\n14. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous\n once a day for 2 days: finish 1982-12-31.\n16. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Six (6)\nunits Subcutaneous qAM: adjust as needed for glycemic control\n(FSBG 80-120).\n17. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Five (5)\nunits Subcutaneous qPM: adjust as needed for goal FSBG 80-120.\n18. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nWalker Group Health System for the Aged - Acute Rehab\n\nDischarge Diagnosis:\nPrimary:\n1.', ' multilobar PNA (community-acquired)\n2. diastolic CHF\nSecondary:\n3. HTN\n4. ? AVNRT/aflutter s/p ablation/pacer\n5. anemia of chronic disease\n6. CKD\n\n\nDischarge Condition:\nstable, on 2L NC and improving daily.\n\n\nDischarge Instructions:\nWeigh yourself every morning, Cruz Recinos MD if weight > 3 lbs.\nAdhere to 2 gm sodium diet\nFluid Restriction: 1500mL\n\nIf you experience any fevers > 101.5, chills, chest pain,\n\nFollowup Instructions:\n1. Provider: Kenna Ivory CALL Phone:228-994-4511\nDate/Time:1917-8-11 10:15\n.\n2. Provider: Frank Moore, M.D. Phone:268-202-7209\nDate/Time:1960-8-25 9:00 (please consider outpt echocardiogram).\n.\n3. Provider: Ethan Son CLINIC Phone:228-994-4511\nDate/Time:2016-10-11 10:30\n\n\n\nCompleted by:1979-6-16']
540	27316	156718.0	2180-02-13	Discharge summary	Report	Admission Date: [2180-2-3] Discharge Date: [2180-2-13] Date of Birth: [2101-3-2] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[First Name3 (LF) 1267] Chief Complaint: Angina Major Surgical or Invasive Procedure: Cabg x4 [2180-2-7] (LIMA to prox. LAD, SVG to distal LAD, SVG to ramus, SVG to OM) History of Present Illness: 78 yo male with history of internmittent angina for the past year, relieved by rest. Failed a recent ETT, and referred for cath which revealed LM 50-60%, 75% LAD, CX 95%, OM 3 70%, RCA 30%, PDA 75%. Referred for CABG. Past Medical History: MI CAD s/p angioplasty [2165] HTN elev. chol. PSH: rem. renal calc. rem. cervical disc [2154] Social History: Retired: lives alone 50 year history of smoking cigars Occasional ETOH Family History: Non-contributory Physical Exam: VS: Wgt: 76.8 kg preop 72.4 HR: 50's SB BP: 104-110/50-60 HEENT unremarkable Neck supple, full ROM, no carotid bruits appreciated Resp: decreased breath sounds bilaterally with crackles 1/4 up on Left Card: RRR, no murmur GI: bowel sounds positive, abdomen soft non-tender/non-distened Extrem: warm, well-perfused, no edema Neuro grossly intact Wound: sternal clean,dry, intact, with staples, no erythema Pulses: 2+ bil. fems/DP/PT/radials Pertinent Results: [2180-2-9] WBC-15.9* RBC-3.31* Hgb-10.5* Hct-29.8 Plt Ct-156 [2180-2-9] Glucose-129* UreaN-12 Creat-0.9 Na-132* K-4.7 Cl-101 HCO3-26 [2180-2-3] 04:46PM BLOOD %HbA1c-5.9 [2180-2-13] WBC-8.2 RBC-2.68* Hgb-8.3* Hct-24.6 Plt Ct-277 [2180-2-13] Glucose-101 UreaN-23* Creat-1.2 Na-141 K-4.4 Cl-105 HCO3-30 [2180-2-13] BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1 CHEST (PA & LAT) [2180-2-13] The patient is status post sternotomy, with mediastinal clips and overlying skin staples. There is prominence of the cardiomediastinal silhouette. There is no CHF. There is some residual increased retrocardiac density and some atelectasis in the left mid zone and right medial base. There is minimal blunting of both costophrenic angles, consistent with small bilateral effusions. Brief Hospital Course: Admitted for cath on [2-3] and started a Plavix washout over the weekend. Underwent successful CABG x4 with Dr. [Last Name (STitle) 4453] on [1-28]. Transferred to the CVICU in stable condition on epinephrine, lidocaine, phenylephrine and propofol drips. Extubated that evening and started on amiodarone the next morning for atrial fibrillation. Transferred to the floor on POD #1 to begin increasing his activity level. He was gently diuresed toward his preoperative weigh. Chest tubes removed on POD #2, and pacing wires removed on POD #3. He converted to a sinus rhythm on POD #4, continued to work with physical therapy. He was started on Coumadin with an INR goal 2.0-3.0. Given 4 mg of coumadin [2180-2-14] for INR 1.1. He was discharged to rehab on POD #6 and will follow-up with Dr. [Last Name (STitle) ] as an outpatient and Dr. [Last Name (STitle) 4454] for coumadin management after discharge from rehab. Medications on Admission: lopressor 25 mg [Hospital1 ] accupril 20 mg daily cardizem CD 120 mg daily vytorin 10/20 mg daily ASA 325 mg daily viagra prn plavix 75 mg daily Vit. E Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1 doses. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 7 days: then 200 mg daily. 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please dose to maintain INR of 2.0-3.0. Discharge Disposition: Extended Care Facility: [Hospital6 ] Hospital @ [Location (un) 4047] Discharge Diagnosis: CAD s/p cabg x4 and angioplasty [2165] MI HTN elev. chol. PSH: removal kidney stone rem. cervical disc [2154] Discharge Condition: good Discharge Instructions: SHOWER daily and pat incisions dry no lotions, creams or powders on any incision no lifting greater than 10 pounds for 10 weeks no driving for one month call for fever greater than 100.5, redness, or drainage coumadin for Afib INR Goal 2.0-3.0 please dose coumadin accordingly Amiodarone 400 mg once daily for 7 days then 200 mg daily Sternal Staple removal in [7-22] days Followup Instructions: Dr. [Last Name (STitle) 4454] in [2-16] weeks call for an appointment after discharge from rehab for coumadin management Call Dr. [Last Name (STitle) 4455] in [3-20] weeks for a follow-up appointment Call Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Completed by:[2180-2-13]	Admission Date: <Date>1977-5-20</Date> Discharge Date: <Date>1945-9-19</Date> Date of Birth: <Date>1972-7-1</Date> Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:<Name>Glenn</Name> Chief Complaint: Angina Major Surgical or Invasive Procedure: Cabg x4 <Date>2004-7-3</Date> (LIMA to prox. LAD, SVG to distal LAD, SVG to ramus, SVG to OM) History of Present Illness: 78 yo male with history of internmittent angina for the past year, relieved by rest. Failed a recent ETT, and referred for cath which revealed LM 50-60%, 75% LAD, CX 95%, OM 3 70%, RCA 30%, PDA 75%. Referred for CABG. Past Medical History: MI CAD s/p angioplasty <Year>1949</Year> HTN elev. chol. PSH: rem. renal calc. rem. cervical disc <Year>1949</Year> Social History: Retired: lives alone 50 year history of smoking cigars Occasional ETOH Family History: Non-contributory Physical Exam: VS: Wgt: 76.8 kg preop 72.4 HR: 50's SB BP: 104-110/50-60 HEENT unremarkable Neck supple, full ROM, no carotid bruits appreciated Resp: decreased breath sounds bilaterally with crackles 1/4 up on Left Card: RRR, no murmur GI: bowel sounds positive, abdomen soft non-tender/non-distened Extrem: warm, well-perfused, no edema Neuro grossly intact Wound: sternal clean,dry, intact, with staples, no erythema Pulses: 2+ bil. fems/DP/PT/radials Pertinent Results: <Date>1938-12-4</Date> WBC-15.9* RBC-3.31* Hgb-10.5* Hct-29.8 Plt Ct-156 <Date>1938-12-4</Date> Glucose-129* UreaN-12 Creat-0.9 Na-132* K-4.7 Cl-101 HCO3-26 <Date>1977-5-20</Date> 04:46PM BLOOD %HbA1c-5.9 <Date>1945-9-19</Date> WBC-8.2 RBC-2.68* Hgb-8.3* Hct-24.6 Plt Ct-277 <Date>1945-9-19</Date> Glucose-101 UreaN-23* Creat-1.2 Na-141 K-4.4 Cl-105 HCO3-30 <Date>1945-9-19</Date> BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1 CHEST (PA & LAT) <Date>1945-9-19</Date> The patient is status post sternotomy, with mediastinal clips and overlying skin staples. There is prominence of the cardiomediastinal silhouette. There is no CHF. There is some residual increased retrocardiac density and some atelectasis in the left mid zone and right medial base. There is minimal blunting of both costophrenic angles, consistent with small bilateral effusions. Brief Hospital Course: Admitted for cath on <Date>10-15</Date> and started a Plavix washout over the weekend. Underwent successful CABG x4 with Dr. <Name>Wilson</Name> on <Date>3-7</Date>. Transferred to the CVICU in stable condition on epinephrine, lidocaine, phenylephrine and propofol drips. Extubated that evening and started on amiodarone the next morning for atrial fibrillation. Transferred to the floor on POD #1 to begin increasing his activity level. He was gently diuresed toward his preoperative weigh. Chest tubes removed on POD #2, and pacing wires removed on POD #3. He converted to a sinus rhythm on POD #4, continued to work with physical therapy. He was started on Coumadin with an INR goal 2.0-3.0. Given 4 mg of coumadin <Date>1916-9-8</Date> for INR 1.1. He was discharged to rehab on POD #6 and will follow-up with Dr. <Name>Ahmed</Name> as an outpatient and Dr. <Name>Walker</Name> for coumadin management after discharge from rehab. Medications on Admission: lopressor 25 mg <Hospital>Burke Inc Medical Center</Hospital> accupril 20 mg daily cardizem CD 120 mg daily vytorin 10/20 mg daily ASA 325 mg daily viagra prn plavix 75 mg daily Vit. E Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1 doses. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 7 days: then 200 mg daily. 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please dose to maintain INR of 2.0-3.0. Discharge Disposition: Extended Care Facility: <Hospital>Bennett and Sons Hospital</Hospital> Hospital @ <Location>27992 Martinez Alley Thompsonfort, SC 16227</Location> Discharge Diagnosis: CAD s/p cabg x4 and angioplasty <Year>1949</Year> MI HTN elev. chol. PSH: removal kidney stone rem. cervical disc <Year>1949</Year> Discharge Condition: good Discharge Instructions: SHOWER daily and pat incisions dry no lotions, creams or powders on any incision no lifting greater than 10 pounds for 10 weeks no driving for one month call for fever greater than 100.5, redness, or drainage coumadin for Afib INR Goal 2.0-3.0 please dose coumadin accordingly Amiodarone 400 mg once daily for 7 days then 200 mg daily Sternal Staple removal in <Date>1-17</Date> days Followup Instructions: Dr. <Name>Walker</Name> in <Date>2-26</Date> weeks call for an appointment after discharge from rehab for coumadin management Call Dr. <Name>Wilson</Name> in <Date>3-29</Date> weeks for a follow-up appointment Call Dr. <Name>Ahmed</Name> in 4 weeks <Telephone>234-314-8422</Telephone> Completed by:<Date>1945-9-19</Date>	00000000000000000111111111000000000000000000000000000000001111111110000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000001111111110000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100001110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111100000000000011111111111111111111111111111111111111111110000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000111111000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000011110000000000000000000000000000000000000000000011111000000000000011111111111100000000000000000111111111	Admission Date: 1977-5-20 Discharge Date: 1945-9-19 Date of Birth: 1972-7-1 Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:Glenn Chief Complaint: Angina Major Surgical or Invasive Procedure: Cabg x4 2004-7-3 (LIMA to prox. LAD, SVG to distal LAD, SVG to ramus, SVG to OM) History of Present Illness: 78 yo male with history of internmittent angina for the past year, relieved by rest. Failed a recent ETT, and referred for cath which revealed LM 50-60%, 75% LAD, CX 95%, OM 3 70%, RCA 30%, PDA 75%. Referred for CABG. Past Medical History: MI CAD s/p angioplasty 1949 HTN elev. chol. PSH: rem. renal calc. rem. cervical disc 1949 Social History: Retired: lives alone 50 year history of smoking cigars Occasional ETOH Family History: Non-contributory Physical Exam: VS: Wgt: 76.8 kg preop 72.4 HR: 50's SB BP: 104-110/50-60 HEENT unremarkable Neck supple, full ROM, no carotid bruits appreciated Resp: decreased breath sounds bilaterally with crackles 1/4 up on Left Card: RRR, no murmur GI: bowel sounds positive, abdomen soft non-tender/non-distened Extrem: warm, well-perfused, no edema Neuro grossly intact Wound: sternal clean,dry, intact, with staples, no erythema Pulses: 2+ bil. fems/DP/PT/radials Pertinent Results: 1938-12-4 WBC-15.9* RBC-3.31* Hgb-10.5* Hct-29.8 Plt Ct-156 1938-12-4 Glucose-129* UreaN-12 Creat-0.9 Na-132* K-4.7 Cl-101 HCO3-26 1977-5-20 04:46PM BLOOD %HbA1c-5.9 1945-9-19 WBC-8.2 RBC-2.68* Hgb-8.3* Hct-24.6 Plt Ct-277 1945-9-19 Glucose-101 UreaN-23* Creat-1.2 Na-141 K-4.4 Cl-105 HCO3-30 1945-9-19 BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1 CHEST (PA & LAT) 1945-9-19 The patient is status post sternotomy, with mediastinal clips and overlying skin staples. There is prominence of the cardiomediastinal silhouette. There is no CHF. There is some residual increased retrocardiac density and some atelectasis in the left mid zone and right medial base. There is minimal blunting of both costophrenic angles, consistent with small bilateral effusions. Brief Hospital Course: Admitted for cath on 10-15 and started a Plavix washout over the weekend. Underwent successful CABG x4 with Dr. Wilson on 3-7. Transferred to the CVICU in stable condition on epinephrine, lidocaine, phenylephrine and propofol drips. Extubated that evening and started on amiodarone the next morning for atrial fibrillation. Transferred to the floor on POD #1 to begin increasing his activity level. He was gently diuresed toward his preoperative weigh. Chest tubes removed on POD #2, and pacing wires removed on POD #3. He converted to a sinus rhythm on POD #4, continued to work with physical therapy. He was started on Coumadin with an INR goal 2.0-3.0. Given 4 mg of coumadin 1916-9-8 for INR 1.1. He was discharged to rehab on POD #6 and will follow-up with Dr. Ahmed as an outpatient and Dr. Walker for coumadin management after discharge from rehab. Medications on Admission: lopressor 25 mg Burke Inc Medical Center accupril 20 mg daily cardizem CD 120 mg daily vytorin 10/20 mg daily ASA 325 mg daily viagra prn plavix 75 mg daily Vit. E Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1 doses. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 7 days: then 200 mg daily. 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please dose to maintain INR of 2.0-3.0. Discharge Disposition: Extended Care Facility: Bennett and Sons Hospital Hospital @ 27992 Martinez Alley Thompsonfort, SC 16227 Discharge Diagnosis: CAD s/p cabg x4 and angioplasty 1949 MI HTN elev. chol. PSH: removal kidney stone rem. cervical disc 1949 Discharge Condition: good Discharge Instructions: SHOWER daily and pat incisions dry no lotions, creams or powders on any incision no lifting greater than 10 pounds for 10 weeks no driving for one month call for fever greater than 100.5, redness, or drainage coumadin for Afib INR Goal 2.0-3.0 please dose coumadin accordingly Amiodarone 400 mg once daily for 7 days then 200 mg daily Sternal Staple removal in 1-17 days Followup Instructions: Dr. Walker in 2-26 weeks call for an appointment after discharge from rehab for coumadin management Call Dr. Wilson in 3-29 weeks for a follow-up appointment Call Dr. Ahmed in 4 weeks 234-314-8422 Completed by:1945-9-19	['Admission Date: 1977-5-20 Discharge Date: 1945-9-19\n\nDate of Birth: 1972-7-1 Sex: M\n\nService: CARDIOTHORACIC\n\nAllergies:\nLipitor\n\nAttending:Glenn\nChief Complaint:\nAngina\n\nMajor Surgical or Invasive Procedure:\nCabg x4 2004-7-3 (LIMA to prox. LAD, SVG to distal LAD, SVG to\nramus, SVG to OM)\n\n\nHistory of Present Illness:\n78 yo male with history of internmittent angina for the past\nyear, relieved by rest. Failed a recent ETT, and referred for\ncath which revealed LM 50-60%, 75% LAD, CX 95%, OM 3 70%, RCA\n30%, PDA 75%. Referred for CABG.\n\nPast Medical History:\nMI\nCAD s/p angioplasty 1949\nHTN\nelev. chol.\n\nPSH: rem. renal calc.\nrem. cervical disc 1949\n\nSocial History:\nRetired: lives alone\n50 year history of smoking cigars\nOccasional ETOH\n\nFamily History:\nNon-contributory\n\nPhysical Exam:\nVS: Wgt: 76.', "8 kg preop 72.4 HR: 50's SB BP: 104-110/50-60\nHEENT unremarkable\nNeck supple, full ROM, no carotid bruits appreciated\nResp: decreased breath sounds bilaterally with crackles 1/4 up\non Left\nCard: RRR, no murmur\nGI: bowel sounds positive, abdomen soft non-tender/non-distened\nExtrem: warm, well-perfused, no edema\nNeuro grossly intact\nWound: sternal clean,dry, intact, with staples, no erythema\nPulses: 2+ bil. fems/DP/PT/radials\n\nPertinent Results:\n1938-12-4 WBC-15.9* RBC-3.31* Hgb-10.5* Hct-29.8 Plt Ct-156\n1938-12-4 Glucose-129* UreaN-12 Creat-0.9 Na-132* K-4.7 Cl-101\nHCO3-26\n1977-5-20 04:46PM BLOOD %HbA1c-5.9\n1945-9-19 WBC-8.2 RBC-2.68* Hgb-8.3* Hct-24.6 Plt Ct-277\n1945-9-19 Glucose-101 UreaN-23* Creat-1.2 Na-141 K-4.4 Cl-105\nHCO3-30\n1945-9-19 BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1\n\nCHEST (PA & LAT) 1945-9-19\n\nThe patient is status post sternotomy, with mediastinal clips\nand overlying skin staples.", ' There is prominence of the\ncardiomediastinal silhouette. There is no CHF. There is some\nresidual increased retrocardiac density and some atelectasis in\nthe left mid zone and right medial base. There is minimal\nblunting of both costophrenic angles, consistent with small\nbilateral effusions.\n\n\nBrief Hospital Course:\nAdmitted for cath on 10-15 and started a Plavix washout over the\nweekend. Underwent successful CABG x4 with Dr. Wilson on 3-7.\nTransferred to the CVICU in stable condition on epinephrine,\nlidocaine, phenylephrine and propofol drips. Extubated that\nevening and started on amiodarone the next morning for atrial\nfibrillation. Transferred to the floor on POD #1 to begin\nincreasing his activity level. He was gently diuresed toward his\npreoperative weigh. Chest tubes removed on POD #2, and pacing\nwires removed on POD #3.', ' He converted to a sinus rhythm on POD\n#4, continued to work with physical therapy. He was started on\nCoumadin with an INR goal 2.0-3.0. Given 4 mg of coumadin\n1916-9-8 for INR 1.1. He was discharged to rehab on POD #6 and\nwill follow-up with Dr. Ahmed as an outpatient and Dr.\nWalker for coumadin management after discharge from rehab.\n\nMedications on Admission:\nlopressor 25 mg Burke Inc Medical Center\naccupril 20 mg daily\ncardizem CD 120 mg daily\nvytorin 10/20 mg daily\nASA 325 mg daily\nviagra prn\nplavix 75 mg daily\nVit. E\n\nDischarge Medications:\n1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day) for 1 months.\nDisp:60 Capsule(s) Refills:0\n2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day) for 1 months.\nDisp:60 Tablet(s) Refills:0\n3.', ' Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:2\n4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4\nhours) as needed.\nDisp:40 Tablet(s) Refills:0\n5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every\n4 hours) as needed.\n6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\nML PO HS (at bedtime) as needed for constipation.\n7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4\nhours) as needed.\n8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:\nOne (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1\ndoses.\n10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily) for 7 days: then 200 mg daily.', '\n11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).\n12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal\nSig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).\n13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):\nPlease dose to maintain INR of 2.0-3.0.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nBennett and Sons Hospital Hospital @ 27992 Martinez Alley\nThompsonfort, SC 16227\n\nDischarge Diagnosis:\nCAD s/p cabg x4 and angioplasty 1949\nMI\nHTN\nelev. chol.\n\nPSH: removal kidney stone\nrem. cervical disc 1949\n\n\nDischarge Condition:\ngood\n\n\nDischarge Instructions:\nSHOWER daily and pat incisions dry\nno lotions, creams or powders on any incision\nno lifting greater than 10 pounds for 10 weeks\nno driving for one month\ncall for fever greater than 100.', '5, redness, or drainage\ncoumadin for Afib INR Goal 2.0-3.0 please dose coumadin\naccordingly\nAmiodarone 400 mg once daily for 7 days then 200 mg daily\nSternal Staple removal in 1-17 days\n\n\nFollowup Instructions:\nDr. Walker in 2-26 weeks call for an appointment after\ndischarge from rehab for coumadin management\nCall Dr. Wilson in 3-29 weeks for a follow-up appointment\nCall Dr. Ahmed in 4 weeks 234-314-8422\n\n\n\nCompleted by:1945-9-19']
541	9761	180241.0	2138-11-19	Discharge summary	Report	Admission Date: [2138-11-15] Discharge Date: [2138-11-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4052] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [Age over 90 ] year old male with a recent diagnosis of prostate cancer (he is follwed by Dr. [First Name4 (NamePattern1) 1313] [Last Name (NamePattern1) ] from urology) who presents with 9-10 days of coughing and generalized weakness. Patient notes light headedness -room spining and orthostatic symptoms over past several days secondary to decreased po intake. He denies abdominal pain, nausea, vomiting or diarrhea. Pt had some mechanical falls recently secondary to instability probably secondary to dehydration. Three weeks ago the patient fell on his right ribs. No obvious head trauma. No fevers, chills or rigors at home at home. Patient has lost 15 pounds in the last six months. No BRBPR, no melena. * In ED the patient received ceftriaxone and azitrhomycin along with 1 L D5NS x 1 L. * While in MICU patient was aggressively hydrated and started on pressors while being maintained on abx. Patient spontaneously converted to sinus rhythym. He states that his shortness of breath has improved. Denies cp, abd pain, dyuria. Is having nl bowel movements. Past Medical History: Prostate cancer - per pt and daughter, no [Name2 (NI) ] diagnosed by serum but pt cannot recall numbers ?h/o c/w BPH S/p appendectomy TIAs-[2135] seen in ED for LH and dizziness. clean MRI and MRA Duodenal ulcer in [2078] Admitted in [2136] with UGI bleed during which On [2127-5-8] the which EGD demonstrated 1. an oozing duodenal ulcer in the distal bulb in the posterolateral wall with a visible vessel which was not spurting but which was cauterized 2. small hiatal hernia with question of a peptic stricture versus Schatzki's ring at the gastroesophageal junction. 3. gastritis per D/C summary 4. EGD in [2135] demonstrates Esophageal ring (dilation) Otherwise normal EGD to third part of the duodenum with nml duodenum and stomach. Blind in right eye secondary to trauma. L retinal tear. Social History: Born in South [Country 480], lived in [Location (un) 4456] until [2123] years ago when he moved to [Location (un) 86], lives alone in an apartment in retirement community, no tobacco, drugs, occasional beer each day Daughter [Name (NI) 4457] cp [Telephone/Fax (1) 4458] very involved in his care. Handles ADLs independently. Walks 4 miles several times a week. Recenlty completed 13 mile walk this [Month (only) ]. Retired electrical engineer. Family History: Sister died of stroke Another sister died of pancreatic or stomach cancer Mother died of pneumonia Physical Exam: Vitals on presentation to ED: T = 96.0, HR = 95, BP = 157/110, RR = 18, 95% sat on room air. General elderly male laying in bed NAD. Talkative, accompanied by daughter. [Name (NI) 4459]: [Name2 (NI) 4460] fixed R pupil, L pupil surgical and non reactive. Dry MMM. Dentures in place CV: Nml S1, S2, ? irregularly irregular - no m/r/g Lungs; Decreased BS at L base with crackles at right Abdomen: nabs, soft, nd, nt Extremities: 2+ DPP, no edema, Neuro: CN II-XII symmetrical Vitals on transfer to floor Temp: 95 Tmax: 100.2 Pulse: 84 (74-125) BP: 114/54 (88-114)/ (50-54) 97% on 4 liters latest blood gas 4/43/33/70 latest CVP was 13 I/O: 1260/1315 General: elderly male sitting in chair. Talkative, accompanied by daughter. [Name (NI) 4459]: right eye swelling, small fixed R pupil, L eye- PERRLA, EOMI. MMM. no jvd CV: rrr, Nml S1, S2, no m/r/g Lungs: Decreased BS at L base, +egophony, cta- in all other fields Abdomen: nabs, soft, nd, nt Extremities: 2+ DPP, no edema, Neuro: CN II-XII intact (excluding R eye cn II, III, VI, IV), moves all four extremities. no focal deficits Pertinent Results: [2138-11-15] 11:30AM GLUCOSE-143* UREA N-24* CREAT-1.5* SODIUM-136 POTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-24 ANION GAP-19 [2138-11-15] 11:30AM WBC-5.2 RBC-3.43* HGB-11.4* HCT-34.4* MCV-100* MCH-33.3* MCHC-33.2 RDW-14.2 [2138-11-15] 11:30AM NEUTS-59 BANDS-15* LYMPHS-16* MONOS-3 EOS-0 BASOS-0 ATYPS-7* METAS-0 MYELOS-0 [2138-11-15] 11:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2138-11-15] 11:30AM PLT COUNT-203 Creatinine = 0.8 2 years ago. Chest PA/L-Dictation [Age over 90 ] y.o. male with cough and fatigue No CHF, no pleural effusion. LLL/lingula opacity, old healed rib fracture ?chronic process since it is under old rib fractures. [2138-11-16] 04:30AM BLOOD WBC-3.2* RBC-2.77* Hgb-9.4* Hct-27.5* MCV-99* MCH-33.8* MCHC-34.0 RDW-14.1 Plt Ct-171 [2138-11-16] 04:30AM BLOOD Neuts-54.7 Lymphs-27.4 Monos-17.6* Eos-0.1 Baso-0.1 [2138-11-16] 04:30AM BLOOD Macrocy-1+ [2138-11-16] 04:30AM BLOOD Plt Ct-171 [2138-11-16] 04:30AM BLOOD Glucose-127* UreaN-18 Creat-0.9 Na-138 K-4.0 Cl-110* HCO3-21* AnGap-11 [2138-11-16] 04:30AM BLOOD CK(CPK)-194* [2138-11-15] 11:30AM BLOOD Lipase-80* [2138-11-16] 04:30AM BLOOD CK-MB-3 cTropnT-0.03* [2138-11-16] 04:30AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.7 [2138-11-15] 11:30AM BLOOD calTIBC-246* VitB12-1129* Folate->20.0 Ferritn-352 TRF-189* [2138-11-15] 11:30AM BLOOD TSH-4.5* [2138-11-15] 11:55PM BLOOD Cortsol-34.0* [2138-11-16] 06:01AM BLOOD Lactate-0.9 [2138-11-16] 06:01AM BLOOD freeCa-1.16 [2138-11-15] 5:20 pm SPUTUM Site: EXPECTORATED GRAM STAIN (Final [2138-11-15]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH OROPHARYNGEAL FLORA. ACID FAST CULTURE (Pending): ACID FAST SMEAR (Pending): [11-15] blood cultures pending Brief Hospital Course: [Age over 90 ] year old healthy male admitted with pneumonia, intermittent Afib with RVR since admission, originally in ICU for treatment under MUST protocol, transfered to the floor after stablization. * 1) Pneumonia: vitals are stable, cxr showed LLL infiltrate, started azithromycin and ceftriaxone on [11-16], will be d/cd with azithromycin and levofloxin for completion of 5 day course. Pt initially presented with bandemia which subsequently resolved with abx. Blood cx are neg uptodate. Sputum cx from [11-17] showed 2+ yeast, 2+ gram pos rod and 2+ gram neg rods. * 2) CV: transient episode of afib in the setting of infection, spontaneous conversion to sinus rhythym, started on metoprolol, continue to be tachy likely secondary to nebs and infection, titrated up metoprolol to 25mg tid and pt d/cd with atenolol 25mg [Hospital1 ] due to pt needs to pay out of pocket [Doctor First Name ] and wants the least expensive meds possible. Need to continue monitor BP (baseline BP runs around 100/70), adjust atenolol dose accordingly. * 3) Acute Renal Failure: likely pre-renal, resolved with rehydration, d/c cr at 0.9-1.0 * 4)Anemia: RDW is nl, ferritin normal, MCV is not decreased, Fe/TIBc ratio is 16%, picture not totally consistent with iron deficieny anemia or chronic disease (?mixed picture), not retic properly, retic count 1.2, ?bactrim suppressing marrow? d/cd bactrim. Hct remained stable since d/cd bactrim. * 7) ?BPH: given BP in the low range, continue terazosin, good urine output. Medications on Admission: Baby aspirin 81 mg 2-3 times per week. Multivitamin, iron, Vitamin C 2,000 mg. Terasozin 5 mg po qd Discharge Medications: 1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 2 days. Disp:2 Capsule(s) Refills:0 2. Terazosin HCl 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:2 Tablet(s) Refills:0 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. Disp:100 puff Refills:0 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 9. Pantoprazole Sodium 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 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 2670] - [Location (un) ] Discharge Diagnosis: Community Acquired PNA afib BPH Discharge Condition: Stable but still require NC oxygen Discharge Instructions: Please call your doctor or come to ED if you develop SOB, chest pain, increased coughing, fevers, fainting or any concerning symptoms Followup Instructions: Please call follow up with Dr. [Last Name (STitle) 1266] within 2 weeks- [Telephone/Fax (1) 608] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 4055] Completed by:[2138-11-19]	Admission Date: <Date>1943-2-28</Date> Discharge Date: <Date>1941-11-10</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Zachary</Name> Chief Complaint: Fatigue Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a <Age>57</Age> year old male with a recent diagnosis of prostate cancer (he is follwed by Dr. <Name>Tammy</Name> <Name>Poff</Name> from urology) who presents with 9-10 days of coughing and generalized weakness. Patient notes light headedness -room spining and orthostatic symptoms over past several days secondary to decreased po intake. He denies abdominal pain, nausea, vomiting or diarrhea. Pt had some mechanical falls recently secondary to instability probably secondary to dehydration. Three weeks ago the patient fell on his right ribs. No obvious head trauma. No fevers, chills or rigors at home at home. Patient has lost 15 pounds in the last six months. No BRBPR, no melena. * In ED the patient received ceftriaxone and azitrhomycin along with 1 L D5NS x 1 L. * While in MICU patient was aggressively hydrated and started on pressors while being maintained on abx. Patient spontaneously converted to sinus rhythym. He states that his shortness of breath has improved. Denies cp, abd pain, dyuria. Is having nl bowel movements. Past Medical History: Prostate cancer - per pt and daughter, no <Name>Millicent Negrete</Name> diagnosed by serum but pt cannot recall numbers ?h/o c/w BPH S/p appendectomy TIAs-<Year>1946</Year> seen in ED for LH and dizziness. clean MRI and MRA Duodenal ulcer in <Year>1946</Year> Admitted in <Year>1946</Year> with UGI bleed during which On <Date>1932-2-21</Date> the which EGD demonstrated 1. an oozing duodenal ulcer in the distal bulb in the posterolateral wall with a visible vessel which was not spurting but which was cauterized 2. small hiatal hernia with question of a peptic stricture versus Schatzki's ring at the gastroesophageal junction. 3. gastritis per D/C summary 4. EGD in <Year>1946</Year> demonstrates Esophageal ring (dilation) Otherwise normal EGD to third part of the duodenum with nml duodenum and stomach. Blind in right eye secondary to trauma. L retinal tear. Social History: Born in South <Country>British Virgin Islands</Country>, lived in <Location>14526 Shaun Heights Apt. 981 Trevinohaven, PR 26932</Location> until <Year>1946</Year> years ago when he moved to <Location>023 Anderson Village Suite 929 South Christian, MA 95934</Location>, lives alone in an apartment in retirement community, no tobacco, drugs, occasional beer each day Daughter <Name>Rama Chowdhury</Name> cp <Telephone>111-680-2732</Telephone> very involved in his care. Handles ADLs independently. Walks 4 miles several times a week. Recenlty completed 13 mile walk this <Month>April</Month>. Retired electrical engineer. Family History: Sister died of stroke Another sister died of pancreatic or stomach cancer Mother died of pneumonia Physical Exam: Vitals on presentation to ED: T = 96.0, HR = 95, BP = 157/110, RR = 18, 95% sat on room air. General elderly male laying in bed NAD. Talkative, accompanied by daughter. <Name>Ebony Lewis</Name>: <Name>Kayla Dortch</Name> fixed R pupil, L pupil surgical and non reactive. Dry MMM. Dentures in place CV: Nml S1, S2, ? irregularly irregular - no m/r/g Lungs; Decreased BS at L base with crackles at right Abdomen: nabs, soft, nd, nt Extremities: 2+ DPP, no edema, Neuro: CN II-XII symmetrical Vitals on transfer to floor Temp: 95 Tmax: 100.2 Pulse: 84 (74-125) BP: 114/54 (88-114)/ (50-54) 97% on 4 liters latest blood gas 4/43/33/70 latest CVP was 13 I/O: 1260/1315 General: elderly male sitting in chair. Talkative, accompanied by daughter. <Name>Ebony Lewis</Name>: right eye swelling, small fixed R pupil, L eye- PERRLA, EOMI. MMM. no jvd CV: rrr, Nml S1, S2, no m/r/g Lungs: Decreased BS at L base, +egophony, cta- in all other fields Abdomen: nabs, soft, nd, nt Extremities: 2+ DPP, no edema, Neuro: CN II-XII intact (excluding R eye cn II, III, VI, IV), moves all four extremities. no focal deficits Pertinent Results: <Date>1943-2-28</Date> 11:30AM GLUCOSE-143* UREA N-24* CREAT-1.5* SODIUM-136 POTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-24 ANION GAP-19 <Date>1943-2-28</Date> 11:30AM WBC-5.2 RBC-3.43* HGB-11.4* HCT-34.4* MCV-100* MCH-33.3* MCHC-33.2 RDW-14.2 <Date>1943-2-28</Date> 11:30AM NEUTS-59 BANDS-15* LYMPHS-16* MONOS-3 EOS-0 BASOS-0 ATYPS-7* METAS-0 MYELOS-0 <Date>1943-2-28</Date> 11:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL <Date>1943-2-28</Date> 11:30AM PLT COUNT-203 Creatinine = 0.8 2 years ago. Chest PA/L-Dictation <Age>57</Age> y.o. male with cough and fatigue No CHF, no pleural effusion. LLL/lingula opacity, old healed rib fracture ?chronic process since it is under old rib fractures. <Date>1922-5-29</Date> 04:30AM BLOOD WBC-3.2* RBC-2.77* Hgb-9.4* Hct-27.5* MCV-99* MCH-33.8* MCHC-34.0 RDW-14.1 Plt Ct-171 <Date>1922-5-29</Date> 04:30AM BLOOD Neuts-54.7 Lymphs-27.4 Monos-17.6* Eos-0.1 Baso-0.1 <Date>1922-5-29</Date> 04:30AM BLOOD Macrocy-1+ <Date>1922-5-29</Date> 04:30AM BLOOD Plt Ct-171 <Date>1922-5-29</Date> 04:30AM BLOOD Glucose-127* UreaN-18 Creat-0.9 Na-138 K-4.0 Cl-110* HCO3-21* AnGap-11 <Date>1922-5-29</Date> 04:30AM BLOOD CK(CPK)-194* <Date>1943-2-28</Date> 11:30AM BLOOD Lipase-80* <Date>1922-5-29</Date> 04:30AM BLOOD CK-MB-3 cTropnT-0.03* <Date>1922-5-29</Date> 04:30AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.7 <Date>1943-2-28</Date> 11:30AM BLOOD calTIBC-246* VitB12-1129* Folate->20.0 Ferritn-352 TRF-189* <Date>1943-2-28</Date> 11:30AM BLOOD TSH-4.5* <Date>1943-2-28</Date> 11:55PM BLOOD Cortsol-34.0* <Date>1922-5-29</Date> 06:01AM BLOOD Lactate-0.9 <Date>1922-5-29</Date> 06:01AM BLOOD freeCa-1.16 <Date>1943-2-28</Date> 5:20 pm SPUTUM Site: EXPECTORATED GRAM STAIN (Final <Date>1943-2-28</Date>): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH OROPHARYNGEAL FLORA. ACID FAST CULTURE (Pending): ACID FAST SMEAR (Pending): <Date>1-19</Date> blood cultures pending Brief Hospital Course: <Age>57</Age> year old healthy male admitted with pneumonia, intermittent Afib with RVR since admission, originally in ICU for treatment under MUST protocol, transfered to the floor after stablization. * 1) Pneumonia: vitals are stable, cxr showed LLL infiltrate, started azithromycin and ceftriaxone on <Date>5-28</Date>, will be d/cd with azithromycin and levofloxin for completion of 5 day course. Pt initially presented with bandemia which subsequently resolved with abx. Blood cx are neg uptodate. Sputum cx from <Date>9-20</Date> showed 2+ yeast, 2+ gram pos rod and 2+ gram neg rods. * 2) CV: transient episode of afib in the setting of infection, spontaneous conversion to sinus rhythym, started on metoprolol, continue to be tachy likely secondary to nebs and infection, titrated up metoprolol to 25mg tid and pt d/cd with atenolol 25mg <Name>Wade</Name> and wants the least expensive meds possible. Need to continue monitor BP (baseline BP runs around 100/70), adjust atenolol dose accordingly. * 3) Acute Renal Failure: likely pre-renal, resolved with rehydration, d/c cr at 0.9-1.0 * 4)Anemia: RDW is nl, ferritin normal, MCV is not decreased, Fe/TIBc ratio is 16%, picture not totally consistent with iron deficieny anemia or chronic disease (?mixed picture), not retic properly, retic count 1.2, ?bactrim suppressing marrow? d/cd bactrim. Hct remained stable since d/cd bactrim. * 7) ?BPH: given BP in the low range, continue terazosin, good urine output. Medications on Admission: Baby aspirin 81 mg 2-3 times per week. Multivitamin, iron, Vitamin C 2,000 mg. Terasozin 5 mg po qd Discharge Medications: 1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 2 days. Disp:2 Capsule(s) Refills:0 2. Terazosin HCl 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:2 Tablet(s) Refills:0 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. Disp:100 puff Refills:0 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 9. Pantoprazole Sodium 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 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Extended Care Facility: <Hospital>Townsend-Christensen Clinic</Hospital> - <Location>699 Karen Tunnel Miguelhaven, PA 93183</Location> Discharge Diagnosis: Community Acquired PNA afib BPH Discharge Condition: Stable but still require NC oxygen Discharge Instructions: Please call your doctor or come to ED if you develop SOB, chest pain, increased coughing, fevers, fainting or any concerning symptoms Followup Instructions: Please call follow up with Dr. <Name>Post</Name> within 2 weeks- <Telephone>184-427-5827</Telephone> <Name>Pamela</Name> <Name>Poff</Name> MD <MD Number>53902345</MD Number> Completed 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Date: 1943-2-28 Discharge Date: 1941-11-10 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Zachary Chief Complaint: Fatigue Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 57 year old male with a recent diagnosis of prostate cancer (he is follwed by Dr. Tammy Poff from urology) who presents with 9-10 days of coughing and generalized weakness. Patient notes light headedness -room spining and orthostatic symptoms over past several days secondary to decreased po intake. He denies abdominal pain, nausea, vomiting or diarrhea. Pt had some mechanical falls recently secondary to instability probably secondary to dehydration. Three weeks ago the patient fell on his right ribs. No obvious head trauma. No fevers, chills or rigors at home at home. Patient has lost 15 pounds in the last six months. No BRBPR, no melena. * In ED the patient received ceftriaxone and azitrhomycin along with 1 L D5NS x 1 L. * While in MICU patient was aggressively hydrated and started on pressors while being maintained on abx. Patient spontaneously converted to sinus rhythym. He states that his shortness of breath has improved. Denies cp, abd pain, dyuria. Is having nl bowel movements. Past Medical History: Prostate cancer - per pt and daughter, no Millicent Negrete diagnosed by serum but pt cannot recall numbers ?h/o c/w BPH S/p appendectomy TIAs-1946 seen in ED for LH and dizziness. clean MRI and MRA Duodenal ulcer in 1946 Admitted in 1946 with UGI bleed during which On 1932-2-21 the which EGD demonstrated 1. an oozing duodenal ulcer in the distal bulb in the posterolateral wall with a visible vessel which was not spurting but which was cauterized 2. small hiatal hernia with question of a peptic stricture versus Schatzki's ring at the gastroesophageal junction. 3. gastritis per D/C summary 4. EGD in 1946 demonstrates Esophageal ring (dilation) Otherwise normal EGD to third part of the duodenum with nml duodenum and stomach. Blind in right eye secondary to trauma. L retinal tear. Social History: Born in South British Virgin Islands, lived in 14526 Shaun Heights Apt. 981 Trevinohaven, PR 26932 until 1946 years ago when he moved to 023 Anderson Village Suite 929 South Christian, MA 95934, lives alone in an apartment in retirement community, no tobacco, drugs, occasional beer each day Daughter Rama Chowdhury cp 111-680-2732 very involved in his care. Handles ADLs independently. Walks 4 miles several times a week. Recenlty completed 13 mile walk this April. Retired electrical engineer. Family History: Sister died of stroke Another sister died of pancreatic or stomach cancer Mother died of pneumonia Physical Exam: Vitals on presentation to ED: T = 96.0, HR = 95, BP = 157/110, RR = 18, 95% sat on room air. General elderly male laying in bed NAD. Talkative, accompanied by daughter. Ebony Lewis: Kayla Dortch fixed R pupil, L pupil surgical and non reactive. Dry MMM. Dentures in place CV: Nml S1, S2, ? irregularly irregular - no m/r/g Lungs; Decreased BS at L base with crackles at right Abdomen: nabs, soft, nd, nt Extremities: 2+ DPP, no edema, Neuro: CN II-XII symmetrical Vitals on transfer to floor Temp: 95 Tmax: 100.2 Pulse: 84 (74-125) BP: 114/54 (88-114)/ (50-54) 97% on 4 liters latest blood gas 4/43/33/70 latest CVP was 13 I/O: 1260/1315 General: elderly male sitting in chair. Talkative, accompanied by daughter. Ebony Lewis: right eye swelling, small fixed R pupil, L eye- PERRLA, EOMI. MMM. no jvd CV: rrr, Nml S1, S2, no m/r/g Lungs: Decreased BS at L base, +egophony, cta- in all other fields Abdomen: nabs, soft, nd, nt Extremities: 2+ DPP, no edema, Neuro: CN II-XII intact (excluding R eye cn II, III, VI, IV), moves all four extremities. no focal deficits Pertinent Results: 1943-2-28 11:30AM GLUCOSE-143* UREA N-24* CREAT-1.5* SODIUM-136 POTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-24 ANION GAP-19 1943-2-28 11:30AM WBC-5.2 RBC-3.43* HGB-11.4* HCT-34.4* MCV-100* MCH-33.3* MCHC-33.2 RDW-14.2 1943-2-28 11:30AM NEUTS-59 BANDS-15* LYMPHS-16* MONOS-3 EOS-0 BASOS-0 ATYPS-7* METAS-0 MYELOS-0 1943-2-28 11:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL 1943-2-28 11:30AM PLT COUNT-203 Creatinine = 0.8 2 years ago. Chest PA/L-Dictation 57 y.o. male with cough and fatigue No CHF, no pleural effusion. LLL/lingula opacity, old healed rib fracture ?chronic process since it is under old rib fractures. 1922-5-29 04:30AM BLOOD WBC-3.2* RBC-2.77* Hgb-9.4* Hct-27.5* MCV-99* MCH-33.8* MCHC-34.0 RDW-14.1 Plt Ct-171 1922-5-29 04:30AM BLOOD Neuts-54.7 Lymphs-27.4 Monos-17.6* Eos-0.1 Baso-0.1 1922-5-29 04:30AM BLOOD Macrocy-1+ 1922-5-29 04:30AM BLOOD Plt Ct-171 1922-5-29 04:30AM BLOOD Glucose-127* UreaN-18 Creat-0.9 Na-138 K-4.0 Cl-110* HCO3-21* AnGap-11 1922-5-29 04:30AM BLOOD CK(CPK)-194* 1943-2-28 11:30AM BLOOD Lipase-80* 1922-5-29 04:30AM BLOOD CK-MB-3 cTropnT-0.03* 1922-5-29 04:30AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.7 1943-2-28 11:30AM BLOOD calTIBC-246* VitB12-1129* Folate->20.0 Ferritn-352 TRF-189* 1943-2-28 11:30AM BLOOD TSH-4.5* 1943-2-28 11:55PM BLOOD Cortsol-34.0* 1922-5-29 06:01AM BLOOD Lactate-0.9 1922-5-29 06:01AM BLOOD freeCa-1.16 1943-2-28 5:20 pm SPUTUM Site: EXPECTORATED GRAM STAIN (Final 1943-2-28): >25 PMNs and 10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (1-19 blood cultures pending Brief Hospital Course: 57 year old healthy male admitted with pneumonia, intermittent Afib with RVR since admission, originally in ICU for treatment under MUST protocol, transfered to the floor after stablization. * 1) Pneumonia: vitals are stable, cxr showed LLL infiltrate, started azithromycin and ceftriaxone on 5-28, will be d/cd with azithromycin and levofloxin for completion of 5 day course. Pt initially presented with bandemia which subsequently resolved with abx. Blood cx are neg uptodate. Sputum cx from 9-20 showed 2+ yeast, 2+ gram pos rod and 2+ gram neg rods. * 2) CV: transient episode of afib in the setting of infection, spontaneous conversion to sinus rhythym, started on metoprolol, continue to be tachy likely secondary to nebs and infection, titrated up metoprolol to 25mg tid and pt d/cd with atenolol 25mg Wade and wants the least expensive meds possible. Need to continue monitor BP (baseline BP runs around 100/70), adjust atenolol dose accordingly. * 3) Acute Renal Failure: likely pre-renal, resolved with rehydration, d/c cr at 0.9-1.0 * 4)Anemia: RDW is nl, ferritin normal, MCV is not decreased, Fe/TIBc ratio is 16%, picture not totally consistent with iron deficieny anemia or chronic disease (?mixed picture), not retic properly, retic count 1.2, ?bactrim suppressing marrow? d/cd bactrim. Hct remained stable since d/cd bactrim. * 7) ?BPH: given BP in the low range, continue terazosin, good urine output. Medications on Admission: Baby aspirin 81 mg 2-3 times per week. Multivitamin, iron, Vitamin C 2,000 mg. Terasozin 5 mg po qd Discharge Medications: 1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 2 days. Disp:2 Capsule(s) Refills:0 2. Terazosin HCl 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:2 Tablet(s) Refills:0 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. Disp:100 puff Refills:0 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 9. Pantoprazole Sodium 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 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Extended Care Facility: Townsend-Christensen Clinic - 699 Karen Tunnel Miguelhaven, PA 93183 Discharge Diagnosis: Community Acquired PNA afib BPH Discharge Condition: Stable but still require NC oxygen Discharge Instructions: Please call your doctor or come to ED if you develop SOB, chest pain, increased coughing, fevers, fainting or any concerning symptoms Followup Instructions: Please call follow up with Dr. Post within 2 weeks- 184-427-5827 Pamela Poff MD 53902345 Completed by:1941-11-10	['Admission Date: 1943-2-28 Discharge Date: 1941-11-10\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Zachary\nChief Complaint:\nFatigue\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\nThe patient is a 57 year old male with a recent diagnosis of\nprostate cancer (he is follwed by Dr. Tammy Poff from urology)\nwho presents with 9-10 days of coughing and generalized\nweakness. Patient notes light headedness -room spining and\northostatic symptoms over past several days secondary to\ndecreased po intake. He denies abdominal pain, nausea, vomiting\nor diarrhea. Pt had some mechanical falls recently secondary to\ninstability probably secondary to dehydration. Three weeks ago\nthe patient fell on his right ribs. No obvious head trauma.', ' No\nfevers, chills or rigors at home at home. Patient has lost 15\npounds in the last six months. No BRBPR, no melena.\n\nIn ED the patient received ceftriaxone and azitrhomycin along\nwith 1 L D5NS x 1 L.\n\nWhile in MICU patient was aggressively hydrated and started on\npressors while being maintained on abx. Patient spontaneously\nconverted to sinus rhythym. He states that his shortness of\nbreath has improved. Denies cp, abd pain, dyuria. Is having nl\nbowel movements.\n\nPast Medical History:\nProstate cancer - per pt and daughter, no Millicent Negrete diagnosed by serum\nbut pt cannot recall numbers ?h/o c/w BPH\nS/p appendectomy\nTIAs-1946 seen in ED for LH and dizziness. clean MRI and MRA\nDuodenal ulcer in 1946\nAdmitted in 1946 with UGI bleed during which On 1932-2-21 the\nwhich EGD demonstrated\n1.', " an oozing duodenal ulcer in the distal bulb in the\nposterolateral wall with a visible vessel which was not spurting\nbut which was cauterized\n2. small hiatal hernia with question of a peptic stricture\nversus Schatzki's ring at the gastroesophageal junction.\n3. gastritis per D/C summary\n4. EGD in 1946 demonstrates Esophageal ring (dilation)\nOtherwise normal EGD to third part of the duodenum with nml\nduodenum and stomach.\nBlind in right eye secondary to trauma.\nL retinal tear.\n\nSocial History:\nBorn in South British Virgin Islands, lived in 14526 Shaun Heights Apt. 981\nTrevinohaven, PR 26932 until 1946 years ago\nwhen\nhe moved to 023 Anderson Village Suite 929\nSouth Christian, MA 95934, lives alone in an apartment in retirement\ncommunity, no tobacco, drugs, occasional beer each day\nDaughter Rama Chowdhury cp 111-680-2732 very involved in his care.", ' Handles\nADLs independently. Walks 4 miles several times a week.\nRecenlty completed 13 mile walk this April.\nRetired electrical engineer.\n\n\nFamily History:\nSister died of stroke\nAnother sister died of pancreatic or stomach cancer\nMother died of pneumonia\n\n\nPhysical Exam:\nVitals on presentation to ED:\nT = 96.0, HR = 95, BP = 157/110, RR = 18, 95% sat on room air.\nGeneral elderly male laying in bed NAD. Talkative, accompanied\nby daughter.\nEbony Lewis: Kayla Dortch fixed R pupil, L pupil surgical and non reactive.\nDry MMM. Dentures in place\nCV: Nml S1, S2, ? irregularly irregular - no m/r/g\nLungs; Decreased BS at L base with crackles at right\nAbdomen: nabs, soft, nd, nt\nExtremities: 2+ DPP, no edema,\nNeuro:\nCN II-XII symmetrical\n\nVitals on transfer to floor\nTemp: 95 Tmax: 100.2\nPulse: 84 (74-125)\nBP: 114/54 (88-114)/ (50-54)\n97% on 4 liters latest blood gas 4/43/33/70\nlatest CVP was 13\nI/O: 1260/1315\nGeneral: elderly male sitting in chair.', ' Talkative, accompanied\nby daughter.\nEbony Lewis: right eye swelling, small fixed R pupil, L eye- PERRLA,\nEOMI. MMM. no jvd\nCV: rrr, Nml S1, S2, no m/r/g\nLungs: Decreased BS at L base, +egophony, cta- in all other\nfields\nAbdomen: nabs, soft, nd, nt\nExtremities: 2+ DPP, no edema,\nNeuro:\nCN II-XII intact (excluding R eye cn II, III, VI, IV), moves all\nfour extremities. no focal deficits\n\n\nPertinent Results:\n1943-2-28 11:30AM GLUCOSE-143* UREA N-24* CREAT-1.5* SODIUM-136\nPOTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-24 ANION GAP-19\n1943-2-28 11:30AM WBC-5.2 RBC-3.43* HGB-11.4* HCT-34.4\nMCV-100 MCH-33.3* MCHC-33.2 RDW-14.2\n1943-2-28 11:30AM NEUTS-59 BANDS-15* LYMPHS-16* MONOS-3 EOS-0\nBASOS-0 ATYPS-7* METAS-0 MYELOS-0\n1943-2-28 11:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL\nMACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL\n1943-2-28 11:30AM PLT COUNT-203\nCreatinine = 0.', '8 2 years ago.\n\nChest PA/L-Dictation\n57 y.o. male with cough and fatigue\nNo CHF, no pleural effusion. LLL/lingula opacity, old healed\nrib fracture\n?chronic process since it is under old rib fractures.\n1922-5-29 04:30AM BLOOD WBC-3.2* RBC-2.77* Hgb-9.4* Hct-27.5\nMCV-99 MCH-33.8* MCHC-34.0 RDW-14.1 Plt Ct-171\n1922-5-29 04:30AM BLOOD Neuts-54.7 Lymphs-27.4 Monos-17.6\nEos-0.1 Baso-0.1\n1922-5-29 04:30AM BLOOD Macrocy-1+\n1922-5-29 04:30AM BLOOD Plt Ct-171\n1922-5-29 04:30AM BLOOD Glucose-127 UreaN-18 Creat-0.9 Na-138\nK-4.0 Cl-110* HCO3-21* AnGap-11\n1922-5-29 04:30AM BLOOD CK(CPK)-194\n1943-2-28 11:30AM BLOOD Lipase-80\n1922-5-29 04:30AM BLOOD CK-MB-3 cTropnT-0.03\n1922-5-29 04:30AM BLOOD Calcium-8.0 Phos-2.6* Mg-1.7\n1943-2-28 11:30AM BLOOD calTIBC-246* VitB12-1129* Folate->20.0\nFerritn-352 TRF-189\n1943-2-28 11:30AM BLOOD TSH-4.', '5\n1943-2-28 11:55PM BLOOD Cortsol-34.0\n1922-5-29 06:01AM BLOOD Lactate-0.9\n1922-5-29 06:01AM BLOOD freeCa-1.16\n\n1943-2-28 5:20 pm SPUTUM Site: EXPECTORATED\n\n GRAM STAIN (Final 1943-2-28):\n >25 PMNs and 10 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH\nPSEUDOHYPHAE.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (1-19 blood cultures pending\n\n\nBrief Hospital Course:\n57 year old healthy male admitted with pneumonia, intermittent\nAfib with RVR since admission, originally in ICU for treatment\nunder MUST protocol, transfered to the floor after stablization.\n\n1) Pneumonia: vitals are stable, cxr showed LLL infiltrate,\nstarted azithromycin and ceftriaxone on 5-28, will be d/cd with\nazithromycin and levofloxin for completion of 5 day course.', ' Pt\ninitially presented with bandemia which subsequently resolved\nwith abx. Blood cx are neg uptodate. Sputum cx from 9-20\nshowed 2+ yeast, 2+ gram pos rod and 2+ gram neg rods.\n\n\n2) CV: transient episode of afib in the setting of infection,\nspontaneous conversion to sinus rhythym, started on metoprolol,\ncontinue to be tachy likely secondary to nebs and infection,\ntitrated up metoprolol to 25mg tid and pt d/cd with atenolol\n25mg Wade and wants the\nleast expensive meds possible. Need to continue monitor BP\n(baseline BP runs around 100/70), adjust atenolol dose\naccordingly.\n\n3) Acute Renal Failure: likely pre-renal, resolved with\nrehydration, d/c cr at 0.9-1.0\n\n4)Anemia: RDW is nl, ferritin normal, MCV is not decreased,\nFe/TIBc ratio is 16%, picture not totally consistent with iron\ndeficieny anemia or chronic disease (?mixed picture), not retic\nproperly, retic count 1.', '2, ?bactrim suppressing marrow? d/cd\nbactrim. Hct remained stable since d/cd bactrim.\n\n7) ?BPH: given BP in the low range, continue terazosin, good\nurine output.\n\n\nMedications on Admission:\nBaby aspirin 81 mg 2-3 times per week.\nMultivitamin,\niron,\nVitamin C 2,000 mg.\nTerasozin 5 mg po qd\n\nDischarge Medications:\n\n1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H\n(every 24 hours) for 2 days.\nDisp:2 Capsule(s) Refills:0\n2. Terazosin HCl 1 mg Capsule Sig: One (1) Capsule PO HS (at\nbedtime).\nDisp:30 Capsule(s) Refills:2\n3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day\nfor 2 days.\nDisp:2 Tablet(s) Refills:0\n4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day.\nDisp:60 Tablet(s) Refills:2\n5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.', '\nDisp:60 Capsule(s) Refills:2\n6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb\nInhalation Q2H (every 2 hours) as needed.\nDisp:100 puff Refills:0\n7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours).\nDisp:120 neb Refills:2\n8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3\ntimes a day).\nDisp:90 Capsule(s) Refills:2\n9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:\nOne (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:2\n10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO once a day.\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:2\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nTownsend-Christensen Clinic - 699 Karen Tunnel\nMiguelhaven, PA 93183\n\nDischarge Diagnosis:\nCommunity Acquired PNA\nafib\nBPH\n\n\nDischarge Condition:\n\nStable but still require NC oxygen\n\nDischarge Instructions:\nPlease call your doctor or come to ED if you develop SOB, chest\npain, increased coughing, fevers, fainting or any concerning\nsymptoms\n\nFollowup Instructions:\nPlease call follow up with Dr.', ' Post within 2 weeks-\n184-427-5827\n\n\n Pamela Poff MD 53902345\n\nCompleted by:1941-11-10']
542	827	135487.0	2174-02-02	Discharge summary	Report	Admission Date: [2174-1-4] Discharge Date: [2174-2-2] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2641] Chief Complaint: hip fracture and subsegmental PE Major Surgical or Invasive Procedure: L HIP ORIF History of Present Illness: [Age over 90 ] year old female with h/o hypothyroidism, anemia, osteoporosis, multiple falls including [2-20] and [3-23], [5-23] who presents [1-4] s/p fall on left hip. Per ambulance report, pt was behind her apartment door with walker, when her physical therapist opened the door which hit her, causing her to fall. She landed on left hip. She denies LOC, dizziness, palpitations and confusion. X-ray confirmed L hip fracture. . Pt taken to OR [1-6] for L ORIF. Intraoperatively she dropped her O2 sats from 100 to 90 and was noted to have an elevated A-a gradient. Hip procedure went well without complications. Post-operatively, the pt left ventilated on SIMV and ortho requested transfer to MICU for further evaluation and treatment. Past Medical History: Frequent falls [4-21], [11-21] GERD Hypothyroidism Hearing loss on Left B12-deficiency, Iron deficiency, Anemia osteoporosis T3 compression fracture UTI Anxiety ECHO [11-21] EF>55%, with 1+ AR, normal LV wall motion. Social History: Social History: - lives in own apartment on [Location (un) 470] - walks with walker - has lifeline - has very actively involved family (niece/HCP) in the area who helps with [Name (NI) 4461]. She has strong feelings as to how her aunt should be taken care of. - Remote tobacco use, no etoh - NOK/HCP is patient's niece (is a social worker) [Name (NI) 17] [Name (NI) ] - [Telephone/Fax (1) 4462] (#1 daughter's room), [Telephone/Fax (1) 4463] (#2 cell phone). Does not want to work with [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ], RN CM. - PCP is [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 572] Family History: NC Physical Exam: Vitals: T 99.2 BP 142/65 HR 84 R 26 Sat 91% 5LNC * PE: G: Elderly female, NAD HEENT: Dry MM Neck: Supple, No JVD Lungs: BS BL, diffuse rhonchi Cardiac: RR, NL rate. NL S1S2. No murmurs Abd: Soft, NT, ND. NL BS. No HSM. Ext: No edema. Neuro: Alert, but thinks she's on a ride ("when does this ride stop?") * Pertinent Results: ADMISSION LABS: [2174-1-4] 07:02PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2174-1-4] 07:02PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2174-1-4] 07:02PM URINE RBC-[2-20]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2174-1-4] 05:40PM GLUCOSE-101 UREA N-34* CREAT-1.2* SODIUM-142 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16 [2174-1-4] 05:40PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.0 [2174-1-4] 05:40PM WBC-6.8 RBC-4.26 HGB-12.1 HCT-35.6* MCV-84 MCH-28.5 MCHC-34.1 RDW-13.3 [2174-1-4] 05:40PM NEUTS-75.1* LYMPHS-20.4 MONOS-2.8 EOS-1.1 BASOS-0.6 [2174-1-4] 05:40PM PLT COUNT-300 [2174-1-4] 05:40PM PT-12.0 PTT-24.1 INR(PT)-0.9 IMAGING: Admission Hip Film ([1-5]): IMPRESSION: Proximal left femoral fracture. Admission CXR ([1-5]): IMPRESSION: No acute pulmonary process. Low lung volumes with right basilar atelectasis. Previously identified right retrocardiac nodular density, not clearly visualized in this study. Gross Path on L Hip Fx: Clinical: Fracture left hip. The specimen is received fresh labeled with "[Known firstname ] [Known lastname 4464]" and "left femoral head" and consists of a femoral head measuring 6.5 x 4.5 x 3.8 cm. The additional separate fragment of bone measuring 2.3 x 1.5 x 1.3 cm. The shape of the femoral head is unremarkable, however, there is extensive eburnation across most of the surface. There is mild, focal osteophytic growth on the edge. It is sectioned to reveal large area of hemorrhage measuring up to 3 cm, and the inferior surface of the femoral head is jagged and hemorrhagic. The bone trabecula are firm and no tumors or other mass lesions are noted on sectioning. Representative sections are submitted in A-B following decalcification. CTA Chest (post-op) [1-7]: IMPRESSION: 1. Single PE visualized in the apical segment of the right lower lobe. 2. Small bilateral pleural effusions. Associated atelectasis. No other areas of consolidation are visualized. 3. Mild/early CHF. CT Abd/Pelvis ([1-9]): IMPRESSION: 1. Patient is status post ORIF of the left proximal femur. There is marked streak artifact from this within the pelvis, however, no definite hematomas are identified. 2. Bilateral small pleural effusions with associated atelectasis. 3. The gallbladder appears full, and contains sludge. If there is clinical concern for acute cholecystitis, evaluation with ultrasound is recommended. US liver/GB ([1-10]): IMPRESSION: Gallbladder sludge and pericholecystic fluid. No gallbladder wall edema or other evidence to suggest acute cholecystitis. Given the presence of hypoalbuminemia, normal LFTs, and the absence of a white count, the gallbladder sludge and gallbladder distention likely reflect a fasting state. CXR [1-12]: IMPRESSION: Improvement of pulmonary edema. Unchanged right pleural effusion. Brief Hospital Course: [Age over 90 ] year old female with h/o hypothyroidism, anemia, osteoporosis, multiple falls including [2-20] and [3-23], [5-23] who presented [1-4] s/p mechanical fall with subsequent L hip fx. She was taken to OR [1-6] for L ORIF. Intraoperatively she dropped her O2 sats from 100 to 90 and was noted to have an elevated A-a gradient. Hip procedure went well without complications. Post-operatively, the pt left ventilated on SIMV and ortho requested transfer to MICU for further evaluation and treatment. In the ICU, she was found to have a subsegmental PE and BL pleural effusions. She developed a fever to 101.9, and was treated empirically for hospital-acquired PNA with CTZ/flagyl (plan for 10 days). She was also started on heparin, and was noted to have had a Hct drop of 10 points on [1-9], which was stable after transfusion. No obvious source was found and her Hct was stable following. During this time ([1-9]), she was also empirically started on Vancomycin for the fevers, but it was d/c'd on [1-13]. No other etiology for the fevers was found, including negative RUQ U/s and CT a/p. Once extubated, the patient failed speech and swallow evaluation, but refused NGT placement. A PICC line was placed for temporary nutrition via TPN. . 1. PE: The patient was anticoagulated initially with heparin gtt then switched to lovenox. Once a PEG was placed, the patient was transitioned over to coumadin with lovenox bridge. Last INR was 2.1 on [2174-2-2], stopped lovenox, discharged on Coumadin 3mg PO qd, please check INR in 2 days and adjust dose of coumadin as needed. At time of discharge, her SaO2 ranged from 92-95 on RA. . 2. ID: The patient was treated empirically with CTZ and Flagyl for a nosocomial/aspiration PNA and remained afebrile while on the floor. However, pt's WBC elevated so Vanco was added to regimen for a 7 day course. A sputum cx from [1-10] grew sparse yeast. The foley was changed and a urine sent for culture; the initial sample was contaminated and grew yeast; the second urine cx grew enterococcus resistant to Vanco 10,000-100,000 colonies. A repeat urine was sent and the foley was removed; cx grew only yeast. She remained afebrile, with a normal WBC, throughout the remainder of her hospitalization. A pCXR on [2173-1-31] showed a question of a new L medical base infiltrate; however, in absence of fever and stable WBC, did not treat with abx, followed clinically. There was a concern that the patient may have experienced an aspiration event; however she did not worsen clinically so no further treatment provided other than measures to reduce aspiration risk. . 3. L Hip fracture, s/p ORIF: The patient was followed by Orthopedics and did well, cleared for WBAT and work with PT/OT; will need PT/OT at rehab when physically able. The patient will f/u with Dr. [Last Name (STitle) 1005] 2 weeks from discharge date (number in discharge paperwork). . 4. Delirium/Dementia: The patient had a waxing/[Doctor Last Name 688] mental status. At one point the patient pulled her IV lines including her PICC line, occasionally requiring the use of soft restraints for her safety. Olanzapine was used on a prn basis for agitation. Frequent reorientation was used. Pt has periods of apparent lucidity and makes insightful comments and conversation. . 5. FEN: The patient failed multiple speech & swallow evaluations. The patient was initially on TPN via the PICC line for nutrition. Extensive discussions were had with the [Hospital 228] healthcare proxy regarding options for enteral nutrition. An albumin was 2.7. A PEG was placed on [2174-1-27] and tube feeds were begun and the patient achieved her TF goal. Electrolytes were stable. There was concern on [2174-1-30] that the patient was aspirating some of her TF [1-20] reflux, despite no residuals when checked; a CXR was unchanged. A day later a repeat CXR showed a question of a new L medial base infiltrate (poor quality film). Reglan was started, and TF were restarted at a slower rate. A PPI was also administered. HOB kept elevated >30-45 degrees at all times. The patient was followed on a sliding scale insulin regimen with good effect. . 6. Hypothyroidism: The patient was initially treated with IV levoxyl since she was NPO; a TSH was checked: 8.5, difficult to interpret in an ill, hospitalized patient. A free T4 was WNL, so pt was maintained on same dose of levoxyl. Once PEG in place, PO levoxyl started at same dosing per Pharmacy recs. . 7. Anemia: Stable during remainder of hospitalization. Baseline Hct appears to be in the low to mid 30s. . . Medications on Admission: Meds on transfer: Propofol gtt Multivitamins 1 CAP PO DAILY Olanzapine prn Oxycodone 5 mg PO Q4-6H:PRN pain Acetaminophen 650 mg PO/PR Q6H Pantoprazole 40 mg PO Q24H Calcium Carbonate 500 mg PO TID Cefazolin 1 gm IV Q8H Duration: 6 Doses Docusate Sodium 100 mg PO BID:PRN Enoxaparin Sodium 40 mg SC Q24H Levothyroxine Sodium 88 mcg PO DAILY Senna 1 TAB PO BID Metoprolol 5 mg IV Q6H Morphine Sulfate 1-2 mg IV Q4-6H:PRN Vitamin D 400 UNIT PO DAILY . Allergies: NKDA Discharge Medications: 1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: via PEG. Tablet(s) 6. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): via PEG. 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): via PEG. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): via PEG, fold for HR<60, SBP<115. 9. Outpatient Lab Work Please check INR in 2 days and adjust coumadin level as needed for goal INR [1-21]. 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) as needed for PE. Discharge Disposition: Extended Care Facility: [Location (un) ] at [Location (un) 701] Discharge Diagnosis: 1. L hip fracture s/p ORIF 2. PE 3. Dementia/delirium 4. Pneumonia (resolved) 5. Anemia (stable) 6. Hypothyroidism Discharge Condition: Fair Discharge Instructions: -Take medications as prescribed -Work with physical therapy as able -Tube feeds via PEG (nothing by mouth until re-evaluation by Speech/Swallow) -Notify your doctor or return to the ER for: * fever>101.4 * chest pain, shortness of breath, abdominal pain * other concerns Followup Instructions: - Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4465], MD Date/Time:[2174-3-7] 1:30 - Orthopedics Dr. [Last Name (STitle) 1005] -- Call [Telephone/Fax (1) 4466] to schedule appointment at a time conveneient for you 2 weeks from your discharge date.	Admission Date: <Date>1914-3-22</Date> Discharge Date: <Date>1954-11-3</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Samuel</Name> Chief Complaint: hip fracture and subsegmental PE Major Surgical or Invasive Procedure: L HIP ORIF History of Present Illness: <Age>59</Age> year old female with h/o hypothyroidism, anemia, osteoporosis, multiple falls including <Date>5-1</Date> and <Date>7-8</Date>, <Date>11-23</Date> who presents <Date>3-31</Date> s/p fall on left hip. Per ambulance report, pt was behind her apartment door with walker, when her physical therapist opened the door which hit her, causing her to fall. She landed on left hip. She denies LOC, dizziness, palpitations and confusion. X-ray confirmed L hip fracture. . Pt taken to OR <Date>12-23</Date> for L ORIF. Intraoperatively she dropped her O2 sats from 100 to 90 and was noted to have an elevated A-a gradient. Hip procedure went well without complications. Post-operatively, the pt left ventilated on SIMV and ortho requested transfer to MICU for further evaluation and treatment. Past Medical History: Frequent falls <Date>4-7</Date>, <Date>2-6</Date> GERD Hypothyroidism Hearing loss on Left B12-deficiency, Iron deficiency, Anemia osteoporosis T3 compression fracture UTI Anxiety ECHO <Date>2-6</Date> EF>55%, with 1+ AR, normal LV wall motion. Social History: Social History: - lives in own apartment on <Location>119 Christopher Ridges Suite 803 Baldwinbury, MP 05640</Location> - walks with walker - has lifeline - has very actively involved family (niece/HCP) in the area who helps with <Name>Mark Kobayashi</Name>. She has strong feelings as to how her aunt should be taken care of. - Remote tobacco use, no etoh - NOK/HCP is patient's niece (is a social worker) <Name>Janet Demong</Name> <Name>Olivia Loveland</Name> - <Telephone>157-598-3540</Telephone> (#1 daughter's room), <Telephone>627-608-8448</Telephone> (#2 cell phone). Does not want to work with <Name>Andrea</Name> <Name>Quinones</Name>, RN CM. - PCP is <Name>Casenhiser</Name>. <Name>Jeffrey</Name> <Name>Lees</Name> Family History: NC Physical Exam: Vitals: T 99.2 BP 142/65 HR 84 R 26 Sat 91% 5LNC * PE: G: Elderly female, NAD HEENT: Dry MM Neck: Supple, No JVD Lungs: BS BL, diffuse rhonchi Cardiac: RR, NL rate. NL S1S2. No murmurs Abd: Soft, NT, ND. NL BS. No HSM. Ext: No edema. Neuro: Alert, but thinks she's on a ride ("when does this ride stop?") * Pertinent Results: ADMISSION LABS: <Date>1914-3-22</Date> 07:02PM URINE COLOR-Yellow APPEAR-Clear SP <Name>Dortch</Name>-1.017 <Date>1914-3-22</Date> 07:02PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG <Date>1914-3-22</Date> 07:02PM URINE RBC-<Date>5-1</Date>* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 <Date>1914-3-22</Date> 05:40PM GLUCOSE-101 UREA N-34* CREAT-1.2* SODIUM-142 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16 <Date>1914-3-22</Date> 05:40PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.0 <Date>1914-3-22</Date> 05:40PM WBC-6.8 RBC-4.26 HGB-12.1 HCT-35.6* MCV-84 MCH-28.5 MCHC-34.1 RDW-13.3 <Date>1914-3-22</Date> 05:40PM NEUTS-75.1* LYMPHS-20.4 MONOS-2.8 EOS-1.1 BASOS-0.6 <Date>1914-3-22</Date> 05:40PM PLT COUNT-300 <Date>1914-3-22</Date> 05:40PM PT-12.0 PTT-24.1 INR(PT)-0.9 IMAGING: Admission Hip Film (<Date>4-5</Date>): IMPRESSION: Proximal left femoral fracture. Admission CXR (<Date>4-5</Date>): IMPRESSION: No acute pulmonary process. Low lung volumes with right basilar atelectasis. Previously identified right retrocardiac nodular density, not clearly visualized in this study. Gross Path on L Hip Fx: Clinical: Fracture left hip. The specimen is received fresh labeled with "<Name>Donna</Name> <Name>Hazelwood</Name>" and "left femoral head" and consists of a femoral head measuring 6.5 x 4.5 x 3.8 cm. The additional separate fragment of bone measuring 2.3 x 1.5 x 1.3 cm. The shape of the femoral head is unremarkable, however, there is extensive eburnation across most of the surface. There is mild, focal osteophytic growth on the edge. It is sectioned to reveal large area of hemorrhage measuring up to 3 cm, and the inferior surface of the femoral head is jagged and hemorrhagic. The bone trabecula are firm and no tumors or other mass lesions are noted on sectioning. Representative sections are submitted in A-B following decalcification. CTA Chest (post-op) <Date>7-7</Date>: IMPRESSION: 1. Single PE visualized in the apical segment of the right lower lobe. 2. Small bilateral pleural effusions. Associated atelectasis. No other areas of consolidation are visualized. 3. Mild/early CHF. CT Abd/Pelvis (<Date>12-26</Date>): IMPRESSION: 1. Patient is status post ORIF of the left proximal femur. There is marked streak artifact from this within the pelvis, however, no definite hematomas are identified. 2. Bilateral small pleural effusions with associated atelectasis. 3. The gallbladder appears full, and contains sludge. If there is clinical concern for acute cholecystitis, evaluation with ultrasound is recommended. US liver/GB (<Date>9-18</Date>): IMPRESSION: Gallbladder sludge and pericholecystic fluid. No gallbladder wall edema or other evidence to suggest acute cholecystitis. Given the presence of hypoalbuminemia, normal LFTs, and the absence of a white count, the gallbladder sludge and gallbladder distention likely reflect a fasting state. CXR <Date>2-27</Date>: IMPRESSION: Improvement of pulmonary edema. Unchanged right pleural effusion. Brief Hospital Course: <Age>59</Age> year old female with h/o hypothyroidism, anemia, osteoporosis, multiple falls including <Date>5-1</Date> and <Date>7-8</Date>, <Date>11-23</Date> who presented <Date>3-31</Date> s/p mechanical fall with subsequent L hip fx. She was taken to OR <Date>12-23</Date> for L ORIF. Intraoperatively she dropped her O2 sats from 100 to 90 and was noted to have an elevated A-a gradient. Hip procedure went well without complications. Post-operatively, the pt left ventilated on SIMV and ortho requested transfer to MICU for further evaluation and treatment. In the ICU, she was found to have a subsegmental PE and BL pleural effusions. She developed a fever to 101.9, and was treated empirically for hospital-acquired PNA with CTZ/flagyl (plan for 10 days). She was also started on heparin, and was noted to have had a Hct drop of 10 points on <Date>12-26</Date>, which was stable after transfusion. No obvious source was found and her Hct was stable following. During this time (<Date>12-26</Date>), she was also empirically started on Vancomycin for the fevers, but it was d/c'd on <Date>3-10</Date>. No other etiology for the fevers was found, including negative RUQ U/s and CT a/p. Once extubated, the patient failed speech and swallow evaluation, but refused NGT placement. A PICC line was placed for temporary nutrition via TPN. . 1. PE: The patient was anticoagulated initially with heparin gtt then switched to lovenox. Once a PEG was placed, the patient was transitioned over to coumadin with lovenox bridge. Last INR was 2.1 on <Date>1954-11-3</Date>, stopped lovenox, discharged on Coumadin 3mg PO qd, please check INR in 2 days and adjust dose of coumadin as needed. At time of discharge, her SaO2 ranged from 92-95 on RA. . 2. ID: The patient was treated empirically with CTZ and Flagyl for a nosocomial/aspiration PNA and remained afebrile while on the floor. However, pt's WBC elevated so Vanco was added to regimen for a 7 day course. A sputum cx from <Date>9-18</Date> grew sparse yeast. The foley was changed and a urine sent for culture; the initial sample was contaminated and grew yeast; the second urine cx grew enterococcus resistant to Vanco 10,000-100,000 colonies. A repeat urine was sent and the foley was removed; cx grew only yeast. She remained afebrile, with a normal WBC, throughout the remainder of her hospitalization. A pCXR on <Date>1939-1-26</Date> showed a question of a new L medical base infiltrate; however, in absence of fever and stable WBC, did not treat with abx, followed clinically. There was a concern that the patient may have experienced an aspiration event; however she did not worsen clinically so no further treatment provided other than measures to reduce aspiration risk. . 3. L Hip fracture, s/p ORIF: The patient was followed by Orthopedics and did well, cleared for WBAT and work with PT/OT; will need PT/OT at rehab when physically able. The patient will f/u with Dr. <Name>Cobbs</Name> 2 weeks from discharge date (number in discharge paperwork). . 4. Delirium/Dementia: The patient had a waxing/<Doctor Name>Dr.Benavidez</Doctor Name> mental status. At one point the patient pulled her IV lines including her PICC line, occasionally requiring the use of soft restraints for her safety. Olanzapine was used on a prn basis for agitation. Frequent reorientation was used. Pt has periods of apparent lucidity and makes insightful comments and conversation. . 5. FEN: The patient failed multiple speech & swallow evaluations. The patient was initially on TPN via the PICC line for nutrition. Extensive discussions were had with the <Hospital>Bridges-Jones Health System</Hospital> healthcare proxy regarding options for enteral nutrition. An albumin was 2.7. A PEG was placed on <Date>1940-1-5</Date> and tube feeds were begun and the patient achieved her TF goal. Electrolytes were stable. There was concern on <Date>2004-5-17</Date> that the patient was aspirating some of her TF <Date>1-7</Date> reflux, despite no residuals when checked; a CXR was unchanged. A day later a repeat CXR showed a question of a new L medial base infiltrate (poor quality film). Reglan was started, and TF were restarted at a slower rate. A PPI was also administered. HOB kept elevated >30-45 degrees at all times. The patient was followed on a sliding scale insulin regimen with good effect. . 6. Hypothyroidism: The patient was initially treated with IV levoxyl since she was NPO; a TSH was checked: 8.5, difficult to interpret in an ill, hospitalized patient. A free T4 was WNL, so pt was maintained on same dose of levoxyl. Once PEG in place, PO levoxyl started at same dosing per Pharmacy recs. . 7. Anemia: Stable during remainder of hospitalization. Baseline Hct appears to be in the low to mid 30s. . . Medications on Admission: Meds on transfer: Propofol gtt Multivitamins 1 CAP PO DAILY Olanzapine prn Oxycodone 5 mg PO Q4-6H:PRN pain Acetaminophen 650 mg PO/PR Q6H Pantoprazole 40 mg PO Q24H Calcium Carbonate 500 mg PO TID Cefazolin 1 gm IV Q8H Duration: 6 Doses Docusate Sodium 100 mg PO BID:PRN Enoxaparin Sodium 40 mg SC Q24H Levothyroxine Sodium 88 mcg PO DAILY Senna 1 TAB PO BID Metoprolol 5 mg IV Q6H Morphine Sulfate 1-2 mg IV Q4-6H:PRN Vitamin D 400 UNIT PO DAILY . Allergies: NKDA Discharge Medications: 1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: via PEG. Tablet(s) 6. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): via PEG. 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): via PEG. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): via PEG, fold for HR<60, SBP<115. 9. Outpatient Lab Work Please check INR in 2 days and adjust coumadin level as needed for goal INR <Date>1-21</Date>. 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical <Hospital>Byrd-Lopez Hospital</Hospital> (2 times a day). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) as needed for PE. Discharge Disposition: Extended Care Facility: <Location>Unit 6427 Box 8843 DPO AE 81914</Location> at <Location>702 Rodriguez Neck Lake Brendan, MH 87908</Location> Discharge Diagnosis: 1. L hip fracture s/p ORIF 2. PE 3. Dementia/delirium 4. Pneumonia (resolved) 5. Anemia (stable) 6. Hypothyroidism Discharge Condition: Fair Discharge Instructions: -Take medications as prescribed -Work with physical therapy as able -Tube feeds via PEG (nothing by mouth until re-evaluation by Speech/Swallow) -Notify your doctor or return to the ER for: * fever>101.4 * chest pain, shortness of breath, abdominal pain * other concerns Followup Instructions: - Provider: <Name>Lissette</Name> <Name>Benhamou</Name>, MD Date/Time:<Date>1915-9-2</Date> 1:30 - Orthopedics Dr. <Name>Cobbs</Name> -- Call <Telephone>320-326-6132</Telephone> to schedule appointment at a time conveneient for you 2 weeks from your discharge 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Date: 1914-3-22 Discharge Date: 1954-11-3 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Samuel Chief Complaint: hip fracture and subsegmental PE Major Surgical or Invasive Procedure: L HIP ORIF History of Present Illness: 59 year old female with h/o hypothyroidism, anemia, osteoporosis, multiple falls including 5-1 and 7-8, 11-23 who presents 3-31 s/p fall on left hip. Per ambulance report, pt was behind her apartment door with walker, when her physical therapist opened the door which hit her, causing her to fall. She landed on left hip. She denies LOC, dizziness, palpitations and confusion. X-ray confirmed L hip fracture. . Pt taken to OR 12-23 for L ORIF. Intraoperatively she dropped her O2 sats from 100 to 90 and was noted to have an elevated A-a gradient. Hip procedure went well without complications. Post-operatively, the pt left ventilated on SIMV and ortho requested transfer to MICU for further evaluation and treatment. Past Medical History: Frequent falls 4-7, 2-6 GERD Hypothyroidism Hearing loss on Left B12-deficiency, Iron deficiency, Anemia osteoporosis T3 compression fracture UTI Anxiety ECHO 2-6 EF>55%, with 1+ AR, normal LV wall motion. Social History: Social History: - lives in own apartment on 119 Christopher Ridges Suite 803 Baldwinbury, MP 05640 - walks with walker - has lifeline - has very actively involved family (niece/HCP) in the area who helps with Mark Kobayashi. She has strong feelings as to how her aunt should be taken care of. - Remote tobacco use, no etoh - NOK/HCP is patient's niece (is a social worker) Janet Demong Olivia Loveland - 157-598-3540 (#1 daughter's room), 627-608-8448 (#2 cell phone). Does not want to work with Andrea Quinones, RN CM. - PCP is Casenhiser. Jeffrey Lees Family History: NC Physical Exam: Vitals: T 99.2 BP 142/65 HR 84 R 26 Sat 91% 5LNC * PE: G: Elderly female, NAD HEENT: Dry MM Neck: Supple, No JVD Lungs: BS BL, diffuse rhonchi Cardiac: RR, NL rate. NL S1S2. No murmurs Abd: Soft, NT, ND. NL BS. No HSM. Ext: No edema. Neuro: Alert, but thinks she's on a ride ("when does this ride stop?") * Pertinent Results: ADMISSION LABS: 1914-3-22 07:02PM URINE COLOR-Yellow APPEAR-Clear SP Dortch-1.017 1914-3-22 07:02PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG 1914-3-22 07:02PM URINE RBC-5-1* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 1914-3-22 05:40PM GLUCOSE-101 UREA N-34* CREAT-1.2* SODIUM-142 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16 1914-3-22 05:40PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.0 1914-3-22 05:40PM WBC-6.8 RBC-4.26 HGB-12.1 HCT-35.6* MCV-84 MCH-28.5 MCHC-34.1 RDW-13.3 1914-3-22 05:40PM NEUTS-75.1* LYMPHS-20.4 MONOS-2.8 EOS-1.1 BASOS-0.6 1914-3-22 05:40PM PLT COUNT-300 1914-3-22 05:40PM PT-12.0 PTT-24.1 INR(PT)-0.9 IMAGING: Admission Hip Film (4-5): IMPRESSION: Proximal left femoral fracture. Admission CXR (4-5): IMPRESSION: No acute pulmonary process. Low lung volumes with right basilar atelectasis. Previously identified right retrocardiac nodular density, not clearly visualized in this study. Gross Path on L Hip Fx: Clinical: Fracture left hip. The specimen is received fresh labeled with "Donna Hazelwood" and "left femoral head" and consists of a femoral head measuring 6.5 x 4.5 x 3.8 cm. The additional separate fragment of bone measuring 2.3 x 1.5 x 1.3 cm. The shape of the femoral head is unremarkable, however, there is extensive eburnation across most of the surface. There is mild, focal osteophytic growth on the edge. It is sectioned to reveal large area of hemorrhage measuring up to 3 cm, and the inferior surface of the femoral head is jagged and hemorrhagic. The bone trabecula are firm and no tumors or other mass lesions are noted on sectioning. Representative sections are submitted in A-B following decalcification. CTA Chest (post-op) 7-7: IMPRESSION: 1. Single PE visualized in the apical segment of the right lower lobe. 2. Small bilateral pleural effusions. Associated atelectasis. No other areas of consolidation are visualized. 3. Mild/early CHF. CT Abd/Pelvis (12-26): IMPRESSION: 1. Patient is status post ORIF of the left proximal femur. There is marked streak artifact from this within the pelvis, however, no definite hematomas are identified. 2. Bilateral small pleural effusions with associated atelectasis. 3. The gallbladder appears full, and contains sludge. If there is clinical concern for acute cholecystitis, evaluation with ultrasound is recommended. US liver/GB (9-18): IMPRESSION: Gallbladder sludge and pericholecystic fluid. No gallbladder wall edema or other evidence to suggest acute cholecystitis. Given the presence of hypoalbuminemia, normal LFTs, and the absence of a white count, the gallbladder sludge and gallbladder distention likely reflect a fasting state. CXR 2-27: IMPRESSION: Improvement of pulmonary edema. Unchanged right pleural effusion. Brief Hospital Course: 59 year old female with h/o hypothyroidism, anemia, osteoporosis, multiple falls including 5-1 and 7-8, 11-23 who presented 3-31 s/p mechanical fall with subsequent L hip fx. She was taken to OR 12-23 for L ORIF. Intraoperatively she dropped her O2 sats from 100 to 90 and was noted to have an elevated A-a gradient. Hip procedure went well without complications. Post-operatively, the pt left ventilated on SIMV and ortho requested transfer to MICU for further evaluation and treatment. In the ICU, she was found to have a subsegmental PE and BL pleural effusions. She developed a fever to 101.9, and was treated empirically for hospital-acquired PNA with CTZ/flagyl (plan for 10 days). She was also started on heparin, and was noted to have had a Hct drop of 10 points on 12-26, which was stable after transfusion. No obvious source was found and her Hct was stable following. During this time (12-26), she was also empirically started on Vancomycin for the fevers, but it was d/c'd on 3-10. No other etiology for the fevers was found, including negative RUQ U/s and CT a/p. Once extubated, the patient failed speech and swallow evaluation, but refused NGT placement. A PICC line was placed for temporary nutrition via TPN. . 1. PE: The patient was anticoagulated initially with heparin gtt then switched to lovenox. Once a PEG was placed, the patient was transitioned over to coumadin with lovenox bridge. Last INR was 2.1 on 1954-11-3, stopped lovenox, discharged on Coumadin 3mg PO qd, please check INR in 2 days and adjust dose of coumadin as needed. At time of discharge, her SaO2 ranged from 92-95 on RA. . 2. ID: The patient was treated empirically with CTZ and Flagyl for a nosocomial/aspiration PNA and remained afebrile while on the floor. However, pt's WBC elevated so Vanco was added to regimen for a 7 day course. A sputum cx from 9-18 grew sparse yeast. The foley was changed and a urine sent for culture; the initial sample was contaminated and grew yeast; the second urine cx grew enterococcus resistant to Vanco 10,000-100,000 colonies. A repeat urine was sent and the foley was removed; cx grew only yeast. She remained afebrile, with a normal WBC, throughout the remainder of her hospitalization. A pCXR on 1939-1-26 showed a question of a new L medical base infiltrate; however, in absence of fever and stable WBC, did not treat with abx, followed clinically. There was a concern that the patient may have experienced an aspiration event; however she did not worsen clinically so no further treatment provided other than measures to reduce aspiration risk. . 3. L Hip fracture, s/p ORIF: The patient was followed by Orthopedics and did well, cleared for WBAT and work with PT/OT; will need PT/OT at rehab when physically able. The patient will f/u with Dr. Cobbs 2 weeks from discharge date (number in discharge paperwork). . 4. Delirium/Dementia: The patient had a waxing/Dr.Benavidez mental status. At one point the patient pulled her IV lines including her PICC line, occasionally requiring the use of soft restraints for her safety. Olanzapine was used on a prn basis for agitation. Frequent reorientation was used. Pt has periods of apparent lucidity and makes insightful comments and conversation. . 5. FEN: The patient failed multiple speech & swallow evaluations. The patient was initially on TPN via the PICC line for nutrition. Extensive discussions were had with the Bridges-Jones Health System healthcare proxy regarding options for enteral nutrition. An albumin was 2.7. A PEG was placed on 1940-1-5 and tube feeds were begun and the patient achieved her TF goal. Electrolytes were stable. There was concern on 2004-5-17 that the patient was aspirating some of her TF 1-7 reflux, despite no residuals when checked; a CXR was unchanged. A day later a repeat CXR showed a question of a new L medial base infiltrate (poor quality film). Reglan was started, and TF were restarted at a slower rate. A PPI was also administered. HOB kept elevated >30-45 degrees at all times. The patient was followed on a sliding scale insulin regimen with good effect. . 6. Hypothyroidism: The patient was initially treated with IV levoxyl since she was NPO; a TSH was checked: 8.5, difficult to interpret in an ill, hospitalized patient. A free T4 was WNL, so pt was maintained on same dose of levoxyl. Once PEG in place, PO levoxyl started at same dosing per Pharmacy recs. . 7. Anemia: Stable during remainder of hospitalization. Baseline Hct appears to be in the low to mid 30s. . . Medications on Admission: Meds on transfer: Propofol gtt Multivitamins 1 CAP PO DAILY Olanzapine prn Oxycodone 5 mg PO Q4-6H:PRN pain Acetaminophen 650 mg PO/PR Q6H Pantoprazole 40 mg PO Q24H Calcium Carbonate 500 mg PO TID Cefazolin 1 gm IV Q8H Duration: 6 Doses Docusate Sodium 100 mg PO BID:PRN Enoxaparin Sodium 40 mg SC Q24H Levothyroxine Sodium 88 mcg PO DAILY Senna 1 TAB PO BID Metoprolol 5 mg IV Q6H Morphine Sulfate 1-2 mg IV Q4-6H:PRN Vitamin D 400 UNIT PO DAILY . Allergies: NKDA Discharge Medications: 1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: via PEG. Tablet(s) 6. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): via PEG. 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): via PEG. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): via PEG, fold for HR1-21. 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical Byrd-Lopez Hospital (2 times a day). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) as needed for PE. Discharge Disposition: Extended Care Facility: Unit 6427 Box 8843 DPO AE 81914 at 702 Rodriguez Neck Lake Brendan, MH 87908 Discharge Diagnosis: 1. L hip fracture s/p ORIF 2. PE 3. Dementia/delirium 4. Pneumonia (resolved) 5. Anemia (stable) 6. Hypothyroidism Discharge Condition: Fair Discharge Instructions: -Take medications as prescribed -Work with physical therapy as able -Tube feeds via PEG (nothing by mouth until re-evaluation by Speech/Swallow) -Notify your doctor or return to the ER for: * fever>101.4 * chest pain, shortness of breath, abdominal pain * other concerns Followup Instructions: - Provider: Lissette Benhamou, MD Date/Time:1915-9-2 1:30 - Orthopedics Dr. Cobbs -- Call 320-326-6132 to schedule appointment at a time conveneient for you 2 weeks from your discharge date.	['Admission Date: 1914-3-22 Discharge Date: 1954-11-3\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Samuel\nChief Complaint:\nhip fracture and subsegmental PE\n\nMajor Surgical or Invasive Procedure:\nL HIP ORIF\n\nHistory of Present Illness:\n59 year old female with h/o hypothyroidism, anemia,\nosteoporosis, multiple falls including 5-1 and 7-8, 11-23 who\npresents 3-31 s/p fall on left hip. Per ambulance report, pt was\nbehind her apartment door with walker, when her physical\ntherapist opened the door which hit her, causing her to fall.\nShe landed on left hip. She denies LOC, dizziness, palpitations\nand confusion. X-ray confirmed L hip fracture.\n.\nPt taken to OR 12-23 for L ORIF. Intraoperatively she dropped her\nO2 sats from 100 to 90 and was noted to have an elevated A-a\ngradient.', " Hip procedure went well without complications.\nPost-operatively, the pt left ventilated on SIMV and ortho\nrequested transfer to MICU for further evaluation and treatment.\n\n\n\nPast Medical History:\nFrequent falls 4-7, 2-6\nGERD\nHypothyroidism\nHearing loss on Left\nB12-deficiency, Iron deficiency, Anemia\nosteoporosis\nT3 compression fracture\nUTI\nAnxiety\nECHO 2-6 EF>55%, with 1+ AR, normal LV wall motion.\n\n\nSocial History:\nSocial History:\n- lives in own apartment on 119 Christopher Ridges Suite 803\nBaldwinbury, MP 05640\n- walks with walker\n- has lifeline\n- has very actively involved family (niece/HCP) in the area who\nhelps with Mark Kobayashi. She has strong feelings as to how her aunt\nshould be taken care of.\n- Remote tobacco use, no etoh\n- NOK/HCP is patient's niece (is a social worker) Janet Demong Olivia Loveland -\n157-598-3540 (#1 daughter's room), 627-608-8448 (#2 cell phone).", '\nDoes not want to work with Andrea Quinones, RN CM.\n- PCP is Casenhiser. Jeffrey Lees\n\n\nFamily History:\nNC\n\nPhysical Exam:\nVitals: T 99.2\nBP 142/65\nHR 84\nR 26\nSat 91% 5LNC\n\nPE: G: Elderly female, NAD\nHEENT: Dry MM\nNeck: Supple, No JVD\nLungs: BS BL, diffuse rhonchi\nCardiac: RR, NL rate. NL S1S2. No murmurs\nAbd: Soft, NT, ND. NL BS. No HSM.\nExt: No edema.\nNeuro: Alert, but thinks she\'s on a ride ("when does this ride\nstop?")\n\n\n\nPertinent Results:\nADMISSION LABS:\n\n1914-3-22 07:02PM URINE COLOR-Yellow APPEAR-Clear SP Dortch-1.017\n1914-3-22 07:02PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG\nGLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0\nLEUK-NEG\n1914-3-22 07:02PM URINE RBC-5-1* WBC-0-2 BACTERIA-FEW YEAST-NONE\nEPI-0-2\n1914-3-22 05:40PM GLUCOSE-101 UREA N-34* CREAT-1.2* SODIUM-142\nPOTASSIUM-4.', '7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16\n1914-3-22 05:40PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.0\n1914-3-22 05:40PM WBC-6.8 RBC-4.26 HGB-12.1 HCT-35.6* MCV-84\nMCH-28.5 MCHC-34.1 RDW-13.3\n1914-3-22 05:40PM NEUTS-75.1* LYMPHS-20.4 MONOS-2.8 EOS-1.1\nBASOS-0.6\n1914-3-22 05:40PM PLT COUNT-300\n1914-3-22 05:40PM PT-12.0 PTT-24.1 INR(PT)-0.9\n\nIMAGING:\nAdmission Hip Film (4-5): IMPRESSION: Proximal left femoral\nfracture.\n\nAdmission CXR (4-5): IMPRESSION: No acute pulmonary process.\nLow lung volumes with right basilar atelectasis. Previously\nidentified right retrocardiac nodular density, not clearly\nvisualized in this study.\n\nGross Path on L Hip Fx: Clinical: Fracture left hip.\nThe specimen is received fresh labeled with "Donna Hazelwood" and\n"left femoral head" and consists of a femoral head measuring 6.', '5\nx 4.5 x 3.8 cm. The additional separate fragment of bone\nmeasuring 2.3 x 1.5 x 1.3 cm. The shape of the femoral head is\nunremarkable, however, there is extensive eburnation across most\nof the surface. There is mild, focal osteophytic growth on the\nedge. It is sectioned to reveal large area of hemorrhage\nmeasuring up to 3 cm, and the inferior surface of the femoral\nhead is jagged and hemorrhagic. The bone trabecula are firm\nand no tumors or other mass lesions are noted on sectioning.\nRepresentative sections are submitted in A-B following\ndecalcification.\n\nCTA Chest (post-op) 7-7:\nIMPRESSION:\n1. Single PE visualized in the apical segment of the right lower\nlobe.\n2. Small bilateral pleural effusions. Associated atelectasis. No\nother areas of consolidation are visualized.\n3. Mild/early CHF.', '\n\nCT Abd/Pelvis (12-26):\nIMPRESSION:\n1. Patient is status post ORIF of the left proximal femur. There\nis marked streak artifact from this within the pelvis, however,\nno definite hematomas are identified.\n2. Bilateral small pleural effusions with associated\natelectasis.\n3. The gallbladder appears full, and contains sludge. If there\nis clinical concern for acute cholecystitis, evaluation with\nultrasound is recommended.\n\nUS liver/GB (9-18):\nIMPRESSION: Gallbladder sludge and pericholecystic fluid. No\ngallbladder wall edema or other evidence to suggest acute\ncholecystitis. Given the presence of hypoalbuminemia, normal\nLFTs, and the absence of a white count, the gallbladder sludge\nand gallbladder distention likely reflect a fasting state.\n\nCXR 2-27: IMPRESSION: Improvement of pulmonary edema. Unchanged\nright pleural effusion.', '\n\n\nBrief Hospital Course:\n59 year old female with h/o hypothyroidism, anemia,\nosteoporosis, multiple falls including 5-1 and 7-8, 11-23 who\npresented 3-31 s/p mechanical fall with subsequent L hip fx.\nShe was taken to OR 12-23 for L ORIF. Intraoperatively she\ndropped her O2 sats from 100 to 90 and was noted to have an\nelevated A-a gradient. Hip procedure went well without\ncomplications. Post-operatively, the pt left ventilated on SIMV\nand ortho requested transfer to MICU for further evaluation and\ntreatment. In the ICU, she was found to have a subsegmental PE\nand BL pleural effusions. She developed a fever to 101.9, and\nwas treated empirically for hospital-acquired PNA with\nCTZ/flagyl (plan for 10 days). She was also started on heparin,\nand was noted to have had a Hct drop of 10 points on 12-26, which\nwas stable after transfusion.', " No obvious source was found and\nher Hct was stable following. During this time (12-26), she was\nalso empirically started on Vancomycin for the fevers, but it\nwas d/c'd on 3-10. No other etiology for the fevers was found,\nincluding negative RUQ U/s and CT a/p. Once extubated, the\npatient failed speech and swallow evaluation, but refused NGT\nplacement. A PICC line was placed for temporary nutrition via\nTPN.\n.\n1. PE: The patient was anticoagulated initially with heparin gtt\nthen switched to lovenox. Once a PEG was placed, the patient was\ntransitioned over to coumadin with lovenox bridge. Last INR was\n2.1 on 1954-11-3, stopped lovenox, discharged on Coumadin 3mg PO\nqd, please check INR in 2 days and adjust dose of coumadin as\nneeded. At time of discharge, her SaO2 ranged from 92-95 on RA.\n.\n2.", " ID: The patient was treated empirically with CTZ and Flagyl\nfor a nosocomial/aspiration PNA and remained afebrile while on\nthe floor. However, pt's WBC elevated so Vanco was added to\nregimen for a 7 day course. A sputum cx from 9-18 grew sparse\nyeast. The foley was changed and a urine sent for culture; the\ninitial sample was contaminated and grew yeast; the second urine\ncx grew enterococcus resistant to Vanco 10,000-100,000 colonies.\nA repeat urine was sent and the foley was removed; cx grew only\nyeast. She remained afebrile, with a normal WBC, throughout the\nremainder of her hospitalization. A pCXR on 1939-1-26 showed a\nquestion of a new L medical base infiltrate; however, in absence\nof fever and stable WBC, did not treat with abx, followed\nclinically. There was a concern that the patient may have\nexperienced an aspiration event; however she did not worsen\nclinically so no further treatment provided other than measures\nto reduce aspiration risk.", '\n.\n3. L Hip fracture, s/p ORIF: The patient was followed by\nOrthopedics and did well, cleared for WBAT and work with PT/OT;\nwill need PT/OT at rehab when physically able. The patient will\nf/u with Dr. Cobbs 2 weeks from discharge date (number in\ndischarge paperwork).\n.\n4. Delirium/Dementia: The patient had a waxing/Dr.Benavidez mental\nstatus. At one point the patient pulled her IV lines including\nher PICC line, occasionally requiring the use of soft restraints\nfor her safety. Olanzapine was used on a prn basis for\nagitation. Frequent reorientation was used. Pt has periods of\napparent lucidity and makes insightful comments and\nconversation.\n.\n5. FEN: The patient failed multiple speech & swallow\nevaluations. The patient was initially on TPN via the PICC line\nfor nutrition. Extensive discussions were had with the Bridges-Jones Health System\nhealthcare proxy regarding options for enteral nutrition.', ' An\nalbumin was 2.7. A PEG was placed on 1940-1-5 and tube feeds were\nbegun and the patient achieved her TF goal. Electrolytes were\nstable. There was concern on 2004-5-17 that the patient was\naspirating some of her TF 1-7 reflux, despite no residuals when\nchecked; a CXR was unchanged. A day later a repeat CXR showed a\nquestion of a new L medial base infiltrate (poor quality film).\nReglan was started, and TF were restarted at a slower rate. A\nPPI was also administered. HOB kept elevated >30-45 degrees at\nall times. The patient was followed on a sliding scale insulin\nregimen with good effect.\n.\n6. Hypothyroidism: The patient was initially treated with IV\nlevoxyl since she was NPO; a TSH was checked: 8.5, difficult to\ninterpret in an ill, hospitalized patient. A free T4 was WNL, so\npt was maintained on same dose of levoxyl.', ' Once PEG in place, PO\nlevoxyl started at same dosing per Pharmacy recs.\n.\n7. Anemia: Stable during remainder of hospitalization. Baseline\nHct appears to be in the low to mid 30s.\n.\n.\n\nMedications on Admission:\nMeds on transfer:\nPropofol gtt\nMultivitamins 1 CAP PO DAILY\nOlanzapine prn\nOxycodone 5 mg PO Q4-6H:PRN pain\nAcetaminophen 650 mg PO/PR Q6H\nPantoprazole 40 mg PO Q24H\nCalcium Carbonate 500 mg PO TID\nCefazolin 1 gm IV Q8H Duration: 6 Doses\nDocusate Sodium 100 mg PO BID:PRN\nEnoxaparin Sodium 40 mg SC Q24H\nLevothyroxine Sodium 88 mcg PO DAILY\nSenna 1 TAB PO BID\nMetoprolol 5 mg IV Q6H\nMorphine Sulfate 1-2 mg IV Q4-6H:PRN\nVitamin D 400 UNIT PO DAILY\n.\nAllergies: NKDA\n\n\nDischarge Medications:\n1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,\nRapid Dissolve PO BID (2 times a day) as needed for agitation.', '\n2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.\n3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every\n6 hours) as needed for pain.\n4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n5. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: via\nPEG. Tablet(s)\n6. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One\n(1) PO DAILY (Daily): via PEG.\n7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every\n6 hours): via PEG.\n8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day): via PEG, fold for HR1-21.\n10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical Byrd-Lopez Hospital\n(2 times a day).\n11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily)\nas needed for PE.', '\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nUnit 6427 Box 8843\nDPO AE 81914 at 702 Rodriguez Neck\nLake Brendan, MH 87908\n\nDischarge Diagnosis:\n1. L hip fracture s/p ORIF\n2. PE\n3. Dementia/delirium\n4. Pneumonia (resolved)\n5. Anemia (stable)\n6. Hypothyroidism\n\n\nDischarge Condition:\nFair\n\n\nDischarge Instructions:\n-Take medications as prescribed\n-Work with physical therapy as able\n-Tube feeds via PEG (nothing by mouth until re-evaluation by\nSpeech/Swallow)\n-Notify your doctor or return to the ER for:\n* fever>101.4\n* chest pain, shortness of breath, abdominal pain\n* other concerns\n\n\nFollowup Instructions:\n- Provider: Lissette Benhamou, MD Date/Time:1915-9-2 1:30\n\n- Orthopedics Dr. Cobbs -- Call 320-326-6132 to schedule\nappointment at a time conveneient for you 2 weeks from your\ndischarge date.', '\n\n\n\n']
543	59637	171676.0	2129-07-12	Discharge summary	Report	Admission Date: [2129-7-7] Discharge Date: [2129-7-12] Date of Birth: [2086-10-2] Sex: M Service: MEDICINE Allergies: Ibuprofen / Ace Inhibitors / Bupropion / Zoloft / Aspirin Attending:[First Name3 (LF) 2195] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Sigmoidoscopy History of Present Illness: Patient is a 42yo male with history of CAD s/p stents x 3 admitted with acute GI bleed. . Patient reports being in his normal state of health until this evening when he developed sudden onset of BRBPR. It occurred around 9pm. He was taken to the ED by his parents where he continued to have lower GI bleed. He has never had a GI bleed before. Pt denied abd pain and n/v, no hematemesis, coffee-ground emesis or melena. Patient states he has on and off suprapubic pain for the past year and that he has frequent constipation with straining and painn with bowel movements. Of note, he is on aspirin and plavix for coronary stent placement. . In the ED, initial vs were: T- 98.0, HR- 118, BP- 184/157, RR- 18, SaO2- 98% on RA. Patient was initially given 250cc NS but had persistent tachycardia and developed lightheadedness. He was then give 3U PRBC and 2L NS with resolution of the tachycardia. He never became hypotensive or had a fever. Abdominal exam was benign. Rectal exam showed bright red [First Name3 (LF) ]. NG lavage was negative. EKG was unchanged from prior. Hct on admission to ED- 45.8 (with normal coags). Patient lost about 1L of [First Name3 (LF) ] from GI tract. . GI was consulted and recommended angiogram with embolization as they were concerned for diverticulosis vs AVM. General surgery was also made aware of the patient and are available if needed. IR-team notified and will be coming in tonight to perform embolization if needed. . On the floor, he remained hemodynamically stable. Vitals on transfer: BP- 126/87, HR- 88, SaO2- 98% on RA, RR- 12, and afebrile. Patient lost another 100cc of [First Name3 (LF) ] on arrival to the floor but remained hemodynamically stable. He denied any nausea/vomiting, chest pain, shortness of breath, dizziness, lightheadedness. He did report some lower abdominal tenderness to palpation (L>R) but was not in any distress and did not demonstrate any signs of acute abdomen. Past Medical History: 1. Inferior MI in [3-13], treated with BMSx3 at [Hospital3 2358] 2. LV systolic dysfunction, EF 40-45% 3. Diabetes type 2 last A1C in [2125] 8.6% 4. Hypertension 5. Depression 6. Hyperlipidemia 7. past h/o cocaine use 8. R knee surgery 9. MRSA leg abscess in the past 10. fracture left tibia in [2123] 11. IBS history Social History: He lives with his parents and was unemployed. He worked yesterday as in HPI. Smoked 2ppd for 25 years and quit in [3-13]. No alcohol in 3 weeks because he was pulled over for a DUI. +marijuana. Cocaine use in teh past. Pt reports that he was doign cocaine when he has his MI in [2128]. Reports he did cocaine last week. Family History: has several relative with MI in their 40's. Maternal grandmother with stroke. Physical Exam: Vitals: T: 97.9 BP: 183/98 P: 87 R: 13 O2: 96% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended. +bowel sounds. Slightly TTP in lower abdomen (L > R)- no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. LUE- fluctuance consistent with cellulitis, TTP. Pertinent Results: Sigmoidoscopy on [2129-7-8]: [Date Range ] in the sigmoid colon and rectum Diverticulosis of the rectum and sigmoid colon Otherwise normal sigmoidoscopy to splenic flexure Recommendations: Diverticular bleed likely with adjacent clot visible. Scope reached mid sigmoid colon. Monitor hematocrit. Surgical consultation for potential hemi-colectomy if continued severe bleeding. Monitor in ICU. Outpatient colonoscopy is indicated. Additional notes: The attending was present for the entire procedure. ADMISSION LABS: [2129-7-7] 10:10PM [Month/Day/Year 3143] WBC-8.2 RBC-5.63 Hgb-15.9 Hct-45.9 MCV-82 MCH-28.2 MCHC-34.7 RDW-14.4 Plt Ct-290 [2129-7-7] 11:09PM [Month/Day/Year 3143] PT-12.6 PTT-24.1 INR(PT)-1.1 [2129-7-7] 10:10PM [Month/Day/Year 3143] Glucose-199* UreaN-23* Creat-1.3* Na-133 K-4.0 Cl-100 HCO3-20* AnGap-17 DISCHARGE LABS: [2129-7-12] 09:35AM [Month/Day/Year 3143] WBC-6.0 RBC-5.61 Hgb-15.6 Hct-45.7 MCV-81* MCH-27.8 MCHC-34.2 RDW-14.3 Plt Ct-332 [2129-7-12] 09:35AM [Month/Day/Year 3143] Plt Ct-332 [2129-7-12] 09:35AM [Month/Day/Year 3143] Glucose-146* UreaN-15 Creat-1.1 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 Brief Hospital Course: 42M with CAD s/p stent (most recent [Month/Day/Year ] in [11-15]) on clopidogrel and ASA, CHF w/EF=40-45%, h/o of MRSA leg abscess, and diet-controlled diabetes (A1C 6.2%) who presented with severe GI bleed [2-8] diverticulosis of sigmoid colon. The patient was given 4 units of pRBC's and stabilized in the ICU, and was discharged in stable condition, with no active bleeding back on his ASA and plavix, and tolerating regular diet and having small, formed, dark brown to black stools. He was also treated with antibiotics for cellulitis in his left arm due to an insect bite. Course summarized by problem below: # GI bleed secondary to diverticulosis of the sigmoid colon: Followed by surery and GI. Tagged red [Month/Day (2) ] cell scan revealed [Month/Day (2) ] in rectal area. GI performed sigmoidoscopy and found diverticuli with [Month/Day (2) ] clots explaining source of the bleed. Admitted to ICU for careful observation in setting of acute GI bleed with significant [Month/Day (2) ] loss. He received 4u of pRBC's, and did not require further transfusions after leaving the ICU. He remained hemodynamically stable throughout his course, with Hcts in the 43-45 range, and was tolerating a regular diet prior to discharge. On the day of discharge he was having small, formed, dark brown to black stools, with no further bright red [Month/Day (2) ]. His aspirin and Plavix were initially held in the setting of his acute bleed, but were re-started during this hospitalization and he had no BRBPR, Hct remained stable. He did have dark BMs during his hospital stay, consistent with old [Month/Day (2) ]. The importance of a high-fiber, high-vegetable content diet with ample hydration was emphasized to the patient and his family. Also, it was emphasized to patient that he MUST NOT stop the ASA or plavix and take both of these medications daily and not stop these without talking to his cardiologist. The patient was scheduled for outpatient follow-up with GI for full colonoscopy. # Coronary artery disease: patient has history of MI s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] in RCA on 11/[2128]. While inpatient, his ASA and plavix were held during acute GI bleed. His aspirin was carefully restarted (ASA desensitization done in ICU) and plavix restarted after patient stabilized. Given the recent placement of a [Year (4 digits) ] in [11-15], as well as his allergy to aspirin and need for desensitization, the importance of strict adherence to this daily regimen was emphasized with both the patient and the family. His home metoprolol was also re-started during admission, after initial stabilization. # Acute renal failure: Cr was slightly elevated at 1.3 on admission, likely secondary to GI losses and pre-renal state. Cr returned to [Location 213] during hospitalization. Cr on discharge was 1.1. # Left arm lesion and cellulitis: Patient reported a "horse fly bite" and was started on Bactrim (1DS [Hospital1 ])for cellulitis one day prior to admission. While inpatient he was given 3 doses (1.5 days) of Vancomycin and then restarted on Doxycycline for a total of 5 days antibiotic treatment, which he finished during his hospital stay. The cellulitis subsided, and the patient remained afebrile throughout. The patient did report 2 year history of myalgias in bilateral calves and shoulders which may suggest possible tick bite and underlying lyme disease. Lyme serologies were pending at time of discharge. Medications on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1) Injection anaphylaxis. 5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO once a day. 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1) Injection anaphylaxis. 5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO once a day. 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Diverticulosis of the sigmoid colon SECONDARY DIAGNOSES: 1. Cellulitis 2. Hypertension 3. Coronary artery disease Discharge Condition: Stable, eating regular diet. With some bowel movements with old dark [Hospital1 ] but no bright red [Hospital1 ] in stool. [Hospital1 ] levels have been stable during whole hospital stay. Discharge Instructions: Dear Mr. [Known lastname 4467], Thank you for allowing us to participate in your care. You were admitted to the hospital for bleeding from your intestines. You were diagnosed with diverticulosis of the sigmoid colon. Diverticulosis is a condition in which there are small outpouchings in the wall of the intestine; in your case, these small outpouchings eroded into a neighboring [Name2 (NI) ] vessel, causing significant bleeding. The sigmoid colon is the lowermost portion of the large intestine before connecting to the rectum and anus. Due to the extensive [Name2 (NI) ] loss from your intestine, you were given a [Name2 (NI) ] transfusion. You were cared for first in the Intensive Care Unit (ICU), then after your condition stabilized, you were transferred to the regular medical floor. Over the course of your stay, you did not have recurrence of bleeding, and you were able to tolerate eating normal food once again. When you were admitted, a test called Sigmoidoscopy was done to look inside the sigmoid colon. Due to the bleeding and inflammation, it was not possible to look inside the rest of the colon, further up, to evaluate for any problems there. It will be very important for you to follow up with a gastroenterologist to be further evaluated and have a full colonoscopy done. Please see below for information on the appointment that has been arranged with Dr. [Last Name (STitle) 1256]. While in the hospital, you were also treated with antibiotics for a skin infection in your left arm due to an apparent insect bite. You finished the course of antibiotics in the hospital. Since the possibility exists that this was a tick bite, a test for Lyme disease was done, but the results of this test were not ready before you left the hospital. You will need to discuss the results of this test with your primary care doctor. Finally, an important note about your medications: during the bleeding from your intestine, your aspirin and Plavix were temporarily stopped. This was done because although these medications did not cause the bleeding, their effect is to worsen any bleeding that may occur for another reason, such as diverticulosis, as in your case. These medications are extremely important to prevent clots from forming at the sites where stents were placed in the [Last Name (STitle) ] vessels in your heart, so they were both re-started once your bleeding stopped. Since you were de-sensitized to aspirin, it is EXTREMELY IMPORTANT that you take aspirin EVERY DAY, since if you skip doses, this may cause you to have a bad reaction to the medication. MEDICATION CHANGES: There were no changes made to your medications. Please continue taking your regular home medications. Followup Instructions: You have a follow up appointment with your primary care doctor: Department: [Hospital3 249] When: FRIDAY [2129-7-22] at 11:30 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage You also have an important follow up appointment with Dr. [Last Name (STitle) 1256], of gastroenterology: Department: GASTROENTEROLOGY When: TUESDAY [2129-7-26] at 9:00 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 1983] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: FRIDAY [2129-7-22] at 11:30 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GASTROENTEROLOGY When: TUESDAY [2129-7-26] at 9:00 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 1983] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: FRIDAY [2129-7-22] at 11:30 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GASTROENTEROLOGY When: TUESDAY [2129-7-26] at 9:00 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 1983] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	Admission Date: <Date>1953-2-16</Date> Discharge Date: <Date>1919-1-13</Date> Date of Birth: <Date>1951-5-11</Date> Sex: M Service: MEDICINE Allergies: Ibuprofen / Ace Inhibitors / Bupropion / Zoloft / Aspirin Attending:<Name>Cornell</Name> Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Sigmoidoscopy History of Present Illness: Patient is a 42yo male with history of CAD s/p stents x 3 admitted with acute GI bleed. . Patient reports being in his normal state of health until this evening when he developed sudden onset of BRBPR. It occurred around 9pm. He was taken to the ED by his parents where he continued to have lower GI bleed. He has never had a GI bleed before. Pt denied abd pain and n/v, no hematemesis, coffee-ground emesis or melena. Patient states he has on and off suprapubic pain for the past year and that he has frequent constipation with straining and painn with bowel movements. Of note, he is on aspirin and plavix for coronary stent placement. . In the ED, initial vs were: T- 98.0, HR- 118, BP- 184/157, RR- 18, SaO2- 98% on RA. Patient was initially given 250cc NS but had persistent tachycardia and developed lightheadedness. He was then give 3U PRBC and 2L NS with resolution of the tachycardia. He never became hypotensive or had a fever. Abdominal exam was benign. Rectal exam showed bright red <Name>Christina</Name>. NG lavage was negative. EKG was unchanged from prior. Hct on admission to ED- 45.8 (with normal coags). Patient lost about 1L of <Name>Christina</Name> from GI tract. . GI was consulted and recommended angiogram with embolization as they were concerned for diverticulosis vs AVM. General surgery was also made aware of the patient and are available if needed. IR-team notified and will be coming in tonight to perform embolization if needed. . On the floor, he remained hemodynamically stable. Vitals on transfer: BP- 126/87, HR- 88, SaO2- 98% on RA, RR- 12, and afebrile. Patient lost another 100cc of <Name>Christina</Name> on arrival to the floor but remained hemodynamically stable. He denied any nausea/vomiting, chest pain, shortness of breath, dizziness, lightheadedness. He did report some lower abdominal tenderness to palpation (L>R) but was not in any distress and did not demonstrate any signs of acute abdomen. Past Medical History: 1. Inferior MI in <Date>10-3</Date>, treated with BMSx3 at <Hospital>Kim, Hurst and Vance Medical Center</Hospital> 2. LV systolic dysfunction, EF 40-45% 3. Diabetes type 2 last A1C in <Year>1945</Year> 8.6% 4. Hypertension 5. Depression 6. Hyperlipidemia 7. past h/o cocaine use 8. R knee surgery 9. MRSA leg abscess in the past 10. fracture left tibia in <Year>1945</Year> 11. IBS history Social History: He lives with his parents and was unemployed. He worked yesterday as in HPI. Smoked 2ppd for 25 years and quit in <Date>10-3</Date>. No alcohol in 3 weeks because he was pulled over for a DUI. +marijuana. Cocaine use in teh past. Pt reports that he was doign cocaine when he has his MI in <Year>1945</Year>. Reports he did cocaine last week. Family History: has several relative with MI in their 40's. Maternal grandmother with stroke. Physical Exam: Vitals: T: 97.9 BP: 183/98 P: 87 R: 13 O2: 96% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended. +bowel sounds. Slightly TTP in lower abdomen (L > R)- no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. LUE- fluctuance consistent with cellulitis, TTP. Pertinent Results: Sigmoidoscopy on <Date>1930-12-24</Date>: <Date Range>1914-6-12 to 1979-7-31</Date Range> in the sigmoid colon and rectum Diverticulosis of the rectum and sigmoid colon Otherwise normal sigmoidoscopy to splenic flexure Recommendations: Diverticular bleed likely with adjacent clot visible. Scope reached mid sigmoid colon. Monitor hematocrit. Surgical consultation for potential hemi-colectomy if continued severe bleeding. Monitor in ICU. Outpatient colonoscopy is indicated. Additional notes: The attending was present for the entire procedure. ADMISSION LABS: <Date>1953-2-16</Date> 10:10PM <Month>April</Month> WBC-8.2 RBC-5.63 Hgb-15.9 Hct-45.9 MCV-82 MCH-28.2 MCHC-34.7 RDW-14.4 Plt Ct-290 <Date>1953-2-16</Date> 11:09PM <Month>April</Month> PT-12.6 PTT-24.1 INR(PT)-1.1 <Date>1953-2-16</Date> 10:10PM <Month>April</Month> Glucose-199* UreaN-23* Creat-1.3* Na-133 K-4.0 Cl-100 HCO3-20* AnGap-17 DISCHARGE LABS: <Date>1919-1-13</Date> 09:35AM <Month>April</Month> WBC-6.0 RBC-5.61 Hgb-15.6 Hct-45.7 MCV-81* MCH-27.8 MCHC-34.2 RDW-14.3 Plt Ct-332 <Date>1919-1-13</Date> 09:35AM <Month>April</Month> Plt Ct-332 <Date>1919-1-13</Date> 09:35AM <Month>April</Month> Glucose-146* UreaN-15 Creat-1.1 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 Brief Hospital Course: 42M with CAD s/p stent (most recent <Month>November</Month> in <Date>10-2</Date>) on clopidogrel and ASA, CHF w/EF=40-45%, h/o of MRSA leg abscess, and diet-controlled diabetes (A1C 6.2%) who presented with severe GI bleed <Date>10-1</Date> diverticulosis of sigmoid colon. The patient was given 4 units of pRBC's and stabilized in the ICU, and was discharged in stable condition, with no active bleeding back on his ASA and plavix, and tolerating regular diet and having small, formed, dark brown to black stools. He was also treated with antibiotics for cellulitis in his left arm due to an insect bite. Course summarized by problem below: # GI bleed secondary to diverticulosis of the sigmoid colon: Followed by surery and GI. Tagged red <Month>February</Month> cell scan revealed <Month>February</Month> in rectal area. GI performed sigmoidoscopy and found diverticuli with <Month>February</Month> clots explaining source of the bleed. Admitted to ICU for careful observation in setting of acute GI bleed with significant <Month>February</Month> loss. He received 4u of pRBC's, and did not require further transfusions after leaving the ICU. He remained hemodynamically stable throughout his course, with Hcts in the 43-45 range, and was tolerating a regular diet prior to discharge. On the day of discharge he was having small, formed, dark brown to black stools, with no further bright red <Month>February</Month>. His aspirin and Plavix were initially held in the setting of his acute bleed, but were re-started during this hospitalization and he had no BRBPR, Hct remained stable. He did have dark BMs during his hospital stay, consistent with old <Month>February</Month>. The importance of a high-fiber, high-vegetable content diet with ample hydration was emphasized to the patient and his family. Also, it was emphasized to patient that he MUST NOT stop the ASA or plavix and take both of these medications daily and not stop these without talking to his cardiologist. The patient was scheduled for outpatient follow-up with GI for full colonoscopy. # Coronary artery disease: patient has history of MI s/<Initial>DA</Initial> <Name>Thomas</Name> <Name>Abdullah</Name> in RCA on 11/<Year>1945</Year>. While inpatient, his ASA and plavix were held during acute GI bleed. His aspirin was carefully restarted (ASA desensitization done in ICU) and plavix restarted after patient stabilized. Given the recent placement of a <Year>1995</Year> in <Date>10-2</Date>, as well as his allergy to aspirin and need for desensitization, the importance of strict adherence to this daily regimen was emphasized with both the patient and the family. His home metoprolol was also re-started during admission, after initial stabilization. # Acute renal failure: Cr was slightly elevated at 1.3 on admission, likely secondary to GI losses and pre-renal state. Cr returned to <Location>790 Christopher Common South Jillian, AL 60803</Location> during hospitalization. Cr on discharge was 1.1. # Left arm lesion and cellulitis: Patient reported a "horse fly bite" and was started on Bactrim (1DS <Hospital>Duffy-Clark Health System</Hospital>)for cellulitis one day prior to admission. While inpatient he was given 3 doses (1.5 days) of Vancomycin and then restarted on Doxycycline for a total of 5 days antibiotic treatment, which he finished during his hospital stay. The cellulitis subsided, and the patient remained afebrile throughout. The patient did report 2 year history of myalgias in bilateral calves and shoulders which may suggest possible tick bite and underlying lyme disease. Lyme serologies were pending at time of discharge. Medications on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1) Injection anaphylaxis. 5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO once a day. 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1) Injection anaphylaxis. 5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO once a day. 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Diverticulosis of the sigmoid colon SECONDARY DIAGNOSES: 1. Cellulitis 2. Hypertension 3. Coronary artery disease Discharge Condition: Stable, eating regular diet. With some bowel movements with old dark <Hospital>Duffy-Clark Health System</Hospital> but no bright red <Hospital>Duffy-Clark Health System</Hospital> in stool. <Hospital>Duffy-Clark Health System</Hospital> levels have been stable during whole hospital stay. Discharge Instructions: Dear Mr. <Name>Kenner</Name>, Thank you for allowing us to participate in your care. You were admitted to the hospital for bleeding from your intestines. You were diagnosed with diverticulosis of the sigmoid colon. Diverticulosis is a condition in which there are small outpouchings in the wall of the intestine; in your case, these small outpouchings eroded into a neighboring <Name>Janell Ceja</Name> vessel, causing significant bleeding. The sigmoid colon is the lowermost portion of the large intestine before connecting to the rectum and anus. Due to the extensive <Name>Janell Ceja</Name> loss from your intestine, you were given a <Name>Janell Ceja</Name> transfusion. You were cared for first in the Intensive Care Unit (ICU), then after your condition stabilized, you were transferred to the regular medical floor. Over the course of your stay, you did not have recurrence of bleeding, and you were able to tolerate eating normal food once again. When you were admitted, a test called Sigmoidoscopy was done to look inside the sigmoid colon. Due to the bleeding and inflammation, it was not possible to look inside the rest of the colon, further up, to evaluate for any problems there. It will be very important for you to follow up with a gastroenterologist to be further evaluated and have a full colonoscopy done. Please see below for information on the appointment that has been arranged with Dr. <Name>Brown</Name>. While in the hospital, you were also treated with antibiotics for a skin infection in your left arm due to an apparent insect bite. You finished the course of antibiotics in the hospital. Since the possibility exists that this was a tick bite, a test for Lyme disease was done, but the results of this test were not ready before you left the hospital. You will need to discuss the results of this test with your primary care doctor. Finally, an important note about your medications: during the bleeding from your intestine, your aspirin and Plavix were temporarily stopped. This was done because although these medications did not cause the bleeding, their effect is to worsen any bleeding that may occur for another reason, such as diverticulosis, as in your case. These medications are extremely important to prevent clots from forming at the sites where stents were placed in the <Name>Lockett</Name> vessels in your heart, so they were both re-started once your bleeding stopped. Since you were de-sensitized to aspirin, it is EXTREMELY IMPORTANT that you take aspirin EVERY DAY, since if you skip doses, this may cause you to have a bad reaction to the medication. MEDICATION CHANGES: There were no changes made to your medications. Please continue taking your regular home medications. Followup Instructions: You have a follow up appointment with your primary care doctor: Department: <Hospital>Brewer-Rodriguez Medical Center</Hospital> When: FRIDAY <Date>2016-12-7</Date> at 11:30 AM With: <Name>Tyler Salgado</Name> <Name>Joe Debelius</Name>, MD <Telephone>514-985-3049</Telephone> Building: <Hospital>Martin, Butler and George Clinic</Hospital> <Location>59927 John Flats Rachelberg, IA 90530</Location> Campus: EAST Best Parking: <Hospital>Cruz and Sons Health System</Hospital> Garage You also have an important follow up appointment with Dr. <Name>Brown</Name>, of gastroenterology: Department: GASTROENTEROLOGY When: TUESDAY <Date>1941-9-8</Date> at 9:00 AM With: <Name>Jermaine</Name> <Name>Joe Debelius</Name>, MD <Telephone>835-369-9332</Telephone> Building: LM <Hospital>Miller Group Hospital</Hospital> Bldg (<Name>Conyers</Name>) <Location>818 Steven Meadows Suite 523 North Nicoleberg, IN 94249</Location> Campus: WEST Best Parking: <Hospital>Miller Group Hospital</Hospital> Garage Department: <Hospital>Brewer-Rodriguez Medical Center</Hospital> When: FRIDAY <Date>2016-12-7</Date> at 11:30 AM With: <Name>Tyler Salgado</Name> <Name>Joe Debelius</Name>, MD <Telephone>514-985-3049</Telephone> Building: <Hospital>Martin, Butler and George Clinic</Hospital> <Location>59927 John Flats Rachelberg, IA 90530</Location> Campus: EAST Best Parking: <Hospital>Cruz and Sons Health System</Hospital> Garage Department: GASTROENTEROLOGY When: TUESDAY <Date>1941-9-8</Date> at 9:00 AM With: <Name>Jermaine</Name> <Name>Joe Debelius</Name>, MD <Telephone>835-369-9332</Telephone> Building: LM <Hospital>Miller Group Hospital</Hospital> Bldg (<Name>Conyers</Name>) <Location>818 Steven Meadows Suite 523 North Nicoleberg, IN 94249</Location> Campus: WEST Best Parking: <Hospital>Miller Group Hospital</Hospital> Garage Department: <Hospital>Brewer-Rodriguez Medical Center</Hospital> When: FRIDAY <Date>2016-12-7</Date> at 11:30 AM With: <Name>Tyler Salgado</Name> <Name>Joe Debelius</Name>, MD <Telephone>514-985-3049</Telephone> Building: <Hospital>Martin, Butler and George Clinic</Hospital> <Location>59927 John Flats Rachelberg, IA 90530</Location> Campus: EAST Best Parking: <Hospital>Cruz and Sons Health System</Hospital> Garage Department: GASTROENTEROLOGY When: TUESDAY <Date>1941-9-8</Date> at 9:00 AM With: <Name>Jermaine</Name> <Name>Joe Debelius</Name>, MD <Telephone>835-369-9332</Telephone> Building: LM <Hospital>Miller Group Hospital</Hospital> Bldg (<Name>Conyers</Name>) <Location>818 Steven Meadows Suite 523 North Nicoleberg, IN 94249</Location> Campus: WEST Best Parking: <Hospital>Miller Group Hospital</Hospital> 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Date: 1953-2-16 Discharge Date: 1919-1-13 Date of Birth: 1951-5-11 Sex: M Service: MEDICINE Allergies: Ibuprofen / Ace Inhibitors / Bupropion / Zoloft / Aspirin Attending:Cornell Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Sigmoidoscopy History of Present Illness: Patient is a 42yo male with history of CAD s/p stents x 3 admitted with acute GI bleed. . Patient reports being in his normal state of health until this evening when he developed sudden onset of BRBPR. It occurred around 9pm. He was taken to the ED by his parents where he continued to have lower GI bleed. He has never had a GI bleed before. Pt denied abd pain and n/v, no hematemesis, coffee-ground emesis or melena. Patient states he has on and off suprapubic pain for the past year and that he has frequent constipation with straining and painn with bowel movements. Of note, he is on aspirin and plavix for coronary stent placement. . In the ED, initial vs were: T- 98.0, HR- 118, BP- 184/157, RR- 18, SaO2- 98% on RA. Patient was initially given 250cc NS but had persistent tachycardia and developed lightheadedness. He was then give 3U PRBC and 2L NS with resolution of the tachycardia. He never became hypotensive or had a fever. Abdominal exam was benign. Rectal exam showed bright red Christina. NG lavage was negative. EKG was unchanged from prior. Hct on admission to ED- 45.8 (with normal coags). Patient lost about 1L of Christina from GI tract. . GI was consulted and recommended angiogram with embolization as they were concerned for diverticulosis vs AVM. General surgery was also made aware of the patient and are available if needed. IR-team notified and will be coming in tonight to perform embolization if needed. . On the floor, he remained hemodynamically stable. Vitals on transfer: BP- 126/87, HR- 88, SaO2- 98% on RA, RR- 12, and afebrile. Patient lost another 100cc of Christina on arrival to the floor but remained hemodynamically stable. He denied any nausea/vomiting, chest pain, shortness of breath, dizziness, lightheadedness. He did report some lower abdominal tenderness to palpation (L>R) but was not in any distress and did not demonstrate any signs of acute abdomen. Past Medical History: 1. Inferior MI in 10-3, treated with BMSx3 at Kim, Hurst and Vance Medical Center 2. LV systolic dysfunction, EF 40-45% 3. Diabetes type 2 last A1C in 1945 8.6% 4. Hypertension 5. Depression 6. Hyperlipidemia 7. past h/o cocaine use 8. R knee surgery 9. MRSA leg abscess in the past 10. fracture left tibia in 1945 11. IBS history Social History: He lives with his parents and was unemployed. He worked yesterday as in HPI. Smoked 2ppd for 25 years and quit in 10-3. No alcohol in 3 weeks because he was pulled over for a DUI. +marijuana. Cocaine use in teh past. Pt reports that he was doign cocaine when he has his MI in 1945. Reports he did cocaine last week. Family History: has several relative with MI in their 40's. Maternal grandmother with stroke. Physical Exam: Vitals: T: 97.9 BP: 183/98 P: 87 R: 13 O2: 96% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended. +bowel sounds. Slightly TTP in lower abdomen (L > R)- no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. LUE- fluctuance consistent with cellulitis, TTP. Pertinent Results: Sigmoidoscopy on 1930-12-24: 1914-6-12 to 1979-7-31 in the sigmoid colon and rectum Diverticulosis of the rectum and sigmoid colon Otherwise normal sigmoidoscopy to splenic flexure Recommendations: Diverticular bleed likely with adjacent clot visible. Scope reached mid sigmoid colon. Monitor hematocrit. Surgical consultation for potential hemi-colectomy if continued severe bleeding. Monitor in ICU. Outpatient colonoscopy is indicated. Additional notes: The attending was present for the entire procedure. ADMISSION LABS: 1953-2-16 10:10PM April WBC-8.2 RBC-5.63 Hgb-15.9 Hct-45.9 MCV-82 MCH-28.2 MCHC-34.7 RDW-14.4 Plt Ct-290 1953-2-16 11:09PM April PT-12.6 PTT-24.1 INR(PT)-1.1 1953-2-16 10:10PM April Glucose-199* UreaN-23* Creat-1.3* Na-133 K-4.0 Cl-100 HCO3-20* AnGap-17 DISCHARGE LABS: 1919-1-13 09:35AM April WBC-6.0 RBC-5.61 Hgb-15.6 Hct-45.7 MCV-81* MCH-27.8 MCHC-34.2 RDW-14.3 Plt Ct-332 1919-1-13 09:35AM April Plt Ct-332 1919-1-13 09:35AM April Glucose-146* UreaN-15 Creat-1.1 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 Brief Hospital Course: 42M with CAD s/p stent (most recent November in 10-2) on clopidogrel and ASA, CHF w/EF=40-45%, h/o of MRSA leg abscess, and diet-controlled diabetes (A1C 6.2%) who presented with severe GI bleed 10-1 diverticulosis of sigmoid colon. The patient was given 4 units of pRBC's and stabilized in the ICU, and was discharged in stable condition, with no active bleeding back on his ASA and plavix, and tolerating regular diet and having small, formed, dark brown to black stools. He was also treated with antibiotics for cellulitis in his left arm due to an insect bite. Course summarized by problem below: # GI bleed secondary to diverticulosis of the sigmoid colon: Followed by surery and GI. Tagged red February cell scan revealed February in rectal area. GI performed sigmoidoscopy and found diverticuli with February clots explaining source of the bleed. Admitted to ICU for careful observation in setting of acute GI bleed with significant February loss. He received 4u of pRBC's, and did not require further transfusions after leaving the ICU. He remained hemodynamically stable throughout his course, with Hcts in the 43-45 range, and was tolerating a regular diet prior to discharge. On the day of discharge he was having small, formed, dark brown to black stools, with no further bright red February. His aspirin and Plavix were initially held in the setting of his acute bleed, but were re-started during this hospitalization and he had no BRBPR, Hct remained stable. He did have dark BMs during his hospital stay, consistent with old February. The importance of a high-fiber, high-vegetable content diet with ample hydration was emphasized to the patient and his family. Also, it was emphasized to patient that he MUST NOT stop the ASA or plavix and take both of these medications daily and not stop these without talking to his cardiologist. The patient was scheduled for outpatient follow-up with GI for full colonoscopy. # Coronary artery disease: patient has history of MI s/DA Thomas Abdullah in RCA on 11/1945. While inpatient, his ASA and plavix were held during acute GI bleed. His aspirin was carefully restarted (ASA desensitization done in ICU) and plavix restarted after patient stabilized. Given the recent placement of a 1995 in 10-2, as well as his allergy to aspirin and need for desensitization, the importance of strict adherence to this daily regimen was emphasized with both the patient and the family. His home metoprolol was also re-started during admission, after initial stabilization. # Acute renal failure: Cr was slightly elevated at 1.3 on admission, likely secondary to GI losses and pre-renal state. Cr returned to 790 Christopher Common South Jillian, AL 60803 during hospitalization. Cr on discharge was 1.1. # Left arm lesion and cellulitis: Patient reported a "horse fly bite" and was started on Bactrim (1DS Duffy-Clark Health System)for cellulitis one day prior to admission. While inpatient he was given 3 doses (1.5 days) of Vancomycin and then restarted on Doxycycline for a total of 5 days antibiotic treatment, which he finished during his hospital stay. The cellulitis subsided, and the patient remained afebrile throughout. The patient did report 2 year history of myalgias in bilateral calves and shoulders which may suggest possible tick bite and underlying lyme disease. Lyme serologies were pending at time of discharge. Medications on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1) Injection anaphylaxis. 5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO once a day. 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1) Injection anaphylaxis. 5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO once a day. 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Diverticulosis of the sigmoid colon SECONDARY DIAGNOSES: 1. Cellulitis 2. Hypertension 3. Coronary artery disease Discharge Condition: Stable, eating regular diet. With some bowel movements with old dark Duffy-Clark Health System but no bright red Duffy-Clark Health System in stool. Duffy-Clark Health System levels have been stable during whole hospital stay. Discharge Instructions: Dear Mr. Kenner, Thank you for allowing us to participate in your care. You were admitted to the hospital for bleeding from your intestines. You were diagnosed with diverticulosis of the sigmoid colon. Diverticulosis is a condition in which there are small outpouchings in the wall of the intestine; in your case, these small outpouchings eroded into a neighboring Janell Ceja vessel, causing significant bleeding. The sigmoid colon is the lowermost portion of the large intestine before connecting to the rectum and anus. Due to the extensive Janell Ceja loss from your intestine, you were given a Janell Ceja transfusion. You were cared for first in the Intensive Care Unit (ICU), then after your condition stabilized, you were transferred to the regular medical floor. Over the course of your stay, you did not have recurrence of bleeding, and you were able to tolerate eating normal food once again. When you were admitted, a test called Sigmoidoscopy was done to look inside the sigmoid colon. Due to the bleeding and inflammation, it was not possible to look inside the rest of the colon, further up, to evaluate for any problems there. It will be very important for you to follow up with a gastroenterologist to be further evaluated and have a full colonoscopy done. Please see below for information on the appointment that has been arranged with Dr. Brown. While in the hospital, you were also treated with antibiotics for a skin infection in your left arm due to an apparent insect bite. You finished the course of antibiotics in the hospital. Since the possibility exists that this was a tick bite, a test for Lyme disease was done, but the results of this test were not ready before you left the hospital. You will need to discuss the results of this test with your primary care doctor. Finally, an important note about your medications: during the bleeding from your intestine, your aspirin and Plavix were temporarily stopped. This was done because although these medications did not cause the bleeding, their effect is to worsen any bleeding that may occur for another reason, such as diverticulosis, as in your case. These medications are extremely important to prevent clots from forming at the sites where stents were placed in the Lockett vessels in your heart, so they were both re-started once your bleeding stopped. Since you were de-sensitized to aspirin, it is EXTREMELY IMPORTANT that you take aspirin EVERY DAY, since if you skip doses, this may cause you to have a bad reaction to the medication. MEDICATION CHANGES: There were no changes made to your medications. Please continue taking your regular home medications. Followup Instructions: You have a follow up appointment with your primary care doctor: Department: Brewer-Rodriguez Medical Center When: FRIDAY 2016-12-7 at 11:30 AM With: Tyler Salgado Joe Debelius, MD 514-985-3049 Building: Martin, Butler and George Clinic 59927 John Flats Rachelberg, IA 90530 Campus: EAST Best Parking: Cruz and Sons Health System Garage You also have an important follow up appointment with Dr. Brown, of gastroenterology: Department: GASTROENTEROLOGY When: TUESDAY 1941-9-8 at 9:00 AM With: Jermaine Joe Debelius, MD 835-369-9332 Building: LM Miller Group Hospital Bldg (Conyers) 818 Steven Meadows Suite 523 North Nicoleberg, IN 94249 Campus: WEST Best Parking: Miller Group Hospital Garage Department: Brewer-Rodriguez Medical Center When: FRIDAY 2016-12-7 at 11:30 AM With: Tyler Salgado Joe Debelius, MD 514-985-3049 Building: Martin, Butler and George Clinic 59927 John Flats Rachelberg, IA 90530 Campus: EAST Best Parking: Cruz and Sons Health System Garage Department: GASTROENTEROLOGY When: TUESDAY 1941-9-8 at 9:00 AM With: Jermaine Joe Debelius, MD 835-369-9332 Building: LM Miller Group Hospital Bldg (Conyers) 818 Steven Meadows Suite 523 North Nicoleberg, IN 94249 Campus: WEST Best Parking: Miller Group Hospital Garage Department: Brewer-Rodriguez Medical Center When: FRIDAY 2016-12-7 at 11:30 AM With: Tyler Salgado Joe Debelius, MD 514-985-3049 Building: Martin, Butler and George Clinic 59927 John Flats Rachelberg, IA 90530 Campus: EAST Best Parking: Cruz and Sons Health System Garage Department: GASTROENTEROLOGY When: TUESDAY 1941-9-8 at 9:00 AM With: Jermaine Joe Debelius, MD 835-369-9332 Building: LM Miller Group Hospital Bldg (Conyers) 818 Steven Meadows Suite 523 North Nicoleberg, IN 94249 Campus: WEST Best Parking: Miller Group Hospital Garage	['Admission Date: 1953-2-16 Discharge Date: 1919-1-13\n\nDate of Birth: 1951-5-11 Sex: M\n\nService: MEDICINE\n\nAllergies:\nIbuprofen / Ace Inhibitors / Bupropion / Zoloft / Aspirin\n\nAttending:Cornell\nChief Complaint:\nGI bleed\n\nMajor Surgical or Invasive Procedure:\nSigmoidoscopy\n\nHistory of Present Illness:\nPatient is a 42yo male with history of CAD s/p stents x 3\nadmitted with acute GI bleed.\n.\nPatient reports being in his normal state of health until this\nevening when he developed sudden onset of BRBPR. It occurred\naround 9pm. He was taken to the ED by his parents where he\ncontinued to have lower GI bleed. He has never had a GI bleed\nbefore. Pt denied abd pain and n/v, no hematemesis,\ncoffee-ground emesis or melena. Patient states he has on and off\nsuprapubic pain for the past year and that he has frequent\nconstipation with straining and painn with bowel movements.', '\nOf note, he is on aspirin and plavix for coronary stent\nplacement.\n.\nIn the ED, initial vs were: T- 98.0, HR- 118, BP- 184/157, RR-\n18, SaO2- 98% on RA. Patient was initially given 250cc NS but\nhad persistent tachycardia and developed lightheadedness. He was\nthen give 3U PRBC and 2L NS with resolution of the tachycardia.\nHe never became hypotensive or had a fever. Abdominal exam was\nbenign. Rectal exam showed bright red Christina. NG lavage was\nnegative. EKG was unchanged from prior. Hct on admission to ED-\n45.8 (with normal coags). Patient lost about 1L of Christina from GI\ntract.\n.\nGI was consulted and recommended angiogram with embolization as\nthey were concerned for diverticulosis vs AVM. General surgery\nwas also made aware of the patient and are available if needed.\nIR-team notified and will be coming in tonight to perform\nembolization if needed.', '\n.\nOn the floor, he remained hemodynamically stable. Vitals on\ntransfer: BP- 126/87, HR- 88, SaO2- 98% on RA, RR- 12, and\nafebrile. Patient lost another 100cc of Christina on arrival to the\nfloor but remained hemodynamically stable. He denied any\nnausea/vomiting, chest pain, shortness of breath, dizziness,\nlightheadedness. He did report some lower abdominal tenderness\nto palpation (L>R) but was not in any distress and did not\ndemonstrate any signs of acute abdomen.\n\n\nPast Medical History:\n1. Inferior MI in 10-3, treated with BMSx3 at Kim, Hurst and Vance Medical Center\n2. LV systolic dysfunction, EF 40-45%\n3. Diabetes type 2 last A1C in 1945 8.6%\n4. Hypertension\n5. Depression\n6. Hyperlipidemia\n7. past h/o cocaine use\n8. R knee surgery\n9. MRSA leg abscess in the past\n10. fracture left tibia in 1945\n11.', " IBS history\n\nSocial History:\nHe lives with his parents and was unemployed. He worked\nyesterday as in HPI. Smoked 2ppd for 25 years and quit in 10-3.\nNo alcohol in 3 weeks because he was pulled over for a DUI.\n+marijuana. Cocaine use in teh past. Pt reports that he was\ndoign cocaine when he has his MI in 1945. Reports he did cocaine\nlast week.\n\n\nFamily History:\nhas several relative with MI in their 40's. Maternal grandmother\nwith stroke.\n\nPhysical Exam:\nVitals: T: 97.9 BP: 183/98 P: 87 R: 13 O2: 96% on RA\nGeneral: Alert, oriented, no acute distress\nHEENT: Sclera anicteric, MMM, oropharynx clear\nNeck: supple, JVP not elevated, no LAD\nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nronchi\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops\nAbdomen: soft, non-tender, non-distended.", ' +bowel sounds.\nSlightly TTP in lower abdomen (L > R)- no rebound tenderness or\nguarding, no organomegaly\nGU: Foley in place\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema. LUE- fluctuance consistent with cellulitis, TTP.\n\n\nPertinent Results:\nSigmoidoscopy on 1930-12-24:\n1914-6-12 to 1979-7-31 in the sigmoid colon and rectum\nDiverticulosis of the rectum and sigmoid colon\nOtherwise normal sigmoidoscopy to splenic flexure\nRecommendations: Diverticular bleed likely with adjacent clot\nvisible. Scope reached mid sigmoid colon. Monitor hematocrit.\nSurgical consultation for potential hemi-colectomy if continued\nsevere bleeding. Monitor in ICU. Outpatient colonoscopy is\nindicated.\nAdditional notes: The attending was present for the entire\nprocedure.\n\nADMISSION LABS:\n\n1953-2-16 10:10PM April WBC-8.', "2 RBC-5.63 Hgb-15.9 Hct-45.9 MCV-82\nMCH-28.2 MCHC-34.7 RDW-14.4 Plt Ct-290\n1953-2-16 11:09PM April PT-12.6 PTT-24.1 INR(PT)-1.1\n1953-2-16 10:10PM April Glucose-199* UreaN-23* Creat-1.3* Na-133\nK-4.0 Cl-100 HCO3-20* AnGap-17\n\nDISCHARGE LABS:\n\n1919-1-13 09:35AM April WBC-6.0 RBC-5.61 Hgb-15.6 Hct-45.7\nMCV-81* MCH-27.8 MCHC-34.2 RDW-14.3 Plt Ct-332\n1919-1-13 09:35AM April Plt Ct-332\n1919-1-13 09:35AM April Glucose-146* UreaN-15 Creat-1.1 Na-138\nK-4.0 Cl-103 HCO3-22 AnGap-17\n\nBrief Hospital Course:\n42M with CAD s/p stent (most recent November in 10-2) on clopidogrel\nand ASA, CHF w/EF=40-45%, h/o of MRSA leg abscess, and\ndiet-controlled diabetes (A1C 6.2%) who presented with severe GI\nbleed 10-1 diverticulosis of sigmoid colon. The patient was\ngiven 4 units of pRBC's and stabilized in the ICU, and was\ndischarged in stable condition, with no active bleeding back on\nhis ASA and plavix, and tolerating regular diet and having\nsmall, formed, dark brown to black stools.", " He was also treated\nwith antibiotics for cellulitis in his left arm due to an insect\nbite. Course summarized by problem below:\n\n# GI bleed secondary to diverticulosis of the sigmoid colon:\nFollowed by surery and GI. Tagged red February cell scan revealed\nFebruary in rectal area. GI performed sigmoidoscopy and found\ndiverticuli with February clots explaining source of the bleed.\nAdmitted to ICU for careful observation in setting of acute GI\nbleed with significant February loss. He received 4u of pRBC's, and\ndid not require further transfusions after leaving the ICU. He\nremained hemodynamically stable throughout his course, with Hcts\nin the 43-45 range, and was tolerating a regular diet prior to\ndischarge. On the day of discharge he was having small, formed,\ndark brown to black stools, with no further bright red February.", '\nHis aspirin and Plavix were initially held in the setting of his\nacute bleed, but were re-started during this hospitalization and\nhe had no BRBPR, Hct remained stable. He did have dark BMs\nduring his hospital stay, consistent with old February. The\nimportance of a high-fiber, high-vegetable content diet with\nample hydration was emphasized to the patient and his family.\nAlso, it was emphasized to patient that he MUST NOT stop the ASA\nor plavix and take both of these medications daily and not stop\nthese without talking to his cardiologist. The patient was\nscheduled for outpatient follow-up with GI for full colonoscopy.\n\n# Coronary artery disease: patient has history of MI s/DA Thomas\nAbdullah in RCA on 11/1945. While inpatient, his ASA and plavix\nwere held during acute GI bleed. His aspirin was carefully\nrestarted (ASA desensitization done in ICU) and plavix restarted\nafter patient stabilized.', ' Given the recent placement of a 1995\nin 10-2, as well as his allergy to aspirin and need for\ndesensitization, the importance of strict adherence to this\ndaily regimen was emphasized with both the patient and the\nfamily. His home metoprolol was also re-started during\nadmission, after initial stabilization.\n\n# Acute renal failure: Cr was slightly elevated at 1.3 on\nadmission, likely secondary to GI losses and pre-renal state. Cr\nreturned to 790 Christopher Common\nSouth Jillian, AL 60803 during hospitalization. Cr on discharge was\n1.1.\n\n# Left arm lesion and cellulitis: Patient reported a "horse fly\nbite" and was started on Bactrim (1DS Duffy-Clark Health System)for cellulitis one day\nprior to admission. While inpatient he was given 3 doses (1.5\ndays) of Vancomycin and then restarted on Doxycycline for a\ntotal of 5 days antibiotic treatment, which he finished during\nhis hospital stay.', ' The cellulitis subsided, and the patient\nremained afebrile throughout. The patient did report 2 year\nhistory of myalgias in bilateral calves and shoulders which may\nsuggest possible tick bite and underlying lyme disease. Lyme\nserologies were pending at time of discharge.\n\nMedications on Admission:\n1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\n4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1)\n Injection anaphylaxis.\n5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO\nonce a day.\n6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.\n\n\nDischarge Medications:\n1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).', '\n2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\n4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1)\n Injection anaphylaxis.\n5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO\nonce a day.\n6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n1. Diverticulosis of the sigmoid colon\n\nSECONDARY DIAGNOSES:\n1. Cellulitis\n2. Hypertension\n3. Coronary artery disease\n\n\nDischarge Condition:\nStable, eating regular diet. With some bowel movements with old\ndark Duffy-Clark Health System but no bright red Duffy-Clark Health System in stool. Duffy-Clark Health System levels have\nbeen stable during whole hospital stay.', '\n\n\nDischarge Instructions:\nDear Mr. Kenner,\n\nThank you for allowing us to participate in your care. You were\nadmitted to the hospital for bleeding from your intestines. You\nwere diagnosed with diverticulosis of the sigmoid colon.\nDiverticulosis is a condition in which there are small\noutpouchings in the wall of the intestine; in your case, these\nsmall outpouchings eroded into a neighboring Janell Ceja vessel,\ncausing significant bleeding. The sigmoid colon is the\nlowermost portion of the large intestine before connecting to\nthe rectum and anus.\n\nDue to the extensive Janell Ceja loss from your intestine, you were\ngiven a Janell Ceja transfusion. You were cared for first in the\nIntensive Care Unit (ICU), then after your condition stabilized,\nyou were transferred to the regular medical floor.', ' Over the\ncourse of your stay, you did not have recurrence of bleeding,\nand you were able to tolerate eating normal food once again.\n\nWhen you were admitted, a test called Sigmoidoscopy was done to\nlook inside the sigmoid colon. Due to the bleeding and\ninflammation, it was not possible to look inside the rest of the\ncolon, further up, to evaluate for any problems there. It will\nbe very important for you to follow up with a gastroenterologist\nto be further evaluated and have a full colonoscopy done.\nPlease see below for information on the appointment that has\nbeen arranged with Dr. Brown.\n\nWhile in the hospital, you were also treated with antibiotics\nfor a skin infection in your left arm due to an apparent insect\nbite. You finished the course of antibiotics in the hospital.\nSince the possibility exists that this was a tick bite, a test\nfor Lyme disease was done, but the results of this test were not\nready before you left the hospital.', ' You will need to discuss\nthe results of this test with your primary care doctor.\n\nFinally, an important note about your medications: during the\nbleeding from your intestine, your aspirin and Plavix were\ntemporarily stopped. This was done because although these\nmedications did not cause the bleeding, their effect is to\nworsen any bleeding that may occur for another reason, such as\ndiverticulosis, as in your case. These medications are\nextremely important to prevent clots from forming at the sites\nwhere stents were placed in the Lockett vessels in your heart, so\nthey were both re-started once your bleeding stopped. Since you\nwere de-sensitized to aspirin, it is EXTREMELY IMPORTANT that\nyou take aspirin EVERY DAY, since if you skip doses, this may\ncause you to have a bad reaction to the medication.', '\n\nMEDICATION CHANGES:\nThere were no changes made to your medications. Please continue\ntaking your regular home medications.\n\nFollowup Instructions:\nYou have a follow up appointment with your primary care doctor:\nDepartment: Brewer-Rodriguez Medical Center\nWhen: FRIDAY 2016-12-7 at 11:30 AM\nWith: Tyler Salgado Joe Debelius, MD 514-985-3049\nBuilding: Martin, Butler and George Clinic 59927 John Flats\nRachelberg, IA 90530\nCampus: EAST Best Parking: Cruz and Sons Health System Garage\n\nYou also have an important follow up appointment with Dr. Brown,\nof gastroenterology:\nDepartment: GASTROENTEROLOGY\nWhen: TUESDAY 1941-9-8 at 9:00 AM\nWith: Jermaine Joe Debelius, MD 835-369-9332\nBuilding: LM Miller Group Hospital Bldg (Conyers) 818 Steven Meadows Suite 523\nNorth Nicoleberg, IN 94249\nCampus: WEST Best Parking: Miller Group Hospital Garage\n\n\n\n\nDepartment: Brewer-Rodriguez Medical Center\nWhen: FRIDAY 2016-12-7 at 11:30 AM\nWith: Tyler Salgado Joe Debelius, MD 514-985-3049\nBuilding: Martin, Butler and George Clinic 59927 John Flats\nRachelberg, IA 90530\nCampus: EAST Best Parking: Cruz and Sons Health System Garage\n\nDepartment: GASTROENTEROLOGY\nWhen: TUESDAY 1941-9-8 at 9:00 AM\nWith: Jermaine Joe Debelius, MD 835-369-9332\nBuilding: LM Miller Group Hospital Bldg (Conyers) 818 Steven Meadows Suite 523\nNorth Nicoleberg, IN 94249\nCampus: WEST Best Parking: Miller Group Hospital Garage\n\nDepartment: Brewer-Rodriguez Medical Center\nWhen: FRIDAY 2016-12-7 at 11:30 AM\nWith: Tyler Salgado Joe Debelius, MD 514-985-3049\nBuilding: Martin, Butler and George Clinic 59927 John Flats\nRachelberg, IA 90530\nCampus: EAST Best Parking: Cruz and Sons Health System Garage\n\nDepartment: GASTROENTEROLOGY\nWhen: TUESDAY 1941-9-8 at 9:00 AM\nWith: Jermaine Joe Debelius, MD 835-369-9332\nBuilding: LM Miller Group Hospital Bldg (Conyers) 818 Steven Meadows Suite 523\nNorth Nicoleberg, IN 94249\nCampus: WEST Best Parking: Miller Group Hospital Garage\n\n\n\n']
544	59227	138122.0	2160-12-24	Discharge summary	Report	Admission Date: [2160-12-15] Discharge Date: [2160-12-24] Service: MEDICINE Allergies: Ibuprofen / Percocet / Naprosyn / Percodan Attending:[First Name3 (LF) 1515] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Valvuloplasty History of Present Illness: [Age over 90 ] yo female with 3VD CAD s/p MI in [2156], POBA LCX, CHF with EF 25% with worsening RV function, dyslipidemia, HTN, rheumatic heart disease, AV stenosis s/p valvuloplasty x2 with recent CHF exacerbation c/[Initials (NamePattern4) ] [Last Name (NamePattern4) ]. Patient had been doing well at rehab. Bumex was restarted [12-12]. Last night developed SOB and was sent to [Hospital ] Hosp ER where they felt she was hypovolemic and treated with 2L IVF and sent her back to [Location (un) ]. This am, the patient experienced worsening SOB. She was treated with Morphine, Bumex 1mg x 2, and [2-2] of a 1/150 SL nitro x 2 b/c pt c/o chest tightness. After taking nitro the pt's BP dropped to 90/s the later returned to baseline 100s. At time of transfer her O2 sat was 94% on 2Lnc but will dip down to 88% with talking or sips of water. . On the floor the patient was complaining of dry mouth and thirst and drinking water. She denied SOB, chest pain, or any other discomfort. She denies cough, fever, chills. However, she stated she had had some delirium at the rehab due to double dose of morphine but was unclear about the exact events. She is aware that she is at [Hospital1 ]. . The patient has severe aortic stenosis with low output (EF = 25%), and she underwent a valvuloplasty in [Month (only) 216]. She also has diffuse disease of the LAD and RCA. Cardiac catheterization confirmed significant gradient in setting of low EF, so another valvuloplasty was performed, which dropped the gradient from 31 to 23 mmHg. The patient tolerated the procedure well and was stable afterwards. She was given Lasix. Her groin site was closed. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: [2160-9-25]: 3VD; Successful POBA to proximal circumflex lesion; successful balloon aortic valvuloplasty 3. OTHER PAST MEDICAL HISTORY: Severe AS s/p aortic balloon valvuloplasty on [9-25] and again on [2160-12-17] CAD s/p MI in [2156]; recent POBA to LCx, 3VD CHF HTN HL CKD Pneumonia Iron deficiency Psoriasis Nephrolithiasis Appendectomy Thrombocytopenia s/p TAH s/p L hip fracture and repair Social History: Lives independently in [Hospital1 ]. Still drives. Walks with cane. Husband died 15 years ago. She has 2 children - son [Name (NI) 4468] in Ca. Daughter [Name (NI) 4051] in [Name (NI) 3844] (HCP). Still volunteers at [Hospital3 ]. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Brother had rheumatic heart disease. Children are healthy. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam: GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of * cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ pitting edema bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Pertinent Results: [12-17] Echo: FOCUSED VIEWS AFTER AORTIC VALVULOPLASTY: The left atrium is dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). The aortic valve leaflets are severely thickened/deformed. Moderate to severe (3+) mitral regurgitation is seen. After initial valvuloplasty inflation: Trace to mild aortic regurgitation. After final valvuloplasty inflation: Mild to moderate aortic regurgitation. Gradient across aortic valve consistent with moderate to severe aortic stenosis. Compared to study from [2160-12-3], the gradient across the aortic valve is reduced (mean gradient 35 mm Hg to 25 mm Hg). The severity of aortic regurgitation is slightly increased. [12-18] Echo: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Severe pulmonic regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of [2160-12-3], the degree of aortic regurgitation has probably increased. The velocity across the aortic valve is similar but some of this velocity is due to increased aortic regurgitation. The degree of stenosis across the valve is probably slightly less (although is calculated as the same). The other findings are similar. . [12-20] CXR MPRESSION: AP chest compared to [12-4] through 19: Severe enlargement of the cardiac silhouette has not improved. Left lower lobe is still collapsed. Right basal atelectasis has worsened, but previous small right pleural effusion has decreased. There is no pulmonary edema or pneumothorax. . [12-20] CT ab/pelvis: ] 1. Hematoma along right medial pelvic wall extending from right groin with retroperitoneal extension on the right. 2. Bilateral small pleural effusions with adjacent opacities at the lung bases, likely atelectasis, cannot exclude superinfection. 3. Small pericardial effusion similar to prior. 4. Moderate atherosclerotic changes in the aorta and iliac vessels. 5. Cholelithiasis with no evidence of cholecystitis. Brief Hospital Course: [Age over 90 ] yo female with 3VD CAD s/p MI in [2156], POBA LCX, CHF with EF 25-30%, dyslipidemia, HTN, rheumatic heart disease, AV stenosis s/p valvuloplasty x2 with recent admission for CHF exacerbation c/[Initials (NamePattern4) ] [Last Name (NamePattern4) ]. Pt now represents for increased SOB and hypervolemia, partially [3-4] recent fluid boluses in OSH ED. She is s/p valvuloplasty [12-17] and continues undergoing diuresis and pain control for pelvic hematoma. On [12-20] patient decided definitively to become hospice/comfort measures only, and discussed with her family who suported her decision. She also also began experiencing decreased urine output and worsening creatinine. She became increasingly delirious and agitated with significant discomfort and was discharged to [Hospital 4470] Rehab for end of life care. . # GOALS OF CARE: Patient decided that she wanted to transition to hospice, have comfort measures only, and does not want to continue planning for valve replacement. She spoke to her daughter and expressed these wishes. She has stated on multiple occasions that "I know I'm dying, I just want to be comfortable." She became increasingly dyspneic and delirious with chest pain. We attempted to diurese for comfort but her kidney function is also decreasing and she has very minimal uop with increasing morphine requirement. Palliative care consulted and recommended the addition of zyprexa. We are also treating empirically for uti as the patient was complaining of bladder pain. She should receive cipro 250mg daily x3days (day 1 = [12-23]). The patient's course has recently been complicated by a paranoid delirium. She sometimes refuses PO medications though has been taking concentrated oral morphine and zydis. She had been agitated by delusions that her children have died or been killed. She is intermittently placated by staff presence, but also becomes paranoid that we are trying to harm her. Her daughter visited and was a calming presence. On day of discharge the patient was increasingly lethargic and non-verbal. She has become anuric. She will be transferred to Alliance [Location (un) 38] for end of life care. . # Congestive heart failure/severe aortic stenosis: On admission patient was s/p aortic balloon valvuloplasty x 2, with recent admission for CHF exacerbation. Has already been evaluated by cardiac surgeons who deem her extreme risk for conventional aortic valve replacement and has been managed medically in an attempt to bridge to percutaneous valve replacement. The patient was diuresed on previous admission to a 2L O2 requirement. However, diuresis was held on discharge due to creatinine increase(1.4-->3.6). She was discharged on Bumex PRN SOB. At rehab Bumex was restarted on [12-12]. On previous admission it was felt that valvuloplasty would not provide significant improvement of functional status or renal perfusion, however, given failure of medical management, valvuloplasty was done to perpetuate cardiac function until percutanous valve replacement becomes available at [Hospital1 18]. Compared to prior echo before valvuloplasty, the degree of aortic regurgitation has probably increased. The velocity across the aortic valve is similar but some of this velocity is due to increased aortic regurgitation. The degree of stenosis across the valve is probably slightly less (although is calculated as the same). However, patient now has deteriorating course and has elected to be comfort measures only. . # Pelvic hematoma: [3-4] perc valvloplasty. Pt is experience significant pain. pain management as above. . # Coronary Artery Disease: Continued ASA and atorvastatin. Now dced [3-4] goals of care. . # Chronic Kidney Disease: Cr increasing. Urine output decreasing. Will not monitor [3-4] goals of care. . # Gout: dced allopurinol [3-4] goals of care. . # GERD: dced pantoprazole [3-4] goals of care. . # CODE: DNR/DNI, COMFORT MEASURES ONLY. Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS (Every 3 Days). 8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 12. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for chest pain. 13. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 14. bumetanide 1 mg Tablet Sig: One (1) Tablet PO as instructed: Give one dose if patient gains 3lbs or develops shortness of breath not relieved with PO morphine. . 15. Outpatient Lab Work Please check Chem 10 on Friday [2160-12-12]. 16. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day). 2. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 4. morphine concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1H (every hour) as needed for pain, discomfort. 5. morphine concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q4H (every 4 hours). Discharge Disposition: Extended Care Facility: [Hospital 4470] HealthCare Center at [Location (un) 38] Discharge Diagnosis: End stage CHF, Severe aortic stenosis. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. [Known lastname 4471], It was a pleasure participating in your care. You were admitted for severe aortic stenosis and heart failure. You underwent aortic valvuloplasty however did not have improvement of your heart function. You decided to become comfort measures only, meaning you will only be treated symptomatically, you no longer want to pursue life-prolonging therapies. You have been having a significant amount of delirium, agitation and pain, which we are attempting to treat with morphine and zyprexa. You also have complained of bladder pain concerning for urinary tract infection and so we will treat you with a 3 day course of cipro. You are being discharged to Alliance in [Location (un) 38**] where you will continue your comfort care. Followup Instructions: none	Admission Date: <Date>1923-3-22</Date> Discharge Date: <Date>1937-8-25</Date> Service: MEDICINE Allergies: Ibuprofen / Percocet / Naprosyn / Percodan Attending:<Name>King</Name> Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Valvuloplasty History of Present Illness: <Age>40</Age> yo female with 3VD CAD s/p MI in <Year>1987</Year>, POBA LCX, CHF with EF 25% with worsening RV function, dyslipidemia, HTN, rheumatic heart disease, AV stenosis s/p valvuloplasty x2 with recent CHF exacerbation c/<Initial>RL</Initial> <Name>Hazelwood</Name>. Patient had been doing well at rehab. Bumex was restarted <Date>11-31</Date>. Last night developed SOB and was sent to <Hospital>Wilson, Campos and Bush Health System</Hospital> Hosp ER where they felt she was hypovolemic and treated with 2L IVF and sent her back to <Location>65263 Rodgers Lake Suite 250 Janicebury, MO 62711</Location>. This am, the patient experienced worsening SOB. She was treated with Morphine, Bumex 1mg x 2, and <Date>1-5</Date> of a 1/150 SL nitro x 2 b/c pt c/o chest tightness. After taking nitro the pt's BP dropped to 90/s the later returned to baseline 100s. At time of transfer her O2 sat was 94% on 2Lnc but will dip down to 88% with talking or sips of water. . On the floor the patient was complaining of dry mouth and thirst and drinking water. She denied SOB, chest pain, or any other discomfort. She denies cough, fever, chills. However, she stated she had had some delirium at the rehab due to double dose of morphine but was unclear about the exact events. She is aware that she is at <Hospital>Hendricks-Mclean Clinic</Hospital>. . The patient has severe aortic stenosis with low output (EF = 25%), and she underwent a valvuloplasty in <Month>November</Month>. She also has diffuse disease of the LAD and RCA. Cardiac catheterization confirmed significant gradient in setting of low EF, so another valvuloplasty was performed, which dropped the gradient from 31 to 23 mmHg. The patient tolerated the procedure well and was stable afterwards. She was given Lasix. Her groin site was closed. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: <Date>1975-1-12</Date>: 3VD; Successful POBA to proximal circumflex lesion; successful balloon aortic valvuloplasty 3. OTHER PAST MEDICAL HISTORY: Severe AS s/p aortic balloon valvuloplasty on <Date>1-26</Date> and again on <Date>2004-9-2</Date> CAD s/p MI in <Year>1987</Year>; recent POBA to LCx, 3VD CHF HTN HL CKD Pneumonia Iron deficiency Psoriasis Nephrolithiasis Appendectomy Thrombocytopenia s/p TAH s/p L hip fracture and repair Social History: Lives independently in <Hospital>Hendricks-Mclean Clinic</Hospital>. Still drives. Walks with cane. Husband died 15 years ago. She has 2 children - son <Name>Orville Deluna</Name> in Ca. Daughter <Name>Teresita Ignacio</Name> in <Name>Sachin Pichardo</Name> (HCP). Still volunteers at <Hospital>Thompson LLC Hospital</Hospital>. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Brother had rheumatic heart disease. Children are healthy. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam: GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of *** cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ pitting edema bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Pertinent Results: <Date>4-11</Date> Echo: FOCUSED VIEWS AFTER AORTIC VALVULOPLASTY: The left atrium is dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). The aortic valve leaflets are severely thickened/deformed. Moderate to severe (3+) mitral regurgitation is seen. After initial valvuloplasty inflation: Trace to mild aortic regurgitation. After final valvuloplasty inflation: Mild to moderate aortic regurgitation. Gradient across aortic valve consistent with moderate to severe aortic stenosis. Compared to study from <Date>2018-7-11</Date>, the gradient across the aortic valve is reduced (mean gradient 35 mm Hg to 25 mm Hg). The severity of aortic regurgitation is slightly increased. <Date>5-14</Date> Echo: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Severe pulmonic regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of <Date>2018-7-11</Date>, the degree of aortic regurgitation has probably increased. The velocity across the aortic valve is similar but some of this velocity is due to increased aortic regurgitation. The degree of stenosis across the valve is probably slightly less (although is calculated as the same). The other findings are similar. . <Date>9-20</Date> CXR MPRESSION: AP chest compared to <Date>6-10</Date> through 19: Severe enlargement of the cardiac silhouette has not improved. Left lower lobe is still collapsed. Right basal atelectasis has worsened, but previous small right pleural effusion has decreased. There is no pulmonary edema or pneumothorax. . <Date>9-20</Date> CT ab/pelvis: ] 1. Hematoma along right medial pelvic wall extending from right groin with retroperitoneal extension on the right. 2. Bilateral small pleural effusions with adjacent opacities at the lung bases, likely atelectasis, cannot exclude superinfection. 3. Small pericardial effusion similar to prior. 4. Moderate atherosclerotic changes in the aorta and iliac vessels. 5. Cholelithiasis with no evidence of cholecystitis. Brief Hospital Course: <Age>40</Age> yo female with 3VD CAD s/p MI in <Year>1987</Year>, POBA LCX, CHF with EF 25-30%, dyslipidemia, HTN, rheumatic heart disease, AV stenosis s/p valvuloplasty x2 with recent admission for CHF exacerbation c/<Initial>RL</Initial> <Name>Hazelwood</Name>. Pt now represents for increased SOB and hypervolemia, partially <Date>4-23</Date> recent fluid boluses in OSH ED. She is s/p valvuloplasty <Date>4-11</Date> and continues undergoing diuresis and pain control for pelvic hematoma. On <Date>9-20</Date> patient decided definitively to become hospice/comfort measures only, and discussed with her family who suported her decision. She also also began experiencing decreased urine output and worsening creatinine. She became increasingly delirious and agitated with significant discomfort and was discharged to <Hospital>Bass, Howell and Franco Medical Center</Hospital> Rehab for end of life care. . # GOALS OF CARE: Patient decided that she wanted to transition to hospice, have comfort measures only, and does not want to continue planning for valve replacement. She spoke to her daughter and expressed these wishes. She has stated on multiple occasions that "I know I'm dying, I just want to be comfortable." She became increasingly dyspneic and delirious with chest pain. We attempted to diurese for comfort but her kidney function is also decreasing and she has very minimal uop with increasing morphine requirement. Palliative care consulted and recommended the addition of zyprexa. We are also treating empirically for uti as the patient was complaining of bladder pain. She should receive cipro 250mg daily x3days (day 1 = <Date>10-27</Date>). The patient's course has recently been complicated by a paranoid delirium. She sometimes refuses PO medications though has been taking concentrated oral morphine and zydis. She had been agitated by delusions that her children have died or been killed. She is intermittently placated by staff presence, but also becomes paranoid that we are trying to harm her. Her daughter visited and was a calming presence. On day of discharge the patient was increasingly lethargic and non-verbal. She has become anuric. She will be transferred to Alliance <Location>94447 Gray Row Johnburgh, PA 04504</Location> for end of life care. . # Congestive heart failure/severe aortic stenosis: On admission patient was s/p aortic balloon valvuloplasty x 2, with recent admission for CHF exacerbation. Has already been evaluated by cardiac surgeons who deem her extreme risk for conventional aortic valve replacement and has been managed medically in an attempt to bridge to percutaneous valve replacement. The patient was diuresed on previous admission to a 2L O2 requirement. However, diuresis was held on discharge due to creatinine increase(1.4-->3.6). She was discharged on Bumex PRN SOB. At rehab Bumex was restarted on <Date>11-31</Date>. On previous admission it was felt that valvuloplasty would not provide significant improvement of functional status or renal perfusion, however, given failure of medical management, valvuloplasty was done to perpetuate cardiac function until percutanous valve replacement becomes available at <Hospital>Williams, Williams and Whitney Health System</Hospital>. Compared to prior echo before valvuloplasty, the degree of aortic regurgitation has probably increased. The velocity across the aortic valve is similar but some of this velocity is due to increased aortic regurgitation. The degree of stenosis across the valve is probably slightly less (although is calculated as the same). However, patient now has deteriorating course and has elected to be comfort measures only. . # Pelvic hematoma: <Date>4-23</Date> perc valvloplasty. Pt is experience significant pain. pain management as above. . # Coronary Artery Disease: Continued ASA and atorvastatin. Now dced <Date>4-23</Date> goals of care. . # Chronic Kidney Disease: Cr increasing. Urine output decreasing. Will not monitor <Date>4-23</Date> goals of care. . # Gout: dced allopurinol <Date>4-23</Date> goals of care. . # GERD: dced pantoprazole <Date>4-23</Date> goals of care. . # CODE: DNR/DNI, COMFORT MEASURES ONLY. Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS (Every 3 Days). 8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 12. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for chest pain. 13. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 14. bumetanide 1 mg Tablet Sig: One (1) Tablet PO as instructed: Give one dose if patient gains 3lbs or develops shortness of breath not relieved with PO morphine. . 15. Outpatient Lab Work Please check Chem 10 on Friday <Date>1971-10-12</Date>. 16. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day). 2. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 4. morphine concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1H (every hour) as needed for pain, discomfort. 5. morphine concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q4H (every 4 hours). Discharge Disposition: Extended Care Facility: <Hospital>Bass, Howell and Franco Medical Center</Hospital> HealthCare Center at <Location>94447 Gray Row Johnburgh, PA 04504</Location> Discharge Diagnosis: End stage CHF, Severe aortic stenosis. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. <Name>Broadnax</Name>, It was a pleasure participating in your care. You were admitted for severe aortic stenosis and heart failure. You underwent aortic valvuloplasty however did not have improvement of your heart function. You decided to become comfort measures only, meaning you will only be treated symptomatically, you no longer want to pursue life-prolonging therapies. You have been having a significant amount of delirium, agitation and pain, which we are attempting to treat with morphine and zyprexa. You also have complained of bladder pain concerning for urinary tract infection and so we will treat you with a 3 day course of cipro. You are being discharged to Alliance in <Location>94447 Gray Row Johnburgh, PA 04504</Location> where you will continue your comfort care. Followup Instructions: 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Date: 1923-3-22 Discharge Date: 1937-8-25 Service: MEDICINE Allergies: Ibuprofen / Percocet / Naprosyn / Percodan Attending:King Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Valvuloplasty History of Present Illness: 40 yo female with 3VD CAD s/p MI in 1987, POBA LCX, CHF with EF 25% with worsening RV function, dyslipidemia, HTN, rheumatic heart disease, AV stenosis s/p valvuloplasty x2 with recent CHF exacerbation c/RL Hazelwood. Patient had been doing well at rehab. Bumex was restarted 11-31. Last night developed SOB and was sent to Wilson, Campos and Bush Health System Hosp ER where they felt she was hypovolemic and treated with 2L IVF and sent her back to 65263 Rodgers Lake Suite 250 Janicebury, MO 62711. This am, the patient experienced worsening SOB. She was treated with Morphine, Bumex 1mg x 2, and 1-5 of a 1/150 SL nitro x 2 b/c pt c/o chest tightness. After taking nitro the pt's BP dropped to 90/s the later returned to baseline 100s. At time of transfer her O2 sat was 94% on 2Lnc but will dip down to 88% with talking or sips of water. . On the floor the patient was complaining of dry mouth and thirst and drinking water. She denied SOB, chest pain, or any other discomfort. She denies cough, fever, chills. However, she stated she had had some delirium at the rehab due to double dose of morphine but was unclear about the exact events. She is aware that she is at Hendricks-Mclean Clinic. . The patient has severe aortic stenosis with low output (EF = 25%), and she underwent a valvuloplasty in November. She also has diffuse disease of the LAD and RCA. Cardiac catheterization confirmed significant gradient in setting of low EF, so another valvuloplasty was performed, which dropped the gradient from 31 to 23 mmHg. The patient tolerated the procedure well and was stable afterwards. She was given Lasix. Her groin site was closed. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: 1975-1-12: 3VD; Successful POBA to proximal circumflex lesion; successful balloon aortic valvuloplasty 3. OTHER PAST MEDICAL HISTORY: Severe AS s/p aortic balloon valvuloplasty on 1-26 and again on 2004-9-2 CAD s/p MI in 1987; recent POBA to LCx, 3VD CHF HTN HL CKD Pneumonia Iron deficiency Psoriasis Nephrolithiasis Appendectomy Thrombocytopenia s/p TAH s/p L hip fracture and repair Social History: Lives independently in Hendricks-Mclean Clinic. Still drives. Walks with cane. Husband died 15 years ago. She has 2 children - son Orville Deluna in Ca. Daughter Teresita Ignacio in Sachin Pichardo (HCP). Still volunteers at Thompson LLC Hospital. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Brother had rheumatic heart disease. Children are healthy. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam: GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of *** cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ pitting edema bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Pertinent Results: 4-11 Echo: FOCUSED VIEWS AFTER AORTIC VALVULOPLASTY: The left atrium is dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). The aortic valve leaflets are severely thickened/deformed. Moderate to severe (3+) mitral regurgitation is seen. After initial valvuloplasty inflation: Trace to mild aortic regurgitation. After final valvuloplasty inflation: Mild to moderate aortic regurgitation. Gradient across aortic valve consistent with moderate to severe aortic stenosis. Compared to study from 2018-7-11, the gradient across the aortic valve is reduced (mean gradient 35 mm Hg to 25 mm Hg). The severity of aortic regurgitation is slightly increased. 5-14 Echo: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Severe pulmonic regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of 2018-7-11, the degree of aortic regurgitation has probably increased. The velocity across the aortic valve is similar but some of this velocity is due to increased aortic regurgitation. The degree of stenosis across the valve is probably slightly less (although is calculated as the same). The other findings are similar. . 9-20 CXR MPRESSION: AP chest compared to 6-10 through 19: Severe enlargement of the cardiac silhouette has not improved. Left lower lobe is still collapsed. Right basal atelectasis has worsened, but previous small right pleural effusion has decreased. There is no pulmonary edema or pneumothorax. . 9-20 CT ab/pelvis: ] 1. Hematoma along right medial pelvic wall extending from right groin with retroperitoneal extension on the right. 2. Bilateral small pleural effusions with adjacent opacities at the lung bases, likely atelectasis, cannot exclude superinfection. 3. Small pericardial effusion similar to prior. 4. Moderate atherosclerotic changes in the aorta and iliac vessels. 5. Cholelithiasis with no evidence of cholecystitis. Brief Hospital Course: 40 yo female with 3VD CAD s/p MI in 1987, POBA LCX, CHF with EF 25-30%, dyslipidemia, HTN, rheumatic heart disease, AV stenosis s/p valvuloplasty x2 with recent admission for CHF exacerbation c/RL Hazelwood. Pt now represents for increased SOB and hypervolemia, partially 4-23 recent fluid boluses in OSH ED. She is s/p valvuloplasty 4-11 and continues undergoing diuresis and pain control for pelvic hematoma. On 9-20 patient decided definitively to become hospice/comfort measures only, and discussed with her family who suported her decision. She also also began experiencing decreased urine output and worsening creatinine. She became increasingly delirious and agitated with significant discomfort and was discharged to Bass, Howell and Franco Medical Center Rehab for end of life care. . # GOALS OF CARE: Patient decided that she wanted to transition to hospice, have comfort measures only, and does not want to continue planning for valve replacement. She spoke to her daughter and expressed these wishes. She has stated on multiple occasions that "I know I'm dying, I just want to be comfortable." She became increasingly dyspneic and delirious with chest pain. We attempted to diurese for comfort but her kidney function is also decreasing and she has very minimal uop with increasing morphine requirement. Palliative care consulted and recommended the addition of zyprexa. We are also treating empirically for uti as the patient was complaining of bladder pain. She should receive cipro 250mg daily x3days (day 1 = 10-27). The patient's course has recently been complicated by a paranoid delirium. She sometimes refuses PO medications though has been taking concentrated oral morphine and zydis. She had been agitated by delusions that her children have died or been killed. She is intermittently placated by staff presence, but also becomes paranoid that we are trying to harm her. Her daughter visited and was a calming presence. On day of discharge the patient was increasingly lethargic and non-verbal. She has become anuric. She will be transferred to Alliance 94447 Gray Row Johnburgh, PA 04504 for end of life care. . # Congestive heart failure/severe aortic stenosis: On admission patient was s/p aortic balloon valvuloplasty x 2, with recent admission for CHF exacerbation. Has already been evaluated by cardiac surgeons who deem her extreme risk for conventional aortic valve replacement and has been managed medically in an attempt to bridge to percutaneous valve replacement. The patient was diuresed on previous admission to a 2L O2 requirement. However, diuresis was held on discharge due to creatinine increase(1.4-->3.6). She was discharged on Bumex PRN SOB. At rehab Bumex was restarted on 11-31. On previous admission it was felt that valvuloplasty would not provide significant improvement of functional status or renal perfusion, however, given failure of medical management, valvuloplasty was done to perpetuate cardiac function until percutanous valve replacement becomes available at Williams, Williams and Whitney Health System. Compared to prior echo before valvuloplasty, the degree of aortic regurgitation has probably increased. The velocity across the aortic valve is similar but some of this velocity is due to increased aortic regurgitation. The degree of stenosis across the valve is probably slightly less (although is calculated as the same). However, patient now has deteriorating course and has elected to be comfort measures only. . # Pelvic hematoma: 4-23 perc valvloplasty. Pt is experience significant pain. pain management as above. . # Coronary Artery Disease: Continued ASA and atorvastatin. Now dced 4-23 goals of care. . # Chronic Kidney Disease: Cr increasing. Urine output decreasing. Will not monitor 4-23 goals of care. . # Gout: dced allopurinol 4-23 goals of care. . # GERD: dced pantoprazole 4-23 goals of care. . # CODE: DNR/DNI, COMFORT MEASURES ONLY. Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS (Every 3 Days). 8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 12. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for chest pain. 13. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 14. bumetanide 1 mg Tablet Sig: One (1) Tablet PO as instructed: Give one dose if patient gains 3lbs or develops shortness of breath not relieved with PO morphine. . 15. Outpatient Lab Work Please check Chem 10 on Friday 1971-10-12. 16. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day). 2. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 4. morphine concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1H (every hour) as needed for pain, discomfort. 5. morphine concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q4H (every 4 hours). Discharge Disposition: Extended Care Facility: Bass, Howell and Franco Medical Center HealthCare Center at 94447 Gray Row Johnburgh, PA 04504 Discharge Diagnosis: End stage CHF, Severe aortic stenosis. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. Broadnax, It was a pleasure participating in your care. You were admitted for severe aortic stenosis and heart failure. You underwent aortic valvuloplasty however did not have improvement of your heart function. You decided to become comfort measures only, meaning you will only be treated symptomatically, you no longer want to pursue life-prolonging therapies. You have been having a significant amount of delirium, agitation and pain, which we are attempting to treat with morphine and zyprexa. You also have complained of bladder pain concerning for urinary tract infection and so we will treat you with a 3 day course of cipro. You are being discharged to Alliance in 94447 Gray Row Johnburgh, PA 04504 where you will continue your comfort care. Followup Instructions: none	['Admission Date: 1923-3-22 Discharge Date: 1937-8-25\n\n\nService: MEDICINE\n\nAllergies:\nIbuprofen / Percocet / Naprosyn / Percodan\n\nAttending:King\nChief Complaint:\nDyspnea\n\nMajor Surgical or Invasive Procedure:\nValvuloplasty\n\nHistory of Present Illness:\n40 yo female with 3VD CAD s/p MI in 1987, POBA LCX, CHF with EF\n25% with worsening RV function, dyslipidemia, HTN, rheumatic\nheart disease, AV stenosis s/p valvuloplasty x2 with recent CHF\nexacerbation c/RL Hazelwood. Patient had been doing well at rehab.\nBumex was restarted 11-31. Last night developed SOB and was sent\nto Wilson, Campos and Bush Health System Hosp ER where they felt she was hypovolemic and\ntreated with 2L IVF and sent her back to 65263 Rodgers Lake Suite 250\nJanicebury, MO 62711. This am, the\npatient experienced worsening SOB.', " She was treated with\nMorphine, Bumex 1mg x 2, and 1-5 of a 1/150 SL nitro x 2 b/c pt\nc/o chest tightness. After taking nitro the pt's BP dropped to\n90/s the later returned to baseline 100s. At time of transfer\nher O2 sat was 94% on 2Lnc but will dip down to 88% with talking\nor sips of water.\n.\nOn the floor the patient was complaining of dry mouth and thirst\nand drinking water. She denied SOB, chest pain, or any other\ndiscomfort. She denies cough, fever, chills. However, she stated\nshe had had some delirium at the rehab due to double dose of\nmorphine but was unclear about the exact events. She is aware\nthat she is at Hendricks-Mclean Clinic.\n.\nThe patient has severe aortic stenosis with low output (EF =\n25%), and she underwent a valvuloplasty in November. She also has\ndiffuse disease of the LAD and RCA.", ' Cardiac catheterization\nconfirmed significant gradient in setting of low EF, so another\nvalvuloplasty was performed, which dropped the gradient from 31\nto 23 mmHg. The patient tolerated the procedure well and was\nstable afterwards. She was given Lasix. Her groin site was\nclosed.\n\n\nPast Medical History:\n1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n2. CARDIAC HISTORY:\n-PERCUTANEOUS CORONARY INTERVENTIONS: 1975-1-12: 3VD; Successful\nPOBA to proximal circumflex lesion; successful balloon aortic\nvalvuloplasty\n3. OTHER PAST MEDICAL HISTORY:\nSevere AS s/p aortic balloon valvuloplasty on 1-26 and again on\n2004-9-2\nCAD s/p MI in 1987; recent POBA to LCx, 3VD\nCHF\nHTN\nHL\nCKD\nPneumonia\nIron deficiency\nPsoriasis\nNephrolithiasis\nAppendectomy\nThrombocytopenia\ns/p TAH\ns/p L hip fracture and repair\n\n\nSocial History:\nLives independently in Hendricks-Mclean Clinic.', ' Still drives. Walks with cane.\nHusband died 15 years ago. She has 2 children - son Orville Deluna in Ca.\nDaughter Teresita Ignacio in Sachin Pichardo (HCP). Still volunteers at\nThompson LLC Hospital.\n-Tobacco history: none\n-ETOH: none\n-Illicit drugs: none\n\n\nFamily History:\nBrother had rheumatic heart disease. Children are healthy.\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death; otherwise non-contributory.\n\n\nPhysical Exam:\nAdmission Exam:\nGENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.\nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were\npink, no pallor or cyanosis of the oral mucosa. No xanthalesma.\n\nNECK: Supple with JVP of *** cm.\nCARDIAC: PMI located in 5th intercostal space, midclavicular\nline. RR, normal S1, S2. No m/r/g. No thrills, lifts.', ' No S3 or\nS4.\nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. CTAB, no crackles,\nwheezes or rhonchi.\nABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not\nenlarged by palpation. No abdominial bruits.\nEXTREMITIES: 2+ pitting edema bilaterally\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES:\nRight: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\nLeft: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n.\n\n\nPertinent Results:\n4-11 Echo:\nFOCUSED VIEWS AFTER AORTIC VALVULOPLASTY: The left atrium is\ndilated. Overall left ventricular systolic function is severely\ndepressed (LVEF= 20-25 %). The aortic valve leaflets are\nseverely thickened/deformed. Moderate to severe (3+) mitral\nregurgitation is seen.\n\nAfter initial valvuloplasty inflation: Trace to mild aortic\nregurgitation.', '\n\nAfter final valvuloplasty inflation: Mild to moderate aortic\nregurgitation. Gradient across aortic valve consistent with\nmoderate to severe aortic stenosis.\n\nCompared to study from 2018-7-11, the gradient across the aortic\nvalve is reduced (mean gradient 35 mm Hg to 25 mm Hg). The\nseverity of aortic regurgitation is slightly increased.\n\n5-14 Echo:\nThe left atrium is dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Overall left\nventricular systolic function is severely depressed (LVEF= 20-25\n%). There is no ventricular septal defect. The right ventricular\ncavity is mildly dilated with mild global free wall hypokinesis.\nThere are three aortic valve leaflets. The aortic valve leaflets\nare severely thickened/deformed. There is severe aortic valve\nstenosis (valve area 0.', '8-1.0cm2). Moderate (2+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Moderate to severe\n(3+) mitral regurgitation is seen. The tricuspid valve leaflets\nare mildly thickened. Moderate [2+] tricuspid regurgitation is\nseen. There is moderate pulmonary artery systolic hypertension.\nSevere pulmonic regurgitation is seen. There is a small\npericardial effusion. There are no echocardiographic signs of\ntamponade. Echocardiographic signs of tamponade may be absent in\nthe presence of elevated right sided pressures.\n\nCompared with the prior study (images reviewed) of 2018-7-11,\nthe degree of aortic regurgitation has probably increased. The\nvelocity across the aortic valve is similar but some of this\nvelocity is due to increased aortic regurgitation.', ' The degree of\nstenosis across the valve is probably slightly less (although is\ncalculated as the same). The other findings are similar.\n.\n9-20 CXR MPRESSION: AP chest compared to 6-10 through 19:\n\n\nSevere enlargement of the cardiac silhouette has not improved.\nLeft lower\nlobe is still collapsed. Right basal atelectasis has worsened,\nbut previous\nsmall right pleural effusion has decreased. There is no\npulmonary edema or\npneumothorax.\n.\n9-20 CT ab/pelvis: ]\n1. Hematoma along right medial pelvic wall extending from right\ngroin with\nretroperitoneal extension on the right.\n2. Bilateral small pleural effusions with adjacent opacities at\nthe lung\nbases, likely atelectasis, cannot exclude superinfection.\n3. Small pericardial effusion similar to prior.\n4. Moderate atherosclerotic changes in the aorta and iliac\nvessels.', '\n5. Cholelithiasis with no evidence of cholecystitis.\n\n\nBrief Hospital Course:\n40 yo female with 3VD CAD s/p MI in 1987, POBA LCX, CHF with EF\n25-30%, dyslipidemia, HTN, rheumatic heart disease, AV stenosis\ns/p valvuloplasty x2 with recent admission for CHF exacerbation\nc/RL Hazelwood. Pt now represents for increased SOB and hypervolemia,\npartially 4-23 recent fluid boluses in OSH ED. She is s/p\nvalvuloplasty 4-11 and continues undergoing diuresis and pain\ncontrol for pelvic hematoma. On 9-20 patient decided\ndefinitively to become hospice/comfort measures only, and\ndiscussed with her family who suported her decision. She also\nalso began experiencing decreased urine output and worsening\ncreatinine. She became increasingly delirious and agitated with\nsignificant discomfort and was discharged to Bass, Howell and Franco Medical Center Rehab for\nend of life care.', '\n.\n# GOALS OF CARE: Patient decided that she wanted to transition\nto hospice, have comfort measures only, and does not want to\ncontinue planning for valve replacement. She spoke to her\ndaughter and expressed these wishes. She has stated on multiple\noccasions that "I know I\'m dying, I just want to be\ncomfortable." She became increasingly dyspneic and delirious\nwith chest pain. We attempted to diurese for comfort but her\nkidney function is also decreasing and she has very minimal uop\nwith increasing morphine requirement. Palliative care consulted\nand recommended the addition of zyprexa. We are also treating\nempirically for uti as the patient was complaining of bladder\npain. She should receive cipro 250mg daily x3days (day 1 =\n10-27). The patient\'s course has recently been complicated by a\nparanoid delirium.', ' She sometimes refuses PO medications though\nhas been taking concentrated oral morphine and zydis. She had\nbeen agitated by delusions that her children have died or been\nkilled. She is intermittently placated by staff presence, but\nalso becomes paranoid that we are trying to harm her. Her\ndaughter visited and was a calming presence. On day of discharge\nthe patient was increasingly lethargic and non-verbal. She has\nbecome anuric. She will be transferred to Alliance 94447 Gray Row\nJohnburgh, PA 04504 for\nend of life care.\n.\n# Congestive heart failure/severe aortic stenosis: On admission\npatient was s/p aortic balloon valvuloplasty x 2, with recent\nadmission for CHF exacerbation. Has already been evaluated by\ncardiac surgeons who deem her extreme risk for conventional\naortic valve replacement and has been managed medically in an\nattempt to bridge to percutaneous valve replacement.', ' The patient\nwas diuresed on previous admission to a 2L O2 requirement.\nHowever, diuresis was held on discharge due to creatinine\nincrease(1.4-->3.6). She was discharged on Bumex PRN SOB. At\nrehab Bumex was restarted on 11-31. On previous admission it was\nfelt that valvuloplasty would not provide significant\nimprovement of functional status or renal perfusion, however,\ngiven failure of medical management, valvuloplasty was done to\nperpetuate cardiac function until percutanous valve replacement\nbecomes available at Williams, Williams and Whitney Health System. Compared to prior echo before\nvalvuloplasty, the degree of aortic regurgitation has probably\nincreased. The velocity across the aortic valve is similar but\nsome of this velocity is due to increased aortic regurgitation.\nThe degree of stenosis across the valve is probably slightly\nless (although is calculated as the same).', ' However, patient now\nhas deteriorating course and has elected to be comfort measures\nonly.\n.\n# Pelvic hematoma: 4-23 perc valvloplasty. Pt is experience\nsignificant pain. pain management as above.\n.\n# Coronary Artery Disease: Continued ASA and atorvastatin. Now\ndced 4-23 goals of care.\n.\n# Chronic Kidney Disease: Cr increasing. Urine output\ndecreasing. Will not monitor 4-23 goals of care.\n.\n# Gout: dced allopurinol 4-23 goals of care.\n.\n# GERD: dced pantoprazole 4-23 goals of care.\n.\n# CODE: DNR/DNI, COMFORT MEASURES ONLY.\n\n\nMedications on Admission:\n1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\n\nPO DAILY (Daily).\n2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)\nTablet PO DAILY (Daily).', '\n5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every\n\n6 hours) as needed for pain.\n6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,\n\nRapid Dissolve PO Q8H (every 8 hours) as needed for nausea.\n7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS\n\n(Every 3 Days).\n8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical\nDAILY (Daily).\n9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\n\ntimes a day).\n10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)\ndose PO DAILY (Daily) as needed for constipation.\n12. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)\n\nas needed for chest pain.\n13. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H\n(every 24 hours) for 3 days.', '\n14. bumetanide 1 mg Tablet Sig: One (1) Tablet PO as instructed:\n\nGive one dose if patient gains 3lbs or develops shortness of\nbreath not relieved with PO morphine. .\n15. Outpatient Lab Work\nPlease check Chem 10 on Friday 1971-10-12.\n16. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1)\nTablet PO once a day.\n\n\nDischarge Medications:\n1. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid\nDissolve PO BID (2 times a day).\n2. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H\n(every 24 hours) for 3 days.\n3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,\nRapid Dissolve PO Q8H (every 8 hours) as needed for nausea.\n4. morphine concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1H\n(every hour) as needed for pain, discomfort.\n5. morphine concentrate 20 mg/mL Solution Sig: Five (5) mg PO\nQ4H (every 4 hours).', '\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nBass, Howell and Franco Medical Center HealthCare Center at 94447 Gray Row\nJohnburgh, PA 04504\n\nDischarge Diagnosis:\nEnd stage CHF, Severe aortic stenosis.\n\n\nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Ambulatory - requires assistance or aid (walker\nor cane).\n\n\nDischarge Instructions:\nDear Mrs. Broadnax,\n It was a pleasure participating in your care. You were\nadmitted for severe aortic stenosis and heart failure. You\nunderwent aortic valvuloplasty however did not have improvement\nof your heart function. You decided to become comfort measures\nonly, meaning you will only be treated symptomatically, you no\nlonger want to pursue life-prolonging therapies. You have been\nhaving a significant amount of delirium, agitation and pain,\nwhich we are attempting to treat with morphine and zyprexa.', ' You\nalso have complained of bladder pain concerning for urinary\ntract infection and so we will treat you with a 3 day course of\ncipro. You are being discharged to Alliance in 94447 Gray Row\nJohnburgh, PA 04504 where\nyou will continue your comfort care.\n\nFollowup Instructions:\nnone\n\n\n\n']
545	6787	157546.0	2175-03-04	Discharge summary	Report	Admission Date: [2175-1-28] Discharge Date: [2175-3-4] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4111] Chief Complaint: aspiration pneumonia Major Surgical or Invasive Procedure: G-J tube replacement PICC line placement History of Present Illness: Patient is a [Age over 90 ] year old man with a long history of a persistent vegetative state recently admitted to [Hospital1 112] with an aspiration pneumonia. He required intubation and was maintained on TPN and tube feedings until he was able to be extubated and discharged to rehab. He returns after only a few days after a presumed episode of reaspiration again requiring intubation and pressor support. Past Medical History: -Alzheimer disease -persistent vegetative state -GERD -h/o aspiration PNA -osteopenia -atrial fibrillation -myoclonus Social History: Has been cared for by his daughter for the past three years. Family History: Noncontributory Physical Exam: Gen unresponsive, resting comfortably Neck flexed with no masses CV RRR no m/r/g Resp coarse BS bilaterally Abd mildly distended, slightly firm, GJ tube in place Ext [12-19]+ LE edema Sacral decub w/dressing in place Neuro unresponsive Pertinent Results: [2175-3-2] 02:43AM BLOOD WBC-10.9 RBC-3.50* Hgb-10.4* Hct-31.8* MCV-91 MCH-29.6 MCHC-32.7 RDW-19.9* Plt Ct-339 [2175-2-24] 02:58AM BLOOD Neuts-71* Bands-2 Lymphs-11* Monos-6 Eos-3 Baso-1 Atyps-1* Metas-3* Myelos-2* [2175-2-24] 02:58AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-1+ Polychr-1+ Schisto-1+ Tear Dr[Last Name (STitle) ]1+ [2175-3-2] 02:43AM BLOOD Plt Ct-339 [2175-2-22] 03:31AM BLOOD PT-16.1* PTT-28.1 INR(PT)-1.5* [2175-3-2] 02:43AM BLOOD Glucose-97 UreaN-35* Creat-1.0 Na-138 K-3.7 Cl-97 HCO3-30 AnGap-15 [2175-2-11] 04:24PM BLOOD ALT-24 AST-36 AlkPhos-150* Amylase-64 TotBili-0.4 [2175-2-11] 04:24PM BLOOD Lipase-72* [2175-3-2] 02:43AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.6 [2175-2-27] 02:17AM BLOOD calTIBC-256* Ferritn-215 TRF-197* [2175-3-2] 08:28AM BLOOD Vanco-20.6* [2175-3-4] 07:25AM BLOOD Vanco-PND [2175-2-18] 02:13AM BLOOD HoldBLu-HOLD [2175-2-18] 10:23PM BLOOD Glucose-110* K-3.8 [2175-2-8] 05:44PM BLOOD O2 Sat-97 [2175-2-27] 02:49AM BLOOD freeCa-1.18 Brief Hospital Course: Neuro-patient is in a persistent vegetative state and remained unresponsive and at his baseline throughout his hospital stay. Cardiovascular-patient was weaned off of pressor support shortly after admission, he was maintained on iv metoprolol with adequate control of his blood pressure. However, the pt. does not tolerate being turned on his right side - his pressures will decrease somewhat. If this occurs - place pt. back to supine position and blood pressure should correct. Respiratory-patient was intubated on admission. A series of discussions were had with the [Hospital 228] health care proxy, his daughter, regarding the need for tracheostomy. Both the primary general surgery team and the thoracic team were consulted regarding the need for tracheostomy. Eventually, a second opinion was requested by the daughter and obtained from general surgery. The daughter was told that the patient would likely benefit from tracheostomy and that extubation could very well lead to reintubation considering the patient's poor functional status. The daughter decided to attempt extubation, the pt. was extubated and has been doing very well for the past several days off of the vent. He has been maintaining O2 saturations in the high 90s with minimal oxygen from the face tent. GI-the patient was started on TPN for nutritional support. He was also given tube feedings. He is currently being maintained on tube feeds and no TPN. His albumin has been stable with this regimen and he should be continued on this: Nepro 45% strength for Osm of 280 at a goal rate of 70cc/hour. GU-Pt. has been getting Lasix throughout his stay for help w/diuresis. He was initially quite volume overloaded and need this to get fluid off so he could be extubated. He is no longer requiring lasix and is making adequate uring on his own. His renal function has also returned to [Location 213]. [Name (NI) ] The pt. received a few transfusions of PRBCs during his and for the past week his hematocrit has been stable. We do not anticipate that he will need any further transfusions. [Name (NI) ] Pt. was initially being treated for aspiration pneumonia and is requiring two more day of antibiotics to complete his course. His WBCs have been stable. Endo- stable Medications on Admission: vancomycin/ceftriaxone/flagyl, colace, lasix, reglan, enoxaparin Discharge Medications: 1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm Intravenous Q 24H (Every 24 Hours): - for 2 days [3-4] and [3-5]. 2. Zosyn 2.25 g Recon Soln Sig: 2.25 gm Intravenous every eight (8) hours for 2 days: - for [3-4] and [3-5]. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-19] Drops Ophthalmic PRN (as needed). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15) ML PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection [Hospital1 ] (2 times a day). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb neb Inhalation Q6H (every 6 hours). 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day: via j-tube. 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 12. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: -persistent vegetative state -pneumonia -bacteremia Discharge Condition: stable Discharge Instructions: -please return to the emergency department if the patient has shortness of breath, inability to tolerate tube feedings, fever >101.4F or any other problems Followup Instructions: Please follow up with Dr. [Last Name (STitle) 957] as necessary. Call [Telephone/Fax (1) 673] for an appointment.	Admission Date: <Date>1932-8-16</Date> Discharge Date: <Date>1956-3-31</Date> Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Leena</Name> Chief Complaint: aspiration pneumonia Major Surgical or Invasive Procedure: G-J tube replacement PICC line placement History of Present Illness: Patient is a <Age>14</Age> year old man with a long history of a persistent vegetative state recently admitted to <Hospital>Flores-Rogers Health System</Hospital> with an aspiration pneumonia. He required intubation and was maintained on TPN and tube feedings until he was able to be extubated and discharged to rehab. He returns after only a few days after a presumed episode of reaspiration again requiring intubation and pressor support. Past Medical History: -Alzheimer disease -persistent vegetative state -GERD -h/o aspiration PNA -osteopenia -atrial fibrillation -myoclonus Social History: Has been cared for by his daughter for the past three years. Family History: Noncontributory Physical Exam: Gen unresponsive, resting comfortably Neck flexed with no masses CV RRR no m/r/g Resp coarse BS bilaterally Abd mildly distended, slightly firm, GJ tube in place Ext <Date>6-31</Date>+ LE edema Sacral decub w/dressing in place Neuro unresponsive Pertinent Results: <Date>1933-6-29</Date> 02:43AM BLOOD WBC-10.9 RBC-3.50* Hgb-10.4* Hct-31.8* MCV-91 MCH-29.6 MCHC-32.7 RDW-19.9* Plt Ct-339 <Date>1945-1-21</Date> 02:58AM BLOOD Neuts-71* Bands-2 Lymphs-11* Monos-6 Eos-3 Baso-1 Atyps-1* Metas-3* Myelos-2* <Date>1945-1-21</Date> 02:58AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-1+ Polychr-1+ Schisto-1+ Tear Dr<Name>Poff</Name>1+ <Date>1933-6-29</Date> 02:43AM BLOOD Plt Ct-339 <Date>1997-1-29</Date> 03:31AM BLOOD PT-16.1* PTT-28.1 INR(PT)-1.5* <Date>1933-6-29</Date> 02:43AM BLOOD Glucose-97 UreaN-35* Creat-1.0 Na-138 K-3.7 Cl-97 HCO3-30 AnGap-15 <Date>1988-7-5</Date> 04:24PM BLOOD ALT-24 AST-36 AlkPhos-150* Amylase-64 TotBili-0.4 <Date>1988-7-5</Date> 04:24PM BLOOD Lipase-72* <Date>1933-6-29</Date> 02:43AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.6 <Date>1942-10-20</Date> 02:17AM BLOOD calTIBC-256* Ferritn-215 TRF-197* <Date>1933-6-29</Date> 08:28AM BLOOD Vanco-20.6* <Date>1956-3-31</Date> 07:25AM BLOOD Vanco-PND <Date>1998-12-18</Date> 02:13AM BLOOD HoldBLu-HOLD <Date>1998-12-18</Date> 10:23PM BLOOD Glucose-110* K-3.8 <Date>1990-9-18</Date> 05:44PM BLOOD O2 Sat-97 <Date>1942-10-20</Date> 02:49AM BLOOD freeCa-1.18 Brief Hospital Course: Neuro-patient is in a persistent vegetative state and remained unresponsive and at his baseline throughout his hospital stay. Cardiovascular-patient was weaned off of pressor support shortly after admission, he was maintained on iv metoprolol with adequate control of his blood pressure. However, the pt. does not tolerate being turned on his right side - his pressures will decrease somewhat. If this occurs - place pt. back to supine position and blood pressure should correct. Respiratory-patient was intubated on admission. A series of discussions were had with the <Hospital>Miller, Scott and Gonzales Medical Center</Hospital> health care proxy, his daughter, regarding the need for tracheostomy. Both the primary general surgery team and the thoracic team were consulted regarding the need for tracheostomy. Eventually, a second opinion was requested by the daughter and obtained from general surgery. The daughter was told that the patient would likely benefit from tracheostomy and that extubation could very well lead to reintubation considering the patient's poor functional status. The daughter decided to attempt extubation, the pt. was extubated and has been doing very well for the past several days off of the vent. He has been maintaining O2 saturations in the high 90s with minimal oxygen from the face tent. GI-the patient was started on TPN for nutritional support. He was also given tube feedings. He is currently being maintained on tube feeds and no TPN. His albumin has been stable with this regimen and he should be continued on this: Nepro 45% strength for Osm of 280 at a goal rate of 70cc/hour. GU-Pt. has been getting Lasix throughout his stay for help w/diuresis. He was initially quite volume overloaded and need this to get fluid off so he could be extubated. He is no longer requiring lasix and is making adequate uring on his own. His renal function has also returned to <Location>911 Caldwell Mill Suite 534 Espinozachester, MA 53284</Location>. <Name>Sharon Scheet</Name> The pt. received a few transfusions of PRBCs during his and for the past week his hematocrit has been stable. We do not anticipate that he will need any further transfusions. <Name>Sharon Scheet</Name> Pt. was initially being treated for aspiration pneumonia and is requiring two more day of antibiotics to complete his course. His WBCs have been stable. Endo- stable Medications on Admission: vancomycin/ceftriaxone/flagyl, colace, lasix, reglan, enoxaparin Discharge Medications: 1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm Intravenous Q 24H (Every 24 Hours): - for 2 days <Date>5-31</Date> and <Date>3-24</Date>. 2. Zosyn 2.25 g Recon Soln Sig: 2.25 gm Intravenous every eight (8) hours for 2 days: - for <Date>5-31</Date> and <Date>3-24</Date>. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: <Date>6-31</Date> Drops Ophthalmic PRN (as needed). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15) ML PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection <Hospital>Mcdonald LLC Clinic</Hospital> (2 times a day). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb neb Inhalation Q6H (every 6 hours). 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day: via j-tube. 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 12. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: <Hospital>Diaz, Davis and Kramer Health System</Hospital> & Rehab Center - <Hospital>Hansen, Wilson and Wolf Health System</Hospital> Discharge Diagnosis: -persistent vegetative state -pneumonia -bacteremia Discharge Condition: stable Discharge Instructions: -please return to the emergency department if the patient has shortness of breath, inability to tolerate tube feedings, fever >101.4F or any other problems Followup Instructions: Please follow up with Dr. <Name>Pichardo</Name> as necessary. Call <Telephone>854-486-4565</Telephone> for an appointment.	0000000000000000011111111100000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110001111111110000000000000000000000000011111111100000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000001111111110000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000001111111110000000000000000000000000001111111110000000000000000000000000111111111100000000000000000000000000001111111111000000000000000000000000000000000011111111100000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111111111111111111111100011111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1932-8-16 Discharge Date: 1956-3-31 Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Leena Chief Complaint: aspiration pneumonia Major Surgical or Invasive Procedure: G-J tube replacement PICC line placement History of Present Illness: Patient is a 14 year old man with a long history of a persistent vegetative state recently admitted to Flores-Rogers Health System with an aspiration pneumonia. He required intubation and was maintained on TPN and tube feedings until he was able to be extubated and discharged to rehab. He returns after only a few days after a presumed episode of reaspiration again requiring intubation and pressor support. Past Medical History: -Alzheimer disease -persistent vegetative state -GERD -h/o aspiration PNA -osteopenia -atrial fibrillation -myoclonus Social History: Has been cared for by his daughter for the past three years. Family History: Noncontributory Physical Exam: Gen unresponsive, resting comfortably Neck flexed with no masses CV RRR no m/r/g Resp coarse BS bilaterally Abd mildly distended, slightly firm, GJ tube in place Ext 6-31+ LE edema Sacral decub w/dressing in place Neuro unresponsive Pertinent Results: 1933-6-29 02:43AM BLOOD WBC-10.9 RBC-3.50* Hgb-10.4* Hct-31.8* MCV-91 MCH-29.6 MCHC-32.7 RDW-19.9* Plt Ct-339 1945-1-21 02:58AM BLOOD Neuts-71* Bands-2 Lymphs-11* Monos-6 Eos-3 Baso-1 Atyps-1* Metas-3* Myelos-2* 1945-1-21 02:58AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-1+ Polychr-1+ Schisto-1+ Tear DrPoff1+ 1933-6-29 02:43AM BLOOD Plt Ct-339 1997-1-29 03:31AM BLOOD PT-16.1* PTT-28.1 INR(PT)-1.5* 1933-6-29 02:43AM BLOOD Glucose-97 UreaN-35* Creat-1.0 Na-138 K-3.7 Cl-97 HCO3-30 AnGap-15 1988-7-5 04:24PM BLOOD ALT-24 AST-36 AlkPhos-150* Amylase-64 TotBili-0.4 1988-7-5 04:24PM BLOOD Lipase-72* 1933-6-29 02:43AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.6 1942-10-20 02:17AM BLOOD calTIBC-256* Ferritn-215 TRF-197* 1933-6-29 08:28AM BLOOD Vanco-20.6* 1956-3-31 07:25AM BLOOD Vanco-PND 1998-12-18 02:13AM BLOOD HoldBLu-HOLD 1998-12-18 10:23PM BLOOD Glucose-110* K-3.8 1990-9-18 05:44PM BLOOD O2 Sat-97 1942-10-20 02:49AM BLOOD freeCa-1.18 Brief Hospital Course: Neuro-patient is in a persistent vegetative state and remained unresponsive and at his baseline throughout his hospital stay. Cardiovascular-patient was weaned off of pressor support shortly after admission, he was maintained on iv metoprolol with adequate control of his blood pressure. However, the pt. does not tolerate being turned on his right side - his pressures will decrease somewhat. If this occurs - place pt. back to supine position and blood pressure should correct. Respiratory-patient was intubated on admission. A series of discussions were had with the Miller, Scott and Gonzales Medical Center health care proxy, his daughter, regarding the need for tracheostomy. Both the primary general surgery team and the thoracic team were consulted regarding the need for tracheostomy. Eventually, a second opinion was requested by the daughter and obtained from general surgery. The daughter was told that the patient would likely benefit from tracheostomy and that extubation could very well lead to reintubation considering the patient's poor functional status. The daughter decided to attempt extubation, the pt. was extubated and has been doing very well for the past several days off of the vent. He has been maintaining O2 saturations in the high 90s with minimal oxygen from the face tent. GI-the patient was started on TPN for nutritional support. He was also given tube feedings. He is currently being maintained on tube feeds and no TPN. His albumin has been stable with this regimen and he should be continued on this: Nepro 45% strength for Osm of 280 at a goal rate of 70cc/hour. GU-Pt. has been getting Lasix throughout his stay for help w/diuresis. He was initially quite volume overloaded and need this to get fluid off so he could be extubated. He is no longer requiring lasix and is making adequate uring on his own. His renal function has also returned to 911 Caldwell Mill Suite 534 Espinozachester, MA 53284. Sharon Scheet The pt. received a few transfusions of PRBCs during his and for the past week his hematocrit has been stable. We do not anticipate that he will need any further transfusions. Sharon Scheet Pt. was initially being treated for aspiration pneumonia and is requiring two more day of antibiotics to complete his course. His WBCs have been stable. Endo- stable Medications on Admission: vancomycin/ceftriaxone/flagyl, colace, lasix, reglan, enoxaparin Discharge Medications: 1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm Intravenous Q 24H (Every 24 Hours): - for 2 days 5-31 and 3-24. 2. Zosyn 2.25 g Recon Soln Sig: 2.25 gm Intravenous every eight (8) hours for 2 days: - for 5-31 and 3-24. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 6-31 Drops Ophthalmic PRN (as needed). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15) ML PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection Mcdonald LLC Clinic (2 times a day). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb neb Inhalation Q6H (every 6 hours). 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day: via j-tube. 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 12. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: Diaz, Davis and Kramer Health System & Rehab Center - Hansen, Wilson and Wolf Health System Discharge Diagnosis: -persistent vegetative state -pneumonia -bacteremia Discharge Condition: stable Discharge Instructions: -please return to the emergency department if the patient has shortness of breath, inability to tolerate tube feedings, fever >101.4F or any other problems Followup Instructions: Please follow up with Dr. Pichardo as necessary. Call 854-486-4565 for an appointment.	['Admission Date: 1932-8-16 Discharge Date: 1956-3-31\n\n\nService: SURGERY\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Leena\nChief Complaint:\naspiration pneumonia\n\nMajor Surgical or Invasive Procedure:\nG-J tube replacement\nPICC line placement\n\n\nHistory of Present Illness:\nPatient is a 14 year old man with a long history of a persistent\nvegetative state recently admitted to Flores-Rogers Health System with an aspiration\npneumonia. He required intubation and was maintained on TPN and\ntube feedings until he was able to be extubated and discharged\nto rehab. He returns after only a few days after a presumed\nepisode of reaspiration again requiring intubation and pressor\nsupport.\n\nPast Medical History:\n-Alzheimer disease\n-persistent vegetative state\n-GERD\n-h/o aspiration PNA\n-osteopenia\n-atrial fibrillation\n-myoclonus\n\nSocial History:\nHas been cared for by his daughter for the past three years.', '\n\nFamily History:\nNoncontributory\n\nPhysical Exam:\nGen unresponsive, resting comfortably\nNeck flexed with no masses\nCV RRR no m/r/g\nResp coarse BS bilaterally\nAbd mildly distended, slightly firm, GJ tube in place\nExt 6-31+ LE edema\nSacral decub w/dressing in place\nNeuro unresponsive\n\nPertinent Results:\n1933-6-29 02:43AM BLOOD WBC-10.9 RBC-3.50* Hgb-10.4* Hct-31.8\nMCV-91 MCH-29.6 MCHC-32.7 RDW-19.9 Plt Ct-339\n1945-1-21 02:58AM BLOOD Neuts-71* Bands-2 Lymphs-11* Monos-6\nEos-3 Baso-1 Atyps-1* Metas-3* Myelos-2\n1945-1-21 02:58AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+\nMacrocy-2+ Microcy-1+ Polychr-1+ Schisto-1+ Tear DrPoff1+\n1933-6-29 02:43AM BLOOD Plt Ct-339\n1997-1-29 03:31AM BLOOD PT-16.1 PTT-28.1 INR(PT)-1.5\n1933-6-29 02:43AM BLOOD Glucose-97 UreaN-35 Creat-1.0 Na-138\nK-3.7 Cl-97 HCO3-30 AnGap-15\n1988-7-5 04:24PM BLOOD ALT-24 AST-36 AlkPhos-150* Amylase-64\nTotBili-0.', '4\n1988-7-5 04:24PM BLOOD Lipase-72\n1933-6-29 02:43AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.6\n1942-10-20 02:17AM BLOOD calTIBC-256 Ferritn-215 TRF-197\n1933-6-29 08:28AM BLOOD Vanco-20.6\n1956-3-31 07:25AM BLOOD Vanco-PND\n1998-12-18 02:13AM BLOOD HoldBLu-HOLD\n1998-12-18 10:23PM BLOOD Glucose-110* K-3.8\n1990-9-18 05:44PM BLOOD O2 Sat-97\n1942-10-20 02:49AM BLOOD freeCa-1.18\n\nBrief Hospital Course:\nNeuro-patient is in a persistent vegetative state and remained\nunresponsive and at his baseline throughout his hospital stay.\n\nCardiovascular-patient was weaned off of pressor support shortly\nafter admission, he was maintained on iv metoprolol with\nadequate control of his blood pressure. However, the pt. does\nnot tolerate being turned on his right side - his pressures will\ndecrease somewhat. If this occurs - place pt.', " back to supine\nposition and blood pressure should correct.\n\nRespiratory-patient was intubated on admission. A series of\ndiscussions were had with the Miller, Scott and Gonzales Medical Center health care proxy, his\ndaughter, regarding the need for tracheostomy. Both the primary\ngeneral surgery team and the thoracic team were consulted\nregarding the need for tracheostomy. Eventually, a second\nopinion was requested by the daughter and obtained from general\nsurgery. The daughter was told that the patient would likely\nbenefit from tracheostomy and that extubation could very well\nlead to reintubation considering the patient's poor functional\nstatus. The daughter decided to attempt extubation, the pt. was\nextubated and has been doing very well for the past several days\noff of the vent. He has been maintaining O2 saturations in the\nhigh 90s with minimal oxygen from the face tent.", '\n\nGI-the patient was started on TPN for nutritional support. He\nwas also given tube feedings. He is currently being maintained\non tube feeds and no TPN. His albumin has been stable with this\nregimen and he should be continued on this: Nepro 45% strength\nfor Osm of 280 at a goal rate of 70cc/hour.\n\nGU-Pt. has been getting Lasix throughout his stay for help\nw/diuresis. He was initially quite volume overloaded and need\nthis to get fluid off so he could be extubated. He is no longer\nrequiring lasix and is making adequate uring on his own. His\nrenal function has also returned to 911 Caldwell Mill Suite 534\nEspinozachester, MA 53284.\n\nSharon Scheet The pt. received a few transfusions of PRBCs during his\nand for the past week his hematocrit has been stable. We do not\nanticipate that he will need any further transfusions.', '\n\nSharon Scheet Pt. was initially being treated for aspiration pneumonia and\nis requiring two more day of antibiotics to complete his course.\n His WBCs have been stable.\n\nEndo- stable\n\nMedications on Admission:\nvancomycin/ceftriaxone/flagyl, colace, lasix, reglan, enoxaparin\n\nDischarge Medications:\n1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm\nIntravenous Q 24H (Every 24 Hours): - for 2 days 5-31 and 3-24.\n\n2. Zosyn 2.25 g Recon Soln Sig: 2.25 gm Intravenous every eight\n(8) hours for 2 days: - for 5-31 and 3-24.\n3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2\ntimes a day).\n4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 6-31\nDrops Ophthalmic PRN (as needed).\n6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15)\nML PO DAILY (Daily).', '\n7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)\nunits Injection Mcdonald LLC Clinic (2 times a day).\n8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours) as needed.\n9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb\nneb Inhalation Q6H (every 6 hours).\n10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:\nThirty (30) mg PO once a day: via j-tube.\n11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One\n(1) ML Intravenous DAILY (Daily) as needed.\n12. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at\nbedtime).\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nDiaz, Davis and Kramer Health System & Rehab Center - Hansen, Wilson and Wolf Health System\n\nDischarge Diagnosis:\n-persistent vegetative state\n-pneumonia\n-bacteremia\n\n\nDischarge Condition:\nstable\n\n\nDischarge Instructions:\n-please return to the emergency department if the patient has\nshortness of breath, inability to tolerate tube feedings, fever\n>101.', '4F or any other problems\n\n\nFollowup Instructions:\nPlease follow up with Dr. Pichardo as necessary. Call\n854-486-4565 for an appointment.\n\n\n\n']
546	6787	103210.0	2175-05-10	Discharge summary	Report	Admission Date: [2175-3-10] Discharge Date: [2175-5-10] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: Aspiration Major Surgical or Invasive Procedure: Intubation, repostitioning G-Tube, change of G-tube to G-J tube History of Present Illness: Mr. [Known lastname 4476] is a [Age over 90 ] year old man with a long history of end-stage dementia for at least 10 years with recurrent aspiration pneumonias and pressure ulcers who presents to the [Hospital1 18] ED from [Hospital ] Rehab with an aspiration. He was recently discharged from [Hospital1 18] [3-3] after he had an aspiration and had a prolonged intubation. He was treated with vanc/zosyn for a two week course which was completed [3-5]. Today, nursing at [Hospital1 ] noted that his abdomen was somewhat distended. A KUB was performed that showed the feeding tube was coiled in his stomach in a different position. Tube feeds were restarted and the feeding tube was noted to be further displaced with the phlange out of place. The patient was turned and began vomiting and gagging and was suctions. His VS when he was evaluated there were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM. . The patient was brought to the [Hospital1 18] ED evaluation. In the ED, he was immediately intubated, and started on levaquin/vanc/flagyl for presumed aspiration pneumonia. He transiently dropped his blood pressure to a systolic of 80's over 30's and was started on levophed. Past Medical History: End-stage Alzheimers Atrial fibrillation Recurrent aspiration pneumonias h/o MRSA and VRE colonization Myoclonus Social History: Recently discharged from [Hospital1 18] to [Hospital ] rehab. Has been cared for by his daughter for the past three years. Family History: Noncontributory Physical Exam: VS: (on arrival to the MICU) T 98.9 HR 100 BP 75/33 RR 21 Sat 98% Vent: AC Tv 500 RR 14 PEEP 8 FiO2 60% GEN: unresponsive, intubated man on a intubated and sedated on a ventilator HEENT: Dry MM, sclerae anicteric, pinpoint pupils. CV: Distant heart sounds, irregular PUL: Coarse rhonchi throughout ABD: Distended, no rebound or guarding. EXT: 1+ edema Pertinent Results: ADMISSION LABS [2175-3-9] 11:00PM BLOOD WBC-9.6 RBC-3.73* Hgb-10.9* Hct-33.8* MCV-91 MCH-29.2 MCHC-32.3 RDW-18.5* Plt Ct-314 [2175-3-9] 11:00PM BLOOD Neuts-69.8 Lymphs-21.3 Monos-4.6 Eos-4.2* Baso-0.2 [2175-3-9] 11:00PM BLOOD PT-13.3* PTT-25.6 INR(PT)-1.2* [2175-3-9] 11:00PM BLOOD Glucose-128* UreaN-32* Creat-1.0 Na-139 K-4.4 Cl-97 HCO3-30 AnGap-16 [2175-3-9] 11:00PM BLOOD ALT-26 AST-41* AlkPhos-159* Amylase-66 TotBili-0.5 [2175-3-9] 11:00PM BLOOD Lipase-63* [2175-3-9] 11:00PM BLOOD Albumin-3.6 Calcium-10.0 Phos-3.6 Mg-2.3 [2175-3-9] 11:00PM BLOOD Cortsol-26.2* [2175-3-9] 11:00PM BLOOD CRP-158.4* [2175-3-10] 04:13AM BLOOD Type-ART pO2-68* pCO2-38 pH-7.49* calHCO3-30 Base XS-5 [2175-3-9] 11:00PM BLOOD Lactate-2.0 LAB TRENDS CBC [2175-3-10] 11:00AM BLOOD WBC-13.9* RBC-3.22* Hgb-9.6* Hct-29.1* MCV-90 MCH-29.9 MCHC-33.1 RDW-19.1* Plt Ct-259 [2175-3-13] 04:28AM BLOOD WBC-10.7 RBC-3.01* Hgb-8.8* Hct-27.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-19.6* Plt Ct-274 [2175-3-16] 03:18AM BLOOD WBC-11.5* RBC-2.90* Hgb-8.9* Hct-26.8* MCV-92 MCH-30.5 MCHC-33.1 RDW-19.3* Plt Ct-286 [2175-3-20] 04:52AM BLOOD WBC-10.0 RBC-2.79* Hgb-8.4* Hct-25.3* MCV-91 MCH-30.3 MCHC-33.4 RDW-19.9* Plt Ct-380 [2175-3-22] 03:00AM BLOOD WBC-9.7 RBC-2.88* Hgb-8.6* Hct-26.3* MCV-91 MCH-29.8 MCHC-32.7 RDW-19.9* Plt Ct-410 [2175-3-26] 03:49AM BLOOD WBC-11.9* RBC-2.68* Hgb-8.1* Hct-24.6* MCV-92 MCH-30.2 MCHC-32.9 RDW-20.4* Plt Ct-283 [2175-4-1] 05:00AM BLOOD WBC-15.0* RBC-2.69* Hgb-8.2* Hct-25.4* MCV-94 MCH-30.3 MCHC-32.2 RDW-21.6* Plt Ct-299 [2175-4-3] 04:10AM BLOOD WBC-15.1* RBC-2.87* Hgb-8.8* Hct-27.3* MCV-95 MCH-30.8 MCHC-32.4 RDW-22.0* Plt Ct-349 [2175-4-7] 05:27AM BLOOD WBC-9.8 RBC-2.50* Hgb-7.5* Hct-23.8* MCV-95 MCH-30.1 MCHC-31.6 RDW-21.8* Plt Ct-334 [2175-4-13] 03:24AM BLOOD WBC-8.1 RBC-3.00* Hgb-9.5* Hct-28.2* MCV-94 MCH-31.5 MCHC-33.6 RDW-19.7* Plt Ct-263 [2175-4-18] 03:42AM BLOOD WBC-7.7 RBC-2.89* Hgb-8.7* Hct-27.5* MCV-95 MCH-30.1 MCHC-31.7 RDW-19.7* Plt Ct-329 CHEMISTRY [2175-3-11] 02:42AM BLOOD Glucose-124* UreaN-23* Creat-0.9 Na-141 K-3.1* Cl-105 HCO3-24 AnGap-15 [2175-3-14] 03:51AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-144 K-4.5 Cl-110* HCO3-24 AnGap-15 [2175-3-17] 03:52AM BLOOD Glucose-118* UreaN-41* Creat-0.9 Na-141 K-4.2 Cl-107 HCO3-25 AnGap-13 [2175-3-18] 04:07AM BLOOD Glucose-710* UreaN-38* Creat-1.0 Na-137 K-5.5* Cl-103 HCO3-26 AnGap-14 [2175-3-20] 04:52AM BLOOD Glucose-87 UreaN-46* Creat-0.9 Na-138 K-3.7 Cl-104 HCO3-27 AnGap-11 [2175-3-23] 05:15AM BLOOD Glucose-105 UreaN-54* Creat-0.9 Na-142 K-3.7 Cl-111* HCO3-21* AnGap-14 [2175-3-27] 03:58AM BLOOD Glucose-127* UreaN-72* Creat-1.1 Na-143 K-4.1 Cl-112* HCO3-21* AnGap-14 [2175-3-30] 02:18AM BLOOD Glucose-125* UreaN-76* Creat-1.2 Na-147* K-4.0 Cl-113* HCO3-22 AnGap-16 [2175-4-3] 04:10AM BLOOD Glucose-122* UreaN-55* Creat-1.2 Na-143 K-4.2 Cl-110* HCO3-23 AnGap-14 [2175-4-8] 01:28AM BLOOD Glucose-139* UreaN-32* Creat-1.3* Na-144 K-4.2 Cl-111* HCO3-21* AnGap-16 [2175-4-15] 01:55AM BLOOD Glucose-103 UreaN-40* Creat-1.3* Na-138 K-3.5 Cl-103 HCO3-23 AnGap-16 [2175-4-18] 02:03PM BLOOD Glucose-128* UreaN-39* Creat-1.4* Na-142 K-3.9 Cl-104 HCO3-28 AnGap-14 COAGS [2175-3-11] 02:42AM BLOOD PT-17.4* PTT-31.4 INR(PT)-1.6* [2175-3-16] 03:18AM BLOOD PT-15.2* INR(PT)-1.4* [2175-3-18] 04:07AM BLOOD PT-14.6* INR(PT)-1.3* [2175-3-31] 12:38PM BLOOD PT-16.6* PTT-29.4 INR(PT)-1.5* [2175-4-8] 01:28AM BLOOD PT-17.1* PTT-31.2 INR(PT)-1.6* [2175-4-18] 03:42AM BLOOD PT-15.5* PTT-30.6 INR(PT)-1.4* ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RADIOLOGY CHEST (PORTABLE AP) [2175-3-9] 10:48 PM IMPRESSION: Bilateral pleural effusions with perihilar haze and upper zone redistribution present. A focal opacity is present in the left mid lung zone. Findings may represent CHF/volume overload with concern for concomitant infection. CHEST (PORTABLE AP) [2175-3-19] 3:49 PM IMPRESSION: Mild-to-moderate pulmonary edema has developed since [3-16], partially obscuring multifocal consolidation, and accompanied by increasing moderate right pleural effusion. Large cardiac silhouette is stable. No pneumothorax. ET tube and right central venous line are in standard placements. No pneumothorax. CHEST (PORTABLE AP) [2175-3-21] 9:51 AM IMPRESSION: Worsening of the left upper lobe and left lower lobe consolidations vs. left pleural effusion. 2) Improvement of the right lower lobe consolidation. CHEST (PORTABLE AP) [2175-4-2] 1:02 PM FINDINGS: There is a frontal and a view dedicated to the right lateral chest. The tracheostomy tube is unchanged. The right IJ line with tip in the superior vena cava is unchanged. There continue to be patchy areas of opacity in both lower lungs and in the perihilar regions suggesting multifocal pneumonia. There could also be an element of CHF C1894 INT.SHTH NOT/GUID,EP,NONLASER [2175-4-5] 1:24 PM CHANGE G-TUBE TO G-J TUBE IMPRESSION: Successful placement of a MIC gastrojejunostomy tube with the tip of the tube in the small bowel loop. This catheter is ready to use CHEST (PORTABLE AP) [2175-4-6] 12:33 PM Right pleural effusion is again demonstrated grossly unchanged as well as pleural effusion on the left. The position of the various lines and tubes is unaltered and the left lower lobe consolidation is again demonstrated CHEST (PORTABLE AP) [2175-4-11] 5:59 AM Moderately severe pulmonary edema and moderate left and small right pleural effusion have increased over the past five days. More discrete region of consolidation seen in the left perihilar lung is now partially obscured but has not cleared and other areas of pneumonia could be obscured by the effusions and edema. Heart size is top normal. Tracheostomy tube and left subclavian central venous catheter are in standard placements. No pneumothorax. CHEST (PORTABLE AP) [2175-4-13] 1:12 PM IMPRESSION: Mild improvement of previously described pulmonary edema CHEST (PORTABLE AP) [2175-4-17] 4:48 AM Elevation of the right lung base which has progressed slowly since early [Month (only) 547] is probably due to a combination of lower lobe atelectasis and moderate right pleural effusion. Left perihilar consolidation and hazy opacification of most of the left lung is probably due to a combination of mild pulmonary edema and increasing moderate left pleural effusion. Although the heart is not grossly enlarged, there is persistent mediastinal venous engorgement. More intense consolidation in the left upper lung is consistent with a coexistent pneumonia, unchanged since [4-14]. ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CARDIOLOGY ECG Study Date of [2175-3-10] 3:51:00 AM Atrial fibrillation with rapid ventricular response Left axis deviation - anterior fascicular block Ant/septal+lateral ST-T changes may be due to myocardial ischemia Repolarization changes may be partly due to rate/rhythm Incomplete right bundle branch block Since previous tracing, right bundle branch block now incomplete ECHO Study Date of [2175-3-11] Conclusions: The left atrium is normal in size. There is symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic root is moderately dilated. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are thickened. There is probably mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. ECG Study Date of [2175-3-19] 12:11:06 PM Atrial fibrillation. Axis to the left. T wave inversion in lead aVL. QR complexes in leads VI-V2. Non-specific T wave inversion in lead aVL and low amplitude T waves in lead I. Right bundle-branch block. Anteroseptal myocardial infarction. Left axis deviation. Atrial fibrillation. Non-specific T wave abnormalities. Compared to the previous tracing of [2175-3-10] atrial fibrillation with tachycardia is no longer present. Quality of tracing does not permit further assessment. ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MICROBIOLOGY Sputum: Pseudomonas multidrug resistant. Sensitve to Tobra, intermediate to [Last Name (un) ] and Gent. KLEBSIELLA PNEUMONIAE MRSA C.Diff positive last on [4-2] Brief Hospital Course: CC:[CC Contact Info 4477]. HPI: Mr. [Known lastname 4476] is a [Age over 90 ] year old man with a long history of end-stage dementia for at least 10 years with recurrent aspiration pneumonias and pressure ulcers who presents to the [Hospital1 18] ED from [Hospital ] Rehab with an aspiration. He was recently discharged from [Hospital1 18] [3-3] after he had an aspiration and had a prolonged intubation. He was treated with vanc/zosyn for a two week course which was completed [3-5]. Today, nursing at [Hospital1 ] noted that his abdomen was somewhat distended. A KUB was performed that showed the feeding tube was coiled in his stomach in a different position. Tube feeds were restarted and the feeding tube was noted to be further displaced with the phlange out of place. The patient was turned and began vomiting and gagging and was suctions. His VS when he was evaluated there were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM. . The patient was brought to the [Hospital1 18] ED evaluation. In the ED, he was immediately intubated, and started on levaquin/vanc/flagyl for presumed aspiration pneumonia. He transiently dropped his blood pressure to a systolic of 80's over 30's and was started on levophed. Surgery was consulted . [Age over 90 ]M with end-stage dementia noncommunicative for last 10 years and inability to be weaned off vent p/w recurrent aspiration pneumonias and likely aspiration. On IV flagyl for +c diff. +Sputum cx pseudamonas on [4-3] in setting of hypotn, elevated WBC and low grade fevers. s/p Tracheostomy [3-31]. . # Pseudomonas pneumonia: Initially admitted with hypoxia, fevers and hypotension with ?aspiration pneumonia however CXR unchanged and started on vancomycin/zosyn ([Date range (1) 4478]) for coverage of nosocomial peumonia. Subsequently abx d/c'd [1-19] +c diff in stool. On [3-24] and [3-26] sputum cx grew resistant pseudamonas ([Last Name (un) 36] tobra, zosyn, meropenum) and pansensitive klebsiella however clinically stable and no clear indication of pna on CXR. s/p trach on [3-31]. [Date range (1) 4479] increasing WBC, hypotn and low grade temp. Initially started on zosyn. Sputum again +for pseudamonas and pt. started on meropenem, tobra. On [4-11] meropenem was d/c and on [4-14] pt. grew pseudomonas out of sputum - ID recommended only starting again if clinical picture worsened. Pt's clinical picture did not worsen after this. Ctx sensitive to zosyn and question if pt. was infected vs. colonized as pt. w/ stable white count and not spiking temperatures so decision was made to switch to single coverage. The decision was made to start Zosyn on [4-23] and was scheduled to complete a 14 day course. Because of the proximity of the end date to the projected date of discharge, vanco and zosyn were continued through the date of discharge. These antibiotics should be discontinued 1-2 days after the patient is transferred to his long term treatment facility. ## C. Diff Colitis: Pt. was also found to have C. diff colitis during hospitalization likely [1-19] antibiotics. Pt. initially started on vanco and flagyl. Per ID recs, pt. only needs single coverage for this, so vanco was d/c and flagyl continued. It is imperative that the patient continue flagyl for 14 days AFTER the last dose of Zosyn. Hence, this would correspond to 16 days after transfer from [Hospital1 18]. . ## Hypotension: likely due to sepsis originally, but responsive to fluid boluses. In SICU, pt. was started on pressors, but stopped on [3-13]. Pt. maintained goal MAPs. IN the MICU pt. likely remained hypotensive due to poor forward flow. - given total clinic pictures decision was made that pressors were not indicated and the goal MAP was b/t 50-60. Throughout stay in MICU, pt. w/ stable BP w/ occassional fluid boluses for decreasting MAPS. and infection responsive to fluid boluses. It was decided by the MICU team, other medical and subspecialty teams directly involved w/ pt's care, ethics committee that CPR was not medically indicated in this pt . ## Acute renal failure: Pt. w/ acute renal failure during his stay at [Hospital1 ]. Renal was consulted and this was felt to be secondary to poor forward flow. Pt. appears to have pre-renal failure in the setting of total volume overload. Per renal, this is not reversible and therefore the decision was made that dialysis was not medically indicated. Pt. w/ increasing creatinine throughout stay. Renal followed and pt. was startd on bicarb. . # Atrial fibrillation: was in good control until arrival to floor but developed some RVR. Stable throughout SICU and MICU stay. Pt. was rate controlled on his own. . # Decubitus ulcers: Pt. w/ sacral decubitus - stage 1 and right heel stage 1. Pt. also w/ multiple skin tears from tape. Pt. w/ hip wound. Wound care following. Pt. w/ wet to dry dressings. . ## G/J Tube - Pt. had a G/J tube placed by IR. During MICU stay, there was a question of increased leakage around tube and surgery was consulted. An IR study was done that showed that tube was in place w/ no evidence of obstruction. On [5-4], it was decided to feed the J portion of the tube and suction the G portion as there was no surgery indicated. On [5-5], there was a hole noted at the distal portion of the feeding tube. Pt. was taken back to IR and a G tube was placed at daughter's insistence despite the strong recommendation by the MICU team and IR team to have G/J tube replaced. . # F/E/N: Pt. was originally on TPN because of aspiration event. When pt. was in the MICU he was on TF. At the end of MICU stay, pt. was tolerating Vivonex. . # Ppx: Throughout hospital stay, pt. was on PPI and Heparin prophylaxis. Medications on Admission: Vancomycin 1gm q24h until [3-5] Zosyn 2.25gm q8h until [3-5] Docusate liquid 150 twice daily ASA 325mg daily Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops Ophthalmic PRN Magnesium Hydroxide 15mg daily Heparin 5000u sc bid Albuterol neb q6h Atrovent neb q6h Lansoprazole 30mg daily Donepezil 10mg qhs Lasix 20mg daily Milk of Magnesia 15cc daily Lopressor 6.25 mg [Hospital1 ] Tylenol elixir prn Tube feeds: Nepro 0.45% @ 70cc/hr Discharge Medications: 1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 5. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Please give 5000 units subcutaneous heparin tid. 13. Potassium Iodide 1 g/mL Solution Sig: Ten (10) Drop PO TID (3 times a day) as needed for via J tube. 14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily) as needed for down J-tube. 15. Artificial Tears Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) sliding scale Injection ASDIR (AS DIRECTED). 17. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 18. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: Please use 10 mL NS followed by 2 ml of 100units/ml heparin (200 units heparin) each lumen daily and PRN. 21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours): please give 40 mg solution IV q 24 hours. 22. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams Recon Solns Intravenous Q 12H (Every 12 Hours) for 2 days: Please give 2.25 g IV q 13 hours. 23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg IV Intravenous Q12H (every 12 hours) for 15 days: Please give 500 mg IV q 12 hrs . 24. Wound Care 25. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 gram Recon Soln(s)IV Intravenous Q8H (every 8 hours). 26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram (200ml piggyback) Intravenous Q48H (every 48 hours). Discharge Disposition: Extended Care Facility: [Location (un) 4480] [Hospital 4094] Hospital - [Location (un) 38] Discharge Diagnosis: Aspiration Pneumonia Acute Renal Failure Hypotension Alzheimers Discharge Condition: Stable Discharge Instructions: IT IS VERY IMPORTANT THAT THIS PT'S TRACH BE HUBBED AT ALL TIMES AS IT SLIPS SOME DUE TO GRANULATION TISSUE IN TRACT. Patient should follow up with your primary care physician in the next week. Please take all the medications as directed. Pleas continue wound care as outlined. Followup Instructions: You should follow up with your primary care physician in the next week. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	Admission Date: <Date>1947-2-11</Date> Discharge Date: <Date>1932-6-29</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Diane</Name> Chief Complaint: Aspiration Major Surgical or Invasive Procedure: Intubation, repostitioning G-Tube, change of G-tube to G-J tube History of Present Illness: Mr. <Name>Grier</Name> is a <Age>87</Age> year old man with a long history of end-stage dementia for at least 10 years with recurrent aspiration pneumonias and pressure ulcers who presents to the <Hospital>Perez-Nguyen Medical Center</Hospital> ED from <Hospital>Heath-Harris Health System</Hospital> Rehab with an aspiration. He was recently discharged from <Hospital>Perez-Nguyen Medical Center</Hospital> <Date>11-30</Date> after he had an aspiration and had a prolonged intubation. He was treated with vanc/zosyn for a two week course which was completed <Date>4-30</Date>. Today, nursing at <Hospital>Hunter, Kim and Braun Medical Center</Hospital> noted that his abdomen was somewhat distended. A KUB was performed that showed the feeding tube was coiled in his stomach in a different position. Tube feeds were restarted and the feeding tube was noted to be further displaced with the phlange out of place. The patient was turned and began vomiting and gagging and was suctions. His VS when he was evaluated there were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM. . The patient was brought to the <Hospital>Perez-Nguyen Medical Center</Hospital> ED evaluation. In the ED, he was immediately intubated, and started on levaquin/vanc/flagyl for presumed aspiration pneumonia. He transiently dropped his blood pressure to a systolic of 80's over 30's and was started on levophed. Past Medical History: End-stage Alzheimers Atrial fibrillation Recurrent aspiration pneumonias h/o MRSA and VRE colonization Myoclonus Social History: Recently discharged from <Hospital>Perez-Nguyen Medical Center</Hospital> to <Hospital>Heath-Harris Health System</Hospital> rehab. Has been cared for by his daughter for the past three years. Family History: Noncontributory Physical Exam: VS: (on arrival to the MICU) T 98.9 HR 100 BP 75/33 RR 21 Sat 98% Vent: AC Tv 500 RR 14 PEEP 8 FiO2 60% GEN: unresponsive, intubated man on a intubated and sedated on a ventilator HEENT: Dry MM, sclerae anicteric, pinpoint pupils. CV: Distant heart sounds, irregular PUL: Coarse rhonchi throughout ABD: Distended, no rebound or guarding. EXT: 1+ edema Pertinent Results: ADMISSION LABS <Date>1980-6-8</Date> 11:00PM BLOOD WBC-9.6 RBC-3.73* Hgb-10.9* Hct-33.8* MCV-91 MCH-29.2 MCHC-32.3 RDW-18.5* Plt Ct-314 <Date>1980-6-8</Date> 11:00PM BLOOD Neuts-69.8 Lymphs-21.3 Monos-4.6 Eos-4.2* Baso-0.2 <Date>1980-6-8</Date> 11:00PM BLOOD PT-13.3* PTT-25.6 INR(PT)-1.2* <Date>1980-6-8</Date> 11:00PM BLOOD Glucose-128* UreaN-32* Creat-1.0 Na-139 K-4.4 Cl-97 HCO3-30 AnGap-16 <Date>1980-6-8</Date> 11:00PM BLOOD ALT-26 AST-41* AlkPhos-159* Amylase-66 TotBili-0.5 <Date>1980-6-8</Date> 11:00PM BLOOD Lipase-63* <Date>1980-6-8</Date> 11:00PM BLOOD Albumin-3.6 Calcium-10.0 Phos-3.6 Mg-2.3 <Date>1980-6-8</Date> 11:00PM BLOOD Cortsol-26.2* <Date>1980-6-8</Date> 11:00PM BLOOD CRP-158.4* <Date>1947-2-11</Date> 04:13AM BLOOD Type-ART pO2-68* pCO2-38 pH-7.49* calHCO3-30 Base XS-5 <Date>1980-6-8</Date> 11:00PM BLOOD Lactate-2.0 LAB TRENDS CBC <Date>1947-2-11</Date> 11:00AM BLOOD WBC-13.9* RBC-3.22* Hgb-9.6* Hct-29.1* MCV-90 MCH-29.9 MCHC-33.1 RDW-19.1* Plt Ct-259 <Date>1900-6-13</Date> 04:28AM BLOOD WBC-10.7 RBC-3.01* Hgb-8.8* Hct-27.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-19.6* Plt Ct-274 <Date>1931-1-6</Date> 03:18AM BLOOD WBC-11.5* RBC-2.90* Hgb-8.9* Hct-26.8* MCV-92 MCH-30.5 MCHC-33.1 RDW-19.3* Plt Ct-286 <Date>1958-10-21</Date> 04:52AM BLOOD WBC-10.0 RBC-2.79* Hgb-8.4* Hct-25.3* MCV-91 MCH-30.3 MCHC-33.4 RDW-19.9* Plt Ct-380 <Date>1958-11-15</Date> 03:00AM BLOOD WBC-9.7 RBC-2.88* Hgb-8.6* Hct-26.3* MCV-91 MCH-29.8 MCHC-32.7 RDW-19.9* Plt Ct-410 <Date>1985-5-4</Date> 03:49AM BLOOD WBC-11.9* RBC-2.68* Hgb-8.1* Hct-24.6* MCV-92 MCH-30.2 MCHC-32.9 RDW-20.4* Plt Ct-283 <Date>1956-4-28</Date> 05:00AM BLOOD WBC-15.0* RBC-2.69* Hgb-8.2* Hct-25.4* MCV-94 MCH-30.3 MCHC-32.2 RDW-21.6* Plt Ct-299 <Date>1994-11-9</Date> 04:10AM BLOOD WBC-15.1* RBC-2.87* Hgb-8.8* Hct-27.3* MCV-95 MCH-30.8 MCHC-32.4 RDW-22.0* Plt Ct-349 <Date>1972-8-12</Date> 05:27AM BLOOD WBC-9.8 RBC-2.50* Hgb-7.5* Hct-23.8* MCV-95 MCH-30.1 MCHC-31.6 RDW-21.8* Plt Ct-334 <Date>1993-8-17</Date> 03:24AM BLOOD WBC-8.1 RBC-3.00* Hgb-9.5* Hct-28.2* MCV-94 MCH-31.5 MCHC-33.6 RDW-19.7* Plt Ct-263 <Date>1915-8-22</Date> 03:42AM BLOOD WBC-7.7 RBC-2.89* Hgb-8.7* Hct-27.5* MCV-95 MCH-30.1 MCHC-31.7 RDW-19.7* Plt Ct-329 CHEMISTRY <Date>2003-8-26</Date> 02:42AM BLOOD Glucose-124* UreaN-23* Creat-0.9 Na-141 K-3.1* Cl-105 HCO3-24 AnGap-15 <Date>1956-6-11</Date> 03:51AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-144 K-4.5 Cl-110* HCO3-24 AnGap-15 <Date>1990-8-29</Date> 03:52AM BLOOD Glucose-118* UreaN-41* Creat-0.9 Na-141 K-4.2 Cl-107 HCO3-25 AnGap-13 <Date>2012-2-15</Date> 04:07AM BLOOD Glucose-710* UreaN-38* Creat-1.0 Na-137 K-5.5* Cl-103 HCO3-26 AnGap-14 <Date>1958-10-21</Date> 04:52AM BLOOD Glucose-87 UreaN-46* Creat-0.9 Na-138 K-3.7 Cl-104 HCO3-27 AnGap-11 <Date>1946-2-2</Date> 05:15AM BLOOD Glucose-105 UreaN-54* Creat-0.9 Na-142 K-3.7 Cl-111* HCO3-21* AnGap-14 <Date>2021-8-13</Date> 03:58AM BLOOD Glucose-127* UreaN-72* Creat-1.1 Na-143 K-4.1 Cl-112* HCO3-21* AnGap-14 <Date>1997-2-17</Date> 02:18AM BLOOD Glucose-125* UreaN-76* Creat-1.2 Na-147* K-4.0 Cl-113* HCO3-22 AnGap-16 <Date>1994-11-9</Date> 04:10AM BLOOD Glucose-122* UreaN-55* Creat-1.2 Na-143 K-4.2 Cl-110* HCO3-23 AnGap-14 <Date>1959-12-14</Date> 01:28AM BLOOD Glucose-139* UreaN-32* Creat-1.3* Na-144 K-4.2 Cl-111* HCO3-21* AnGap-16 <Date>1994-5-10</Date> 01:55AM BLOOD Glucose-103 UreaN-40* Creat-1.3* Na-138 K-3.5 Cl-103 HCO3-23 AnGap-16 <Date>1915-8-22</Date> 02:03PM BLOOD Glucose-128* UreaN-39* Creat-1.4* Na-142 K-3.9 Cl-104 HCO3-28 AnGap-14 COAGS <Date>2003-8-26</Date> 02:42AM BLOOD PT-17.4* PTT-31.4 INR(PT)-1.6* <Date>1931-1-6</Date> 03:18AM BLOOD PT-15.2* INR(PT)-1.4* <Date>2012-2-15</Date> 04:07AM BLOOD PT-14.6* INR(PT)-1.3* <Date>1972-2-15</Date> 12:38PM BLOOD PT-16.6* PTT-29.4 INR(PT)-1.5* <Date>1959-12-14</Date> 01:28AM BLOOD PT-17.1* PTT-31.2 INR(PT)-1.6* <Date>1915-8-22</Date> 03:42AM BLOOD PT-15.5* PTT-30.6 INR(PT)-1.4* ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RADIOLOGY CHEST (PORTABLE AP) <Date>1980-6-8</Date> 10:48 PM IMPRESSION: Bilateral pleural effusions with perihilar haze and upper zone redistribution present. A focal opacity is present in the left mid lung zone. Findings may represent CHF/volume overload with concern for concomitant infection. CHEST (PORTABLE AP) <Date>1980-11-25</Date> 3:49 PM IMPRESSION: Mild-to-moderate pulmonary edema has developed since <Date>1-5</Date>, partially obscuring multifocal consolidation, and accompanied by increasing moderate right pleural effusion. Large cardiac silhouette is stable. No pneumothorax. ET tube and right central venous line are in standard placements. No pneumothorax. CHEST (PORTABLE AP) <Date>2003-2-29</Date> 9:51 AM IMPRESSION: Worsening of the left upper lobe and left lower lobe consolidations vs. left pleural effusion. 2) Improvement of the right lower lobe consolidation. CHEST (PORTABLE AP) <Date>2016-1-7</Date> 1:02 PM FINDINGS: There is a frontal and a view dedicated to the right lateral chest. The tracheostomy tube is unchanged. The right IJ line with tip in the superior vena cava is unchanged. There continue to be patchy areas of opacity in both lower lungs and in the perihilar regions suggesting multifocal pneumonia. There could also be an element of CHF C1894 INT.SHTH NOT/GUID,EP,NONLASER <Date>1978-7-9</Date> 1:24 PM CHANGE G-TUBE TO G-J TUBE IMPRESSION: Successful placement of a MIC gastrojejunostomy tube with the tip of the tube in the small bowel loop. This catheter is ready to use CHEST (PORTABLE AP) <Date>1995-11-1</Date> 12:33 PM Right pleural effusion is again demonstrated grossly unchanged as well as pleural effusion on the left. The position of the various lines and tubes is unaltered and the left lower lobe consolidation is again demonstrated CHEST (PORTABLE AP) <Date>1975-10-8</Date> 5:59 AM Moderately severe pulmonary edema and moderate left and small right pleural effusion have increased over the past five days. More discrete region of consolidation seen in the left perihilar lung is now partially obscured but has not cleared and other areas of pneumonia could be obscured by the effusions and edema. Heart size is top normal. Tracheostomy tube and left subclavian central venous catheter are in standard placements. No pneumothorax. CHEST (PORTABLE AP) <Date>1993-8-17</Date> 1:12 PM IMPRESSION: Mild improvement of previously described pulmonary edema CHEST (PORTABLE AP) <Date>1994-6-2</Date> 4:48 AM Elevation of the right lung base which has progressed slowly since early <Month>August</Month> is probably due to a combination of lower lobe atelectasis and moderate right pleural effusion. Left perihilar consolidation and hazy opacification of most of the left lung is probably due to a combination of mild pulmonary edema and increasing moderate left pleural effusion. Although the heart is not grossly enlarged, there is persistent mediastinal venous engorgement. More intense consolidation in the left upper lung is consistent with a coexistent pneumonia, unchanged since <Date>8-22</Date>. ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CARDIOLOGY ECG Study Date of <Date>1947-2-11</Date> 3:51:00 AM Atrial fibrillation with rapid ventricular response Left axis deviation - anterior fascicular block Ant/septal+lateral ST-T changes may be due to myocardial ischemia Repolarization changes may be partly due to rate/rhythm Incomplete right bundle branch block Since previous tracing, right bundle branch block now incomplete ECHO Study Date of <Date>2003-8-26</Date> Conclusions: The left atrium is normal in size. There is symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic root is moderately dilated. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are thickened. There is probably mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. ECG Study Date of <Date>1980-11-25</Date> 12:11:06 PM Atrial fibrillation. Axis to the left. T wave inversion in lead aVL. QR complexes in leads VI-V2. Non-specific T wave inversion in lead aVL and low amplitude T waves in lead I. Right bundle-branch block. Anteroseptal myocardial infarction. Left axis deviation. Atrial fibrillation. Non-specific T wave abnormalities. Compared to the previous tracing of <Date>1947-2-11</Date> atrial fibrillation with tachycardia is no longer present. Quality of tracing does not permit further assessment. ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MICROBIOLOGY Sputum: Pseudomonas multidrug resistant. Sensitve to Tobra, intermediate to <Name>Thompson</Name> and Gent. KLEBSIELLA PNEUMONIAE MRSA C.Diff positive last on <Date>10-4</Date> Brief Hospital Course: CC:<Contact Info>[email protected]</Contact Info>. HPI: Mr. <Name>Grier</Name> is a <Age>87</Age> year old man with a long history of end-stage dementia for at least 10 years with recurrent aspiration pneumonias and pressure ulcers who presents to the <Hospital>Perez-Nguyen Medical Center</Hospital> ED from <Hospital>Heath-Harris Health System</Hospital> Rehab with an aspiration. He was recently discharged from <Hospital>Perez-Nguyen Medical Center</Hospital> <Date>11-30</Date> after he had an aspiration and had a prolonged intubation. He was treated with vanc/zosyn for a two week course which was completed <Date>4-30</Date>. Today, nursing at <Hospital>Hunter, Kim and Braun Medical Center</Hospital> noted that his abdomen was somewhat distended. A KUB was performed that showed the feeding tube was coiled in his stomach in a different position. Tube feeds were restarted and the feeding tube was noted to be further displaced with the phlange out of place. The patient was turned and began vomiting and gagging and was suctions. His VS when he was evaluated there were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM. . The patient was brought to the <Hospital>Perez-Nguyen Medical Center</Hospital> ED evaluation. In the ED, he was immediately intubated, and started on levaquin/vanc/flagyl for presumed aspiration pneumonia. He transiently dropped his blood pressure to a systolic of 80's over 30's and was started on levophed. Surgery was consulted . <Age>87</Age>M with end-stage dementia noncommunicative for last 10 years and inability to be weaned off vent p/w recurrent aspiration pneumonias and likely aspiration. On IV flagyl for +c diff. +Sputum cx pseudamonas on <Date>8-4</Date> in setting of hypotn, elevated WBC and low grade fevers. s/p Tracheostomy <Date>6-8</Date>. . # Pseudomonas pneumonia: Initially admitted with hypoxia, fevers and hypotension with ?aspiration pneumonia however CXR unchanged and started on vancomycin/zosyn (<Date Range>1962-9-27 to 1983-8-4</Date Range>) for coverage of nosocomial peumonia. Subsequently abx d/c'd <Date>8-27</Date> +c diff in stool. On <Date>6-18</Date> and <Date>2-11</Date> sputum cx grew resistant pseudamonas (<Name>Quinones</Name> tobra, zosyn, meropenum) and pansensitive klebsiella however clinically stable and no clear indication of pna on CXR. s/p trach on <Date>6-8</Date>. <Date Range>1904-2-27 to 1921-8-12</Date Range> increasing WBC, hypotn and low grade temp. Initially started on zosyn. Sputum again +for pseudamonas and pt. started on meropenem, tobra. On <Date>8-22</Date> meropenem was d/c and on <Date>8-22</Date> pt. grew pseudomonas out of sputum - ID recommended only starting again if clinical picture worsened. Pt's clinical picture did not worsen after this. Ctx sensitive to zosyn and question if pt. was infected vs. colonized as pt. w/ stable white count and not spiking temperatures so decision was made to switch to single coverage. The decision was made to start Zosyn on <Date>6-25</Date> and was scheduled to complete a 14 day course. Because of the proximity of the end date to the projected date of discharge, vanco and zosyn were continued through the date of discharge. These antibiotics should be discontinued 1-2 days after the patient is transferred to his long term treatment facility. ## C. Diff Colitis: Pt. was also found to have C. diff colitis during hospitalization likely <Date>8-27</Date> antibiotics. Pt. initially started on vanco and flagyl. Per ID recs, pt. only needs single coverage for this, so vanco was d/c and flagyl continued. It is imperative that the patient continue flagyl for 14 days AFTER the last dose of Zosyn. Hence, this would correspond to 16 days after transfer from <Hospital>Perez-Nguyen Medical Center</Hospital>. . ## Hypotension: likely due to sepsis originally, but responsive to fluid boluses. In SICU, pt. was started on pressors, but stopped on <Date>10-7</Date>. Pt. maintained goal MAPs. IN the MICU pt. likely remained hypotensive due to poor forward flow. - given total clinic pictures decision was made that pressors were not indicated and the goal MAP was b/t 50-60. Throughout stay in MICU, pt. w/ stable BP w/ occassional fluid boluses for decreasting MAPS. and infection responsive to fluid boluses. It was decided by the MICU team, other medical and subspecialty teams directly involved w/ pt's care, ethics committee that CPR was not medically indicated in this pt . ## Acute renal failure: Pt. w/ acute renal failure during his stay at <Hospital>Hunter, Kim and Braun Medical Center</Hospital>. Renal was consulted and this was felt to be secondary to poor forward flow. Pt. appears to have pre-renal failure in the setting of total volume overload. Per renal, this is not reversible and therefore the decision was made that dialysis was not medically indicated. Pt. w/ increasing creatinine throughout stay. Renal followed and pt. was startd on bicarb. . # Atrial fibrillation: was in good control until arrival to floor but developed some RVR. Stable throughout SICU and MICU stay. Pt. was rate controlled on his own. . # Decubitus ulcers: Pt. w/ sacral decubitus - stage 1 and right heel stage 1. Pt. also w/ multiple skin tears from tape. Pt. w/ hip wound. Wound care following. Pt. w/ wet to dry dressings. . ## G/J Tube - Pt. had a G/J tube placed by IR. During MICU stay, there was a question of increased leakage around tube and surgery was consulted. An IR study was done that showed that tube was in place w/ no evidence of obstruction. On <Date>5-4</Date>, it was decided to feed the J portion of the tube and suction the G portion as there was no surgery indicated. On <Date>5-8</Date>, there was a hole noted at the distal portion of the feeding tube. Pt. was taken back to IR and a G tube was placed at daughter's insistence despite the strong recommendation by the MICU team and IR team to have G/J tube replaced. . # F/E/N: Pt. was originally on TPN because of aspiration event. When pt. was in the MICU he was on TF. At the end of MICU stay, pt. was tolerating Vivonex. . # Ppx: Throughout hospital stay, pt. was on PPI and Heparin prophylaxis. Medications on Admission: Vancomycin 1gm q24h until <Date>4-30</Date> Zosyn 2.25gm q8h until <Date>4-30</Date> Docusate liquid 150 twice daily ASA 325mg daily Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops Ophthalmic PRN Magnesium Hydroxide 15mg daily Heparin 5000u sc bid Albuterol neb q6h Atrovent neb q6h Lansoprazole 30mg daily Donepezil 10mg qhs Lasix 20mg daily Milk of Magnesia 15cc daily Lopressor 6.25 mg <Hospital>Hunter, Kim and Braun Medical Center</Hospital> Tylenol elixir prn Tube feeds: Nepro 0.45% @ 70cc/hr Discharge Medications: 1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical <Hospital>Hunter, Kim and Braun Medical Center</Hospital> (2 times a day). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 5. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical <Hospital>Hunter, Kim and Braun Medical Center</Hospital> (2 times a day). 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Please give 5000 units subcutaneous heparin tid. 13. Potassium Iodide 1 g/mL Solution Sig: Ten (10) Drop PO TID (3 times a day) as needed for via J tube. 14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily) as needed for down J-tube. 15. Artificial Tears Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) sliding scale Injection ASDIR (AS DIRECTED). 17. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 18. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: Please use 10 mL NS followed by 2 ml of 100units/ml heparin (200 units heparin) each lumen daily and PRN. 21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours): please give 40 mg solution IV q 24 hours. 22. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams Recon Solns Intravenous Q 12H (Every 12 Hours) for 2 days: Please give 2.25 g IV q 13 hours. 23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg IV Intravenous Q12H (every 12 hours) for 15 days: Please give 500 mg IV q 12 hrs . 24. Wound Care 25. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 gram Recon Soln(s)IV Intravenous Q8H (every 8 hours). 26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram (200ml piggyback) Intravenous Q48H (every 48 hours). Discharge Disposition: Extended Care Facility: <Location>7786 Santos Pike Apt. 249 Lake Ronald, AK 96718</Location> <Hospital>Hall-Moore Medical Center</Hospital> Hospital - <Location>84934 Marcus Crescent Suite 418 East Laura, UT 21100</Location> Discharge Diagnosis: Aspiration Pneumonia Acute Renal Failure Hypotension Alzheimers Discharge Condition: Stable Discharge Instructions: IT IS VERY IMPORTANT THAT THIS PT'S TRACH BE HUBBED AT ALL TIMES AS IT SLIPS SOME DUE TO GRANULATION TISSUE IN TRACT. Patient should follow up with your primary care physician in the next week. Please take all the medications as directed. Pleas continue wound care as outlined. Followup Instructions: You should follow up with your primary care physician in the next week. <Name>Cornell</Name> <Name>Ignacio</Name> MD <MD Number>30880106</MD 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0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111110111111100001111111100	Admission Date: 1947-2-11 Discharge Date: 1932-6-29 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Diane Chief Complaint: Aspiration Major Surgical or Invasive Procedure: Intubation, repostitioning G-Tube, change of G-tube to G-J tube History of Present Illness: Mr. Grier is a 87 year old man with a long history of end-stage dementia for at least 10 years with recurrent aspiration pneumonias and pressure ulcers who presents to the Perez-Nguyen Medical Center ED from Heath-Harris Health System Rehab with an aspiration. He was recently discharged from Perez-Nguyen Medical Center 11-30 after he had an aspiration and had a prolonged intubation. He was treated with vanc/zosyn for a two week course which was completed 4-30. Today, nursing at Hunter, Kim and Braun Medical Center noted that his abdomen was somewhat distended. A KUB was performed that showed the feeding tube was coiled in his stomach in a different position. Tube feeds were restarted and the feeding tube was noted to be further displaced with the phlange out of place. The patient was turned and began vomiting and gagging and was suctions. His VS when he was evaluated there were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM. . The patient was brought to the Perez-Nguyen Medical Center ED evaluation. In the ED, he was immediately intubated, and started on levaquin/vanc/flagyl for presumed aspiration pneumonia. He transiently dropped his blood pressure to a systolic of 80's over 30's and was started on levophed. Past Medical History: End-stage Alzheimers Atrial fibrillation Recurrent aspiration pneumonias h/o MRSA and VRE colonization Myoclonus Social History: Recently discharged from Perez-Nguyen Medical Center to Heath-Harris Health System rehab. Has been cared for by his daughter for the past three years. Family History: Noncontributory Physical Exam: VS: (on arrival to the MICU) T 98.9 HR 100 BP 75/33 RR 21 Sat 98% Vent: AC Tv 500 RR 14 PEEP 8 FiO2 60% GEN: unresponsive, intubated man on a intubated and sedated on a ventilator HEENT: Dry MM, sclerae anicteric, pinpoint pupils. CV: Distant heart sounds, irregular PUL: Coarse rhonchi throughout ABD: Distended, no rebound or guarding. EXT: 1+ edema Pertinent Results: ADMISSION LABS 1980-6-8 11:00PM BLOOD WBC-9.6 RBC-3.73* Hgb-10.9* Hct-33.8* MCV-91 MCH-29.2 MCHC-32.3 RDW-18.5* Plt Ct-314 1980-6-8 11:00PM BLOOD Neuts-69.8 Lymphs-21.3 Monos-4.6 Eos-4.2* Baso-0.2 1980-6-8 11:00PM BLOOD PT-13.3* PTT-25.6 INR(PT)-1.2* 1980-6-8 11:00PM BLOOD Glucose-128* UreaN-32* Creat-1.0 Na-139 K-4.4 Cl-97 HCO3-30 AnGap-16 1980-6-8 11:00PM BLOOD ALT-26 AST-41* AlkPhos-159* Amylase-66 TotBili-0.5 1980-6-8 11:00PM BLOOD Lipase-63* 1980-6-8 11:00PM BLOOD Albumin-3.6 Calcium-10.0 Phos-3.6 Mg-2.3 1980-6-8 11:00PM BLOOD Cortsol-26.2* 1980-6-8 11:00PM BLOOD CRP-158.4* 1947-2-11 04:13AM BLOOD Type-ART pO2-68* pCO2-38 pH-7.49* calHCO3-30 Base XS-5 1980-6-8 11:00PM BLOOD Lactate-2.0 LAB TRENDS CBC 1947-2-11 11:00AM BLOOD WBC-13.9* RBC-3.22* Hgb-9.6* Hct-29.1* MCV-90 MCH-29.9 MCHC-33.1 RDW-19.1* Plt Ct-259 1900-6-13 04:28AM BLOOD WBC-10.7 RBC-3.01* Hgb-8.8* Hct-27.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-19.6* Plt Ct-274 1931-1-6 03:18AM BLOOD WBC-11.5* RBC-2.90* Hgb-8.9* Hct-26.8* MCV-92 MCH-30.5 MCHC-33.1 RDW-19.3* Plt Ct-286 1958-10-21 04:52AM BLOOD WBC-10.0 RBC-2.79* Hgb-8.4* Hct-25.3* MCV-91 MCH-30.3 MCHC-33.4 RDW-19.9* Plt Ct-380 1958-11-15 03:00AM BLOOD WBC-9.7 RBC-2.88* Hgb-8.6* Hct-26.3* MCV-91 MCH-29.8 MCHC-32.7 RDW-19.9* Plt Ct-410 1985-5-4 03:49AM BLOOD WBC-11.9* RBC-2.68* Hgb-8.1* Hct-24.6* MCV-92 MCH-30.2 MCHC-32.9 RDW-20.4* Plt Ct-283 1956-4-28 05:00AM BLOOD WBC-15.0* RBC-2.69* Hgb-8.2* Hct-25.4* MCV-94 MCH-30.3 MCHC-32.2 RDW-21.6* Plt Ct-299 1994-11-9 04:10AM BLOOD WBC-15.1* RBC-2.87* Hgb-8.8* Hct-27.3* MCV-95 MCH-30.8 MCHC-32.4 RDW-22.0* Plt Ct-349 1972-8-12 05:27AM BLOOD WBC-9.8 RBC-2.50* Hgb-7.5* Hct-23.8* MCV-95 MCH-30.1 MCHC-31.6 RDW-21.8* Plt Ct-334 1993-8-17 03:24AM BLOOD WBC-8.1 RBC-3.00* Hgb-9.5* Hct-28.2* MCV-94 MCH-31.5 MCHC-33.6 RDW-19.7* Plt Ct-263 1915-8-22 03:42AM BLOOD WBC-7.7 RBC-2.89* Hgb-8.7* Hct-27.5* MCV-95 MCH-30.1 MCHC-31.7 RDW-19.7* Plt Ct-329 CHEMISTRY 2003-8-26 02:42AM BLOOD Glucose-124* UreaN-23* Creat-0.9 Na-141 K-3.1* Cl-105 HCO3-24 AnGap-15 1956-6-11 03:51AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-144 K-4.5 Cl-110* HCO3-24 AnGap-15 1990-8-29 03:52AM BLOOD Glucose-118* UreaN-41* Creat-0.9 Na-141 K-4.2 Cl-107 HCO3-25 AnGap-13 2012-2-15 04:07AM BLOOD Glucose-710* UreaN-38* Creat-1.0 Na-137 K-5.5* Cl-103 HCO3-26 AnGap-14 1958-10-21 04:52AM BLOOD Glucose-87 UreaN-46* Creat-0.9 Na-138 K-3.7 Cl-104 HCO3-27 AnGap-11 1946-2-2 05:15AM BLOOD Glucose-105 UreaN-54* Creat-0.9 Na-142 K-3.7 Cl-111* HCO3-21* AnGap-14 2021-8-13 03:58AM BLOOD Glucose-127* UreaN-72* Creat-1.1 Na-143 K-4.1 Cl-112* HCO3-21* AnGap-14 1997-2-17 02:18AM BLOOD Glucose-125* UreaN-76* Creat-1.2 Na-147* K-4.0 Cl-113* HCO3-22 AnGap-16 1994-11-9 04:10AM BLOOD Glucose-122* UreaN-55* Creat-1.2 Na-143 K-4.2 Cl-110* HCO3-23 AnGap-14 1959-12-14 01:28AM BLOOD Glucose-139* UreaN-32* Creat-1.3* Na-144 K-4.2 Cl-111* HCO3-21* AnGap-16 1994-5-10 01:55AM BLOOD Glucose-103 UreaN-40* Creat-1.3* Na-138 K-3.5 Cl-103 HCO3-23 AnGap-16 1915-8-22 02:03PM BLOOD Glucose-128* UreaN-39* Creat-1.4* Na-142 K-3.9 Cl-104 HCO3-28 AnGap-14 COAGS 2003-8-26 02:42AM BLOOD PT-17.4* PTT-31.4 INR(PT)-1.6* 1931-1-6 03:18AM BLOOD PT-15.2* INR(PT)-1.4* 2012-2-15 04:07AM BLOOD PT-14.6* INR(PT)-1.3* 1972-2-15 12:38PM BLOOD PT-16.6* PTT-29.4 INR(PT)-1.5* 1959-12-14 01:28AM BLOOD PT-17.1* PTT-31.2 INR(PT)-1.6* 1915-8-22 03:42AM BLOOD PT-15.5* PTT-30.6 INR(PT)-1.4* ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RADIOLOGY CHEST (PORTABLE AP) 1980-6-8 10:48 PM IMPRESSION: Bilateral pleural effusions with perihilar haze and upper zone redistribution present. A focal opacity is present in the left mid lung zone. Findings may represent CHF/volume overload with concern for concomitant infection. CHEST (PORTABLE AP) 1980-11-25 3:49 PM IMPRESSION: Mild-to-moderate pulmonary edema has developed since 1-5, partially obscuring multifocal consolidation, and accompanied by increasing moderate right pleural effusion. Large cardiac silhouette is stable. No pneumothorax. ET tube and right central venous line are in standard placements. No pneumothorax. CHEST (PORTABLE AP) 2003-2-29 9:51 AM IMPRESSION: Worsening of the left upper lobe and left lower lobe consolidations vs. left pleural effusion. 2) Improvement of the right lower lobe consolidation. CHEST (PORTABLE AP) 2016-1-7 1:02 PM FINDINGS: There is a frontal and a view dedicated to the right lateral chest. The tracheostomy tube is unchanged. The right IJ line with tip in the superior vena cava is unchanged. There continue to be patchy areas of opacity in both lower lungs and in the perihilar regions suggesting multifocal pneumonia. There could also be an element of CHF C1894 INT.SHTH NOT/GUID,EP,NONLASER 1978-7-9 1:24 PM CHANGE G-TUBE TO G-J TUBE IMPRESSION: Successful placement of a MIC gastrojejunostomy tube with the tip of the tube in the small bowel loop. This catheter is ready to use CHEST (PORTABLE AP) 1995-11-1 12:33 PM Right pleural effusion is again demonstrated grossly unchanged as well as pleural effusion on the left. The position of the various lines and tubes is unaltered and the left lower lobe consolidation is again demonstrated CHEST (PORTABLE AP) 1975-10-8 5:59 AM Moderately severe pulmonary edema and moderate left and small right pleural effusion have increased over the past five days. More discrete region of consolidation seen in the left perihilar lung is now partially obscured but has not cleared and other areas of pneumonia could be obscured by the effusions and edema. Heart size is top normal. Tracheostomy tube and left subclavian central venous catheter are in standard placements. No pneumothorax. CHEST (PORTABLE AP) 1993-8-17 1:12 PM IMPRESSION: Mild improvement of previously described pulmonary edema CHEST (PORTABLE AP) 1994-6-2 4:48 AM Elevation of the right lung base which has progressed slowly since early August is probably due to a combination of lower lobe atelectasis and moderate right pleural effusion. Left perihilar consolidation and hazy opacification of most of the left lung is probably due to a combination of mild pulmonary edema and increasing moderate left pleural effusion. Although the heart is not grossly enlarged, there is persistent mediastinal venous engorgement. More intense consolidation in the left upper lung is consistent with a coexistent pneumonia, unchanged since 8-22. ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CARDIOLOGY ECG Study Date of 1947-2-11 3:51:00 AM Atrial fibrillation with rapid ventricular response Left axis deviation - anterior fascicular block Ant/septal+lateral ST-T changes may be due to myocardial ischemia Repolarization changes may be partly due to rate/rhythm Incomplete right bundle branch block Since previous tracing, right bundle branch block now incomplete ECHO Study Date of 2003-8-26 Conclusions: The left atrium is normal in size. There is symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic root is moderately dilated. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are thickened. There is probably mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. ECG Study Date of 1980-11-25 12:11:06 PM Atrial fibrillation. Axis to the left. T wave inversion in lead aVL. QR complexes in leads VI-V2. Non-specific T wave inversion in lead aVL and low amplitude T waves in lead I. Right bundle-branch block. Anteroseptal myocardial infarction. Left axis deviation. Atrial fibrillation. Non-specific T wave abnormalities. Compared to the previous tracing of 1947-2-11 atrial fibrillation with tachycardia is no longer present. Quality of tracing does not permit further assessment. ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MICROBIOLOGY Sputum: Pseudomonas multidrug resistant. Sensitve to Tobra, intermediate to Thompson and Gent. KLEBSIELLA PNEUMONIAE MRSA C.Diff positive last on 10-4 Brief Hospital Course: CC:[email protected]. HPI: Mr. Grier is a 87 year old man with a long history of end-stage dementia for at least 10 years with recurrent aspiration pneumonias and pressure ulcers who presents to the Perez-Nguyen Medical Center ED from Heath-Harris Health System Rehab with an aspiration. He was recently discharged from Perez-Nguyen Medical Center 11-30 after he had an aspiration and had a prolonged intubation. He was treated with vanc/zosyn for a two week course which was completed 4-30. Today, nursing at Hunter, Kim and Braun Medical Center noted that his abdomen was somewhat distended. A KUB was performed that showed the feeding tube was coiled in his stomach in a different position. Tube feeds were restarted and the feeding tube was noted to be further displaced with the phlange out of place. The patient was turned and began vomiting and gagging and was suctions. His VS when he was evaluated there were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM. . The patient was brought to the Perez-Nguyen Medical Center ED evaluation. In the ED, he was immediately intubated, and started on levaquin/vanc/flagyl for presumed aspiration pneumonia. He transiently dropped his blood pressure to a systolic of 80's over 30's and was started on levophed. Surgery was consulted . 87M with end-stage dementia noncommunicative for last 10 years and inability to be weaned off vent p/w recurrent aspiration pneumonias and likely aspiration. On IV flagyl for +c diff. +Sputum cx pseudamonas on 8-4 in setting of hypotn, elevated WBC and low grade fevers. s/p Tracheostomy 6-8. . # Pseudomonas pneumonia: Initially admitted with hypoxia, fevers and hypotension with ?aspiration pneumonia however CXR unchanged and started on vancomycin/zosyn (1962-9-27 to 1983-8-4) for coverage of nosocomial peumonia. Subsequently abx d/c'd 8-27 +c diff in stool. On 6-18 and 2-11 sputum cx grew resistant pseudamonas (Quinones tobra, zosyn, meropenum) and pansensitive klebsiella however clinically stable and no clear indication of pna on CXR. s/p trach on 6-8. 1904-2-27 to 1921-8-12 increasing WBC, hypotn and low grade temp. Initially started on zosyn. Sputum again +for pseudamonas and pt. started on meropenem, tobra. On 8-22 meropenem was d/c and on 8-22 pt. grew pseudomonas out of sputum - ID recommended only starting again if clinical picture worsened. Pt's clinical picture did not worsen after this. Ctx sensitive to zosyn and question if pt. was infected vs. colonized as pt. w/ stable white count and not spiking temperatures so decision was made to switch to single coverage. The decision was made to start Zosyn on 6-25 and was scheduled to complete a 14 day course. Because of the proximity of the end date to the projected date of discharge, vanco and zosyn were continued through the date of discharge. These antibiotics should be discontinued 1-2 days after the patient is transferred to his long term treatment facility. ## C. Diff Colitis: Pt. was also found to have C. diff colitis during hospitalization likely 8-27 antibiotics. Pt. initially started on vanco and flagyl. Per ID recs, pt. only needs single coverage for this, so vanco was d/c and flagyl continued. It is imperative that the patient continue flagyl for 14 days AFTER the last dose of Zosyn. Hence, this would correspond to 16 days after transfer from Perez-Nguyen Medical Center. . ## Hypotension: likely due to sepsis originally, but responsive to fluid boluses. In SICU, pt. was started on pressors, but stopped on 10-7. Pt. maintained goal MAPs. IN the MICU pt. likely remained hypotensive due to poor forward flow. - given total clinic pictures decision was made that pressors were not indicated and the goal MAP was b/t 50-60. Throughout stay in MICU, pt. w/ stable BP w/ occassional fluid boluses for decreasting MAPS. and infection responsive to fluid boluses. It was decided by the MICU team, other medical and subspecialty teams directly involved w/ pt's care, ethics committee that CPR was not medically indicated in this pt . ## Acute renal failure: Pt. w/ acute renal failure during his stay at Hunter, Kim and Braun Medical Center. Renal was consulted and this was felt to be secondary to poor forward flow. Pt. appears to have pre-renal failure in the setting of total volume overload. Per renal, this is not reversible and therefore the decision was made that dialysis was not medically indicated. Pt. w/ increasing creatinine throughout stay. Renal followed and pt. was startd on bicarb. . # Atrial fibrillation: was in good control until arrival to floor but developed some RVR. Stable throughout SICU and MICU stay. Pt. was rate controlled on his own. . # Decubitus ulcers: Pt. w/ sacral decubitus - stage 1 and right heel stage 1. Pt. also w/ multiple skin tears from tape. Pt. w/ hip wound. Wound care following. Pt. w/ wet to dry dressings. . ## G/J Tube - Pt. had a G/J tube placed by IR. During MICU stay, there was a question of increased leakage around tube and surgery was consulted. An IR study was done that showed that tube was in place w/ no evidence of obstruction. On 5-4, it was decided to feed the J portion of the tube and suction the G portion as there was no surgery indicated. On 5-8, there was a hole noted at the distal portion of the feeding tube. Pt. was taken back to IR and a G tube was placed at daughter's insistence despite the strong recommendation by the MICU team and IR team to have G/J tube replaced. . # F/E/N: Pt. was originally on TPN because of aspiration event. When pt. was in the MICU he was on TF. At the end of MICU stay, pt. was tolerating Vivonex. . # Ppx: Throughout hospital stay, pt. was on PPI and Heparin prophylaxis. Medications on Admission: Vancomycin 1gm q24h until 4-30 Zosyn 2.25gm q8h until 4-30 Docusate liquid 150 twice daily ASA 325mg daily Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops Ophthalmic PRN Magnesium Hydroxide 15mg daily Heparin 5000u sc bid Albuterol neb q6h Atrovent neb q6h Lansoprazole 30mg daily Donepezil 10mg qhs Lasix 20mg daily Milk of Magnesia 15cc daily Lopressor 6.25 mg Hunter, Kim and Braun Medical Center Tylenol elixir prn Tube feeds: Nepro 0.45% @ 70cc/hr Discharge Medications: 1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical Hunter, Kim and Braun Medical Center (2 times a day). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 5. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical Hunter, Kim and Braun Medical Center (2 times a day). 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Please give 5000 units subcutaneous heparin tid. 13. Potassium Iodide 1 g/mL Solution Sig: Ten (10) Drop PO TID (3 times a day) as needed for via J tube. 14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily) as needed for down J-tube. 15. Artificial Tears Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) sliding scale Injection ASDIR (AS DIRECTED). 17. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 18. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: Please use 10 mL NS followed by 2 ml of 100units/ml heparin (200 units heparin) each lumen daily and PRN. 21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours): please give 40 mg solution IV q 24 hours. 22. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams Recon Solns Intravenous Q 12H (Every 12 Hours) for 2 days: Please give 2.25 g IV q 13 hours. 23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg IV Intravenous Q12H (every 12 hours) for 15 days: Please give 500 mg IV q 12 hrs . 24. Wound Care 25. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 gram Recon Soln(s)IV Intravenous Q8H (every 8 hours). 26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram (200ml piggyback) Intravenous Q48H (every 48 hours). Discharge Disposition: Extended Care Facility: 7786 Santos Pike Apt. 249 Lake Ronald, AK 96718 Hall-Moore Medical Center Hospital - 84934 Marcus Crescent Suite 418 East Laura, UT 21100 Discharge Diagnosis: Aspiration Pneumonia Acute Renal Failure Hypotension Alzheimers Discharge Condition: Stable Discharge Instructions: IT IS VERY IMPORTANT THAT THIS PT'S TRACH BE HUBBED AT ALL TIMES AS IT SLIPS SOME DUE TO GRANULATION TISSUE IN TRACT. Patient should follow up with your primary care physician in the next week. Please take all the medications as directed. Pleas continue wound care as outlined. Followup Instructions: You should follow up with your primary care physician in the next week. Cornell Ignacio MD 30880106	['Admission Date: 1947-2-11 Discharge Date: 1932-6-29\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Diane\nChief Complaint:\nAspiration\n\nMajor Surgical or Invasive Procedure:\nIntubation, repostitioning G-Tube, change of G-tube to G-J tube\n\nHistory of Present Illness:\nMr. Grier is a 87 year old man with a long history of\nend-stage dementia for at least 10 years with recurrent\naspiration pneumonias and pressure ulcers who presents to the\nPerez-Nguyen Medical Center ED from Heath-Harris Health System Rehab with an aspiration. He was recently\ndischarged from Perez-Nguyen Medical Center 11-30 after he had an aspiration and had a\nprolonged intubation. He was treated with vanc/zosyn for a two\nweek course which was completed 4-30. Today, nursing at Hunter, Kim and Braun Medical Center\nnoted that his abdomen was somewhat distended.', " A KUB was\nperformed that showed the feeding tube was coiled in his stomach\nin a different position. Tube feeds were restarted and the\nfeeding tube was noted to be further displaced with the phlange\nout of place. The patient was turned and began vomiting and\ngagging and was suctions. His VS when he was evaluated there\nwere T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM.\n.\nThe patient was brought to the Perez-Nguyen Medical Center ED evaluation. In the ED,\nhe was immediately intubated, and started on\nlevaquin/vanc/flagyl for presumed aspiration pneumonia. He\ntransiently dropped his blood pressure to a systolic of 80's\nover 30's and was started on levophed.\n\n\nPast Medical History:\nEnd-stage Alzheimers\nAtrial fibrillation\nRecurrent aspiration pneumonias\nh/o MRSA and VRE colonization\nMyoclonus\n\n\nSocial History:\nRecently discharged from Perez-Nguyen Medical Center to Heath-Harris Health System rehab.", '\nHas been cared for by his daughter for the past three years.\n\n\nFamily History:\nNoncontributory\n\nPhysical Exam:\nVS: (on arrival to the MICU) T 98.9 HR 100 BP 75/33 RR 21 Sat\n98%\nVent: AC Tv 500 RR 14 PEEP 8 FiO2 60%\nGEN: unresponsive, intubated man on a intubated and sedated on a\nventilator\nHEENT: Dry MM, sclerae anicteric, pinpoint pupils.\nCV: Distant heart sounds, irregular\nPUL: Coarse rhonchi throughout\nABD: Distended, no rebound or guarding.\nEXT: 1+ edema\n\n\nPertinent Results:\nADMISSION LABS\n1980-6-8 11:00PM BLOOD WBC-9.6 RBC-3.73* Hgb-10.9* Hct-33.8\nMCV-91 MCH-29.2 MCHC-32.3 RDW-18.5 Plt Ct-314\n1980-6-8 11:00PM BLOOD Neuts-69.8 Lymphs-21.3 Monos-4.6 Eos-4.2\nBaso-0.2\n1980-6-8 11:00PM BLOOD PT-13.3 PTT-25.6 INR(PT)-1.2\n1980-6-8 11:00PM BLOOD Glucose-128 UreaN-32* Creat-1.0 Na-139\nK-4.', '4 Cl-97 HCO3-30 AnGap-16\n1980-6-8 11:00PM BLOOD ALT-26 AST-41* AlkPhos-159* Amylase-66\nTotBili-0.5\n1980-6-8 11:00PM BLOOD Lipase-63\n1980-6-8 11:00PM BLOOD Albumin-3.6 Calcium-10.0 Phos-3.6 Mg-2.3\n1980-6-8 11:00PM BLOOD Cortsol-26.2\n1980-6-8 11:00PM BLOOD CRP-158.4\n1947-2-11 04:13AM BLOOD Type-ART pO2-68 pCO2-38 pH-7.49\ncalHCO3-30 Base XS-5\n1980-6-8 11:00PM BLOOD Lactate-2.0\n\nLAB TRENDS\nCBC\n1947-2-11 11:00AM BLOOD WBC-13.9 RBC-3.22* Hgb-9.6* Hct-29.1\nMCV-90 MCH-29.9 MCHC-33.1 RDW-19.1 Plt Ct-259\n1900-6-13 04:28AM BLOOD WBC-10.7 RBC-3.01* Hgb-8.8* Hct-27.5\nMCV-92 MCH-29.4 MCHC-32.1 RDW-19.6 Plt Ct-274\n1931-1-6 03:18AM BLOOD WBC-11.5* RBC-2.90* Hgb-8.9* Hct-26.8\nMCV-92 MCH-30.5 MCHC-33.1 RDW-19.3 Plt Ct-286\n1958-10-21 04:52AM BLOOD WBC-10.0 RBC-2.79* Hgb-8.4* Hct-25.3\nMCV-91 MCH-30.', '3 MCHC-33.4 RDW-19.9 Plt Ct-380\n1958-11-15 03:00AM BLOOD WBC-9.7 RBC-2.88* Hgb-8.6* Hct-26.3\nMCV-91 MCH-29.8 MCHC-32.7 RDW-19.9 Plt Ct-410\n1985-5-4 03:49AM BLOOD WBC-11.9* RBC-2.68* Hgb-8.1* Hct-24.6\nMCV-92 MCH-30.2 MCHC-32.9 RDW-20.4 Plt Ct-283\n1956-4-28 05:00AM BLOOD WBC-15.0* RBC-2.69* Hgb-8.2* Hct-25.4\nMCV-94 MCH-30.3 MCHC-32.2 RDW-21.6 Plt Ct-299\n1994-11-9 04:10AM BLOOD WBC-15.1* RBC-2.87* Hgb-8.8* Hct-27.3\nMCV-95 MCH-30.8 MCHC-32.4 RDW-22.0 Plt Ct-349\n1972-8-12 05:27AM BLOOD WBC-9.8 RBC-2.50* Hgb-7.5* Hct-23.8\nMCV-95 MCH-30.1 MCHC-31.6 RDW-21.8 Plt Ct-334\n1993-8-17 03:24AM BLOOD WBC-8.1 RBC-3.00* Hgb-9.5* Hct-28.2\nMCV-94 MCH-31.5 MCHC-33.6 RDW-19.7 Plt Ct-263\n1915-8-22 03:42AM BLOOD WBC-7.7 RBC-2.89* Hgb-8.7* Hct-27.5\nMCV-95 MCH-30.1 MCHC-31.7 RDW-19.7 Plt Ct-329\n\nCHEMISTRY\n2003-8-26 02:42AM BLOOD Glucose-124* UreaN-23* Creat-0.', '9 Na-141\nK-3.1* Cl-105 HCO3-24 AnGap-15\n1956-6-11 03:51AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-144\nK-4.5 Cl-110* HCO3-24 AnGap-15\n1990-8-29 03:52AM BLOOD Glucose-118* UreaN-41* Creat-0.9 Na-141\nK-4.2 Cl-107 HCO3-25 AnGap-13\n2012-2-15 04:07AM BLOOD Glucose-710* UreaN-38* Creat-1.0 Na-137\nK-5.5* Cl-103 HCO3-26 AnGap-14\n1958-10-21 04:52AM BLOOD Glucose-87 UreaN-46* Creat-0.9 Na-138\nK-3.7 Cl-104 HCO3-27 AnGap-11\n1946-2-2 05:15AM BLOOD Glucose-105 UreaN-54* Creat-0.9 Na-142\nK-3.7 Cl-111* HCO3-21* AnGap-14\n2021-8-13 03:58AM BLOOD Glucose-127* UreaN-72* Creat-1.1 Na-143\nK-4.1 Cl-112* HCO3-21* AnGap-14\n1997-2-17 02:18AM BLOOD Glucose-125* UreaN-76* Creat-1.2 Na-147\nK-4.0 Cl-113 HCO3-22 AnGap-16\n1994-11-9 04:10AM BLOOD Glucose-122* UreaN-55* Creat-1.2 Na-143\nK-4.2 Cl-110* HCO3-23 AnGap-14\n1959-12-14 01:28AM BLOOD Glucose-139* UreaN-32* Creat-1.', '3* Na-144\nK-4.2 Cl-111* HCO3-21* AnGap-16\n1994-5-10 01:55AM BLOOD Glucose-103 UreaN-40* Creat-1.3* Na-138\nK-3.5 Cl-103 HCO3-23 AnGap-16\n1915-8-22 02:03PM BLOOD Glucose-128* UreaN-39* Creat-1.4* Na-142\nK-3.9 Cl-104 HCO3-28 AnGap-14\n\nCOAGS\n2003-8-26 02:42AM BLOOD PT-17.4* PTT-31.4 INR(PT)-1.6\n1931-1-6 03:18AM BLOOD PT-15.2 INR(PT)-1.4\n2012-2-15 04:07AM BLOOD PT-14.6 INR(PT)-1.3\n1972-2-15 12:38PM BLOOD PT-16.6 PTT-29.4 INR(PT)-1.5\n1959-12-14 01:28AM BLOOD PT-17.1 PTT-31.2 INR(PT)-1.6\n1915-8-22 03:42AM BLOOD PT-15.5 PTT-30.6 INR(PT)-1.4*\n\n~\n~\n~\n~\n~\n~\n~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~\nRADIOLOGY\nCHEST (PORTABLE AP) 1980-6-8 10:48 PM\nIMPRESSION: Bilateral pleural effusions with perihilar haze and\nupper zone redistribution present. A focal opacity is present in\nthe left mid lung zone.', ' Findings may represent CHF/volume\noverload with concern for concomitant infection.\n\nCHEST (PORTABLE AP) 1980-11-25 3:49 PM\nIMPRESSION: Mild-to-moderate pulmonary edema has developed since\n1-5, partially obscuring multifocal consolidation, and\naccompanied by increasing moderate right pleural effusion. Large\ncardiac silhouette is stable. No pneumothorax. ET tube and right\ncentral venous line are in standard placements. No pneumothorax.\n\nCHEST (PORTABLE AP) 2003-2-29 9:51 AM\nIMPRESSION: Worsening of the left upper lobe and left lower lobe\nconsolidations vs. left pleural effusion. 2) Improvement of the\nright lower lobe consolidation.\n\nCHEST (PORTABLE AP) 2016-1-7 1:02 PM\nFINDINGS: There is a frontal and a view dedicated to the right\nlateral chest. The tracheostomy tube is unchanged. The right IJ\nline with tip in the superior vena cava is unchanged.', ' There\ncontinue to be patchy areas of opacity in both lower lungs and\nin the perihilar regions suggesting multifocal pneumonia. There\ncould also be an element of CHF\n\nC1894 INT.SHTH NOT/GUID,EP,NONLASER 1978-7-9 1:24 PM\nCHANGE G-TUBE TO G-J TUBE\nIMPRESSION: Successful placement of a MIC gastrojejunostomy tube\nwith the tip of the tube in the small bowel loop. This catheter\nis ready to use\n\nCHEST (PORTABLE AP) 1995-11-1 12:33 PM\nRight pleural effusion is again demonstrated grossly unchanged\nas well as pleural effusion on the left. The position of the\nvarious lines and tubes is unaltered and the left lower lobe\nconsolidation is again demonstrated\n\nCHEST (PORTABLE AP) 1975-10-8 5:59 AM\nModerately severe pulmonary edema and moderate left and small\nright pleural effusion have increased over the past five days.', '\nMore discrete region of consolidation seen in the left perihilar\nlung is now partially obscured but has not cleared and other\nareas of pneumonia could be obscured by the effusions and edema.\nHeart size is top normal. Tracheostomy tube and left subclavian\ncentral venous catheter are in standard placements. No\npneumothorax.\n\nCHEST (PORTABLE AP) 1993-8-17 1:12 PM\nIMPRESSION: Mild improvement of previously described pulmonary\nedema\n\nCHEST (PORTABLE AP) 1994-6-2 4:48 AM\nElevation of the right lung base which has progressed slowly\nsince early August is probably due to a combination of lower lobe\natelectasis and moderate right pleural effusion. Left perihilar\nconsolidation and hazy opacification of most of the left lung is\nprobably due to a combination of mild pulmonary edema and\nincreasing moderate left pleural effusion.', ' Although the heart is\nnot grossly enlarged, there is persistent mediastinal venous\nengorgement. More intense consolidation in the left upper lung\nis consistent with a coexistent pneumonia, unchanged since 8-22.\n~\n~\n~\n~\n~\n~\n~\n~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~\nCARDIOLOGY\nECG Study Date of 1947-2-11 3:51:00 AM\nAtrial fibrillation with rapid ventricular response\nLeft axis deviation - anterior fascicular block\nAnt/septal+lateral ST-T changes may be due to myocardial\nischemia\nRepolarization changes may be partly due to rate/rhythm\nIncomplete right bundle branch block\nSince previous tracing, right bundle branch block now incomplete\n\n\nECHO Study Date of 2003-8-26\nConclusions:\nThe left atrium is normal in size. There is symmetric left\nventricular\nhypertrophy. Due to suboptimal technical quality, a focal wall\nmotion\nabnormality cannot be fully excluded.', ' Overall left ventricular\nsystolic\nfunction is normal (LVEF>55%). The right ventricular cavity is\nmildly dilated. Right ventricular systolic function is normal.\nThe aortic root is moderately dilated. The ascending aorta is\nmildly dilated. The number of aortic valve leaflets cannot be\ndetermined. The aortic valve leaflets are thickened. There is\nprobably mild aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is\nno mitral valve prolapse. Trivial mitral regurgitation is seen.\nThe tricuspid valve leaflets are mildly thickened. There is\nmoderate pulmonary artery systolic hypertension.\n\nECG Study Date of 1980-11-25 12:11:06 PM\nAtrial fibrillation. Axis to the left. T wave inversion in lead\naVL.\nQR complexes in leads VI-V2. Non-specific T wave inversion in\nlead aVL and low amplitude T waves in lead I.', ' Right\nbundle-branch block. Anteroseptal myocardial infarction. Left\naxis deviation. Atrial fibrillation. Non-specific T wave\nabnormalities. Compared to the previous tracing of 1947-2-11\natrial fibrillation with tachycardia is no longer present.\nQuality of tracing does not permit further assessment.\n~\n~\n~\n~\n~\n~\n~\n~\n~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~\nMICROBIOLOGY\nSputum: Pseudomonas multidrug resistant. Sensitve to Tobra,\nintermediate to Thompson and Gent.\nKLEBSIELLA PNEUMONIAE\nMRSA\n\nC.Diff positive last on 10-4\n\nBrief Hospital Course:\nCC:[email protected].\nHPI:\nMr. Grier is a 87 year old man with a long history of\nend-stage dementia for at least 10 years with recurrent\naspiration pneumonias and pressure ulcers who presents to the\nPerez-Nguyen Medical Center ED from Heath-Harris Health System Rehab with an aspiration.', ' He was recently\ndischarged from Perez-Nguyen Medical Center 11-30 after he had an aspiration and had a\nprolonged intubation. He was treated with vanc/zosyn for a two\nweek course which was completed 4-30. Today, nursing at Hunter, Kim and Braun Medical Center\nnoted that his abdomen was somewhat distended. A KUB was\nperformed that showed the feeding tube was coiled in his stomach\nin a different position. Tube feeds were restarted and the\nfeeding tube was noted to be further displaced with the phlange\nout of place. The patient was turned and began vomiting and\ngagging and was suctions. His VS when he was evaluated there\nwere T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM.\n.\nThe patient was brought to the Perez-Nguyen Medical Center ED evaluation. In the ED,\nhe was immediately intubated, and started on\nlevaquin/vanc/flagyl for presumed aspiration pneumonia.', " He\ntransiently dropped his blood pressure to a systolic of 80's\nover 30's and was started on levophed.\nSurgery was consulted\n.\n87M with end-stage dementia noncommunicative for last 10 years\nand inability to be weaned off vent p/w recurrent aspiration\npneumonias and likely aspiration. On IV flagyl for +c diff.\n+Sputum cx pseudamonas on 8-4 in setting of hypotn, elevated\nWBC and low grade fevers. s/p Tracheostomy 6-8.\n.\n# Pseudomonas pneumonia: Initially admitted with hypoxia, fevers\nand hypotension with ?aspiration pneumonia however CXR unchanged\nand started on vancomycin/zosyn (1962-9-27 to 1983-8-4) for coverage of\nnosocomial peumonia. Subsequently abx d/c'd 8-27 +c diff in\nstool. On 6-18 and 2-11 sputum cx grew resistant pseudamonas\n(Quinones tobra, zosyn, meropenum) and pansensitive klebsiella\nhowever clinically stable and no clear indication of pna on CXR.", "\ns/p trach on 6-8. 1904-2-27 to 1921-8-12 increasing WBC, hypotn and low\ngrade temp. Initially started on zosyn. Sputum again +for\npseudamonas and pt. started on meropenem, tobra. On 8-22\nmeropenem was d/c and on 8-22 pt. grew pseudomonas out of sputum\n- ID recommended only starting again if clinical picture\nworsened. Pt's clinical picture did not worsen after this. Ctx\nsensitive to zosyn and question if pt. was infected vs.\ncolonized as pt. w/ stable white count and not spiking\ntemperatures so decision was made to switch to single coverage.\nThe decision was made to start Zosyn on 6-25 and was scheduled to\ncomplete a 14 day course. Because of the proximity of the end\ndate to the projected date of discharge, vanco and zosyn were\ncontinued through the date of discharge. These antibiotics\nshould be discontinued 1-2 days after the patient is transferred\nto his long term treatment facility.", '\n\n## C. Diff Colitis: Pt. was also found to have C. diff colitis\nduring hospitalization likely 8-27 antibiotics. Pt. initially\nstarted on vanco and flagyl. Per ID recs, pt. only needs single\ncoverage for this, so vanco was d/c and flagyl continued. It is\nimperative that the patient continue flagyl for 14 days AFTER\nthe last dose of Zosyn. Hence, this would correspond to 16 days\nafter transfer from Perez-Nguyen Medical Center.\n.\n## Hypotension: likely due to sepsis originally, but responsive\nto fluid boluses. In SICU, pt. was started on pressors, but\nstopped on 10-7. Pt. maintained goal MAPs. IN the MICU pt.\nlikely remained hypotensive due to poor forward flow. - given\ntotal clinic pictures decision was made that pressors were not\nindicated and the goal MAP was b/t 50-60. Throughout stay in\nMICU, pt.', " w/ stable BP w/ occassional fluid boluses for\ndecreasting MAPS. and infection responsive to fluid boluses. It\nwas decided by the MICU team, other medical and subspecialty\nteams directly involved w/ pt's care, ethics committee that CPR\nwas not medically indicated in this pt\n.\n## Acute renal failure: Pt. w/ acute renal failure during his\nstay at Hunter, Kim and Braun Medical Center. Renal was consulted and this was felt to be\nsecondary to poor forward flow. Pt. appears to have pre-renal\nfailure in the setting of total volume overload. Per renal,\nthis is not reversible and therefore the decision was made that\ndialysis was not medically indicated. Pt. w/ increasing\ncreatinine throughout stay. Renal followed and pt. was startd\non bicarb.\n.\n# Atrial fibrillation: was in good control until arrival to\nfloor but developed some RVR.", " Stable throughout SICU and MICU\nstay. Pt. was rate controlled on his own.\n.\n# Decubitus ulcers: Pt. w/ sacral decubitus - stage 1 and right\nheel stage 1. Pt. also w/ multiple skin tears from tape. Pt.\nw/ hip wound. Wound care following. Pt. w/ wet to dry\ndressings.\n.\n## G/J Tube - Pt. had a G/J tube placed by IR. During MICU\nstay, there was a question of increased leakage around tube and\nsurgery was consulted. An IR study was done that showed that\ntube was in place w/ no evidence of obstruction. On 5-4, it\nwas decided to feed the J portion of the tube and suction the G\nportion as there was no surgery indicated. On 5-8, there was a\nhole noted at the distal portion of the feeding tube. Pt. was\ntaken back to IR and a G tube was placed at daughter's\ninsistence despite the strong recommendation by the MICU team\nand IR team to have G/J tube replaced.", '\n.\n# F/E/N: Pt. was originally on TPN because of aspiration event.\nWhen pt. was in the MICU he was on TF. At the end of MICU stay,\npt. was tolerating Vivonex.\n.\n# Ppx: Throughout hospital stay, pt. was on PPI and Heparin\nprophylaxis.\n\n\nMedications on Admission:\nVancomycin 1gm q24h until 4-30\nZosyn 2.25gm q8h until 4-30\nDocusate liquid 150 twice daily\nASA 325mg daily\nPolyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops\nOphthalmic PRN\nMagnesium Hydroxide 15mg daily\nHeparin 5000u sc bid\nAlbuterol neb q6h\nAtrovent neb q6h\nLansoprazole 30mg daily\nDonepezil 10mg qhs\nLasix 20mg daily\nMilk of Magnesia 15cc daily\nLopressor 6.25 mg Hunter, Kim and Braun Medical Center\nTylenol elixir prn\nTube feeds: Nepro 0.45% @ 70cc/hr\n\nDischarge Medications:\n1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical Hunter, Kim and Braun Medical Center (2\ntimes a day).', '\n2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff\nInhalation Q6H (every 6 hours).\n3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)\nPuff Inhalation Q6H (every 6 hours).\n4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID\n(4 times a day) as needed.\n5. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical\nQID (4 times a day) as needed.\n6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every\n4 to 6 hours) as needed for fever.\n7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical Hunter, Kim and Braun Medical Center\n(2 times a day).\n8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).\n\n9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY\n(Daily).\n11. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO\nDAILY (Daily).', '\n12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)\nInjection TID (3 times a day): Please give 5000 units\nsubcutaneous heparin tid.\n13. Potassium Iodide 1 g/mL Solution Sig: Ten (10) Drop PO TID\n(3 times a day) as needed for via J tube.\n14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY\n(Daily) as needed for down J-tube.\n15. Artificial Tears Drops Sig: 1-2 Drops Ophthalmic PRN\n(as needed).\n16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)\nsliding scale Injection ASDIR (AS DIRECTED).\n17. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID\n(3 times a day).\n18. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times\na day).\n19. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO Q4H\n(every 4 hours).\n20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two\n(2) ML Intravenous DAILY (Daily) as needed: Please use 10 mL NS\nfollowed by 2 ml of 100units/ml heparin (200 units heparin) each\nlumen daily and PRN.', "\n21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln\nIntravenous Q24H (every 24 hours): please give 40 mg solution\nIV q 24 hours.\n22. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams\nRecon Solns Intravenous Q 12H (Every 12 Hours) for 2 days:\nPlease give 2.25 g IV q 13 hours.\n23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:\nFive Hundred (500) mg IV Intravenous Q12H (every 12 hours) for\n15 days: Please give 500 mg IV q 12 hrs .\n24. Wound Care\n25. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 gram\nRecon Soln(s)IV Intravenous Q8H (every 8 hours).\n26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)\ngram (200ml piggyback) Intravenous Q48H (every 48 hours).\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\n7786 Santos Pike Apt. 249\nLake Ronald, AK 96718 Hall-Moore Medical Center Hospital - 84934 Marcus Crescent Suite 418\nEast Laura, UT 21100\n\nDischarge Diagnosis:\nAspiration Pneumonia\nAcute Renal Failure\nHypotension\nAlzheimers\n\n\nDischarge Condition:\nStable\n\n\nDischarge Instructions:\nIT IS VERY IMPORTANT THAT THIS PT'S TRACH BE HUBBED AT ALL TIMES\nAS IT SLIPS SOME DUE TO GRANULATION TISSUE IN TRACT.", '\n\nPatient should follow up with your primary care physician in the\nnext week. Please take all the medications as directed. Pleas\ncontinue wound care as outlined.\n\nFollowup Instructions:\nYou should follow up with your primary care physician in the\nnext week.\n\n\n Cornell Ignacio MD 30880106\n\n']
547	27349	126991.0	2116-12-25	Discharge summary	Report	Admission Date: [2116-12-14] Discharge Date: [2116-12-25] Date of Birth: [2037-1-21] Sex: M Service: NEUROSURGERY Allergies: Codeine Attending:[First Name3 (LF) 1271] Chief Complaint: Weakness for one week Major Surgical or Invasive Procedure: RIGHT CRANIOTOMY FOR EVACUATION OF SUBDURAL HEMORRHAGE History of Present Illness: 79 year old male presents with generalized weakness for the last week. He says that he feels like he has been moving slow and his wife notes that he has needed help getting dressed and it seems like he is dragging his left leg sometimes. He denies any falls but does note that he sometimes feels like he loses his balance. No other complaints, no history of trauma, no headaches. (per admission note) Past Medical History: chronic UTIs, hypercholesterolemia, HTN Social History: lives with wife, denies tobacco or EtOH use Family History: n/c Physical Exam: PHYSICAL EXAM ON ADMISSION: O: T: 97.1 BP: 126/74 HR: 60 R 16 O2Sats 97% 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 and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [3-22], except L deltoid/bicep/tricep 5-. No pronator drift Sensation: Intact to light touch, Pertinent Results: [2116-12-24] 05:40AM BLOOD WBC-9.3 RBC-3.69* Hgb-10.8* Hct-31.0* MCV-84 MCH-29.3 MCHC-34.8 RDW-13.6 Plt Ct-204 [2116-12-23] 01:53AM BLOOD WBC-9.6 RBC-3.89* Hgb-11.6* Hct-32.7* MCV-84 MCH-29.7 MCHC-35.3* RDW-13.9 Plt Ct-209 [2116-12-22] 06:45AM BLOOD WBC-8.2 RBC-4.23* Hgb-13.0* Hct-35.7* MCV-84 MCH-30.8 MCHC-36.5* RDW-14.0 Plt Ct-172 [2116-12-21] 03:25PM BLOOD WBC-9.6 RBC-3.84* Hgb-11.5* Hct-32.2* MCV-84 MCH-29.8 MCHC-35.6* RDW-13.6 Plt Ct-208 [2116-12-23] 01:53AM BLOOD Neuts-79.1* Lymphs-13.2* Monos-6.2 Eos-1.2 Baso-0.3 [2116-12-14] 10:28AM BLOOD Neuts-63.4 Lymphs-26.9 Monos-6.0 Eos-3.5 Baso-0.2 [2116-12-24] 05:40AM BLOOD Plt Ct-204 [2116-12-23] 04:50AM BLOOD PT-13.2 PTT-28.3 INR(PT)-1.1 [2116-12-23] 01:53AM BLOOD Plt Ct-209 [2116-12-23] 01:53AM BLOOD PT-22.2* PTT-49.2* INR(PT)-2.1* [2116-12-22] 06:45AM BLOOD Plt Ct-172 [2116-12-21] 03:25PM BLOOD Plt Ct-208 [2116-12-19] 03:01AM BLOOD Plt Ct-141* [2116-12-16] 02:15AM BLOOD Ret Aut-2.6 [2116-12-24] 05:40AM BLOOD Glucose-140* UreaN-13 Creat-0.6 Na-133 K-3.6 Cl-101 HCO3-25 AnGap-11 [2116-12-23] 01:53AM BLOOD Glucose-164* UreaN-19 Creat-0.7 Na-133 K-3.9 Cl-100 HCO3-24 AnGap-13 [2116-12-22] 06:45AM BLOOD Glucose-173* UreaN-14 Creat-0.7 Na-133 K-4.5 Cl-97 HCO3-23 AnGap-18 [2116-12-21] 03:25PM BLOOD Glucose-192* UreaN-13 Creat-0.6 Na-135 K-4.1 Cl-100 HCO3-25 AnGap-14 [2116-12-24] 05:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.3 [2116-12-23] 01:53AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.4 [2116-12-22] 06:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 [2116-12-24] 05:40AM BLOOD Phenyto-12.5 [2116-12-23] 01:53AM BLOOD Phenyto-14.3 [2116-12-22] 06:45AM BLOOD Phenyto-10.7 CT HEAD W/O CONTRAST [2116-12-22] 9:07 AM CT HEAD W/O CONTRAST Reason: f/u [Hospital 93] MEDICAL CONDITION: 79 year old man with subdural hematoma evacuated REASON FOR THIS EXAMINATION: f/u CONTRAINDICATIONS for IV CONTRAST: None. ROUTINE UNENHANCED CT HEAD Comparison is made with [2116-12-19]. FINDINGS: There are changes from a right frontal craniotomy. Mixed density right frontal temporal subdural hematoma is unchanged in size and appearance. There is stable midline shift to the left. Otherwise, no change from prior study is seen. There is scattered ethmoid opacification bilaterally. IMPRESSION: Stable mixed density right hemispheric subdural hematoma. MR HEAD W/O CONTRAST [2116-12-22] 3:03 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: 79 year old man with SDH, stable on CT, increased left [Hospital 4481] [Hospital 93] MEDICAL CONDITION: 79 year old man with SDH, stable on CT, increased left weakness, r/o stroke, DWI REASON FOR THIS EXAMINATION: 79 year old man with SDH, stable on CT, increased left weakness, r/o stroke, DWI CONTRAINDICATIONS for IV CONTRAST: None. MR HEAD HISTORY: 79-year-old man with subdural hematoma with increased left-sided weakness, assess for stroke. TECHNIQUE: Multiplanar multisequence MR images of the head was attempted but was incomplete due to patient motion despite medication and restraints. Specifically, DWI was not performed. FINDINGS: Study is markedly limited by patient motion. Comparison is made to CT from the same date. Again seen is a large subdural hematoma overlying the left cerebral convexity, which is not significantly changed. There is right to left shift of the normally midline structures as before. The ventricles appear unchanged in size. IMPRESSION: Markedly limited study due to patient motion. DWI was not performed. No significant change in large right-sided subdural hematoma causing right to left midline shift. Brief Hospital Course: The patient is a 79-year-old male who presents with progressive decline in mental status. CT scan showed a large right subdural hematoma with different ages of blood and multiple membranes. Surgery was suggested by dr. [Last Name (STitle) 739], and the patient as well as the family decided to proceed with the procedure. He underwent a Right craniotomy for subdural hematoma evacuation, and his post-op neuro exam was intact. Post-op CT shows partial evacuation of hematoma with some residual SDH. His UA was negative for UTI. On [12-16] he was transfered to step down and his Foley was d/c. On [12-17] he was transfered to floor. Repeated CT on [12-17] showed enlarged SDH, and the patient was transfer to ICU. On [12-18] his head CT was slightly worse; however his neuro exam had improved. On the same day he was tranfused with Platelets. On [12-19] repeated is CT stable, and was transfered to floor. His neuro exam was improved as well, and he was alert and oriented x 3. On [12-22] he developed altered mental status, MRI, Chest XR, EKG, blood cultures, UA, was done, and Ceftriaxone was started. On the same day he was transfered to ICU. MRI imaging was limited, with unchanged SDH. On [12-23] his mental status and neuro exam had greatly improved and he was transfered to floor ID was consulted and recomended Amoxicillin, to be followed with his outpatient dose of Cipro. Physical therapy was consulted as well, and they have recommended rehabilitation placement. On [2116-12-25] mr. [Known lastname 4482] is AxO x 3, neuro exam greatly improved with minimal L pronator drift. His overall BUE stregth is [3-22], and BLE stregth IP is 5-/5, and rest of muscle groups is [3-22]. Mr. [Known lastname 4482] and the family agree with rehabilitation placement and plan. Medications on Admission: Cipro 500mg qod, lipitor 10mg qd, terazosin 1mg qd, ASA 325 qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic QHS (once a day (at bedtime)). 10. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 14 days: [2116-12-23] - [2117-1-6] (this includes 2 days of Ceftriaxone). 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO q 48 hours: Please start after Amox therapy finished. 14. Outpatient Lab Work WEEKLY DILANTIN LEVEL Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Right SUBDURAL HEMORRHAGE Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: ?????? Have a member of rehabilitation facility check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE HAVE WEEKLY DILANTIN LEVEL DONE AT THE REHABILITATION FACILITY AND THEREAFTER UNTIL YOUR FOLLOW UP WITH DR. [Last Name (STitle) ]. PLEASE HAVE THE RESULTS FAXED TO [Telephone/Fax (1) 4483] PLEASE HAVE YOUR STAPLES REMOVED ON [2116-12-29] AT THE REHABILITATION FACILITY BY A HEALTH CARE PROVIDER PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PLEASE CALL [Telephone/Fax (1) 2284] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) 91] IN UROLOGY IN TWO WEEKS. YOU [Month (only) ] NEED TO FOLLOW UP WITH INFECTIOUS DISEASE PER DR.[Doctor Last Name 4484] DISCRETION. Provider: [Name10 (NameIs) ],[Name11 (NameIs) 569] PASTOR ENDOSCOPY SUITES Date/Time:[2117-3-1] 9:30 Provider: [Name Initial (NameIs) ] SUITE GI ROOMS Date/Time:[2117-3-1] 9:30 [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2116-12-25]	Admission Date: <Date>1927-6-15</Date> Discharge Date: <Date>1953-9-4</Date> Date of Birth: <Date>1914-7-2</Date> Sex: M Service: NEUROSURGERY Allergies: Codeine Attending:<Name>Janet</Name> Chief Complaint: Weakness for one week Major Surgical or Invasive Procedure: RIGHT CRANIOTOMY FOR EVACUATION OF SUBDURAL HEMORRHAGE History of Present Illness: 79 year old male presents with generalized weakness for the last week. He says that he feels like he has been moving slow and his wife notes that he has needed help getting dressed and it seems like he is dragging his left leg sometimes. He denies any falls but does note that he sometimes feels like he loses his balance. No other complaints, no history of trauma, no headaches. (per admission note) Past Medical History: chronic UTIs, hypercholesterolemia, HTN Social History: lives with wife, denies tobacco or EtOH use Family History: n/c Physical Exam: PHYSICAL EXAM ON ADMISSION: O: T: 97.1 BP: 126/74 HR: 60 R 16 O2Sats 97% 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 and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. <Name>Larry</Name>: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power <Date>6-4</Date>, except L deltoid/bicep/tricep 5-. No pronator drift Sensation: Intact to light touch, Pertinent Results: <Date>1994-3-22</Date> 05:40AM BLOOD WBC-9.3 RBC-3.69* Hgb-10.8* Hct-31.0* MCV-84 MCH-29.3 MCHC-34.8 RDW-13.6 Plt Ct-204 <Date>2019-4-22</Date> 01:53AM BLOOD WBC-9.6 RBC-3.89* Hgb-11.6* Hct-32.7* MCV-84 MCH-29.7 MCHC-35.3* RDW-13.9 Plt Ct-209 <Date>1971-12-27</Date> 06:45AM BLOOD WBC-8.2 RBC-4.23* Hgb-13.0* Hct-35.7* MCV-84 MCH-30.8 MCHC-36.5* RDW-14.0 Plt Ct-172 <Date>1922-5-6</Date> 03:25PM BLOOD WBC-9.6 RBC-3.84* Hgb-11.5* Hct-32.2* MCV-84 MCH-29.8 MCHC-35.6* RDW-13.6 Plt Ct-208 <Date>2019-4-22</Date> 01:53AM BLOOD Neuts-79.1* Lymphs-13.2* Monos-6.2 Eos-1.2 Baso-0.3 <Date>1927-6-15</Date> 10:28AM BLOOD Neuts-63.4 Lymphs-26.9 Monos-6.0 Eos-3.5 Baso-0.2 <Date>1994-3-22</Date> 05:40AM BLOOD Plt Ct-204 <Date>2019-4-22</Date> 04:50AM BLOOD PT-13.2 PTT-28.3 INR(PT)-1.1 <Date>2019-4-22</Date> 01:53AM BLOOD Plt Ct-209 <Date>2019-4-22</Date> 01:53AM BLOOD PT-22.2* PTT-49.2* INR(PT)-2.1* <Date>1971-12-27</Date> 06:45AM BLOOD Plt Ct-172 <Date>1922-5-6</Date> 03:25PM BLOOD Plt Ct-208 <Date>2013-10-11</Date> 03:01AM BLOOD Plt Ct-141* <Date>1908-1-16</Date> 02:15AM BLOOD Ret Aut-2.6 <Date>1994-3-22</Date> 05:40AM BLOOD Glucose-140* UreaN-13 Creat-0.6 Na-133 K-3.6 Cl-101 HCO3-25 AnGap-11 <Date>2019-4-22</Date> 01:53AM BLOOD Glucose-164* UreaN-19 Creat-0.7 Na-133 K-3.9 Cl-100 HCO3-24 AnGap-13 <Date>1971-12-27</Date> 06:45AM BLOOD Glucose-173* UreaN-14 Creat-0.7 Na-133 K-4.5 Cl-97 HCO3-23 AnGap-18 <Date>1922-5-6</Date> 03:25PM BLOOD Glucose-192* UreaN-13 Creat-0.6 Na-135 K-4.1 Cl-100 HCO3-25 AnGap-14 <Date>1994-3-22</Date> 05:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.3 <Date>2019-4-22</Date> 01:53AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.4 <Date>1971-12-27</Date> 06:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 <Date>1994-3-22</Date> 05:40AM BLOOD Phenyto-12.5 <Date>2019-4-22</Date> 01:53AM BLOOD Phenyto-14.3 <Date>1971-12-27</Date> 06:45AM BLOOD Phenyto-10.7 CT HEAD W/O CONTRAST <Date>1971-12-27</Date> 9:07 AM CT HEAD W/O CONTRAST Reason: f/u <Hospital>Mccoy Inc Clinic</Hospital> MEDICAL CONDITION: 79 year old man with subdural hematoma evacuated REASON FOR THIS EXAMINATION: f/u CONTRAINDICATIONS for IV CONTRAST: None. ROUTINE UNENHANCED CT HEAD Comparison is made with <Date>2013-10-11</Date>. FINDINGS: There are changes from a right frontal craniotomy. Mixed density right frontal temporal subdural hematoma is unchanged in size and appearance. There is stable midline shift to the left. Otherwise, no change from prior study is seen. There is scattered ethmoid opacification bilaterally. IMPRESSION: Stable mixed density right hemispheric subdural hematoma. MR HEAD W/O CONTRAST <Date>1971-12-27</Date> 3:03 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: 79 year old man with SDH, stable on CT, increased left <Hospital>Jordan, Flynn and Foster Hospital</Hospital> <Hospital>Mccoy Inc Clinic</Hospital> MEDICAL CONDITION: 79 year old man with SDH, stable on CT, increased left weakness, r/o stroke, DWI REASON FOR THIS EXAMINATION: 79 year old man with SDH, stable on CT, increased left weakness, r/o stroke, DWI CONTRAINDICATIONS for IV CONTRAST: None. MR HEAD HISTORY: 79-year-old man with subdural hematoma with increased left-sided weakness, assess for stroke. TECHNIQUE: Multiplanar multisequence MR images of the head was attempted but was incomplete due to patient motion despite medication and restraints. Specifically, DWI was not performed. FINDINGS: Study is markedly limited by patient motion. Comparison is made to CT from the same date. Again seen is a large subdural hematoma overlying the left cerebral convexity, which is not significantly changed. There is right to left shift of the normally midline structures as before. The ventricles appear unchanged in size. IMPRESSION: Markedly limited study due to patient motion. DWI was not performed. No significant change in large right-sided subdural hematoma causing right to left midline shift. Brief Hospital Course: The patient is a 79-year-old male who presents with progressive decline in mental status. CT scan showed a large right subdural hematoma with different ages of blood and multiple membranes. Surgery was suggested by dr. <Name>Martin</Name>, and the patient as well as the family decided to proceed with the procedure. He underwent a Right craniotomy for subdural hematoma evacuation, and his post-op neuro exam was intact. Post-op CT shows partial evacuation of hematoma with some residual SDH. His UA was negative for UTI. On <Date>9-9</Date> he was transfered to step down and his Foley was d/c. On <Date>5-3</Date> he was transfered to floor. Repeated CT on <Date>5-3</Date> showed enlarged SDH, and the patient was transfer to ICU. On <Date>10-28</Date> his head CT was slightly worse; however his neuro exam had improved. On the same day he was tranfused with Platelets. On <Date>5-11</Date> repeated is CT stable, and was transfered to floor. His neuro exam was improved as well, and he was alert and oriented x 3. On <Date>2-4</Date> he developed altered mental status, MRI, Chest XR, EKG, blood cultures, UA, was done, and Ceftriaxone was started. On the same day he was transfered to ICU. MRI imaging was limited, with unchanged SDH. On <Date>9-28</Date> his mental status and neuro exam had greatly improved and he was transfered to floor ID was consulted and recomended Amoxicillin, to be followed with his outpatient dose of Cipro. Physical therapy was consulted as well, and they have recommended rehabilitation placement. On <Date>1953-9-4</Date> mr. <Name>Poff</Name> is AxO x 3, neuro exam greatly improved with minimal L pronator drift. His overall BUE stregth is <Date>6-4</Date>, and BLE stregth IP is 5-/5, and rest of muscle groups is <Date>6-4</Date>. Mr. <Name>Poff</Name> and the family agree with rehabilitation placement and plan. Medications on Admission: Cipro 500mg qod, lipitor 10mg qd, terazosin 1mg qd, ASA 325 qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic QHS (once a day (at bedtime)). 10. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 14 days: <Date>2019-4-22</Date> - <Date>1992-10-4</Date> (this includes 2 days of Ceftriaxone). 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO q 48 hours: Please start after Amox therapy finished. 14. Outpatient Lab Work WEEKLY DILANTIN LEVEL Discharge Disposition: Extended Care Facility: <Hospital>Mccarthy-Clark Clinic</Hospital> for the Aged - MACU Discharge Diagnosis: Right SUBDURAL HEMORRHAGE Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: ?????? Have a member of rehabilitation facility check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE HAVE WEEKLY DILANTIN LEVEL DONE AT THE REHABILITATION FACILITY AND THEREAFTER UNTIL YOUR FOLLOW UP WITH DR. <Name>Lockett</Name>. PLEASE HAVE THE RESULTS FAXED TO <Telephone>178-622-1774</Telephone> PLEASE HAVE YOUR STAPLES REMOVED ON <Date>1918-5-20</Date> AT THE REHABILITATION FACILITY BY A HEALTH CARE PROVIDER PLEASE CALL <Telephone>134-785-3364</Telephone> TO SCHEDULE AN APPOINTMENT WITH DR. <Name>Lockett</Name> TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PLEASE CALL <Telephone>558-487-4739</Telephone> TO SCHEDULE AN APPOINTMENT WITH DR. <Name>Shipley</Name> IN UROLOGY IN TWO WEEKS. YOU <Month>October</Month> NEED TO FOLLOW UP WITH INFECTIOUS DISEASE PER DR.<Doctor Name>Dr.Ivory</Doctor Name> DISCRETION. Provider: <Name>Teressa Salgado</Name>,<Name>Joe Naegelin</Name> PASTOR ENDOSCOPY SUITES Date/Time:<Date>2016-11-18</Date> 9:30 Provider: <Name>Kelly Pegram</Name> SUITE GI ROOMS Date/Time:<Date>2016-11-18</Date> 9:30 <Name>Latonya Waldon</Name> <Name>Tarek Demong</Name> MD <MD Number>70131140</MD Number> Completed by:<Date>1953-9-4</Date>	0000000000000000011111111100000000000000000000000000000000111111110000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000011111111100000000000000000000000000000000000000000000111111111000000000000000000000000001111111110000000000000000000000000000000000000000000000011111111110000000000000000000000000011111111000000000000000000000000001111111111000000000000000000000000000111111111000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000111111111000000000000000000000000000011111111100000000000000000000000000001111111111000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000011111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111110111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1927-6-15 Discharge Date: 1953-9-4 Date of Birth: 1914-7-2 Sex: M Service: NEUROSURGERY Allergies: Codeine Attending:Janet Chief Complaint: Weakness for one week Major Surgical or Invasive Procedure: RIGHT CRANIOTOMY FOR EVACUATION OF SUBDURAL HEMORRHAGE History of Present Illness: 79 year old male presents with generalized weakness for the last week. He says that he feels like he has been moving slow and his wife notes that he has needed help getting dressed and it seems like he is dragging his left leg sometimes. He denies any falls but does note that he sometimes feels like he loses his balance. No other complaints, no history of trauma, no headaches. (per admission note) Past Medical History: chronic UTIs, hypercholesterolemia, HTN Social History: lives with wife, denies tobacco or EtOH use Family History: n/c Physical Exam: PHYSICAL EXAM ON ADMISSION: O: T: 97.1 BP: 126/74 HR: 60 R 16 O2Sats 97% 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 and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. Larry: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power 6-4, except L deltoid/bicep/tricep 5-. No pronator drift Sensation: Intact to light touch, Pertinent Results: 1994-3-22 05:40AM BLOOD WBC-9.3 RBC-3.69* Hgb-10.8* Hct-31.0* MCV-84 MCH-29.3 MCHC-34.8 RDW-13.6 Plt Ct-204 2019-4-22 01:53AM BLOOD WBC-9.6 RBC-3.89* Hgb-11.6* Hct-32.7* MCV-84 MCH-29.7 MCHC-35.3* RDW-13.9 Plt Ct-209 1971-12-27 06:45AM BLOOD WBC-8.2 RBC-4.23* Hgb-13.0* Hct-35.7* MCV-84 MCH-30.8 MCHC-36.5* RDW-14.0 Plt Ct-172 1922-5-6 03:25PM BLOOD WBC-9.6 RBC-3.84* Hgb-11.5* Hct-32.2* MCV-84 MCH-29.8 MCHC-35.6* RDW-13.6 Plt Ct-208 2019-4-22 01:53AM BLOOD Neuts-79.1* Lymphs-13.2* Monos-6.2 Eos-1.2 Baso-0.3 1927-6-15 10:28AM BLOOD Neuts-63.4 Lymphs-26.9 Monos-6.0 Eos-3.5 Baso-0.2 1994-3-22 05:40AM BLOOD Plt Ct-204 2019-4-22 04:50AM BLOOD PT-13.2 PTT-28.3 INR(PT)-1.1 2019-4-22 01:53AM BLOOD Plt Ct-209 2019-4-22 01:53AM BLOOD PT-22.2* PTT-49.2* INR(PT)-2.1* 1971-12-27 06:45AM BLOOD Plt Ct-172 1922-5-6 03:25PM BLOOD Plt Ct-208 2013-10-11 03:01AM BLOOD Plt Ct-141* 1908-1-16 02:15AM BLOOD Ret Aut-2.6 1994-3-22 05:40AM BLOOD Glucose-140* UreaN-13 Creat-0.6 Na-133 K-3.6 Cl-101 HCO3-25 AnGap-11 2019-4-22 01:53AM BLOOD Glucose-164* UreaN-19 Creat-0.7 Na-133 K-3.9 Cl-100 HCO3-24 AnGap-13 1971-12-27 06:45AM BLOOD Glucose-173* UreaN-14 Creat-0.7 Na-133 K-4.5 Cl-97 HCO3-23 AnGap-18 1922-5-6 03:25PM BLOOD Glucose-192* UreaN-13 Creat-0.6 Na-135 K-4.1 Cl-100 HCO3-25 AnGap-14 1994-3-22 05:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.3 2019-4-22 01:53AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.4 1971-12-27 06:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 1994-3-22 05:40AM BLOOD Phenyto-12.5 2019-4-22 01:53AM BLOOD Phenyto-14.3 1971-12-27 06:45AM BLOOD Phenyto-10.7 CT HEAD W/O CONTRAST 1971-12-27 9:07 AM CT HEAD W/O CONTRAST Reason: f/u Mccoy Inc Clinic MEDICAL CONDITION: 79 year old man with subdural hematoma evacuated REASON FOR THIS EXAMINATION: f/u CONTRAINDICATIONS for IV CONTRAST: None. ROUTINE UNENHANCED CT HEAD Comparison is made with 2013-10-11. FINDINGS: There are changes from a right frontal craniotomy. Mixed density right frontal temporal subdural hematoma is unchanged in size and appearance. There is stable midline shift to the left. Otherwise, no change from prior study is seen. There is scattered ethmoid opacification bilaterally. IMPRESSION: Stable mixed density right hemispheric subdural hematoma. MR HEAD W/O CONTRAST 1971-12-27 3:03 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: 79 year old man with SDH, stable on CT, increased left Jordan, Flynn and Foster Hospital Mccoy Inc Clinic MEDICAL CONDITION: 79 year old man with SDH, stable on CT, increased left weakness, r/o stroke, DWI REASON FOR THIS EXAMINATION: 79 year old man with SDH, stable on CT, increased left weakness, r/o stroke, DWI CONTRAINDICATIONS for IV CONTRAST: None. MR HEAD HISTORY: 79-year-old man with subdural hematoma with increased left-sided weakness, assess for stroke. TECHNIQUE: Multiplanar multisequence MR images of the head was attempted but was incomplete due to patient motion despite medication and restraints. Specifically, DWI was not performed. FINDINGS: Study is markedly limited by patient motion. Comparison is made to CT from the same date. Again seen is a large subdural hematoma overlying the left cerebral convexity, which is not significantly changed. There is right to left shift of the normally midline structures as before. The ventricles appear unchanged in size. IMPRESSION: Markedly limited study due to patient motion. DWI was not performed. No significant change in large right-sided subdural hematoma causing right to left midline shift. Brief Hospital Course: The patient is a 79-year-old male who presents with progressive decline in mental status. CT scan showed a large right subdural hematoma with different ages of blood and multiple membranes. Surgery was suggested by dr. Martin, and the patient as well as the family decided to proceed with the procedure. He underwent a Right craniotomy for subdural hematoma evacuation, and his post-op neuro exam was intact. Post-op CT shows partial evacuation of hematoma with some residual SDH. His UA was negative for UTI. On 9-9 he was transfered to step down and his Foley was d/c. On 5-3 he was transfered to floor. Repeated CT on 5-3 showed enlarged SDH, and the patient was transfer to ICU. On 10-28 his head CT was slightly worse; however his neuro exam had improved. On the same day he was tranfused with Platelets. On 5-11 repeated is CT stable, and was transfered to floor. His neuro exam was improved as well, and he was alert and oriented x 3. On 2-4 he developed altered mental status, MRI, Chest XR, EKG, blood cultures, UA, was done, and Ceftriaxone was started. On the same day he was transfered to ICU. MRI imaging was limited, with unchanged SDH. On 9-28 his mental status and neuro exam had greatly improved and he was transfered to floor ID was consulted and recomended Amoxicillin, to be followed with his outpatient dose of Cipro. Physical therapy was consulted as well, and they have recommended rehabilitation placement. On 1953-9-4 mr. Poff is AxO x 3, neuro exam greatly improved with minimal L pronator drift. His overall BUE stregth is 6-4, and BLE stregth IP is 5-/5, and rest of muscle groups is 6-4. Mr. Poff and the family agree with rehabilitation placement and plan. Medications on Admission: Cipro 500mg qod, lipitor 10mg qd, terazosin 1mg qd, ASA 325 qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic QHS (once a day (at bedtime)). 10. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 14 days: 2019-4-22 - 1992-10-4 (this includes 2 days of Ceftriaxone). 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO q 48 hours: Please start after Amox therapy finished. 14. Outpatient Lab Work WEEKLY DILANTIN LEVEL Discharge Disposition: Extended Care Facility: Mccarthy-Clark Clinic for the Aged - MACU Discharge Diagnosis: Right SUBDURAL HEMORRHAGE Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: ?????? Have a member of rehabilitation facility check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE HAVE WEEKLY DILANTIN LEVEL DONE AT THE REHABILITATION FACILITY AND THEREAFTER UNTIL YOUR FOLLOW UP WITH DR. Lockett. PLEASE HAVE THE RESULTS FAXED TO 178-622-1774 PLEASE HAVE YOUR STAPLES REMOVED ON 1918-5-20 AT THE REHABILITATION FACILITY BY A HEALTH CARE PROVIDER PLEASE CALL 134-785-3364 TO SCHEDULE AN APPOINTMENT WITH DR. Lockett TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PLEASE CALL 558-487-4739 TO SCHEDULE AN APPOINTMENT WITH DR. Shipley IN UROLOGY IN TWO WEEKS. YOU October NEED TO FOLLOW UP WITH INFECTIOUS DISEASE PER DR.Dr.Ivory DISCRETION. Provider: Teressa Salgado,Joe Naegelin PASTOR ENDOSCOPY SUITES Date/Time:2016-11-18 9:30 Provider: Kelly Pegram SUITE GI ROOMS Date/Time:2016-11-18 9:30 Latonya Waldon Tarek Demong MD 70131140 Completed by:1953-9-4	['Admission Date: 1927-6-15 Discharge Date: 1953-9-4\n\nDate of Birth: 1914-7-2 Sex: M\n\nService: NEUROSURGERY\n\nAllergies:\nCodeine\n\nAttending:Janet\nChief Complaint:\nWeakness for one week\n\nMajor Surgical or Invasive Procedure:\nRIGHT CRANIOTOMY FOR EVACUATION OF SUBDURAL HEMORRHAGE\n\n\nHistory of Present Illness:\n79 year old male presents with generalized weakness for the\nlast week. He says that he feels like he has been moving slow\nand his wife notes that he has needed help getting dressed and\nit\nseems like he is dragging his left leg sometimes. He denies any\nfalls but does note that he sometimes feels like he loses his\nbalance. No other complaints, no history of trauma, no\nheadaches.\n(per admission note)\n\nPast Medical History:\nchronic UTIs, hypercholesterolemia, HTN\n\n\nSocial History:\nlives with wife, denies tobacco or EtOH use\n\n\nFamily History:\nn/c\n\nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION:\nO: T: 97.', '1 BP: 126/74 HR: 60 R 16 O2Sats 97% RA\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: PERRL EOMs intact\nNeck: Supple.\nLungs: CTA bilaterally.\nCardiac: RRR. S1/S2.\nAbd: Soft, NT, BS+\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place, and date.\nLanguage: Speech fluent with good comprehension and repetition.\nNaming intact. No dysarthria or paraphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 3mm to 2mm\nmm bilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.', '\nLarry: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power 6-4, except L deltoid/bicep/tricep\n5-. No pronator drift\n\nSensation: Intact to light touch,\n\n\nPertinent Results:\n1994-3-22 05:40AM BLOOD WBC-9.3 RBC-3.69* Hgb-10.8* Hct-31.0\nMCV-84 MCH-29.3 MCHC-34.8 RDW-13.6 Plt Ct-204\n2019-4-22 01:53AM BLOOD WBC-9.6 RBC-3.89 Hgb-11.6* Hct-32.7\nMCV-84 MCH-29.7 MCHC-35.3 RDW-13.9 Plt Ct-209\n1971-12-27 06:45AM BLOOD WBC-8.2 RBC-4.23* Hgb-13.0* Hct-35.7\nMCV-84 MCH-30.8 MCHC-36.5 RDW-14.0 Plt Ct-172\n1922-5-6 03:25PM BLOOD WBC-9.6 RBC-3.84* Hgb-11.5* Hct-32.2\nMCV-84 MCH-29.8 MCHC-35.6 RDW-13.6 Plt Ct-208\n\n2019-4-22 01:53AM BLOOD Neuts-79.1* Lymphs-13.2* Monos-6.', '2\nEos-1.2 Baso-0.3\n1927-6-15 10:28AM BLOOD Neuts-63.4 Lymphs-26.9 Monos-6.0 Eos-3.5\nBaso-0.2\n1994-3-22 05:40AM BLOOD Plt Ct-204\n2019-4-22 04:50AM BLOOD PT-13.2 PTT-28.3 INR(PT)-1.1\n2019-4-22 01:53AM BLOOD Plt Ct-209\n2019-4-22 01:53AM BLOOD PT-22.2* PTT-49.2* INR(PT)-2.1\n1971-12-27 06:45AM BLOOD Plt Ct-172\n1922-5-6 03:25PM BLOOD Plt Ct-208\n2013-10-11 03:01AM BLOOD Plt Ct-141\n1908-1-16 02:15AM BLOOD Ret Aut-2.6\n1994-3-22 05:40AM BLOOD Glucose-140* UreaN-13 Creat-0.6 Na-133\nK-3.6 Cl-101 HCO3-25 AnGap-11\n2019-4-22 01:53AM BLOOD Glucose-164* UreaN-19 Creat-0.7 Na-133\nK-3.9 Cl-100 HCO3-24 AnGap-13\n1971-12-27 06:45AM BLOOD Glucose-173* UreaN-14 Creat-0.7 Na-133\nK-4.5 Cl-97 HCO3-23 AnGap-18\n1922-5-6 03:25PM BLOOD Glucose-192* UreaN-13 Creat-0.6 Na-135\nK-4.1 Cl-100 HCO3-25 AnGap-14\n1994-3-22 05:40AM BLOOD Calcium-8.', '5 Phos-3.0 Mg-2.3\n2019-4-22 01:53AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.4\n1971-12-27 06:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2\n1994-3-22 05:40AM BLOOD Phenyto-12.5\n2019-4-22 01:53AM BLOOD Phenyto-14.3\n1971-12-27 06:45AM BLOOD Phenyto-10.7\n\nCT HEAD W/O CONTRAST 1971-12-27 9:07 AM\nCT HEAD W/O CONTRAST\nReason: f/u\nMccoy Inc Clinic MEDICAL CONDITION:\n79 year old man with subdural hematoma evacuated\nREASON FOR THIS EXAMINATION:\nf/u\nCONTRAINDICATIONS for IV CONTRAST: None.\nROUTINE UNENHANCED CT HEAD\nComparison is made with 2013-10-11.\nFINDINGS:\nThere are changes from a right frontal craniotomy. Mixed density\nright frontal temporal subdural hematoma is unchanged in size\nand appearance. There is stable midline shift to the left.\nOtherwise, no change from prior study is seen. There is\nscattered ethmoid opacification bilaterally.', '\nIMPRESSION:\nStable mixed density right hemispheric subdural hematoma.\n\nMR HEAD W/O CONTRAST 1971-12-27 3:03 PM\nMR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST\nReason: 79 year old man with SDH, stable on CT, increased left\nJordan, Flynn and Foster Hospital\nMccoy Inc Clinic MEDICAL CONDITION:\n79 year old man with SDH, stable on CT, increased left weakness,\nr/o stroke, DWI\nREASON FOR THIS EXAMINATION:\n79 year old man with SDH, stable on CT, increased left weakness,\nr/o stroke, DWI\nCONTRAINDICATIONS for IV CONTRAST: None.\n\nMR HEAD\nHISTORY: 79-year-old man with subdural hematoma with increased\nleft-sided weakness, assess for stroke.\nTECHNIQUE: Multiplanar multisequence MR images of the head was\nattempted but was incomplete due to patient motion despite\nmedication and restraints. Specifically, DWI was not performed.', '\nFINDINGS: Study is markedly limited by patient motion.\nComparison is made to CT from the same date.\nAgain seen is a large subdural hematoma overlying the left\ncerebral convexity, which is not significantly changed. There is\nright to left shift of the normally midline structures as\nbefore. The ventricles appear unchanged in size.\nIMPRESSION: Markedly limited study due to patient motion. DWI\nwas not performed.\nNo significant change in large right-sided subdural hematoma\ncausing right to left midline shift.\n\n\nBrief Hospital Course:\nThe patient is a 79-year-old male who presents with progressive\ndecline in mental status. CT scan showed a large right subdural\nhematoma with different ages of blood and multiple membranes.\nSurgery was suggested by dr. Martin, and the patient as\nwell as the family decided to proceed with the procedure.', '\nHe underwent a Right craniotomy for subdural hematoma\nevacuation, and his post-op neuro exam was intact. Post-op CT\nshows partial evacuation of hematoma with some residual SDH. His\nUA was negative for UTI.\nOn 9-9 he was transfered to step down and his Foley was d/c.\nOn 5-3 he was transfered to floor. Repeated CT on 5-3 showed\nenlarged SDH, and the patient was transfer to ICU.\nOn 10-28 his head CT was slightly worse; however his neuro exam\nhad improved. On the same day he was tranfused with Platelets.\nOn 5-11 repeated is CT stable, and was transfered to floor. His\nneuro exam was improved as well, and he was alert and oriented x\n3.\nOn 2-4 he developed altered mental status, MRI, Chest XR, EKG,\nblood cultures, UA, was done, and Ceftriaxone was started. On\nthe same day he was transfered to ICU.', ' MRI imaging was limited,\nwith unchanged SDH.\nOn 9-28 his mental status and neuro exam had greatly improved and\nhe was transfered to floor\nID was consulted and recomended Amoxicillin, to be followed with\nhis outpatient dose of Cipro.\nPhysical therapy was consulted as well, and they have\nrecommended rehabilitation placement.\nOn 1953-9-4 mr. Poff is AxO x 3, neuro exam greatly improved\nwith minimal L pronator drift. His overall BUE stregth is 6-4,\nand BLE stregth IP is 5-/5, and rest of muscle groups is 6-4.\nMr. Poff and the family agree with rehabilitation placement\nand plan.\n\nMedications on Admission:\nCipro 500mg qod,\nlipitor 10mg qd,\nterazosin 1mg qd,\nASA 325 qd\n\n\nDischarge Medications:\n1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\nhours) as needed for pain/fever.\n2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).', '\n3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.\n5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed.\n6. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at\nbedtime).\n7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule\nPO TID (3 times a day).\n9. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic QHS (once a\nday (at bedtime)).\n10. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\n11. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n12. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q8H\n(every 8 hours) for 14 days: 2019-4-22 - 1992-10-4 (this includes 2\ndays of Ceftriaxone).', '\n13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO q 48\nhours: Please start after Amox therapy finished.\n14. Outpatient Lab Work\nWEEKLY DILANTIN LEVEL\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nMccarthy-Clark Clinic for the Aged - MACU\n\nDischarge Diagnosis:\nRight SUBDURAL HEMORRHAGE\n\n\nDischarge Condition:\nNEUROLOGICALLY STABLE\n\n\nDischarge Instructions:\n??????\tHave a member of rehabilitation facility check your incision\ndaily for signs of infection\n??????\tTake your pain medicine as prescribed\n??????\tExercise should be limited to walking; no lifting, straining,\nexcessive bending\n??????\tYou may wash your hair only after sutures and/or staples have\nbeen removed\n??????\tYou may shower before this time with assistance and use of a\nshower cap\n??????\tIncrease your intake of fluids and fiber as pain medicine\n(narcotics) can cause constipation\n??????\tUnless directed by your doctor, do not take any\nanti-inflammatory medicines such as Motrin, aspirin, Advil,\nIbuprofen etc.', '\n??????\tIf you have been prescribed an anti-seizure medicine, take it\nas prescribed and follow up with laboratory blood drawing as\nordered\n??????\tClearance to drive and return to work will be addressed at\nyour post-operative office visit\n\nCALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE\nFOLLOWING:\n\n??????\tNew onset of tremors or seizures\n??????\tAny confusion or change in mental status\n??????\tAny numbness, tingling, weakness in your extremities\n??????\tPain or headache that is continually increasing or not\nrelieved by pain medication\n??????\tAny signs of infection at the wound site: redness, swelling,\ntenderness, drainage\n??????\tFever greater than or equal to 101?????? F\n\n\nFollowup Instructions:\nPLEASE HAVE WEEKLY DILANTIN LEVEL DONE AT THE REHABILITATION\nFACILITY AND THEREAFTER UNTIL YOUR FOLLOW UP WITH DR.', '\nLockett. PLEASE HAVE THE RESULTS FAXED TO 178-622-1774\n\nPLEASE HAVE YOUR STAPLES REMOVED ON 1918-5-20 AT THE\nREHABILITATION FACILITY BY A HEALTH CARE PROVIDER\n\nPLEASE CALL 134-785-3364 TO SCHEDULE AN APPOINTMENT WITH DR.\nLockett TO BE SEEN IN 4 WEEKS.\nYOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST\n\nPLEASE CALL 558-487-4739 TO SCHEDULE AN APPOINTMENT WITH DR.\nShipley IN UROLOGY IN TWO WEEKS.\nYOU October NEED TO FOLLOW UP WITH INFECTIOUS DISEASE PER DR.Dr.Ivory\nDISCRETION.\nProvider: Teressa Salgado,Joe Naegelin PASTOR ENDOSCOPY SUITES Date/Time:2016-11-18\n9:30\nProvider: Kelly Pegram SUITE GI ROOMS Date/Time:2016-11-18 9:30\n\n\n Latonya Waldon Tarek Demong MD 70131140\n\nCompleted by:1953-9-4']
548	76709	115291.0	2107-06-09	Discharge summary	Report	Admission Date: [2107-5-26] Discharge Date: [2107-6-9] Date of Birth: [2029-5-6] Sex: F Service: SURGERY Allergies: Cortisone / Percocet / Prednisone / Advair Diskus Attending:[First Name3 (LF) 3376] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [2107-5-26]: Exploratory laparotomy with ileocolectomy History of Present Illness: 78F s/p laparoscopic converted to open right hemicolectomy for Stage 1 (T1N0) right colon cancer on [2106-10-29], now being transferred from OSH with diffuse abdominal pain and guarding on exam. She started with diffuse abdominal pain at 9am yesterday and went to [Hospital3 4485] at 9pm. She had some nausea and bilious emesis x5, but had been passing flatus and bowel movements. A non-contrast CT was performed and she was sent here as her abdominal exam was concerning. In ED with A.fib w/RVR, hypertension up to 200/100. Past Medical History: CAD s/p PCI (last '[02]), pAFib, CHF, HTN, hyperchol, interstitial lung disease, GIB, GERD, CRI (baseline Cr 1.3-1.8), NIDDM, hypothyroid, TIA, parkinson's, low back pain Past Surgical History: Diverting transverse loop colostomy after colonic perforation from colonoscopy,, colostomy reversal, ventral hernia repair with mesh, Laparoscopic converted to open right hemicolectomy [2106-11-15]. Social History: Patient is retired, lives at home with husband. Former [Name2 (NI) 1818]. Denies alcohol or other drugs. Family History: NC Physical Exam: On admission: Vitals: T 101.1 HR 160 BP 120/90 RR 20 SO2 96% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Firm, nondistended, severely tender diffusely, mild rebound tenderness and voluntary guarding. DRE: normal tone, no gross or occult blood Ext: 1+ LE edema b/l, LE warm and well perfused On Discharge: Pertinent Results: ADMISSION LABS -------------- [2107-5-26] 12:30AM BLOOD WBC-29.3# RBC-4.63# Hgb-13.3# Hct-42.3# MCV-91 MCH-28.8 MCHC-31.5 RDW-15.8 Plt Ct-263# [2107-5-26] 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0* [2107-5-26] 12:30AM BLOOD Glucose-182* UreaN-40* Creat-1.6* Na-143 K-6.0* Cl-107 HCO3-19* AnGap-23* [2107-5-26]: TEE No intracardiac thrombus. Mild mitral regurgitation. [2107-5-26]: CT abd/pelvis: - Diffuse bowel wall dilatation, with lack of mural enhancement in the distal ileum, concerning for bowel ischemia or necrosis. There is an occlusion of an ileal branch of the superior mesenteric artery suggesting an embolic cause for bowel ischemia upstream of affected areas. - Extensive atherosclerotic disease of the aorta and iliac arteries. [2107-5-30]: MRI Head - Acute infarction in the left middle cerebral artery distribution involving the left parietal lobe. - Small old infarct in the right cerebellum. - No evidence of susceptibility artifact to suggest intracranial hemorrhage. [2107-6-3]: KUB - ileus [2107-6-4]: KUB - There has been no significant change. There remains air and stool seen throughout the colon and some mildly prominent loops of small bowel. Left side down decubitus radiograph, shows no free intra-abdominal gas present. Surgical skin staples are seen projecting over the midline. [2107-6-4]: CT HEAD: - Evolving left parietal infarct. No evidence of hemorrhagic transformation. - Global atrophy and chronic small vessel change. - Small old right cerebellar infarct. [2107-6-8] 05:10AM BLOOD WBC-7.8 RBC-3.43* Hgb-10.1* Hct-31.3* MCV-91 MCH-29.6 MCHC-32.4 RDW-15.6* Plt Ct-454* [2107-6-7] 05:22AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.5* Hct-30.5* MCV-93 MCH-29.1 MCHC-31.3 RDW-15.8* Plt Ct-438 [2107-6-6] 05:00AM BLOOD WBC-7.8 RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.4 MCHC-32.0 RDW-15.9* Plt Ct-361 [2107-6-5] 05:37PM BLOOD WBC-8.8 RBC-3.24* Hgb-9.2* Hct-29.2* MCV-90 MCH-28.4 MCHC-31.5 RDW-16.3* Plt Ct-313 [2107-6-5] 09:24AM BLOOD WBC-8.0 RBC-3.16* Hgb-9.3* Hct-28.5* MCV-90 MCH-29.3 MCHC-32.5 RDW-16.2* Plt Ct-310 [2107-6-5] 01:42AM BLOOD WBC-7.3 RBC-3.02* Hgb-9.2* Hct-26.5* MCV-88 MCH-30.6 MCHC-34.9 RDW-15.9* Plt Ct-268 [2107-6-4] 12:11AM BLOOD WBC-7.1 RBC-3.61* Hgb-10.6* Hct-32.7* MCV-91 MCH-29.5 MCHC-32.5 RDW-16.3* Plt Ct-307 [2107-6-3] 05:12AM BLOOD WBC-5.3 RBC-3.42* Hgb-10.0* Hct-31.5* MCV-92 MCH-29.3 MCHC-31.8 RDW-15.9* Plt Ct-245 [2107-6-2] 05:25AM BLOOD WBC-4.1 RBC-3.44* Hgb-10.1* Hct-31.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-15.8* Plt Ct-200 [2107-6-1] 05:20AM BLOOD WBC-3.0* RBC-3.64* Hgb-10.9* Hct-32.8* MCV-90 MCH-29.8 MCHC-33.1 RDW-15.8* Plt Ct-157 [2107-5-31] 05:10AM BLOOD WBC-4.0# RBC-3.83* Hgb-11.4* Hct-34.1* MCV-89 MCH-29.8 MCHC-33.5 RDW-15.9* Plt Ct-132* [2107-5-26] 12:30AM BLOOD Neuts-93* Bands-0 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2107-5-26] 12:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr[Last Name (STitle) 833] [Name (STitle) 4486] [2107-6-9] 11:10AM BLOOD PT-24.3* PTT-26.1 INR(PT)-2.3* [2107-6-8] 05:10AM BLOOD Plt Ct-454* [2107-6-8] 05:10AM BLOOD PT-25.3* PTT-28.1 INR(PT)-2.4* [2107-6-7] 05:22AM BLOOD Plt Ct-438 [2107-6-7] 05:22AM BLOOD PT-39.7* PTT-29.9 INR(PT)-4.1* [2107-6-6] 05:00AM BLOOD Plt Ct-361 [2107-6-6] 05:00AM BLOOD PT-39.0* PTT-29.5 INR(PT)-4.0* [2107-6-5] 05:37PM BLOOD Plt Ct-313 [2107-6-5] 09:24AM BLOOD Plt Ct-310 [2107-6-5] 01:42AM BLOOD Plt Ct-268 [2107-6-5] 01:42AM BLOOD PT-39.8* PTT-28.6 INR(PT)-4.1* [2107-6-4] 12:11AM BLOOD Plt Ct-307 [2107-6-4] 12:11AM BLOOD PT-38.6* PTT-26.7 INR(PT)-3.9* [2107-6-3] 05:12AM BLOOD PT-38.4* PTT-27.4 INR(PT)-3.9* [2107-6-2] 11:20AM BLOOD PT-34.5* PTT-68.9* INR(PT)-3.5* [2107-6-1] 12:58PM BLOOD PT-17.7* PTT-45.5* INR(PT)-1.6* [2107-6-1] 05:20AM BLOOD Plt Ct-157 [2107-6-1] 05:20AM BLOOD PT-16.7* PTT-44.1* INR(PT)-1.5* [2107-5-31] 05:10AM BLOOD PT-16.1* PTT-26.0 INR(PT)-1.4* [2107-5-30] 03:20PM BLOOD PT-17.6* PTT-25.5 INR(PT)-1.6* [2107-5-28] 03:10AM BLOOD PT-16.8* PTT-28.7 INR(PT)-1.5* [2107-5-27] 12:26PM BLOOD Plt Ct-120* [2107-5-27] 12:26PM BLOOD PT-23.0* PTT-32.7 INR(PT)-2.1* [2107-5-27] 03:29AM BLOOD PT-31.2* PTT-35.1* INR(PT)-3.1* [2107-5-26] 07:22AM BLOOD PT-19.8* PTT-29.8 INR(PT)-1.8* [2107-5-26] 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0* [2107-6-9] 11:10AM BLOOD Glucose-90 UreaN-13 Creat-1.3* Na-146* K-3.6 Cl-111* HCO3-23 AnGap-16 [2107-6-8] 05:10AM BLOOD Glucose-90 UreaN-13 Creat-1.2* Na-141 K-3.1* Cl-112* HCO3-21* AnGap-11 [2107-6-7] 05:22AM BLOOD Glucose-93 UreaN-16 Creat-1.3* Na-141 K-3.8 Cl-108 HCO3-21* AnGap-16 [2107-6-6] 05:00AM BLOOD Glucose-91 UreaN-15 Creat-1.3* Na-142 K-4.1 Cl-111* HCO3-21* AnGap-14 [2107-6-5] 05:37PM BLOOD Glucose-110* UreaN-15 Creat-1.3* Na-140 K-4.2 Cl-111* HCO3-20* AnGap-13 [2107-6-5] 07:23AM BLOOD Creat-1.3* Na-140 K-4.2 Cl-113* [2107-6-5] 01:42AM BLOOD Glucose-125* UreaN-17 Creat-1.4* Na-139 K-4.0 Cl-110* HCO3-21* AnGap-12 [2107-6-4] 12:11AM BLOOD Glucose-136* UreaN-16 Creat-1.1 Na-141 K-3.4 Cl-110* HCO3-22 AnGap-12 [2107-6-3] 05:12AM BLOOD Glucose-94 UreaN-17 Creat-1.2* Na-143 K-3.4 Cl-111* HCO3-21* AnGap-14 [2107-6-2] 05:25AM BLOOD Glucose-109* UreaN-23* Creat-1.3* Na-143 K-3.3 Cl-111* HCO3-21* AnGap-14 [2107-6-1] 12:44PM BLOOD Glucose-118* UreaN-29* Creat-1.4* Na-142 K-3.4 Cl-108 HCO3-23 AnGap-14 [2107-6-1] 05:20AM BLOOD Glucose-102* UreaN-30* Creat-1.4* Na-142 K-3.3 Cl-107 HCO3-23 AnGap-15 [2107-5-31] 05:10AM BLOOD Glucose-120* UreaN-36* Creat-1.4* Na-143 K-3.6 Cl-107 HCO3-24 AnGap-16 [2107-5-29] 07:55PM BLOOD Glucose-121* UreaN-36* Creat-1.4* Na-140 K-3.5 Cl-105 HCO3-20* AnGap-19 [2107-5-29] 01:35AM BLOOD Glucose-97 UreaN-39* Creat-1.8* Na-142 K-3.8 Cl-110* HCO3-21* AnGap-15 [2107-5-28] 03:10AM BLOOD Glucose-90 UreaN-36* Creat-1.7* Na-141 K-4.6 Cl-108 HCO3-22 AnGap-16 [2107-6-6] 05:00AM BLOOD ALT-9 AST-13 LD(LDH)-178 AlkPhos-40 TotBili-0.3 [2107-5-26] 12:30AM BLOOD ALT-14 AST-42* AlkPhos-41 TotBili-0.3 [2107-6-7] 05:50PM BLOOD CK-MB-5 cTropnT-0.04* [2107-5-29] 01:35AM BLOOD CK-MB-2 cTropnT-0.05* [2107-6-9] 11:10AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8 [2107-6-8] 05:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9 [2107-6-7] 05:22AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.9 [2107-6-6] 05:00AM BLOOD Calcium-7.8* Phos-4.2 Mg-2.0 [2107-6-5] 05:37PM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 [2107-6-4] 12:11AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0 [2107-6-3] 05:12AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.3 [2107-6-2] 05:25AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9 [2107-6-1] 12:44PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 [2107-5-31] 05:10AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.1 Cholest-97 [2107-5-30] 05:35AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.1 [2107-5-29] 01:35AM BLOOD Calcium-8.2* Phos-3.7# Mg-2.3 [2107-5-28] 03:10AM BLOOD Calcium-8.7 Phos-5.5* Mg-2.1 [2107-5-27] 12:26PM BLOOD Calcium-7.9* Phos-4.5 Mg-2.0 [2107-6-2] 05:25AM BLOOD Triglyc-193* [2107-5-31] 05:10AM BLOOD Triglyc-212* HDL-16 CHOL/HD-6.1 LDLcalc-39 [2107-5-31] 05:10AM BLOOD Vanco-19.5 [2107-5-28] 06:00AM BLOOD Vanco-13.7 [2107-6-6] 05:00AM BLOOD Digoxin-0.9 [2107-5-28] 03:10AM BLOOD Digoxin-0.7* Brief Hospital Course: Ms. [Known lastname ] was taken emergently to the OR for exploratory laparatomy on [2107-5-26]. She was transferred to the SICU in fair condition postoperatively, intubated and sedated. Her hospital course is discussed below by system: Neuro: Patient's pain was controlled with PCA and transitioned to IV and po pain medications when appropriate. During her ICU stay, she was noted to have word finding difficult and sundowning. Family felt that patient was confused but otherwise at baseline and her neurologic exam was nonfocal. As her overall condition improved and sundowning resolved, her word finding difficulty became more apparent and an MRI of her head was performed on [2107-5-30] with acute infarction in the left middle cerebral artery distribution involving the left parietal lobe noted. She was started on a heparin drip and her afib was controlled as below. Over the following 48 hours, her speech improved and a speech and swallow evaluation was performed prior to starting po intake. Patient improved daily until [2107-6-3] when she developed hypertension into the 200s with associated worsening speech. A CT head was performed which showed no hemorrhagic conversion and evolving stroke. She was continued on coumadin once therapeutic on heparin, and her dose of this was titrated to an appropriate level. She had been initially supratherapeutic with a maximum INR during her admission of 4.1, following which her coumadin was held. This was restarted on 0.5mg of Warfarin at discharge with a plan to follow her INR at rehab. CV: Patient was in Afib RVR upon admission. IV metoprolol was used for rate control. TEE showed no evidence of intracardiac thrombus to explain her synchronous embolization to her small bowel and brain. Patient required multiple IV antihypertensives (metop, labetalol, hydralazine) for BP control. On [2107-6-3], patient's hypertensive episode prompted a transfer to ICU where she was controlled with a labetalol drip to maintain systolic blood pressure <140. Patient was eventually transitioned to PO metoprolol and IV metoprolol PRN and transferred back to the general surgery service. Following transfer she was started on lisinopril and her blood pressure remained stable and appropriate and continued on an increased dose of Lopressor. Her blood pressure was improved and appropriate. Resp: Patient showed evidence of moderate pulmonary edema and was diuresed with IV lasix. She was given nebulizer treatments and encourage to use her IS. Her O2 was weaned. Abd: Patient's abdomen was distended with a prolonged ileus postoperatively. Initial attempts at diet advanced with speech and swallow recommendations were met with abdominal distension and pain. On [2107-6-3], patient complained of severe abdominal pain with nausea. KUB showed an ileus. NG tube was placed with 500 cc of bile drained and improvement in pain. NG tube was removed while patient in ICU and abominal distension was improved. Her diet was advanced to a regular diet and calorie counts were followed. She was given supplementation with ensure and was instructed to continue this on discharge. Wound: The midline surgical incision was closed with staples post-operatively. The inicsion line was intact without signs of infection. These staples were removed on discharge and replaced with steri-strips. The patient was to wear an abdominal binder when out of bed. Renal: Patient's mild renal insufficiency was unchanged throughout admission. Heme: Patient received one unit of FFP prior to ex lap on [5-27], one unit of PRBC on [2107-5-29] and one unit of PRBC on [2107-6-3] for low Hct. Her INR rose from 1.4 to 3.5 with one dose of coumadin once therapeutic on heparin. Her INR peaked at 4.1 and then trended down. She was kept therapeutic on her coumadin thereafter with a low dose. Patient was also kept on Heparin SC with venodynes for DVT prophylaxis. ID: The patient was ruled out for C. Diff suring this admission. Consulting teams: During this admission the patient was followed closely by neurology, geriatric medicine, speech and swallow, phyiscal therapy, and social work. Medications on Admission: Coumadin 2', ASA 81', toprol XL 75', digoxin 0.125qod, lipitor 40', omeprazole 20', glipizide 2.5', fentanyl patch 50, topamax 25', sinemet 25/100''', seroquel 25'am-50'pm-100'hs, remeron 30'hs, divalproex 250am/500pm, ativan 0.5'''prn, ambien 10'prn, MVI, colace 100", CaCarb 1000''', Fe 65', fish oil, ?lasix 20', toprol 75', mirtazapine 30', Omeprazole 20', Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 15. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 17. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 19. metoprolol tartrate 25 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Disp:150 Tablet(s) Refills:2 20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 21. warfarin 1 mg Tablet Sig: [1-30] Tablet PO QHS (once a day (at bedtime)) for 1 doses: Please give at 1600 on [2107-6-9] and recheck INR on [2107-6-10]. Goal INR 2.0-3.0, pt have been difficult to manage, very sensitive to warfarin. Discharge Disposition: Home With Service Facility: [Hospital6 ] in [Location (un) ] Discharge Diagnosis: Mesenteric Ischemia Ileal Resection CVA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after a an open colectomy for surgical management of your mesenteric ischemia. It is thought that this mesenteric ischemia was caused by a blood clot in the membranes attatched to your intestine caused by your heart condition atrial fibrillation. During this time, it is thought that you also suffered from a stroke related to a blood clot which traveled to your brain. It is very important that you continue your coumadin therapy which ahs been difficult to manage, however, will be managed by the [Hospital 4487] hospital providers. You have recovered from this surgery well and you are now ready to be discharged to rehabilitation. From the stoke, you have difficulty saying words and it is our hope as well as the hope of the neurology team that this will improve over time with the help of occpational therapy and speech therapy. Please continue to hope and work for improvement in your symptoms. Please participate in physical therapy to regain your strength. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. Please monitor your bowel function closely. You have had a bowel movement. After anesthesia it is not uncommon for patient??????s to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are explected however, if you notice that you are passing bright red blood with bowel movments or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonges loose stool, or constipation. You have a long vertical incision on your abdomen the staples have been removed prior to your discharged and steri-strips have been applied. This incision can be left open to air or covered with a dry sterile gauze dressing if the incision becomes irritated from clothing. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. Please wear an abdominal binder provided to you at all times while out of bed. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. [Last Name (STitle) 1120] or Dr. [Last Name (STitle) ]. You may gradually increase your activity as tolerated but clear heavy excersise after follow up. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. You will take 0.5mg coumadin today [2107-6-9]. Your INR today [2107-6-9] is 2.3. The rehab facility will need to check daily INRs until your INR is stable and therapeutic, with a goal INR of 2.0-3.0. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Please plan to follow up in Dr. [Last Name (STitle) 4488] clinic in approximately 2 weeks. Call ([Telephone/Fax (1) 3378] to make an appointment. Completed by:[2107-6-9]	Admission Date: <Date>1966-1-27</Date> Discharge Date: <Date>1973-3-5</Date> Date of Birth: <Date>1905-4-26</Date> Sex: F Service: SURGERY Allergies: Cortisone / Percocet / Prednisone / Advair Diskus Attending:<Name>Marlon</Name> Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: <Date>1966-1-27</Date>: Exploratory laparotomy with ileocolectomy History of Present Illness: 78F s/p laparoscopic converted to open right hemicolectomy for Stage 1 (T1N0) right colon cancer on <Date>1917-9-29</Date>, now being transferred from OSH with diffuse abdominal pain and guarding on exam. She started with diffuse abdominal pain at 9am yesterday and went to <Hospital>Rush, Bowen and Flores Medical Center</Hospital> at 9pm. She had some nausea and bilious emesis x5, but had been passing flatus and bowel movements. A non-contrast CT was performed and she was sent here as her abdominal exam was concerning. In ED with A.fib w/RVR, hypertension up to 200/100. Past Medical History: CAD s/p PCI (last '<Digit>26</Digit>), pAFib, CHF, HTN, hyperchol, interstitial lung disease, GIB, GERD, CRI (baseline Cr 1.3-1.8), NIDDM, hypothyroid, TIA, parkinson's, low back pain Past Surgical History: Diverting transverse loop colostomy after colonic perforation from colonoscopy,, colostomy reversal, ventral hernia repair with mesh, Laparoscopic converted to open right hemicolectomy <Date>1992-6-22</Date>. Social History: Patient is retired, lives at home with husband. Former <Name>Tracy Grose</Name>. Denies alcohol or other drugs. Family History: NC Physical Exam: On admission: Vitals: T 101.1 HR 160 BP 120/90 RR 20 SO2 96% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Firm, nondistended, severely tender diffusely, mild rebound tenderness and voluntary guarding. DRE: normal tone, no gross or occult blood Ext: 1+ LE edema b/l, LE warm and well perfused On Discharge: Pertinent Results: ADMISSION LABS -------------- <Date>1966-1-27</Date> 12:30AM BLOOD WBC-29.3# RBC-4.63# Hgb-13.3# Hct-42.3# MCV-91 MCH-28.8 MCHC-31.5 RDW-15.8 Plt Ct-263# <Date>1966-1-27</Date> 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0* <Date>1966-1-27</Date> 12:30AM BLOOD Glucose-182* UreaN-40* Creat-1.6* Na-143 K-6.0* Cl-107 HCO3-19* AnGap-23* <Date>1966-1-27</Date>: TEE No intracardiac thrombus. Mild mitral regurgitation. <Date>1966-1-27</Date>: CT abd/pelvis: - Diffuse bowel wall dilatation, with lack of mural enhancement in the distal ileum, concerning for bowel ischemia or necrosis. There is an occlusion of an ileal branch of the superior mesenteric artery suggesting an embolic cause for bowel ischemia upstream of affected areas. - Extensive atherosclerotic disease of the aorta and iliac arteries. <Date>2017-8-19</Date>: MRI Head - Acute infarction in the left middle cerebral artery distribution involving the left parietal lobe. - Small old infarct in the right cerebellum. - No evidence of susceptibility artifact to suggest intracranial hemorrhage. <Date>1933-6-17</Date>: KUB - ileus <Date>1960-4-5</Date>: KUB - There has been no significant change. There remains air and stool seen throughout the colon and some mildly prominent loops of small bowel. Left side down decubitus radiograph, shows no free intra-abdominal gas present. Surgical skin staples are seen projecting over the midline. <Date>1960-4-5</Date>: CT HEAD: - Evolving left parietal infarct. No evidence of hemorrhagic transformation. - Global atrophy and chronic small vessel change. - Small old right cerebellar infarct. <Date>1934-10-31</Date> 05:10AM BLOOD WBC-7.8 RBC-3.43* Hgb-10.1* Hct-31.3* MCV-91 MCH-29.6 MCHC-32.4 RDW-15.6* Plt Ct-454* <Date>1916-9-16</Date> 05:22AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.5* Hct-30.5* MCV-93 MCH-29.1 MCHC-31.3 RDW-15.8* Plt Ct-438 <Date>1930-3-26</Date> 05:00AM BLOOD WBC-7.8 RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.4 MCHC-32.0 RDW-15.9* Plt Ct-361 <Date>1921-12-10</Date> 05:37PM BLOOD WBC-8.8 RBC-3.24* Hgb-9.2* Hct-29.2* MCV-90 MCH-28.4 MCHC-31.5 RDW-16.3* Plt Ct-313 <Date>1921-12-10</Date> 09:24AM BLOOD WBC-8.0 RBC-3.16* Hgb-9.3* Hct-28.5* MCV-90 MCH-29.3 MCHC-32.5 RDW-16.2* Plt Ct-310 <Date>1921-12-10</Date> 01:42AM BLOOD WBC-7.3 RBC-3.02* Hgb-9.2* Hct-26.5* MCV-88 MCH-30.6 MCHC-34.9 RDW-15.9* Plt Ct-268 <Date>1960-4-5</Date> 12:11AM BLOOD WBC-7.1 RBC-3.61* Hgb-10.6* Hct-32.7* MCV-91 MCH-29.5 MCHC-32.5 RDW-16.3* Plt Ct-307 <Date>1933-6-17</Date> 05:12AM BLOOD WBC-5.3 RBC-3.42* Hgb-10.0* Hct-31.5* MCV-92 MCH-29.3 MCHC-31.8 RDW-15.9* Plt Ct-245 <Date>1985-3-8</Date> 05:25AM BLOOD WBC-4.1 RBC-3.44* Hgb-10.1* Hct-31.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-15.8* Plt Ct-200 <Date>2013-11-4</Date> 05:20AM BLOOD WBC-3.0* RBC-3.64* Hgb-10.9* Hct-32.8* MCV-90 MCH-29.8 MCHC-33.1 RDW-15.8* Plt Ct-157 <Date>1913-5-31</Date> 05:10AM BLOOD WBC-4.0# RBC-3.83* Hgb-11.4* Hct-34.1* MCV-89 MCH-29.8 MCHC-33.5 RDW-15.9* Plt Ct-132* <Date>1966-1-27</Date> 12:30AM BLOOD Neuts-93* Bands-0 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 <Date>1966-1-27</Date> 12:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr<Name>Islam</Name> <Name>Christian Tamaro</Name> <Date>1973-3-5</Date> 11:10AM BLOOD PT-24.3* PTT-26.1 INR(PT)-2.3* <Date>1934-10-31</Date> 05:10AM BLOOD Plt Ct-454* <Date>1934-10-31</Date> 05:10AM BLOOD PT-25.3* PTT-28.1 INR(PT)-2.4* <Date>1916-9-16</Date> 05:22AM BLOOD Plt Ct-438 <Date>1916-9-16</Date> 05:22AM BLOOD PT-39.7* PTT-29.9 INR(PT)-4.1* <Date>1930-3-26</Date> 05:00AM BLOOD Plt Ct-361 <Date>1930-3-26</Date> 05:00AM BLOOD PT-39.0* PTT-29.5 INR(PT)-4.0* <Date>1921-12-10</Date> 05:37PM BLOOD Plt Ct-313 <Date>1921-12-10</Date> 09:24AM BLOOD Plt Ct-310 <Date>1921-12-10</Date> 01:42AM BLOOD Plt Ct-268 <Date>1921-12-10</Date> 01:42AM BLOOD PT-39.8* PTT-28.6 INR(PT)-4.1* <Date>1960-4-5</Date> 12:11AM BLOOD Plt Ct-307 <Date>1960-4-5</Date> 12:11AM BLOOD PT-38.6* PTT-26.7 INR(PT)-3.9* <Date>1933-6-17</Date> 05:12AM BLOOD PT-38.4* PTT-27.4 INR(PT)-3.9* <Date>1985-3-8</Date> 11:20AM BLOOD PT-34.5* PTT-68.9* INR(PT)-3.5* <Date>2013-11-4</Date> 12:58PM BLOOD PT-17.7* PTT-45.5* INR(PT)-1.6* <Date>2013-11-4</Date> 05:20AM BLOOD Plt Ct-157 <Date>2013-11-4</Date> 05:20AM BLOOD PT-16.7* PTT-44.1* INR(PT)-1.5* <Date>1913-5-31</Date> 05:10AM BLOOD PT-16.1* PTT-26.0 INR(PT)-1.4* <Date>2017-8-19</Date> 03:20PM BLOOD PT-17.6* PTT-25.5 INR(PT)-1.6* <Date>1999-1-2</Date> 03:10AM BLOOD PT-16.8* PTT-28.7 INR(PT)-1.5* <Date>2012-6-9</Date> 12:26PM BLOOD Plt Ct-120* <Date>2012-6-9</Date> 12:26PM BLOOD PT-23.0* PTT-32.7 INR(PT)-2.1* <Date>2012-6-9</Date> 03:29AM BLOOD PT-31.2* PTT-35.1* INR(PT)-3.1* <Date>1966-1-27</Date> 07:22AM BLOOD PT-19.8* PTT-29.8 INR(PT)-1.8* <Date>1966-1-27</Date> 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0* <Date>1973-3-5</Date> 11:10AM BLOOD Glucose-90 UreaN-13 Creat-1.3* Na-146* K-3.6 Cl-111* HCO3-23 AnGap-16 <Date>1934-10-31</Date> 05:10AM BLOOD Glucose-90 UreaN-13 Creat-1.2* Na-141 K-3.1* Cl-112* HCO3-21* AnGap-11 <Date>1916-9-16</Date> 05:22AM BLOOD Glucose-93 UreaN-16 Creat-1.3* Na-141 K-3.8 Cl-108 HCO3-21* AnGap-16 <Date>1930-3-26</Date> 05:00AM BLOOD Glucose-91 UreaN-15 Creat-1.3* Na-142 K-4.1 Cl-111* HCO3-21* AnGap-14 <Date>1921-12-10</Date> 05:37PM BLOOD Glucose-110* UreaN-15 Creat-1.3* Na-140 K-4.2 Cl-111* HCO3-20* AnGap-13 <Date>1921-12-10</Date> 07:23AM BLOOD Creat-1.3* Na-140 K-4.2 Cl-113* <Date>1921-12-10</Date> 01:42AM BLOOD Glucose-125* UreaN-17 Creat-1.4* Na-139 K-4.0 Cl-110* HCO3-21* AnGap-12 <Date>1960-4-5</Date> 12:11AM BLOOD Glucose-136* UreaN-16 Creat-1.1 Na-141 K-3.4 Cl-110* HCO3-22 AnGap-12 <Date>1933-6-17</Date> 05:12AM BLOOD Glucose-94 UreaN-17 Creat-1.2* Na-143 K-3.4 Cl-111* HCO3-21* AnGap-14 <Date>1985-3-8</Date> 05:25AM BLOOD Glucose-109* UreaN-23* Creat-1.3* Na-143 K-3.3 Cl-111* HCO3-21* AnGap-14 <Date>2013-11-4</Date> 12:44PM BLOOD Glucose-118* UreaN-29* Creat-1.4* Na-142 K-3.4 Cl-108 HCO3-23 AnGap-14 <Date>2013-11-4</Date> 05:20AM BLOOD Glucose-102* UreaN-30* Creat-1.4* Na-142 K-3.3 Cl-107 HCO3-23 AnGap-15 <Date>1913-5-31</Date> 05:10AM BLOOD Glucose-120* UreaN-36* Creat-1.4* Na-143 K-3.6 Cl-107 HCO3-24 AnGap-16 <Date>1913-5-5</Date> 07:55PM BLOOD Glucose-121* UreaN-36* Creat-1.4* Na-140 K-3.5 Cl-105 HCO3-20* AnGap-19 <Date>1913-5-5</Date> 01:35AM BLOOD Glucose-97 UreaN-39* Creat-1.8* Na-142 K-3.8 Cl-110* HCO3-21* AnGap-15 <Date>1999-1-2</Date> 03:10AM BLOOD Glucose-90 UreaN-36* Creat-1.7* Na-141 K-4.6 Cl-108 HCO3-22 AnGap-16 <Date>1930-3-26</Date> 05:00AM BLOOD ALT-9 AST-13 LD(LDH)-178 AlkPhos-40 TotBili-0.3 <Date>1966-1-27</Date> 12:30AM BLOOD ALT-14 AST-42* AlkPhos-41 TotBili-0.3 <Date>1916-9-16</Date> 05:50PM BLOOD CK-MB-5 cTropnT-0.04* <Date>1913-5-5</Date> 01:35AM BLOOD CK-MB-2 cTropnT-0.05* <Date>1973-3-5</Date> 11:10AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8 <Date>1934-10-31</Date> 05:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9 <Date>1916-9-16</Date> 05:22AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.9 <Date>1930-3-26</Date> 05:00AM BLOOD Calcium-7.8* Phos-4.2 Mg-2.0 <Date>1921-12-10</Date> 05:37PM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 <Date>1960-4-5</Date> 12:11AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0 <Date>1933-6-17</Date> 05:12AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.3 <Date>1985-3-8</Date> 05:25AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9 <Date>2013-11-4</Date> 12:44PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 <Date>1913-5-31</Date> 05:10AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.1 Cholest-97 <Date>2017-8-19</Date> 05:35AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.1 <Date>1913-5-5</Date> 01:35AM BLOOD Calcium-8.2* Phos-3.7# Mg-2.3 <Date>1999-1-2</Date> 03:10AM BLOOD Calcium-8.7 Phos-5.5* Mg-2.1 <Date>2012-6-9</Date> 12:26PM BLOOD Calcium-7.9* Phos-4.5 Mg-2.0 <Date>1985-3-8</Date> 05:25AM BLOOD Triglyc-193* <Date>1913-5-31</Date> 05:10AM BLOOD Triglyc-212* HDL-16 CHOL/HD-6.1 LDLcalc-39 <Date>1913-5-31</Date> 05:10AM BLOOD Vanco-19.5 <Date>1999-1-2</Date> 06:00AM BLOOD Vanco-13.7 <Date>1930-3-26</Date> 05:00AM BLOOD Digoxin-0.9 <Date>1999-1-2</Date> 03:10AM BLOOD Digoxin-0.7* Brief Hospital Course: Ms. <Name>Sakkas</Name> was taken emergently to the OR for exploratory laparatomy on <Date>1966-1-27</Date>. She was transferred to the SICU in fair condition postoperatively, intubated and sedated. Her hospital course is discussed below by system: Neuro: Patient's pain was controlled with PCA and transitioned to IV and po pain medications when appropriate. During her ICU stay, she was noted to have word finding difficult and sundowning. Family felt that patient was confused but otherwise at baseline and her neurologic exam was nonfocal. As her overall condition improved and sundowning resolved, her word finding difficulty became more apparent and an MRI of her head was performed on <Date>2017-8-19</Date> with acute infarction in the left middle cerebral artery distribution involving the left parietal lobe noted. She was started on a heparin drip and her afib was controlled as below. Over the following 48 hours, her speech improved and a speech and swallow evaluation was performed prior to starting po intake. Patient improved daily until <Date>1933-6-17</Date> when she developed hypertension into the 200s with associated worsening speech. A CT head was performed which showed no hemorrhagic conversion and evolving stroke. She was continued on coumadin once therapeutic on heparin, and her dose of this was titrated to an appropriate level. She had been initially supratherapeutic with a maximum INR during her admission of 4.1, following which her coumadin was held. This was restarted on 0.5mg of Warfarin at discharge with a plan to follow her INR at rehab. CV: Patient was in Afib RVR upon admission. IV metoprolol was used for rate control. TEE showed no evidence of intracardiac thrombus to explain her synchronous embolization to her small bowel and brain. Patient required multiple IV antihypertensives (metop, labetalol, hydralazine) for BP control. On <Date>1933-6-17</Date>, patient's hypertensive episode prompted a transfer to ICU where she was controlled with a labetalol drip to maintain systolic blood pressure <140. Patient was eventually transitioned to PO metoprolol and IV metoprolol PRN and transferred back to the general surgery service. Following transfer she was started on lisinopril and her blood pressure remained stable and appropriate and continued on an increased dose of Lopressor. Her blood pressure was improved and appropriate. Resp: Patient showed evidence of moderate pulmonary edema and was diuresed with IV lasix. She was given nebulizer treatments and encourage to use her IS. Her O2 was weaned. Abd: Patient's abdomen was distended with a prolonged ileus postoperatively. Initial attempts at diet advanced with speech and swallow recommendations were met with abdominal distension and pain. On <Date>1933-6-17</Date>, patient complained of severe abdominal pain with nausea. KUB showed an ileus. NG tube was placed with 500 cc of bile drained and improvement in pain. NG tube was removed while patient in ICU and abominal distension was improved. Her diet was advanced to a regular diet and calorie counts were followed. She was given supplementation with ensure and was instructed to continue this on discharge. Wound: The midline surgical incision was closed with staples post-operatively. The inicsion line was intact without signs of infection. These staples were removed on discharge and replaced with steri-strips. The patient was to wear an abdominal binder when out of bed. Renal: Patient's mild renal insufficiency was unchanged throughout admission. Heme: Patient received one unit of FFP prior to ex lap on <Date>9-28</Date>, one unit of PRBC on <Date>1913-5-5</Date> and one unit of PRBC on <Date>1933-6-17</Date> for low Hct. Her INR rose from 1.4 to 3.5 with one dose of coumadin once therapeutic on heparin. Her INR peaked at 4.1 and then trended down. She was kept therapeutic on her coumadin thereafter with a low dose. Patient was also kept on Heparin SC with venodynes for DVT prophylaxis. ID: The patient was ruled out for C. Diff suring this admission. Consulting teams: During this admission the patient was followed closely by neurology, geriatric medicine, speech and swallow, phyiscal therapy, and social work. Medications on Admission: Coumadin 2', ASA 81', toprol XL 75', digoxin 0.125qod, lipitor 40', omeprazole 20', glipizide 2.5', fentanyl patch 50, topamax 25', sinemet 25/100''', seroquel 25'am-50'pm-100'hs, remeron 30'hs, divalproex 250am/500pm, ativan 0.5'''prn, ambien 10'prn, MVI, colace 100", CaCarb 1000''', Fe 65', fish oil, ?lasix 20', toprol 75', mirtazapine 30', Omeprazole 20', Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 15. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 17. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 19. metoprolol tartrate 25 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Disp:150 Tablet(s) Refills:2 20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 21. warfarin 1 mg Tablet Sig: <Date>11-8</Date> Tablet PO QHS (once a day (at bedtime)) for 1 doses: Please give at 1600 on <Date>1973-3-5</Date> and recheck INR on <Date>1998-3-11</Date>. Goal INR 2.0-3.0, pt have been difficult to manage, very sensitive to warfarin. Discharge Disposition: Home With Service Facility: <Hospital>Duncan-Mcdonald Health System</Hospital> in <Location>10762 Michelle Greens Apt. 995 South Anthony, NC 94467</Location> Discharge Diagnosis: Mesenteric Ischemia Ileal Resection CVA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after a an open colectomy for surgical management of your mesenteric ischemia. It is thought that this mesenteric ischemia was caused by a blood clot in the membranes attatched to your intestine caused by your heart condition atrial fibrillation. During this time, it is thought that you also suffered from a stroke related to a blood clot which traveled to your brain. It is very important that you continue your coumadin therapy which ahs been difficult to manage, however, will be managed by the <Hospital>Smith, Evans and Walker Clinic</Hospital> hospital providers. You have recovered from this surgery well and you are now ready to be discharged to rehabilitation. From the stoke, you have difficulty saying words and it is our hope as well as the hope of the neurology team that this will improve over time with the help of occpational therapy and speech therapy. Please continue to hope and work for improvement in your symptoms. Please participate in physical therapy to regain your strength. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. Please monitor your bowel function closely. You have had a bowel movement. After anesthesia it is not uncommon for patient??????s to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are explected however, if you notice that you are passing bright red blood with bowel movments or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonges loose stool, or constipation. You have a long vertical incision on your abdomen the staples have been removed prior to your discharged and steri-strips have been applied. This incision can be left open to air or covered with a dry sterile gauze dressing if the incision becomes irritated from clothing. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. Please wear an abdominal binder provided to you at all times while out of bed. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. <Name>Clapp</Name> or Dr. <Name>Post</Name>. You may gradually increase your activity as tolerated but clear heavy excersise after follow up. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. You will take 0.5mg coumadin today <Date>1973-3-5</Date>. Your INR today <Date>1973-3-5</Date> is 2.3. The rehab facility will need to check daily INRs until your INR is stable and therapeutic, with a goal INR of 2.0-3.0. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Please plan to follow up in Dr. <Name>Merino</Name> clinic in approximately 2 weeks. Call (<Telephone>175-551-9816</Telephone> to make an appointment. Completed 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Date: 1966-1-27 Discharge Date: 1973-3-5 Date of Birth: 1905-4-26 Sex: F Service: SURGERY Allergies: Cortisone / Percocet / Prednisone / Advair Diskus Attending:Marlon Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: 1966-1-27: Exploratory laparotomy with ileocolectomy History of Present Illness: 78F s/p laparoscopic converted to open right hemicolectomy for Stage 1 (T1N0) right colon cancer on 1917-9-29, now being transferred from OSH with diffuse abdominal pain and guarding on exam. She started with diffuse abdominal pain at 9am yesterday and went to Rush, Bowen and Flores Medical Center at 9pm. She had some nausea and bilious emesis x5, but had been passing flatus and bowel movements. A non-contrast CT was performed and she was sent here as her abdominal exam was concerning. In ED with A.fib w/RVR, hypertension up to 200/100. Past Medical History: CAD s/p PCI (last '26), pAFib, CHF, HTN, hyperchol, interstitial lung disease, GIB, GERD, CRI (baseline Cr 1.3-1.8), NIDDM, hypothyroid, TIA, parkinson's, low back pain Past Surgical History: Diverting transverse loop colostomy after colonic perforation from colonoscopy,, colostomy reversal, ventral hernia repair with mesh, Laparoscopic converted to open right hemicolectomy 1992-6-22. Social History: Patient is retired, lives at home with husband. Former Tracy Grose. Denies alcohol or other drugs. Family History: NC Physical Exam: On admission: Vitals: T 101.1 HR 160 BP 120/90 RR 20 SO2 96% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Firm, nondistended, severely tender diffusely, mild rebound tenderness and voluntary guarding. DRE: normal tone, no gross or occult blood Ext: 1+ LE edema b/l, LE warm and well perfused On Discharge: Pertinent Results: ADMISSION LABS -------------- 1966-1-27 12:30AM BLOOD WBC-29.3# RBC-4.63# Hgb-13.3# Hct-42.3# MCV-91 MCH-28.8 MCHC-31.5 RDW-15.8 Plt Ct-263# 1966-1-27 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0* 1966-1-27 12:30AM BLOOD Glucose-182* UreaN-40* Creat-1.6* Na-143 K-6.0* Cl-107 HCO3-19* AnGap-23* 1966-1-27: TEE No intracardiac thrombus. Mild mitral regurgitation. 1966-1-27: CT abd/pelvis: - Diffuse bowel wall dilatation, with lack of mural enhancement in the distal ileum, concerning for bowel ischemia or necrosis. There is an occlusion of an ileal branch of the superior mesenteric artery suggesting an embolic cause for bowel ischemia upstream of affected areas. - Extensive atherosclerotic disease of the aorta and iliac arteries. 2017-8-19: MRI Head - Acute infarction in the left middle cerebral artery distribution involving the left parietal lobe. - Small old infarct in the right cerebellum. - No evidence of susceptibility artifact to suggest intracranial hemorrhage. 1933-6-17: KUB - ileus 1960-4-5: KUB - There has been no significant change. There remains air and stool seen throughout the colon and some mildly prominent loops of small bowel. Left side down decubitus radiograph, shows no free intra-abdominal gas present. Surgical skin staples are seen projecting over the midline. 1960-4-5: CT HEAD: - Evolving left parietal infarct. No evidence of hemorrhagic transformation. - Global atrophy and chronic small vessel change. - Small old right cerebellar infarct. 1934-10-31 05:10AM BLOOD WBC-7.8 RBC-3.43* Hgb-10.1* Hct-31.3* MCV-91 MCH-29.6 MCHC-32.4 RDW-15.6* Plt Ct-454* 1916-9-16 05:22AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.5* Hct-30.5* MCV-93 MCH-29.1 MCHC-31.3 RDW-15.8* Plt Ct-438 1930-3-26 05:00AM BLOOD WBC-7.8 RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.4 MCHC-32.0 RDW-15.9* Plt Ct-361 1921-12-10 05:37PM BLOOD WBC-8.8 RBC-3.24* Hgb-9.2* Hct-29.2* MCV-90 MCH-28.4 MCHC-31.5 RDW-16.3* Plt Ct-313 1921-12-10 09:24AM BLOOD WBC-8.0 RBC-3.16* Hgb-9.3* Hct-28.5* MCV-90 MCH-29.3 MCHC-32.5 RDW-16.2* Plt Ct-310 1921-12-10 01:42AM BLOOD WBC-7.3 RBC-3.02* Hgb-9.2* Hct-26.5* MCV-88 MCH-30.6 MCHC-34.9 RDW-15.9* Plt Ct-268 1960-4-5 12:11AM BLOOD WBC-7.1 RBC-3.61* Hgb-10.6* Hct-32.7* MCV-91 MCH-29.5 MCHC-32.5 RDW-16.3* Plt Ct-307 1933-6-17 05:12AM BLOOD WBC-5.3 RBC-3.42* Hgb-10.0* Hct-31.5* MCV-92 MCH-29.3 MCHC-31.8 RDW-15.9* Plt Ct-245 1985-3-8 05:25AM BLOOD WBC-4.1 RBC-3.44* Hgb-10.1* Hct-31.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-15.8* Plt Ct-200 2013-11-4 05:20AM BLOOD WBC-3.0* RBC-3.64* Hgb-10.9* Hct-32.8* MCV-90 MCH-29.8 MCHC-33.1 RDW-15.8* Plt Ct-157 1913-5-31 05:10AM BLOOD WBC-4.0# RBC-3.83* Hgb-11.4* Hct-34.1* MCV-89 MCH-29.8 MCHC-33.5 RDW-15.9* Plt Ct-132* 1966-1-27 12:30AM BLOOD Neuts-93* Bands-0 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 1966-1-27 12:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear DrIslam Christian Tamaro 1973-3-5 11:10AM BLOOD PT-24.3* PTT-26.1 INR(PT)-2.3* 1934-10-31 05:10AM BLOOD Plt Ct-454* 1934-10-31 05:10AM BLOOD PT-25.3* PTT-28.1 INR(PT)-2.4* 1916-9-16 05:22AM BLOOD Plt Ct-438 1916-9-16 05:22AM BLOOD PT-39.7* PTT-29.9 INR(PT)-4.1* 1930-3-26 05:00AM BLOOD Plt Ct-361 1930-3-26 05:00AM BLOOD PT-39.0* PTT-29.5 INR(PT)-4.0* 1921-12-10 05:37PM BLOOD Plt Ct-313 1921-12-10 09:24AM BLOOD Plt Ct-310 1921-12-10 01:42AM BLOOD Plt Ct-268 1921-12-10 01:42AM BLOOD PT-39.8* PTT-28.6 INR(PT)-4.1* 1960-4-5 12:11AM BLOOD Plt Ct-307 1960-4-5 12:11AM BLOOD PT-38.6* PTT-26.7 INR(PT)-3.9* 1933-6-17 05:12AM BLOOD PT-38.4* PTT-27.4 INR(PT)-3.9* 1985-3-8 11:20AM BLOOD PT-34.5* PTT-68.9* INR(PT)-3.5* 2013-11-4 12:58PM BLOOD PT-17.7* PTT-45.5* INR(PT)-1.6* 2013-11-4 05:20AM BLOOD Plt Ct-157 2013-11-4 05:20AM BLOOD PT-16.7* PTT-44.1* INR(PT)-1.5* 1913-5-31 05:10AM BLOOD PT-16.1* PTT-26.0 INR(PT)-1.4* 2017-8-19 03:20PM BLOOD PT-17.6* PTT-25.5 INR(PT)-1.6* 1999-1-2 03:10AM BLOOD PT-16.8* PTT-28.7 INR(PT)-1.5* 2012-6-9 12:26PM BLOOD Plt Ct-120* 2012-6-9 12:26PM BLOOD PT-23.0* PTT-32.7 INR(PT)-2.1* 2012-6-9 03:29AM BLOOD PT-31.2* PTT-35.1* INR(PT)-3.1* 1966-1-27 07:22AM BLOOD PT-19.8* PTT-29.8 INR(PT)-1.8* 1966-1-27 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0* 1973-3-5 11:10AM BLOOD Glucose-90 UreaN-13 Creat-1.3* Na-146* K-3.6 Cl-111* HCO3-23 AnGap-16 1934-10-31 05:10AM BLOOD Glucose-90 UreaN-13 Creat-1.2* Na-141 K-3.1* Cl-112* HCO3-21* AnGap-11 1916-9-16 05:22AM BLOOD Glucose-93 UreaN-16 Creat-1.3* Na-141 K-3.8 Cl-108 HCO3-21* AnGap-16 1930-3-26 05:00AM BLOOD Glucose-91 UreaN-15 Creat-1.3* Na-142 K-4.1 Cl-111* HCO3-21* AnGap-14 1921-12-10 05:37PM BLOOD Glucose-110* UreaN-15 Creat-1.3* Na-140 K-4.2 Cl-111* HCO3-20* AnGap-13 1921-12-10 07:23AM BLOOD Creat-1.3* Na-140 K-4.2 Cl-113* 1921-12-10 01:42AM BLOOD Glucose-125* UreaN-17 Creat-1.4* Na-139 K-4.0 Cl-110* HCO3-21* AnGap-12 1960-4-5 12:11AM BLOOD Glucose-136* UreaN-16 Creat-1.1 Na-141 K-3.4 Cl-110* HCO3-22 AnGap-12 1933-6-17 05:12AM BLOOD Glucose-94 UreaN-17 Creat-1.2* Na-143 K-3.4 Cl-111* HCO3-21* AnGap-14 1985-3-8 05:25AM BLOOD Glucose-109* UreaN-23* Creat-1.3* Na-143 K-3.3 Cl-111* HCO3-21* AnGap-14 2013-11-4 12:44PM BLOOD Glucose-118* UreaN-29* Creat-1.4* Na-142 K-3.4 Cl-108 HCO3-23 AnGap-14 2013-11-4 05:20AM BLOOD Glucose-102* UreaN-30* Creat-1.4* Na-142 K-3.3 Cl-107 HCO3-23 AnGap-15 1913-5-31 05:10AM BLOOD Glucose-120* UreaN-36* Creat-1.4* Na-143 K-3.6 Cl-107 HCO3-24 AnGap-16 1913-5-5 07:55PM BLOOD Glucose-121* UreaN-36* Creat-1.4* Na-140 K-3.5 Cl-105 HCO3-20* AnGap-19 1913-5-5 01:35AM BLOOD Glucose-97 UreaN-39* Creat-1.8* Na-142 K-3.8 Cl-110* HCO3-21* AnGap-15 1999-1-2 03:10AM BLOOD Glucose-90 UreaN-36* Creat-1.7* Na-141 K-4.6 Cl-108 HCO3-22 AnGap-16 1930-3-26 05:00AM BLOOD ALT-9 AST-13 LD(LDH)-178 AlkPhos-40 TotBili-0.3 1966-1-27 12:30AM BLOOD ALT-14 AST-42* AlkPhos-41 TotBili-0.3 1916-9-16 05:50PM BLOOD CK-MB-5 cTropnT-0.04* 1913-5-5 01:35AM BLOOD CK-MB-2 cTropnT-0.05* 1973-3-5 11:10AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8 1934-10-31 05:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9 1916-9-16 05:22AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.9 1930-3-26 05:00AM BLOOD Calcium-7.8* Phos-4.2 Mg-2.0 1921-12-10 05:37PM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 1960-4-5 12:11AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0 1933-6-17 05:12AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.3 1985-3-8 05:25AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9 2013-11-4 12:44PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 1913-5-31 05:10AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.1 Cholest-97 2017-8-19 05:35AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.1 1913-5-5 01:35AM BLOOD Calcium-8.2* Phos-3.7# Mg-2.3 1999-1-2 03:10AM BLOOD Calcium-8.7 Phos-5.5* Mg-2.1 2012-6-9 12:26PM BLOOD Calcium-7.9* Phos-4.5 Mg-2.0 1985-3-8 05:25AM BLOOD Triglyc-193* 1913-5-31 05:10AM BLOOD Triglyc-212* HDL-16 CHOL/HD-6.1 LDLcalc-39 1913-5-31 05:10AM BLOOD Vanco-19.5 1999-1-2 06:00AM BLOOD Vanco-13.7 1930-3-26 05:00AM BLOOD Digoxin-0.9 1999-1-2 03:10AM BLOOD Digoxin-0.7* Brief Hospital Course: Ms. Sakkas was taken emergently to the OR for exploratory laparatomy on 1966-1-27. She was transferred to the SICU in fair condition postoperatively, intubated and sedated. Her hospital course is discussed below by system: Neuro: Patient's pain was controlled with PCA and transitioned to IV and po pain medications when appropriate. During her ICU stay, she was noted to have word finding difficult and sundowning. Family felt that patient was confused but otherwise at baseline and her neurologic exam was nonfocal. As her overall condition improved and sundowning resolved, her word finding difficulty became more apparent and an MRI of her head was performed on 2017-8-19 with acute infarction in the left middle cerebral artery distribution involving the left parietal lobe noted. She was started on a heparin drip and her afib was controlled as below. Over the following 48 hours, her speech improved and a speech and swallow evaluation was performed prior to starting po intake. Patient improved daily until 1933-6-17 when she developed hypertension into the 200s with associated worsening speech. A CT head was performed which showed no hemorrhagic conversion and evolving stroke. She was continued on coumadin once therapeutic on heparin, and her dose of this was titrated to an appropriate level. She had been initially supratherapeutic with a maximum INR during her admission of 4.1, following which her coumadin was held. This was restarted on 0.5mg of Warfarin at discharge with a plan to follow her INR at rehab. CV: Patient was in Afib RVR upon admission. IV metoprolol was used for rate control. TEE showed no evidence of intracardiac thrombus to explain her synchronous embolization to her small bowel and brain. Patient required multiple IV antihypertensives (metop, labetalol, hydralazine) for BP control. On 1933-6-17, patient's hypertensive episode prompted a transfer to ICU where she was controlled with a labetalol drip to maintain systolic blood pressure 1933-6-17, patient complained of severe abdominal pain with nausea. KUB showed an ileus. NG tube was placed with 500 cc of bile drained and improvement in pain. NG tube was removed while patient in ICU and abominal distension was improved. Her diet was advanced to a regular diet and calorie counts were followed. She was given supplementation with ensure and was instructed to continue this on discharge. Wound: The midline surgical incision was closed with staples post-operatively. The inicsion line was intact without signs of infection. These staples were removed on discharge and replaced with steri-strips. The patient was to wear an abdominal binder when out of bed. Renal: Patient's mild renal insufficiency was unchanged throughout admission. Heme: Patient received one unit of FFP prior to ex lap on 9-28, one unit of PRBC on 1913-5-5 and one unit of PRBC on 1933-6-17 for low Hct. Her INR rose from 1.4 to 3.5 with one dose of coumadin once therapeutic on heparin. Her INR peaked at 4.1 and then trended down. She was kept therapeutic on her coumadin thereafter with a low dose. Patient was also kept on Heparin SC with venodynes for DVT prophylaxis. ID: The patient was ruled out for C. Diff suring this admission. Consulting teams: During this admission the patient was followed closely by neurology, geriatric medicine, speech and swallow, phyiscal therapy, and social work. Medications on Admission: Coumadin 2', ASA 81', toprol XL 75', digoxin 0.125qod, lipitor 40', omeprazole 20', glipizide 2.5', fentanyl patch 50, topamax 25', sinemet 25/100''', seroquel 25'am-50'pm-100'hs, remeron 30'hs, divalproex 250am/500pm, ativan 0.5'''prn, ambien 10'prn, MVI, colace 100", CaCarb 1000''', Fe 65', fish oil, ?lasix 20', toprol 75', mirtazapine 30', Omeprazole 20', Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 15. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 17. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 19. metoprolol tartrate 25 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Disp:150 Tablet(s) Refills:2 20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 21. warfarin 1 mg Tablet Sig: 11-8 Tablet PO QHS (once a day (at bedtime)) for 1 doses: Please give at 1600 on 1973-3-5 and recheck INR on 1998-3-11. Goal INR 2.0-3.0, pt have been difficult to manage, very sensitive to warfarin. Discharge Disposition: Home With Service Facility: Duncan-Mcdonald Health System in 10762 Michelle Greens Apt. 995 South Anthony, NC 94467 Discharge Diagnosis: Mesenteric Ischemia Ileal Resection CVA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after a an open colectomy for surgical management of your mesenteric ischemia. It is thought that this mesenteric ischemia was caused by a blood clot in the membranes attatched to your intestine caused by your heart condition atrial fibrillation. During this time, it is thought that you also suffered from a stroke related to a blood clot which traveled to your brain. It is very important that you continue your coumadin therapy which ahs been difficult to manage, however, will be managed by the Smith, Evans and Walker Clinic hospital providers. You have recovered from this surgery well and you are now ready to be discharged to rehabilitation. From the stoke, you have difficulty saying words and it is our hope as well as the hope of the neurology team that this will improve over time with the help of occpational therapy and speech therapy. Please continue to hope and work for improvement in your symptoms. Please participate in physical therapy to regain your strength. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. Please monitor your bowel function closely. You have had a bowel movement. After anesthesia it is not uncommon for patient??????s to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are explected however, if you notice that you are passing bright red blood with bowel movments or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonges loose stool, or constipation. You have a long vertical incision on your abdomen the staples have been removed prior to your discharged and steri-strips have been applied. This incision can be left open to air or covered with a dry sterile gauze dressing if the incision becomes irritated from clothing. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. Please wear an abdominal binder provided to you at all times while out of bed. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. Clapp or Dr. Post. You may gradually increase your activity as tolerated but clear heavy excersise after follow up. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. You will take 0.5mg coumadin today 1973-3-5. Your INR today 1973-3-5 is 2.3. The rehab facility will need to check daily INRs until your INR is stable and therapeutic, with a goal INR of 2.0-3.0. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Please plan to follow up in Dr. Merino clinic in approximately 2 weeks. Call (175-551-9816 to make an appointment. Completed by:1973-3-5	['Admission Date: 1966-1-27 Discharge Date: 1973-3-5\n\nDate of Birth: 1905-4-26 Sex: F\n\nService: SURGERY\n\nAllergies:\nCortisone / Percocet / Prednisone / Advair Diskus\n\nAttending:Marlon\nChief Complaint:\nAbdominal pain\n\nMajor Surgical or Invasive Procedure:\n1966-1-27: Exploratory laparotomy with ileocolectomy\n\nHistory of Present Illness:\n78F s/p laparoscopic converted to open right hemicolectomy for\nStage 1 (T1N0) right colon cancer on 1917-9-29, now being\ntransferred from OSH with diffuse abdominal pain and guarding on\nexam. She started with diffuse abdominal pain at 9am yesterday\nand went to Rush, Bowen and Flores Medical Center at 9pm. She had some nausea and\nbilious emesis x5, but had been passing flatus and bowel\nmovements. A non-contrast CT was performed and she was sent here\nas her abdominal exam was concerning.', " In ED with A.fib w/RVR,\nhypertension up to 200/100.\n\nPast Medical History:\nCAD s/p PCI (last '26), pAFib, CHF, HTN,\nhyperchol, interstitial lung disease, GIB, GERD, CRI (baseline\nCr\n1.3-1.8), NIDDM, hypothyroid, TIA, parkinson's, low back pain\n\nPast Surgical History:\nDiverting transverse loop colostomy after colonic perforation\nfrom colonoscopy,, colostomy reversal, ventral hernia repair\nwith mesh, Laparoscopic converted to open right hemicolectomy\n1992-6-22.\n\nSocial History:\nPatient is retired, lives at home with husband. Former Tracy Grose.\nDenies alcohol or other drugs.\n\n\nFamily History:\nNC\n\nPhysical Exam:\nOn admission:\nVitals: T 101.1 HR 160 BP 120/90 RR 20 SO2 96%\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Firm, nondistended, severely tender diffusely, mild rebound\ntenderness and voluntary guarding.", '\nDRE: normal tone, no gross or occult blood\nExt: 1+ LE edema b/l, LE warm and well perfused\n\nOn Discharge:\n\nPertinent Results:\nADMISSION LABS\n--------------\n1966-1-27 12:30AM BLOOD WBC-29.3# RBC-4.63# Hgb-13.3# Hct-42.3#\nMCV-91 MCH-28.8 MCHC-31.5 RDW-15.8 Plt Ct-263#\n1966-1-27 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0\n1966-1-27 12:30AM BLOOD Glucose-182 UreaN-40* Creat-1.6* Na-143\nK-6.0* Cl-107 HCO3-19* AnGap-23\n\n1966-1-27: TEE\nNo intracardiac thrombus. Mild mitral regurgitation.\n\n1966-1-27: CT abd/pelvis:\n- Diffuse bowel wall dilatation, with lack of mural enhancement\nin the\ndistal ileum, concerning for bowel ischemia or necrosis. There\nis an\nocclusion of an ileal branch of the superior mesenteric artery\nsuggesting an embolic cause for bowel ischemia upstream of\naffected areas.\n- Extensive atherosclerotic disease of the aorta and iliac\narteries.', '\n\n2017-8-19: MRI Head\n- Acute infarction in the left middle cerebral artery\ndistribution involving the left parietal lobe.\n- Small old infarct in the right cerebellum.\n- No evidence of susceptibility artifact to suggest intracranial\nhemorrhage.\n\n1933-6-17: KUB\n- ileus\n\n1960-4-5: KUB\n- There has been no significant change. There remains air and\nstool seen\nthroughout the colon and some mildly prominent loops of small\nbowel. Left\nside down decubitus radiograph, shows no free intra-abdominal\ngas present. Surgical skin staples are seen projecting over the\nmidline.\n\n1960-4-5: CT HEAD:\n- Evolving left parietal infarct. No evidence of hemorrhagic\ntransformation.\n- Global atrophy and chronic small vessel change.\n- Small old right cerebellar infarct.\n1934-10-31 05:10AM BLOOD WBC-7.8 RBC-3.43 Hgb-10.', '1* Hct-31.3\nMCV-91 MCH-29.6 MCHC-32.4 RDW-15.6 Plt Ct-454\n1916-9-16 05:22AM BLOOD WBC-7.6 RBC-3.28 Hgb-9.5* Hct-30.5\nMCV-93 MCH-29.1 MCHC-31.3 RDW-15.8 Plt Ct-438\n1930-3-26 05:00AM BLOOD WBC-7.8 RBC-3.15* Hgb-9.3* Hct-29.0\nMCV-92 MCH-29.4 MCHC-32.0 RDW-15.9 Plt Ct-361\n1921-12-10 05:37PM BLOOD WBC-8.8 RBC-3.24* Hgb-9.2* Hct-29.2\nMCV-90 MCH-28.4 MCHC-31.5 RDW-16.3 Plt Ct-313\n1921-12-10 09:24AM BLOOD WBC-8.0 RBC-3.16* Hgb-9.3* Hct-28.5\nMCV-90 MCH-29.3 MCHC-32.5 RDW-16.2 Plt Ct-310\n1921-12-10 01:42AM BLOOD WBC-7.3 RBC-3.02* Hgb-9.2* Hct-26.5\nMCV-88 MCH-30.6 MCHC-34.9 RDW-15.9 Plt Ct-268\n1960-4-5 12:11AM BLOOD WBC-7.1 RBC-3.61* Hgb-10.6* Hct-32.7\nMCV-91 MCH-29.5 MCHC-32.5 RDW-16.3 Plt Ct-307\n1933-6-17 05:12AM BLOOD WBC-5.3 RBC-3.42* Hgb-10.0* Hct-31.5\nMCV-92 MCH-29.3 MCHC-31.8 RDW-15.', '9 Plt Ct-245\n1985-3-8 05:25AM BLOOD WBC-4.1 RBC-3.44* Hgb-10.1* Hct-31.5\nMCV-92 MCH-29.4 MCHC-32.1 RDW-15.8 Plt Ct-200\n2013-11-4 05:20AM BLOOD WBC-3.0* RBC-3.64* Hgb-10.9* Hct-32.8\nMCV-90 MCH-29.8 MCHC-33.1 RDW-15.8 Plt Ct-157\n1913-5-31 05:10AM BLOOD WBC-4.0# RBC-3.83* Hgb-11.4* Hct-34.1\nMCV-89 MCH-29.8 MCHC-33.5 RDW-15.9 Plt Ct-132\n1966-1-27 12:30AM BLOOD Neuts-93 Bands-0 Lymphs-2* Monos-5 Eos-0\nBaso-0 Atyps-0 Metas-0 Myelos-0\n1966-1-27 12:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+\nMacrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear\nDrIslam Christian Tamaro\n1973-3-5 11:10AM BLOOD PT-24.3* PTT-26.1 INR(PT)-2.3\n1934-10-31 05:10AM BLOOD Plt Ct-454\n1934-10-31 05:10AM BLOOD PT-25.3* PTT-28.1 INR(PT)-2.4\n1916-9-16 05:22AM BLOOD Plt Ct-438\n1916-9-16 05:22AM BLOOD PT-39.', '7 PTT-29.9 INR(PT)-4.1\n1930-3-26 05:00AM BLOOD Plt Ct-361\n1930-3-26 05:00AM BLOOD PT-39.0 PTT-29.5 INR(PT)-4.0\n1921-12-10 05:37PM BLOOD Plt Ct-313\n1921-12-10 09:24AM BLOOD Plt Ct-310\n1921-12-10 01:42AM BLOOD Plt Ct-268\n1921-12-10 01:42AM BLOOD PT-39.8 PTT-28.6 INR(PT)-4.1\n1960-4-5 12:11AM BLOOD Plt Ct-307\n1960-4-5 12:11AM BLOOD PT-38.6 PTT-26.7 INR(PT)-3.9\n1933-6-17 05:12AM BLOOD PT-38.4 PTT-27.4 INR(PT)-3.9\n1985-3-8 11:20AM BLOOD PT-34.5 PTT-68.9* INR(PT)-3.5\n2013-11-4 12:58PM BLOOD PT-17.7 PTT-45.5* INR(PT)-1.6\n2013-11-4 05:20AM BLOOD Plt Ct-157\n2013-11-4 05:20AM BLOOD PT-16.7 PTT-44.1* INR(PT)-1.5\n1913-5-31 05:10AM BLOOD PT-16.1 PTT-26.0 INR(PT)-1.4\n2017-8-19 03:20PM BLOOD PT-17.6 PTT-25.5 INR(PT)-1.6\n1999-1-2 03:10AM BLOOD PT-16.8 PTT-28.7 INR(PT)-1.5\n2012-6-9 12:26PM BLOOD Plt Ct-120\n2012-6-9 12:26PM BLOOD PT-23.', '0* PTT-32.7 INR(PT)-2.1\n2012-6-9 03:29AM BLOOD PT-31.2 PTT-35.1* INR(PT)-3.1\n1966-1-27 07:22AM BLOOD PT-19.8 PTT-29.8 INR(PT)-1.8\n1966-1-27 12:30AM BLOOD PT-30.3 PTT-23.7 INR(PT)-3.0\n1973-3-5 11:10AM BLOOD Glucose-90 UreaN-13 Creat-1.3 Na-146\nK-3.6 Cl-111 HCO3-23 AnGap-16\n1934-10-31 05:10AM BLOOD Glucose-90 UreaN-13 Creat-1.2* Na-141\nK-3.1* Cl-112* HCO3-21* AnGap-11\n1916-9-16 05:22AM BLOOD Glucose-93 UreaN-16 Creat-1.3* Na-141\nK-3.8 Cl-108 HCO3-21* AnGap-16\n1930-3-26 05:00AM BLOOD Glucose-91 UreaN-15 Creat-1.3* Na-142\nK-4.1 Cl-111* HCO3-21* AnGap-14\n1921-12-10 05:37PM BLOOD Glucose-110* UreaN-15 Creat-1.3* Na-140\nK-4.2 Cl-111* HCO3-20* AnGap-13\n1921-12-10 07:23AM BLOOD Creat-1.3* Na-140 K-4.2 Cl-113\n1921-12-10 01:42AM BLOOD Glucose-125 UreaN-17 Creat-1.4* Na-139\nK-4.0 Cl-110* HCO3-21* AnGap-12\n1960-4-5 12:11AM BLOOD Glucose-136* UreaN-16 Creat-1.', '1 Na-141\nK-3.4 Cl-110* HCO3-22 AnGap-12\n1933-6-17 05:12AM BLOOD Glucose-94 UreaN-17 Creat-1.2* Na-143\nK-3.4 Cl-111* HCO3-21* AnGap-14\n1985-3-8 05:25AM BLOOD Glucose-109* UreaN-23* Creat-1.3* Na-143\nK-3.3 Cl-111* HCO3-21* AnGap-14\n2013-11-4 12:44PM BLOOD Glucose-118* UreaN-29* Creat-1.4* Na-142\nK-3.4 Cl-108 HCO3-23 AnGap-14\n2013-11-4 05:20AM BLOOD Glucose-102* UreaN-30* Creat-1.4* Na-142\nK-3.3 Cl-107 HCO3-23 AnGap-15\n1913-5-31 05:10AM BLOOD Glucose-120* UreaN-36* Creat-1.4* Na-143\nK-3.6 Cl-107 HCO3-24 AnGap-16\n1913-5-5 07:55PM BLOOD Glucose-121* UreaN-36* Creat-1.4* Na-140\nK-3.5 Cl-105 HCO3-20* AnGap-19\n1913-5-5 01:35AM BLOOD Glucose-97 UreaN-39* Creat-1.8* Na-142\nK-3.8 Cl-110* HCO3-21* AnGap-15\n1999-1-2 03:10AM BLOOD Glucose-90 UreaN-36* Creat-1.7* Na-141\nK-4.6 Cl-108 HCO3-22 AnGap-16\n1930-3-26 05:00AM BLOOD ALT-9 AST-13 LD(LDH)-178 AlkPhos-40\nTotBili-0.', '3\n1966-1-27 12:30AM BLOOD ALT-14 AST-42* AlkPhos-41 TotBili-0.3\n1916-9-16 05:50PM BLOOD CK-MB-5 cTropnT-0.04\n1913-5-5 01:35AM BLOOD CK-MB-2 cTropnT-0.05\n1973-3-5 11:10AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8\n1934-10-31 05:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9\n1916-9-16 05:22AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.9\n1930-3-26 05:00AM BLOOD Calcium-7.8* Phos-4.2 Mg-2.0\n1921-12-10 05:37PM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0\n1960-4-5 12:11AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0\n1933-6-17 05:12AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.3\n1985-3-8 05:25AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9\n2013-11-4 12:44PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0\n1913-5-31 05:10AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.1 Cholest-97\n2017-8-19 05:35AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.1\n1913-5-5 01:35AM BLOOD Calcium-8.2* Phos-3.7# Mg-2.3\n1999-1-2 03:10AM BLOOD Calcium-8.', "7 Phos-5.5* Mg-2.1\n2012-6-9 12:26PM BLOOD Calcium-7.9* Phos-4.5 Mg-2.0\n1985-3-8 05:25AM BLOOD Triglyc-193\n1913-5-31 05:10AM BLOOD Triglyc-212 HDL-16 CHOL/HD-6.1\nLDLcalc-39\n1913-5-31 05:10AM BLOOD Vanco-19.5\n1999-1-2 06:00AM BLOOD Vanco-13.7\n1930-3-26 05:00AM BLOOD Digoxin-0.9\n1999-1-2 03:10AM BLOOD Digoxin-0.7\n\nBrief Hospital Course:\nMs. Sakkas was taken emergently to the OR for exploratory\nlaparatomy on 1966-1-27. She was transferred to the SICU in fair\ncondition postoperatively, intubated and sedated. Her hospital\ncourse is discussed below by system:\n\nNeuro: Patient's pain was controlled with PCA and transitioned\nto IV and po pain medications when appropriate. During her ICU\nstay, she was noted to have word finding difficult and\nsundowning. Family felt that patient was confused but otherwise\nat baseline and her neurologic exam was nonfocal.", ' As her overall\ncondition improved and sundowning resolved, her word finding\ndifficulty became more apparent and an MRI of her head was\nperformed on 2017-8-19 with acute infarction in the left middle\ncerebral artery distribution involving the left parietal lobe\nnoted. She was started on a heparin drip and her afib was\ncontrolled as below. Over the following 48 hours, her speech\nimproved and a speech and swallow evaluation was performed prior\nto starting po intake. Patient improved daily until 1933-6-17 when\nshe developed hypertension into the 200s with associated\nworsening speech. A CT head was performed which showed no\nhemorrhagic conversion and evolving stroke. She was continued on\ncoumadin once therapeutic on heparin, and her dose of this was\ntitrated to an appropriate level. She had been initially\nsupratherapeutic with a maximum INR during her admission of 4.', "1,\nfollowing which her coumadin was held. This was restarted on\n0.5mg of Warfarin at discharge with a plan to follow her INR at\nrehab.\n\nCV: Patient was in Afib RVR upon admission. IV metoprolol was\nused for rate control. TEE showed no evidence of intracardiac\nthrombus to explain her synchronous embolization to her small\nbowel and brain. Patient required multiple IV antihypertensives\n(metop, labetalol, hydralazine) for BP control. On 1933-6-17,\npatient's hypertensive episode prompted a transfer to ICU where\nshe was controlled with a labetalol drip to maintain systolic\nblood pressure 1933-6-17, patient complained of severe abdominal pain\nwith nausea. KUB showed an ileus. NG tube was placed with 500 cc\nof bile drained and improvement in pain. NG tube was removed\nwhile patient in ICU and abominal distension was improved.", " Her\ndiet was advanced to a regular diet and calorie counts were\nfollowed. She was given supplementation with ensure and was\ninstructed to continue this on discharge.\n\nWound: The midline surgical incision was closed with staples\npost-operatively. The inicsion line was intact without signs of\ninfection. These staples were removed on discharge and replaced\nwith steri-strips. The patient was to wear an abdominal binder\nwhen out of bed.\n\nRenal: Patient's mild renal insufficiency was unchanged\nthroughout admission.\n\nHeme: Patient received one unit of FFP prior to ex lap on 9-28,\none unit of PRBC on 1913-5-5 and one unit of PRBC on 1933-6-17 for\nlow Hct. Her INR rose from 1.4 to 3.5 with one dose of coumadin\nonce therapeutic on heparin. Her INR peaked at 4.1 and then\ntrended down. She was kept therapeutic on her coumadin\nthereafter with a low dose.", ' Patient was also kept on Heparin SC\nwith venodynes for DVT prophylaxis.\n\nID: The patient was ruled out for C. Diff suring this admission.\n\n\nConsulting teams: During this admission the patient was followed\nclosely by neurology, geriatric medicine, speech and swallow,\nphyiscal therapy, and social work.\n\nMedications on Admission:\nCoumadin 2\', ASA 81\', toprol XL 75\', digoxin\n0.125qod, lipitor 40\', omeprazole 20\', glipizide 2.5\', fentanyl\npatch 50, topamax 25\', sinemet 25/100\'\'\', seroquel\n25\'am-50\'pm-100\'hs, remeron 30\'hs, divalproex 250am/500pm,\nativan\n0.5\'\'\'prn, ambien 10\'prn, MVI, colace 100", CaCarb 1000\'\'\', Fe\n65\', fish oil, ?lasix 20\', toprol 75\', mirtazapine 30\',\nOmeprazole 20\',\n\n\nDischarge Medications:\n1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.', 'C.) PO DAILY (Daily) as needed for\nconstipation.\n2. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\nCapsule, Delayed Release(E.C.) PO once a day.\n4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY\n(Every Other Day).\n6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n7. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).\n8. topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n9. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO\nTID (3 times a day).\n10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a\nday (in the morning)).\n11. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QPM (once a\nday (in the evening)).', '\n12. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a\nday (at bedtime)).\n13. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime).\n14. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the\nmorning)).\n15. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the\nevening)).\n16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8\nhours) as needed for anxiety.\n17. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\n18. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).\nDisp:30 Tablet(s)* Refills:2\n19. metoprolol tartrate 25 mg Tablet Sig: 2.5 Tablets PO BID (2\ntimes a day).\nDisp:150 Tablet(s) Refills:2\n20.', ' acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H\n(every 6 hours) as needed for pain.\nDisp:50 Tablet(s) Refills:0\n21. warfarin 1 mg Tablet Sig: 11-8 Tablet PO QHS (once a day (at\nbedtime)) for 1 doses: Please give at 1600 on 1973-3-5 and\nrecheck INR on 1998-3-11. Goal INR 2.0-3.0, pt have been difficult\nto manage, very sensitive to warfarin.\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nDuncan-Mcdonald Health System in 10762 Michelle Greens Apt. 995\nSouth Anthony, NC 94467\n\nDischarge Diagnosis:\nMesenteric Ischemia\nIleal Resection\nCVA\n\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker\nor cane).\n\n\nDischarge Instructions:\nYou were admitted to the hospital after a an open colectomy for\nsurgical management of your mesenteric ischemia.', ' It is thought\nthat this mesenteric ischemia was caused by a blood clot in the\nmembranes attatched to your intestine caused by your heart\ncondition atrial fibrillation. During this time, it is thought\nthat you also suffered from a stroke related to a blood clot\nwhich traveled to your brain. It is very important that you\ncontinue your coumadin therapy which ahs been difficult to\nmanage, however, will be managed by the Smith, Evans and Walker Clinic hospital\nproviders. You have recovered from this surgery well and you are\nnow ready to be discharged to rehabilitation. From the stoke,\nyou have difficulty saying words and it is our hope as well as\nthe hope of the neurology team that this will improve over time\nwith the help of occpational therapy and speech therapy. Please\ncontinue to hope and work for improvement in your symptoms.', '\nPlease participate in physical therapy to regain your strength.\nYou have tolerated a regular diet, passing gas and your pain is\ncontrolled with pain medications by mouth.\n\nPlease monitor your bowel function closely. You have had a bowel\nmovement. After anesthesia it is not uncommon for patient??????s to\nhave some decrease in bowel function but your should not have\nprolonged constipation. Some loose stool and passing of small\namounts of dark, old appearing blood are explected however, if\nyou notice that you are passing bright red blood with bowel\nmovments or having loose stool without improvement please call\nthe office or go to the emergency room if the symptoms are\nsevere. If you are taking narcotic pain medications there is a\nrisk that you will have some constipation. Please take an over\nthe counter stool softener such as Colace, and if the symptoms\ndoes not improve call the office.', ' If you have any of the\nfollowing symptoms please call the office for advice or go to\nthe emergency room if severe: increasing abdominal distension,\nincreasing abdominal pain, nausea, vomiting, inability to\ntolerate food or liquids, prolonges loose stool, or\nconstipation.\n\nYou have a long vertical incision on your abdomen the staples\nhave been removed prior to your discharged and steri-strips have\nbeen applied. This incision can be left open to air or covered\nwith a dry sterile gauze dressing if the incision becomes\nirritated from clothing. Please monitor the incision for signs\nand symptoms of infection including: increasing redness at the\nincision, opening of the incision, increased pain at the\nincision line, draining of white/green/yellow/foul smelling\ndrainage, or if you develop a fever.', ' Please call the office if\nyou develop these symptoms or go to the emergency room if the\nsymptoms are severe. You may shower, let the warm water run\nover the incision line and pat the area dry with a towel, do not\nrub. Please wear an abdominal binder provided to you at all\ntimes while out of bed.\n\nNo heavy lifting for at least 6 weeks after surgery unless\ninstructed otherwise by Dr. Clapp or Dr. Post. You may\ngradually increase your activity as tolerated but clear heavy\nexcersise after follow up.\nYou may take Tylenol as recommended for pain. Please do not take\nmore than 4000mg of Tylenol daily. Do not drink alcohol while\ntaking narcotic pain medication or Tylenol.\n\nYou will take 0.5mg coumadin today 1973-3-5. Your INR today\n1973-3-5 is 2.3. The rehab facility will need to check daily INRs\nuntil your INR is stable and therapeutic, with a goal INR of\n2.', '0-3.0.\n\nThank you for allowing us to participate in your care! Our hope\nis that you will have a quick return to your life and usual\nactivities. Good luck!\n\n\nFollowup Instructions:\nPlease plan to follow up in Dr. Merino clinic in approximately 2\nweeks. Call (175-551-9816 to make an appointment.\n\n\n\nCompleted by:1973-3-5']
549	85490	196435.0	2110-02-24	Discharge summary	Report	Admission Date: [2110-2-21] Discharge Date: [2110-2-24] Date of Birth: [2052-12-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 57 y/o man with a history of aoritc valve replacement [2102] [2-24] congenital bicuspid valve, copd, HTN, prior alcohol abuse, who is admitted to the [Hospital Ward Name ] ICU with dyspnea and transient hypotension. . The patient was recently admitted to [Hospital1 18] from [2110-1-28] to [2110-2-2] for dyspnea and was treated for a COPD excaerbation with steroids and azithromycin. An echocardiogram performed during the admission was normal, without significant impairment in relaxation. He completed his course, but continued to have symtpoms. In fact, VNA contact[Name (NI) ] his PCP (who had not yet met him), on [2-13] with concerns that included continued dyspnea, a reported 20lb weight gain, and lower extremity edema. The patient began 20mg lasix at that time. . On presentation to his new PCPs office [2110-2-21], he had a continued oxygen requirment of 3L at rest, sating 95% and 90% with ambulation. The patient endorsed dyspnea walking even 30 feet. He was sent to the ED for a rule out of PE. per reports, he was moving air well at that time and did not have wheezing. He had just completed his prescribed steroid taper on [2-19] which was a total of 14 days. . On arrival to the ED he was 96.9 124/59 91 24 95%on 3L In the ED he was given lasix 40mg IV x 1 and a CTA was obtained. The CTA was negatvie for PE. The lasix dropped his blood pressure transiently to 75/40 which was response to a total of 2L normal saline challenge. He was not given steroids or nebulizers. Despite resolution of his hypotension, he was sent to the [Hospital Unit Name 153]. . Further review of systemts notable for minimal cough, no fever, and no chest pain. He does not occasional paroxysmal abdominal pain for which a RUQ u/s on [1-28] was negative for acute pathology. He notes leg swelling, for which tight socks have helped. He also reports difficulty sleeping, requiring 3 pillows at night. He reports that he did not feel completely better during his hospitlization at [Hospital1 18], notable that he did not try and walk around much. He thinks that his shortness of breath has been much worse since [2109-12-23], allthough clearly he must have marked dysfunction given disability [2-24] dyspnea. Former patient of [Hospital1 2177], and a comprehensive review of old records is not available at this time. . Past Medical History: # COPD - was seen frequently at [Hospital6 ]. Has smoked 3 packs /day x 45 years, quit on last admission to [Hospital1 18]. No PFTs in our system. # Congential Bicuspid Aortic Valve; s/p porcicine repair [2102]. Echo in [2110] on recent admission within normal limits # Hypertension # Lower Extremity Edema # Hypertension . Social History: Smoked 3pks ppd x 45 years. Former head of maintence at [Hospital1 4505], also a car mechanic. Now on disability due to dyspnea. Lives wtih girlfriend. Minimal etoh now though former heavy alcohol user. Family History: Parents with heart disease Physical Exam: On Presentation: 116/66, HR 86 and sinus, sating 96% on 2LNC. Weight 125kg, up from 119kg on admission [2110-1-28]. GEN: In some distress. barrel chested, unable to speak comfortably in full sentences HEENT: no oral ulcers CV: RRR s1, s2, soft holosystolic murmur present. No increased P2. RESP: high pitched expiratory wheezing heard in upper posterior lung fields. ABD: soft, obese, some minimal tenderness to palpation of RUQ EXT: marked venous stasis changes of distal extremities bilaterally. only 1+ edema at this time, but patient reports has been much worse. Skin: diffuse acne Pertinent Results: [2110-2-21] 06:10PM GLUCOSE-74 UREA N-20 CREAT-0.8 SODIUM-140 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13 [2110-2-21] 06:10PM ALT(SGPT)-53* AST(SGOT)-28 LD(LDH)-384* CK(CPK)-143 ALK PHOS-93 TOT BILI-0.5 [2110-2-21] 06:10PM LIPASE-16 [2110-2-21] 06:10PM cTropnT-0.02* [2110-2-21] 06:10PM CK-MB-7 proBNP-150 [2110-2-21] 06:10PM TOT PROT-6.5 [2110-2-21] 06:10PM WBC-9.1 RBC-5.19 HGB-15.4 HCT-45.4 MCV-87 MCH-29.6 MCHC-33.9 RDW-13.4 [2110-2-21] 06:10PM NEUTS-66.8 LYMPHS-25.0 MONOS-5.9 EOS-2.0 BASOS-0.3 [2110-2-21] 06:10PM PLT COUNT-204 [2110-2-21] 06:10PM PT-12.6 PTT-26.0 INR(PT)-1.1 [2-21] CXR: No evidence of congestive heart failure. Lung hyperinflation. Questionable left hilar mass. Evaluation with CT chest with contrast is recommended for precise characterization. [2-21] CTA: 1. No pulmonary embolus, no evidence of aortic dissection. 2. Small nodular densities in left lower lobe, with secretions in the trachea, likely small foci of aspiration. 3. Emphysema. Brief Hospital Course: 57 y/o man with long smokign history admitted to [Hospital Unit Name 153] with makred dypnea and lower extremity swelling likely due to a COPD exacerbation. # Dyspnea: Likely COPD exacerbation with recent overall decline given new O2 requirement this month. Also likely has an element of OSA given his inability to sleep laying down (3-pillow orthopnea) as COPD alone would not cause this. CHF essentially ruled out by normal BNP and hypotension after lasix. Echo was normal 2 weeks prior. Given wheezing and marked smoking history, it seems that this is a continued presentation of a partially treated, severe COPD exacerbation. PE was ruled out with CTA. He was started on a prolonged prednisone taper: start at 60mg po for 1 week and will be discharged on a slow taper. He was also restarted on advair, spiriva, singulair, and albuterol. He will need outpatient [Hospital Unit Name 1570] evaluation. He is already scheduled in pulmonary clinic for a complete evaluation. . # Likely obstructive sleep apnea: Patient was tried on CPAP overnight, and had one successful night, and a second without relief. His settings were 3 L of oxygen and pressure of 11 and a formal sleep study for treatment of his suspected OSA. . # Lower Extremity Edema: Appears consistent with chronic venous insufficiency, not CHF as above. Could have some element of cor pulmonale, but echo 2 weeks ago inconclusive though showed mild RV dilation but no TR. He was encouraged to wear compression stockings and elevate his legs. He was also continued on a higher dose of lasix. . # RUQ abdominal pain: The patient has intermittent sharp, RUQ abdominal pain as an outpatient and had an episode overnight which resolved within 30 minutes. Not related to food intake, however the sharp quality and location raise concern for cholecysistis. Had a RUQ US recently which was unremarkable. LFTs this revealed only a slightly elevated ALT. His repeat abdominal ultrasound was negative for gall stones. He will need abdominal CT if the pain persists. It was relieved with low dose oxycodone, and he was discharged on percocet. . # Hypertension: The patient was continued on his home regimen of lisinopril and extended release diltiazem. . Medications on Admission: Singulair 10mg po Qday Protonix 40mg po Qday ASA 325mg po Qday Dilt SR 240 mg capsule po Qday Lisinopril 10mg po Qday albuterol prn Flovent discus 250 acutaltion Serevent 50mcg discus Lasix 20mg po Qday (started [2-13]) Discharge Medications: 1. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Prednisone 5 mg Tablet Sig: Taper PO once a day for Taper days: 60 mg (12 pills) for 2 days, then 55 mg (11 pills) for 2 days, then decrease by 1 pill every other day until off. Disp:156 Tablet(s) Refills:0 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB. 9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. Disp:30 Tablet(s) Refills:0 11. Pulmonary rehabilitation Please evaluate and treat. 12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) tablet Inhalation once a day. Discharge Disposition: Home Discharge Diagnosis: Hypercarbic respiratory failure COPD with acute exacerbation Small pneumonia, possible aspiration. Lower extremity edema Abdominal pain, Right upper quadrant. Obesity. Likely obstructive sleep apnea. Discharge Condition: Stable. Discharge Instructions: You were admitted with shortness of breath, due to a asthma/obstructive lung disease exacerbation. You had a chest CT to evaluate for a blood clot that was negative. You just have emphysema. You also have evidence on your chest CT of a possible mild pneumonia. Your abdominal pain was evaluated with an ultrasound, and you have no gall stones. . Return to the emergency room if you get worse, with worse shortness of breath, abdominal pain, LE swelling, nausea or vomiting, chest pain. Followup Instructions: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2110-3-3] 9:40 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2110-3-3] 10:00 Provider: [Initials (NamePattern4) ] [Last Name (NamePattern4) 4506] NP/DR [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2110-3-3] 10:00 . Sleep study, to be arranged as outpatient. . PCP [Name Initial (PRE) ] 1 month. . Pulmonary rehab appt set for [2110-3-10]	Admission Date: <Date>1904-10-6</Date> Discharge Date: <Date>1962-7-4</Date> Date of Birth: <Date>1960-5-13</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Bradley</Name> Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 57 y/o man with a history of aoritc valve replacement <Year>1961</Year> <Date>4-20</Date> congenital bicuspid valve, copd, HTN, prior alcohol abuse, who is admitted to the <Hospital>Boyd, Marshall and Francis Health System</Hospital> ICU with dyspnea and transient hypotension. . The patient was recently admitted to <Hospital>Medina PLC Clinic</Hospital> from <Date>1922-10-30</Date> to <Date>2019-3-26</Date> for dyspnea and was treated for a COPD excaerbation with steroids and azithromycin. An echocardiogram performed during the admission was normal, without significant impairment in relaxation. He completed his course, but continued to have symtpoms. In fact, VNA contact<Name>Susana Finateri</Name> his PCP (who had not yet met him), on <Date>6-21</Date> with concerns that included continued dyspnea, a reported 20lb weight gain, and lower extremity edema. The patient began 20mg lasix at that time. . On presentation to his new PCPs office <Date>1904-10-6</Date>, he had a continued oxygen requirment of 3L at rest, sating 95% and 90% with ambulation. The patient endorsed dyspnea walking even 30 feet. He was sent to the ED for a rule out of PE. per reports, he was moving air well at that time and did not have wheezing. He had just completed his prescribed steroid taper on <Date>2-25</Date> which was a total of 14 days. . On arrival to the ED he was 96.9 124/59 91 24 95%on 3L In the ED he was given lasix 40mg IV x 1 and a CTA was obtained. The CTA was negatvie for PE. The lasix dropped his blood pressure transiently to 75/40 which was response to a total of 2L normal saline challenge. He was not given steroids or nebulizers. Despite resolution of his hypotension, he was sent to the <Hospital>Lara, Doyle and Mcneil Medical Center</Hospital>. . Further review of systemts notable for minimal cough, no fever, and no chest pain. He does not occasional paroxysmal abdominal pain for which a RUQ u/s on <Date>2-30</Date> was negative for acute pathology. He notes leg swelling, for which tight socks have helped. He also reports difficulty sleeping, requiring 3 pillows at night. He reports that he did not feel completely better during his hospitlization at <Hospital>Medina PLC Clinic</Hospital>, notable that he did not try and walk around much. He thinks that his shortness of breath has been much worse since <Date>1911-7-31</Date>, allthough clearly he must have marked dysfunction given disability <Date>4-20</Date> dyspnea. Former patient of <Hospital>Fowler, Thomas and Velasquez Health System</Hospital>, and a comprehensive review of old records is not available at this time. . Past Medical History: # COPD - was seen frequently at <Hospital>Shepard, Owen and Lowe Health System</Hospital>. Has smoked 3 packs /day x 45 years, quit on last admission to <Hospital>Medina PLC Clinic</Hospital>. No PFTs in our system. # Congential Bicuspid Aortic Valve; s/p porcicine repair <Year>1961</Year>. Echo in <Year>1961</Year> on recent admission within normal limits # Hypertension # Lower Extremity Edema # Hypertension . Social History: Smoked 3pks ppd x 45 years. Former head of maintence at <Hospital>Gallagher-Gentry Medical Center</Hospital>, also a car mechanic. Now on disability due to dyspnea. Lives wtih girlfriend. Minimal etoh now though former heavy alcohol user. Family History: Parents with heart disease Physical Exam: On Presentation: 116/66, HR 86 and sinus, sating 96% on 2LNC. Weight 125kg, up from 119kg on admission <Date>1922-10-30</Date>. GEN: In some distress. barrel chested, unable to speak comfortably in full sentences HEENT: no oral ulcers CV: RRR s1, s2, soft holosystolic murmur present. No increased P2. RESP: high pitched expiratory wheezing heard in upper posterior lung fields. ABD: soft, obese, some minimal tenderness to palpation of RUQ EXT: marked venous stasis changes of distal extremities bilaterally. only 1+ edema at this time, but patient reports has been much worse. Skin: diffuse acne Pertinent Results: <Date>1904-10-6</Date> 06:10PM GLUCOSE-74 UREA N-20 CREAT-0.8 SODIUM-140 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13 <Date>1904-10-6</Date> 06:10PM ALT(SGPT)-53* AST(SGOT)-28 LD(LDH)-384* CK(CPK)-143 ALK PHOS-93 TOT BILI-0.5 <Date>1904-10-6</Date> 06:10PM LIPASE-16 <Date>1904-10-6</Date> 06:10PM cTropnT-0.02* <Date>1904-10-6</Date> 06:10PM CK-MB-7 proBNP-150 <Date>1904-10-6</Date> 06:10PM TOT PROT-6.5 <Date>1904-10-6</Date> 06:10PM WBC-9.1 RBC-5.19 HGB-15.4 HCT-45.4 MCV-87 MCH-29.6 MCHC-33.9 RDW-13.4 <Date>1904-10-6</Date> 06:10PM NEUTS-66.8 LYMPHS-25.0 MONOS-5.9 EOS-2.0 BASOS-0.3 <Date>1904-10-6</Date> 06:10PM PLT COUNT-204 <Date>1904-10-6</Date> 06:10PM PT-12.6 PTT-26.0 INR(PT)-1.1 <Date>8-23</Date> CXR: No evidence of congestive heart failure. Lung hyperinflation. Questionable left hilar mass. Evaluation with CT chest with contrast is recommended for precise characterization. <Date>8-23</Date> CTA: 1. No pulmonary embolus, no evidence of aortic dissection. 2. Small nodular densities in left lower lobe, with secretions in the trachea, likely small foci of aspiration. 3. Emphysema. Brief Hospital Course: 57 y/o man with long smokign history admitted to <Hospital>Lara, Doyle and Mcneil Medical Center</Hospital> with makred dypnea and lower extremity swelling likely due to a COPD exacerbation. # Dyspnea: Likely COPD exacerbation with recent overall decline given new O2 requirement this month. Also likely has an element of OSA given his inability to sleep laying down (3-pillow orthopnea) as COPD alone would not cause this. CHF essentially ruled out by normal BNP and hypotension after lasix. Echo was normal 2 weeks prior. Given wheezing and marked smoking history, it seems that this is a continued presentation of a partially treated, severe COPD exacerbation. PE was ruled out with CTA. He was started on a prolonged prednisone taper: start at 60mg po for 1 week and will be discharged on a slow taper. He was also restarted on advair, spiriva, singulair, and albuterol. He will need outpatient <Hospital>Harris-Harrison Medical Center</Hospital> evaluation. He is already scheduled in pulmonary clinic for a complete evaluation. . # Likely obstructive sleep apnea: Patient was tried on CPAP overnight, and had one successful night, and a second without relief. His settings were 3 L of oxygen and pressure of 11 and a formal sleep study for treatment of his suspected OSA. . # Lower Extremity Edema: Appears consistent with chronic venous insufficiency, not CHF as above. Could have some element of cor pulmonale, but echo 2 weeks ago inconclusive though showed mild RV dilation but no TR. He was encouraged to wear compression stockings and elevate his legs. He was also continued on a higher dose of lasix. . # RUQ abdominal pain: The patient has intermittent sharp, RUQ abdominal pain as an outpatient and had an episode overnight which resolved within 30 minutes. Not related to food intake, however the sharp quality and location raise concern for cholecysistis. Had a RUQ US recently which was unremarkable. LFTs this revealed only a slightly elevated ALT. His repeat abdominal ultrasound was negative for gall stones. He will need abdominal CT if the pain persists. It was relieved with low dose oxycodone, and he was discharged on percocet. . # Hypertension: The patient was continued on his home regimen of lisinopril and extended release diltiazem. . Medications on Admission: Singulair 10mg po Qday Protonix 40mg po Qday ASA 325mg po Qday Dilt SR 240 mg capsule po Qday Lisinopril 10mg po Qday albuterol prn Flovent discus 250 acutaltion Serevent 50mcg discus Lasix 20mg po Qday (started <Date>6-21</Date>) Discharge Medications: 1. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Prednisone 5 mg Tablet Sig: Taper PO once a day for Taper days: 60 mg (12 pills) for 2 days, then 55 mg (11 pills) for 2 days, then decrease by 1 pill every other day until off. Disp:156 Tablet(s) Refills:0 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation <Hospital>Moss, Cooper and Ortega Hospital</Hospital> (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB. 9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. Disp:30 Tablet(s) Refills:0 11. Pulmonary rehabilitation Please evaluate and treat. 12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) tablet Inhalation once a day. Discharge Disposition: Home Discharge Diagnosis: Hypercarbic respiratory failure COPD with acute exacerbation Small pneumonia, possible aspiration. Lower extremity edema Abdominal pain, Right upper quadrant. Obesity. Likely obstructive sleep apnea. Discharge Condition: Stable. Discharge Instructions: You were admitted with shortness of breath, due to a asthma/obstructive lung disease exacerbation. You had a chest CT to evaluate for a blood clot that was negative. You just have emphysema. You also have evidence on your chest CT of a possible mild pneumonia. Your abdominal pain was evaluated with an ultrasound, and you have no gall stones. . Return to the emergency room if you get worse, with worse shortness of breath, abdominal pain, LE swelling, nausea or vomiting, chest pain. Followup Instructions: Provider: <Name>Emma Debelius</Name> FUNCTION LAB Phone:<Telephone>393-517-7182</Telephone> Date/Time:<Date>2020-3-31</Date> 9:40 Provider: <Name>Angus Ornelas</Name>,INTERPRET W/LAB NO CHECK-IN <Name>Angus Ornelas</Name> INTEPRETATION BILLING Date/Time:<Date>2020-3-31</Date> 10:00 Provider: <Initial>FD</Initial> <Name>Benavidez</Name> NP/DR <Name>Dortch</Name> Phone:<Telephone>413-783-1162</Telephone> Date/Time:<Date>2020-3-31</Date> 10:00 . Sleep study, to be arranged as outpatient. . PCP <Name>Emory Recinos</Name> 1 month. . Pulmonary rehab appt set for 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Date: 1904-10-6 Discharge Date: 1962-7-4 Date of Birth: 1960-5-13 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Bradley Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 57 y/o man with a history of aoritc valve replacement 1961 4-20 congenital bicuspid valve, copd, HTN, prior alcohol abuse, who is admitted to the Boyd, Marshall and Francis Health System ICU with dyspnea and transient hypotension. . The patient was recently admitted to Medina PLC Clinic from 1922-10-30 to 2019-3-26 for dyspnea and was treated for a COPD excaerbation with steroids and azithromycin. An echocardiogram performed during the admission was normal, without significant impairment in relaxation. He completed his course, but continued to have symtpoms. In fact, VNA contactSusana Finateri his PCP (who had not yet met him), on 6-21 with concerns that included continued dyspnea, a reported 20lb weight gain, and lower extremity edema. The patient began 20mg lasix at that time. . On presentation to his new PCPs office 1904-10-6, he had a continued oxygen requirment of 3L at rest, sating 95% and 90% with ambulation. The patient endorsed dyspnea walking even 30 feet. He was sent to the ED for a rule out of PE. per reports, he was moving air well at that time and did not have wheezing. He had just completed his prescribed steroid taper on 2-25 which was a total of 14 days. . On arrival to the ED he was 96.9 124/59 91 24 95%on 3L In the ED he was given lasix 40mg IV x 1 and a CTA was obtained. The CTA was negatvie for PE. The lasix dropped his blood pressure transiently to 75/40 which was response to a total of 2L normal saline challenge. He was not given steroids or nebulizers. Despite resolution of his hypotension, he was sent to the Lara, Doyle and Mcneil Medical Center. . Further review of systemts notable for minimal cough, no fever, and no chest pain. He does not occasional paroxysmal abdominal pain for which a RUQ u/s on 2-30 was negative for acute pathology. He notes leg swelling, for which tight socks have helped. He also reports difficulty sleeping, requiring 3 pillows at night. He reports that he did not feel completely better during his hospitlization at Medina PLC Clinic, notable that he did not try and walk around much. He thinks that his shortness of breath has been much worse since 1911-7-31, allthough clearly he must have marked dysfunction given disability 4-20 dyspnea. Former patient of Fowler, Thomas and Velasquez Health System, and a comprehensive review of old records is not available at this time. . Past Medical History: # COPD - was seen frequently at Shepard, Owen and Lowe Health System. Has smoked 3 packs /day x 45 years, quit on last admission to Medina PLC Clinic. No PFTs in our system. # Congential Bicuspid Aortic Valve; s/p porcicine repair 1961. Echo in 1961 on recent admission within normal limits # Hypertension # Lower Extremity Edema # Hypertension . Social History: Smoked 3pks ppd x 45 years. Former head of maintence at Gallagher-Gentry Medical Center, also a car mechanic. Now on disability due to dyspnea. Lives wtih girlfriend. Minimal etoh now though former heavy alcohol user. Family History: Parents with heart disease Physical Exam: On Presentation: 116/66, HR 86 and sinus, sating 96% on 2LNC. Weight 125kg, up from 119kg on admission 1922-10-30. GEN: In some distress. barrel chested, unable to speak comfortably in full sentences HEENT: no oral ulcers CV: RRR s1, s2, soft holosystolic murmur present. No increased P2. RESP: high pitched expiratory wheezing heard in upper posterior lung fields. ABD: soft, obese, some minimal tenderness to palpation of RUQ EXT: marked venous stasis changes of distal extremities bilaterally. only 1+ edema at this time, but patient reports has been much worse. Skin: diffuse acne Pertinent Results: 1904-10-6 06:10PM GLUCOSE-74 UREA N-20 CREAT-0.8 SODIUM-140 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13 1904-10-6 06:10PM ALT(SGPT)-53* AST(SGOT)-28 LD(LDH)-384* CK(CPK)-143 ALK PHOS-93 TOT BILI-0.5 1904-10-6 06:10PM LIPASE-16 1904-10-6 06:10PM cTropnT-0.02* 1904-10-6 06:10PM CK-MB-7 proBNP-150 1904-10-6 06:10PM TOT PROT-6.5 1904-10-6 06:10PM WBC-9.1 RBC-5.19 HGB-15.4 HCT-45.4 MCV-87 MCH-29.6 MCHC-33.9 RDW-13.4 1904-10-6 06:10PM NEUTS-66.8 LYMPHS-25.0 MONOS-5.9 EOS-2.0 BASOS-0.3 1904-10-6 06:10PM PLT COUNT-204 1904-10-6 06:10PM PT-12.6 PTT-26.0 INR(PT)-1.1 8-23 CXR: No evidence of congestive heart failure. Lung hyperinflation. Questionable left hilar mass. Evaluation with CT chest with contrast is recommended for precise characterization. 8-23 CTA: 1. No pulmonary embolus, no evidence of aortic dissection. 2. Small nodular densities in left lower lobe, with secretions in the trachea, likely small foci of aspiration. 3. Emphysema. Brief Hospital Course: 57 y/o man with long smokign history admitted to Lara, Doyle and Mcneil Medical Center with makred dypnea and lower extremity swelling likely due to a COPD exacerbation. # Dyspnea: Likely COPD exacerbation with recent overall decline given new O2 requirement this month. Also likely has an element of OSA given his inability to sleep laying down (3-pillow orthopnea) as COPD alone would not cause this. CHF essentially ruled out by normal BNP and hypotension after lasix. Echo was normal 2 weeks prior. Given wheezing and marked smoking history, it seems that this is a continued presentation of a partially treated, severe COPD exacerbation. PE was ruled out with CTA. He was started on a prolonged prednisone taper: start at 60mg po for 1 week and will be discharged on a slow taper. He was also restarted on advair, spiriva, singulair, and albuterol. He will need outpatient Harris-Harrison Medical Center evaluation. He is already scheduled in pulmonary clinic for a complete evaluation. . # Likely obstructive sleep apnea: Patient was tried on CPAP overnight, and had one successful night, and a second without relief. His settings were 3 L of oxygen and pressure of 11 and a formal sleep study for treatment of his suspected OSA. . # Lower Extremity Edema: Appears consistent with chronic venous insufficiency, not CHF as above. Could have some element of cor pulmonale, but echo 2 weeks ago inconclusive though showed mild RV dilation but no TR. He was encouraged to wear compression stockings and elevate his legs. He was also continued on a higher dose of lasix. . # RUQ abdominal pain: The patient has intermittent sharp, RUQ abdominal pain as an outpatient and had an episode overnight which resolved within 30 minutes. Not related to food intake, however the sharp quality and location raise concern for cholecysistis. Had a RUQ US recently which was unremarkable. LFTs this revealed only a slightly elevated ALT. His repeat abdominal ultrasound was negative for gall stones. He will need abdominal CT if the pain persists. It was relieved with low dose oxycodone, and he was discharged on percocet. . # Hypertension: The patient was continued on his home regimen of lisinopril and extended release diltiazem. . Medications on Admission: Singulair 10mg po Qday Protonix 40mg po Qday ASA 325mg po Qday Dilt SR 240 mg capsule po Qday Lisinopril 10mg po Qday albuterol prn Flovent discus 250 acutaltion Serevent 50mcg discus Lasix 20mg po Qday (started 6-21) Discharge Medications: 1. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Prednisone 5 mg Tablet Sig: Taper PO once a day for Taper days: 60 mg (12 pills) for 2 days, then 55 mg (11 pills) for 2 days, then decrease by 1 pill every other day until off. Disp:156 Tablet(s) Refills:0 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Moss, Cooper and Ortega Hospital (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB. 9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. Disp:30 Tablet(s) Refills:0 11. Pulmonary rehabilitation Please evaluate and treat. 12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) tablet Inhalation once a day. Discharge Disposition: Home Discharge Diagnosis: Hypercarbic respiratory failure COPD with acute exacerbation Small pneumonia, possible aspiration. Lower extremity edema Abdominal pain, Right upper quadrant. Obesity. Likely obstructive sleep apnea. Discharge Condition: Stable. Discharge Instructions: You were admitted with shortness of breath, due to a asthma/obstructive lung disease exacerbation. You had a chest CT to evaluate for a blood clot that was negative. You just have emphysema. You also have evidence on your chest CT of a possible mild pneumonia. Your abdominal pain was evaluated with an ultrasound, and you have no gall stones. . Return to the emergency room if you get worse, with worse shortness of breath, abdominal pain, LE swelling, nausea or vomiting, chest pain. Followup Instructions: Provider: Emma Debelius FUNCTION LAB Phone:393-517-7182 Date/Time:2020-3-31 9:40 Provider: Angus Ornelas,INTERPRET W/LAB NO CHECK-IN Angus Ornelas INTEPRETATION BILLING Date/Time:2020-3-31 10:00 Provider: FD Benavidez NP/DR Dortch Phone:413-783-1162 Date/Time:2020-3-31 10:00 . Sleep study, to be arranged as outpatient. . PCP Emory Recinos 1 month. . Pulmonary rehab appt set for 1946-5-17	['Admission Date: 1904-10-6 Discharge Date: 1962-7-4\n\nDate of Birth: 1960-5-13 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Bradley\nChief Complaint:\nDyspnea\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\n57 y/o man with a history of aoritc valve replacement 1961 4-20\ncongenital bicuspid valve, copd, HTN, prior alcohol abuse, who\nis admitted to the Boyd, Marshall and Francis Health System ICU with dyspnea and transient\nhypotension.\n.\nThe patient was recently admitted to Medina PLC Clinic from 1922-10-30 to\n2019-3-26 for dyspnea and was treated for a COPD excaerbation with\nsteroids and azithromycin. An echocardiogram performed during\nthe admission was normal, without significant impairment in\nrelaxation.', ' He completed his course, but continued to have\nsymtpoms. In fact, VNA contactSusana Finateri his PCP (who had not yet met\nhim), on 6-21 with concerns that included continued dyspnea, a\nreported 20lb weight gain, and lower extremity edema. The\npatient began 20mg lasix at that time.\n.\nOn presentation to his new PCPs office 1904-10-6, he had a\ncontinued oxygen requirment of 3L at rest, sating 95% and 90%\nwith ambulation. The patient endorsed dyspnea walking even 30\nfeet. He was sent to the ED for a rule out of PE. per reports,\nhe was moving air well at that time and did not have wheezing.\nHe had just completed his prescribed steroid taper on 2-25 which\nwas a total of 14 days.\n.\nOn arrival to the ED he was 96.9 124/59 91 24 95%on 3L\nIn the ED he was given lasix 40mg IV x 1 and a CTA was obtained.', '\nThe CTA was negatvie for PE. The lasix dropped his blood\npressure transiently to 75/40 which was response to a total of\n2L normal saline challenge. He was not given steroids or\nnebulizers. Despite resolution of his hypotension, he was sent\nto the Lara, Doyle and Mcneil Medical Center.\n.\nFurther review of systemts notable for minimal cough, no fever,\nand no chest pain. He does not occasional paroxysmal abdominal\npain for which a RUQ u/s on 2-30 was negative for acute\npathology. He notes leg swelling, for which tight socks have\nhelped. He also reports difficulty sleeping, requiring 3 pillows\nat night. He reports that he did not feel completely better\nduring his hospitlization at Medina PLC Clinic, notable that he did not try\nand walk around much. He thinks that his shortness of breath has\nbeen much worse since 1911-7-31, allthough clearly he must\nhave marked dysfunction given disability 4-20 dyspnea.', ' Former\npatient of Fowler, Thomas and Velasquez Health System, and a comprehensive review of old records is not\navailable at this time.\n.\n\n\nPast Medical History:\n# COPD - was seen frequently at Shepard, Owen and Lowe Health System. Has\nsmoked 3 packs /day x 45 years, quit on last admission to Medina PLC Clinic.\nNo PFTs in our system.\n# Congential Bicuspid Aortic Valve; s/p porcicine repair 1961.\nEcho in 1961 on recent admission within normal limits\n# Hypertension\n# Lower Extremity Edema\n# Hypertension\n.\n\n\nSocial History:\nSmoked 3pks ppd x 45 years. Former head of maintence at Gallagher-Gentry Medical Center, also a car mechanic. Now on disability due\nto dyspnea. Lives wtih girlfriend. Minimal etoh now though\nformer heavy alcohol user.\n\n\n\nFamily History:\nParents with heart disease\n\n\nPhysical Exam:\nOn Presentation:\n\n116/66, HR 86 and sinus, sating 96% on 2LNC.', ' Weight 125kg, up\nfrom 119kg on admission 1922-10-30.\nGEN: In some distress. barrel chested, unable to speak\ncomfortably in full sentences\nHEENT: no oral ulcers\nCV: RRR s1, s2, soft holosystolic murmur present. No increased\nP2.\nRESP: high pitched expiratory wheezing heard in upper posterior\nlung fields.\nABD: soft, obese, some minimal tenderness to palpation of RUQ\nEXT: marked venous stasis changes of distal extremities\nbilaterally. only 1+ edema at this time, but patient reports has\nbeen much worse.\nSkin: diffuse acne\n\n\nPertinent Results:\n1904-10-6 06:10PM GLUCOSE-74 UREA N-20 CREAT-0.8 SODIUM-140\nPOTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13\n1904-10-6 06:10PM ALT(SGPT)-53* AST(SGOT)-28 LD(LDH)-384\nCK(CPK)-143 ALK PHOS-93 TOT BILI-0.5\n1904-10-6 06:10PM LIPASE-16\n1904-10-6 06:10PM cTropnT-0.', '02\n1904-10-6 06:10PM CK-MB-7 proBNP-150\n1904-10-6 06:10PM TOT PROT-6.5\n1904-10-6 06:10PM WBC-9.1 RBC-5.19 HGB-15.4 HCT-45.4 MCV-87\nMCH-29.6 MCHC-33.9 RDW-13.4\n1904-10-6 06:10PM NEUTS-66.8 LYMPHS-25.0 MONOS-5.9 EOS-2.0\nBASOS-0.3\n1904-10-6 06:10PM PLT COUNT-204\n1904-10-6 06:10PM PT-12.6 PTT-26.0 INR(PT)-1.1\n\n8-23 CXR: No evidence of congestive heart failure. Lung\nhyperinflation. Questionable left hilar mass. Evaluation with CT\nchest with contrast is recommended for precise characterization.\n\n\n8-23 CTA:\n1. No pulmonary embolus, no evidence of aortic dissection.\n2. Small nodular densities in left lower lobe, with secretions\nin the\ntrachea, likely small foci of aspiration.\n3. Emphysema.\n\nBrief Hospital Course:\n57 y/o man with long smokign history admitted to Lara, Doyle and Mcneil Medical Center with\nmakred dypnea and lower extremity swelling likely due to a COPD\nexacerbation.', '\n\n# Dyspnea: Likely COPD exacerbation with recent overall decline\ngiven new O2 requirement this month. Also likely has an element\nof OSA given his inability to sleep laying down (3-pillow\northopnea) as COPD alone would not cause this. CHF essentially\nruled out by normal BNP and hypotension after lasix. Echo was\nnormal 2 weeks prior. Given wheezing and marked smoking history,\nit seems that this is a continued presentation of a partially\ntreated, severe COPD exacerbation. PE was ruled out with CTA. He\nwas started on a prolonged prednisone taper: start at 60mg po\nfor 1 week and will be discharged on a slow taper. He was also\nrestarted on advair, spiriva, singulair, and albuterol. He\nwill need outpatient Harris-Harrison Medical Center evaluation. He is already scheduled in\npulmonary clinic for a complete evaluation.', '\n.\n# Likely obstructive sleep apnea: Patient was tried on CPAP\novernight, and had one successful night, and a second without\nrelief. His settings were 3 L of oxygen and pressure of 11 and\na formal sleep study for treatment of his suspected OSA.\n.\n# Lower Extremity Edema: Appears consistent with chronic venous\ninsufficiency, not CHF as above. Could have some element of cor\npulmonale, but echo 2 weeks ago inconclusive though showed mild\nRV dilation but no TR. He was encouraged to wear compression\nstockings and elevate his legs. He was also continued on a\nhigher dose of lasix.\n.\n# RUQ abdominal pain: The patient has intermittent sharp, RUQ\nabdominal pain as an outpatient and had an episode overnight\nwhich resolved within 30 minutes. Not related to food intake,\nhowever the sharp quality and location raise concern for\ncholecysistis.', ' Had a RUQ US recently which was unremarkable.\nLFTs this revealed only a slightly elevated ALT. His repeat\nabdominal ultrasound was negative for gall stones. He will need\nabdominal CT if the pain persists. It was relieved with low\ndose oxycodone, and he was discharged on percocet.\n.\n# Hypertension: The patient was continued on his home regimen of\nlisinopril and extended release diltiazem.\n.\n\n\nMedications on Admission:\nSingulair 10mg po Qday\nProtonix 40mg po Qday\nASA 325mg po Qday\nDilt SR 240 mg capsule po Qday\nLisinopril 10mg po Qday\nalbuterol prn\nFlovent discus 250 acutaltion\nSerevent 50mcg discus\nLasix 20mg po Qday (started 6-21)\n\n\nDischarge Medications:\n1. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)\nCapsule, Sustained Release PO DAILY (Daily).\n2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).', '\n\n3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n6. Prednisone 5 mg Tablet Sig: Taper PO once a day for Taper\ndays: 60 mg (12 pills) for 2 days, then 55 mg (11 pills) for 2\ndays, then decrease by 1 pill every other day until off.\nDisp:156 Tablet(s) Refills:0\n7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:\nOne (1) Disk with Device Inhalation Moss, Cooper and Ortega Hospital (2 times a day).\n8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff\nInhalation Q4H (every 4 hours) as needed for SOB.\n9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a\nday for 7 days.', '\nDisp:14 Tablet(s) Refills:0\n10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)\nhours.\nDisp:30 Tablet(s) Refills:0\n11. Pulmonary rehabilitation\nPlease evaluate and treat.\n12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device\nSig: One (1) tablet Inhalation once a day.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nHypercarbic respiratory failure\nCOPD with acute exacerbation\nSmall pneumonia, possible aspiration.\nLower extremity edema\nAbdominal pain, Right upper quadrant.\nObesity.\nLikely obstructive sleep apnea.\n\nDischarge Condition:\nStable.\n\nDischarge Instructions:\nYou were admitted with shortness of breath, due to a\nasthma/obstructive lung disease exacerbation. You had a chest\nCT to evaluate for a blood clot that was negative. You just\nhave emphysema. You also have evidence on your chest CT of a\npossible mild pneumonia.', ' Your abdominal pain was evaluated with\nan ultrasound, and you have no gall stones.\n.\nReturn to the emergency room if you get worse, with worse\nshortness of breath, abdominal pain, LE swelling, nausea or\nvomiting, chest pain.\n\nFollowup Instructions:\nProvider: Emma Debelius FUNCTION LAB Phone:393-517-7182\nDate/Time:2020-3-31 9:40\nProvider: Angus Ornelas,INTERPRET W/LAB NO CHECK-IN Angus Ornelas INTEPRETATION\nBILLING Date/Time:2020-3-31 10:00\nProvider: FD Benavidez NP/DR Dortch Phone:413-783-1162\nDate/Time:2020-3-31 10:00\n.\nSleep study, to be arranged as outpatient.\n.\nPCP Emory Recinos 1 month.\n.\nPulmonary rehab appt set for 1946-5-17\n\n\n\n']
550	85490	177636.0	2112-05-12	Discharge summary	Report	Admission Date: [2112-5-6] Discharge Date: [2112-5-12] Date of Birth: [2052-12-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1253] Chief Complaint: Respiratory distress. Major Surgical or Invasive Procedure: 1. Inubation 2. Placement of central venous access via the right internal jugular History of Present Illness: Mr. [Known lastname 4509] is a 59yo M with history of severe COPD and pulmonary hypertension who was brought in by ambulance for respiratory distress. Per report, when EMS arrived all of his inhalers were empty. . In the ED, initial vs were: T 98.8 P 121 BP 100/67 R 17 O2 sat 100%. He was immediately intubated for respiratory distress as he wasn't able to speak few words. He was on propofol for sedation. His pressures were in the 90s and dipped to the 80s so R IJ was placed and levophed was started. CXR showed fluffy bilateral infiltrates and ABG was significant for hypcarbia to 106. He received 125mg IV solumedrol, albuterol, magnesium, levaquin, ceftriaxone and was started on versed/fent drips. . In the ICU, patient is intubated and sedated. Past Medical History: # COPD - was seen frequently at [Hospital6 ]. Has smoked 3 packs /day x 45 years, quit on last admission to [Hospital1 18]. No PFTs in our system. # Congential Bicuspid Aortic Valve; s/p porcicine repair [2102]. Echo in [2110] on recent admission within normal limits # Hypertension # Lower Extremity Edema # Hypertension Social History: Smoked 3pks ppd x 45 years. Former head of maintence at [Hospital1 756] and women's hospital, also a car mechanic. No exposure to asbestos. Now on disability due to dyspnea. Lives wtih girlfriend. Minimal etoh now though former heavy alcohol user Family History: Parents with heart disease - MIs. Sister with arrhythmia that went away. No fhx of cancers. Physical Exam: Upon admission: T: 99.5 BP: 91/55 P: 94 100% on AC 550x18, 50% Fi02, PEEP 5 General: Sedated, intubated, not following commands HEENT: Pinpoint pupils bilaterally slightly responsive to light, sclera anicteric, MMM, oropharynx clear, tongue with abnormal fasciculations Neck: supple, JVP unable to be assessed, no LAD Lungs: Bilateral coarse wheezing CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley Ext: warm, well perfused, 1+ DP pulses bilaterally, bilateral lower extremities with chronic venous stasis changes, no clubbing, cyanosis or edema . At discharge: VS: 97.3 129/78 (149/86) 94 (88) 20 92-97 on 3L NC I/O not well recorded yesterday General: NAD, sitting up in bed, pleasant, funny and interactive HEENT: MMM tongue with no abnormal fasciculations Lungs: Bilateral coarse sounds, very tight, scattered wheezes throughout lung fields. CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 1+ DP pulses bilaterally, bilateral lower extremities with chronic venous stasis changes, no clubbing, cyanosis or edema Pertinent Results: ADMISSION [2112-5-6] 06:25AM FIBRINOGE-651* [2112-5-6] 06:25AM PLT COUNT-146* [2112-5-6] 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93 MCH-30.7 MCHC-33.0 RDW-12.6 [2112-5-6] 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93 MCH-30.7 MCHC-33.0 RDW-12.6 [2112-5-6] 06:25AM LIPASE-11 [2112-5-6] 10:58AM LACTATE-0.9 [2112-5-6] 11:51AM PT-12.6 PTT-27.6 INR(PT)-1.1 [2112-5-6] 11:51AM GLUCOSE-165* UREA N-20 CREAT-0.5 SODIUM-140 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-40* ANION GAP-8 . DISCHARGE [2112-5-12] 06:25AM BLOOD WBC-7.4 RBC-4.65 Hgb-13.7* Hct-42.5 MCV-92 MCH-29.6 MCHC-32.3 RDW-13.1 Plt Ct-185 [2112-5-8] 02:46AM BLOOD Neuts-80.0* Lymphs-14.2* Monos-5.5 Eos-0.2 Baso-0.1 [2112-5-12] 06:25AM BLOOD Glucose-121* UreaN-15 Creat-0.5 Na-143 K-3.5 Cl-97 HCO3-37* AnGap-13 [2112-5-12] 06:25AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0 [2112-5-8] 02:56AM BLOOD Type-[Last Name (un) ] Temp-36.7 Rates-16/ Tidal V-550 PEEP-5 FiO2-40 pO2-46* pCO2-64* pH-7.39 calTCO2-40* Base XS-10 -ASSIST/CON Intubat-INTUBATED . IMAGING STUDIES CHEST XRAY ADMISSION [5-6] PORTABLE AP CHEST RADIOGRAPH: Sternotomy wires are midline and intact. Surgical clips are noted in the midline. The ET tube is above the thoracic inlet, approximately 7.5 cm above the expected location of the carina. Nasogastric tube is traced best up to the level of the mid esophagus, uncle[Name (NI) 4510] traced thereafter. A tube-like structure within the expected region of the stomach may represent the continuation of the nasogastric tube, however uncertain. Bilateral low lung volumes are noted with appearance suggestive of pulmonary fibrosis. . CHEST XRAY [5-9] Frontal view of the chest is compared to multiple prior examinations. Right IJ catheter terminates in superior vena cava. Remainder of lines and tubes are unchanged. There is moderate congestive failure, small bilateral pleural effusions and atelectasis at the right lung base. Heart and mediastinum are stable. . CT SCAN [5-6] FINAL REPORT IMPRESSION: 1. Diffuse ground glass and nodular opacities with an appearance most consistent with mycoplasma pneumonia. Extensive mediastinal and hilar lymphadenopathy, likely reactive. Trace bilateral pleural effusions. 2. Endotracheal tube ends approximately 1 cm above the carina. . CT SCAN WITH AND WIHTOUT CONTRAST [5-6] 1. No acute intracranial process. 2. Intubation, with retained sinonasal secretions. Brief Hospital Course: HOSPITAL COURSE Mr. [Known lastname 4509] is a 59yo M with history of severe COPD and pulmonary hypertension who presented with hypercarbic respiratory distress requiring intubation. He did well after extubation and was discharged to pulmonary rehabilitation for further care. . ACTIVE ISSUES # Hypercarbic respiratory failure: His respiratory distress was likely related to extreme hypercarbia due to his underlying COPD. His COPD flare was likely due to medication noncompliance in setting of running out of inhalers. Chest CT showed diffuse bronchopulmonary pneumonia concerning for a mycoplasma/atypical process. He was started levofloxacin and will complete a 7 day course on the night of discharge. He was started on solumedrol and then switched to prednisone. Extubated [5-9] without complication. He was continued on 60mg prednisone on transfer to the floor. A slow prednisone taper was initiated on discharge to pulmonary rehab where additional titration of nebulizer therapy will be continued and initation of home inhaler regimen of advair and spiriva will be started. His Bipap was continued but at lower settings of 18/16, and his supplemental oxygen was 3L at discharge. He was encouraged to stop smoking. He will have pulmonary follow up after discharge from pulmonary rehab. . # Hypotension: He is likely hypertensive at baseline given lisinopril on med list but recent baseline is unknown. Hypotension in MICU was possibly related to sedation surrounding intubation or from decrease in right heart filling pressure with positive pressure ventilation. Normal lactate and lack of leukocytosis are reassuring. He was started on levophed in the ED and this was weaned off as fluid boluses given. # Tongue movement: His abnormal tongue movement in MICU was concerning for possible fasciculation or seizure activity. He does not have a history of seizures and recent events leading to hospitalization. These events did not continue and no further work up pursued. . # Hypertension with Diastolic Dysfunction: Previously on lisinopril and lasix - has not refilled Rx in two years. He was restarted on lisinopril and aspirin with a lower dose of lasix. His blood pressure was well controlled and renal function stable. His peripheral edema slowly improved. It is likely that his lasix will need to be uptitrated in the outpatient setting. . TRANSITIONAL ISSUES # Disposition: Pulmonary Rehabilitation with close Pulmonary and Cardiology follow-up Mr. [Known lastname 4509] has not had medical follow-up in over 2 years and medication compliance a significant issue in future management. # Code: Full Medications on Admission: Medications: Per list from [2110], unknown if patient taking these now: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 vial via nebulizer Every 6-8 hours as needed for shortness of breath/wheezing ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) by mouth every four (4) to six (6) hours as needed for cough/wheezing FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff(s) inhaled Twice daily Rinse mouth after use FUROSEMIDE - 80 mg Tablet - 1 Tablet(s) by mouth daily LIDOCAINE - (Prescribed by Other Provider) - 5 % (700 mg/patch) Adhesive Patch, Medicated - LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth daily NAPROXEN - 500 mg Tablet - 1 Tablet(s) by mouth Twiec a day ([Hospital1 ]) For 2 week course OXYGEN - (Prescribed by Other Provider) - - 2L at rest via NC; 3L with activity PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 capsule inhaled Once daily ACETAMINOPHEN [TYLENOL ARTHRITIS] - (OTC) - 650 mg Tablet Extended Release - Tablet(s) by mouth ASPIRIN [ASPIR-81] - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 7. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours. 8. prednisone 10 mg Tablet Sig: 6 pills x 3 days, 5 pills x 3 days, 4 pills x 3 days, 3 pills x 3 days, 2 pills x 3 days, 1 pill x three days then STOP Tablets PO once a day: Prednisone taper. 9. Bipap BiPap 18/16 when sleeping or napping. 10. Oxygen therapy Oxygen 3L. Titrate to keep sats >90%, unknown home flow rate. 11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 doses: Please give on [5-12]. 12. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: Acute Exacerbation of Chronic Obtructive Pulmonary Disease, Community Acquired Pneumonia, Tobacco Abuse Secondary Diagnosis: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for managment of respiratory distress likely caused by pneumonia and a COPD exacerbation. You were intubated for three days to assist with your breathing. You were treated with antibiotics for a pneumonia, and bronchodilator and steroid therapy for management of your COPD. You continued to improve. While you were here, we restarted many of the medications that were prescribed to you in the past. It is very important that you continue these medications and follow-up with your primary care physician, [Name10 (NameIs) 2085] and pulmonologist as your underyling pulmonary and cardiac issues have not been evaluated in some time. It is likely that some of these medications will need to be changed or adjusted. You are being discharged to a pulmonary rehabilitation center prior to going home given the severity of your symptoms. They will prepare you for discharge to home. We strongly encourage you to quit smoking as this is one of the few things that will increase your life expectancy related to your lung disease. The following changes were made to your medication list: 1. START lisinopril 10mg daily 2. START lasix 20mg daily 3. START albuterol Nebulyzer therapy 4. START ipratropium Nebulyzer therapy 5. START Nicotine Patch 6. START Monteleukast 7. COMPLETE Prednisone taper as prescribed 8. CONTINUE aspirin and protonix as you have been taking 9. CONTINUE supplemental oxygen 10. CONTINUE BIPAP at night and while napping Please talk to your PCP if you are having any problems with obtaining these medications. These medications may change upon discharge from Pulmonary Rehab. Followup Instructions: PULMONOLOGY The office of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] will call you to set up an appointment on discharge. If you have not heard from his office when you leave Pulmonary Rehab: Please call ([Telephone/Fax (1) 513] to schedule an appointment. CARDIOLOGY Department: CARDIAC SERVICES When: FRIDAY [2112-6-3] at 11:20 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4511], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	Admission Date: <Date>1955-1-22</Date> Discharge Date: <Date>1930-3-28</Date> Date of Birth: <Date>1954-7-31</Date> Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Chloe</Name> Chief Complaint: Respiratory distress. Major Surgical or Invasive Procedure: 1. Inubation 2. Placement of central venous access via the right internal jugular History of Present Illness: Mr. <Name>Pleasant</Name> is a 59yo M with history of severe COPD and pulmonary hypertension who was brought in by ambulance for respiratory distress. Per report, when EMS arrived all of his inhalers were empty. . In the ED, initial vs were: T 98.8 P 121 BP 100/67 R 17 O2 sat 100%. He was immediately intubated for respiratory distress as he wasn't able to speak few words. He was on propofol for sedation. His pressures were in the 90s and dipped to the 80s so R IJ was placed and levophed was started. CXR showed fluffy bilateral infiltrates and ABG was significant for hypcarbia to 106. He received 125mg IV solumedrol, albuterol, magnesium, levaquin, ceftriaxone and was started on versed/fent drips. . In the ICU, patient is intubated and sedated. Past Medical History: # COPD - was seen frequently at <Hospital>Lewis and Sons Hospital</Hospital>. Has smoked 3 packs /day x 45 years, quit on last admission to <Hospital>Porter PLC Medical Center</Hospital>. No PFTs in our system. # Congential Bicuspid Aortic Valve; s/p porcicine repair <Year>1968</Year>. Echo in <Year>1968</Year> on recent admission within normal limits # Hypertension # Lower Extremity Edema # Hypertension Social History: Smoked 3pks ppd x 45 years. Former head of maintence at <Hospital>Jackson-Farley Clinic</Hospital> and women's hospital, also a car mechanic. No exposure to asbestos. Now on disability due to dyspnea. Lives wtih girlfriend. Minimal etoh now though former heavy alcohol user Family History: Parents with heart disease - MIs. Sister with arrhythmia that went away. No fhx of cancers. Physical Exam: Upon admission: T: 99.5 BP: 91/55 P: 94 100% on AC 550x18, 50% Fi02, PEEP 5 General: Sedated, intubated, not following commands HEENT: Pinpoint pupils bilaterally slightly responsive to light, sclera anicteric, MMM, oropharynx clear, tongue with abnormal fasciculations Neck: supple, JVP unable to be assessed, no LAD Lungs: Bilateral coarse wheezing CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley Ext: warm, well perfused, 1+ DP pulses bilaterally, bilateral lower extremities with chronic venous stasis changes, no clubbing, cyanosis or edema . At discharge: VS: 97.3 129/78 (149/86) 94 (88) 20 92-97 on 3L NC I/O not well recorded yesterday General: NAD, sitting up in bed, pleasant, funny and interactive HEENT: MMM tongue with no abnormal fasciculations Lungs: Bilateral coarse sounds, very tight, scattered wheezes throughout lung fields. CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 1+ DP pulses bilaterally, bilateral lower extremities with chronic venous stasis changes, no clubbing, cyanosis or edema Pertinent Results: ADMISSION <Date>1955-1-22</Date> 06:25AM FIBRINOGE-651* <Date>1955-1-22</Date> 06:25AM PLT COUNT-146* <Date>1955-1-22</Date> 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93 MCH-30.7 MCHC-33.0 RDW-12.6 <Date>1955-1-22</Date> 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93 MCH-30.7 MCHC-33.0 RDW-12.6 <Date>1955-1-22</Date> 06:25AM LIPASE-11 <Date>1955-1-22</Date> 10:58AM LACTATE-0.9 <Date>1955-1-22</Date> 11:51AM PT-12.6 PTT-27.6 INR(PT)-1.1 <Date>1955-1-22</Date> 11:51AM GLUCOSE-165* UREA N-20 CREAT-0.5 SODIUM-140 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-40* ANION GAP-8 . DISCHARGE <Date>1930-3-28</Date> 06:25AM BLOOD WBC-7.4 RBC-4.65 Hgb-13.7* Hct-42.5 MCV-92 MCH-29.6 MCHC-32.3 RDW-13.1 Plt Ct-185 <Date>2005-5-23</Date> 02:46AM BLOOD Neuts-80.0* Lymphs-14.2* Monos-5.5 Eos-0.2 Baso-0.1 <Date>1930-3-28</Date> 06:25AM BLOOD Glucose-121* UreaN-15 Creat-0.5 Na-143 K-3.5 Cl-97 HCO3-37* AnGap-13 <Date>1930-3-28</Date> 06:25AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0 <Date>2005-5-23</Date> 02:56AM BLOOD Type-<Name>Miller</Name> Temp-36.7 Rates-16/ Tidal V-550 PEEP-5 FiO2-40 pO2-46* pCO2-64* pH-7.39 calTCO2-40* Base XS-10 -ASSIST/CON Intubat-INTUBATED . IMAGING STUDIES CHEST XRAY ADMISSION <Date>9-18</Date> PORTABLE AP CHEST RADIOGRAPH: Sternotomy wires are midline and intact. Surgical clips are noted in the midline. The ET tube is above the thoracic inlet, approximately 7.5 cm above the expected location of the carina. Nasogastric tube is traced best up to the level of the mid esophagus, uncle<Name>Latoya Benhamou</Name> traced thereafter. A tube-like structure within the expected region of the stomach may represent the continuation of the nasogastric tube, however uncertain. Bilateral low lung volumes are noted with appearance suggestive of pulmonary fibrosis. . CHEST XRAY <Date>11-29</Date> Frontal view of the chest is compared to multiple prior examinations. Right IJ catheter terminates in superior vena cava. Remainder of lines and tubes are unchanged. There is moderate congestive failure, small bilateral pleural effusions and atelectasis at the right lung base. Heart and mediastinum are stable. . CT SCAN <Date>9-18</Date> FINAL REPORT IMPRESSION: 1. Diffuse ground glass and nodular opacities with an appearance most consistent with mycoplasma pneumonia. Extensive mediastinal and hilar lymphadenopathy, likely reactive. Trace bilateral pleural effusions. 2. Endotracheal tube ends approximately 1 cm above the carina. . CT SCAN WITH AND WIHTOUT CONTRAST <Date>9-18</Date> 1. No acute intracranial process. 2. Intubation, with retained sinonasal secretions. Brief Hospital Course: HOSPITAL COURSE Mr. <Name>Pleasant</Name> is a 59yo M with history of severe COPD and pulmonary hypertension who presented with hypercarbic respiratory distress requiring intubation. He did well after extubation and was discharged to pulmonary rehabilitation for further care. . ACTIVE ISSUES # Hypercarbic respiratory failure: His respiratory distress was likely related to extreme hypercarbia due to his underlying COPD. His COPD flare was likely due to medication noncompliance in setting of running out of inhalers. Chest CT showed diffuse bronchopulmonary pneumonia concerning for a mycoplasma/atypical process. He was started levofloxacin and will complete a 7 day course on the night of discharge. He was started on solumedrol and then switched to prednisone. Extubated <Date>11-29</Date> without complication. He was continued on 60mg prednisone on transfer to the floor. A slow prednisone taper was initiated on discharge to pulmonary rehab where additional titration of nebulizer therapy will be continued and initation of home inhaler regimen of advair and spiriva will be started. His Bipap was continued but at lower settings of 18/16, and his supplemental oxygen was 3L at discharge. He was encouraged to stop smoking. He will have pulmonary follow up after discharge from pulmonary rehab. . # Hypotension: He is likely hypertensive at baseline given lisinopril on med list but recent baseline is unknown. Hypotension in MICU was possibly related to sedation surrounding intubation or from decrease in right heart filling pressure with positive pressure ventilation. Normal lactate and lack of leukocytosis are reassuring. He was started on levophed in the ED and this was weaned off as fluid boluses given. # Tongue movement: His abnormal tongue movement in MICU was concerning for possible fasciculation or seizure activity. He does not have a history of seizures and recent events leading to hospitalization. These events did not continue and no further work up pursued. . # Hypertension with Diastolic Dysfunction: Previously on lisinopril and lasix - has not refilled Rx in two years. He was restarted on lisinopril and aspirin with a lower dose of lasix. His blood pressure was well controlled and renal function stable. His peripheral edema slowly improved. It is likely that his lasix will need to be uptitrated in the outpatient setting. . TRANSITIONAL ISSUES # Disposition: Pulmonary Rehabilitation with close Pulmonary and Cardiology follow-up Mr. <Name>Pleasant</Name> has not had medical follow-up in over 2 years and medication compliance a significant issue in future management. # Code: Full Medications on Admission: Medications: Per list from <Year>1968</Year>, unknown if patient taking these now: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 vial via nebulizer Every 6-8 hours as needed for shortness of breath/wheezing ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) by mouth every four (4) to six (6) hours as needed for cough/wheezing FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff(s) inhaled Twice daily Rinse mouth after use FUROSEMIDE - 80 mg Tablet - 1 Tablet(s) by mouth daily LIDOCAINE - (Prescribed by Other Provider) - 5 % (700 mg/patch) Adhesive Patch, Medicated - LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth daily NAPROXEN - 500 mg Tablet - 1 Tablet(s) by mouth Twiec a day (<Hospital>Herrera LLC Hospital</Hospital>) For 2 week course OXYGEN - (Prescribed by Other Provider) - - 2L at rest via NC; 3L with activity PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 capsule inhaled Once daily ACETAMINOPHEN [TYLENOL ARTHRITIS] - (OTC) - 650 mg Tablet Extended Release - Tablet(s) by mouth ASPIRIN [ASPIR-81] - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 7. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours. 8. prednisone 10 mg Tablet Sig: 6 pills x 3 days, 5 pills x 3 days, 4 pills x 3 days, 3 pills x 3 days, 2 pills x 3 days, 1 pill x three days then STOP Tablets PO once a day: Prednisone taper. 9. Bipap BiPap 18/16 when sleeping or napping. 10. Oxygen therapy Oxygen 3L. Titrate to keep sats >90%, unknown home flow rate. 11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 doses: Please give on <Date>9-21</Date>. 12. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: <Hospital>Anderson-Price Medical Center</Hospital> - <Location>224 Rachel Rapid Suite 154 South Sheenaton, MT 17779</Location> Discharge Diagnosis: Primary Diagnosis: Acute Exacerbation of Chronic Obtructive Pulmonary Disease, Community Acquired Pneumonia, Tobacco Abuse Secondary Diagnosis: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for managment of respiratory distress likely caused by pneumonia and a COPD exacerbation. You were intubated for three days to assist with your breathing. You were treated with antibiotics for a pneumonia, and bronchodilator and steroid therapy for management of your COPD. You continued to improve. While you were here, we restarted many of the medications that were prescribed to you in the past. It is very important that you continue these medications and follow-up with your primary care physician, <Name>Omer Ignacio</Name> and pulmonologist as your underyling pulmonary and cardiac issues have not been evaluated in some time. It is likely that some of these medications will need to be changed or adjusted. You are being discharged to a pulmonary rehabilitation center prior to going home given the severity of your symptoms. They will prepare you for discharge to home. We strongly encourage you to quit smoking as this is one of the few things that will increase your life expectancy related to your lung disease. The following changes were made to your medication list: 1. START lisinopril 10mg daily 2. START lasix 20mg daily 3. START albuterol Nebulyzer therapy 4. START ipratropium Nebulyzer therapy 5. START Nicotine Patch 6. START Monteleukast 7. COMPLETE Prednisone taper as prescribed 8. CONTINUE aspirin and protonix as you have been taking 9. CONTINUE supplemental oxygen 10. CONTINUE BIPAP at night and while napping Please talk to your PCP if you are having any problems with obtaining these medications. These medications may change upon discharge from Pulmonary Rehab. Followup Instructions: PULMONOLOGY The office of Dr. <Name>Liz</Name> <Name>Lofft</Name> will call you to set up an appointment on discharge. If you have not heard from his office when you leave Pulmonary Rehab: Please call (<Telephone>251-715-2026</Telephone> to schedule an appointment. CARDIOLOGY Department: CARDIAC SERVICES When: FRIDAY <Date>1954-7-25</Date> at 11:20 AM With: <Name>Ivory</Name> <Name>Ahmed</Name>, MD <Telephone>119-804-4538</Telephone> Building: <Hospital>Fisher-Alexander Medical Center</Hospital> <Location>8933 Christina Cliff Apt. 304 Garzastad, OH 23216</Location> Campus: EAST Best Parking: <Hospital>Dawson Ltd Clinic</Hospital> 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Date: 1955-1-22 Discharge Date: 1930-3-28 Date of Birth: 1954-7-31 Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Chloe Chief Complaint: Respiratory distress. Major Surgical or Invasive Procedure: 1. Inubation 2. Placement of central venous access via the right internal jugular History of Present Illness: Mr. Pleasant is a 59yo M with history of severe COPD and pulmonary hypertension who was brought in by ambulance for respiratory distress. Per report, when EMS arrived all of his inhalers were empty. . In the ED, initial vs were: T 98.8 P 121 BP 100/67 R 17 O2 sat 100%. He was immediately intubated for respiratory distress as he wasn't able to speak few words. He was on propofol for sedation. His pressures were in the 90s and dipped to the 80s so R IJ was placed and levophed was started. CXR showed fluffy bilateral infiltrates and ABG was significant for hypcarbia to 106. He received 125mg IV solumedrol, albuterol, magnesium, levaquin, ceftriaxone and was started on versed/fent drips. . In the ICU, patient is intubated and sedated. Past Medical History: # COPD - was seen frequently at Lewis and Sons Hospital. Has smoked 3 packs /day x 45 years, quit on last admission to Porter PLC Medical Center. No PFTs in our system. # Congential Bicuspid Aortic Valve; s/p porcicine repair 1968. Echo in 1968 on recent admission within normal limits # Hypertension # Lower Extremity Edema # Hypertension Social History: Smoked 3pks ppd x 45 years. Former head of maintence at Jackson-Farley Clinic and women's hospital, also a car mechanic. No exposure to asbestos. Now on disability due to dyspnea. Lives wtih girlfriend. Minimal etoh now though former heavy alcohol user Family History: Parents with heart disease - MIs. Sister with arrhythmia that went away. No fhx of cancers. Physical Exam: Upon admission: T: 99.5 BP: 91/55 P: 94 100% on AC 550x18, 50% Fi02, PEEP 5 General: Sedated, intubated, not following commands HEENT: Pinpoint pupils bilaterally slightly responsive to light, sclera anicteric, MMM, oropharynx clear, tongue with abnormal fasciculations Neck: supple, JVP unable to be assessed, no LAD Lungs: Bilateral coarse wheezing CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley Ext: warm, well perfused, 1+ DP pulses bilaterally, bilateral lower extremities with chronic venous stasis changes, no clubbing, cyanosis or edema . At discharge: VS: 97.3 129/78 (149/86) 94 (88) 20 92-97 on 3L NC I/O not well recorded yesterday General: NAD, sitting up in bed, pleasant, funny and interactive HEENT: MMM tongue with no abnormal fasciculations Lungs: Bilateral coarse sounds, very tight, scattered wheezes throughout lung fields. CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 1+ DP pulses bilaterally, bilateral lower extremities with chronic venous stasis changes, no clubbing, cyanosis or edema Pertinent Results: ADMISSION 1955-1-22 06:25AM FIBRINOGE-651* 1955-1-22 06:25AM PLT COUNT-146* 1955-1-22 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93 MCH-30.7 MCHC-33.0 RDW-12.6 1955-1-22 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93 MCH-30.7 MCHC-33.0 RDW-12.6 1955-1-22 06:25AM LIPASE-11 1955-1-22 10:58AM LACTATE-0.9 1955-1-22 11:51AM PT-12.6 PTT-27.6 INR(PT)-1.1 1955-1-22 11:51AM GLUCOSE-165* UREA N-20 CREAT-0.5 SODIUM-140 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-40* ANION GAP-8 . DISCHARGE 1930-3-28 06:25AM BLOOD WBC-7.4 RBC-4.65 Hgb-13.7* Hct-42.5 MCV-92 MCH-29.6 MCHC-32.3 RDW-13.1 Plt Ct-185 2005-5-23 02:46AM BLOOD Neuts-80.0* Lymphs-14.2* Monos-5.5 Eos-0.2 Baso-0.1 1930-3-28 06:25AM BLOOD Glucose-121* UreaN-15 Creat-0.5 Na-143 K-3.5 Cl-97 HCO3-37* AnGap-13 1930-3-28 06:25AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0 2005-5-23 02:56AM BLOOD Type-Miller Temp-36.7 Rates-16/ Tidal V-550 PEEP-5 FiO2-40 pO2-46* pCO2-64* pH-7.39 calTCO2-40* Base XS-10 -ASSIST/CON Intubat-INTUBATED . IMAGING STUDIES CHEST XRAY ADMISSION 9-18 PORTABLE AP CHEST RADIOGRAPH: Sternotomy wires are midline and intact. Surgical clips are noted in the midline. The ET tube is above the thoracic inlet, approximately 7.5 cm above the expected location of the carina. Nasogastric tube is traced best up to the level of the mid esophagus, uncleLatoya Benhamou traced thereafter. A tube-like structure within the expected region of the stomach may represent the continuation of the nasogastric tube, however uncertain. Bilateral low lung volumes are noted with appearance suggestive of pulmonary fibrosis. . CHEST XRAY 11-29 Frontal view of the chest is compared to multiple prior examinations. Right IJ catheter terminates in superior vena cava. Remainder of lines and tubes are unchanged. There is moderate congestive failure, small bilateral pleural effusions and atelectasis at the right lung base. Heart and mediastinum are stable. . CT SCAN 9-18 FINAL REPORT IMPRESSION: 1. Diffuse ground glass and nodular opacities with an appearance most consistent with mycoplasma pneumonia. Extensive mediastinal and hilar lymphadenopathy, likely reactive. Trace bilateral pleural effusions. 2. Endotracheal tube ends approximately 1 cm above the carina. . CT SCAN WITH AND WIHTOUT CONTRAST 9-18 1. No acute intracranial process. 2. Intubation, with retained sinonasal secretions. Brief Hospital Course: HOSPITAL COURSE Mr. Pleasant is a 59yo M with history of severe COPD and pulmonary hypertension who presented with hypercarbic respiratory distress requiring intubation. He did well after extubation and was discharged to pulmonary rehabilitation for further care. . ACTIVE ISSUES # Hypercarbic respiratory failure: His respiratory distress was likely related to extreme hypercarbia due to his underlying COPD. His COPD flare was likely due to medication noncompliance in setting of running out of inhalers. Chest CT showed diffuse bronchopulmonary pneumonia concerning for a mycoplasma/atypical process. He was started levofloxacin and will complete a 7 day course on the night of discharge. He was started on solumedrol and then switched to prednisone. Extubated 11-29 without complication. He was continued on 60mg prednisone on transfer to the floor. A slow prednisone taper was initiated on discharge to pulmonary rehab where additional titration of nebulizer therapy will be continued and initation of home inhaler regimen of advair and spiriva will be started. His Bipap was continued but at lower settings of 18/16, and his supplemental oxygen was 3L at discharge. He was encouraged to stop smoking. He will have pulmonary follow up after discharge from pulmonary rehab. . # Hypotension: He is likely hypertensive at baseline given lisinopril on med list but recent baseline is unknown. Hypotension in MICU was possibly related to sedation surrounding intubation or from decrease in right heart filling pressure with positive pressure ventilation. Normal lactate and lack of leukocytosis are reassuring. He was started on levophed in the ED and this was weaned off as fluid boluses given. # Tongue movement: His abnormal tongue movement in MICU was concerning for possible fasciculation or seizure activity. He does not have a history of seizures and recent events leading to hospitalization. These events did not continue and no further work up pursued. . # Hypertension with Diastolic Dysfunction: Previously on lisinopril and lasix - has not refilled Rx in two years. He was restarted on lisinopril and aspirin with a lower dose of lasix. His blood pressure was well controlled and renal function stable. His peripheral edema slowly improved. It is likely that his lasix will need to be uptitrated in the outpatient setting. . TRANSITIONAL ISSUES # Disposition: Pulmonary Rehabilitation with close Pulmonary and Cardiology follow-up Mr. Pleasant has not had medical follow-up in over 2 years and medication compliance a significant issue in future management. # Code: Full Medications on Admission: Medications: Per list from 1968, unknown if patient taking these now: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 vial via nebulizer Every 6-8 hours as needed for shortness of breath/wheezing ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) by mouth every four (4) to six (6) hours as needed for cough/wheezing FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff(s) inhaled Twice daily Rinse mouth after use FUROSEMIDE - 80 mg Tablet - 1 Tablet(s) by mouth daily LIDOCAINE - (Prescribed by Other Provider) - 5 % (700 mg/patch) Adhesive Patch, Medicated - LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth daily NAPROXEN - 500 mg Tablet - 1 Tablet(s) by mouth Twiec a day (Herrera LLC Hospital) For 2 week course OXYGEN - (Prescribed by Other Provider) - - 2L at rest via NC; 3L with activity PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 capsule inhaled Once daily ACETAMINOPHEN [TYLENOL ARTHRITIS] - (OTC) - 650 mg Tablet Extended Release - Tablet(s) by mouth ASPIRIN [ASPIR-81] - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 7. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours. 8. prednisone 10 mg Tablet Sig: 6 pills x 3 days, 5 pills x 3 days, 4 pills x 3 days, 3 pills x 3 days, 2 pills x 3 days, 1 pill x three days then STOP Tablets PO once a day: Prednisone taper. 9. Bipap BiPap 18/16 when sleeping or napping. 10. Oxygen therapy Oxygen 3L. Titrate to keep sats >90%, unknown home flow rate. 11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 doses: Please give on 9-21. 12. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Anderson-Price Medical Center - 224 Rachel Rapid Suite 154 South Sheenaton, MT 17779 Discharge Diagnosis: Primary Diagnosis: Acute Exacerbation of Chronic Obtructive Pulmonary Disease, Community Acquired Pneumonia, Tobacco Abuse Secondary Diagnosis: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for managment of respiratory distress likely caused by pneumonia and a COPD exacerbation. You were intubated for three days to assist with your breathing. You were treated with antibiotics for a pneumonia, and bronchodilator and steroid therapy for management of your COPD. You continued to improve. While you were here, we restarted many of the medications that were prescribed to you in the past. It is very important that you continue these medications and follow-up with your primary care physician, Omer Ignacio and pulmonologist as your underyling pulmonary and cardiac issues have not been evaluated in some time. It is likely that some of these medications will need to be changed or adjusted. You are being discharged to a pulmonary rehabilitation center prior to going home given the severity of your symptoms. They will prepare you for discharge to home. We strongly encourage you to quit smoking as this is one of the few things that will increase your life expectancy related to your lung disease. The following changes were made to your medication list: 1. START lisinopril 10mg daily 2. START lasix 20mg daily 3. START albuterol Nebulyzer therapy 4. START ipratropium Nebulyzer therapy 5. START Nicotine Patch 6. START Monteleukast 7. COMPLETE Prednisone taper as prescribed 8. CONTINUE aspirin and protonix as you have been taking 9. CONTINUE supplemental oxygen 10. CONTINUE BIPAP at night and while napping Please talk to your PCP if you are having any problems with obtaining these medications. These medications may change upon discharge from Pulmonary Rehab. Followup Instructions: PULMONOLOGY The office of Dr. Liz Lofft will call you to set up an appointment on discharge. If you have not heard from his office when you leave Pulmonary Rehab: Please call (251-715-2026 to schedule an appointment. CARDIOLOGY Department: CARDIAC SERVICES When: FRIDAY 1954-7-25 at 11:20 AM With: Ivory Ahmed, MD 119-804-4538 Building: Fisher-Alexander Medical Center 8933 Christina Cliff Apt. 304 Garzastad, OH 23216 Campus: EAST Best Parking: Dawson Ltd Clinic Garage	["Admission Date: 1955-1-22 Discharge Date: 1930-3-28\n\nDate of Birth: 1954-7-31 Sex: M\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Chloe\nChief Complaint:\nRespiratory distress.\n\nMajor Surgical or Invasive Procedure:\n1. Inubation\n2. Placement of central venous access via the right internal\njugular\n\n\nHistory of Present Illness:\nMr. Pleasant is a 59yo M with history of severe COPD and pulmonary\nhypertension who was brought in by ambulance for respiratory\ndistress. Per report, when EMS arrived all of his inhalers were\nempty.\n.\nIn the ED, initial vs were: T 98.8 P 121 BP 100/67 R 17 O2 sat\n100%. He was immediately intubated for respiratory distress as\nhe wasn't able to speak few words. He was on propofol for\nsedation. His pressures were in the 90s and dipped to the 80s\nso R IJ was placed and levophed was started.", " CXR showed fluffy\nbilateral infiltrates and ABG was significant for hypcarbia to\n106. He received 125mg IV solumedrol, albuterol, magnesium,\nlevaquin, ceftriaxone and was started on versed/fent drips.\n.\nIn the ICU, patient is intubated and sedated.\n\nPast Medical History:\n# COPD - was seen frequently at Lewis and Sons Hospital. Has\nsmoked 3 packs /day x 45 years, quit on last admission to Porter PLC Medical Center.\n\nNo PFTs in our system.\n# Congential Bicuspid Aortic Valve; s/p porcicine repair 1968.\nEcho in 1968 on recent admission within normal limits\n# Hypertension\n# Lower Extremity Edema\n# Hypertension\n\nSocial History:\nSmoked 3pks ppd x 45 years. Former head of maintence at Jackson-Farley Clinic\n\nand women's hospital, also a car mechanic. No exposure to\nasbestos. Now on disability due to dyspnea.", ' Lives wtih\ngirlfriend. Minimal etoh now though former heavy alcohol user\n\n\nFamily History:\nParents with heart disease - MIs. Sister with arrhythmia that\nwent away.\nNo fhx of cancers.\n\nPhysical Exam:\nUpon admission:\nT: 99.5 BP: 91/55 P: 94 100% on AC 550x18, 50% Fi02, PEEP 5\nGeneral: Sedated, intubated, not following commands\nHEENT: Pinpoint pupils bilaterally slightly responsive to light,\nsclera anicteric, MMM, oropharynx clear, tongue with abnormal\nfasciculations\nNeck: supple, JVP unable to be assessed, no LAD\nLungs: Bilateral coarse wheezing\nCV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,\nrubs, gallops\nAbdomen: obese, soft, non-tender, non-distended, bowel sounds\npresent, no rebound tenderness or guarding, no organomegaly\nGU: Foley\nExt: warm, well perfused, 1+ DP pulses bilaterally, bilateral\nlower extremities with chronic venous stasis changes, no\nclubbing, cyanosis or edema\n.', '\nAt discharge:\nVS: 97.3 129/78 (149/86) 94 (88) 20 92-97 on 3L NC\nI/O not well recorded yesterday\nGeneral: NAD, sitting up in bed, pleasant, funny and interactive\n\nHEENT: MMM tongue with no abnormal fasciculations\nLungs: Bilateral coarse sounds, very tight, scattered wheezes\nthroughout lung fields.\nCV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,\nrubs, gallops\nAbdomen: obese, soft, non-tender, non-distended, bowel sounds\npresent, no rebound tenderness or guarding, no organomegaly\nExt: warm, well perfused, 1+ DP pulses bilaterally, bilateral\nlower extremities with chronic venous stasis changes, no\nclubbing, cyanosis or edema\n\nPertinent Results:\nADMISSION\n1955-1-22 06:25AM FIBRINOGE-651\n1955-1-22 06:25AM PLT COUNT-146\n1955-1-22 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93\nMCH-30.', '7 MCHC-33.0 RDW-12.6\n1955-1-22 06:25AM WBC-10.0 RBC-5.08 HGB-15.6 HCT-47.2 MCV-93\nMCH-30.7 MCHC-33.0 RDW-12.6\n1955-1-22 06:25AM LIPASE-11\n1955-1-22 10:58AM LACTATE-0.9\n1955-1-22 11:51AM PT-12.6 PTT-27.6 INR(PT)-1.1\n1955-1-22 11:51AM GLUCOSE-165* UREA N-20 CREAT-0.5 SODIUM-140\nPOTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-40* ANION GAP-8\n.\nDISCHARGE\n1930-3-28 06:25AM BLOOD WBC-7.4 RBC-4.65 Hgb-13.7* Hct-42.5\nMCV-92 MCH-29.6 MCHC-32.3 RDW-13.1 Plt Ct-185\n2005-5-23 02:46AM BLOOD Neuts-80.0* Lymphs-14.2* Monos-5.5\nEos-0.2 Baso-0.1\n1930-3-28 06:25AM BLOOD Glucose-121* UreaN-15 Creat-0.5 Na-143\nK-3.5 Cl-97 HCO3-37* AnGap-13\n1930-3-28 06:25AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0\n2005-5-23 02:56AM BLOOD Type-Miller Temp-36.7 Rates-16/ Tidal V-550\nPEEP-5 FiO2-40 pO2-46* pCO2-64* pH-7.39 calTCO2-40* Base XS-10\n-ASSIST/CON Intubat-INTUBATED\n.', '\nIMAGING STUDIES\nCHEST XRAY ADMISSION 9-18\nPORTABLE AP CHEST RADIOGRAPH: Sternotomy wires are midline and\nintact.\nSurgical clips are noted in the midline. The ET tube is above\nthe thoracic\ninlet, approximately 7.5 cm above the expected location of the\ncarina.\nNasogastric tube is traced best up to the level of the mid\nesophagus,\nuncleLatoya Benhamou traced thereafter. A tube-like structure within the\nexpected region of the stomach may represent the continuation of\nthe nasogastric tube, however uncertain. Bilateral low lung\nvolumes are noted with appearance suggestive of pulmonary\nfibrosis.\n.\nCHEST XRAY 11-29\nFrontal view of the chest is compared to multiple prior\nexaminations. Right IJ catheter terminates in superior vena\ncava. Remainder of lines and tubes are unchanged. There is\nmoderate congestive failure, small bilateral pleural effusions\nand atelectasis at the right lung base.', ' Heart and mediastinum\nare stable.\n.\nCT SCAN 9-18 FINAL REPORT\nIMPRESSION:\n1. Diffuse ground glass and nodular opacities with an appearance\nmost consistent with mycoplasma pneumonia. Extensive mediastinal\nand hilar lymphadenopathy, likely reactive. Trace bilateral\npleural effusions.\n2. Endotracheal tube ends approximately 1 cm above the carina.\n.\nCT SCAN WITH AND WIHTOUT CONTRAST 9-18\n1. No acute intracranial process.\n2. Intubation, with retained sinonasal secretions.\n\nBrief Hospital Course:\nHOSPITAL COURSE\nMr. Pleasant is a 59yo M with history of severe COPD and pulmonary\nhypertension who presented with hypercarbic respiratory distress\nrequiring intubation. He did well after extubation and was\ndischarged to pulmonary rehabilitation for further care.\n.\nACTIVE ISSUES\n# Hypercarbic respiratory failure: His respiratory distress was\nlikely related to extreme hypercarbia due to his underlying\nCOPD.', ' His COPD flare was likely due to medication noncompliance\nin setting of running out of inhalers. Chest CT showed diffuse\nbronchopulmonary pneumonia concerning for a mycoplasma/atypical\nprocess. He was started levofloxacin and will complete a 7 day\ncourse on the night of discharge. He was started on solumedrol\nand then switched to prednisone. Extubated 11-29 without\ncomplication. He was continued on 60mg prednisone on transfer to\nthe floor. A slow prednisone taper was initiated on discharge\nto pulmonary rehab where additional titration of nebulizer\ntherapy will be continued and initation of home inhaler regimen\nof advair and spiriva will be started. His Bipap was continued\nbut at lower settings of 18/16, and his supplemental oxygen was\n3L at discharge. He was encouraged to stop smoking.', ' He will\nhave pulmonary follow up after discharge from pulmonary rehab.\n.\n# Hypotension: He is likely hypertensive at baseline given\nlisinopril on med list but recent baseline is unknown.\nHypotension in MICU was possibly related to sedation surrounding\nintubation or from decrease in right heart filling pressure with\npositive pressure ventilation. Normal lactate and lack of\nleukocytosis are reassuring. He was started on levophed in the\nED and this was weaned off as fluid boluses given.\n\n# Tongue movement: His abnormal tongue movement in MICU was\nconcerning for possible fasciculation or seizure activity. He\ndoes not have a history of seizures and recent events leading to\nhospitalization. These events did not continue and no further\nwork up pursued.\n.\n# Hypertension with Diastolic Dysfunction: Previously on\nlisinopril and lasix - has not refilled Rx in two years.', ' He was\nrestarted on lisinopril and aspirin with a lower dose of lasix.\nHis blood pressure was well controlled and renal function\nstable. His peripheral edema slowly improved. It is likely\nthat his lasix will need to be uptitrated in the outpatient\nsetting.\n.\nTRANSITIONAL ISSUES\n# Disposition: Pulmonary Rehabilitation with close Pulmonary and\nCardiology follow-up\nMr. Pleasant has not had medical follow-up in over 2 years and\nmedication compliance a significant issue in future management.\n# Code: Full\n\nMedications on Admission:\nMedications: Per list from 1968, unknown if patient taking these\nnow:\nALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for\nNebulization - 1 vial via nebulizer Every 6-8 hours as needed\nfor shortness of breath/wheezing\nALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -\n1-2 puffs(s) by mouth every four (4) to six (6) hours as needed\nfor cough/wheezing\nFLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose\nDisk with Device - 1 puff(s) inhaled Twice daily Rinse mouth\nafter use\nFUROSEMIDE - 80 mg Tablet - 1 Tablet(s) by mouth daily\nLIDOCAINE - (Prescribed by Other Provider) - 5 % (700 mg/patch)\nAdhesive Patch, Medicated -\nLISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily\nMONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth\ndaily\nNAPROXEN - 500 mg Tablet - 1 Tablet(s) by mouth Twiec a day\n(Herrera LLC Hospital) For 2 week course\nOXYGEN - (Prescribed by Other Provider) - - 2L at rest via\nNC; 3L with activity\nPANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.', 'C.) -\n1 Tablet(s) by mouth twice a day\nTIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,\nw/Inhalation Device - 1 capsule inhaled Once daily\nACETAMINOPHEN [TYLENOL ARTHRITIS] - (OTC) - 650 mg Tablet\nExtended Release - Tablet(s) by mouth\nASPIRIN [ASPIR-81] - 81 mg Tablet, Delayed Release (E.C.) - 1\nTablet(s) by mouth daily\n\n\nDischarge Medications:\n1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) neb Inhalation every six (6) hours as\nneeded for shortness of breath or wheezing.\n2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.\n3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr\nTransdermal DAILY (Daily).\n4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.', 'C.) PO once a day.\n6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO once a day.\n7. ipratropium bromide 0.02 % Solution Sig: One (1) neb\nInhalation every six (6) hours.\n8. prednisone 10 mg Tablet Sig: 6 pills x 3 days, 5 pills x 3\ndays, 4 pills x 3 days, 3 pills x 3 days, 2 pills x 3 days, 1\npill x three days then STOP Tablets PO once a day: Prednisone\ntaper.\n9. Bipap\nBiPap 18/16 when sleeping or napping.\n10. Oxygen therapy\nOxygen 3L. Titrate to keep sats >90%, unknown home flow rate.\n11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO at bedtime\nfor 1 doses: Please give on 9-21.\n12. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.\n\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nAnderson-Price Medical Center - 224 Rachel Rapid Suite 154\nSouth Sheenaton, MT 17779\n\nDischarge Diagnosis:\nPrimary Diagnosis: Acute Exacerbation of Chronic Obtructive\nPulmonary Disease, Community Acquired Pneumonia, Tobacco Abuse\nSecondary Diagnosis: Hypertension\n\n\nDischarge Condition:\nMental Status: Clear and coherent.', '\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker\nor cane).\n\n\nDischarge Instructions:\nYou were admitted for managment of respiratory distress likely\ncaused by pneumonia and a COPD exacerbation. You were intubated\nfor three days to assist with your breathing. You were treated\nwith antibiotics for a pneumonia, and bronchodilator and steroid\ntherapy for management of your COPD. You continued to improve.\n\nWhile you were here, we restarted many of the medications that\nwere prescribed to you in the past. It is very important that\nyou continue these medications and follow-up with your primary\ncare physician, Omer Ignacio and pulmonologist as your\nunderyling pulmonary and cardiac issues have not been evaluated\nin some time. It is likely that some of these medications will\nneed to be changed or adjusted.', '\n\nYou are being discharged to a pulmonary rehabilitation center\nprior to going home given the severity of your symptoms. They\nwill prepare you for discharge to home.\n\nWe strongly encourage you to quit smoking as this is one of the\nfew things that will increase your life expectancy related to\nyour lung disease.\n\nThe following changes were made to your medication list:\n1. START lisinopril 10mg daily\n2. START lasix 20mg daily\n3. START albuterol Nebulyzer therapy\n4. START ipratropium Nebulyzer therapy\n5. START Nicotine Patch\n6. START Monteleukast\n7. COMPLETE Prednisone taper as prescribed\n8. CONTINUE aspirin and protonix as you have been taking\n9. CONTINUE supplemental oxygen\n10. CONTINUE BIPAP at night and while napping\n\nPlease talk to your PCP if you are having any problems with\nobtaining these medications.', '\n\nThese medications may change upon discharge from Pulmonary\nRehab.\n\nFollowup Instructions:\nPULMONOLOGY\nThe office of Dr. Liz Lofft will call you to set up an\nappointment on discharge. If you have not heard from his office\nwhen you leave Pulmonary Rehab: Please call (251-715-2026 to\nschedule an appointment.\n\nCARDIOLOGY\nDepartment: CARDIAC SERVICES\nWhen: FRIDAY 1954-7-25 at 11:20 AM\nWith: Ivory Ahmed, MD 119-804-4538\nBuilding: Fisher-Alexander Medical Center 8933 Christina Cliff Apt. 304\nGarzastad, OH 23216\nCampus: EAST Best Parking: Dawson Ltd Clinic Garage\n\n\n\n']
551	23637	166493.0	2194-08-03	Discharge summary	Report	Admission Date: [2194-7-24] Discharge Date: [2194-8-3] Service: [Hospital1 139] - Medicine and MICU HISTORY OF PRESENT ILLNESS: This 84-year-old female with a history of diverticula, CREST and irritable bowel syndrome presented to the Emergency Room with a chief complaint of epigastric pain, lightheadedness, nausea without emesis and dark stools. She denied chest pain, shortness of breath, cough, fevers, chills and night sweats. In the Emergency Room she was found to have a blood pressure of 130/palp with a heart rate of 72. One hour later this was 119/39 with a pulse of 100. She had heme positive stool and hematocrit was found to be 16.6. The patient therefore had an emergent EGD in the GI unit. No nasogastric lavage was performed. PAST MEDICAL HISTORY: The patient has Sjogren's with sicca syndrome and presumed CREST with a history of dysphagia and dyspepsia. The patient's primary gastroenterologist is Dr. [Last Name (STitle) 1940]. Patient has a history of hypertension, hypothyroidism, irritable bowel syndrome with chronic diarrhea, Raynaud's, history of TAH, cholecystectomy and pericholecystectomy hernia repair, COPD and bronchiectasis, right bronchial sclerosis and Sjogren's, history of bladder stretchings, negative MRCP [6-18] except for some liver cysts, diverticula on colonoscopy [7-/2193] with possibility of Crohn's noted. SOCIAL HISTORY: The patient smoked some tobacco in the past but it was a small amount. She drinks no alcohol. FAMILY HISTORY: Crohn's disease. ALLERGIES: Penicillin, Bactrim and Sulfa. MEDICATIONS: Norvasc 10 mg q d, Atenolol 50 mg q d, Levoxyl 1.25 mg q d, Dyazide 37.5/25 q d, Serax prn, occasional NSAIDs, Premarin .625 mg q d and Aspirin. PHYSICAL EXAMINATION: Temperature 97, blood pressure 95/69, respiratory rate 14, satting 100% on two liters. The patient was alert and oriented times three, she was fully conversant and awake, interactive and appropriate. She was in no acute distress. Conjunctiva were pale. She had dry mucus membranes. She was normocephalic, atraumatic, extraocular movements intact, pupils were equal, round and reactive to light. There was no JVD. Neck was supple. TMs were normal. There was no lymphadenopathy of the neck, faint bibasilar crackles were heard on lung exam. The patient was tachycardic with a normal S1 and S2 with 2/6 systolic ejection murmur radiating to the axilla. Abdomen was soft and non distended with normal bowel sounds, was mildly tender to deep palpation. Extremities without clubbing, cyanosis or edema. Fingers were cool as were the toes but she had 1+ pulses times four. Cranial nerves II through XII were intact. Motor was 5/5 strength globally, symmetric. Deep tendon reflexes were 2+ globally and were symmetric. LABORATORY DATA: White count 12.8, hematocrit 16.6, platelet count 282,000, MCV 89. Chem 7, sodium 140, potassium 4.8, chloride 105, CO2 21, BUN 53 with a baseline of 10, creatinine .9, glucose 98, anion gap 14, ESR 60, ALT 52, AST 84, alkaline phosphatase 313, thyroid peroxidase antibody and endomesial antibodies were positive. Note was made of prior alkaline phosphatase elevations as well as a GGT of 469 and a lipase of 199. TSH was 6.4. [Doctor First Name ] was positive at greater than 1:1280. Gastrin was normal in 9-00 at 92. EKG showed normal sinus rhythm at 100, left axis deviation, intervals were 184/74/422. There was a small T wave inversion in 1 and AVL, question of left anterior fascicular block, small ST deviation similar to prior on [2193-7-21]. CT done [7-/2193] for abdominal pain showed emphysema, no acute cardiopulmonary disease, hypoattenuation of liver and fibrotic lung changes. HOSPITAL COURSE: 1. GI and Cardiovascular: On [7-24] the patient presented with malaise, epigastric pain, nausea for three days, lightheadedness, black stools and was found to have a hematocrit of 15.6 from a baseline of 43 and BUN of 53. The patient was admitted to the MICU. Two peripheral IVs were placed, fluids and blood was applied, Protonix was begun IV. Emergent EGD was performed that showed a stomach full of blood, a probable AVM which was treated with electrocautery. The patient ruled out for MI because she had inferolateral EKG changes with ST depression which later resolved after a blood transfusion. She had relative hypotension given her history of hypertension. On the 7th she was evaluated by surgery and told that operation for her bleed would be high risk and high morbidity and would involve partial gastrectomy so she declined the operation. A groin line was placed. On the 8th a repeat EGD was similar to the first with large amounts of blood and the patient was taken to interventional radiology where she had her left gastric artery embolized. No further IR options were available after this procedure. In total the patient received 11 units of blood, ending on the 8th and hematocrits through the 10th were approximately 40 and stable. Vascular access was initiated during the stay and on transfer to the floor [7-28], the patient had only one PID. Groin line was removed on the 8th because of fever and stool contamination and on the 9th the triple lumen was removed because the patient felt she had no definitive options if she did have a massive bleed. The patient was made DNR, DNI at her request and plans were to make her comfort care if she had a large recurrent bleed, although she later indicated that short-term central line would be acceptable. On transfer to the floor her issues were mild sinus tachycardia thought to be due to beta blocker withdrawal since it persisted through blood and volume repletion. A repeat EGD was performed [7-29] since the patient's lesion was never well visualized with all the blood in her stomach. This showed only gastritis with friability and the same findings in the duodenum. Beta blocker was increased to treat her hypertension and tachycardia but with caution since she was at risk for rebleed. Diarrhea was noted and C. diff and fecal leukocytes were checked and were negative. This was then attributed to melena and it trailed off when she had stable hematocrit. On the 12th the patient was noted to have a decreased hematocrit which declined from 42 to 32.8 with an apparent rebleed with increased melena post EGD. It remained stable thereafter through the 15th at 33.5. Simethicone was given for gassy distension and ambulation was encouraged to decrease this as well. 2. Fluids, Electrolytes & Nutrition: Lytes especially potassium and phosphorus were repleted. 3. Endocrine: Synthroid was continued for hypothyroidism and it increased to 150 since her TSH was high. This needs to be followed up with a repeat TSH. 4. Pulmonary: With her persistent tachycardia on BVL replacement, concern for PE rose and a chest x-ray which showed a right upper lobe process thought to be early pneumonia was performed. CT angio was then done on the 12th which showed no PE but a large right upper lobe consolidation and left upper lobe and left lower lobe consolidations adjacent to an effusion as well. She was therefore treated for multifocal PNA thought to be related to possible aspiration at the time of her EGD with Levofloxacin and Flagyl with resultant decrease in white blood count. Nebs were provided for wheezing, most likely related to COPD. 5. The patient was seen for question of aspiration and it was felt her meds should be crushed and administered in apple sauce and that soft moist solids and liquids would serve her best but she was not a major aspiration risk. 6. ID: As per pulmonary, patient also had a positive urinalysis and a culture showing 1,000 to 100,000 proteus and pseudomonas but since transferring to the floor, the patient complained of no urinary discomfort so this was not treated. Repeat urinalysis [7-31] showed no UTI. The patient was followed by physical therapy and assisted with ambulation. 7. Patient's CREST and Sjogren's were treated with solutions to mouth and eyes as per her routine. Calcium channel blocker for question esophageal spasm was held given the risk of re-bleed and hypotension. 8. Renal: Patient's creatinine clearance was estimated at slightly more than 50 cc per minute and was stable throughout. DISCHARGE MEDICATIONS: Protonix 40 mg [Hospital1 ], Simethicone 80-125 mg qid prn, Serax 10 mg po prn, Trazodone 25 mg po prn insomnia, Metoprolol 50 mg po tid, Synthroid 150 mcg q d, Colace 100 mg po bid, Milk of Magnesia prn. Patient's own mouth rinses and eyedrops were sicca syndrome. Levofloxacin 500 mg po q d through [2194-8-10], Flagyl 500 mg po tid through [2194-8-10]. DISCHARGE CONDITION: Stable. FOLLOW-UP: To arrange with Dr. [Last Name (STitle) 1940] of gastroenterology and the patient's primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 4427]. DISCHARGE DIAGNOSIS: As per HPI plus: 1. GI bleed secondary to gastritis and AVM (arteriovenous malformation). DR.[Last Name (STitle) ],[First Name3 (LF) 4514] J. 12-424 Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2194-8-4] 08:20 T: [2194-8-7] 20:35 JOB#: [Job Number 4515]	Admission Date: <Date>1952-2-18</Date> Discharge Date: <Date>2021-6-22</Date> Service: <Hospital>Cook Ltd Medical Center</Hospital> - Medicine and MICU HISTORY OF PRESENT ILLNESS: This 84-year-old female with a history of diverticula, CREST and irritable bowel syndrome presented to the Emergency Room with a chief complaint of epigastric pain, lightheadedness, nausea without emesis and dark stools. She denied chest pain, shortness of breath, cough, fevers, chills and night sweats. In the Emergency Room she was found to have a blood pressure of 130/palp with a heart rate of 72. One hour later this was 119/39 with a pulse of 100. She had heme positive stool and hematocrit was found to be 16.6. The patient therefore had an emergent EGD in the GI unit. No nasogastric lavage was performed. PAST MEDICAL HISTORY: The patient has Sjogren's with sicca syndrome and presumed CREST with a history of dysphagia and dyspepsia. The patient's primary gastroenterologist is Dr. <Name>Broadnax</Name>. Patient has a history of hypertension, hypothyroidism, irritable bowel syndrome with chronic diarrhea, Raynaud's, history of TAH, cholecystectomy and pericholecystectomy hernia repair, COPD and bronchiectasis, right bronchial sclerosis and Sjogren's, history of bladder stretchings, negative MRCP <Date>12-15</Date> except for some liver cysts, diverticula on colonoscopy <Date>9-1910</Date> with possibility of Crohn's noted. SOCIAL HISTORY: The patient smoked some tobacco in the past but it was a small amount. She drinks no alcohol. FAMILY HISTORY: Crohn's disease. ALLERGIES: Penicillin, Bactrim and Sulfa. MEDICATIONS: Norvasc 10 mg q d, Atenolol 50 mg q d, Levoxyl 1.25 mg q d, Dyazide 37.5/25 q d, Serax prn, occasional NSAIDs, Premarin .625 mg q d and Aspirin. PHYSICAL EXAMINATION: Temperature 97, blood pressure 95/69, respiratory rate 14, satting 100% on two liters. The patient was alert and oriented times three, she was fully conversant and awake, interactive and appropriate. She was in no acute distress. Conjunctiva were pale. She had dry mucus membranes. She was normocephalic, atraumatic, extraocular movements intact, pupils were equal, round and reactive to light. There was no JVD. Neck was supple. TMs were normal. There was no lymphadenopathy of the neck, faint bibasilar crackles were heard on lung exam. The patient was tachycardic with a normal S1 and S2 with 2/6 systolic ejection murmur radiating to the axilla. Abdomen was soft and non distended with normal bowel sounds, was mildly tender to deep palpation. Extremities without clubbing, cyanosis or edema. Fingers were cool as were the toes but she had 1+ pulses times four. Cranial nerves II through XII were intact. Motor was 5/5 strength globally, symmetric. Deep tendon reflexes were 2+ globally and were symmetric. LABORATORY DATA: White count 12.8, hematocrit 16.6, platelet count 282,000, MCV 89. Chem 7, sodium 140, potassium 4.8, chloride 105, CO2 21, BUN 53 with a baseline of 10, creatinine .9, glucose 98, anion gap 14, ESR 60, ALT 52, AST 84, alkaline phosphatase 313, thyroid peroxidase antibody and endomesial antibodies were positive. Note was made of prior alkaline phosphatase elevations as well as a GGT of 469 and a lipase of 199. TSH was 6.4. <Name>Liz</Name> was positive at greater than 1:1280. Gastrin was normal in 9-00 at 92. EKG showed normal sinus rhythm at 100, left axis deviation, intervals were 184/74/422. There was a small T wave inversion in 1 and AVL, question of left anterior fascicular block, small ST deviation similar to prior on <Date>1910-9-27</Date>. CT done <Date>9-1910</Date> for abdominal pain showed emphysema, no acute cardiopulmonary disease, hypoattenuation of liver and fibrotic lung changes. HOSPITAL COURSE: 1. GI and Cardiovascular: On <Date>5-28</Date> the patient presented with malaise, epigastric pain, nausea for three days, lightheadedness, black stools and was found to have a hematocrit of 15.6 from a baseline of 43 and BUN of 53. The patient was admitted to the MICU. Two peripheral IVs were placed, fluids and blood was applied, Protonix was begun IV. Emergent EGD was performed that showed a stomach full of blood, a probable AVM which was treated with electrocautery. The patient ruled out for MI because she had inferolateral EKG changes with ST depression which later resolved after a blood transfusion. She had relative hypotension given her history of hypertension. On the 7th she was evaluated by surgery and told that operation for her bleed would be high risk and high morbidity and would involve partial gastrectomy so she declined the operation. A groin line was placed. On the 8th a repeat EGD was similar to the first with large amounts of blood and the patient was taken to interventional radiology where she had her left gastric artery embolized. No further IR options were available after this procedure. In total the patient received 11 units of blood, ending on the 8th and hematocrits through the 10th were approximately 40 and stable. Vascular access was initiated during the stay and on transfer to the floor <Date>9-30</Date>, the patient had only one PID. Groin line was removed on the 8th because of fever and stool contamination and on the 9th the triple lumen was removed because the patient felt she had no definitive options if she did have a massive bleed. The patient was made DNR, DNI at her request and plans were to make her comfort care if she had a large recurrent bleed, although she later indicated that short-term central line would be acceptable. On transfer to the floor her issues were mild sinus tachycardia thought to be due to beta blocker withdrawal since it persisted through blood and volume repletion. A repeat EGD was performed <Date>8-23</Date> since the patient's lesion was never well visualized with all the blood in her stomach. This showed only gastritis with friability and the same findings in the duodenum. Beta blocker was increased to treat her hypertension and tachycardia but with caution since she was at risk for rebleed. Diarrhea was noted and C. diff and fecal leukocytes were checked and were negative. This was then attributed to melena and it trailed off when she had stable hematocrit. On the 12th the patient was noted to have a decreased hematocrit which declined from 42 to 32.8 with an apparent rebleed with increased melena post EGD. It remained stable thereafter through the 15th at 33.5. Simethicone was given for gassy distension and ambulation was encouraged to decrease this as well. 2. Fluids, Electrolytes & Nutrition: Lytes especially potassium and phosphorus were repleted. 3. Endocrine: Synthroid was continued for hypothyroidism and it increased to 150 since her TSH was high. This needs to be followed up with a repeat TSH. 4. Pulmonary: With her persistent tachycardia on BVL replacement, concern for PE rose and a chest x-ray which showed a right upper lobe process thought to be early pneumonia was performed. CT angio was then done on the 12th which showed no PE but a large right upper lobe consolidation and left upper lobe and left lower lobe consolidations adjacent to an effusion as well. She was therefore treated for multifocal PNA thought to be related to possible aspiration at the time of her EGD with Levofloxacin and Flagyl with resultant decrease in white blood count. Nebs were provided for wheezing, most likely related to COPD. 5. The patient was seen for question of aspiration and it was felt her meds should be crushed and administered in apple sauce and that soft moist solids and liquids would serve her best but she was not a major aspiration risk. 6. ID: As per pulmonary, patient also had a positive urinalysis and a culture showing 1,000 to 100,000 proteus and pseudomonas but since transferring to the floor, the patient complained of no urinary discomfort so this was not treated. Repeat urinalysis <Date>7-11</Date> showed no UTI. The patient was followed by physical therapy and assisted with ambulation. 7. Patient's CREST and Sjogren's were treated with solutions to mouth and eyes as per her routine. Calcium channel blocker for question esophageal spasm was held given the risk of re-bleed and hypotension. 8. Renal: Patient's creatinine clearance was estimated at slightly more than 50 cc per minute and was stable throughout. DISCHARGE MEDICATIONS: Protonix 40 mg <Hospital>Allen, Torres and Thompson Health System</Hospital>, Simethicone 80-125 mg qid prn, Serax 10 mg po prn, Trazodone 25 mg po prn insomnia, Metoprolol 50 mg po tid, Synthroid 150 mcg q d, Colace 100 mg po bid, Milk of Magnesia prn. Patient's own mouth rinses and eyedrops were sicca syndrome. Levofloxacin 500 mg po q d through <Date>1935-2-19</Date>, Flagyl 500 mg po tid through <Date>1935-2-19</Date>. DISCHARGE CONDITION: Stable. FOLLOW-UP: To arrange with Dr. <Name>Broadnax</Name> of gastroenterology and the patient's primary care physician, <Name>Booker</Name>. <Name>Benhamou</Name>. DISCHARGE DIAGNOSIS: As per HPI plus: 1. GI bleed secondary to gastritis and AVM (arteriovenous malformation). DR.<Name>Kaur</Name>,<Name>Uma</Name> J. 12-424 Dictated By:<Name>Thompson</Name> MEDQUIST36 D: <Date>2005-7-5</Date> 08:20 T: <Date>2020-4-25</Date> 20:35 JOB#: <Job Number>Farmer and Sons-1903-639966</Job 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Date: 1952-2-18 Discharge Date: 2021-6-22 Service: Cook Ltd Medical Center - Medicine and MICU HISTORY OF PRESENT ILLNESS: This 84-year-old female with a history of diverticula, CREST and irritable bowel syndrome presented to the Emergency Room with a chief complaint of epigastric pain, lightheadedness, nausea without emesis and dark stools. She denied chest pain, shortness of breath, cough, fevers, chills and night sweats. In the Emergency Room she was found to have a blood pressure of 130/palp with a heart rate of 72. One hour later this was 119/39 with a pulse of 100. She had heme positive stool and hematocrit was found to be 16.6. The patient therefore had an emergent EGD in the GI unit. No nasogastric lavage was performed. PAST MEDICAL HISTORY: The patient has Sjogren's with sicca syndrome and presumed CREST with a history of dysphagia and dyspepsia. The patient's primary gastroenterologist is Dr. Broadnax. Patient has a history of hypertension, hypothyroidism, irritable bowel syndrome with chronic diarrhea, Raynaud's, history of TAH, cholecystectomy and pericholecystectomy hernia repair, COPD and bronchiectasis, right bronchial sclerosis and Sjogren's, history of bladder stretchings, negative MRCP 12-15 except for some liver cysts, diverticula on colonoscopy 9-1910 with possibility of Crohn's noted. SOCIAL HISTORY: The patient smoked some tobacco in the past but it was a small amount. She drinks no alcohol. FAMILY HISTORY: Crohn's disease. ALLERGIES: Penicillin, Bactrim and Sulfa. MEDICATIONS: Norvasc 10 mg q d, Atenolol 50 mg q d, Levoxyl 1.25 mg q d, Dyazide 37.5/25 q d, Serax prn, occasional NSAIDs, Premarin .625 mg q d and Aspirin. PHYSICAL EXAMINATION: Temperature 97, blood pressure 95/69, respiratory rate 14, satting 100% on two liters. The patient was alert and oriented times three, she was fully conversant and awake, interactive and appropriate. She was in no acute distress. Conjunctiva were pale. She had dry mucus membranes. She was normocephalic, atraumatic, extraocular movements intact, pupils were equal, round and reactive to light. There was no JVD. Neck was supple. TMs were normal. There was no lymphadenopathy of the neck, faint bibasilar crackles were heard on lung exam. The patient was tachycardic with a normal S1 and S2 with 2/6 systolic ejection murmur radiating to the axilla. Abdomen was soft and non distended with normal bowel sounds, was mildly tender to deep palpation. Extremities without clubbing, cyanosis or edema. Fingers were cool as were the toes but she had 1+ pulses times four. Cranial nerves II through XII were intact. Motor was 5/5 strength globally, symmetric. Deep tendon reflexes were 2+ globally and were symmetric. LABORATORY DATA: White count 12.8, hematocrit 16.6, platelet count 282,000, MCV 89. Chem 7, sodium 140, potassium 4.8, chloride 105, CO2 21, BUN 53 with a baseline of 10, creatinine .9, glucose 98, anion gap 14, ESR 60, ALT 52, AST 84, alkaline phosphatase 313, thyroid peroxidase antibody and endomesial antibodies were positive. Note was made of prior alkaline phosphatase elevations as well as a GGT of 469 and a lipase of 199. TSH was 6.4. Liz was positive at greater than 1:1280. Gastrin was normal in 9-00 at 92. EKG showed normal sinus rhythm at 100, left axis deviation, intervals were 184/74/422. There was a small T wave inversion in 1 and AVL, question of left anterior fascicular block, small ST deviation similar to prior on 1910-9-27. CT done 9-1910 for abdominal pain showed emphysema, no acute cardiopulmonary disease, hypoattenuation of liver and fibrotic lung changes. HOSPITAL COURSE: 1. GI and Cardiovascular: On 5-28 the patient presented with malaise, epigastric pain, nausea for three days, lightheadedness, black stools and was found to have a hematocrit of 15.6 from a baseline of 43 and BUN of 53. The patient was admitted to the MICU. Two peripheral IVs were placed, fluids and blood was applied, Protonix was begun IV. Emergent EGD was performed that showed a stomach full of blood, a probable AVM which was treated with electrocautery. The patient ruled out for MI because she had inferolateral EKG changes with ST depression which later resolved after a blood transfusion. She had relative hypotension given her history of hypertension. On the 7th she was evaluated by surgery and told that operation for her bleed would be high risk and high morbidity and would involve partial gastrectomy so she declined the operation. A groin line was placed. On the 8th a repeat EGD was similar to the first with large amounts of blood and the patient was taken to interventional radiology where she had her left gastric artery embolized. No further IR options were available after this procedure. In total the patient received 11 units of blood, ending on the 8th and hematocrits through the 10th were approximately 40 and stable. Vascular access was initiated during the stay and on transfer to the floor 9-30, the patient had only one PID. Groin line was removed on the 8th because of fever and stool contamination and on the 9th the triple lumen was removed because the patient felt she had no definitive options if she did have a massive bleed. The patient was made DNR, DNI at her request and plans were to make her comfort care if she had a large recurrent bleed, although she later indicated that short-term central line would be acceptable. On transfer to the floor her issues were mild sinus tachycardia thought to be due to beta blocker withdrawal since it persisted through blood and volume repletion. A repeat EGD was performed 8-23 since the patient's lesion was never well visualized with all the blood in her stomach. This showed only gastritis with friability and the same findings in the duodenum. Beta blocker was increased to treat her hypertension and tachycardia but with caution since she was at risk for rebleed. Diarrhea was noted and C. diff and fecal leukocytes were checked and were negative. This was then attributed to melena and it trailed off when she had stable hematocrit. On the 12th the patient was noted to have a decreased hematocrit which declined from 42 to 32.8 with an apparent rebleed with increased melena post EGD. It remained stable thereafter through the 15th at 33.5. Simethicone was given for gassy distension and ambulation was encouraged to decrease this as well. 2. Fluids, Electrolytes & Nutrition: Lytes especially potassium and phosphorus were repleted. 3. Endocrine: Synthroid was continued for hypothyroidism and it increased to 150 since her TSH was high. This needs to be followed up with a repeat TSH. 4. Pulmonary: With her persistent tachycardia on BVL replacement, concern for PE rose and a chest x-ray which showed a right upper lobe process thought to be early pneumonia was performed. CT angio was then done on the 12th which showed no PE but a large right upper lobe consolidation and left upper lobe and left lower lobe consolidations adjacent to an effusion as well. She was therefore treated for multifocal PNA thought to be related to possible aspiration at the time of her EGD with Levofloxacin and Flagyl with resultant decrease in white blood count. Nebs were provided for wheezing, most likely related to COPD. 5. The patient was seen for question of aspiration and it was felt her meds should be crushed and administered in apple sauce and that soft moist solids and liquids would serve her best but she was not a major aspiration risk. 6. ID: As per pulmonary, patient also had a positive urinalysis and a culture showing 1,000 to 100,000 proteus and pseudomonas but since transferring to the floor, the patient complained of no urinary discomfort so this was not treated. Repeat urinalysis 7-11 showed no UTI. The patient was followed by physical therapy and assisted with ambulation. 7. Patient's CREST and Sjogren's were treated with solutions to mouth and eyes as per her routine. Calcium channel blocker for question esophageal spasm was held given the risk of re-bleed and hypotension. 8. Renal: Patient's creatinine clearance was estimated at slightly more than 50 cc per minute and was stable throughout. DISCHARGE MEDICATIONS: Protonix 40 mg Allen, Torres and Thompson Health System, Simethicone 80-125 mg qid prn, Serax 10 mg po prn, Trazodone 25 mg po prn insomnia, Metoprolol 50 mg po tid, Synthroid 150 mcg q d, Colace 100 mg po bid, Milk of Magnesia prn. Patient's own mouth rinses and eyedrops were sicca syndrome. Levofloxacin 500 mg po q d through 1935-2-19, Flagyl 500 mg po tid through 1935-2-19. DISCHARGE CONDITION: Stable. FOLLOW-UP: To arrange with Dr. Broadnax of gastroenterology and the patient's primary care physician, Booker. Benhamou. DISCHARGE DIAGNOSIS: As per HPI plus: 1. GI bleed secondary to gastritis and AVM (arteriovenous malformation). DR.Kaur,Uma J. 12-424 Dictated By:Thompson MEDQUIST36 D: 2005-7-5 08:20 T: 2020-4-25 20:35 JOB#: Farmer and Sons-1903-639966	["Admission Date: 1952-2-18 Discharge Date: 2021-6-22\n\n\nService: Cook Ltd Medical Center - Medicine and MICU\n\nHISTORY OF PRESENT ILLNESS: This 84-year-old female with a\nhistory of diverticula, CREST and irritable bowel syndrome\npresented to the Emergency Room with a chief complaint of\nepigastric pain, lightheadedness, nausea without emesis and\ndark stools. She denied chest pain, shortness of breath,\ncough, fevers, chills and night sweats. In the Emergency\nRoom she was found to have a blood pressure of 130/palp with\na heart rate of 72. One hour later this was 119/39 with a\npulse of 100. She had heme positive stool and hematocrit was\nfound to be 16.6. The patient therefore had an emergent EGD\nin the GI unit. No nasogastric lavage was performed.\n\nPAST MEDICAL HISTORY: The patient has Sjogren's with sicca\nsyndrome and presumed CREST with a history of dysphagia and\ndyspepsia.", " The patient's primary gastroenterologist is Dr.\nBroadnax. Patient has a history of hypertension,\nhypothyroidism, irritable bowel syndrome with chronic\ndiarrhea, Raynaud's, history of TAH, cholecystectomy and\npericholecystectomy hernia repair, COPD and bronchiectasis,\nright bronchial sclerosis and Sjogren's, history of bladder\nstretchings, negative MRCP 12-15 except for some liver cysts,\ndiverticula on colonoscopy 9-1910 with possibility of Crohn's\nnoted.\n\nSOCIAL HISTORY: The patient smoked some tobacco in the past\nbut it was a small amount. She drinks no alcohol.\n\nFAMILY HISTORY: Crohn's disease.\n\nALLERGIES: Penicillin, Bactrim and Sulfa.\n\nMEDICATIONS: Norvasc 10 mg q d, Atenolol 50 mg q d, Levoxyl\n1.25 mg q d, Dyazide 37.5/25 q d, Serax prn, occasional\nNSAIDs, Premarin .625 mg q d and Aspirin.", '\n\nPHYSICAL EXAMINATION: Temperature 97, blood pressure 95/69,\nrespiratory rate 14, satting 100% on two liters. The patient\nwas alert and oriented times three, she was fully conversant\nand awake, interactive and appropriate. She was in no acute\ndistress. Conjunctiva were pale. She had dry mucus\nmembranes. She was normocephalic, atraumatic, extraocular\nmovements intact, pupils were equal, round and reactive to\nlight. There was no JVD. Neck was supple. TMs were normal.\nThere was no lymphadenopathy of the neck, faint bibasilar\ncrackles were heard on lung exam. The patient was\ntachycardic with a normal S1 and S2 with 2/6 systolic\nejection murmur radiating to the axilla. Abdomen was soft\nand non distended with normal bowel sounds, was mildly tender\nto deep palpation. Extremities without clubbing, cyanosis or\nedema.', ' Fingers were cool as were the toes but she had 1+\npulses times four. Cranial nerves II through XII were\nintact. Motor was 5/5 strength globally, symmetric. Deep\ntendon reflexes were 2+ globally and were symmetric.\n\nLABORATORY DATA: White count 12.8, hematocrit 16.6, platelet\ncount 282,000, MCV 89. Chem 7, sodium 140, potassium 4.8,\nchloride 105, CO2 21, BUN 53 with a baseline of 10,\ncreatinine .9, glucose 98, anion gap 14, ESR 60, ALT 52, AST\n84, alkaline phosphatase 313, thyroid peroxidase antibody and\nendomesial antibodies were positive. Note was made of prior\nalkaline phosphatase elevations as well as a GGT of 469 and a\nlipase of 199. TSH was 6.4. Liz was positive at greater\nthan 1:1280. Gastrin was normal in 9-00 at 92. EKG showed\nnormal sinus rhythm at 100, left axis deviation, intervals\nwere 184/74/422.', ' There was a small T wave inversion in 1 and\nAVL, question of left anterior fascicular block, small ST\ndeviation similar to prior on 1910-9-27. CT done 9-1910 for\nabdominal pain showed emphysema, no acute cardiopulmonary\ndisease, hypoattenuation of liver and fibrotic lung changes.\n\nHOSPITAL COURSE:\n1. GI and Cardiovascular: On 5-28 the patient presented with\nmalaise, epigastric pain, nausea for three days,\nlightheadedness, black stools and was found to have a\nhematocrit of 15.6 from a baseline of 43 and BUN of 53. The\npatient was admitted to the MICU. Two peripheral IVs were\nplaced, fluids and blood was applied, Protonix was begun IV.\nEmergent EGD was performed that showed a stomach full of\nblood, a probable AVM which was treated with electrocautery.\nThe patient ruled out for MI because she had inferolateral\nEKG changes with ST depression which later resolved after a\nblood transfusion.', ' She had relative hypotension given her\nhistory of hypertension. On the 7th she was evaluated by\nsurgery and told that operation for her bleed would be high\nrisk and high morbidity and would involve partial gastrectomy\nso she declined the operation. A groin line was placed. On\nthe 8th a repeat EGD was similar to the first with large\namounts of blood and the patient was taken to interventional\nradiology where she had her left gastric artery embolized.\nNo further IR options were available after this procedure.\nIn total the patient received 11 units of blood, ending on\nthe 8th and hematocrits through the 10th were approximately\n40 and stable. Vascular access was initiated during the stay\nand on transfer to the floor 9-30, the patient had only one\nPID. Groin line was removed on the 8th because of fever and\nstool contamination and on the 9th the triple lumen was\nremoved because the patient felt she had no definitive\noptions if she did have a massive bleed.', " The patient was\nmade DNR, DNI at her request and plans were to make her\ncomfort care if she had a large recurrent bleed, although she\nlater indicated that short-term central line would be\nacceptable. On transfer to the floor her issues were mild\nsinus tachycardia thought to be due to beta blocker\nwithdrawal since it persisted through blood and volume\nrepletion. A repeat EGD was performed 8-23 since the\npatient's lesion was never well visualized with all the blood\nin her stomach. This showed only gastritis with friability\nand the same findings in the duodenum. Beta blocker was\nincreased to treat her hypertension and tachycardia but with\ncaution since she was at risk for rebleed. Diarrhea was\nnoted and C. diff and fecal leukocytes were checked and were\nnegative. This was then attributed to melena and it trailed\noff when she had stable hematocrit.", ' On the 12th the patient\nwas noted to have a decreased hematocrit which declined from\n42 to 32.8 with an apparent rebleed with increased melena\npost EGD. It remained stable thereafter through the 15th at\n33.5. Simethicone was given for gassy distension and\nambulation was encouraged to decrease this as well.\n\n2. Fluids, Electrolytes & Nutrition: Lytes especially\npotassium and phosphorus were repleted.\n\n3. Endocrine: Synthroid was continued for hypothyroidism\nand it increased to 150 since her TSH was high. This needs\nto be followed up with a repeat TSH.\n\n4. Pulmonary: With her persistent tachycardia on BVL\nreplacement, concern for PE rose and a chest x-ray which\nshowed a right upper lobe process thought to be early\npneumonia was performed. CT angio was then done on the 12th\nwhich showed no PE but a large right upper lobe consolidation\nand left upper lobe and left lower lobe consolidations\nadjacent to an effusion as well.', ' She was therefore treated\nfor multifocal PNA thought to be related to possible\naspiration at the time of her EGD with Levofloxacin and\nFlagyl with resultant decrease in white blood count. Nebs\nwere provided for wheezing, most likely related to COPD.\n\n5. The patient was seen for question of aspiration and it\nwas felt her meds should be crushed and administered in apple\nsauce and that soft moist solids and liquids would serve her\nbest but she was not a major aspiration risk.\n\n6. ID: As per pulmonary, patient also had a positive\nurinalysis and a culture showing 1,000 to 100,000 proteus and\npseudomonas but since transferring to the floor, the patient\ncomplained of no urinary discomfort so this was not treated.\nRepeat urinalysis 7-11 showed no UTI. The patient was\nfollowed by physical therapy and assisted with ambulation.', "\n\n7. Patient's CREST and Sjogren's were treated with solutions\nto mouth and eyes as per her routine. Calcium channel blocker\nfor question esophageal spasm was held given the risk of\nre-bleed and hypotension.\n\n8. Renal: Patient's creatinine clearance was estimated at\nslightly more than 50 cc per minute and was stable\nthroughout.\n\nDISCHARGE MEDICATIONS: Protonix 40 mg Allen, Torres and Thompson Health System, Simethicone\n80-125 mg qid prn, Serax 10 mg po prn, Trazodone 25 mg po prn\ninsomnia, Metoprolol 50 mg po tid, Synthroid 150 mcg q d,\nColace 100 mg po bid, Milk of Magnesia prn. Patient's own\nmouth rinses and eyedrops were sicca syndrome. Levofloxacin\n500 mg po q d through 1935-2-19, Flagyl 500 mg po tid through\n1935-2-19.\n\nDISCHARGE CONDITION: Stable.\n\nFOLLOW-UP: To arrange with Dr.", " Broadnax of gastroenterology\nand the patient's primary care physician, Booker. Benhamou.\n\nDISCHARGE DIAGNOSIS: As per HPI plus:\n1. GI bleed secondary to gastritis and AVM (arteriovenous\nmalformation).\n\n\n\n\n DR.Kaur,Uma J. 12-424\n\nDictated By:Thompson\n\nMEDQUIST36\n\nD: 2005-7-5 08:20\nT: 2020-4-25 20:35\nJOB#: Farmer and Sons-1903-639966\n"]
552	23637	157391.0	2195-07-07	Discharge summary	Report	Admission Date: [2195-6-17] Discharge Date: [2195-7-7] Service: [Hospital1 ] HISTORY OF PRESENT ILLNESS: This is an 84 year-old female with a history of CREST, diverticular disease, irritable bowel syndrome, and prior upper GI bleed in [7-19] secondary to AVM and gastritis. Her previous UGIB required hospitalization, which was notable for a hematocrit of 16 on during stay, 2 units of fresh frozen platelets, esophagogastroduodenoscopy showing gastritis and normal duodenum, cauterization of a gastric AVM, and angiography followed by embolization of left gastric artery. She presented to the Emergency Room at this time with a chief complaint of two days of dark stools, left lower abdominal breath, lightheadedness, fevers or chills, and night sweats. No bright red blood per rectum, no hematemesis. In the Emergency Room she was found to be in no acute distress and with a temperature of 99.5, blood pressure 143/53, pulse 86, respirations 16, 98% on room air. Nasogastric suction revealed 200 cc of coffee grounds and lavage with 250 cc H20 showed coffee grounds and a bright red tinge, but lavage was stopped, because of patient discomfort. Central line in femoral vein was placed and she was given one liter of normal saline. PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome CREST with a history of dysphagia and dyspepsia (followed by gastroenterologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1940]). 2. Hypertension. 3. Hypothyroidism. 4. Irritable bowel syndrome with chronic diarrhea, constipation and abdominal pain. 5. Diverticula seen on colonoscopy [7-/2193]. 6. Chronic obstructive pulmonary disease with bronchiectasis, right bronchial sclerosis. 7. History of bladder stretching. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Pericholecystectomy hernia repair. 3. Hysterectomy. SOCIAL HISTORY: Three pack years of smoking, quit twenty years ago. Drinks no alcohol. FAMILY HISTORY: Son has Crohn's disease times forty two years. ALLERGIES: Penicillin and sulfa. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2. Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid 175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30 mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a day. PHYSICAL EXAMINATION: General, thin elderly woman in no acute distress. Vital signs temperature 99.5. Blood pressure 120/60. Pulse 86. Respiratory rate 18. Skin normal capillary refill, plus telangiectasias on the back. HEENT right ptosis. No scleral icterus. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are dry. No lower dentition. Neck supple. No lymphadenopathy. Jugular veins flat. Chest clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at right upper sternal border. No gallops or rubs. Abdomen flat. Scar along right abdomen. Positive bowel sounds, nondistended. No tenderness to palpation. No hepatosplenomegaly. Extremities no clubbing, cyanosis or edema. Fingers and toes cool to touch. 2+ radial and dorsalis pedis pulses. Rectal guaiac positive in the Emergency Department. Neurological alert and oriented times three. Pleasant affect. Cranial nerves II through XII are intact. No asterixics. LABORATORIES AND STUDIES: White blood cell count 11.1, hemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH 29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0, monocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128, potassium 4.6, chloride 94, bicarbonate 27, BUN 47, creatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8, phosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis negative. Electrocardiogram heart rate 84 beats per minute, normal sinus rhythm, left axis deviation. No acute ischemic changes. HOSPITAL COURSE: 1. Gastrointestinal: The patient presented with an upper gastrointestinal bleed with a hematocrit of 29.9, melena left lower quadrant pain and coffee grounds with red tinge on nasogastric lavage. To look for a source of bleed, several procedures were done. An esophagogastroduodenoscopy was done on [6-18], which showed diffuse gastritis and a normal duodenum consistent with what was seen during admission a year before. On [6-25], enteroscopy showed improved gastritis and a normal duodenum and jejunum. Colonoscopy on [6-29] showed retained melena and multiple nonbleeding diverticula, but no source of bleeding. A tagged red cell scan on [6-23] did not identify a source of gastrointestinal bleeding either. H-pylori antibody test was negative. She was on supportive therapy with Protonix 40 mg b.i.d. and Carafate, but she had continuous gastrointestinal bleed as manifested by guaiac positive stools, both melena and bloody stool and unstable hematocrit throughout most of her stay. On the evening of [7-1] (hospital day fifteen), the patient had a dramatic gastric bleed with a hematocrit drop from 27.7 to 17.4. The patient became more tachycardic then baseline to 130s, but maintained her blood pressure. Nasogastric lavage at this point revealed bright red blood with clots that did not clear with 420 cc of H20. She was transferred to the MICU where she received 6 units of packed red blood cells and 2 units of fresh frozen platelets. She was taken to the IR the next morning where the left gastroduodenal artery was embolized empirically. By hospital day seventeen, the patient decided that she wanted no more blood product transfusions and wanted CMO. On the evening of hospital day seventeen, the patient was transferred back to the Medicine Floor with stable hematocrit of 36.7. However, one day after the transfer, her hematocrit dropped to 24.1 with bloody diarrhea. The patient reexpressed her wishes for CMO and did not want any more laboratory tests or any blood product transfusions. By hospital day twenty the patient appeared stable with stable tachycardia and blood pressure. It appeared that gastrointestinal bleeding either slowed or stopped, so after discussion between the patient and the family and a hematocrit check was done, which at the value of 26.4 showed that she had stopped bleeding. Two more units of red blood cells were transfused to increase her hematocrit to at least greater then 30. 2. Hematology: At presentation the patient's hematocrit was 29.9 and was unstable throughout most of the admission. She received a total of 20 units of packed red blood cells. Some hematologic workup was done to look for other causes of continued bleed, which was negative for GIC, hemolysis and [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] disease. Two of five studies (epinephrine and arachidonic acid) for platelet aggregation were abnormal so she was given Desmopressin intravenous times two doses ([6-24] and [6-27]) and one bag of platelets, which did not help stabilize her hematocrit. A total of 5 units of fresh frozen platelets were also given, because of multiple red blood cells could have diluted the concentration of her clotting factors and less likely, because of the possibility that she had a coagulopathy given one PTT value. Hematology/oncology consult did not feel that the patient had platelet aggregation abnormalities or a coagulopathy. 3. Cardiovascular: The patient's antihypertensive medications (Atenolol, Aldactone, Lasix) were held during her hospital stay so that if she were to stop bleeding briskly, her sympathetic system may respond appropriately to maintain blood pressure. Her vital signs remained stable with a blood pressure in the 140s/80s and heart rate in 80s until hospital day five when she started having sinus tachycardic 100 to 130s. At this time she also developed a urinary tract infection, so the tachycardia was thought to be secondary to infection or dehydration. She was given normal saline intravenous to lower the heart rate to the 110s. During the remainder of th hospital course her heart rate remained elevated in the 100s. When it rose again to 120 to 130s or the patient was symptomatic with palpitations, administration of normal saline intravenous helped control the tachycardia. After the precipitous hematocrit drop on hospital day fifteen, the patient's cardiac enzymes were checked and they revealed a mild enzyme leak with CK 118 and 128, MB 8 and 9 and troponin 0.9. However, full enzyme cycling was not done, because the patient decided on full CMO measures. The patient was also found to have 3 out of 6 systolic murmur loudest at right upper sternal border, radiating to subclavian arteries. Consider outpatient workup with primary care physician. 4. Pulmonary: During the MICU stay, where she was given 6 units of packed red blood cells and 2 units of fresh frozen platelets she developed dyspnea and bilateral pleural effusion. She was given 2 doses of Lasix 20 mg intravenous after which her dyspnea improved. 5. Infectious disease: On hospital day five the patient spiked a temperature to 101.5. Urinalysis showed 245 white blood cells and blood culture was negative. She was treated with Levofloxacin 500 mg once a day for eight days. During the MICU stay her white blood cells spiked to 19.9, but she was afebrile and there was no clear source of infection (no pneumonia on chest x-ray, negative urine culture). The white blood cells went down to 12.3 after transfer to the medicine floor. 6. Lines: Access on this patient was difficult to obtain and maintain. Access ranged as follows, femoral central line, peripheral line and left IJ central line by IR. 7. FEN: Potassium, calcium, magnesium and phosphate were repleted as needed. 8. Endocrine: Synthroid was continued for hypothyroidism. 9. CREST/Sjogren's: The patient uses Evoxac at home for [Last Name (un) ], but this was held during hospitalization. As it is a cholinergic agonist it could have led to increased gastric motility and dampen CVA response to hypotension. DISCHARGE CONDITION: Stable. The patient will be discharged to rehab with clear instructions on how she would like to be cared for if she were to present with recurrent gastrointestinal bleed. DISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2. Atenolol 20 mg once a day hold for systolic blood pressure less then 110, heart rate less then 60. 3. Synthroid 175 micrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet one tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg po prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for diarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5 mg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin q.d. FOLLOW UP: To arrange with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1940] of gastroenterology and the patient's primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 4427]. DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed secondary to gastritis. [First Name11 (Name Pattern1) 2515] [Last Name (NamePattern4) 4517], M.D. [MD Number(1) 4518] Dictated By:[Doctor Last Name 4519] MEDQUIST36 D: [2195-7-6] 15:16 T: [2195-7-7] 08:18 JOB#: [Job Number 4520]	Admission Date: <Date>1989-8-4</Date> Discharge Date: <Date>1989-2-18</Date> Service: <Hospital>White Group Hospital</Hospital> HISTORY OF PRESENT ILLNESS: This is an 84 year-old female with a history of CREST, diverticular disease, irritable bowel syndrome, and prior upper GI bleed in <Date>11-29</Date> secondary to AVM and gastritis. Her previous UGIB required hospitalization, which was notable for a hematocrit of 16 on during stay, 2 units of fresh frozen platelets, esophagogastroduodenoscopy showing gastritis and normal duodenum, cauterization of a gastric AVM, and angiography followed by embolization of left gastric artery. She presented to the Emergency Room at this time with a chief complaint of two days of dark stools, left lower abdominal breath, lightheadedness, fevers or chills, and night sweats. No bright red blood per rectum, no hematemesis. In the Emergency Room she was found to be in no acute distress and with a temperature of 99.5, blood pressure 143/53, pulse 86, respirations 16, 98% on room air. Nasogastric suction revealed 200 cc of coffee grounds and lavage with 250 cc H20 showed coffee grounds and a bright red tinge, but lavage was stopped, because of patient discomfort. Central line in femoral vein was placed and she was given one liter of normal saline. PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome CREST with a history of dysphagia and dyspepsia (followed by gastroenterologist Dr. <Name>Chloe</Name> <Name>Kuykendall</Name>). 2. Hypertension. 3. Hypothyroidism. 4. Irritable bowel syndrome with chronic diarrhea, constipation and abdominal pain. 5. Diverticula seen on colonoscopy <Date>5-2012</Date>. 6. Chronic obstructive pulmonary disease with bronchiectasis, right bronchial sclerosis. 7. History of bladder stretching. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Pericholecystectomy hernia repair. 3. Hysterectomy. SOCIAL HISTORY: Three pack years of smoking, quit twenty years ago. Drinks no alcohol. FAMILY HISTORY: Son has Crohn's disease times forty two years. ALLERGIES: Penicillin and sulfa. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2. Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid 175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30 mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a day. PHYSICAL EXAMINATION: General, thin elderly woman in no acute distress. Vital signs temperature 99.5. Blood pressure 120/60. Pulse 86. Respiratory rate 18. Skin normal capillary refill, plus telangiectasias on the back. HEENT right ptosis. No scleral icterus. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are dry. No lower dentition. Neck supple. No lymphadenopathy. Jugular veins flat. Chest clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at right upper sternal border. No gallops or rubs. Abdomen flat. Scar along right abdomen. Positive bowel sounds, nondistended. No tenderness to palpation. No hepatosplenomegaly. Extremities no clubbing, cyanosis or edema. Fingers and toes cool to touch. 2+ radial and dorsalis pedis pulses. Rectal guaiac positive in the Emergency Department. Neurological alert and oriented times three. Pleasant affect. Cranial nerves II through XII are intact. No asterixics. LABORATORIES AND STUDIES: White blood cell count 11.1, hemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH 29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0, monocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128, potassium 4.6, chloride 94, bicarbonate 27, BUN 47, creatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8, phosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis negative. Electrocardiogram heart rate 84 beats per minute, normal sinus rhythm, left axis deviation. No acute ischemic changes. HOSPITAL COURSE: 1. Gastrointestinal: The patient presented with an upper gastrointestinal bleed with a hematocrit of 29.9, melena left lower quadrant pain and coffee grounds with red tinge on nasogastric lavage. To look for a source of bleed, several procedures were done. An esophagogastroduodenoscopy was done on <Date>10-23</Date>, which showed diffuse gastritis and a normal duodenum consistent with what was seen during admission a year before. On <Date>5-17</Date>, enteroscopy showed improved gastritis and a normal duodenum and jejunum. Colonoscopy on <Date>6-4</Date> showed retained melena and multiple nonbleeding diverticula, but no source of bleeding. A tagged red cell scan on <Date>2-2</Date> did not identify a source of gastrointestinal bleeding either. H-pylori antibody test was negative. She was on supportive therapy with Protonix 40 mg b.i.d. and Carafate, but she had continuous gastrointestinal bleed as manifested by guaiac positive stools, both melena and bloody stool and unstable hematocrit throughout most of her stay. On the evening of <Date>10-15</Date> (hospital day fifteen), the patient had a dramatic gastric bleed with a hematocrit drop from 27.7 to 17.4. The patient became more tachycardic then baseline to 130s, but maintained her blood pressure. Nasogastric lavage at this point revealed bright red blood with clots that did not clear with 420 cc of H20. She was transferred to the MICU where she received 6 units of packed red blood cells and 2 units of fresh frozen platelets. She was taken to the IR the next morning where the left gastroduodenal artery was embolized empirically. By hospital day seventeen, the patient decided that she wanted no more blood product transfusions and wanted CMO. On the evening of hospital day seventeen, the patient was transferred back to the Medicine Floor with stable hematocrit of 36.7. However, one day after the transfer, her hematocrit dropped to 24.1 with bloody diarrhea. The patient reexpressed her wishes for CMO and did not want any more laboratory tests or any blood product transfusions. By hospital day twenty the patient appeared stable with stable tachycardia and blood pressure. It appeared that gastrointestinal bleeding either slowed or stopped, so after discussion between the patient and the family and a hematocrit check was done, which at the value of 26.4 showed that she had stopped bleeding. Two more units of red blood cells were transfused to increase her hematocrit to at least greater then 30. 2. Hematology: At presentation the patient's hematocrit was 29.9 and was unstable throughout most of the admission. She received a total of 20 units of packed red blood cells. Some hematologic workup was done to look for other causes of continued bleed, which was negative for GIC, hemolysis and <Name>Norine</Name> <Name>Kobayashi</Name> disease. Two of five studies (epinephrine and arachidonic acid) for platelet aggregation were abnormal so she was given Desmopressin intravenous times two doses (<Date>8-8</Date> and <Date>10-5</Date>) and one bag of platelets, which did not help stabilize her hematocrit. A total of 5 units of fresh frozen platelets were also given, because of multiple red blood cells could have diluted the concentration of her clotting factors and less likely, because of the possibility that she had a coagulopathy given one PTT value. Hematology/oncology consult did not feel that the patient had platelet aggregation abnormalities or a coagulopathy. 3. Cardiovascular: The patient's antihypertensive medications (Atenolol, Aldactone, Lasix) were held during her hospital stay so that if she were to stop bleeding briskly, her sympathetic system may respond appropriately to maintain blood pressure. Her vital signs remained stable with a blood pressure in the 140s/80s and heart rate in 80s until hospital day five when she started having sinus tachycardic 100 to 130s. At this time she also developed a urinary tract infection, so the tachycardia was thought to be secondary to infection or dehydration. She was given normal saline intravenous to lower the heart rate to the 110s. During the remainder of th hospital course her heart rate remained elevated in the 100s. When it rose again to 120 to 130s or the patient was symptomatic with palpitations, administration of normal saline intravenous helped control the tachycardia. After the precipitous hematocrit drop on hospital day fifteen, the patient's cardiac enzymes were checked and they revealed a mild enzyme leak with CK 118 and 128, MB 8 and 9 and troponin 0.9. However, full enzyme cycling was not done, because the patient decided on full CMO measures. The patient was also found to have 3 out of 6 systolic murmur loudest at right upper sternal border, radiating to subclavian arteries. Consider outpatient workup with primary care physician. 4. Pulmonary: During the MICU stay, where she was given 6 units of packed red blood cells and 2 units of fresh frozen platelets she developed dyspnea and bilateral pleural effusion. She was given 2 doses of Lasix 20 mg intravenous after which her dyspnea improved. 5. Infectious disease: On hospital day five the patient spiked a temperature to 101.5. Urinalysis showed 245 white blood cells and blood culture was negative. She was treated with Levofloxacin 500 mg once a day for eight days. During the MICU stay her white blood cells spiked to 19.9, but she was afebrile and there was no clear source of infection (no pneumonia on chest x-ray, negative urine culture). The white blood cells went down to 12.3 after transfer to the medicine floor. 6. Lines: Access on this patient was difficult to obtain and maintain. Access ranged as follows, femoral central line, peripheral line and left IJ central line by IR. 7. FEN: Potassium, calcium, magnesium and phosphate were repleted as needed. 8. Endocrine: Synthroid was continued for hypothyroidism. 9. CREST/Sjogren's: The patient uses Evoxac at home for <Name>Edward</Name>, but this was held during hospitalization. As it is a cholinergic agonist it could have led to increased gastric motility and dampen CVA response to hypotension. DISCHARGE CONDITION: Stable. The patient will be discharged to rehab with clear instructions on how she would like to be cared for if she were to present with recurrent gastrointestinal bleed. DISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2. Atenolol 20 mg once a day hold for systolic blood pressure less then 110, heart rate less then 60. 3. Synthroid 175 micrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet one tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg po prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for diarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5 mg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin q.d. FOLLOW UP: To arrange with Dr. <Name>Chloe</Name> <Name>Kuykendall</Name> of gastroenterology and the patient's primary care physician <Name>Ornelas</Name>. <Name>Kaur</Name>. DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed secondary to gastritis. <Name>Lakisha</Name> <Name>Salgado</Name>, M.D. <MD Number>18734027</MD Number> Dictated By:<Doctor Name>Dr.Lyna</Doctor Name> MEDQUIST36 D: <Date>1940-10-21</Date> 15:16 T: <Date>1989-2-18</Date> 08:18 JOB#: <Job Number>Hess Inc-1920-525414</Job 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Date: 1989-8-4 Discharge Date: 1989-2-18 Service: White Group Hospital HISTORY OF PRESENT ILLNESS: This is an 84 year-old female with a history of CREST, diverticular disease, irritable bowel syndrome, and prior upper GI bleed in 11-29 secondary to AVM and gastritis. Her previous UGIB required hospitalization, which was notable for a hematocrit of 16 on during stay, 2 units of fresh frozen platelets, esophagogastroduodenoscopy showing gastritis and normal duodenum, cauterization of a gastric AVM, and angiography followed by embolization of left gastric artery. She presented to the Emergency Room at this time with a chief complaint of two days of dark stools, left lower abdominal breath, lightheadedness, fevers or chills, and night sweats. No bright red blood per rectum, no hematemesis. In the Emergency Room she was found to be in no acute distress and with a temperature of 99.5, blood pressure 143/53, pulse 86, respirations 16, 98% on room air. Nasogastric suction revealed 200 cc of coffee grounds and lavage with 250 cc H20 showed coffee grounds and a bright red tinge, but lavage was stopped, because of patient discomfort. Central line in femoral vein was placed and she was given one liter of normal saline. PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome CREST with a history of dysphagia and dyspepsia (followed by gastroenterologist Dr. Chloe Kuykendall). 2. Hypertension. 3. Hypothyroidism. 4. Irritable bowel syndrome with chronic diarrhea, constipation and abdominal pain. 5. Diverticula seen on colonoscopy 5-2012. 6. Chronic obstructive pulmonary disease with bronchiectasis, right bronchial sclerosis. 7. History of bladder stretching. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Pericholecystectomy hernia repair. 3. Hysterectomy. SOCIAL HISTORY: Three pack years of smoking, quit twenty years ago. Drinks no alcohol. FAMILY HISTORY: Son has Crohn's disease times forty two years. ALLERGIES: Penicillin and sulfa. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2. Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid 175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30 mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a day. PHYSICAL EXAMINATION: General, thin elderly woman in no acute distress. Vital signs temperature 99.5. Blood pressure 120/60. Pulse 86. Respiratory rate 18. Skin normal capillary refill, plus telangiectasias on the back. HEENT right ptosis. No scleral icterus. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are dry. No lower dentition. Neck supple. No lymphadenopathy. Jugular veins flat. Chest clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at right upper sternal border. No gallops or rubs. Abdomen flat. Scar along right abdomen. Positive bowel sounds, nondistended. No tenderness to palpation. No hepatosplenomegaly. Extremities no clubbing, cyanosis or edema. Fingers and toes cool to touch. 2+ radial and dorsalis pedis pulses. Rectal guaiac positive in the Emergency Department. Neurological alert and oriented times three. Pleasant affect. Cranial nerves II through XII are intact. No asterixics. LABORATORIES AND STUDIES: White blood cell count 11.1, hemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH 29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0, monocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128, potassium 4.6, chloride 94, bicarbonate 27, BUN 47, creatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8, phosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis negative. Electrocardiogram heart rate 84 beats per minute, normal sinus rhythm, left axis deviation. No acute ischemic changes. HOSPITAL COURSE: 1. Gastrointestinal: The patient presented with an upper gastrointestinal bleed with a hematocrit of 29.9, melena left lower quadrant pain and coffee grounds with red tinge on nasogastric lavage. To look for a source of bleed, several procedures were done. An esophagogastroduodenoscopy was done on 10-23, which showed diffuse gastritis and a normal duodenum consistent with what was seen during admission a year before. On 5-17, enteroscopy showed improved gastritis and a normal duodenum and jejunum. Colonoscopy on 6-4 showed retained melena and multiple nonbleeding diverticula, but no source of bleeding. A tagged red cell scan on 2-2 did not identify a source of gastrointestinal bleeding either. H-pylori antibody test was negative. She was on supportive therapy with Protonix 40 mg b.i.d. and Carafate, but she had continuous gastrointestinal bleed as manifested by guaiac positive stools, both melena and bloody stool and unstable hematocrit throughout most of her stay. On the evening of 10-15 (hospital day fifteen), the patient had a dramatic gastric bleed with a hematocrit drop from 27.7 to 17.4. The patient became more tachycardic then baseline to 130s, but maintained her blood pressure. Nasogastric lavage at this point revealed bright red blood with clots that did not clear with 420 cc of H20. She was transferred to the MICU where she received 6 units of packed red blood cells and 2 units of fresh frozen platelets. She was taken to the IR the next morning where the left gastroduodenal artery was embolized empirically. By hospital day seventeen, the patient decided that she wanted no more blood product transfusions and wanted CMO. On the evening of hospital day seventeen, the patient was transferred back to the Medicine Floor with stable hematocrit of 36.7. However, one day after the transfer, her hematocrit dropped to 24.1 with bloody diarrhea. The patient reexpressed her wishes for CMO and did not want any more laboratory tests or any blood product transfusions. By hospital day twenty the patient appeared stable with stable tachycardia and blood pressure. It appeared that gastrointestinal bleeding either slowed or stopped, so after discussion between the patient and the family and a hematocrit check was done, which at the value of 26.4 showed that she had stopped bleeding. Two more units of red blood cells were transfused to increase her hematocrit to at least greater then 30. 2. Hematology: At presentation the patient's hematocrit was 29.9 and was unstable throughout most of the admission. She received a total of 20 units of packed red blood cells. Some hematologic workup was done to look for other causes of continued bleed, which was negative for GIC, hemolysis and Norine Kobayashi disease. Two of five studies (epinephrine and arachidonic acid) for platelet aggregation were abnormal so she was given Desmopressin intravenous times two doses (8-8 and 10-5) and one bag of platelets, which did not help stabilize her hematocrit. A total of 5 units of fresh frozen platelets were also given, because of multiple red blood cells could have diluted the concentration of her clotting factors and less likely, because of the possibility that she had a coagulopathy given one PTT value. Hematology/oncology consult did not feel that the patient had platelet aggregation abnormalities or a coagulopathy. 3. Cardiovascular: The patient's antihypertensive medications (Atenolol, Aldactone, Lasix) were held during her hospital stay so that if she were to stop bleeding briskly, her sympathetic system may respond appropriately to maintain blood pressure. Her vital signs remained stable with a blood pressure in the 140s/80s and heart rate in 80s until hospital day five when she started having sinus tachycardic 100 to 130s. At this time she also developed a urinary tract infection, so the tachycardia was thought to be secondary to infection or dehydration. She was given normal saline intravenous to lower the heart rate to the 110s. During the remainder of th hospital course her heart rate remained elevated in the 100s. When it rose again to 120 to 130s or the patient was symptomatic with palpitations, administration of normal saline intravenous helped control the tachycardia. After the precipitous hematocrit drop on hospital day fifteen, the patient's cardiac enzymes were checked and they revealed a mild enzyme leak with CK 118 and 128, MB 8 and 9 and troponin 0.9. However, full enzyme cycling was not done, because the patient decided on full CMO measures. The patient was also found to have 3 out of 6 systolic murmur loudest at right upper sternal border, radiating to subclavian arteries. Consider outpatient workup with primary care physician. 4. Pulmonary: During the MICU stay, where she was given 6 units of packed red blood cells and 2 units of fresh frozen platelets she developed dyspnea and bilateral pleural effusion. She was given 2 doses of Lasix 20 mg intravenous after which her dyspnea improved. 5. Infectious disease: On hospital day five the patient spiked a temperature to 101.5. Urinalysis showed 245 white blood cells and blood culture was negative. She was treated with Levofloxacin 500 mg once a day for eight days. During the MICU stay her white blood cells spiked to 19.9, but she was afebrile and there was no clear source of infection (no pneumonia on chest x-ray, negative urine culture). The white blood cells went down to 12.3 after transfer to the medicine floor. 6. Lines: Access on this patient was difficult to obtain and maintain. Access ranged as follows, femoral central line, peripheral line and left IJ central line by IR. 7. FEN: Potassium, calcium, magnesium and phosphate were repleted as needed. 8. Endocrine: Synthroid was continued for hypothyroidism. 9. CREST/Sjogren's: The patient uses Evoxac at home for Edward, but this was held during hospitalization. As it is a cholinergic agonist it could have led to increased gastric motility and dampen CVA response to hypotension. DISCHARGE CONDITION: Stable. The patient will be discharged to rehab with clear instructions on how she would like to be cared for if she were to present with recurrent gastrointestinal bleed. DISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2. Atenolol 20 mg once a day hold for systolic blood pressure less then 110, heart rate less then 60. 3. Synthroid 175 micrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet one tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg po prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for diarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5 mg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin q.d. FOLLOW UP: To arrange with Dr. Chloe Kuykendall of gastroenterology and the patient's primary care physician Ornelas. Kaur. DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed secondary to gastritis. Lakisha Salgado, M.D. 18734027 Dictated By:Dr.Lyna MEDQUIST36 D: 1940-10-21 15:16 T: 1989-2-18 08:18 JOB#: Hess Inc-1920-525414	['Admission Date: 1989-8-4 Discharge Date: 1989-2-18\n\n\nService: White Group Hospital\nHISTORY OF PRESENT ILLNESS: This is an 84 year-old female\nwith a history of CREST, diverticular disease, irritable\nbowel syndrome, and prior upper GI bleed in 11-29 secondary to\nAVM and gastritis. Her previous UGIB required\nhospitalization, which was notable for a hematocrit of 16 on\nduring stay, 2 units of fresh frozen platelets,\nesophagogastroduodenoscopy showing gastritis and normal\nduodenum, cauterization of a gastric AVM, and angiography\nfollowed by embolization of left gastric artery.\n\nShe presented to the Emergency Room at this time with a chief\ncomplaint of two days of dark stools, left lower abdominal\nbreath, lightheadedness, fevers or chills, and night sweats.\nNo bright red blood per rectum, no hematemesis.', " In the\nEmergency Room she was found to be in no acute distress and\nwith a temperature of 99.5, blood pressure 143/53, pulse 86,\nrespirations 16, 98% on room air. Nasogastric suction\nrevealed 200 cc of coffee grounds and lavage with 250 cc H20\nshowed coffee grounds and a bright red tinge, but lavage was\nstopped, because of patient discomfort. Central line in\nfemoral vein was placed and she was given one liter of normal\nsaline.\n\nPAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome\nCREST with a history of dysphagia and dyspepsia (followed by\ngastroenterologist Dr. Chloe Kuykendall). 2. Hypertension.\n3. Hypothyroidism. 4. Irritable bowel syndrome with\nchronic diarrhea, constipation and abdominal pain. 5.\nDiverticula seen on colonoscopy 5-2012. 6. Chronic\nobstructive pulmonary disease with bronchiectasis, right\nbronchial sclerosis.", " 7. History of bladder stretching.\n\nPAST SURGICAL HISTORY: 1. Cholecystectomy. 2.\nPericholecystectomy hernia repair. 3. Hysterectomy.\n\nSOCIAL HISTORY: Three pack years of smoking, quit twenty\nyears ago. Drinks no alcohol.\n\nFAMILY HISTORY: Son has Crohn's disease times forty two\nyears.\n\nALLERGIES: Penicillin and sulfa.\n\nMEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2.\nAldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid\n175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30\nmg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a\nday.\n\nPHYSICAL EXAMINATION: General, thin elderly woman in no\nacute distress. Vital signs temperature 99.5. Blood\npressure 120/60. Pulse 86. Respiratory rate 18. Skin\nnormal capillary refill, plus telangiectasias on the back.\nHEENT right ptosis.", ' No scleral icterus. Pupils are equal,\nround and reactive to light. Extraocular movements intact.\nMucous membranes are dry. No lower dentition. Neck supple.\nNo lymphadenopathy. Jugular veins flat. Chest clear to\nauscultation bilaterally. Cardiovascular regular rate and\nrhythm. S1 and S2. 3 out of 6 systolic murmur loudest at\nright upper sternal border. No gallops or rubs. Abdomen\nflat. Scar along right abdomen. Positive bowel sounds,\nnondistended. No tenderness to palpation. No\nhepatosplenomegaly. Extremities no clubbing, cyanosis or\nedema. Fingers and toes cool to touch. 2+ radial and\ndorsalis pedis pulses. Rectal guaiac positive in the\nEmergency Department. Neurological alert and oriented times\nthree. Pleasant affect. Cranial nerves II through XII are\nintact. No asterixics.', '\n\nLABORATORIES AND STUDIES: White blood cell count 11.1,\nhemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH\n29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0,\nmonocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128,\npotassium 4.6, chloride 94, bicarbonate 27, BUN 47,\ncreatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8,\nphosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis\nnegative. Electrocardiogram heart rate 84 beats per minute,\nnormal sinus rhythm, left axis deviation. No acute ischemic\nchanges.\n\nHOSPITAL COURSE: 1. Gastrointestinal: The patient presented\nwith an upper gastrointestinal bleed with a hematocrit of\n29.9, melena left lower quadrant pain and coffee grounds with\nred tinge on nasogastric lavage. To look for a source of\nbleed, several procedures were done.', ' An\nesophagogastroduodenoscopy was done on 10-23, which showed\ndiffuse gastritis and a normal duodenum consistent with what\nwas seen during admission a year before. On 5-17, enteroscopy\nshowed improved gastritis and a normal duodenum and jejunum.\nColonoscopy on 6-4 showed retained melena and multiple\nnonbleeding diverticula, but no source of bleeding. A tagged\nred cell scan on 2-2 did not identify a source of\ngastrointestinal bleeding either. H-pylori antibody test was\nnegative. She was on supportive therapy with Protonix 40 mg\nb.i.d. and Carafate, but she had continuous gastrointestinal\nbleed as manifested by guaiac positive stools, both melena\nand bloody stool and unstable hematocrit throughout most of\nher stay.\n\nOn the evening of 10-15 (hospital day fifteen), the patient\nhad a dramatic gastric bleed with a hematocrit drop from 27.', '7\nto 17.4. The patient became more tachycardic then baseline\nto 130s, but maintained her blood pressure. Nasogastric\nlavage at this point revealed bright red blood with clots\nthat did not clear with 420 cc of H20. She was transferred\nto the MICU where she received 6 units of packed red blood\ncells and 2 units of fresh frozen platelets. She was taken\nto the IR the next morning where the left gastroduodenal\nartery was embolized empirically. By hospital day seventeen,\nthe patient decided that she wanted no more blood product\ntransfusions and wanted CMO.\n\nOn the evening of hospital day seventeen, the patient was\ntransferred back to the Medicine Floor with stable hematocrit\nof 36.7. However, one day after the transfer, her hematocrit\ndropped to 24.1 with bloody diarrhea. The patient\nreexpressed her wishes for CMO and did not want any more\nlaboratory tests or any blood product transfusions.', "\n\nBy hospital day twenty the patient appeared stable with\nstable tachycardia and blood pressure. It appeared that\ngastrointestinal bleeding either slowed or stopped, so after\ndiscussion between the patient and the family and a\nhematocrit check was done, which at the value of 26.4 showed\nthat she had stopped bleeding. Two more units of red blood\ncells were transfused to increase her hematocrit to at least\ngreater then 30.\n\n2. Hematology: At presentation the patient's hematocrit was\n29.9 and was unstable throughout most of the admission. She\nreceived a total of 20 units of packed red blood cells. Some\nhematologic workup was done to look for other causes of\ncontinued bleed, which was negative for GIC, hemolysis and\nNorine Kobayashi disease. Two of five studies (epinephrine\nand arachidonic acid) for platelet aggregation were abnormal\nso she was given Desmopressin intravenous times two doses\n(8-8 and 10-5) and one bag of platelets, which did not help\nstabilize her hematocrit.", " A total of 5 units of fresh frozen\nplatelets were also given, because of multiple red blood\ncells could have diluted the concentration of her clotting\nfactors and less likely, because of the possibility that she\nhad a coagulopathy given one PTT value. Hematology/oncology\nconsult did not feel that the patient had platelet\naggregation abnormalities or a coagulopathy.\n\n3. Cardiovascular: The patient's antihypertensive\nmedications (Atenolol, Aldactone, Lasix) were held during her\nhospital stay so that if she were to stop bleeding briskly,\nher sympathetic system may respond appropriately to maintain\nblood pressure. Her vital signs remained stable with a blood\npressure in the 140s/80s and heart rate in 80s until hospital\nday five when she started having sinus tachycardic 100 to\n130s. At this time she also developed a urinary tract\ninfection, so the tachycardia was thought to be secondary to\ninfection or dehydration.", " She was given normal saline\nintravenous to lower the heart rate to the 110s. During the\nremainder of th hospital course her heart rate remained\nelevated in the 100s. When it rose again to 120 to 130s or\nthe patient was symptomatic with palpitations, administration\nof normal saline intravenous helped control the tachycardia.\nAfter the precipitous hematocrit drop on hospital day\nfifteen, the patient's cardiac enzymes were checked and they\nrevealed a mild enzyme leak with CK 118 and 128, MB 8 and 9\nand troponin 0.9. However, full enzyme cycling was not done,\nbecause the patient decided on full CMO measures. The\npatient was also found to have 3 out of 6 systolic murmur\nloudest at right upper sternal border, radiating to\nsubclavian arteries. Consider outpatient workup with primary\ncare physician.", '\n\n4. Pulmonary: During the MICU stay, where she was given 6\nunits of packed red blood cells and 2 units of fresh frozen\nplatelets she developed dyspnea and bilateral pleural\neffusion. She was given 2 doses of Lasix 20 mg intravenous\nafter which her dyspnea improved.\n\n5. Infectious disease: On hospital day five the patient\nspiked a temperature to 101.5. Urinalysis showed 245 white\nblood cells and blood culture was negative. She was treated\nwith Levofloxacin 500 mg once a day for eight days. During\nthe MICU stay her white blood cells spiked to 19.9, but she\nwas afebrile and there was no clear source of infection (no\npneumonia on chest x-ray, negative urine culture). The white\nblood cells went down to 12.3 after transfer to the medicine\nfloor.\n\n6. Lines: Access on this patient was difficult to obtain\nand maintain.', " Access ranged as follows, femoral central\nline, peripheral line and left IJ central line by IR.\n\n7. FEN: Potassium, calcium, magnesium and phosphate were\nrepleted as needed.\n\n8. Endocrine: Synthroid was continued for hypothyroidism.\n\n9. CREST/Sjogren's: The patient uses Evoxac at home for\nEdward, but this was held during hospitalization. As it is a\ncholinergic agonist it could have led to increased gastric\nmotility and dampen CVA response to hypotension.\n\nDISCHARGE CONDITION: Stable. The patient will be discharged\nto rehab with clear instructions on how she would like to be\ncared for if she were to present with recurrent\ngastrointestinal bleed.\n\nDISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2.\nAtenolol 20 mg once a day hold for systolic blood pressure\nless then 110, heart rate less then 60.", " 3. Synthroid 175\nmicrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet\none tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg\npo prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for\ndiarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5\nmg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin\nq.d.\n\nFOLLOW UP: To arrange with Dr. Chloe Kuykendall of\ngastroenterology and the patient's primary care physician Ornelas.\nKaur.\n\nDISCHARGE DIAGNOSIS:\nUpper gastrointestinal bleed secondary to gastritis.\n\n\n\n\n\n\n Lakisha Salgado, M.D. 18734027\n\nDictated By:Dr.Lyna\nMEDQUIST36\n\nD: 1940-10-21 15:16\nT: 1989-2-18 08:18\nJOB#: Hess Inc-1920-525414\n"]
553	23637	157391.0	2195-07-07	Discharge summary	Report	Admission Date: [2195-6-17] Discharge Date: [2195-7-7] Service: [Hospital1 ] HISTORY OF PRESENT ILLNESS: This is an 84 year-old female with a history of CREST, diverticular disease, irritable bowel syndrome, and prior upper GI bleed in [7-19] secondary to AVM and gastritis. Her previous UGIB required hospitalization, which was notable for a hematocrit of 16 on admission, 11 units of packed red blood cells transfusion during stay, 2 units of fresh frozen platelets, esophagogastroduodenoscopy showing gastritis and normal duodenum, cauterization of a gastric AVM, and angiography followed by embolization of left gastric artery. She presented to the Emergency Room at this time with a chief complaint of two days of dark stools, left lower abdominal pain and weakness. She denied chest pain, shortness of breath, lightheadedness, fevers or chills, and night sweats. No bright red blood per rectum, no hematemesis. In the Emergency Room she was found to be in no acute distress and with a temperature of 99.5, blood pressure 143/53, pulse 86, respirations 16, 98% on room air. Nasogastric suction revealed 200 cc of coffee grounds and lavage with 250 cc H20 showed coffee grounds and a bright red tinge, but lavage was stopped, because of patient discomfort. Central line in femoral vein was placed and she was given one liter of normal saline. PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome CREST with a history of dysphagia and dyspepsia (followed by gastroenterologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1940]). 2. Hypertension. 3. Hypothyroidism. 4. Irritable bowel syndrome with chronic diarrhea, constipation and abdominal pain. 5. Diverticula seen on colonoscopy [7-/2193]. 6. Chronic obstructive pulmonary disease with bronchiectasis, right bronchial sclerosis. 7. History of bladder stretching. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Pericholecystectomy hernia repair. 3. Hysterectomy. SOCIAL HISTORY: Three pack years of smoking, quit twenty years ago. Drinks no alcohol. FAMILY HISTORY: Son has Crohn's disease times forty two years. ALLERGIES: Penicillin and sulfa. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2. Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid 175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30 mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a day. PHYSICAL EXAMINATION: General, thin elderly woman in no acute distress. Vital signs temperature 99.5. Blood pressure 120/60. Pulse 86. Respiratory rate 18. Skin normal capillary refill, plus telangiectasias on the back. HEENT right ptosis. No scleral icterus. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are dry. No lower dentition. Neck supple. No lymphadenopathy. Jugular veins flat. Chest clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at right upper sternal border. No gallops or rubs. Abdomen flat. Scar along right abdomen. Positive bowel sounds, nondistended. No tenderness to palpation. No hepatosplenomegaly. Extremities no clubbing, cyanosis or edema. Fingers and toes cool to touch. 2+ radial and dorsalis pedis pulses. Rectal guaiac positive in the Emergency Department. Neurological alert and oriented times three. Pleasant affect. Cranial nerves II through XII are intact. No asterixics. LABORATORIES AND STUDIES: White blood cell count 11.1, hemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH 29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0, monocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128, potassium 4.6, chloride 94, bicarbonate 27, BUN 47, creatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8, phosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis negative. Electrocardiogram heart rate 84 beats per minute, normal sinus rhythm, left axis deviation. No acute ischemic changes. HOSPITAL COURSE: 1. Gastrointestinal: The patient presented with an upper gastrointestinal bleed with a hematocrit of 29.9, melena left lower quadrant pain and coffee grounds with red tinge on nasogastric lavage. To look for a source of bleed, several procedures were done. An esophagogastroduodenoscopy was done on [6-18], which showed diffuse gastritis and a normal duodenum consistent with what was seen during admission a year before. On [6-25], enteroscopy showed improved gastritis and a normal duodenum and jejunum. Colonoscopy on [6-29] showed retained melena and multiple nonbleeding diverticula, but no source of bleeding. A tagged red cell scan on [6-23] did not identify a source of gastrointestinal bleeding either. H-pylori antibody test was negative. She was on supportive therapy with Protonix 40 mg b.i.d. and Carafate, but she had continuous gastrointestinal bleed as manifested by guaiac positive stools, both melena and bloody stool and unstable hematocrit throughout most of her stay. On the evening of [7-1] (hospital day fifteen), the patient had a dramatic gastric bleed with a hematocrit drop from 27.7 to 17.4. The patient became more tachycardic then baseline to 130s, but maintained her blood pressure. Nasogastric lavage at this point revealed bright red blood with clots that did not clear with 420 cc of H20. She was transferred to the MICU where she received 6 units of packed red blood cells and 2 units of fresh frozen platelets. She was taken to the IR the next morning where the left gastroduodenal artery was embolized empirically. By hospital day seventeen, the patient decided that she wanted no more blood product transfusions and wanted CMO. On the evening of hospital day seventeen, the patient was transferred back to the Medicine Floor with stable hematocrit of 36.7. However, one day after the transfer, her hematocrit dropped to 24.1 with bloody diarrhea. The patient reexpressed her wishes for CMO and did not want any more laboratory tests or any blood product transfusions. By hospital day twenty the patient appeared stable with stable tachycardia and blood pressure. It appeared that gastrointestinal bleeding either slowed or stopped, so after discussion between the patient and the family and a hematocrit check was done, which at the value of 26.4 showed that she had stopped bleeding. Two more units of red blood cells were transfused to increase her hematocrit to at least greater then 30. 2. Hematology: At presentation the patient's hematocrit was 29.9 and was unstable throughout most of the admission. She received a total of 20 units of packed red blood cells. Some hematologic workup was done to look for other causes of continued bleed, which was negative for GIC, hemolysis and [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] disease. Two of five studies (epinephrine and arachidonic acid) for platelet aggregation were abnormal so she was given Desmopressin intravenous times two doses ([6-24] and [6-27]) and one bag of platelets, which did not help stabilize her hematocrit. A total of 5 units of fresh frozen platelets were also given, because of multiple red blood cells could have diluted the concentration of her clotting factors and less likely, because of the possibility that she had a coagulopathy given one PTT value. Hematology/oncology consult did not feel that the patient had platelet aggregation abnormalities or a coagulopathy. 3. Cardiovascular: The patient's antihypertensive medications (Atenolol, Aldactone, Lasix) were held during her hospital stay so that if she were to stop bleeding briskly, her sympathetic system may respond appropriately to maintain blood pressure. Her vital signs remained stable with a blood pressure in the 140s/80s and heart rate in 80s until hospital day five when she started having sinus tachycardic 100 to 130s. At this time she also developed a urinary tract infection, so the tachycardia was thought to be secondary to infection or dehydration. She was given normal saline intravenous to lower the heart rate to the 110s. During the remainder of th hospital course her heart rate remained elevated in the 100s. When it rose again to 120 to 130s or the patient was symptomatic with palpitations, administration of normal saline intravenous helped control the tachycardia. After the precipitous hematocrit drop on hospital day fifteen, the patient's cardiac enzymes were checked and they revealed a mild enzyme leak with CK 118 and 128, MB 8 and 9 and troponin 0.9. However, full enzyme cycling was not done, because the patient decided on full CMO measures. The patient was also found to have 3 out of 6 systolic murmur loudest at right upper sternal border, radiating to subclavian arteries. Consider outpatient workup with primary care physician. 4. Pulmonary: During the MICU stay, where she was given 6 units of packed red blood cells and 2 units of fresh frozen platelets she developed dyspnea and bilateral pleural effusion. She was given 2 doses of Lasix 20 mg intravenous after which her dyspnea improved. 5. Infectious disease: On hospital day five the patient spiked a temperature to 101.5. Urinalysis showed 245 white blood cells and blood culture was negative. She was treated with Levofloxacin 500 mg once a day for eight days. During the MICU stay her white blood cells spiked to 19.9, but she was afebrile and there was no clear source of infection (no pneumonia on chest x-ray, negative urine culture). The white blood cells went down to 12.3 after transfer to the medicine floor. 6. Lines: Access on this patient was difficult to obtain and maintain. Access ranged as follows, femoral central line, peripheral line and left IJ central line by IR. 7. FEN: Potassium, calcium, magnesium and phosphate were repleted as needed. 8. Endocrine: Synthroid was continued for hypothyroidism. 9. CREST/Sjogren's: The patient uses Evoxac at home for [Last Name (un) ], but this was held during hospitalization. As it is a cholinergic agonist it could have led to increased gastric motility and dampen CVA response to hypotension. DISCHARGE CONDITION: Stable. The patient will be discharged to rehab with clear instructions on how she would like to be cared for if she were to present with recurrent gastrointestinal bleed. DISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2. Atenolol 20 mg once a day hold for systolic blood pressure less then 110, heart rate less then 60. 3. Synthroid 175 micrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet one tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg po prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for diarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5 mg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin q.d. FOLLOW UP: To arrange with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1940] of gastroenterology and the patient's primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 4427]. DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed secondary to gastritis. [First Name11 (Name Pattern1) 2515] [Last Name (NamePattern4) 4517], M.D. [MD Number(1) 4521] Dictated By:[Doctor Last Name 4519] MEDQUIST36 D: [2195-7-6] 15:16 T: [2195-7-7] 08:18 JOB#: [Job Number 4520]	Admission Date: <Date>1929-5-1</Date> Discharge Date: <Date>1930-8-13</Date> Service: <Hospital>Randall-Johnson Clinic</Hospital> HISTORY OF PRESENT ILLNESS: This is an 84 year-old female with a history of CREST, diverticular disease, irritable bowel syndrome, and prior upper GI bleed in <Date>6-2</Date> secondary to AVM and gastritis. Her previous UGIB required hospitalization, which was notable for a hematocrit of 16 on admission, 11 units of packed red blood cells transfusion during stay, 2 units of fresh frozen platelets, esophagogastroduodenoscopy showing gastritis and normal duodenum, cauterization of a gastric AVM, and angiography followed by embolization of left gastric artery. She presented to the Emergency Room at this time with a chief complaint of two days of dark stools, left lower abdominal pain and weakness. She denied chest pain, shortness of breath, lightheadedness, fevers or chills, and night sweats. No bright red blood per rectum, no hematemesis. In the Emergency Room she was found to be in no acute distress and with a temperature of 99.5, blood pressure 143/53, pulse 86, respirations 16, 98% on room air. Nasogastric suction revealed 200 cc of coffee grounds and lavage with 250 cc H20 showed coffee grounds and a bright red tinge, but lavage was stopped, because of patient discomfort. Central line in femoral vein was placed and she was given one liter of normal saline. PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome CREST with a history of dysphagia and dyspepsia (followed by gastroenterologist Dr. <Name>Brandon</Name> <Name>Feudner</Name>). 2. Hypertension. 3. Hypothyroidism. 4. Irritable bowel syndrome with chronic diarrhea, constipation and abdominal pain. 5. Diverticula seen on colonoscopy <Date>9-1969</Date>. 6. Chronic obstructive pulmonary disease with bronchiectasis, right bronchial sclerosis. 7. History of bladder stretching. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Pericholecystectomy hernia repair. 3. Hysterectomy. SOCIAL HISTORY: Three pack years of smoking, quit twenty years ago. Drinks no alcohol. FAMILY HISTORY: Son has Crohn's disease times forty two years. ALLERGIES: Penicillin and sulfa. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2. Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid 175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30 mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a day. PHYSICAL EXAMINATION: General, thin elderly woman in no acute distress. Vital signs temperature 99.5. Blood pressure 120/60. Pulse 86. Respiratory rate 18. Skin normal capillary refill, plus telangiectasias on the back. HEENT right ptosis. No scleral icterus. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are dry. No lower dentition. Neck supple. No lymphadenopathy. Jugular veins flat. Chest clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at right upper sternal border. No gallops or rubs. Abdomen flat. Scar along right abdomen. Positive bowel sounds, nondistended. No tenderness to palpation. No hepatosplenomegaly. Extremities no clubbing, cyanosis or edema. Fingers and toes cool to touch. 2+ radial and dorsalis pedis pulses. Rectal guaiac positive in the Emergency Department. Neurological alert and oriented times three. Pleasant affect. Cranial nerves II through XII are intact. No asterixics. LABORATORIES AND STUDIES: White blood cell count 11.1, hemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH 29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0, monocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128, potassium 4.6, chloride 94, bicarbonate 27, BUN 47, creatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8, phosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis negative. Electrocardiogram heart rate 84 beats per minute, normal sinus rhythm, left axis deviation. No acute ischemic changes. HOSPITAL COURSE: 1. Gastrointestinal: The patient presented with an upper gastrointestinal bleed with a hematocrit of 29.9, melena left lower quadrant pain and coffee grounds with red tinge on nasogastric lavage. To look for a source of bleed, several procedures were done. An esophagogastroduodenoscopy was done on <Date>10-10</Date>, which showed diffuse gastritis and a normal duodenum consistent with what was seen during admission a year before. On <Date>9-21</Date>, enteroscopy showed improved gastritis and a normal duodenum and jejunum. Colonoscopy on <Date>11-10</Date> showed retained melena and multiple nonbleeding diverticula, but no source of bleeding. A tagged red cell scan on <Date>11-31</Date> did not identify a source of gastrointestinal bleeding either. H-pylori antibody test was negative. She was on supportive therapy with Protonix 40 mg b.i.d. and Carafate, but she had continuous gastrointestinal bleed as manifested by guaiac positive stools, both melena and bloody stool and unstable hematocrit throughout most of her stay. On the evening of <Date>8-2</Date> (hospital day fifteen), the patient had a dramatic gastric bleed with a hematocrit drop from 27.7 to 17.4. The patient became more tachycardic then baseline to 130s, but maintained her blood pressure. Nasogastric lavage at this point revealed bright red blood with clots that did not clear with 420 cc of H20. She was transferred to the MICU where she received 6 units of packed red blood cells and 2 units of fresh frozen platelets. She was taken to the IR the next morning where the left gastroduodenal artery was embolized empirically. By hospital day seventeen, the patient decided that she wanted no more blood product transfusions and wanted CMO. On the evening of hospital day seventeen, the patient was transferred back to the Medicine Floor with stable hematocrit of 36.7. However, one day after the transfer, her hematocrit dropped to 24.1 with bloody diarrhea. The patient reexpressed her wishes for CMO and did not want any more laboratory tests or any blood product transfusions. By hospital day twenty the patient appeared stable with stable tachycardia and blood pressure. It appeared that gastrointestinal bleeding either slowed or stopped, so after discussion between the patient and the family and a hematocrit check was done, which at the value of 26.4 showed that she had stopped bleeding. Two more units of red blood cells were transfused to increase her hematocrit to at least greater then 30. 2. Hematology: At presentation the patient's hematocrit was 29.9 and was unstable throughout most of the admission. She received a total of 20 units of packed red blood cells. Some hematologic workup was done to look for other causes of continued bleed, which was negative for GIC, hemolysis and <Name>Creighton</Name> <Name>Thompson</Name> disease. Two of five studies (epinephrine and arachidonic acid) for platelet aggregation were abnormal so she was given Desmopressin intravenous times two doses (<Date>9-19</Date> and <Date>3-2</Date>) and one bag of platelets, which did not help stabilize her hematocrit. A total of 5 units of fresh frozen platelets were also given, because of multiple red blood cells could have diluted the concentration of her clotting factors and less likely, because of the possibility that she had a coagulopathy given one PTT value. Hematology/oncology consult did not feel that the patient had platelet aggregation abnormalities or a coagulopathy. 3. Cardiovascular: The patient's antihypertensive medications (Atenolol, Aldactone, Lasix) were held during her hospital stay so that if she were to stop bleeding briskly, her sympathetic system may respond appropriately to maintain blood pressure. Her vital signs remained stable with a blood pressure in the 140s/80s and heart rate in 80s until hospital day five when she started having sinus tachycardic 100 to 130s. At this time she also developed a urinary tract infection, so the tachycardia was thought to be secondary to infection or dehydration. She was given normal saline intravenous to lower the heart rate to the 110s. During the remainder of th hospital course her heart rate remained elevated in the 100s. When it rose again to 120 to 130s or the patient was symptomatic with palpitations, administration of normal saline intravenous helped control the tachycardia. After the precipitous hematocrit drop on hospital day fifteen, the patient's cardiac enzymes were checked and they revealed a mild enzyme leak with CK 118 and 128, MB 8 and 9 and troponin 0.9. However, full enzyme cycling was not done, because the patient decided on full CMO measures. The patient was also found to have 3 out of 6 systolic murmur loudest at right upper sternal border, radiating to subclavian arteries. Consider outpatient workup with primary care physician. 4. Pulmonary: During the MICU stay, where she was given 6 units of packed red blood cells and 2 units of fresh frozen platelets she developed dyspnea and bilateral pleural effusion. She was given 2 doses of Lasix 20 mg intravenous after which her dyspnea improved. 5. Infectious disease: On hospital day five the patient spiked a temperature to 101.5. Urinalysis showed 245 white blood cells and blood culture was negative. She was treated with Levofloxacin 500 mg once a day for eight days. During the MICU stay her white blood cells spiked to 19.9, but she was afebrile and there was no clear source of infection (no pneumonia on chest x-ray, negative urine culture). The white blood cells went down to 12.3 after transfer to the medicine floor. 6. Lines: Access on this patient was difficult to obtain and maintain. Access ranged as follows, femoral central line, peripheral line and left IJ central line by IR. 7. FEN: Potassium, calcium, magnesium and phosphate were repleted as needed. 8. Endocrine: Synthroid was continued for hypothyroidism. 9. CREST/Sjogren's: The patient uses Evoxac at home for <Name>Tejada</Name>, but this was held during hospitalization. As it is a cholinergic agonist it could have led to increased gastric motility and dampen CVA response to hypotension. DISCHARGE CONDITION: Stable. The patient will be discharged to rehab with clear instructions on how she would like to be cared for if she were to present with recurrent gastrointestinal bleed. DISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2. Atenolol 20 mg once a day hold for systolic blood pressure less then 110, heart rate less then 60. 3. Synthroid 175 micrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet one tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg po prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for diarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5 mg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin q.d. FOLLOW UP: To arrange with Dr. <Name>Brandon</Name> <Name>Feudner</Name> of gastroenterology and the patient's primary care physician <Name>Grier</Name>. <Name>Feudner</Name>. DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed secondary to gastritis. <Name>Kayla</Name> <Name>Kaur</Name>, M.D. <MD Number>40304134</MD Number> Dictated By:<Doctor Name>Dr.Lees</Doctor Name> MEDQUIST36 D: <Date>2000-11-17</Date> 15:16 T: <Date>1930-8-13</Date> 08:18 JOB#: <Job Number>Jones-Nunez-1928-402939</Job 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Date: 1929-5-1 Discharge Date: 1930-8-13 Service: Randall-Johnson Clinic HISTORY OF PRESENT ILLNESS: This is an 84 year-old female with a history of CREST, diverticular disease, irritable bowel syndrome, and prior upper GI bleed in 6-2 secondary to AVM and gastritis. Her previous UGIB required hospitalization, which was notable for a hematocrit of 16 on admission, 11 units of packed red blood cells transfusion during stay, 2 units of fresh frozen platelets, esophagogastroduodenoscopy showing gastritis and normal duodenum, cauterization of a gastric AVM, and angiography followed by embolization of left gastric artery. She presented to the Emergency Room at this time with a chief complaint of two days of dark stools, left lower abdominal pain and weakness. She denied chest pain, shortness of breath, lightheadedness, fevers or chills, and night sweats. No bright red blood per rectum, no hematemesis. In the Emergency Room she was found to be in no acute distress and with a temperature of 99.5, blood pressure 143/53, pulse 86, respirations 16, 98% on room air. Nasogastric suction revealed 200 cc of coffee grounds and lavage with 250 cc H20 showed coffee grounds and a bright red tinge, but lavage was stopped, because of patient discomfort. Central line in femoral vein was placed and she was given one liter of normal saline. PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome CREST with a history of dysphagia and dyspepsia (followed by gastroenterologist Dr. Brandon Feudner). 2. Hypertension. 3. Hypothyroidism. 4. Irritable bowel syndrome with chronic diarrhea, constipation and abdominal pain. 5. Diverticula seen on colonoscopy 9-1969. 6. Chronic obstructive pulmonary disease with bronchiectasis, right bronchial sclerosis. 7. History of bladder stretching. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Pericholecystectomy hernia repair. 3. Hysterectomy. SOCIAL HISTORY: Three pack years of smoking, quit twenty years ago. Drinks no alcohol. FAMILY HISTORY: Son has Crohn's disease times forty two years. ALLERGIES: Penicillin and sulfa. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2. Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid 175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30 mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a day. PHYSICAL EXAMINATION: General, thin elderly woman in no acute distress. Vital signs temperature 99.5. Blood pressure 120/60. Pulse 86. Respiratory rate 18. Skin normal capillary refill, plus telangiectasias on the back. HEENT right ptosis. No scleral icterus. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are dry. No lower dentition. Neck supple. No lymphadenopathy. Jugular veins flat. Chest clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at right upper sternal border. No gallops or rubs. Abdomen flat. Scar along right abdomen. Positive bowel sounds, nondistended. No tenderness to palpation. No hepatosplenomegaly. Extremities no clubbing, cyanosis or edema. Fingers and toes cool to touch. 2+ radial and dorsalis pedis pulses. Rectal guaiac positive in the Emergency Department. Neurological alert and oriented times three. Pleasant affect. Cranial nerves II through XII are intact. No asterixics. LABORATORIES AND STUDIES: White blood cell count 11.1, hemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH 29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0, monocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128, potassium 4.6, chloride 94, bicarbonate 27, BUN 47, creatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8, phosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis negative. Electrocardiogram heart rate 84 beats per minute, normal sinus rhythm, left axis deviation. No acute ischemic changes. HOSPITAL COURSE: 1. Gastrointestinal: The patient presented with an upper gastrointestinal bleed with a hematocrit of 29.9, melena left lower quadrant pain and coffee grounds with red tinge on nasogastric lavage. To look for a source of bleed, several procedures were done. An esophagogastroduodenoscopy was done on 10-10, which showed diffuse gastritis and a normal duodenum consistent with what was seen during admission a year before. On 9-21, enteroscopy showed improved gastritis and a normal duodenum and jejunum. Colonoscopy on 11-10 showed retained melena and multiple nonbleeding diverticula, but no source of bleeding. A tagged red cell scan on 11-31 did not identify a source of gastrointestinal bleeding either. H-pylori antibody test was negative. She was on supportive therapy with Protonix 40 mg b.i.d. and Carafate, but she had continuous gastrointestinal bleed as manifested by guaiac positive stools, both melena and bloody stool and unstable hematocrit throughout most of her stay. On the evening of 8-2 (hospital day fifteen), the patient had a dramatic gastric bleed with a hematocrit drop from 27.7 to 17.4. The patient became more tachycardic then baseline to 130s, but maintained her blood pressure. Nasogastric lavage at this point revealed bright red blood with clots that did not clear with 420 cc of H20. She was transferred to the MICU where she received 6 units of packed red blood cells and 2 units of fresh frozen platelets. She was taken to the IR the next morning where the left gastroduodenal artery was embolized empirically. By hospital day seventeen, the patient decided that she wanted no more blood product transfusions and wanted CMO. On the evening of hospital day seventeen, the patient was transferred back to the Medicine Floor with stable hematocrit of 36.7. However, one day after the transfer, her hematocrit dropped to 24.1 with bloody diarrhea. The patient reexpressed her wishes for CMO and did not want any more laboratory tests or any blood product transfusions. By hospital day twenty the patient appeared stable with stable tachycardia and blood pressure. It appeared that gastrointestinal bleeding either slowed or stopped, so after discussion between the patient and the family and a hematocrit check was done, which at the value of 26.4 showed that she had stopped bleeding. Two more units of red blood cells were transfused to increase her hematocrit to at least greater then 30. 2. Hematology: At presentation the patient's hematocrit was 29.9 and was unstable throughout most of the admission. She received a total of 20 units of packed red blood cells. Some hematologic workup was done to look for other causes of continued bleed, which was negative for GIC, hemolysis and Creighton Thompson disease. Two of five studies (epinephrine and arachidonic acid) for platelet aggregation were abnormal so she was given Desmopressin intravenous times two doses (9-19 and 3-2) and one bag of platelets, which did not help stabilize her hematocrit. A total of 5 units of fresh frozen platelets were also given, because of multiple red blood cells could have diluted the concentration of her clotting factors and less likely, because of the possibility that she had a coagulopathy given one PTT value. Hematology/oncology consult did not feel that the patient had platelet aggregation abnormalities or a coagulopathy. 3. Cardiovascular: The patient's antihypertensive medications (Atenolol, Aldactone, Lasix) were held during her hospital stay so that if she were to stop bleeding briskly, her sympathetic system may respond appropriately to maintain blood pressure. Her vital signs remained stable with a blood pressure in the 140s/80s and heart rate in 80s until hospital day five when she started having sinus tachycardic 100 to 130s. At this time she also developed a urinary tract infection, so the tachycardia was thought to be secondary to infection or dehydration. She was given normal saline intravenous to lower the heart rate to the 110s. During the remainder of th hospital course her heart rate remained elevated in the 100s. When it rose again to 120 to 130s or the patient was symptomatic with palpitations, administration of normal saline intravenous helped control the tachycardia. After the precipitous hematocrit drop on hospital day fifteen, the patient's cardiac enzymes were checked and they revealed a mild enzyme leak with CK 118 and 128, MB 8 and 9 and troponin 0.9. However, full enzyme cycling was not done, because the patient decided on full CMO measures. The patient was also found to have 3 out of 6 systolic murmur loudest at right upper sternal border, radiating to subclavian arteries. Consider outpatient workup with primary care physician. 4. Pulmonary: During the MICU stay, where she was given 6 units of packed red blood cells and 2 units of fresh frozen platelets she developed dyspnea and bilateral pleural effusion. She was given 2 doses of Lasix 20 mg intravenous after which her dyspnea improved. 5. Infectious disease: On hospital day five the patient spiked a temperature to 101.5. Urinalysis showed 245 white blood cells and blood culture was negative. She was treated with Levofloxacin 500 mg once a day for eight days. During the MICU stay her white blood cells spiked to 19.9, but she was afebrile and there was no clear source of infection (no pneumonia on chest x-ray, negative urine culture). The white blood cells went down to 12.3 after transfer to the medicine floor. 6. Lines: Access on this patient was difficult to obtain and maintain. Access ranged as follows, femoral central line, peripheral line and left IJ central line by IR. 7. FEN: Potassium, calcium, magnesium and phosphate were repleted as needed. 8. Endocrine: Synthroid was continued for hypothyroidism. 9. CREST/Sjogren's: The patient uses Evoxac at home for Tejada, but this was held during hospitalization. As it is a cholinergic agonist it could have led to increased gastric motility and dampen CVA response to hypotension. DISCHARGE CONDITION: Stable. The patient will be discharged to rehab with clear instructions on how she would like to be cared for if she were to present with recurrent gastrointestinal bleed. DISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2. Atenolol 20 mg once a day hold for systolic blood pressure less then 110, heart rate less then 60. 3. Synthroid 175 micrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet one tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg po prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for diarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5 mg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin q.d. FOLLOW UP: To arrange with Dr. Brandon Feudner of gastroenterology and the patient's primary care physician Grier. Feudner. DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed secondary to gastritis. Kayla Kaur, M.D. 40304134 Dictated By:Dr.Lees MEDQUIST36 D: 2000-11-17 15:16 T: 1930-8-13 08:18 JOB#: Jones-Nunez-1928-402939	['Admission Date: 1929-5-1 Discharge Date: 1930-8-13\n\n\nService: Randall-Johnson Clinic\n\nHISTORY OF PRESENT ILLNESS: This is an 84 year-old female\nwith a history of CREST, diverticular disease, irritable\nbowel syndrome, and prior upper GI bleed in 6-2 secondary to\nAVM and gastritis. Her previous UGIB required\nhospitalization, which was notable for a hematocrit of 16 on\nadmission, 11 units of packed red blood cells transfusion\nduring stay, 2 units of fresh frozen platelets,\nesophagogastroduodenoscopy showing gastritis and normal\nduodenum, cauterization of a gastric AVM, and angiography\nfollowed by embolization of left gastric artery.\n\nShe presented to the Emergency Room at this time with a chief\ncomplaint of two days of dark stools, left lower abdominal\npain and weakness. She denied chest pain, shortness of\nbreath, lightheadedness, fevers or chills, and night sweats.', "\nNo bright red blood per rectum, no hematemesis. In the\nEmergency Room she was found to be in no acute distress and\nwith a temperature of 99.5, blood pressure 143/53, pulse 86,\nrespirations 16, 98% on room air. Nasogastric suction\nrevealed 200 cc of coffee grounds and lavage with 250 cc H20\nshowed coffee grounds and a bright red tinge, but lavage was\nstopped, because of patient discomfort. Central line in\nfemoral vein was placed and she was given one liter of normal\nsaline.\n\nPAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome\nCREST with a history of dysphagia and dyspepsia (followed by\ngastroenterologist Dr. Brandon Feudner). 2. Hypertension.\n3. Hypothyroidism. 4. Irritable bowel syndrome with\nchronic diarrhea, constipation and abdominal pain. 5.\nDiverticula seen on colonoscopy 9-1969.", " 6. Chronic\nobstructive pulmonary disease with bronchiectasis, right\nbronchial sclerosis. 7. History of bladder stretching.\n\nPAST SURGICAL HISTORY: 1. Cholecystectomy. 2.\nPericholecystectomy hernia repair. 3. Hysterectomy.\n\nSOCIAL HISTORY: Three pack years of smoking, quit twenty\nyears ago. Drinks no alcohol.\n\nFAMILY HISTORY: Son has Crohn's disease times forty two\nyears.\n\nALLERGIES: Penicillin and sulfa.\n\nMEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2.\nAldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid\n175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30\nmg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a\nday.\n\nPHYSICAL EXAMINATION: General, thin elderly woman in no\nacute distress. Vital signs temperature 99.5. Blood\npressure 120/60. Pulse 86.", ' Respiratory rate 18. Skin\nnormal capillary refill, plus telangiectasias on the back.\nHEENT right ptosis. No scleral icterus. Pupils are equal,\nround and reactive to light. Extraocular movements intact.\nMucous membranes are dry. No lower dentition. Neck supple.\nNo lymphadenopathy. Jugular veins flat. Chest clear to\nauscultation bilaterally. Cardiovascular regular rate and\nrhythm. S1 and S2. 3 out of 6 systolic murmur loudest at\nright upper sternal border. No gallops or rubs. Abdomen\nflat. Scar along right abdomen. Positive bowel sounds,\nnondistended. No tenderness to palpation. No\nhepatosplenomegaly. Extremities no clubbing, cyanosis or\nedema. Fingers and toes cool to touch. 2+ radial and\ndorsalis pedis pulses. Rectal guaiac positive in the\nEmergency Department. Neurological alert and oriented times\nthree.', ' Pleasant affect. Cranial nerves II through XII are\nintact. No asterixics.\n\nLABORATORIES AND STUDIES: White blood cell count 11.1,\nhemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH\n29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0,\nmonocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128,\npotassium 4.6, chloride 94, bicarbonate 27, BUN 47,\ncreatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8,\nphosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis\nnegative. Electrocardiogram heart rate 84 beats per minute,\nnormal sinus rhythm, left axis deviation. No acute ischemic\nchanges.\n\nHOSPITAL COURSE: 1. Gastrointestinal: The patient presented\nwith an upper gastrointestinal bleed with a hematocrit of\n29.9, melena left lower quadrant pain and coffee grounds with\nred tinge on nasogastric lavage.', ' To look for a source of\nbleed, several procedures were done. An\nesophagogastroduodenoscopy was done on 10-10, which showed\ndiffuse gastritis and a normal duodenum consistent with what\nwas seen during admission a year before. On 9-21, enteroscopy\nshowed improved gastritis and a normal duodenum and jejunum.\nColonoscopy on 11-10 showed retained melena and multiple\nnonbleeding diverticula, but no source of bleeding. A tagged\nred cell scan on 11-31 did not identify a source of\ngastrointestinal bleeding either. H-pylori antibody test was\nnegative. She was on supportive therapy with Protonix 40 mg\nb.i.d. and Carafate, but she had continuous gastrointestinal\nbleed as manifested by guaiac positive stools, both melena\nand bloody stool and unstable hematocrit throughout most of\nher stay.\n\nOn the evening of 8-2 (hospital day fifteen), the patient\nhad a dramatic gastric bleed with a hematocrit drop from 27.', '7\nto 17.4. The patient became more tachycardic then baseline\nto 130s, but maintained her blood pressure. Nasogastric\nlavage at this point revealed bright red blood with clots\nthat did not clear with 420 cc of H20. She was transferred\nto the MICU where she received 6 units of packed red blood\ncells and 2 units of fresh frozen platelets. She was taken\nto the IR the next morning where the left gastroduodenal\nartery was embolized empirically. By hospital day seventeen,\nthe patient decided that she wanted no more blood product\ntransfusions and wanted CMO.\n\nOn the evening of hospital day seventeen, the patient was\ntransferred back to the Medicine Floor with stable hematocrit\nof 36.7. However, one day after the transfer, her hematocrit\ndropped to 24.1 with bloody diarrhea. The patient\nreexpressed her wishes for CMO and did not want any more\nlaboratory tests or any blood product transfusions.', "\n\nBy hospital day twenty the patient appeared stable with\nstable tachycardia and blood pressure. It appeared that\ngastrointestinal bleeding either slowed or stopped, so after\ndiscussion between the patient and the family and a\nhematocrit check was done, which at the value of 26.4 showed\nthat she had stopped bleeding. Two more units of red blood\ncells were transfused to increase her hematocrit to at least\ngreater then 30.\n\n2. Hematology: At presentation the patient's hematocrit was\n29.9 and was unstable throughout most of the admission. She\nreceived a total of 20 units of packed red blood cells. Some\nhematologic workup was done to look for other causes of\ncontinued bleed, which was negative for GIC, hemolysis and\nCreighton Thompson disease. Two of five studies (epinephrine\nand arachidonic acid) for platelet aggregation were abnormal\nso she was given Desmopressin intravenous times two doses\n(9-19 and 3-2) and one bag of platelets, which did not help\nstabilize her hematocrit.", " A total of 5 units of fresh frozen\nplatelets were also given, because of multiple red blood\ncells could have diluted the concentration of her clotting\nfactors and less likely, because of the possibility that she\nhad a coagulopathy given one PTT value. Hematology/oncology\nconsult did not feel that the patient had platelet\naggregation abnormalities or a coagulopathy.\n\n3. Cardiovascular: The patient's antihypertensive\nmedications (Atenolol, Aldactone, Lasix) were held during her\nhospital stay so that if she were to stop bleeding briskly,\nher sympathetic system may respond appropriately to maintain\nblood pressure. Her vital signs remained stable with a blood\npressure in the 140s/80s and heart rate in 80s until hospital\nday five when she started having sinus tachycardic 100 to\n130s. At this time she also developed a urinary tract\ninfection, so the tachycardia was thought to be secondary to\ninfection or dehydration.", " She was given normal saline\nintravenous to lower the heart rate to the 110s. During the\nremainder of th hospital course her heart rate remained\nelevated in the 100s. When it rose again to 120 to 130s or\nthe patient was symptomatic with palpitations, administration\nof normal saline intravenous helped control the tachycardia.\nAfter the precipitous hematocrit drop on hospital day\nfifteen, the patient's cardiac enzymes were checked and they\nrevealed a mild enzyme leak with CK 118 and 128, MB 8 and 9\nand troponin 0.9. However, full enzyme cycling was not done,\nbecause the patient decided on full CMO measures. The\npatient was also found to have 3 out of 6 systolic murmur\nloudest at right upper sternal border, radiating to\nsubclavian arteries. Consider outpatient workup with primary\ncare physician.", '\n\n4. Pulmonary: During the MICU stay, where she was given 6\nunits of packed red blood cells and 2 units of fresh frozen\nplatelets she developed dyspnea and bilateral pleural\neffusion. She was given 2 doses of Lasix 20 mg intravenous\nafter which her dyspnea improved.\n\n5. Infectious disease: On hospital day five the patient\nspiked a temperature to 101.5. Urinalysis showed 245 white\nblood cells and blood culture was negative. She was treated\nwith Levofloxacin 500 mg once a day for eight days. During\nthe MICU stay her white blood cells spiked to 19.9, but she\nwas afebrile and there was no clear source of infection (no\npneumonia on chest x-ray, negative urine culture). The white\nblood cells went down to 12.3 after transfer to the medicine\nfloor.\n\n6. Lines: Access on this patient was difficult to obtain\nand maintain.', " Access ranged as follows, femoral central\nline, peripheral line and left IJ central line by IR.\n\n7. FEN: Potassium, calcium, magnesium and phosphate were\nrepleted as needed.\n\n8. Endocrine: Synthroid was continued for hypothyroidism.\n\n9. CREST/Sjogren's: The patient uses Evoxac at home for\nTejada, but this was held during hospitalization. As it is a\ncholinergic agonist it could have led to increased gastric\nmotility and dampen CVA response to hypotension.\n\nDISCHARGE CONDITION: Stable. The patient will be discharged\nto rehab with clear instructions on how she would like to be\ncared for if she were to present with recurrent\ngastrointestinal bleed.\n\nDISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2.\nAtenolol 20 mg once a day hold for systolic blood pressure\nless then 110, heart rate less then 60.", " 3. Synthroid 175\nmicrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet\none tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg\npo prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for\ndiarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5\nmg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin\nq.d.\n\nFOLLOW UP: To arrange with Dr. Brandon Feudner of\ngastroenterology and the patient's primary care physician Grier.\nFeudner.\n\nDISCHARGE DIAGNOSIS:\nUpper gastrointestinal bleed secondary to gastritis.\n\n\n\n\n\n\n Kayla Kaur, M.D. 40304134\n\nDictated By:Dr.Lees\nMEDQUIST36\n\nD: 2000-11-17 15:16\nT: 1930-8-13 08:18\nJOB#: Jones-Nunez-1928-402939\n"]
554	23637	117843.0	2196-05-16	Discharge summary	Report	Admission Date: [2196-5-13] Discharge Date: [2196-5-16] Service: CHIEF COMPLAINT: GI bleed, transfer from [Hospital3 4527]. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old woman with a history of Sjogren syndrome with sicca syndrome and also CREST with predominant Raynaud's, history of GI bleed in the past thought secondary to gastritis and arteriovenous malformations, status post left gastric and left gastroduodenal artery embolizations in [7-18] and [6-18] respectively. She presented to [Hospital3 4527] in mid-[2196-4-17] with bright red blood per rectum and an hematocrit drop from 34 to 28. Her work-up at that time consisted of an abdominal CT that revealed a pancolitis, increased splenomegaly, and new ascites. She was transfused two units and discharged to rehabilitation on [2196-5-7], and then two to three days prior to admission the patient noted dark stools and on the morning prior to admission the patient had nausea, decreased appetite, and an episode of vomiting bright red blood. She subsequently went to [Hospital3 4527] on [2196-5-12] in the morning. In the emergency room there her systolic was in the 90s, hematocrit was 18, down from 28 on discharge. Her INR was 1.7. She had a left IJ triple-lumen catheter placed, a right EJ peripheral line, and she subsequently underwent EGD which revealed grade 0-1 esophageal varices, portal gastropathy, gastric varices, but no active bleed, although there were multiple blood clots in the stomach. She was treated with IV Protonix and was started an octreotide drip. She was transfused several units, which improved her hematocrit from 18 to 28, and then on the morning of the 27th around 1 AM she had a repeat episode of hematemesis, and nasogastric lavage did not clear after two liters of saline. An emergency EGD was performed that revealed a large varix at the gastroesophageal junction, and there was blood in the fundus. Sclerotherapy was attempted, which resulted in an initial blood spurt, however the bleeding subsequently stabilized and overall during the resuscitative efforts, she was given six units of red cells and four units of fresh frozen plasma, and she was transferred to [Hospital1 346] for evaluation of emerging TIPS. Here in the intensive care unit the patient was comfortable with no nausea or vomiting, no further hematemesis. She denied any abdominal pain. PAST MEDICAL HISTORY: 1. Sjogren's with sicca syndrome. 2. CREST with predominant Raynaud's. 3. History of GI bleed status post left gastric artery embolization in [7-18], and left gastroduodenal artery embolization in [6-18]. 4. History of pancolitis. 5. Recent episode of bleeding points. 6. Irritable bowel syndrome. 7. Hypertension. 8. Hashimoto's hypothyroidism with positive antibody. 9. Diverticulosis. 10. History of left femoral DVT in [6-18]. 11. History of chronic obstructive pulmonary disease/bronchitis. MEDICATIONS: 1. Octreotide drip at 50 mcg per minute. 2. Protonix 40 IV b.i.d. 3. Ativan p.r.n. 4. Atrovent, albuterol nebulizers. 5. Vitamin K subcutaneous x 3. ALLERGIES: The patient is allergic to sulfa and penicillin. SOCIAL HISTORY: The patient lives in [Location (un) 4528] skilled nursing facility. Her son lives locally, daughter is on the west coast. Minimal alcohol history and remote tobacco. The patient has a son with [Name (NI) 4522] disease. PHYSICAL EXAMINATION: On arrival her temperature was 98, blood pressure 160/80, heart rate 80s, respiratory rate 16, saturating 95% on two liters. General: She was a well-appearing, elderly, frail woman. HEENT: She had crusted blood in her oropharynx. Pupils equal, round and reactive to light. Sclerae anicteric. Neck: Supple, with no lymphadenopathy. Chest: Examination revealed decreased breath sounds at the left base and bronchial breath sounds at the right base. Cardiac: There was a [12-24] crescendo/decrescendo systolic murmur at the right upper sternal border without radiation. Abdomen: Benign, positive bowel sounds, nontender. There was no fluid wave. No liver edge was appreciated. Extremities: There was no peripheral edema. Skin: There was no jaundice notable. Neurologic: The patient was alert and oriented x 3, otherwise nonfocal. LABORATORY DATA: On the morning of admission white count was 10.8, hematocrit 31.9, which had been up from 22 earlier in the morning, platelet count 68, which was around her baseline, SMA-7 was unremarkable. BUN and creatinine were normal. INR was 1.3. PT 14.1, PTT 32.8, fibrinogen was 161, albumin 3.2. ALT, AST, and alkaline phosphatase were within normal limits. Total bilirubin was 2.1. Urinalysis on the morning of arrival had been negative. EKG showed sinus tachycardia at [Street Address(2) 4529] depressions in 2, 3, aVF, V4 to V6, but no acute change compared to old. HOSPITAL COURSE: 1. Upper GI bleed/variceal bleed: Patient was thought to have cirrhosis of unclear etiology with new ascites and new splenomegaly on recent abdominal CT, and on endoscopy at the outside hospital, portal gastropathy and esophageal varices were found. The patient was initially transferred to [Hospital1 69] for evaluation for emerging TIPS. The patient had a type and cross with four units of red cells and fresh frozen plasma on hold. She had a central line in her left neck as well as a right EJ. She was continued on octreotide drip at 50 mcg per hour. She was continued on Protonix 40 IV b.i.d. Her coagulopathy, her hematocrit and platelet count were corrected with products as needed. The patient was evaluated by the liver team, who felt that given her comfortable status and high risk of precipitating encephalopathy, TIPS would not be the best strategy; rather the patient was observed on octreotide drip. Her daughter and son were available as well as the patient during this conversation and agreed that conservative management of her varices was the best route. The patient was continued on octreotide drip for the plan of five days, and was continued on Protonix IV b.i.d. She was started on nadolol for further decrease of her portal hypertension, and a work-up was initiated for her etiology of cirrhosis including hepatitis panel, [Doctor First Name ], SPEP, and antimitochondrial antibody. A right upper quadrant ultrasound was performed that revealed no evidence of portal vein thrombus and a cirrhotic liver. The patient had no further episodes of hematemesis during her hospitalization. Her hematocrit remained stable throughout her hospitalization. 2. Mental status change: The patient initially was alert and oriented upon arrival, however became delirious within 24 hours of her hospitalization. Further work-up revealed a positive urinalysis consistent with a urinary tract infection, probably catheter related. The patient also had 4/4 bottles positive for gram-positive cocci in clusters in her blood, which were drawn off a left IJ, consistent with a line infection with sepsis. The patient had already been DNR, however now the patient's code status after discussion with her daughter and son, was changed to DNR/DNI, and made comfort measures. No antibiotics were given for her line infection. The line was not changed due to the morbidity involved in a central line procedure, and unfortunately, the passed away likely due to overwhelming sepsis both from line infection and urinary tract infection. The patient was pronounced at 10:20 PM on [2196-5-16]. Daughter and son were present at the bedside. DISCHARGE DIAGNOSES: 1. Line infection/sepsis. 2. Urinary tract infection. 3. Variceal bleed/hemorrhage. 4. New diagnosis of cirrhosis in addition to her diagnoses on arrival. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 2439] MEDQUIST36 D: [2196-6-21] 11:09 T: [2196-6-27] 07:14 JOB#: [Job Number 4530]	Admission Date: <Date>1949-2-28</Date> Discharge Date: <Date>2013-1-22</Date> Service: CHIEF COMPLAINT: GI bleed, transfer from <Hospital>Coffey Group Hospital</Hospital>. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old woman with a history of Sjogren syndrome with sicca syndrome and also CREST with predominant Raynaud's, history of GI bleed in the past thought secondary to gastritis and arteriovenous malformations, status post left gastric and left gastroduodenal artery embolizations in <Date>11-8</Date> and <Date>4-13</Date> respectively. She presented to <Hospital>Coffey Group Hospital</Hospital> in mid-<Date>2011-11-8</Date> with bright red blood per rectum and an hematocrit drop from 34 to 28. Her work-up at that time consisted of an abdominal CT that revealed a pancolitis, increased splenomegaly, and new ascites. She was transfused two units and discharged to rehabilitation on <Date>1971-3-28</Date>, and then two to three days prior to admission the patient noted dark stools and on the morning prior to admission the patient had nausea, decreased appetite, and an episode of vomiting bright red blood. She subsequently went to <Hospital>Coffey Group Hospital</Hospital> on <Date>1953-9-25</Date> in the morning. In the emergency room there her systolic was in the 90s, hematocrit was 18, down from 28 on discharge. Her INR was 1.7. She had a left IJ triple-lumen catheter placed, a right EJ peripheral line, and she subsequently underwent EGD which revealed grade 0-1 esophageal varices, portal gastropathy, gastric varices, but no active bleed, although there were multiple blood clots in the stomach. She was treated with IV Protonix and was started an octreotide drip. She was transfused several units, which improved her hematocrit from 18 to 28, and then on the morning of the 27th around 1 AM she had a repeat episode of hematemesis, and nasogastric lavage did not clear after two liters of saline. An emergency EGD was performed that revealed a large varix at the gastroesophageal junction, and there was blood in the fundus. Sclerotherapy was attempted, which resulted in an initial blood spurt, however the bleeding subsequently stabilized and overall during the resuscitative efforts, she was given six units of red cells and four units of fresh frozen plasma, and she was transferred to <Hospital>Williams, Alvarado and Sullivan Health System</Hospital> for evaluation of emerging TIPS. Here in the intensive care unit the patient was comfortable with no nausea or vomiting, no further hematemesis. She denied any abdominal pain. PAST MEDICAL HISTORY: 1. Sjogren's with sicca syndrome. 2. CREST with predominant Raynaud's. 3. History of GI bleed status post left gastric artery embolization in <Date>11-8</Date>, and left gastroduodenal artery embolization in <Date>4-13</Date>. 4. History of pancolitis. 5. Recent episode of bleeding points. 6. Irritable bowel syndrome. 7. Hypertension. 8. Hashimoto's hypothyroidism with positive antibody. 9. Diverticulosis. 10. History of left femoral DVT in <Date>4-13</Date>. 11. History of chronic obstructive pulmonary disease/bronchitis. MEDICATIONS: 1. Octreotide drip at 50 mcg per minute. 2. Protonix 40 IV b.i.d. 3. Ativan p.r.n. 4. Atrovent, albuterol nebulizers. 5. Vitamin K subcutaneous x 3. ALLERGIES: The patient is allergic to sulfa and penicillin. SOCIAL HISTORY: The patient lives in <Location>6094 Lang Crest New Jennifer, NV 06275</Location> skilled nursing facility. Her son lives locally, daughter is on the west coast. Minimal alcohol history and remote tobacco. The patient has a son with <Name>Travis Beamon</Name> disease. PHYSICAL EXAMINATION: On arrival her temperature was 98, blood pressure 160/80, heart rate 80s, respiratory rate 16, saturating 95% on two liters. General: She was a well-appearing, elderly, frail woman. HEENT: She had crusted blood in her oropharynx. Pupils equal, round and reactive to light. Sclerae anicteric. Neck: Supple, with no lymphadenopathy. Chest: Examination revealed decreased breath sounds at the left base and bronchial breath sounds at the right base. Cardiac: There was a <Date>8-24</Date> crescendo/decrescendo systolic murmur at the right upper sternal border without radiation. Abdomen: Benign, positive bowel sounds, nontender. There was no fluid wave. No liver edge was appreciated. Extremities: There was no peripheral edema. Skin: There was no jaundice notable. Neurologic: The patient was alert and oriented x 3, otherwise nonfocal. LABORATORY DATA: On the morning of admission white count was 10.8, hematocrit 31.9, which had been up from 22 earlier in the morning, platelet count 68, which was around her baseline, SMA-7 was unremarkable. BUN and creatinine were normal. INR was 1.3. PT 14.1, PTT 32.8, fibrinogen was 161, albumin 3.2. ALT, AST, and alkaline phosphatase were within normal limits. Total bilirubin was 2.1. Urinalysis on the morning of arrival had been negative. EKG showed sinus tachycardia at <Location>24223 Mills Walks Suite 516 Smithburgh, CT 43461</Location> depressions in 2, 3, aVF, V4 to V6, but no acute change compared to old. HOSPITAL COURSE: 1. Upper GI bleed/variceal bleed: Patient was thought to have cirrhosis of unclear etiology with new ascites and new splenomegaly on recent abdominal CT, and on endoscopy at the outside hospital, portal gastropathy and esophageal varices were found. The patient was initially transferred to <Hospital>Brown-Davis Clinic</Hospital> for evaluation for emerging TIPS. The patient had a type and cross with four units of red cells and fresh frozen plasma on hold. She had a central line in her left neck as well as a right EJ. She was continued on octreotide drip at 50 mcg per hour. She was continued on Protonix 40 IV b.i.d. Her coagulopathy, her hematocrit and platelet count were corrected with products as needed. The patient was evaluated by the liver team, who felt that given her comfortable status and high risk of precipitating encephalopathy, TIPS would not be the best strategy; rather the patient was observed on octreotide drip. Her daughter and son were available as well as the patient during this conversation and agreed that conservative management of her varices was the best route. The patient was continued on octreotide drip for the plan of five days, and was continued on Protonix IV b.i.d. She was started on nadolol for further decrease of her portal hypertension, and a work-up was initiated for her etiology of cirrhosis including hepatitis panel, <Name>Teressa</Name>, SPEP, and antimitochondrial antibody. A right upper quadrant ultrasound was performed that revealed no evidence of portal vein thrombus and a cirrhotic liver. The patient had no further episodes of hematemesis during her hospitalization. Her hematocrit remained stable throughout her hospitalization. 2. Mental status change: The patient initially was alert and oriented upon arrival, however became delirious within 24 hours of her hospitalization. Further work-up revealed a positive urinalysis consistent with a urinary tract infection, probably catheter related. The patient also had 4/4 bottles positive for gram-positive cocci in clusters in her blood, which were drawn off a left IJ, consistent with a line infection with sepsis. The patient had already been DNR, however now the patient's code status after discussion with her daughter and son, was changed to DNR/DNI, and made comfort measures. No antibiotics were given for her line infection. The line was not changed due to the morbidity involved in a central line procedure, and unfortunately, the passed away likely due to overwhelming sepsis both from line infection and urinary tract infection. The patient was pronounced at 10:20 PM on <Date>2013-1-22</Date>. Daughter and son were present at the bedside. DISCHARGE DIAGNOSES: 1. Line infection/sepsis. 2. Urinary tract infection. 3. Variceal bleed/hemorrhage. 4. New diagnosis of cirrhosis in addition to her diagnoses on arrival. <Name>Jessie Hazelwood</Name> <Name>Keiko Prieto</Name>, M.D. <MD Number>60519753</MD Number> Dictated By:<Name>Kayla Moore</Name> MEDQUIST36 D: <Date>2001-6-17</Date> 11:09 T: <Date>1903-9-22</Date> 07:14 JOB#: <Job Number>Carpenter, Kelly and Larson-2018-595603</Job 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Date: 1949-2-28 Discharge Date: 2013-1-22 Service: CHIEF COMPLAINT: GI bleed, transfer from Coffey Group Hospital. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old woman with a history of Sjogren syndrome with sicca syndrome and also CREST with predominant Raynaud's, history of GI bleed in the past thought secondary to gastritis and arteriovenous malformations, status post left gastric and left gastroduodenal artery embolizations in 11-8 and 4-13 respectively. She presented to Coffey Group Hospital in mid-2011-11-8 with bright red blood per rectum and an hematocrit drop from 34 to 28. Her work-up at that time consisted of an abdominal CT that revealed a pancolitis, increased splenomegaly, and new ascites. She was transfused two units and discharged to rehabilitation on 1971-3-28, and then two to three days prior to admission the patient noted dark stools and on the morning prior to admission the patient had nausea, decreased appetite, and an episode of vomiting bright red blood. She subsequently went to Coffey Group Hospital on 1953-9-25 in the morning. In the emergency room there her systolic was in the 90s, hematocrit was 18, down from 28 on discharge. Her INR was 1.7. She had a left IJ triple-lumen catheter placed, a right EJ peripheral line, and she subsequently underwent EGD which revealed grade 0-1 esophageal varices, portal gastropathy, gastric varices, but no active bleed, although there were multiple blood clots in the stomach. She was treated with IV Protonix and was started an octreotide drip. She was transfused several units, which improved her hematocrit from 18 to 28, and then on the morning of the 27th around 1 AM she had a repeat episode of hematemesis, and nasogastric lavage did not clear after two liters of saline. An emergency EGD was performed that revealed a large varix at the gastroesophageal junction, and there was blood in the fundus. Sclerotherapy was attempted, which resulted in an initial blood spurt, however the bleeding subsequently stabilized and overall during the resuscitative efforts, she was given six units of red cells and four units of fresh frozen plasma, and she was transferred to Williams, Alvarado and Sullivan Health System for evaluation of emerging TIPS. Here in the intensive care unit the patient was comfortable with no nausea or vomiting, no further hematemesis. She denied any abdominal pain. PAST MEDICAL HISTORY: 1. Sjogren's with sicca syndrome. 2. CREST with predominant Raynaud's. 3. History of GI bleed status post left gastric artery embolization in 11-8, and left gastroduodenal artery embolization in 4-13. 4. History of pancolitis. 5. Recent episode of bleeding points. 6. Irritable bowel syndrome. 7. Hypertension. 8. Hashimoto's hypothyroidism with positive antibody. 9. Diverticulosis. 10. History of left femoral DVT in 4-13. 11. History of chronic obstructive pulmonary disease/bronchitis. MEDICATIONS: 1. Octreotide drip at 50 mcg per minute. 2. Protonix 40 IV b.i.d. 3. Ativan p.r.n. 4. Atrovent, albuterol nebulizers. 5. Vitamin K subcutaneous x 3. ALLERGIES: The patient is allergic to sulfa and penicillin. SOCIAL HISTORY: The patient lives in 6094 Lang Crest New Jennifer, NV 06275 skilled nursing facility. Her son lives locally, daughter is on the west coast. Minimal alcohol history and remote tobacco. The patient has a son with Travis Beamon disease. PHYSICAL EXAMINATION: On arrival her temperature was 98, blood pressure 160/80, heart rate 80s, respiratory rate 16, saturating 95% on two liters. General: She was a well-appearing, elderly, frail woman. HEENT: She had crusted blood in her oropharynx. Pupils equal, round and reactive to light. Sclerae anicteric. Neck: Supple, with no lymphadenopathy. Chest: Examination revealed decreased breath sounds at the left base and bronchial breath sounds at the right base. Cardiac: There was a 8-24 crescendo/decrescendo systolic murmur at the right upper sternal border without radiation. Abdomen: Benign, positive bowel sounds, nontender. There was no fluid wave. No liver edge was appreciated. Extremities: There was no peripheral edema. Skin: There was no jaundice notable. Neurologic: The patient was alert and oriented x 3, otherwise nonfocal. LABORATORY DATA: On the morning of admission white count was 10.8, hematocrit 31.9, which had been up from 22 earlier in the morning, platelet count 68, which was around her baseline, SMA-7 was unremarkable. BUN and creatinine were normal. INR was 1.3. PT 14.1, PTT 32.8, fibrinogen was 161, albumin 3.2. ALT, AST, and alkaline phosphatase were within normal limits. Total bilirubin was 2.1. Urinalysis on the morning of arrival had been negative. EKG showed sinus tachycardia at 24223 Mills Walks Suite 516 Smithburgh, CT 43461 depressions in 2, 3, aVF, V4 to V6, but no acute change compared to old. HOSPITAL COURSE: 1. Upper GI bleed/variceal bleed: Patient was thought to have cirrhosis of unclear etiology with new ascites and new splenomegaly on recent abdominal CT, and on endoscopy at the outside hospital, portal gastropathy and esophageal varices were found. The patient was initially transferred to Brown-Davis Clinic for evaluation for emerging TIPS. The patient had a type and cross with four units of red cells and fresh frozen plasma on hold. She had a central line in her left neck as well as a right EJ. She was continued on octreotide drip at 50 mcg per hour. She was continued on Protonix 40 IV b.i.d. Her coagulopathy, her hematocrit and platelet count were corrected with products as needed. The patient was evaluated by the liver team, who felt that given her comfortable status and high risk of precipitating encephalopathy, TIPS would not be the best strategy; rather the patient was observed on octreotide drip. Her daughter and son were available as well as the patient during this conversation and agreed that conservative management of her varices was the best route. The patient was continued on octreotide drip for the plan of five days, and was continued on Protonix IV b.i.d. She was started on nadolol for further decrease of her portal hypertension, and a work-up was initiated for her etiology of cirrhosis including hepatitis panel, Teressa, SPEP, and antimitochondrial antibody. A right upper quadrant ultrasound was performed that revealed no evidence of portal vein thrombus and a cirrhotic liver. The patient had no further episodes of hematemesis during her hospitalization. Her hematocrit remained stable throughout her hospitalization. 2. Mental status change: The patient initially was alert and oriented upon arrival, however became delirious within 24 hours of her hospitalization. Further work-up revealed a positive urinalysis consistent with a urinary tract infection, probably catheter related. The patient also had 4/4 bottles positive for gram-positive cocci in clusters in her blood, which were drawn off a left IJ, consistent with a line infection with sepsis. The patient had already been DNR, however now the patient's code status after discussion with her daughter and son, was changed to DNR/DNI, and made comfort measures. No antibiotics were given for her line infection. The line was not changed due to the morbidity involved in a central line procedure, and unfortunately, the passed away likely due to overwhelming sepsis both from line infection and urinary tract infection. The patient was pronounced at 10:20 PM on 2013-1-22. Daughter and son were present at the bedside. DISCHARGE DIAGNOSES: 1. Line infection/sepsis. 2. Urinary tract infection. 3. Variceal bleed/hemorrhage. 4. New diagnosis of cirrhosis in addition to her diagnoses on arrival. Jessie Hazelwood Keiko Prieto, M.D. 60519753 Dictated By:Kayla Moore MEDQUIST36 D: 2001-6-17 11:09 T: 1903-9-22 07:14 JOB#: Carpenter, Kelly and Larson-2018-595603	["Admission Date: 1949-2-28 Discharge Date: 2013-1-22\n\n\nService:\n\nCHIEF COMPLAINT: GI bleed, transfer from Coffey Group Hospital.\n\nHISTORY OF PRESENT ILLNESS: The patient is an 85-year-old\nwoman with a history of Sjogren syndrome with sicca syndrome\nand also CREST with predominant Raynaud's, history of GI\nbleed in the past thought secondary to gastritis and\narteriovenous malformations, status post left gastric and\nleft gastroduodenal artery embolizations in 11-8 and 4-13\nrespectively. She presented to Coffey Group Hospital in mid-2011-11-8 with bright red blood per rectum and an hematocrit drop\nfrom 34 to 28. Her work-up at that time consisted of an\nabdominal CT that revealed a pancolitis, increased\nsplenomegaly, and new ascites. She was transfused two units\nand discharged to rehabilitation on 1971-3-28, and then two to\nthree days prior to admission the patient noted dark stools\nand on the morning prior to admission the patient had nausea,\ndecreased appetite, and an episode of vomiting bright red\nblood.", ' She subsequently went to Coffey Group Hospital on 1953-9-25\nin the morning. In the emergency room there her systolic was\nin the 90s, hematocrit was 18, down from 28 on discharge.\nHer INR was 1.7. She had a left IJ triple-lumen catheter\nplaced, a right EJ peripheral line, and she subsequently\nunderwent EGD which revealed grade 0-1 esophageal varices,\nportal gastropathy, gastric varices, but no active bleed,\nalthough there were multiple blood clots in the stomach. She\nwas treated with IV Protonix and was started an octreotide\ndrip. She was transfused several units, which improved her\nhematocrit from 18 to 28, and then on the morning of the 27th\naround 1 AM she had a repeat episode of hematemesis, and\nnasogastric lavage did not clear after two liters of saline.\nAn emergency EGD was performed that revealed a large varix at\nthe gastroesophageal junction, and there was blood in the\nfundus.', " Sclerotherapy was attempted, which resulted in an\ninitial blood spurt, however the bleeding subsequently\nstabilized and overall during the resuscitative efforts, she\nwas given six units of red cells and four units of fresh\nfrozen plasma, and she was transferred to Williams, Alvarado and Sullivan Health System for evaluation of emerging TIPS.\n\nHere in the intensive care unit the patient was comfortable\nwith no nausea or vomiting, no further hematemesis. She\ndenied any abdominal pain.\n\nPAST MEDICAL HISTORY: 1. Sjogren's with sicca syndrome. 2.\nCREST with predominant Raynaud's. 3. History of GI bleed\nstatus post left gastric artery embolization in 11-8, and\nleft gastroduodenal artery embolization in 4-13. 4. History\nof pancolitis. 5. Recent episode of bleeding points. 6.\nIrritable bowel syndrome.", " 7. Hypertension. 8. Hashimoto's\nhypothyroidism with positive antibody. 9. Diverticulosis.\n10. History of left femoral DVT in 4-13. 11. History of\nchronic obstructive pulmonary disease/bronchitis.\n\nMEDICATIONS: 1. Octreotide drip at 50 mcg per minute. 2.\nProtonix 40 IV b.i.d. 3. Ativan p.r.n. 4. Atrovent,\nalbuterol nebulizers. 5. Vitamin K subcutaneous x 3.\n\nALLERGIES: The patient is allergic to sulfa and penicillin.\n\nSOCIAL HISTORY: The patient lives in 6094 Lang Crest\nNew Jennifer, NV 06275 skilled\nnursing facility. Her son lives locally, daughter is on the\nwest coast. Minimal alcohol history and remote tobacco. The\npatient has a son with Travis Beamon disease.\n\nPHYSICAL EXAMINATION: On arrival her temperature was 98,\nblood pressure 160/80, heart rate 80s, respiratory rate 16,\nsaturating 95% on two liters.", ' General: She was a\nwell-appearing, elderly, frail woman. HEENT: She had\ncrusted blood in her oropharynx. Pupils equal, round and\nreactive to light. Sclerae anicteric. Neck: Supple, with\nno lymphadenopathy. Chest: Examination revealed decreased\nbreath sounds at the left base and bronchial breath sounds at\nthe right base. Cardiac: There was a 8-24\ncrescendo/decrescendo systolic murmur at the right upper\nsternal border without radiation. Abdomen: Benign, positive\nbowel sounds, nontender. There was no fluid wave. No liver\nedge was appreciated. Extremities: There was no peripheral\nedema. Skin: There was no jaundice notable. Neurologic:\nThe patient was alert and oriented x 3, otherwise nonfocal.\n\nLABORATORY DATA: On the morning of admission white count was\n10.8, hematocrit 31.', '9, which had been up from 22 earlier in\nthe morning, platelet count 68, which was around her\nbaseline, SMA-7 was unremarkable. BUN and creatinine were\nnormal. INR was 1.3. PT 14.1, PTT 32.8, fibrinogen was 161,\nalbumin 3.2. ALT, AST, and alkaline phosphatase were within\nnormal limits. Total bilirubin was 2.1. Urinalysis on the\nmorning of arrival had been negative.\n\nEKG showed sinus tachycardia at 24223 Mills Walks Suite 516\nSmithburgh, CT 43461 depressions in 2,\n3, aVF, V4 to V6, but no acute change compared to old.\n\nHOSPITAL COURSE: 1. Upper GI bleed/variceal bleed: Patient\nwas thought to have cirrhosis of unclear etiology with new\nascites and new splenomegaly on recent abdominal CT, and on\nendoscopy at the outside hospital, portal gastropathy and\nesophageal varices were found. The patient was initially\ntransferred to Brown-Davis Clinic for\nevaluation for emerging TIPS.', ' The patient had a type and\ncross with four units of red cells and fresh frozen plasma on\nhold. She had a central line in her left neck as well as a\nright EJ. She was continued on octreotide drip at 50 mcg per\nhour. She was continued on Protonix 40 IV b.i.d. Her\ncoagulopathy, her hematocrit and platelet count were\ncorrected with products as needed. The patient was evaluated\nby the liver team, who felt that given her comfortable status\nand high risk of precipitating encephalopathy, TIPS would not\nbe the best strategy; rather the patient was observed on\noctreotide drip. Her daughter and son were available as well\nas the patient during this conversation and agreed that\nconservative management of her varices was the best route.\nThe patient was continued on octreotide drip for the plan of\nfive days, and was continued on Protonix IV b.', 'i.d. She was\nstarted on nadolol for further decrease of her portal\nhypertension, and a work-up was initiated for her etiology of\ncirrhosis including hepatitis panel, Teressa, SPEP, and\nantimitochondrial antibody.\n\nA right upper quadrant ultrasound was performed that revealed\nno evidence of portal vein thrombus and a cirrhotic liver.\nThe patient had no further episodes of hematemesis during her\nhospitalization. Her hematocrit remained stable throughout\nher hospitalization.\n\n2. Mental status change: The patient initially was alert and\noriented upon arrival, however became delirious within 24\nhours of her hospitalization. Further work-up revealed a\npositive urinalysis consistent with a urinary tract\ninfection, probably catheter related. The patient also had\n4/4 bottles positive for gram-positive cocci in clusters in\nher blood, which were drawn off a left IJ, consistent with a\nline infection with sepsis.', " The patient had already been\nDNR, however now the patient's code status after discussion\nwith her daughter and son, was changed to DNR/DNI, and made\ncomfort measures. No antibiotics were given for her line\ninfection. The line was not changed due to the morbidity\ninvolved in a central line procedure, and unfortunately, the\npassed away likely due to overwhelming sepsis both from line\ninfection and urinary tract infection.\n\nThe patient was pronounced at 10:20 PM on 2013-1-22. Daughter\nand son were present at the bedside.\n\nDISCHARGE DIAGNOSES:\n1. Line infection/sepsis.\n2. Urinary tract infection.\n3. Variceal bleed/hemorrhage.\n4. New diagnosis of cirrhosis in addition to her diagnoses on\narrival.\n\n\n\n\n\n\n Jessie Hazelwood Keiko Prieto, M.D. 60519753\n\nDictated By:Kayla Moore\n\nMEDQUIST36\n\nD: 2001-6-17 11:09\nT: 1903-9-22 07:14\nJOB#: Carpenter, Kelly and Larson-2018-595603\n"]
555	74913	180080.0	2193-08-07	Discharge summary	Report	Admission Date: [2193-8-5] Discharge Date: [2193-8-7] Date of Birth: [2118-7-9] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1711] Chief Complaint: s/p VF arrest Major Surgical or Invasive Procedure: A-line placement History of Present Illness: 75 yo female with DM presenting with VF arrest. Per patient's husband, patient was at home with her husband this morning. Husband was outside walking the dog, and when he walked in heard his wife call out for him then heard her collapse. He was at her side immediately, could not feel a pulse. He gave her glucagon as she has a history of hypoglycemia, with no effect. He called 911 within 5-10 minutes of finding her down. 911 responded within 2 minutes and defibrillated immediately. She received three rounds of epinephrine, intubated and started on dopamine gtt. . Initial vital signs in ED were HR 120, BP 75/p. EKG showed afib with rate [Street Address(2) 4531] depressions in V1-V5. Initial labs showed no leukocytosis, normal hematocrit and were significant for a pH of 7.17, lactate of 8.8, bicarb of 16 and glucose of 178. Patient was given a lidocaine bolus and started on a drip. She was also given levophed for further pressure support in addition to dopamine drip. She was seen by cardiology and given an amiodarone bolus and drip for rate control. Post cardiac arrest hypothermia protocol was initiated. . On arrival to the CCU, patient's VS were HR90 in SR with frequent PVCs, BP 111/55 on levophed (dopamine was discontinued prior to transfer). . According to husband, patient had no recent complaints of chest pain, shortness of breath, orthopnea or paroxysmal nocturnal dyspnea. She has known cardiac history. She is a type I diabetic and has neuropathy and diabetic retinopathy. She is legally blind. Past Medical History: 1. CARDIAC RISK FACTORS: Type I diabetes 2. CARDIAC HISTORY: - None. 3. OTHER PAST MEDICAL HISTORY: - Type I diabetes - Glaucoma - Diabetic neuropathy - Diabetic retinopathy, legally blind Social History: Lives with husband who was an ophthalmologist. Active in community. No children. - Tobacco history: Never - ETOH: Occasional - Illicit drugs: Denies Family History: Non contributory Physical Exam: Admission Physical Exam: VS: T= 94.6 (bladder) BP= 100/64 HR= 78 O2 sat= 98% on CMV- Fi02 100%, R14, PIP 23, PEEP 5, TV 500 GENERAL: Intubated, not responsive. HEENT: NCAT. NECK: C-spine collar in place CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: On ventilator. CTA anteriorly, no wheezes, ronchi, rales. ABDOMEN: Artic sun cooling device in place around abdomen. +BS, soft, ND. EXTREMITIES: Cool, good capillary refill. No lower extremity edema or venous stasis changes. PULSES: Right: Femoral 2+ DP 1+ PT 1+ Left: Femoral 2+ DP 1+ PT 1+ Pertinent Results: Admission labs: WBC 7.1 Hgb 11.8 Hct 37.0 Lactate 8.8 INR 1.1 pH 7.17 EKG ([2193-8-5] @10:26): Atrial fibrillation with rapid ventricular response, ST depressions in V1-V4 with widening of the QRS (144ms). EKG ([2193-8-5] @10:55): Atrial fibrillation with rapid ventricular response, ST depressions in V1-V6 with ST elevations in II, III, avF. Head CT ([2193-8-5]): 1. No acute intracranial process. CXR ([2193-8-5]): No acute intrathoracic process. Echo ([2193-8-5]): Mild to moderate focal LV systolic dysfunction consistent with inferior ischemia/infarction. Mild pulmonary artery systolic hypertension. EEG ([2193-8-6]): Burst suppression with seizure activity Brief Hospital Course: 75yo female with Type I diabetes s/p ventricular arrest now on post-arrest hypothermia protocol. . #s/p VF arrest: Underlying cause of VF arrest is unclear at this time. EKG was concerning for potential RCA infarction vs vasospasm. Patient treated for acute coronary syndrome given questionable EKG with [Last Name (LF) 4532], [First Name3 (LF) ] and heparin gtt. It is possible that she had an arrhythmia. Patient has no history of arrhythmia and electrolytes were all normal on arrival. Patient's last fingerstick prior to event was 73, so unlikely to have been related to hypoglycemia. Patient was pulseless for at least 5-10 minutes prior to defibrillation. On arrival to the ED, she was cooled with artic hypothermia protocol. She continued to have lots of ectopy with tachycardia. She initially required amiodarone gtt but returned to sinus rhythm. EEG showed burst suppression with seizure activity. Patient was given a loading dose of valproic acid. Patient was rewarmed after 24 hours of cooling. Following rewarming patient was in status epilepticus. Neurology was consulted and determined that the patient had a very poor likelihood of having a neurologic recovery. [Name (NI) ] husband [Name (NI) 382] decided to make patient [Name (NI) 3225]. Pressure support was withdrawn at this time. Patient was continued on fentanyl for pain, propofol for sedation and ativan for suppression of seizure activity. Ventilation support was withdrawn and the electrical activity was no longer seen on the monitor. Death was confirmed with absence of corneal reflex, pupillary response, withdrawal to painful stimuli, as well as absence of breath sounds and cardiac sounds while auscultating for 60 seconds. #Hypotension: Patient has required pressure support since she was found down. She is currently on levophed. This is likely due to cardiogenic shock in the setting of stunning myocardium. As above, patient's pressure was supported with levophed. An arterial line was placed for close hemodynamic monitoring. When the decision was made for patient to be comfort measures, levophed was discontinued. #Type I diabetes: Patient is on lantus 14-15U qAM at home. Blood sugars were controlled with home lantus dose in addition to an insulin drop. Please see death note for further information. Medications on Admission: Lantus 14U qAM Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Primary cardiac arrhythmia, respiratory failure. Death Discharge Condition: Death. Discharge Instructions: n/a Followup Instructions: n/a	Admission Date: <Date>1948-1-20</Date> Discharge Date: <Date>1923-11-2</Date> Date of Birth: <Date>1941-6-29</Date> Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:<Name>Zachary</Name> Chief Complaint: s/p VF arrest Major Surgical or Invasive Procedure: A-line placement History of Present Illness: 75 yo female with DM presenting with VF arrest. Per patient's husband, patient was at home with her husband this morning. Husband was outside walking the dog, and when he walked in heard his wife call out for him then heard her collapse. He was at her side immediately, could not feel a pulse. He gave her glucagon as she has a history of hypoglycemia, with no effect. He called 911 within 5-10 minutes of finding her down. 911 responded within 2 minutes and defibrillated immediately. She received three rounds of epinephrine, intubated and started on dopamine gtt. . Initial vital signs in ED were HR 120, BP 75/p. EKG showed afib with rate <Location>7795 Stanley Landing Marymouth, IN 92586</Location> depressions in V1-V5. Initial labs showed no leukocytosis, normal hematocrit and were significant for a pH of 7.17, lactate of 8.8, bicarb of 16 and glucose of 178. Patient was given a lidocaine bolus and started on a drip. She was also given levophed for further pressure support in addition to dopamine drip. She was seen by cardiology and given an amiodarone bolus and drip for rate control. Post cardiac arrest hypothermia protocol was initiated. . On arrival to the CCU, patient's VS were HR90 in SR with frequent PVCs, BP 111/55 on levophed (dopamine was discontinued prior to transfer). . According to husband, patient had no recent complaints of chest pain, shortness of breath, orthopnea or paroxysmal nocturnal dyspnea. She has known cardiac history. She is a type I diabetic and has neuropathy and diabetic retinopathy. She is legally blind. Past Medical History: 1. CARDIAC RISK FACTORS: Type I diabetes 2. CARDIAC HISTORY: - None. 3. OTHER PAST MEDICAL HISTORY: - Type I diabetes - Glaucoma - Diabetic neuropathy - Diabetic retinopathy, legally blind Social History: Lives with husband who was an ophthalmologist. Active in community. No children. - Tobacco history: Never - ETOH: Occasional - Illicit drugs: Denies Family History: Non contributory Physical Exam: Admission Physical Exam: VS: T= 94.6 (bladder) BP= 100/64 HR= 78 O2 sat= 98% on CMV- Fi02 100%, R14, PIP 23, PEEP 5, TV 500 GENERAL: Intubated, not responsive. HEENT: NCAT. NECK: C-spine collar in place CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: On ventilator. CTA anteriorly, no wheezes, ronchi, rales. ABDOMEN: Artic sun cooling device in place around abdomen. +BS, soft, ND. EXTREMITIES: Cool, good capillary refill. No lower extremity edema or venous stasis changes. PULSES: Right: Femoral 2+ DP 1+ PT 1+ Left: Femoral 2+ DP 1+ PT 1+ Pertinent Results: Admission labs: WBC 7.1 Hgb 11.8 Hct 37.0 Lactate 8.8 INR 1.1 pH 7.17 EKG (<Date>1948-1-20</Date> @10:26): Atrial fibrillation with rapid ventricular response, ST depressions in V1-V4 with widening of the QRS (144ms). EKG (<Date>1948-1-20</Date> @10:55): Atrial fibrillation with rapid ventricular response, ST depressions in V1-V6 with ST elevations in II, III, avF. Head CT (<Date>1948-1-20</Date>): 1. No acute intracranial process. CXR (<Date>1948-1-20</Date>): No acute intrathoracic process. Echo (<Date>1948-1-20</Date>): Mild to moderate focal LV systolic dysfunction consistent with inferior ischemia/infarction. Mild pulmonary artery systolic hypertension. EEG (<Date>2002-3-24</Date>): Burst suppression with seizure activity Brief Hospital Course: 75yo female with Type I diabetes s/p ventricular arrest now on post-arrest hypothermia protocol. . #s/p VF arrest: Underlying cause of VF arrest is unclear at this time. EKG was concerning for potential RCA infarction vs vasospasm. Patient treated for acute coronary syndrome given questionable EKG with <Name>Post</Name>, <Name>Marvin</Name> and heparin gtt. It is possible that she had an arrhythmia. Patient has no history of arrhythmia and electrolytes were all normal on arrival. Patient's last fingerstick prior to event was 73, so unlikely to have been related to hypoglycemia. Patient was pulseless for at least 5-10 minutes prior to defibrillation. On arrival to the ED, she was cooled with artic hypothermia protocol. She continued to have lots of ectopy with tachycardia. She initially required amiodarone gtt but returned to sinus rhythm. EEG showed burst suppression with seizure activity. Patient was given a loading dose of valproic acid. Patient was rewarmed after 24 hours of cooling. Following rewarming patient was in status epilepticus. Neurology was consulted and determined that the patient had a very poor likelihood of having a neurologic recovery. <Name>Griselda Cobbs</Name> husband <Name>Rama Walker</Name> decided to make patient <Name>Jessie Pleasant</Name>. Pressure support was withdrawn at this time. Patient was continued on fentanyl for pain, propofol for sedation and ativan for suppression of seizure activity. Ventilation support was withdrawn and the electrical activity was no longer seen on the monitor. Death was confirmed with absence of corneal reflex, pupillary response, withdrawal to painful stimuli, as well as absence of breath sounds and cardiac sounds while auscultating for 60 seconds. #Hypotension: Patient has required pressure support since she was found down. She is currently on levophed. This is likely due to cardiogenic shock in the setting of stunning myocardium. As above, patient's pressure was supported with levophed. An arterial line was placed for close hemodynamic monitoring. When the decision was made for patient to be comfort measures, levophed was discontinued. #Type I diabetes: Patient is on lantus 14-15U qAM at home. Blood sugars were controlled with home lantus dose in addition to an insulin drop. Please see death note for further information. Medications on Admission: Lantus 14U qAM Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Primary cardiac arrhythmia, respiratory failure. Death Discharge Condition: Death. Discharge Instructions: n/a Followup Instructions: 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0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000	Admission Date: 1948-1-20 Discharge Date: 1923-11-2 Date of Birth: 1941-6-29 Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:Zachary Chief Complaint: s/p VF arrest Major Surgical or Invasive Procedure: A-line placement History of Present Illness: 75 yo female with DM presenting with VF arrest. Per patient's husband, patient was at home with her husband this morning. Husband was outside walking the dog, and when he walked in heard his wife call out for him then heard her collapse. He was at her side immediately, could not feel a pulse. He gave her glucagon as she has a history of hypoglycemia, with no effect. He called 911 within 5-10 minutes of finding her down. 911 responded within 2 minutes and defibrillated immediately. She received three rounds of epinephrine, intubated and started on dopamine gtt. . Initial vital signs in ED were HR 120, BP 75/p. EKG showed afib with rate 7795 Stanley Landing Marymouth, IN 92586 depressions in V1-V5. Initial labs showed no leukocytosis, normal hematocrit and were significant for a pH of 7.17, lactate of 8.8, bicarb of 16 and glucose of 178. Patient was given a lidocaine bolus and started on a drip. She was also given levophed for further pressure support in addition to dopamine drip. She was seen by cardiology and given an amiodarone bolus and drip for rate control. Post cardiac arrest hypothermia protocol was initiated. . On arrival to the CCU, patient's VS were HR90 in SR with frequent PVCs, BP 111/55 on levophed (dopamine was discontinued prior to transfer). . According to husband, patient had no recent complaints of chest pain, shortness of breath, orthopnea or paroxysmal nocturnal dyspnea. She has known cardiac history. She is a type I diabetic and has neuropathy and diabetic retinopathy. She is legally blind. Past Medical History: 1. CARDIAC RISK FACTORS: Type I diabetes 2. CARDIAC HISTORY: - None. 3. OTHER PAST MEDICAL HISTORY: - Type I diabetes - Glaucoma - Diabetic neuropathy - Diabetic retinopathy, legally blind Social History: Lives with husband who was an ophthalmologist. Active in community. No children. - Tobacco history: Never - ETOH: Occasional - Illicit drugs: Denies Family History: Non contributory Physical Exam: Admission Physical Exam: VS: T= 94.6 (bladder) BP= 100/64 HR= 78 O2 sat= 98% on CMV- Fi02 100%, R14, PIP 23, PEEP 5, TV 500 GENERAL: Intubated, not responsive. HEENT: NCAT. NECK: C-spine collar in place CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: On ventilator. CTA anteriorly, no wheezes, ronchi, rales. ABDOMEN: Artic sun cooling device in place around abdomen. +BS, soft, ND. EXTREMITIES: Cool, good capillary refill. No lower extremity edema or venous stasis changes. PULSES: Right: Femoral 2+ DP 1+ PT 1+ Left: Femoral 2+ DP 1+ PT 1+ Pertinent Results: Admission labs: WBC 7.1 Hgb 11.8 Hct 37.0 Lactate 8.8 INR 1.1 pH 7.17 EKG (1948-1-20 @10:26): Atrial fibrillation with rapid ventricular response, ST depressions in V1-V4 with widening of the QRS (144ms). EKG (1948-1-20 @10:55): Atrial fibrillation with rapid ventricular response, ST depressions in V1-V6 with ST elevations in II, III, avF. Head CT (1948-1-20): 1. No acute intracranial process. CXR (1948-1-20): No acute intrathoracic process. Echo (1948-1-20): Mild to moderate focal LV systolic dysfunction consistent with inferior ischemia/infarction. Mild pulmonary artery systolic hypertension. EEG (2002-3-24): Burst suppression with seizure activity Brief Hospital Course: 75yo female with Type I diabetes s/p ventricular arrest now on post-arrest hypothermia protocol. . #s/p VF arrest: Underlying cause of VF arrest is unclear at this time. EKG was concerning for potential RCA infarction vs vasospasm. Patient treated for acute coronary syndrome given questionable EKG with Post, Marvin and heparin gtt. It is possible that she had an arrhythmia. Patient has no history of arrhythmia and electrolytes were all normal on arrival. Patient's last fingerstick prior to event was 73, so unlikely to have been related to hypoglycemia. Patient was pulseless for at least 5-10 minutes prior to defibrillation. On arrival to the ED, she was cooled with artic hypothermia protocol. She continued to have lots of ectopy with tachycardia. She initially required amiodarone gtt but returned to sinus rhythm. EEG showed burst suppression with seizure activity. Patient was given a loading dose of valproic acid. Patient was rewarmed after 24 hours of cooling. Following rewarming patient was in status epilepticus. Neurology was consulted and determined that the patient had a very poor likelihood of having a neurologic recovery. Griselda Cobbs husband Rama Walker decided to make patient Jessie Pleasant. Pressure support was withdrawn at this time. Patient was continued on fentanyl for pain, propofol for sedation and ativan for suppression of seizure activity. Ventilation support was withdrawn and the electrical activity was no longer seen on the monitor. Death was confirmed with absence of corneal reflex, pupillary response, withdrawal to painful stimuli, as well as absence of breath sounds and cardiac sounds while auscultating for 60 seconds. #Hypotension: Patient has required pressure support since she was found down. She is currently on levophed. This is likely due to cardiogenic shock in the setting of stunning myocardium. As above, patient's pressure was supported with levophed. An arterial line was placed for close hemodynamic monitoring. When the decision was made for patient to be comfort measures, levophed was discontinued. #Type I diabetes: Patient is on lantus 14-15U qAM at home. Blood sugars were controlled with home lantus dose in addition to an insulin drop. Please see death note for further information. Medications on Admission: Lantus 14U qAM Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Primary cardiac arrhythmia, respiratory failure. Death Discharge Condition: Death. Discharge Instructions: n/a Followup Instructions: n/a	["Admission Date: 1948-1-20 Discharge Date: 1923-11-2\n\nDate of Birth: 1941-6-29 Sex: F\n\nService: MEDICINE\n\nAllergies:\nSulfa (Sulfonamide Antibiotics)\n\nAttending:Zachary\nChief Complaint:\ns/p VF arrest\n\nMajor Surgical or Invasive Procedure:\nA-line placement\n\nHistory of Present Illness:\n75 yo female with DM presenting with VF arrest. Per patient's\nhusband, patient was at home with her husband this morning.\nHusband was outside walking the dog, and when he walked in heard\nhis wife call out for him then heard her collapse. He was at\nher side immediately, could not feel a pulse. He gave her\nglucagon as she has a history of hypoglycemia, with no effect.\nHe called 911 within 5-10 minutes of finding her down. 911\nresponded within 2 minutes and defibrillated immediately.", " She\nreceived three rounds of epinephrine, intubated and started on\ndopamine gtt.\n.\nInitial vital signs in ED were HR 120, BP 75/p. EKG showed afib\nwith rate 7795 Stanley Landing\nMarymouth, IN 92586 depressions in V1-V5. Initial labs showed\nno leukocytosis, normal hematocrit and were significant for a pH\nof 7.17, lactate of 8.8, bicarb of 16 and glucose of 178.\nPatient was given a lidocaine bolus and started on a drip. She\nwas also given levophed for further pressure support in addition\nto dopamine drip. She was seen by cardiology and given an\namiodarone bolus and drip for rate control. Post cardiac arrest\nhypothermia protocol was initiated.\n.\nOn arrival to the CCU, patient's VS were HR90 in SR with\nfrequent PVCs, BP 111/55 on levophed (dopamine was discontinued\nprior to transfer).\n.\nAccording to husband, patient had no recent complaints of chest\npain, shortness of breath, orthopnea or paroxysmal nocturnal\ndyspnea.", ' She has known cardiac history. She is a type I\ndiabetic and has neuropathy and diabetic retinopathy. She is\nlegally blind.\n\n\nPast Medical History:\n1. CARDIAC RISK FACTORS: Type I diabetes\n2. CARDIAC HISTORY:\n- None.\n3. OTHER PAST MEDICAL HISTORY:\n- Type I diabetes\n- Glaucoma\n- Diabetic neuropathy\n- Diabetic retinopathy, legally blind\n\nSocial History:\nLives with husband who was an ophthalmologist. Active in\ncommunity. No children.\n- Tobacco history: Never\n- ETOH: Occasional\n- Illicit drugs: Denies\n\nFamily History:\nNon contributory\n\nPhysical Exam:\nAdmission Physical Exam:\nVS: T= 94.6 (bladder) BP= 100/64 HR= 78\nO2 sat= 98% on CMV- Fi02 100%, R14, PIP 23, PEEP 5, TV 500\nGENERAL: Intubated, not responsive.\nHEENT: NCAT.\nNECK: C-spine collar in place\nCARDIAC: PMI located in 5th intercostal space, midclavicular\nline.', ' RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or\nS4.\nLUNGS: On ventilator. CTA anteriorly, no wheezes, ronchi, rales.\nABDOMEN: Artic sun cooling device in place around abdomen. +BS,\nsoft, ND.\nEXTREMITIES: Cool, good capillary refill. No lower extremity\nedema or venous stasis changes.\nPULSES:\nRight: Femoral 2+ DP 1+ PT 1+\nLeft: Femoral 2+ DP 1+ PT 1+\n\n\nPertinent Results:\nAdmission labs:\nWBC 7.1 Hgb 11.8 Hct 37.0\nLactate 8.8\nINR 1.1\npH 7.17\n\nEKG (1948-1-20 @10:26): Atrial fibrillation with rapid ventricular\nresponse, ST depressions in V1-V4 with widening of the QRS\n(144ms).\n\nEKG (1948-1-20 @10:55): Atrial fibrillation with rapid ventricular\nresponse, ST depressions in V1-V6 with ST elevations in II, III,\navF.\n\nHead CT (1948-1-20): 1. No acute intracranial process.\n\nCXR (1948-1-20): No acute intrathoracic process.', "\n\nEcho (1948-1-20): Mild to moderate focal LV systolic dysfunction\nconsistent with inferior ischemia/infarction. Mild pulmonary\nartery systolic hypertension.\n\nEEG (2002-3-24): Burst suppression with seizure activity\n\n\nBrief Hospital Course:\n75yo female with Type I diabetes s/p ventricular arrest now on\npost-arrest hypothermia protocol.\n.\n#s/p VF arrest: Underlying cause of VF arrest is unclear at\nthis time. EKG was concerning for potential RCA infarction vs\nvasospasm. Patient treated for acute coronary syndrome given\nquestionable EKG with Post, Marvin and heparin gtt. It is\npossible that she had an arrhythmia. Patient has no history of\narrhythmia and electrolytes were all normal on arrival.\nPatient's last fingerstick prior to event was 73, so unlikely to\nhave been related to hypoglycemia.", ' Patient was pulseless for at\nleast 5-10 minutes prior to defibrillation. On arrival to the\nED, she was cooled with artic hypothermia protocol. She\ncontinued to have lots of ectopy with tachycardia. She initially\nrequired amiodarone gtt but returned to sinus rhythm. EEG showed\nburst suppression with seizure activity. Patient was given a\nloading dose of valproic acid. Patient was rewarmed after 24\nhours of cooling. Following rewarming patient was in status\nepilepticus. Neurology was consulted and determined that the\npatient had a very poor likelihood of having a neurologic\nrecovery. Griselda Cobbs husband Rama Walker decided to make patient Jessie Pleasant.\nPressure support was withdrawn at this time. Patient was\ncontinued on fentanyl for pain, propofol for sedation and ativan\nfor suppression of seizure activity.', " Ventilation support was\nwithdrawn and the electrical activity was no longer seen on the\nmonitor. Death was confirmed with absence of corneal reflex,\npupillary response, withdrawal to painful stimuli, as well as\nabsence of breath sounds and cardiac sounds while auscultating\nfor 60 seconds.\n\n#Hypotension: Patient has required pressure support since she\nwas found down. She is currently on levophed. This is likely\ndue to cardiogenic shock in the setting of stunning myocardium.\nAs above, patient's pressure was supported with levophed. An\narterial line was placed for close hemodynamic monitoring. When\nthe decision was made for patient to be comfort measures,\nlevophed was discontinued.\n\n#Type I diabetes: Patient is on lantus 14-15U qAM at home.\nBlood sugars were controlled with home lantus dose in addition\nto an insulin drop.", '\n\nPlease see death note for further information.\n\nMedications on Admission:\nLantus 14U qAM\n\nDischarge Medications:\nNone.\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\nPrimary cardiac arrhythmia, respiratory failure. Death\n\nDischarge Condition:\nDeath.\n\nDischarge Instructions:\nn/a\n\nFollowup Instructions:\nn/a\n\n\n']
556	90363	171833.0	2157-05-21	Discharge summary	Report	Admission Date: [2157-5-16] Discharge Date: [2157-5-21] Date of Birth: [2088-4-1] Sex: F Service: UROLOGY Allergies: Aspirin / Motrin / Trilisate / Naprosyn / Toradol / Vicodin / Percocet / Indocin / Dilaudid / Zomig Attending:[First Name3 (LF) 4533] Chief Complaint: Kidney stone Major Surgical or Invasive Procedure: Left pyeloscopy with laser lithotripsy and stent exchange, [2157-5-16], Dr. [First Name (STitle) ] Flexible sigmoidoscopy, [2157-5-20], GI service. PICC, [2157-5-21] History of Present Illness: Ms. [Known lastname ] is a 69-year-old female who presented in [Month (only) 958] with an obstructing 5-mm left UPJ stone with mild hydronephrosis. She was managed at that time with stent placement and delayed stone management given acute diverticulitis at that time. The patient presented on admission for definitive stone management and she elected to undergo ureteroscopy with laser lithotripsy and stent change. Of note, on preoperative testing she had a white count of 19.0. Given concern for diverticulitis, she was given ceftriaxone and Flagyl before the time of surgery and was scheduled to be admitted for observation. Past Medical History: NIDDM, HTN, hypercholesterolemia Incisional ventral hernia repair [5-16] TAH '[30] R knee arthroscopy Social History: non-contributory Family History: non-contributory Physical Exam: Discharge Exam: AVSS Gen: NAD CV: RRR Resp: CTA-B Abd: obese, s/nt/nd; no CVA tenderness bilaterally Extr: no c/c/e T/L/D: PICC in place Pertinent Results: [2157-5-20] 06:20AM BLOOD WBC-10.7 RBC-3.29* Hgb-8.7* Hct-26.2* MCV-80* MCH-26.4* MCHC-33.1 RDW-15.8* Plt Ct-371 [2157-5-20] 06:20AM BLOOD Glucose-140* UreaN-22* Creat-1.6* Na-137 K-3.6 Cl-109* HCO3-16* AnGap-16 [2157-5-20] 06:20AM BLOOD ALT-19 AST-13 LD(LDH)-198 AlkPhos-75 TotBili-0.3 [2157-5-18] 03:00PM BLOOD Lactate-0.9 Na-134* K-3.5 Cl-109 [2157-5-19] 7:28 pm STOOL CONSISTENCY: LOOSE Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): OVA + PARASITES (Pending): CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2157-5-19]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [2157-5-16] 3:49 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Preliminary): PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. DR [First Name (STitle) ] REQUESTED SENSITIVITIES TO AZTREONAM AND COLISTIN [2157-5-19]. RESISTANT TO AZTREONAM sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENT TO [Hospital1 4534] LABORATORIES FOR COLISTIN SUSCEPTIBILITY. YEAST, PRESUMPTIVELY NOT C. ALBICANS. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| AMIKACIN-------------- 4 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ =>16 R Aerobic Bottle Gram Stain (Final [2157-5-17]): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO [Last Name (LF) ], [First Name3 (LF) ] @ 1621 ON [2157-5-17]. Anaerobic Bottle Gram Stain (Final [2157-5-19]): REPORTED BY PHONE TO DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] PAGER [Numeric Identifier 4535] @ 0707 ON [2157-5-18]. BUDDING YEAST. GRAM NEGATIVE ROD(S). [2157-5-16] 8:49 pm BLOOD CULTURE Source: Line-PIV #2. Blood Culture, Routine (Preliminary): YEAST, PRESUMPTIVELY NOT C. ALBICANS. Anaerobic Bottle Gram Stain (Final [2157-5-19]): BUDDING YEAST. [2157-5-17] 8:15 pm BLOOD CULTURE Source: Line-radial artery. Blood Culture, Routine (Preliminary): YEAST. Anaerobic Bottle Gram Stain (Final [2157-5-20]): BUDDING YEAST. [2157-5-18] 6:08 am BLOOD CULTURE Source: Line-radial artery. Blood Culture, Routine (Preliminary): YEAST. Anaerobic Bottle Gram Stain (Final [2157-5-20]): BUDDING YEAST. BCx [Date range (1) 4536]: NGTD [2157-5-16] 6:37 pm URINE Source: CVS. FINAL REPORT [2157-5-17] URINE CULTURE (Final [2157-5-17]): YEAST. 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: Ms. [Known lastname ] was admitted after siagnostic pyeloscopy, left ureteroscopy with laser lithotripsy, left ureteral stent exchange on [2157-5-16]. In the PACU, developed fever to 103 and rigors, brought to ICU for observation and broad spectrum antibiotics. Blood cultures identified yeast and multi-drug resistant pseudomonas, urine culture identified yeast; PICC placed [2157-5-21]; managed with zosyn and micafungin and followed by ID team. Opthomology examined her and found no evidence of fungal infection of the eye. She noted loose stools over the last few months, started on low-residue diet and seen by nutririon; flexible sigmoidoscopy identified polyps, started on immodium with improvement of loose stools, to follow-up in GI fellow's clinic for colonoscopy and biopsy reports within the next month. Her metformin has been held given Cr >1.4, diabetes managed with addition of an insulin sliding scale. Foley removed POD4 and voiding without difficulty. At discharge patient without pain and improvement in loose stools, afebrile with no leukocytosis, tolerating low-residual diet, FSBS under 250, ambulating without assistance, and voiding without difficulty. She is being traanferred to [Hospital1 1501] for continued IV antibiotics and diabetes management under care of her PCP who is an ID specialist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. She will follow-up with Dr. [First Name (STitle) ] for stent removal prior to completion of her antibiotics, call for appointment. Medications on Admission: MEDS: Metformin 1000mg [Hospital1 ] Lisinopril/HCTZ 20mg/12.5mg daily Glipizide XL 10mg DAILY Lipitor 80mg DAILY Atenolol 25mg DAILY Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain, fever. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 6. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale Subcutaneous ASDIR (AS DIRECTED): continue until able to restart metformin. 10. Micafungin 50 mg Recon Soln Sig: One (1) Recon Soln Intravenous DAILY (Daily) for 1 weeks. 11. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q6H (every 6 hours) for 1 weeks. 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for PRN diarrhea. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Fungemia, bactermia, sigmoid polyp Discharge Condition: Stable Discharge Instructions: Continue IV zosyn and micafungin as prescribed until urine and blood cultures are finalized, check LFTs weekly while on these medications, antibiotics and duration per accepting physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Call Dr. [First Name (STitle) ] to schedule stent removal, [Telephone/Fax (1) 4537]. Call [Hospital ] clinic to schedule colonoscopy, [Telephone/Fax (1) 4538]. Followup Instructions: Call Dr. [First Name (STitle) ] for stent removal and with any urological questions. [Telephone/Fax (1) 4537] Call [Hospital ] clinic to schedule colonoscopy and review biopsy results within 1 month with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4539] (Fellow's clinic) [Telephone/Fax (1) 4538].	Admission Date: <Date>2014-8-13</Date> Discharge Date: <Date>1982-8-30</Date> Date of Birth: <Date>1911-5-29</Date> Sex: F Service: UROLOGY Allergies: Aspirin / Motrin / Trilisate / Naprosyn / Toradol / Vicodin / Percocet / Indocin / Dilaudid / Zomig Attending:<Name>Susana</Name> Chief Complaint: Kidney stone Major Surgical or Invasive Procedure: Left pyeloscopy with laser lithotripsy and stent exchange, <Date>2014-8-13</Date>, Dr. <Name>Emory</Name> Flexible sigmoidoscopy, <Date>2000-9-1</Date>, GI service. PICC, <Date>1982-8-30</Date> History of Present Illness: Ms. <Name>Lyna</Name> is a 69-year-old female who presented in <Month>July</Month> with an obstructing 5-mm left UPJ stone with mild hydronephrosis. She was managed at that time with stent placement and delayed stone management given acute diverticulitis at that time. The patient presented on admission for definitive stone management and she elected to undergo ureteroscopy with laser lithotripsy and stent change. Of note, on preoperative testing she had a white count of 19.0. Given concern for diverticulitis, she was given ceftriaxone and Flagyl before the time of surgery and was scheduled to be admitted for observation. Past Medical History: NIDDM, HTN, hypercholesterolemia Incisional ventral hernia repair <Date>2-3</Date> TAH '<Digit>23</Digit> R knee arthroscopy Social History: non-contributory Family History: non-contributory Physical Exam: Discharge Exam: AVSS Gen: NAD CV: RRR Resp: CTA-B Abd: obese, s/nt/nd; no CVA tenderness bilaterally Extr: no c/c/e T/L/D: PICC in place Pertinent Results: <Date>2000-9-1</Date> 06:20AM BLOOD WBC-10.7 RBC-3.29* Hgb-8.7* Hct-26.2* MCV-80* MCH-26.4* MCHC-33.1 RDW-15.8* Plt Ct-371 <Date>2000-9-1</Date> 06:20AM BLOOD Glucose-140* UreaN-22* Creat-1.6* Na-137 K-3.6 Cl-109* HCO3-16* AnGap-16 <Date>2000-9-1</Date> 06:20AM BLOOD ALT-19 AST-13 LD(LDH)-198 AlkPhos-75 TotBili-0.3 <Date>2020-12-25</Date> 03:00PM BLOOD Lactate-0.9 Na-134* K-3.5 Cl-109 <Date>1999-10-5</Date> 7:28 pm STOOL CONSISTENCY: LOOSE Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): OVA + PARASITES (Pending): CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final <Date>1999-10-5</Date>): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). <Date>2014-8-13</Date> 3:49 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Preliminary): PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. DR <Name>Emory</Name> REQUESTED SENSITIVITIES TO AZTREONAM AND COLISTIN <Date>1999-10-5</Date>. RESISTANT TO AZTREONAM sensitivity testing performed by <Name>Reginald</Name> <Name>Clapp</Name>. SENT TO <Hospital>Thompson-Horton Hospital</Hospital> LABORATORIES FOR COLISTIN SUSCEPTIBILITY. YEAST, PRESUMPTIVELY NOT C. ALBICANS. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| AMIKACIN-------------- 4 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ =>16 R Aerobic Bottle Gram Stain (Final <Date>1978-11-8</Date>): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO <Name>Grose</Name>, <Name>Celeste</Name> @ 1621 ON <Date>1978-11-8</Date>. Anaerobic Bottle Gram Stain (Final <Date>1999-10-5</Date>): REPORTED BY PHONE TO DR. <Name>Nikolai</Name> <Name>Kaur</Name> PAGER <Numeric Identifier>7977058</Numeric Identifier> @ 0707 ON <Date>2020-12-25</Date>. BUDDING YEAST. GRAM NEGATIVE ROD(S). <Date>2014-8-13</Date> 8:49 pm BLOOD CULTURE Source: Line-PIV #2. Blood Culture, Routine (Preliminary): YEAST, PRESUMPTIVELY NOT C. ALBICANS. Anaerobic Bottle Gram Stain (Final <Date>1999-10-5</Date>): BUDDING YEAST. <Date>1978-11-8</Date> 8:15 pm BLOOD CULTURE Source: Line-radial artery. Blood Culture, Routine (Preliminary): YEAST. Anaerobic Bottle Gram Stain (Final <Date>2000-9-1</Date>): BUDDING YEAST. <Date>2020-12-25</Date> 6:08 am BLOOD CULTURE Source: Line-radial artery. Blood Culture, Routine (Preliminary): YEAST. Anaerobic Bottle Gram Stain (Final <Date>2000-9-1</Date>): BUDDING YEAST. BCx <Date Range>1939-10-24 to 1996-12-25</Date Range>: NGTD <Date>2014-8-13</Date> 6:37 pm URINE Source: CVS. FINAL REPORT <Date>1978-11-8</Date> URINE CULTURE (Final <Date>1978-11-8</Date>): YEAST. 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: Ms. <Name>Lyna</Name> was admitted after siagnostic pyeloscopy, left ureteroscopy with laser lithotripsy, left ureteral stent exchange on <Date>2014-8-13</Date>. In the PACU, developed fever to 103 and rigors, brought to ICU for observation and broad spectrum antibiotics. Blood cultures identified yeast and multi-drug resistant pseudomonas, urine culture identified yeast; PICC placed <Date>1982-8-30</Date>; managed with zosyn and micafungin and followed by ID team. Opthomology examined her and found no evidence of fungal infection of the eye. She noted loose stools over the last few months, started on low-residue diet and seen by nutririon; flexible sigmoidoscopy identified polyps, started on immodium with improvement of loose stools, to follow-up in GI fellow's clinic for colonoscopy and biopsy reports within the next month. Her metformin has been held given Cr >1.4, diabetes managed with addition of an insulin sliding scale. Foley removed POD4 and voiding without difficulty. At discharge patient without pain and improvement in loose stools, afebrile with no leukocytosis, tolerating low-residual diet, FSBS under 250, ambulating without assistance, and voiding without difficulty. She is being traanferred to <Hospital>Jones-Riley Clinic</Hospital> for continued IV antibiotics and diabetes management under care of her PCP who is an ID specialist, Dr. <Name>Bradley</Name> <Name>Kaur</Name>. She will follow-up with Dr. <Name>Emory</Name> for stent removal prior to completion of her antibiotics, call for appointment. Medications on Admission: MEDS: Metformin 1000mg <Hospital>Smith Inc Hospital</Hospital> Lisinopril/HCTZ 20mg/12.5mg daily Glipizide XL 10mg DAILY Lipitor 80mg DAILY Atenolol 25mg DAILY Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain, fever. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 6. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale Subcutaneous ASDIR (AS DIRECTED): continue until able to restart metformin. 10. Micafungin 50 mg Recon Soln Sig: One (1) Recon Soln Intravenous DAILY (Daily) for 1 weeks. 11. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q6H (every 6 hours) for 1 weeks. 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for PRN diarrhea. Discharge Disposition: Extended Care Facility: <Hospital>Henderson Inc Clinic</Hospital> - <Location>Unit 0570 Box 4853 DPO AA 12136</Location> Discharge Diagnosis: Fungemia, bactermia, sigmoid polyp Discharge Condition: Stable Discharge Instructions: Continue IV zosyn and micafungin as prescribed until urine and blood cultures are finalized, check LFTs weekly while on these medications, antibiotics and duration per accepting physician <Name>Lees</Name>. <Name>Bradley</Name> <Name>Kaur</Name>. Call Dr. <Name>Emory</Name> to schedule stent removal, <Telephone>541-246-6856</Telephone>. Call <Hospital>Mckay PLC Health System</Hospital> clinic to schedule colonoscopy, <Telephone>801-415-1353</Telephone>. Followup Instructions: Call Dr. <Name>Emory</Name> for stent removal and with any urological questions. <Telephone>541-246-6856</Telephone> Call <Hospital>Mckay PLC Health System</Hospital> clinic to schedule colonoscopy and review biopsy results within 1 month with Dr. <Name>Nikolai</Name> <Name>Grose</Name> (Fellow's clinic) <Telephone>801-415-1353</Telephone>.	00000000000000000111111111000000000000000000000000000000001111111110000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000111110000000000000000000000000111111110000000000000000000011111111100000000000000000000000000000000000111100000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111000000110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000011111111000000000011111000000000001111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000>000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000011111001111111000000000001111111110000000000000000000000000000000000000000011111111100000000000000000000000000000000001111111011110000000111111100000000000000000111111111100000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000001111111111111111111111110000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 2014-8-13 Discharge Date: 1982-8-30 Date of Birth: 1911-5-29 Sex: F Service: UROLOGY Allergies: Aspirin / Motrin / Trilisate / Naprosyn / Toradol / Vicodin / Percocet / Indocin / Dilaudid / Zomig Attending:Susana Chief Complaint: Kidney stone Major Surgical or Invasive Procedure: Left pyeloscopy with laser lithotripsy and stent exchange, 2014-8-13, Dr. Emory Flexible sigmoidoscopy, 2000-9-1, GI service. PICC, 1982-8-30 History of Present Illness: Ms. Lyna is a 69-year-old female who presented in July with an obstructing 5-mm left UPJ stone with mild hydronephrosis. She was managed at that time with stent placement and delayed stone management given acute diverticulitis at that time. The patient presented on admission for definitive stone management and she elected to undergo ureteroscopy with laser lithotripsy and stent change. Of note, on preoperative testing she had a white count of 19.0. Given concern for diverticulitis, she was given ceftriaxone and Flagyl before the time of surgery and was scheduled to be admitted for observation. Past Medical History: NIDDM, HTN, hypercholesterolemia Incisional ventral hernia repair 2-3 TAH '23 R knee arthroscopy Social History: non-contributory Family History: non-contributory Physical Exam: Discharge Exam: AVSS Gen: NAD CV: RRR Resp: CTA-B Abd: obese, s/nt/nd; no CVA tenderness bilaterally Extr: no c/c/e T/L/D: PICC in place Pertinent Results: 2000-9-1 06:20AM BLOOD WBC-10.7 RBC-3.29* Hgb-8.7* Hct-26.2* MCV-80* MCH-26.4* MCHC-33.1 RDW-15.8* Plt Ct-371 2000-9-1 06:20AM BLOOD Glucose-140* UreaN-22* Creat-1.6* Na-137 K-3.6 Cl-109* HCO3-16* AnGap-16 2000-9-1 06:20AM BLOOD ALT-19 AST-13 LD(LDH)-198 AlkPhos-75 TotBili-0.3 2020-12-25 03:00PM BLOOD Lactate-0.9 Na-134* K-3.5 Cl-109 1999-10-5 7:28 pm STOOL CONSISTENCY: LOOSE Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): OVA + PARASITES (Pending): CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final 1999-10-5): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). 2014-8-13 3:49 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Preliminary): PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. DR Emory REQUESTED SENSITIVITIES TO AZTREONAM AND COLISTIN 1999-10-5. RESISTANT TO AZTREONAM sensitivity testing performed by Reginald Clapp. SENT TO Thompson-Horton Hospital LABORATORIES FOR COLISTIN SUSCEPTIBILITY. YEAST, PRESUMPTIVELY NOT C. ALBICANS. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| AMIKACIN-------------- 4 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ =>16 R Aerobic Bottle Gram Stain (Final 1978-11-8): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO Grose, Celeste @ 1621 ON 1978-11-8. Anaerobic Bottle Gram Stain (Final 1999-10-5): REPORTED BY PHONE TO DR. Nikolai Kaur PAGER 7977058 @ 0707 ON 2020-12-25. BUDDING YEAST. GRAM NEGATIVE ROD(S). 2014-8-13 8:49 pm BLOOD CULTURE Source: Line-PIV #2. Blood Culture, Routine (Preliminary): YEAST, PRESUMPTIVELY NOT C. ALBICANS. Anaerobic Bottle Gram Stain (Final 1999-10-5): BUDDING YEAST. 1978-11-8 8:15 pm BLOOD CULTURE Source: Line-radial artery. Blood Culture, Routine (Preliminary): YEAST. Anaerobic Bottle Gram Stain (Final 2000-9-1): BUDDING YEAST. 2020-12-25 6:08 am BLOOD CULTURE Source: Line-radial artery. Blood Culture, Routine (Preliminary): YEAST. Anaerobic Bottle Gram Stain (Final 2000-9-1): BUDDING YEAST. BCx 1939-10-24 to 1996-12-25: NGTD 2014-8-13 6:37 pm URINE Source: CVS. FINAL REPORT 1978-11-8 URINE CULTURE (Final 1978-11-8): YEAST. 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: Ms. Lyna was admitted after siagnostic pyeloscopy, left ureteroscopy with laser lithotripsy, left ureteral stent exchange on 2014-8-13. In the PACU, developed fever to 103 and rigors, brought to ICU for observation and broad spectrum antibiotics. Blood cultures identified yeast and multi-drug resistant pseudomonas, urine culture identified yeast; PICC placed 1982-8-30; managed with zosyn and micafungin and followed by ID team. Opthomology examined her and found no evidence of fungal infection of the eye. She noted loose stools over the last few months, started on low-residue diet and seen by nutririon; flexible sigmoidoscopy identified polyps, started on immodium with improvement of loose stools, to follow-up in GI fellow's clinic for colonoscopy and biopsy reports within the next month. Her metformin has been held given Cr >1.4, diabetes managed with addition of an insulin sliding scale. Foley removed POD4 and voiding without difficulty. At discharge patient without pain and improvement in loose stools, afebrile with no leukocytosis, tolerating low-residual diet, FSBS under 250, ambulating without assistance, and voiding without difficulty. She is being traanferred to Jones-Riley Clinic for continued IV antibiotics and diabetes management under care of her PCP who is an ID specialist, Dr. Bradley Kaur. She will follow-up with Dr. Emory for stent removal prior to completion of her antibiotics, call for appointment. Medications on Admission: MEDS: Metformin 1000mg Smith Inc Hospital Lisinopril/HCTZ 20mg/12.5mg daily Glipizide XL 10mg DAILY Lipitor 80mg DAILY Atenolol 25mg DAILY Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain, fever. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 6. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale Subcutaneous ASDIR (AS DIRECTED): continue until able to restart metformin. 10. Micafungin 50 mg Recon Soln Sig: One (1) Recon Soln Intravenous DAILY (Daily) for 1 weeks. 11. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q6H (every 6 hours) for 1 weeks. 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for PRN diarrhea. Discharge Disposition: Extended Care Facility: Henderson Inc Clinic - Unit 0570 Box 4853 DPO AA 12136 Discharge Diagnosis: Fungemia, bactermia, sigmoid polyp Discharge Condition: Stable Discharge Instructions: Continue IV zosyn and micafungin as prescribed until urine and blood cultures are finalized, check LFTs weekly while on these medications, antibiotics and duration per accepting physician Lees. Bradley Kaur. Call Dr. Emory to schedule stent removal, 541-246-6856. Call Mckay PLC Health System clinic to schedule colonoscopy, 801-415-1353. Followup Instructions: Call Dr. Emory for stent removal and with any urological questions. 541-246-6856 Call Mckay PLC Health System clinic to schedule colonoscopy and review biopsy results within 1 month with Dr. Nikolai Grose (Fellow's clinic) 801-415-1353.	['Admission Date: 2014-8-13 Discharge Date: 1982-8-30\n\nDate of Birth: 1911-5-29 Sex: F\n\nService: UROLOGY\n\nAllergies:\nAspirin / Motrin / Trilisate / Naprosyn / Toradol / Vicodin /\nPercocet / Indocin / Dilaudid / Zomig\n\nAttending:Susana\nChief Complaint:\nKidney stone\n\nMajor Surgical or Invasive Procedure:\nLeft pyeloscopy with laser lithotripsy and stent exchange,\n2014-8-13, Dr. Emory\nFlexible sigmoidoscopy, 2000-9-1, GI service.\nPICC, 1982-8-30\n\n\nHistory of Present Illness:\nMs. Lyna is a 69-year-old female\nwho presented in July with an obstructing 5-mm left UPJ\nstone with mild hydronephrosis. She was managed at that time\nwith stent placement and delayed stone management given acute\ndiverticulitis at that time. The patient presented on admission\nfor\ndefinitive stone management and she elected to undergo\nureteroscopy with laser lithotripsy and stent change.', " Of\nnote, on preoperative testing she had a white count of 19.0.\nGiven concern for diverticulitis, she was given ceftriaxone\nand Flagyl before the time of surgery and was scheduled to be\nadmitted for observation.\n\n\nPast Medical History:\nNIDDM, HTN, hypercholesterolemia\n\nIncisional ventral hernia repair 2-3\nTAH '23\nR knee arthroscopy\n\n\nSocial History:\nnon-contributory\n\n\nFamily History:\nnon-contributory\n\nPhysical Exam:\nDischarge Exam:\nAVSS\nGen: NAD\nCV: RRR\nResp: CTA-B\nAbd: obese, s/nt/nd; no CVA tenderness bilaterally\nExtr: no c/c/e\nT/L/D: PICC in place\n\nPertinent Results:\n2000-9-1 06:20AM BLOOD WBC-10.7 RBC-3.29* Hgb-8.7* Hct-26.2\nMCV-80 MCH-26.4* MCHC-33.1 RDW-15.8* Plt Ct-371\n2000-9-1 06:20AM BLOOD Glucose-140* UreaN-22* Creat-1.6* Na-137\nK-3.6 Cl-109* HCO3-16* AnGap-16\n2000-9-1 06:20AM BLOOD ALT-19 AST-13 LD(LDH)-198 AlkPhos-75\nTotBili-0.", '3\n2020-12-25 03:00PM BLOOD Lactate-0.9 Na-134* K-3.5 Cl-109\n\n1999-10-5 7:28 pm STOOL CONSISTENCY: LOOSE Source:\nStool.\n\n FECAL CULTURE (Pending):\n\n CAMPYLOBACTER CULTURE (Pending):\n\n OVA + PARASITES (Pending):\n\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final 1999-10-5):\n Feces negative for C.difficile toxin A & B by EIA.\n (Reference Range-Negative).\n\n2014-8-13 3:49 pm BLOOD CULTURE 2 OF 2.\n\n Blood Culture, Routine (Preliminary):\n PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.\n DR Emory REQUESTED SENSITIVITIES TO AZTREONAM AND\nCOLISTIN 1999-10-5.\n RESISTANT TO AZTREONAM sensitivity testing performed by\nReginald\n Clapp. SENT TO Thompson-Horton Hospital LABORATORIES FOR COLISTIN\nSUSCEPTIBILITY.\n YEAST, PRESUMPTIVELY NOT C.', ' ALBICANS.\n\n SENSITIVITIES: MIC expressed in\nMCG/ML\n\n_________________________________________________________\n PSEUDOMONAS AERUGINOSA\n \|\nAMIKACIN-------------- 4 S\nCEFEPIME-------------- 16 I\nCEFTAZIDIME----------- 16 I\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ =>16 R\nMEROPENEM------------- =>16 R\nPIPERACILLIN---------- R\nPIPERACILLIN/TAZO----- 64 S\nTOBRAMYCIN------------ =>16 R\n\n Aerobic Bottle Gram Stain (Final 1978-11-8):\n GRAM NEGATIVE ROD(S).\n REPORTED BY PHONE TO Grose, Celeste @ 1621 ON\n1978-11-8.\n\n Anaerobic Bottle Gram Stain (Final 1999-10-5):\n REPORTED BY PHONE TO DR. Nikolai Kaur PAGER 7977058 @\n0707 ON\n 2020-12-25.\n BUDDING YEAST.\n GRAM NEGATIVE ROD(S).', '\n\n2014-8-13 8:49 pm BLOOD CULTURE Source: Line-PIV #2.\n\n Blood Culture, Routine (Preliminary):\n YEAST, PRESUMPTIVELY NOT C. ALBICANS.\n\n Anaerobic Bottle Gram Stain (Final 1999-10-5): BUDDING\nYEAST.\n\n1978-11-8 8:15 pm BLOOD CULTURE Source: Line-radial artery.\n\n Blood Culture, Routine (Preliminary):\n YEAST.\n\n Anaerobic Bottle Gram Stain (Final 2000-9-1): BUDDING\nYEAST.\n\n2020-12-25 6:08 am BLOOD CULTURE Source: Line-radial artery.\n\n Blood Culture, Routine (Preliminary):\n YEAST.\n\n Anaerobic Bottle Gram Stain (Final 2000-9-1): BUDDING\nYEAST.\n\nBCx 1939-10-24 to 1996-12-25: NGTD\n\n2014-8-13 6:37 pm URINE Source: CVS.\n\n FINAL REPORT 1978-11-8\n\n URINE CULTURE (Final 1978-11-8):\n YEAST. 10,000-100,000 ORGANISMS/ML.', ".\n\n\nBrief Hospital Course:\nMs. Lyna was admitted after siagnostic pyeloscopy, left\nureteroscopy with laser\nlithotripsy, left ureteral stent exchange on 2014-8-13. In the\nPACU, developed fever to 103 and rigors, brought to ICU for\nobservation and broad spectrum antibiotics. Blood cultures\nidentified yeast and multi-drug resistant pseudomonas, urine\nculture identified yeast; PICC placed 1982-8-30; managed with zosyn\nand micafungin and followed by ID team. Opthomology examined her\nand found no evidence of fungal infection of the eye. She noted\nloose stools over the last few months, started on low-residue\ndiet and seen by nutririon; flexible sigmoidoscopy identified\npolyps, started on immodium with improvement of loose stools, to\nfollow-up in GI fellow's clinic for colonoscopy and biopsy\nreports within the next month.", ' Her metformin has been held given\nCr >1.4, diabetes managed with addition of an insulin sliding\nscale. Foley removed POD4 and voiding without difficulty.\n\nAt discharge patient without pain and improvement in loose\nstools, afebrile with no leukocytosis, tolerating low-residual\ndiet, FSBS under 250, ambulating without assistance, and voiding\nwithout difficulty. She is being traanferred to Jones-Riley Clinic for\ncontinued IV antibiotics and diabetes management under care of\nher PCP who is an ID specialist, Dr. Bradley Kaur. She will\nfollow-up with Dr. Emory for stent removal prior to completion\nof her antibiotics, call for appointment.\n\nMedications on Admission:\nMEDS:\nMetformin 1000mg Smith Inc Hospital\nLisinopril/HCTZ 20mg/12.5mg daily\nGlipizide XL 10mg DAILY\nLipitor 80mg DAILY\nAtenolol 25mg DAILY\n\n\nDischarge Medications:\n1.', ' Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every\n6 hours) as needed for Pain, fever.\n4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) Inhalation Q6H (every 6 hours) as\nneeded for wheeze.\n5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed for wheeze.\n6. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO\nDAILY (Daily).\n9. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale\nSubcutaneous ASDIR (AS DIRECTED): continue until able to restart\nmetformin.', '\n10. Micafungin 50 mg Recon Soln Sig: One (1) Recon Soln\nIntravenous DAILY (Daily) for 1 weeks.\n11. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback\nSig: One (1) Intravenous Q6H (every 6 hours) for 1 weeks.\n12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily) as needed for PRN diarrhea.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nHenderson Inc Clinic - Unit 0570 Box 4853\nDPO AA 12136\n\nDischarge Diagnosis:\nFungemia, bactermia, sigmoid polyp\n\n\nDischarge Condition:\nStable\n\n\nDischarge Instructions:\nContinue IV zosyn and micafungin as prescribed until urine and\nblood cultures are finalized, check LFTs weekly while on these\nmedications, antibiotics and duration per accepting physician\nLees. Bradley Kaur. Call Dr. Emory to schedule stent removal,\n541-246-6856. Call Mckay PLC Health System clinic to schedule colonoscopy,\n801-415-1353.', "\n\nFollowup Instructions:\nCall Dr. Emory for stent removal and with any urological\nquestions.\n541-246-6856\nCall Mckay PLC Health System clinic to schedule colonoscopy and review biopsy results\nwithin 1 month with Dr. Nikolai Grose (Fellow's clinic)\n801-415-1353.\n\n\n\n"]
557	15646	102898.0	2145-11-18	Discharge summary	Report	Admission Date: [2145-11-14] Discharge Date: [2145-11-18] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Found Down Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] yo male with chronic kidney disease who presents to the ED after being found down at apt. Pt found by landlord after not being seen in 2 days and found in own feces. . ED: While in the ED, found to have K of 7, creat of 10, trop of 3 with nl CK. Received 10 U Insulin/ 1 amp D 50, Haldol/ativan, Kayexalate PR, Calcium gluconate 1 g x 2. Patient pulled foley catheter and NGT was unable to be placed. . When arrived on MICU floor, patient agitated and not responsive to questions. Withdraws to pain. Past Medical History: 1. Hypertension. 2. Chronic renal insufficiency (with a baseline creatinine of 4 documented as far back at [2140]). The patient has refused a workup for this in the past. Social History: Patient living alone, wife in rehab/[Hospital1 1501]. Per OMR: He is a former [Company 2318] worker. He use to drink heavily in his youth. No alcohol at all in the last 10 years. No tobacco. Family History: NC Physical Exam: t 97 BP 122/71 RR 19, 02 91-100%, HR 111 GEN: Arousable, agitated HEENT: MM dry, PERRL, EOMI Neck: JVP 6 cm CV: RRR, [2-15] murmur at LLSB Pulm: occ exp wheezes, otherwise clear bilaterally Abd: + bs-hypoactive, soft, non-distended, no masses Ext: [1-11] + pulses, no edema Skin: excoriations of LE and UE Neuro: moves all extremities Pertinent Results: [2145-11-14] 05:15PM WBC-7.8 RBC-2.90* HGB-10.0* HCT-31.1* MCV-107* MCH-34.3* MCHC-32.0 RDW-14.6 [2145-11-14] 05:15PM NEUTS-81.1* LYMPHS-11.0* MONOS-3.8 EOS-3.8 BASOS-0.3 [2145-11-14] 05:15PM PLT COUNT-292 [2145-11-14] 05:15PM PT-13.2* PTT-25.3 INR(PT)-1.2* [2145-11-14] 05:15PM TSH-0.26* [2145-11-14] 05:15PM ALBUMIN-3.4 CALCIUM-9.4 PHOSPHATE-9.3# MAGNESIUM-3.0 [2145-11-14] 05:15PM cTropnT-3.02* [2145-11-14] 05:15PM GLUCOSE-128* UREA N-204* CREAT-10.0# SODIUM-157 POTASSIUM-7.1* CHLORIDE-127* TOTAL CO2-8* ANION GAP-29* [2145-11-14] 05:15PM AST(SGOT)-25 CK(CPK)-98 ALK PHOS-234* AMYLASE-197* TOT BILI-0.2 [2145-11-14] 05:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: [Age over 90 ] yo male with acute on chronic renal failure with severe electrolyte disturbances and azotemia. . ARF- Patient with longstanding renal failure with current azotemia and electrolyte disturbance consistent with acute worsening. The cause of the acute worsening was unclear but may have been partially due to hypovolemia causing a prerenal worsening of the function. Per renal recommendations, the patient was not immediately a candidate for dialysis treated with IV fluids and electrolytes were monitored. . Elevated troponin- no clear signs of cardiac ischemia, but does have significantly elevated troponin. No CK increase. Either purely due to ARF or recent ischemic event. . Social Issues - the patient had no health [Doctor First Name 4540] proxy upon admission, and we managed to contact a next of [Doctor First Name ] ([Name (NI) ] [Name (NI) 4541], nephew) after three days. Until that point, patient was deemed full code and was evaluated by both renal and orthopedics for hemodialysis and fractured femur respectively. We also contact[Name (NI) ] the patient's PCP, [Name10 (NameIs) 1023] provided us with ample documentation of the patient's history of refusing treatments, including blood draws, colonoscopy, and chronic dialysis. Upon contacting the next of [Doctor First Name ], the patient was made DNR/DNI, but preparations were made to proceed with dialysis. On the morning of [11-18], the patient became apneic and subsequently went into cardiopulmonary arrest with no obvious etiology. He was pronounced at 12:29pm, and the next of [Doctor First Name ] was alerted. Medications on Admission: Nicardipine and toprol Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased	Admission Date: <Date>1943-1-25</Date> Discharge Date: <Date>1922-9-17</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Joyce</Name> Chief Complaint: Found Down Major Surgical or Invasive Procedure: None History of Present Illness: <Age>71</Age> yo male with chronic kidney disease who presents to the ED after being found down at apt. Pt found by landlord after not being seen in 2 days and found in own feces. . ED: While in the ED, found to have K of 7, creat of 10, trop of 3 with nl CK. Received 10 U Insulin/ 1 amp D 50, Haldol/ativan, Kayexalate PR, Calcium gluconate 1 g x 2. Patient pulled foley catheter and NGT was unable to be placed. . When arrived on MICU floor, patient agitated and not responsive to questions. Withdraws to pain. Past Medical History: 1. Hypertension. 2. Chronic renal insufficiency (with a baseline creatinine of 4 documented as far back at <Year>1940</Year>). The patient has refused a workup for this in the past. Social History: Patient living alone, wife in rehab/<Hospital>Smith, Williamson and Schneider Hospital</Hospital>. Per OMR: He is a former <Company>Michael, Barnes and Davis</Company> worker. He use to drink heavily in his youth. No alcohol at all in the last 10 years. No tobacco. Family History: NC Physical Exam: t 97 BP 122/71 RR 19, 02 91-100%, HR 111 GEN: Arousable, agitated HEENT: MM dry, PERRL, EOMI Neck: JVP 6 cm CV: RRR, <Date>5-26</Date> murmur at LLSB Pulm: occ exp wheezes, otherwise clear bilaterally Abd: + bs-hypoactive, soft, non-distended, no masses Ext: <Date>8-30</Date> + pulses, no edema Skin: excoriations of LE and UE Neuro: moves all extremities Pertinent Results: <Date>1943-1-25</Date> 05:15PM WBC-7.8 RBC-2.90* HGB-10.0* HCT-31.1* MCV-107* MCH-34.3* MCHC-32.0 RDW-14.6 <Date>1943-1-25</Date> 05:15PM NEUTS-81.1* LYMPHS-11.0* MONOS-3.8 EOS-3.8 BASOS-0.3 <Date>1943-1-25</Date> 05:15PM PLT COUNT-292 <Date>1943-1-25</Date> 05:15PM PT-13.2* PTT-25.3 INR(PT)-1.2* <Date>1943-1-25</Date> 05:15PM TSH-0.26* <Date>1943-1-25</Date> 05:15PM ALBUMIN-3.4 CALCIUM-9.4 PHOSPHATE-9.3# MAGNESIUM-3.0 <Date>1943-1-25</Date> 05:15PM cTropnT-3.02* <Date>1943-1-25</Date> 05:15PM GLUCOSE-128* UREA N-204* CREAT-10.0# SODIUM-157 POTASSIUM-7.1* CHLORIDE-127* TOTAL CO2-8* ANION GAP-29* <Date>1943-1-25</Date> 05:15PM AST(SGOT)-25 CK(CPK)-98 ALK PHOS-234* AMYLASE-197* TOT BILI-0.2 <Date>1943-1-25</Date> 05:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: <Age>71</Age> yo male with acute on chronic renal failure with severe electrolyte disturbances and azotemia. . ARF- Patient with longstanding renal failure with current azotemia and electrolyte disturbance consistent with acute worsening. The cause of the acute worsening was unclear but may have been partially due to hypovolemia causing a prerenal worsening of the function. Per renal recommendations, the patient was not immediately a candidate for dialysis treated with IV fluids and electrolytes were monitored. . Elevated troponin- no clear signs of cardiac ischemia, but does have significantly elevated troponin. No CK increase. Either purely due to ARF or recent ischemic event. . Social Issues - the patient had no health <Name>Judy</Name> proxy upon admission, and we managed to contact a next of <Name>Aparna</Name> (<Name>Kelly Ivory</Name> <Name>Idalia Martin</Name>, nephew) after three days. Until that point, patient was deemed full code and was evaluated by both renal and orthopedics for hemodialysis and fractured femur respectively. We also contact<Name>Kelly Ivory</Name> the patient's PCP, <Name>Isaias Grose</Name> provided us with ample documentation of the patient's history of refusing treatments, including blood draws, colonoscopy, and chronic dialysis. Upon contacting the next of <Name>Aparna</Name>, the patient was made DNR/DNI, but preparations were made to proceed with dialysis. On the morning of <Date>5-25</Date>, the patient became apneic and subsequently went into cardiopulmonary arrest with no obvious etiology. He was pronounced at 12:29pm, and the next of <Name>Aparna</Name> was alerted. Medications on Admission: Nicardipine and toprol Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased	00000000000000000111111111000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111111111111111100000000000000000000000000111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000111111111000000000000000000000000000000000000000000111111111000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000011111100111111111110111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111000000000000000000001111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000	Admission Date: 1943-1-25 Discharge Date: 1922-9-17 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Joyce Chief Complaint: Found Down Major Surgical or Invasive Procedure: None History of Present Illness: 71 yo male with chronic kidney disease who presents to the ED after being found down at apt. Pt found by landlord after not being seen in 2 days and found in own feces. . ED: While in the ED, found to have K of 7, creat of 10, trop of 3 with nl CK. Received 10 U Insulin/ 1 amp D 50, Haldol/ativan, Kayexalate PR, Calcium gluconate 1 g x 2. Patient pulled foley catheter and NGT was unable to be placed. . When arrived on MICU floor, patient agitated and not responsive to questions. Withdraws to pain. Past Medical History: 1. Hypertension. 2. Chronic renal insufficiency (with a baseline creatinine of 4 documented as far back at 1940). The patient has refused a workup for this in the past. Social History: Patient living alone, wife in rehab/Smith, Williamson and Schneider Hospital. Per OMR: He is a former Michael, Barnes and Davis worker. He use to drink heavily in his youth. No alcohol at all in the last 10 years. No tobacco. Family History: NC Physical Exam: t 97 BP 122/71 RR 19, 02 91-100%, HR 111 GEN: Arousable, agitated HEENT: MM dry, PERRL, EOMI Neck: JVP 6 cm CV: RRR, 5-26 murmur at LLSB Pulm: occ exp wheezes, otherwise clear bilaterally Abd: + bs-hypoactive, soft, non-distended, no masses Ext: 8-30 + pulses, no edema Skin: excoriations of LE and UE Neuro: moves all extremities Pertinent Results: 1943-1-25 05:15PM WBC-7.8 RBC-2.90* HGB-10.0* HCT-31.1* MCV-107* MCH-34.3* MCHC-32.0 RDW-14.6 1943-1-25 05:15PM NEUTS-81.1* LYMPHS-11.0* MONOS-3.8 EOS-3.8 BASOS-0.3 1943-1-25 05:15PM PLT COUNT-292 1943-1-25 05:15PM PT-13.2* PTT-25.3 INR(PT)-1.2* 1943-1-25 05:15PM TSH-0.26* 1943-1-25 05:15PM ALBUMIN-3.4 CALCIUM-9.4 PHOSPHATE-9.3# MAGNESIUM-3.0 1943-1-25 05:15PM cTropnT-3.02* 1943-1-25 05:15PM GLUCOSE-128* UREA N-204* CREAT-10.0# SODIUM-157 POTASSIUM-7.1* CHLORIDE-127* TOTAL CO2-8* ANION GAP-29* 1943-1-25 05:15PM AST(SGOT)-25 CK(CPK)-98 ALK PHOS-234* AMYLASE-197* TOT BILI-0.2 1943-1-25 05:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: 71 yo male with acute on chronic renal failure with severe electrolyte disturbances and azotemia. . ARF- Patient with longstanding renal failure with current azotemia and electrolyte disturbance consistent with acute worsening. The cause of the acute worsening was unclear but may have been partially due to hypovolemia causing a prerenal worsening of the function. Per renal recommendations, the patient was not immediately a candidate for dialysis treated with IV fluids and electrolytes were monitored. . Elevated troponin- no clear signs of cardiac ischemia, but does have significantly elevated troponin. No CK increase. Either purely due to ARF or recent ischemic event. . Social Issues - the patient had no health Judy proxy upon admission, and we managed to contact a next of Aparna (Kelly Ivory Idalia Martin, nephew) after three days. Until that point, patient was deemed full code and was evaluated by both renal and orthopedics for hemodialysis and fractured femur respectively. We also contactKelly Ivory the patient's PCP, Isaias Grose provided us with ample documentation of the patient's history of refusing treatments, including blood draws, colonoscopy, and chronic dialysis. Upon contacting the next of Aparna, the patient was made DNR/DNI, but preparations were made to proceed with dialysis. On the morning of 5-25, the patient became apneic and subsequently went into cardiopulmonary arrest with no obvious etiology. He was pronounced at 12:29pm, and the next of Aparna was alerted. Medications on Admission: Nicardipine and toprol Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased	['Admission Date: 1943-1-25 Discharge Date: 1922-9-17\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Joyce\nChief Complaint:\nFound Down\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\n71 yo male with chronic kidney disease who presents to the ED\nafter being found down at apt. Pt found by landlord after not\nbeing seen in 2 days and found in own feces.\n.\nED: While in the ED, found to have K of 7, creat of 10, trop of\n3 with nl CK. Received 10 U Insulin/ 1 amp D 50, Haldol/ativan,\nKayexalate PR, Calcium gluconate 1 g x 2. Patient pulled foley\ncatheter and NGT was unable to be placed.\n.\nWhen arrived on MICU floor, patient agitated and not responsive\nto questions. Withdraws to pain.\n\nPast Medical History:\n1.', ' Hypertension.\n2. Chronic renal insufficiency (with a baseline creatinine\nof 4 documented as far back at 1940). The patient has\nrefused a workup for this in the past.\n\n\nSocial History:\nPatient living alone, wife in rehab/Smith, Williamson and Schneider Hospital. Per OMR: He is a former\nMichael, Barnes and Davis worker. He use to drink heavily in his youth. No alcohol at\nall in the last 10\nyears. No tobacco.\n\n\nFamily History:\nNC\n\nPhysical Exam:\n t 97 BP 122/71 RR 19, 02 91-100%, HR 111\nGEN: Arousable, agitated\nHEENT: MM dry, PERRL, EOMI\nNeck: JVP 6 cm\nCV: RRR, 5-26 murmur at LLSB\nPulm: occ exp wheezes, otherwise clear bilaterally\nAbd: + bs-hypoactive, soft, non-distended, no masses\nExt: 8-30 + pulses, no edema\nSkin: excoriations of LE and UE\nNeuro: moves all extremities\n\n\nPertinent Results:\n1943-1-25 05:15PM WBC-7.', '8 RBC-2.90* HGB-10.0* HCT-31.1\nMCV-107 MCH-34.3* MCHC-32.0 RDW-14.6\n1943-1-25 05:15PM NEUTS-81.1* LYMPHS-11.0* MONOS-3.8 EOS-3.8\nBASOS-0.3\n1943-1-25 05:15PM PLT COUNT-292\n1943-1-25 05:15PM PT-13.2* PTT-25.3 INR(PT)-1.2\n1943-1-25 05:15PM TSH-0.26\n1943-1-25 05:15PM ALBUMIN-3.4 CALCIUM-9.4 PHOSPHATE-9.3#\nMAGNESIUM-3.0\n1943-1-25 05:15PM cTropnT-3.02\n1943-1-25 05:15PM GLUCOSE-128 UREA N-204* CREAT-10.0#\nSODIUM-157 POTASSIUM-7.1* CHLORIDE-127* TOTAL CO2-8* ANION\nGAP-29\n1943-1-25 05:15PM AST(SGOT)-25 CK(CPK)-98 ALK PHOS-234\nAMYLASE-197* TOT BILI-0.2\n1943-1-25 05:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0\nLEUK-NEG\n\nBrief Hospital Course:\n71 yo male with acute on chronic renal failure with severe\nelectrolyte disturbances and azotemia.', '\n.\nARF- Patient with longstanding renal failure with current\nazotemia and electrolyte disturbance consistent with acute\nworsening. The cause of the acute worsening was unclear but may\nhave been partially due to hypovolemia causing a prerenal\nworsening of the function.\nPer renal recommendations, the patient was not immediately a\ncandidate for dialysis treated with IV fluids and electrolytes\nwere monitored.\n.\nElevated troponin- no clear signs of cardiac ischemia, but does\nhave significantly elevated troponin. No CK increase. Either\npurely due to ARF or recent ischemic event.\n.\nSocial Issues - the patient had no health Judy proxy upon\nadmission, and we managed to contact a next of Aparna (Kelly Ivory\nIdalia Martin, nephew) after three days. Until that point, patient was\ndeemed full code and was evaluated by both renal and orthopedics\nfor hemodialysis and fractured femur respectively.', " We also\ncontactKelly Ivory the patient's PCP, Isaias Grose provided us with ample\ndocumentation of the patient's history of refusing treatments,\nincluding blood draws, colonoscopy, and chronic dialysis. Upon\ncontacting the next of Aparna, the patient was made DNR/DNI, but\npreparations were made to proceed with dialysis. On the morning\nof 5-25, the patient became apneic and subsequently went into\ncardiopulmonary arrest with no obvious etiology. He was\npronounced at 12:29pm, and the next of Aparna was alerted.\n\nMedications on Admission:\nNicardipine and toprol\n\nDischarge Medications:\nn/a\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\ndeceased\n\nDischarge Condition:\ndeceased\n\nDischarge Instructions:\ndeceased\n\nFollowup Instructions:\ndeceased\n\n\n"]
558	89544	167160.0	2164-10-04	Discharge summary	Report	Admission Date: [2164-10-1] Discharge Date: [2164-10-4] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation central line placement History of Present Illness: History of Present Illness: 88F w/ h/o Grave's disease, ?CRI/?HTN & recently diagnosed RUL lung mass with LAD & liver mets who presents from rehab with altered mental. Per her rehabilitation facility, the patient is usually responsive to her name and this evening became unresponsive to name. It is unclear her baseline mental status. There is no evidence of fever from rehabilitation records. Patient to altered to tell us her symptoms. In the ED, initial VS were: 86 84/40 18 100% 2L NC. CVL was placed in RIJ. Labs were notable for acute kidney injury (Cr 4.3 <- 1.2 on [2164-9-11]), leukocytosis with WBC 24.1 (up from recent baseline of 17) w/ 91% polys, no bands & HCO3 15. Transaminases, alk phos and lipase were elevated, however the specimen was hemolyzed which can falsely elevate these values. Lactate 2.3. Prelim read of CT head & abd/pelvis were negative for acute process. Patient received 3L lactated ringers as well as vancomycin 1g IV and zosyn 4.5mg IV empirically. While in the ED, patient's BPs were 90s/60s (EMS) -> 84/40s (on presentation) -> got 3L fluids with no change in BP -> 90s/40s -> started levophed gtt @ 0.09 & BPs increased to 100-107/43-52. VS on transfer were 78, 20, 100%2L, CVP 7->12, 98 rectal. . On arrival to the MICU, the patient is non-verbal and unable to partake in a review of systems questions. Past Medical History: Grave's disease HTN thoracic spine fx s/p hysterectomy urinary retention constipation osteoarthritis possible chronic kidney disease Social History: Lives alone, no biologic children, minimal contact with step children no ETOH, [Name (NI) ] Family History: None relevant to fall Physical Exam: Physical Exam on Discharge: Vitals: 95.3 79/64 83 20 96% on RA General: Extubated, still altered, not talking in words. Not in any painful distress, but obviously not oriented. HEENT: Sclerae anicteric, very dry mucous membranes, +dry eyes Neck: supple, unable to assess JVP, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, rhonchi Abdomen: soft, diffusely tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, bilateral DP pulses observed by doppler, no clubbing, cyanosis or edema Pertinent Results: [2164-10-1] 01:15AM BLOOD WBC-24.1* RBC-4.41 Hgb-11.1* Hct-35.9* MCV-81* MCH-25.3* MCHC-31.1 RDW-19.6* Plt Ct-264 [2164-10-3] 03:25AM BLOOD WBC-26.1* RBC-3.50* Hgb-9.1* Hct-26.6* MCV-76* MCH-26.1* MCHC-34.3 RDW-20.1* Plt Ct-286 [2164-10-3] 03:25AM BLOOD Neuts-78* Bands-0 Lymphs-13* Monos-6 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [2164-10-3] 03:25AM BLOOD PT-22.4* PTT-58.1* INR(PT)-2.1* [2164-10-3] 03:25AM BLOOD Glucose-143* UreaN-84* Creat-3.2* Na-137 K-3.4 Cl-108 HCO3-15* AnGap-17 [2164-10-2] 03:06AM BLOOD ALT-105* AST-183* AlkPhos-363* Amylase-88 TotBili-1.8* [2164-10-3] 03:25AM BLOOD Calcium-8.4 Phos-3.0# Mg-2.7* [2164-10-2] 03:06AM BLOOD Cortsol-42.1* [2164-10-2] 11:48PM BLOOD Vanco-19.9 [2164-10-3] 03:45AM BLOOD Lactate-2.6* CT [2164-10-1] FINDINGS: There is no evidence of hemorrhage, edema, mass effect or infarction. The ventricles and sulci are markedly prominent, likely secondary to age-related global atrophy. There is no shift of normally midline structures. The [Doctor Last Name 352]-white matter differentiation is grossly preserved. There is no evidence of fracture. A large mucous retention cyst is noted in the right maxillary sinus. The remaining visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. No acute intracranial process. 2. Significant global atrophy, likely age-related. 3. Large mucous retention cyst in the right maxillary sinus. CT [2164-10-1] IMPRESSION: 1. Limited study without IV contrast. 2. Similar 1.6 x 1.9 cm spiculated right upper lobe lesion with associated right hilar and mediastinal lymphadenopathy, highly concerning for malignancy. 3. 2-mm left upper lobe nodule, apparently new. Bibasilar atelectasis and left lower lobe discoid atelectasis. No definite focal airspace consolidations. 4. Multifocal large hypodense lesions in the liver, incompletely assessed without IV contrast but compatible with widespread hepatic metastases. 5. Moderate-sized hiatal hernia. 6. Evidence of tracheomalacia. 7. Large fibroid uterus. 8. Similar significant T11 and T12 compression fractures. Brief Hospital Course: Assessment and Plan: This is a 88 yo female that presented with altered mental status, hypotension, a right upper mass concerning for lung cancer and evidence of metastatic spread. . #. Hypotension: The patient presented with hypotension likely due to a combination of hypovolemia (poor PO intake for the preceeding days) and distributive/septic shock (given a WBC 24). The infectious source was not found. CT of chest/abdomen/pelvis was not revealing. UA was negative. Blood, Urine, and Sputum cultures were unrevealing for an infectious source. The patient was started on levophed gtt, but was discontinued and made CMO (see below). The patient was initially place on vancomycin and zosyn, which were discontinued after she was made CMO. . #. Altered mental status from toxic metabolic encephalopathy in the context of multiple insults including hypotension and infection. A CT of her head was negative for an obvious cause of altered mental status. Broad spectrim antibotics were started, but stopped when made CMO. . #. Right Upper Lung Mass- The patient presented with a right upper lung mass concerning for malignance with evidence of an 8th rib fracture and hepatic metastases A further work up was deferred after the patient was made CMO. . #. hypercarbic respiratory failure- The patient presented with metabolic acidosis (likely from sepsis) with inappropriate respiratory compensation. She was intubated and placed on mechanical ventilation for hypercarbic respiratory failure. She was extubated and made CMO. . #. Comfort Measures Only- The patient was made CMO after confirming with the patient's next of kind that the patient's wish would be to remain as comfortable as possible until she died. She was extubated. Pressors were stopped. The patient was started on artificial tears, morphine prn, and all medication were stopped other than those to maintain comfort. . #. Acute kidney Injury. The patient presented hypovolemic and labs consistent with pre-renal/ATN. All medications were renally dose. Nephrotoxic drugs were avoided. The [Initials (NamePattern4) 228] [Last Name (NamePattern4) ] improved after fluid resuscitation. . #. [Name (NI) 4545] Pt home dose of levothyroxine was continued until made CMO . #. Microcytic anemia: Likely from anemia of chronic inflammation given labs results. Medications on Admission: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [1-8] Drops Ophthalmic DAILY (Daily). 4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for intertrigo. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY 7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [1-8] Drops Ophthalmic DAILY (Daily). 2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 5. pain management please start morphine sulfate 1-5 mg IV Q2H:PRN SOB, pain management. Please titrate to comfort. Discharge Disposition: Extended Care Facility: [Hospital 4542] Rehabilitation and Nursing of [Location (un) 38] Discharge Diagnosis: hypoxemia respiratory failure hypotension right upper lobe mass Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to [Hospital1 69] for altered mental status. We found that you had low blood pressure, which we treated by giving you intravenous fluids and medications to raise the blood pressure. We also found that you had difficult breathing, which we treated by intubation you and having a ventilator help you breath. We also found evidence of a likely cancer that has spread around your body. Medication: Stop taking all medications, except the folllowing: Acetaminophen 650 every 6 hours for pain Artificial tears 1-2 drops both eyes daily Morphine sulfate as needed Followup Instructions: please see your primary care providor as needed [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	Admission Date: <Date>1903-2-13</Date> Discharge Date: <Date>1999-9-22</Date> Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Tennity</Name> Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation central line placement History of Present Illness: History of Present Illness: 88F w/ h/o Grave's disease, ?CRI/?HTN & recently diagnosed RUL lung mass with LAD & liver mets who presents from rehab with altered mental. Per her rehabilitation facility, the patient is usually responsive to her name and this evening became unresponsive to name. It is unclear her baseline mental status. There is no evidence of fever from rehabilitation records. Patient to altered to tell us her symptoms. In the ED, initial VS were: 86 84/40 18 100% 2L NC. CVL was placed in RIJ. Labs were notable for acute kidney injury (Cr 4.3 <- 1.2 on <Date>1933-11-19</Date>), leukocytosis with WBC 24.1 (up from recent baseline of 17) w/ 91% polys, no bands & HCO3 15. Transaminases, alk phos and lipase were elevated, however the specimen was hemolyzed which can falsely elevate these values. Lactate 2.3. Prelim read of CT head & abd/pelvis were negative for acute process. Patient received 3L lactated ringers as well as vancomycin 1g IV and zosyn 4.5mg IV empirically. While in the ED, patient's BPs were 90s/60s (EMS) -> 84/40s (on presentation) -> got 3L fluids with no change in BP -> 90s/40s -> started levophed gtt @ 0.09 & BPs increased to 100-107/43-52. VS on transfer were 78, 20, 100%2L, CVP 7->12, 98 rectal. . On arrival to the MICU, the patient is non-verbal and unable to partake in a review of systems questions. Past Medical History: Grave's disease HTN thoracic spine fx s/p hysterectomy urinary retention constipation osteoarthritis possible chronic kidney disease Social History: Lives alone, no biologic children, minimal contact with step children no ETOH, <Name>Adam Casenhiser</Name> Family History: None relevant to fall Physical Exam: Physical Exam on Discharge: Vitals: 95.3 79/64 83 20 96% on RA General: Extubated, still altered, not talking in words. Not in any painful distress, but obviously not oriented. HEENT: Sclerae anicteric, very dry mucous membranes, +dry eyes Neck: supple, unable to assess JVP, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, rhonchi Abdomen: soft, diffusely tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, bilateral DP pulses observed by doppler, no clubbing, cyanosis or edema Pertinent Results: <Date>1903-2-13</Date> 01:15AM BLOOD WBC-24.1* RBC-4.41 Hgb-11.1* Hct-35.9* MCV-81* MCH-25.3* MCHC-31.1 RDW-19.6* Plt Ct-264 <Date>1924-9-9</Date> 03:25AM BLOOD WBC-26.1* RBC-3.50* Hgb-9.1* Hct-26.6* MCV-76* MCH-26.1* MCHC-34.3 RDW-20.1* Plt Ct-286 <Date>1924-9-9</Date> 03:25AM BLOOD Neuts-78* Bands-0 Lymphs-13* Monos-6 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 <Date>1924-9-9</Date> 03:25AM BLOOD PT-22.4* PTT-58.1* INR(PT)-2.1* <Date>1924-9-9</Date> 03:25AM BLOOD Glucose-143* UreaN-84* Creat-3.2* Na-137 K-3.4 Cl-108 HCO3-15* AnGap-17 <Date>1985-9-10</Date> 03:06AM BLOOD ALT-105* AST-183* AlkPhos-363* Amylase-88 TotBili-1.8* <Date>1924-9-9</Date> 03:25AM BLOOD Calcium-8.4 Phos-3.0# Mg-2.7* <Date>1985-9-10</Date> 03:06AM BLOOD Cortsol-42.1* <Date>1985-9-10</Date> 11:48PM BLOOD Vanco-19.9 <Date>1924-9-9</Date> 03:45AM BLOOD Lactate-2.6* CT <Date>1903-2-13</Date> FINDINGS: There is no evidence of hemorrhage, edema, mass effect or infarction. The ventricles and sulci are markedly prominent, likely secondary to age-related global atrophy. There is no shift of normally midline structures. The <Doctor Name>Dr.Johnson</Doctor Name>-white matter differentiation is grossly preserved. There is no evidence of fracture. A large mucous retention cyst is noted in the right maxillary sinus. The remaining visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. No acute intracranial process. 2. Significant global atrophy, likely age-related. 3. Large mucous retention cyst in the right maxillary sinus. CT <Date>1903-2-13</Date> IMPRESSION: 1. Limited study without IV contrast. 2. Similar 1.6 x 1.9 cm spiculated right upper lobe lesion with associated right hilar and mediastinal lymphadenopathy, highly concerning for malignancy. 3. 2-mm left upper lobe nodule, apparently new. Bibasilar atelectasis and left lower lobe discoid atelectasis. No definite focal airspace consolidations. 4. Multifocal large hypodense lesions in the liver, incompletely assessed without IV contrast but compatible with widespread hepatic metastases. 5. Moderate-sized hiatal hernia. 6. Evidence of tracheomalacia. 7. Large fibroid uterus. 8. Similar significant T11 and T12 compression fractures. Brief Hospital Course: Assessment and Plan: This is a 88 yo female that presented with altered mental status, hypotension, a right upper mass concerning for lung cancer and evidence of metastatic spread. . #. Hypotension: The patient presented with hypotension likely due to a combination of hypovolemia (poor PO intake for the preceeding days) and distributive/septic shock (given a WBC 24). The infectious source was not found. CT of chest/abdomen/pelvis was not revealing. UA was negative. Blood, Urine, and Sputum cultures were unrevealing for an infectious source. The patient was started on levophed gtt, but was discontinued and made CMO (see below). The patient was initially place on vancomycin and zosyn, which were discontinued after she was made CMO. . #. Altered mental status from toxic metabolic encephalopathy in the context of multiple insults including hypotension and infection. A CT of her head was negative for an obvious cause of altered mental status. Broad spectrim antibotics were started, but stopped when made CMO. . #. Right Upper Lung Mass- The patient presented with a right upper lung mass concerning for malignance with evidence of an 8th rib fracture and hepatic metastases A further work up was deferred after the patient was made CMO. . #. hypercarbic respiratory failure- The patient presented with metabolic acidosis (likely from sepsis) with inappropriate respiratory compensation. She was intubated and placed on mechanical ventilation for hypercarbic respiratory failure. She was extubated and made CMO. . #. Comfort Measures Only- The patient was made CMO after confirming with the patient's next of kind that the patient's wish would be to remain as comfortable as possible until she died. She was extubated. Pressors were stopped. The patient was started on artificial tears, morphine prn, and all medication were stopped other than those to maintain comfort. . #. Acute kidney Injury. The patient presented hypovolemic and labs consistent with pre-renal/ATN. All medications were renally dose. Nephrotoxic drugs were avoided. The <Initial>YS</Initial> <Name>Hasan</Name> improved after fluid resuscitation. . #. <Name>German Naegelin</Name> Pt home dose of levothyroxine was continued until made CMO . #. Microcytic anemia: Likely from anemia of chronic inflammation given labs results. Medications on Admission: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: <Date>10-19</Date> Drops Ophthalmic DAILY (Daily). 4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical <Hospital>Olson-Christensen Hospital</Hospital> (2 times a day) as needed for intertrigo. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY 7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: <Date>10-19</Date> Drops Ophthalmic DAILY (Daily). 2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 5. pain management please start morphine sulfate 1-5 mg IV Q2H:PRN SOB, pain management. Please titrate to comfort. Discharge Disposition: Extended Care Facility: <Hospital>Sanchez, Smith and Burke Medical Center</Hospital> Rehabilitation and Nursing of <Location>Unit 8762 Box 2779 DPO AA 12152</Location> Discharge Diagnosis: hypoxemia respiratory failure hypotension right upper lobe mass Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to <Hospital>Lowe and Sons Hospital</Hospital> for altered mental status. We found that you had low blood pressure, which we treated by giving you intravenous fluids and medications to raise the blood pressure. We also found that you had difficult breathing, which we treated by intubation you and having a ventilator help you breath. We also found evidence of a likely cancer that has spread around your body. Medication: Stop taking all medications, except the folllowing: Acetaminophen 650 every 6 hours for pain Artificial tears 1-2 drops both eyes daily Morphine sulfate as needed Followup Instructions: please see your primary care providor as needed <Initial>NA</Initial> <Name>Hasan</Name> <Name>Tracy Smith</Name> MD <MD Number>98838152</MD 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Date: 1903-2-13 Discharge Date: 1999-9-22 Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Tennity Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation central line placement History of Present Illness: History of Present Illness: 88F w/ h/o Grave's disease, ?CRI/?HTN & recently diagnosed RUL lung mass with LAD & liver mets who presents from rehab with altered mental. Per her rehabilitation facility, the patient is usually responsive to her name and this evening became unresponsive to name. It is unclear her baseline mental status. There is no evidence of fever from rehabilitation records. Patient to altered to tell us her symptoms. In the ED, initial VS were: 86 84/40 18 100% 2L NC. CVL was placed in RIJ. Labs were notable for acute kidney injury (Cr 4.3 1933-11-19), leukocytosis with WBC 24.1 (up from recent baseline of 17) w/ 91% polys, no bands & HCO3 15. Transaminases, alk phos and lipase were elevated, however the specimen was hemolyzed which can falsely elevate these values. Lactate 2.3. Prelim read of CT head & abd/pelvis were negative for acute process. Patient received 3L lactated ringers as well as vancomycin 1g IV and zosyn 4.5mg IV empirically. While in the ED, patient's BPs were 90s/60s (EMS) -> 84/40s (on presentation) -> got 3L fluids with no change in BP -> 90s/40s -> started levophed gtt @ 0.09 & BPs increased to 100-107/43-52. VS on transfer were 78, 20, 100%2L, CVP 7->12, 98 rectal. . On arrival to the MICU, the patient is non-verbal and unable to partake in a review of systems questions. Past Medical History: Grave's disease HTN thoracic spine fx s/p hysterectomy urinary retention constipation osteoarthritis possible chronic kidney disease Social History: Lives alone, no biologic children, minimal contact with step children no ETOH, Adam Casenhiser Family History: None relevant to fall Physical Exam: Physical Exam on Discharge: Vitals: 95.3 79/64 83 20 96% on RA General: Extubated, still altered, not talking in words. Not in any painful distress, but obviously not oriented. HEENT: Sclerae anicteric, very dry mucous membranes, +dry eyes Neck: supple, unable to assess JVP, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, rhonchi Abdomen: soft, diffusely tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, bilateral DP pulses observed by doppler, no clubbing, cyanosis or edema Pertinent Results: 1903-2-13 01:15AM BLOOD WBC-24.1* RBC-4.41 Hgb-11.1* Hct-35.9* MCV-81* MCH-25.3* MCHC-31.1 RDW-19.6* Plt Ct-264 1924-9-9 03:25AM BLOOD WBC-26.1* RBC-3.50* Hgb-9.1* Hct-26.6* MCV-76* MCH-26.1* MCHC-34.3 RDW-20.1* Plt Ct-286 1924-9-9 03:25AM BLOOD Neuts-78* Bands-0 Lymphs-13* Monos-6 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 1924-9-9 03:25AM BLOOD PT-22.4* PTT-58.1* INR(PT)-2.1* 1924-9-9 03:25AM BLOOD Glucose-143* UreaN-84* Creat-3.2* Na-137 K-3.4 Cl-108 HCO3-15* AnGap-17 1985-9-10 03:06AM BLOOD ALT-105* AST-183* AlkPhos-363* Amylase-88 TotBili-1.8* 1924-9-9 03:25AM BLOOD Calcium-8.4 Phos-3.0# Mg-2.7* 1985-9-10 03:06AM BLOOD Cortsol-42.1* 1985-9-10 11:48PM BLOOD Vanco-19.9 1924-9-9 03:45AM BLOOD Lactate-2.6* CT 1903-2-13 FINDINGS: There is no evidence of hemorrhage, edema, mass effect or infarction. The ventricles and sulci are markedly prominent, likely secondary to age-related global atrophy. There is no shift of normally midline structures. The Dr.Johnson-white matter differentiation is grossly preserved. There is no evidence of fracture. A large mucous retention cyst is noted in the right maxillary sinus. The remaining visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. No acute intracranial process. 2. Significant global atrophy, likely age-related. 3. Large mucous retention cyst in the right maxillary sinus. CT 1903-2-13 IMPRESSION: 1. Limited study without IV contrast. 2. Similar 1.6 x 1.9 cm spiculated right upper lobe lesion with associated right hilar and mediastinal lymphadenopathy, highly concerning for malignancy. 3. 2-mm left upper lobe nodule, apparently new. Bibasilar atelectasis and left lower lobe discoid atelectasis. No definite focal airspace consolidations. 4. Multifocal large hypodense lesions in the liver, incompletely assessed without IV contrast but compatible with widespread hepatic metastases. 5. Moderate-sized hiatal hernia. 6. Evidence of tracheomalacia. 7. Large fibroid uterus. 8. Similar significant T11 and T12 compression fractures. Brief Hospital Course: Assessment and Plan: This is a 88 yo female that presented with altered mental status, hypotension, a right upper mass concerning for lung cancer and evidence of metastatic spread. . #. Hypotension: The patient presented with hypotension likely due to a combination of hypovolemia (poor PO intake for the preceeding days) and distributive/septic shock (given a WBC 24). The infectious source was not found. CT of chest/abdomen/pelvis was not revealing. UA was negative. Blood, Urine, and Sputum cultures were unrevealing for an infectious source. The patient was started on levophed gtt, but was discontinued and made CMO (see below). The patient was initially place on vancomycin and zosyn, which were discontinued after she was made CMO. . #. Altered mental status from toxic metabolic encephalopathy in the context of multiple insults including hypotension and infection. A CT of her head was negative for an obvious cause of altered mental status. Broad spectrim antibotics were started, but stopped when made CMO. . #. Right Upper Lung Mass- The patient presented with a right upper lung mass concerning for malignance with evidence of an 8th rib fracture and hepatic metastases A further work up was deferred after the patient was made CMO. . #. hypercarbic respiratory failure- The patient presented with metabolic acidosis (likely from sepsis) with inappropriate respiratory compensation. She was intubated and placed on mechanical ventilation for hypercarbic respiratory failure. She was extubated and made CMO. . #. Comfort Measures Only- The patient was made CMO after confirming with the patient's next of kind that the patient's wish would be to remain as comfortable as possible until she died. She was extubated. Pressors were stopped. The patient was started on artificial tears, morphine prn, and all medication were stopped other than those to maintain comfort. . #. Acute kidney Injury. The patient presented hypovolemic and labs consistent with pre-renal/ATN. All medications were renally dose. Nephrotoxic drugs were avoided. The YS Hasan improved after fluid resuscitation. . #. German Naegelin Pt home dose of levothyroxine was continued until made CMO . #. Microcytic anemia: Likely from anemia of chronic inflammation given labs results. Medications on Admission: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: 10-19 Drops Ophthalmic DAILY (Daily). 4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical Olson-Christensen Hospital (2 times a day) as needed for intertrigo. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY 7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: 10-19 Drops Ophthalmic DAILY (Daily). 2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 5. pain management please start morphine sulfate 1-5 mg IV Q2H:PRN SOB, pain management. Please titrate to comfort. Discharge Disposition: Extended Care Facility: Sanchez, Smith and Burke Medical Center Rehabilitation and Nursing of Unit 8762 Box 2779 DPO AA 12152 Discharge Diagnosis: hypoxemia respiratory failure hypotension right upper lobe mass Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to Lowe and Sons Hospital for altered mental status. We found that you had low blood pressure, which we treated by giving you intravenous fluids and medications to raise the blood pressure. We also found that you had difficult breathing, which we treated by intubation you and having a ventilator help you breath. We also found evidence of a likely cancer that has spread around your body. Medication: Stop taking all medications, except the folllowing: Acetaminophen 650 every 6 hours for pain Artificial tears 1-2 drops both eyes daily Morphine sulfate as needed Followup Instructions: please see your primary care providor as needed NA Hasan Tracy Smith MD 98838152	["Admission Date: 1903-2-13 Discharge Date: 1999-9-22\n\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Tennity\nChief Complaint:\naltered mental status\n\nMajor Surgical or Invasive Procedure:\nintubation\ncentral line placement\n\n\nHistory of Present Illness:\nHistory of Present Illness: 88F w/ h/o Grave's disease,\n?CRI/?HTN & recently diagnosed RUL lung mass with LAD & liver\nmets who presents from rehab with altered mental. Per her\nrehabilitation facility, the patient is usually responsive to\nher name and this evening became unresponsive to name. It is\nunclear her baseline mental status. There is no evidence of\nfever from rehabilitation records. Patient to altered to tell us\nher symptoms.\n\nIn the ED, initial VS were: 86 84/40 18 100% 2L NC. CVL was\nplaced in RIJ.", " Labs were notable for acute kidney injury (Cr 4.3\n1933-11-19), leukocytosis with WBC 24.1 (up from recent\nbaseline of 17) w/ 91% polys, no bands & HCO3 15. Transaminases,\nalk phos and lipase were elevated, however the specimen was\nhemolyzed which can falsely elevate these values. Lactate 2.3.\nPrelim read of CT head & abd/pelvis were negative for acute\nprocess. Patient received 3L lactated ringers as well as\nvancomycin 1g IV and zosyn 4.5mg IV empirically. While in the\nED, patient's BPs were 90s/60s (EMS) -> 84/40s (on presentation)\n-> got 3L fluids with no change in BP -> 90s/40s -> started\nlevophed gtt @ 0.09 & BPs increased to 100-107/43-52. VS on\ntransfer were 78, 20, 100%2L, CVP 7->12, 98 rectal.\n.\nOn arrival to the MICU, the patient is non-verbal and unable to\npartake in a review of systems questions.", "\n\n\nPast Medical History:\nGrave's disease\nHTN\nthoracic spine fx\ns/p hysterectomy\nurinary retention\nconstipation\nosteoarthritis\npossible chronic kidney disease\n\nSocial History:\nLives alone, no biologic children, minimal contact with step\nchildren\nno ETOH, Adam Casenhiser\n\n\nFamily History:\nNone relevant to fall\n\nPhysical Exam:\nPhysical Exam on Discharge:\nVitals: 95.3 79/64 83 20 96% on RA\nGeneral: Extubated, still altered, not talking in words. Not in\nany painful distress, but obviously not oriented.\nHEENT: Sclerae anicteric, very dry mucous membranes, +dry eyes\nNeck: supple, unable to assess JVP, no LAD\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops\nLungs: Clear to auscultation anteriorly, no wheezes, rales,\nrhonchi\nAbdomen: soft, diffusely tender, non-distended, bowel sounds\npresent, no organomegaly\nGU: foley in place\nExt: warm, bilateral DP pulses observed by doppler, no clubbing,\ncyanosis or edema\n\n\nPertinent Results:\n1903-2-13 01:15AM BLOOD WBC-24.", '1* RBC-4.41 Hgb-11.1* Hct-35.9\nMCV-81 MCH-25.3* MCHC-31.1 RDW-19.6* Plt Ct-264\n1924-9-9 03:25AM BLOOD WBC-26.1* RBC-3.50* Hgb-9.1* Hct-26.6\nMCV-76 MCH-26.1* MCHC-34.3 RDW-20.1* Plt Ct-286\n1924-9-9 03:25AM BLOOD Neuts-78* Bands-0 Lymphs-13* Monos-6\nEos-3 Baso-0 Atyps-0 Metas-0 Myelos-0\n1924-9-9 03:25AM BLOOD PT-22.4* PTT-58.1* INR(PT)-2.1\n1924-9-9 03:25AM BLOOD Glucose-143 UreaN-84* Creat-3.2* Na-137\nK-3.4 Cl-108 HCO3-15* AnGap-17\n1985-9-10 03:06AM BLOOD ALT-105* AST-183* AlkPhos-363* Amylase-88\nTotBili-1.8\n1924-9-9 03:25AM BLOOD Calcium-8.4 Phos-3.0# Mg-2.7\n1985-9-10 03:06AM BLOOD Cortsol-42.1\n1985-9-10 11:48PM BLOOD Vanco-19.9\n1924-9-9 03:45AM BLOOD Lactate-2.6\n\nCT 1903-2-13\nFINDINGS: There is no evidence of hemorrhage, edema, mass effect\nor\ninfarction. The ventricles and sulci are markedly prominent,\nlikely secondary to age-related global atrophy.', ' There is no\nshift of normally midline structures. The Dr.Johnson-white matter\ndifferentiation is grossly preserved. There is no evidence of\nfracture. A large mucous retention cyst is noted in the right\nmaxillary sinus. The remaining visualized paranasal sinuses and\nmastoid air cells are clear.\n\nIMPRESSION:\n1. No acute intracranial process.\n2. Significant global atrophy, likely age-related.\n3. Large mucous retention cyst in the right maxillary sinus.\n\nCT 1903-2-13\nIMPRESSION:\n1. Limited study without IV contrast.\n2. Similar 1.6 x 1.9 cm spiculated right upper lobe lesion with\nassociated\nright hilar and mediastinal lymphadenopathy, highly concerning\nfor malignancy.\n3. 2-mm left upper lobe nodule, apparently new. Bibasilar\natelectasis and\nleft lower lobe discoid atelectasis. No definite focal airspace\nconsolidations.', '\n4. Multifocal large hypodense lesions in the liver, incompletely\nassessed\nwithout IV contrast but compatible with widespread hepatic\nmetastases.\n5. Moderate-sized hiatal hernia.\n6. Evidence of tracheomalacia.\n7. Large fibroid uterus.\n8. Similar significant T11 and T12 compression fractures.\n\n\nBrief Hospital Course:\nAssessment and Plan:\nThis is a 88 yo female that presented with altered mental\nstatus, hypotension, a right upper mass concerning for lung\ncancer and evidence of metastatic spread.\n.\n#. Hypotension: The patient presented with hypotension likely\ndue to a combination of hypovolemia (poor PO intake for the\npreceeding days) and distributive/septic shock (given a WBC 24).\n The infectious source was not found. CT of\nchest/abdomen/pelvis was not revealing. UA was negative. Blood,\nUrine, and Sputum cultures were unrevealing for an infectious\nsource.', ' The patient was started on levophed gtt, but was\ndiscontinued and made CMO (see below). The patient was\ninitially place on vancomycin and zosyn, which were discontinued\nafter she was made CMO.\n.\n#. Altered mental status from toxic metabolic encephalopathy in\nthe context of multiple insults including hypotension and\ninfection. A CT of her head was negative for an obvious cause of\naltered mental status. Broad spectrim antibotics were started,\nbut stopped when made CMO.\n.\n#. Right Upper Lung Mass- The patient presented with a right\nupper lung mass concerning for malignance with evidence of an\n8th rib fracture and hepatic metastases\nA further work up was deferred after the patient was made CMO.\n.\n#. hypercarbic respiratory failure- The patient presented with\nmetabolic acidosis (likely from sepsis) with inappropriate\nrespiratory compensation.', " She was intubated and placed on\nmechanical ventilation for hypercarbic respiratory failure. She\nwas extubated and made CMO.\n.\n#. Comfort Measures Only- The patient was made CMO after\nconfirming with the patient's next of kind that the patient's\nwish would be to remain as comfortable as possible until she\ndied. She was extubated. Pressors were stopped. The patient\nwas started on artificial tears, morphine prn, and all\nmedication were stopped other than those to maintain comfort.\n.\n#. Acute kidney Injury. The patient presented hypovolemic and\nlabs consistent with pre-renal/ATN. All medications were\nrenally dose. Nephrotoxic drugs were avoided. The YS Hasan\nimproved after fluid resuscitation.\n.\n#. German Naegelin Pt home dose of levothyroxine was continued\nuntil made CMO\n.\n#. Microcytic anemia: Likely from anemia of chronic inflammation\ngiven labs results.", '\n\n\nMedications on Admission:\n1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for Constipation.\n2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: 10-19\nDrops Ophthalmic DAILY (Daily).\n4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical Olson-Christensen Hospital\n(2 times a day) as needed for intertrigo.\n5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) Inhalation Q6H (every 6 hours) as\nneeded for wheezing.\n6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY\n7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H\n(every 8 hours) as needed for constipation.\n\n\nDischarge Medications:\n1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: 10-19\nDrops Ophthalmic DAILY (Daily).', '\n2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H\n(every 6 hours) as needed for pain.\n3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for constipation.\n4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2\ntimes a day) as needed for constipation.\n5. pain management\nplease start morphine sulfate 1-5 mg IV Q2H:PRN SOB, pain\nmanagement. Please titrate to comfort.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nSanchez, Smith and Burke Medical Center Rehabilitation and Nursing of Unit 8762 Box 2779\nDPO AA 12152\n\nDischarge Diagnosis:\nhypoxemia respiratory failure\nhypotension\nright upper lobe mass\n\n\nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic and not arousable.\nActivity Status: Bedbound.\n\n\nDischarge Instructions:\nYou were admitted to Lowe and Sons Hospital for\naltered mental status.', ' We found that you had low blood\npressure, which we treated by giving you intravenous fluids and\nmedications to raise the blood pressure. We also found that you\nhad difficult breathing, which we treated by intubation you and\nhaving a ventilator help you breath. We also found evidence of\na likely cancer that has spread around your body.\n\nMedication:\nStop taking all medications, except the folllowing:\nAcetaminophen 650 every 6 hours for pain\nArtificial tears 1-2 drops both eyes daily\nMorphine sulfate as needed\n\nFollowup Instructions:\nplease see your primary care providor as needed\n\n\n NA Hasan Tracy Smith MD 98838152\n\n']
559	12762	176023.0	2172-07-13	Discharge summary	Report	Admission Date: [2172-7-3] Discharge Date: [2172-7-13] Service: MED Allergies: Amoxicillin / Aspirin / Clindamycin / Erythromycin Base / Bactrim Attending:[Last Name (NamePattern4) 290] Chief Complaint: confusion Major Surgical or Invasive Procedure: EGD Brief Hospital Course: Respiratory failure: The patient was intubated and maintained on pressure support ventilation from the time of admission due to respiratory failure with blood gas consistent with hypoxia. Respiratory failure in this patient was presumably due to impending hemodynamic collapse. There was no clear evidence of pneumonia or other primary pulmonary process on chest x-ray or on examination. The patient had small right pleural effusion on admission and developed left pleural effusion during her hospital stay, but these effusions were small and unlikely to contribute to respiratory distress. The patient was maintained on pressure support ventilation during her admission and oxygenation was maintained with acceptable parameters. Hypotension: The patient was hypotensive on admission with blood pressure as low as 60 over palpation in the emergency department. This was most likely secondary to GI bleed; although, the patient's elevated white count on admission and continuous hemodynamic instability during her hospital stay despite stable hematocrit indicated that there were likely other contributing factors. The patient was initially suspected of having sepsis, and was begun on empiric therapy with levofloxacin and Flagyl. In addition, cosyntropin stimulation test was performed to evaluate for adrenal insufficiency. This test was normal indicating that hypoadrenalism was likely not contributing to her hypotension. The patient was treated with levofloxacin and Flagyl during her entire hospital admission as empiric therapy for possible sepsis. She displayed labile blood pressure during her entire admission and required occasional fluid boluses to maintain her mean arterial pressure greater than 60. She required intermittent use of pressure medications during her admission with Dopamine being the principle [Doctor Last Name 360]. Upper GI bleed: The patient was admitted with hematocrit of 22 and signs of GI bleed including bright red blood per rectum. EGD on [2172-7-5] demonstrated a bleeding mass in the stomach suspicious for malignancy of the linitis plastica type. Biopsies were taken and showed adenocarcinoma of the stomach and also diffuse gastritis. This gastritis was likely the cause of the patient's GI bleed. On admission, the patient was transfused with 2 units of packed red blood cells raising her hematocrit to 27. Hematocrit was monitored closely during her hospital stay and the patient was transfused an additional time to raise her hematocrit to greater than 30. Her hematocrit remained stable at 30 during the majority of her hospitalization, indicating that GI bleed had stabilized after her admission. The patient was also treated with Protonix IV b.i.d., sucralfate 1 gram by NG tube q.i.d., and fluid resuscitation. No treatment was available for her diffuse gastric carcinoma and gastritis other than the above mentioned medications. Thrombocytopenia: The patient was admitted with normal platelet count, and platelets decreased suddenly to 87,000 early in her hospital admission. Given the stability of her white blood cell count and hematocrit, it was unlikely that this was a dilutional phenomenon. The possibility of consumptive coagulopathy was most concerning in this patient with gastric carcinoma. Fibrinogen and FDP were checked to evaluate for DIC, and were found to be within normal limits. Platelets were followed and were observed to raise to normal levels. The patient demonstrated no sequelae of thrombocytopenia during her admission. Pain: The patient was treated with Fentanyl drip in order to provide adequate analgesia. She was observed to be comfortable initially on Fentanyl drip with no signs of pain. There was no hypertension, tachycardia, or physical sign of pain. Eventually, the patient demonstrated physical signs of discomfort, and required Fentanyl boluses in addition to her Fentanyl drip. Fentanyl boluses were administered as required to maintain strong level of analgesia in the patient. Communication: The intensive care unit team was in frequent communication with the patient's family, especially the patient's daughter who was her healthcare proxy. The patient's family initially was hopeful of achieving cure in this patient, such that the patient would be able to convalesce at home and to recover among her family. However, during the hospital course, it became apparent to the intensive care unit team and to the family that the patient's disease was not amenable to cure, and that the patient would likely die of her disease during this admission. The family asked appropriate questions about end of life issues and end of life care and the family meeting was held to discuss the patient's code status and goal of care. On [2172-7-10], the family embraced comfort care as a goal of treatment. They directed that the intensive care unit team should withhold laboratory tests and medications except for medications that would maintain the patient's comfort. The patient was treated with Fentanyl drip and Fentanyl boluses to maintain analgesia and was observed to be comfortable during her hospital stay. After this decision was made, the patient's blood pressure was observed to trend down slowly and the patient's respiratory status was maintained with ventilation. On [2172-7-13], the patient died of cardiovascular collapse, secondary to her diffuse hemorrhagic gastric carcinoma. Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	Admission Date: <Date>1987-6-15</Date> Discharge Date: <Date>1985-11-31</Date> Service: MED Allergies: Amoxicillin / Aspirin / Clindamycin / Erythromycin Base / Bactrim Attending:<Name>Blanchar</Name> Chief Complaint: confusion Major Surgical or Invasive Procedure: EGD Brief Hospital Course: Respiratory failure: The patient was intubated and maintained on pressure support ventilation from the time of admission due to respiratory failure with blood gas consistent with hypoxia. Respiratory failure in this patient was presumably due to impending hemodynamic collapse. There was no clear evidence of pneumonia or other primary pulmonary process on chest x-ray or on examination. The patient had small right pleural effusion on admission and developed left pleural effusion during her hospital stay, but these effusions were small and unlikely to contribute to respiratory distress. The patient was maintained on pressure support ventilation during her admission and oxygenation was maintained with acceptable parameters. Hypotension: The patient was hypotensive on admission with blood pressure as low as 60 over palpation in the emergency department. This was most likely secondary to GI bleed; although, the patient's elevated white count on admission and continuous hemodynamic instability during her hospital stay despite stable hematocrit indicated that there were likely other contributing factors. The patient was initially suspected of having sepsis, and was begun on empiric therapy with levofloxacin and Flagyl. In addition, cosyntropin stimulation test was performed to evaluate for adrenal insufficiency. This test was normal indicating that hypoadrenalism was likely not contributing to her hypotension. The patient was treated with levofloxacin and Flagyl during her entire hospital admission as empiric therapy for possible sepsis. She displayed labile blood pressure during her entire admission and required occasional fluid boluses to maintain her mean arterial pressure greater than 60. She required intermittent use of pressure medications during her admission with Dopamine being the principle <Doctor Name>Dr.Benavidez</Doctor Name>. Upper GI bleed: The patient was admitted with hematocrit of 22 and signs of GI bleed including bright red blood per rectum. EGD on <Date>2021-12-5</Date> demonstrated a bleeding mass in the stomach suspicious for malignancy of the linitis plastica type. Biopsies were taken and showed adenocarcinoma of the stomach and also diffuse gastritis. This gastritis was likely the cause of the patient's GI bleed. On admission, the patient was transfused with 2 units of packed red blood cells raising her hematocrit to 27. Hematocrit was monitored closely during her hospital stay and the patient was transfused an additional time to raise her hematocrit to greater than 30. Her hematocrit remained stable at 30 during the majority of her hospitalization, indicating that GI bleed had stabilized after her admission. The patient was also treated with Protonix IV b.i.d., sucralfate 1 gram by NG tube q.i.d., and fluid resuscitation. No treatment was available for her diffuse gastric carcinoma and gastritis other than the above mentioned medications. Thrombocytopenia: The patient was admitted with normal platelet count, and platelets decreased suddenly to 87,000 early in her hospital admission. Given the stability of her white blood cell count and hematocrit, it was unlikely that this was a dilutional phenomenon. The possibility of consumptive coagulopathy was most concerning in this patient with gastric carcinoma. Fibrinogen and FDP were checked to evaluate for DIC, and were found to be within normal limits. Platelets were followed and were observed to raise to normal levels. The patient demonstrated no sequelae of thrombocytopenia during her admission. Pain: The patient was treated with Fentanyl drip in order to provide adequate analgesia. She was observed to be comfortable initially on Fentanyl drip with no signs of pain. There was no hypertension, tachycardia, or physical sign of pain. Eventually, the patient demonstrated physical signs of discomfort, and required Fentanyl boluses in addition to her Fentanyl drip. Fentanyl boluses were administered as required to maintain strong level of analgesia in the patient. Communication: The intensive care unit team was in frequent communication with the patient's family, especially the patient's daughter who was her healthcare proxy. The patient's family initially was hopeful of achieving cure in this patient, such that the patient would be able to convalesce at home and to recover among her family. However, during the hospital course, it became apparent to the intensive care unit team and to the family that the patient's disease was not amenable to cure, and that the patient would likely die of her disease during this admission. The family asked appropriate questions about end of life issues and end of life care and the family meeting was held to discuss the patient's code status and goal of care. On <Date>1927-10-27</Date>, the family embraced comfort care as a goal of treatment. They directed that the intensive care unit team should withhold laboratory tests and medications except for medications that would maintain the patient's comfort. The patient was treated with Fentanyl drip and Fentanyl boluses to maintain analgesia and was observed to be comfortable during her hospital stay. After this decision was made, the patient's blood pressure was observed to trend down slowly and the patient's respiratory status was maintained with ventilation. On <Date>1985-11-31</Date>, the patient died of cardiovascular collapse, secondary to her diffuse hemorrhagic gastric carcinoma. Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased <Initial>WG</Initial> <Name>Moblo</Name> <Name>Hattie Ornelas</Name> MD <MD Number>37499212</MD 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000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001101111101111111111111100001111111100	Admission Date: 1987-6-15 Discharge Date: 1985-11-31 Service: MED Allergies: Amoxicillin / Aspirin / Clindamycin / Erythromycin Base / Bactrim Attending:Blanchar Chief Complaint: confusion Major Surgical or Invasive Procedure: EGD Brief Hospital Course: Respiratory failure: The patient was intubated and maintained on pressure support ventilation from the time of admission due to respiratory failure with blood gas consistent with hypoxia. Respiratory failure in this patient was presumably due to impending hemodynamic collapse. There was no clear evidence of pneumonia or other primary pulmonary process on chest x-ray or on examination. The patient had small right pleural effusion on admission and developed left pleural effusion during her hospital stay, but these effusions were small and unlikely to contribute to respiratory distress. The patient was maintained on pressure support ventilation during her admission and oxygenation was maintained with acceptable parameters. Hypotension: The patient was hypotensive on admission with blood pressure as low as 60 over palpation in the emergency department. This was most likely secondary to GI bleed; although, the patient's elevated white count on admission and continuous hemodynamic instability during her hospital stay despite stable hematocrit indicated that there were likely other contributing factors. The patient was initially suspected of having sepsis, and was begun on empiric therapy with levofloxacin and Flagyl. In addition, cosyntropin stimulation test was performed to evaluate for adrenal insufficiency. This test was normal indicating that hypoadrenalism was likely not contributing to her hypotension. The patient was treated with levofloxacin and Flagyl during her entire hospital admission as empiric therapy for possible sepsis. She displayed labile blood pressure during her entire admission and required occasional fluid boluses to maintain her mean arterial pressure greater than 60. She required intermittent use of pressure medications during her admission with Dopamine being the principle Dr.Benavidez. Upper GI bleed: The patient was admitted with hematocrit of 22 and signs of GI bleed including bright red blood per rectum. EGD on 2021-12-5 demonstrated a bleeding mass in the stomach suspicious for malignancy of the linitis plastica type. Biopsies were taken and showed adenocarcinoma of the stomach and also diffuse gastritis. This gastritis was likely the cause of the patient's GI bleed. On admission, the patient was transfused with 2 units of packed red blood cells raising her hematocrit to 27. Hematocrit was monitored closely during her hospital stay and the patient was transfused an additional time to raise her hematocrit to greater than 30. Her hematocrit remained stable at 30 during the majority of her hospitalization, indicating that GI bleed had stabilized after her admission. The patient was also treated with Protonix IV b.i.d., sucralfate 1 gram by NG tube q.i.d., and fluid resuscitation. No treatment was available for her diffuse gastric carcinoma and gastritis other than the above mentioned medications. Thrombocytopenia: The patient was admitted with normal platelet count, and platelets decreased suddenly to 87,000 early in her hospital admission. Given the stability of her white blood cell count and hematocrit, it was unlikely that this was a dilutional phenomenon. The possibility of consumptive coagulopathy was most concerning in this patient with gastric carcinoma. Fibrinogen and FDP were checked to evaluate for DIC, and were found to be within normal limits. Platelets were followed and were observed to raise to normal levels. The patient demonstrated no sequelae of thrombocytopenia during her admission. Pain: The patient was treated with Fentanyl drip in order to provide adequate analgesia. She was observed to be comfortable initially on Fentanyl drip with no signs of pain. There was no hypertension, tachycardia, or physical sign of pain. Eventually, the patient demonstrated physical signs of discomfort, and required Fentanyl boluses in addition to her Fentanyl drip. Fentanyl boluses were administered as required to maintain strong level of analgesia in the patient. Communication: The intensive care unit team was in frequent communication with the patient's family, especially the patient's daughter who was her healthcare proxy. The patient's family initially was hopeful of achieving cure in this patient, such that the patient would be able to convalesce at home and to recover among her family. However, during the hospital course, it became apparent to the intensive care unit team and to the family that the patient's disease was not amenable to cure, and that the patient would likely die of her disease during this admission. The family asked appropriate questions about end of life issues and end of life care and the family meeting was held to discuss the patient's code status and goal of care. On 1927-10-27, the family embraced comfort care as a goal of treatment. They directed that the intensive care unit team should withhold laboratory tests and medications except for medications that would maintain the patient's comfort. The patient was treated with Fentanyl drip and Fentanyl boluses to maintain analgesia and was observed to be comfortable during her hospital stay. After this decision was made, the patient's blood pressure was observed to trend down slowly and the patient's respiratory status was maintained with ventilation. On 1985-11-31, the patient died of cardiovascular collapse, secondary to her diffuse hemorrhagic gastric carcinoma. Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased WG Moblo Hattie Ornelas MD 37499212	['Admission Date: 1987-6-15 Discharge Date: 1985-11-31\n\n\nService: MED\n\nAllergies:\nAmoxicillin / Aspirin / Clindamycin / Erythromycin Base /\nBactrim\n\nAttending:Blanchar\nChief Complaint:\nconfusion\n\nMajor Surgical or Invasive Procedure:\nEGD\n\nBrief Hospital Course:\nRespiratory failure: The patient was\nintubated and maintained on pressure support ventilation from\nthe time of admission due to respiratory failure with blood\ngas consistent with hypoxia. Respiratory failure in this\npatient was presumably due to impending hemodynamic collapse.\nThere was no clear evidence of pneumonia or other primary\npulmonary process on chest x-ray or on examination. The\npatient had small right pleural effusion on admission and\ndeveloped left pleural effusion during her hospital stay, but\nthese effusions were small and unlikely to contribute to\nrespiratory distress.', " The patient was maintained on pressure\nsupport ventilation during her admission and oxygenation was\nmaintained with acceptable parameters.\n\nHypotension: The patient was hypotensive on admission with\nblood pressure as low as 60 over palpation in the emergency\ndepartment. This was most likely secondary to GI bleed;\nalthough, the patient's elevated white count on admission and\ncontinuous hemodynamic instability during her hospital stay\ndespite stable hematocrit indicated that there were likely\nother contributing factors. The patient was initially\nsuspected of having sepsis, and was begun on empiric therapy\nwith levofloxacin and Flagyl. In addition, cosyntropin\nstimulation test was performed to evaluate for adrenal\ninsufficiency. This test was normal indicating that\nhypoadrenalism was likely not contributing to her\nhypotension.", " The patient was treated with levofloxacin and\nFlagyl during her entire hospital admission as empiric\ntherapy for possible sepsis. She displayed labile blood\npressure during her entire admission and required occasional\nfluid boluses to maintain her mean arterial pressure greater\nthan 60. She required intermittent use of pressure\nmedications during her admission with Dopamine being the\nprinciple Dr.Benavidez.\n\nUpper GI bleed: The patient was admitted with hematocrit of\n22 and signs of GI bleed including bright red blood per\nrectum. EGD on 2021-12-5 demonstrated a bleeding mass in the\nstomach suspicious for malignancy of the linitis plastica\ntype. Biopsies were taken and showed adenocarcinoma of the\nstomach and also diffuse gastritis. This gastritis was\nlikely the cause of the patient's GI bleed.", ' On admission,\nthe patient was transfused with 2 units of packed red blood\ncells raising her hematocrit to 27. Hematocrit was monitored\nclosely during her hospital stay and the patient was\ntransfused an additional time to raise her hematocrit to\ngreater than 30. Her hematocrit remained stable at 30 during\nthe majority of her hospitalization, indicating that GI bleed\nhad stabilized after her admission. The patient was also\ntreated with Protonix IV b.i.d., sucralfate 1 gram by NG tube\nq.i.d., and fluid resuscitation. No treatment was available\nfor her diffuse gastric carcinoma and gastritis other than\nthe above mentioned medications.\n\nThrombocytopenia: The patient was admitted with normal\nplatelet count, and platelets decreased suddenly to 87,000\nearly in her hospital admission. Given the stability of her\nwhite blood cell count and hematocrit, it was unlikely that\nthis was a dilutional phenomenon.', ' The possibility of\nconsumptive coagulopathy was most concerning in this patient\nwith gastric carcinoma. Fibrinogen and FDP were checked to\nevaluate for DIC, and were found to be within normal limits.\nPlatelets were followed and were observed to raise to normal\nlevels. The patient demonstrated no sequelae of\nthrombocytopenia during her admission.\n\nPain: The patient was treated with Fentanyl drip in order to\nprovide adequate analgesia. She was observed to be\ncomfortable initially on Fentanyl drip with no signs of pain.\nThere was no hypertension, tachycardia, or physical sign of\npain. Eventually, the patient demonstrated physical signs of\ndiscomfort, and required Fentanyl boluses in addition to her\nFentanyl drip. Fentanyl boluses were administered as\nrequired to maintain strong level of analgesia in the\npatient.', "\n\nCommunication: The intensive care unit team was in frequent\ncommunication with the patient's family, especially the\npatient's daughter who was her healthcare proxy. The\npatient's family initially was hopeful of achieving cure in\nthis patient, such that the patient would be able to\nconvalesce at home and to recover among her family. However,\nduring the hospital course, it became apparent to the\nintensive care unit team and to the family that the patient's\ndisease was not amenable to cure, and that the patient would\nlikely die of her disease during this admission. The family\nasked appropriate questions about end of life issues and end\nof life care and the family meeting was held to discuss the\npatient's code status and goal of care. On 1927-10-27, the\nfamily embraced comfort care as a goal of treatment.", " They\ndirected that the intensive care unit team should withhold\nlaboratory tests and medications except for medications that\nwould maintain the patient's comfort. The patient was\ntreated with Fentanyl drip and Fentanyl boluses to maintain\nanalgesia and was observed to be comfortable during her\nhospital stay. After this decision was made, the patient's\nblood pressure was observed to trend down slowly and the\npatient's respiratory status was maintained with ventilation.\nOn 1985-11-31, the patient died of cardiovascular collapse,\nsecondary to her diffuse hemorrhagic gastric carcinoma.\n\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\ndeceased\n\nDischarge Condition:\ndeceased\n\n WG Moblo Hattie Ornelas MD 37499212\n\n"]
560	65513	127865.0	2146-07-26	Discharge summary	Report	Admission Date: [2146-7-21] Discharge Date: [2146-7-26] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 4549] is a [Age over 90 ] y/o female with CAD/ CHF, afib, diabetes, presenting from clinic with dyspnea: [2146-5-30]: corneal transplant. 10 days ago: increasing dyspnea/ orthopnea 5 days ago: Markedly worse dyspnea and chills, can no longer walk without dyspnea. 1 day ago: shoulder pain relieved with lidocaine. At her baseline she is legally blind and ambulates with a cane; she has had falls in the past. Denies weight gain, cough, chest pain, N/V. Has subjective chills at home. Positve right shoulder pain as above. Patient also states that she has not been drinking more water than normal or eating more salt than normal. She also states that she has not had any stepwise changes in her dyspnea. No sick contacts. Patient was referred from clinic where her respiratory rate was 36 and was labored. Her pulse was 105 and irregular. Her O2 sat was between 89% and 91% on room air. In the ED, initial vs were: T 97.5, HR 117, BP 116/78, and she triggered for RR 36, POx 95%. She was noted to have moderate respiratory distress. Exam revealed rales bilaterally. Labs notable for WBC 12.1 (89% N, no bands), Cr 1.8 (no prior baseline in OMR), BNP [Numeric Identifier 4550], lactate 2.3. CXR showed mild pulmonary edema, small left pleural effusion, and left lung base atelectasis vs. infiltrate. She was given Ceftriaxone and Azithromycin (no cultures drawn prior), and was admitted to Medicine for PNA vs. CHF. VS prior to transfer were: On arrival to the floor, patient reports continued dyspnea. Otherwise, no acute complaints. ROS: some fatigue and chills without fevers. She does report that she has numbness and muscle weakness and pain in many joints. Occasional headaches, abdominal pain. Denies night sweats, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: diabetes Atrial fibrillation Coronary artery disease hypertension hyperlipidemia. Recent had a corneal transplant. legally blind. Social History: She is retired professor [First Name8 (NamePattern2) ] [Last Name (Titles) 533] at the [Location (un) ] in [Location (un) 4551]. She lives alone, but is frequently monitored by her daughter who lives close by. She has never smoked cigarettes, she drinks socially, and does not do drugs. Family History: Non contributory, patient does not recall cardiac disease in parents. Physical Exam: Admission: VS 95.3, 116/87, 96, 26, 95% 3L, FS 352 GEN Alert, oriented, tachypnic HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Tacyhpnic, Good aeration, CTAB no wheezes, rales, ronchi> I didn no CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions Discharge: N/A, deceased Pertinent Results: Admisson: [2146-7-21] 10:45AM BLOOD WBC-12.1* RBC-4.86 Hgb-14.4 Hct-46.3 MCV-95 MCH-29.7 MCHC-31.2 RDW-15.0 Plt Ct-239 [2146-7-22] 07:22AM BLOOD WBC-10.2 RBC-4.38 Hgb-13.3 Hct-41.9 MCV-96 MCH-30.3 MCHC-31.7 RDW-15.0 Plt Ct-239 [2146-7-21] 10:45AM BLOOD Neuts-89.0* Lymphs-7.7* Monos-2.8 Eos-0.2 Baso-0.2 [2146-7-21] 10:45AM BLOOD PT-13.9* PTT-43.5* INR(PT)-1.3* [2146-7-21] 10:45AM BLOOD Glucose-348* UreaN-58* Creat-1.8* Na-140 K-5.2* Cl-109* HCO3-16* AnGap-20 [2146-7-22] 07:22AM BLOOD Glucose-141* UreaN-60* Creat-1.9* Na-143 K-4.3 Cl-110* HCO3-19* AnGap-18 [2146-7-21] 03:00PM BLOOD CK(CPK)-59 [2146-7-21] 10:45AM BLOOD proBNP-[Numeric Identifier 4550]* [2146-7-21] 10:45AM BLOOD cTropnT-0.01 [2146-7-21] 03:00PM BLOOD CK-MB-4 cTropnT-<0.01 [2146-7-22] 07:22AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.7 [2146-7-21] 10:45AM BLOOD TSH-1.1 [2146-7-21] 10:45AM BLOOD Free T4-1.6 [2146-7-21] 12:06PM BLOOD Lactate-2.3* [2146-7-22] 05:20AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 [2146-7-22] 05:20AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2146-7-22] 05:20AM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 [2146-7-22] 05:20AM URINE CastHy-17* Micro: -Blood cx ([7-21]): PENDING -Urine cx ([7-22]): NEGATIVE -Urine Legionalla Ag ([7-22]): NEGATIVE -Urine cx ([7-25]): PENDING EKG ([2146-7-21]): Atrial fibrillation with a moderate ventricular response. Non-specific ST-T wave changes, most notable in leads VI-V2. Compared to the previous tracing of [2128-5-11] atrial fibrillation has replaced sinus bradycardia. The septal T wave changes have been previously noted. TTE ([2146-7-21]): The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension, with evidence of right ventricular pressure overload and consequent ventricular interaction. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. AP PORTAL CHEST X-RAY ([2146-7-21]): 1. Mild pulmonary edema and small left pleural effusion. 2. Ill-defined opacity in the left lung base is nonspecific, but could reflect an area of atelectasis, or possibly infection. PA/LATERAL CHEST X-RAY ([2146-7-22]): There is unchanged cardiomegaly. There is persistent atelectasis versus developing infiltrate at the left lung base. This is stable. There are no signs for overt pulmonary edema or pneumothoraces. Overall, there has been no interval change. PA/LATERAL CHEST X-RAY ([2146-7-24]): Cardiac silhouette is enlarged. There is some atelectasis at the lung bases. There are no signs for overt pulmonary edema. There is some prominence of some of the interstitial markings and atelectasis of the left lung base which is stable. There is minimal wedging of several mid thoracic vertebral bodies. AP PORTABLE CHEST X-RAY ([2146-7-25]): Lung volumes are lower today, exaggerating relative caliber of distended mediastinal veins and the extent of moderate cardiomegaly. Thoracic aorta is quite tortuous and aneurysm is not really evaluated by this study. Pleural effusion is minimal if any. No pneumothorax. V/Q SCAN ([2146-7-25]): Multiple mismatched perfusion defects bilaterally consistent with very high likelihood ratio of acute pulmonary embolus. Brief Hospital Course: Ms. [Known lastname 4549] is a [Age over 90 ] y/o female with CAD/ CHF, afib, diabetes, presenting from clinic with dyspnea. # Dyspnea secondary to pulmonary embolism: Initially attributed to diastolic CHF based on age, history of diabetes, JVP of 10-12cm and pleural effusion on CXR and BNP >10k, although dry mucus membranes and no edema peripherally. Diastolic dysfunction was confirmed by echo. Also initially considered was PNA given hypothermia, but no history of cough and only mild leukocytosis to 12.1k. Initially Troponins negative x2 and no evidence of ischemia by EKG. Pulmonary embolism was also initially considered, but other etiologies including diastolic dysfunction were more likely initially and despite vague shoulder pain, no frank chest pain and no stepwise changes in dyspnea; patient described it as progressive shortness of breath. Patient treated on admission with 40IV lasix and was 1L negative and the following day treated with 80mg PO lasix. This was repeated as the patient was not negative with 60mg IV lasix. Patient was also emperically started on ceftriaxone 1g IV q24h and Azithromycin 500mg PO q24h on admission. She was then switched to PO levoquin and dyspnea continued, with desaturations to the 80s with ambulation. When patient did not improve with aggressive diuresis and leukocytosis increased to 20K, other etiologies were reconsidered. Repeat troponins were not consistent with an acute ischemic event. AGB was consistent with primary metabolic acidosis, with normal anion gap, with superimposed respiratory alkalosis and an Aa gradient of approximately 50. [2146-7-25] VQ scan was consistent with right > left sided pulmonary embolism. Patient was started on IV heparin and warfarin PO. Her troponins began to increase and her urine output decreaed. The evening of [7-25], patient's entered atrial fibrillation with RVR with decreasing O2 saturations, decreasing blood pressure to 80s systolic and no urine output. Patient was transferred to the ICU for further care. On arrival to the ICU patient was hypotensive to 80s, tachycardic to 150s (AFib with RVR), satting in high 80s on NRB. She was noted to have dusky, cool, pulseless LLE, possibly arterial thrombus showered from atrium in setting of RVR. Failed rate control with beta blockade. She was started on peripheral norepinephrine and levophed drips for hypotension. As her presentation was consistent with massive PE causing hemodynamic instability, lysis with TPA was attempted. Before this, ICU team spoke with daughter (HCP) in detail about risks/benefits of TPA. Daughter specified she did not want central line placed, and updated code status to DNR/DNI in light of severity of her illness. Over the next six hours after TPA infusion, patient's oxygen requirements continued to increase and she became increasingly hypotensive with rising pressor requirements and agonal breathing. In light of her failure to respond to lysis, spoke with family again and patient was transitioned to CMO with morphine drip for comfort. She passed away at 11:49 am with family by the bedside. # Presentation Hypothermia: 96.2/35.6 rectally, not quite meeting SIRS criteria of <35. ? infection as above versus other process as hypothyroidism or poor cardiac output. UA is clear except for protein. TSH and Free T4 normal. Resolving the following day with antibiotics and diuresis as above. Patient was normothermic during the remainder of the hospitalization. # CAD: Per history. No evidence of Q waves on EKG. Echo without wall motion abnormalities. Patient was continued on ASA 81mg qd and simvastatin 40 mg daily # DM complicated by protinuria. Patient was treated with an insulin sliding scale, Lantus 10 units subcutaneously every morning, which was increased to 14 units prior to transfer to the unit for sugars in the 250 range. We held glipizide 5 mg daily # Atrial fibrillation: CHADS 2 of 4, although not anticoagulated due to risk. At home, on Toprol XL 50 mg daily. Prior to discovering the pulmonary embolism, we increased metoprolol succinate 75mg qd for heart rate control to attempt to improve forward flow and ASA 81mg qd # Hypertension: Fair control initially. We held isosorbide mononitrate 10 mg daily as patient is normotensive and substituted Lisinopril 5mg qd in place of fosinopril 10 mg daily. This was discontinued on [7-25] when patient entered into [Last Name (un) ] from combination of diuresis and pulmonary embolism # Recent corneal transplant with history of glaucoma. We continued: - brimonidine (Alphagan) P 0.1 % Eye Drops: 1 drop each eye [Hospital1 ] - prednisolone acetate 1 %: 1 drop to right eye TID # Transitional Medications on Admission: aspirin 81 mg 2-3 times per week Toprol XL 50 mg daily isosorbide mononitrate 10 mg daily fosinopril 10 mg daily simvastatin 40 mg daily Lantus 10 units subcutaneously every morning glipizide 5 mg daily omeprazole 40 mg daily PRN Qvar 80 mcg/actuation Aerosol Inhaler: 2 puffs [Hospital1 ] brimonidine (Alphagan) P 0.1 % Eye Drops: 1 drop each eye [Hospital1 ] prednisolone acetate 1 %: 1 drop to right eye TID senna 8.6 mg daily beclomethasone dipropionate [Qvar] 80 mcg Aerosol 2 puff(s) twice a day (using 3 puffs, 4-5X/day as emergency med) Discharge Medications: N/A, deceased Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: N/A, deceased Discharge Condition: N/A, deceased Discharge Instructions: N/A, deceased Followup Instructions: N/A, deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	Admission Date: <Date>1958-12-21</Date> Discharge Date: <Date>2021-6-11</Date> Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Whitehead</Name> Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. <Name>Kuykendall</Name> is a <Age>56</Age> y/o female with CAD/ CHF, afib, diabetes, presenting from clinic with dyspnea: <Date>2011-8-10</Date>: corneal transplant. 10 days ago: increasing dyspnea/ orthopnea 5 days ago: Markedly worse dyspnea and chills, can no longer walk without dyspnea. 1 day ago: shoulder pain relieved with lidocaine. At her baseline she is legally blind and ambulates with a cane; she has had falls in the past. Denies weight gain, cough, chest pain, N/V. Has subjective chills at home. Positve right shoulder pain as above. Patient also states that she has not been drinking more water than normal or eating more salt than normal. She also states that she has not had any stepwise changes in her dyspnea. No sick contacts. Patient was referred from clinic where her respiratory rate was 36 and was labored. Her pulse was 105 and irregular. Her O2 sat was between 89% and 91% on room air. In the ED, initial vs were: T 97.5, HR 117, BP 116/78, and she triggered for RR 36, POx 95%. She was noted to have moderate respiratory distress. Exam revealed rales bilaterally. Labs notable for WBC 12.1 (89% N, no bands), Cr 1.8 (no prior baseline in OMR), BNP <Numeric Identifier>6378120</Numeric Identifier>, lactate 2.3. CXR showed mild pulmonary edema, small left pleural effusion, and left lung base atelectasis vs. infiltrate. She was given Ceftriaxone and Azithromycin (no cultures drawn prior), and was admitted to Medicine for PNA vs. CHF. VS prior to transfer were: On arrival to the floor, patient reports continued dyspnea. Otherwise, no acute complaints. ROS: some fatigue and chills without fevers. She does report that she has numbness and muscle weakness and pain in many joints. Occasional headaches, abdominal pain. Denies night sweats, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: diabetes Atrial fibrillation Coronary artery disease hypertension hyperlipidemia. Recent had a corneal transplant. legally blind. Social History: She is retired professor <Name>Octavia</Name> <Name>Merino</Name> at the <Location>36074 Lisa Green Apt. 340 Harrismouth, TN 71454</Location> in <Location>0715 Gordon Inlet Apt. 351 Port Scott, FM 51276</Location>. She lives alone, but is frequently monitored by her daughter who lives close by. She has never smoked cigarettes, she drinks socially, and does not do drugs. Family History: Non contributory, patient does not recall cardiac disease in parents. Physical Exam: Admission: VS 95.3, 116/87, 96, 26, 95% 3L, FS 352 GEN Alert, oriented, tachypnic HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Tacyhpnic, Good aeration, CTAB no wheezes, rales, ronchi> I didn no CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions Discharge: N/A, deceased Pertinent Results: Admisson: <Date>1958-12-21</Date> 10:45AM BLOOD WBC-12.1* RBC-4.86 Hgb-14.4 Hct-46.3 MCV-95 MCH-29.7 MCHC-31.2 RDW-15.0 Plt Ct-239 <Date>2002-10-25</Date> 07:22AM BLOOD WBC-10.2 RBC-4.38 Hgb-13.3 Hct-41.9 MCV-96 MCH-30.3 MCHC-31.7 RDW-15.0 Plt Ct-239 <Date>1958-12-21</Date> 10:45AM BLOOD Neuts-89.0* Lymphs-7.7* Monos-2.8 Eos-0.2 Baso-0.2 <Date>1958-12-21</Date> 10:45AM BLOOD PT-13.9* PTT-43.5* INR(PT)-1.3* <Date>1958-12-21</Date> 10:45AM BLOOD Glucose-348* UreaN-58* Creat-1.8* Na-140 K-5.2* Cl-109* HCO3-16* AnGap-20 <Date>2002-10-25</Date> 07:22AM BLOOD Glucose-141* UreaN-60* Creat-1.9* Na-143 K-4.3 Cl-110* HCO3-19* AnGap-18 <Date>1958-12-21</Date> 03:00PM BLOOD CK(CPK)-59 <Date>1958-12-21</Date> 10:45AM BLOOD proBNP-<Numeric Identifier>6378120</Numeric Identifier>* <Date>1958-12-21</Date> 10:45AM BLOOD cTropnT-0.01 <Date>1958-12-21</Date> 03:00PM BLOOD CK-MB-4 cTropnT-<0.01 <Date>2002-10-25</Date> 07:22AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.7 <Date>1958-12-21</Date> 10:45AM BLOOD TSH-1.1 <Date>1958-12-21</Date> 10:45AM BLOOD Free T4-1.6 <Date>1958-12-21</Date> 12:06PM BLOOD Lactate-2.3* <Date>2002-10-25</Date> 05:20AM URINE Color-Yellow Appear-Clear Sp <Name>Gauthier</Name>-1.011 <Date>2002-10-25</Date> 05:20AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG <Date>2002-10-25</Date> 05:20AM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 <Date>2002-10-25</Date> 05:20AM URINE CastHy-17* Micro: -Blood cx (<Date>11-27</Date>): PENDING -Urine cx (<Date>9-31</Date>): NEGATIVE -Urine Legionalla Ag (<Date>9-31</Date>): NEGATIVE -Urine cx (<Date>4-13</Date>): PENDING EKG (<Date>1958-12-21</Date>): Atrial fibrillation with a moderate ventricular response. Non-specific ST-T wave changes, most notable in leads VI-V2. Compared to the previous tracing of <Date>1991-7-15</Date> atrial fibrillation has replaced sinus bradycardia. The septal T wave changes have been previously noted. TTE (<Date>1958-12-21</Date>): The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension, with evidence of right ventricular pressure overload and consequent ventricular interaction. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. AP PORTAL CHEST X-RAY (<Date>1958-12-21</Date>): 1. Mild pulmonary edema and small left pleural effusion. 2. Ill-defined opacity in the left lung base is nonspecific, but could reflect an area of atelectasis, or possibly infection. PA/LATERAL CHEST X-RAY (<Date>2002-10-25</Date>): There is unchanged cardiomegaly. There is persistent atelectasis versus developing infiltrate at the left lung base. This is stable. There are no signs for overt pulmonary edema or pneumothoraces. Overall, there has been no interval change. PA/LATERAL CHEST X-RAY (<Date>1982-2-22</Date>): Cardiac silhouette is enlarged. There is some atelectasis at the lung bases. There are no signs for overt pulmonary edema. There is some prominence of some of the interstitial markings and atelectasis of the left lung base which is stable. There is minimal wedging of several mid thoracic vertebral bodies. AP PORTABLE CHEST X-RAY (<Date>1971-6-3</Date>): Lung volumes are lower today, exaggerating relative caliber of distended mediastinal veins and the extent of moderate cardiomegaly. Thoracic aorta is quite tortuous and aneurysm is not really evaluated by this study. Pleural effusion is minimal if any. No pneumothorax. V/Q SCAN (<Date>1971-6-3</Date>): Multiple mismatched perfusion defects bilaterally consistent with very high likelihood ratio of acute pulmonary embolus. Brief Hospital Course: Ms. <Name>Kuykendall</Name> is a <Age>56</Age> y/o female with CAD/ CHF, afib, diabetes, presenting from clinic with dyspnea. # Dyspnea secondary to pulmonary embolism: Initially attributed to diastolic CHF based on age, history of diabetes, JVP of 10-12cm and pleural effusion on CXR and BNP >10k, although dry mucus membranes and no edema peripherally. Diastolic dysfunction was confirmed by echo. Also initially considered was PNA given hypothermia, but no history of cough and only mild leukocytosis to 12.1k. Initially Troponins negative x2 and no evidence of ischemia by EKG. Pulmonary embolism was also initially considered, but other etiologies including diastolic dysfunction were more likely initially and despite vague shoulder pain, no frank chest pain and no stepwise changes in dyspnea; patient described it as progressive shortness of breath. Patient treated on admission with 40IV lasix and was 1L negative and the following day treated with 80mg PO lasix. This was repeated as the patient was not negative with 60mg IV lasix. Patient was also emperically started on ceftriaxone 1g IV q24h and Azithromycin 500mg PO q24h on admission. She was then switched to PO levoquin and dyspnea continued, with desaturations to the 80s with ambulation. When patient did not improve with aggressive diuresis and leukocytosis increased to 20K, other etiologies were reconsidered. Repeat troponins were not consistent with an acute ischemic event. AGB was consistent with primary metabolic acidosis, with normal anion gap, with superimposed respiratory alkalosis and an Aa gradient of approximately 50. <Date>1971-6-3</Date> VQ scan was consistent with right > left sided pulmonary embolism. Patient was started on IV heparin and warfarin PO. Her troponins began to increase and her urine output decreaed. The evening of <Date>4-13</Date>, patient's entered atrial fibrillation with RVR with decreasing O2 saturations, decreasing blood pressure to 80s systolic and no urine output. Patient was transferred to the ICU for further care. On arrival to the ICU patient was hypotensive to 80s, tachycardic to 150s (AFib with RVR), satting in high 80s on NRB. She was noted to have dusky, cool, pulseless LLE, possibly arterial thrombus showered from atrium in setting of RVR. Failed rate control with beta blockade. She was started on peripheral norepinephrine and levophed drips for hypotension. As her presentation was consistent with massive PE causing hemodynamic instability, lysis with TPA was attempted. Before this, ICU team spoke with daughter (HCP) in detail about risks/benefits of TPA. Daughter specified she did not want central line placed, and updated code status to DNR/DNI in light of severity of her illness. Over the next six hours after TPA infusion, patient's oxygen requirements continued to increase and she became increasingly hypotensive with rising pressor requirements and agonal breathing. In light of her failure to respond to lysis, spoke with family again and patient was transitioned to CMO with morphine drip for comfort. She passed away at 11:49 am with family by the bedside. # Presentation Hypothermia: 96.2/35.6 rectally, not quite meeting SIRS criteria of <35. ? infection as above versus other process as hypothyroidism or poor cardiac output. UA is clear except for protein. TSH and Free T4 normal. Resolving the following day with antibiotics and diuresis as above. Patient was normothermic during the remainder of the hospitalization. # CAD: Per history. No evidence of Q waves on EKG. Echo without wall motion abnormalities. Patient was continued on ASA 81mg qd and simvastatin 40 mg daily # DM complicated by protinuria. Patient was treated with an insulin sliding scale, Lantus 10 units subcutaneously every morning, which was increased to 14 units prior to transfer to the unit for sugars in the 250 range. We held glipizide 5 mg daily # Atrial fibrillation: CHADS 2 of 4, although not anticoagulated due to risk. At home, on Toprol XL 50 mg daily. Prior to discovering the pulmonary embolism, we increased metoprolol succinate 75mg qd for heart rate control to attempt to improve forward flow and ASA 81mg qd # Hypertension: Fair control initially. We held isosorbide mononitrate 10 mg daily as patient is normotensive and substituted Lisinopril 5mg qd in place of fosinopril 10 mg daily. This was discontinued on <Date>4-13</Date> when patient entered into <Name>Gauthier</Name> from combination of diuresis and pulmonary embolism # Recent corneal transplant with history of glaucoma. We continued: - brimonidine (Alphagan) P 0.1 % Eye Drops: 1 drop each eye <Hospital>Miranda-Brown Health System</Hospital> - prednisolone acetate 1 %: 1 drop to right eye TID # Transitional Medications on Admission: aspirin 81 mg 2-3 times per week Toprol XL 50 mg daily isosorbide mononitrate 10 mg daily fosinopril 10 mg daily simvastatin 40 mg daily Lantus 10 units subcutaneously every morning glipizide 5 mg daily omeprazole 40 mg daily PRN Qvar 80 mcg/actuation Aerosol Inhaler: 2 puffs <Hospital>Miranda-Brown Health System</Hospital> brimonidine (Alphagan) P 0.1 % Eye Drops: 1 drop each eye <Hospital>Miranda-Brown Health System</Hospital> prednisolone acetate 1 %: 1 drop to right eye TID senna 8.6 mg daily beclomethasone dipropionate [Qvar] 80 mcg Aerosol 2 puff(s) twice a day (using 3 puffs, 4-5X/day as emergency med) Discharge Medications: N/A, deceased Discharge Disposition: Home With Service Facility: <Hospital>Matthews-Jordan Hospital</Hospital> Homecare Discharge Diagnosis: N/A, deceased Discharge Condition: N/A, deceased Discharge Instructions: N/A, deceased Followup Instructions: N/A, deceased <Initial>AI</Initial> <Name>Bogle</Name> <Name>Arthur Casenhiser</Name> MD <MD Number>88667631</MD 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Date: 1958-12-21 Discharge Date: 2021-6-11 Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Whitehead Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. Kuykendall is a 56 y/o female with CAD/ CHF, afib, diabetes, presenting from clinic with dyspnea: 2011-8-10: corneal transplant. 10 days ago: increasing dyspnea/ orthopnea 5 days ago: Markedly worse dyspnea and chills, can no longer walk without dyspnea. 1 day ago: shoulder pain relieved with lidocaine. At her baseline she is legally blind and ambulates with a cane; she has had falls in the past. Denies weight gain, cough, chest pain, N/V. Has subjective chills at home. Positve right shoulder pain as above. Patient also states that she has not been drinking more water than normal or eating more salt than normal. She also states that she has not had any stepwise changes in her dyspnea. No sick contacts. Patient was referred from clinic where her respiratory rate was 36 and was labored. Her pulse was 105 and irregular. Her O2 sat was between 89% and 91% on room air. In the ED, initial vs were: T 97.5, HR 117, BP 116/78, and she triggered for RR 36, POx 95%. She was noted to have moderate respiratory distress. Exam revealed rales bilaterally. Labs notable for WBC 12.1 (89% N, no bands), Cr 1.8 (no prior baseline in OMR), BNP 6378120, lactate 2.3. CXR showed mild pulmonary edema, small left pleural effusion, and left lung base atelectasis vs. infiltrate. She was given Ceftriaxone and Azithromycin (no cultures drawn prior), and was admitted to Medicine for PNA vs. CHF. VS prior to transfer were: On arrival to the floor, patient reports continued dyspnea. Otherwise, no acute complaints. ROS: some fatigue and chills without fevers. She does report that she has numbness and muscle weakness and pain in many joints. Occasional headaches, abdominal pain. Denies night sweats, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: diabetes Atrial fibrillation Coronary artery disease hypertension hyperlipidemia. Recent had a corneal transplant. legally blind. Social History: She is retired professor Octavia Merino at the 36074 Lisa Green Apt. 340 Harrismouth, TN 71454 in 0715 Gordon Inlet Apt. 351 Port Scott, FM 51276. She lives alone, but is frequently monitored by her daughter who lives close by. She has never smoked cigarettes, she drinks socially, and does not do drugs. Family History: Non contributory, patient does not recall cardiac disease in parents. Physical Exam: Admission: VS 95.3, 116/87, 96, 26, 95% 3L, FS 352 GEN Alert, oriented, tachypnic HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Tacyhpnic, Good aeration, CTAB no wheezes, rales, ronchi> I didn no CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions Discharge: N/A, deceased Pertinent Results: Admisson: 1958-12-21 10:45AM BLOOD WBC-12.1* RBC-4.86 Hgb-14.4 Hct-46.3 MCV-95 MCH-29.7 MCHC-31.2 RDW-15.0 Plt Ct-239 2002-10-25 07:22AM BLOOD WBC-10.2 RBC-4.38 Hgb-13.3 Hct-41.9 MCV-96 MCH-30.3 MCHC-31.7 RDW-15.0 Plt Ct-239 1958-12-21 10:45AM BLOOD Neuts-89.0* Lymphs-7.7* Monos-2.8 Eos-0.2 Baso-0.2 1958-12-21 10:45AM BLOOD PT-13.9* PTT-43.5* INR(PT)-1.3* 1958-12-21 10:45AM BLOOD Glucose-348* UreaN-58* Creat-1.8* Na-140 K-5.2* Cl-109* HCO3-16* AnGap-20 2002-10-25 07:22AM BLOOD Glucose-141* UreaN-60* Creat-1.9* Na-143 K-4.3 Cl-110* HCO3-19* AnGap-18 1958-12-21 03:00PM BLOOD CK(CPK)-59 1958-12-21 10:45AM BLOOD proBNP-6378120* 1958-12-21 10:45AM BLOOD cTropnT-0.01 1958-12-21 03:00PM BLOOD CK-MB-4 cTropnT-2002-10-25 07:22AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.7 1958-12-21 10:45AM BLOOD TSH-1.1 1958-12-21 10:45AM BLOOD Free T4-1.6 1958-12-21 12:06PM BLOOD Lactate-2.3* 2002-10-25 05:20AM URINE Color-Yellow Appear-Clear Sp Gauthier-1.011 2002-10-25 05:20AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG 2002-10-25 05:20AM URINE RBC-2002-10-25 05:20AM URINE CastHy-17* Micro: -Blood cx (11-27): PENDING -Urine cx (9-31): NEGATIVE -Urine Legionalla Ag (9-31): NEGATIVE -Urine cx (4-13): PENDING EKG (1958-12-21): Atrial fibrillation with a moderate ventricular response. Non-specific ST-T wave changes, most notable in leads VI-V2. Compared to the previous tracing of 1991-7-15 atrial fibrillation has replaced sinus bradycardia. The septal T wave changes have been previously noted. TTE (1958-12-21): The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension, with evidence of right ventricular pressure overload and consequent ventricular interaction. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. AP PORTAL CHEST X-RAY (1958-12-21): 1. Mild pulmonary edema and small left pleural effusion. 2. Ill-defined opacity in the left lung base is nonspecific, but could reflect an area of atelectasis, or possibly infection. PA/LATERAL CHEST X-RAY (2002-10-25): There is unchanged cardiomegaly. There is persistent atelectasis versus developing infiltrate at the left lung base. This is stable. There are no signs for overt pulmonary edema or pneumothoraces. Overall, there has been no interval change. PA/LATERAL CHEST X-RAY (1982-2-22): Cardiac silhouette is enlarged. There is some atelectasis at the lung bases. There are no signs for overt pulmonary edema. There is some prominence of some of the interstitial markings and atelectasis of the left lung base which is stable. There is minimal wedging of several mid thoracic vertebral bodies. AP PORTABLE CHEST X-RAY (1971-6-3): Lung volumes are lower today, exaggerating relative caliber of distended mediastinal veins and the extent of moderate cardiomegaly. Thoracic aorta is quite tortuous and aneurysm is not really evaluated by this study. Pleural effusion is minimal if any. No pneumothorax. V/Q SCAN (1971-6-3): Multiple mismatched perfusion defects bilaterally consistent with very high likelihood ratio of acute pulmonary embolus. Brief Hospital Course: Ms. Kuykendall is a 56 y/o female with CAD/ CHF, afib, diabetes, presenting from clinic with dyspnea. # Dyspnea secondary to pulmonary embolism: Initially attributed to diastolic CHF based on age, history of diabetes, JVP of 10-12cm and pleural effusion on CXR and BNP >10k, although dry mucus membranes and no edema peripherally. Diastolic dysfunction was confirmed by echo. Also initially considered was PNA given hypothermia, but no history of cough and only mild leukocytosis to 12.1k. Initially Troponins negative x2 and no evidence of ischemia by EKG. Pulmonary embolism was also initially considered, but other etiologies including diastolic dysfunction were more likely initially and despite vague shoulder pain, no frank chest pain and no stepwise changes in dyspnea; patient described it as progressive shortness of breath. Patient treated on admission with 40IV lasix and was 1L negative and the following day treated with 80mg PO lasix. This was repeated as the patient was not negative with 60mg IV lasix. Patient was also emperically started on ceftriaxone 1g IV q24h and Azithromycin 500mg PO q24h on admission. She was then switched to PO levoquin and dyspnea continued, with desaturations to the 80s with ambulation. When patient did not improve with aggressive diuresis and leukocytosis increased to 20K, other etiologies were reconsidered. Repeat troponins were not consistent with an acute ischemic event. AGB was consistent with primary metabolic acidosis, with normal anion gap, with superimposed respiratory alkalosis and an Aa gradient of approximately 50. 1971-6-3 VQ scan was consistent with right > left sided pulmonary embolism. Patient was started on IV heparin and warfarin PO. Her troponins began to increase and her urine output decreaed. The evening of 4-13, patient's entered atrial fibrillation with RVR with decreasing O2 saturations, decreasing blood pressure to 80s systolic and no urine output. Patient was transferred to the ICU for further care. On arrival to the ICU patient was hypotensive to 80s, tachycardic to 150s (AFib with RVR), satting in high 80s on NRB. She was noted to have dusky, cool, pulseless LLE, possibly arterial thrombus showered from atrium in setting of RVR. Failed rate control with beta blockade. She was started on peripheral norepinephrine and levophed drips for hypotension. As her presentation was consistent with massive PE causing hemodynamic instability, lysis with TPA was attempted. Before this, ICU team spoke with daughter (HCP) in detail about risks/benefits of TPA. Daughter specified she did not want central line placed, and updated code status to DNR/DNI in light of severity of her illness. Over the next six hours after TPA infusion, patient's oxygen requirements continued to increase and she became increasingly hypotensive with rising pressor requirements and agonal breathing. In light of her failure to respond to lysis, spoke with family again and patient was transitioned to CMO with morphine drip for comfort. She passed away at 11:49 am with family by the bedside. # Presentation Hypothermia: 96.2/35.6 rectally, not quite meeting SIRS criteria of 4-13 when patient entered into Gauthier from combination of diuresis and pulmonary embolism # Recent corneal transplant with history of glaucoma. We continued: - brimonidine (Alphagan) P 0.1 % Eye Drops: 1 drop each eye Miranda-Brown Health System - prednisolone acetate 1 %: 1 drop to right eye TID # Transitional Medications on Admission: aspirin 81 mg 2-3 times per week Toprol XL 50 mg daily isosorbide mononitrate 10 mg daily fosinopril 10 mg daily simvastatin 40 mg daily Lantus 10 units subcutaneously every morning glipizide 5 mg daily omeprazole 40 mg daily PRN Qvar 80 mcg/actuation Aerosol Inhaler: 2 puffs Miranda-Brown Health System brimonidine (Alphagan) P 0.1 % Eye Drops: 1 drop each eye Miranda-Brown Health System prednisolone acetate 1 %: 1 drop to right eye TID senna 8.6 mg daily beclomethasone dipropionate [Qvar] 80 mcg Aerosol 2 puff(s) twice a day (using 3 puffs, 4-5X/day as emergency med) Discharge Medications: N/A, deceased Discharge Disposition: Home With Service Facility: Matthews-Jordan Hospital Homecare Discharge Diagnosis: N/A, deceased Discharge Condition: N/A, deceased Discharge Instructions: N/A, deceased Followup Instructions: N/A, deceased AI Bogle Arthur Casenhiser MD 88667631	['Admission Date: 1958-12-21 Discharge Date: 2021-6-11\n\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Whitehead\nChief Complaint:\nDyspnea\n\nMajor Surgical or Invasive Procedure:\nNone\n\n\nHistory of Present Illness:\nMs. Kuykendall is a 56 y/o female with CAD/ CHF, afib, diabetes,\npresenting from clinic with dyspnea:\n\n2011-8-10: corneal transplant.\n10 days ago: increasing dyspnea/ orthopnea\n5 days ago: Markedly worse dyspnea and chills, can no longer\nwalk without dyspnea.\n1 day ago: shoulder pain relieved with lidocaine.\n\nAt her baseline she is legally blind and ambulates with a cane;\nshe has had falls in the past.\n\nDenies weight gain, cough, chest pain, N/V. Has subjective\nchills at home. Positve right shoulder pain as above. Patient\nalso states that she has not been drinking more water than\nnormal or eating more salt than normal.', ' She also states that\nshe has not had any stepwise changes in her dyspnea. No sick\ncontacts.\n\nPatient was referred from clinic where her respiratory rate was\n36 and was labored. Her pulse was 105 and irregular. Her O2\nsat was between 89% and 91% on room air.\n\nIn the ED, initial vs were: T 97.5, HR 117, BP 116/78, and she\ntriggered for RR 36, POx 95%. She was noted to have moderate\nrespiratory distress. Exam revealed rales bilaterally. Labs\nnotable for WBC 12.1 (89% N, no bands), Cr 1.8 (no prior\nbaseline in OMR), BNP 6378120, lactate 2.3. CXR showed mild\npulmonary edema, small left pleural effusion, and left lung base\natelectasis vs. infiltrate. She was given Ceftriaxone and\nAzithromycin (no cultures drawn prior), and was admitted to\nMedicine for PNA vs. CHF. VS prior to transfer were:\n\nOn arrival to the floor, patient reports continued dyspnea.', '\nOtherwise, no acute complaints.\n\nROS:\nsome fatigue and chills without fevers. She does report that\nshe has\nnumbness and muscle weakness and pain in many joints. Occasional\nheadaches, abdominal pain.\n\nDenies night sweats, vision changes, rhinorrhea, congestion,\nsore throat, cough, chest pain, nausea, vomiting, diarrhea,\nconstipation, BRBPR, melena, hematochezia, dysuria, hematuria.\nAll other 10-system review negative in detail.\n\nPast Medical History:\ndiabetes\nAtrial fibrillation\nCoronary artery disease\nhypertension\nhyperlipidemia.\nRecent had a corneal transplant.\nlegally blind.\n\nSocial History:\nShe is retired professor Octavia Merino at the 36074 Lisa Green Apt. 340\nHarrismouth, TN 71454 in 0715 Gordon Inlet Apt. 351\nPort Scott, FM 51276.\nShe lives alone, but is frequently monitored by her daughter who\nlives close by.', ' She has never smoked cigarettes, she drinks\nsocially, and does not do drugs.\n\nFamily History:\nNon contributory, patient does not recall cardiac disease in\nparents.\n\nPhysical Exam:\nAdmission:\nVS 95.3, 116/87, 96, 26, 95% 3L, FS 352\nGEN Alert, oriented, tachypnic\nHEENT NCAT MMM EOMI sclera anicteric, OP clear\nNECK supple, no JVD, no LAD\nPULM Tacyhpnic, Good aeration, CTAB no wheezes, rales, ronchi>\nI didn no\nCV RRR normal S1/S2, no mrg\nABD soft NT ND normoactive bowel sounds, no r/g\nEXT WWP 2+ pulses palpable bilaterally, no c/c/e\nNEURO CNs2-12 intact, motor function grossly normal\nSKIN no ulcers or lesions\n\nDischarge: N/A, deceased\n\n\nPertinent Results:\nAdmisson:\n\n1958-12-21 10:45AM BLOOD WBC-12.1* RBC-4.86 Hgb-14.4 Hct-46.3\nMCV-95 MCH-29.7 MCHC-31.2 RDW-15.0 Plt Ct-239\n2002-10-25 07:22AM BLOOD WBC-10.', '2 RBC-4.38 Hgb-13.3 Hct-41.9\nMCV-96 MCH-30.3 MCHC-31.7 RDW-15.0 Plt Ct-239\n1958-12-21 10:45AM BLOOD Neuts-89.0* Lymphs-7.7* Monos-2.8 Eos-0.2\nBaso-0.2\n1958-12-21 10:45AM BLOOD PT-13.9* PTT-43.5* INR(PT)-1.3\n1958-12-21 10:45AM BLOOD Glucose-348 UreaN-58* Creat-1.8* Na-140\nK-5.2* Cl-109* HCO3-16* AnGap-20\n2002-10-25 07:22AM BLOOD Glucose-141* UreaN-60* Creat-1.9* Na-143\nK-4.3 Cl-110* HCO3-19* AnGap-18\n1958-12-21 03:00PM BLOOD CK(CPK)-59\n1958-12-21 10:45AM BLOOD proBNP-6378120\n1958-12-21 10:45AM BLOOD cTropnT-0.01\n1958-12-21 03:00PM BLOOD CK-MB-4 cTropnT-2002-10-25 07:22AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.7\n1958-12-21 10:45AM BLOOD TSH-1.1\n1958-12-21 10:45AM BLOOD Free T4-1.6\n1958-12-21 12:06PM BLOOD Lactate-2.3\n2002-10-25 05:20AM URINE Color-Yellow Appear-Clear Sp Gauthier-1.011\n2002-10-25 05:20AM URINE Blood-NEG Nitrite-NEG Protein-TR\nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.', '0 Leuks-NEG\n2002-10-25 05:20AM URINE RBC-2002-10-25 05:20AM URINE CastHy-17*\n\nMicro:\n-Blood cx (11-27): PENDING\n-Urine cx (9-31): NEGATIVE\n-Urine Legionalla Ag (9-31): NEGATIVE\n-Urine cx (4-13): PENDING\n\nEKG (1958-12-21): Atrial fibrillation with a moderate ventricular\nresponse. Non-specific ST-T wave changes, most notable in leads\nVI-V2. Compared to the previous tracing of 1991-7-15 atrial\nfibrillation has replaced sinus bradycardia. The septal T wave\nchanges have been previously noted.\n\nTTE (1958-12-21): The left atrium is moderately dilated. The right\natrium is moderately dilated. Left ventricular wall thicknesses\nare normal. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is low normal (LVEF 50%). The\nright ventricular free wall is hypertrophied. Right ventricular\nchamber size is normal with depressed free wall contractility.', '\nThe aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. There is at least moderate pulmonary\nartery systolic hypertension, with evidence of right ventricular\npressure overload and consequent ventricular interaction. There\nis a very small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nAP PORTAL CHEST X-RAY (1958-12-21):\n1. Mild pulmonary edema and small left pleural effusion.\n2. Ill-defined opacity in the left lung base is nonspecific, but\ncould\nreflect an area of atelectasis, or possibly infection.\n\nPA/LATERAL CHEST X-RAY (2002-10-25): There is unchanged\ncardiomegaly. There is persistent atelectasis versus developing\ninfiltrate at the left lung base.', ' This is stable. There are no\nsigns for overt pulmonary edema or pneumothoraces. Overall,\nthere has been no interval change.\n\nPA/LATERAL CHEST X-RAY (1982-2-22): Cardiac silhouette is\nenlarged. There is some atelectasis at the lung bases. There are\nno signs for overt pulmonary edema. There is some prominence of\nsome of the interstitial markings and atelectasis of the left\nlung base which is stable. There is minimal wedging of several\nmid thoracic vertebral bodies.\n\nAP PORTABLE CHEST X-RAY (1971-6-3): Lung volumes are lower today,\nexaggerating relative caliber of distended mediastinal veins and\nthe extent of moderate cardiomegaly. Thoracic aorta is quite\ntortuous and aneurysm is not really evaluated by this study.\nPleural effusion is minimal if any. No pneumothorax.\n\nV/Q SCAN (1971-6-3): Multiple mismatched perfusion defects\nbilaterally consistent with very high likelihood ratio of acute\npulmonary embolus.', '\n\nBrief Hospital Course:\nMs. Kuykendall is a 56 y/o female with CAD/ CHF, afib, diabetes,\npresenting from clinic with dyspnea.\n\n# Dyspnea secondary to pulmonary embolism: Initially attributed\nto diastolic CHF based on age, history of diabetes, JVP of\n10-12cm and pleural effusion on CXR and BNP >10k, although dry\nmucus membranes and no edema peripherally. Diastolic\ndysfunction was confirmed by echo. Also initially considered\nwas PNA given hypothermia, but no history of cough and only mild\nleukocytosis to 12.1k. Initially Troponins negative x2 and no\nevidence of ischemia by EKG. Pulmonary embolism was also\ninitially considered, but other etiologies including diastolic\ndysfunction were more likely initially and despite vague\nshoulder pain, no frank chest pain and no stepwise changes in\ndyspnea; patient described it as progressive shortness of\nbreath.', '\n\nPatient treated on admission with 40IV lasix and was 1L negative\nand the following day treated with 80mg PO lasix. This was\nrepeated as the patient was not negative with 60mg IV lasix.\nPatient was also emperically started on ceftriaxone 1g IV q24h\nand Azithromycin 500mg PO q24h on admission. She was then\nswitched to PO levoquin and dyspnea continued, with\ndesaturations to the 80s with ambulation.\n\nWhen patient did not improve with aggressive diuresis and\nleukocytosis increased to 20K, other etiologies were\nreconsidered. Repeat troponins were not consistent with an\nacute ischemic event. AGB was consistent with primary metabolic\nacidosis, with normal anion gap, with superimposed respiratory\nalkalosis and an Aa gradient of approximately 50. 1971-6-3 VQ\nscan was consistent with right > left sided pulmonary embolism.', "\nPatient was started on IV heparin and warfarin PO. Her\ntroponins began to increase and her urine output decreaed. The\nevening of 4-13, patient's entered atrial fibrillation with RVR\nwith decreasing O2 saturations, decreasing blood pressure to 80s\nsystolic and no urine output. Patient was transferred to the ICU\nfor further care.\n\nOn arrival to the ICU patient was hypotensive to 80s,\ntachycardic to 150s (AFib with RVR), satting in high 80s on NRB.\nShe was noted to have dusky, cool, pulseless LLE, possibly\narterial thrombus showered from atrium in setting of RVR. Failed\nrate control with beta blockade. She was started on peripheral\nnorepinephrine and levophed drips for hypotension.\n\nAs her presentation was consistent with massive PE causing\nhemodynamic instability, lysis with TPA was attempted.", " Before\nthis, ICU team spoke with daughter (HCP) in detail about\nrisks/benefits of TPA. Daughter specified she did not want\ncentral line placed, and updated code status to DNR/DNI in light\nof severity of her illness. Over the next six hours after TPA\ninfusion, patient's oxygen requirements continued to increase\nand she became increasingly hypotensive with rising pressor\nrequirements and agonal breathing. In light of her failure to\nrespond to lysis, spoke with family again and patient was\ntransitioned to CMO with morphine drip for comfort. She passed\naway at 11:49 am with family by the bedside.\n\n# Presentation Hypothermia: 96.2/35.6 rectally, not quite\nmeeting SIRS criteria of 4-13 when patient entered into\nGauthier from combination of diuresis and pulmonary embolism\n\n# Recent corneal transplant with history of glaucoma.", ' We\ncontinued:\n- brimonidine (Alphagan) P 0.1 % Eye Drops: 1 drop each eye Miranda-Brown Health System\n- prednisolone acetate 1 %: 1 drop to right eye TID\n\n# Transitional\n\n\nMedications on Admission:\naspirin 81 mg 2-3 times per week\nToprol XL 50 mg daily\nisosorbide mononitrate 10 mg daily\nfosinopril 10 mg daily\nsimvastatin 40 mg daily\nLantus 10 units subcutaneously every morning\nglipizide 5 mg daily\nomeprazole 40 mg daily PRN\nQvar 80 mcg/actuation Aerosol Inhaler: 2 puffs Miranda-Brown Health System\nbrimonidine (Alphagan) P 0.1 % Eye Drops: 1 drop each eye Miranda-Brown Health System\nprednisolone acetate 1 %: 1 drop to right eye TID\nsenna 8.6 mg daily\nbeclomethasone dipropionate [Qvar] 80 mcg Aerosol 2 puff(s)\ntwice a day (using 3 puffs, 4-5X/day as emergency med)\n\nDischarge Medications:\nN/A, deceased\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nMatthews-Jordan Hospital Homecare\n\nDischarge Diagnosis:\nN/A, deceased\n\nDischarge Condition:\nN/A, deceased\n\nDischarge Instructions:\nN/A, deceased\n\nFollowup Instructions:\nN/A, deceased\n\n AI Bogle Arthur Casenhiser MD 88667631\n\n']
561	21414	162875.0	2139-06-07	Discharge summary	Report	Admission Date: [2139-6-3] Discharge Date: [2139-6-7] Date of Birth: [2059-2-14] Sex: M Service: MEDICINE Allergies: Sulfonamides / Quinine / Chloramphenicol Attending:[First Name3 (LF) 4232] Chief Complaint: urosepsis Major Surgical or Invasive Procedure: central line placement and removal History of Present Illness: This is an 80 y/o male with a h/o mental retardation, GERD c/b severe erosive esophagitis, prostate CA s/p TURP without additional treatment, who presented to the ED with fever to 103, subjective dyspnea, foul smelling urine and hypotension with SBPs in the 70s. Pt is not communicative at baseline, but did report lower abdominal pain, denied any CP, SOB, cough. Pt otherwise not able to give a more detailed history due to baseline mental retardation. . In [Name (NI) ], pt was hypotensive, febrile to 103. His lab values were notable for an elevated WBC at 18.5, elevated transaminases, elevated lactate at 7.6, and an elevated Cr to 1.9. He was given 5L NS, and after placing a R femoral CVL, started on Levophed for BP support. He was empirically started on broad spectrum antibiotics of vancomycin, levofloxacin and flagyl, and admitted to the ICU for further care. . In the ICU, patient transiently required levaphed for pressure support. Infectious work up included blood cultures which are NGTD, CXR which was negative, RUQ U/S which was negative, and urine culture with was positive for e. coli, fluoroquinolone sensitive. He was maintained on vancomycin, levofloxacin, and flagyl. On this regimen, the patient stablized, as his BP returned and levophed was discontinued, his WBC decreased, his fever resolved. His renal failure also resolved with fluid rescusitation. His LFTs trended down. His lactate came down. . His ICU course was otherwise notable for a transient episode of atrial fibrillation, which was broken with lopressor 5mg IV x 1, and the patient was subsequently started on lopressor 12.5mg [Hospital1 ]. . His course thus far was also notable for platelets decreased from 130 -> 78, and therefore anti-HIT antibodies were sent (pending) and his SC heparin was discontinued. . Currently, he is afebrile X 24hrs and denies any shortness of breath, fever, chills, chest pain, or abdominal pain. Past Medical History: 1. Prostate CA, PSA 7, s/p TURP, no hx of treatment for CA 2. GERD c/b erosive esophagitis 3. Mental retardation. 4. Frequent UTIs. 5. G6PD deficiency. 6. S/p ccy. 7. h/o sz d/o as child. 8. h/o guiaic (+) stool, not able to visualize past sigmoid on scope due to poor prep (no lesion noted to sigmoid), EGD with esophagitis as above Social History: Lives at group home ([Street Address(1) 4552], [Location (un) 3307], MA), where he performs some ADLs and walks without assist. Sister, [Name (NI) 1743] [Name (NI) 4553] is guardian. Family History: unknown Physical Exam: VS: T101.8 HR84 BP72/40 RR18 o2sat: 100% on 10L face tent GEN: Elderly male, grunting, in NAD, in mild discomfort HEENT: Anicteric sclera NECK: No elev JVP CV: Regular, nml s1,s2. No s3 or murmurs RESP: Coarse BS throughout. ABD: Soft, mild TTP over suprapubic area. R femoral line in groin EXT: No edema bilat. Pulses 2+. No CVAT bilat. NEURO: Able to answer with 1 word answers. Moves all ext spont. SKIN: No jaundice. Pertinent Results: Labs on admission significant for: WBC 9.3 with 23% bands, Cr 1.9, lactate 7.6, AST 315, ALT 258, AP 178 UA: >50 RBC, >50 WBC, many bacteria, neg glu/ketones . Imaging: EKG: NSR, 97. Nml axis, nml intervals. Pseudonormalization of TW V4-V6, no ST changes from previous. . CXR [6-3]: AP supine portable view. Several thick skin folds limit the evaluation of the right hemithorax. Linear opacities at the right lung base are unchanged, representing atelectasis or scarring. The remainder of the right lung is grossly clear. The left lung is clear. Heart size is top normal. There is no pulmonary edema or pleural effusion. . Abdominal US [2139-6-4]: Limited study. No evidence of intra- or extra-hepatic biliary ductal dilatation or focal hepatic mass. Trace amount of fluid is seen adjacent to the upper pole of the right kidney of unclear etiology. . . Labs on discharge: [2139-6-6] 07:17AM BLOOD WBC-6.7 RBC-3.81* Hgb-10.5* Hct-31.5* MCV-83 MCH-27.5 MCHC-33.3 RDW-17.1* Plt Ct-83* [2139-6-6] 07:17AM BLOOD Glucose-103 UreaN-11 Creat-0.7 Na-141 K-4.1 Cl-110* HCO3-26 AnGap-9 Albumin-2.5* Calcium-8.1* Phos-2.1* Mg-1.7 [2139-6-6] 07:17AM BLOOD ALT-105* AST-43* AlkPhos-133* TotBili-0.3 [2139-6-5] 11:48AM BLOOD TSH-1.4 [2139-6-3] 11:55AM BLOOD Cortsol-50.3* [2139-6-3] 11:55AM BLOOD CRP-77.0* [2139-6-5] 02:01AM BLOOD Vanco-8.1* [2139-6-4] 02:32AM BLOOD Lactate-2.3* Brief Hospital Course: A/P: 80 y/o male with a h/o mental retardation, GERD c/b severe erosive esophagitis, prostate CA s/p TURP without additional treatment, who presents with fever to 103, subjective dyspnea, foul smelling urine and hypotension with SBPs in the 70s. 1. Septic Shock: Pt with sepsis and hypotension, with lactate 7.8 in the ED and bandemia of 23%. Given 5L NS in the ED, started on levophed to maintain MAP >65. Likely source is urine, given markedly positive U/A and foul-smelling urine. No pneumonia on CXR. Patient was admitted to the ICU and was empirically started on Vanco and Levaquin IV. Urine culture positive for E. coli, sensitive to levofloxacin, and was switched to Levo 250mg PO. After aggressive IVF resuscitation, the patient was weaned off of levophed with SBPs in 90s-100s. Patient remained afebrile, WBC trended downward, and was transferred to the medicine floor. . While on the medicine floor, he was afebrile with SBP's in the 120's and HR in the 70's, O2 sat was 95% on 2L. . 2. Respiratory distress: On admission, patient in respiratory distress, but no clear PNA seen on pulmonary exam. The Levaquin IV for urosepsis also provided coverage for CAP. Patient was on a face tent with 40% FiO2 but would not tolerate it very well and would pull in off his face. O2 sats remained >92%, even on room air. He was given nebs prn and switched to nasal cannula with sats>94%. . 3. ARF: Pt with a normal baseline Cr of 0.7 and admitted with Cr of 1.9, most likely due to prerenal azotemia given profound dehydration in the setting of sepsis as above. Cr trended down after IVF resuscitation and was back to baseline at time of discharge. . 4. A-fib: On morning of transfer from ICU to floor, patient went into a-fib with rates in the 140's-170's. He was given 5mg lopressor and rate decreased to 80's-120's and returned to [Location 213] sinus rhythm. He was then started on metoprolol 12.5 [Hospital1 ] PO with no further episodes of atrial fibrillation on telemetry. . 5. Mild transaminitis: On admission, he had a mild transaminitis likely in setting of sepsis. Abdominal US was performed to r/o biliary/hepatic pathology. US Showed no evidence of intra or extra hepatic biliary ductal dilitation. The LFTs trended downward during the course of hospital stay. . 6. Heparin induced thrombocytopenia: During the hospital stay, pts platelets fell from 128 to 78 overnight. As he was receiving SQ heparin for DVT prophylaxis, there was concern for HIT. All heparin products were stopped, heparin dependent antibodies were sent and pending at the time of discharge, and the platelet counts stabilized. . 7. Mild coagulopathy: On admission, he had a mild coagulopathy likely in setting of sepsis. A peripheral smear was negative for any schistocytes. INR was followed and trended downward appropriately. . 8. GERD: no active issues during this admission and patient remained on pantoprazole Q12h. . 9. Conjunctivitis: He developed some white exudate and injection in left eye concerning for conjunctivitis. Erythromycin eye drops were started. . 10. FEN: Patient given aggressive IVF resusciation with electrolytes repleted as necessary. Speech and swallow evaluated patient and recommended pureed diet and thickened liquid diet. Patient was started on PO prior to transfer, and tolerated his meals well while on the floor. . 9. DISPO: DNR/DNI. . Comm: HCP [Name (NI) ] [Name (NI) 4554]. [Telephone/Fax (1) 4555] Medications on Admission: Carbamazepine 200mg qAM, 300mg qhs Prilosec 20 [Hospital1 ] Vit C 500 qD FeSO4 325 Eucerin cream Tianctin Baby Shampoo/[Name2 (NI) ] A&D ointment Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:8 Tablet(s) Refills:0 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 4. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Erythromycin 5 mg/g Ointment Sig: 1-2 drops Ophthalmic QID (4 times a day) for 2 weeks. Disp:qs tubes Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing/SOB for 1 weeks. 9. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: urinary tract infection septic shock Secondary: mental retardation GERD prostate cancer s/p TURP Discharge Condition: good Discharge Instructions: You had a urinary tract infection and went into septic shock. . Please call 911 or come to the emergency room if you have any symptoms of fever >101, chills, shortness of breath, chest pain, or any other concerning symptoms. Followup Instructions: Please follow-up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] [Telephone/Fax (1) 608]. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 4236]	Admission Date: <Date>1939-7-24</Date> Discharge Date: <Date>1973-5-13</Date> Date of Birth: <Date>1927-9-22</Date> Sex: M Service: MEDICINE Allergies: Sulfonamides / Quinine / Chloramphenicol Attending:<Name>Meena</Name> Chief Complaint: urosepsis Major Surgical or Invasive Procedure: central line placement and removal History of Present Illness: This is an 80 y/o male with a h/o mental retardation, GERD c/b severe erosive esophagitis, prostate CA s/p TURP without additional treatment, who presented to the ED with fever to 103, subjective dyspnea, foul smelling urine and hypotension with SBPs in the 70s. Pt is not communicative at baseline, but did report lower abdominal pain, denied any CP, SOB, cough. Pt otherwise not able to give a more detailed history due to baseline mental retardation. . In <Name>Felecia Hazelwood</Name>, pt was hypotensive, febrile to 103. His lab values were notable for an elevated WBC at 18.5, elevated transaminases, elevated lactate at 7.6, and an elevated Cr to 1.9. He was given 5L NS, and after placing a R femoral CVL, started on Levophed for BP support. He was empirically started on broad spectrum antibiotics of vancomycin, levofloxacin and flagyl, and admitted to the ICU for further care. . In the ICU, patient transiently required levaphed for pressure support. Infectious work up included blood cultures which are NGTD, CXR which was negative, RUQ U/S which was negative, and urine culture with was positive for e. coli, fluoroquinolone sensitive. He was maintained on vancomycin, levofloxacin, and flagyl. On this regimen, the patient stablized, as his BP returned and levophed was discontinued, his WBC decreased, his fever resolved. His renal failure also resolved with fluid rescusitation. His LFTs trended down. His lactate came down. . His ICU course was otherwise notable for a transient episode of atrial fibrillation, which was broken with lopressor 5mg IV x 1, and the patient was subsequently started on lopressor 12.5mg <Hospital>Lopez-Goodwin Hospital</Hospital>. . His course thus far was also notable for platelets decreased from 130 -> 78, and therefore anti-HIT antibodies were sent (pending) and his SC heparin was discontinued. . Currently, he is afebrile X 24hrs and denies any shortness of breath, fever, chills, chest pain, or abdominal pain. Past Medical History: 1. Prostate CA, PSA 7, s/p TURP, no hx of treatment for CA 2. GERD c/b erosive esophagitis 3. Mental retardation. 4. Frequent UTIs. 5. G6PD deficiency. 6. S/p ccy. 7. h/o sz d/o as child. 8. h/o guiaic (+) stool, not able to visualize past sigmoid on scope due to poor prep (no lesion noted to sigmoid), EGD with esophagitis as above Social History: Lives at group home (<Location>0799 Hansen Skyway Phillipsborough, ME 28491</Location>, <Location>8804 Guerra Shoal Apt. 334 Saundersstad, SD 21251</Location>, MA), where he performs some ADLs and walks without assist. Sister, <Name>Larry Luu</Name> <Name>Curtis Thompkins</Name> is guardian. Family History: unknown Physical Exam: VS: T101.8 HR84 BP72/40 RR18 o2sat: 100% on 10L face tent GEN: Elderly male, grunting, in NAD, in mild discomfort HEENT: Anicteric sclera NECK: No elev JVP CV: Regular, nml s1,s2. No s3 or murmurs RESP: Coarse BS throughout. ABD: Soft, mild TTP over suprapubic area. R femoral line in groin EXT: No edema bilat. Pulses 2+. No CVAT bilat. NEURO: Able to answer with 1 word answers. Moves all ext spont. SKIN: No jaundice. Pertinent Results: Labs on admission significant for: WBC 9.3 with 23% bands, Cr 1.9, lactate 7.6, AST 315, ALT 258, AP 178 UA: >50 RBC, >50 WBC, many bacteria, neg glu/ketones . Imaging: EKG: NSR, 97. Nml axis, nml intervals. Pseudonormalization of TW V4-V6, no ST changes from previous. . CXR <Date>12-26</Date>: AP supine portable view. Several thick skin folds limit the evaluation of the right hemithorax. Linear opacities at the right lung base are unchanged, representing atelectasis or scarring. The remainder of the right lung is grossly clear. The left lung is clear. Heart size is top normal. There is no pulmonary edema or pleural effusion. . Abdominal US <Date>1900-5-7</Date>: Limited study. No evidence of intra- or extra-hepatic biliary ductal dilatation or focal hepatic mass. Trace amount of fluid is seen adjacent to the upper pole of the right kidney of unclear etiology. . . Labs on discharge: <Date>1968-12-4</Date> 07:17AM BLOOD WBC-6.7 RBC-3.81* Hgb-10.5* Hct-31.5* MCV-83 MCH-27.5 MCHC-33.3 RDW-17.1* Plt Ct-83* <Date>1968-12-4</Date> 07:17AM BLOOD Glucose-103 UreaN-11 Creat-0.7 Na-141 K-4.1 Cl-110* HCO3-26 AnGap-9 Albumin-2.5* Calcium-8.1* Phos-2.1* Mg-1.7 <Date>1968-12-4</Date> 07:17AM BLOOD ALT-105* AST-43* AlkPhos-133* TotBili-0.3 <Date>1908-3-15</Date> 11:48AM BLOOD TSH-1.4 <Date>1939-7-24</Date> 11:55AM BLOOD Cortsol-50.3* <Date>1939-7-24</Date> 11:55AM BLOOD CRP-77.0* <Date>1908-3-15</Date> 02:01AM BLOOD Vanco-8.1* <Date>1900-5-7</Date> 02:32AM BLOOD Lactate-2.3* Brief Hospital Course: A/P: 80 y/o male with a h/o mental retardation, GERD c/b severe erosive esophagitis, prostate CA s/p TURP without additional treatment, who presents with fever to 103, subjective dyspnea, foul smelling urine and hypotension with SBPs in the 70s. 1. Septic Shock: Pt with sepsis and hypotension, with lactate 7.8 in the ED and bandemia of 23%. Given 5L NS in the ED, started on levophed to maintain MAP >65. Likely source is urine, given markedly positive U/A and foul-smelling urine. No pneumonia on CXR. Patient was admitted to the ICU and was empirically started on Vanco and Levaquin IV. Urine culture positive for E. coli, sensitive to levofloxacin, and was switched to Levo 250mg PO. After aggressive IVF resuscitation, the patient was weaned off of levophed with SBPs in 90s-100s. Patient remained afebrile, WBC trended downward, and was transferred to the medicine floor. . While on the medicine floor, he was afebrile with SBP's in the 120's and HR in the 70's, O2 sat was 95% on 2L. . 2. Respiratory distress: On admission, patient in respiratory distress, but no clear PNA seen on pulmonary exam. The Levaquin IV for urosepsis also provided coverage for CAP. Patient was on a face tent with 40% FiO2 but would not tolerate it very well and would pull in off his face. O2 sats remained >92%, even on room air. He was given nebs prn and switched to nasal cannula with sats>94%. . 3. ARF: Pt with a normal baseline Cr of 0.7 and admitted with Cr of 1.9, most likely due to prerenal azotemia given profound dehydration in the setting of sepsis as above. Cr trended down after IVF resuscitation and was back to baseline at time of discharge. . 4. A-fib: On morning of transfer from ICU to floor, patient went into a-fib with rates in the 140's-170's. He was given 5mg lopressor and rate decreased to 80's-120's and returned to <Location>USCGC Jackson FPO AP 27844</Location> sinus rhythm. He was then started on metoprolol 12.5 <Hospital>Lopez-Goodwin Hospital</Hospital> PO with no further episodes of atrial fibrillation on telemetry. . 5. Mild transaminitis: On admission, he had a mild transaminitis likely in setting of sepsis. Abdominal US was performed to r/o biliary/hepatic pathology. US Showed no evidence of intra or extra hepatic biliary ductal dilitation. The LFTs trended downward during the course of hospital stay. . 6. Heparin induced thrombocytopenia: During the hospital stay, pts platelets fell from 128 to 78 overnight. As he was receiving SQ heparin for DVT prophylaxis, there was concern for HIT. All heparin products were stopped, heparin dependent antibodies were sent and pending at the time of discharge, and the platelet counts stabilized. . 7. Mild coagulopathy: On admission, he had a mild coagulopathy likely in setting of sepsis. A peripheral smear was negative for any schistocytes. INR was followed and trended downward appropriately. . 8. GERD: no active issues during this admission and patient remained on pantoprazole Q12h. . 9. Conjunctivitis: He developed some white exudate and injection in left eye concerning for conjunctivitis. Erythromycin eye drops were started. . 10. FEN: Patient given aggressive IVF resusciation with electrolytes repleted as necessary. Speech and swallow evaluated patient and recommended pureed diet and thickened liquid diet. Patient was started on PO prior to transfer, and tolerated his meals well while on the floor. . 9. DISPO: DNR/DNI. . Comm: HCP <Name>Felecia Hazelwood</Name> <Name>Babette Spikes</Name>. <Telephone>778-899-8067</Telephone> Medications on Admission: Carbamazepine 200mg qAM, 300mg qhs Prilosec 20 <Hospital>Lopez-Goodwin Hospital</Hospital> Vit C 500 qD FeSO4 325 Eucerin cream Tianctin Baby Shampoo/<Name>Billy Edward</Name> A&D ointment Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:8 Tablet(s) Refills:0 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 4. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Erythromycin 5 mg/g Ointment Sig: 1-2 drops Ophthalmic QID (4 times a day) for 2 weeks. Disp:qs tubes Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing/SOB for 1 weeks. 9. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. Discharge Disposition: Home With Service Facility: <Hospital>Taylor, Phillips and Hensley Hospital</Hospital> Homecare Discharge Diagnosis: Primary: urinary tract infection septic shock Secondary: mental retardation GERD prostate cancer s/p TURP Discharge Condition: good Discharge Instructions: You had a urinary tract infection and went into septic shock. . Please call 911 or come to the emergency room if you have any symptoms of fever >101, chills, shortness of breath, chest pain, or any other concerning symptoms. Followup Instructions: Please follow-up with your primary care physician, <Name>Medrano</Name>. <Name>Whitehead</Name> <Telephone>447-188-9394</Telephone>. <Name>Latasha Naegelin</Name> <Name>Patrick Clapp</Name> MD <MD Number>77521757</MD 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sion Date: 1939-7-24 Discharge Date: 1973-5-13 Date of Birth: 1927-9-22 Sex: M Service: MEDICINE Allergies: Sulfonamides / Quinine / Chloramphenicol Attending:Meena Chief Complaint: urosepsis Major Surgical or Invasive Procedure: central line placement and removal History of Present Illness: This is an 80 y/o male with a h/o mental retardation, GERD c/b severe erosive esophagitis, prostate CA s/p TURP without additional treatment, who presented to the ED with fever to 103, subjective dyspnea, foul smelling urine and hypotension with SBPs in the 70s. Pt is not communicative at baseline, but did report lower abdominal pain, denied any CP, SOB, cough. Pt otherwise not able to give a more detailed history due to baseline mental retardation. . In Felecia Hazelwood, pt was hypotensive, febrile to 103. His lab values were notable for an elevated WBC at 18.5, elevated transaminases, elevated lactate at 7.6, and an elevated Cr to 1.9. He was given 5L NS, and after placing a R femoral CVL, started on Levophed for BP support. He was empirically started on broad spectrum antibiotics of vancomycin, levofloxacin and flagyl, and admitted to the ICU for further care. . In the ICU, patient transiently required levaphed for pressure support. Infectious work up included blood cultures which are NGTD, CXR which was negative, RUQ U/S which was negative, and urine culture with was positive for e. coli, fluoroquinolone sensitive. He was maintained on vancomycin, levofloxacin, and flagyl. On this regimen, the patient stablized, as his BP returned and levophed was discontinued, his WBC decreased, his fever resolved. His renal failure also resolved with fluid rescusitation. His LFTs trended down. His lactate came down. . His ICU course was otherwise notable for a transient episode of atrial fibrillation, which was broken with lopressor 5mg IV x 1, and the patient was subsequently started on lopressor 12.5mg Lopez-Goodwin Hospital. . His course thus far was also notable for platelets decreased from 130 -> 78, and therefore anti-HIT antibodies were sent (pending) and his SC heparin was discontinued. . Currently, he is afebrile X 24hrs and denies any shortness of breath, fever, chills, chest pain, or abdominal pain. Past Medical History: 1. Prostate CA, PSA 7, s/p TURP, no hx of treatment for CA 2. GERD c/b erosive esophagitis 3. Mental retardation. 4. Frequent UTIs. 5. G6PD deficiency. 6. S/p ccy. 7. h/o sz d/o as child. 8. h/o guiaic (+) stool, not able to visualize past sigmoid on scope due to poor prep (no lesion noted to sigmoid), EGD with esophagitis as above Social History: Lives at group home (0799 Hansen Skyway Phillipsborough, ME 28491, 8804 Guerra Shoal Apt. 334 Saundersstad, SD 21251, MA), where he performs some ADLs and walks without assist. Sister, Larry Luu Curtis Thompkins is guardian. Family History: unknown Physical Exam: VS: T101.8 HR84 BP72/40 RR18 o2sat: 100% on 10L face tent GEN: Elderly male, grunting, in NAD, in mild discomfort HEENT: Anicteric sclera NECK: No elev JVP CV: Regular, nml s1,s2. No s3 or murmurs RESP: Coarse BS throughout. ABD: Soft, mild TTP over suprapubic area. R femoral line in groin EXT: No edema bilat. Pulses 2+. No CVAT bilat. NEURO: Able to answer with 1 word answers. Moves all ext spont. SKIN: No jaundice. Pertinent Results: Labs on admission significant for: WBC 9.3 with 23% bands, Cr 1.9, lactate 7.6, AST 315, ALT 258, AP 178 UA: >50 RBC, >50 WBC, many bacteria, neg glu/ketones . Imaging: EKG: NSR, 97. Nml axis, nml intervals. Pseudonormalization of TW V4-V6, no ST changes from previous. . CXR 12-26: AP supine portable view. Several thick skin folds limit the evaluation of the right hemithorax. Linear opacities at the right lung base are unchanged, representing atelectasis or scarring. The remainder of the right lung is grossly clear. The left lung is clear. Heart size is top normal. There is no pulmonary edema or pleural effusion. . Abdominal US 1900-5-7: Limited study. No evidence of intra- or extra-hepatic biliary ductal dilatation or focal hepatic mass. Trace amount of fluid is seen adjacent to the upper pole of the right kidney of unclear etiology. . . Labs on discharge: 1968-12-4 07:17AM BLOOD WBC-6.7 RBC-3.81* Hgb-10.5* Hct-31.5* MCV-83 MCH-27.5 MCHC-33.3 RDW-17.1* Plt Ct-83* 1968-12-4 07:17AM BLOOD Glucose-103 UreaN-11 Creat-0.7 Na-141 K-4.1 Cl-110* HCO3-26 AnGap-9 Albumin-2.5* Calcium-8.1* Phos-2.1* Mg-1.7 1968-12-4 07:17AM BLOOD ALT-105* AST-43* AlkPhos-133* TotBili-0.3 1908-3-15 11:48AM BLOOD TSH-1.4 1939-7-24 11:55AM BLOOD Cortsol-50.3* 1939-7-24 11:55AM BLOOD CRP-77.0* 1908-3-15 02:01AM BLOOD Vanco-8.1* 1900-5-7 02:32AM BLOOD Lactate-2.3* Brief Hospital Course: A/P: 80 y/o male with a h/o mental retardation, GERD c/b severe erosive esophagitis, prostate CA s/p TURP without additional treatment, who presents with fever to 103, subjective dyspnea, foul smelling urine and hypotension with SBPs in the 70s. 1. Septic Shock: Pt with sepsis and hypotension, with lactate 7.8 in the ED and bandemia of 23%. Given 5L NS in the ED, started on levophed to maintain MAP >65. Likely source is urine, given markedly positive U/A and foul-smelling urine. No pneumonia on CXR. Patient was admitted to the ICU and was empirically started on Vanco and Levaquin IV. Urine culture positive for E. coli, sensitive to levofloxacin, and was switched to Levo 250mg PO. After aggressive IVF resuscitation, the patient was weaned off of levophed with SBPs in 90s-100s. Patient remained afebrile, WBC trended downward, and was transferred to the medicine floor. . While on the medicine floor, he was afebrile with SBP's in the 120's and HR in the 70's, O2 sat was 95% on 2L. . 2. Respiratory distress: On admission, patient in respiratory distress, but no clear PNA seen on pulmonary exam. The Levaquin IV for urosepsis also provided coverage for CAP. Patient was on a face tent with 40% FiO2 but would not tolerate it very well and would pull in off his face. O2 sats remained >92%, even on room air. He was given nebs prn and switched to nasal cannula with sats>94%. . 3. ARF: Pt with a normal baseline Cr of 0.7 and admitted with Cr of 1.9, most likely due to prerenal azotemia given profound dehydration in the setting of sepsis as above. Cr trended down after IVF resuscitation and was back to baseline at time of discharge. . 4. A-fib: On morning of transfer from ICU to floor, patient went into a-fib with rates in the 140's-170's. He was given 5mg lopressor and rate decreased to 80's-120's and returned to USCGC Jackson FPO AP 27844 sinus rhythm. He was then started on metoprolol 12.5 Lopez-Goodwin Hospital PO with no further episodes of atrial fibrillation on telemetry. . 5. Mild transaminitis: On admission, he had a mild transaminitis likely in setting of sepsis. Abdominal US was performed to r/o biliary/hepatic pathology. US Showed no evidence of intra or extra hepatic biliary ductal dilitation. The LFTs trended downward during the course of hospital stay. . 6. Heparin induced thrombocytopenia: During the hospital stay, pts platelets fell from 128 to 78 overnight. As he was receiving SQ heparin for DVT prophylaxis, there was concern for HIT. All heparin products were stopped, heparin dependent antibodies were sent and pending at the time of discharge, and the platelet counts stabilized. . 7. Mild coagulopathy: On admission, he had a mild coagulopathy likely in setting of sepsis. A peripheral smear was negative for any schistocytes. INR was followed and trended downward appropriately. . 8. GERD: no active issues during this admission and patient remained on pantoprazole Q12h. . 9. Conjunctivitis: He developed some white exudate and injection in left eye concerning for conjunctivitis. Erythromycin eye drops were started. . 10. FEN: Patient given aggressive IVF resusciation with electrolytes repleted as necessary. Speech and swallow evaluated patient and recommended pureed diet and thickened liquid diet. Patient was started on PO prior to transfer, and tolerated his meals well while on the floor. . 9. DISPO: DNR/DNI. . Comm: HCP Felecia Hazelwood Babette Spikes. 778-899-8067 Medications on Admission: Carbamazepine 200mg qAM, 300mg qhs Prilosec 20 Lopez-Goodwin Hospital Vit C 500 qD FeSO4 325 Eucerin cream Tianctin Baby Shampoo/Billy Edward A&D ointment Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:8 Tablet(s) Refills:0 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 4. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Erythromycin 5 mg/g Ointment Sig: 1-2 drops Ophthalmic QID (4 times a day) for 2 weeks. Disp:qs tubes Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing/SOB for 1 weeks. 9. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. Discharge Disposition: Home With Service Facility: Taylor, Phillips and Hensley Hospital Homecare Discharge Diagnosis: Primary: urinary tract infection septic shock Secondary: mental retardation GERD prostate cancer s/p TURP Discharge Condition: good Discharge Instructions: You had a urinary tract infection and went into septic shock. . Please call 911 or come to the emergency room if you have any symptoms of fever >101, chills, shortness of breath, chest pain, or any other concerning symptoms. Followup Instructions: Please follow-up with your primary care physician, Medrano. Whitehead 447-188-9394. Latasha Naegelin Patrick Clapp MD 77521757	['Admission Date: 1939-7-24 Discharge Date: 1973-5-13\n\nDate of Birth: 1927-9-22 Sex: M\n\nService: MEDICINE\n\nAllergies:\nSulfonamides / Quinine / Chloramphenicol\n\nAttending:Meena\nChief Complaint:\nurosepsis\n\nMajor Surgical or Invasive Procedure:\ncentral line placement and removal\n\nHistory of Present Illness:\nThis is an 80 y/o male with a h/o mental retardation, GERD c/b\nsevere erosive esophagitis, prostate CA s/p TURP without\nadditional treatment, who presented to the ED with fever to 103,\nsubjective dyspnea, foul smelling urine and hypotension with\nSBPs in the 70s. Pt is not communicative at baseline, but did\nreport lower abdominal pain, denied any CP, SOB, cough. Pt\notherwise not able to give a more detailed history due to\nbaseline mental retardation.\n.\nIn Felecia Hazelwood, pt was hypotensive, febrile to 103.', ' His lab values were\nnotable for an elevated WBC at 18.5, elevated transaminases,\nelevated lactate at 7.6, and an elevated Cr to 1.9. He was given\n5L NS, and after placing a R femoral CVL, started on Levophed\nfor BP support. He was empirically started on broad spectrum\nantibiotics of vancomycin, levofloxacin and flagyl, and admitted\nto the ICU for further care.\n.\nIn the ICU, patient transiently required levaphed for pressure\nsupport. Infectious work up included blood cultures which are\nNGTD, CXR which was negative, RUQ U/S which was negative, and\nurine culture with was positive for e. coli, fluoroquinolone\nsensitive. He was maintained on vancomycin, levofloxacin, and\nflagyl. On this regimen, the patient stablized, as his BP\nreturned and levophed was discontinued, his WBC decreased, his\nfever resolved.', ' His renal failure also resolved with fluid\nrescusitation. His LFTs trended down. His lactate came down.\n.\nHis ICU course was otherwise notable for a transient episode of\natrial fibrillation, which was broken with lopressor 5mg IV x 1,\nand the patient was subsequently started on lopressor 12.5mg\nLopez-Goodwin Hospital.\n.\nHis course thus far was also notable for platelets decreased\nfrom 130 -> 78, and therefore anti-HIT antibodies were sent\n(pending) and his SC heparin was discontinued.\n.\nCurrently, he is afebrile X 24hrs and denies any shortness of\nbreath, fever, chills, chest pain, or abdominal pain.\n\nPast Medical History:\n1. Prostate CA, PSA 7, s/p TURP, no hx of treatment for CA\n2. GERD c/b erosive esophagitis\n3. Mental retardation.\n4. Frequent UTIs.\n5. G6PD deficiency.\n6. S/p ccy.\n7. h/o sz d/o as child.', '\n8. h/o guiaic (+) stool, not able to visualize past sigmoid on\nscope due to poor prep (no lesion noted to sigmoid), EGD with\nesophagitis as above\n\n\nSocial History:\nLives at group home (0799 Hansen Skyway\nPhillipsborough, ME 28491, 8804 Guerra Shoal Apt. 334\nSaundersstad, SD 21251, MA), where he\nperforms some ADLs and walks without assist. Sister, Larry Luu\nCurtis Thompkins is guardian.\n\n\nFamily History:\nunknown\n\nPhysical Exam:\nVS: T101.8 HR84 BP72/40 RR18 o2sat: 100% on 10L face tent\nGEN: Elderly male, grunting, in NAD, in mild discomfort\nHEENT: Anicteric sclera\nNECK: No elev JVP\nCV: Regular, nml s1,s2. No s3 or murmurs\nRESP: Coarse BS throughout.\nABD: Soft, mild TTP over suprapubic area. R femoral line in\ngroin\nEXT: No edema bilat. Pulses 2+. No CVAT bilat.\nNEURO: Able to answer with 1 word answers.', ' Moves all ext spont.\n\nSKIN: No jaundice.\n\n\nPertinent Results:\nLabs on admission significant for:\nWBC 9.3 with 23% bands, Cr 1.9, lactate 7.6, AST 315, ALT 258,\nAP 178\nUA: >50 RBC, >50 WBC, many bacteria, neg glu/ketones\n.\nImaging: EKG: NSR, 97. Nml axis, nml intervals.\nPseudonormalization of TW V4-V6, no ST changes from previous.\n.\nCXR 12-26: AP supine portable view. Several thick skin folds limit\nthe\nevaluation of the right hemithorax. Linear opacities at the\nright lung base are unchanged, representing atelectasis or\nscarring. The remainder of the right lung is grossly clear. The\nleft lung is clear. Heart size is top normal. There is no\npulmonary edema or pleural effusion.\n.\nAbdominal US 1900-5-7: Limited study. No evidence of intra- or\nextra-hepatic biliary ductal dilatation or focal hepatic mass.', '\nTrace amount of fluid is seen adjacent to the upper pole of the\nright kidney of unclear etiology.\n.\n.\nLabs on discharge:\n1968-12-4 07:17AM BLOOD WBC-6.7 RBC-3.81* Hgb-10.5* Hct-31.5\nMCV-83 MCH-27.5 MCHC-33.3 RDW-17.1 Plt Ct-83\n1968-12-4 07:17AM BLOOD Glucose-103 UreaN-11 Creat-0.7 Na-141\nK-4.1 Cl-110 HCO3-26 AnGap-9 Albumin-2.5* Calcium-8.1\nPhos-2.1 Mg-1.7\n1968-12-4 07:17AM BLOOD ALT-105* AST-43* AlkPhos-133* TotBili-0.3\n1908-3-15 11:48AM BLOOD TSH-1.4\n1939-7-24 11:55AM BLOOD Cortsol-50.3\n1939-7-24 11:55AM BLOOD CRP-77.0\n1908-3-15 02:01AM BLOOD Vanco-8.1\n1900-5-7 02:32AM BLOOD Lactate-2.3\n\nBrief Hospital Course:\nA/P: 80 y/o male with a h/o mental retardation, GERD c/b severe\nerosive esophagitis, prostate CA s/p TURP without additional\ntreatment, who presents with fever to 103, subjective dyspnea,\nfoul smelling urine and hypotension with SBPs in the 70s.', "\n\n1. Septic Shock: Pt with sepsis and hypotension, with lactate\n7.8 in the ED and bandemia of 23%. Given 5L NS in the ED,\nstarted on levophed to maintain MAP >65. Likely source is urine,\ngiven markedly positive U/A and foul-smelling urine. No\npneumonia on CXR. Patient was admitted to the ICU and was\nempirically started on Vanco and Levaquin IV. Urine culture\npositive for E. coli, sensitive to levofloxacin, and was\nswitched to Levo 250mg PO. After aggressive IVF resuscitation,\nthe patient was weaned off of levophed with SBPs in 90s-100s.\nPatient remained afebrile, WBC trended downward, and was\ntransferred to the medicine floor.\n.\nWhile on the medicine floor, he was afebrile with SBP's in the\n120's and HR in the 70's, O2 sat was 95% on 2L.\n.\n2. Respiratory distress: On admission, patient in respiratory\ndistress, but no clear PNA seen on pulmonary exam.", " The Levaquin\nIV for urosepsis also provided coverage for CAP. Patient was on\na face tent with 40% FiO2 but would not tolerate it very well\nand would pull in off his face. O2 sats remained >92%, even on\nroom air. He was given nebs prn and switched to nasal cannula\nwith sats>94%.\n.\n3. ARF: Pt with a normal baseline Cr of 0.7 and admitted with\nCr of 1.9, most likely due to prerenal azotemia given profound\ndehydration in the setting of sepsis as above. Cr trended down\nafter IVF resuscitation and was back to baseline at time of\ndischarge.\n.\n4. A-fib: On morning of transfer from ICU to floor, patient went\ninto a-fib with rates in the 140's-170's. He was given 5mg\nlopressor and rate decreased to 80's-120's and returned to\nUSCGC Jackson\nFPO AP 27844 sinus rhythm. He was then started on metoprolol 12.", '5 Lopez-Goodwin Hospital\nPO with no further episodes of atrial fibrillation on telemetry.\n\n.\n5. Mild transaminitis: On admission, he had a mild transaminitis\nlikely in setting of sepsis. Abdominal US was performed to r/o\nbiliary/hepatic pathology. US Showed no evidence of intra or\nextra hepatic biliary ductal dilitation. The LFTs trended\ndownward during the course of hospital stay.\n.\n6. Heparin induced thrombocytopenia: During the hospital stay,\npts platelets fell from 128 to 78 overnight. As he was receiving\nSQ heparin for DVT prophylaxis, there was concern for HIT. All\nheparin products were stopped, heparin dependent antibodies were\nsent and pending at the time of discharge, and the platelet\ncounts stabilized.\n.\n7. Mild coagulopathy: On admission, he had a mild coagulopathy\nlikely in setting of sepsis.', ' A peripheral smear was negative for\nany schistocytes. INR was followed and trended downward\nappropriately.\n.\n8. GERD: no active issues during this admission and patient\nremained on pantoprazole Q12h.\n.\n9. Conjunctivitis: He developed some white exudate and injection\nin left eye concerning for conjunctivitis. Erythromycin eye\ndrops were started.\n.\n10. FEN: Patient given aggressive IVF resusciation with\nelectrolytes repleted as necessary. Speech and swallow\nevaluated patient and recommended pureed diet and thickened\nliquid diet. Patient was started on PO prior to transfer, and\ntolerated his meals well while on the floor.\n.\n9. DISPO: DNR/DNI.\n.\nComm: HCP Felecia Hazelwood Babette Spikes. 778-899-8067\n\n\nMedications on Admission:\nCarbamazepine 200mg qAM, 300mg qhs\nPrilosec 20 Lopez-Goodwin Hospital\nVit C 500 qD\nFeSO4 325\nEucerin cream\nTianctin\nBaby Shampoo/Billy Edward\nA&D ointment\n\n\nDischarge Medications:\n1.', ' Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every\n24 hours) for 8 days.\nDisp:8 Tablet(s) Refills:0\n2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).\n3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once\na day (in the morning)).\n4. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO QHS (once a\nday (at bedtime)).\n5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\n6. Erythromycin 5 mg/g Ointment Sig: 1-2 drops Ophthalmic QID\n(4 times a day) for 2 weeks.\nDisp:qs tubes Refills:0\n7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2\ntimes a day).\n8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours) as needed for wheezing/SOB for 1\nweeks.', '\n9. Acetaminophen 650 mg Suppository Sig: One (1) Suppository\nRectal Q6H (every 6 hours) as needed.\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nTaylor, Phillips and Hensley Hospital Homecare\n\nDischarge Diagnosis:\nPrimary:\nurinary tract infection\nseptic shock\nSecondary:\nmental retardation\nGERD\nprostate cancer s/p TURP\n\n\nDischarge Condition:\ngood\n\n\nDischarge Instructions:\nYou had a urinary tract infection and went into septic shock.\n.\nPlease call 911 or come to the emergency room if you have any\nsymptoms of fever >101, chills, shortness of breath, chest pain,\nor any other concerning symptoms.\n\nFollowup Instructions:\nPlease follow-up with your primary care physician, Medrano. Whitehead\n447-188-9394.\n\n\n Latasha Naegelin Patrick Clapp MD 77521757\n\n']
562	8616	190070.0	2131-06-15	Discharge summary	Report	Admission Date: [2131-6-1] Discharge Date: [2131-6-15] Service: CSU CHIEF COMPLAINT: Increasing fatigue, decreasing appetite, and weight loss. HISTORY OF PRESENT ILLNESS: Ms. [Known lastname ] is an 81-year-old woman with multiple episodes of congestive heart failure with known significant mitral regurgitation and chronic atrial fibrillation (on Coumadin for her atrial fibrillation) admitted preoperatively to come off of her Coumadin and be placed on IV heparin while awaiting her INR to come back to normal levels. The patient underwent a cardiac catheterization in [2131-6-20] which showed a cardiac index of 1.4, 30% to 60% RCA lesion, 4+ MR, with positive MAC. She had a TEE done also in [2131-4-20] that showed mild aortic insufficiency, moderate mitral regurgitation, mild mitral stenosis, moderate tricuspid regurgitation, an EF of 35% to 40%, and a dilated left atrium without any thrombus. PAST MEDICAL HISTORY: Significant for hypertension, mitral regurgitation, aortic insufficiency, COPD, hypercholesterolemia, rheumatic heart disease, paroxysmal atrial fibrillation, left retinal artery embolus, cardiomyopathy, and pulmonary hypertension. PAST SURGICAL HISTORY: Significant for hysterectomy secondary to endometrial cancer. MEDICATIONS PRIOR TO ADMISSION: Include Zocor 10 mg daily, Coumadin, multivitamin 1 tablet daily, Lopressor 100 mg b.i.d., calcium 3 tablets daily, aspirin 325 mg daily, digoxin 0.125 mg daily, Lasix 20 mg daily, lisinopril 20 mg daily, Remeron 15 mg daily, amiodarone 400 mg daily, Restoril 7.5 mg p.r.n., Protonix 40 mg daily, and Diamox (no dose or schedule given). ALLERGIES: The patient states no known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She has a remote tobacco history; quit many years ago. She lives alone; however, immediately prior to admission to [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] she was in a rehabilitation setting. The patient also denies alcohol use. PHYSICAL EXAMINATION ON ADMISSION: Height of 5 feet 3 inches, weight of 112 pounds, heart rate of 54 (atrial fibrillation), blood pressure of 104/56 on the right and 100/60 on the left, and respiratory rate of 20. Neurologically, grossly intact. Pulmonary reveals clear to auscultation bilaterally. Cardiac reveals irregularly irregular. The abdomen is soft, nontender, and nondistended with positive bowel sounds and no masses appreciated. The extremities are warm and well perfused with no edema. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the cardiothoracic service and begun on heparin while awaiting her INR to return to normal levels. Her last dose of Coumadin prior to admission was on [5-31]. The patient was noted to have an admission INR of 6.1. Therefore, the patient was administered vitamin K on both the day of admission and on hospital day 1. The patient has stated that she had a 3-week history of diarrhea prior to admission to the [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ]. Therefore, the gastroenterology service was consulted. Reportedly, the patient had been worked up by her primary care physician with all culture data being negative to date. She had recommended a lactose-free diet, additional stool cultures, and an outpatient colonoscopy. Over the next several days the patient remained hemodynamically stable. Her blood work was followed daily, and she was given p.r.n. vitamin K. Ultimately, on [6-5], the patient was brought to the operating room where she underwent mitral valve replacement with a #27 Mosaic valve. Please see the OR report for full details. In summary, she had mitral valve replacement. Her bypass time was 87 minutes with a cross-clamp time of 66 minutes. She tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer the patient was in atrial fibrillation at 76 beats per minute, with a CVP of 6, and PA pressures of 30/15. She had Neo-Synephrine at 0.5 mcg/kg/min and propofol at 20 mcg/kg/min. In the immediate postoperative period the patient had a somewhat [Male First Name (un) 3928] course with a labile blood pressure requiring large volumes of fluid, and ultimately she was begun on milrinone for a low cardiac index. Over the next 12 hours the patient did extremely well. Her anesthesia was reversed. Her sedation was discontinued. She was weaned from the ventilator and successfully extubated. On postoperative day 1, she was weaned from her milrinone infusion. However, she did require a Nipride infusion to maintain a somewhat normalized blood pressure. On postoperative day 2, she was begun on an ACE inhibitor as well as beta blockade and weaned from her Nipride infusion. Additionally, the patient's PA catheter was removed. Additionally, the patient had a swallow evaluation; and she was transferred from the cardiothoracic intensive care unit to [Hospital Ward Name 121] Two for continuing postoperative care and cardiac rehabilitation. On postoperative day 3, the patient remained hemodynamically stable. However, she had dwindling urine output, and her Foley catheter was re-placed. Additionally, the patient had a swallow evaluation that did not demonstrate any signs of aspiration, and she was restarted on her Coumadin. On postoperative day 4, the patient remained hemodynamically stable. Her temporary pacing wires were discontinued. Her beta blockade and Lasix doses were adjusted, and her activity level was gradually increased with the assistance of the nursing staff and physical therapy. On postoperative day 6, the patient was noted to have an INR of 7; which was repeated and found to be accurate. She was transferred from the floor back to the cardiothoracic intensive care unit and treated with FFP and vitamin K; following which her INR returned to 2. However, she continued to be monitored in the cardiothoracic intensive care unit for an additional 2 days. On postoperative day 8, she was again transferred back to [Hospital Ward Name 121] Two. She had an uneventful course throughout the remainder of her hospitalization. On postoperative day 9, it was felt that the following day the patient would be stable and ready to be transferred to rehabilitation for continuing care and recovery from her cardiac surgery. At this time the patient's physical exam reveals a temperature of 96.6, heart rate of 85 (atrial fibrillation), blood pressure of 139/91, respiratory rate of 18, and O2 saturation of 95% on room air. Weight is 60 kilograms. Laboratory data reveals a white count of 8, hematocrit of 37, and platelets of 172. PT is 15, PTT is 27, and INR is 1.5. Sodium is 146, potassium is 5.5, chloride is 104, CO2 is 30, BUN is 43, creatinine is 1.4, and glucose is 113. In general, in no acute distress. Neurologically, alert and oriented. Moves all extremities. Follows commands. A nonfocal exam. Pulmonary reveals diminished at the bases without any rales or rhonchi. Cardiovascular reveals irregularly irregular, S1 and S2, with no murmurs. The sternum is stable. Incision with Steri-Strips, clean and dry, no drainage or erythema. The abdomen is soft and nontender with normal active bowel sounds. The extremities are warm and well perfused with 1+ edema. DISCHARGE DISPOSITION: The patient is expected to be discharged to an extended care facility. CONDITION ON TRANSFER: Good. DISCHARGE DIAGNOSES: 1. Status post mitral valve replacement with a #27 Mosaic valve. 2. Mitral regurgitation. 3. Paroxysmal atrial fibrillation. 4. Hypertension. 5. Chronic obstructive pulmonary disease. 6. Hypercholesterolemia. 7. Left retinal artery embolus. 8. Cardiomyopathy. 9. Pulmonary hypertension. 10. Rheumatic heart disease. 11. Hysterectomy. DI[Last Name (STitle) 408]E FOLLOWUP: The patient is to have followup in the [Hospital 409] Clinic in 2 weeks, followup with Dr. [Last Name (STitle) 1655] in 2 to 3 weeks, and followup with Dr. [Last Name (Prefixes) ] in 4 weeks. MEDICATIONS ON DISCHARGE: Include Remeron 15 mg at bedtime, amiodarone 400 mg daily, Protonix 40 mg daily, Lasix 20 mg b.i.d. x 2 weeks and then 20 mg daily, Colace 100 mg b.i.d., aspirin 81 mg daily, warfarin as directed to maintain a target INR of 2 to 2.5 (the patient received 1 mg on the [6-14]), Percocet 5/325 1 to 2 tablets every 4 to 6 hours as needed (for pain), lisinopril 5 mg daily, Lopressor 50 mg b.i.d., potassium chloride 20 mEq daily. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2131-6-14] 18:03:31 T: [2131-6-14] 18:52:49 Job#: [Job Number 4557]	Admission Date: <Date>1965-10-5</Date> Discharge Date: <Date>1938-6-24</Date> Service: CSU CHIEF COMPLAINT: Increasing fatigue, decreasing appetite, and weight loss. HISTORY OF PRESENT ILLNESS: Ms. <Name>Son</Name> is an 81-year-old woman with multiple episodes of congestive heart failure with known significant mitral regurgitation and chronic atrial fibrillation (on Coumadin for her atrial fibrillation) admitted preoperatively to come off of her Coumadin and be placed on IV heparin while awaiting her INR to come back to normal levels. The patient underwent a cardiac catheterization in <Date>1910-6-3</Date> which showed a cardiac index of 1.4, 30% to 60% RCA lesion, 4+ MR, with positive MAC. She had a TEE done also in <Date>1947-2-4</Date> that showed mild aortic insufficiency, moderate mitral regurgitation, mild mitral stenosis, moderate tricuspid regurgitation, an EF of 35% to 40%, and a dilated left atrium without any thrombus. PAST MEDICAL HISTORY: Significant for hypertension, mitral regurgitation, aortic insufficiency, COPD, hypercholesterolemia, rheumatic heart disease, paroxysmal atrial fibrillation, left retinal artery embolus, cardiomyopathy, and pulmonary hypertension. PAST SURGICAL HISTORY: Significant for hysterectomy secondary to endometrial cancer. MEDICATIONS PRIOR TO ADMISSION: Include Zocor 10 mg daily, Coumadin, multivitamin 1 tablet daily, Lopressor 100 mg b.i.d., calcium 3 tablets daily, aspirin 325 mg daily, digoxin 0.125 mg daily, Lasix 20 mg daily, lisinopril 20 mg daily, Remeron 15 mg daily, amiodarone 400 mg daily, Restoril 7.5 mg p.r.n., Protonix 40 mg daily, and Diamox (no dose or schedule given). ALLERGIES: The patient states no known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She has a remote tobacco history; quit many years ago. She lives alone; however, immediately prior to admission to <Hospital>Munoz-Taylor Clinic</Hospital> <Hospital>Munoz-Taylor Clinic</Hospital> <Name>Andrea</Name> <Name>Lewis</Name> she was in a rehabilitation setting. The patient also denies alcohol use. PHYSICAL EXAMINATION ON ADMISSION: Height of 5 feet 3 inches, weight of 112 pounds, heart rate of 54 (atrial fibrillation), blood pressure of 104/56 on the right and 100/60 on the left, and respiratory rate of 20. Neurologically, grossly intact. Pulmonary reveals clear to auscultation bilaterally. Cardiac reveals irregularly irregular. The abdomen is soft, nontender, and nondistended with positive bowel sounds and no masses appreciated. The extremities are warm and well perfused with no edema. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the cardiothoracic service and begun on heparin while awaiting her INR to return to normal levels. Her last dose of Coumadin prior to admission was on <Date>7-27</Date>. The patient was noted to have an admission INR of 6.1. Therefore, the patient was administered vitamin K on both the day of admission and on hospital day 1. The patient has stated that she had a 3-week history of diarrhea prior to admission to the <Hospital>Munoz-Taylor Clinic</Hospital> <Hospital>Munoz-Taylor Clinic</Hospital> <Name>Andrea</Name> <Name>Lewis</Name>. Therefore, the gastroenterology service was consulted. Reportedly, the patient had been worked up by her primary care physician with all culture data being negative to date. She had recommended a lactose-free diet, additional stool cultures, and an outpatient colonoscopy. Over the next several days the patient remained hemodynamically stable. Her blood work was followed daily, and she was given p.r.n. vitamin K. Ultimately, on <Date>6-25</Date>, the patient was brought to the operating room where she underwent mitral valve replacement with a #27 Mosaic valve. Please see the OR report for full details. In summary, she had mitral valve replacement. Her bypass time was 87 minutes with a cross-clamp time of 66 minutes. She tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer the patient was in atrial fibrillation at 76 beats per minute, with a CVP of 6, and PA pressures of 30/15. She had Neo-Synephrine at 0.5 mcg/kg/min and propofol at 20 mcg/kg/min. In the immediate postoperative period the patient had a somewhat <Name>Marvin</Name> course with a labile blood pressure requiring large volumes of fluid, and ultimately she was begun on milrinone for a low cardiac index. Over the next 12 hours the patient did extremely well. Her anesthesia was reversed. Her sedation was discontinued. She was weaned from the ventilator and successfully extubated. On postoperative day 1, she was weaned from her milrinone infusion. However, she did require a Nipride infusion to maintain a somewhat normalized blood pressure. On postoperative day 2, she was begun on an ACE inhibitor as well as beta blockade and weaned from her Nipride infusion. Additionally, the patient's PA catheter was removed. Additionally, the patient had a swallow evaluation; and she was transferred from the cardiothoracic intensive care unit to <Hospital>Grant-Hughes Hospital</Hospital> Two for continuing postoperative care and cardiac rehabilitation. On postoperative day 3, the patient remained hemodynamically stable. However, she had dwindling urine output, and her Foley catheter was re-placed. Additionally, the patient had a swallow evaluation that did not demonstrate any signs of aspiration, and she was restarted on her Coumadin. On postoperative day 4, the patient remained hemodynamically stable. Her temporary pacing wires were discontinued. Her beta blockade and Lasix doses were adjusted, and her activity level was gradually increased with the assistance of the nursing staff and physical therapy. On postoperative day 6, the patient was noted to have an INR of 7; which was repeated and found to be accurate. She was transferred from the floor back to the cardiothoracic intensive care unit and treated with FFP and vitamin K; following which her INR returned to 2. However, she continued to be monitored in the cardiothoracic intensive care unit for an additional 2 days. On postoperative day 8, she was again transferred back to <Hospital>Grant-Hughes Hospital</Hospital> Two. She had an uneventful course throughout the remainder of her hospitalization. On postoperative day 9, it was felt that the following day the patient would be stable and ready to be transferred to rehabilitation for continuing care and recovery from her cardiac surgery. At this time the patient's physical exam reveals a temperature of 96.6, heart rate of 85 (atrial fibrillation), blood pressure of 139/91, respiratory rate of 18, and O2 saturation of 95% on room air. Weight is 60 kilograms. Laboratory data reveals a white count of 8, hematocrit of 37, and platelets of 172. PT is 15, PTT is 27, and INR is 1.5. Sodium is 146, potassium is 5.5, chloride is 104, CO2 is 30, BUN is 43, creatinine is 1.4, and glucose is 113. In general, in no acute distress. Neurologically, alert and oriented. Moves all extremities. Follows commands. A nonfocal exam. Pulmonary reveals diminished at the bases without any rales or rhonchi. Cardiovascular reveals irregularly irregular, S1 and S2, with no murmurs. The sternum is stable. Incision with Steri-Strips, clean and dry, no drainage or erythema. The abdomen is soft and nontender with normal active bowel sounds. The extremities are warm and well perfused with 1+ edema. DISCHARGE DISPOSITION: The patient is expected to be discharged to an extended care facility. CONDITION ON TRANSFER: Good. DISCHARGE DIAGNOSES: 1. Status post mitral valve replacement with a #27 Mosaic valve. 2. Mitral regurgitation. 3. Paroxysmal atrial fibrillation. 4. Hypertension. 5. Chronic obstructive pulmonary disease. 6. Hypercholesterolemia. 7. Left retinal artery embolus. 8. Cardiomyopathy. 9. Pulmonary hypertension. 10. Rheumatic heart disease. 11. Hysterectomy. DI<Name>Moore</Name>E FOLLOWUP: The patient is to have followup in the <Hospital>Flores, Williams and Grant Health System</Hospital> Clinic in 2 weeks, followup with Dr. <Name>Feguson</Name> in 2 to 3 weeks, and followup with Dr. <Name>Camargo</Name> in 4 weeks. MEDICATIONS ON DISCHARGE: Include Remeron 15 mg at bedtime, amiodarone 400 mg daily, Protonix 40 mg daily, Lasix 20 mg b.i.d. x 2 weeks and then 20 mg daily, Colace 100 mg b.i.d., aspirin 81 mg daily, warfarin as directed to maintain a target INR of 2 to 2.5 (the patient received 1 mg on the <Date>6-14</Date>), Percocet 5/325 1 to 2 tablets every 4 to 6 hours as needed (for pain), lisinopril 5 mg daily, Lopressor 50 mg b.i.d., potassium chloride 20 mEq daily. <Doctor Name>Dr.Gauthier</Doctor Name> <Name>Camargo</Name>, M.D. <MD Number>11961282</MD Number> Dictated By:<Name>Luu</Name> MEDQUIST36 D: <Date>1902-10-4</Date> 18:03:31 T: <Date>1902-10-4</Date> 18:52:49 Job#: <Job Number>Ross Inc-1931-401179</Job Number>	000000000000000011111111100000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111011111111111111111110111111011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111110111111111111111111101111110111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1965-10-5 Discharge Date: 1938-6-24 Service: CSU CHIEF COMPLAINT: Increasing fatigue, decreasing appetite, and weight loss. HISTORY OF PRESENT ILLNESS: Ms. Son is an 81-year-old woman with multiple episodes of congestive heart failure with known significant mitral regurgitation and chronic atrial fibrillation (on Coumadin for her atrial fibrillation) admitted preoperatively to come off of her Coumadin and be placed on IV heparin while awaiting her INR to come back to normal levels. The patient underwent a cardiac catheterization in 1910-6-3 which showed a cardiac index of 1.4, 30% to 60% RCA lesion, 4+ MR, with positive MAC. She had a TEE done also in 1947-2-4 that showed mild aortic insufficiency, moderate mitral regurgitation, mild mitral stenosis, moderate tricuspid regurgitation, an EF of 35% to 40%, and a dilated left atrium without any thrombus. PAST MEDICAL HISTORY: Significant for hypertension, mitral regurgitation, aortic insufficiency, COPD, hypercholesterolemia, rheumatic heart disease, paroxysmal atrial fibrillation, left retinal artery embolus, cardiomyopathy, and pulmonary hypertension. PAST SURGICAL HISTORY: Significant for hysterectomy secondary to endometrial cancer. MEDICATIONS PRIOR TO ADMISSION: Include Zocor 10 mg daily, Coumadin, multivitamin 1 tablet daily, Lopressor 100 mg b.i.d., calcium 3 tablets daily, aspirin 325 mg daily, digoxin 0.125 mg daily, Lasix 20 mg daily, lisinopril 20 mg daily, Remeron 15 mg daily, amiodarone 400 mg daily, Restoril 7.5 mg p.r.n., Protonix 40 mg daily, and Diamox (no dose or schedule given). ALLERGIES: The patient states no known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She has a remote tobacco history; quit many years ago. She lives alone; however, immediately prior to admission to Munoz-Taylor Clinic Munoz-Taylor Clinic Andrea Lewis she was in a rehabilitation setting. The patient also denies alcohol use. PHYSICAL EXAMINATION ON ADMISSION: Height of 5 feet 3 inches, weight of 112 pounds, heart rate of 54 (atrial fibrillation), blood pressure of 104/56 on the right and 100/60 on the left, and respiratory rate of 20. Neurologically, grossly intact. Pulmonary reveals clear to auscultation bilaterally. Cardiac reveals irregularly irregular. The abdomen is soft, nontender, and nondistended with positive bowel sounds and no masses appreciated. The extremities are warm and well perfused with no edema. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the cardiothoracic service and begun on heparin while awaiting her INR to return to normal levels. Her last dose of Coumadin prior to admission was on 7-27. The patient was noted to have an admission INR of 6.1. Therefore, the patient was administered vitamin K on both the day of admission and on hospital day 1. The patient has stated that she had a 3-week history of diarrhea prior to admission to the Munoz-Taylor Clinic Munoz-Taylor Clinic Andrea Lewis. Therefore, the gastroenterology service was consulted. Reportedly, the patient had been worked up by her primary care physician with all culture data being negative to date. She had recommended a lactose-free diet, additional stool cultures, and an outpatient colonoscopy. Over the next several days the patient remained hemodynamically stable. Her blood work was followed daily, and she was given p.r.n. vitamin K. Ultimately, on 6-25, the patient was brought to the operating room where she underwent mitral valve replacement with a #27 Mosaic valve. Please see the OR report for full details. In summary, she had mitral valve replacement. Her bypass time was 87 minutes with a cross-clamp time of 66 minutes. She tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer the patient was in atrial fibrillation at 76 beats per minute, with a CVP of 6, and PA pressures of 30/15. She had Neo-Synephrine at 0.5 mcg/kg/min and propofol at 20 mcg/kg/min. In the immediate postoperative period the patient had a somewhat Marvin course with a labile blood pressure requiring large volumes of fluid, and ultimately she was begun on milrinone for a low cardiac index. Over the next 12 hours the patient did extremely well. Her anesthesia was reversed. Her sedation was discontinued. She was weaned from the ventilator and successfully extubated. On postoperative day 1, she was weaned from her milrinone infusion. However, she did require a Nipride infusion to maintain a somewhat normalized blood pressure. On postoperative day 2, she was begun on an ACE inhibitor as well as beta blockade and weaned from her Nipride infusion. Additionally, the patient's PA catheter was removed. Additionally, the patient had a swallow evaluation; and she was transferred from the cardiothoracic intensive care unit to Grant-Hughes Hospital Two for continuing postoperative care and cardiac rehabilitation. On postoperative day 3, the patient remained hemodynamically stable. However, she had dwindling urine output, and her Foley catheter was re-placed. Additionally, the patient had a swallow evaluation that did not demonstrate any signs of aspiration, and she was restarted on her Coumadin. On postoperative day 4, the patient remained hemodynamically stable. Her temporary pacing wires were discontinued. Her beta blockade and Lasix doses were adjusted, and her activity level was gradually increased with the assistance of the nursing staff and physical therapy. On postoperative day 6, the patient was noted to have an INR of 7; which was repeated and found to be accurate. She was transferred from the floor back to the cardiothoracic intensive care unit and treated with FFP and vitamin K; following which her INR returned to 2. However, she continued to be monitored in the cardiothoracic intensive care unit for an additional 2 days. On postoperative day 8, she was again transferred back to Grant-Hughes Hospital Two. She had an uneventful course throughout the remainder of her hospitalization. On postoperative day 9, it was felt that the following day the patient would be stable and ready to be transferred to rehabilitation for continuing care and recovery from her cardiac surgery. At this time the patient's physical exam reveals a temperature of 96.6, heart rate of 85 (atrial fibrillation), blood pressure of 139/91, respiratory rate of 18, and O2 saturation of 95% on room air. Weight is 60 kilograms. Laboratory data reveals a white count of 8, hematocrit of 37, and platelets of 172. PT is 15, PTT is 27, and INR is 1.5. Sodium is 146, potassium is 5.5, chloride is 104, CO2 is 30, BUN is 43, creatinine is 1.4, and glucose is 113. In general, in no acute distress. Neurologically, alert and oriented. Moves all extremities. Follows commands. A nonfocal exam. Pulmonary reveals diminished at the bases without any rales or rhonchi. Cardiovascular reveals irregularly irregular, S1 and S2, with no murmurs. The sternum is stable. Incision with Steri-Strips, clean and dry, no drainage or erythema. The abdomen is soft and nontender with normal active bowel sounds. The extremities are warm and well perfused with 1+ edema. DISCHARGE DISPOSITION: The patient is expected to be discharged to an extended care facility. CONDITION ON TRANSFER: Good. DISCHARGE DIAGNOSES: 1. Status post mitral valve replacement with a #27 Mosaic valve. 2. Mitral regurgitation. 3. Paroxysmal atrial fibrillation. 4. Hypertension. 5. Chronic obstructive pulmonary disease. 6. Hypercholesterolemia. 7. Left retinal artery embolus. 8. Cardiomyopathy. 9. Pulmonary hypertension. 10. Rheumatic heart disease. 11. Hysterectomy. DIMooreE FOLLOWUP: The patient is to have followup in the Flores, Williams and Grant Health System Clinic in 2 weeks, followup with Dr. Feguson in 2 to 3 weeks, and followup with Dr. Camargo in 4 weeks. MEDICATIONS ON DISCHARGE: Include Remeron 15 mg at bedtime, amiodarone 400 mg daily, Protonix 40 mg daily, Lasix 20 mg b.i.d. x 2 weeks and then 20 mg daily, Colace 100 mg b.i.d., aspirin 81 mg daily, warfarin as directed to maintain a target INR of 2 to 2.5 (the patient received 1 mg on the 6-14), Percocet 5/325 1 to 2 tablets every 4 to 6 hours as needed (for pain), lisinopril 5 mg daily, Lopressor 50 mg b.i.d., potassium chloride 20 mEq daily. Dr.Gauthier Camargo, M.D. 11961282 Dictated By:Luu MEDQUIST36 D: 1902-10-4 18:03:31 T: 1902-10-4 18:52:49 Job#: Ross Inc-1931-401179	['Admission Date: 1965-10-5 Discharge Date: 1938-6-24\n\n\nService: CSU\n\n\nCHIEF COMPLAINT: Increasing fatigue, decreasing appetite,\nand weight loss.\n\nHISTORY OF PRESENT ILLNESS: Ms. Son is an 81-year-old woman\nwith multiple episodes of congestive heart failure with known\nsignificant mitral regurgitation and chronic atrial\nfibrillation (on Coumadin for her atrial fibrillation)\nadmitted preoperatively to come off of her Coumadin and be\nplaced on IV heparin while awaiting her INR to come back to\nnormal levels.\n\nThe patient underwent a cardiac catheterization in 1910-6-3 which showed a cardiac index of 1.4, 30% to 60% RCA\nlesion, 4+ MR, with positive MAC. She had a TEE done also in\n1947-2-4 that showed mild aortic insufficiency, moderate\nmitral regurgitation, mild mitral stenosis, moderate\ntricuspid regurgitation, an EF of 35% to 40%, and a dilated\nleft atrium without any thrombus.', '\n\nPAST MEDICAL HISTORY: Significant for hypertension, mitral\nregurgitation, aortic insufficiency, COPD,\nhypercholesterolemia, rheumatic heart disease, paroxysmal\natrial fibrillation, left retinal artery embolus,\ncardiomyopathy, and pulmonary hypertension.\n\nPAST SURGICAL HISTORY: Significant for hysterectomy\nsecondary to endometrial cancer.\n\nMEDICATIONS PRIOR TO ADMISSION: Include Zocor 10 mg daily,\nCoumadin, multivitamin 1 tablet daily, Lopressor 100 mg\nb.i.d., calcium 3 tablets daily, aspirin 325 mg daily,\ndigoxin 0.125 mg daily, Lasix 20 mg daily, lisinopril 20 mg\ndaily, Remeron 15 mg daily, amiodarone 400 mg daily, Restoril\n7.5 mg p.r.n., Protonix 40 mg daily, and Diamox (no dose or\nschedule given).\n\nALLERGIES: The patient states no known drug allergies.\n\nFAMILY HISTORY: Noncontributory.', '\n\nSOCIAL HISTORY: She has a remote tobacco history; quit many\nyears ago. She lives alone; however, immediately prior to\nadmission to Munoz-Taylor Clinic Munoz-Taylor Clinic Andrea Lewis she was in a\nrehabilitation setting. The patient also denies alcohol use.\n\nPHYSICAL EXAMINATION ON ADMISSION: Height of 5 feet 3\ninches, weight of 112 pounds, heart rate of 54 (atrial\nfibrillation), blood pressure of 104/56 on the right and\n100/60 on the left, and respiratory rate of 20.\nNeurologically, grossly intact. Pulmonary reveals clear to\nauscultation bilaterally. Cardiac reveals irregularly\nirregular. The abdomen is soft, nontender, and nondistended\nwith positive bowel sounds and no masses appreciated. The\nextremities are warm and well perfused with no edema.\n\nSUMMARY OF HOSPITAL COURSE: The patient was admitted to the\ncardiothoracic service and begun on heparin while awaiting\nher INR to return to normal levels.', ' Her last dose of Coumadin\nprior to admission was on 7-27. The patient was noted to\nhave an admission INR of 6.1. Therefore, the patient was\nadministered vitamin K on both the day of admission and on\nhospital day 1. The patient has stated that she had a 3-week\nhistory of diarrhea prior to admission to the Munoz-Taylor Clinic Munoz-Taylor Clinic\nAndrea Lewis. Therefore, the gastroenterology service was\nconsulted. Reportedly, the patient had been worked up by her\nprimary care physician with all culture data being negative\nto date. She had recommended a lactose-free diet, additional\nstool cultures, and an outpatient colonoscopy.\n\nOver the next several days the patient remained\nhemodynamically stable. Her blood work was followed daily,\nand she was given p.r.n. vitamin K. Ultimately, on 6-25,\nthe patient was brought to the operating room where she\nunderwent mitral valve replacement with a #27 Mosaic valve.', '\nPlease see the OR report for full details. In summary, she\nhad mitral valve replacement. Her bypass time was 87 minutes\nwith a cross-clamp time of 66 minutes. She tolerated the\noperation well and was transferred from the operating room to\nthe cardiothoracic intensive care unit. At the time of\ntransfer the patient was in atrial fibrillation at 76 beats\nper minute, with a CVP of 6, and PA pressures of 30/15. She\nhad Neo-Synephrine at 0.5 mcg/kg/min and propofol at 20\nmcg/kg/min.\n\nIn the immediate postoperative period the patient had a\nsomewhat Marvin course with a labile blood pressure requiring\nlarge volumes of fluid, and ultimately she was begun on\nmilrinone for a low cardiac index. Over the next 12 hours the\npatient did extremely well. Her anesthesia was reversed. Her\nsedation was discontinued.', " She was weaned from the ventilator\nand successfully extubated. On postoperative day 1, she was\nweaned from her milrinone infusion. However, she did require\na Nipride infusion to maintain a somewhat normalized blood\npressure.\n\nOn postoperative day 2, she was begun on an ACE inhibitor as\nwell as beta blockade and weaned from her Nipride infusion.\nAdditionally, the patient's PA catheter was removed.\nAdditionally, the patient had a swallow evaluation; and she\nwas transferred from the cardiothoracic intensive care unit\nto Grant-Hughes Hospital Two for continuing postoperative care and cardiac\nrehabilitation.\n\nOn postoperative day 3, the patient remained hemodynamically\nstable. However, she had dwindling urine output, and her\nFoley catheter was re-placed. Additionally, the patient had a\nswallow evaluation that did not demonstrate any signs of\naspiration, and she was restarted on her Coumadin.", '\n\nOn postoperative day 4, the patient remained hemodynamically\nstable. Her temporary pacing wires were discontinued. Her\nbeta blockade and Lasix doses were adjusted, and her activity\nlevel was gradually increased with the assistance of the\nnursing staff and physical therapy.\n\nOn postoperative day 6, the patient was noted to have an INR\nof 7; which was repeated and found to be accurate. She was\ntransferred from the floor back to the cardiothoracic\nintensive care unit and treated with FFP and vitamin K;\nfollowing which her INR returned to 2. However, she continued\nto be monitored in the cardiothoracic intensive care unit for\nan additional 2 days.\n\nOn postoperative day 8, she was again transferred back to\nGrant-Hughes Hospital Two. She had an uneventful course throughout the\nremainder of her hospitalization.', "\n\nOn postoperative day 9, it was felt that the following day\nthe patient would be stable and ready to be transferred to\nrehabilitation for continuing care and recovery from her\ncardiac surgery.\n\nAt this time the patient's physical exam reveals a\ntemperature of 96.6, heart rate of 85 (atrial fibrillation),\nblood pressure of 139/91, respiratory rate of 18, and O2\nsaturation of 95% on room air. Weight is 60 kilograms.\nLaboratory data reveals a white count of 8, hematocrit of 37,\nand platelets of 172. PT is 15, PTT is 27, and INR is 1.5.\nSodium is 146, potassium is 5.5, chloride is 104, CO2 is 30,\nBUN is 43, creatinine is 1.4, and glucose is 113. In general,\nin no acute distress. Neurologically, alert and oriented.\nMoves all extremities. Follows commands. A nonfocal exam.\nPulmonary reveals diminished at the bases without any rales\nor rhonchi.", ' Cardiovascular reveals irregularly irregular, S1\nand S2, with no murmurs. The sternum is stable. Incision with\nSteri-Strips, clean and dry, no drainage or erythema. The\nabdomen is soft and nontender with normal active bowel\nsounds. The extremities are warm and well perfused with 1+\nedema.\n\nDISCHARGE DISPOSITION: The patient is expected to be\ndischarged to an extended care facility.\n\nCONDITION ON TRANSFER: Good.\n\nDISCHARGE DIAGNOSES:\n1. Status post mitral valve replacement with a #27 Mosaic\n valve.\n2. Mitral regurgitation.\n3. Paroxysmal atrial fibrillation.\n4. Hypertension.\n5. Chronic obstructive pulmonary disease.\n6. Hypercholesterolemia.\n7. Left retinal artery embolus.\n8. Cardiomyopathy.\n9. Pulmonary hypertension.\n10. Rheumatic heart disease.\n11. Hysterectomy.\n\n\nDIMooreE FOLLOWUP: The patient is to have followup in the\nFlores, Williams and Grant Health System Clinic in 2 weeks, followup with Dr.', ' Feguson in 2 to 3\nweeks, and followup with Dr. Camargo in 4 weeks.\n\nMEDICATIONS ON DISCHARGE: Include Remeron 15 mg at bedtime,\namiodarone 400 mg daily, Protonix 40 mg daily, Lasix 20 mg\nb.i.d. x 2 weeks and then 20 mg daily, Colace 100 mg b.i.d.,\naspirin 81 mg daily, warfarin as directed to maintain a\ntarget INR of 2 to 2.5 (the patient received 1 mg on the 6-14), Percocet 5/325 1 to 2 tablets every 4 to 6 hours as\nneeded (for pain), lisinopril 5 mg daily, Lopressor 50 mg\nb.i.d., potassium chloride 20 mEq daily.\n\n\n\n Dr.Gauthier Camargo, M.D. 11961282\n\nDictated By:Luu\nMEDQUIST36\nD: 1902-10-4 18:03:31\nT: 1902-10-4 18:52:49\nJob#: Ross Inc-1931-401179\n']
563	8616	190070.0	2131-06-15	Discharge summary	Report	Admission Date: [2131-6-1] Discharge Date: [2131-6-15] Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[First Name3 (LF) 1283] Chief Complaint: Mitral regurgitation Major Surgical or Invasive Procedure: 1. Mitral valve replacement (#27 mosaic) History of Present Illness: 81F c mitral regurgitation by TEE with symptoms of increasing fatigue, decrease mobility, weight loss. Evaluated as outpatient with echo showing mild AI, mod MR, mild MS, mod TR, dilated LA, and EF 40%, and cardiac cath showing no significant CAD. She was admitted for preop heparin gtt. Past Medical History: 1. MR 2. AI 3. HTN 4. COPD 5. Hypercholesterolemia 6. Paroxysmal afib 7. h/o L retinal artery occlusion 8. Pulmonary HTN 9. s/p TAH for endometrial CA Social History: Noncontributory Family History: Noncontributory Physical Exam: Afebrile, VSS NAD, alert Neck: no bruits, no JVD Heart: Irregular, [2-25] murmur Lungs: CTAB Abd: soft, NT, ND, + BS Ext: no edema Pertinent Results: [2131-6-9] 06:20AM BLOOD WBC-9.3 RBC-4.27 Hgb-12.7 Hct-37.8 MCV-89 MCH-29.8 MCHC-33.7 RDW-17.3* Plt Ct-78* [2131-6-9] 06:20AM BLOOD Glucose-120* UreaN-29* Creat-1.3* Na-141 K-4.0 Cl-103 HCO3-25 AnGap-17 Brief Hospital Course: 81F c mitral regurgitation by TEE with symptoms of increasing fatigue, decrease mobility, weight loss. Evaluated as outpatient with echo showing mild AI, mod MR, mild MS, mod TR, dilated LA, and EF 40%, and cardiac cath showing no significant CAD. She was admitted for preop heparin gtt. She went to the OR [2131-6-5] for MVR (#27 Mosaic). For more detailed account, please see operative note. Post-op, she was transferred to the CSRU where she required dobutamine, milrinone, and volume resuscitation for low cardiac index. These issues rapidly resolved and she was extubated on POD 1. She was tranferred to the floor on POD 2. She re-started her coumadin on POD 4. PT recommended rehab placement. Medications on Admission: 1. Zocor 2. Coumadin 3. Lopressor 100 mg PO BID 4. Calcium 5. ASA 325 mg PO QD 6. Digoxin 0.125 mg PO QD 7. Lasix 10 mg PO QD 8. Lisinopril 20 mg PO QD 9. Remeron 15 mg PO QD 10. Amiodarone taper 11. Protonix 40 mg PO QD 12. Diamox Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:56 Capsule, Sustained Release(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. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Pantoprazole Sodium 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 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 9. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for tonights dose. Disp:30 Tablet(s) Refills:2 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: 1. Mitral regurgitation 2. Paroxysmal atrial fib 3. HTN 4. COPD 5. Hypercholesterolemia Discharge Condition: Good Discharge Instructions: 1. Medications as directed. 2. Follow up INR with PCP or cardiologist. 3. Call office or go to ER if fever/chills, discharge from sternal incision, chest pain, dyspnea. Followup Instructions: PCP, 2 weeks, please call for appointment. Cardiologist, 2 weeks, please call for appointment. Dr[Last Name (Prefixes) 4558], 4 weeks, please call for appointment.	Admission Date: <Date>2020-9-18</Date> Discharge Date: <Date>1987-7-8</Date> Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:<Name>Iliana</Name> Chief Complaint: Mitral regurgitation Major Surgical or Invasive Procedure: 1. Mitral valve replacement (#27 mosaic) History of Present Illness: 81F c mitral regurgitation by TEE with symptoms of increasing fatigue, decrease mobility, weight loss. Evaluated as outpatient with echo showing mild AI, mod MR, mild MS, mod TR, dilated LA, and EF 40%, and cardiac cath showing no significant CAD. She was admitted for preop heparin gtt. Past Medical History: 1. MR 2. AI 3. HTN 4. COPD 5. Hypercholesterolemia 6. Paroxysmal afib 7. h/o L retinal artery occlusion 8. Pulmonary HTN 9. s/p TAH for endometrial CA Social History: Noncontributory Family History: Noncontributory Physical Exam: Afebrile, VSS NAD, alert Neck: no bruits, no JVD Heart: Irregular, <Date>4-26</Date> murmur Lungs: CTAB Abd: soft, NT, ND, + BS Ext: no edema Pertinent Results: <Date>1955-4-7</Date> 06:20AM BLOOD WBC-9.3 RBC-4.27 Hgb-12.7 Hct-37.8 MCV-89 MCH-29.8 MCHC-33.7 RDW-17.3* Plt Ct-78* <Date>1955-4-7</Date> 06:20AM BLOOD Glucose-120* UreaN-29* Creat-1.3* Na-141 K-4.0 Cl-103 HCO3-25 AnGap-17 Brief Hospital Course: 81F c mitral regurgitation by TEE with symptoms of increasing fatigue, decrease mobility, weight loss. Evaluated as outpatient with echo showing mild AI, mod MR, mild MS, mod TR, dilated LA, and EF 40%, and cardiac cath showing no significant CAD. She was admitted for preop heparin gtt. She went to the OR <Date>2018-4-18</Date> for MVR (#27 Mosaic). For more detailed account, please see operative note. Post-op, she was transferred to the CSRU where she required dobutamine, milrinone, and volume resuscitation for low cardiac index. These issues rapidly resolved and she was extubated on POD 1. She was tranferred to the floor on POD 2. She re-started her coumadin on POD 4. PT recommended rehab placement. Medications on Admission: 1. Zocor 2. Coumadin 3. Lopressor 100 mg PO BID 4. Calcium 5. ASA 325 mg PO QD 6. Digoxin 0.125 mg PO QD 7. Lasix 10 mg PO QD 8. Lisinopril 20 mg PO QD 9. Remeron 15 mg PO QD 10. Amiodarone taper 11. Protonix 40 mg PO QD 12. Diamox Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:56 Capsule, Sustained Release(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. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Pantoprazole Sodium 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 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 9. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for tonights dose. Disp:30 Tablet(s) Refills:2 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: <Hospital>Pineda, Johnson and Trujillo Clinic</Hospital> of <Location>Unit 7745 Box 0286 DPO AA 79973</Location> Discharge Diagnosis: 1. Mitral regurgitation 2. Paroxysmal atrial fib 3. HTN 4. COPD 5. Hypercholesterolemia Discharge Condition: Good Discharge Instructions: 1. Medications as directed. 2. Follow up INR with PCP or cardiologist. 3. Call office or go to ER if fever/chills, discharge from sternal incision, chest pain, dyspnea. Followup Instructions: PCP, 2 weeks, please call for appointment. Cardiologist, 2 weeks, please call for appointment. Dr<Name>Moore</Name>, 4 weeks, please call for appointment.	00000000000000000111111111000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111100001111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000	Admission Date: 2020-9-18 Discharge Date: 1987-7-8 Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:Iliana Chief Complaint: Mitral regurgitation Major Surgical or Invasive Procedure: 1. Mitral valve replacement (#27 mosaic) History of Present Illness: 81F c mitral regurgitation by TEE with symptoms of increasing fatigue, decrease mobility, weight loss. Evaluated as outpatient with echo showing mild AI, mod MR, mild MS, mod TR, dilated LA, and EF 40%, and cardiac cath showing no significant CAD. She was admitted for preop heparin gtt. Past Medical History: 1. MR 2. AI 3. HTN 4. COPD 5. Hypercholesterolemia 6. Paroxysmal afib 7. h/o L retinal artery occlusion 8. Pulmonary HTN 9. s/p TAH for endometrial CA Social History: Noncontributory Family History: Noncontributory Physical Exam: Afebrile, VSS NAD, alert Neck: no bruits, no JVD Heart: Irregular, 4-26 murmur Lungs: CTAB Abd: soft, NT, ND, + BS Ext: no edema Pertinent Results: 1955-4-7 06:20AM BLOOD WBC-9.3 RBC-4.27 Hgb-12.7 Hct-37.8 MCV-89 MCH-29.8 MCHC-33.7 RDW-17.3* Plt Ct-78* 1955-4-7 06:20AM BLOOD Glucose-120* UreaN-29* Creat-1.3* Na-141 K-4.0 Cl-103 HCO3-25 AnGap-17 Brief Hospital Course: 81F c mitral regurgitation by TEE with symptoms of increasing fatigue, decrease mobility, weight loss. Evaluated as outpatient with echo showing mild AI, mod MR, mild MS, mod TR, dilated LA, and EF 40%, and cardiac cath showing no significant CAD. She was admitted for preop heparin gtt. She went to the OR 2018-4-18 for MVR (#27 Mosaic). For more detailed account, please see operative note. Post-op, she was transferred to the CSRU where she required dobutamine, milrinone, and volume resuscitation for low cardiac index. These issues rapidly resolved and she was extubated on POD 1. She was tranferred to the floor on POD 2. She re-started her coumadin on POD 4. PT recommended rehab placement. Medications on Admission: 1. Zocor 2. Coumadin 3. Lopressor 100 mg PO BID 4. Calcium 5. ASA 325 mg PO QD 6. Digoxin 0.125 mg PO QD 7. Lasix 10 mg PO QD 8. Lisinopril 20 mg PO QD 9. Remeron 15 mg PO QD 10. Amiodarone taper 11. Protonix 40 mg PO QD 12. Diamox Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:56 Capsule, Sustained Release(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. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Pantoprazole Sodium 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 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 9. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for tonights dose. Disp:30 Tablet(s) Refills:2 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: Pineda, Johnson and Trujillo Clinic of Unit 7745 Box 0286 DPO AA 79973 Discharge Diagnosis: 1. Mitral regurgitation 2. Paroxysmal atrial fib 3. HTN 4. COPD 5. Hypercholesterolemia Discharge Condition: Good Discharge Instructions: 1. Medications as directed. 2. Follow up INR with PCP or cardiologist. 3. Call office or go to ER if fever/chills, discharge from sternal incision, chest pain, dyspnea. Followup Instructions: PCP, 2 weeks, please call for appointment. Cardiologist, 2 weeks, please call for appointment. DrMoore, 4 weeks, please call for appointment.	['Admission Date: 2020-9-18 Discharge Date: 1987-7-8\n\n\nService: CARDIOTHORACIC\n\nAllergies:\nHeparin Agents\n\nAttending:Iliana\nChief Complaint:\nMitral regurgitation\n\nMajor Surgical or Invasive Procedure:\n1. Mitral valve replacement (#27 mosaic)\n\n\nHistory of Present Illness:\n81F c mitral regurgitation by TEE with symptoms of increasing\nfatigue, decrease mobility, weight loss. Evaluated as\noutpatient with echo showing mild AI, mod MR, mild MS, mod TR,\ndilated LA, and EF 40%, and cardiac cath showing no significant\nCAD. She was admitted for preop heparin gtt.\n\nPast Medical History:\n1. MR\n2. AI\n3. HTN\n4. COPD\n5. Hypercholesterolemia\n6. Paroxysmal afib\n7. h/o L retinal artery occlusion\n8. Pulmonary HTN\n9. s/p TAH for endometrial CA\n\nSocial History:\nNoncontributory\n\nFamily History:\nNoncontributory\n\nPhysical Exam:\nAfebrile, VSS\nNAD, alert\nNeck: no bruits, no JVD\nHeart: Irregular, 4-26 murmur\nLungs: CTAB\nAbd: soft, NT, ND, + BS\nExt: no edema\n\nPertinent Results:\n1955-4-7 06:20AM BLOOD WBC-9.', '3 RBC-4.27 Hgb-12.7 Hct-37.8 MCV-89\nMCH-29.8 MCHC-33.7 RDW-17.3* Plt Ct-78\n1955-4-7 06:20AM BLOOD Glucose-120 UreaN-29* Creat-1.3* Na-141\nK-4.0 Cl-103 HCO3-25 AnGap-17\n\nBrief Hospital Course:\n81F c mitral regurgitation by TEE with symptoms of increasing\nfatigue, decrease mobility, weight loss. Evaluated as outpatient\nwith echo showing mild AI, mod MR, mild MS, mod TR, dilated LA,\nand EF 40%, and cardiac cath showing no significant CAD. She was\nadmitted for preop heparin gtt.\n\nShe went to the OR 2018-4-18 for MVR (#27 Mosaic). For more\ndetailed account, please see operative note. Post-op, she was\ntransferred to the CSRU where she required dobutamine,\nmilrinone, and volume resuscitation for low cardiac index.\nThese issues rapidly resolved and she was extubated on POD 1.\nShe was tranferred to the floor on POD 2.', ' She re-started her\ncoumadin on POD 4. PT recommended rehab placement.\n\nMedications on Admission:\n1. Zocor\n2. Coumadin\n3. Lopressor 100 mg PO BID\n4. Calcium\n5. ASA 325 mg PO QD\n6. Digoxin 0.125 mg PO QD\n7. Lasix 10 mg PO QD\n8. Lisinopril 20 mg PO QD\n9. Remeron 15 mg PO QD\n10. Amiodarone taper\n11. Protonix 40 mg PO QD\n12. Diamox\n\nDischarge Medications:\n1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two\n(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2\nweeks.\nDisp:56 Capsule, Sustained Release(s) Refills:0\n2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:2\n3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:2\n4.', ' Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime).\nDisp:30 Tablet(s) Refills:2\n5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\nDisp:60 Tablet(s) Refills:2\n6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:\nOne (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:2\n7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\nDisp:60 Tablet(s) Refills:2\n8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) for 2 weeks.\nDisp:28 Tablet(s) Refills:0\n9. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime) as needed for tonights dose.\nDisp:30 Tablet(s) Refills:2\n10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours).', '\nDisp:120 neb Refills:2\n11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours).\nDisp:120 neb Refills:2\n12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\nDisp:30 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nPineda, Johnson and Trujillo Clinic of Unit 7745 Box 0286\nDPO AA 79973\n\nDischarge Diagnosis:\n1. Mitral regurgitation\n2. Paroxysmal atrial fib\n3. HTN\n4. COPD\n5. Hypercholesterolemia\n\n\nDischarge Condition:\nGood\n\nDischarge Instructions:\n1. Medications as directed.\n2. Follow up INR with PCP or cardiologist.\n3. Call office or go to ER if fever/chills, discharge from\nsternal incision, chest pain, dyspnea.\n\nFollowup Instructions:\nPCP, 2 weeks, please call for appointment.\n\nCardiologist, 2 weeks, please call for appointment.', '\n\nDrMoore, 4 weeks, please call for appointment.\n\n\n\n']
300	62762	138258.0	2118-12-03	Discharge summary	Report	Admission Date: [2118-12-1] Discharge Date: [2118-12-3] Date of Birth: [2037-12-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: weakness and cough Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo M with PMH of HTN, congenital deafness and osteoporosis who presents with fevers, cough and weakness. History is taken from patient and his home caregiver and also his HCP by phone. . Patient was recently admitted after a fall and found to have a C7 fracture. He was placed in a [Location (un) 2848] J collar and returned to rehab. Per his caregiver, over the last two days he has become more weak (not using his walker but requiring a wheelchair to get around), coughing and sounded "congested." He has been noted to have poor PO intake and coughing with all liquids and foods. His HCP says that he had a speech and swallow in the past and they recommended crushing his medications in apple sauce and avoiding thin liquids. The patient has recently refused this and has been taking thin liquids and coughing signficantly with them. Today, his caregivers brought him to his PCPs office. They got a CXR and labs. His sodium returned at 115 and his CXR suggested aspiration pneumonia with bilateral basilar infiltrates. He was sent to the ED. . In the ED, his vital signs were T 98.6, BP 117/61, HR 103, RR 22, O2sat 96% RA. He had a rectal temp of 102 while in the ED. His blood pressure transiently dropped to 78/50 and responded to fluids. He received a total of 1.8L NS. He was also given levofloxacin and clindamycin for pneumonia. He was admitted to the ICU for further care. . Currently he complains of the mask from the nebulizer and of the [Location (un) 2848] J collar. He is coughing. He denies CP, SOB, n/v, f/c. Denies constipation or dysuria. He does have trouble with incontinence. He is congenitally deaf and reads lips. Past Medical History: Frequent falls Hypertension Osteoporosis Congenital deafness Macular degeneration Vitamin B12 deficiency Benign prostatic hypertrophy Urinary incontinence Insomnia Social History: Retired acountant. Widowed. Lives in [Hospital3 ]. Denies tobacco, EtOH. Congenital deafness and reads lips. Does not use sign language. Family History: Non-contributory Physical Exam: Gen: NAD sitting up in bed with hard cervical collar in place. HEENT: PERRL EOMI. anicteric sclera, non-injected conjunctiva. dry MM, OP clear otherwise. JVP not assessed since collar in place. CV: RRR, no m/r/g Lungs: bilateral rhonchi with some wheeze on left side. Upper airway secretions as well. Abd: +BS, soft, NT, ND, no HSM. Extrem: No C/C/E. Neuro: CNIII-X and XII in tact except hearing- he reads lips. Did not assess [Doctor First Name 81] given collar in place. Poor muscle bulk in arms and legs bilaterally. Left arm rigidity. Toes mute bilaterally. Bicep, brachioradialis and patellar reflexes intact. Sensation to light touch appears to be intact. Pertinent Results: Admission Labs: WBC-16.4# RBC-3.31 Hgb-12.5* Hct-34.8* MCV-105* MCH-37.7* MCHC-35.9* RDW-12.9 Plt Ct-286 Neuts-90* Bands-3 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL [Name (NI) 2849] [Name (NI) 2850] PT-18.7* PTT-35.5* INR(PT)-1.7* UreaN-22* Creat-0.8 Na-115* K-4.8 Cl-80* HCO3-23 AnGap-17 Calcium-9.9 Phos-2.9 Mg-1.9 [2118-12-1] 03:27PM BLOOD CK(CPK)-597* CK-MB-14* MB Indx-2.3 [2118-12-1] 05:32PM BLOOD cTropnT-0.02* [2118-12-1] 09:04PM BLOOD CK(CPK)-529* CK-MB-12* MB Indx-2.3 cTropnT-0.02* [2118-12-2] 02:54AM BLOOD CK(CPK)-435* CK-MB-15* MB Indx-3.4 cTropnT-0.02* [2118-12-3] 03:06AM BLOOD proBNP-[Numeric Identifier 2851]* . Studies: [2118-12-1] EKG: Baseline artifact. Sinus tachycardia. Left axis deviation. RSR' pattern in lead VI. Consider inferior wall myocardial infarction of undetermined age. Since the previous tracing of [2118-11-7] the rate has increased. The R waves in leads III and aVF are not apparent. The axis is more leftward. Clinical correlation is suggested. . [2118-12-1] CXR - IMPRESSION: Bibasilar patchy opacities compatible with the history of aspiration. . [2118-12-3] CXR - IMPRESSION: Possibly worsening. Brief Hospital Course: 80 yo M with PMH of congential deafness, HTN, osteoporosis who presents with likely aspiration pneumonia and hyponatremia. #1 Aspiration Pneumonia / Respiratory Failure: The patient's clinical presentation, CXR findings, elevated lactate, and elevated WBC count with bands were consistent with an aspiration pneumonia. He received levofloxacin and clindamycin in the ED. As sputum gram stain showed a mixture of different organisms, he was started on broad spectrum antibiotic coverage with vancomycin, zosyn, and flagyl. Following his admission to the ICU the patient continued to be in respiratory distress with epsidoes of tachypnia and tachycardia with a heart rate to the 150??????s. An EKG showed MAT. His respiratory distress was consistently improved with morphine. It was felt that Mr. [Known lastname 2852] was unlikely to recover from his pneumonia given his inability to wean off bipap and to cough to clear his own secretions. As he was DNI status he could not be intubated to have secretions suctioned out. In addition, the patient appeared visibly uncomfortable on BiPAP and quickly desaturated into the 70??????s without it. Because the patient was given several liters of fluid for hyponatremia, there was the possibility that diuresis could improve his oxygenation enough to enable him to wean off the bipap, however, this did not prove to be the case. He was also given nebs prn. Upon discussing the patient's poor prognosis with his health care proxy the decision was made to make him CMO. Antibiotics and BiPAP were withdrawn and the patient died shortly thereafter. #2 Hyponatremia: The patient presented with hyponatremia, likely hypovolemic hyponatremia. On admission he appeared dry and had a history of poor PO intake, although he was mentating well. He received 1000 ml NS boluses overnight with maintenance fluids. The patient does have a history of low sodium but usually to the 130 range, whereas his admission sodium was 115. His sodium improving slowly with IVF. #3 Hypertension: The patient's home regimen of atenolol was held given concern for possible sepsis in the setting of pneumonia. Aspirin was continued. #4 Multifocal atrial tachycardia: Occurred in the setting of anxiety and tachypnea and improved with morphine. Rate control with a beta blocker or calcium channel blocker was held due to concern for hypotension in the setting of an infection. #5 spinal fracture: The patient was in a [Location (un) 2848] J collar on admission. Per discussion with neurosurgery, the patient needed to wear the collar due to an unstable spinal fracture. His collar was removed when he was made CMO. #6 BPH with incontinence: The patient's home regimen of oxybutynin was continued. #7 Macrocytic anemia: The patient usually has a macrocytic anemia and presented with a normal hematocrit, indicating that he was quite volume depleted. B12 supplementation was continued. # Osteoporosis: Calcium, vitamin D, and Fosamax were continued. # Depression: Escitalopram was continued. Medications on Admission: tylenol 1g TID alendronate 70mg qsunday asa EC 325mg daily atenolol 25mg daily colace flomax 0.4mg [1-12] after meal folic acid 1mg daily lexapro 10mg daily metamucil in AM oxybutynin 5mg [Hospital1 ] senna qhs trazodone 100mg qhs tums TID vit B12 1000mcg daily vit D 400 units [Hospital1 ] Discharge Medications: n/a, patient expired Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: Aspiration pneumonia Respiratory failure Hyponatremia Discharge Condition: Expired Discharge Instructions: Not applicable, patient expired Followup Instructions: Patient expired	Admission Date: <Date>1949-5-13</Date> Discharge Date: <Date>1939-3-25</Date> Date of Birth: <Date>1997-6-28</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Shannon</Name> Chief Complaint: weakness and cough Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo M with PMH of HTN, congenital deafness and osteoporosis who presents with fevers, cough and weakness. History is taken from patient and his home caregiver and also his HCP by phone. . Patient was recently admitted after a fall and found to have a C7 fracture. He was placed in a <Location>0904 Hill Island Suite 898 Lake Johnbury, ND 85002</Location> J collar and returned to rehab. Per his caregiver, over the last two days he has become more weak (not using his walker but requiring a wheelchair to get around), coughing and sounded "congested." He has been noted to have poor PO intake and coughing with all liquids and foods. His HCP says that he had a speech and swallow in the past and they recommended crushing his medications in apple sauce and avoiding thin liquids. The patient has recently refused this and has been taking thin liquids and coughing signficantly with them. Today, his caregivers brought him to his PCPs office. They got a CXR and labs. His sodium returned at 115 and his CXR suggested aspiration pneumonia with bilateral basilar infiltrates. He was sent to the ED. . In the ED, his vital signs were T 98.6, BP 117/61, HR 103, RR 22, O2sat 96% RA. He had a rectal temp of 102 while in the ED. His blood pressure transiently dropped to 78/50 and responded to fluids. He received a total of 1.8L NS. He was also given levofloxacin and clindamycin for pneumonia. He was admitted to the ICU for further care. . Currently he complains of the mask from the nebulizer and of the <Location>0904 Hill Island Suite 898 Lake Johnbury, ND 85002</Location> J collar. He is coughing. He denies CP, SOB, n/v, f/c. Denies constipation or dysuria. He does have trouble with incontinence. He is congenitally deaf and reads lips. Past Medical History: Frequent falls Hypertension Osteoporosis Congenital deafness Macular degeneration Vitamin B12 deficiency Benign prostatic hypertrophy Urinary incontinence Insomnia Social History: Retired acountant. Widowed. Lives in <Hospital>Steele LLC Medical Center</Hospital>. Denies tobacco, EtOH. Congenital deafness and reads lips. Does not use sign language. Family History: Non-contributory Physical Exam: Gen: NAD sitting up in bed with hard cervical collar in place. HEENT: PERRL EOMI. anicteric sclera, non-injected conjunctiva. dry MM, OP clear otherwise. JVP not assessed since collar in place. CV: RRR, no m/r/g Lungs: bilateral rhonchi with some wheeze on left side. Upper airway secretions as well. Abd: +BS, soft, NT, ND, no HSM. Extrem: No C/C/E. Neuro: CNIII-X and XII in tact except hearing- he reads lips. Did not assess <Name>Caleb</Name> given collar in place. Poor muscle bulk in arms and legs bilaterally. Left arm rigidity. Toes mute bilaterally. Bicep, brachioradialis and patellar reflexes intact. Sensation to light touch appears to be intact. Pertinent Results: Admission Labs: WBC-16.4# RBC-3.31 Hgb-12.5* Hct-34.8* MCV-105* MCH-37.7* MCHC-35.9* RDW-12.9 Plt Ct-286 Neuts-90* Bands-3 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL <Name>Danilo Recinos</Name> <Name>Brianna Lees</Name> PT-18.7* PTT-35.5* INR(PT)-1.7* UreaN-22* Creat-0.8 Na-115* K-4.8 Cl-80* HCO3-23 AnGap-17 Calcium-9.9 Phos-2.9 Mg-1.9 <Date>1949-5-13</Date> 03:27PM BLOOD CK(CPK)-597* CK-MB-14* MB Indx-2.3 <Date>1949-5-13</Date> 05:32PM BLOOD cTropnT-0.02* <Date>1949-5-13</Date> 09:04PM BLOOD CK(CPK)-529* CK-MB-12* MB Indx-2.3 cTropnT-0.02* <Date>1986-11-26</Date> 02:54AM BLOOD CK(CPK)-435* CK-MB-15* MB Indx-3.4 cTropnT-0.02* <Date>1939-3-25</Date> 03:06AM BLOOD proBNP-<Numeric Identifier>4252974</Numeric Identifier>* . Studies: <Date>1949-5-13</Date> EKG: Baseline artifact. Sinus tachycardia. Left axis deviation. RSR' pattern in lead VI. Consider inferior wall myocardial infarction of undetermined age. Since the previous tracing of <Date>2017-6-10</Date> the rate has increased. The R waves in leads III and aVF are not apparent. The axis is more leftward. Clinical correlation is suggested. . <Date>1949-5-13</Date> CXR - IMPRESSION: Bibasilar patchy opacities compatible with the history of aspiration. . <Date>1939-3-25</Date> CXR - IMPRESSION: Possibly worsening. Brief Hospital Course: 80 yo M with PMH of congential deafness, HTN, osteoporosis who presents with likely aspiration pneumonia and hyponatremia. #1 Aspiration Pneumonia / Respiratory Failure: The patient's clinical presentation, CXR findings, elevated lactate, and elevated WBC count with bands were consistent with an aspiration pneumonia. He received levofloxacin and clindamycin in the ED. As sputum gram stain showed a mixture of different organisms, he was started on broad spectrum antibiotic coverage with vancomycin, zosyn, and flagyl. Following his admission to the ICU the patient continued to be in respiratory distress with epsidoes of tachypnia and tachycardia with a heart rate to the 150??????s. An EKG showed MAT. His respiratory distress was consistently improved with morphine. It was felt that Mr. <Name>Shipley</Name> was unlikely to recover from his pneumonia given his inability to wean off bipap and to cough to clear his own secretions. As he was DNI status he could not be intubated to have secretions suctioned out. In addition, the patient appeared visibly uncomfortable on BiPAP and quickly desaturated into the 70??????s without it. Because the patient was given several liters of fluid for hyponatremia, there was the possibility that diuresis could improve his oxygenation enough to enable him to wean off the bipap, however, this did not prove to be the case. He was also given nebs prn. Upon discussing the patient's poor prognosis with his health care proxy the decision was made to make him CMO. Antibiotics and BiPAP were withdrawn and the patient died shortly thereafter. #2 Hyponatremia: The patient presented with hyponatremia, likely hypovolemic hyponatremia. On admission he appeared dry and had a history of poor PO intake, although he was mentating well. He received 1000 ml NS boluses overnight with maintenance fluids. The patient does have a history of low sodium but usually to the 130 range, whereas his admission sodium was 115. His sodium improving slowly with IVF. #3 Hypertension: The patient's home regimen of atenolol was held given concern for possible sepsis in the setting of pneumonia. Aspirin was continued. #4 Multifocal atrial tachycardia: Occurred in the setting of anxiety and tachypnea and improved with morphine. Rate control with a beta blocker or calcium channel blocker was held due to concern for hypotension in the setting of an infection. #5 spinal fracture: The patient was in a <Location>0904 Hill Island Suite 898 Lake Johnbury, ND 85002</Location> J collar on admission. Per discussion with neurosurgery, the patient needed to wear the collar due to an unstable spinal fracture. His collar was removed when he was made CMO. #6 BPH with incontinence: The patient's home regimen of oxybutynin was continued. #7 Macrocytic anemia: The patient usually has a macrocytic anemia and presented with a normal hematocrit, indicating that he was quite volume depleted. B12 supplementation was continued. # Osteoporosis: Calcium, vitamin D, and Fosamax were continued. # Depression: Escitalopram was continued. Medications on Admission: tylenol 1g TID alendronate 70mg qsunday asa EC 325mg daily atenolol 25mg daily colace flomax 0.4mg <Date>3-1</Date> after meal folic acid 1mg daily lexapro 10mg daily metamucil in AM oxybutynin 5mg <Hospital>Stein-Lee Health System</Hospital> senna qhs trazodone 100mg qhs tums TID vit B12 1000mcg daily vit D 400 units <Hospital>Stein-Lee Health System</Hospital> Discharge Medications: n/a, patient expired Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: Aspiration pneumonia Respiratory failure Hyponatremia Discharge Condition: Expired Discharge Instructions: Not applicable, patient expired Followup Instructions: Patient expired	000000000000000001111111110000000000000000000000000000000011111111100000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111011111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000001111111110000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000001111111000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1949-5-13 Discharge Date: 1939-3-25 Date of Birth: 1997-6-28 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Shannon Chief Complaint: weakness and cough Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo M with PMH of HTN, congenital deafness and osteoporosis who presents with fevers, cough and weakness. History is taken from patient and his home caregiver and also his HCP by phone. . Patient was recently admitted after a fall and found to have a C7 fracture. He was placed in a 0904 Hill Island Suite 898 Lake Johnbury, ND 85002 J collar and returned to rehab. Per his caregiver, over the last two days he has become more weak (not using his walker but requiring a wheelchair to get around), coughing and sounded "congested." He has been noted to have poor PO intake and coughing with all liquids and foods. His HCP says that he had a speech and swallow in the past and they recommended crushing his medications in apple sauce and avoiding thin liquids. The patient has recently refused this and has been taking thin liquids and coughing signficantly with them. Today, his caregivers brought him to his PCPs office. They got a CXR and labs. His sodium returned at 115 and his CXR suggested aspiration pneumonia with bilateral basilar infiltrates. He was sent to the ED. . In the ED, his vital signs were T 98.6, BP 117/61, HR 103, RR 22, O2sat 96% RA. He had a rectal temp of 102 while in the ED. His blood pressure transiently dropped to 78/50 and responded to fluids. He received a total of 1.8L NS. He was also given levofloxacin and clindamycin for pneumonia. He was admitted to the ICU for further care. . Currently he complains of the mask from the nebulizer and of the 0904 Hill Island Suite 898 Lake Johnbury, ND 85002 J collar. He is coughing. He denies CP, SOB, n/v, f/c. Denies constipation or dysuria. He does have trouble with incontinence. He is congenitally deaf and reads lips. Past Medical History: Frequent falls Hypertension Osteoporosis Congenital deafness Macular degeneration Vitamin B12 deficiency Benign prostatic hypertrophy Urinary incontinence Insomnia Social History: Retired acountant. Widowed. Lives in Steele LLC Medical Center. Denies tobacco, EtOH. Congenital deafness and reads lips. Does not use sign language. Family History: Non-contributory Physical Exam: Gen: NAD sitting up in bed with hard cervical collar in place. HEENT: PERRL EOMI. anicteric sclera, non-injected conjunctiva. dry MM, OP clear otherwise. JVP not assessed since collar in place. CV: RRR, no m/r/g Lungs: bilateral rhonchi with some wheeze on left side. Upper airway secretions as well. Abd: +BS, soft, NT, ND, no HSM. Extrem: No C/C/E. Neuro: CNIII-X and XII in tact except hearing- he reads lips. Did not assess Caleb given collar in place. Poor muscle bulk in arms and legs bilaterally. Left arm rigidity. Toes mute bilaterally. Bicep, brachioradialis and patellar reflexes intact. Sensation to light touch appears to be intact. Pertinent Results: Admission Labs: WBC-16.4# RBC-3.31 Hgb-12.5* Hct-34.8* MCV-105* MCH-37.7* MCHC-35.9* RDW-12.9 Plt Ct-286 Neuts-90* Bands-3 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Danilo Recinos Brianna Lees PT-18.7* PTT-35.5* INR(PT)-1.7* UreaN-22* Creat-0.8 Na-115* K-4.8 Cl-80* HCO3-23 AnGap-17 Calcium-9.9 Phos-2.9 Mg-1.9 1949-5-13 03:27PM BLOOD CK(CPK)-597* CK-MB-14* MB Indx-2.3 1949-5-13 05:32PM BLOOD cTropnT-0.02* 1949-5-13 09:04PM BLOOD CK(CPK)-529* CK-MB-12* MB Indx-2.3 cTropnT-0.02* 1986-11-26 02:54AM BLOOD CK(CPK)-435* CK-MB-15* MB Indx-3.4 cTropnT-0.02* 1939-3-25 03:06AM BLOOD proBNP-4252974* . Studies: 1949-5-13 EKG: Baseline artifact. Sinus tachycardia. Left axis deviation. RSR' pattern in lead VI. Consider inferior wall myocardial infarction of undetermined age. Since the previous tracing of 2017-6-10 the rate has increased. The R waves in leads III and aVF are not apparent. The axis is more leftward. Clinical correlation is suggested. . 1949-5-13 CXR - IMPRESSION: Bibasilar patchy opacities compatible with the history of aspiration. . 1939-3-25 CXR - IMPRESSION: Possibly worsening. Brief Hospital Course: 80 yo M with PMH of congential deafness, HTN, osteoporosis who presents with likely aspiration pneumonia and hyponatremia. #1 Aspiration Pneumonia / Respiratory Failure: The patient's clinical presentation, CXR findings, elevated lactate, and elevated WBC count with bands were consistent with an aspiration pneumonia. He received levofloxacin and clindamycin in the ED. As sputum gram stain showed a mixture of different organisms, he was started on broad spectrum antibiotic coverage with vancomycin, zosyn, and flagyl. Following his admission to the ICU the patient continued to be in respiratory distress with epsidoes of tachypnia and tachycardia with a heart rate to the 150??????s. An EKG showed MAT. His respiratory distress was consistently improved with morphine. It was felt that Mr. Shipley was unlikely to recover from his pneumonia given his inability to wean off bipap and to cough to clear his own secretions. As he was DNI status he could not be intubated to have secretions suctioned out. In addition, the patient appeared visibly uncomfortable on BiPAP and quickly desaturated into the 70??????s without it. Because the patient was given several liters of fluid for hyponatremia, there was the possibility that diuresis could improve his oxygenation enough to enable him to wean off the bipap, however, this did not prove to be the case. He was also given nebs prn. Upon discussing the patient's poor prognosis with his health care proxy the decision was made to make him CMO. Antibiotics and BiPAP were withdrawn and the patient died shortly thereafter. #2 Hyponatremia: The patient presented with hyponatremia, likely hypovolemic hyponatremia. On admission he appeared dry and had a history of poor PO intake, although he was mentating well. He received 1000 ml NS boluses overnight with maintenance fluids. The patient does have a history of low sodium but usually to the 130 range, whereas his admission sodium was 115. His sodium improving slowly with IVF. #3 Hypertension: The patient's home regimen of atenolol was held given concern for possible sepsis in the setting of pneumonia. Aspirin was continued. #4 Multifocal atrial tachycardia: Occurred in the setting of anxiety and tachypnea and improved with morphine. Rate control with a beta blocker or calcium channel blocker was held due to concern for hypotension in the setting of an infection. #5 spinal fracture: The patient was in a 0904 Hill Island Suite 898 Lake Johnbury, ND 85002 J collar on admission. Per discussion with neurosurgery, the patient needed to wear the collar due to an unstable spinal fracture. His collar was removed when he was made CMO. #6 BPH with incontinence: The patient's home regimen of oxybutynin was continued. #7 Macrocytic anemia: The patient usually has a macrocytic anemia and presented with a normal hematocrit, indicating that he was quite volume depleted. B12 supplementation was continued. # Osteoporosis: Calcium, vitamin D, and Fosamax were continued. # Depression: Escitalopram was continued. Medications on Admission: tylenol 1g TID alendronate 70mg qsunday asa EC 325mg daily atenolol 25mg daily colace flomax 0.4mg 3-1 after meal folic acid 1mg daily lexapro 10mg daily metamucil in AM oxybutynin 5mg Stein-Lee Health System senna qhs trazodone 100mg qhs tums TID vit B12 1000mcg daily vit D 400 units Stein-Lee Health System Discharge Medications: n/a, patient expired Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: Aspiration pneumonia Respiratory failure Hyponatremia Discharge Condition: Expired Discharge Instructions: Not applicable, patient expired Followup Instructions: Patient expired	['Admission Date: 1949-5-13 Discharge Date: 1939-3-25\n\nDate of Birth: 1997-6-28 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Shannon\nChief Complaint:\nweakness and cough\n\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\n80 yo M with PMH of HTN, congenital deafness and osteoporosis\nwho presents with fevers, cough and weakness. History is taken\nfrom patient and his home caregiver and also his HCP by phone.\n.\nPatient was recently admitted after a fall and found to have a\nC7 fracture. He was placed in a 0904 Hill Island Suite 898\nLake Johnbury, ND 85002 J collar and returned to\nrehab. Per his caregiver, over the last two days he has become\nmore weak (not using his walker but requiring a wheelchair to\nget around), coughing and sounded "congested.', '" He has been\nnoted to have poor PO intake and coughing with all liquids and\nfoods. His HCP says that he had a speech and swallow in the past\nand they recommended crushing his medications in apple sauce and\navoiding thin liquids. The patient has recently refused this and\nhas been taking thin liquids and coughing signficantly with\nthem. Today, his caregivers brought him to his PCPs office. They\ngot a CXR and labs. His sodium returned at 115 and his CXR\nsuggested aspiration pneumonia with bilateral basilar\ninfiltrates. He was sent to the ED.\n.\nIn the ED, his vital signs were T 98.6, BP 117/61, HR 103, RR\n22, O2sat 96% RA. He had a rectal temp of 102 while in the ED.\nHis blood pressure transiently dropped to 78/50 and responded to\nfluids. He received a total of 1.8L NS. He was also given\nlevofloxacin and clindamycin for pneumonia.', ' He was admitted to\nthe ICU for further care.\n.\nCurrently he complains of the mask from the nebulizer and of the\n0904 Hill Island Suite 898\nLake Johnbury, ND 85002 J collar. He is coughing. He denies CP, SOB, n/v, f/c.\nDenies constipation or dysuria. He does have trouble with\nincontinence. He is congenitally deaf and reads lips.\n\n\nPast Medical History:\nFrequent falls\nHypertension\nOsteoporosis\nCongenital deafness\nMacular degeneration\nVitamin B12 deficiency\nBenign prostatic hypertrophy\nUrinary incontinence\nInsomnia\n\n\nSocial History:\nRetired acountant. Widowed. Lives in Steele LLC Medical Center. Denies\ntobacco, EtOH. Congenital deafness and reads lips. Does not use\nsign language.\n\n\nFamily History:\nNon-contributory\n\nPhysical Exam:\nGen: NAD sitting up in bed with hard cervical collar in place.', '\nHEENT: PERRL EOMI. anicteric sclera, non-injected conjunctiva.\ndry MM, OP clear otherwise. JVP not assessed since collar in\nplace.\nCV: RRR, no m/r/g\nLungs: bilateral rhonchi with some wheeze on left side. Upper\nairway secretions as well.\nAbd: +BS, soft, NT, ND, no HSM.\nExtrem: No C/C/E.\nNeuro: CNIII-X and XII in tact except hearing- he reads lips.\nDid not assess Caleb given collar in place. Poor muscle bulk in\narms and legs bilaterally. Left arm rigidity. Toes mute\nbilaterally.\nBicep, brachioradialis and patellar reflexes intact. Sensation\nto light touch appears to be intact.\n\n\nPertinent Results:\nAdmission Labs:\nWBC-16.4# RBC-3.31 Hgb-12.5* Hct-34.8* MCV-105* MCH-37.7\nMCHC-35.9 RDW-12.9 Plt Ct-286\nNeuts-90* Bands-3 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0\nMyelos-0\nHypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL\nDanilo Recinos Brianna Lees\nPT-18.', "7* PTT-35.5* INR(PT)-1.7\nUreaN-22 Creat-0.8 Na-115* K-4.8 Cl-80* HCO3-23 AnGap-17\nCalcium-9.9 Phos-2.9 Mg-1.9\n1949-5-13 03:27PM BLOOD CK(CPK)-597* CK-MB-14* MB Indx-2.3\n1949-5-13 05:32PM BLOOD cTropnT-0.02\n1949-5-13 09:04PM BLOOD CK(CPK)-529 CK-MB-12* MB Indx-2.3\ncTropnT-0.02\n1986-11-26 02:54AM BLOOD CK(CPK)-435 CK-MB-15* MB Indx-3.4\ncTropnT-0.02\n1939-3-25 03:06AM BLOOD proBNP-4252974\n.\nStudies:\n1949-5-13 EKG: Baseline artifact. Sinus tachycardia. Left axis\ndeviation. RSR' pattern in lead VI. Consider inferior wall\nmyocardial infarction of undetermined age. Since the previous\ntracing of 2017-6-10 the rate has increased. The R waves in leads\nIII and aVF are not apparent. The axis is more leftward.\nClinical correlation is suggested.\n.\n1949-5-13 CXR - IMPRESSION: Bibasilar patchy opacities compatible\nwith the history of aspiration.", "\n.\n1939-3-25 CXR - IMPRESSION: Possibly worsening.\n\n\nBrief Hospital Course:\n80 yo M with PMH of congential deafness, HTN, osteoporosis who\npresents with likely aspiration pneumonia and hyponatremia.\n\n#1 Aspiration Pneumonia / Respiratory Failure: The patient's\nclinical presentation, CXR findings, elevated lactate, and\nelevated WBC count with bands were consistent with an aspiration\npneumonia. He received levofloxacin and clindamycin in the ED.\nAs sputum gram stain showed a mixture of different organisms, he\nwas started on broad spectrum antibiotic coverage with\nvancomycin, zosyn, and flagyl. Following his admission to the\nICU the patient continued to be in respiratory distress with\nepsidoes of tachypnia and tachycardia with a heart rate to the\n150??????s. An EKG showed MAT. His respiratory distress was\nconsistently improved with morphine.", " It was felt that Mr.\nShipley was unlikely to recover from his pneumonia given his\ninability to wean off bipap and to cough to clear his own\nsecretions. As he was DNI status he could not be intubated to\nhave secretions suctioned out. In addition, the patient\nappeared visibly uncomfortable on BiPAP and quickly desaturated\ninto the 70??????s without it.\n\nBecause the patient was given several liters of fluid for\nhyponatremia, there was the possibility that diuresis could\nimprove his oxygenation enough to enable him to wean off the\nbipap, however, this did not prove to be the case. He was also\ngiven nebs prn. Upon discussing the patient's poor prognosis\nwith his health care proxy the decision was made to make him\nCMO. Antibiotics and BiPAP were withdrawn and the patient died\nshortly thereafter.", "\n\n#2 Hyponatremia: The patient presented with hyponatremia, likely\nhypovolemic hyponatremia. On admission he appeared dry and had\na history of poor PO intake, although he was mentating well. He\nreceived 1000 ml NS boluses overnight with maintenance fluids.\nThe patient does have a history of low sodium but usually to the\n130 range, whereas his admission sodium was 115. His sodium\nimproving slowly with IVF.\n\n#3 Hypertension: The patient's home regimen of atenolol was held\ngiven concern for possible sepsis in the setting of pneumonia.\nAspirin was continued.\n\n#4 Multifocal atrial tachycardia: Occurred in the setting of\nanxiety and tachypnea and improved with morphine. Rate control\nwith a beta blocker or calcium channel blocker was held due to\nconcern for hypotension in the setting of an infection.", "\n\n#5 spinal fracture: The patient was in a 0904 Hill Island Suite 898\nLake Johnbury, ND 85002 J collar on\nadmission. Per discussion with neurosurgery, the patient needed\nto wear the collar due to an unstable spinal fracture. His\ncollar was removed when he was made CMO.\n\n#6 BPH with incontinence: The patient's home regimen of\noxybutynin was continued.\n\n#7 Macrocytic anemia: The patient usually has a macrocytic\nanemia and presented with a normal hematocrit, indicating that\nhe was quite volume depleted. B12 supplementation was\ncontinued.\n\n# Osteoporosis: Calcium, vitamin D, and Fosamax were continued.\n\n# Depression: Escitalopram was continued.\n\n\nMedications on Admission:\ntylenol 1g TID\nalendronate 70mg qsunday\nasa EC 325mg daily\natenolol 25mg daily\ncolace\nflomax 0.4mg 3-1 after meal\nfolic acid 1mg daily\nlexapro 10mg daily\nmetamucil in AM\noxybutynin 5mg Stein-Lee Health System\nsenna qhs\ntrazodone 100mg qhs\ntums TID\nvit B12 1000mcg daily\nvit D 400 units Stein-Lee Health System\n\n\nDischarge Medications:\nn/a, patient expired\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\nPrimary Diagnoses:\nAspiration pneumonia\nRespiratory failure\nHyponatremia\n\nDischarge Condition:\nExpired\n\nDischarge Instructions:\nNot applicable, patient expired\n\nFollowup Instructions:\nPatient expired\n\n\n"]
301	40734	128964.0	2157-04-08	Discharge summary	Report	Admission Date: [2157-3-29] Discharge Date: [2157-4-8] Date of Birth: [2074-4-2] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Subdural Hematoma Major Surgical or Invasive Procedure: none History of Present Illness: 82F w/ h/o multiple myeloma, peripheral neuropathy recently hospitalized on neuro service for work-up of multiple falls transferred from [Hospital3 2783] with dx of right SDH. The patient was found down, awake, in the afternoon by staff at nursing home where she lives. She was admitted at [Hospital1 18] about 2 weeks ago to work up the falls and at that time had negative intracranial imaging (see detailed neurology note from [2157-3-15]). The falls were thought to be due to a combination of neuropathy post chemotherapy and mild cervical spondylosis and she was discharged to a nursing home. The current fall was unwitnessed and it is not clear if there was any LOC. Patient denies any dizziness, lightheadedness, vertigo, nausea/vomiting. She also comes with a new dx of PNA, possible aspiration PNA and was treated with levaquin at OSH prior to arrival. . In the ED, initial vs were: T98.1, HR 80, BP 104/56, RR 14-16, O2 99%RA. Patient was alert but somewhat confused. Head CT showed no interval change in mid-line shift or size of SDH. Neurosurgery recommended 6-pack of plt's, DDAVP, Vit K (10mg IV) and 2L NS. Patient also received CTX for finding of pneumonia on CXR. Was admitted to MICU for q1H neuro checks and treatment of pneumonia. At time of transfer, VS 97.8, HR 80, Bp 96/41, RR 22 O2 97% 3L NC, RA sat of 93-94% Past Medical History: 1. Multiple myeloma s/p chemotherapy, followed by Dr. [First Name (STitle) 2856] at [Company 2860]. Seen by oncology for decreased counts on last admit and recommended to receive pulse steroids. 2. HTN 3. Peripheral neuropathy due to chemotherapy 4. s/p both hips, knees replacement and L ankle surgery 5. OA 6. s/p cholecystectomy 7. s/p hysterectomy 8. Frequent falls Social History: SH: Was living alone until recent falls with subdural requiring rehab - does not drive but pays own bills, takes own meds and etc. Used to be a waitress. Has 2 grown children. No cigarettes or EtOH. Family History: FH: NC Physical Exam: T97.3 HR 84, BP 92/60, O2 Sat 97% 3L NC General Appearance: No acute distress, Thin, very pleasant and comfortable appearing Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: No(t) Normal, Loud), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic), At Erb's point Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bilaterally) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: , No(t) Obese Extremities: Right: Absent, Left: Absent Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): place, knows why she is in hospital, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Normal, [6-7] full strength in UE bilaterally, diminished strength 4/5 b/l in LE, and nml cranial nerves Pertinent Results: [2157-3-28] 09:20PM PT-15.1* PTT-33.5 INR(PT)-1.3* [2157-3-28] 09:20PM WBC-16.6# RBC-2.69 HGB-9.2* HCT-25.5* MCV-95 MCH-34.3* MCHC-36.1* RDW-19.7* [2157-3-28] 09:20PM ALT(SGPT)-23 AST(SGOT)-41* ALK PHOS-67 TOT BILI-1.6* [2157-3-28] 09:39PM LACTATE-1.2 [3-28] CT Head: IMPRESSION: Acute on chronic right subdural hematoma, unchanged in comparison study from five hours prior. 1-2mm of leftward shift of normally midline structures. [3-29] CT Head: Evolution of acute-on-chronic right subdural hematoma with posterior layering of the acute component, now tracking along the tentorium. There is no evidence for new hemorrhage, increased mass effect, or edema. [4-2] CT Head: There has been not significant change in size of an acute on chronic subdural hematoma, but evolution of blood products within the hematoma is seen. There is no shift of minimal mass effect on subjacent right occipital gyri remains seen, and sulci are unchanged in configuration. The sulci are otherwise prominent, compatible with age-related involution. The ventricular configuration is unchanged. Again seen is scattered periventricular white matter hypodensities, consistent with chronic microvascular ischemia. Surrounding soft tissues and osseous structures are stable in appearance. There is no fracture. Imaged paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Evolution of right subdural hematoma without evidence for new hemorrhage or increased mass effect. No new hemorrhage. [3-28] CT C-spine: 1. No fracture or prevertebral soft tissue swelling. 2. Multilevel degenerative changes, predominantly at C5-6 and C6-7, unchanged in comparison to MRI [2157-3-18]. [3-28] Echo: The left atrium is mildly dilated. The estimated right atrial pressure is 10-15mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Preserved biventricular global and regional systolic function. Mild resting outflow tract gradient, likely due to vigorous left ventricular function. Severe pulmonary hypertension. Brief Hospital Course: # Subdural Hematoma: Patient continued to have decreased level of consciousness throughout the hospital stay. Neurosurgery was consulted for acute on chronic SDH. Vitamin K given for INR 1.3. ddavp given in ED given h/o aspirin use. Neurosurgery was consulted and recommended transfusing plt's with goal of >80, received 1 6-pack in ED. CT head and subsequent MRI/MRA were significant for stable SDH but chronic embolic events. Neurology was consulted and an EEG showed spike and wave patterns consistent with pre-seizure activity. Dilantin was given throughout the hospital course with no seizures noted. . # Hopsital Acquired Pneumonia. Has known PNA on CXR, treated from the start. Abx treatment included vanco and cefepime started [3-29]. Did get one dose of ceftriaxone. Was started on levo for atypical coverage on [3-29] which was stopped [4-2]. Flagyl was started [4-2]. Culture data only positive for GPCs in sputum, no speciation done. Remained tachypneic but oxygentating well until the date of death. The patient continued to require high O2 supplementation on [2157-4-8] and over the course of the day, the O2 sat declined, with a sharp decline in HR and BP. The patient became hypoxic and bradycardic, and expired in the afternoon. The family was contact[Name (NI) ] and came to the hospital for viewing. The PCP was notified. . # Falls/?Syncope: recent admit with extensive work-up attributing LE weakness and falls to cervical spondylosis and multilevel degenerative disease with myelopathy and neuropathy. Unclear if LOC with fall so would pursue syncope w/u, which is likely [3-7] UE neuropathy, weakness, ? seizure in setting of SDH. MRA showed no lesions. . # Myeloma: On pulse decadron as per heme-onc for tx of myeloma. . # Pancytopenia: [3-7] to myeloma. Stable. . # Renal Failure: At baseline from last admission. Unclear etiology to CKD, but may represent complication from myeloma. . # Code: After family meeting, DNR/DNI was established. Medications on Admission: Medications: (On discharge from [2157-3-21]) 1. Aspirin 325 mg Tablet 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) 3. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID 5. Dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO DAILY (Daily) for 4 days. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Nifedipine 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 8. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day: Give qAM and qPM. 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a day: Afternoon dose. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 11. Humalog insulin sliding scale Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Subdural [Hospital 2861] Hospital Acquired Pneumonia Secondary Diagnosis: Multiple Myeloma Thrombocytopenia Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2157-5-9]	Admission Date: <Date>1992-10-27</Date> Discharge Date: <Date>1965-8-5</Date> Date of Birth: <Date>2005-10-26</Date> Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Nicki</Name> Chief Complaint: Subdural Hematoma Major Surgical or Invasive Procedure: none History of Present Illness: 82F w/ h/o multiple myeloma, peripheral neuropathy recently hospitalized on neuro service for work-up of multiple falls transferred from <Hospital>Craig-Jensen Medical Center</Hospital> with dx of right SDH. The patient was found down, awake, in the afternoon by staff at nursing home where she lives. She was admitted at <Hospital>Mendez-Thompson Health System</Hospital> about 2 weeks ago to work up the falls and at that time had negative intracranial imaging (see detailed neurology note from <Date>1928-3-9</Date>). The falls were thought to be due to a combination of neuropathy post chemotherapy and mild cervical spondylosis and she was discharged to a nursing home. The current fall was unwitnessed and it is not clear if there was any LOC. Patient denies any dizziness, lightheadedness, vertigo, nausea/vomiting. She also comes with a new dx of PNA, possible aspiration PNA and was treated with levaquin at OSH prior to arrival. . In the ED, initial vs were: T98.1, HR 80, BP 104/56, RR 14-16, O2 99%RA. Patient was alert but somewhat confused. Head CT showed no interval change in mid-line shift or size of SDH. Neurosurgery recommended 6-pack of plt's, DDAVP, Vit K (10mg IV) and 2L NS. Patient also received CTX for finding of pneumonia on CXR. Was admitted to MICU for q1H neuro checks and treatment of pneumonia. At time of transfer, VS 97.8, HR 80, Bp 96/41, RR 22 O2 97% 3L NC, RA sat of 93-94% Past Medical History: 1. Multiple myeloma s/p chemotherapy, followed by Dr. <Name>Guadalupe</Name> at <Company>Patrick, Jackson and Herrera</Company>. Seen by oncology for decreased counts on last admit and recommended to receive pulse steroids. 2. HTN 3. Peripheral neuropathy due to chemotherapy 4. s/p both hips, knees replacement and L ankle surgery 5. OA 6. s/p cholecystectomy 7. s/p hysterectomy 8. Frequent falls Social History: SH: Was living alone until recent falls with subdural requiring rehab - does not drive but pays own bills, takes own meds and etc. Used to be a waitress. Has 2 grown children. No cigarettes or EtOH. Family History: FH: NC Physical Exam: T97.3 HR 84, BP 92/60, O2 Sat 97% 3L NC General Appearance: No acute distress, Thin, very pleasant and comfortable appearing Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: No(t) Normal, Loud), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic), At Erb's point Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bilaterally) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: , No(t) Obese Extremities: Right: Absent, Left: Absent Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): place, knows why she is in hospital, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Normal, <Date>12-5</Date> full strength in UE bilaterally, diminished strength 4/5 b/l in LE, and nml cranial nerves Pertinent Results: <Date>1964-5-19</Date> 09:20PM PT-15.1* PTT-33.5 INR(PT)-1.3* <Date>1964-5-19</Date> 09:20PM WBC-16.6# RBC-2.69 HGB-9.2* HCT-25.5* MCV-95 MCH-34.3* MCHC-36.1* RDW-19.7* <Date>1964-5-19</Date> 09:20PM ALT(SGPT)-23 AST(SGOT)-41* ALK PHOS-67 TOT BILI-1.6* <Date>1964-5-19</Date> 09:39PM LACTATE-1.2 <Date>8-11</Date> CT Head: IMPRESSION: Acute on chronic right subdural hematoma, unchanged in comparison study from five hours prior. 1-2mm of leftward shift of normally midline structures. <Date>8-21</Date> CT Head: Evolution of acute-on-chronic right subdural hematoma with posterior layering of the acute component, now tracking along the tentorium. There is no evidence for new hemorrhage, increased mass effect, or edema. <Date>4-26</Date> CT Head: There has been not significant change in size of an acute on chronic subdural hematoma, but evolution of blood products within the hematoma is seen. There is no shift of minimal mass effect on subjacent right occipital gyri remains seen, and sulci are unchanged in configuration. The sulci are otherwise prominent, compatible with age-related involution. The ventricular configuration is unchanged. Again seen is scattered periventricular white matter hypodensities, consistent with chronic microvascular ischemia. Surrounding soft tissues and osseous structures are stable in appearance. There is no fracture. Imaged paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Evolution of right subdural hematoma without evidence for new hemorrhage or increased mass effect. No new hemorrhage. <Date>8-11</Date> CT C-spine: 1. No fracture or prevertebral soft tissue swelling. 2. Multilevel degenerative changes, predominantly at C5-6 and C6-7, unchanged in comparison to MRI <Date>1965-6-8</Date>. <Date>8-11</Date> Echo: The left atrium is mildly dilated. The estimated right atrial pressure is 10-15mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Preserved biventricular global and regional systolic function. Mild resting outflow tract gradient, likely due to vigorous left ventricular function. Severe pulmonary hypertension. Brief Hospital Course: # Subdural Hematoma: Patient continued to have decreased level of consciousness throughout the hospital stay. Neurosurgery was consulted for acute on chronic SDH. Vitamin K given for INR 1.3. ddavp given in ED given h/o aspirin use. Neurosurgery was consulted and recommended transfusing plt's with goal of >80, received 1 6-pack in ED. CT head and subsequent MRI/MRA were significant for stable SDH but chronic embolic events. Neurology was consulted and an EEG showed spike and wave patterns consistent with pre-seizure activity. Dilantin was given throughout the hospital course with no seizures noted. . # Hopsital Acquired Pneumonia. Has known PNA on CXR, treated from the start. Abx treatment included vanco and cefepime started <Date>8-21</Date>. Did get one dose of ceftriaxone. Was started on levo for atypical coverage on <Date>8-21</Date> which was stopped <Date>4-26</Date>. Flagyl was started <Date>4-26</Date>. Culture data only positive for GPCs in sputum, no speciation done. Remained tachypneic but oxygentating well until the date of death. The patient continued to require high O2 supplementation on <Date>1965-8-5</Date> and over the course of the day, the O2 sat declined, with a sharp decline in HR and BP. The patient became hypoxic and bradycardic, and expired in the afternoon. The family was contact<Name>Andreas Naegelin</Name> and came to the hospital for viewing. The PCP was notified. . # Falls/?Syncope: recent admit with extensive work-up attributing LE weakness and falls to cervical spondylosis and multilevel degenerative disease with myelopathy and neuropathy. Unclear if LOC with fall so would pursue syncope w/u, which is likely <Date>5-5</Date> UE neuropathy, weakness, ? seizure in setting of SDH. MRA showed no lesions. . # Myeloma: On pulse decadron as per heme-onc for tx of myeloma. . # Pancytopenia: <Date>5-5</Date> to myeloma. Stable. . # Renal Failure: At baseline from last admission. Unclear etiology to CKD, but may represent complication from myeloma. . # Code: After family meeting, DNR/DNI was established. Medications on Admission: Medications: (On discharge from <Date>1912-12-30</Date>) 1. Aspirin 325 mg Tablet 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) 3. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID 5. Dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO DAILY (Daily) for 4 days. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Nifedipine 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 8. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day: Give qAM and qPM. 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a day: Afternoon dose. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 11. Humalog insulin sliding scale Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Subdural <Hospital>Richardson PLC Hospital</Hospital> Hospital Acquired Pneumonia Secondary Diagnosis: Multiple Myeloma Thrombocytopenia Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:<Date>2018-3-25</Date>	000000000000000001111111111000000000000000000000000000000001111111100000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000011111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1992-10-27 Discharge Date: 1965-8-5 Date of Birth: 2005-10-26 Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Nicki Chief Complaint: Subdural Hematoma Major Surgical or Invasive Procedure: none History of Present Illness: 82F w/ h/o multiple myeloma, peripheral neuropathy recently hospitalized on neuro service for work-up of multiple falls transferred from Craig-Jensen Medical Center with dx of right SDH. The patient was found down, awake, in the afternoon by staff at nursing home where she lives. She was admitted at Mendez-Thompson Health System about 2 weeks ago to work up the falls and at that time had negative intracranial imaging (see detailed neurology note from 1928-3-9). The falls were thought to be due to a combination of neuropathy post chemotherapy and mild cervical spondylosis and she was discharged to a nursing home. The current fall was unwitnessed and it is not clear if there was any LOC. Patient denies any dizziness, lightheadedness, vertigo, nausea/vomiting. She also comes with a new dx of PNA, possible aspiration PNA and was treated with levaquin at OSH prior to arrival. . In the ED, initial vs were: T98.1, HR 80, BP 104/56, RR 14-16, O2 99%RA. Patient was alert but somewhat confused. Head CT showed no interval change in mid-line shift or size of SDH. Neurosurgery recommended 6-pack of plt's, DDAVP, Vit K (10mg IV) and 2L NS. Patient also received CTX for finding of pneumonia on CXR. Was admitted to MICU for q1H neuro checks and treatment of pneumonia. At time of transfer, VS 97.8, HR 80, Bp 96/41, RR 22 O2 97% 3L NC, RA sat of 93-94% Past Medical History: 1. Multiple myeloma s/p chemotherapy, followed by Dr. Guadalupe at Patrick, Jackson and Herrera. Seen by oncology for decreased counts on last admit and recommended to receive pulse steroids. 2. HTN 3. Peripheral neuropathy due to chemotherapy 4. s/p both hips, knees replacement and L ankle surgery 5. OA 6. s/p cholecystectomy 7. s/p hysterectomy 8. Frequent falls Social History: SH: Was living alone until recent falls with subdural requiring rehab - does not drive but pays own bills, takes own meds and etc. Used to be a waitress. Has 2 grown children. No cigarettes or EtOH. Family History: FH: NC Physical Exam: T97.3 HR 84, BP 92/60, O2 Sat 97% 3L NC General Appearance: No acute distress, Thin, very pleasant and comfortable appearing Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: No(t) Normal, Loud), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic), At Erb's point Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bilaterally) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: , No(t) Obese Extremities: Right: Absent, Left: Absent Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): place, knows why she is in hospital, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Normal, 12-5 full strength in UE bilaterally, diminished strength 4/5 b/l in LE, and nml cranial nerves Pertinent Results: 1964-5-19 09:20PM PT-15.1* PTT-33.5 INR(PT)-1.3* 1964-5-19 09:20PM WBC-16.6# RBC-2.69 HGB-9.2* HCT-25.5* MCV-95 MCH-34.3* MCHC-36.1* RDW-19.7* 1964-5-19 09:20PM ALT(SGPT)-23 AST(SGOT)-41* ALK PHOS-67 TOT BILI-1.6* 1964-5-19 09:39PM LACTATE-1.2 8-11 CT Head: IMPRESSION: Acute on chronic right subdural hematoma, unchanged in comparison study from five hours prior. 1-2mm of leftward shift of normally midline structures. 8-21 CT Head: Evolution of acute-on-chronic right subdural hematoma with posterior layering of the acute component, now tracking along the tentorium. There is no evidence for new hemorrhage, increased mass effect, or edema. 4-26 CT Head: There has been not significant change in size of an acute on chronic subdural hematoma, but evolution of blood products within the hematoma is seen. There is no shift of minimal mass effect on subjacent right occipital gyri remains seen, and sulci are unchanged in configuration. The sulci are otherwise prominent, compatible with age-related involution. The ventricular configuration is unchanged. Again seen is scattered periventricular white matter hypodensities, consistent with chronic microvascular ischemia. Surrounding soft tissues and osseous structures are stable in appearance. There is no fracture. Imaged paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Evolution of right subdural hematoma without evidence for new hemorrhage or increased mass effect. No new hemorrhage. 8-11 CT C-spine: 1. No fracture or prevertebral soft tissue swelling. 2. Multilevel degenerative changes, predominantly at C5-6 and C6-7, unchanged in comparison to MRI 1965-6-8. 8-11 Echo: The left atrium is mildly dilated. The estimated right atrial pressure is 10-15mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Preserved biventricular global and regional systolic function. Mild resting outflow tract gradient, likely due to vigorous left ventricular function. Severe pulmonary hypertension. Brief Hospital Course: # Subdural Hematoma: Patient continued to have decreased level of consciousness throughout the hospital stay. Neurosurgery was consulted for acute on chronic SDH. Vitamin K given for INR 1.3. ddavp given in ED given h/o aspirin use. Neurosurgery was consulted and recommended transfusing plt's with goal of >80, received 1 6-pack in ED. CT head and subsequent MRI/MRA were significant for stable SDH but chronic embolic events. Neurology was consulted and an EEG showed spike and wave patterns consistent with pre-seizure activity. Dilantin was given throughout the hospital course with no seizures noted. . # Hopsital Acquired Pneumonia. Has known PNA on CXR, treated from the start. Abx treatment included vanco and cefepime started 8-21. Did get one dose of ceftriaxone. Was started on levo for atypical coverage on 8-21 which was stopped 4-26. Flagyl was started 4-26. Culture data only positive for GPCs in sputum, no speciation done. Remained tachypneic but oxygentating well until the date of death. The patient continued to require high O2 supplementation on 1965-8-5 and over the course of the day, the O2 sat declined, with a sharp decline in HR and BP. The patient became hypoxic and bradycardic, and expired in the afternoon. The family was contactAndreas Naegelin and came to the hospital for viewing. The PCP was notified. . # Falls/?Syncope: recent admit with extensive work-up attributing LE weakness and falls to cervical spondylosis and multilevel degenerative disease with myelopathy and neuropathy. Unclear if LOC with fall so would pursue syncope w/u, which is likely 5-5 UE neuropathy, weakness, ? seizure in setting of SDH. MRA showed no lesions. . # Myeloma: On pulse decadron as per heme-onc for tx of myeloma. . # Pancytopenia: 5-5 to myeloma. Stable. . # Renal Failure: At baseline from last admission. Unclear etiology to CKD, but may represent complication from myeloma. . # Code: After family meeting, DNR/DNI was established. Medications on Admission: Medications: (On discharge from 1912-12-30) 1. Aspirin 325 mg Tablet 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) 3. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID 5. Dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO DAILY (Daily) for 4 days. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Nifedipine 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 8. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day: Give qAM and qPM. 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a day: Afternoon dose. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 11. Humalog insulin sliding scale Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Subdural Richardson PLC Hospital Hospital Acquired Pneumonia Secondary Diagnosis: Multiple Myeloma Thrombocytopenia Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:2018-3-25	['Admission Date: 1992-10-27 Discharge Date: 1965-8-5\n\nDate of Birth: 2005-10-26 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Nicki\nChief Complaint:\nSubdural Hematoma\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\n82F w/ h/o multiple myeloma, peripheral neuropathy recently\nhospitalized on neuro service for work-up of multiple falls\ntransferred from Craig-Jensen Medical Center with dx of right SDH. The\npatient was found down, awake, in the afternoon by staff at\nnursing home where she lives. She was admitted at Mendez-Thompson Health System about 2\nweeks ago to work up the falls and at that time had negative\nintracranial imaging (see detailed neurology note from 1928-3-9).\nThe falls were thought to be due to a combination of neuropathy\npost chemotherapy and mild cervical spondylosis and she was\ndischarged to a nursing home.', " The current fall was unwitnessed\nand it is not clear if there was any LOC. Patient denies any\ndizziness, lightheadedness, vertigo, nausea/vomiting. She also\ncomes with a new dx of PNA, possible aspiration PNA and was\ntreated with levaquin at OSH prior to arrival.\n\n.\n\nIn the ED, initial vs were: T98.1, HR 80, BP 104/56, RR 14-16,\nO2 99%RA. Patient was alert but somewhat confused. Head CT\nshowed no interval change in mid-line shift or size of SDH.\nNeurosurgery recommended 6-pack of plt's, DDAVP, Vit K (10mg IV)\nand 2L NS. Patient also received CTX for finding of pneumonia\non CXR. Was admitted to MICU for q1H neuro checks and treatment\nof pneumonia. At time of transfer, VS 97.8, HR 80, Bp 96/41, RR\n22 O2 97% 3L NC, RA sat of 93-94%\n\n\nPast Medical History:\n1. Multiple myeloma s/p chemotherapy, followed by Dr.", " Guadalupe\nat Patrick, Jackson and Herrera. Seen by oncology for decreased counts on last admit\nand recommended to receive pulse steroids.\n\n2. HTN\n\n3. Peripheral neuropathy due to chemotherapy\n\n4. s/p both hips, knees replacement and L ankle surgery\n\n5. OA\n\n6. s/p cholecystectomy\n\n7. s/p hysterectomy\n\n8. Frequent falls\n\n\nSocial History:\nSH: Was living alone until recent falls with subdural requiring\nrehab - does not drive but pays own bills, takes own meds and\netc. Used to be a waitress. Has 2 grown children. No\ncigarettes or EtOH.\n\n\n\nFamily History:\nFH: NC\n\n\n\nPhysical Exam:\nT97.3 HR 84, BP 92/60, O2 Sat 97% 3L NC\nGeneral Appearance: No acute distress, Thin, very pleasant and\ncomfortable appearing\n\nEyes / Conjunctiva: PERRL\n\nHead, Ears, Nose, Throat: Normocephalic\n\nCardiovascular: (S1: Normal), (S2: No(t) Normal, Loud), No(t)\nS3, No(t) S4, No(t) Rub, (Murmur: Systolic), At Erb's point\n\nPeripheral Vascular: (Right radial pulse: Present), (Left radial\npulse: Present), (Right DP pulse: Present), (Left DP pulse:\nPresent)\n\nRespiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\nCrackles : bilaterally)\n\nAbdominal: Soft, Non-tender, Bowel sounds present, No(t)\nDistended, No(t) Tender: , No(t) Obese\n\nExtremities: Right: Absent, Left: Absent\n\nSkin: Not assessed\n\nNeurologic: Attentive, Follows simple commands, Responds to:\nVerbal stimuli, Oriented (to): place, knows why she is in\nhospital, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed,\nTone: Normal, 12-5 full strength in UE bilaterally, diminished\nstrength 4/5 b/l in LE, and nml cranial nerves\n\n\nPertinent Results:\n1964-5-19 09:20PM PT-15.", '1* PTT-33.5 INR(PT)-1.3\n1964-5-19 09:20PM WBC-16.6# RBC-2.69* HGB-9.2* HCT-25.5\nMCV-95 MCH-34.3 MCHC-36.1* RDW-19.7\n1964-5-19 09:20PM ALT(SGPT)-23 AST(SGOT)-41 ALK PHOS-67 TOT\nBILI-1.6*\n1964-5-19 09:39PM LACTATE-1.2\n\n8-11 CT Head:\nIMPRESSION: Acute on chronic right subdural hematoma, unchanged\nin comparison\nstudy from five hours prior. 1-2mm of leftward shift of normally\nmidline\nstructures.\n\n8-21 CT Head:\nEvolution of acute-on-chronic right subdural hematoma with\nposterior layering of the acute component, now tracking along\nthe tentorium. There is no evidence for new hemorrhage,\nincreased mass effect, or edema.\n\n4-26 CT Head:\nThere has been not significant change in size of an acute on\nchronic subdural hematoma, but evolution of blood products\nwithin the\nhematoma is seen. There is no shift of minimal mass effect on\nsubjacent right occipital gyri remains seen, and sulci are\nunchanged in configuration.', ' The sulci are otherwise prominent,\ncompatible with age-related involution. The ventricular\nconfiguration is unchanged. Again seen is scattered\nperiventricular white matter hypodensities, consistent with\nchronic microvascular ischemia.\n\nSurrounding soft tissues and osseous structures are stable in\nappearance.\nThere is no fracture. Imaged paranasal sinuses and mastoid air\ncells are well aerated.\n\nIMPRESSION: Evolution of right subdural hematoma without\nevidence for new\nhemorrhage or increased mass effect. No new hemorrhage.\n\n8-11 CT C-spine:\n1. No fracture or prevertebral soft tissue swelling.\n2. Multilevel degenerative changes, predominantly at C5-6 and\nC6-7, unchanged in comparison to MRI 1965-6-8.\n\n8-11 Echo:\nThe left atrium is mildly dilated. The estimated right atrial\npressure is 10-15mmHg.', ' Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF\n>55%). There is a mild resting left ventricular outflow tract\nobstruction. Right ventricular chamber size and free wall motion\nare normal. The number of aortic valve leaflets cannot be\ndetermined. The aortic valve leaflets are mildly thickened.\nThere is no valvular aortic stenosis. The increased transaortic\nvelocity is likely related to high cardiac output. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Trivial mitral\nregurgitation is seen. There is severe pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Preserved biventricular global and regional systolic\nfunction. Mild resting outflow tract gradient, likely due to\nvigorous left ventricular function.', " Severe pulmonary\nhypertension.\n\n\nBrief Hospital Course:\n# Subdural Hematoma: Patient continued to have decreased level\nof consciousness throughout the hospital stay. Neurosurgery was\nconsulted for acute on chronic SDH.\nVitamin K given for INR 1.3. ddavp given in ED given h/o aspirin\nuse. Neurosurgery was consulted and recommended transfusing\nplt's with goal of >80, received 1 6-pack in ED. CT head and\nsubsequent MRI/MRA were significant for stable SDH but chronic\nembolic events. Neurology was consulted and an EEG showed spike\nand wave patterns consistent with pre-seizure activity. Dilantin\nwas given throughout the hospital course with no seizures noted.\n.\n# Hopsital Acquired Pneumonia. Has known PNA on CXR, treated\nfrom the start. Abx treatment included vanco and cefepime\nstarted 8-21. Did get one dose of ceftriaxone.", ' Was started on\nlevo for atypical coverage on 8-21 which was stopped 4-26.\nFlagyl was started 4-26. Culture data only positive for GPCs in\nsputum, no speciation done. Remained tachypneic but\noxygentating well until the date of death. The patient continued\nto require high O2 supplementation on 1965-8-5 and over the course\nof the day, the O2 sat declined, with a sharp decline in HR and\nBP. The patient became hypoxic and bradycardic, and expired in\nthe afternoon. The family was contactAndreas Naegelin and came to the hospital\nfor viewing. The PCP was notified.\n.\n# Falls/?Syncope: recent admit with extensive work-up\nattributing LE weakness and falls to cervical spondylosis and\nmultilevel degenerative disease with myelopathy and neuropathy.\nUnclear if LOC with fall so would pursue syncope w/u, which is\nlikely 5-5 UE neuropathy, weakness, ? seizure in setting of SDH.', '\nMRA showed no lesions.\n.\n# Myeloma: On pulse decadron as per heme-onc for tx of myeloma.\n.\n# Pancytopenia: 5-5 to myeloma. Stable.\n.\n# Renal Failure: At baseline from last admission. Unclear\netiology to CKD, but may represent complication from myeloma.\n.\n# Code: After family meeting, DNR/DNI was established.\n\n\nMedications on Admission:\nMedications: (On discharge from 1912-12-30)\n\n1. Aspirin 325 mg Tablet\n\n2. Omeprazole 20 mg Capsule, Delayed Release(E.C.)\n\n3. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID\n\n4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID\n\n5. Dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO DAILY\n\n(Daily) for 4 days.\n\n6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice\n\n\na day.\n\n7. Nifedipine 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)\n\nTab,Sust Rel Osmotic Push 24hr PO once a day.', '\n\n8. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day:\n\nGive qAM and qPM.\n\n9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a day:\n\n\nAfternoon dose.\n\n10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\n\n\nhours) as needed for fever or pain.\n\n11. Humalog insulin sliding scale\n\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\nPrimary Diagnosis:\nAcute on Chronic Subdural Richardson PLC Hospital\nHospital Acquired Pneumonia\n\nSecondary Diagnosis:\nMultiple Myeloma\nThrombocytopenia\n\nDischarge Condition:\nExpired\n\nDischarge Instructions:\nN/A\n\nFollowup Instructions:\nN/A\n\n\nCompleted by:2018-3-25']

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