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
174	22532	167853.0	2151-08-04	Discharge summary	Report	Admission Date: [2151-7-16] Discharge Date: [2151-8-4] Service: ADDENDUM: RADIOLOGIC STUDIES: Radiologic studies also included a chest CT, which confirmed cavitary lesions in the left lung apex consistent with infectious process/tuberculosis. This also moderate-sized left pleural effusion. HEAD CT: Head CT showed no intracranial hemorrhage or mass effect, but old infarction consistent with past medical history. ABDOMINAL CT: Abdominal CT showed lesions of T10 and sacrum most likely secondary to osteoporosis. These can be followed by repeat imaging as an outpatient. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1775] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1776] Dictated By:[Hospital 1807] MEDQUIST36 D: [2151-8-5] 12:11 T: [2151-8-5] 12:21 JOB#: [Job Number 1808]	Admission Date: <Date>1924-11-21</Date> Discharge Date: <Date>1981-5-29</Date> Service: ADDENDUM: RADIOLOGIC STUDIES: Radiologic studies also included a chest CT, which confirmed cavitary lesions in the left lung apex consistent with infectious process/tuberculosis. This also moderate-sized left pleural effusion. HEAD CT: Head CT showed no intracranial hemorrhage or mass effect, but old infarction consistent with past medical history. ABDOMINAL CT: Abdominal CT showed lesions of T10 and sacrum most likely secondary to osteoporosis. These can be followed by repeat imaging as an outpatient. <Name>Isabella</Name> <Name>Reba</Name> <Name>White</Name>, M.D. <MD Number>48143768</MD Number> Dictated By:<Hospital>Moore LLC Health System</Hospital> MEDQUIST36 D: <Date>1975-2-7</Date> 12:11 T: <Date>1975-2-7</Date> 12:21 JOB#: <Job Number>Medina, Haynes and Martinez-1904-904257</Job Number>	0000000000000000011111111110000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111101111011111000000001111111100000000000000111111111111111111111110000000000000000011111111000000000000111111110000000000000001111111111111111111111111111111111111110	Admission Date: 1924-11-21 Discharge Date: 1981-5-29 Service: ADDENDUM: RADIOLOGIC STUDIES: Radiologic studies also included a chest CT, which confirmed cavitary lesions in the left lung apex consistent with infectious process/tuberculosis. This also moderate-sized left pleural effusion. HEAD CT: Head CT showed no intracranial hemorrhage or mass effect, but old infarction consistent with past medical history. ABDOMINAL CT: Abdominal CT showed lesions of T10 and sacrum most likely secondary to osteoporosis. These can be followed by repeat imaging as an outpatient. Isabella Reba White, M.D. 48143768 Dictated By:Moore LLC Health System MEDQUIST36 D: 1975-2-7 12:11 T: 1975-2-7 12:21 JOB#: Medina, Haynes and Martinez-1904-904257	['Admission Date: 1924-11-21 Discharge Date: 1981-5-29\n\n\nService:\nADDENDUM:\n\nRADIOLOGIC STUDIES: Radiologic studies also included a chest\nCT, which confirmed cavitary lesions in the left lung apex\nconsistent with infectious process/tuberculosis. This also\nmoderate-sized left pleural effusion.\n\nHEAD CT: Head CT showed no intracranial hemorrhage or mass\neffect, but old infarction consistent with past medical\nhistory.\n\nABDOMINAL CT: Abdominal CT showed lesions of\nT10 and sacrum most likely secondary to osteoporosis. These can\nbe followed by repeat imaging as an outpatient.\n\n\n\n Isabella Reba White, M.D. 48143768\n\nDictated By:Moore LLC Health System\nMEDQUIST36\n\nD: 1975-2-7 12:11\nT: 1975-2-7 12:21\nJOB#: Medina, Haynes and Martinez-1904-904257\n']
175	13702	107527.0	2118-06-14	Discharge summary	Report	Admission Date: [2118-6-2] Discharge Date: [2118-6-14] Date of Birth: Sex: F Service: MICU and then to [Doctor Last Name ] Medicine HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with a history of emphysema (not on home O2), who presents with three days of shortness of breath thought by her primary care doctor to be a COPD flare. Two days prior to admission, she was started on a prednisone taper and one day prior to admission she required oxygen at home in order to maintain oxygen saturation greater than 90%. She has also been on levofloxacin and nebulizers, and was not getting better, and presented to the [Hospital1 18] Emergency Room. In the [Hospital3 ] Emergency Room, her oxygen saturation was 100% on CPAP. She was not able to be weaned off of this despite nebulizer treatment and Solu-Medrol 125 mg IV x2. Review of systems is negative for the following: Fevers, chills, nausea, vomiting, night sweats, change in weight, gastrointestinal complaints, neurologic changes, rashes, palpitations, orthopnea. Is positive for the following: Chest pressure occasionally with shortness of breath with exertion, some shortness of breath that is positionally related, but is improved with nebulizer treatment. PAST MEDICAL HISTORY: 1. COPD. Last pulmonary function tests in [2117-11-3] demonstrated a FVC of 52% of predicted, a FEV1 of 54% of predicted, a MMF of 23% of predicted, and a FEV1:FVC ratio of 67% of predicted, that does not improve with bronchodilator treatment. The FVC, however, does significantly improve with bronchodilator treatment consistent with her known reversible air flow obstruction in addition to an underlying restrictive ventilatory defect. The patient has never been on home oxygen prior to this recent episode. She has never been on steroid taper or been intubated in the past. 2. Lacunar CVA. MRI of the head in [2114-11-4] demonstrates "mild degree of multiple small foci of high T2 signal within the white matter of both cerebral hemispheres as well as the pons, in the latter region predominantly to the right of midline. The abnormalities, while nonspecific in etiology, are most likely secondary to chronic microvascular infarction. There is no mass, lesion, shift of the normal midline strictures or hydrocephalus. The major vascular flow patterns are preserved. There is moderate right maxillary, moderate bilateral ethmoid, mild left maxillary, minimal right sphenoid, and frontal sinus mucosal thickening. These abnormalities could represent an allergic or some other type of inflammatory process. Additionally noted is a moderately enlarged subtotally empty sella turcica". 3. Angina: Most recent stress test was in [2118-1-3] going for four minutes with a rate pressure product of 10,000, 64% of maximum predicted heart rate without evidence of ischemic EKG changes or symptoms. The imaging portion of the study demonstrated no evidence of myocardial ischemia and a calculated ejection fraction of 84%. The patient denies angina at rest and gets angina with walking a few blocks. Are alleviated by sublingual nitroglycerin. 4. Hypothyroidism on Synthroid. 5. Depression on Lexapro. 6. Motor vehicle accident with head injury approximately 10 years ago. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 q.d. 2. Prednisone 60 mg, 50 mg, 40 mg, 20 mg. 3. Levofloxacin 500 mg q.d. 4. Imdur 60 mg q.d. 5. Synthroid 75 mcg q.d. 6. Pulmicort nebulizer b.i.d. 7. Albuterol nebulizer q.4. prn. 8. Lexapro 10 mg q.d. 9. Protonix 40 mg q.d. 10. Aspirin 81 mg q.d. ALLERGIES: Norvasc leads to lightheadedness and headache. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives with her husband, Dr. [Known lastname 1809] an eminent Pediatric Neurologist at [Hospital3 1810]. The patient is a prior smoker, but has not smoked in over 10 years. She has no known alcohol use and she is a full code. PHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure 142/76, heart rate 100 and regular, respirations at 17-21, and 97% axillary temperature. She was saturating at 100% on CPAP with dry mucous membranes. An elderly female in no apparent distress. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx difficult to assess due to CPAP machine. No evidence of jugular venous pressure, however, the strap from the CPAP machine obscures the neck exam. Cranial nerves II through XII are grossly intact. Neck is supple without lymphadenopathy. Heart exam: Tachycardic, regular, obscured by loud bilateral wheezing with increase in the expiratory phase as well as profuse scattered rhonchi throughout the lung fields. Positive bowel sounds, soft, nontender, nondistended, obese, no masses. Mild edema of the lower extremities without clubbing or cyanosis, no rashes. There is a right hand hematoma. Strength is assessed as [5-9] in the lower extremities, [5-9] in the upper extremities with a normal mental status and cognition. LABORATORY STUDIES: White count 19, hematocrit 41, platelets 300. Chem-7: 127, 3.6, 88, 29, 17, 0.6, 143. Troponin was negative. CKs were negative times three. Initial blood gas showed a pH of 7.4, pO2 of 66, pCO2 of 54. Chest x-ray demonstrates a moderate sized hiatal hernia, segmental atelectasis, left lower lobe infiltrate versus segmental atelectasis. EKG shows normal sinus rhythm at 113 beats per minute, normal axis, no evidence of ST-T wave changes. BRIEF SUMMARY OF HOSPITAL COURSE: 1. COPD/dyspnea/pneumonia: The patient was initially placed on an aggressive steroid taper and admitted to the Medical Intensive Care Unit due to her difficulty with oxygenation despite CPAP machine. She was also given nebulizer treatments q.4h. as well as chest PT. The nebulizers were increased to q.1h. due to the fact that she continued to have labored breathing. Due to persistent respiratory failure and labored breathing, the patient was intubated on [2118-6-7] in order to improve oxygenation, ventilation, and ability to suction. A bronchoscopy was performed on [2118-6-7], which demonstrated marked narrowing of the airways with expiration consistent with tracheomalacia. On [2118-6-9], two silicone stents were placed, one in the left main stem (12 x 25 and one in the trachea 16 x 40) by Dr. [First Name (STitle) ] [Name (STitle) ] under rigid bronchoscopy with general anesthesia. On [2118-6-11], the patient was extubated to a cool mist shovel mask and her oxygen was titrated down to 2 liters nasal cannula at which time she was transferred to the medical floor. On the medical floor, the steroids were weaned to off on [2118-6-14], and the patient was saturating at 97% on 2 liters, 92% on room air. On [2118-6-14], the patient was seen again by the Interventional Pulmonology service, who agreed that she looked much improved and recommended that she go to pulmonary rehabilitation with followup within six weeks' time status post placement of stents in respiratory failure. 2. Cardiovascular: The patient was ruled out for a MI. She did have another episode on the medical floor of chest pain, which showed no evidence of EKG changes and negative troponin, negative CKs x3. She was continued on aspirin, Imdur, and diltiazem for rate control per her outpatient regimen. 3. Hypertension: She was maintained on diltiazem and hydrochlorothiazide with adequate blood pressure control and normalization of electrolytes. 4. Hematuria: The patient had intermittent hematuria likely secondary to Foley placement. The Foley catheter was discontinued on [2118-6-14]. She had serial urinalyses, which were all negative for signs of infection. 5. Hyperglycemia: Patient was placed on insulin-sliding scale due to hyperglycemia, which was steroid induced. This worked quite well and her glucose came back to normal levels once the steroids were tapered to off. 6. Leukocytosis: Patient did have a profound leukocytosis of 20 to 22 during much of her hospital course. As the steroids were tapered to off, her white blood cell count on [2118-6-14] was 15,000. It was felt that the leukocytosis was secondary to both steroids as well as question of a left lower lobe pneumonia. 7. For the left lower lobe pneumonia, the patient had initially received a course of levofloxacin 500 p.o. q.d. from [2118-6-4] to [2118-6-10]. This was restarted on [2118-6-12] for an additional seven day course given the fact that she still had the leukocytosis and still had marked rales at the left lower lobe. 8. Hypothyroidism: The patient was continued on outpatient medical regimen. 9. Depression: The patient was continued on Lexapro per outpatient regimen. It is recommended that she follow up with a therapist as an outpatient due to the fact that she did have a blunted affect throughout much of the hospital course, and did appear clinically to be depressed. 10. Prophylaxis: She was maintained on proton-pump inhibitor with subQ Heparin. 11. Sore throat: The patient did have a sore throat for much of the hospital course post extubation. This was treated with Cepacol lozenges as well as KBL liquid (a solution containing Kaopectate, Bismuth, and lidocaine) at bedtime. 12. Communication/code status: The patient was full code throughout her hospital course, and communication was maintained with the patient and her husband. 13. Muscle weakness: The patient did have profound muscle weakness and was evaluated by Physical Therapy, and was found to have impaired functional mobility, impaired musculoskeletal performance, impaired gas exchange, impaired endurance, impaired ventilation, and needed help with supine to sit. However, she was able to tolerate sitting in a chair for approximately one hour. On motor exam, her flexors and extensors of the lower extremities were [4-8] at the knee, [4-8] at the ankle, [4-8] at the elbows, and [4-8] hips. It was felt that this weakness was most likely due to a combination of steroid myopathy as well as muscle atrophy secondary to deconditioning after a prolonged hospital course. 14. Speech/swallow: The patient had a Speech and Swallow evaluation showing no evidence of dysphagia, no evidence of vocal cord damage status post tracheal stent placement. DISCHARGE CONDITION: The patient was able to oxygenate on room air at 93% at the time of discharge. She was profoundly weak, but was no longer tachycardic and had a normal blood pressure. Her respirations were much improved albeit with transmitted upper airway sounds. DISCHARGE STATUS: The patient will be discharged to [Hospital1 ] for both pulmonary and physical rehabilitation. DISCHARGE MEDICATIONS: 1. Levothyroxine 75 mcg p.o. q.d. 2. Citalopram 10 mg p.o. q.d. 3. Aspirin 81 mg p.o. q.d. 4. Fluticasone 110 mcg two puffs inhaled b.i.d. 5. Salmeterol Diskus one inhalation b.i.d. 6. Acetaminophen 325-650 mg p.o. q.4-6h. prn. 7. Ipratropium bromide MDI two puffs inhaled q.2h. prn. 8. Albuterol 1-2 puffs inhaled q.2h. prn. 9. Zolpidem tartrate 5 mg p.o. q.h.s. prn. 10. Isosorbide dinitrate 10 mg p.o. t.i.d. 11. Diltiazem 60 mg p.o. q.i.d. 12. Pantoprazole 40 mg p.o. q.24h. 13. Trazodone 25 mg p.o. q.h.s. prn. 14. SubQ Heparin 5000 units subcutaneous b.i.d. until such time that the patient is able to get out of bed twice a day. 15. Cepacol lozenges q.2h. prn. 16. Levofloxacin 500 mg p.o. q.d. for a seven day course to be completed on [2118-6-21]. 17. Kaopectate/Benadryl/lidocaine 5 mL p.o. b.i.d. prn, not to be given around mealtimes for concern of dysphagia induced by lidocaine. 18. Lorazepam 0.5-2 mg IV q.6h. prn. FOLLOW-UP PLANS: The patient is recommended to followup with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1407], [Telephone/Fax (1) 1408] within two weeks of leaving of the hospital. She is also recommended to followup with the Interventional Pulmonary service for followup status post stent placement. She is also recommended to followup with a neurologist if her muscle weakness does not improve within one week on physical therapy with concern for steroid-induced myopathy. FINAL DIAGNOSES: 1. Tracheomalacia status post tracheal and left main stem bronchial stent placement. 2. Hypertension. 3. Hypothyroidism. 4. Restrictive lung defect. 5. Depression. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-207 Dictated By:[Last Name (NamePattern1) 1811] MEDQUIST36 D: [2118-6-14] 11:30 T: [2118-6-14] 11:33 JOB#: [Job Number 1812]	Admission Date: <Date>1995-1-11</Date> Discharge Date: <Date>2011-4-19</Date> Date of Birth: Sex: F Service: MICU and then to <Doctor Name>Dr.Luu</Doctor Name> Medicine HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with a history of emphysema (not on home O2), who presents with three days of shortness of breath thought by her primary care doctor to be a COPD flare. Two days prior to admission, she was started on a prednisone taper and one day prior to admission she required oxygen at home in order to maintain oxygen saturation greater than 90%. She has also been on levofloxacin and nebulizers, and was not getting better, and presented to the <Hospital>Barry, Johnson and Clark Health System</Hospital> Emergency Room. In the <Hospital>Moody-Conner Health System</Hospital> Emergency Room, her oxygen saturation was 100% on CPAP. She was not able to be weaned off of this despite nebulizer treatment and Solu-Medrol 125 mg IV x2. Review of systems is negative for the following: Fevers, chills, nausea, vomiting, night sweats, change in weight, gastrointestinal complaints, neurologic changes, rashes, palpitations, orthopnea. Is positive for the following: Chest pressure occasionally with shortness of breath with exertion, some shortness of breath that is positionally related, but is improved with nebulizer treatment. PAST MEDICAL HISTORY: 1. COPD. Last pulmonary function tests in <Date>1938-6-14</Date> demonstrated a FVC of 52% of predicted, a FEV1 of 54% of predicted, a MMF of 23% of predicted, and a FEV1:FVC ratio of 67% of predicted, that does not improve with bronchodilator treatment. The FVC, however, does significantly improve with bronchodilator treatment consistent with her known reversible air flow obstruction in addition to an underlying restrictive ventilatory defect. The patient has never been on home oxygen prior to this recent episode. She has never been on steroid taper or been intubated in the past. 2. Lacunar CVA. MRI of the head in <Date>1913-1-14</Date> demonstrates "mild degree of multiple small foci of high T2 signal within the white matter of both cerebral hemispheres as well as the pons, in the latter region predominantly to the right of midline. The abnormalities, while nonspecific in etiology, are most likely secondary to chronic microvascular infarction. There is no mass, lesion, shift of the normal midline strictures or hydrocephalus. The major vascular flow patterns are preserved. There is moderate right maxillary, moderate bilateral ethmoid, mild left maxillary, minimal right sphenoid, and frontal sinus mucosal thickening. These abnormalities could represent an allergic or some other type of inflammatory process. Additionally noted is a moderately enlarged subtotally empty sella turcica". 3. Angina: Most recent stress test was in <Date>2016-10-24</Date> going for four minutes with a rate pressure product of 10,000, 64% of maximum predicted heart rate without evidence of ischemic EKG changes or symptoms. The imaging portion of the study demonstrated no evidence of myocardial ischemia and a calculated ejection fraction of 84%. The patient denies angina at rest and gets angina with walking a few blocks. Are alleviated by sublingual nitroglycerin. 4. Hypothyroidism on Synthroid. 5. Depression on Lexapro. 6. Motor vehicle accident with head injury approximately 10 years ago. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 q.d. 2. Prednisone 60 mg, 50 mg, 40 mg, 20 mg. 3. Levofloxacin 500 mg q.d. 4. Imdur 60 mg q.d. 5. Synthroid 75 mcg q.d. 6. Pulmicort nebulizer b.i.d. 7. Albuterol nebulizer q.4. prn. 8. Lexapro 10 mg q.d. 9. Protonix 40 mg q.d. 10. Aspirin 81 mg q.d. ALLERGIES: Norvasc leads to lightheadedness and headache. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives with her husband, Dr. <Name>Anderson</Name> an eminent Pediatric Neurologist at <Hospital>Scott LLC Medical Center</Hospital>. The patient is a prior smoker, but has not smoked in over 10 years. She has no known alcohol use and she is a full code. PHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure 142/76, heart rate 100 and regular, respirations at 17-21, and 97% axillary temperature. She was saturating at 100% on CPAP with dry mucous membranes. An elderly female in no apparent distress. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx difficult to assess due to CPAP machine. No evidence of jugular venous pressure, however, the strap from the CPAP machine obscures the neck exam. Cranial nerves II through XII are grossly intact. Neck is supple without lymphadenopathy. Heart exam: Tachycardic, regular, obscured by loud bilateral wheezing with increase in the expiratory phase as well as profuse scattered rhonchi throughout the lung fields. Positive bowel sounds, soft, nontender, nondistended, obese, no masses. Mild edema of the lower extremities without clubbing or cyanosis, no rashes. There is a right hand hematoma. Strength is assessed as <Date>11-10</Date> in the lower extremities, <Date>11-10</Date> in the upper extremities with a normal mental status and cognition. LABORATORY STUDIES: White count 19, hematocrit 41, platelets 300. Chem-7: 127, 3.6, 88, 29, 17, 0.6, 143. Troponin was negative. CKs were negative times three. Initial blood gas showed a pH of 7.4, pO2 of 66, pCO2 of 54. Chest x-ray demonstrates a moderate sized hiatal hernia, segmental atelectasis, left lower lobe infiltrate versus segmental atelectasis. EKG shows normal sinus rhythm at 113 beats per minute, normal axis, no evidence of ST-T wave changes. BRIEF SUMMARY OF HOSPITAL COURSE: 1. COPD/dyspnea/pneumonia: The patient was initially placed on an aggressive steroid taper and admitted to the Medical Intensive Care Unit due to her difficulty with oxygenation despite CPAP machine. She was also given nebulizer treatments q.4h. as well as chest PT. The nebulizers were increased to q.1h. due to the fact that she continued to have labored breathing. Due to persistent respiratory failure and labored breathing, the patient was intubated on <Date>2009-12-31</Date> in order to improve oxygenation, ventilation, and ability to suction. A bronchoscopy was performed on <Date>2009-12-31</Date>, which demonstrated marked narrowing of the airways with expiration consistent with tracheomalacia. On <Date>2007-12-5</Date>, two silicone stents were placed, one in the left main stem (12 x 25 and one in the trachea 16 x 40) by Dr. <Name>Joe</Name> <Name>Chloe Miller</Name> under rigid bronchoscopy with general anesthesia. On <Date>1921-5-11</Date>, the patient was extubated to a cool mist shovel mask and her oxygen was titrated down to 2 liters nasal cannula at which time she was transferred to the medical floor. On the medical floor, the steroids were weaned to off on <Date>2011-4-19</Date>, and the patient was saturating at 97% on 2 liters, 92% on room air. On <Date>2011-4-19</Date>, the patient was seen again by the Interventional Pulmonology service, who agreed that she looked much improved and recommended that she go to pulmonary rehabilitation with followup within six weeks' time status post placement of stents in respiratory failure. 2. Cardiovascular: The patient was ruled out for a MI. She did have another episode on the medical floor of chest pain, which showed no evidence of EKG changes and negative troponin, negative CKs x3. She was continued on aspirin, Imdur, and diltiazem for rate control per her outpatient regimen. 3. Hypertension: She was maintained on diltiazem and hydrochlorothiazide with adequate blood pressure control and normalization of electrolytes. 4. Hematuria: The patient had intermittent hematuria likely secondary to Foley placement. The Foley catheter was discontinued on <Date>2011-4-19</Date>. She had serial urinalyses, which were all negative for signs of infection. 5. Hyperglycemia: Patient was placed on insulin-sliding scale due to hyperglycemia, which was steroid induced. This worked quite well and her glucose came back to normal levels once the steroids were tapered to off. 6. Leukocytosis: Patient did have a profound leukocytosis of 20 to 22 during much of her hospital course. As the steroids were tapered to off, her white blood cell count on <Date>2011-4-19</Date> was 15,000. It was felt that the leukocytosis was secondary to both steroids as well as question of a left lower lobe pneumonia. 7. For the left lower lobe pneumonia, the patient had initially received a course of levofloxacin 500 p.o. q.d. from <Date>1941-12-6</Date> to <Date>1919-3-23</Date>. This was restarted on <Date>1941-3-21</Date> for an additional seven day course given the fact that she still had the leukocytosis and still had marked rales at the left lower lobe. 8. Hypothyroidism: The patient was continued on outpatient medical regimen. 9. Depression: The patient was continued on Lexapro per outpatient regimen. It is recommended that she follow up with a therapist as an outpatient due to the fact that she did have a blunted affect throughout much of the hospital course, and did appear clinically to be depressed. 10. Prophylaxis: She was maintained on proton-pump inhibitor with subQ Heparin. 11. Sore throat: The patient did have a sore throat for much of the hospital course post extubation. This was treated with Cepacol lozenges as well as KBL liquid (a solution containing Kaopectate, Bismuth, and lidocaine) at bedtime. 12. Communication/code status: The patient was full code throughout her hospital course, and communication was maintained with the patient and her husband. 13. Muscle weakness: The patient did have profound muscle weakness and was evaluated by Physical Therapy, and was found to have impaired functional mobility, impaired musculoskeletal performance, impaired gas exchange, impaired endurance, impaired ventilation, and needed help with supine to sit. However, she was able to tolerate sitting in a chair for approximately one hour. On motor exam, her flexors and extensors of the lower extremities were <Date>5-14</Date> at the knee, <Date>5-14</Date> at the ankle, <Date>5-14</Date> at the elbows, and <Date>5-14</Date> hips. It was felt that this weakness was most likely due to a combination of steroid myopathy as well as muscle atrophy secondary to deconditioning after a prolonged hospital course. 14. Speech/swallow: The patient had a Speech and Swallow evaluation showing no evidence of dysphagia, no evidence of vocal cord damage status post tracheal stent placement. DISCHARGE CONDITION: The patient was able to oxygenate on room air at 93% at the time of discharge. She was profoundly weak, but was no longer tachycardic and had a normal blood pressure. Her respirations were much improved albeit with transmitted upper airway sounds. DISCHARGE STATUS: The patient will be discharged to <Hospital>Chambers, Knight and Torres Clinic</Hospital> for both pulmonary and physical rehabilitation. DISCHARGE MEDICATIONS: 1. Levothyroxine 75 mcg p.o. q.d. 2. Citalopram 10 mg p.o. q.d. 3. Aspirin 81 mg p.o. q.d. 4. Fluticasone 110 mcg two puffs inhaled b.i.d. 5. Salmeterol Diskus one inhalation b.i.d. 6. Acetaminophen 325-650 mg p.o. q.4-6h. prn. 7. Ipratropium bromide MDI two puffs inhaled q.2h. prn. 8. Albuterol 1-2 puffs inhaled q.2h. prn. 9. Zolpidem tartrate 5 mg p.o. q.h.s. prn. 10. Isosorbide dinitrate 10 mg p.o. t.i.d. 11. Diltiazem 60 mg p.o. q.i.d. 12. Pantoprazole 40 mg p.o. q.24h. 13. Trazodone 25 mg p.o. q.h.s. prn. 14. SubQ Heparin 5000 units subcutaneous b.i.d. until such time that the patient is able to get out of bed twice a day. 15. Cepacol lozenges q.2h. prn. 16. Levofloxacin 500 mg p.o. q.d. for a seven day course to be completed on <Date>2016-5-12</Date>. 17. Kaopectate/Benadryl/lidocaine 5 mL p.o. b.i.d. prn, not to be given around mealtimes for concern of dysphagia induced by lidocaine. 18. Lorazepam 0.5-2 mg IV q.6h. prn. FOLLOW-UP PLANS: The patient is recommended to followup with Dr. <Name>Omer</Name> <Name>Wilson</Name>, <Telephone>663-918-8473</Telephone> within two weeks of leaving of the hospital. She is also recommended to followup with the Interventional Pulmonary service for followup status post stent placement. She is also recommended to followup with a neurologist if her muscle weakness does not improve within one week on physical therapy with concern for steroid-induced myopathy. FINAL DIAGNOSES: 1. Tracheomalacia status post tracheal and left main stem bronchial stent placement. 2. Hypertension. 3. Hypothyroidism. 4. Restrictive lung defect. 5. Depression. DR.<Name>Moblo</Name>,<Name>Percy</Name> 12-207 Dictated By:<Name>Ngo</Name> MEDQUIST36 D: <Date>2011-4-19</Date> 11:30 T: <Date>2011-4-19</Date> 11:33 JOB#: <Job Number>Sanchez PLC-2016-791366</Job 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Date: 1995-1-11 Discharge Date: 2011-4-19 Date of Birth: Sex: F Service: MICU and then to Dr.Luu Medicine HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with a history of emphysema (not on home O2), who presents with three days of shortness of breath thought by her primary care doctor to be a COPD flare. Two days prior to admission, she was started on a prednisone taper and one day prior to admission she required oxygen at home in order to maintain oxygen saturation greater than 90%. She has also been on levofloxacin and nebulizers, and was not getting better, and presented to the Barry, Johnson and Clark Health System Emergency Room. In the Moody-Conner Health System Emergency Room, her oxygen saturation was 100% on CPAP. She was not able to be weaned off of this despite nebulizer treatment and Solu-Medrol 125 mg IV x2. Review of systems is negative for the following: Fevers, chills, nausea, vomiting, night sweats, change in weight, gastrointestinal complaints, neurologic changes, rashes, palpitations, orthopnea. Is positive for the following: Chest pressure occasionally with shortness of breath with exertion, some shortness of breath that is positionally related, but is improved with nebulizer treatment. PAST MEDICAL HISTORY: 1. COPD. Last pulmonary function tests in 1938-6-14 demonstrated a FVC of 52% of predicted, a FEV1 of 54% of predicted, a MMF of 23% of predicted, and a FEV1:FVC ratio of 67% of predicted, that does not improve with bronchodilator treatment. The FVC, however, does significantly improve with bronchodilator treatment consistent with her known reversible air flow obstruction in addition to an underlying restrictive ventilatory defect. The patient has never been on home oxygen prior to this recent episode. She has never been on steroid taper or been intubated in the past. 2. Lacunar CVA. MRI of the head in 1913-1-14 demonstrates "mild degree of multiple small foci of high T2 signal within the white matter of both cerebral hemispheres as well as the pons, in the latter region predominantly to the right of midline. The abnormalities, while nonspecific in etiology, are most likely secondary to chronic microvascular infarction. There is no mass, lesion, shift of the normal midline strictures or hydrocephalus. The major vascular flow patterns are preserved. There is moderate right maxillary, moderate bilateral ethmoid, mild left maxillary, minimal right sphenoid, and frontal sinus mucosal thickening. These abnormalities could represent an allergic or some other type of inflammatory process. Additionally noted is a moderately enlarged subtotally empty sella turcica". 3. Angina: Most recent stress test was in 2016-10-24 going for four minutes with a rate pressure product of 10,000, 64% of maximum predicted heart rate without evidence of ischemic EKG changes or symptoms. The imaging portion of the study demonstrated no evidence of myocardial ischemia and a calculated ejection fraction of 84%. The patient denies angina at rest and gets angina with walking a few blocks. Are alleviated by sublingual nitroglycerin. 4. Hypothyroidism on Synthroid. 5. Depression on Lexapro. 6. Motor vehicle accident with head injury approximately 10 years ago. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 q.d. 2. Prednisone 60 mg, 50 mg, 40 mg, 20 mg. 3. Levofloxacin 500 mg q.d. 4. Imdur 60 mg q.d. 5. Synthroid 75 mcg q.d. 6. Pulmicort nebulizer b.i.d. 7. Albuterol nebulizer q.4. prn. 8. Lexapro 10 mg q.d. 9. Protonix 40 mg q.d. 10. Aspirin 81 mg q.d. ALLERGIES: Norvasc leads to lightheadedness and headache. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives with her husband, Dr. Anderson an eminent Pediatric Neurologist at Scott LLC Medical Center. The patient is a prior smoker, but has not smoked in over 10 years. She has no known alcohol use and she is a full code. PHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure 142/76, heart rate 100 and regular, respirations at 17-21, and 97% axillary temperature. She was saturating at 100% on CPAP with dry mucous membranes. An elderly female in no apparent distress. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx difficult to assess due to CPAP machine. No evidence of jugular venous pressure, however, the strap from the CPAP machine obscures the neck exam. Cranial nerves II through XII are grossly intact. Neck is supple without lymphadenopathy. Heart exam: Tachycardic, regular, obscured by loud bilateral wheezing with increase in the expiratory phase as well as profuse scattered rhonchi throughout the lung fields. Positive bowel sounds, soft, nontender, nondistended, obese, no masses. Mild edema of the lower extremities without clubbing or cyanosis, no rashes. There is a right hand hematoma. Strength is assessed as 11-10 in the lower extremities, 11-10 in the upper extremities with a normal mental status and cognition. LABORATORY STUDIES: White count 19, hematocrit 41, platelets 300. Chem-7: 127, 3.6, 88, 29, 17, 0.6, 143. Troponin was negative. CKs were negative times three. Initial blood gas showed a pH of 7.4, pO2 of 66, pCO2 of 54. Chest x-ray demonstrates a moderate sized hiatal hernia, segmental atelectasis, left lower lobe infiltrate versus segmental atelectasis. EKG shows normal sinus rhythm at 113 beats per minute, normal axis, no evidence of ST-T wave changes. BRIEF SUMMARY OF HOSPITAL COURSE: 1. COPD/dyspnea/pneumonia: The patient was initially placed on an aggressive steroid taper and admitted to the Medical Intensive Care Unit due to her difficulty with oxygenation despite CPAP machine. She was also given nebulizer treatments q.4h. as well as chest PT. The nebulizers were increased to q.1h. due to the fact that she continued to have labored breathing. Due to persistent respiratory failure and labored breathing, the patient was intubated on 2009-12-31 in order to improve oxygenation, ventilation, and ability to suction. A bronchoscopy was performed on 2009-12-31, which demonstrated marked narrowing of the airways with expiration consistent with tracheomalacia. On 2007-12-5, two silicone stents were placed, one in the left main stem (12 x 25 and one in the trachea 16 x 40) by Dr. Joe Chloe Miller under rigid bronchoscopy with general anesthesia. On 1921-5-11, the patient was extubated to a cool mist shovel mask and her oxygen was titrated down to 2 liters nasal cannula at which time she was transferred to the medical floor. On the medical floor, the steroids were weaned to off on 2011-4-19, and the patient was saturating at 97% on 2 liters, 92% on room air. On 2011-4-19, the patient was seen again by the Interventional Pulmonology service, who agreed that she looked much improved and recommended that she go to pulmonary rehabilitation with followup within six weeks' time status post placement of stents in respiratory failure. 2. Cardiovascular: The patient was ruled out for a MI. She did have another episode on the medical floor of chest pain, which showed no evidence of EKG changes and negative troponin, negative CKs x3. She was continued on aspirin, Imdur, and diltiazem for rate control per her outpatient regimen. 3. Hypertension: She was maintained on diltiazem and hydrochlorothiazide with adequate blood pressure control and normalization of electrolytes. 4. Hematuria: The patient had intermittent hematuria likely secondary to Foley placement. The Foley catheter was discontinued on 2011-4-19. She had serial urinalyses, which were all negative for signs of infection. 5. Hyperglycemia: Patient was placed on insulin-sliding scale due to hyperglycemia, which was steroid induced. This worked quite well and her glucose came back to normal levels once the steroids were tapered to off. 6. Leukocytosis: Patient did have a profound leukocytosis of 20 to 22 during much of her hospital course. As the steroids were tapered to off, her white blood cell count on 2011-4-19 was 15,000. It was felt that the leukocytosis was secondary to both steroids as well as question of a left lower lobe pneumonia. 7. For the left lower lobe pneumonia, the patient had initially received a course of levofloxacin 500 p.o. q.d. from 1941-12-6 to 1919-3-23. This was restarted on 1941-3-21 for an additional seven day course given the fact that she still had the leukocytosis and still had marked rales at the left lower lobe. 8. Hypothyroidism: The patient was continued on outpatient medical regimen. 9. Depression: The patient was continued on Lexapro per outpatient regimen. It is recommended that she follow up with a therapist as an outpatient due to the fact that she did have a blunted affect throughout much of the hospital course, and did appear clinically to be depressed. 10. Prophylaxis: She was maintained on proton-pump inhibitor with subQ Heparin. 11. Sore throat: The patient did have a sore throat for much of the hospital course post extubation. This was treated with Cepacol lozenges as well as KBL liquid (a solution containing Kaopectate, Bismuth, and lidocaine) at bedtime. 12. Communication/code status: The patient was full code throughout her hospital course, and communication was maintained with the patient and her husband. 13. Muscle weakness: The patient did have profound muscle weakness and was evaluated by Physical Therapy, and was found to have impaired functional mobility, impaired musculoskeletal performance, impaired gas exchange, impaired endurance, impaired ventilation, and needed help with supine to sit. However, she was able to tolerate sitting in a chair for approximately one hour. On motor exam, her flexors and extensors of the lower extremities were 5-14 at the knee, 5-14 at the ankle, 5-14 at the elbows, and 5-14 hips. It was felt that this weakness was most likely due to a combination of steroid myopathy as well as muscle atrophy secondary to deconditioning after a prolonged hospital course. 14. Speech/swallow: The patient had a Speech and Swallow evaluation showing no evidence of dysphagia, no evidence of vocal cord damage status post tracheal stent placement. DISCHARGE CONDITION: The patient was able to oxygenate on room air at 93% at the time of discharge. She was profoundly weak, but was no longer tachycardic and had a normal blood pressure. Her respirations were much improved albeit with transmitted upper airway sounds. DISCHARGE STATUS: The patient will be discharged to Chambers, Knight and Torres Clinic for both pulmonary and physical rehabilitation. DISCHARGE MEDICATIONS: 1. Levothyroxine 75 mcg p.o. q.d. 2. Citalopram 10 mg p.o. q.d. 3. Aspirin 81 mg p.o. q.d. 4. Fluticasone 110 mcg two puffs inhaled b.i.d. 5. Salmeterol Diskus one inhalation b.i.d. 6. Acetaminophen 325-650 mg p.o. q.4-6h. prn. 7. Ipratropium bromide MDI two puffs inhaled q.2h. prn. 8. Albuterol 1-2 puffs inhaled q.2h. prn. 9. Zolpidem tartrate 5 mg p.o. q.h.s. prn. 10. Isosorbide dinitrate 10 mg p.o. t.i.d. 11. Diltiazem 60 mg p.o. q.i.d. 12. Pantoprazole 40 mg p.o. q.24h. 13. Trazodone 25 mg p.o. q.h.s. prn. 14. SubQ Heparin 5000 units subcutaneous b.i.d. until such time that the patient is able to get out of bed twice a day. 15. Cepacol lozenges q.2h. prn. 16. Levofloxacin 500 mg p.o. q.d. for a seven day course to be completed on 2016-5-12. 17. Kaopectate/Benadryl/lidocaine 5 mL p.o. b.i.d. prn, not to be given around mealtimes for concern of dysphagia induced by lidocaine. 18. Lorazepam 0.5-2 mg IV q.6h. prn. FOLLOW-UP PLANS: The patient is recommended to followup with Dr. Omer Wilson, 663-918-8473 within two weeks of leaving of the hospital. She is also recommended to followup with the Interventional Pulmonary service for followup status post stent placement. She is also recommended to followup with a neurologist if her muscle weakness does not improve within one week on physical therapy with concern for steroid-induced myopathy. FINAL DIAGNOSES: 1. Tracheomalacia status post tracheal and left main stem bronchial stent placement. 2. Hypertension. 3. Hypothyroidism. 4. Restrictive lung defect. 5. Depression. DR.Moblo,Percy 12-207 Dictated By:Ngo MEDQUIST36 D: 2011-4-19 11:30 T: 2011-4-19 11:33 JOB#: Sanchez PLC-2016-791366	['Admission Date: 1995-1-11 Discharge Date: 2011-4-19\n\nDate of Birth: Sex: F\n\nService: MICU and then to Dr.Luu Medicine\n\nHISTORY OF PRESENT ILLNESS: This is an 81-year-old female\nwith a history of emphysema (not on home O2), who presents\nwith three days of shortness of breath thought by her primary\ncare doctor to be a COPD flare. Two days prior to admission,\nshe was started on a prednisone taper and one day prior to\nadmission she required oxygen at home in order to maintain\noxygen saturation greater than 90%. She has also been on\nlevofloxacin and nebulizers, and was not getting better, and\npresented to the Barry, Johnson and Clark Health System Emergency Room.\n\nIn the Moody-Conner Health System Emergency Room, her oxygen saturation was\n100% on CPAP. She was not able to be weaned off of this\ndespite nebulizer treatment and Solu-Medrol 125 mg IV x2.', '\n\nReview of systems is negative for the following: Fevers,\nchills, nausea, vomiting, night sweats, change in weight,\ngastrointestinal complaints, neurologic changes, rashes,\npalpitations, orthopnea. Is positive for the following:\nChest pressure occasionally with shortness of breath with\nexertion, some shortness of breath that is positionally\nrelated, but is improved with nebulizer treatment.\n\nPAST MEDICAL HISTORY:\n1. COPD. Last pulmonary function tests in 1938-6-14\ndemonstrated a FVC of 52% of predicted, a FEV1 of 54% of\npredicted, a MMF of 23% of predicted, and a FEV1:FVC ratio of\n67% of predicted, that does not improve with bronchodilator\ntreatment. The FVC, however, does significantly improve with\nbronchodilator treatment consistent with her known reversible\nair flow obstruction in addition to an underlying restrictive\nventilatory defect.', ' The patient has never been on home\noxygen prior to this recent episode. She has never been on\nsteroid taper or been intubated in the past.\n2. Lacunar CVA. MRI of the head in 1913-1-14\ndemonstrates "mild degree of multiple small foci of high T2\nsignal within the white matter of both cerebral hemispheres\nas well as the pons, in the latter region predominantly to\nthe right of midline. The abnormalities, while nonspecific\nin etiology, are most likely secondary to chronic\nmicrovascular infarction. There is no mass, lesion, shift of\nthe normal midline strictures or hydrocephalus. The major\nvascular flow patterns are preserved. There is moderate\nright maxillary, moderate bilateral ethmoid, mild left\nmaxillary, minimal right sphenoid, and frontal sinus mucosal\nthickening. These abnormalities could represent an allergic\nor some other type of inflammatory process.', ' Additionally\nnoted is a moderately enlarged subtotally empty sella\nturcica".\n3. Angina: Most recent stress test was in 2016-10-24\ngoing for four minutes with a rate pressure product of\n10,000, 64% of maximum predicted heart rate without evidence\nof ischemic EKG changes or symptoms. The imaging portion of\nthe study demonstrated no evidence of myocardial ischemia and\na calculated ejection fraction of 84%. The patient denies\nangina at rest and gets angina with walking a few blocks.\nAre alleviated by sublingual nitroglycerin.\n4. Hypothyroidism on Synthroid.\n5. Depression on Lexapro.\n6. Motor vehicle accident with head injury approximately 10\nyears ago.\n\nMEDICATIONS ON ADMISSION:\n1. Hydrochlorothiazide 25 q.d.\n2. Prednisone 60 mg, 50 mg, 40 mg, 20 mg.\n3. Levofloxacin 500 mg q.d.\n4. Imdur 60 mg q.', 'd.\n5. Synthroid 75 mcg q.d.\n6. Pulmicort nebulizer b.i.d.\n7. Albuterol nebulizer q.4. prn.\n8. Lexapro 10 mg q.d.\n9. Protonix 40 mg q.d.\n10. Aspirin 81 mg q.d.\n\nALLERGIES: Norvasc leads to lightheadedness and headache.\n\nFAMILY HISTORY: Noncontributory.\n\nSOCIAL HISTORY: Lives with her husband, Dr. Anderson an\neminent Pediatric Neurologist at Scott LLC Medical Center. The\npatient is a prior smoker, but has not smoked in over 10\nyears. She has no known alcohol use and she is a full code.\n\nPHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure 142/76,\nheart rate 100 and regular, respirations at 17-21, and 97%\naxillary temperature. She was saturating at 100% on CPAP\nwith dry mucous membranes. An elderly female in no apparent\ndistress. Pupils are equal, round, and reactive to light and\naccommodation.', ' Extraocular movements are intact. Oropharynx\ndifficult to assess due to CPAP machine. No evidence of\njugular venous pressure, however, the strap from the CPAP\nmachine obscures the neck exam. Cranial nerves II through\nXII are grossly intact. Neck is supple without\nlymphadenopathy. Heart exam: Tachycardic, regular, obscured\nby loud bilateral wheezing with increase in the expiratory\nphase as well as profuse scattered rhonchi throughout the\nlung fields. Positive bowel sounds, soft, nontender,\nnondistended, obese, no masses. Mild edema of the lower\nextremities without clubbing or cyanosis, no rashes. There\nis a right hand hematoma. Strength is assessed as 11-10 in the\nlower extremities, 11-10 in the upper extremities with a normal\nmental status and cognition.\n\nLABORATORY STUDIES: White count 19, hematocrit 41, platelets\n300.', ' Chem-7: 127, 3.6, 88, 29, 17, 0.6, 143. Troponin was\nnegative. CKs were negative times three. Initial blood gas\nshowed a pH of 7.4, pO2 of 66, pCO2 of 54.\n\nChest x-ray demonstrates a moderate sized hiatal hernia,\nsegmental atelectasis, left lower lobe infiltrate versus\nsegmental atelectasis.\n\nEKG shows normal sinus rhythm at 113 beats per minute, normal\naxis, no evidence of ST-T wave changes.\n\nBRIEF SUMMARY OF HOSPITAL COURSE:\n1. COPD/dyspnea/pneumonia: The patient was initially placed\non an aggressive steroid taper and admitted to the Medical\nIntensive Care Unit due to her difficulty with oxygenation\ndespite CPAP machine. She was also given nebulizer\ntreatments q.4h. as well as chest PT. The nebulizers were\nincreased to q.1h. due to the fact that she continued to have\nlabored breathing.', '\n\nDue to persistent respiratory failure and labored breathing,\nthe patient was intubated on 2009-12-31 in order to improve\noxygenation, ventilation, and ability to suction. A\nbronchoscopy was performed on 2009-12-31, which demonstrated\nmarked narrowing of the airways with expiration consistent\nwith tracheomalacia.\n\nOn 2007-12-5, two silicone stents were placed, one in the left\nmain stem (12 x 25 and one in the trachea 16 x 40) by Dr.\nJoe Chloe Miller under rigid bronchoscopy with general anesthesia.\n\nOn 1921-5-11, the patient was extubated to a cool mist shovel\nmask and her oxygen was titrated down to 2 liters nasal\ncannula at which time she was transferred to the medical\nfloor. On the medical floor, the steroids were weaned to off\non 2011-4-19, and the patient was saturating at 97% on 2\nliters, 92% on room air.', "\n\nOn 2011-4-19, the patient was seen again by the Interventional\nPulmonology service, who agreed that she looked much improved\nand recommended that she go to pulmonary rehabilitation with\nfollowup within six weeks' time status post placement of\nstents in respiratory failure.\n\n2. Cardiovascular: The patient was ruled out for a MI. She\ndid have another episode on the medical floor of chest pain,\nwhich showed no evidence of EKG changes and negative\ntroponin, negative CKs x3. She was continued on aspirin,\nImdur, and diltiazem for rate control per her outpatient\nregimen.\n\n3. Hypertension: She was maintained on diltiazem and\nhydrochlorothiazide with adequate blood pressure control and\nnormalization of electrolytes.\n\n4. Hematuria: The patient had intermittent hematuria likely\nsecondary to Foley placement.", ' The Foley catheter was\ndiscontinued on 2011-4-19. She had serial urinalyses, which\nwere all negative for signs of infection.\n\n5. Hyperglycemia: Patient was placed on insulin-sliding\nscale due to hyperglycemia, which was steroid induced. This\nworked quite well and her glucose came back to normal levels\nonce the steroids were tapered to off.\n\n6. Leukocytosis: Patient did have a profound leukocytosis of\n20 to 22 during much of her hospital course. As the steroids\nwere tapered to off, her white blood cell count on 2011-4-19\nwas 15,000. It was felt that the leukocytosis was secondary\nto both steroids as well as question of a left lower lobe\npneumonia.\n\n7. For the left lower lobe pneumonia, the patient had\ninitially received a course of levofloxacin 500 p.o. q.d.\nfrom 1941-12-6 to 1919-3-23.', ' This was restarted on 1941-3-21\nfor an additional seven day course given the fact that she\nstill had the leukocytosis and still had marked rales at the\nleft lower lobe.\n\n8. Hypothyroidism: The patient was continued on outpatient\nmedical regimen.\n\n9. Depression: The patient was continued on Lexapro per\noutpatient regimen. It is recommended that she follow up\nwith a therapist as an outpatient due to the fact that she\ndid have a blunted affect throughout much of the hospital\ncourse, and did appear clinically to be depressed.\n\n10. Prophylaxis: She was maintained on proton-pump inhibitor\nwith subQ Heparin.\n\n11. Sore throat: The patient did have a sore throat for much\nof the hospital course post extubation. This was treated\nwith Cepacol lozenges as well as KBL liquid (a solution\ncontaining Kaopectate, Bismuth, and lidocaine) at bedtime.', '\n\n12. Communication/code status: The patient was full code\nthroughout her hospital course, and communication was\nmaintained with the patient and her husband.\n\n13. Muscle weakness: The patient did have profound muscle\nweakness and was evaluated by Physical Therapy, and was found\nto have impaired functional mobility, impaired\nmusculoskeletal performance, impaired gas exchange, impaired\nendurance, impaired ventilation, and needed help with supine\nto sit. However, she was able to tolerate sitting in a chair\nfor approximately one hour.\n\nOn motor exam, her flexors and extensors of the lower\nextremities were 5-14 at the knee, 5-14 at the ankle, 5-14 at\nthe elbows, and 5-14 hips. It was felt that this weakness was\nmost likely due to a combination of steroid myopathy as well\nas muscle atrophy secondary to deconditioning after a\nprolonged hospital course.', '\n\n14. Speech/swallow: The patient had a Speech and Swallow\nevaluation showing no evidence of dysphagia, no evidence of\nvocal cord damage status post tracheal stent placement.\n\nDISCHARGE CONDITION: The patient was able to oxygenate on\nroom air at 93% at the time of discharge. She was profoundly\nweak, but was no longer tachycardic and had a normal blood\npressure. Her respirations were much improved albeit with\ntransmitted upper airway sounds.\n\nDISCHARGE STATUS: The patient will be discharged to Chambers, Knight and Torres Clinic\nfor both pulmonary and physical rehabilitation.\n\nDISCHARGE MEDICATIONS:\n1. Levothyroxine 75 mcg p.o. q.d.\n2. Citalopram 10 mg p.o. q.d.\n3. Aspirin 81 mg p.o. q.d.\n4. Fluticasone 110 mcg two puffs inhaled b.i.d.\n5. Salmeterol Diskus one inhalation b.i.d.\n6. Acetaminophen 325-650 mg p.', 'o. q.4-6h. prn.\n7. Ipratropium bromide MDI two puffs inhaled q.2h. prn.\n8. Albuterol 1-2 puffs inhaled q.2h. prn.\n9. Zolpidem tartrate 5 mg p.o. q.h.s. prn.\n10. Isosorbide dinitrate 10 mg p.o. t.i.d.\n11. Diltiazem 60 mg p.o. q.i.d.\n12. Pantoprazole 40 mg p.o. q.24h.\n13. Trazodone 25 mg p.o. q.h.s. prn.\n14. SubQ Heparin 5000 units subcutaneous b.i.d. until such\ntime that the patient is able to get out of bed twice a day.\n15. Cepacol lozenges q.2h. prn.\n16. Levofloxacin 500 mg p.o. q.d. for a seven day course to\nbe completed on 2016-5-12.\n17. Kaopectate/Benadryl/lidocaine 5 mL p.o. b.i.d. prn, not\nto be given around mealtimes for concern of dysphagia induced\nby lidocaine.\n18. Lorazepam 0.5-2 mg IV q.6h. prn.\n\nFOLLOW-UP PLANS: The patient is recommended to followup with\nDr. Omer Wilson, 663-918-8473 within two weeks of leaving\nof the hospital.', ' She is also recommended to followup with\nthe Interventional Pulmonary service for followup status post\nstent placement. She is also recommended to followup with a\nneurologist if her muscle weakness does not improve within\none week on physical therapy with concern for steroid-induced\nmyopathy.\n\nFINAL DIAGNOSES:\n1. Tracheomalacia status post tracheal and left main stem\nbronchial stent placement.\n2. Hypertension.\n3. Hypothyroidism.\n4. Restrictive lung defect.\n5. Depression.\n\n\n DR.Moblo,Percy 12-207\n\n\nDictated By:Ngo\nMEDQUIST36\n\nD: 2011-4-19 11:30\nT: 2011-4-19 11:33\nJOB#: Sanchez PLC-2016-791366\n']
176	13702	167118.0	2119-05-25	Discharge summary	Report	Admission Date: [2119-5-4] Discharge Date: [2119-5-25] Service: CARDIOTHORACIC Allergies: Amlodipine Attending:[Last Name (NamePattern1) 1561] Chief Complaint: 81 yo F smoker w/ COPD, severe TBM, s/p tracheobronchoplasty [5-5] s/p perc trach [5-13] Major Surgical or Invasive Procedure: bronchoscopy 3/31,4/2,3,[6-12], [5-17], [5-19] s/p trachealplasty [5-5] percutaneous tracheostomy [5-13] after failed extubation down size trach on [5-25] to size 6 cuffless History of Present Illness: This 81 year old woman has a history of COPD. Over the past five years she has had progressive difficulties with her breathing. In [2118-6-4] she was admitted to [Hospital1 18] for respiratory failure due to a COPD exacerbation. Due to persistent hypoxemia, she required intubation and a eventual bronchoscopy on [2118-6-9] revealed marked narrowing of the airways on expiration consistent with tracheomalacia. She subsequently underwent placement of two silicone stents, one in the left main stem and one in the trachea. During the admission the patient had complaints of chest pain and ruled out for an MI. She was subsequently discharged to [Hospital1 ] for physical and pulmonary rehab. Repeat bronchoscopy on [2118-8-1] revealed granulation tissue at the distal right lateral wall of the tracheal stent. There was significant malacia of the peripheral and central airways with complete collapse of the airways on coughing and forced expiration. Small nodules were also noted on the vocal cords. She has noticed improvement in her respiratory status, but most recently has been in discussion with Dr. [First Name4 (NamePattern1) 951] [Last Name (NamePattern1) 952] regarding possible tracheobronchial plasty with mesh. Tracheal stents d/c [2119-4-19] in anticipation of surgery. In terms of symptoms, she describes many years of intermittent chest pain that she describes as left sided and occurring at any time. Currently, she notices it about three times a week, and states that it seems to resolve after three nitroglycerin. She currently is dependent on oxygen and wears 1.5-2 liters around the clock. She has frequent coughing and brings up "dark sputum". Past Medical History: COPD flare [6-7] s/p intubation, s/p distal tracheal to Left Main Stem stents placed [2118-6-9]. Stents d/c'd [2119-4-19], CAD w/ atypical angina (LAD 30%, RCA 30%, EF 63%), ^chol, hypothyroidism, htn, hiatal hernia, lacunar CVA, s/p ped struck -> head injury & rib fx, depression PMH: COPD, s/p admit [6-7] for exacerbation requiring intubation tracheobronchomalacia, s/p bronchial stenting Large hiatal hernia Lacunar CVA Hypothyroidism by records in CCC, although patient denies and is not taking any medication Depression MVA, s/p head injury approximately 10 years ago Hypertension Hysterectomy Social History: Social History: The patient is married and worked as a clinical psychologist. Her husband is a pediatric neurologist at [Hospital3 ]. They have several children, one of which is a nurse. Family History: Family History: (+) FHx CAD; Father with an MI in his 40's, died of a CVA at age 59 Physical Exam: Admit H+P General-lovely 81 yr old feamle in NAD. Neuro- intermittently anxious, MAE, PERRLA, L eye ptosis, symetrical smile, gossly intact. HEENT-PERRLA, sclera anicteric, pharynx- no exud or erythema Resp-clear upper, diffuse ronchi, intermit exp wheezes Cor- RRR, No M, R, G Abd- soft, NT, ND, no masses. Slight protrusion at area of hiatal hernia Ext- no edema or clubbing Brief Hospital Course: 82 y/o female admitted [2119-5-4] for consideration of tracheoplasty. Bronchoscopy done [5-4] confirming severe TBM. Underwent tracheoplasty [5-5], complicated by resp failure d/t mucous plugging, hypoxia requiring re-intubation resulting in prolonged ICU and hospital course. Also developed right upper extrem DVT from mid line. Pain- Epidural accidently d/c'd POD#1, pt briefly used dilaudid PCA intermittently w/ fair pain control. Pt required re-intubation for resp failure d/t secretions and PCA d/c at that time. Propofol for sedation while intubated. Sedation d/c'd [5-12] for weaning trial w/ ETT- failed trial. Trach [5-13]-weaning efforts as below. Minimal c/o pain since [5-13]. Presently pain free. Neuro- Initially intact- post op aggitation, inhibiting weaning efforts [5-16]. Psych eval [5-18]-Started on zyprexa and ativan w/ improvement in anxiety. Presently A+Ox3- cooperative and lovely. Resp- Extubated POD#2 then required re-intub [5-7] for hypoxia d/t poor cough and mucous plugging. SIMV/PS alt w/CMV at night x4-5d, with CPAP attempts during day. Bronchoscopy qd [Date range (1) 1813] for secretion management. Bronch [5-9] revealed swollen epiglottis, bronch [5-10] - good leak w/ ETT cuff deflated. Bronch [5-13] for eval/trach placement. Last bronch [5-19] w/ min secretions present, sputum sent. [5-13] perc trach done(#8 Portex- cuffed low pressure maintained to preserve tracheoplasty site). [5-13] CPAP15/peep5 initiated post trach placement. Weaning ongoing. [Date range (1) 1814]- Aggressive weaning w/ increasing episodes of CPAP, progressing to Trach Mask. [2033-5-20]-Trach mask overnight w/ no episodes of SOB, or hemodynamic instability. Trach changed to #6 portex- capped and [Last Name (un) 1815] well x48hrs on 2LNP. productive cough. Aggressive PT as well w/ OOB > chair [Hospital1 ]-tid to total 4-6hr qd. Ambulation ~100-120 ft [5-22] w/ PT assist. ID- Vancomycin started post-op for graft prophylaxis. Fever spike [2119-5-8] w/ BAl & sputum sent> + MRSA. Vanco cont to [4-7] weeks post trachealplasty. Fever low grade [5-12], [5-15]> cultured- no new results. [5-19]- WBC 20.8 . Cardiac-Hypertension controlled w/ hydralazine IV, then d/c and cont controlled. HR 65-75 NSR. Avoiding B Blockers. Lasix 20mg IV qd. [5-15]- RUE redness and swelling at site of midline, RUE DVT by ultrasound, midline d/c; heparin gtt started and therapeutic range monitored. [5-22] changed to Lovenox sq [Hospital1 ]. Coags in good control [5-23] (48.2/13.8/1.2) Access- R midline placed [2119-5-9] for access- clotted [2119-5-15] and d/c'd. RUE redness and swelling and DVT via ultrasound. [5-15]- L brachial PICC line placed- TPN resumed. GI-Large hiatal hernia- unable to place enteral feeding tube at bedside or underfluoro. Re-attempt [5-17] by EGD doboff tube placed distal esophagus, dislodged in 12hours and removed. Nutrition- PPN/TPN initiated [2119-5-8]- [2119-5-25]. PICC placed [2119-5-15]. Speech and Swallow eval [5-22]- rec change trach form #8 to #6 Portex to allow improved epiglotis and oropharyngeal movement to assist w/ swallowing. Then re-eval. Trach changed [5-23] to #6 cuffless portex trach. Passed repeat swallow eval and [Last Name (un) 1815] diet of regular solids w/ thin liquids- CHIN TUCK to swallow thin liquids. Give meds whole w/ apple sauce. WOULD RECOMMEND repeat video swallow eval in [8-17] days to possibly eliminate chin tuck- see page 3 referral. Endo- Hypothyroid, maintained on levoxyl. Muscu/Skel- OOB> chair 4-6hours/day, PT consulting. Medications on Admission: advair 250/50", atrovent, imdur 60', lasix 40', lexapro 20', lipitor 10', prilosec 20', mucinex 600", synthroid 75', detrol LA 4', ambien 5', trazadone 75', melatonin prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [2-5] Sprays Nasal QID (4 times a day) as needed. 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 10. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed. 11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: COPD, Coronary Artery Disease/atypical angina (LAD 30%, RCA 30%, EF 63%), hypercholesterolemia, hypothyroidism, Hypertension, hiatal hernia, Cerebral Vascular Accident,s/p Motor Vehicle Colision-> head injury & rib fracture. TBM- s/p tracheoplasty. Discharge Condition: good Discharge Instructions: please update Dr.[Name (NI) 1816] [Telephone/Fax (1) 170] office for: fever, shortness of breath, chest pain , productive cough or if you have any questions or concerns. Completed by:[2119-5-25]	Admission Date: <Date>1962-9-15</Date> Discharge Date: <Date>1965-9-18</Date> Service: CARDIOTHORACIC Allergies: Amlodipine Attending:<Name>Pleasant</Name> Chief Complaint: 81 yo F smoker w/ COPD, severe TBM, s/p tracheobronchoplasty <Date>1-28</Date> s/p perc trach <Date>7-7</Date> Major Surgical or Invasive Procedure: bronchoscopy 3/31,4/2,3,<Date>9-8</Date>, <Date>12-13</Date>, <Date>11-8</Date> s/p trachealplasty <Date>1-28</Date> percutaneous tracheostomy <Date>7-7</Date> after failed extubation down size trach on <Date>12-9</Date> to size 6 cuffless History of Present Illness: This 81 year old woman has a history of COPD. Over the past five years she has had progressive difficulties with her breathing. In <Date>1946-12-15</Date> she was admitted to <Hospital>Smith and Sons Hospital</Hospital> for respiratory failure due to a COPD exacerbation. Due to persistent hypoxemia, she required intubation and a eventual bronchoscopy on <Date>1975-9-16</Date> revealed marked narrowing of the airways on expiration consistent with tracheomalacia. She subsequently underwent placement of two silicone stents, one in the left main stem and one in the trachea. During the admission the patient had complaints of chest pain and ruled out for an MI. She was subsequently discharged to <Hospital>Austin PLC Medical Center</Hospital> for physical and pulmonary rehab. Repeat bronchoscopy on <Date>1980-1-10</Date> revealed granulation tissue at the distal right lateral wall of the tracheal stent. There was significant malacia of the peripheral and central airways with complete collapse of the airways on coughing and forced expiration. Small nodules were also noted on the vocal cords. She has noticed improvement in her respiratory status, but most recently has been in discussion with Dr. <Name>Jackson</Name> <Name>Lockett</Name> regarding possible tracheobronchial plasty with mesh. Tracheal stents d/c <Date>1941-2-15</Date> in anticipation of surgery. In terms of symptoms, she describes many years of intermittent chest pain that she describes as left sided and occurring at any time. Currently, she notices it about three times a week, and states that it seems to resolve after three nitroglycerin. She currently is dependent on oxygen and wears 1.5-2 liters around the clock. She has frequent coughing and brings up "dark sputum". Past Medical History: COPD flare <Date>7-2</Date> s/p intubation, s/p distal tracheal to Left Main Stem stents placed <Date>1975-9-16</Date>. Stents d/c'd <Date>1941-2-15</Date>, CAD w/ atypical angina (LAD 30%, RCA 30%, EF 63%), ^chol, hypothyroidism, htn, hiatal hernia, lacunar CVA, s/p ped struck -> head injury & rib fx, depression PMH: COPD, s/p admit <Date>7-2</Date> for exacerbation requiring intubation tracheobronchomalacia, s/p bronchial stenting Large hiatal hernia Lacunar CVA Hypothyroidism by records in CCC, although patient denies and is not taking any medication Depression MVA, s/p head injury approximately 10 years ago Hypertension Hysterectomy Social History: Social History: The patient is married and worked as a clinical psychologist. Her husband is a pediatric neurologist at <Hospital>Lyons-Nolan Medical Center</Hospital>. They have several children, one of which is a nurse. Family History: Family History: (+) FHx CAD; Father with an MI in his 40's, died of a CVA at age 59 Physical Exam: Admit H+P General-lovely 81 yr old feamle in NAD. Neuro- intermittently anxious, MAE, PERRLA, L eye ptosis, symetrical smile, gossly intact. HEENT-PERRLA, sclera anicteric, pharynx- no exud or erythema Resp-clear upper, diffuse ronchi, intermit exp wheezes Cor- RRR, No M, R, G Abd- soft, NT, ND, no masses. Slight protrusion at area of hiatal hernia Ext- no edema or clubbing Brief Hospital Course: 82 y/o female admitted <Date>1962-9-15</Date> for consideration of tracheoplasty. Bronchoscopy done <Date>7-13</Date> confirming severe TBM. Underwent tracheoplasty <Date>1-28</Date>, complicated by resp failure d/t mucous plugging, hypoxia requiring re-intubation resulting in prolonged ICU and hospital course. Also developed right upper extrem DVT from mid line. Pain- Epidural accidently d/c'd POD#1, pt briefly used dilaudid PCA intermittently w/ fair pain control. Pt required re-intubation for resp failure d/t secretions and PCA d/c at that time. Propofol for sedation while intubated. Sedation d/c'd <Date>4-12</Date> for weaning trial w/ ETT- failed trial. Trach <Date>7-7</Date>-weaning efforts as below. Minimal c/o pain since <Date>7-7</Date>. Presently pain free. Neuro- Initially intact- post op aggitation, inhibiting weaning efforts <Date>4-8</Date>. Psych eval <Date>8-21</Date>-Started on zyprexa and ativan w/ improvement in anxiety. Presently A+Ox3- cooperative and lovely. Resp- Extubated POD#2 then required re-intub <Date>9-18</Date> for hypoxia d/t poor cough and mucous plugging. SIMV/PS alt w/CMV at night x4-5d, with CPAP attempts during day. Bronchoscopy qd <Date Range>1916-3-19 to 2014-6-18</Date Range> for secretion management. Bronch <Date>11-26</Date> revealed swollen epiglottis, bronch <Date>3-6</Date> - good leak w/ ETT cuff deflated. Bronch <Date>7-7</Date> for eval/trach placement. Last bronch <Date>11-8</Date> w/ min secretions present, sputum sent. <Date>7-7</Date> perc trach done(#8 Portex- cuffed low pressure maintained to preserve tracheoplasty site). <Date>7-7</Date> CPAP15/peep5 initiated post trach placement. Weaning ongoing. <Date Range>1939-7-26 to 1962-6-13</Date Range>- Aggressive weaning w/ increasing episodes of CPAP, progressing to Trach Mask. <Date>2008-3-15</Date>-Trach mask overnight w/ no episodes of SOB, or hemodynamic instability. Trach changed to #6 portex- capped and <Name>Kibler</Name> well x48hrs on 2LNP. productive cough. Aggressive PT as well w/ OOB > chair <Hospital>Austin PLC Medical Center</Hospital>-tid to total 4-6hr qd. Ambulation ~100-120 ft <Date>3-12</Date> w/ PT assist. ID- Vancomycin started post-op for graft prophylaxis. Fever spike <Date>1951-7-9</Date> w/ BAl & sputum sent> + MRSA. Vanco cont to <Date>2-24</Date> weeks post trachealplasty. Fever low grade <Date>4-12</Date>, <Date>9-9</Date>> cultured- no new results. <Date>11-8</Date>- WBC 20.8 . Cardiac-Hypertension controlled w/ hydralazine IV, then d/c and cont controlled. HR 65-75 NSR. Avoiding B Blockers. Lasix 20mg IV qd. <Date>9-9</Date>- RUE redness and swelling at site of midline, RUE DVT by ultrasound, midline d/c; heparin gtt started and therapeutic range monitored. <Date>3-12</Date> changed to Lovenox sq <Hospital>Austin PLC Medical Center</Hospital>. Coags in good control <Date>4-20</Date> (48.2/13.8/1.2) Access- R midline placed <Date>1971-6-20</Date> for access- clotted <Date>1965-7-15</Date> and d/c'd. RUE redness and swelling and DVT via ultrasound. <Date>9-9</Date>- L brachial PICC line placed- TPN resumed. GI-Large hiatal hernia- unable to place enteral feeding tube at bedside or underfluoro. Re-attempt <Date>12-13</Date> by EGD doboff tube placed distal esophagus, dislodged in 12hours and removed. Nutrition- PPN/TPN initiated <Date>1951-7-9</Date>- <Date>1965-9-18</Date>. PICC placed <Date>1965-7-15</Date>. Speech and Swallow eval <Date>3-12</Date>- rec change trach form #8 to #6 Portex to allow improved epiglotis and oropharyngeal movement to assist w/ swallowing. Then re-eval. Trach changed <Date>4-20</Date> to #6 cuffless portex trach. Passed repeat swallow eval and <Name>Kibler</Name> diet of regular solids w/ thin liquids- CHIN TUCK to swallow thin liquids. Give meds whole w/ apple sauce. WOULD RECOMMEND repeat video swallow eval in <Date>1-16</Date> days to possibly eliminate chin tuck- see page 3 referral. Endo- Hypothyroid, maintained on levoxyl. Muscu/Skel- OOB> chair 4-6hours/day, PT consulting. Medications on Admission: advair 250/50", atrovent, imdur 60', lasix 40', lexapro 20', lipitor 10', prilosec 20', mucinex 600", synthroid 75', detrol LA 4', ambien 5', trazadone 75', melatonin prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation <Hospital>Austin PLC Medical Center</Hospital> (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: <Date>12-10</Date> Sprays Nasal QID (4 times a day) as needed. 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 10. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed. 11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical <Hospital>Austin PLC Medical Center</Hospital> (2 times a day). 13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: <Hospital>Brown-Lee Hospital</Hospital> & Rehab Center - <Hospital>Jacobs LLC Hospital</Hospital> Discharge Diagnosis: COPD, Coronary Artery Disease/atypical angina (LAD 30%, RCA 30%, EF 63%), hypercholesterolemia, hypothyroidism, Hypertension, hiatal hernia, Cerebral Vascular Accident,s/p Motor Vehicle Colision-> head injury & rib fracture. TBM- s/p tracheoplasty. Discharge Condition: good Discharge Instructions: please update Dr.<Name>Miriam Edward</Name> <Telephone>783-584-2272</Telephone> office for: fever, shortness of breath, chest pain , productive cough or if you have any questions or concerns. Completed 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Date: 1962-9-15 Discharge Date: 1965-9-18 Service: CARDIOTHORACIC Allergies: Amlodipine Attending:Pleasant Chief Complaint: 81 yo F smoker w/ COPD, severe TBM, s/p tracheobronchoplasty 1-28 s/p perc trach 7-7 Major Surgical or Invasive Procedure: bronchoscopy 3/31,4/2,3,9-8, 12-13, 11-8 s/p trachealplasty 1-28 percutaneous tracheostomy 7-7 after failed extubation down size trach on 12-9 to size 6 cuffless History of Present Illness: This 81 year old woman has a history of COPD. Over the past five years she has had progressive difficulties with her breathing. In 1946-12-15 she was admitted to Smith and Sons Hospital for respiratory failure due to a COPD exacerbation. Due to persistent hypoxemia, she required intubation and a eventual bronchoscopy on 1975-9-16 revealed marked narrowing of the airways on expiration consistent with tracheomalacia. She subsequently underwent placement of two silicone stents, one in the left main stem and one in the trachea. During the admission the patient had complaints of chest pain and ruled out for an MI. She was subsequently discharged to Austin PLC Medical Center for physical and pulmonary rehab. Repeat bronchoscopy on 1980-1-10 revealed granulation tissue at the distal right lateral wall of the tracheal stent. There was significant malacia of the peripheral and central airways with complete collapse of the airways on coughing and forced expiration. Small nodules were also noted on the vocal cords. She has noticed improvement in her respiratory status, but most recently has been in discussion with Dr. Jackson Lockett regarding possible tracheobronchial plasty with mesh. Tracheal stents d/c 1941-2-15 in anticipation of surgery. In terms of symptoms, she describes many years of intermittent chest pain that she describes as left sided and occurring at any time. Currently, she notices it about three times a week, and states that it seems to resolve after three nitroglycerin. She currently is dependent on oxygen and wears 1.5-2 liters around the clock. She has frequent coughing and brings up "dark sputum". Past Medical History: COPD flare 7-2 s/p intubation, s/p distal tracheal to Left Main Stem stents placed 1975-9-16. Stents d/c'd 1941-2-15, CAD w/ atypical angina (LAD 30%, RCA 30%, EF 63%), ^chol, hypothyroidism, htn, hiatal hernia, lacunar CVA, s/p ped struck -> head injury & rib fx, depression PMH: COPD, s/p admit 7-2 for exacerbation requiring intubation tracheobronchomalacia, s/p bronchial stenting Large hiatal hernia Lacunar CVA Hypothyroidism by records in CCC, although patient denies and is not taking any medication Depression MVA, s/p head injury approximately 10 years ago Hypertension Hysterectomy Social History: Social History: The patient is married and worked as a clinical psychologist. Her husband is a pediatric neurologist at Lyons-Nolan Medical Center. They have several children, one of which is a nurse. Family History: Family History: (+) FHx CAD; Father with an MI in his 40's, died of a CVA at age 59 Physical Exam: Admit H+P General-lovely 81 yr old feamle in NAD. Neuro- intermittently anxious, MAE, PERRLA, L eye ptosis, symetrical smile, gossly intact. HEENT-PERRLA, sclera anicteric, pharynx- no exud or erythema Resp-clear upper, diffuse ronchi, intermit exp wheezes Cor- RRR, No M, R, G Abd- soft, NT, ND, no masses. Slight protrusion at area of hiatal hernia Ext- no edema or clubbing Brief Hospital Course: 82 y/o female admitted 1962-9-15 for consideration of tracheoplasty. Bronchoscopy done 7-13 confirming severe TBM. Underwent tracheoplasty 1-28, complicated by resp failure d/t mucous plugging, hypoxia requiring re-intubation resulting in prolonged ICU and hospital course. Also developed right upper extrem DVT from mid line. Pain- Epidural accidently d/c'd POD#1, pt briefly used dilaudid PCA intermittently w/ fair pain control. Pt required re-intubation for resp failure d/t secretions and PCA d/c at that time. Propofol for sedation while intubated. Sedation d/c'd 4-12 for weaning trial w/ ETT- failed trial. Trach 7-7-weaning efforts as below. Minimal c/o pain since 7-7. Presently pain free. Neuro- Initially intact- post op aggitation, inhibiting weaning efforts 4-8. Psych eval 8-21-Started on zyprexa and ativan w/ improvement in anxiety. Presently A+Ox3- cooperative and lovely. Resp- Extubated POD#2 then required re-intub 9-18 for hypoxia d/t poor cough and mucous plugging. SIMV/PS alt w/CMV at night x4-5d, with CPAP attempts during day. Bronchoscopy qd 1916-3-19 to 2014-6-18 for secretion management. Bronch 11-26 revealed swollen epiglottis, bronch 3-6 - good leak w/ ETT cuff deflated. Bronch 7-7 for eval/trach placement. Last bronch 11-8 w/ min secretions present, sputum sent. 7-7 perc trach done(#8 Portex- cuffed low pressure maintained to preserve tracheoplasty site). 7-7 CPAP15/peep5 initiated post trach placement. Weaning ongoing. 1939-7-26 to 1962-6-13- Aggressive weaning w/ increasing episodes of CPAP, progressing to Trach Mask. 2008-3-15-Trach mask overnight w/ no episodes of SOB, or hemodynamic instability. Trach changed to #6 portex- capped and Kibler well x48hrs on 2LNP. productive cough. Aggressive PT as well w/ OOB > chair Austin PLC Medical Center-tid to total 4-6hr qd. Ambulation ~100-120 ft 3-12 w/ PT assist. ID- Vancomycin started post-op for graft prophylaxis. Fever spike 1951-7-9 w/ BAl & sputum sent> + MRSA. Vanco cont to 2-24 weeks post trachealplasty. Fever low grade 4-12, 9-9> cultured- no new results. 11-8- WBC 20.8 . Cardiac-Hypertension controlled w/ hydralazine IV, then d/c and cont controlled. HR 65-75 NSR. Avoiding B Blockers. Lasix 20mg IV qd. 9-9- RUE redness and swelling at site of midline, RUE DVT by ultrasound, midline d/c; heparin gtt started and therapeutic range monitored. 3-12 changed to Lovenox sq Austin PLC Medical Center. Coags in good control 4-20 (48.2/13.8/1.2) Access- R midline placed 1971-6-20 for access- clotted 1965-7-15 and d/c'd. RUE redness and swelling and DVT via ultrasound. 9-9- L brachial PICC line placed- TPN resumed. GI-Large hiatal hernia- unable to place enteral feeding tube at bedside or underfluoro. Re-attempt 12-13 by EGD doboff tube placed distal esophagus, dislodged in 12hours and removed. Nutrition- PPN/TPN initiated 1951-7-9- 1965-9-18. PICC placed 1965-7-15. Speech and Swallow eval 3-12- rec change trach form #8 to #6 Portex to allow improved epiglotis and oropharyngeal movement to assist w/ swallowing. Then re-eval. Trach changed 4-20 to #6 cuffless portex trach. Passed repeat swallow eval and Kibler diet of regular solids w/ thin liquids- CHIN TUCK to swallow thin liquids. Give meds whole w/ apple sauce. WOULD RECOMMEND repeat video swallow eval in 1-16 days to possibly eliminate chin tuck- see page 3 referral. Endo- Hypothyroid, maintained on levoxyl. Muscu/Skel- OOB> chair 4-6hours/day, PT consulting. Medications on Admission: advair 250/50", atrovent, imdur 60', lasix 40', lexapro 20', lipitor 10', prilosec 20', mucinex 600", synthroid 75', detrol LA 4', ambien 5', trazadone 75', melatonin prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Austin PLC Medical Center (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: 12-10 Sprays Nasal QID (4 times a day) as needed. 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 10. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed. 11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical Austin PLC Medical Center (2 times a day). 13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: Brown-Lee Hospital & Rehab Center - Jacobs LLC Hospital Discharge Diagnosis: COPD, Coronary Artery Disease/atypical angina (LAD 30%, RCA 30%, EF 63%), hypercholesterolemia, hypothyroidism, Hypertension, hiatal hernia, Cerebral Vascular Accident,s/p Motor Vehicle Colision-> head injury & rib fracture. TBM- s/p tracheoplasty. Discharge Condition: good Discharge Instructions: please update Dr.Miriam Edward 783-584-2272 office for: fever, shortness of breath, chest pain , productive cough or if you have any questions or concerns. Completed by:1965-9-18	['Admission Date: 1962-9-15 Discharge Date: 1965-9-18\n\n\nService: CARDIOTHORACIC\n\nAllergies:\nAmlodipine\n\nAttending:Pleasant\nChief Complaint:\n81 yo F smoker w/ COPD, severe TBM, s/p tracheobronchoplasty 1-28\ns/p perc trach 7-7\n\nMajor Surgical or Invasive Procedure:\nbronchoscopy 3/31,4/2,3,9-8, 12-13, 11-8\ns/p trachealplasty 1-28\npercutaneous tracheostomy 7-7 after failed extubation\ndown size trach on 12-9 to size 6 cuffless\n\n\nHistory of Present Illness:\nThis 81 year old woman has a history of COPD. Over the past five\n\nyears she has had progressive difficulties with her breathing.\nIn\n1946-12-15 she was admitted to Smith and Sons Hospital for respiratory failure\ndue\nto a COPD exacerbation. Due to persistent hypoxemia, she\nrequired\nintubation and a eventual bronchoscopy on 1975-9-16 revealed marked\n\nnarrowing of the airways on expiration consistent with\ntracheomalacia.', '\nShe subsequently underwent placement of two\nsilicone stents, one in the left main stem and one in the\ntrachea. During the admission the patient had complaints of\nchest\npain and ruled out for an MI. She was subsequently discharged to\n\nAustin PLC Medical Center for physical and pulmonary rehab. Repeat bronchoscopy\non\n1980-1-10 revealed granulation tissue at the distal right lateral\nwall of the tracheal stent. There was significant malacia of the\n\nperipheral and central airways with complete collapse of the\nairways on coughing and forced expiration. Small nodules were\nalso noted on the vocal cords. She has noticed improvement in\nher\nrespiratory status, but most recently has been in discussion\nwith Dr. Jackson Lockett regarding possible tracheobronchial plasty\n\nwith mesh. Tracheal stents d/c 1941-2-15 in anticipation of\nsurgery.', '\nIn terms of symptoms, she describes many years of intermittent\nchest pain that she describes as left sided and occurring at any\n\ntime. Currently, she notices it about three times a week, and\nstates that it seems to resolve after three nitroglycerin.\nShe currently is dependent on oxygen and wears 1.5-2 liters\naround the clock. She has frequent coughing and brings up "dark\nsputum".\n\n\n\nPast Medical History:\nCOPD flare 7-2 s/p intubation, s/p distal tracheal to Left Main\nStem stents placed 1975-9-16. Stents d/c\'d 1941-2-15, CAD w/ atypical\nangina (LAD 30%, RCA 30%, EF 63%), ^chol, hypothyroidism, htn,\nhiatal hernia, lacunar CVA, s/p ped struck -> head injury & rib\nfx, depression\nPMH:\nCOPD, s/p admit 7-2 for exacerbation requiring intubation\ntracheobronchomalacia, s/p bronchial stenting\nLarge hiatal hernia\nLacunar CVA\nHypothyroidism by records in CCC, although patient denies and is\n\nnot taking any medication\nDepression\nMVA, s/p head injury approximately 10 years ago\nHypertension\nHysterectomy\n\n\nSocial History:\nSocial History: The patient is married and worked as a clinical\npsychologist.', " Her husband is a pediatric neurologist at\nLyons-Nolan Medical Center. They have several children, one of which is\n\na nurse.\n\n\nFamily History:\nFamily History: (+) FHx CAD; Father with an MI in his 40's, died\n\nof a CVA at age 59\n\n\nPhysical Exam:\nAdmit H+P\nGeneral-lovely 81 yr old feamle in NAD.\nNeuro- intermittently anxious, MAE, PERRLA, L eye ptosis,\nsymetrical smile, gossly intact.\nHEENT-PERRLA, sclera anicteric, pharynx- no exud or erythema\nResp-clear upper, diffuse ronchi, intermit exp wheezes\nCor- RRR, No M, R, G\nAbd- soft, NT, ND, no masses. Slight protrusion at area of\nhiatal hernia\nExt- no edema or clubbing\n\nBrief Hospital Course:\n82 y/o female admitted 1962-9-15 for consideration of\ntracheoplasty.\nBronchoscopy done 7-13 confirming severe TBM. Underwent\ntracheoplasty 1-28, complicated by resp failure d/t mucous\nplugging, hypoxia requiring re-intubation resulting in prolonged\nICU and hospital course.", " Also developed right upper extrem DVT\nfrom mid line.\n\nPain- Epidural accidently d/c'd POD#1, pt briefly used dilaudid\nPCA intermittently w/ fair pain control. Pt required\nre-intubation for resp failure d/t secretions and PCA d/c at\nthat time. Propofol for sedation while intubated. Sedation d/c'd\n4-12 for weaning trial w/ ETT- failed trial. Trach 7-7-weaning\nefforts as below. Minimal c/o pain since 7-7. Presently pain\nfree.\n\nNeuro- Initially intact- post op aggitation, inhibiting weaning\nefforts 4-8. Psych eval 8-21-Started on zyprexa and ativan w/\nimprovement in anxiety. Presently A+Ox3- cooperative and lovely.\n\nResp- Extubated POD#2 then required re-intub 9-18 for hypoxia\nd/t poor cough and mucous plugging. SIMV/PS alt w/CMV at night\nx4-5d, with CPAP attempts during day.\nBronchoscopy qd 1916-3-19 to 2014-6-18 for secretion management.", ' Bronch 11-26\nrevealed swollen epiglottis, bronch 3-6 - good leak w/ ETT cuff\ndeflated. Bronch 7-7 for eval/trach placement. Last bronch 11-8\nw/ min secretions present, sputum sent.\n7-7 perc trach done(#8 Portex- cuffed low pressure maintained to\npreserve tracheoplasty site). 7-7 CPAP15/peep5 initiated post\ntrach placement. Weaning ongoing. 1939-7-26 to 1962-6-13- Aggressive weaning\nw/ increasing episodes of CPAP, progressing to Trach Mask.\n2008-3-15-Trach mask overnight w/ no episodes of SOB, or\nhemodynamic instability. Trach changed to #6 portex- capped and\nKibler well x48hrs on 2LNP. productive cough. Aggressive PT as\nwell w/ OOB > chair Austin PLC Medical Center-tid to total 4-6hr qd. Ambulation\n~100-120 ft 3-12 w/ PT assist.\n\nID- Vancomycin started post-op for graft prophylaxis. Fever\nspike 1951-7-9 w/ BAl & sputum sent> + MRSA.', " Vanco cont to 2-24\nweeks post trachealplasty. Fever low grade 4-12, 9-9> cultured-\nno new results. 11-8- WBC 20.8 .\n\nCardiac-Hypertension controlled w/ hydralazine IV, then d/c and\ncont controlled. HR 65-75 NSR. Avoiding B Blockers. Lasix 20mg\nIV qd.\n9-9- RUE redness and swelling at site of midline, RUE DVT by\nultrasound, midline d/c; heparin gtt started and therapeutic\nrange monitored. 3-12 changed to Lovenox sq Austin PLC Medical Center. Coags in good\ncontrol 4-20 (48.2/13.8/1.2)\nAccess- R midline placed 1971-6-20 for access- clotted 1965-7-15 and\nd/c'd. RUE redness and swelling and DVT via ultrasound. 9-9- L\nbrachial PICC line placed- TPN resumed.\n\nGI-Large hiatal hernia- unable to place enteral feeding tube at\nbedside or underfluoro. Re-attempt 12-13 by EGD doboff tube\nplaced distal esophagus, dislodged in 12hours and removed.", '\n\nNutrition- PPN/TPN initiated 1951-7-9- 1965-9-18. PICC placed\n1965-7-15. Speech and Swallow eval 3-12- rec change trach form #8\nto #6 Portex to allow improved epiglotis and oropharyngeal\nmovement to assist w/ swallowing. Then re-eval. Trach changed\n4-20 to #6 cuffless portex trach. Passed repeat swallow eval and\nKibler diet of regular solids w/ thin liquids- CHIN TUCK to\nswallow thin liquids. Give meds whole w/ apple sauce. WOULD\nRECOMMEND repeat video swallow eval in 1-16 days to possibly\neliminate chin tuck- see page 3 referral.\n\nEndo- Hypothyroid, maintained on levoxyl.\n\nMuscu/Skel- OOB> chair 4-6hours/day, PT consulting.\n\n\nMedications on Admission:\nadvair 250/50", atrovent, imdur 60\', lasix 40\', lexapro 20\',\nlipitor 10\', prilosec 20\', mucinex 600", synthroid 75\', detrol\nLA 4\', ambien 5\', trazadone 75\', melatonin prn\n\nDischarge Medications:\n1.', ' Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed for wheezing.\n2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed for wheezing.\n3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:\nOne (1) Disk with Device Inhalation Austin PLC Medical Center (2 times a day).\n4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation\nQ6H (every 6 hours) as needed.\n5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)\nPuff Inhalation QID (4 times a day).\n6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every\n4 to 6 hours) as needed.\n7. Sodium Chloride 0.65 % Aerosol, Spray Sig: 12-10 Sprays Nasal\nQID (4 times a day) as needed.\n8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical\nTID (3 times a day) as needed.', '\n9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1)\nSubcutaneous Q12H (every 12 hours).\n10. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at\nbedtime) as needed.\n11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO\nDAILY (Daily).\n12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical Austin PLC Medical Center\n(2 times a day).\n13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)\nSig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24\nhours).\n14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\n15. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\n16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One\n(1) ML Intravenous DAILY (Daily) as needed.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nBrown-Lee Hospital & Rehab Center - Jacobs LLC Hospital\n\nDischarge Diagnosis:\nCOPD, Coronary Artery Disease/atypical angina (LAD 30%, RCA 30%,\nEF 63%), hypercholesterolemia, hypothyroidism, Hypertension,\nhiatal hernia, Cerebral Vascular Accident,s/p Motor Vehicle\nColision-> head injury & rib fracture.', '\nTBM- s/p tracheoplasty.\n\n\nDischarge Condition:\ngood\n\nDischarge Instructions:\nplease update Dr.Miriam Edward 783-584-2272 office for: fever,\nshortness of breath, chest pain , productive cough or if you\nhave any questions or concerns.\n\n\nCompleted by:1965-9-18']
177	13702	196489.0	2124-08-18	Discharge summary	Report	Admission Date: [2124-7-21] Discharge Date: [2124-8-18] Service: MEDICINE Allergies: Amlodipine Attending:[First Name3 (LF) 898] Chief Complaint: COPD exacerbation/Shortness of Breath Major Surgical or Invasive Procedure: Intubation arterial line placement PICC line placement Esophagogastroduodenoscopy History of Present Illness: 87 yo F with h/o CHF, COPD on 5 L oxygen at baseline, tracheobronchomalacia s/p stent, presents with acute dyspnea over several days, and lethargy. This morning patient developed an acute worsening in dyspnea, and called EMS. EMS found patient tachypnic at saturating 90% on 5L. Patient was noted to be tripoding. She was given a nebulizer and brought to the ER. . According the patient's husband, she was experiencing symptoms consistent with prior COPD flares. Apparently patient was without cough, chest pain, fevers, chills, orthopnea, PND, dysuria, diarrhea, confusion and neck pain. Her husband is a physician and gave her a dose of levaquin this morning. . In the ED, patient was saturating 96% on NRB. CXR did not reveal any consolidation. Per report EKG was unremarkable. Laboratory evaluation revealed a leukocytosis if 14 and lactate of 2.2. Patient received combivent nebs, solumedrol 125 mg IV x1, aspirin 325 mg po x1. Mg sulfate 2 g IV x1, azithromycin 500 mg IVx1, levofloxacin 750 mg IVx1, and Cefrtiaxone 1g IVx1. Patient became tachpnic so was trialed on non-invasive ventilation but became hypotensive to systolics of 80, so noninvasive was removed and patient did well on NRB and nebulizers for about 2 hours. At that time patient became agitated, hypoxic to 87% and tachypnic to the 40s, so patient was intubated. Post intubation ABG was 7.3/60/88/31. Propafol was switched to fentanyl/midazolam for hypotension to the 80s. Received 2L of NS. On transfer, patient VS were 102, 87/33, 100% on 60% 450 x 18 PEEP 5. Patient has peripheral access x2. . In the ICU, patient appeared comfortable. Review of sytems: limited due to patient sedation Past Medical History: # COPD flare FEV1 40% in [2120], on 5L oxygen, s/p intubation [6-6], s/p distal tracheal to Left Main Stem stents placed [2118-6-9]. Stents d/c'd [2119-4-19]. Tracheobronchoplasty performed [6-6], [2119] # CAD w/ atypical angina (cath [2119] - LAD 30%, RCA 30%, EF 63%) # Dyslipidemia # Hypothyroidism, # Hypertension # Hiatal hernia, # lacunar CVA, # s/p ped struck -> head injury & rib fx, # depression Social History: The patient is married and worked as a clinical psychologist. Her husband is a pediatric neurologist at [Hospital3 ]. They have several children, one of which is a nurse. [First Name (Titles) 1817] [Last Name (Titles) 1818] with 40 pack years, quit 5 years ago. Social ethanol user. No history of IVDU, but remote history of marijuana use. Family History: (+) FHx CAD; Father with an MI in his 40's, died of a CVA at age 59 Physical Exam: On admission Vitals: T: BP: 116/46 P: 92 O2: 100% TV 60% 450 x 18 PEEP 5 General: Intubated, sedated, no apparent discomfort HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: crackles bases bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Initial Labs [2124-7-21] 10:55AM BLOOD WBC-14.1# RBC-4.20# Hgb-12.6# Hct-39.1# MCV-93 MCH-30.1 MCHC-32.3 RDW-12.6 Plt Ct-319 [2124-7-21] 10:55AM BLOOD Neuts-93.9 Lymphs-4.4* Monos-1.3* Eos-0.2 Baso-0.2 [2124-7-22] 03:50AM BLOOD PT-11.0 PTT-28.7 INR(PT)-0.9 [2124-7-21] 10:55AM BLOOD Glucose-168* UreaN-13 Creat-0.8 Na-140 K-3.5 Cl-92* HCO3-36* AnGap-16 [2124-7-22] 03:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1 Cardiac Biomarkers [2124-7-21] 10:55AM BLOOD CK(CPK)-321* cTropnT-0.02* [2124-7-21] 06:25PM BLOOD CK(CPK)-345* CK-MB-14* MB Indx-4.1 cTropnT-0.01 [2124-7-22] 03:50AM BLOOD CK(CPK)-845* CK-MB-15* MB Indx-1.8 cTropnT-0.01 [2124-7-22] 12:04PM BLOOD CK(CPK)-1030* CK-MB-15* MB Indx-1.5 cTropnT-0.01 [2124-7-23] 03:15AM BLOOD CK(CPK)-530* CK-MB-9 cTropnT-0.01 proBNP-2535* CXR ([2124-7-21]) - IMPRESSION: Hiatal hernia, otherwise unremarkable. Limited exam. Echo ([2124-7-24]) - There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with normal 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. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal biventricular systolic function. Moderate pulmonary artery systolic hypertension. CXR ([2124-8-5]) - Kyphotic positioning. Compared with one day earlier and allowing for technical differences, the right-sided effusion may be slightly larger. Otherwise, no significant change is detected. Again seen is retrocardiac opacity consistent with left lower lobe collapse and/or consolidation and a small left effusion. As noted, a right effusion is again seen, possibly slightly larger on the current examination, with underlying collapse and/or consolidation. Doubt CHF. Degenerative changes of the thoracic spine are noted. Cardiac Enzymes [2124-8-12]: Trop<0.01 [2124-8-13]: Trop 0.03 [2124-8-14]: Trop 0.02 LABS AT DISCHARGE: [2124-8-16] 05:40AM BLOOD WBC-9.5 RBC-3.08* Hgb-9.6* Hct-28.3* MCV-92 MCH-31.2 MCHC-33.9 RDW-13.5 Plt Ct-360 [2124-8-16] 05:40AM BLOOD PT-10.4 PTT-22.8 INR(PT)-0.8* [2124-8-17] 05:30AM BLOOD Glucose-114* UreaN-18 Creat-0.8 Na-142 K-3.5 Cl-101 HCO3-36* AnGap-9 [2124-8-16] 05:40AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.3 [2124-8-16] 05:40AM BLOOD TSH-0.87 Brief Hospital Course: 87 yo F with h/o CHF, COPD on 5 L oxygen at baseline, tracheobronchomalacia s/p stent, presents with acute dyspnea over several days, no s/p intubation for hypercarbic respiratory failure. # Hypercarbic respiratory failure: Presents with dyspnea, but no clear cough or fevers. Per report, patient felt like this with prior COPD exacerbations. Leukocytosis supports possible pneumonia, but history and CXR not entirely consistent with this. EKG with signs of demand, but ROMI negative. Sputum gram stain unremarkable, but respitatory viral culture grew parainfluenze type 3 on [7-24]. Patient was initially managed on solumedrol 60 mg IV Q8H, and was eventually tapered. With no evidence of pneumonia on CXR and sputum gram stain, antibiotics were stopped [7-25]. Beta-agonists and anticholinergics were continued around the clock. TTE revealed mild symmetric lvh with normal ef, increased pcwp (>18mmHg), Normal RV, and moderate pulmonary artery systolic hypertension. On [7-26], bronchoscopy revealed collapsible, unremarkable airways. Patient had difficulty weaning from the vent, and would become interimittenty hypertensive to SBP 200s and tachypnic to the 50s. Patient was extubatied on [7-27] after passing SBT 0/5, but required re-intubation 30 minutes later for worsening secretions, lack of gag reflex, and tachypnea to the 50s. Of note, on [8-1], the patient was found to have MRSA growing in sputum samples. Although it was felt that this likely represented colonization as opposed to true infection, the patient was started on a course of vancomycin (which was stopped after 5 days). After multiple discussions between the patient's family and the ICU team, the patient's PCP, [Name10 (NameIs) ] the palliative care service, the patient's family ultimately decided that she would not want a tracheostomy. On [2124-8-3], extubation was pursued again and was successful. After extubation, her respiratory status improved and she was ultimately called out to the medical floor. On the floor she was progressively weaned to 2LNC with nebs (better than her baseline 5L @home). Because of clinical exams revealing mild volume overload, she was intermittently diuresed. She also experienced intermittent shortness of breath with tachypnea but this was thought to be the result of attacks of anxiety with tachypnea. After receiving prn morphine, her breathing status would typically improve. A steroid taper was begun. The patient should continue prednisone 30 mg daily for 3 more days, then 20 mg daily for 4 days, then 10 mg daily for 4 days, then 5 mg daily for 4 days, then stop. . # Upper GI bleeding: On [7-22], patient had coffee grounds from OG tube. Lavage for approx 600ccs with clearance. GI perfomred EGD which revealed esophagitis, ulcers and blood in the stomach body, D2 diverticulum and large hiatal hernia. H pylori was negative. Patient was continued on IV PPI, with plan for repeat EGD in 8 weeks, and upper GI series once clinically improved given abnormal anatomy on EGD. Her hematocrit remained stable with no further episodes of upper GI bleeding throughout the patient's hospitalization. On the floor she was switched to PO pantoprazole twice daily. Aspirin was held. . # Weakness: The patient was found to have generalized weakness at the end of her hospitalization. Neurology was consulted and they felt it was likely due to a combination of steroid myopathy and deconditioning from her prolonged bedbound status. A TSH was checked which was normal. They recommended pulmonary and physical rehab. . # CAD: History of LAD and RCA stenosis on Cath, but no stents. Continued statin and beta blocker, but held aspirin for GI bleeding (see above) . # Nutrition: Unable to pass NG without direct visualization due to hiatal hernia. IR guided post pyloric NG tube was placed on [7-26] for TFs and po medications. NG tube was pulled when patient was extubated on [2124-8-3]. Speech and swallow were consulted following the patient's extubation and she was eventually moved to soft solids and thin liquids with 1:1 supervision. # Goals of care: PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 1407] was very involved in discussions regarding patient's code status. Palliative care also followed along with the patient. Ultimately, at the time of the patient's extubation on [2124-8-3], it was decided that the patient would be DNR/DNI (although this was later change). The patient's family felt that she would not want a tracheostomy. It was decided that she would not be reintubated and that, if her respiratory status were to worsen after intubation, care would be focused on comfort. However, her status improved in the MICU and on the floor and it was then decided that she would remain DNR with intubation (but no tracheostomy) if her breathing deteriorated. After several days with stable or improved overall clinical status, she was deemed suitable for rehabilitation. At the timem of discharge, the patient's code status was do not resuscitate, okay to intubate. Medications on Admission: # Omeprazole 20 mg daily # Furosemide 20 mg daily # Toprol XL 50 mg daily # Lipitor 20 mg daily # Folic Acid 1 mg daily # Centrum daily # Diovan 80 mg daily # Trazodone 75-100 mg qhs # Melatonin 3 mg qhs # [Doctor Last Name 1819] Aspirin 325 mg daily # Albuterol neb prn # Duoneb prn # Advair 250/50 [Hospital1 ] # Zolpidem 2.5 mg qhs prn # Synthroid 100 mcg daily # Lexapro 20 mg daily Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. Melatonin 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Valsartan 160 mg Tablet Sig: 1.5 Tablets PO once a day. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 11. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 4 days: Start after 3 days of 30 mg daily. 14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 4 days: Start after 4 days of 20 mg daily. 15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 4 days: Start after 4 days of 10 mg daily. 16. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 18. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO every four (4) hours as needed for respiratory discomfort: Hold for oversedation or RR<12. 19. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 3 days. 20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 22. Humalog insulin sliding scale Please use attached Humalog insulin sliding scale while on steroids. Discharge Disposition: Extended Care Facility: [Location 1820] center at [Location (un) 1821] Discharge Diagnosis: Primary: 1. Chronic Obstructive Pulmonary Disease Exacerbation 2. Respiratory failure with intubation 3. Upper gastrointestinal bleed/Peptic Ulcer Disease 4. Hypertension 5. Anxiety Secondary: 1. Coronary Artery Disease 2. Hypothyroidism Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with shortness of breath and respiratory failure and lethargy. In the emergency department, you were breathing very fast and a breathing tube was inserted into your airway to help you breathe. You were admitted to the intensive care unit. There, you were managed with steroids and antibiotics and the tube was eventually removed from your airway, allowing you to breathe on your own. You also underwent bronchoscopy which looked at the inside of your airways. . During your time in the intensive care unit, you developed a gastrointestinal bleed. A tube was placed into your stomach and you underwent an endoscopic procedure to look at your esophagus and stomach. This showed inflammation in your esophagusand ulcers in your stomach. . You should continue to use nasal oxygen by nasal cannula as needed. You should continue the steroid taper as instructed. You should call your doctor or return to the emergency room if you have increasing difficulty breathing or shortness of breath, wheezing, chest pain, blood in your stool or vomiting blood. . There are some changes in your medications. START pantoprazole 40 mg twice daily and STOP omeprazole START hydrochlorothiazide START prednisone, taking 30 mg for 3 days, then 20 mg for 4 days, then 10 mg for 4 days, then 5 mg for 4 days, then stop. START colace and senna as needed for constipation Can use morphine to alleviate symptoms of respiratory discomfort STOP furosemide STOP zolpidem STOP aspirin INCREASE Diovan to 240 mg daily DECREASE trazodone to 50 mg daily . Follow up as indicated below. Followup Instructions: You have an appointment to follow up with Dr. [Last Name (STitle) 1407], your primary care physician, [Name10 (NameIs) ] [8-29] at 1pm. His address is [Location (un) 1822], [Apartment Address(1) 1823], [Location (un) ],[Numeric Identifier 1700]. The phone is [Telephone/Fax (1) 1408]. You have an appointment to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 174] in the [Hospital ] clinic on [8-30] at 3pm in the [Hospital Unit Name 1824] at [Hospital1 18] on the [Location (un) 453]. Their phone number is [Telephone/Fax (1) 463]. Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2124-8-30] at 3:00 PM With: [First Name4 (NamePattern1) 1386] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage	Admission Date: <Date>1906-7-15</Date> Discharge Date: <Date>1903-2-31</Date> Service: MEDICINE Allergies: Amlodipine Attending:<Name>Ava</Name> Chief Complaint: COPD exacerbation/Shortness of Breath Major Surgical or Invasive Procedure: Intubation arterial line placement PICC line placement Esophagogastroduodenoscopy History of Present Illness: 87 yo F with h/o CHF, COPD on 5 L oxygen at baseline, tracheobronchomalacia s/p stent, presents with acute dyspnea over several days, and lethargy. This morning patient developed an acute worsening in dyspnea, and called EMS. EMS found patient tachypnic at saturating 90% on 5L. Patient was noted to be tripoding. She was given a nebulizer and brought to the ER. . According the patient's husband, she was experiencing symptoms consistent with prior COPD flares. Apparently patient was without cough, chest pain, fevers, chills, orthopnea, PND, dysuria, diarrhea, confusion and neck pain. Her husband is a physician and gave her a dose of levaquin this morning. . In the ED, patient was saturating 96% on NRB. CXR did not reveal any consolidation. Per report EKG was unremarkable. Laboratory evaluation revealed a leukocytosis if 14 and lactate of 2.2. Patient received combivent nebs, solumedrol 125 mg IV x1, aspirin 325 mg po x1. Mg sulfate 2 g IV x1, azithromycin 500 mg IVx1, levofloxacin 750 mg IVx1, and Cefrtiaxone 1g IVx1. Patient became tachpnic so was trialed on non-invasive ventilation but became hypotensive to systolics of 80, so noninvasive was removed and patient did well on NRB and nebulizers for about 2 hours. At that time patient became agitated, hypoxic to 87% and tachypnic to the 40s, so patient was intubated. Post intubation ABG was 7.3/60/88/31. Propafol was switched to fentanyl/midazolam for hypotension to the 80s. Received 2L of NS. On transfer, patient VS were 102, 87/33, 100% on 60% 450 x 18 PEEP 5. Patient has peripheral access x2. . In the ICU, patient appeared comfortable. Review of sytems: limited due to patient sedation Past Medical History: # COPD flare FEV1 40% in <Year>1922</Year>, on 5L oxygen, s/p intubation <Date>7-21</Date>, s/p distal tracheal to Left Main Stem stents placed <Date>1967-11-25</Date>. Stents d/c'd <Date>1926-3-10</Date>. Tracheobronchoplasty performed <Date>7-21</Date>, <Year>1922</Year> # CAD w/ atypical angina (cath <Year>1922</Year> - LAD 30%, RCA 30%, EF 63%) # Dyslipidemia # Hypothyroidism, # Hypertension # Hiatal hernia, # lacunar CVA, # s/p ped struck -> head injury & rib fx, # depression Social History: The patient is married and worked as a clinical psychologist. Her husband is a pediatric neurologist at <Hospital>Henry, Ward and Brown Medical Center</Hospital>. They have several children, one of which is a nurse. <Name>Millicent</Name> <Name>Cobbs</Name> with 40 pack years, quit 5 years ago. Social ethanol user. No history of IVDU, but remote history of marijuana use. Family History: (+) FHx CAD; Father with an MI in his 40's, died of a CVA at age 59 Physical Exam: On admission Vitals: T: BP: 116/46 P: 92 O2: 100% TV 60% 450 x 18 PEEP 5 General: Intubated, sedated, no apparent discomfort HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: crackles bases bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Initial Labs <Date>1906-7-15</Date> 10:55AM BLOOD WBC-14.1# RBC-4.20# Hgb-12.6# Hct-39.1# MCV-93 MCH-30.1 MCHC-32.3 RDW-12.6 Plt Ct-319 <Date>1906-7-15</Date> 10:55AM BLOOD Neuts-93.9 Lymphs-4.4* Monos-1.3* Eos-0.2 Baso-0.2 <Date>1952-1-7</Date> 03:50AM BLOOD PT-11.0 PTT-28.7 INR(PT)-0.9 <Date>1906-7-15</Date> 10:55AM BLOOD Glucose-168* UreaN-13 Creat-0.8 Na-140 K-3.5 Cl-92* HCO3-36* AnGap-16 <Date>1952-1-7</Date> 03:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1 Cardiac Biomarkers <Date>1906-7-15</Date> 10:55AM BLOOD CK(CPK)-321* cTropnT-0.02* <Date>1906-7-15</Date> 06:25PM BLOOD CK(CPK)-345* CK-MB-14* MB Indx-4.1 cTropnT-0.01 <Date>1952-1-7</Date> 03:50AM BLOOD CK(CPK)-845* CK-MB-15* MB Indx-1.8 cTropnT-0.01 <Date>1952-1-7</Date> 12:04PM BLOOD CK(CPK)-1030* CK-MB-15* MB Indx-1.5 cTropnT-0.01 <Date>1988-7-5</Date> 03:15AM BLOOD CK(CPK)-530* CK-MB-9 cTropnT-0.01 proBNP-2535* CXR (<Date>1906-7-15</Date>) - IMPRESSION: Hiatal hernia, otherwise unremarkable. Limited exam. Echo (<Date>1928-6-13</Date>) - There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with normal 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. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal biventricular systolic function. Moderate pulmonary artery systolic hypertension. CXR (<Date>1990-9-31</Date>) - Kyphotic positioning. Compared with one day earlier and allowing for technical differences, the right-sided effusion may be slightly larger. Otherwise, no significant change is detected. Again seen is retrocardiac opacity consistent with left lower lobe collapse and/or consolidation and a small left effusion. As noted, a right effusion is again seen, possibly slightly larger on the current examination, with underlying collapse and/or consolidation. Doubt CHF. Degenerative changes of the thoracic spine are noted. Cardiac Enzymes <Date>1961-7-17</Date>: Trop<0.01 <Date>1988-2-8</Date>: Trop 0.03 <Date>1920-3-29</Date>: Trop 0.02 LABS AT DISCHARGE: <Date>1999-6-3</Date> 05:40AM BLOOD WBC-9.5 RBC-3.08* Hgb-9.6* Hct-28.3* MCV-92 MCH-31.2 MCHC-33.9 RDW-13.5 Plt Ct-360 <Date>1999-6-3</Date> 05:40AM BLOOD PT-10.4 PTT-22.8 INR(PT)-0.8* <Date>1902-1-1</Date> 05:30AM BLOOD Glucose-114* UreaN-18 Creat-0.8 Na-142 K-3.5 Cl-101 HCO3-36* AnGap-9 <Date>1999-6-3</Date> 05:40AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.3 <Date>1999-6-3</Date> 05:40AM BLOOD TSH-0.87 Brief Hospital Course: 87 yo F with h/o CHF, COPD on 5 L oxygen at baseline, tracheobronchomalacia s/p stent, presents with acute dyspnea over several days, no s/p intubation for hypercarbic respiratory failure. # Hypercarbic respiratory failure: Presents with dyspnea, but no clear cough or fevers. Per report, patient felt like this with prior COPD exacerbations. Leukocytosis supports possible pneumonia, but history and CXR not entirely consistent with this. EKG with signs of demand, but ROMI negative. Sputum gram stain unremarkable, but respitatory viral culture grew parainfluenze type 3 on <Date>8-21</Date>. Patient was initially managed on solumedrol 60 mg IV Q8H, and was eventually tapered. With no evidence of pneumonia on CXR and sputum gram stain, antibiotics were stopped <Date>9-4</Date>. Beta-agonists and anticholinergics were continued around the clock. TTE revealed mild symmetric lvh with normal ef, increased pcwp (>18mmHg), Normal RV, and moderate pulmonary artery systolic hypertension. On <Date>1-30</Date>, bronchoscopy revealed collapsible, unremarkable airways. Patient had difficulty weaning from the vent, and would become interimittenty hypertensive to SBP 200s and tachypnic to the 50s. Patient was extubatied on <Date>12-16</Date> after passing SBT 0/5, but required re-intubation 30 minutes later for worsening secretions, lack of gag reflex, and tachypnea to the 50s. Of note, on <Date>1-16</Date>, the patient was found to have MRSA growing in sputum samples. Although it was felt that this likely represented colonization as opposed to true infection, the patient was started on a course of vancomycin (which was stopped after 5 days). After multiple discussions between the patient's family and the ICU team, the patient's PCP, <Name>Kathi Bogle</Name> the palliative care service, the patient's family ultimately decided that she would not want a tracheostomy. On <Date>1907-11-30</Date>, extubation was pursued again and was successful. After extubation, her respiratory status improved and she was ultimately called out to the medical floor. On the floor she was progressively weaned to 2LNC with nebs (better than her baseline 5L @home). Because of clinical exams revealing mild volume overload, she was intermittently diuresed. She also experienced intermittent shortness of breath with tachypnea but this was thought to be the result of attacks of anxiety with tachypnea. After receiving prn morphine, her breathing status would typically improve. A steroid taper was begun. The patient should continue prednisone 30 mg daily for 3 more days, then 20 mg daily for 4 days, then 10 mg daily for 4 days, then 5 mg daily for 4 days, then stop. . # Upper GI bleeding: On <Date>5-6</Date>, patient had coffee grounds from OG tube. Lavage for approx 600ccs with clearance. GI perfomred EGD which revealed esophagitis, ulcers and blood in the stomach body, D2 diverticulum and large hiatal hernia. H pylori was negative. Patient was continued on IV PPI, with plan for repeat EGD in 8 weeks, and upper GI series once clinically improved given abnormal anatomy on EGD. Her hematocrit remained stable with no further episodes of upper GI bleeding throughout the patient's hospitalization. On the floor she was switched to PO pantoprazole twice daily. Aspirin was held. . # Weakness: The patient was found to have generalized weakness at the end of her hospitalization. Neurology was consulted and they felt it was likely due to a combination of steroid myopathy and deconditioning from her prolonged bedbound status. A TSH was checked which was normal. They recommended pulmonary and physical rehab. . # CAD: History of LAD and RCA stenosis on Cath, but no stents. Continued statin and beta blocker, but held aspirin for GI bleeding (see above) . # Nutrition: Unable to pass NG without direct visualization due to hiatal hernia. IR guided post pyloric NG tube was placed on <Date>1-30</Date> for TFs and po medications. NG tube was pulled when patient was extubated on <Date>1907-11-30</Date>. Speech and swallow were consulted following the patient's extubation and she was eventually moved to soft solids and thin liquids with 1:1 supervision. # Goals of care: PCP <Name>Quinones</Name>. <Name>Whitehead</Name> was very involved in discussions regarding patient's code status. Palliative care also followed along with the patient. Ultimately, at the time of the patient's extubation on <Date>1907-11-30</Date>, it was decided that the patient would be DNR/DNI (although this was later change). The patient's family felt that she would not want a tracheostomy. It was decided that she would not be reintubated and that, if her respiratory status were to worsen after intubation, care would be focused on comfort. However, her status improved in the MICU and on the floor and it was then decided that she would remain DNR with intubation (but no tracheostomy) if her breathing deteriorated. After several days with stable or improved overall clinical status, she was deemed suitable for rehabilitation. At the timem of discharge, the patient's code status was do not resuscitate, okay to intubate. Medications on Admission: # Omeprazole 20 mg daily # Furosemide 20 mg daily # Toprol XL 50 mg daily # Lipitor 20 mg daily # Folic Acid 1 mg daily # Centrum daily # Diovan 80 mg daily # Trazodone 75-100 mg qhs # Melatonin 3 mg qhs # <Doctor Name>Dr.Heflin</Doctor Name> Aspirin 325 mg daily # Albuterol neb prn # Duoneb prn # Advair 250/50 <Hospital>Mercado PLC Medical Center</Hospital> # Zolpidem 2.5 mg qhs prn # Synthroid 100 mcg daily # Lexapro 20 mg daily Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. Melatonin 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Valsartan 160 mg Tablet Sig: 1.5 Tablets PO once a day. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 11. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 4 days: Start after 3 days of 30 mg daily. 14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 4 days: Start after 4 days of 20 mg daily. 15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 4 days: Start after 4 days of 10 mg daily. 16. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 18. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO every four (4) hours as needed for respiratory discomfort: Hold for oversedation or RR<12. 19. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 3 days. 20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 22. Humalog insulin sliding scale Please use attached Humalog insulin sliding scale while on steroids. Discharge Disposition: Extended Care Facility: <Location>941 Courtney Mountain East Gregorybury, MN 49290</Location> center at <Location>735 Dawn Place North James, MA 15781</Location> Discharge Diagnosis: Primary: 1. Chronic Obstructive Pulmonary Disease Exacerbation 2. Respiratory failure with intubation 3. Upper gastrointestinal bleed/Peptic Ulcer Disease 4. Hypertension 5. Anxiety Secondary: 1. Coronary Artery Disease 2. Hypothyroidism Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with shortness of breath and respiratory failure and lethargy. In the emergency department, you were breathing very fast and a breathing tube was inserted into your airway to help you breathe. You were admitted to the intensive care unit. There, you were managed with steroids and antibiotics and the tube was eventually removed from your airway, allowing you to breathe on your own. You also underwent bronchoscopy which looked at the inside of your airways. . During your time in the intensive care unit, you developed a gastrointestinal bleed. A tube was placed into your stomach and you underwent an endoscopic procedure to look at your esophagus and stomach. This showed inflammation in your esophagusand ulcers in your stomach. . You should continue to use nasal oxygen by nasal cannula as needed. You should continue the steroid taper as instructed. You should call your doctor or return to the emergency room if you have increasing difficulty breathing or shortness of breath, wheezing, chest pain, blood in your stool or vomiting blood. . There are some changes in your medications. START pantoprazole 40 mg twice daily and STOP omeprazole START hydrochlorothiazide START prednisone, taking 30 mg for 3 days, then 20 mg for 4 days, then 10 mg for 4 days, then 5 mg for 4 days, then stop. START colace and senna as needed for constipation Can use morphine to alleviate symptoms of respiratory discomfort STOP furosemide STOP zolpidem STOP aspirin INCREASE Diovan to 240 mg daily DECREASE trazodone to 50 mg daily . Follow up as indicated below. Followup Instructions: You have an appointment to follow up with Dr. <Name>Whitehead</Name>, your primary care physician, <Name>Kathi Bogle</Name> <Date>10-24</Date> at 1pm. His address is <Location>665 Fitzgerald Square South Daniellehaven, NM 07822</Location>, <Location>56791 Brianna Terrace Apt. 047 West Kristystad, VI 14567</Location>, <Location>72829 Sanchez Track East Dianehaven, RI 11760</Location>,<Numeric Identifier>8792779</Numeric Identifier>. The phone is <Telephone>663-452-3855</Telephone>. You have an appointment to follow up with Dr. <Name>Luisa</Name> <Name>Feudner</Name> in the <Hospital>Brown-Williams Hospital</Hospital> clinic on <Date>6-23</Date> at 3pm in the <Hospital>Sanchez and Sons Clinic</Hospital> at <Hospital>Alexander-Walker Health System</Hospital> on the <Location>415 Margaret Lodge Suite 096 Khanton, KS 18007</Location>. Their phone number is <Telephone>692-518-9398</Telephone>. Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY <Date>2022-4-28</Date> at 3:00 PM With: <Name>Antoinette</Name> <Name>Pegram</Name>, MD <Telephone>692-518-9398</Telephone> Building: Ra <Hospital>Herrera, Harris and Barry Hospital</Hospital> (<Hospital>Brown Group Clinic</Hospital>/<Hospital>Cabrera, Burton and Long Health System</Hospital> Complex) <Location>72829 Sanchez Track East Dianehaven, RI 11760</Location> Campus: EAST Best Parking: Main 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Date: 1906-7-15 Discharge Date: 1903-2-31 Service: MEDICINE Allergies: Amlodipine Attending:Ava Chief Complaint: COPD exacerbation/Shortness of Breath Major Surgical or Invasive Procedure: Intubation arterial line placement PICC line placement Esophagogastroduodenoscopy History of Present Illness: 87 yo F with h/o CHF, COPD on 5 L oxygen at baseline, tracheobronchomalacia s/p stent, presents with acute dyspnea over several days, and lethargy. This morning patient developed an acute worsening in dyspnea, and called EMS. EMS found patient tachypnic at saturating 90% on 5L. Patient was noted to be tripoding. She was given a nebulizer and brought to the ER. . According the patient's husband, she was experiencing symptoms consistent with prior COPD flares. Apparently patient was without cough, chest pain, fevers, chills, orthopnea, PND, dysuria, diarrhea, confusion and neck pain. Her husband is a physician and gave her a dose of levaquin this morning. . In the ED, patient was saturating 96% on NRB. CXR did not reveal any consolidation. Per report EKG was unremarkable. Laboratory evaluation revealed a leukocytosis if 14 and lactate of 2.2. Patient received combivent nebs, solumedrol 125 mg IV x1, aspirin 325 mg po x1. Mg sulfate 2 g IV x1, azithromycin 500 mg IVx1, levofloxacin 750 mg IVx1, and Cefrtiaxone 1g IVx1. Patient became tachpnic so was trialed on non-invasive ventilation but became hypotensive to systolics of 80, so noninvasive was removed and patient did well on NRB and nebulizers for about 2 hours. At that time patient became agitated, hypoxic to 87% and tachypnic to the 40s, so patient was intubated. Post intubation ABG was 7.3/60/88/31. Propafol was switched to fentanyl/midazolam for hypotension to the 80s. Received 2L of NS. On transfer, patient VS were 102, 87/33, 100% on 60% 450 x 18 PEEP 5. Patient has peripheral access x2. . In the ICU, patient appeared comfortable. Review of sytems: limited due to patient sedation Past Medical History: # COPD flare FEV1 40% in 1922, on 5L oxygen, s/p intubation 7-21, s/p distal tracheal to Left Main Stem stents placed 1967-11-25. Stents d/c'd 1926-3-10. Tracheobronchoplasty performed 7-21, 1922 # CAD w/ atypical angina (cath 1922 - LAD 30%, RCA 30%, EF 63%) # Dyslipidemia # Hypothyroidism, # Hypertension # Hiatal hernia, # lacunar CVA, # s/p ped struck -> head injury & rib fx, # depression Social History: The patient is married and worked as a clinical psychologist. Her husband is a pediatric neurologist at Henry, Ward and Brown Medical Center. They have several children, one of which is a nurse. Millicent Cobbs with 40 pack years, quit 5 years ago. Social ethanol user. No history of IVDU, but remote history of marijuana use. Family History: (+) FHx CAD; Father with an MI in his 40's, died of a CVA at age 59 Physical Exam: On admission Vitals: T: BP: 116/46 P: 92 O2: 100% TV 60% 450 x 18 PEEP 5 General: Intubated, sedated, no apparent discomfort HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: crackles bases bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Initial Labs 1906-7-15 10:55AM BLOOD WBC-14.1# RBC-4.20# Hgb-12.6# Hct-39.1# MCV-93 MCH-30.1 MCHC-32.3 RDW-12.6 Plt Ct-319 1906-7-15 10:55AM BLOOD Neuts-93.9 Lymphs-4.4* Monos-1.3* Eos-0.2 Baso-0.2 1952-1-7 03:50AM BLOOD PT-11.0 PTT-28.7 INR(PT)-0.9 1906-7-15 10:55AM BLOOD Glucose-168* UreaN-13 Creat-0.8 Na-140 K-3.5 Cl-92* HCO3-36* AnGap-16 1952-1-7 03:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1 Cardiac Biomarkers 1906-7-15 10:55AM BLOOD CK(CPK)-321* cTropnT-0.02* 1906-7-15 06:25PM BLOOD CK(CPK)-345* CK-MB-14* MB Indx-4.1 cTropnT-0.01 1952-1-7 03:50AM BLOOD CK(CPK)-845* CK-MB-15* MB Indx-1.8 cTropnT-0.01 1952-1-7 12:04PM BLOOD CK(CPK)-1030* CK-MB-15* MB Indx-1.5 cTropnT-0.01 1988-7-5 03:15AM BLOOD CK(CPK)-530* CK-MB-9 cTropnT-0.01 proBNP-2535* CXR (1906-7-15) - IMPRESSION: Hiatal hernia, otherwise unremarkable. Limited exam. Echo (1928-6-13) - There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with normal 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. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal biventricular systolic function. Moderate pulmonary artery systolic hypertension. CXR (1990-9-31) - Kyphotic positioning. Compared with one day earlier and allowing for technical differences, the right-sided effusion may be slightly larger. Otherwise, no significant change is detected. Again seen is retrocardiac opacity consistent with left lower lobe collapse and/or consolidation and a small left effusion. As noted, a right effusion is again seen, possibly slightly larger on the current examination, with underlying collapse and/or consolidation. Doubt CHF. Degenerative changes of the thoracic spine are noted. Cardiac Enzymes 1961-7-17: Trop1988-2-8: Trop 0.03 1920-3-29: Trop 0.02 LABS AT DISCHARGE: 1999-6-3 05:40AM BLOOD WBC-9.5 RBC-3.08* Hgb-9.6* Hct-28.3* MCV-92 MCH-31.2 MCHC-33.9 RDW-13.5 Plt Ct-360 1999-6-3 05:40AM BLOOD PT-10.4 PTT-22.8 INR(PT)-0.8* 1902-1-1 05:30AM BLOOD Glucose-114* UreaN-18 Creat-0.8 Na-142 K-3.5 Cl-101 HCO3-36* AnGap-9 1999-6-3 05:40AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.3 1999-6-3 05:40AM BLOOD TSH-0.87 Brief Hospital Course: 87 yo F with h/o CHF, COPD on 5 L oxygen at baseline, tracheobronchomalacia s/p stent, presents with acute dyspnea over several days, no s/p intubation for hypercarbic respiratory failure. # Hypercarbic respiratory failure: Presents with dyspnea, but no clear cough or fevers. Per report, patient felt like this with prior COPD exacerbations. Leukocytosis supports possible pneumonia, but history and CXR not entirely consistent with this. EKG with signs of demand, but ROMI negative. Sputum gram stain unremarkable, but respitatory viral culture grew parainfluenze type 3 on 8-21. Patient was initially managed on solumedrol 60 mg IV Q8H, and was eventually tapered. With no evidence of pneumonia on CXR and sputum gram stain, antibiotics were stopped 9-4. Beta-agonists and anticholinergics were continued around the clock. TTE revealed mild symmetric lvh with normal ef, increased pcwp (>18mmHg), Normal RV, and moderate pulmonary artery systolic hypertension. On 1-30, bronchoscopy revealed collapsible, unremarkable airways. Patient had difficulty weaning from the vent, and would become interimittenty hypertensive to SBP 200s and tachypnic to the 50s. Patient was extubatied on 12-16 after passing SBT 0/5, but required re-intubation 30 minutes later for worsening secretions, lack of gag reflex, and tachypnea to the 50s. Of note, on 1-16, the patient was found to have MRSA growing in sputum samples. Although it was felt that this likely represented colonization as opposed to true infection, the patient was started on a course of vancomycin (which was stopped after 5 days). After multiple discussions between the patient's family and the ICU team, the patient's PCP, Kathi Bogle the palliative care service, the patient's family ultimately decided that she would not want a tracheostomy. On 1907-11-30, extubation was pursued again and was successful. After extubation, her respiratory status improved and she was ultimately called out to the medical floor. On the floor she was progressively weaned to 2LNC with nebs (better than her baseline 5L @home). Because of clinical exams revealing mild volume overload, she was intermittently diuresed. She also experienced intermittent shortness of breath with tachypnea but this was thought to be the result of attacks of anxiety with tachypnea. After receiving prn morphine, her breathing status would typically improve. A steroid taper was begun. The patient should continue prednisone 30 mg daily for 3 more days, then 20 mg daily for 4 days, then 10 mg daily for 4 days, then 5 mg daily for 4 days, then stop. . # Upper GI bleeding: On 5-6, patient had coffee grounds from OG tube. Lavage for approx 600ccs with clearance. GI perfomred EGD which revealed esophagitis, ulcers and blood in the stomach body, D2 diverticulum and large hiatal hernia. H pylori was negative. Patient was continued on IV PPI, with plan for repeat EGD in 8 weeks, and upper GI series once clinically improved given abnormal anatomy on EGD. Her hematocrit remained stable with no further episodes of upper GI bleeding throughout the patient's hospitalization. On the floor she was switched to PO pantoprazole twice daily. Aspirin was held. . # Weakness: The patient was found to have generalized weakness at the end of her hospitalization. Neurology was consulted and they felt it was likely due to a combination of steroid myopathy and deconditioning from her prolonged bedbound status. A TSH was checked which was normal. They recommended pulmonary and physical rehab. . # CAD: History of LAD and RCA stenosis on Cath, but no stents. Continued statin and beta blocker, but held aspirin for GI bleeding (see above) . # Nutrition: Unable to pass NG without direct visualization due to hiatal hernia. IR guided post pyloric NG tube was placed on 1-30 for TFs and po medications. NG tube was pulled when patient was extubated on 1907-11-30. Speech and swallow were consulted following the patient's extubation and she was eventually moved to soft solids and thin liquids with 1:1 supervision. # Goals of care: PCP Quinones. Whitehead was very involved in discussions regarding patient's code status. Palliative care also followed along with the patient. Ultimately, at the time of the patient's extubation on 1907-11-30, it was decided that the patient would be DNR/DNI (although this was later change). The patient's family felt that she would not want a tracheostomy. It was decided that she would not be reintubated and that, if her respiratory status were to worsen after intubation, care would be focused on comfort. However, her status improved in the MICU and on the floor and it was then decided that she would remain DNR with intubation (but no tracheostomy) if her breathing deteriorated. After several days with stable or improved overall clinical status, she was deemed suitable for rehabilitation. At the timem of discharge, the patient's code status was do not resuscitate, okay to intubate. Medications on Admission: # Omeprazole 20 mg daily # Furosemide 20 mg daily # Toprol XL 50 mg daily # Lipitor 20 mg daily # Folic Acid 1 mg daily # Centrum daily # Diovan 80 mg daily # Trazodone 75-100 mg qhs # Melatonin 3 mg qhs # Dr.Heflin Aspirin 325 mg daily # Albuterol neb prn # Duoneb prn # Advair 250/50 Mercado PLC Medical Center # Zolpidem 2.5 mg qhs prn # Synthroid 100 mcg daily # Lexapro 20 mg daily Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. Melatonin 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Valsartan 160 mg Tablet Sig: 1.5 Tablets PO once a day. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 11. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 4 days: Start after 3 days of 30 mg daily. 14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 4 days: Start after 4 days of 20 mg daily. 15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 4 days: Start after 4 days of 10 mg daily. 16. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 18. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO every four (4) hours as needed for respiratory discomfort: Hold for oversedation or RR941 Courtney Mountain East Gregorybury, MN 49290 center at 735 Dawn Place North James, MA 15781 Discharge Diagnosis: Primary: 1. Chronic Obstructive Pulmonary Disease Exacerbation 2. Respiratory failure with intubation 3. Upper gastrointestinal bleed/Peptic Ulcer Disease 4. Hypertension 5. Anxiety Secondary: 1. Coronary Artery Disease 2. Hypothyroidism Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with shortness of breath and respiratory failure and lethargy. In the emergency department, you were breathing very fast and a breathing tube was inserted into your airway to help you breathe. You were admitted to the intensive care unit. There, you were managed with steroids and antibiotics and the tube was eventually removed from your airway, allowing you to breathe on your own. You also underwent bronchoscopy which looked at the inside of your airways. . During your time in the intensive care unit, you developed a gastrointestinal bleed. A tube was placed into your stomach and you underwent an endoscopic procedure to look at your esophagus and stomach. This showed inflammation in your esophagusand ulcers in your stomach. . You should continue to use nasal oxygen by nasal cannula as needed. You should continue the steroid taper as instructed. You should call your doctor or return to the emergency room if you have increasing difficulty breathing or shortness of breath, wheezing, chest pain, blood in your stool or vomiting blood. . There are some changes in your medications. START pantoprazole 40 mg twice daily and STOP omeprazole START hydrochlorothiazide START prednisone, taking 30 mg for 3 days, then 20 mg for 4 days, then 10 mg for 4 days, then 5 mg for 4 days, then stop. START colace and senna as needed for constipation Can use morphine to alleviate symptoms of respiratory discomfort STOP furosemide STOP zolpidem STOP aspirin INCREASE Diovan to 240 mg daily DECREASE trazodone to 50 mg daily . Follow up as indicated below. Followup Instructions: You have an appointment to follow up with Dr. Whitehead, your primary care physician, Kathi Bogle 10-24 at 1pm. His address is 665 Fitzgerald Square South Daniellehaven, NM 07822, 56791 Brianna Terrace Apt. 047 West Kristystad, VI 14567, 72829 Sanchez Track East Dianehaven, RI 11760,8792779. The phone is 663-452-3855. You have an appointment to follow up with Dr. Luisa Feudner in the Brown-Williams Hospital clinic on 6-23 at 3pm in the Sanchez and Sons Clinic at Alexander-Walker Health System on the 415 Margaret Lodge Suite 096 Khanton, KS 18007. Their phone number is 692-518-9398. Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY 2022-4-28 at 3:00 PM With: Antoinette Pegram, MD 692-518-9398 Building: Ra Herrera, Harris and Barry Hospital (Brown Group Clinic/Cabrera, Burton and Long Health System Complex) 72829 Sanchez Track East Dianehaven, RI 11760 Campus: EAST Best Parking: Main Garage	["Admission Date: 1906-7-15 Discharge Date: 1903-2-31\n\n\nService: MEDICINE\n\nAllergies:\nAmlodipine\n\nAttending:Ava\nChief Complaint:\nCOPD exacerbation/Shortness of Breath\n\nMajor Surgical or Invasive Procedure:\nIntubation\narterial line placement\nPICC line placement\nEsophagogastroduodenoscopy\n\n\nHistory of Present Illness:\n87 yo F with h/o CHF, COPD on 5 L oxygen at baseline,\ntracheobronchomalacia s/p stent, presents with acute dyspnea\nover several days, and lethargy. This morning patient developed\nan acute worsening in dyspnea, and called EMS. EMS found patient\ntachypnic at saturating 90% on 5L. Patient was noted to be\ntripoding. She was given a nebulizer and brought to the ER.\n.\nAccording the patient's husband, she was experiencing symptoms\nconsistent with prior COPD flares. Apparently patient was\nwithout cough, chest pain, fevers, chills, orthopnea, PND,\ndysuria, diarrhea, confusion and neck pain.", ' Her husband is a\nphysician and gave her a dose of levaquin this morning.\n.\nIn the ED, patient was saturating 96% on NRB. CXR did not reveal\nany consolidation. Per report EKG was unremarkable. Laboratory\nevaluation revealed a leukocytosis if 14 and lactate of 2.2.\nPatient received combivent nebs, solumedrol 125 mg IV x1,\naspirin 325 mg po x1. Mg sulfate 2 g IV x1, azithromycin 500 mg\nIVx1, levofloxacin 750 mg IVx1, and Cefrtiaxone 1g IVx1. Patient\nbecame tachpnic so was trialed on non-invasive ventilation but\nbecame hypotensive to systolics of 80, so noninvasive was\nremoved and patient did well on NRB and nebulizers for about 2\nhours. At that time patient became agitated, hypoxic to 87% and\ntachypnic to the 40s, so patient was intubated. Post intubation\nABG was 7.3/60/88/31. Propafol was switched to\nfentanyl/midazolam for hypotension to the 80s.', " Received 2L of\nNS. On transfer, patient VS were 102, 87/33, 100% on 60% 450 x\n18 PEEP 5. Patient has peripheral access x2.\n.\nIn the ICU, patient appeared comfortable.\n\nReview of sytems:\nlimited due to patient sedation\n\n\nPast Medical History:\n# COPD flare FEV1 40% in 1922, on 5L oxygen, s/p intubation\n7-21, s/p distal tracheal to Left Main Stem stents placed\n1967-11-25. Stents d/c'd 1926-3-10. Tracheobronchoplasty performed 7-21, 1922\n# CAD w/ atypical angina (cath 1922 - LAD 30%, RCA 30%, EF 63%)\n# Dyslipidemia\n# Hypothyroidism,\n# Hypertension\n# Hiatal hernia,\n# lacunar CVA,\n# s/p ped struck -> head injury & rib fx,\n# depression\n\nSocial History:\nThe patient is married and worked as a clinical\npsychologist. Her husband is a pediatric neurologist at\nHenry, Ward and Brown Medical Center. They have several children, one of which is\na nurse.", " Millicent Cobbs with 40 pack years, quit 5 years ago.\nSocial ethanol user. No history of IVDU, but remote history of\nmarijuana use.\n\nFamily History:\n(+) FHx CAD; Father with an MI in his 40's, died\nof a CVA at age 59\n\nPhysical Exam:\nOn admission\nVitals: T: BP: 116/46 P: 92 O2: 100%\nTV 60% 450 x 18 PEEP 5\nGeneral: Intubated, sedated, no apparent discomfort\nHEENT: Sclera anicteric, MMM, oropharynx clear\nNeck: supple, JVP not elevated, no LAD\nLungs: crackles bases bilaterally\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: no foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema\n\n\nPertinent Results:\nInitial Labs\n1906-7-15 10:55AM BLOOD WBC-14.", '1# RBC-4.20# Hgb-12.6# Hct-39.1#\nMCV-93 MCH-30.1 MCHC-32.3 RDW-12.6 Plt Ct-319\n1906-7-15 10:55AM BLOOD Neuts-93.9 Lymphs-4.4* Monos-1.3\nEos-0.2 Baso-0.2\n1952-1-7 03:50AM BLOOD PT-11.0 PTT-28.7 INR(PT)-0.9\n1906-7-15 10:55AM BLOOD Glucose-168 UreaN-13 Creat-0.8 Na-140\nK-3.5 Cl-92* HCO3-36* AnGap-16\n1952-1-7 03:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1\n\nCardiac Biomarkers\n1906-7-15 10:55AM BLOOD CK(CPK)-321* cTropnT-0.02\n1906-7-15 06:25PM BLOOD CK(CPK)-345 CK-MB-14* MB Indx-4.1\ncTropnT-0.01\n1952-1-7 03:50AM BLOOD CK(CPK)-845* CK-MB-15* MB Indx-1.8\ncTropnT-0.01\n1952-1-7 12:04PM BLOOD CK(CPK)-1030* CK-MB-15* MB Indx-1.5\ncTropnT-0.01\n1988-7-5 03:15AM BLOOD CK(CPK)-530* CK-MB-9 cTropnT-0.01\nproBNP-2535\n\nCXR (1906-7-15) - IMPRESSION: Hiatal hernia, otherwise\nunremarkable. Limited exam.\n\nEcho (1928-6-13) - There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic\nfunction (LVEF>55%).', ' The estimated cardiac index is normal\n(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased\nleft ventricular filling pressure (PCWP>18mmHg). Right\nventricular chamber size is normal. with normal free wall\ncontractility. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic\nhypertension. There is an anterior space which most likely\nrepresents a prominent fat pad.\nIMPRESSION: Normal biventricular systolic function. Moderate\npulmonary artery systolic hypertension.\n\nCXR (1990-9-31) - Kyphotic positioning. Compared with one day\nearlier and allowing for technical differences, the right-sided\neffusion may be slightly larger.', ' Otherwise, no significant\nchange is detected. Again seen is retrocardiac opacity\nconsistent with left lower lobe collapse and/or consolidation\nand a small left effusion. As noted, a right effusion is again\nseen, possibly slightly larger on the current examination, with\nunderlying collapse and/or consolidation. Doubt CHF.\nDegenerative changes of the thoracic spine are noted.\n\nCardiac Enzymes 1961-7-17: Trop1988-2-8: Trop 0.03\n 1920-3-29: Trop 0.02\n\nLABS AT DISCHARGE:\n\n1999-6-3 05:40AM BLOOD WBC-9.5 RBC-3.08 Hgb-9.6* Hct-28.3\nMCV-92 MCH-31.2 MCHC-33.9 RDW-13.5 Plt Ct-360\n1999-6-3 05:40AM BLOOD PT-10.4 PTT-22.8 INR(PT)-0.8\n1902-1-1 05:30AM BLOOD Glucose-114* UreaN-18 Creat-0.8 Na-142\nK-3.5 Cl-101 HCO3-36* AnGap-9\n1999-6-3 05:40AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.3\n1999-6-3 05:40AM BLOOD TSH-0.', '87\n\nBrief Hospital Course:\n87 yo F with h/o CHF, COPD on 5 L oxygen at baseline,\ntracheobronchomalacia s/p stent, presents with acute dyspnea\nover several days, no s/p intubation for hypercarbic respiratory\nfailure.\n\n# Hypercarbic respiratory failure: Presents with dyspnea, but no\nclear cough or fevers. Per report, patient felt like this with\nprior COPD exacerbations. Leukocytosis supports possible\npneumonia, but history and CXR not entirely consistent with\nthis. EKG with signs of demand, but ROMI negative. Sputum gram\nstain unremarkable, but respitatory viral culture grew\nparainfluenze type 3 on 8-21. Patient was initially managed on\nsolumedrol 60 mg IV Q8H, and was eventually tapered. With no\nevidence of pneumonia on CXR and sputum gram stain, antibiotics\nwere stopped 9-4. Beta-agonists and anticholinergics were\ncontinued around the clock.', " TTE revealed mild symmetric lvh with\nnormal ef, increased pcwp (>18mmHg), Normal RV, and moderate\npulmonary artery systolic hypertension. On 1-30, bronchoscopy\nrevealed collapsible, unremarkable airways. Patient had\ndifficulty weaning from the vent, and would become\ninterimittenty hypertensive to SBP 200s and tachypnic to the\n50s. Patient was extubatied on 12-16 after passing SBT 0/5, but\nrequired re-intubation 30 minutes later for worsening\nsecretions, lack of gag reflex, and tachypnea to the 50s. Of\nnote, on 1-16, the patient was found to have MRSA growing in\nsputum samples. Although it was felt that this likely\nrepresented colonization as opposed to true infection, the\npatient was started on a course of vancomycin (which was stopped\nafter 5 days). After multiple discussions between the patient's\nfamily and the ICU team, the patient's PCP, Kathi Bogle the palliative\ncare service, the patient's family ultimately decided that she\nwould not want a tracheostomy.", ' On 1907-11-30, extubation was pursued\nagain and was successful. After extubation, her respiratory\nstatus improved and she was ultimately called out to the medical\nfloor. On the floor she was progressively weaned to 2LNC with\nnebs (better than her baseline 5L @home). Because of clinical\nexams revealing mild volume overload, she was intermittently\ndiuresed. She also experienced intermittent shortness of breath\nwith tachypnea but this was thought to be the result of attacks\nof anxiety with tachypnea. After receiving prn morphine, her\nbreathing status would typically improve. A steroid taper was\nbegun. The patient should continue prednisone 30 mg daily for 3\nmore days, then 20 mg daily for 4 days, then 10 mg daily for 4\ndays, then 5 mg daily for 4 days, then stop.\n.\n# Upper GI bleeding: On 5-6, patient had coffee grounds from OG\ntube.', " Lavage for approx 600ccs with clearance. GI perfomred EGD\nwhich revealed esophagitis, ulcers and blood in the stomach\nbody, D2 diverticulum and large hiatal hernia. H pylori was\nnegative. Patient was continued on IV PPI, with plan for repeat\nEGD in 8 weeks, and upper GI series once clinically improved\ngiven abnormal anatomy on EGD. Her hematocrit remained stable\nwith no further episodes of upper GI bleeding throughout the\npatient's hospitalization. On the floor she was switched to PO\npantoprazole twice daily. Aspirin was held.\n.\n# Weakness: The patient was found to have generalized weakness\nat the end of her hospitalization. Neurology was consulted and\nthey felt it was likely due to a combination of steroid myopathy\nand deconditioning from her prolonged bedbound status. A TSH was\nchecked which was normal.", " They recommended pulmonary and\nphysical rehab.\n.\n# CAD: History of LAD and RCA stenosis on Cath, but no stents.\nContinued statin and beta blocker, but held aspirin for GI\nbleeding (see above)\n.\n# Nutrition: Unable to pass NG without direct visualization due\nto hiatal hernia. IR guided post pyloric NG tube was placed on\n1-30 for TFs and po medications. NG tube was pulled when patient\nwas extubated on 1907-11-30. Speech and swallow were consulted\nfollowing the patient's extubation and she was eventually moved\nto soft solids and thin liquids with 1:1 supervision.\n\n# Goals of care: PCP Quinones. Whitehead was very involved in discussions\nregarding patient's code status. Palliative care also followed\nalong with the patient. Ultimately, at the time of the patient's\nextubation on 1907-11-30, it was decided that the patient would be\nDNR/DNI (although this was later change).", " The patient's family\nfelt that she would not want a tracheostomy. It was decided that\nshe would not be reintubated and that, if her respiratory status\nwere to worsen after intubation, care would be focused on\ncomfort. However, her status improved in the MICU and on the\nfloor and it was then decided that she would remain DNR with\nintubation (but no tracheostomy) if her breathing deteriorated.\nAfter several days with stable or improved overall clinical\nstatus, she was deemed suitable for rehabilitation. At the timem\nof discharge, the patient's code status was do not resuscitate,\nokay to intubate.\n\nMedications on Admission:\n# Omeprazole 20 mg daily\n# Furosemide 20 mg daily\n# Toprol XL 50 mg daily\n# Lipitor 20 mg daily\n# Folic Acid 1 mg daily\n# Centrum daily\n# Diovan 80 mg daily\n# Trazodone 75-100 mg qhs\n# Melatonin 3 mg qhs\n# Dr.", 'Heflin Aspirin 325 mg daily\n# Albuterol neb prn\n# Duoneb prn\n# Advair 250/50 Mercado PLC Medical Center\n# Zolpidem 2.5 mg qhs prn\n# Synthroid 100 mcg daily\n# Lexapro 20 mg daily\n\n\nDischarge Medications:\n1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO once a day.\n2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as\nneeded for insomnia.\n6. Melatonin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.\n7. Valsartan 160 mg Tablet Sig: 1.5 Tablets PO once a day.\n8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) neb Inhalation every 4-6 hours as\nneeded for shortness of breath or wheezing.', '\n9. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for\nNebulization Sig: One (1) neb Inhalation every six (6) hours as\nneeded for shortness of breath or wheezing.\n10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:\nOne (1) puff Inhalation twice a day.\n11. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n12. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for\n4 days: Start after 3 days of 30 mg daily.\n14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for\n4 days: Start after 4 days of 20 mg daily.\n15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 4\ndays: Start after 4 days of 10 mg daily.\n16. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO\nDAILY (Daily).', '\n17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO twice a day.\n18. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO every four\n(4) hours as needed for respiratory discomfort: Hold for\noversedation or RR941 Courtney Mountain\nEast Gregorybury, MN 49290 center at 735 Dawn Place\nNorth James, MA 15781\n\nDischarge Diagnosis:\nPrimary:\n1. Chronic Obstructive Pulmonary Disease Exacerbation\n2. Respiratory failure with intubation\n3. Upper gastrointestinal bleed/Peptic Ulcer Disease\n4. Hypertension\n5. Anxiety\n\nSecondary:\n1. Coronary Artery Disease\n2. Hypothyroidism\n\n\nDischarge Condition:\nMental Status: Confused - sometimes.\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 the hospital with shortness of breath and\nrespiratory failure and lethargy.', ' In the emergency department,\nyou were breathing very fast and a breathing tube was inserted\ninto your airway to help you breathe. You were admitted to the\nintensive care unit. There, you were managed with steroids and\nantibiotics and the tube was eventually removed from your\nairway, allowing you to breathe on your own. You also underwent\nbronchoscopy which looked at the inside of your airways.\n.\nDuring your time in the intensive care unit, you developed a\ngastrointestinal bleed. A tube was placed into your stomach and\nyou underwent an endoscopic procedure to look at your esophagus\nand stomach. This showed inflammation in your esophagusand\nulcers in your stomach.\n.\nYou should continue to use nasal oxygen by nasal cannula as\nneeded. You should continue the steroid taper as instructed. You\nshould call your doctor or return to the emergency room if you\nhave increasing difficulty breathing or shortness of breath,\nwheezing, chest pain, blood in your stool or vomiting blood.', '\n.\nThere are some changes in your medications.\nSTART pantoprazole 40 mg twice daily and STOP omeprazole\nSTART hydrochlorothiazide\nSTART prednisone, taking 30 mg for 3 days, then 20 mg for 4\ndays, then 10 mg for 4 days, then 5 mg for 4 days, then stop.\nSTART colace and senna as needed for constipation\nCan use morphine to alleviate symptoms of respiratory discomfort\nSTOP furosemide\nSTOP zolpidem\nSTOP aspirin\nINCREASE Diovan to 240 mg daily\nDECREASE trazodone to 50 mg daily\n.\nFollow up as indicated below.\n\nFollowup Instructions:\nYou have an appointment to follow up with Dr. Whitehead, your\nprimary care physician, Kathi Bogle 10-24 at 1pm. His address is 665 Fitzgerald Square\nSouth Daniellehaven, NM 07822, 56791 Brianna Terrace Apt. 047\nWest Kristystad, VI 14567, 72829 Sanchez Track\nEast Dianehaven, RI 11760,8792779.', ' The phone is\n663-452-3855.\n\nYou have an appointment to follow up with Dr. Luisa Feudner in\nthe Brown-Williams Hospital clinic on 6-23 at 3pm in the Sanchez and Sons Clinic at Alexander-Walker Health System on the 415 Margaret Lodge Suite 096\nKhanton, KS 18007. Their phone number is\n692-518-9398.\n\nDepartment: DIV. OF GASTROENTEROLOGY\nWhen: WEDNESDAY 2022-4-28 at 3:00 PM\nWith: Antoinette Pegram, MD 692-518-9398\nBuilding: Ra Herrera, Harris and Barry Hospital (Brown Group Clinic/Cabrera, Burton and Long Health System Complex) 72829 Sanchez Track\nEast Dianehaven, RI 11760\nCampus: EAST Best Parking: Main Garage\n\n\n\n']
178	26880	135453.0	2162-03-25	Discharge summary	Report	Admission Date: [2162-3-3] Discharge Date: [2162-3-25] Date of Birth: [2080-1-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1828] Chief Complaint: Mr. [Known lastname 1829] was seen at [Hospital1 18] after a mechanical fall from a height of 10 feet. CT scan noted unstable fracture of C6-7 & posterior elements. Major Surgical or Invasive Procedure: 1. Anterior cervical osteotomy, C6-C7, with decompression and excision of ossification of the posterior longitudinal ligament. 2. Anterior cervical deformity correction. 3. Interbody reconstruction. 4. Anterior cervical fusion, C5-C6-C7. 5. Plate instrumentation, C5-C6-C7. 6. Cervical laminectomy C6-C7, T1. 7. Posterior cervical arthrodesis C4-T1. 8. Cervical instrumentation C4-T1. 9. Arthrodesis augmentation with autograft, allograft and demineralized bone matrix. History of Present Illness: Mr. [Known lastname 1829] is a 82 year old male who had a slip and fall of approximately 10 feet from a balcony. He was ambulatory at the scene. He presented to the ED here at [Hospital1 18]. CT scan revealed unstable C spine fracture. He was intubated secondary to agitation. Patient admitted to trauma surgery service Past Medical History: Coronary artery disease s/p CABG CHF HTN AICD Atrial fibrillation Stroke Social History: Patient recently discharged from [Hospital1 ] for severe depression. Family reports patient was very sad and attempted to kill himself by wrapping a telephone cord around his neck. Lives with his elderly wife, worked as a chemist in [Country 532]. Family History: Non contributory Physical Exam: Phycial exam prior to surgery was not obtained since patient was intubated and sedated. Post surgical physical exam: (TSICU per surgery team) Breathing without assistance NAD Vitals: T 97.5, HR 61, BP 145/67, RR22, SaO2 98 A-fib, rate controlled Abd soft non-tender Anterior/Posterior cervical incisions [Name (NI) 1830] Pt is edemitous in all four extremities, no facial edema Able to grossly move all four extremities, neurointact to light touch Distal pulses weakly intact Medicine Consult: VS: Tm/c 98.9 142/70 61 20 96%RA I/O BM yesterday 220/770 Gen: awake, calm, cooperative and pleasant, lying in bed Neck: c-collar removed CV: irregular, normal S1, S2. No m/r/g. lungs: cta anteriolry Abd: Obese, Soft, NTND, decreased bs Ext: trace b/l le edema, 1+ UE edema neuro/cognition: thought [3-17], "8", not to place, Pertinent Results: ==================== ADMISSION LABS ==================== WBC-8.4 RBC-4.43* Hgb-11.9* Hct-38.6* MCV-87 MCH-26.9* MCHC-30.9* RDW-17.3* Plt Ct-191 PT-20.4* PTT-28.1 INR(PT)-1.9* CK(CPK)-183* Amylase-70 Calcium-8.5 Phos-2.0* Mg-1.9 Glucose-121* Lactate-2.3* Na-140 K-4.3 Cl-101 calHCO3-26 ================== RADIOLOGY ================== CT scan C spine [2162-3-3]: IMPRESSION: 1. Fracture of the C6 as described involving the right pedicle (extending to the inferior facet) and left lamina. Anterior widening at the C6-7 disc space and mild widening of left C6-7 facet also noted. Prevertebral hematoma at C6 with likely rupture of the anterior longitudinal ligament. 2. Lucency in the right posterior C1 ring may represent a chronic injury. Likely old avulsion fracture at T2 pedicle on the left. 3. Ossification of both anterior and posterior longitudinal ligaments with compromise of the central spinal canal. Degenerative disease is further described above. CT ABDOMEN/PELVIS ([2162-3-3]) IMPRESSION: 1. No acute injuries in the chest, abdomen, or pelvis. 2. Three discrete pleural fluid collections in the right hemithorax, likely pseudotumors. 3. Small hypodense lesion in the pancreatic body is of unclear etiology, may represent pseudicyst or cystic tumor. Further evaluation with MRI may be performed on a non- emergent basis. 4. Bilateral renal cysts. 5. Foley catheter balloon inflated within the prostatic urethra. Recommend emergent repositioning. CT SINUS/MAXILLOFACIAL ([2162-3-3]) 1. Bilateral nasal bone fractures. 2. Left frontal scalp hematoma with preseptal soft tissue swelling. Question foreign body anterior to the left globe. Recommend clinical correlation. Small amount of extraconal hematoma in the superior aspect of the left orbit. 3. Linear lucency in the right posterior ring of C1. Correlate with CT C- spine performed concurrently. HEAD CT ([2162-3-3]) 1. No acute intracranial hemprrhage. 2. Left frontal scalp hematoma. 3. Nasal bone fractures. Recommend correlation with report from facial bone CT scan. 4. Lucency in the right posterior ring of C1. Please refer to dedeicated CT C-spine for further detail. 5. Left cerebellar encephalomalacia, likely due to old infarction. CHEST [2162-3-10] The Dobbhoff tube passes below the diaphragm with its tip most likely terminating in the stomach. The bilateral pacemakers are demonstrated with one lead terminating in right atrium and three leads terminating in right ventricle. The patient is in mild pulmonary edema with no change in the loculated pleural fluid within the major fissure. CT HEAD [2162-3-11] 1. A tiny amount of intraventricular hemorrhage layers along the occipital horns of the ventricles bilaterally. Recommend followp imaging. 2. Left frontal scalp hematoma has decreased in size. 3. Unchanged left cerebellar encephalomalacia. 4. Nasal bone fractures are better evaluated on dedicated maxillofacial CT. RIGHT SHOULDER X-RAY ([2162-3-11]) Mild glenohumeral and acromioclavicular joint osteoarthritis. Nonspecific ossification projecting over the upper margin of the scapular body and adjacent to the lesser tuberosity. Diagnostic considerations include the sequela of chronic calcific bursitis, intraarticular bodies, and/or calcific tendinitis of the subscapularis tendon. Increased opacity projecting over the right hemithorax and minor fissure, better delineated on recent chest radiographs and chest CT RIGHT UPPER EXTREMITY ULTRASOUND ([2162-3-13]) 1. Deep venous thrombosis in the right axillary vein, extending proximally into the right subclavian vein, and distally to involve the brachial veins, portion of the basilic vein, and the right cephalic vein. 2. Likely 2.0 cm left axillary lymph node, with unusual son[Name (NI) 493] features somewhat suspicious for malignancy. Followup ultrasound is recommended in 4 weeks, and FNA/biopsy may be considered at that time if no interval improvement. [2162-3-14] CT ABDOMEN WITH IV CONTRAST: There are small-to-moderate bilateral pleural effusions, on the right with a loculated appearance. There is associated compressive atelectasis. The visualized portion of the heart suggests mild cardiomegaly. There is no pericardial effusion. There is a 9-mm hypoattenuating, well-defined lesion in the left lobe of the liver (2:12) too small to accurately characterize but statistically most likely representing a cyst. There are bilateral, partially exophytic renal cysts. The spleen is normal in size. There is a 5-mm hypoattenuating focus in the pancreatic body, most likely representing focal fat. The gallbladder and adrenal glands are unremarkable. An NG tube terminates in the stomach. There is no ascites. The large and small bowel loops appear unremarkable without wall thickening or pneumatosis. Oral contrast material has passed into the ascending colon without evidence of obstruction. There is no ascites and no free air. There is a small pocket of air in the left rectus muscle, tracking over a distance of approximately 10 cm. CT PELVIS WITH IV CONTRAST: The pelvic small and large bowel loops, collapsed bladder containing Foley catheter and seminal vesicles appear unremarkable. The prostate is enlarged, measuring 5.9 cm in transverse diameter. The rectum contains a moderate amount of dried stool. There is no free air or free fluid. BONE WINDOWS: No suspicious lytic or sclerotic lesions. There is DISH of the entire visualized thoracolumbar spine. There also are degenerative changes about the hip joints with large acetabular osteophytes. IMPRESSION: 1. Stable bilateral pleural effusions, loculated on the right. 2. New focus of air tracking within the left rectus muscle with associated tiny amount of extraperitoneal air (2:53). No associated stranding or fluid collection. Please correlate clinically if this could be iatrogenic, such as due to s.q. injections. 3. 5-mm hypoattenuating focus in the pancreatic body. This could represent focal fat, although a cystic tumor cannot be excluded. If this is of concern, then MRI is again recommended for further evaluation. 4. Hypoattenuating focus in the left lobe of the liver, too small to accurately characterize. 5. Bilateral partially exophytic renal cysts. 6. Moderate amount of dried stool within the rectum. A wet read was placed and the pertinent findings were discussed by Dr. [First Name (STitle) 1831] [Name (STitle) 1832] with Dr. [First Name (STitle) 1833] at 11:30 p.m. on [2162-3-14]. [2162-3-16] VIDEO OROPHARYNGEAL SWALLOW FINDINGS: Real-time video fluoroscopic evaluation was performed after oral administration of thin and puree consistency of barium, in conjunction with the speech pathologist. ORAL PHASE: Normal bolus formation, bolus control, AP tongue movement, oral transit time, and no oral cavity residue. PHARYNGEAL PHASE: There is normal swallow initiation and velar elevation. There is mild-to-moderate impairment of laryngeal elevation with absent epiglottic deflection. There is moderate-to-severe increase in pharyngeal transit time. There is residue in the valleculae and piriform sinuses with moderate impairment of bolus propulsion. There was aspiration of both thin and puree barium. IMPRESSION: Aspiration of thin liquids and puree. For additional information, please see the speech and swallow therapist's report from the same day. [2162-3-18] CT Head w/out: FINDINGS: There is a small amount of blood layering in the occipital horns of both lateral ventricles, unchanged though not as dense given evolution. No new hemorrhage is identified. The ventricles, cisterns, and sulci are enlarged secondary to involutional change. Periventricular white matter hyperdensities are sequelae of chronic small vessel ischemia. Encephalomalacia in the left cerebellar hemisphere secondary to old infarction is unchanged. The osseous structures are unremarkable. The visualized paranasal sinuses and mastoid air cells are clear. Skin staples are noted along the superior- posterior neck secondary to recent spinal surgery. IMPRESSION: No interval change with a very small intraventricular hemorrhage. No discharge labs as patient CMO. Brief Hospital Course: Mr. [Known lastname 1829] was seen at [Hospital1 18] after his fall from a height of approximatly 10 feet. CT scans of his chest, abdomen and pelvis were negative for pathology. CT scan of his C-spine showed fracture of anterior and posterior elements at C6-7. He was also shown to have a right nasal bone fracture. C-spine fracture: Mr. [Known lastname 1829] [Last Name (Titles) 1834] two surgical procedures to stabilized his c-spine. [2162-3-4]: anterior cervical decompression/fusion at C6-7. [2162-3-5]: Cervical laminectomy C6-C7 & T1 with Posterior cervical arthrodesis C4-T1. He tolerated the procedures well. He was extubated without complication. After his surgical procedures, Mr. [Known lastname 1829] was transfered to the medicine service at [Hospital1 18] for his medical care. While on the medicine service, patient was found to be persistently aspirating and failed his speech and swallow evaluation. Patient and family were not interested in an NG tube or PEG for nutrition. Patient also developed a venous clot of the right upper extremity and the decision was made to not proceed with medical treatment. Goals of care were changed to comfort measures only. A foley was placed after patient had difficulty with urinary retention and straight cathing. A palliative care consult was obtained for symptom management and patient was discharged to hospice with morphine, olanzapine, and a foley in place for symptomatic relief. Medications on Admission: Coumadin seroquel docusate metoprolol folate lovastatin captopril ASA ipratroium inhaler Ferrous sulfate furosemide citalopram isosorbide meprazole Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: [12-30] Suppositorys Rectal DAILY (Daily) as needed for constipation. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) solution Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed for pain: may shorten interval as needed to control pain. 5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for agitation. 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily): may be discontinued if patient not tolerating pills or refusing to take. Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: 1. Cervical spondylosis with calcification of posterior longitudinal ligament. 2. Fracture dislocation C6-C7. 3. Ossification of the posterior longitudinal ligament. 4. Aspiration Pneumonia 1. Cervical spondylosis with calcification of posterior longitudinal ligament. 2. Fracture dislocation C6-C7. 3. Ossification of the posterior longitudinal ligament. 4. Aspiration Pneumonia 1. Cervical spondylosis with calcification of posterior longitudinal ligament. 2. Fracture dislocation C6-C7. 3. Ossification of the posterior longitudinal ligament. 4. Aspiration Pneumonia Discharge Condition: Stable to outside facility Discharge Instructions: Patient has been made CMO at the request of him and his family. He has a foley placed for urinary retention. Please use morphine as needed for pain and olanzapine as needed for agitiation. Patient has known history of aspiration documented on speech and swallow. It is the patient and the family's wish for him to continue to eat and drink as desired. Followup Instructions: Follow up with your primary care physician as needed.	Admission Date: <Date>1989-8-1</Date> Discharge Date: <Date>1909-12-28</Date> Date of Birth: <Date>1990-3-12</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Nguyen</Name> Chief Complaint: Mr. <Name>Tamaro</Name> was seen at <Hospital>Johnson, Perez and Wells Health System</Hospital> after a mechanical fall from a height of 10 feet. CT scan noted unstable fracture of C6-7 & posterior elements. Major Surgical or Invasive Procedure: 1. Anterior cervical osteotomy, C6-C7, with decompression and excision of ossification of the posterior longitudinal ligament. 2. Anterior cervical deformity correction. 3. Interbody reconstruction. 4. Anterior cervical fusion, C5-C6-C7. 5. Plate instrumentation, C5-C6-C7. 6. Cervical laminectomy C6-C7, T1. 7. Posterior cervical arthrodesis C4-T1. 8. Cervical instrumentation C4-T1. 9. Arthrodesis augmentation with autograft, allograft and demineralized bone matrix. History of Present Illness: Mr. <Name>Tamaro</Name> is a 82 year old male who had a slip and fall of approximately 10 feet from a balcony. He was ambulatory at the scene. He presented to the ED here at <Hospital>Johnson, Perez and Wells Health System</Hospital>. CT scan revealed unstable C spine fracture. He was intubated secondary to agitation. Patient admitted to trauma surgery service Past Medical History: Coronary artery disease s/p CABG CHF HTN AICD Atrial fibrillation Stroke Social History: Patient recently discharged from <Hospital>Chandler Group Medical Center</Hospital> for severe depression. Family reports patient was very sad and attempted to kill himself by wrapping a telephone cord around his neck. Lives with his elderly wife, worked as a chemist in <Country>Cyprus</Country>. Family History: Non contributory Physical Exam: Phycial exam prior to surgery was not obtained since patient was intubated and sedated. Post surgical physical exam: (TSICU per surgery team) Breathing without assistance NAD Vitals: T 97.5, HR 61, BP 145/67, RR22, SaO2 98 A-fib, rate controlled Abd soft non-tender Anterior/Posterior cervical incisions <Name>Jere Beamon</Name> Pt is edemitous in all four extremities, no facial edema Able to grossly move all four extremities, neurointact to light touch Distal pulses weakly intact Medicine Consult: VS: Tm/c 98.9 142/70 61 20 96%RA I/O BM yesterday 220/770 Gen: awake, calm, cooperative and pleasant, lying in bed Neck: c-collar removed CV: irregular, normal S1, S2. No m/r/g. lungs: cta anteriolry Abd: Obese, Soft, NTND, decreased bs Ext: trace b/l le edema, 1+ UE edema neuro/cognition: thought <Date>4-19</Date>, "8", not to place, Pertinent Results: ==================== ADMISSION LABS ==================== WBC-8.4 RBC-4.43* Hgb-11.9* Hct-38.6* MCV-87 MCH-26.9* MCHC-30.9* RDW-17.3* Plt Ct-191 PT-20.4* PTT-28.1 INR(PT)-1.9* CK(CPK)-183* Amylase-70 Calcium-8.5 Phos-2.0* Mg-1.9 Glucose-121* Lactate-2.3* Na-140 K-4.3 Cl-101 calHCO3-26 ================== RADIOLOGY ================== CT scan C spine <Date>1989-8-1</Date>: IMPRESSION: 1. Fracture of the C6 as described involving the right pedicle (extending to the inferior facet) and left lamina. Anterior widening at the C6-7 disc space and mild widening of left C6-7 facet also noted. Prevertebral hematoma at C6 with likely rupture of the anterior longitudinal ligament. 2. Lucency in the right posterior C1 ring may represent a chronic injury. Likely old avulsion fracture at T2 pedicle on the left. 3. Ossification of both anterior and posterior longitudinal ligaments with compromise of the central spinal canal. Degenerative disease is further described above. CT ABDOMEN/PELVIS (<Date>1989-8-1</Date>) IMPRESSION: 1. No acute injuries in the chest, abdomen, or pelvis. 2. Three discrete pleural fluid collections in the right hemithorax, likely pseudotumors. 3. Small hypodense lesion in the pancreatic body is of unclear etiology, may represent pseudicyst or cystic tumor. Further evaluation with MRI may be performed on a non- emergent basis. 4. Bilateral renal cysts. 5. Foley catheter balloon inflated within the prostatic urethra. Recommend emergent repositioning. CT SINUS/MAXILLOFACIAL (<Date>1989-8-1</Date>) 1. Bilateral nasal bone fractures. 2. Left frontal scalp hematoma with preseptal soft tissue swelling. Question foreign body anterior to the left globe. Recommend clinical correlation. Small amount of extraconal hematoma in the superior aspect of the left orbit. 3. Linear lucency in the right posterior ring of C1. Correlate with CT C- spine performed concurrently. HEAD CT (<Date>1989-8-1</Date>) 1. No acute intracranial hemprrhage. 2. Left frontal scalp hematoma. 3. Nasal bone fractures. Recommend correlation with report from facial bone CT scan. 4. Lucency in the right posterior ring of C1. Please refer to dedeicated CT C-spine for further detail. 5. Left cerebellar encephalomalacia, likely due to old infarction. CHEST <Date>1921-11-7</Date> The Dobbhoff tube passes below the diaphragm with its tip most likely terminating in the stomach. The bilateral pacemakers are demonstrated with one lead terminating in right atrium and three leads terminating in right ventricle. The patient is in mild pulmonary edema with no change in the loculated pleural fluid within the major fissure. CT HEAD <Date>1996-2-13</Date> 1. A tiny amount of intraventricular hemorrhage layers along the occipital horns of the ventricles bilaterally. Recommend followp imaging. 2. Left frontal scalp hematoma has decreased in size. 3. Unchanged left cerebellar encephalomalacia. 4. Nasal bone fractures are better evaluated on dedicated maxillofacial CT. RIGHT SHOULDER X-RAY (<Date>1996-2-13</Date>) Mild glenohumeral and acromioclavicular joint osteoarthritis. Nonspecific ossification projecting over the upper margin of the scapular body and adjacent to the lesser tuberosity. Diagnostic considerations include the sequela of chronic calcific bursitis, intraarticular bodies, and/or calcific tendinitis of the subscapularis tendon. Increased opacity projecting over the right hemithorax and minor fissure, better delineated on recent chest radiographs and chest CT RIGHT UPPER EXTREMITY ULTRASOUND (<Date>1993-9-20</Date>) 1. Deep venous thrombosis in the right axillary vein, extending proximally into the right subclavian vein, and distally to involve the brachial veins, portion of the basilic vein, and the right cephalic vein. 2. Likely 2.0 cm left axillary lymph node, with unusual son<Name>Karthik Casenhiser</Name> features somewhat suspicious for malignancy. Followup ultrasound is recommended in 4 weeks, and FNA/biopsy may be considered at that time if no interval improvement. <Date>2001-11-14</Date> CT ABDOMEN WITH IV CONTRAST: There are small-to-moderate bilateral pleural effusions, on the right with a loculated appearance. There is associated compressive atelectasis. The visualized portion of the heart suggests mild cardiomegaly. There is no pericardial effusion. There is a 9-mm hypoattenuating, well-defined lesion in the left lobe of the liver (2:12) too small to accurately characterize but statistically most likely representing a cyst. There are bilateral, partially exophytic renal cysts. The spleen is normal in size. There is a 5-mm hypoattenuating focus in the pancreatic body, most likely representing focal fat. The gallbladder and adrenal glands are unremarkable. An NG tube terminates in the stomach. There is no ascites. The large and small bowel loops appear unremarkable without wall thickening or pneumatosis. Oral contrast material has passed into the ascending colon without evidence of obstruction. There is no ascites and no free air. There is a small pocket of air in the left rectus muscle, tracking over a distance of approximately 10 cm. CT PELVIS WITH IV CONTRAST: The pelvic small and large bowel loops, collapsed bladder containing Foley catheter and seminal vesicles appear unremarkable. The prostate is enlarged, measuring 5.9 cm in transverse diameter. The rectum contains a moderate amount of dried stool. There is no free air or free fluid. BONE WINDOWS: No suspicious lytic or sclerotic lesions. There is DISH of the entire visualized thoracolumbar spine. There also are degenerative changes about the hip joints with large acetabular osteophytes. IMPRESSION: 1. Stable bilateral pleural effusions, loculated on the right. 2. New focus of air tracking within the left rectus muscle with associated tiny amount of extraperitoneal air (2:53). No associated stranding or fluid collection. Please correlate clinically if this could be iatrogenic, such as due to s.q. injections. 3. 5-mm hypoattenuating focus in the pancreatic body. This could represent focal fat, although a cystic tumor cannot be excluded. If this is of concern, then MRI is again recommended for further evaluation. 4. Hypoattenuating focus in the left lobe of the liver, too small to accurately characterize. 5. Bilateral partially exophytic renal cysts. 6. Moderate amount of dried stool within the rectum. A wet read was placed and the pertinent findings were discussed by Dr. <Name>Jeremy</Name> <Name>Antoinette Taylor</Name> with Dr. <Name>Tracy</Name> at 11:30 p.m. on <Date>2001-11-14</Date>. <Date>1984-4-4</Date> VIDEO OROPHARYNGEAL SWALLOW FINDINGS: Real-time video fluoroscopic evaluation was performed after oral administration of thin and puree consistency of barium, in conjunction with the speech pathologist. ORAL PHASE: Normal bolus formation, bolus control, AP tongue movement, oral transit time, and no oral cavity residue. PHARYNGEAL PHASE: There is normal swallow initiation and velar elevation. There is mild-to-moderate impairment of laryngeal elevation with absent epiglottic deflection. There is moderate-to-severe increase in pharyngeal transit time. There is residue in the valleculae and piriform sinuses with moderate impairment of bolus propulsion. There was aspiration of both thin and puree barium. IMPRESSION: Aspiration of thin liquids and puree. For additional information, please see the speech and swallow therapist's report from the same day. <Date>2020-7-24</Date> CT Head w/out: FINDINGS: There is a small amount of blood layering in the occipital horns of both lateral ventricles, unchanged though not as dense given evolution. No new hemorrhage is identified. The ventricles, cisterns, and sulci are enlarged secondary to involutional change. Periventricular white matter hyperdensities are sequelae of chronic small vessel ischemia. Encephalomalacia in the left cerebellar hemisphere secondary to old infarction is unchanged. The osseous structures are unremarkable. The visualized paranasal sinuses and mastoid air cells are clear. Skin staples are noted along the superior- posterior neck secondary to recent spinal surgery. IMPRESSION: No interval change with a very small intraventricular hemorrhage. No discharge labs as patient CMO. Brief Hospital Course: Mr. <Name>Tamaro</Name> was seen at <Hospital>Johnson, Perez and Wells Health System</Hospital> after his fall from a height of approximatly 10 feet. CT scans of his chest, abdomen and pelvis were negative for pathology. CT scan of his C-spine showed fracture of anterior and posterior elements at C6-7. He was also shown to have a right nasal bone fracture. C-spine fracture: Mr. <Name>Tamaro</Name> <Name>Martin</Name> two surgical procedures to stabilized his c-spine. <Date>2013-6-16</Date>: anterior cervical decompression/fusion at C6-7. <Date>1933-10-14</Date>: Cervical laminectomy C6-C7 & T1 with Posterior cervical arthrodesis C4-T1. He tolerated the procedures well. He was extubated without complication. After his surgical procedures, Mr. <Name>Tamaro</Name> was transfered to the medicine service at <Hospital>Johnson, Perez and Wells Health System</Hospital> for his medical care. While on the medicine service, patient was found to be persistently aspirating and failed his speech and swallow evaluation. Patient and family were not interested in an NG tube or PEG for nutrition. Patient also developed a venous clot of the right upper extremity and the decision was made to not proceed with medical treatment. Goals of care were changed to comfort measures only. A foley was placed after patient had difficulty with urinary retention and straight cathing. A palliative care consult was obtained for symptom management and patient was discharged to hospice with morphine, olanzapine, and a foley in place for symptomatic relief. Medications on Admission: Coumadin seroquel docusate metoprolol folate lovastatin captopril ASA ipratroium inhaler Ferrous sulfate furosemide citalopram isosorbide meprazole Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: <Date>2-10</Date> Suppositorys Rectal DAILY (Daily) as needed for constipation. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) solution Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed for pain: may shorten interval as needed to control pain. 5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for agitation. 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily): may be discontinued if patient not tolerating pills or refusing to take. Discharge Disposition: Extended Care Facility: <Hospital>Garcia LLC Medical Center</Hospital> of <Location>50589 Tiffany Extension Apt. 851 New Melissa, CA 54712</Location> Discharge Diagnosis: 1. Cervical spondylosis with calcification of posterior longitudinal ligament. 2. Fracture dislocation C6-C7. 3. Ossification of the posterior longitudinal ligament. 4. Aspiration Pneumonia 1. Cervical spondylosis with calcification of posterior longitudinal ligament. 2. Fracture dislocation C6-C7. 3. Ossification of the posterior longitudinal ligament. 4. Aspiration Pneumonia 1. Cervical spondylosis with calcification of posterior longitudinal ligament. 2. Fracture dislocation C6-C7. 3. Ossification of the posterior longitudinal ligament. 4. Aspiration Pneumonia Discharge Condition: Stable to outside facility Discharge Instructions: Patient has been made CMO at the request of him and his family. He has a foley placed for urinary retention. Please use morphine as needed for pain and olanzapine as needed for agitiation. Patient has known history of aspiration documented on speech and swallow. It is the patient and the family's wish for him to continue to eat and drink as desired. Followup Instructions: Follow up with your primary care physician as needed.	000000000000000001111111100000000000000000000000000000000111111111100000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000011111100000000000001111111111111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1989-8-1 Discharge Date: 1909-12-28 Date of Birth: 1990-3-12 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Nguyen Chief Complaint: Mr. Tamaro was seen at Johnson, Perez and Wells Health System after a mechanical fall from a height of 10 feet. CT scan noted unstable fracture of C6-7 & posterior elements. Major Surgical or Invasive Procedure: 1. Anterior cervical osteotomy, C6-C7, with decompression and excision of ossification of the posterior longitudinal ligament. 2. Anterior cervical deformity correction. 3. Interbody reconstruction. 4. Anterior cervical fusion, C5-C6-C7. 5. Plate instrumentation, C5-C6-C7. 6. Cervical laminectomy C6-C7, T1. 7. Posterior cervical arthrodesis C4-T1. 8. Cervical instrumentation C4-T1. 9. Arthrodesis augmentation with autograft, allograft and demineralized bone matrix. History of Present Illness: Mr. Tamaro is a 82 year old male who had a slip and fall of approximately 10 feet from a balcony. He was ambulatory at the scene. He presented to the ED here at Johnson, Perez and Wells Health System. CT scan revealed unstable C spine fracture. He was intubated secondary to agitation. Patient admitted to trauma surgery service Past Medical History: Coronary artery disease s/p CABG CHF HTN AICD Atrial fibrillation Stroke Social History: Patient recently discharged from Chandler Group Medical Center for severe depression. Family reports patient was very sad and attempted to kill himself by wrapping a telephone cord around his neck. Lives with his elderly wife, worked as a chemist in Cyprus. Family History: Non contributory Physical Exam: Phycial exam prior to surgery was not obtained since patient was intubated and sedated. Post surgical physical exam: (TSICU per surgery team) Breathing without assistance NAD Vitals: T 97.5, HR 61, BP 145/67, RR22, SaO2 98 A-fib, rate controlled Abd soft non-tender Anterior/Posterior cervical incisions Jere Beamon Pt is edemitous in all four extremities, no facial edema Able to grossly move all four extremities, neurointact to light touch Distal pulses weakly intact Medicine Consult: VS: Tm/c 98.9 142/70 61 20 96%RA I/O BM yesterday 220/770 Gen: awake, calm, cooperative and pleasant, lying in bed Neck: c-collar removed CV: irregular, normal S1, S2. No m/r/g. lungs: cta anteriolry Abd: Obese, Soft, NTND, decreased bs Ext: trace b/l le edema, 1+ UE edema neuro/cognition: thought 4-19, "8", not to place, Pertinent Results: ==================== ADMISSION LABS ==================== WBC-8.4 RBC-4.43* Hgb-11.9* Hct-38.6* MCV-87 MCH-26.9* MCHC-30.9* RDW-17.3* Plt Ct-191 PT-20.4* PTT-28.1 INR(PT)-1.9* CK(CPK)-183* Amylase-70 Calcium-8.5 Phos-2.0* Mg-1.9 Glucose-121* Lactate-2.3* Na-140 K-4.3 Cl-101 calHCO3-26 ================== RADIOLOGY ================== CT scan C spine 1989-8-1: IMPRESSION: 1. Fracture of the C6 as described involving the right pedicle (extending to the inferior facet) and left lamina. Anterior widening at the C6-7 disc space and mild widening of left C6-7 facet also noted. Prevertebral hematoma at C6 with likely rupture of the anterior longitudinal ligament. 2. Lucency in the right posterior C1 ring may represent a chronic injury. Likely old avulsion fracture at T2 pedicle on the left. 3. Ossification of both anterior and posterior longitudinal ligaments with compromise of the central spinal canal. Degenerative disease is further described above. CT ABDOMEN/PELVIS (1989-8-1) IMPRESSION: 1. No acute injuries in the chest, abdomen, or pelvis. 2. Three discrete pleural fluid collections in the right hemithorax, likely pseudotumors. 3. Small hypodense lesion in the pancreatic body is of unclear etiology, may represent pseudicyst or cystic tumor. Further evaluation with MRI may be performed on a non- emergent basis. 4. Bilateral renal cysts. 5. Foley catheter balloon inflated within the prostatic urethra. Recommend emergent repositioning. CT SINUS/MAXILLOFACIAL (1989-8-1) 1. Bilateral nasal bone fractures. 2. Left frontal scalp hematoma with preseptal soft tissue swelling. Question foreign body anterior to the left globe. Recommend clinical correlation. Small amount of extraconal hematoma in the superior aspect of the left orbit. 3. Linear lucency in the right posterior ring of C1. Correlate with CT C- spine performed concurrently. HEAD CT (1989-8-1) 1. No acute intracranial hemprrhage. 2. Left frontal scalp hematoma. 3. Nasal bone fractures. Recommend correlation with report from facial bone CT scan. 4. Lucency in the right posterior ring of C1. Please refer to dedeicated CT C-spine for further detail. 5. Left cerebellar encephalomalacia, likely due to old infarction. CHEST 1921-11-7 The Dobbhoff tube passes below the diaphragm with its tip most likely terminating in the stomach. The bilateral pacemakers are demonstrated with one lead terminating in right atrium and three leads terminating in right ventricle. The patient is in mild pulmonary edema with no change in the loculated pleural fluid within the major fissure. CT HEAD 1996-2-13 1. A tiny amount of intraventricular hemorrhage layers along the occipital horns of the ventricles bilaterally. Recommend followp imaging. 2. Left frontal scalp hematoma has decreased in size. 3. Unchanged left cerebellar encephalomalacia. 4. Nasal bone fractures are better evaluated on dedicated maxillofacial CT. RIGHT SHOULDER X-RAY (1996-2-13) Mild glenohumeral and acromioclavicular joint osteoarthritis. Nonspecific ossification projecting over the upper margin of the scapular body and adjacent to the lesser tuberosity. Diagnostic considerations include the sequela of chronic calcific bursitis, intraarticular bodies, and/or calcific tendinitis of the subscapularis tendon. Increased opacity projecting over the right hemithorax and minor fissure, better delineated on recent chest radiographs and chest CT RIGHT UPPER EXTREMITY ULTRASOUND (1993-9-20) 1. Deep venous thrombosis in the right axillary vein, extending proximally into the right subclavian vein, and distally to involve the brachial veins, portion of the basilic vein, and the right cephalic vein. 2. Likely 2.0 cm left axillary lymph node, with unusual sonKarthik Casenhiser features somewhat suspicious for malignancy. Followup ultrasound is recommended in 4 weeks, and FNA/biopsy may be considered at that time if no interval improvement. 2001-11-14 CT ABDOMEN WITH IV CONTRAST: There are small-to-moderate bilateral pleural effusions, on the right with a loculated appearance. There is associated compressive atelectasis. The visualized portion of the heart suggests mild cardiomegaly. There is no pericardial effusion. There is a 9-mm hypoattenuating, well-defined lesion in the left lobe of the liver (2:12) too small to accurately characterize but statistically most likely representing a cyst. There are bilateral, partially exophytic renal cysts. The spleen is normal in size. There is a 5-mm hypoattenuating focus in the pancreatic body, most likely representing focal fat. The gallbladder and adrenal glands are unremarkable. An NG tube terminates in the stomach. There is no ascites. The large and small bowel loops appear unremarkable without wall thickening or pneumatosis. Oral contrast material has passed into the ascending colon without evidence of obstruction. There is no ascites and no free air. There is a small pocket of air in the left rectus muscle, tracking over a distance of approximately 10 cm. CT PELVIS WITH IV CONTRAST: The pelvic small and large bowel loops, collapsed bladder containing Foley catheter and seminal vesicles appear unremarkable. The prostate is enlarged, measuring 5.9 cm in transverse diameter. The rectum contains a moderate amount of dried stool. There is no free air or free fluid. BONE WINDOWS: No suspicious lytic or sclerotic lesions. There is DISH of the entire visualized thoracolumbar spine. There also are degenerative changes about the hip joints with large acetabular osteophytes. IMPRESSION: 1. Stable bilateral pleural effusions, loculated on the right. 2. New focus of air tracking within the left rectus muscle with associated tiny amount of extraperitoneal air (2:53). No associated stranding or fluid collection. Please correlate clinically if this could be iatrogenic, such as due to s.q. injections. 3. 5-mm hypoattenuating focus in the pancreatic body. This could represent focal fat, although a cystic tumor cannot be excluded. If this is of concern, then MRI is again recommended for further evaluation. 4. Hypoattenuating focus in the left lobe of the liver, too small to accurately characterize. 5. Bilateral partially exophytic renal cysts. 6. Moderate amount of dried stool within the rectum. A wet read was placed and the pertinent findings were discussed by Dr. Jeremy Antoinette Taylor with Dr. Tracy at 11:30 p.m. on 2001-11-14. 1984-4-4 VIDEO OROPHARYNGEAL SWALLOW FINDINGS: Real-time video fluoroscopic evaluation was performed after oral administration of thin and puree consistency of barium, in conjunction with the speech pathologist. ORAL PHASE: Normal bolus formation, bolus control, AP tongue movement, oral transit time, and no oral cavity residue. PHARYNGEAL PHASE: There is normal swallow initiation and velar elevation. There is mild-to-moderate impairment of laryngeal elevation with absent epiglottic deflection. There is moderate-to-severe increase in pharyngeal transit time. There is residue in the valleculae and piriform sinuses with moderate impairment of bolus propulsion. There was aspiration of both thin and puree barium. IMPRESSION: Aspiration of thin liquids and puree. For additional information, please see the speech and swallow therapist's report from the same day. 2020-7-24 CT Head w/out: FINDINGS: There is a small amount of blood layering in the occipital horns of both lateral ventricles, unchanged though not as dense given evolution. No new hemorrhage is identified. The ventricles, cisterns, and sulci are enlarged secondary to involutional change. Periventricular white matter hyperdensities are sequelae of chronic small vessel ischemia. Encephalomalacia in the left cerebellar hemisphere secondary to old infarction is unchanged. The osseous structures are unremarkable. The visualized paranasal sinuses and mastoid air cells are clear. Skin staples are noted along the superior- posterior neck secondary to recent spinal surgery. IMPRESSION: No interval change with a very small intraventricular hemorrhage. No discharge labs as patient CMO. Brief Hospital Course: Mr. Tamaro was seen at Johnson, Perez and Wells Health System after his fall from a height of approximatly 10 feet. CT scans of his chest, abdomen and pelvis were negative for pathology. CT scan of his C-spine showed fracture of anterior and posterior elements at C6-7. He was also shown to have a right nasal bone fracture. C-spine fracture: Mr. Tamaro Martin two surgical procedures to stabilized his c-spine. 2013-6-16: anterior cervical decompression/fusion at C6-7. 1933-10-14: Cervical laminectomy C6-C7 & T1 with Posterior cervical arthrodesis C4-T1. He tolerated the procedures well. He was extubated without complication. After his surgical procedures, Mr. Tamaro was transfered to the medicine service at Johnson, Perez and Wells Health System for his medical care. While on the medicine service, patient was found to be persistently aspirating and failed his speech and swallow evaluation. Patient and family were not interested in an NG tube or PEG for nutrition. Patient also developed a venous clot of the right upper extremity and the decision was made to not proceed with medical treatment. Goals of care were changed to comfort measures only. A foley was placed after patient had difficulty with urinary retention and straight cathing. A palliative care consult was obtained for symptom management and patient was discharged to hospice with morphine, olanzapine, and a foley in place for symptomatic relief. Medications on Admission: Coumadin seroquel docusate metoprolol folate lovastatin captopril ASA ipratroium inhaler Ferrous sulfate furosemide citalopram isosorbide meprazole Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: 2-10 Suppositorys Rectal DAILY (Daily) as needed for constipation. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) solution Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed for pain: may shorten interval as needed to control pain. 5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for agitation. 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily): may be discontinued if patient not tolerating pills or refusing to take. Discharge Disposition: Extended Care Facility: Garcia LLC Medical Center of 50589 Tiffany Extension Apt. 851 New Melissa, CA 54712 Discharge Diagnosis: 1. Cervical spondylosis with calcification of posterior longitudinal ligament. 2. Fracture dislocation C6-C7. 3. Ossification of the posterior longitudinal ligament. 4. Aspiration Pneumonia 1. Cervical spondylosis with calcification of posterior longitudinal ligament. 2. Fracture dislocation C6-C7. 3. Ossification of the posterior longitudinal ligament. 4. Aspiration Pneumonia 1. Cervical spondylosis with calcification of posterior longitudinal ligament. 2. Fracture dislocation C6-C7. 3. Ossification of the posterior longitudinal ligament. 4. Aspiration Pneumonia Discharge Condition: Stable to outside facility Discharge Instructions: Patient has been made CMO at the request of him and his family. He has a foley placed for urinary retention. Please use morphine as needed for pain and olanzapine as needed for agitiation. Patient has known history of aspiration documented on speech and swallow. It is the patient and the family's wish for him to continue to eat and drink as desired. Followup Instructions: Follow up with your primary care physician as needed.	['Admission Date: 1989-8-1 Discharge Date: 1909-12-28\n\nDate of Birth: 1990-3-12 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Nguyen\nChief Complaint:\nMr. Tamaro was seen at Johnson, Perez and Wells Health System after a mechanical fall from\na height of 10 feet. CT scan noted unstable fracture of C6-7 &\nposterior elements.\n\nMajor Surgical or Invasive Procedure:\n1. Anterior cervical osteotomy, C6-C7, with decompression and\nexcision of ossification of the posterior longitudinal ligament.\n2. Anterior cervical deformity correction.\n3. Interbody reconstruction.\n4. Anterior cervical fusion, C5-C6-C7.\n5. Plate instrumentation, C5-C6-C7.\n6. Cervical laminectomy C6-C7, T1.\n7. Posterior cervical arthrodesis C4-T1.\n8.', ' Cervical instrumentation C4-T1.\n9. Arthrodesis augmentation with autograft, allograft and\ndemineralized bone matrix.\n\n\nHistory of Present Illness:\nMr. Tamaro is a 82 year old male who had a slip and fall\nof approximately 10 feet from a balcony. He was ambulatory at\nthe scene. He presented to the ED here at Johnson, Perez and Wells Health System. CT scan\nrevealed unstable C spine fracture. He was intubated secondary\nto agitation.\n\nPatient admitted to trauma surgery service\n\nPast Medical History:\nCoronary artery disease s/p CABG\nCHF\nHTN\nAICD\nAtrial fibrillation\nStroke\n\nSocial History:\nPatient recently discharged from Chandler Group Medical Center for severe\ndepression. Family reports patient was very sad and attempted to\nkill himself by wrapping a telephone cord around his neck. Lives\nwith his elderly wife, worked as a chemist in Cyprus.', '\n\nFamily History:\nNon contributory\n\nPhysical Exam:\nPhycial exam prior to surgery was not obtained since patient was\nintubated and sedated.\n\nPost surgical physical exam: (TSICU per surgery team)\n\nBreathing without assistance\nNAD\nVitals: T 97.5, HR 61, BP 145/67, RR22, SaO2 98\nA-fib, rate controlled\nAbd soft non-tender\nAnterior/Posterior cervical incisions Jere Beamon\nPt is edemitous in all four extremities, no facial edema\nAble to grossly move all four extremities, neurointact to light\ntouch\nDistal pulses weakly intact\n\nMedicine Consult:\nVS: Tm/c 98.9 142/70 61 20 96%RA\nI/O BM yesterday 220/770\nGen: awake, calm, cooperative and pleasant, lying in bed\nNeck: c-collar removed\nCV: irregular, normal S1, S2. No m/r/g.\nlungs: cta anteriolry\nAbd: Obese, Soft, NTND, decreased bs\nExt: trace b/l le edema, 1+ UE edema\nneuro/cognition: thought 4-19, "8", not to place,\n\n\nPertinent Results:\n====================\n ADMISSION LABS\n====================\n\nWBC-8.', '4 RBC-4.43* Hgb-11.9* Hct-38.6* MCV-87 MCH-26.9\nMCHC-30.9 RDW-17.3* Plt Ct-191\nPT-20.4* PTT-28.1 INR(PT)-1.9\nCK(CPK)-183 Amylase-70\nCalcium-8.5 Phos-2.0* Mg-1.9\nGlucose-121* Lactate-2.3* Na-140 K-4.3 Cl-101 calHCO3-26\n\n==================\n RADIOLOGY\n==================\n\nCT scan C spine 1989-8-1:\nIMPRESSION:\n1. Fracture of the C6 as described involving the right pedicle\n(extending to the inferior facet) and left lamina. Anterior\nwidening at the C6-7 disc space and mild widening of left C6-7\nfacet also noted. Prevertebral hematoma at C6 with likely\nrupture of the anterior longitudinal ligament.\n\n2. Lucency in the right posterior C1 ring may represent a\nchronic injury.\nLikely old avulsion fracture at T2 pedicle on the left.\n\n3. Ossification of both anterior and posterior longitudinal\nligaments with\ncompromise of the central spinal canal.', ' Degenerative disease is\nfurther\ndescribed above.\n\nCT ABDOMEN/PELVIS (1989-8-1)\nIMPRESSION:\n1. No acute injuries in the chest, abdomen, or pelvis.\n2. Three discrete pleural fluid collections in the right\nhemithorax, likely pseudotumors.\n3. Small hypodense lesion in the pancreatic body is of unclear\netiology, may represent pseudicyst or cystic tumor. Further\nevaluation with MRI may be performed on a non- emergent basis.\n4. Bilateral renal cysts.\n5. Foley catheter balloon inflated within the prostatic urethra.\nRecommend emergent repositioning.\n\nCT SINUS/MAXILLOFACIAL (1989-8-1)\n1. Bilateral nasal bone fractures.\n2. Left frontal scalp hematoma with preseptal soft tissue\nswelling. Question foreign body anterior to the left globe.\nRecommend clinical correlation. Small amount of extraconal\nhematoma in the superior aspect of the left orbit.', '\n3. Linear lucency in the right posterior ring of C1. Correlate\nwith CT C- spine performed concurrently.\n\nHEAD CT (1989-8-1)\n1. No acute intracranial hemprrhage.\n2. Left frontal scalp hematoma.\n3. Nasal bone fractures. Recommend correlation with report from\nfacial bone CT scan.\n4. Lucency in the right posterior ring of C1. Please refer to\ndedeicated CT C-spine for further detail.\n5. Left cerebellar encephalomalacia, likely due to old\ninfarction.\n\nCHEST 1921-11-7\nThe Dobbhoff tube passes below the diaphragm with its tip most\nlikely terminating in the stomach. The bilateral pacemakers are\ndemonstrated with one lead terminating in right atrium and three\nleads terminating in right ventricle. The patient is in mild\npulmonary edema with no change in the loculated pleural fluid\nwithin the major fissure.', '\n\nCT HEAD 1996-2-13\n1. A tiny amount of intraventricular hemorrhage layers along the\noccipital horns of the ventricles bilaterally. Recommend followp\nimaging.\n2. Left frontal scalp hematoma has decreased in size.\n3. Unchanged left cerebellar encephalomalacia.\n4. Nasal bone fractures are better evaluated on dedicated\nmaxillofacial CT.\n\nRIGHT SHOULDER X-RAY (1996-2-13)\nMild glenohumeral and acromioclavicular joint osteoarthritis.\nNonspecific ossification projecting over the upper margin of the\nscapular body and adjacent to the lesser tuberosity. Diagnostic\nconsiderations include the sequela of chronic calcific bursitis,\nintraarticular bodies, and/or calcific tendinitis of the\nsubscapularis tendon.\nIncreased opacity projecting over the right hemithorax and minor\nfissure, better delineated on recent chest radiographs and chest\nCT\n\nRIGHT UPPER EXTREMITY ULTRASOUND (1993-9-20)\n1.', ' Deep venous thrombosis in the right axillary vein, extending\nproximally into the right subclavian vein, and distally to\ninvolve the brachial veins, portion of the basilic vein, and the\nright cephalic vein.\n2. Likely 2.0 cm left axillary lymph node, with unusual\nsonKarthik Casenhiser features somewhat suspicious for malignancy.\nFollowup ultrasound is recommended in 4 weeks, and FNA/biopsy\nmay be considered at that time if no interval improvement.\n\n2001-11-14\nCT ABDOMEN WITH IV CONTRAST: There are small-to-moderate\nbilateral pleural effusions, on the right with a loculated\nappearance. There is associated compressive atelectasis. The\nvisualized portion of the heart suggests mild cardiomegaly.\nThere is no pericardial effusion. There is a 9-mm\nhypoattenuating, well-defined lesion in the left lobe of the\nliver (2:12) too small to accurately characterize but\nstatistically most likely representing a cyst.', ' There are\nbilateral, partially exophytic renal cysts. The spleen is normal\nin size. There is a 5-mm hypoattenuating focus in the pancreatic\nbody, most likely representing focal fat. The gallbladder and\nadrenal glands are unremarkable. An NG tube terminates in the\nstomach. There is no ascites. The large and small bowel loops\nappear unremarkable without wall thickening or pneumatosis. Oral\ncontrast material has passed into the ascending colon without\nevidence of obstruction. There is no ascites and no free air.\nThere is a small pocket of air in the left rectus muscle,\ntracking over a distance of approximately 10 cm.\n\nCT PELVIS WITH IV CONTRAST: The pelvic small and large bowel\nloops, collapsed bladder containing Foley catheter and seminal\nvesicles appear unremarkable. The prostate is enlarged,\nmeasuring 5.', '9 cm in transverse diameter. The rectum contains a\nmoderate amount of dried stool. There is no free air or free\nfluid.\n\nBONE WINDOWS: No suspicious lytic or sclerotic lesions. There is\nDISH of the entire visualized thoracolumbar spine. There also\nare degenerative changes about the hip joints with large\nacetabular osteophytes.\n\nIMPRESSION:\n1. Stable bilateral pleural effusions, loculated on the right.\n2. New focus of air tracking within the left rectus muscle with\nassociated tiny amount of extraperitoneal air (2:53). No\nassociated stranding or fluid collection. Please correlate\nclinically if this could be iatrogenic, such as due to s.q.\ninjections.\n3. 5-mm hypoattenuating focus in the pancreatic body. This could\nrepresent focal fat, although a cystic tumor cannot be excluded.\nIf this is of concern, then MRI is again recommended for further\nevaluation.', '\n4. Hypoattenuating focus in the left lobe of the liver, too\nsmall to accurately characterize.\n5. Bilateral partially exophytic renal cysts.\n6. Moderate amount of dried stool within the rectum.\n\nA wet read was placed and the pertinent findings were discussed\nby Dr. Jeremy Antoinette Taylor with Dr. Tracy at 11:30 p.m. on 2001-11-14.\n\n1984-4-4\nVIDEO OROPHARYNGEAL SWALLOW FINDINGS: Real-time video\nfluoroscopic evaluation was performed after oral administration\nof thin and puree consistency of barium, in conjunction with the\nspeech pathologist.\n\nORAL PHASE: Normal bolus formation, bolus control, AP tongue\nmovement, oral transit time, and no oral cavity residue.\n\nPHARYNGEAL PHASE: There is normal swallow initiation and velar\nelevation. There is mild-to-moderate impairment of laryngeal\nelevation with absent epiglottic deflection.', " There is\nmoderate-to-severe increase in pharyngeal transit time. There is\nresidue in the valleculae and piriform sinuses with moderate\nimpairment of bolus propulsion. There was aspiration of both\nthin and puree barium.\n\nIMPRESSION: Aspiration of thin liquids and puree. For additional\ninformation, please see the speech and swallow therapist's\nreport from the same day.\n\n2020-7-24 CT Head w/out:\nFINDINGS: There is a small amount of blood layering in the\noccipital horns of both lateral ventricles, unchanged though not\nas dense given evolution. No new hemorrhage is identified. The\nventricles, cisterns, and sulci are enlarged secondary to\ninvolutional change. Periventricular white matter hyperdensities\nare sequelae of chronic small vessel ischemia. Encephalomalacia\nin the left cerebellar hemisphere secondary to old infarction is\nunchanged.", ' The osseous structures are unremarkable. The\nvisualized paranasal sinuses and mastoid air cells are clear.\nSkin staples are noted along the superior- posterior neck\nsecondary to recent spinal surgery.\n\nIMPRESSION: No interval change with a very small\nintraventricular hemorrhage.\n\nNo discharge labs as patient CMO.\n\nBrief Hospital Course:\nMr. Tamaro was seen at Johnson, Perez and Wells Health System after his fall from a height\nof approximatly 10 feet. CT scans of his chest, abdomen and\npelvis were negative for pathology. CT scan of his C-spine\nshowed fracture of anterior and posterior elements at C6-7. He\nwas also shown to have a right nasal bone fracture.\n\nC-spine fracture: Mr. Tamaro Martin two surgical\nprocedures to stabilized his c-spine. 2013-6-16: anterior\ncervical decompression/fusion at C6-7.', ' 1933-10-14: Cervical\nlaminectomy C6-C7 & T1 with Posterior cervical arthrodesis\nC4-T1. He tolerated the procedures well. He was extubated\nwithout complication.\n\nAfter his surgical procedures, Mr. Tamaro was transfered\nto the medicine service at Johnson, Perez and Wells Health System for his medical care. While on\nthe medicine service, patient was found to be persistently\naspirating and failed his speech and swallow evaluation. Patient\nand family were not interested in an NG tube or PEG for\nnutrition. Patient also developed a venous clot of the right\nupper extremity and the decision was made to not proceed with\nmedical treatment. Goals of care were changed to comfort\nmeasures only. A foley was placed after patient had difficulty\nwith urinary retention and straight cathing. A palliative care\nconsult was obtained for symptom management and patient was\ndischarged to hospice with morphine, olanzapine, and a foley in\nplace for symptomatic relief.', '\n\nMedications on Admission:\nCoumadin\nseroquel\ndocusate\nmetoprolol\nfolate\nlovastatin\ncaptopril\nASA\nipratroium inhaler\nFerrous sulfate\nfurosemide\ncitalopram\nisosorbide\nmeprazole\n\nDischarge Medications:\n1. Bisacodyl 10 mg Suppository Sig: 2-10 Suppositorys Rectal\nDAILY (Daily) as needed for constipation.\n2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer\nInhalation Q6H (every 6 hours) as needed for wheezing.\n3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:\nOne (1) solution Inhalation Q6H (every 6 hours) as needed for\nwheezing.\n4. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q4H\n(every 4 hours) as needed for pain: may shorten interval as\nneeded to control pain.\n5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid\nDissolve PO QHS (once a day (at bedtime)) as needed for\nagitation.', '\n6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)\nCapsule, Sust. Release 24 hr PO DAILY (Daily): may be\ndiscontinued if patient not tolerating pills or refusing to\ntake.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nGarcia LLC Medical Center of 50589 Tiffany Extension Apt. 851\nNew Melissa, CA 54712\n\nDischarge Diagnosis:\n1. Cervical spondylosis with calcification of posterior\nlongitudinal ligament.\n2. Fracture dislocation C6-C7.\n3. Ossification of the posterior longitudinal ligament.\n4. Aspiration Pneumonia\n\n\n1. Cervical spondylosis with calcification of posterior\n longitudinal ligament.\n2. Fracture dislocation C6-C7.\n3. Ossification of the posterior longitudinal ligament.\n4. Aspiration Pneumonia\n\n1. Cervical spondylosis with calcification of posterior\n longitudinal ligament.', "\n2. Fracture dislocation C6-C7.\n3. Ossification of the posterior longitudinal ligament.\n4. Aspiration Pneumonia\n\n\nDischarge Condition:\nStable to outside facility\n\n\nDischarge Instructions:\nPatient has been made CMO at the request of him and his family.\nHe has a foley placed for urinary retention. Please use morphine\nas needed for pain and olanzapine as needed for agitiation.\nPatient has known history of aspiration documented on speech and\nswallow. It is the patient and the family's wish for him to\ncontinue to eat and drink as desired.\n\nFollowup Instructions:\nFollow up with your primary care physician as needed.\n\n\n\n"]
179	53181	170490.0	2172-03-08	Discharge summary	Report	Admission Date: [2172-3-5] Discharge Date: [2172-3-8] Date of Birth: [2109-10-8] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: Meningioma Major Surgical or Invasive Procedure: Right Craniotomy History of Present Illness: [Known firstname 622] [Known lastname 1836] is a 62-year-old woman, with longstanding history of rheumatoid arthritis, probable Sweet's syndrome, and multiple joint complications requiring orthopedic interventions. She was found to hve a right cavernous sinus and nasopharyngeal mass. She underwent a biopsy of hte nasopharyngeal mass by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1837] and the pathology, including flow cytometry, was reactive for T-cell lymphoid hyperplasia only. She has a longstanding history of rheumatoid arthritis that involved small and large joints in her body. Her disease is currently controlled by abatacept, hydroxychloroquine, and methotrexate. She also has a remote history of erythematous nodules at her shins, dermatosis (probable Sweet's disease), severe holocranial headache with an intensity of [9-28], and dysphagia. But her symptoms resolved with treatment for autoimmune disease. Please refer additional past medical history, past surgical history, facial history, and social history to the initial note on [2171-11-4]. She cam to the BTC for discussion about management of her right cavernous sinus mass that extends into the middle cranial fossa. She had a recent head CT at the [Hospital1 756] and Woman's Hospital on [2171-11-29], when she went for a consultation there. She is neurologically stable without headache, nausea, vomiting, seizure, imbalance, or fall. She has no new systemic complaints. Her neurological problem started [9-/2171] when she experienced frontal pressure-like sensations. There was no temporal pattern; but they may occur more often in the evening. She had fullness in her ear and she also had a cold coinciding to the onset of her headache. By late [Month (only) 359] and early [2171-10-21], she also developed a sharp pain intermittently in the right temple region. She did not have nausea, vomiting, blurry vision, imbalance, or fall. A gadolinium-enhanced head MRI, performed at [Hospital1 346] on [2171-10-30], showed a bright mass involving the cavernous sinus. Past Medical History: She has a history of rheumatoid arthritis unspecified dermatosis, right knee replacement, left hip replacement, and fusion of subtalar joint, and resection of a benign left parotid gland tumor. Social History: She is married. She had smoked for approximately a year and a half when she was younger, but is not currently smoking. She has approximately one glass of wine per week. She is retired but was employed as a teacher. Family History: Cancer, diabetes, hearing loss, and heart disease. Physical Exam: AF VSS HEENT normal no LNN Neck supple. RRR CTA NTTP warm peripherals Neurological Examination: Her Karnofsky Performance Score is 100. She is neurologically intact. Pertinent Results: MRI [3-5] Right middle cranial fossa mass likely represents a meningioma and is stable since MRI of [2172-2-11]. The previously seen midline nasopharyngeal mass has decreased in size since MRI of [2168-2-11]. Direct visual inspection would be helpful for further assessment of the nasopharyngeal mass. Brief Hospital Course: Patient presented electively for meningioma resection of [3-5]. She tolerated the procedure well and was extubated in the operating room. She was trasnported to the ICU post-operatively for management. She had no complications and was transferred to the floor and observed for 24 hours. Prelim path is consistent with meningioma. She has dissolvable sutures, and will need to come to neurosurgery clinic in [6-28] days for wound check only. She will need to be scheduled for brain tumor clinic. She will complete Decadron taper on [3-10] and then restart her maintenance dose of prednisone. She will also be taking Keppra for seizure prophlyaxis. Her neurologic examination was intact with no deficits at discharge. She was tolerating regular diet. She should continue to take over the counter laxatives as needed. Medications on Admission: bactrim, famotidine,folic acid, fosamax, lorezapam, methotrexate, mvi, orencia, plaquenil, prednisone 20qd Discharge Medications: 1. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): start the day after Decadron taper is complete-. 4. dexamethasone 0.5 mg Tablet Sig: Four (4) Tablet PO q6h () for 2 days: take 4 tabs every 6 hours on [3-9] and take 2 tabs every 6 hours on [3-10] then stop. Disp:20 Tablet(s) Refills:0 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: brain lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam intact. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ?????? Please return to the office in [6-28] days (from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP.	Admission Date: <Date>1933-8-28</Date> Discharge Date: <Date>1951-10-10</Date> Date of Birth: <Date>2015-8-18</Date> Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Janell</Name> Chief Complaint: Meningioma Major Surgical or Invasive Procedure: Right Craniotomy History of Present Illness: <Name>Evan</Name> <Name>Casenhiser</Name> is a 62-year-old woman, with longstanding history of rheumatoid arthritis, probable Sweet's syndrome, and multiple joint complications requiring orthopedic interventions. She was found to hve a right cavernous sinus and nasopharyngeal mass. She underwent a biopsy of hte nasopharyngeal mass by Dr. <Name>Orville</Name> <Name>Kibler</Name> and the pathology, including flow cytometry, was reactive for T-cell lymphoid hyperplasia only. She has a longstanding history of rheumatoid arthritis that involved small and large joints in her body. Her disease is currently controlled by abatacept, hydroxychloroquine, and methotrexate. She also has a remote history of erythematous nodules at her shins, dermatosis (probable Sweet's disease), severe holocranial headache with an intensity of <Date>6-19</Date>, and dysphagia. But her symptoms resolved with treatment for autoimmune disease. Please refer additional past medical history, past surgical history, facial history, and social history to the initial note on <Date>1966-10-15</Date>. She cam to the BTC for discussion about management of her right cavernous sinus mass that extends into the middle cranial fossa. She had a recent head CT at the <Hospital>Smith Ltd Hospital</Hospital> and Woman's Hospital on <Date>1997-7-22</Date>, when she went for a consultation there. She is neurologically stable without headache, nausea, vomiting, seizure, imbalance, or fall. She has no new systemic complaints. Her neurological problem started <Date>12-1997</Date> when she experienced frontal pressure-like sensations. There was no temporal pattern; but they may occur more often in the evening. She had fullness in her ear and she also had a cold coinciding to the onset of her headache. By late <Month>September</Month> and early <Date>1938-5-25</Date>, she also developed a sharp pain intermittently in the right temple region. She did not have nausea, vomiting, blurry vision, imbalance, or fall. A gadolinium-enhanced head MRI, performed at <Hospital>Skinner-Snow Health System</Hospital> on <Date>2008-9-8</Date>, showed a bright mass involving the cavernous sinus. Past Medical History: She has a history of rheumatoid arthritis unspecified dermatosis, right knee replacement, left hip replacement, and fusion of subtalar joint, and resection of a benign left parotid gland tumor. Social History: She is married. She had smoked for approximately a year and a half when she was younger, but is not currently smoking. She has approximately one glass of wine per week. She is retired but was employed as a teacher. Family History: Cancer, diabetes, hearing loss, and heart disease. Physical Exam: AF VSS HEENT normal no LNN Neck supple. RRR CTA NTTP warm peripherals Neurological Examination: Her Karnofsky Performance Score is 100. She is neurologically intact. Pertinent Results: MRI <Date>1-21</Date> Right middle cranial fossa mass likely represents a meningioma and is stable since MRI of <Date>1941-5-31</Date>. The previously seen midline nasopharyngeal mass has decreased in size since MRI of <Date>1931-7-4</Date>. Direct visual inspection would be helpful for further assessment of the nasopharyngeal mass. Brief Hospital Course: Patient presented electively for meningioma resection of <Date>1-21</Date>. She tolerated the procedure well and was extubated in the operating room. She was trasnported to the ICU post-operatively for management. She had no complications and was transferred to the floor and observed for 24 hours. Prelim path is consistent with meningioma. She has dissolvable sutures, and will need to come to neurosurgery clinic in <Date>1-3</Date> days for wound check only. She will need to be scheduled for brain tumor clinic. She will complete Decadron taper on <Date>11-26</Date> and then restart her maintenance dose of prednisone. She will also be taking Keppra for seizure prophlyaxis. Her neurologic examination was intact with no deficits at discharge. She was tolerating regular diet. She should continue to take over the counter laxatives as needed. Medications on Admission: bactrim, famotidine,folic acid, fosamax, lorezapam, methotrexate, mvi, orencia, plaquenil, prednisone 20qd Discharge Medications: 1. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): start the day after Decadron taper is complete-. 4. dexamethasone 0.5 mg Tablet Sig: Four (4) Tablet PO q6h () for 2 days: take 4 tabs every 6 hours on <Date>5-17</Date> and take 2 tabs every 6 hours on <Date>11-26</Date> then stop. Disp:20 Tablet(s) Refills:0 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: brain lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam intact. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to <Telephone>116-154-6492</Telephone>. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ?????? Please return to the office in <Date>1-3</Date> days (from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling <Telephone>727-671-8931</Telephone>. If you live quite a distance from our office, please make arrangements for the same, with your 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Date: 1933-8-28 Discharge Date: 1951-10-10 Date of Birth: 2015-8-18 Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:Janell Chief Complaint: Meningioma Major Surgical or Invasive Procedure: Right Craniotomy History of Present Illness: Evan Casenhiser is a 62-year-old woman, with longstanding history of rheumatoid arthritis, probable Sweet's syndrome, and multiple joint complications requiring orthopedic interventions. She was found to hve a right cavernous sinus and nasopharyngeal mass. She underwent a biopsy of hte nasopharyngeal mass by Dr. Orville Kibler and the pathology, including flow cytometry, was reactive for T-cell lymphoid hyperplasia only. She has a longstanding history of rheumatoid arthritis that involved small and large joints in her body. Her disease is currently controlled by abatacept, hydroxychloroquine, and methotrexate. She also has a remote history of erythematous nodules at her shins, dermatosis (probable Sweet's disease), severe holocranial headache with an intensity of 6-19, and dysphagia. But her symptoms resolved with treatment for autoimmune disease. Please refer additional past medical history, past surgical history, facial history, and social history to the initial note on 1966-10-15. She cam to the BTC for discussion about management of her right cavernous sinus mass that extends into the middle cranial fossa. She had a recent head CT at the Smith Ltd Hospital and Woman's Hospital on 1997-7-22, when she went for a consultation there. She is neurologically stable without headache, nausea, vomiting, seizure, imbalance, or fall. She has no new systemic complaints. Her neurological problem started 12-1997 when she experienced frontal pressure-like sensations. There was no temporal pattern; but they may occur more often in the evening. She had fullness in her ear and she also had a cold coinciding to the onset of her headache. By late September and early 1938-5-25, she also developed a sharp pain intermittently in the right temple region. She did not have nausea, vomiting, blurry vision, imbalance, or fall. A gadolinium-enhanced head MRI, performed at Skinner-Snow Health System on 2008-9-8, showed a bright mass involving the cavernous sinus. Past Medical History: She has a history of rheumatoid arthritis unspecified dermatosis, right knee replacement, left hip replacement, and fusion of subtalar joint, and resection of a benign left parotid gland tumor. Social History: She is married. She had smoked for approximately a year and a half when she was younger, but is not currently smoking. She has approximately one glass of wine per week. She is retired but was employed as a teacher. Family History: Cancer, diabetes, hearing loss, and heart disease. Physical Exam: AF VSS HEENT normal no LNN Neck supple. RRR CTA NTTP warm peripherals Neurological Examination: Her Karnofsky Performance Score is 100. She is neurologically intact. Pertinent Results: MRI 1-21 Right middle cranial fossa mass likely represents a meningioma and is stable since MRI of 1941-5-31. The previously seen midline nasopharyngeal mass has decreased in size since MRI of 1931-7-4. Direct visual inspection would be helpful for further assessment of the nasopharyngeal mass. Brief Hospital Course: Patient presented electively for meningioma resection of 1-21. She tolerated the procedure well and was extubated in the operating room. She was trasnported to the ICU post-operatively for management. She had no complications and was transferred to the floor and observed for 24 hours. Prelim path is consistent with meningioma. She has dissolvable sutures, and will need to come to neurosurgery clinic in 1-3 days for wound check only. She will need to be scheduled for brain tumor clinic. She will complete Decadron taper on 11-26 and then restart her maintenance dose of prednisone. She will also be taking Keppra for seizure prophlyaxis. Her neurologic examination was intact with no deficits at discharge. She was tolerating regular diet. She should continue to take over the counter laxatives as needed. Medications on Admission: bactrim, famotidine,folic acid, fosamax, lorezapam, methotrexate, mvi, orencia, plaquenil, prednisone 20qd Discharge Medications: 1. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): start the day after Decadron taper is complete-. 4. dexamethasone 0.5 mg Tablet Sig: Four (4) Tablet PO q6h () for 2 days: take 4 tabs every 6 hours on 5-17 and take 2 tabs every 6 hours on 11-26 then stop. Disp:20 Tablet(s) Refills:0 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: brain lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam intact. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to 116-154-6492. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ?????? Please return to the office in 1-3 days (from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling 727-671-8931. If you live quite a distance from our office, please make arrangements for the same, with your PCP.	["Admission Date: 1933-8-28 Discharge Date: 1951-10-10\n\nDate of Birth: 2015-8-18 Sex: F\n\nService: NEUROSURGERY\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Janell\nChief Complaint:\nMeningioma\n\nMajor Surgical or Invasive Procedure:\nRight Craniotomy\n\n\nHistory of Present Illness:\nEvan Casenhiser is a 62-year-old woman, with longstanding\nhistory of rheumatoid arthritis, probable Sweet's syndrome, and\nmultiple joint complications requiring orthopedic interventions.\nShe was found to hve a right cavernous sinus and nasopharyngeal\nmass. She underwent a biopsy of hte nasopharyngeal mass by Dr.\nOrville Kibler and the pathology, including flow\ncytometry,\nwas reactive for T-cell lymphoid hyperplasia only.\n\nShe has a longstanding history of rheumatoid arthritis that\ninvolved small and large joints in her body.", " Her disease is\ncurrently controlled by abatacept, hydroxychloroquine, and\nmethotrexate. She also has a remote history of erythematous\nnodules at her shins, dermatosis (probable Sweet's disease),\nsevere holocranial headache with an intensity of 6-19, and\ndysphagia. But her symptoms resolved with treatment for\nautoimmune disease. Please refer additional past medical\nhistory, past surgical history, facial history, and social\nhistory to the initial note on 1966-10-15.\n\nShe cam to the BTC for discussion about management of her right\ncavernous sinus mass that extends into the middle cranial fossa.\n\n\nShe had a recent head CT at the Smith Ltd Hospital and Woman's Hospital on\n1997-7-22, when she went for a consultation there.\nShe is neurologically stable without headache, nausea, vomiting,\nseizure, imbalance, or fall.", ' She has no new systemic complaints.\n\nHer neurological problem started 12-1997 when she experienced\nfrontal pressure-like sensations. There was no temporal\npattern;\nbut they may occur more often in the evening.\nShe had fullness in her ear and she also had a cold coinciding\nto\nthe onset of her headache. By late September and early 1938-5-25, she also developed a sharp pain intermittently in the\nright\ntemple region.\nShe did not have nausea, vomiting, blurry vision, imbalance, or\nfall. A gadolinium-enhanced head MRI, performed at Skinner-Snow Health System on 2008-9-8, showed a bright mass\ninvolving the cavernous sinus.\n\nPast Medical History:\nShe has a history of rheumatoid arthritis unspecified\ndermatosis, right knee replacement, left hip replacement, and\nfusion of subtalar joint, and resection of a benign left parotid\ngland tumor.', '\n\n\nSocial History:\nShe is married. She had smoked for approximately a year and a\nhalf when she was younger, but is not currently smoking. She\nhas approximately one glass of wine per week. She is retired\nbut was employed as a teacher.\n\n\nFamily History:\nCancer, diabetes, hearing loss, and heart disease.\n\n\nPhysical Exam:\nAF VSS\nHEENT normal\nno LNN\nNeck supple.\nRRR\nCTA\nNTTP\nwarm peripherals\n\nNeurological Examination: Her Karnofsky Performance Score is\n100. She is neurologically intact.\n\n\nPertinent Results:\nMRI 1-21\nRight middle cranial fossa mass likely represents a meningioma\nand is stable since MRI of 1941-5-31. The previously seen\nmidline nasopharyngeal mass has decreased in size since MRI of\n1931-7-4. Direct visual inspection would be helpful for\nfurther assessment of the nasopharyngeal mass.', '\n\n\nBrief Hospital Course:\nPatient presented electively for meningioma resection of 1-21.\nShe tolerated the procedure well and was extubated in the\noperating room. She was trasnported to the ICU post-operatively\nfor management. She had no complications and was transferred to\nthe floor and observed for 24 hours. Prelim path is consistent\nwith meningioma.\nShe has dissolvable sutures, and will need to come to\nneurosurgery clinic in 1-3 days for wound check only.\nShe will need to be scheduled for brain tumor clinic. She will\ncomplete Decadron taper on 11-26 and then restart her maintenance\ndose of prednisone. She will also be taking Keppra for seizure\nprophlyaxis.\nHer neurologic examination was intact with no deficits at\ndischarge. She was tolerating regular diet. She should continue\nto take over the counter laxatives as needed.', '\n\nMedications on Admission:\nbactrim, famotidine,folic acid, fosamax, lorezapam,\nmethotrexate, mvi, orencia, plaquenil, prednisone 20qd\n\n\nDischarge Medications:\n1. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day).\nDisp:60 Tablet(s) Refills:2\n3. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):\nstart the day after Decadron taper is complete-.\n4. dexamethasone 0.5 mg Tablet Sig: Four (4) Tablet PO q6h ()\nfor 2 days: take 4 tabs every 6 hours on 5-17 and take 2 tabs\nevery 6 hours on 11-26 then stop.\nDisp:20 Tablet(s) Refills:0\n5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\nDisp:60 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nbrain lesion\n\nDischarge Condition:\nMental Status: Clear and coherent.', '\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\nNeuro exam intact.\n\nDischarge Instructions:\n??????\tHave a friend/family member check your incision daily for\nsigns of infection.\n??????\tTake your pain medicine as prescribed.\n??????\tExercise should be limited to walking; no lifting, straining,\nor excessive bending.\n??????\tYou have dissolvable sutures, you must keep that area dry for\n10 days.\n??????\tYou may shower before this time using a shower cap to cover\nyour head.\n??????\tIncrease your intake of fluids and fiber, as narcotic pain\nmedicine can cause constipation. We generally recommend taking\nan over the counter stool softener, such as Docusate (Colace)\nwhile taking narcotic pain medication.\n??????\tUnless directed by your doctor, do not take any\nanti-inflammatory medicines such as Motrin, Aspirin, Advil, and\nIbuprofen etc.', '\n??????\tIf you have been prescribed Dilantin (Phenytoin) for\nanti-seizure medicine, take it as prescribed and follow up with\nlaboratory blood drawing in one week. This can be drawn at your\nPCP??????s office, but please have the results faxed to 116-154-6492.\nIf you have been discharged on Keppra (Levetiracetam), you will\nnot require blood work monitoring.\n??????\tIf you are being sent home on steroid medication, make sure\nyou are taking a medication to protect your stomach (Prilosec,\nProtonix, or Pepcid), as these medications can cause stomach\nirritation. Make sure to take your steroid medication with\nmeals, or a glass of milk.\n??????\tClearance to drive and return to work will be addressed at\nyour post-operative office visit.\n??????\tMake sure to continue to use your incentive spirometer while\nat home.', '\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: increasing redness,\nincreased swelling, increased tenderness, or drainage.\n??????\tFever greater than or equal to 101?????? F.\n\nFollowup Instructions:\n??????\tPlease return to the office in 1-3 days (from your date of\nsurgery) for a wound check. This appointment can be made with\nthe Nurse Practitioner. Please make this appointment by calling\n727-671-8931. If you live quite a distance from our office,\nplease make arrangements for the same, with your PCP.', '\n\n\n\n']
180	20646	134727.0	2112-12-10	Discharge summary	Report	Admission Date: [2112-12-8] Discharge Date: [2112-12-10] Service: MEDICINE Allergies: Sulfonamides Attending:[First Name3 (LF) 1850] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo F with CAD, CHF, HTN, recent PE ([10-17]), who presents from rehab with hypoxia and SOB despite Abx treatment for PNA x 3 days. The patient was in rehab after being discharged from here for PE. She was scheduled to be discharged on [12-6]; on the day prior to discharge she deveoped fever, hypoxia, and SOB. CXR showed b/t lower lobe infiltrates. She was started on levoflox and ceftriaxone on [12-5]. When she became hypoxic on NC they brought her in to the ED. . In the [Hospital1 18] ED she was febrile to 102.7, P 109 BP 135/56 R 34 O2 90% on 3L. She was started on vanc and zosyn for broader coverage, tylenol, and 2L NS. . The patient reports having sweats and cough before admission. She complains of SOB and some upper back pain. She denies chest pain, URI sx, nausea/vomiting, diarrhea, or dysuria. Of note she had had a rash and was given prednisone for 7 days, ending [12-3]. The rash was speculated to be due to coumadin, but she was able to be continued on coumadin. Past Medical History: CAD s/p stent in [2109] CHF HTN PE - [10-17] pancreatic mass [10-17] Depression--on fluoxetine Social History: The patient has been in rehab for the past month. She used to live alone, but has 2 grown daughters living nearby who are involved. They are at the bedside and actively disagreeing about the patient's code status and what their mothers's goals of care are. It is unclear if either are HCPs. Family History: Doesn't know about siblings health. Children alive and healthy. No medical problems. Physical Exam: VS: T 99 BP 101/78 P 96 R 23 O2 96% on 100% NRB Gen: lying in bed in mild respiratory distress. talking in phrases. HEENT: PERRL, EOMI. MMM, OP clear Chest: bilateral crackles to mid-lung fields, clear anteriorly CV: RRR. nl s1/s2, no M/R/G Abd: + BS present; soft, ND/NT. guaiac positive stool in ED Ext: no c/c/e Neuro: A&O x 2. follow commands, MAE. Pertinent Results: [2112-12-8] 06:26PM BLOOD WBC-9.6 RBC-3.33* Hgb-8.9* Hct-27.0* MCV-81* MCH-26.7* MCHC-32.9 RDW-14.4 Plt Ct-291 [2112-12-10] 12:17AM BLOOD Hct-27.1* [2112-12-8] 06:26PM BLOOD Neuts-81.0* Lymphs-14.9* Monos-2.0 Eos-1.9 Baso-0.2 [2112-12-8] 06:26PM BLOOD PT-21.7* PTT-45.7* INR(PT)-3.4 [2112-12-9] 04:11AM BLOOD Plt Ct-273 [2112-12-8] 06:26PM BLOOD Glucose-104 UreaN-36* Creat-1.4* Na-138 K-4.8 Cl-104 HCO3-18* AnGap-21* [2112-12-9] 04:11PM BLOOD Glucose-103 UreaN-22* Creat-1.1 Na-138 K-3.5 Cl-107 HCO3-17* AnGap-18 [2112-12-8] 06:26PM BLOOD CK(CPK)-56 [2112-12-8] 06:26PM BLOOD CK-MB-NotDone cTropnT-0.01 [2112-12-8] 06:26PM BLOOD Calcium-8.9 Phos-3.2 Mg-1.7 [2112-12-9] 04:11PM BLOOD Calcium-7.9* Phos-3.6 Mg-2.2 [2112-12-8] 06:32PM BLOOD Lactate-3.8* [2112-12-9] 01:08AM BLOOD Lactate-1.1 [2112-12-10] 01:16AM BLOOD K-3.5 . [2112-12-8] PORTABLE AP CHEST RADIOGRAPH: The heart size and mediastinal contours are within normal limits. No definite pleural effusions are seen. There is diffusely increased interstitial opacity disease, predominantly in the lower lung zones. No pneumothorax seen. The osseous structures are stable. A hiatal hernia is noted. Tiny left pleural effusion is noted. IMPRESSION: Diffusely increased interstitial opacities. This appearance is consistent with pulmonary vascular congestion superimposed upon chronic interstitial changes. . [2112-12-9] IMPRESSION: AP chest compared to [11-19] and [12-8]: Severe progressive interstitial abnormality accompanied by pulmonary and mediastinal vascular congestion is most likely edema, but severe interstitial pneumonia either infectious or drug related could simulate these findings. Chronic hiatus hernia unchanged. Brief Hospital Course: 82 yo F with CAD, CHF, HTN, recent PE ([10-17]), who presents from rehab with PNA and hypoxia. . Chest x-ray revealed bilateral infiltrates. Patient was started on Zosyn and vancomycin for pneumonia. Her fluid status was closely monitored given her underlying CHF. On admission her daughters were in disagreement over her code status and her original long standing DNR/DNI status was changed to allow for intubation if needed. However, when the patient's respiratory status continued to decline to the point of need for intubation, the patient refused intubation. Her family was notified and agreed that their mother's wishes should be fulfilled. She was started on IV morphine then converted to morphine drip on HD #3 for comfort and all other medications were discontinued. Her family was at her bedside and their Rabbi was called. She died on [2112-12-10] at 2:20 pm. An autopsy was offered, but the family declined. Medications on Admission: ACETAMINOPHEN 1000 mg Q6 prn ALPRAZOLAM 0.25MG Qhs prn ASPIRIN 81 MG CA CARB. 500 mg PO BID FLUOXETINE 10 MG QHS FUROSEMIDE 40 mg QD IMDUR 30MG QD LIPITOR 40MG QD LISINOPRIL 10MG QD MECLIZINE HCL 12.5MG TID prn MULTIVITAMIN OMEPRAZOLE 20 mg QD WARFARIN Qhs dosed daily Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Discharge Condition: expired Discharge Instructions: NA Followup Instructions: NA [First Name8 (NamePattern2) 1176] [Name8 (MD) 1177] MD [MD Number(2) 1851]	Admission Date: <Date>1995-12-10</Date> Discharge Date: <Date>1931-3-22</Date> Service: MEDICINE Allergies: Sulfonamides Attending:<Name>Cindy</Name> Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo F with CAD, CHF, HTN, recent PE (<Date>8-27</Date>), who presents from rehab with hypoxia and SOB despite Abx treatment for PNA x 3 days. The patient was in rehab after being discharged from here for PE. She was scheduled to be discharged on <Date>8-9</Date>; on the day prior to discharge she deveoped fever, hypoxia, and SOB. CXR showed b/t lower lobe infiltrates. She was started on levoflox and ceftriaxone on <Date>3-19</Date>. When she became hypoxic on NC they brought her in to the ED. . In the <Hospital>Brooks Inc Health System</Hospital> ED she was febrile to 102.7, P 109 BP 135/56 R 34 O2 90% on 3L. She was started on vanc and zosyn for broader coverage, tylenol, and 2L NS. . The patient reports having sweats and cough before admission. She complains of SOB and some upper back pain. She denies chest pain, URI sx, nausea/vomiting, diarrhea, or dysuria. Of note she had had a rash and was given prednisone for 7 days, ending <Date>2-30</Date>. The rash was speculated to be due to coumadin, but she was able to be continued on coumadin. Past Medical History: CAD s/p stent in <Year>1918</Year> CHF HTN PE - <Date>8-27</Date> pancreatic mass <Date>8-27</Date> Depression--on fluoxetine Social History: The patient has been in rehab for the past month. She used to live alone, but has 2 grown daughters living nearby who are involved. They are at the bedside and actively disagreeing about the patient's code status and what their mothers's goals of care are. It is unclear if either are HCPs. Family History: Doesn't know about siblings health. Children alive and healthy. No medical problems. Physical Exam: VS: T 99 BP 101/78 P 96 R 23 O2 96% on 100% NRB Gen: lying in bed in mild respiratory distress. talking in phrases. HEENT: PERRL, EOMI. MMM, OP clear Chest: bilateral crackles to mid-lung fields, clear anteriorly CV: RRR. nl s1/s2, no M/R/G Abd: + BS present; soft, ND/NT. guaiac positive stool in ED Ext: no c/c/e Neuro: A&O x 2. follow commands, MAE. Pertinent Results: <Date>1995-12-10</Date> 06:26PM BLOOD WBC-9.6 RBC-3.33* Hgb-8.9* Hct-27.0* MCV-81* MCH-26.7* MCHC-32.9 RDW-14.4 Plt Ct-291 <Date>1931-3-22</Date> 12:17AM BLOOD Hct-27.1* <Date>1995-12-10</Date> 06:26PM BLOOD Neuts-81.0* Lymphs-14.9* Monos-2.0 Eos-1.9 Baso-0.2 <Date>1995-12-10</Date> 06:26PM BLOOD PT-21.7* PTT-45.7* INR(PT)-3.4 <Date>1993-1-6</Date> 04:11AM BLOOD Plt Ct-273 <Date>1995-12-10</Date> 06:26PM BLOOD Glucose-104 UreaN-36* Creat-1.4* Na-138 K-4.8 Cl-104 HCO3-18* AnGap-21* <Date>1993-1-6</Date> 04:11PM BLOOD Glucose-103 UreaN-22* Creat-1.1 Na-138 K-3.5 Cl-107 HCO3-17* AnGap-18 <Date>1995-12-10</Date> 06:26PM BLOOD CK(CPK)-56 <Date>1995-12-10</Date> 06:26PM BLOOD CK-MB-NotDone cTropnT-0.01 <Date>1995-12-10</Date> 06:26PM BLOOD Calcium-8.9 Phos-3.2 Mg-1.7 <Date>1993-1-6</Date> 04:11PM BLOOD Calcium-7.9* Phos-3.6 Mg-2.2 <Date>1995-12-10</Date> 06:32PM BLOOD Lactate-3.8* <Date>1993-1-6</Date> 01:08AM BLOOD Lactate-1.1 <Date>1931-3-22</Date> 01:16AM BLOOD K-3.5 . <Date>1995-12-10</Date> PORTABLE AP CHEST RADIOGRAPH: The heart size and mediastinal contours are within normal limits. No definite pleural effusions are seen. There is diffusely increased interstitial opacity disease, predominantly in the lower lung zones. No pneumothorax seen. The osseous structures are stable. A hiatal hernia is noted. Tiny left pleural effusion is noted. IMPRESSION: Diffusely increased interstitial opacities. This appearance is consistent with pulmonary vascular congestion superimposed upon chronic interstitial changes. . <Date>1993-1-6</Date> IMPRESSION: AP chest compared to <Date>2-14</Date> and <Date>1-8</Date>: Severe progressive interstitial abnormality accompanied by pulmonary and mediastinal vascular congestion is most likely edema, but severe interstitial pneumonia either infectious or drug related could simulate these findings. Chronic hiatus hernia unchanged. Brief Hospital Course: 82 yo F with CAD, CHF, HTN, recent PE (<Date>8-27</Date>), who presents from rehab with PNA and hypoxia. . Chest x-ray revealed bilateral infiltrates. Patient was started on Zosyn and vancomycin for pneumonia. Her fluid status was closely monitored given her underlying CHF. On admission her daughters were in disagreement over her code status and her original long standing DNR/DNI status was changed to allow for intubation if needed. However, when the patient's respiratory status continued to decline to the point of need for intubation, the patient refused intubation. Her family was notified and agreed that their mother's wishes should be fulfilled. She was started on IV morphine then converted to morphine drip on HD #3 for comfort and all other medications were discontinued. Her family was at her bedside and their Rabbi was called. She died on <Date>1931-3-22</Date> at 2:20 pm. An autopsy was offered, but the family declined. Medications on Admission: ACETAMINOPHEN 1000 mg Q6 prn ALPRAZOLAM 0.25MG Qhs prn ASPIRIN 81 MG CA CARB. 500 mg PO BID FLUOXETINE 10 MG QHS FUROSEMIDE 40 mg QD IMDUR 30MG QD LIPITOR 40MG QD LISINOPRIL 10MG QD MECLIZINE HCL 12.5MG TID prn MULTIVITAMIN OMEPRAZOLE 20 mg QD WARFARIN Qhs dosed daily Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Discharge Condition: expired Discharge Instructions: NA Followup Instructions: NA <Name>Angela</Name> <Name>Kaushik Conyers</Name> MD <MD Number>45816937</MD 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00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111011111111111111100001111111100	Admission Date: 1995-12-10 Discharge Date: 1931-3-22 Service: MEDICINE Allergies: Sulfonamides Attending:Cindy Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo F with CAD, CHF, HTN, recent PE (8-27), who presents from rehab with hypoxia and SOB despite Abx treatment for PNA x 3 days. The patient was in rehab after being discharged from here for PE. She was scheduled to be discharged on 8-9; on the day prior to discharge she deveoped fever, hypoxia, and SOB. CXR showed b/t lower lobe infiltrates. She was started on levoflox and ceftriaxone on 3-19. When she became hypoxic on NC they brought her in to the ED. . In the Brooks Inc Health System ED she was febrile to 102.7, P 109 BP 135/56 R 34 O2 90% on 3L. She was started on vanc and zosyn for broader coverage, tylenol, and 2L NS. . The patient reports having sweats and cough before admission. She complains of SOB and some upper back pain. She denies chest pain, URI sx, nausea/vomiting, diarrhea, or dysuria. Of note she had had a rash and was given prednisone for 7 days, ending 2-30. The rash was speculated to be due to coumadin, but she was able to be continued on coumadin. Past Medical History: CAD s/p stent in 1918 CHF HTN PE - 8-27 pancreatic mass 8-27 Depression--on fluoxetine Social History: The patient has been in rehab for the past month. She used to live alone, but has 2 grown daughters living nearby who are involved. They are at the bedside and actively disagreeing about the patient's code status and what their mothers's goals of care are. It is unclear if either are HCPs. Family History: Doesn't know about siblings health. Children alive and healthy. No medical problems. Physical Exam: VS: T 99 BP 101/78 P 96 R 23 O2 96% on 100% NRB Gen: lying in bed in mild respiratory distress. talking in phrases. HEENT: PERRL, EOMI. MMM, OP clear Chest: bilateral crackles to mid-lung fields, clear anteriorly CV: RRR. nl s1/s2, no M/R/G Abd: + BS present; soft, ND/NT. guaiac positive stool in ED Ext: no c/c/e Neuro: A&O x 2. follow commands, MAE. Pertinent Results: 1995-12-10 06:26PM BLOOD WBC-9.6 RBC-3.33* Hgb-8.9* Hct-27.0* MCV-81* MCH-26.7* MCHC-32.9 RDW-14.4 Plt Ct-291 1931-3-22 12:17AM BLOOD Hct-27.1* 1995-12-10 06:26PM BLOOD Neuts-81.0* Lymphs-14.9* Monos-2.0 Eos-1.9 Baso-0.2 1995-12-10 06:26PM BLOOD PT-21.7* PTT-45.7* INR(PT)-3.4 1993-1-6 04:11AM BLOOD Plt Ct-273 1995-12-10 06:26PM BLOOD Glucose-104 UreaN-36* Creat-1.4* Na-138 K-4.8 Cl-104 HCO3-18* AnGap-21* 1993-1-6 04:11PM BLOOD Glucose-103 UreaN-22* Creat-1.1 Na-138 K-3.5 Cl-107 HCO3-17* AnGap-18 1995-12-10 06:26PM BLOOD CK(CPK)-56 1995-12-10 06:26PM BLOOD CK-MB-NotDone cTropnT-0.01 1995-12-10 06:26PM BLOOD Calcium-8.9 Phos-3.2 Mg-1.7 1993-1-6 04:11PM BLOOD Calcium-7.9* Phos-3.6 Mg-2.2 1995-12-10 06:32PM BLOOD Lactate-3.8* 1993-1-6 01:08AM BLOOD Lactate-1.1 1931-3-22 01:16AM BLOOD K-3.5 . 1995-12-10 PORTABLE AP CHEST RADIOGRAPH: The heart size and mediastinal contours are within normal limits. No definite pleural effusions are seen. There is diffusely increased interstitial opacity disease, predominantly in the lower lung zones. No pneumothorax seen. The osseous structures are stable. A hiatal hernia is noted. Tiny left pleural effusion is noted. IMPRESSION: Diffusely increased interstitial opacities. This appearance is consistent with pulmonary vascular congestion superimposed upon chronic interstitial changes. . 1993-1-6 IMPRESSION: AP chest compared to 2-14 and 1-8: Severe progressive interstitial abnormality accompanied by pulmonary and mediastinal vascular congestion is most likely edema, but severe interstitial pneumonia either infectious or drug related could simulate these findings. Chronic hiatus hernia unchanged. Brief Hospital Course: 82 yo F with CAD, CHF, HTN, recent PE (8-27), who presents from rehab with PNA and hypoxia. . Chest x-ray revealed bilateral infiltrates. Patient was started on Zosyn and vancomycin for pneumonia. Her fluid status was closely monitored given her underlying CHF. On admission her daughters were in disagreement over her code status and her original long standing DNR/DNI status was changed to allow for intubation if needed. However, when the patient's respiratory status continued to decline to the point of need for intubation, the patient refused intubation. Her family was notified and agreed that their mother's wishes should be fulfilled. She was started on IV morphine then converted to morphine drip on HD #3 for comfort and all other medications were discontinued. Her family was at her bedside and their Rabbi was called. She died on 1931-3-22 at 2:20 pm. An autopsy was offered, but the family declined. Medications on Admission: ACETAMINOPHEN 1000 mg Q6 prn ALPRAZOLAM 0.25MG Qhs prn ASPIRIN 81 MG CA CARB. 500 mg PO BID FLUOXETINE 10 MG QHS FUROSEMIDE 40 mg QD IMDUR 30MG QD LIPITOR 40MG QD LISINOPRIL 10MG QD MECLIZINE HCL 12.5MG TID prn MULTIVITAMIN OMEPRAZOLE 20 mg QD WARFARIN Qhs dosed daily Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Discharge Condition: expired Discharge Instructions: NA Followup Instructions: NA Angela Kaushik Conyers MD 45816937	['Admission Date: 1995-12-10 Discharge Date: 1931-3-22\n\n\nService: MEDICINE\n\nAllergies:\nSulfonamides\n\nAttending:Cindy\nChief Complaint:\nHypoxia\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\n82 yo F with CAD, CHF, HTN, recent PE (8-27), who presents from\nrehab with hypoxia and SOB despite Abx treatment for PNA x 3\ndays. The patient was in rehab after being discharged from here\nfor PE. She was scheduled to be discharged on 8-9; on the day\nprior to discharge she deveoped fever, hypoxia, and SOB. CXR\nshowed b/t lower lobe infiltrates. She was started on levoflox\nand ceftriaxone on 3-19. When she became hypoxic on NC they\nbrought her in to the ED.\n.\nIn the Brooks Inc Health System ED she was febrile to 102.7, P 109 BP 135/56 R 34\nO2 90% on 3L. She was started on vanc and zosyn for broader\ncoverage, tylenol, and 2L NS.', "\n.\nThe patient reports having sweats and cough before admission.\nShe complains of SOB and some upper back pain. She denies chest\npain, URI sx, nausea/vomiting, diarrhea, or dysuria. Of note she\nhad had a rash and was given prednisone for 7 days, ending\n2-30. The rash was speculated to be due to coumadin, but she\nwas able to be continued on coumadin.\n\n\nPast Medical History:\nCAD s/p stent in 1918\nCHF\nHTN\nPE - 8-27\npancreatic mass 8-27\nDepression--on fluoxetine\n\n\nSocial History:\nThe patient has been in rehab for the past month. She used to\nlive alone, but has 2 grown daughters living nearby who are\ninvolved. They are at the bedside and actively disagreeing about\nthe patient's code status and what their mothers's goals of care\nare. It is unclear if either are HCPs.\n\nFamily History:\nDoesn't know about siblings health.", '\nChildren alive and healthy. No medical problems.\n\nPhysical Exam:\nVS: T 99 BP 101/78 P 96 R 23 O2 96% on 100% NRB\nGen: lying in bed in mild respiratory distress. talking in\nphrases.\nHEENT: PERRL, EOMI. MMM, OP clear\nChest: bilateral crackles to mid-lung fields, clear anteriorly\nCV: RRR. nl s1/s2, no M/R/G\nAbd: + BS present; soft, ND/NT. guaiac positive stool in ED\nExt: no c/c/e\nNeuro: A&O x 2. follow commands, MAE.\n\n\nPertinent Results:\n1995-12-10 06:26PM BLOOD WBC-9.6 RBC-3.33* Hgb-8.9* Hct-27.0\nMCV-81 MCH-26.7* MCHC-32.9 RDW-14.4 Plt Ct-291\n1931-3-22 12:17AM BLOOD Hct-27.1\n1995-12-10 06:26PM BLOOD Neuts-81.0 Lymphs-14.9* Monos-2.0\nEos-1.9 Baso-0.2\n1995-12-10 06:26PM BLOOD PT-21.7* PTT-45.7* INR(PT)-3.4\n1993-1-6 04:11AM BLOOD Plt Ct-273\n1995-12-10 06:26PM BLOOD Glucose-104 UreaN-36* Creat-1.', '4* Na-138\nK-4.8 Cl-104 HCO3-18* AnGap-21\n1993-1-6 04:11PM BLOOD Glucose-103 UreaN-22 Creat-1.1 Na-138\nK-3.5 Cl-107 HCO3-17* AnGap-18\n1995-12-10 06:26PM BLOOD CK(CPK)-56\n1995-12-10 06:26PM BLOOD CK-MB-NotDone cTropnT-0.01\n1995-12-10 06:26PM BLOOD Calcium-8.9 Phos-3.2 Mg-1.7\n1993-1-6 04:11PM BLOOD Calcium-7.9* Phos-3.6 Mg-2.2\n1995-12-10 06:32PM BLOOD Lactate-3.8*\n1993-1-6 01:08AM BLOOD Lactate-1.1\n1931-3-22 01:16AM BLOOD K-3.5\n.\n1995-12-10 PORTABLE AP CHEST RADIOGRAPH: The heart size and\nmediastinal contours are within normal limits. No definite\npleural effusions are seen. There is diffusely increased\ninterstitial opacity disease, predominantly in the lower lung\nzones. No pneumothorax seen. The osseous structures are stable.\nA hiatal hernia is noted. Tiny left pleural effusion is noted.\n\nIMPRESSION: Diffusely increased interstitial opacities.', ' This\nappearance is consistent with pulmonary vascular congestion\nsuperimposed upon chronic interstitial changes.\n.\n1993-1-6 IMPRESSION: AP chest compared to 2-14 and\n1-8:\n\nSevere progressive interstitial abnormality accompanied by\npulmonary and mediastinal vascular congestion is most likely\nedema, but severe interstitial pneumonia either infectious or\ndrug related could simulate these findings. Chronic hiatus\nhernia unchanged.\n\n\nBrief Hospital Course:\n82 yo F with CAD, CHF, HTN, recent PE (8-27), who presents from\nrehab with PNA and hypoxia.\n.\nChest x-ray revealed bilateral infiltrates. Patient was started\non Zosyn and vancomycin for pneumonia. Her fluid status was\nclosely monitored given her underlying CHF. On admission her\ndaughters were in disagreement over her code status and her\noriginal long standing DNR/DNI status was changed to allow for\nintubation if needed.', " However, when the patient's respiratory\nstatus continued to decline to the point of need for intubation,\nthe patient refused intubation. Her family was notified and\nagreed that their mother's wishes should be fulfilled. She was\nstarted on IV morphine then converted to morphine drip on HD #3\nfor comfort and all other medications were discontinued. Her\nfamily was at her bedside and their Rabbi was called. She died\non 1931-3-22 at 2:20 pm. An autopsy was offered, but the family\ndeclined.\n\n\n\n\nMedications on Admission:\nACETAMINOPHEN 1000 mg Q6 prn\nALPRAZOLAM 0.25MG Qhs prn\nASPIRIN 81 MG\nCA CARB. 500 mg PO BID\nFLUOXETINE 10 MG QHS\nFUROSEMIDE 40 mg QD\nIMDUR 30MG QD\nLIPITOR 40MG QD\nLISINOPRIL 10MG QD\nMECLIZINE HCL 12.5MG TID prn\nMULTIVITAMIN\nOMEPRAZOLE 20 mg QD\nWARFARIN Qhs dosed daily\n\n\nDischarge Medications:\nNA\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\nPneumonia\n\nDischarge Condition:\nexpired\n\nDischarge Instructions:\nNA\n\nFollowup Instructions:\nNA\n\n Angela Kaushik Conyers MD 45816937\n\n"]
181	42130	114236.0	2150-03-01	Discharge summary	Report	Admission Date: [2150-2-25] Discharge Date: [2150-3-1] Date of Birth: [2086-12-19] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: left sided brain lesion Major Surgical or Invasive Procedure: [2-25] Left Craniotomy for mass resection History of Present Illness: [Known firstname ] [Known lastname 1852] is a 62-year-old left-handed man who is here for a follow up of his left sphenoid meningioma. I last saw him on [2149-11-17] and his head CT showed growth of the left sphenoid meningioma. He is seizure free. Today, he is here with his wife and daughter. [Name (NI) ] does not have headache, nausea, vomiting, urinary incontinence, or fall. His neurological problem began on [2142-6-22] when he became confused and disoriented in a hotel bathroom. At that time, he was visiting his daughter for a wedding. His wife found him slumped over in the bath tube. According to her, his eyes looked funny. He could not stand up. His verbal output did not make sense. He was brought to [Doctor First Name 1853] Hospital in Placentia, CA. He woke up 7 to 8 hours later in the emergency room. He felt very tired after the event. He was hospitalized from [2142-6-22] to [2142-6-25]. He had a cardiac pacemaker placement due to irregular heart rate and bradycardia. He also had a head MRI that showed a less than 1 cm diameter sphenoid meningioma. Past Medical History: Cardiac arrhythmia as noted above, has a pacemaker in place, prostate cancer with prostatectomy, and hypertension. Social History: Lives with his wife. Retired, works parttime driving a school bus. Family History: NC Physical Exam: Temperature is 97.8 F. His blood pressure is 150/92. Pulse is 80. Respiration is 16. His skin has full turgor. HEENT is unremarkable. Neck is supple. Cardiac examination reveals regular rate and rhythms. His lungs are clear. His abdomen is soft with good bowel sounds. His extremities do not show clubbing, cyanosis, or edema. Neurological Examination: His Karnofsky Performance Score is 100. He is awake, alert, and oriented times 3. There His language is fluent with good comprehension. His recent recall is intact. Cranial Nerve Examination: His pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. There is no nystagmus. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He does not have a drift. His muscle strengths are [5-16] at all muscle groups. His muscle tone is normal. His reflexes are 0 in upper and lower extremities bilaterally. His ankle jerks are absent. His toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. His gait is normal. He can do tandem. He does not have a Romberg. PHYSICAL EXAM UPON DISCHARGE: non focal incision c/d/i, dissolvable sutures Pertinent Results: [2-25] CT Head: IMPRESSION: 1. Likely meningioma along the greater [Doctor First Name 362] of the left sphenoid bone, measuring 18 mm in diameter, unchanged since the most recent study of [11/2149], with reactive bony changes, as above. 2. Bifrontal cortical atrophy, which has progressed slightly over the series of studies since the earliest studies of [2142]. [2-25] CT Head: IMPRESSION: Expected post-operative changes with the left frontal craniotomy including subcutaneous air and soft tissue swelling, moderate pneumocephalus overlying predominantly the bilateral frontal lobes, and foci of hemorrhage in the surgical bed. No evidence of residual tumor on this non contrast CT. [2-26] CXR: FINDINGS: The lung volumes are rather low. There is moderate cardiomegaly without evidence of overt pulmonary edema. No areas of atelectasis or pneumonia. Right pectoral pacemaker in situ, with correct lead placement. [2-28] Head CT /c contrast: IMPRESSION: Status post left frontal craniotomy changes with improvement of pneumocephalus and stable 3 mm left to right midline shift; focus of hemorrhage with/without residual tumor in the resection bed is similar in appearance to prior exam but now with more surrounding vasogenic edema. Stable appearance of subarachnoid hemorrhage. Followup to assess for residual tumor/ interval change. Brief Hospital Course: Patient presented electively on [2-25] for left sided craniotomy for mass resection. he tolerated the procedure well and was taken to the Trauma ICU post-operatively still intubated. Shortly thereafter he was deemed fit for extubation which was done without difficulty. At post-op check he was neurologically intact. On [2-26] he was neurologically intact and cleared for transfer to the stepdown unit. This did not happen due to bed shortage. A CT with contrast was ordered for post op evaluation. On [2-27] he was again stable and cleared for transfer to the floor. Decadron taper was initiated. He was seen by PT and cleared for discharge home. On [2-28] the patient was being prepped for discharge but was noted to have intermittent heart rate in the 130-170's. His other vitals were stable. Electrophysiology was consulted and they recommended increasing the metoprolol XL dose to 100mg Qday. The patient was kept overnight to monitor this new dose. On [3-1] her remained stable neurologically and hemodynamically therefore he was cleared for discharge. Medications on Admission: coumadin, keppra, toprol xl, diovan, zocor Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 2. senna 8.6 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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain or fever > 101.4. 5. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. 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 9. metoprolol succinate 100 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 10. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 6 days: 3mg Q8hr on [3-1], then 2mg Q8hr x2 day, 1mg Q8hr x2 day, 1mg Q12hr x1 day then d/c. Disp:qs Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left sided brain lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures so you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????You need an appointment in the Brain [Hospital 341] Clinic. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. They will call you with an appointment within the next 2 weeks. Please call if you do not hear from the, you need to change your appointment, or require additional directions. ?????? Changes were made to your heart rate/blood pressure medication while you were in house. You were seen by the cardiology team who made these recommendations. Please follow up with your PCP within one week to check your heart rate and blood pressure. Completed by:[2150-3-1]	Admission Date: <Date>2014-1-6</Date> Discharge Date: <Date>2015-12-27</Date> Date of Birth: <Date>1999-12-1</Date> Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Sylvester</Name> Chief Complaint: left sided brain lesion Major Surgical or Invasive Procedure: <Date>6-28</Date> Left Craniotomy for mass resection History of Present Illness: <Name>Tammy</Name> <Name>Thompkins</Name> is a 62-year-old left-handed man who is here for a follow up of his left sphenoid meningioma. I last saw him on <Date>1968-11-31</Date> and his head CT showed growth of the left sphenoid meningioma. He is seizure free. Today, he is here with his wife and daughter. <Name>Olivia Waldon</Name> does not have headache, nausea, vomiting, urinary incontinence, or fall. His neurological problem began on <Date>1935-5-8</Date> when he became confused and disoriented in a hotel bathroom. At that time, he was visiting his daughter for a wedding. His wife found him slumped over in the bath tube. According to her, his eyes looked funny. He could not stand up. His verbal output did not make sense. He was brought to <Name>Liz</Name> Hospital in Placentia, CA. He woke up 7 to 8 hours later in the emergency room. He felt very tired after the event. He was hospitalized from <Date>1935-5-8</Date> to <Date>1952-8-21</Date>. He had a cardiac pacemaker placement due to irregular heart rate and bradycardia. He also had a head MRI that showed a less than 1 cm diameter sphenoid meningioma. Past Medical History: Cardiac arrhythmia as noted above, has a pacemaker in place, prostate cancer with prostatectomy, and hypertension. Social History: Lives with his wife. Retired, works parttime driving a school bus. Family History: NC Physical Exam: Temperature is 97.8 F. His blood pressure is 150/92. Pulse is 80. Respiration is 16. His skin has full turgor. HEENT is unremarkable. Neck is supple. Cardiac examination reveals regular rate and rhythms. His lungs are clear. His abdomen is soft with good bowel sounds. His extremities do not show clubbing, cyanosis, or edema. Neurological Examination: His Karnofsky Performance Score is 100. He is awake, alert, and oriented times 3. There His language is fluent with good comprehension. His recent recall is intact. Cranial Nerve Examination: His pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. There is no nystagmus. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He does not have a drift. His muscle strengths are <Date>11-27</Date> at all muscle groups. His muscle tone is normal. His reflexes are 0 in upper and lower extremities bilaterally. His ankle jerks are absent. His toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. His gait is normal. He can do tandem. He does not have a Romberg. PHYSICAL EXAM UPON DISCHARGE: non focal incision c/d/i, dissolvable sutures Pertinent Results: <Date>6-28</Date> CT Head: IMPRESSION: 1. Likely meningioma along the greater <Name>Alphonso</Name> of the left sphenoid bone, measuring 18 mm in diameter, unchanged since the most recent study of <Date>10/1934</Date>, with reactive bony changes, as above. 2. Bifrontal cortical atrophy, which has progressed slightly over the series of studies since the earliest studies of <Year>1989</Year>. <Date>6-28</Date> CT Head: IMPRESSION: Expected post-operative changes with the left frontal craniotomy including subcutaneous air and soft tissue swelling, moderate pneumocephalus overlying predominantly the bilateral frontal lobes, and foci of hemorrhage in the surgical bed. No evidence of residual tumor on this non contrast CT. <Date>1-12</Date> CXR: FINDINGS: The lung volumes are rather low. There is moderate cardiomegaly without evidence of overt pulmonary edema. No areas of atelectasis or pneumonia. Right pectoral pacemaker in situ, with correct lead placement. <Date>9-29</Date> Head CT /c contrast: IMPRESSION: Status post left frontal craniotomy changes with improvement of pneumocephalus and stable 3 mm left to right midline shift; focus of hemorrhage with/without residual tumor in the resection bed is similar in appearance to prior exam but now with more surrounding vasogenic edema. Stable appearance of subarachnoid hemorrhage. Followup to assess for residual tumor/ interval change. Brief Hospital Course: Patient presented electively on <Date>6-28</Date> for left sided craniotomy for mass resection. he tolerated the procedure well and was taken to the Trauma ICU post-operatively still intubated. Shortly thereafter he was deemed fit for extubation which was done without difficulty. At post-op check he was neurologically intact. On <Date>1-12</Date> he was neurologically intact and cleared for transfer to the stepdown unit. This did not happen due to bed shortage. A CT with contrast was ordered for post op evaluation. On <Date>3-13</Date> he was again stable and cleared for transfer to the floor. Decadron taper was initiated. He was seen by PT and cleared for discharge home. On <Date>9-29</Date> the patient was being prepped for discharge but was noted to have intermittent heart rate in the 130-170's. His other vitals were stable. Electrophysiology was consulted and they recommended increasing the metoprolol XL dose to 100mg Qday. The patient was kept overnight to monitor this new dose. On <Date>2-20</Date> her remained stable neurologically and hemodynamically therefore he was cleared for discharge. Medications on Admission: coumadin, keppra, toprol xl, diovan, zocor Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 2. senna 8.6 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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain or fever > 101.4. 5. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. 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 9. metoprolol succinate 100 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 10. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 6 days: 3mg Q8hr on <Date>2-20</Date>, then 2mg Q8hr x2 day, 1mg Q8hr x2 day, 1mg Q12hr x1 day then d/c. Disp:qs Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left sided brain lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures so you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????You need an appointment in the Brain <Hospital>Kim-Jackson Medical Center</Hospital> Clinic. The Brain <Hospital>Kim-Jackson Medical Center</Hospital> Clinic is located on the <Hospital>Marquez, Hunt and Frank Medical Center</Hospital> of <Hospital>Robinson Group Hospital</Hospital>, in the <Hospital>Alexander, Lopez and Frye Medical Center</Hospital> Building, <Location>USNV Sims FPO AE 73732</Location>. Their phone number is <Telephone>418-830-8495</Telephone>. They will call you with an appointment within the next 2 weeks. Please call if you do not hear from the, you need to change your appointment, or require additional directions. ?????? Changes were made to your heart rate/blood pressure medication while you were in house. You were seen by the cardiology team who made these recommendations. Please follow up with your PCP within one week to check your heart rate and blood pressure. Completed 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Date: 2014-1-6 Discharge Date: 2015-12-27 Date of Birth: 1999-12-1 Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:Sylvester Chief Complaint: left sided brain lesion Major Surgical or Invasive Procedure: 6-28 Left Craniotomy for mass resection History of Present Illness: Tammy Thompkins is a 62-year-old left-handed man who is here for a follow up of his left sphenoid meningioma. I last saw him on 1968-11-31 and his head CT showed growth of the left sphenoid meningioma. He is seizure free. Today, he is here with his wife and daughter. Olivia Waldon does not have headache, nausea, vomiting, urinary incontinence, or fall. His neurological problem began on 1935-5-8 when he became confused and disoriented in a hotel bathroom. At that time, he was visiting his daughter for a wedding. His wife found him slumped over in the bath tube. According to her, his eyes looked funny. He could not stand up. His verbal output did not make sense. He was brought to Liz Hospital in Placentia, CA. He woke up 7 to 8 hours later in the emergency room. He felt very tired after the event. He was hospitalized from 1935-5-8 to 1952-8-21. He had a cardiac pacemaker placement due to irregular heart rate and bradycardia. He also had a head MRI that showed a less than 1 cm diameter sphenoid meningioma. Past Medical History: Cardiac arrhythmia as noted above, has a pacemaker in place, prostate cancer with prostatectomy, and hypertension. Social History: Lives with his wife. Retired, works parttime driving a school bus. Family History: NC Physical Exam: Temperature is 97.8 F. His blood pressure is 150/92. Pulse is 80. Respiration is 16. His skin has full turgor. HEENT is unremarkable. Neck is supple. Cardiac examination reveals regular rate and rhythms. His lungs are clear. His abdomen is soft with good bowel sounds. His extremities do not show clubbing, cyanosis, or edema. Neurological Examination: His Karnofsky Performance Score is 100. He is awake, alert, and oriented times 3. There His language is fluent with good comprehension. His recent recall is intact. Cranial Nerve Examination: His pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. There is no nystagmus. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He does not have a drift. His muscle strengths are 11-27 at all muscle groups. His muscle tone is normal. His reflexes are 0 in upper and lower extremities bilaterally. His ankle jerks are absent. His toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. His gait is normal. He can do tandem. He does not have a Romberg. PHYSICAL EXAM UPON DISCHARGE: non focal incision c/d/i, dissolvable sutures Pertinent Results: 6-28 CT Head: IMPRESSION: 1. Likely meningioma along the greater Alphonso of the left sphenoid bone, measuring 18 mm in diameter, unchanged since the most recent study of 10/1934, with reactive bony changes, as above. 2. Bifrontal cortical atrophy, which has progressed slightly over the series of studies since the earliest studies of 1989. 6-28 CT Head: IMPRESSION: Expected post-operative changes with the left frontal craniotomy including subcutaneous air and soft tissue swelling, moderate pneumocephalus overlying predominantly the bilateral frontal lobes, and foci of hemorrhage in the surgical bed. No evidence of residual tumor on this non contrast CT. 1-12 CXR: FINDINGS: The lung volumes are rather low. There is moderate cardiomegaly without evidence of overt pulmonary edema. No areas of atelectasis or pneumonia. Right pectoral pacemaker in situ, with correct lead placement. 9-29 Head CT /c contrast: IMPRESSION: Status post left frontal craniotomy changes with improvement of pneumocephalus and stable 3 mm left to right midline shift; focus of hemorrhage with/without residual tumor in the resection bed is similar in appearance to prior exam but now with more surrounding vasogenic edema. Stable appearance of subarachnoid hemorrhage. Followup to assess for residual tumor/ interval change. Brief Hospital Course: Patient presented electively on 6-28 for left sided craniotomy for mass resection. he tolerated the procedure well and was taken to the Trauma ICU post-operatively still intubated. Shortly thereafter he was deemed fit for extubation which was done without difficulty. At post-op check he was neurologically intact. On 1-12 he was neurologically intact and cleared for transfer to the stepdown unit. This did not happen due to bed shortage. A CT with contrast was ordered for post op evaluation. On 3-13 he was again stable and cleared for transfer to the floor. Decadron taper was initiated. He was seen by PT and cleared for discharge home. On 9-29 the patient was being prepped for discharge but was noted to have intermittent heart rate in the 130-170's. His other vitals were stable. Electrophysiology was consulted and they recommended increasing the metoprolol XL dose to 100mg Qday. The patient was kept overnight to monitor this new dose. On 2-20 her remained stable neurologically and hemodynamically therefore he was cleared for discharge. Medications on Admission: coumadin, keppra, toprol xl, diovan, zocor Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 2. senna 8.6 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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain or fever > 101.4. 5. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. 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 9. metoprolol succinate 100 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 10. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 6 days: 3mg Q8hr on 2-20, then 2mg Q8hr x2 day, 1mg Q8hr x2 day, 1mg Q12hr x1 day then d/c. Disp:qs Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left sided brain lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures so you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????You need an appointment in the Brain Kim-Jackson Medical Center Clinic. The Brain Kim-Jackson Medical Center Clinic is located on the Marquez, Hunt and Frank Medical Center of Robinson Group Hospital, in the Alexander, Lopez and Frye Medical Center Building, USNV Sims FPO AE 73732. Their phone number is 418-830-8495. They will call you with an appointment within the next 2 weeks. Please call if you do not hear from the, you need to change your appointment, or require additional directions. ?????? Changes were made to your heart rate/blood pressure medication while you were in house. You were seen by the cardiology team who made these recommendations. Please follow up with your PCP within one week to check your heart rate and blood pressure. Completed by:2015-12-27	['Admission Date: 2014-1-6 Discharge Date: 2015-12-27\n\nDate of Birth: 1999-12-1 Sex: M\n\nService: NEUROSURGERY\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Sylvester\nChief Complaint:\nleft sided brain lesion\n\nMajor Surgical or Invasive Procedure:\n6-28 Left Craniotomy for mass resection\n\n\nHistory of Present Illness:\nTammy Thompkins is a 62-year-old left-handed man who is here for a\nfollow up of his left sphenoid meningioma. I last saw him on\n1968-11-31 and his head CT showed growth of the left sphenoid\nmeningioma. He is seizure free. Today, he is here with his\nwife\nand daughter. Olivia Waldon does not have headache, nausea, vomiting,\nurinary incontinence, or fall.\n\nHis neurological problem began on 1935-5-8 when he became\nconfused and disoriented in a hotel bathroom.', ' At that time, he\nwas visiting his daughter for a wedding. His wife found him\nslumped over in the bath tube. According to her, his eyes\nlooked\nfunny. He could not stand up. His verbal output did not make\nsense. He was brought to Liz Hospital in Placentia,\nCA. He woke up 7 to 8 hours later in the emergency room. He\nfelt very tired after the event. He was hospitalized from\n1935-5-8 to 1952-8-21. He had a cardiac pacemaker placement due\nto irregular heart rate and bradycardia. He also had a head MRI\nthat showed a less than 1 cm diameter sphenoid meningioma.\n\n\nPast Medical History:\nCardiac arrhythmia as noted above, has a\npacemaker in place, prostate cancer with prostatectomy, and\nhypertension.\n\n\nSocial History:\nLives with his wife. Retired, works parttime\ndriving a school bus.\n\n\nFamily History:\nNC\n\nPhysical Exam:\nTemperature is 97.', '8 F. His blood pressure\nis 150/92. Pulse is 80. Respiration is 16. His skin\nhas full turgor. HEENT is unremarkable. Neck is supple.\nCardiac examination reveals regular rate and rhythms. His lungs\nare clear. His abdomen is soft with good bowel sounds. His\nextremities do not show clubbing, cyanosis, or edema.\n\nNeurological Examination: His Karnofsky Performance Score is\n100. He is awake, alert, and oriented times 3. There His\nlanguage is fluent with good comprehension. His recent recall\nis\nintact. Cranial Nerve Examination: His pupils are equal and\nreactive to light, 4 mm to 2 mm bilaterally. Extraocular\nmovements are full. There is no nystagmus. Visual fields are\nfull to confrontation. Funduscopic examination reveals sharp\ndisks margins bilaterally. His face is symmetric.', ' Facial\nsensation is intact bilaterally. His hearing is intact\nbilaterally. His tongue is midline. Palate goes up in the\nmidline. Sternocleidomastoids and upper trapezius are strong.\nMotor Examination: He does not have a drift. His muscle\nstrengths are 11-27 at all muscle groups. His muscle tone is\nnormal. His reflexes are 0 in upper and lower extremities\nbilaterally. His ankle jerks are absent. His toes are\ndown going. Sensory examination is intact to touch and\nproprioception. Coordination examination does not reveal\ndysmetria. His gait is normal. He can do tandem. He does not\nhave a Romberg.\n\nPHYSICAL EXAM UPON DISCHARGE:\nnon focal\nincision c/d/i, dissolvable sutures\n\nPertinent Results:\n6-28 CT Head: IMPRESSION:\n1. Likely meningioma along the greater Alphonso of the left sphenoid\nbone,\nmeasuring 18 mm in diameter, unchanged since the most recent\nstudy of 10/1934, with reactive bony changes, as above.', '\n2. Bifrontal cortical atrophy, which has progressed slightly\nover the series of studies since the earliest studies of 1989.\n\n6-28 CT Head: IMPRESSION:\nExpected post-operative changes with the left frontal craniotomy\nincluding\nsubcutaneous air and soft tissue swelling, moderate\npneumocephalus overlying predominantly the bilateral frontal\nlobes, and foci of hemorrhage in the surgical bed. No evidence\nof residual tumor on this non contrast CT.\n\n1-12 CXR: FINDINGS: The lung volumes are rather low. There is\nmoderate cardiomegaly without evidence of overt pulmonary edema.\nNo areas of atelectasis or pneumonia. Right pectoral pacemaker\nin situ, with correct lead placement.\n\n\n9-29 Head CT /c contrast: IMPRESSION: Status post left frontal\ncraniotomy changes with improvement of pneumocephalus and stable\n3 mm left to right midline shift; focus of hemorrhage\nwith/without residual tumor in the resection bed is similar in\nappearance to prior exam but now with more surrounding vasogenic\nedema.', " Stable appearance of subarachnoid hemorrhage. Followup to\nassess for residual tumor/ interval change.\n\n\nBrief Hospital Course:\nPatient presented electively on 6-28 for left sided craniotomy\nfor mass resection. he tolerated the procedure well and was\ntaken to the Trauma ICU post-operatively still intubated.\nShortly thereafter he was deemed fit for extubation which was\ndone without difficulty. At post-op check he was neurologically\nintact.\nOn 1-12 he was neurologically intact and cleared for transfer to\nthe stepdown unit. This did not happen due to bed shortage. A CT\nwith contrast was ordered for post op evaluation.\nOn 3-13 he was again stable and cleared for transfer to the\nfloor. Decadron taper was initiated. He was seen by PT and\ncleared for discharge home.\nOn 9-29 the patient was being prepped for discharge but was\nnoted to have intermittent heart rate in the 130-170's.", ' His\nother vitals were stable. Electrophysiology was consulted and\nthey recommended increasing the metoprolol XL dose to 100mg\nQday. The patient was kept overnight to monitor this new dose.\nOn 2-20 her remained stable neurologically and hemodynamically\ntherefore he was cleared for discharge.\n\nMedications on Admission:\ncoumadin, keppra, toprol xl, diovan, zocor\n\nDischarge Medications:\n1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)\nas needed for pain.\nDisp:60 Tablet(s) Refills:0\n2. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every\n6 hours) as needed for Pain or fever > 101.4.\n5. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).', '\n\n6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n7. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2\ntimes a day).\n8. 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\n9. metoprolol succinate 100 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\n10. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 6\ndays: 3mg Q8hr on 2-20, then 2mg Q8hr x2 day, 1mg Q8hr x2 day,\n1mg Q12hr x1 day then d/c.\nDisp:qs Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nLeft sided brain lesion\n\n\nDischarge Condition:\nMental Status: Clear and coherent.', '\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n\nDischarge Instructions:\nGeneral Instructions/Information\n\n??????\tHave a friend/family member check your incision daily for\nsigns of infection.\n??????\tTake your pain medicine as prescribed.\n??????\tExercise should be limited to walking; no lifting, straining,\nor excessive bending.\n??????\tYou have dissolvable sutures so you may wash your hair and get\nyour incision wet day 3 after surgery. You may shower before\nthis time using a shower cap to cover your head.\n??????\tIncrease your intake of fluids and fiber, as narcotic pain\nmedicine can cause constipation. We generally recommend taking\nan over the counter stool softener, such as Docusate (Colace) &\nSenna while taking narcotic pain medication.\n??????\tUnless directed by your doctor, do not take any\nanti-inflammatory medicines such as Motrin, Aspirin, Advil, and\nIbuprofen etc.', '\n??????\t If you have been discharged on Keppra (Levetiracetam), you\nwill not require blood work monitoring.\n??????\tYou are being sent home on steroid medication, make sure you\nare taking a medication to protect your stomach (Prilosec,\nProtonix, or Pepcid), as these medications can cause stomach\nirritation. Make sure to take your steroid medication with\nmeals, or a glass of milk.\n??????\tClearance to drive and return to work will be addressed at\nyour post-operative office visit.\n??????\tMake sure to continue to use your incentive spirometer while\nat home.\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: increasing redness,\nincreased swelling, increased tenderness, or drainage.\n??????\tFever greater than or equal to 101?????? F.\n\n\nFollowup Instructions:\n??????You need an appointment in the Brain Kim-Jackson Medical Center Clinic. The Brain\nKim-Jackson Medical Center Clinic is located on the Marquez, Hunt and Frank Medical Center of Robinson Group Hospital, in the\nAlexander, Lopez and Frye Medical Center Building, USNV Sims\nFPO AE 73732. Their phone number is 418-830-8495.\nThey will call you with an appointment within the next 2 weeks.\nPlease call if you do not hear from the, you need to change your\nappointment, or require additional directions.\n\n?????? Changes were made to your heart rate/blood pressure\nmedication while you were in house.', ' You were seen by the\ncardiology team who made these recommendations. Please follow up\nwith your PCP within one week to check your heart rate and blood\npressure.\n\n\n\nCompleted by:2015-12-27']
182	56174	163469.0	2118-08-12	Discharge summary	Report	Admission Date: [2118-8-10] Discharge Date: [2118-8-12] Date of Birth: [2073-12-25] Sex: F Service: NEUROSURGERY Allergies: Codeine Attending:[First Name3 (LF) 1854] Chief Complaint: elective admission for radionecrosis resection due to radiosurgery of AVM Major Surgical or Invasive Procedure: Left craniotomy for radionecrosis resection History of Present Illness: Presents for resection of radionecrosis s/p radiosurgery for AVM Past Medical History: seizures,h/o radio therapy for avm has resid edema causing seizures; Dysrhythmia (palps w/ panic attacks), Recent Upper Respiratory Infection Social History: NC Family History: NC Physical Exam: Upon discharge: The patient was alert and oriented. She followed commands easily. PERRL, EOMs intact. Face symmetric, tongue midline. Strength was full throughout and sensation was intact to light touch. Incision was clean, dry, and intact. Pertinent Results: [2118-8-10] 02:09PM GLUCOSE-161* UREA N-10 CREAT-0.8 SODIUM-142 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 [2118-8-10] 02:09PM WBC-12.2# RBC-4.03 HGB-11.5* HCT-34.5* MCV-86 MCH-28.4 MCHC-33.2 RDW-13.3 Pathology Report from [2118-8-10]: DIAGNOSIS: 1. Brain, left frontal (A): 1. Vascular malformation consistent with arteriovenous malformation of cortical [Doctor Last Name 352] and white matter with radiation induced fibrinoid necrosis. 2. Focal hemosiderin deposition suggesting prior hemorrhages. 2. Left frontal radionecrosis and residual AVM (B): 1. Vascular malformation consistent with arteriovenous malformation of cortical [Doctor Last Name 352] and white matter with radiation induced fibrinoid necrosis. 2. Focal hemosiderin deposition suggesting prior hemorrhages. Clinical: Radionecrosis. CT Head post-op [8-10]: FINDINGS: There is a left-sided frontal craniotomy with surgical resection of the enhancing "mass" noted in previous studies. There is extensive confluent hypodensity in the left frontoparietal region, that likely represents post-radiation vasogenic edema with resultant 8.5-mm shift of normally-midline structures, not significantly changed from the previous MR. There is a tiny focus of hyperdensity in the postoperative field which may represent a small amount of hemorrhage. There is expost-operative pneumocephalus and subcutaneous air noted. IMPRESSION: Status post left craniotomy and resection of AVM and possible "mass"-like radiation necrosis, with small hyperdense focus in the operative bed, likely representing very small hemorrhage. Extensive vasogenic edema persists. Brief Hospital Course: Post-operatively she was admitted to the ICU for observation s/p resection. Her Post-op head CT was negative for bleeding. She remained intubated immediately post-op. She was weaned and extubated on [8-11] and did very well neurologically. The patient was transferred out of the ICU later that day. She was ambulating without difficulty, her pain was well-controlled, and she was taking in food with no nausea/vomiting. Her post-operative MRI was done on [8-12] and showed expected post-operative changes. She was discharged on [2118-8-12]. Medications on Admission: Acetaminophen, Effexor 50 [Hospital1 ], Ibuprofen [Motrin, Advil], Keppra (Levetiracetam) (25oomg Discharge Medications: 1. 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 2. Venlafaxine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: No driving while on this medication. Disp:50 Tablet(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours) for 1 doses: Taper to 2mg TID x 3 doses on [8-13]. Taper to 1mg TID x 3 doses on [8-14]. Disp:12 Tablet(s) Refills:0 She will continue her Keppra and has a prescription at home. Discharge Disposition: Home Discharge Diagnosis: AVM Radionecrosis Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ??????Have a family member check your incision daily for signs of infection ??????Take your pain medicine as prescribed ??????Exercise should be limited to walking; no lifting, straining, excessive bending ??????You may wash your hair only after sutures 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 in 7 days and fax results to [Telephone/Fax (1) 87]. ??????Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ??????New onset of tremors or seizures ??????Any confusion or change in mental status ??????Any numbness, tingling, weakness in your extremities ??????Pain or headache that is continually increasing or not relieved by pain medication ??????Any signs of infection at the wound site: redness, swelling, tenderness, drainage ??????Fever greater than or equal to 101?????? F Followup Instructions: PLEASE RETURN TO THE OFFICE IN 8 DAYS FOR REMOVAL OF YOUR SUTURES 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 PRIOR TO THE APPOINTMENT Completed by:[2118-8-12]	Admission Date: <Date>1911-9-19</Date> Discharge Date: <Date>1958-3-14</Date> Date of Birth: <Date>1966-12-12</Date> Sex: F Service: NEUROSURGERY Allergies: Codeine Attending:<Name>Rama</Name> Chief Complaint: elective admission for radionecrosis resection due to radiosurgery of AVM Major Surgical or Invasive Procedure: Left craniotomy for radionecrosis resection History of Present Illness: Presents for resection of radionecrosis s/p radiosurgery for AVM Past Medical History: seizures,h/o radio therapy for avm has resid edema causing seizures; Dysrhythmia (palps w/ panic attacks), Recent Upper Respiratory Infection Social History: NC Family History: NC Physical Exam: Upon discharge: The patient was alert and oriented. She followed commands easily. PERRL, EOMs intact. Face symmetric, tongue midline. Strength was full throughout and sensation was intact to light touch. Incision was clean, dry, and intact. Pertinent Results: <Date>1911-9-19</Date> 02:09PM GLUCOSE-161* UREA N-10 CREAT-0.8 SODIUM-142 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 <Date>1911-9-19</Date> 02:09PM WBC-12.2# RBC-4.03 HGB-11.5* HCT-34.5* MCV-86 MCH-28.4 MCHC-33.2 RDW-13.3 Pathology Report from <Date>1911-9-19</Date>: DIAGNOSIS: 1. Brain, left frontal (A): 1. Vascular malformation consistent with arteriovenous malformation of cortical <Doctor Name>Dr.Thompson</Doctor Name> and white matter with radiation induced fibrinoid necrosis. 2. Focal hemosiderin deposition suggesting prior hemorrhages. 2. Left frontal radionecrosis and residual AVM (B): 1. Vascular malformation consistent with arteriovenous malformation of cortical <Doctor Name>Dr.Thompson</Doctor Name> and white matter with radiation induced fibrinoid necrosis. 2. Focal hemosiderin deposition suggesting prior hemorrhages. Clinical: Radionecrosis. CT Head post-op <Date>12-3</Date>: FINDINGS: There is a left-sided frontal craniotomy with surgical resection of the enhancing "mass" noted in previous studies. There is extensive confluent hypodensity in the left frontoparietal region, that likely represents post-radiation vasogenic edema with resultant 8.5-mm shift of normally-midline structures, not significantly changed from the previous MR. There is a tiny focus of hyperdensity in the postoperative field which may represent a small amount of hemorrhage. There is expost-operative pneumocephalus and subcutaneous air noted. IMPRESSION: Status post left craniotomy and resection of AVM and possible "mass"-like radiation necrosis, with small hyperdense focus in the operative bed, likely representing very small hemorrhage. Extensive vasogenic edema persists. Brief Hospital Course: Post-operatively she was admitted to the ICU for observation s/p resection. Her Post-op head CT was negative for bleeding. She remained intubated immediately post-op. She was weaned and extubated on <Date>6-4</Date> and did very well neurologically. The patient was transferred out of the ICU later that day. She was ambulating without difficulty, her pain was well-controlled, and she was taking in food with no nausea/vomiting. Her post-operative MRI was done on <Date>1-4</Date> and showed expected post-operative changes. She was discharged on <Date>1958-3-14</Date>. Medications on Admission: Acetaminophen, Effexor 50 <Hospital>Brown, Rios and Myers Hospital</Hospital>, Ibuprofen [Motrin, Advil], Keppra (Levetiracetam) (25oomg Discharge Medications: 1. 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 2. Venlafaxine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: No driving while on this medication. Disp:50 Tablet(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours) for 1 doses: Taper to 2mg TID x 3 doses on <Date>12-27</Date>. Taper to 1mg TID x 3 doses on <Date>1-30</Date>. Disp:12 Tablet(s) Refills:0 She will continue her Keppra and has a prescription at home. Discharge Disposition: Home Discharge Diagnosis: AVM Radionecrosis Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ??????Have a family member check your incision daily for signs of infection ??????Take your pain medicine as prescribed ??????Exercise should be limited to walking; no lifting, straining, excessive bending ??????You may wash your hair only after sutures 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 in 7 days and fax results to <Telephone>987-645-2742</Telephone>. ??????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 RETURN TO THE OFFICE IN 8 DAYS FOR REMOVAL OF YOUR SUTURES PLEASE CALL <Telephone>831-893-5802</Telephone> TO SCHEDULE AN APPOINTMENT WITH DR. <Name>Hazelwood</Name> TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PRIOR TO THE APPOINTMENT Completed by:<Date>1958-3-14</Date>	000000000000000001111111110000000000000000000000000000000011111111100000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001110000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000011111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111110000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111	Admission Date: 1911-9-19 Discharge Date: 1958-3-14 Date of Birth: 1966-12-12 Sex: F Service: NEUROSURGERY Allergies: Codeine Attending:Rama Chief Complaint: elective admission for radionecrosis resection due to radiosurgery of AVM Major Surgical or Invasive Procedure: Left craniotomy for radionecrosis resection History of Present Illness: Presents for resection of radionecrosis s/p radiosurgery for AVM Past Medical History: seizures,h/o radio therapy for avm has resid edema causing seizures; Dysrhythmia (palps w/ panic attacks), Recent Upper Respiratory Infection Social History: NC Family History: NC Physical Exam: Upon discharge: The patient was alert and oriented. She followed commands easily. PERRL, EOMs intact. Face symmetric, tongue midline. Strength was full throughout and sensation was intact to light touch. Incision was clean, dry, and intact. Pertinent Results: 1911-9-19 02:09PM GLUCOSE-161* UREA N-10 CREAT-0.8 SODIUM-142 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 1911-9-19 02:09PM WBC-12.2# RBC-4.03 HGB-11.5* HCT-34.5* MCV-86 MCH-28.4 MCHC-33.2 RDW-13.3 Pathology Report from 1911-9-19: DIAGNOSIS: 1. Brain, left frontal (A): 1. Vascular malformation consistent with arteriovenous malformation of cortical Dr.Thompson and white matter with radiation induced fibrinoid necrosis. 2. Focal hemosiderin deposition suggesting prior hemorrhages. 2. Left frontal radionecrosis and residual AVM (B): 1. Vascular malformation consistent with arteriovenous malformation of cortical Dr.Thompson and white matter with radiation induced fibrinoid necrosis. 2. Focal hemosiderin deposition suggesting prior hemorrhages. Clinical: Radionecrosis. CT Head post-op 12-3: FINDINGS: There is a left-sided frontal craniotomy with surgical resection of the enhancing "mass" noted in previous studies. There is extensive confluent hypodensity in the left frontoparietal region, that likely represents post-radiation vasogenic edema with resultant 8.5-mm shift of normally-midline structures, not significantly changed from the previous MR. There is a tiny focus of hyperdensity in the postoperative field which may represent a small amount of hemorrhage. There is expost-operative pneumocephalus and subcutaneous air noted. IMPRESSION: Status post left craniotomy and resection of AVM and possible "mass"-like radiation necrosis, with small hyperdense focus in the operative bed, likely representing very small hemorrhage. Extensive vasogenic edema persists. Brief Hospital Course: Post-operatively she was admitted to the ICU for observation s/p resection. Her Post-op head CT was negative for bleeding. She remained intubated immediately post-op. She was weaned and extubated on 6-4 and did very well neurologically. The patient was transferred out of the ICU later that day. She was ambulating without difficulty, her pain was well-controlled, and she was taking in food with no nausea/vomiting. Her post-operative MRI was done on 1-4 and showed expected post-operative changes. She was discharged on 1958-3-14. Medications on Admission: Acetaminophen, Effexor 50 Brown, Rios and Myers Hospital, Ibuprofen [Motrin, Advil], Keppra (Levetiracetam) (25oomg Discharge Medications: 1. 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 2. Venlafaxine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: No driving while on this medication. Disp:50 Tablet(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours) for 1 doses: Taper to 2mg TID x 3 doses on 12-27. Taper to 1mg TID x 3 doses on 1-30. Disp:12 Tablet(s) Refills:0 She will continue her Keppra and has a prescription at home. Discharge Disposition: Home Discharge Diagnosis: AVM Radionecrosis Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ??????Have a family member check your incision daily for signs of infection ??????Take your pain medicine as prescribed ??????Exercise should be limited to walking; no lifting, straining, excessive bending ??????You may wash your hair only after sutures 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 in 7 days and fax results to 987-645-2742. ??????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 RETURN TO THE OFFICE IN 8 DAYS FOR REMOVAL OF YOUR SUTURES PLEASE CALL 831-893-5802 TO SCHEDULE AN APPOINTMENT WITH DR. Hazelwood TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PRIOR TO THE APPOINTMENT Completed by:1958-3-14	['Admission Date: 1911-9-19 Discharge Date: 1958-3-14\n\nDate of Birth: 1966-12-12 Sex: F\n\nService: NEUROSURGERY\n\nAllergies:\nCodeine\n\nAttending:Rama\nChief Complaint:\nelective admission for radionecrosis resection due to\nradiosurgery of AVM\n\nMajor Surgical or Invasive Procedure:\nLeft craniotomy for radionecrosis resection\n\n\nHistory of Present Illness:\nPresents for resection of radionecrosis s/p radiosurgery for AVM\n\nPast Medical History:\nseizures,h/o radio therapy for avm has resid edema causing\nseizures; Dysrhythmia (palps w/ panic attacks), Recent Upper\nRespiratory Infection\n\n\nSocial History:\nNC\n\nFamily History:\nNC\n\nPhysical Exam:\nUpon discharge:\nThe patient was alert and oriented. She followed commands\neasily.\nPERRL, EOMs intact.\nFace symmetric, tongue midline.\nStrength was full throughout and sensation was intact to light\ntouch.', '\nIncision was clean, dry, and intact.\n\nPertinent Results:\n1911-9-19 02:09PM GLUCOSE-161* UREA N-10 CREAT-0.8 SODIUM-142\nPOTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13\n1911-9-19 02:09PM WBC-12.2# RBC-4.03 HGB-11.5* HCT-34.5\nMCV-86 MCH-28.4 MCHC-33.2 RDW-13.3\n\nPathology Report from 1911-9-19:\nDIAGNOSIS:\n1. Brain, left frontal (A):\n 1. Vascular malformation consistent with arteriovenous\nmalformation\n of cortical Dr.Thompson and white matter with radiation induced\nfibrinoid\n necrosis.\n 2. Focal hemosiderin deposition suggesting prior\nhemorrhages.\n2. Left frontal radionecrosis and residual AVM (B):\n 1. Vascular malformation consistent with arteriovenous\nmalformation\n of cortical Dr.Thompson and white matter with radiation induced\nfibrinoid\n necrosis.\n 2.', ' Focal hemosiderin deposition suggesting prior\nhemorrhages.\nClinical: Radionecrosis.\n\nCT Head post-op 12-3:\nFINDINGS: There is a left-sided frontal craniotomy with surgical\nresection of the enhancing "mass" noted in previous studies.\nThere is extensive confluent hypodensity in the left\nfrontoparietal region, that likely represents post-radiation\nvasogenic edema with resultant 8.5-mm shift of normally-midline\nstructures, not significantly changed from the previous MR.\nThere is a tiny focus of hyperdensity in the postoperative field\nwhich may represent a small amount of hemorrhage. There is\nexpost-operative pneumocephalus and subcutaneous air noted.\n\nIMPRESSION: Status post left craniotomy and resection of AVM and\npossible\n"mass"-like radiation necrosis, with small hyperdense focus in\nthe operative bed, likely representing very small hemorrhage.', '\nExtensive vasogenic edema persists.\n\n\n\n\nBrief Hospital Course:\nPost-operatively she was admitted to the ICU for observation s/p\nresection. Her Post-op head CT was negative for bleeding. She\nremained intubated immediately post-op. She was weaned and\nextubated on 6-4 and did very well neurologically. The patient\nwas transferred out of the ICU later that day. She was\nambulating without difficulty, her pain was well-controlled, and\nshe was taking in food with no nausea/vomiting. Her\npost-operative MRI was done on 1-4 and showed expected\npost-operative changes. She was discharged on 1958-3-14.\n\nMedications on Admission:\nAcetaminophen, Effexor 50 Brown, Rios and Myers Hospital, Ibuprofen [Motrin, Advil], Keppra\n(Levetiracetam) (25oomg\n\nDischarge Medications:\n1. 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\n2. Venlafaxine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times\na day).\n3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)\nhours as needed for pain: No driving while on this medication.\nDisp:50 Tablet(s) Refills:0\n4. 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\n5. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO Q8H (every\n8 hours) for 1 doses: Taper to 2mg TID x 3 doses on 12-27.\nTaper to 1mg TID x 3 doses on 1-30.\nDisp:12 Tablet(s) Refills:0\n\nShe will continue her Keppra and has a prescription at home.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nAVM\nRadionecrosis\n\n\nDischarge Condition:\nNeurologically stable\n\n\nDischarge Instructions:\nDISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY\n\n??????Have a family member check your incision daily for signs of\ninfection\n??????Take your pain medicine as prescribed\n??????Exercise should be limited to walking; no lifting, straining,\nexcessive bending\n??????You may wash your hair only after sutures have been removed\n??????You may shower before this time with assistance and use of a\nshower cap\n??????Increase your intake of fluids and fiber as pain medicine\n(narcotics) can cause constipation\n??????Unless directed by your doctor, do not take any\nanti-inflammatory medicines such as Motrin, aspirin, Advil,\nIbuprofen etc.', '\n??????If you have been prescribed an anti-seizure medicine, take it\nas prescribed and follow up with laboratory blood drawing in 7\ndays and fax results to 987-645-2742.\n??????Clearance to drive and return to work will be addressed at your\npost-operative office visit\n\nCALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE\nFOLLOWING:\n\n??????New onset of tremors or seizures\n??????Any confusion or change in mental status\n??????Any numbness, tingling, weakness in your extremities\n??????Pain or headache that is continually increasing or not relieved\nby pain medication\n??????Any signs of infection at the wound site: redness, swelling,\ntenderness, drainage\n??????Fever greater than or equal to 101?????? F\n\n\nFollowup Instructions:\nPLEASE RETURN TO THE OFFICE IN 8 DAYS FOR REMOVAL OF YOUR\nSUTURES\n\nPLEASE CALL 831-893-5802 TO SCHEDULE AN APPOINTMENT WITH DR.', '\nHazelwood TO BE SEEN IN 4 WEEKS.\nYOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PRIOR TO\nTHE APPOINTMENT\n\n\n\nCompleted by:1958-3-14']
183	56174	189681.0	2118-12-09	Discharge summary	Report	Admission Date: [2118-12-7] Discharge Date: [2118-12-9] Date of Birth: [2073-12-25] Sex: F Service: NEUROSURGERY Allergies: Codeine Attending:[First Name3 (LF) 1854] Chief Complaint: Skull defect Major Surgical or Invasive Procedure: s/p cranioplasty on [2118-12-7] History of Present Illness: 44 yo female with a h/o left frontal AVM in the supplementary motor area. The AVM was treated with stereotactic radiosurgery (Gamma Knife)in [2114]. In [2116], the patient developed a seizure disorder. [2118-5-27] she developed headaches and after an MRI and a digital angiogram showed no residual pathological vessels, a contrast enhancing lesion with massive focal residual edema was diagnosed- very likely represents radionecrosis. The patient had midline shift and mass effect. On [2118-8-10] she had a left craniotomy for resection of the radionecrosis. She then presented to the office in [2118-8-27] with increased left facial swelling and incision drainage, she was taken to the OR for a wound washout and craniectomy. She now returns for a cranioplasty after a long course of outpatient IV antibiotic therapy. Past Medical History: seizures,h/o radio therapy for avm has resid edema causing seizures; Dysrhythmia (palps w/ panic attacks), Recent Upper Respiratory Infection Palpitations with panic attacks Panic, anxiety Depression h/o nephrolithiasis (at 20yrs old) TB as a child (treated) Social History: Married. Lives with husband. Family History: Non-contributory Physical Exam: On admission: AOx3, PERRL, Face symm, tongue midline. EOM intact w/o nystagmus. Speech clear and fluent. Comprehension intact. Follows commands. No pronator. MAE [5-31] Upon discharge: AOx3. Neuro intact. MAE [5-31]. Incision C/D/I. Ambulating, tolerating POs Pertinent Results: CT Head [2118-12-7]: (Post-Op) Patient is status post left frontal cranioplasty. Persistent vasogenic edema in the left frontal lobe, unchanged. No shift of normally midline structures or acute hemorrhage identified. ***************** [2118-12-7*] 03:13PM WBC-13.8# RBC-4.76 HGB-12.8 HCT-37.6 MCV-79* MCH-27.0 MCHC-34.2 RDW-14.4 [2118-12-7] 03:13PM PLT COUNT-555* [2118-12-7] 03:13PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.3 [2118-12-7] 03:13PM estGFR-Using this [2118-12-7] 03:13PM GLUCOSE-128* CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13 Brief Hospital Course: 44 yo female who was electively admitted for a cranioplasty with Dr. [Last Name (STitle) ]. Immediately post-op she remained in the PACU overnight. Overnight she voided 4L and received 1L NS bolus. POD 1 she was transferred to the floor. Prior to transfer she was noted to have increase HR, low BP, and low urine output thus received 1L of NS. On the floor, she was OOB to chair, tolerating a regular diet. She was neurologically intact and cleared for discharge on [2118-12-9]. Medications on Admission: FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - 50 mcg Spray, Suspension - 2 sprays(s) each nostril daily as needed for nasal congestion LEVETIRACETAM [KEPPRA] - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day - No Substitution LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 1 Tablet(s) by mouth at bedtime - No Substitution LEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth four times a day - No Substitution OSELTAMIVIR [TAMIFLU] - 75 mg Capsule - one Capsule(s) by mouth twice a day x 5 days VENLAFAXINE - 50 mg Tablet - One Tablet(s) by mouth twice a day ACETAMINOPHEN [TYLENOL] - (OTC) - Dosage uncertain IBUPROFEN [ADVIL MIGRAINE] - (OTC) - 200 mg Capsule - 1 Capsule(s) by mouth once a day as needed for headache Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/t>100/HA. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Venlafaxine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily) as needed for nasal congestion. 7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 6 days: Take 2mg Q6hrs [Date range (1) 1855], take 2mg Q12 [Date range (1) 1856], Take 2mg Q24 [12-14], then stop. Disp:16 Tablet(s) Refills:0 8. Levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Skull defect s/p cranioplasty Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: You will need to see the nurse practitioner 14 days post-operatively for suture removal. Please call [Telephone/Fax (1) 1669] for the appointment. You will need to follow up with Dr. [Last Name (STitle) ] in 4 weeks with a Head CT of the brain. Completed by:[2118-12-9]	Admission Date: <Date>1926-4-8</Date> Discharge Date: <Date>1953-6-27</Date> Date of Birth: <Date>1920-7-11</Date> Sex: F Service: NEUROSURGERY Allergies: Codeine Attending:<Name>Carl</Name> Chief Complaint: Skull defect Major Surgical or Invasive Procedure: s/p cranioplasty on <Date>1926-4-8</Date> History of Present Illness: 44 yo female with a h/o left frontal AVM in the supplementary motor area. The AVM was treated with stereotactic radiosurgery (Gamma Knife)in <Year>1972</Year>. In <Year>1972</Year>, the patient developed a seizure disorder. <Date>2008-11-14</Date> she developed headaches and after an MRI and a digital angiogram showed no residual pathological vessels, a contrast enhancing lesion with massive focal residual edema was diagnosed- very likely represents radionecrosis. The patient had midline shift and mass effect. On <Date>1935-6-29</Date> she had a left craniotomy for resection of the radionecrosis. She then presented to the office in <Date>1904-5-3</Date> with increased left facial swelling and incision drainage, she was taken to the OR for a wound washout and craniectomy. She now returns for a cranioplasty after a long course of outpatient IV antibiotic therapy. Past Medical History: seizures,h/o radio therapy for avm has resid edema causing seizures; Dysrhythmia (palps w/ panic attacks), Recent Upper Respiratory Infection Palpitations with panic attacks Panic, anxiety Depression h/o nephrolithiasis (at 20yrs old) TB as a child (treated) Social History: Married. Lives with husband. Family History: Non-contributory Physical Exam: On admission: AOx3, PERRL, Face symm, tongue midline. EOM intact w/o nystagmus. Speech clear and fluent. Comprehension intact. Follows commands. No pronator. MAE <Date>6-10</Date> Upon discharge: AOx3. Neuro intact. MAE <Date>6-10</Date>. Incision C/D/I. Ambulating, tolerating POs Pertinent Results: CT Head <Date>1926-4-8</Date>: (Post-Op) Patient is status post left frontal cranioplasty. Persistent vasogenic edema in the left frontal lobe, unchanged. No shift of normally midline structures or acute hemorrhage identified. ******************* <Date>1926-4-8</Date> 03:13PM WBC-13.8# RBC-4.76 HGB-12.8 HCT-37.6 MCV-79 MCH-27.0 MCHC-34.2 RDW-14.4 <Date>1926-4-8</Date> 03:13PM PLT COUNT-555* <Date>1926-4-8</Date> 03:13PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.3 <Date>1926-4-8</Date> 03:13PM estGFR-Using this <Date>1926-4-8</Date> 03:13PM GLUCOSE-128* CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13 Brief Hospital Course: 44 yo female who was electively admitted for a cranioplasty with Dr. <Name>Beamon</Name>. Immediately post-op she remained in the PACU overnight. Overnight she voided 4L and received 1L NS bolus. POD 1 she was transferred to the floor. Prior to transfer she was noted to have increase HR, low BP, and low urine output thus received 1L of NS. On the floor, she was OOB to chair, tolerating a regular diet. She was neurologically intact and cleared for discharge on <Date>1953-6-27</Date>. Medications on Admission: FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - 50 mcg Spray, Suspension - 2 sprays(s) each nostril daily as needed for nasal congestion LEVETIRACETAM [KEPPRA] - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day - No Substitution LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 1 Tablet(s) by mouth at bedtime - No Substitution LEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth four times a day - No Substitution OSELTAMIVIR [TAMIFLU] - 75 mg Capsule - one Capsule(s) by mouth twice a day x 5 days VENLAFAXINE - 50 mg Tablet - One Tablet(s) by mouth twice a day ACETAMINOPHEN [TYLENOL] - (OTC) - Dosage uncertain IBUPROFEN [ADVIL MIGRAINE] - (OTC) - 200 mg Capsule - 1 Capsule(s) by mouth once a day as needed for headache Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/t>100/HA. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Venlafaxine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily) as needed for nasal congestion. 7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 6 days: Take 2mg Q6hrs <Date Range>1917-9-15 to 1961-7-2</Date Range>, take 2mg Q12 <Date Range>1990-4-31 to 2017-12-11</Date Range>, Take 2mg Q24 <Date>6-8</Date>, then stop. Disp:16 Tablet(s) Refills:0 8. Levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Skull defect s/p cranioplasty Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: You will need to see the nurse practitioner 14 days post-operatively for suture removal. Please call <Telephone>766-455-7263</Telephone> for the appointment. You will need to follow up with Dr. <Name>Beamon</Name> in 4 weeks with a Head CT of the brain. Completed 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00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111110000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000111111111	Admission Date: 1926-4-8 Discharge Date: 1953-6-27 Date of Birth: 1920-7-11 Sex: F Service: NEUROSURGERY Allergies: Codeine Attending:Carl Chief Complaint: Skull defect Major Surgical or Invasive Procedure: s/p cranioplasty on 1926-4-8 History of Present Illness: 44 yo female with a h/o left frontal AVM in the supplementary motor area. The AVM was treated with stereotactic radiosurgery (Gamma Knife)in 1972. In 1972, the patient developed a seizure disorder. 2008-11-14 she developed headaches and after an MRI and a digital angiogram showed no residual pathological vessels, a contrast enhancing lesion with massive focal residual edema was diagnosed- very likely represents radionecrosis. The patient had midline shift and mass effect. On 1935-6-29 she had a left craniotomy for resection of the radionecrosis. She then presented to the office in 1904-5-3 with increased left facial swelling and incision drainage, she was taken to the OR for a wound washout and craniectomy. She now returns for a cranioplasty after a long course of outpatient IV antibiotic therapy. Past Medical History: seizures,h/o radio therapy for avm has resid edema causing seizures; Dysrhythmia (palps w/ panic attacks), Recent Upper Respiratory Infection Palpitations with panic attacks Panic, anxiety Depression h/o nephrolithiasis (at 20yrs old) TB as a child (treated) Social History: Married. Lives with husband. Family History: Non-contributory Physical Exam: On admission: AOx3, PERRL, Face symm, tongue midline. EOM intact w/o nystagmus. Speech clear and fluent. Comprehension intact. Follows commands. No pronator. MAE 6-10 Upon discharge: AOx3. Neuro intact. MAE 6-10. Incision C/D/I. Ambulating, tolerating POs Pertinent Results: CT Head 1926-4-8: (Post-Op) Patient is status post left frontal cranioplasty. Persistent vasogenic edema in the left frontal lobe, unchanged. No shift of normally midline structures or acute hemorrhage identified. ******************* 1926-4-8 03:13PM WBC-13.8# RBC-4.76 HGB-12.8 HCT-37.6 MCV-79 MCH-27.0 MCHC-34.2 RDW-14.4 1926-4-8 03:13PM PLT COUNT-555* 1926-4-8 03:13PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.3 1926-4-8 03:13PM estGFR-Using this 1926-4-8 03:13PM GLUCOSE-128* CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13 Brief Hospital Course: 44 yo female who was electively admitted for a cranioplasty with Dr. Beamon. Immediately post-op she remained in the PACU overnight. Overnight she voided 4L and received 1L NS bolus. POD 1 she was transferred to the floor. Prior to transfer she was noted to have increase HR, low BP, and low urine output thus received 1L of NS. On the floor, she was OOB to chair, tolerating a regular diet. She was neurologically intact and cleared for discharge on 1953-6-27. Medications on Admission: FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - 50 mcg Spray, Suspension - 2 sprays(s) each nostril daily as needed for nasal congestion LEVETIRACETAM [KEPPRA] - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day - No Substitution LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 1 Tablet(s) by mouth at bedtime - No Substitution LEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth four times a day - No Substitution OSELTAMIVIR [TAMIFLU] - 75 mg Capsule - one Capsule(s) by mouth twice a day x 5 days VENLAFAXINE - 50 mg Tablet - One Tablet(s) by mouth twice a day ACETAMINOPHEN [TYLENOL] - (OTC) - Dosage uncertain IBUPROFEN [ADVIL MIGRAINE] - (OTC) - 200 mg Capsule - 1 Capsule(s) by mouth once a day as needed for headache Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/t>100/HA. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Venlafaxine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily) as needed for nasal congestion. 7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 6 days: Take 2mg Q6hrs 1917-9-15 to 1961-7-2, take 2mg Q12 1990-4-31 to 2017-12-11, Take 2mg Q24 6-8, then stop. Disp:16 Tablet(s) Refills:0 8. Levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Skull defect s/p cranioplasty Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: You will need to see the nurse practitioner 14 days post-operatively for suture removal. Please call 766-455-7263 for the appointment. You will need to follow up with Dr. Beamon in 4 weeks with a Head CT of the brain. Completed by:1953-6-27	['Admission Date: 1926-4-8 Discharge Date: 1953-6-27\n\nDate of Birth: 1920-7-11 Sex: F\n\nService: NEUROSURGERY\n\nAllergies:\nCodeine\n\nAttending:Carl\nChief Complaint:\nSkull defect\n\nMajor Surgical or Invasive Procedure:\ns/p cranioplasty on 1926-4-8\n\n\nHistory of Present Illness:\n44 yo female with a h/o left frontal AVM in the supplementary\nmotor area. The AVM was treated with stereotactic radiosurgery\n(Gamma Knife)in 1972. In 1972, the patient developed a seizure\ndisorder. 2008-11-14 she developed\nheadaches and after an MRI and a digital angiogram showed no\nresidual pathological vessels, a contrast enhancing lesion\nwith massive focal residual edema was diagnosed- very\nlikely represents radionecrosis. The patient had midline\nshift and mass effect. On 1935-6-29 she had a left craniotomy for\nresection of the radionecrosis.', ' She then presented to the office\nin 1904-5-3 with increased left facial swelling and incision\ndrainage, she was taken to the OR for a wound washout and\ncraniectomy. She now returns for a cranioplasty after a long\ncourse of outpatient IV antibiotic therapy.\n\n\nPast Medical History:\nseizures,h/o radio therapy for avm has resid edema causing\nseizures; Dysrhythmia (palps w/ panic attacks), Recent Upper\nRespiratory Infection\nPalpitations with panic attacks\nPanic, anxiety\nDepression\nh/o nephrolithiasis (at 20yrs old)\nTB as a child (treated)\n\n\nSocial History:\nMarried. Lives with husband.\n\nFamily History:\nNon-contributory\n\nPhysical Exam:\nOn admission:\nAOx3, PERRL, Face symm, tongue midline. EOM intact w/o\nnystagmus. Speech clear and fluent. Comprehension intact.\nFollows commands. No pronator. MAE 6-10\n\nUpon discharge:\nAOx3.', ' Neuro intact. MAE 6-10. Incision C/D/I. Ambulating,\ntolerating POs\n\nPertinent Results:\nCT Head 1926-4-8: (Post-Op)\nPatient is status post left frontal cranioplasty. Persistent\nvasogenic edema in the left frontal lobe, unchanged. No shift of\nnormally\nmidline structures or acute hemorrhage identified.\n\n******************\n\n1926-4-8 03:13PM WBC-13.8# RBC-4.76 HGB-12.8 HCT-37.6 MCV-79\nMCH-27.0 MCHC-34.2 RDW-14.4\n1926-4-8 03:13PM PLT COUNT-555\n1926-4-8 03:13PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.3\n1926-4-8 03:13PM estGFR-Using this\n1926-4-8 03:13PM GLUCOSE-128* CREAT-0.9 SODIUM-141\nPOTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13\n\nBrief Hospital Course:\n44 yo female who was electively admitted for a cranioplasty with\nDr. Beamon. Immediately post-op she remained in the PACU\novernight.', ' Overnight she voided 4L and received 1L NS bolus. POD\n1 she was transferred to the floor. Prior to transfer she was\nnoted to have increase HR, low BP, and low urine output thus\nreceived 1L of NS. On the floor, she was OOB to chair,\ntolerating a regular diet. She was neurologically intact and\ncleared for discharge on 1953-6-27.\n\nMedications on Admission:\nFLUTICASONE [FLONASE] - (Prescribed by Other Provider) - 50 mcg\nSpray, Suspension - 2 sprays(s) each nostril daily as needed for\nnasal congestion\nLEVETIRACETAM [KEPPRA] - 1,000 mg Tablet - 1 Tablet(s) by mouth\ntwice a day - No Substitution\nLEVETIRACETAM [KEPPRA] - 500 mg Tablet - 1 Tablet(s) by mouth at\nbedtime - No Substitution\nLEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth\nfour times a day - No Substitution\nOSELTAMIVIR [TAMIFLU] - 75 mg Capsule - one Capsule(s) by mouth\ntwice a day x 5 days\nVENLAFAXINE - 50 mg Tablet - One Tablet(s) by mouth twice a day\nACETAMINOPHEN [TYLENOL] - (OTC) - Dosage uncertain\nIBUPROFEN [ADVIL MIGRAINE] - (OTC) - 200 mg Capsule - 1\nCapsule(s) by mouth once a day as needed for headache\n\n\nDischarge Medications:\n1.', ' Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4\nhours) as needed for pain/t>100/HA.\n2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for\nconstipation.\n3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\nDisp:60 Capsule(s) Refills:2\n4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4\nhours) as needed for pain.\nDisp:30 Tablet(s) Refills:0\n5. Venlafaxine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times\na day).\n6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)\nSpray Nasal DAILY (Daily) as needed for nasal congestion.\n7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\nhours) for 6 days: Take 2mg Q6hrs 1917-9-15 to 1961-7-2, take 2mg Q12\n1990-4-31 to 2017-12-11, Take 2mg Q24 6-8, then stop.', '\nDisp:16 Tablet(s) Refills:0\n8. Levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times\na day).\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nSkull defect\ns/p cranioplasty\n\n\nDischarge Condition:\nNeurologically Stable\n\n\nDischarge Instructions:\nGeneral Instructions\n\n??????\tHave a friend/family member check your incision daily for\nsigns of infection.\n??????\tTake your pain medicine as prescribed.\n??????\tExercise should be limited to walking; no lifting, straining,\nor excessive bending.\n??????\tYou may wash your hair only after sutures and/or staples have\nbeen removed.\n??????\tYou may shower before this time using a shower cap to cover\nyour head.\n??????\tIncrease your intake of fluids and fiber, as narcotic pain\nmedicine can cause constipation. We generally recommend taking\nan over the counter stool softener, such as Docusate (Colace)\nwhile taking narcotic pain medication.', '\n??????\tUnless directed by your doctor, do not take any\nanti-inflammatory medicines such as Motrin, Aspirin, Advil, and\nIbuprofen etc.\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, or drainage.\n??????\tFever greater than or equal to 101?????? F.\n\n\nFollowup Instructions:\nYou will need to see the nurse practitioner 14 days\npost-operatively for suture removal.', ' Please call 766-455-7263\nfor the appointment.\nYou will need to follow up with Dr. Beamon in 4 weeks with a\nHead CT of the brain.\n\n\n\nCompleted by:1953-6-27']
184	28063	121936.0	2125-02-16	Discharge summary	Report	Admission Date: [2125-2-9] Discharge Date: [2125-2-16] Service: MEDICINE Allergies: Zocor / Lescol Attending:[Doctor Last Name 1857] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Central venous line insertion (right internal jugular vein) History of Present Illness: Mr. [Known lastname 1858] is an 84 yo man with moderate aortic stenosis (outside hospital echo in [2124] with [Location (un) 109] 1 cm2, gradient 28 mmHg, moderate mitral regurgitation, mild aortic insufficiency), chronic left ventricular systolic heart failure with EF 25-30%, hypertension, hyperlipidemia, diabetes mellitus, CAD s/p CABG in [2099] with SVG-LAD-Diagonal, SVG-OM, and SVG-RPDA-RPL, with a re-do CABG in [9-/2117] with LIMA-LAD, SVG-OM, SVG-diagonal, and SVG-RCA. He also has severe peripheral arterial disease s/p peripheral bypass surgery. He presented to [Hospital 1474] Hospital ER this morning with shortness of breath and chest pain and was found to be in heart failure. He states he was in his usual state of health until 10:30 last evening when he woke up feeling cold; 1 hour later he developed moderate to severe sharp chest pain radiating across his chest associated with nausea, diaphoresis, and dypsnea. The pain was fairly constant and did not resolve until he was given sL NTG at 6 am by EMS. He has been pain free since. Presenting vitals BP 109/66, HR 71, O2 sat 88% on RA. CXR showed congestive heart failure; initial troponin-I was mildly elevated at 0.4, CK 70. He given aspirin and furosemide 80 mg IV (with ~600cc diuresis), Nitropaste [1-3]", and Lovenox 80 mg SQ. During the ambulance transfer to the [Hospital1 18], he also received ~500 cc IVF for ? low BP). On further questioning, Mr. [Known lastname 1858] has very poor exercise tolerance due to knee pain that he attributes to osteoarthritis. But he says that he gets chest pain (similar to pain he had last night) with fairly minimal exertion (picking up his 11 lb cat, carrying 1 gallon jug of water, first getting up from sitting to walk outside or to walk to the bedroom). The pain is associated with dyspnea and is relieved with few minutes rest. His symptoms occur about every day to every other day and have been stable over the past year. He denies orthopnea, paroxysmal nocturnal dyspnea, but does endorse exertional dyspnea (he cannot identify the amount of exertion required). Currently, he is dyspneic and feels somewhat better sitting up; he reports no chest pain. ROS is also positive for a nose bleed requiring ED visit several months ago (and cessation of Plavix for a few days), and currently gross hematuria after Foley placement and Lovenox. Past Medical History: 1. Coronary artery disease s/p CABG twice (vide infra). 2. Hypertension. 3. Diabetes mellitus. 4. Hyperlipidemia. 5. Peripheral arterial disease with occluded left common iliac artery, S/P right iliac artery stenting and femoral-to-femoral bypass, further angioplasty to the right profunda. 5. Ischemic cardiomyopathy and chronic LV systolic heart failure, reported LVEF 25-30%. 6. Moderate-severe aortic stenosis. 7. Osteoarthritis. CAD: Diabetes, Dyslipidemia, Hypertension Cardiac History: CABG in [2099] (SVG-LAD-Diagonal, SVG-OM, and SVG-RPDA-RPL), with a re-do CABG in [9-/2117] (LIMA-LAD, SVG-OM, SVG-diagonal, and SVG-RCA) Percutaneous coronary intervention, in [2120] anatomy as follows: Patent SVG to OM1, patent SVG to PDA which filled the distal PDA as well as the R-PL via a jump segment. Stump occlusion of a graft presumably to the right system as well as one stump that could be documented of a graft to the left. Other SVG's were not able to be selectively engaged. Supravalvular aortography demonstrated no other patent grafts. Patent LIMA to mid-LAD, which also back-perfused the diagonal via a patent jump graft that was interposed between the LAD and the diagonal. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is extensive family history of early coronary disease (father died of MI at 44, one brother died in 40's, one in 50's, sister had stroke). Physical Exam: Gen: Elderly white male in NAD. Oriented x3. VS T 101 BP 88/54 HR 122 in A-Fib RR 27 O2 sat 97 % on 100 % NRB. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: JVP of near angle of the jaw. CV: PMI diffuse and laterally displaced. Rate irregular, normal S1, S2 with mid-late peaking 3/6 systolic murmur heart throughout precordium, loudest at apex. No gallop. Chest: Appear tachypneic, some accesorry muscle use. No chest wall deformities, scoliosis or kyphosis. Lungs with crackles [1-3] way up L>R. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No femoral bruits, could not palpate DP or TP pulses but Dopplerable. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2125-2-10] 03:44AM BLOOD WBC-8.1# RBC-4.11* Hgb-13.3* Hct-37.9* MCV-92 MCH-32.4* MCHC-35.0 RDW-14.1 Plt Ct-111* [2125-2-10] 08:00PM BLOOD Neuts-74.3* Lymphs-21.9 Monos-3.0 Eos-0.7 Baso-0.1 [2125-2-10] 03:44AM BLOOD Plt Ct-111* LPlt-2+ [2125-2-10] 08:00PM BLOOD Fibrino-760# [2125-2-9] 09:15PM BLOOD Glucose-195 UreaN-30* Creat-1.4* Na-133 K-4.6 Cl-96 HCO3-25 AnGap-17 CK 257* --> 189* --> 192* --> 193* --> 176 --> 82 [2125-2-10] 08:00PM BLOOD ALT-38 AST-46* AlkPhos-66 TotBili-1.0 DirBili-0.3 IndBili-0.7 [2125-2-9] 09:15PM BLOOD CK-MB-10 MB Indx-3.9 cTropnT-0.66* proBNP-[Numeric Identifier 1859]* [2125-2-10] 03:44AM BLOOD CK-MB-7 cTropnT-0.69* [2125-2-10] 11:40AM BLOOD CK-MB-8 cTropnT-0.67* [2125-2-10] 04:55PM BLOOD CK-MB-7 cTropnT-0.65* [2125-2-10] 08:00PM BLOOD CK-MB-7 cTropnT-0.64* [2125-2-11] 05:41AM BLOOD CK-MB-63* MB Indx-6.3* cTropnT-2.61* [2125-2-9] 09:15PM BLOOD calTIBC-334 Ferritn-93 TRF-257 [2125-2-10] 08:00PM BLOOD TSH-5.4* ECG [2125-2-9] 9:36:38 PM Rhythm is most likely sinus rhythm with frequent ventricular premature beats with occasional ventricular bigeminal pattern. There are also frequent atrial premature beats. Intraventricular conduction defect. Left ventricular hypertrophy. ST-T wave changes most likely related to left ventricular hypertrophy. Compared to the previous tracing of [2124-4-9] ventricular premature beats are more frequent, as are atrial premature beats. Clinical correlation is suggested. CXR [2125-2-9]: The patient is after median sternotomy and CABG. The heart size appears slightly enlarged compared to the previous study. Bilateral perihilar haziness continues toward the lower lungs is new consistent with new moderate- to-severe pulmonary edema. Bilateral pleural effusion is present, also new, most likely part of the heart failure. Left and right retrocardiac opacities consistent with atelectasis. ECHO [2125-2-11]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal half of the inferior and inferolaterl walls. There is mild hypokinesis of the remaining segments (LVEF = 25-30 %). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with moderate global free wall hypokinesis. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area 0.6 cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-3]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior report (images unavailable of [2119-5-8], left ventricular systolic function is now depressed and the severity of aortic stenosis has increased. Brief Hospital Course: Patient is a 84 yo man with CAD s/p CABG twice with daily angina, presenting with chest pain, dyspnea, and congestive heart failure. # CAD: The patient was transferred to [Hospital1 18] for further workup and treatment of chest pain. A chest X-ray performed on admission showed moderate-severe pulmonary edema. He did have a stably elevated troponin thought to be related to acute heart failure or demand ischemia. He was started on a Lasix drop at 10 mg/hr for initiation of diuresis. He initially tolerated this well, however at approximately 8 pm on [2125-2-10], Mr. [Known lastname 1858] was transferred from the floor to the CCU after complaining of chest pain when he was sitting in bed after dinner. As he was being evaluated by the housestaff, he became unresponsive and developed pulseless electrical arrest. Chest compressions were started, but within approximately 2 minutes, he became responsive and regained a palpable pulse. His rhythm appeared to be atrial fibrillation with ventricular rate initially in the 50s but rising to the 110's. Review of his telemetry showed that he had developed atrial fibillation earlier in the evening without obvious ventricular arrhythmias immediately prior to his arrest (which was attributed to a vasovagal episode in the setting of heart failure and aortic stenosis). On transfer to the CCU, he was started on levophed for hypotension and amiodarone IV for AFib. Chest x-ray on [2125-2-10] showed interval worsening of pulmonary edema, bilateral pleural effusions and bibasilar atelectasis. At this time his cardiac enzymes became very elevated with EKG changes consistent of a NSTEMI with a CK to 1006 and troponin to 3.82. On [2125-2-11], he had a transthoracic echocardiogram which showed moderate regional left ventricular systolic dysfunction with akinesis of the basal half of the inferior and inferolateral walls. LVEF was 25-30 %, with severe aortic stenosis and [1-3]+ mitral regurgitation. He was aggressively diuresed with an IV Lasix drip with improvement in his oxygen requirement and chest x-ray. Levophed was discontinued on [2-12], and blood pressures remained stable off pressors with MAP's 60 - 70. On [2125-2-13], he was transferred back to the floor team on PO amiodarone. He remained in normal sinus rhythm on telemetry on po amiodarone, and diuresis was continued with a Lasix drip with good urine output and improvement of renal function. He remained asymptomatic with no shortness of breath or chest pain after transfer. He was maintained on a heparin drip bridging to Coumadin for paroxysmal atrial fibrillation. His metoprolol was held for hypotension in the ICU and relative hypotension with SBP in 90s and low 100s upon transfer to the floor. ACE-inhibitor was held due to relative hypotension and renal insufficiency with Creat 1.7. A cardiac surgery consult deemed him an acceptable candidate for a 3rd open heart surgery for aortic valve replacement pending re-assessment of his coronary anatomy. The intermediate-term plan was to allow recovery from the current episode and discussion as an outpatient with his primary cardiologist regarding the risks and benefits of aortic valve replacement. On [2-16], the patient became hypotensive to SBPs to 60s-70s after getting into a chair after breakfast. He was given 1L NS with no response in BP. The patient was mentating but became short of breath with IVF. He had worsening EKG changes. He was started on Levophed without improvement in his blood pressure. He was brought to the catherization laboratory for potential emergent aortic valvuloplasty and was intubated. At that point, he suffered a PEA arrest and could not be resuscitated. He was pronounced deceased at 12:33pm. # Pump: As above. The patient had severe pulmonary edema with initial exam revealing crackles throughout his lung fields. He was treated with a Lasix drip which was transitioned on [2-16] to po Lasix 80 mg po twice daily. # Rhythm: Patient was in NSR on admission. On HD #2, he had chest pain, then went into PEA arrest as described above. Telemetry showed atrial fibrillation prior to the event. In the CCU, he was started on amiodarone 400 mg po tid to be tapered over the subsequent weeks. # Acute renal failure: Renal function initially declined (creatinine to 2.1), then improved on Lasix gtt, but stayed 1.7 - 1.9 (above baseline of 1.3). # Hematuria: He had hematuria (no clots) after traumatic Foley placement at the outside hospital. The catheter was removed on [2-16] with gradual resolution of hematuria. # Diabetes: Due to acute renal failre, metformin was discontinued and the patient was maintained on a Humalog sliding scale with 30 units of Lantus at bedtime. # Hematoma. The patient developed a small hematoma at the site of his right internal jugular venous access after catheter removal. This was treated with local compression. Medications on Admission: Aspirin 81 mg Plavix 75 mg Atenolol 50 mg Isordil 5 mg [Hospital1 ] HCTZ 25 mg daily Lisinopril 40 mg Gemfibrozil 600 mg Simvastatin 20 mg Glipizide 5 mg XL daily Metformin unknown dose Protonix 40 mg Thiamine, B12, B6, folate Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1) Severe aortic stenosis 2) Coronary artery disease with non-ST segment myocardial infarction 3) Cardiogenic shock requiring pressor support 4) Atrial fibrillation 5) Pulseless electrical activity arrest, twice 6) Severe acute on chronic left ventricular systolic and diastolic heart failure 7) Acute on chronic renal failure 8) Traumatic hematuria 9) Diabetes mellitus 10) Hypertension 11) Peripheral arterial disease 12) Hyperlipidemia Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None [Doctor First Name ] [First Name8 (NamePattern2) ] [Name6 (MD) ] [Name8 (MD) ] MD, MSC 12-339	Admission Date: <Date>1934-11-14</Date> Discharge Date: <Date>1940-9-14</Date> Service: MEDICINE Allergies: Zocor / Lescol Attending:<Doctor Name>Dr.Scheet</Doctor Name> Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Central venous line insertion (right internal jugular vein) History of Present Illness: Mr. <Name>Smith</Name> is an 84 yo man with moderate aortic stenosis (outside hospital echo in <Year>1950</Year> with <Location>917 Jenkins Branch West Alexanderhaven, HI 36889</Location> 1 cm2, gradient 28 mmHg, moderate mitral regurgitation, mild aortic insufficiency), chronic left ventricular systolic heart failure with EF 25-30%, hypertension, hyperlipidemia, diabetes mellitus, CAD s/p CABG in <Year>1950</Year> with SVG-LAD-Diagonal, SVG-OM, and SVG-RPDA-RPL, with a re-do CABG in <Date>6-1924</Date> with LIMA-LAD, SVG-OM, SVG-diagonal, and SVG-RCA. He also has severe peripheral arterial disease s/p peripheral bypass surgery. He presented to <Hospital>Vega, Fields and Sutton Hospital</Hospital> Hospital ER this morning with shortness of breath and chest pain and was found to be in heart failure. He states he was in his usual state of health until 10:30 last evening when he woke up feeling cold; 1 hour later he developed moderate to severe sharp chest pain radiating across his chest associated with nausea, diaphoresis, and dypsnea. The pain was fairly constant and did not resolve until he was given sL NTG at 6 am by EMS. He has been pain free since. Presenting vitals BP 109/66, HR 71, O2 sat 88% on RA. CXR showed congestive heart failure; initial troponin-I was mildly elevated at 0.4, CK 70. He given aspirin and furosemide 80 mg IV (with ~600cc diuresis), Nitropaste <Date>9-21</Date>", and Lovenox 80 mg SQ. During the ambulance transfer to the <Hospital>Davis, Kelly and Stevens Clinic</Hospital>, he also received ~500 cc IVF for ? low BP). On further questioning, Mr. <Name>Smith</Name> has very poor exercise tolerance due to knee pain that he attributes to osteoarthritis. But he says that he gets chest pain (similar to pain he had last night) with fairly minimal exertion (picking up his 11 lb cat, carrying 1 gallon jug of water, first getting up from sitting to walk outside or to walk to the bedroom). The pain is associated with dyspnea and is relieved with few minutes rest. His symptoms occur about every day to every other day and have been stable over the past year. He denies orthopnea, paroxysmal nocturnal dyspnea, but does endorse exertional dyspnea (he cannot identify the amount of exertion required). Currently, he is dyspneic and feels somewhat better sitting up; he reports no chest pain. ROS is also positive for a nose bleed requiring ED visit several months ago (and cessation of Plavix for a few days), and currently gross hematuria after Foley placement and Lovenox. Past Medical History: 1. Coronary artery disease s/p CABG twice (vide infra). 2. Hypertension. 3. Diabetes mellitus. 4. Hyperlipidemia. 5. Peripheral arterial disease with occluded left common iliac artery, S/P right iliac artery stenting and femoral-to-femoral bypass, further angioplasty to the right profunda. 5. Ischemic cardiomyopathy and chronic LV systolic heart failure, reported LVEF 25-30%. 6. Moderate-severe aortic stenosis. 7. Osteoarthritis. CAD: Diabetes, Dyslipidemia, Hypertension Cardiac History: CABG in <Year>1950</Year> (SVG-LAD-Diagonal, SVG-OM, and SVG-RPDA-RPL), with a re-do CABG in <Date>6-1924</Date> (LIMA-LAD, SVG-OM, SVG-diagonal, and SVG-RCA) Percutaneous coronary intervention, in <Year>1950</Year> anatomy as follows: Patent SVG to OM1, patent SVG to PDA which filled the distal PDA as well as the R-PL via a jump segment. Stump occlusion of a graft presumably to the right system as well as one stump that could be documented of a graft to the left. Other SVG's were not able to be selectively engaged. Supravalvular aortography demonstrated no other patent grafts. Patent LIMA to mid-LAD, which also back-perfused the diagonal via a patent jump graft that was interposed between the LAD and the diagonal. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is extensive family history of early coronary disease (father died of MI at 44, one brother died in 40's, one in 50's, sister had stroke). Physical Exam: Gen: Elderly white male in NAD. Oriented x3. VS T 101 BP 88/54 HR 122 in A-Fib RR 27 O2 sat 97 % on 100 % NRB. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: JVP of near angle of the jaw. CV: PMI diffuse and laterally displaced. Rate irregular, normal S1, S2 with mid-late peaking 3/6 systolic murmur heart throughout precordium, loudest at apex. No gallop. Chest: Appear tachypneic, some accesorry muscle use. No chest wall deformities, scoliosis or kyphosis. Lungs with crackles <Date>9-21</Date> way up L>R. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No femoral bruits, could not palpate DP or TP pulses but Dopplerable. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: <Date>1917-7-19</Date> 03:44AM BLOOD WBC-8.1# RBC-4.11* Hgb-13.3* Hct-37.9* MCV-92 MCH-32.4* MCHC-35.0 RDW-14.1 Plt Ct-111* <Date>1917-7-19</Date> 08:00PM BLOOD Neuts-74.3* Lymphs-21.9 Monos-3.0 Eos-0.7 Baso-0.1 <Date>1917-7-19</Date> 03:44AM BLOOD Plt Ct-111* LPlt-2+ <Date>1917-7-19</Date> 08:00PM BLOOD Fibrino-760# <Date>1934-11-14</Date> 09:15PM BLOOD Glucose-195 UreaN-30* Creat-1.4* Na-133 K-4.6 Cl-96 HCO3-25 AnGap-17 CK 257* --> 189* --> 192* --> 193* --> 176 --> 82 <Date>1917-7-19</Date> 08:00PM BLOOD ALT-38 AST-46* AlkPhos-66 TotBili-1.0 DirBili-0.3 IndBili-0.7 <Date>1934-11-14</Date> 09:15PM BLOOD CK-MB-10 MB Indx-3.9 cTropnT-0.66* proBNP-<Numeric Identifier>1469907</Numeric Identifier>* <Date>1917-7-19</Date> 03:44AM BLOOD CK-MB-7 cTropnT-0.69* <Date>1917-7-19</Date> 11:40AM BLOOD CK-MB-8 cTropnT-0.67* <Date>1917-7-19</Date> 04:55PM BLOOD CK-MB-7 cTropnT-0.65* <Date>1917-7-19</Date> 08:00PM BLOOD CK-MB-7 cTropnT-0.64* <Date>1916-2-4</Date> 05:41AM BLOOD CK-MB-63* MB Indx-6.3* cTropnT-2.61* <Date>1934-11-14</Date> 09:15PM BLOOD calTIBC-334 Ferritn-93 TRF-257 <Date>1917-7-19</Date> 08:00PM BLOOD TSH-5.4* ECG <Date>1934-11-14</Date> 9:36:38 PM Rhythm is most likely sinus rhythm with frequent ventricular premature beats with occasional ventricular bigeminal pattern. There are also frequent atrial premature beats. Intraventricular conduction defect. Left ventricular hypertrophy. ST-T wave changes most likely related to left ventricular hypertrophy. Compared to the previous tracing of <Date>1955-3-16</Date> ventricular premature beats are more frequent, as are atrial premature beats. Clinical correlation is suggested. CXR <Date>1934-11-14</Date>: The patient is after median sternotomy and CABG. The heart size appears slightly enlarged compared to the previous study. Bilateral perihilar haziness continues toward the lower lungs is new consistent with new moderate- to-severe pulmonary edema. Bilateral pleural effusion is present, also new, most likely part of the heart failure. Left and right retrocardiac opacities consistent with atelectasis. ECHO <Date>1916-2-4</Date>: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal half of the inferior and inferolaterl walls. There is mild hypokinesis of the remaining segments (LVEF = 25-30 %). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with moderate global free wall hypokinesis. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area 0.6 cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (<Date>9-21</Date>+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior report (images unavailable of <Date>1928-3-15</Date>, left ventricular systolic function is now depressed and the severity of aortic stenosis has increased. Brief Hospital Course: Patient is a 84 yo man with CAD s/p CABG twice with daily angina, presenting with chest pain, dyspnea, and congestive heart failure. # CAD: The patient was transferred to <Hospital>Davis, Kelly and Stevens Clinic</Hospital> for further workup and treatment of chest pain. A chest X-ray performed on admission showed moderate-severe pulmonary edema. He did have a stably elevated troponin thought to be related to acute heart failure or demand ischemia. He was started on a Lasix drop at 10 mg/hr for initiation of diuresis. He initially tolerated this well, however at approximately 8 pm on <Date>1917-7-19</Date>, Mr. <Name>Smith</Name> was transferred from the floor to the CCU after complaining of chest pain when he was sitting in bed after dinner. As he was being evaluated by the housestaff, he became unresponsive and developed pulseless electrical arrest. Chest compressions were started, but within approximately 2 minutes, he became responsive and regained a palpable pulse. His rhythm appeared to be atrial fibrillation with ventricular rate initially in the 50s but rising to the 110's. Review of his telemetry showed that he had developed atrial fibillation earlier in the evening without obvious ventricular arrhythmias immediately prior to his arrest (which was attributed to a vasovagal episode in the setting of heart failure and aortic stenosis). On transfer to the CCU, he was started on levophed for hypotension and amiodarone IV for AFib. Chest x-ray on <Date>1917-7-19</Date> showed interval worsening of pulmonary edema, bilateral pleural effusions and bibasilar atelectasis. At this time his cardiac enzymes became very elevated with EKG changes consistent of a NSTEMI with a CK to 1006 and troponin to 3.82. On <Date>1916-2-4</Date>, he had a transthoracic echocardiogram which showed moderate regional left ventricular systolic dysfunction with akinesis of the basal half of the inferior and inferolateral walls. LVEF was 25-30 %, with severe aortic stenosis and <Date>9-21</Date>+ mitral regurgitation. He was aggressively diuresed with an IV Lasix drip with improvement in his oxygen requirement and chest x-ray. Levophed was discontinued on <Date>3-22</Date>, and blood pressures remained stable off pressors with MAP's 60 - 70. On <Date>1974-9-2</Date>, he was transferred back to the floor team on PO amiodarone. He remained in normal sinus rhythm on telemetry on po amiodarone, and diuresis was continued with a Lasix drip with good urine output and improvement of renal function. He remained asymptomatic with no shortness of breath or chest pain after transfer. He was maintained on a heparin drip bridging to Coumadin for paroxysmal atrial fibrillation. His metoprolol was held for hypotension in the ICU and relative hypotension with SBP in 90s and low 100s upon transfer to the floor. ACE-inhibitor was held due to relative hypotension and renal insufficiency with Creat 1.7. A cardiac surgery consult deemed him an acceptable candidate for a 3rd open heart surgery for aortic valve replacement pending re-assessment of his coronary anatomy. The intermediate-term plan was to allow recovery from the current episode and discussion as an outpatient with his primary cardiologist regarding the risks and benefits of aortic valve replacement. On <Date>3-4</Date>, the patient became hypotensive to SBPs to 60s-70s after getting into a chair after breakfast. He was given 1L NS with no response in BP. The patient was mentating but became short of breath with IVF. He had worsening EKG changes. He was started on Levophed without improvement in his blood pressure. He was brought to the catherization laboratory for potential emergent aortic valvuloplasty and was intubated. At that point, he suffered a PEA arrest and could not be resuscitated. He was pronounced deceased at 12:33pm. # Pump: As above. The patient had severe pulmonary edema with initial exam revealing crackles throughout his lung fields. He was treated with a Lasix drip which was transitioned on <Date>3-4</Date> to po Lasix 80 mg po twice daily. # Rhythm: Patient was in NSR on admission. On HD #2, he had chest pain, then went into PEA arrest as described above. Telemetry showed atrial fibrillation prior to the event. In the CCU, he was started on amiodarone 400 mg po tid to be tapered over the subsequent weeks. # Acute renal failure: Renal function initially declined (creatinine to 2.1), then improved on Lasix gtt, but stayed 1.7 - 1.9 (above baseline of 1.3). # Hematuria: He had hematuria (no clots) after traumatic Foley placement at the outside hospital. The catheter was removed on <Date>3-4</Date> with gradual resolution of hematuria. # Diabetes: Due to acute renal failre, metformin was discontinued and the patient was maintained on a Humalog sliding scale with 30 units of Lantus at bedtime. # Hematoma. The patient developed a small hematoma at the site of his right internal jugular venous access after catheter removal. This was treated with local compression. Medications on Admission: Aspirin 81 mg Plavix 75 mg Atenolol 50 mg Isordil 5 mg <Hospital>Davis Inc Medical Center</Hospital> HCTZ 25 mg daily Lisinopril 40 mg Gemfibrozil 600 mg Simvastatin 20 mg Glipizide 5 mg XL daily Metformin unknown dose Protonix 40 mg Thiamine, B12, B6, folate Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1) Severe aortic stenosis 2) Coronary artery disease with non-ST segment myocardial infarction 3) Cardiogenic shock requiring pressor support 4) Atrial fibrillation 5) Pulseless electrical activity arrest, twice 6) Severe acute on chronic left ventricular systolic and diastolic heart failure 7) Acute on chronic renal failure 8) Traumatic hematuria 9) Diabetes mellitus 10) Hypertension 11) Peripheral arterial disease 12) Hyperlipidemia Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None <Name>Ethan</Name> <Name>Linda</Name> <Name>Meena Porras</Name> <Name>Haydee Ignacio</Name> MD, MSC 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Date: 1934-11-14 Discharge Date: 1940-9-14 Service: MEDICINE Allergies: Zocor / Lescol Attending:Dr.Scheet Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Central venous line insertion (right internal jugular vein) History of Present Illness: Mr. Smith is an 84 yo man with moderate aortic stenosis (outside hospital echo in 1950 with 917 Jenkins Branch West Alexanderhaven, HI 36889 1 cm2, gradient 28 mmHg, moderate mitral regurgitation, mild aortic insufficiency), chronic left ventricular systolic heart failure with EF 25-30%, hypertension, hyperlipidemia, diabetes mellitus, CAD s/p CABG in 1950 with SVG-LAD-Diagonal, SVG-OM, and SVG-RPDA-RPL, with a re-do CABG in 6-1924 with LIMA-LAD, SVG-OM, SVG-diagonal, and SVG-RCA. He also has severe peripheral arterial disease s/p peripheral bypass surgery. He presented to Vega, Fields and Sutton Hospital Hospital ER this morning with shortness of breath and chest pain and was found to be in heart failure. He states he was in his usual state of health until 10:30 last evening when he woke up feeling cold; 1 hour later he developed moderate to severe sharp chest pain radiating across his chest associated with nausea, diaphoresis, and dypsnea. The pain was fairly constant and did not resolve until he was given sL NTG at 6 am by EMS. He has been pain free since. Presenting vitals BP 109/66, HR 71, O2 sat 88% on RA. CXR showed congestive heart failure; initial troponin-I was mildly elevated at 0.4, CK 70. He given aspirin and furosemide 80 mg IV (with ~600cc diuresis), Nitropaste 9-21", and Lovenox 80 mg SQ. During the ambulance transfer to the Davis, Kelly and Stevens Clinic, he also received ~500 cc IVF for ? low BP). On further questioning, Mr. Smith has very poor exercise tolerance due to knee pain that he attributes to osteoarthritis. But he says that he gets chest pain (similar to pain he had last night) with fairly minimal exertion (picking up his 11 lb cat, carrying 1 gallon jug of water, first getting up from sitting to walk outside or to walk to the bedroom). The pain is associated with dyspnea and is relieved with few minutes rest. His symptoms occur about every day to every other day and have been stable over the past year. He denies orthopnea, paroxysmal nocturnal dyspnea, but does endorse exertional dyspnea (he cannot identify the amount of exertion required). Currently, he is dyspneic and feels somewhat better sitting up; he reports no chest pain. ROS is also positive for a nose bleed requiring ED visit several months ago (and cessation of Plavix for a few days), and currently gross hematuria after Foley placement and Lovenox. Past Medical History: 1. Coronary artery disease s/p CABG twice (vide infra). 2. Hypertension. 3. Diabetes mellitus. 4. Hyperlipidemia. 5. Peripheral arterial disease with occluded left common iliac artery, S/P right iliac artery stenting and femoral-to-femoral bypass, further angioplasty to the right profunda. 5. Ischemic cardiomyopathy and chronic LV systolic heart failure, reported LVEF 25-30%. 6. Moderate-severe aortic stenosis. 7. Osteoarthritis. CAD: Diabetes, Dyslipidemia, Hypertension Cardiac History: CABG in 1950 (SVG-LAD-Diagonal, SVG-OM, and SVG-RPDA-RPL), with a re-do CABG in 6-1924 (LIMA-LAD, SVG-OM, SVG-diagonal, and SVG-RCA) Percutaneous coronary intervention, in 1950 anatomy as follows: Patent SVG to OM1, patent SVG to PDA which filled the distal PDA as well as the R-PL via a jump segment. Stump occlusion of a graft presumably to the right system as well as one stump that could be documented of a graft to the left. Other SVG's were not able to be selectively engaged. Supravalvular aortography demonstrated no other patent grafts. Patent LIMA to mid-LAD, which also back-perfused the diagonal via a patent jump graft that was interposed between the LAD and the diagonal. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is extensive family history of early coronary disease (father died of MI at 44, one brother died in 40's, one in 50's, sister had stroke). Physical Exam: Gen: Elderly white male in NAD. Oriented x3. VS T 101 BP 88/54 HR 122 in A-Fib RR 27 O2 sat 97 % on 100 % NRB. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: JVP of near angle of the jaw. CV: PMI diffuse and laterally displaced. Rate irregular, normal S1, S2 with mid-late peaking 3/6 systolic murmur heart throughout precordium, loudest at apex. No gallop. Chest: Appear tachypneic, some accesorry muscle use. No chest wall deformities, scoliosis or kyphosis. Lungs with crackles 9-21 way up L>R. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No femoral bruits, could not palpate DP or TP pulses but Dopplerable. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: 1917-7-19 03:44AM BLOOD WBC-8.1# RBC-4.11* Hgb-13.3* Hct-37.9* MCV-92 MCH-32.4* MCHC-35.0 RDW-14.1 Plt Ct-111* 1917-7-19 08:00PM BLOOD Neuts-74.3* Lymphs-21.9 Monos-3.0 Eos-0.7 Baso-0.1 1917-7-19 03:44AM BLOOD Plt Ct-111* LPlt-2+ 1917-7-19 08:00PM BLOOD Fibrino-760# 1934-11-14 09:15PM BLOOD Glucose-195 UreaN-30* Creat-1.4* Na-133 K-4.6 Cl-96 HCO3-25 AnGap-17 CK 257* --> 189* --> 192* --> 193* --> 176 --> 82 1917-7-19 08:00PM BLOOD ALT-38 AST-46* AlkPhos-66 TotBili-1.0 DirBili-0.3 IndBili-0.7 1934-11-14 09:15PM BLOOD CK-MB-10 MB Indx-3.9 cTropnT-0.66* proBNP-1469907* 1917-7-19 03:44AM BLOOD CK-MB-7 cTropnT-0.69* 1917-7-19 11:40AM BLOOD CK-MB-8 cTropnT-0.67* 1917-7-19 04:55PM BLOOD CK-MB-7 cTropnT-0.65* 1917-7-19 08:00PM BLOOD CK-MB-7 cTropnT-0.64* 1916-2-4 05:41AM BLOOD CK-MB-63* MB Indx-6.3* cTropnT-2.61* 1934-11-14 09:15PM BLOOD calTIBC-334 Ferritn-93 TRF-257 1917-7-19 08:00PM BLOOD TSH-5.4* ECG 1934-11-14 9:36:38 PM Rhythm is most likely sinus rhythm with frequent ventricular premature beats with occasional ventricular bigeminal pattern. There are also frequent atrial premature beats. Intraventricular conduction defect. Left ventricular hypertrophy. ST-T wave changes most likely related to left ventricular hypertrophy. Compared to the previous tracing of 1955-3-16 ventricular premature beats are more frequent, as are atrial premature beats. Clinical correlation is suggested. CXR 1934-11-14: The patient is after median sternotomy and CABG. The heart size appears slightly enlarged compared to the previous study. Bilateral perihilar haziness continues toward the lower lungs is new consistent with new moderate- to-severe pulmonary edema. Bilateral pleural effusion is present, also new, most likely part of the heart failure. Left and right retrocardiac opacities consistent with atelectasis. ECHO 1916-2-4: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal half of the inferior and inferolaterl walls. There is mild hypokinesis of the remaining segments (LVEF = 25-30 %). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with moderate global free wall hypokinesis. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area 0.6 cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (9-21+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior report (images unavailable of 1928-3-15, left ventricular systolic function is now depressed and the severity of aortic stenosis has increased. Brief Hospital Course: Patient is a 84 yo man with CAD s/p CABG twice with daily angina, presenting with chest pain, dyspnea, and congestive heart failure. # CAD: The patient was transferred to Davis, Kelly and Stevens Clinic for further workup and treatment of chest pain. A chest X-ray performed on admission showed moderate-severe pulmonary edema. He did have a stably elevated troponin thought to be related to acute heart failure or demand ischemia. He was started on a Lasix drop at 10 mg/hr for initiation of diuresis. He initially tolerated this well, however at approximately 8 pm on 1917-7-19, Mr. Smith was transferred from the floor to the CCU after complaining of chest pain when he was sitting in bed after dinner. As he was being evaluated by the housestaff, he became unresponsive and developed pulseless electrical arrest. Chest compressions were started, but within approximately 2 minutes, he became responsive and regained a palpable pulse. His rhythm appeared to be atrial fibrillation with ventricular rate initially in the 50s but rising to the 110's. Review of his telemetry showed that he had developed atrial fibillation earlier in the evening without obvious ventricular arrhythmias immediately prior to his arrest (which was attributed to a vasovagal episode in the setting of heart failure and aortic stenosis). On transfer to the CCU, he was started on levophed for hypotension and amiodarone IV for AFib. Chest x-ray on 1917-7-19 showed interval worsening of pulmonary edema, bilateral pleural effusions and bibasilar atelectasis. At this time his cardiac enzymes became very elevated with EKG changes consistent of a NSTEMI with a CK to 1006 and troponin to 3.82. On 1916-2-4, he had a transthoracic echocardiogram which showed moderate regional left ventricular systolic dysfunction with akinesis of the basal half of the inferior and inferolateral walls. LVEF was 25-30 %, with severe aortic stenosis and 9-21+ mitral regurgitation. He was aggressively diuresed with an IV Lasix drip with improvement in his oxygen requirement and chest x-ray. Levophed was discontinued on 3-22, and blood pressures remained stable off pressors with MAP's 60 - 70. On 1974-9-2, he was transferred back to the floor team on PO amiodarone. He remained in normal sinus rhythm on telemetry on po amiodarone, and diuresis was continued with a Lasix drip with good urine output and improvement of renal function. He remained asymptomatic with no shortness of breath or chest pain after transfer. He was maintained on a heparin drip bridging to Coumadin for paroxysmal atrial fibrillation. His metoprolol was held for hypotension in the ICU and relative hypotension with SBP in 90s and low 100s upon transfer to the floor. ACE-inhibitor was held due to relative hypotension and renal insufficiency with Creat 1.7. A cardiac surgery consult deemed him an acceptable candidate for a 3rd open heart surgery for aortic valve replacement pending re-assessment of his coronary anatomy. The intermediate-term plan was to allow recovery from the current episode and discussion as an outpatient with his primary cardiologist regarding the risks and benefits of aortic valve replacement. On 3-4, the patient became hypotensive to SBPs to 60s-70s after getting into a chair after breakfast. He was given 1L NS with no response in BP. The patient was mentating but became short of breath with IVF. He had worsening EKG changes. He was started on Levophed without improvement in his blood pressure. He was brought to the catherization laboratory for potential emergent aortic valvuloplasty and was intubated. At that point, he suffered a PEA arrest and could not be resuscitated. He was pronounced deceased at 12:33pm. # Pump: As above. The patient had severe pulmonary edema with initial exam revealing crackles throughout his lung fields. He was treated with a Lasix drip which was transitioned on 3-4 to po Lasix 80 mg po twice daily. # Rhythm: Patient was in NSR on admission. On HD #2, he had chest pain, then went into PEA arrest as described above. Telemetry showed atrial fibrillation prior to the event. In the CCU, he was started on amiodarone 400 mg po tid to be tapered over the subsequent weeks. # Acute renal failure: Renal function initially declined (creatinine to 2.1), then improved on Lasix gtt, but stayed 1.7 - 1.9 (above baseline of 1.3). # Hematuria: He had hematuria (no clots) after traumatic Foley placement at the outside hospital. The catheter was removed on 3-4 with gradual resolution of hematuria. # Diabetes: Due to acute renal failre, metformin was discontinued and the patient was maintained on a Humalog sliding scale with 30 units of Lantus at bedtime. # Hematoma. The patient developed a small hematoma at the site of his right internal jugular venous access after catheter removal. This was treated with local compression. Medications on Admission: Aspirin 81 mg Plavix 75 mg Atenolol 50 mg Isordil 5 mg Davis Inc Medical Center HCTZ 25 mg daily Lisinopril 40 mg Gemfibrozil 600 mg Simvastatin 20 mg Glipizide 5 mg XL daily Metformin unknown dose Protonix 40 mg Thiamine, B12, B6, folate Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1) Severe aortic stenosis 2) Coronary artery disease with non-ST segment myocardial infarction 3) Cardiogenic shock requiring pressor support 4) Atrial fibrillation 5) Pulseless electrical activity arrest, twice 6) Severe acute on chronic left ventricular systolic and diastolic heart failure 7) Acute on chronic renal failure 8) Traumatic hematuria 9) Diabetes mellitus 10) Hypertension 11) Peripheral arterial disease 12) Hyperlipidemia Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None Ethan Linda Meena Porras Haydee Ignacio MD, MSC 12-339	['Admission Date: 1934-11-14 Discharge Date: 1940-9-14\n\n\nService: MEDICINE\n\nAllergies:\nZocor / Lescol\n\nAttending:Dr.Scheet\nChief Complaint:\nChest pain\n\nMajor Surgical or Invasive Procedure:\nCentral venous line insertion (right internal jugular vein)\n\nHistory of Present Illness:\nMr. Smith is an 84 yo man with moderate aortic stenosis (outside\nhospital echo in 1950 with 917 Jenkins Branch\nWest Alexanderhaven, HI 36889 1 cm2, gradient 28 mmHg, moderate\nmitral regurgitation, mild aortic insufficiency), chronic left\nventricular systolic heart failure with EF 25-30%, hypertension,\nhyperlipidemia, diabetes mellitus, CAD s/p CABG in 1950 with\nSVG-LAD-Diagonal, SVG-OM, and SVG-RPDA-RPL, with a re-do CABG in\n6-1924 with LIMA-LAD, SVG-OM, SVG-diagonal, and SVG-RCA. He also\nhas severe peripheral arterial disease s/p peripheral bypass\nsurgery.', ' He presented to Vega, Fields and Sutton Hospital Hospital ER this morning with\nshortness of breath and chest pain and was found to be in heart\nfailure.\n\nHe states he was in his usual state of health until 10:30 last\nevening when he woke up feeling cold; 1 hour later he developed\nmoderate to severe sharp chest pain radiating across his chest\nassociated with nausea, diaphoresis, and dypsnea. The pain was\nfairly constant and did not resolve until he was given sL NTG at\n6 am by EMS. He has been pain free since. Presenting vitals BP\n109/66, HR 71, O2 sat 88% on RA. CXR showed congestive heart\nfailure; initial troponin-I was mildly elevated at 0.4, CK 70.\nHe given aspirin and furosemide 80 mg IV (with ~600cc diuresis),\nNitropaste 9-21", and Lovenox 80 mg SQ. During the ambulance\ntransfer to the Davis, Kelly and Stevens Clinic, he also received ~500 cc IVF for ? low\nBP).', '\n\nOn further questioning, Mr. Smith has very poor exercise\ntolerance due to knee pain that he attributes to osteoarthritis.\nBut he says that he gets chest pain (similar to pain he had last\nnight) with fairly minimal exertion (picking up his 11 lb cat,\ncarrying 1 gallon jug of water, first getting up from sitting to\nwalk outside or to walk to the bedroom). The pain is associated\nwith dyspnea and is relieved with few minutes rest. His symptoms\noccur about every day to every other day and have been stable\nover the past year. He denies orthopnea, paroxysmal nocturnal\ndyspnea, but does endorse exertional dyspnea (he cannot identify\nthe amount of exertion required). Currently, he is dyspneic and\nfeels somewhat better sitting up; he reports no chest pain.\n\nROS is also positive for a nose bleed requiring ED visit several\nmonths ago (and cessation of Plavix for a few days), and\ncurrently gross hematuria after Foley placement and Lovenox.', '\n\nPast Medical History:\n1. Coronary artery disease s/p CABG twice (vide infra).\n2. Hypertension.\n3. Diabetes mellitus.\n4. Hyperlipidemia.\n5. Peripheral arterial disease with occluded left common iliac\nartery, S/P right iliac artery stenting and femoral-to-femoral\nbypass, further angioplasty to the right profunda.\n5. Ischemic cardiomyopathy and chronic LV systolic heart\nfailure, reported LVEF 25-30%.\n6. Moderate-severe aortic stenosis.\n7. Osteoarthritis.\n\nCAD: Diabetes, Dyslipidemia, Hypertension\n\nCardiac History: CABG in 1950 (SVG-LAD-Diagonal, SVG-OM, and\nSVG-RPDA-RPL), with a re-do CABG in 6-1924 (LIMA-LAD, SVG-OM,\nSVG-diagonal, and SVG-RCA)\n\nPercutaneous coronary intervention, in 1950 anatomy as follows:\nPatent SVG to OM1, patent SVG to PDA which filled the distal PDA\nas well as the R-PL via a jump segment.', " Stump occlusion of a\ngraft presumably to the right system as well as one stump that\ncould be documented of a graft to the left. Other SVG's were not\nable to be selectively engaged. Supravalvular aortography\ndemonstrated no other patent grafts. Patent LIMA to mid-LAD,\nwhich also back-perfused the diagonal via a patent jump graft\nthat was interposed between the LAD and the diagonal.\n\nSocial History:\nSocial history is significant for the absence of current tobacco\nuse. There is no history of alcohol abuse.\n\nFamily History:\nThere is extensive family history of early coronary disease\n(father died of MI at 44, one brother died in 40's, one in 50's,\nsister had stroke).\n\nPhysical Exam:\nGen: Elderly white male in NAD. Oriented x3.\nVS T 101 BP 88/54 HR 122 in A-Fib RR 27 O2 sat 97 % on 100 %\nNRB.\nHEENT: NCAT.", ' Sclera anicteric. PERRL, EOMI. Conjunctiva were\npink, no pallor or cyanosis of the oral mucosa. No xanthalesma.\nNeck: JVP of near angle of the jaw.\nCV: PMI diffuse and laterally displaced. Rate irregular, normal\nS1, S2 with mid-late peaking 3/6 systolic murmur heart\nthroughout precordium, loudest at apex. No gallop.\nChest: Appear tachypneic, some accesorry muscle use. No chest\nwall deformities, scoliosis or kyphosis. Lungs with crackles 9-21\nway up L>R.\nAbd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\npalpation. No abdominial bruits.\nExt: No femoral bruits, could not palpate DP or TP pulses but\nDopplerable.\nSkin: No stasis dermatitis, ulcers, scars, or xanthomas.\n\nPertinent Results:\n1917-7-19 03:44AM BLOOD WBC-8.1# RBC-4.11* Hgb-13.3* Hct-37.9\nMCV-92 MCH-32.4 MCHC-35.0 RDW-14.', '1 Plt Ct-111\n1917-7-19 08:00PM BLOOD Neuts-74.3 Lymphs-21.9 Monos-3.0 Eos-0.7\nBaso-0.1\n1917-7-19 03:44AM BLOOD Plt Ct-111* LPlt-2+\n1917-7-19 08:00PM BLOOD Fibrino-760#\n1934-11-14 09:15PM BLOOD Glucose-195 UreaN-30* Creat-1.4* Na-133\nK-4.6 Cl-96 HCO3-25 AnGap-17\n\nCK 257* --> 189* --> 192* --> 193* --> 176 --> 82\n1917-7-19 08:00PM BLOOD ALT-38 AST-46* AlkPhos-66 TotBili-1.0\nDirBili-0.3 IndBili-0.7\n\n1934-11-14 09:15PM BLOOD CK-MB-10 MB Indx-3.9 cTropnT-0.66\nproBNP-1469907\n1917-7-19 03:44AM BLOOD CK-MB-7 cTropnT-0.69\n1917-7-19 11:40AM BLOOD CK-MB-8 cTropnT-0.67\n1917-7-19 04:55PM BLOOD CK-MB-7 cTropnT-0.65\n1917-7-19 08:00PM BLOOD CK-MB-7 cTropnT-0.64\n1916-2-4 05:41AM BLOOD CK-MB-63* MB Indx-6.3* cTropnT-2.61\n\n1934-11-14 09:15PM BLOOD calTIBC-334 Ferritn-93 TRF-257\n1917-7-19 08:00PM BLOOD TSH-5.', '4\n\nECG 1934-11-14 9:36:38 PM\nRhythm is most likely sinus rhythm with frequent ventricular\npremature beats with occasional ventricular bigeminal pattern.\nThere are also frequent atrial premature beats. Intraventricular\nconduction defect. Left ventricular hypertrophy. ST-T wave\nchanges most likely related to left ventricular hypertrophy.\nCompared to the previous tracing of 1955-3-16 ventricular premature\nbeats are more frequent, as are atrial premature beats. Clinical\ncorrelation is suggested.\n\nCXR 1934-11-14: The patient is after median sternotomy and CABG.\nThe heart size appears slightly enlarged compared to the\nprevious study. Bilateral perihilar haziness continues toward\nthe lower lungs is new consistent with new moderate- to-severe\npulmonary edema. Bilateral pleural effusion is present, also\nnew, most likely part of the heart failure.', ' Left and right\nretrocardiac opacities consistent with atelectasis.\n\nECHO 1916-2-4: The left atrium is mildly dilated. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size.\nThere is moderate regional left ventricular systolic dysfunction\nwith akinesis of the basal half of the inferior and inferolaterl\nwalls. There is mild hypokinesis of the remaining segments (LVEF\n= 25-30 %). No masses or thrombi are seen in the left ventricle.\nTissue Doppler imaging suggests an increased left ventricular\nfilling pressure (PCWP>18mmHg). Right ventricular chamber size\nis normal. with moderate global free wall hypokinesis. The\naortic valve leaflets are moderately thickened. There is severe\naortic valve stenosis (area 0.6 cm2). Trace aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened.', ' Mild to\nmoderate (9-21+) mitral regurgitation is seen. The pulmonary\nartery systolic pressure could not be determined. There is no\npericardial effusion. Compared with the prior report (images\nunavailable of 1928-3-15, left ventricular systolic function is now\ndepressed and the severity of aortic stenosis has increased.\n\nBrief Hospital Course:\nPatient is a 84 yo man with CAD s/p CABG twice with daily\nangina, presenting with chest pain, dyspnea, and congestive\nheart failure.\n\n# CAD: The patient was transferred to Davis, Kelly and Stevens Clinic for further workup\nand treatment of chest pain. A chest X-ray performed on\nadmission showed moderate-severe pulmonary edema. He did have a\nstably elevated troponin thought to be related to acute heart\nfailure or demand ischemia. He was started on a Lasix drop at 10\nmg/hr for initiation of diuresis.', " He initially tolerated this\nwell, however at approximately 8 pm on 1917-7-19, Mr. Smith was\ntransferred from the floor to the CCU after complaining of chest\npain when he was sitting in bed after dinner. As he was being\nevaluated by the housestaff, he became unresponsive and\ndeveloped pulseless electrical arrest. Chest compressions were\nstarted, but within approximately 2 minutes, he became\nresponsive and regained a palpable pulse. His rhythm appeared to\nbe atrial fibrillation with ventricular rate initially in the\n50s but rising to the 110's. Review of his telemetry showed that\nhe had developed atrial fibillation earlier in the evening\nwithout obvious ventricular arrhythmias immediately prior to his\narrest (which was attributed to a vasovagal episode in the\nsetting of heart failure and aortic stenosis).", " On transfer to\nthe CCU, he was started on levophed for hypotension and\namiodarone IV for AFib. Chest x-ray on 1917-7-19 showed interval\nworsening of pulmonary edema, bilateral pleural effusions and\nbibasilar atelectasis. At this time his cardiac enzymes became\nvery elevated with EKG changes consistent of a NSTEMI with a CK\nto 1006 and troponin to 3.82. On 1916-2-4, he had a transthoracic\nechocardiogram which showed moderate regional left ventricular\nsystolic dysfunction with akinesis of the basal half of the\ninferior and inferolateral walls. LVEF was 25-30 %, with severe\naortic stenosis and 9-21+ mitral regurgitation. He was\naggressively diuresed with an IV Lasix drip with improvement in\nhis oxygen requirement and chest x-ray. Levophed was\ndiscontinued on 3-22, and blood pressures remained stable off\npressors with MAP's 60 - 70.", ' On 1974-9-2, he was transferred\nback to the floor team on PO amiodarone. He remained in normal\nsinus rhythm on telemetry on po amiodarone, and diuresis was\ncontinued with a Lasix drip with good urine output and\nimprovement of renal function. He remained asymptomatic with no\nshortness of breath or chest pain after transfer. He was\nmaintained on a heparin drip bridging to Coumadin for paroxysmal\natrial fibrillation. His metoprolol was held for hypotension in\nthe ICU and relative hypotension with SBP in 90s and low 100s\nupon transfer to the floor. ACE-inhibitor was held due to\nrelative hypotension and renal insufficiency with Creat 1.7. A\ncardiac surgery consult deemed him an acceptable candidate for a\n3rd open heart surgery for aortic valve replacement pending\nre-assessment of his coronary anatomy.', ' The intermediate-term\nplan was to allow recovery from the current episode and\ndiscussion as an outpatient with his primary cardiologist\nregarding the risks and benefits of aortic valve replacement.\n\nOn 3-4, the patient became hypotensive to SBPs to\n60s-70s after getting into a chair after breakfast. He was given\n1L NS with no response in BP. The patient was mentating but\nbecame short of breath with IVF. He had worsening EKG changes.\nHe was started on Levophed without improvement in his blood\npressure. He was brought to the catherization laboratory for\npotential emergent aortic valvuloplasty and was intubated. At\nthat point, he suffered a PEA arrest and could not be\nresuscitated. He was pronounced deceased at 12:33pm.\n\n# Pump: As above. The patient had severe pulmonary edema with\ninitial exam revealing crackles throughout his lung fields.', ' He\nwas treated with a Lasix drip which was transitioned on 3-4 to\npo Lasix 80 mg po twice daily.\n\n# Rhythm: Patient was in NSR on admission. On HD #2, he had\nchest pain, then went into PEA arrest as described above.\nTelemetry showed atrial fibrillation prior to the event. In the\nCCU, he was started on amiodarone 400 mg po tid to be tapered\nover the subsequent weeks.\n\n# Acute renal failure: Renal function initially declined\n(creatinine to 2.1), then improved on Lasix gtt, but stayed 1.7\n- 1.9 (above baseline of 1.3).\n\n# Hematuria: He had hematuria (no clots) after traumatic Foley\nplacement at the outside hospital. The catheter was removed on\n3-4 with gradual resolution of hematuria.\n\n# Diabetes: Due to acute renal failre, metformin was\ndiscontinued and the patient was maintained on a Humalog sliding\nscale with 30 units of Lantus at bedtime.', '\n\n# Hematoma. The patient developed a small hematoma at the site\nof his right internal jugular venous access after catheter\nremoval. This was treated with local compression.\n\nMedications on Admission:\nAspirin 81 mg\nPlavix 75 mg\nAtenolol 50 mg\nIsordil 5 mg Davis Inc Medical Center\nHCTZ 25 mg daily\nLisinopril 40 mg\nGemfibrozil 600 mg\nSimvastatin 20 mg\nGlipizide 5 mg XL daily\nMetformin unknown dose\nProtonix 40 mg\nThiamine, B12, B6, folate\n\nDischarge Medications:\nNone\n\nDischarge Disposition:\nExpired\n\nDischarge Diagnosis:\n1) Severe aortic stenosis\n2) Coronary artery disease with non-ST segment myocardial\ninfarction\n3) Cardiogenic shock requiring pressor support\n4) Atrial fibrillation\n5) Pulseless electrical activity arrest, twice\n6) Severe acute on chronic left ventricular systolic and\ndiastolic heart failure\n7) Acute on chronic renal failure\n8) Traumatic hematuria\n9) Diabetes mellitus\n10) Hypertension\n11) Peripheral arterial disease\n12) Hyperlipidemia\n\nDischarge Condition:\nDeceased\n\nDischarge Instructions:\nNone\n\nFollowup Instructions:\nNone\n\n Ethan Linda Meena Porras Haydee Ignacio MD, MSC 12-339\n\n']
185	1136	139574.0	2192-05-23	Discharge summary	Report	Admission Date: [2192-4-19] Discharge Date: [2192-5-23] Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 1865] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [Known lastname ] is an 84 yo f h/o CRI, HTN, GERD, colon ca, neprhotic syndrome, dc'd [3-31] after low anterior resection of colon. Now p/w 1wk h/o diarrhea worsened one day prior to admission, found to have wbcc 30 in ED, admitted [4-19] and started on both p.o. vanco and IV flagyl. Began to have brbpr on [4-25], on [4-30] had flex sigmoidoscopy showing pseudomembranes with recurrent c.diff vs. bowel ischemia as etiology. Then developed some sob/fluid overload and was started on lasix and neseritide gtt's. Had had some intermittent afib which was thought to be contributing to presumed diastolic dysfunction. Tx to CCU [2192-5-12] for worsening tachypnea and oliguria on nesiritide and lasix gtt. Was cardioverted chemically with good result. Also developed acute on chronic renal failure for which nephrology has been following, zenith of 6.0, now back at baseline creatinine of 2.0's. Past Medical History: Recent admission to [Hospital1 18] from [2192-2-17] to [2192-2-29] for treatment of likely viral gastroenteritis, PNA, transaminitis, discharged to [Hospital ] Rehab in [Hospital1 8] - RAS: MRI ([2185]) atrophic R kidney, mod stenosis of R renal artery, L renal artery normal - CRI/nephrotic range proteinuria: [2191] baseline Cr 2.5; followed by Dr. [Last Name (STitle) 1860] (Nephrology) - PVD/Claudication - nephrotic range proteinuria - GERD - HTN: poorly controlled (SBP in 200s), Echo [2188] EF >55%, Mod AR, Mild MR, ascending aorta mildly dilated, Abdm aorta mildly dilated, Ao valve leaflets mildly thickened - Hyperlipidemia - Total Chol 255 ([2190]), LDL 138 ([1-/2192]), HDL 31, ([1-/2192]), Tg 312 ([2191]) - Glaucoma - Rheumatic Fever - Anemia - [2190]-[2191] mid 30s - Hyperkalemia - Osteoarthritis - Osteopenia Social History: living alone independently prior to last hospitalization. Several children and grandchildren in the area who are involved in her care. denies alcohol or tobacco use. Family History: Noncontributory. Physical Exam: tm 95.7, bp 108/50, p 93, r 25, 98% ra PERRL. OP clr JVP not appreciable. Regular s1,s2. no m/r/g LCA b/l +bs. soft. nt. nd. 2+ Lower and Upper Ext edema Pertinent Results: Admission Labs: . CBC: WBC-41.4# RBC-4.35 HGB-13.0 HCT-37.5# MCV-86 MCH-29.8 PLT 167 DIFF: NEUTS-93.1 BANDS-0 LYMPHS-5.6* MONOS-1.1* EOS-0.1 BASOS-0.2 . CHEM 7:GLUCOSE-81 UREA N-64* CREAT-4.1# SODIUM-135 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-20 ANION GAP-17 ALBUMIN-1.8* CALCIUM-7.3* PHOSPHATE-4.0 MAGNESIUM-2.0 . LFTs: ALT(SGPT)-10 AST(SGOT)-24 ALK PHOS-150* TOT BILI-0.4 . CT: 1. Extensive pan colitis consistent with the clinical diagnosis of C-dif colitis. There is no evidence of toxic megacolon or perforation or abscess. 2. New small bilateral pleural effusions. 3. Small amount of ascites. . Right IJ central line with the tip in the right atrium. No evidence of pneumothorax. . Micro: Cdiff [5-7]: negative Cdiff [5-6]: negative Cdiff [5-4]: negative Cdiff [5-3]: negative Cdiff [4-20]: negative * Blood Cx [4-18]: negative Urine Cx [4-18]: <10,000 organisms Brief Hospital Course: 84 yo f w/ h/o CRI, htn, h/o nephrotic syndrome, w/ diarrhea, c.diff pos at rehab, failure to respond to flagyl, w/ elev wbc, and negative ct. A brief-problem based hospital course is outlined below. 1) presumed c.diff infxn- Admitted and started on p.o. vancomyin and IV metronidazole, w/ addition of levofloxacin for broad spectrum coverage given recent abd surgery. Cholestyramine was initially given for toxin binding. WBC was 30 on admission and trended down with ABX; however, C.diff toxin neg x5, so diagnosis remains presumptive. C. diff B toxin was sent and was negative as well. She completed a 3 week course of PO vanco and IV flagyl antibiotics, which was completed on [5-14]. She subsequently remained afebrile without further diarrhea, and was able to tolerate PO's. 2) [Name (NI) 1866] Pt began having episodes of BRBPR on [4-25] with resultant slow HCT drop. GI and surgery were consulted. Pt had no abdominal pain, but given recent surgery and low albumin, we were concerned that the bleed may be evidence of ischemic bowel or dehiscence. Pt was also having intermittent episodes of tachycardia, raising the possibility that she was having embolic phenomena with acute ischemia. However, she had no abdominal pain to suggest this. Colonoscopy was done on [4-30], showing severe c dif vs. ischemic bowel. Surgery found that pt was not surgical candidate and believed her bleeding and mucosal damage was [2-29] c dif and would continue to improve. Biopsy results showed no evidence of c.dif, but given pt's tenuous status, po vanco and iv flagyl were continued while awaiting toxin B. It is quite possible that the mucosal changes seen on colonoscopy were the result of C dif infxn, which had been treated w/ABX and resolved, leaving the mucosae to heal. As well, GI felt there may be a superimposed ischemic insult. No further work-up was performed since she had good clinical resolution of her colitis, following completion of cdiff treatment. 2) acute renal failure w/ CRI- Renal team was consulted on admisison. Baseline cr is approx 2.0. On admission this was significantly elevated to 4.1. FENA was c/w prerenal etiology and patient had R IJ placed in ED, started on NS for volume resusciation. This was undertaken slowly given that pt had an albumin of 1.4 and pleural effusions were noted on CT. Fluids were changed to 1/2NS w/ bicarb on HD2. Cr trended down each day and the patient has maintained oxygenation. Alb/cr ratio not c/w nephrotic range proteinuria- thus it was felt that the low alb was likely multifactorial. Pt initially required boluses of 500cc NS to maintain Uop ~20-30cc/hr. With hydration and improvement in her diarrhea, her Cr steadily decreased and returned to baseline of 1.6. She was seen by renal who felt that her increase in creatinine may have been secondary to ATN/hypotension and recommended avoiding aggressive overdiuresis. She did subsequently require aggressive diuresis given her rapid afib/chf with lasix and niseritide drips. However her creatinine remained at baseline of 1.7-2.0 with diuresis. She did develop a transient metabolic alkalosis, which was felt likely from volume contraction alkalosis. Therefore her lasix was weaned to 40mg daily and her bicarb trended back down to 30. Her creatinine was stable at 1.6 at the time of discharge. 3) [Name (NI) 1867] Pt was noted to be mildly thrombocytopenic on admisison. Unclear why it was low when patient presented. Most likely [2-29] extreme inflammatory/SIRS response (given elev lactate on admission). Her PLT count dropped to 95 and DIC workup and HIT Ab were sent, both negative. Her PLT count rose as her clinical condition improved and remained in normal range for the duration of her hosital course. 4) HTN - Pt's baseline SBP is in the 180s-200s range. On admission, BP was low [2-29] 3rd spacing and early sepsis. Her BP responded to fluids and she remained relatively normotensive. She was continued on metoprolol for HR/BP control and isordil/hydral was added for afterload reduction. 5) CHF - Evidence of CHF on initial CXR. Her EF was found to be 40% (previously normal), bringing up concern for ischemic event precipitating her failure. In support of this she was noted to have wall motion abnormalities on ECHO with inferoseptal/basal hypokinesis. Diagnostic catheritization was not performed due to her renal insufficiency and decompensated CHF. She was managed medically, and on [5-10] the CHF service was consulted for management. She was initiated on aggressive diuresis with IV lasix for goal -1.5L per day. She was transferred to the CCU briefly on [5-12] for more tailored therapy and diuresis for her CHF (lasix boluses and nesiritide) with good effect (negative approximately 500 cc overnight). She was transferred back to the floor on lasix boluses. Due to continued evidence of volume overload she was given 160mg IV [Month/Year (2) 1868] + started on lasix drip at 10mg/hr. Then started nesiritide [Month/Year (2) 1868] (1mcg/kg) followed by gtt at 0.01mcg/kg/min. Diuresed well to this and maintained BP well, however after increasing natrecor to 0.015, went back into rapid afib. Stopped natrecor on [5-17]. Stopped lasix gtt on [5-18] given persistent good diuresis. Now tapered down to 40mg daily lasix/day + afterload reduction w/ Isordil/Hydral on [5-22]. At the time of discharge, she was felt to be euvolemic with goal of matching ins and outs daily. We will continue her on this regimen upon discharge. 7. Atrial fibrillation: Initially converted from RAF by medical cardioversion performed with procainamide gtt in the CCU at 13mg/kg/hr x10min load followed by 2mg/hr for 2h trial. Became hypotensive to 60's systolic, but subsequently recovered. Then again went into RAF on [5-17] early am. Initially HR controlled w/ IV lopressor/IV dilt. Then [Hospital 1869] medical cardioversion w/ procainamide. Became hypotensive to 70's systolic after about 10 minutes on procainamide [Last Name (LF) 1868], [First Name3 (LF) ] this was stopped and her blood pressures normalized. She then converted 10 min later to NSR. She has been in NSR the remainder of her hospital course. She is not on coumadin due to risk for bleed. In addition, amiodorone was discussed as a medical option for continued rythm control. However, given the side effect profile, the family and patient were more comfortable with holding off on adding amiodorone at this time. They understand that there is a higher risk of conversion back to atrial fibrillation and increased risk for stroke without amiodorone. We will continue rate control with metoprolol as mentioned at 25mg TID, and may titrate up as needed to maintain HR <80. 8. CAD- wall motion abnormalities on ECHO w/ inferoseptal/basal HK. currently chest pain free. continuing with medical management. On statin/b-blocker. No plan for cath at this time given her renal insuff/co-morbiditites. Also holding off on aspirin currently given her bleed risk. This will be re-addressed as an outpatient through her PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ]. 9. Anemia- Initially had episode of GI bleed with blood loss anemia requiring 3 units of packed red blood cells. Hematocrit subsequently normalized. However, she subsequently was noted to have a low, but stable, hematocrit at 28-29. Repeat stool guaiacs were all negative and she had no further evidence of bleed or hemolysis. Iron stores were also found to be within normal limits, with low TIBC and high ferritin suggesting anemia of chronic disease. This was felt likely secondary to chronic renal insufficiency. She was started on EPO 2,000 Units q m,w,fr on [5-22]. The goal transfusion criteria would be 30 given her history of CAD, however, we have held off on further transfusion at this time given her known CHF with recent severe volume overload. We have set transfusion goal at hct>28, and transfused with 1 unit packed red blood cells and 20mg IV lasix for hct <28. 10. tachypnea- Resolved. Her transient tachypnea was felt likely secondary to volume overload. There was no evidence of infiltrate by CXR. Her ABG at the time on [5-15] showed 7.29/43/99. Her respiratory status subsequently improved that same day on [5-15] following IV lasix and atrovent nebulizers. Avoided albuterol nebulizers over concern for tachycardia. 11. F/E/N- Started on TPN for nutritional supplementation. She also had a swallow study which showed ability to tolerated regular solids and thin liquids. She has been taking in PO's as tolerated, but has continued to require TPN to reach nutritional goals. This will be continued upon discharge at rehab. Medications on Admission: ASPIRIN 81MG--One by mouth every day CALCIUM --One tablet three times a day CLONIDINE HCL 0.1 mg--4 tablet(s) by mouth twice a day COLACE 100MG--Take one pill twice a day as needed for constipation LASIX 20 mg--1 tablet(s) by mouth once a day LOPRESSOR 50MG--One half tablet by mouth twice a day NIZORAL 2%--Use as directed NORVASC 10MG--One by mouth every day PHOSLO 667MG--Two tabs three times a day with meals per renal PLETAL 50MG--As per dr [First Name (STitle) 1870] TYLENOL/CODEINE NO.3 30-300MG--One tablet by mouth q 6 hours as needed for pain ULTRAM 50MG--One half tablet by mouth twice a day as needed for leg pain VITAMIN D [Numeric Identifier 1871] UNIT--One tablet q week Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 2. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-29] Sprays Nasal QID (4 times a day) as needed for dry nasal mucosa. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H () as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 9. Loteprednol Etabonate 0.5 % Drops, Suspension Sig: One (1) Ophthalmic daily (). 10. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic [Hospital1 ] (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) mL Injection QMOWEFR (Monday -Wednesday-Friday). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Rapid Atrial Fibrillation 2. Congestive Heart Failure (EF 40%) 3. Hypotension 4. Gastrointestinal bleed 5. Coronary Artery Disease 6. Refractory C.Diff 7. Non-healing Surgical Wound 8. Deconditioning 9. Malnutrition 10. Contraction Alkalosis 11. Chronic Renal Insufficiency Discharge Condition: Stable. Discharge Instructions: You are being discharged to [Hospital ] Rehab. Please follow-up with Dr. [Last Name (STitle) ] 1-2 weeks after discharge from Rehab. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] 1 week after discharge from Rehab. You may call to make an appointment at [Telephone/Fax (1) 250]	Admission Date: <Date>1960-6-12</Date> Discharge Date: <Date>1915-4-22</Date> Service: MEDICINE Allergies: Lisinopril Attending:<Name>Eric</Name> Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. <Name>Harris</Name> is an 84 yo f h/o CRI, HTN, GERD, colon ca, neprhotic syndrome, dc'd <Date>8-16</Date> after low anterior resection of colon. Now p/w 1wk h/o diarrhea worsened one day prior to admission, found to have wbcc 30 in ED, admitted <Date>5-6</Date> and started on both p.o. vanco and IV flagyl. Began to have brbpr on <Date>10-16</Date>, on <Date>5-15</Date> had flex sigmoidoscopy showing pseudomembranes with recurrent c.diff vs. bowel ischemia as etiology. Then developed some sob/fluid overload and was started on lasix and neseritide gtt's. Had had some intermittent afib which was thought to be contributing to presumed diastolic dysfunction. Tx to CCU <Date>1908-2-21</Date> for worsening tachypnea and oliguria on nesiritide and lasix gtt. Was cardioverted chemically with good result. Also developed acute on chronic renal failure for which nephrology has been following, zenith of 6.0, now back at baseline creatinine of 2.0's. Past Medical History: Recent admission to <Hospital>Shaffer Group Clinic</Hospital> from <Date>1954-11-16</Date> to <Date>1987-1-4</Date> for treatment of likely viral gastroenteritis, PNA, transaminitis, discharged to <Hospital>Estrada LLC Medical Center</Hospital> Rehab in <Hospital>Cross Ltd Health System</Hospital> - RAS: MRI (<Year>1986</Year>) atrophic R kidney, mod stenosis of R renal artery, L renal artery normal - CRI/nephrotic range proteinuria: <Year>1986</Year> baseline Cr 2.5; followed by Dr. <Name>Broadnax</Name> (Nephrology) - PVD/Claudication - nephrotic range proteinuria - GERD - HTN: poorly controlled (SBP in 200s), Echo <Year>1986</Year> EF >55%, Mod AR, Mild MR, ascending aorta mildly dilated, Abdm aorta mildly dilated, Ao valve leaflets mildly thickened - Hyperlipidemia - Total Chol 255 (<Year>1986</Year>), LDL 138 (<Date>9-2011</Date>), HDL 31, (<Date>9-2011</Date>), Tg 312 (<Year>1986</Year>) - Glaucoma - Rheumatic Fever - Anemia - <Year>1986</Year>-<Year>1986</Year> mid 30s - Hyperkalemia - Osteoarthritis - Osteopenia Social History: living alone independently prior to last hospitalization. Several children and grandchildren in the area who are involved in her care. denies alcohol or tobacco use. Family History: Noncontributory. Physical Exam: tm 95.7, bp 108/50, p 93, r 25, 98% ra PERRL. OP clr JVP not appreciable. Regular s1,s2. no m/r/g LCA b/l +bs. soft. nt. nd. 2+ Lower and Upper Ext edema Pertinent Results: Admission Labs: . CBC: WBC-41.4# RBC-4.35 HGB-13.0 HCT-37.5# MCV-86 MCH-29.8 PLT 167 DIFF: NEUTS-93.1 BANDS-0 LYMPHS-5.6* MONOS-1.1* EOS-0.1 BASOS-0.2 . CHEM 7:GLUCOSE-81 UREA N-64* CREAT-4.1# SODIUM-135 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-20 ANION GAP-17 ALBUMIN-1.8* CALCIUM-7.3* PHOSPHATE-4.0 MAGNESIUM-2.0 . LFTs: ALT(SGPT)-10 AST(SGOT)-24 ALK PHOS-150* TOT BILI-0.4 . CT: 1. Extensive pan colitis consistent with the clinical diagnosis of C-dif colitis. There is no evidence of toxic megacolon or perforation or abscess. 2. New small bilateral pleural effusions. 3. Small amount of ascites. . Right IJ central line with the tip in the right atrium. No evidence of pneumothorax. . Micro: Cdiff <Date>10-4</Date>: negative Cdiff <Date>6-9</Date>: negative Cdiff <Date>5-28</Date>: negative Cdiff <Date>3-12</Date>: negative Cdiff <Date>11-10</Date>: negative * Blood Cx <Date>10-2</Date>: negative Urine Cx <Date>10-2</Date>: <10,000 organisms Brief Hospital Course: 84 yo f w/ h/o CRI, htn, h/o nephrotic syndrome, w/ diarrhea, c.diff pos at rehab, failure to respond to flagyl, w/ elev wbc, and negative ct. A brief-problem based hospital course is outlined below. 1) presumed c.diff infxn- Admitted and started on p.o. vancomyin and IV metronidazole, w/ addition of levofloxacin for broad spectrum coverage given recent abd surgery. Cholestyramine was initially given for toxin binding. WBC was 30 on admission and trended down with ABX; however, C.diff toxin neg x5, so diagnosis remains presumptive. C. diff B toxin was sent and was negative as well. She completed a 3 week course of PO vanco and IV flagyl antibiotics, which was completed on <Date>12-7</Date>. She subsequently remained afebrile without further diarrhea, and was able to tolerate PO's. 2) <Name>Janell Starks</Name> Pt began having episodes of BRBPR on <Date>10-16</Date> with resultant slow HCT drop. GI and surgery were consulted. Pt had no abdominal pain, but given recent surgery and low albumin, we were concerned that the bleed may be evidence of ischemic bowel or dehiscence. Pt was also having intermittent episodes of tachycardia, raising the possibility that she was having embolic phenomena with acute ischemia. However, she had no abdominal pain to suggest this. Colonoscopy was done on <Date>5-15</Date>, showing severe c dif vs. ischemic bowel. Surgery found that pt was not surgical candidate and believed her bleeding and mucosal damage was <Date>3-11</Date> c dif and would continue to improve. Biopsy results showed no evidence of c.dif, but given pt's tenuous status, po vanco and iv flagyl were continued while awaiting toxin B. It is quite possible that the mucosal changes seen on colonoscopy were the result of C dif infxn, which had been treated w/ABX and resolved, leaving the mucosae to heal. As well, GI felt there may be a superimposed ischemic insult. No further work-up was performed since she had good clinical resolution of her colitis, following completion of cdiff treatment. 2) acute renal failure w/ CRI- Renal team was consulted on admisison. Baseline cr is approx 2.0. On admission this was significantly elevated to 4.1. FENA was c/w prerenal etiology and patient had R IJ placed in ED, started on NS for volume resusciation. This was undertaken slowly given that pt had an albumin of 1.4 and pleural effusions were noted on CT. Fluids were changed to 1/2NS w/ bicarb on HD2. Cr trended down each day and the patient has maintained oxygenation. Alb/cr ratio not c/w nephrotic range proteinuria- thus it was felt that the low alb was likely multifactorial. Pt initially required boluses of 500cc NS to maintain Uop ~20-30cc/hr. With hydration and improvement in her diarrhea, her Cr steadily decreased and returned to baseline of 1.6. She was seen by renal who felt that her increase in creatinine may have been secondary to ATN/hypotension and recommended avoiding aggressive overdiuresis. She did subsequently require aggressive diuresis given her rapid afib/chf with lasix and niseritide drips. However her creatinine remained at baseline of 1.7-2.0 with diuresis. She did develop a transient metabolic alkalosis, which was felt likely from volume contraction alkalosis. Therefore her lasix was weaned to 40mg daily and her bicarb trended back down to 30. Her creatinine was stable at 1.6 at the time of discharge. 3) <Name>Michelle Kuykendall</Name> Pt was noted to be mildly thrombocytopenic on admisison. Unclear why it was low when patient presented. Most likely <Date>3-11</Date> extreme inflammatory/SIRS response (given elev lactate on admission). Her PLT count dropped to 95 and DIC workup and HIT Ab were sent, both negative. Her PLT count rose as her clinical condition improved and remained in normal range for the duration of her hosital course. 4) HTN - Pt's baseline SBP is in the 180s-200s range. On admission, BP was low <Date>3-11</Date> 3rd spacing and early sepsis. Her BP responded to fluids and she remained relatively normotensive. She was continued on metoprolol for HR/BP control and isordil/hydral was added for afterload reduction. 5) CHF - Evidence of CHF on initial CXR. Her EF was found to be 40% (previously normal), bringing up concern for ischemic event precipitating her failure. In support of this she was noted to have wall motion abnormalities on ECHO with inferoseptal/basal hypokinesis. Diagnostic catheritization was not performed due to her renal insufficiency and decompensated CHF. She was managed medically, and on <Date>1-12</Date> the CHF service was consulted for management. She was initiated on aggressive diuresis with IV lasix for goal -1.5L per day. She was transferred to the CCU briefly on <Date>9-17</Date> for more tailored therapy and diuresis for her CHF (lasix boluses and nesiritide) with good effect (negative approximately 500 cc overnight). She was transferred back to the floor on lasix boluses. Due to continued evidence of volume overload she was given 160mg IV <Month>October</Month> + started on lasix drip at 10mg/hr. Then started nesiritide <Month>October</Month> (1mcg/kg) followed by gtt at 0.01mcg/kg/min. Diuresed well to this and maintained BP well, however after increasing natrecor to 0.015, went back into rapid afib. Stopped natrecor on <Date>2-21</Date>. Stopped lasix gtt on <Date>6-4</Date> given persistent good diuresis. Now tapered down to 40mg daily lasix/day + afterload reduction w/ Isordil/Hydral on <Date>4-16</Date>. At the time of discharge, she was felt to be euvolemic with goal of matching ins and outs daily. We will continue her on this regimen upon discharge. 7. Atrial fibrillation: Initially converted from RAF by medical cardioversion performed with procainamide gtt in the CCU at 13mg/kg/hr x10min load followed by 2mg/hr for 2h trial. Became hypotensive to 60's systolic, but subsequently recovered. Then again went into RAF on <Date>2-21</Date> early am. Initially HR controlled w/ IV lopressor/IV dilt. Then <Hospital>Hayes and Sons Clinic</Hospital> medical cardioversion w/ procainamide. Became hypotensive to 70's systolic after about 10 minutes on procainamide <Name>Islam</Name>, <Name>Joan</Name> this was stopped and her blood pressures normalized. She then converted 10 min later to NSR. She has been in NSR the remainder of her hospital course. She is not on coumadin due to risk for bleed. In addition, amiodorone was discussed as a medical option for continued rythm control. However, given the side effect profile, the family and patient were more comfortable with holding off on adding amiodorone at this time. They understand that there is a higher risk of conversion back to atrial fibrillation and increased risk for stroke without amiodorone. We will continue rate control with metoprolol as mentioned at 25mg TID, and may titrate up as needed to maintain HR <80. 8. CAD- wall motion abnormalities on ECHO w/ inferoseptal/basal HK. currently chest pain free. continuing with medical management. On statin/b-blocker. No plan for cath at this time given her renal insuff/co-morbiditites. Also holding off on aspirin currently given her bleed risk. This will be re-addressed as an outpatient through her PCP <Name>Hazelwood</Name>. <Name>Taylor</Name>. 9. Anemia- Initially had episode of GI bleed with blood loss anemia requiring 3 units of packed red blood cells. Hematocrit subsequently normalized. However, she subsequently was noted to have a low, but stable, hematocrit at 28-29. Repeat stool guaiacs were all negative and she had no further evidence of bleed or hemolysis. Iron stores were also found to be within normal limits, with low TIBC and high ferritin suggesting anemia of chronic disease. This was felt likely secondary to chronic renal insufficiency. She was started on EPO 2,000 Units q m,w,fr on <Date>4-16</Date>. The goal transfusion criteria would be 30 given her history of CAD, however, we have held off on further transfusion at this time given her known CHF with recent severe volume overload. We have set transfusion goal at hct>28, and transfused with 1 unit packed red blood cells and 20mg IV lasix for hct <28. 10. tachypnea- Resolved. Her transient tachypnea was felt likely secondary to volume overload. There was no evidence of infiltrate by CXR. Her ABG at the time on <Date>12-15</Date> showed 7.29/43/99. Her respiratory status subsequently improved that same day on <Date>12-15</Date> following IV lasix and atrovent nebulizers. Avoided albuterol nebulizers over concern for tachycardia. 11. F/E/N- Started on TPN for nutritional supplementation. She also had a swallow study which showed ability to tolerated regular solids and thin liquids. She has been taking in PO's as tolerated, but has continued to require TPN to reach nutritional goals. This will be continued upon discharge at rehab. Medications on Admission: ASPIRIN 81MG--One by mouth every day CALCIUM --One tablet three times a day CLONIDINE HCL 0.1 mg--4 tablet(s) by mouth twice a day COLACE 100MG--Take one pill twice a day as needed for constipation LASIX 20 mg--1 tablet(s) by mouth once a day LOPRESSOR 50MG--One half tablet by mouth twice a day NIZORAL 2%--Use as directed NORVASC 10MG--One by mouth every day PHOSLO 667MG--Two tabs three times a day with meals per renal PLETAL 50MG--As per dr <Name>Caleb</Name> TYLENOL/CODEINE NO.3 30-300MG--One tablet by mouth q 6 hours as needed for pain ULTRAM 50MG--One half tablet by mouth twice a day as needed for leg pain VITAMIN D <Numeric Identifier>4431968</Numeric Identifier> UNIT--One tablet q week Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 2. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 4. Sodium Chloride 0.65 % Aerosol, Spray Sig: <Date>12-11</Date> Sprays Nasal QID (4 times a day) as needed for dry nasal mucosa. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H () as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic <Hospital>Wong Group Health System</Hospital> (2 times a day). 9. Loteprednol Etabonate 0.5 % Drops, Suspension Sig: One (1) Ophthalmic daily (). 10. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic <Hospital>Wong Group Health System</Hospital> (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) mL Injection QMOWEFR (Monday -Wednesday-Friday). Discharge Disposition: Extended Care Facility: <Hospital>Ramirez Ltd Health System</Hospital> & Rehab Center - <Hospital>Cross Ltd Health System</Hospital> Discharge Diagnosis: 1. Rapid Atrial Fibrillation 2. Congestive Heart Failure (EF 40%) 3. Hypotension 4. Gastrointestinal bleed 5. Coronary Artery Disease 6. Refractory C.Diff 7. Non-healing Surgical Wound 8. Deconditioning 9. Malnutrition 10. Contraction Alkalosis 11. Chronic Renal Insufficiency Discharge Condition: Stable. Discharge Instructions: You are being discharged to <Hospital>Estrada LLC Medical Center</Hospital> Rehab. Please follow-up with Dr. <Name>Taylor</Name> 1-2 weeks after discharge from Rehab. Followup Instructions: Please follow-up with Dr. <Name>Taylor</Name> 1 week after discharge from Rehab. You may call to make an appointment at <Telephone>578-336-5771</Telephone>	000000000000000001111111110000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011100000000000000000000000000000000000000000000000000000000000000000000001111100000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111110000001111111111000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111000000000011111111111111111111111000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000>0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000011111100000000000001111110000000000011110000000000000000000000000000000000000000001111011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000111000000000000000001111000000000000000001111000000000000000001111100000000000000000000001111000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1960-6-12 Discharge Date: 1915-4-22 Service: MEDICINE Allergies: Lisinopril Attending:Eric Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. Harris is an 84 yo f h/o CRI, HTN, GERD, colon ca, neprhotic syndrome, dc'd 8-16 after low anterior resection of colon. Now p/w 1wk h/o diarrhea worsened one day prior to admission, found to have wbcc 30 in ED, admitted 5-6 and started on both p.o. vanco and IV flagyl. Began to have brbpr on 10-16, on 5-15 had flex sigmoidoscopy showing pseudomembranes with recurrent c.diff vs. bowel ischemia as etiology. Then developed some sob/fluid overload and was started on lasix and neseritide gtt's. Had had some intermittent afib which was thought to be contributing to presumed diastolic dysfunction. Tx to CCU 1908-2-21 for worsening tachypnea and oliguria on nesiritide and lasix gtt. Was cardioverted chemically with good result. Also developed acute on chronic renal failure for which nephrology has been following, zenith of 6.0, now back at baseline creatinine of 2.0's. Past Medical History: Recent admission to Shaffer Group Clinic from 1954-11-16 to 1987-1-4 for treatment of likely viral gastroenteritis, PNA, transaminitis, discharged to Estrada LLC Medical Center Rehab in Cross Ltd Health System - RAS: MRI (1986) atrophic R kidney, mod stenosis of R renal artery, L renal artery normal - CRI/nephrotic range proteinuria: 1986 baseline Cr 2.5; followed by Dr. Broadnax (Nephrology) - PVD/Claudication - nephrotic range proteinuria - GERD - HTN: poorly controlled (SBP in 200s), Echo 1986 EF >55%, Mod AR, Mild MR, ascending aorta mildly dilated, Abdm aorta mildly dilated, Ao valve leaflets mildly thickened - Hyperlipidemia - Total Chol 255 (1986), LDL 138 (9-2011), HDL 31, (9-2011), Tg 312 (1986) - Glaucoma - Rheumatic Fever - Anemia - 1986-1986 mid 30s - Hyperkalemia - Osteoarthritis - Osteopenia Social History: living alone independently prior to last hospitalization. Several children and grandchildren in the area who are involved in her care. denies alcohol or tobacco use. Family History: Noncontributory. Physical Exam: tm 95.7, bp 108/50, p 93, r 25, 98% ra PERRL. OP clr JVP not appreciable. Regular s1,s2. no m/r/g LCA b/l +bs. soft. nt. nd. 2+ Lower and Upper Ext edema Pertinent Results: Admission Labs: . CBC: WBC-41.4# RBC-4.35 HGB-13.0 HCT-37.5# MCV-86 MCH-29.8 PLT 167 DIFF: NEUTS-93.1 BANDS-0 LYMPHS-5.6* MONOS-1.1* EOS-0.1 BASOS-0.2 . CHEM 7:GLUCOSE-81 UREA N-64* CREAT-4.1# SODIUM-135 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-20 ANION GAP-17 ALBUMIN-1.8* CALCIUM-7.3* PHOSPHATE-4.0 MAGNESIUM-2.0 . LFTs: ALT(SGPT)-10 AST(SGOT)-24 ALK PHOS-150* TOT BILI-0.4 . CT: 1. Extensive pan colitis consistent with the clinical diagnosis of C-dif colitis. There is no evidence of toxic megacolon or perforation or abscess. 2. New small bilateral pleural effusions. 3. Small amount of ascites. . Right IJ central line with the tip in the right atrium. No evidence of pneumothorax. . Micro: Cdiff 10-4: negative Cdiff 6-9: negative Cdiff 5-28: negative Cdiff 3-12: negative Cdiff 11-10: negative * Blood Cx 10-2: negative Urine Cx 10-2: 12-7. She subsequently remained afebrile without further diarrhea, and was able to tolerate PO's. 2) Janell Starks Pt began having episodes of BRBPR on 10-16 with resultant slow HCT drop. GI and surgery were consulted. Pt had no abdominal pain, but given recent surgery and low albumin, we were concerned that the bleed may be evidence of ischemic bowel or dehiscence. Pt was also having intermittent episodes of tachycardia, raising the possibility that she was having embolic phenomena with acute ischemia. However, she had no abdominal pain to suggest this. Colonoscopy was done on 5-15, showing severe c dif vs. ischemic bowel. Surgery found that pt was not surgical candidate and believed her bleeding and mucosal damage was 3-11 c dif and would continue to improve. Biopsy results showed no evidence of c.dif, but given pt's tenuous status, po vanco and iv flagyl were continued while awaiting toxin B. It is quite possible that the mucosal changes seen on colonoscopy were the result of C dif infxn, which had been treated w/ABX and resolved, leaving the mucosae to heal. As well, GI felt there may be a superimposed ischemic insult. No further work-up was performed since she had good clinical resolution of her colitis, following completion of cdiff treatment. 2) acute renal failure w/ CRI- Renal team was consulted on admisison. Baseline cr is approx 2.0. On admission this was significantly elevated to 4.1. FENA was c/w prerenal etiology and patient had R IJ placed in ED, started on NS for volume resusciation. This was undertaken slowly given that pt had an albumin of 1.4 and pleural effusions were noted on CT. Fluids were changed to 1/2NS w/ bicarb on HD2. Cr trended down each day and the patient has maintained oxygenation. Alb/cr ratio not c/w nephrotic range proteinuria- thus it was felt that the low alb was likely multifactorial. Pt initially required boluses of 500cc NS to maintain Uop ~20-30cc/hr. With hydration and improvement in her diarrhea, her Cr steadily decreased and returned to baseline of 1.6. She was seen by renal who felt that her increase in creatinine may have been secondary to ATN/hypotension and recommended avoiding aggressive overdiuresis. She did subsequently require aggressive diuresis given her rapid afib/chf with lasix and niseritide drips. However her creatinine remained at baseline of 1.7-2.0 with diuresis. She did develop a transient metabolic alkalosis, which was felt likely from volume contraction alkalosis. Therefore her lasix was weaned to 40mg daily and her bicarb trended back down to 30. Her creatinine was stable at 1.6 at the time of discharge. 3) Michelle Kuykendall Pt was noted to be mildly thrombocytopenic on admisison. Unclear why it was low when patient presented. Most likely 3-11 extreme inflammatory/SIRS response (given elev lactate on admission). Her PLT count dropped to 95 and DIC workup and HIT Ab were sent, both negative. Her PLT count rose as her clinical condition improved and remained in normal range for the duration of her hosital course. 4) HTN - Pt's baseline SBP is in the 180s-200s range. On admission, BP was low 3-11 3rd spacing and early sepsis. Her BP responded to fluids and she remained relatively normotensive. She was continued on metoprolol for HR/BP control and isordil/hydral was added for afterload reduction. 5) CHF - Evidence of CHF on initial CXR. Her EF was found to be 40% (previously normal), bringing up concern for ischemic event precipitating her failure. In support of this she was noted to have wall motion abnormalities on ECHO with inferoseptal/basal hypokinesis. Diagnostic catheritization was not performed due to her renal insufficiency and decompensated CHF. She was managed medically, and on 1-12 the CHF service was consulted for management. She was initiated on aggressive diuresis with IV lasix for goal -1.5L per day. She was transferred to the CCU briefly on 9-17 for more tailored therapy and diuresis for her CHF (lasix boluses and nesiritide) with good effect (negative approximately 500 cc overnight). She was transferred back to the floor on lasix boluses. Due to continued evidence of volume overload she was given 160mg IV October + started on lasix drip at 10mg/hr. Then started nesiritide October (1mcg/kg) followed by gtt at 0.01mcg/kg/min. Diuresed well to this and maintained BP well, however after increasing natrecor to 0.015, went back into rapid afib. Stopped natrecor on 2-21. Stopped lasix gtt on 6-4 given persistent good diuresis. Now tapered down to 40mg daily lasix/day + afterload reduction w/ Isordil/Hydral on 4-16. At the time of discharge, she was felt to be euvolemic with goal of matching ins and outs daily. We will continue her on this regimen upon discharge. 7. Atrial fibrillation: Initially converted from RAF by medical cardioversion performed with procainamide gtt in the CCU at 13mg/kg/hr x10min load followed by 2mg/hr for 2h trial. Became hypotensive to 60's systolic, but subsequently recovered. Then again went into RAF on 2-21 early am. Initially HR controlled w/ IV lopressor/IV dilt. Then Hayes and Sons Clinic medical cardioversion w/ procainamide. Became hypotensive to 70's systolic after about 10 minutes on procainamide Islam, Joan this was stopped and her blood pressures normalized. She then converted 10 min later to NSR. She has been in NSR the remainder of her hospital course. She is not on coumadin due to risk for bleed. In addition, amiodorone was discussed as a medical option for continued rythm control. However, given the side effect profile, the family and patient were more comfortable with holding off on adding amiodorone at this time. They understand that there is a higher risk of conversion back to atrial fibrillation and increased risk for stroke without amiodorone. We will continue rate control with metoprolol as mentioned at 25mg TID, and may titrate up as needed to maintain HR Hazelwood. Taylor. 9. Anemia- Initially had episode of GI bleed with blood loss anemia requiring 3 units of packed red blood cells. Hematocrit subsequently normalized. However, she subsequently was noted to have a low, but stable, hematocrit at 28-29. Repeat stool guaiacs were all negative and she had no further evidence of bleed or hemolysis. Iron stores were also found to be within normal limits, with low TIBC and high ferritin suggesting anemia of chronic disease. This was felt likely secondary to chronic renal insufficiency. She was started on EPO 2,000 Units q m,w,fr on 4-16. The goal transfusion criteria would be 30 given her history of CAD, however, we have held off on further transfusion at this time given her known CHF with recent severe volume overload. We have set transfusion goal at hct>28, and transfused with 1 unit packed red blood cells and 20mg IV lasix for hct 12-15 showed 7.29/43/99. Her respiratory status subsequently improved that same day on 12-15 following IV lasix and atrovent nebulizers. Avoided albuterol nebulizers over concern for tachycardia. 11. F/E/N- Started on TPN for nutritional supplementation. She also had a swallow study which showed ability to tolerated regular solids and thin liquids. She has been taking in PO's as tolerated, but has continued to require TPN to reach nutritional goals. This will be continued upon discharge at rehab. Medications on Admission: ASPIRIN 81MG--One by mouth every day CALCIUM --One tablet three times a day CLONIDINE HCL 0.1 mg--4 tablet(s) by mouth twice a day COLACE 100MG--Take one pill twice a day as needed for constipation LASIX 20 mg--1 tablet(s) by mouth once a day LOPRESSOR 50MG--One half tablet by mouth twice a day NIZORAL 2%--Use as directed NORVASC 10MG--One by mouth every day PHOSLO 667MG--Two tabs three times a day with meals per renal PLETAL 50MG--As per dr Caleb TYLENOL/CODEINE NO.3 30-300MG--One tablet by mouth q 6 hours as needed for pain ULTRAM 50MG--One half tablet by mouth twice a day as needed for leg pain VITAMIN D 4431968 UNIT--One tablet q week Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 2. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 4. Sodium Chloride 0.65 % Aerosol, Spray Sig: 12-11 Sprays Nasal QID (4 times a day) as needed for dry nasal mucosa. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H () as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic Wong Group Health System (2 times a day). 9. Loteprednol Etabonate 0.5 % Drops, Suspension Sig: One (1) Ophthalmic daily (). 10. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic Wong Group Health System (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) mL Injection QMOWEFR (Monday -Wednesday-Friday). Discharge Disposition: Extended Care Facility: Ramirez Ltd Health System & Rehab Center - Cross Ltd Health System Discharge Diagnosis: 1. Rapid Atrial Fibrillation 2. Congestive Heart Failure (EF 40%) 3. Hypotension 4. Gastrointestinal bleed 5. Coronary Artery Disease 6. Refractory C.Diff 7. Non-healing Surgical Wound 8. Deconditioning 9. Malnutrition 10. Contraction Alkalosis 11. Chronic Renal Insufficiency Discharge Condition: Stable. Discharge Instructions: You are being discharged to Estrada LLC Medical Center Rehab. Please follow-up with Dr. Taylor 1-2 weeks after discharge from Rehab. Followup Instructions: Please follow-up with Dr. Taylor 1 week after discharge from Rehab. You may call to make an appointment at 578-336-5771	["Admission Date: 1960-6-12 Discharge Date: 1915-4-22\n\n\nService: MEDICINE\n\nAllergies:\nLisinopril\n\nAttending:Eric\nChief Complaint:\nDiarrhea\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\nMrs. Harris is an 84 yo f h/o CRI, HTN, GERD, colon ca,\nneprhotic syndrome, dc'd 8-16 after low anterior resection of\ncolon. Now p/w 1wk h/o diarrhea worsened one day prior to\nadmission, found to have wbcc 30 in ED, admitted 5-6 and\nstarted on both p.o. vanco and IV flagyl. Began to have brbpr on\n10-16, on 5-15 had flex sigmoidoscopy showing pseudomembranes with\nrecurrent c.diff vs. bowel ischemia as etiology. Then developed\nsome sob/fluid overload and was started on lasix and neseritide\ngtt's. Had had some intermittent afib which was thought to be\ncontributing to presumed diastolic dysfunction.", " Tx to CCU\n1908-2-21 for worsening tachypnea and oliguria on nesiritide and\nlasix gtt. Was cardioverted chemically with good result. Also\ndeveloped acute on chronic renal failure for which nephrology\nhas been following, zenith of 6.0, now back at baseline\ncreatinine of 2.0's.\n\n\nPast Medical History:\nRecent admission to Shaffer Group Clinic from 1954-11-16 to 1987-1-4 for treatment\nof likely viral gastroenteritis, PNA, transaminitis, discharged\nto Estrada LLC Medical Center Rehab in Cross Ltd Health System\n\n- RAS: MRI (1986) atrophic R kidney, mod stenosis of R renal\nartery, L renal artery normal\n- CRI/nephrotic range proteinuria: 1986 baseline Cr 2.5;\nfollowed by Dr. Broadnax (Nephrology)\n- PVD/Claudication - nephrotic range proteinuria\n- GERD\n- HTN: poorly controlled (SBP in 200s), Echo 1986 EF >55%, Mod\nAR, Mild MR, ascending aorta mildly dilated, Abdm aorta mildly\ndilated, Ao valve leaflets mildly thickened\n- Hyperlipidemia - Total Chol 255 (1986), LDL 138 (9-2011), HDL\n\n31, (9-2011), Tg 312 (1986)\n- Glaucoma\n- Rheumatic Fever\n- Anemia - 1986-1986 mid 30s\n- Hyperkalemia\n- Osteoarthritis\n- Osteopenia\n\n\nSocial History:\nliving alone independently prior to last hospitalization.", '\nSeveral children and grandchildren in the area who are involved\nin her care. denies alcohol or tobacco use.\n\nFamily History:\nNoncontributory.\n\nPhysical Exam:\ntm 95.7, bp 108/50, p 93, r 25, 98% ra\nPERRL.\nOP clr\nJVP not appreciable.\nRegular s1,s2. no m/r/g\nLCA b/l\n+bs. soft. nt. nd.\n2+ Lower and Upper Ext edema\n\n\n\nPertinent Results:\nAdmission Labs:\n.\nCBC: WBC-41.4# RBC-4.35 HGB-13.0 HCT-37.5# MCV-86 MCH-29.8 PLT\n167\nDIFF: NEUTS-93.1 BANDS-0 LYMPHS-5.6* MONOS-1.1* EOS-0.1\nBASOS-0.2\n.\nCHEM 7:GLUCOSE-81 UREA N-64* CREAT-4.1# SODIUM-135\nPOTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-20 ANION GAP-17\nALBUMIN-1.8* CALCIUM-7.3* PHOSPHATE-4.0 MAGNESIUM-2.0\n.\nLFTs: ALT(SGPT)-10 AST(SGOT)-24 ALK PHOS-150* TOT BILI-0.4\n.\nCT:\n1. Extensive pan colitis consistent with the clinical diagnosis\nof C-dif colitis. There is no evidence of toxic megacolon or\nperforation or abscess.', "\n2. New small bilateral pleural effusions.\n3. Small amount of ascites.\n.\nRight IJ central line with the tip in the right atrium. No\nevidence of pneumothorax.\n.\nMicro:\nCdiff 10-4: negative\nCdiff 6-9: negative\nCdiff 5-28: negative\nCdiff 3-12: negative\nCdiff 11-10: negative\n*\nBlood Cx 10-2: negative\nUrine Cx 10-2: 12-7. She\nsubsequently remained afebrile without further diarrhea, and was\nable to tolerate PO's.\n\n2) Janell Starks Pt began having episodes of BRBPR on 10-16 with\nresultant slow HCT drop. GI and surgery were consulted. Pt had\nno abdominal pain, but given recent surgery and low albumin, we\nwere concerned that the bleed may be evidence of ischemic bowel\nor dehiscence. Pt was also having intermittent episodes of\ntachycardia, raising the possibility that she was having embolic\nphenomena with acute ischemia.", " However, she had no abdominal\npain to suggest this. Colonoscopy was done on 5-15, showing\nsevere c dif vs. ischemic bowel. Surgery found that pt was not\nsurgical candidate and believed her bleeding and mucosal damage\nwas 3-11 c dif and would continue to improve. Biopsy results\nshowed no evidence of c.dif, but given pt's tenuous status, po\nvanco and iv flagyl were continued while awaiting toxin B. It is\nquite possible that the mucosal changes seen on colonoscopy were\nthe result of C dif infxn, which had been treated w/ABX and\nresolved, leaving the mucosae to heal. As well, GI felt there\nmay be a superimposed ischemic insult. No further work-up was\nperformed since she had good clinical resolution of her colitis,\nfollowing completion of cdiff treatment.\n\n2) acute renal failure w/ CRI- Renal team was consulted on\nadmisison.", ' Baseline cr is approx 2.0. On admission this was\nsignificantly elevated to 4.1. FENA was c/w prerenal etiology\nand patient had R IJ placed in ED, started on NS for volume\nresusciation. This was undertaken slowly given that pt had an\nalbumin of 1.4 and pleural effusions were noted on CT. Fluids\nwere changed to 1/2NS w/ bicarb on HD2. Cr trended down each day\nand the patient has maintained oxygenation. Alb/cr ratio not\nc/w nephrotic range proteinuria- thus it was felt that the low\nalb was likely multifactorial. Pt initially required boluses of\n500cc NS to maintain Uop ~20-30cc/hr. With hydration and\nimprovement in her diarrhea, her Cr steadily decreased and\nreturned to baseline of 1.6. She was seen by renal who felt that\nher increase in creatinine may have been secondary to\nATN/hypotension and recommended avoiding aggressive\noverdiuresis.', ' She did subsequently require aggressive diuresis\ngiven her rapid afib/chf with lasix and niseritide drips.\nHowever her creatinine remained at baseline of 1.7-2.0 with\ndiuresis. She did develop a transient metabolic alkalosis, which\nwas felt likely from volume contraction alkalosis. Therefore her\nlasix was weaned to 40mg daily and her bicarb trended back down\nto 30. Her creatinine was stable at 1.6 at the time of\ndischarge.\n\n3) Michelle Kuykendall Pt was noted to be mildly thrombocytopenic\non admisison. Unclear why it was low when patient presented.\nMost likely 3-11 extreme inflammatory/SIRS response (given elev\nlactate on admission). Her PLT count dropped to 95 and DIC\nworkup and HIT Ab were sent, both negative. Her PLT count rose\nas her clinical condition improved and remained in normal range\nfor the duration of her hosital course.', "\n\n4) HTN - Pt's baseline SBP is in the 180s-200s range. On\nadmission, BP was low 3-11 3rd spacing and early sepsis. Her BP\nresponded to fluids and she remained relatively normotensive.\nShe was continued on metoprolol for HR/BP control and\nisordil/hydral was added for afterload reduction.\n\n5) CHF - Evidence of CHF on initial CXR. Her EF was found to be\n40% (previously normal), bringing up concern for ischemic event\nprecipitating her failure. In support of this she was noted to\nhave wall motion abnormalities on ECHO with inferoseptal/basal\nhypokinesis. Diagnostic catheritization was not performed due to\nher renal insufficiency and decompensated CHF. She was managed\nmedically, and on 1-12 the CHF service was consulted for\nmanagement. She was initiated on aggressive diuresis with IV\nlasix for goal -1.", '5L per day. She was transferred to the CCU\nbriefly on 9-17 for more tailored therapy and diuresis for her\nCHF (lasix boluses and nesiritide) with good effect (negative\napproximately 500 cc overnight). She was transferred back to the\nfloor on lasix boluses.\n\nDue to continued evidence of volume overload she was given 160mg\nIV October + started on lasix drip at 10mg/hr. Then started\nnesiritide October (1mcg/kg) followed by gtt at 0.01mcg/kg/min.\nDiuresed well to this and maintained BP well, however after\nincreasing natrecor to 0.015, went back into rapid afib. Stopped\nnatrecor on 2-21. Stopped lasix gtt on 6-4 given persistent\ngood diuresis. Now tapered down to 40mg daily lasix/day +\nafterload reduction w/ Isordil/Hydral on 4-16. At the time of\ndischarge, she was felt to be euvolemic with goal of matching\nins and outs daily.', " We will continue her on this regimen upon\ndischarge.\n\n7. Atrial fibrillation: Initially converted from RAF by medical\ncardioversion performed with procainamide gtt in the CCU at\n13mg/kg/hr x10min load followed by 2mg/hr for 2h trial. Became\nhypotensive to 60's systolic, but subsequently recovered. Then\nagain went into RAF on 2-21 early am. Initially HR controlled w/\nIV lopressor/IV dilt. Then Hayes and Sons Clinic medical cardioversion w/\nprocainamide. Became hypotensive to 70's systolic after about 10\nminutes on procainamide Islam, Joan this was stopped and her blood\npressures normalized. She then converted 10 min later to NSR.\nShe has been in NSR the remainder of her hospital course. She is\nnot on coumadin due to risk for bleed. In addition, amiodorone\nwas discussed as a medical option for continued rythm control.", '\nHowever, given the side effect profile, the family and patient\nwere more comfortable with holding off on adding amiodorone at\nthis time. They understand that there is a higher risk of\nconversion back to atrial fibrillation and increased risk for\nstroke without amiodorone. We will continue rate control with\nmetoprolol as mentioned at 25mg TID, and may titrate up as\nneeded to maintain HR Hazelwood. Taylor.\n\n9. Anemia- Initially had episode of GI bleed with blood loss\nanemia requiring 3 units of packed red blood cells. Hematocrit\nsubsequently normalized. However, she subsequently was noted to\nhave a low, but stable, hematocrit at 28-29. Repeat stool\nguaiacs were all negative and she had no further evidence of\nbleed or hemolysis. Iron stores were also found to be within\nnormal limits, with low TIBC and high ferritin suggesting anemia\nof chronic disease.', " This was felt likely secondary to chronic\nrenal insufficiency. She was started on EPO 2,000 Units q m,w,fr\non 4-16. The goal transfusion criteria would be 30 given her\nhistory of CAD, however, we have held off on further transfusion\nat this time given her known CHF with recent severe volume\noverload. We have set transfusion goal at hct>28, and transfused\nwith 1 unit packed red blood cells and 20mg IV lasix for hct\n12-15 showed\n7.29/43/99. Her respiratory status subsequently improved that\nsame day on 12-15 following IV lasix and atrovent nebulizers.\nAvoided albuterol nebulizers over concern for tachycardia.\n\n11. F/E/N- Started on TPN for nutritional supplementation. She\nalso had a swallow study which showed ability to tolerated\nregular solids and thin liquids. She has been taking in PO's as\ntolerated, but has continued to require TPN to reach nutritional\ngoals.", ' This will be continued upon discharge at rehab.\n\n\nMedications on Admission:\nASPIRIN 81MG--One by mouth every day\nCALCIUM --One tablet three times a day\nCLONIDINE HCL 0.1 mg--4 tablet(s) by mouth twice a day\nCOLACE 100MG--Take one pill twice a day as needed for\nconstipation\nLASIX 20 mg--1 tablet(s) by mouth once a day\nLOPRESSOR 50MG--One half tablet by mouth twice a day\nNIZORAL 2%--Use as directed\nNORVASC 10MG--One by mouth every day\nPHOSLO 667MG--Two tabs three times a day with meals per renal\nPLETAL 50MG--As per dr Caleb\nTYLENOL/CODEINE NO.3 30-300MG--One tablet by mouth q 6 hours as\nneeded for pain\nULTRAM 50MG--One half tablet by mouth twice a day as needed for\nleg pain\nVITAMIN D 4431968 UNIT--One tablet q week\n\nDischarge Medications:\n1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every\n4 to 6 hours) as needed for fever, pain.', '\n2. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop\nOphthalmic Q8H (every 8 hours).\n3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID\n(4 times a day) as needed.\n4. Sodium Chloride 0.65 % Aerosol, Spray Sig: 12-11 Sprays Nasal\nQID (4 times a day) as needed for dry nasal mucosa.\n5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation\nQ3-4H () as needed.\n6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed.\n7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\n8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic Wong Group Health System\n(2 times a day).\n9. Loteprednol Etabonate 0.5 % Drops, Suspension Sig: One (1)\nOphthalmic daily ().\n10. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic\nWong Group Health System (2 times a day).', '\n11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID\n(3 times a day).\n12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n13. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3\ntimes a day).\n14. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID\n(3 times a day).\n15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n16. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) mL\nInjection QMOWEFR (Monday -Wednesday-Friday).\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nRamirez Ltd Health System & Rehab Center - Cross Ltd Health System\n\nDischarge Diagnosis:\n1. Rapid Atrial Fibrillation\n2. Congestive Heart Failure (EF 40%)\n3. Hypotension\n4. Gastrointestinal bleed\n5. Coronary Artery Disease\n6. Refractory C.Diff\n7. Non-healing Surgical Wound\n8.', ' Deconditioning\n9. Malnutrition\n10. Contraction Alkalosis\n11. Chronic Renal Insufficiency\n\n\nDischarge Condition:\nStable.\n\nDischarge Instructions:\nYou are being discharged to Estrada LLC Medical Center Rehab. Please follow-up\nwith Dr. Taylor 1-2 weeks after discharge from Rehab.\n\n\nFollowup Instructions:\nPlease follow-up with Dr. Taylor 1 week after discharge from\nRehab. You may call to make an appointment at 578-336-5771\n\n\n\n']
223	5350	169684.0	2143-04-30	Discharge summary	Report	Admission Date: [2143-4-25] Discharge Date: [2143-4-30] Date of Birth: [2076-8-18] Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Chest pain, 3-vessel disease on catheterization. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male transferred from [Hospital6 33] to the [Hospital1 346] status post catheterization, revealing 3-vessel cardiac disease. The patient presented to [Hospital6 33] with gradually increasing chest pain over the past three to four months to the point that he had chest pain with minimal exertion. PAST MEDICAL HISTORY: 1. Known coronary artery disease, status post catheterization 10 years ago at [Hospital1 ]. 2. Heavy smoker. 3. Hypertension. 4. Gastroesophageal reflux disease/peptic ulcer disease. 5. Wegener granulomatosis with complete resolution. 6. Glaucoma. PAST SURGICAL HISTORY: Perforated ulcer. MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Cosopt eyedrops, Alphagan eyedrops, Travatan eyedrops, lansoprazole 50 mg p.o. q.d. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient underwent an elective coronary artery bypass graft times three on [2143-4-26] with grafts being a left internal mammary artery to left anterior descending artery, saphenous vein graft to ramus, and saphenous vein graft to posterior descending artery. He was extubated on the day of surgery. On postoperative day one, his nasogastric tubes were discontinued. He was transferred to the regular floor on postoperative day one. He subsequently had a smooth postoperative course. His pacing wires were discontinued on postoperative day three. By postoperative day, he was ambulating well. He was comfortable on p.o. pain medication, and he was ready for discharge home. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q.d. (for one week). 2. KCL 20 mEq p.o. q.d. (for one week). 3. Colace 100 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d. 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Alphagan eyedrops. 7. Lopressor 50 mg p.o. b.i.d. 8. Nicoderm patch 22 mg q.d. 9. Percocet one to two tablets p.o. q.4-6h. p.r.n. DI[Last Name (STitle) 408]E FOLLOWUP: Follow up with primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2208], in two weeks and with Dr. [Last Name (Prefixes) ] in four weeks. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharged to home. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2143-4-30] 15:09 T: [2143-4-30] 15:31 JOB#: [Job Number 2210]	Admission Date: <Date>2020-7-18</Date> Discharge Date: <Date>2005-1-18</Date> Date of Birth: <Date>1937-6-7</Date> Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Chest pain, 3-vessel disease on catheterization. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male transferred from <Hospital>Schmidt-Williams Hospital</Hospital> to the <Hospital>Barnett, Sanchez and Miller Hospital</Hospital> status post catheterization, revealing 3-vessel cardiac disease. The patient presented to <Hospital>Schmidt-Williams Hospital</Hospital> with gradually increasing chest pain over the past three to four months to the point that he had chest pain with minimal exertion. PAST MEDICAL HISTORY: 1. Known coronary artery disease, status post catheterization 10 years ago at <Hospital>Bush-Graham Clinic</Hospital>. 2. Heavy smoker. 3. Hypertension. 4. Gastroesophageal reflux disease/peptic ulcer disease. 5. Wegener granulomatosis with complete resolution. 6. Glaucoma. PAST SURGICAL HISTORY: Perforated ulcer. MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Cosopt eyedrops, Alphagan eyedrops, Travatan eyedrops, lansoprazole 50 mg p.o. q.d. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient underwent an elective coronary artery bypass graft times three on <Date>1957-11-22</Date> with grafts being a left internal mammary artery to left anterior descending artery, saphenous vein graft to ramus, and saphenous vein graft to posterior descending artery. He was extubated on the day of surgery. On postoperative day one, his nasogastric tubes were discontinued. He was transferred to the regular floor on postoperative day one. He subsequently had a smooth postoperative course. His pacing wires were discontinued on postoperative day three. By postoperative day, he was ambulating well. He was comfortable on p.o. pain medication, and he was ready for discharge home. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q.d. (for one week). 2. KCL 20 mEq p.o. q.d. (for one week). 3. Colace 100 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d. 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Alphagan eyedrops. 7. Lopressor 50 mg p.o. b.i.d. 8. Nicoderm patch 22 mg q.d. 9. Percocet one to two tablets p.o. q.4-6h. p.r.n. DI<Name>Feudner</Name>E FOLLOWUP: Follow up with primary care physician, <Name>Johnson</Name>. <Name>Joe</Name> <Name>William</Name>, in two weeks and with Dr. <Name>Pettway</Name> in four weeks. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharged to home. <Doctor Name>Dr.William</Doctor Name> <Name>Beamon</Name>, M.D. <MD Number>42511278</MD Number> Dictated By:<Name>Gauthier</Name> MEDQUIST36 D: <Date>2005-1-18</Date> 15:09 T: <Date>2005-1-18</Date> 15:31 JOB#: <Job Number>Hall-Odonnell-1979-206231</Job Number>	00000000000000000111111111000000000000000000000011111111100000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111110000000011111111111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111100000000000000000000000000000000000000000000000000001111111001110111111100000000000000000000000000001111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111101111110000000011111111000000000000001111111100000000000000000011111111100000000000011111111100000000000000011111111111111111111111110	Admission Date: 2020-7-18 Discharge Date: 2005-1-18 Date of Birth: 1937-6-7 Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Chest pain, 3-vessel disease on catheterization. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male transferred from Schmidt-Williams Hospital to the Barnett, Sanchez and Miller Hospital status post catheterization, revealing 3-vessel cardiac disease. The patient presented to Schmidt-Williams Hospital with gradually increasing chest pain over the past three to four months to the point that he had chest pain with minimal exertion. PAST MEDICAL HISTORY: 1. Known coronary artery disease, status post catheterization 10 years ago at Bush-Graham Clinic. 2. Heavy smoker. 3. Hypertension. 4. Gastroesophageal reflux disease/peptic ulcer disease. 5. Wegener granulomatosis with complete resolution. 6. Glaucoma. PAST SURGICAL HISTORY: Perforated ulcer. MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Cosopt eyedrops, Alphagan eyedrops, Travatan eyedrops, lansoprazole 50 mg p.o. q.d. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient underwent an elective coronary artery bypass graft times three on 1957-11-22 with grafts being a left internal mammary artery to left anterior descending artery, saphenous vein graft to ramus, and saphenous vein graft to posterior descending artery. He was extubated on the day of surgery. On postoperative day one, his nasogastric tubes were discontinued. He was transferred to the regular floor on postoperative day one. He subsequently had a smooth postoperative course. His pacing wires were discontinued on postoperative day three. By postoperative day, he was ambulating well. He was comfortable on p.o. pain medication, and he was ready for discharge home. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q.d. (for one week). 2. KCL 20 mEq p.o. q.d. (for one week). 3. Colace 100 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d. 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Alphagan eyedrops. 7. Lopressor 50 mg p.o. b.i.d. 8. Nicoderm patch 22 mg q.d. 9. Percocet one to two tablets p.o. q.4-6h. p.r.n. DIFeudnerE FOLLOWUP: Follow up with primary care physician, Johnson. Joe William, in two weeks and with Dr. Pettway in four weeks. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharged to home. Dr.William Beamon, M.D. 42511278 Dictated By:Gauthier MEDQUIST36 D: 2005-1-18 15:09 T: 2005-1-18 15:31 JOB#: Hall-Odonnell-1979-206231	['Admission Date: 2020-7-18 Discharge Date: 2005-1-18\n\nDate of Birth: 1937-6-7 Sex: M\n\nService: Cardiac Surgery\n\nCHIEF COMPLAINT: Chest pain, 3-vessel disease on\ncatheterization.\n\nHISTORY OF PRESENT ILLNESS: The patient is a 66-year-old\nmale transferred from Schmidt-Williams Hospital to the Barnett, Sanchez and Miller Hospital status post catheterization,\nrevealing 3-vessel cardiac disease.\n\nThe patient presented to Schmidt-Williams Hospital with gradually\nincreasing chest pain over the past three to four months to\nthe point that he had chest pain with minimal exertion.\n\nPAST MEDICAL HISTORY:\n1. Known coronary artery disease, status post\ncatheterization 10 years ago at Bush-Graham Clinic.\n2. Heavy smoker.\n3. Hypertension.\n4. Gastroesophageal reflux disease/peptic ulcer disease.', '\n5. Wegener granulomatosis with complete resolution.\n6. Glaucoma.\n\nPAST SURGICAL HISTORY: Perforated ulcer.\n\nMEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d.,\nPrilosec 20 mg p.o. q.d., Cosopt eyedrops, Alphagan eyedrops,\nTravatan eyedrops, lansoprazole 50 mg p.o. q.d.\n\nALLERGIES: No known drug allergies.\n\nHOSPITAL COURSE: The patient underwent an elective coronary\nartery bypass graft times three on 1957-11-22 with grafts\nbeing a left internal mammary artery to left anterior\ndescending artery, saphenous vein graft to ramus, and\nsaphenous vein graft to posterior descending artery. He was\nextubated on the day of surgery. On postoperative day one,\nhis nasogastric tubes were discontinued.\n\nHe was transferred to the regular floor on postoperative day\none. He subsequently had a smooth postoperative course.', ' His\npacing wires were discontinued on postoperative day three.\n\nBy postoperative day, he was ambulating well. He was\ncomfortable on p.o. pain medication, and he was ready for\ndischarge home.\n\nMEDICATIONS ON DISCHARGE:\n1. Lasix 20 mg p.o. q.d. (for one week).\n2. KCL 20 mEq p.o. q.d. (for one week).\n3. Colace 100 mg p.o. b.i.d.\n4. Zantac 150 mg p.o. b.i.d.\n5. Enteric-coated aspirin 325 mg p.o. q.d.\n6. Alphagan eyedrops.\n7. Lopressor 50 mg p.o. b.i.d.\n8. Nicoderm patch 22 mg q.d.\n9. Percocet one to two tablets p.o. q.4-6h. p.r.n.\n\nDIFeudnerE FOLLOWUP: Follow up with primary care physician,\nJohnson. Joe William, in two weeks and with Dr. Pettway in\nfour weeks.\n\nCONDITION AT DISCHARGE: Condition on discharge was stable.\n\nDISCHARGE STATUS: Discharged to home.\n\n\n\n\n Dr.', 'William Beamon, M.D. 42511278\n\nDictated By:Gauthier\n\nMEDQUIST36\n\nD: 2005-1-18 15:09\nT: 2005-1-18 15:31\nJOB#: Hall-Odonnell-1979-206231\n']
224	5350	169684.0	2143-04-30	Discharge summary	Report	Admission Date: [2143-4-25] Discharge Date: [2143-4-30] Date of Birth: [2076-8-18] Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Chest pain, 3-vessel disease on catheterization. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male transferred from [Hospital6 33] to the [Hospital1 346] status post catheterization, revealing 3-vessel cardiac disease. The patient presented to [Hospital6 33] with gradually increasing chest pain over the past three to four months to the point that he had chest pain with minimal exertion. PAST MEDICAL HISTORY: 1. Known coronary artery disease, status post catheterization 10 years ago at [Hospital1 ]. 2. Heavy smoker. 3. Hypertension. 4. Gastroesophageal reflux disease/peptic ulcer disease. 5. Wegener granulomatosis with complete resolution. 6. Glaucoma. PAST SURGICAL HISTORY: Perforated ulcer. MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Cosopt eyedrops, Alphagan eyedrops, Travatan eyedrops, lansoprazole 50 mg p.o. q.d. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient underwent an elective coronary artery bypass graft times three on [2143-4-26] with grafts being a left internal mammary artery to left anterior descending artery, saphenous vein graft to ramus, and saphenous vein graft to posterior descending artery. He was extubated on the day of surgery. On postoperative day one, his nasogastric tubes were discontinued. He was transferred to the regular floor on postoperative day one. He subsequently had a smooth postoperative course. His pacing wires were discontinued on postoperative day three. By postoperative day, he was ambulating well. He was comfortable on p.o. pain medication, and he was ready for discharge home. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q.d. (for one week). 2. KCL 20 mEq p.o. q.d. (for one week). 3. Colace 100 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d. 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Alphagan eyedrops. 7. Lopressor 50 mg p.o. b.i.d. 8. Nicoderm patch 22 mg q.d. 9. Percocet one to two tablets p.o. q.4-6h. p.r.n. DI[Last Name (STitle) 408]E FOLLOWUP: Follow up with primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2208], in two weeks and with Dr. [Last Name (Prefixes) ] in four weeks. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharged to home. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2143-4-30] 15:09 T: [2143-4-30] 15:31 JOB#: [Job Number 2211]	Admission Date: <Date>2010-4-16</Date> Discharge Date: <Date>1923-9-17</Date> Date of Birth: <Date>2007-6-8</Date> Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Chest pain, 3-vessel disease on catheterization. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male transferred from <Hospital>Smith-Smith Medical Center</Hospital> to the <Hospital>Richardson Ltd Hospital</Hospital> status post catheterization, revealing 3-vessel cardiac disease. The patient presented to <Hospital>Smith-Smith Medical Center</Hospital> with gradually increasing chest pain over the past three to four months to the point that he had chest pain with minimal exertion. PAST MEDICAL HISTORY: 1. Known coronary artery disease, status post catheterization 10 years ago at <Hospital>Horton-Stewart Medical Center</Hospital>. 2. Heavy smoker. 3. Hypertension. 4. Gastroesophageal reflux disease/peptic ulcer disease. 5. Wegener granulomatosis with complete resolution. 6. Glaucoma. PAST SURGICAL HISTORY: Perforated ulcer. MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Cosopt eyedrops, Alphagan eyedrops, Travatan eyedrops, lansoprazole 50 mg p.o. q.d. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient underwent an elective coronary artery bypass graft times three on <Date>1944-8-4</Date> with grafts being a left internal mammary artery to left anterior descending artery, saphenous vein graft to ramus, and saphenous vein graft to posterior descending artery. He was extubated on the day of surgery. On postoperative day one, his nasogastric tubes were discontinued. He was transferred to the regular floor on postoperative day one. He subsequently had a smooth postoperative course. His pacing wires were discontinued on postoperative day three. By postoperative day, he was ambulating well. He was comfortable on p.o. pain medication, and he was ready for discharge home. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q.d. (for one week). 2. KCL 20 mEq p.o. q.d. (for one week). 3. Colace 100 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d. 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Alphagan eyedrops. 7. Lopressor 50 mg p.o. b.i.d. 8. Nicoderm patch 22 mg q.d. 9. Percocet one to two tablets p.o. q.4-6h. p.r.n. DI<Name>Beamon</Name>E FOLLOWUP: Follow up with primary care physician, <Name>Islam</Name>. <Name>Wade</Name> <Name>Benavidez</Name>, in two weeks and with Dr. <Name>Ignacio</Name> in four weeks. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharged to home. <Doctor Name>Dr.Taylor</Doctor Name> <Name>Hui</Name>, M.D. <MD Number>93495490</MD Number> Dictated By:<Name>Islam</Name> MEDQUIST36 D: <Date>1923-9-17</Date> 15:09 T: <Date>1923-9-17</Date> 15:31 JOB#: <Job Number>Morales-King-1910-921592</Job Number>	0000000000000000011111111100000000000000000000001111111110000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111100000000111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111110000000000000000000000000000000000000000000000000000111110011110111111111000000000000000000000000000011111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110111000000001111111100000000000000111110000000000000000001111111110000000000001111111110000000000000001111111111111111111111110	Admission Date: 2010-4-16 Discharge Date: 1923-9-17 Date of Birth: 2007-6-8 Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Chest pain, 3-vessel disease on catheterization. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male transferred from Smith-Smith Medical Center to the Richardson Ltd Hospital status post catheterization, revealing 3-vessel cardiac disease. The patient presented to Smith-Smith Medical Center with gradually increasing chest pain over the past three to four months to the point that he had chest pain with minimal exertion. PAST MEDICAL HISTORY: 1. Known coronary artery disease, status post catheterization 10 years ago at Horton-Stewart Medical Center. 2. Heavy smoker. 3. Hypertension. 4. Gastroesophageal reflux disease/peptic ulcer disease. 5. Wegener granulomatosis with complete resolution. 6. Glaucoma. PAST SURGICAL HISTORY: Perforated ulcer. MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Cosopt eyedrops, Alphagan eyedrops, Travatan eyedrops, lansoprazole 50 mg p.o. q.d. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient underwent an elective coronary artery bypass graft times three on 1944-8-4 with grafts being a left internal mammary artery to left anterior descending artery, saphenous vein graft to ramus, and saphenous vein graft to posterior descending artery. He was extubated on the day of surgery. On postoperative day one, his nasogastric tubes were discontinued. He was transferred to the regular floor on postoperative day one. He subsequently had a smooth postoperative course. His pacing wires were discontinued on postoperative day three. By postoperative day, he was ambulating well. He was comfortable on p.o. pain medication, and he was ready for discharge home. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q.d. (for one week). 2. KCL 20 mEq p.o. q.d. (for one week). 3. Colace 100 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d. 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Alphagan eyedrops. 7. Lopressor 50 mg p.o. b.i.d. 8. Nicoderm patch 22 mg q.d. 9. Percocet one to two tablets p.o. q.4-6h. p.r.n. DIBeamonE FOLLOWUP: Follow up with primary care physician, Islam. Wade Benavidez, in two weeks and with Dr. Ignacio in four weeks. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharged to home. Dr.Taylor Hui, M.D. 93495490 Dictated By:Islam MEDQUIST36 D: 1923-9-17 15:09 T: 1923-9-17 15:31 JOB#: Morales-King-1910-921592	['Admission Date: 2010-4-16 Discharge Date: 1923-9-17\n\nDate of Birth: 2007-6-8 Sex: M\n\nService: Cardiac Surgery\n\nCHIEF COMPLAINT: Chest pain, 3-vessel disease on\ncatheterization.\n\nHISTORY OF PRESENT ILLNESS: The patient is a 66-year-old\nmale transferred from Smith-Smith Medical Center to the Richardson Ltd Hospital status post catheterization,\nrevealing 3-vessel cardiac disease.\n\nThe patient presented to Smith-Smith Medical Center with gradually\nincreasing chest pain over the past three to four months to\nthe point that he had chest pain with minimal exertion.\n\nPAST MEDICAL HISTORY:\n1. Known coronary artery disease, status post\ncatheterization 10 years ago at Horton-Stewart Medical Center.\n2. Heavy smoker.\n3. Hypertension.\n4. Gastroesophageal reflux disease/peptic ulcer disease.', '\n5. Wegener granulomatosis with complete resolution.\n6. Glaucoma.\n\nPAST SURGICAL HISTORY: Perforated ulcer.\n\nMEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d.,\nPrilosec 20 mg p.o. q.d., Cosopt eyedrops, Alphagan eyedrops,\nTravatan eyedrops, lansoprazole 50 mg p.o. q.d.\n\nALLERGIES: No known drug allergies.\n\nHOSPITAL COURSE: The patient underwent an elective coronary\nartery bypass graft times three on 1944-8-4 with grafts\nbeing a left internal mammary artery to left anterior\ndescending artery, saphenous vein graft to ramus, and\nsaphenous vein graft to posterior descending artery. He was\nextubated on the day of surgery. On postoperative day one,\nhis nasogastric tubes were discontinued.\n\nHe was transferred to the regular floor on postoperative day\none. He subsequently had a smooth postoperative course.', ' His\npacing wires were discontinued on postoperative day three.\n\nBy postoperative day, he was ambulating well. He was\ncomfortable on p.o. pain medication, and he was ready for\ndischarge home.\n\nMEDICATIONS ON DISCHARGE:\n1. Lasix 20 mg p.o. q.d. (for one week).\n2. KCL 20 mEq p.o. q.d. (for one week).\n3. Colace 100 mg p.o. b.i.d.\n4. Zantac 150 mg p.o. b.i.d.\n5. Enteric-coated aspirin 325 mg p.o. q.d.\n6. Alphagan eyedrops.\n7. Lopressor 50 mg p.o. b.i.d.\n8. Nicoderm patch 22 mg q.d.\n9. Percocet one to two tablets p.o. q.4-6h. p.r.n.\n\nDIBeamonE FOLLOWUP: Follow up with primary care physician,\nIslam. Wade Benavidez, in two weeks and with Dr. Ignacio in\nfour weeks.\n\nCONDITION AT DISCHARGE: Condition on discharge was stable.\n\nDISCHARGE STATUS: Discharged to home.\n\n\n\n\n Dr.', 'Taylor Hui, M.D. 93495490\n\nDictated By:Islam\n\nMEDQUIST36\n\nD: 1923-9-17 15:09\nT: 1923-9-17 15:31\nJOB#: Morales-King-1910-921592\n']
225	11369	121504.0	2199-02-14	Discharge summary	Report	Admission Date: [2199-2-8] Discharge Date: [2199-2-14] Date of Birth: [2161-11-27] Sex: M Service: TRAUMA SURGERY HISTORY OF THE PRESENT ILLNESS: Mr. [Known lastname 2212] is a 37-year-old male who was stabbed by a four inch knife to the left upper abdomen. In the field, his blood pressure was 120/palpable, heart rate 120. A pressure dressing was applied to the wound. Reportedly, the knife penetrated about 1.5 inches. PAST MEDICAL HISTORY: 1. HIV positive for 21 years. 2. History of intravenous drug abuse. 3. Hypertension. 4. Congestive heart failure. 5. Right above the knee amputation after being hit by a truck in the past. 6. Tricuspid regurgitation. ADMISSION MEDICATIONS: 1. Epivir. 2. Ziagen. 3. Bactrim Double Strength. 4. Lasix. 5. Methadone. 6. Lopressor. 7. Prilosec. 8. Risperdal. 9. Aldactone. 10. Folate. 11. Multivitamins. 12. Thiamine. ALLERGIES: The patient has an allergy to penicillin. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.3, heart rate 116, blood pressure 140/palpable, respiratory rate 16, pulse oximetry of 100%. General: He was alert and oriented times three with a GCS of 15. HEENT: Normocephalic, atraumatic. Extraocular motions were intact. The pupils were equal, round, and reactive to light and accommodation. The oropharynx was clear. The TMs were clear. Chest: Clear to auscultation bilaterally with no subcutaneous air noted. Cardiac: No murmurs, rubs, or gallops. Regular rate and rhythm. Abdomen: There was a 1.5 cm left upper quadrant wound, otherwise diffusely tender. Back: No step-off. No deformities. Nontender. Extremities: A right above the knee amputation with prosthesis. Left leg with chronic venostasis changes. Rectal: Good tone. Contaminated by external blood. Neurological: No focal deficits. LABORATORY DATA UPON ADMISSION: Chemistries generally normal with creatinine of 1.2. Blood gas 7.39/49/341/31/4, lactate 2.5, amylase 107, fibrinogen 171. PT 15.8, PTT 36.1, INR 1.7. His white blood count was 5.1, hematocrit 34.4. Urine toxicology was not performed. A chest x-ray was within normal limits, status post left subclavian line placement which was in place. HOSPITAL COURSE: The patient was taken to the Operating Room for wound exploration directly from the Trauma Room. The patient was taken to the Operating Room, as mentioned above, for an exploratory laparotomy, extensive lysis of adhesions, and control of rectus and omental bleeding. The estimated blood loss was approximately 1,000 cc. Please see the operative note dictated by Dr. [Last Name (STitle) ] on [2199-2-8] for complete report. The patient was then transferred to the SICU where his coagulopathy was corrected. He received 4 units of packed red cells, 4 units of FFP, and 1 cryoprecipitate. While on the unit, he was extubated on [2199-2-10], SICU day number three and he was noted to have progressive thrombocytopenia. His home p.o. medications were restarted as well. On [2199-2-11], hospital day number four, the patient was transferred to the floor. His diet was advanced and he was placed on an aggressive bowel regimen to get his bowels moving postsurgically. The Pain Service was also consulted because of the patient's history of narcotic abuse and his continued complaints of pain. They recommended increasing his dose of Klonopin and starting MSIR. On hospital day number five, the patient was noted to have a heparin-induced antibody which may be one of the reasons he was coagulopathic on admission, although his HIV disease and other drug abuse cannot be ruled out as cause. His platelet count remained relatively stable, however, as did his hematocrit. By hospital day number six, the patient was doing somewhat better; however, after being noted to be somewhat sedated, his Klonopin dose as well as MSIR and methadone were decreased. The patient did work with Physical Therapy and was able to ambulate, hop a bit out of bed. Additionally, Case Management spoke with the patient's long-term nurse practitioner, who stated that at baseline he normally uses a wheelchair and occasionally walks on his prosthesis. Additionally, the nurse practitioner stated that the patient does chronically abuse drugs, both prescriptions and illicits, and advised not to give the patient any pain prescriptions upon discharge as he had more than enough at home. It was also discussed that the patient would often try to prolong his hospital courses in the past in an attempt to get more narcotics. On the date of discharge, the patient will be set up with VNA Services for home to change his dressings. He will also be instructed to follow-up with his primary care doctor or Trauma Clinic to have the staples removed from his abdominal wound. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home with services. DISCHARGE MEDICATIONS: Same as on admission. FOLLOW-UP PLANS: As mentioned above, with the Trauma Clinic and his primary care doctor. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Last Name (NamePattern1) 2215] MEDQUIST36 D: [2199-2-13] 11:15 T: [2199-2-17] 08:56 JOB#: [Job Number 2216]	Admission Date: <Date>1917-2-18</Date> Discharge Date: <Date>2013-9-31</Date> Date of Birth: <Date>1983-11-23</Date> Sex: M Service: TRAUMA SURGERY HISTORY OF THE PRESENT ILLNESS: Mr. <Name>Blanchar</Name> is a 37-year-old male who was stabbed by a four inch knife to the left upper abdomen. In the field, his blood pressure was 120/palpable, heart rate 120. A pressure dressing was applied to the wound. Reportedly, the knife penetrated about 1.5 inches. PAST MEDICAL HISTORY: 1. HIV positive for 21 years. 2. History of intravenous drug abuse. 3. Hypertension. 4. Congestive heart failure. 5. Right above the knee amputation after being hit by a truck in the past. 6. Tricuspid regurgitation. ADMISSION MEDICATIONS: 1. Epivir. 2. Ziagen. 3. Bactrim Double Strength. 4. Lasix. 5. Methadone. 6. Lopressor. 7. Prilosec. 8. Risperdal. 9. Aldactone. 10. Folate. 11. Multivitamins. 12. Thiamine. ALLERGIES: The patient has an allergy to penicillin. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.3, heart rate 116, blood pressure 140/palpable, respiratory rate 16, pulse oximetry of 100%. General: He was alert and oriented times three with a GCS of 15. HEENT: Normocephalic, atraumatic. Extraocular motions were intact. The pupils were equal, round, and reactive to light and accommodation. The oropharynx was clear. The TMs were clear. Chest: Clear to auscultation bilaterally with no subcutaneous air noted. Cardiac: No murmurs, rubs, or gallops. Regular rate and rhythm. Abdomen: There was a 1.5 cm left upper quadrant wound, otherwise diffusely tender. Back: No step-off. No deformities. Nontender. Extremities: A right above the knee amputation with prosthesis. Left leg with chronic venostasis changes. Rectal: Good tone. Contaminated by external blood. Neurological: No focal deficits. LABORATORY DATA UPON ADMISSION: Chemistries generally normal with creatinine of 1.2. Blood gas 7.39/49/341/31/4, lactate 2.5, amylase 107, fibrinogen 171. PT 15.8, PTT 36.1, INR 1.7. His white blood count was 5.1, hematocrit 34.4. Urine toxicology was not performed. A chest x-ray was within normal limits, status post left subclavian line placement which was in place. HOSPITAL COURSE: The patient was taken to the Operating Room for wound exploration directly from the Trauma Room. The patient was taken to the Operating Room, as mentioned above, for an exploratory laparotomy, extensive lysis of adhesions, and control of rectus and omental bleeding. The estimated blood loss was approximately 1,000 cc. Please see the operative note dictated by Dr. <Name>Grier</Name> on <Date>1917-2-18</Date> for complete report. The patient was then transferred to the SICU where his coagulopathy was corrected. He received 4 units of packed red cells, 4 units of FFP, and 1 cryoprecipitate. While on the unit, he was extubated on <Date>2018-9-16</Date>, SICU day number three and he was noted to have progressive thrombocytopenia. His home p.o. medications were restarted as well. On <Date>1954-12-16</Date>, hospital day number four, the patient was transferred to the floor. His diet was advanced and he was placed on an aggressive bowel regimen to get his bowels moving postsurgically. The Pain Service was also consulted because of the patient's history of narcotic abuse and his continued complaints of pain. They recommended increasing his dose of Klonopin and starting MSIR. On hospital day number five, the patient was noted to have a heparin-induced antibody which may be one of the reasons he was coagulopathic on admission, although his HIV disease and other drug abuse cannot be ruled out as cause. His platelet count remained relatively stable, however, as did his hematocrit. By hospital day number six, the patient was doing somewhat better; however, after being noted to be somewhat sedated, his Klonopin dose as well as MSIR and methadone were decreased. The patient did work with Physical Therapy and was able to ambulate, hop a bit out of bed. Additionally, Case Management spoke with the patient's long-term nurse practitioner, who stated that at baseline he normally uses a wheelchair and occasionally walks on his prosthesis. Additionally, the nurse practitioner stated that the patient does chronically abuse drugs, both prescriptions and illicits, and advised not to give the patient any pain prescriptions upon discharge as he had more than enough at home. It was also discussed that the patient would often try to prolong his hospital courses in the past in an attempt to get more narcotics. On the date of discharge, the patient will be set up with VNA Services for home to change his dressings. He will also be instructed to follow-up with his primary care doctor or Trauma Clinic to have the staples removed from his abdominal wound. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home with services. DISCHARGE MEDICATIONS: Same as on admission. FOLLOW-UP PLANS: As mentioned above, with the Trauma Clinic and his primary care doctor. <Name>Jacki</Name> <Name>Ahmed</Name>, M.D. <MD Number>08988583</MD Number> Dictated By:<Name>Kwan</Name> MEDQUIST36 D: <Date>2013-4-13</Date> 11:15 T: <Date>2002-7-17</Date> 08:56 JOB#: <Job Number>Daugherty-James-1924-382278</Job 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00000000000001111101111100000000111111110000000000000011110000000000000000001111111110000000000001111111110000000000000001111111111111111111111111110	Admission Date: 1917-2-18 Discharge Date: 2013-9-31 Date of Birth: 1983-11-23 Sex: M Service: TRAUMA SURGERY HISTORY OF THE PRESENT ILLNESS: Mr. Blanchar is a 37-year-old male who was stabbed by a four inch knife to the left upper abdomen. In the field, his blood pressure was 120/palpable, heart rate 120. A pressure dressing was applied to the wound. Reportedly, the knife penetrated about 1.5 inches. PAST MEDICAL HISTORY: 1. HIV positive for 21 years. 2. History of intravenous drug abuse. 3. Hypertension. 4. Congestive heart failure. 5. Right above the knee amputation after being hit by a truck in the past. 6. Tricuspid regurgitation. ADMISSION MEDICATIONS: 1. Epivir. 2. Ziagen. 3. Bactrim Double Strength. 4. Lasix. 5. Methadone. 6. Lopressor. 7. Prilosec. 8. Risperdal. 9. Aldactone. 10. Folate. 11. Multivitamins. 12. Thiamine. ALLERGIES: The patient has an allergy to penicillin. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.3, heart rate 116, blood pressure 140/palpable, respiratory rate 16, pulse oximetry of 100%. General: He was alert and oriented times three with a GCS of 15. HEENT: Normocephalic, atraumatic. Extraocular motions were intact. The pupils were equal, round, and reactive to light and accommodation. The oropharynx was clear. The TMs were clear. Chest: Clear to auscultation bilaterally with no subcutaneous air noted. Cardiac: No murmurs, rubs, or gallops. Regular rate and rhythm. Abdomen: There was a 1.5 cm left upper quadrant wound, otherwise diffusely tender. Back: No step-off. No deformities. Nontender. Extremities: A right above the knee amputation with prosthesis. Left leg with chronic venostasis changes. Rectal: Good tone. Contaminated by external blood. Neurological: No focal deficits. LABORATORY DATA UPON ADMISSION: Chemistries generally normal with creatinine of 1.2. Blood gas 7.39/49/341/31/4, lactate 2.5, amylase 107, fibrinogen 171. PT 15.8, PTT 36.1, INR 1.7. His white blood count was 5.1, hematocrit 34.4. Urine toxicology was not performed. A chest x-ray was within normal limits, status post left subclavian line placement which was in place. HOSPITAL COURSE: The patient was taken to the Operating Room for wound exploration directly from the Trauma Room. The patient was taken to the Operating Room, as mentioned above, for an exploratory laparotomy, extensive lysis of adhesions, and control of rectus and omental bleeding. The estimated blood loss was approximately 1,000 cc. Please see the operative note dictated by Dr. Grier on 1917-2-18 for complete report. The patient was then transferred to the SICU where his coagulopathy was corrected. He received 4 units of packed red cells, 4 units of FFP, and 1 cryoprecipitate. While on the unit, he was extubated on 2018-9-16, SICU day number three and he was noted to have progressive thrombocytopenia. His home p.o. medications were restarted as well. On 1954-12-16, hospital day number four, the patient was transferred to the floor. His diet was advanced and he was placed on an aggressive bowel regimen to get his bowels moving postsurgically. The Pain Service was also consulted because of the patient's history of narcotic abuse and his continued complaints of pain. They recommended increasing his dose of Klonopin and starting MSIR. On hospital day number five, the patient was noted to have a heparin-induced antibody which may be one of the reasons he was coagulopathic on admission, although his HIV disease and other drug abuse cannot be ruled out as cause. His platelet count remained relatively stable, however, as did his hematocrit. By hospital day number six, the patient was doing somewhat better; however, after being noted to be somewhat sedated, his Klonopin dose as well as MSIR and methadone were decreased. The patient did work with Physical Therapy and was able to ambulate, hop a bit out of bed. Additionally, Case Management spoke with the patient's long-term nurse practitioner, who stated that at baseline he normally uses a wheelchair and occasionally walks on his prosthesis. Additionally, the nurse practitioner stated that the patient does chronically abuse drugs, both prescriptions and illicits, and advised not to give the patient any pain prescriptions upon discharge as he had more than enough at home. It was also discussed that the patient would often try to prolong his hospital courses in the past in an attempt to get more narcotics. On the date of discharge, the patient will be set up with VNA Services for home to change his dressings. He will also be instructed to follow-up with his primary care doctor or Trauma Clinic to have the staples removed from his abdominal wound. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home with services. DISCHARGE MEDICATIONS: Same as on admission. FOLLOW-UP PLANS: As mentioned above, with the Trauma Clinic and his primary care doctor. Jacki Ahmed, M.D. 08988583 Dictated By:Kwan MEDQUIST36 D: 2013-4-13 11:15 T: 2002-7-17 08:56 JOB#: Daugherty-James-1924-382278	['Admission Date: 1917-2-18 Discharge Date: 2013-9-31\n\nDate of Birth: 1983-11-23 Sex: M\n\nService: TRAUMA SURGERY\n\nHISTORY OF THE PRESENT ILLNESS: Mr. Blanchar is a 37-year-old\nmale who was stabbed by a four inch knife to the left upper\nabdomen. In the field, his blood pressure was 120/palpable,\nheart rate 120. A pressure dressing was applied to the\nwound. Reportedly, the knife penetrated about 1.5 inches.\n\nPAST MEDICAL HISTORY:\n1. HIV positive for 21 years.\n2. History of intravenous drug abuse.\n3. Hypertension.\n4. Congestive heart failure.\n5. Right above the knee amputation after being hit by a\ntruck in the past.\n6. Tricuspid regurgitation.\n\nADMISSION MEDICATIONS:\n1. Epivir.\n2. Ziagen.\n3. Bactrim Double Strength.\n4. Lasix.\n5. Methadone.\n6. Lopressor.\n7. Prilosec.', '\n8. Risperdal.\n9. Aldactone.\n10. Folate.\n11. Multivitamins.\n12. Thiamine.\n\nALLERGIES: The patient has an allergy to penicillin.\n\nPHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature\n97.3, heart rate 116, blood pressure 140/palpable,\nrespiratory rate 16, pulse oximetry of 100%. General: He\nwas alert and oriented times three with a GCS of 15. HEENT:\nNormocephalic, atraumatic. Extraocular motions were intact.\nThe pupils were equal, round, and reactive to light and\naccommodation. The oropharynx was clear. The TMs were\nclear. Chest: Clear to auscultation bilaterally with no\nsubcutaneous air noted. Cardiac: No murmurs, rubs, or\ngallops. Regular rate and rhythm. Abdomen: There was a 1.5\ncm left upper quadrant wound, otherwise diffusely tender.\nBack: No step-off. No deformities.', ' Nontender.\nExtremities: A right above the knee amputation with\nprosthesis. Left leg with chronic venostasis changes.\nRectal: Good tone. Contaminated by external blood.\nNeurological: No focal deficits.\n\nLABORATORY DATA UPON ADMISSION: Chemistries generally normal\nwith creatinine of 1.2. Blood gas 7.39/49/341/31/4, lactate\n2.5, amylase 107, fibrinogen 171. PT 15.8, PTT 36.1, INR\n1.7. His white blood count was 5.1, hematocrit 34.4. Urine\ntoxicology was not performed.\n\nA chest x-ray was within normal limits, status post left\nsubclavian line placement which was in place.\n\nHOSPITAL COURSE: The patient was taken to the Operating Room\nfor wound exploration directly from the Trauma Room. The\npatient was taken to the Operating Room, as mentioned above,\nfor an exploratory laparotomy, extensive lysis of adhesions,\nand control of rectus and omental bleeding.', " The estimated\nblood loss was approximately 1,000 cc. Please see the\noperative note dictated by Dr. Grier on 1917-2-18 for\ncomplete report.\n\nThe patient was then transferred to the SICU where his\ncoagulopathy was corrected. He received 4 units of packed\nred cells, 4 units of FFP, and 1 cryoprecipitate.\n\nWhile on the unit, he was extubated on 2018-9-16, SICU\nday number three and he was noted to have progressive\nthrombocytopenia. His home p.o. medications were restarted\nas well.\n\nOn 1954-12-16, hospital day number four, the patient\nwas transferred to the floor. His diet was advanced and he\nwas placed on an aggressive bowel regimen to get his bowels\nmoving postsurgically. The Pain Service was also consulted\nbecause of the patient's history of narcotic abuse and his\ncontinued complaints of pain.", " They recommended increasing\nhis dose of Klonopin and starting MSIR.\n\nOn hospital day number five, the patient was noted to have a\nheparin-induced antibody which may be one of the reasons he\nwas coagulopathic on admission, although his HIV disease and\nother drug abuse cannot be ruled out as cause. His platelet\ncount remained relatively stable, however, as did his\nhematocrit.\n\nBy hospital day number six, the patient was doing somewhat\nbetter; however, after being noted to be somewhat sedated,\nhis Klonopin dose as well as MSIR and methadone were\ndecreased. The patient did work with Physical Therapy and\nwas able to ambulate, hop a bit out of bed.\n\nAdditionally, Case Management spoke with the patient's\nlong-term nurse practitioner, who stated that at baseline he\nnormally uses a wheelchair and occasionally walks on his\nprosthesis.", ' Additionally, the nurse practitioner stated that\nthe patient does chronically abuse drugs, both prescriptions\nand illicits, and advised not to give the patient any pain\nprescriptions upon discharge as he had more than enough at\nhome. It was also discussed that the patient would often try\nto prolong his hospital courses in the past in an attempt to\nget more narcotics.\n\nOn the date of discharge, the patient will be set up with VNA\nServices for home to change his dressings. He will also be\ninstructed to follow-up with his primary care doctor or\nTrauma Clinic to have the staples removed from his abdominal\nwound.\n\nCONDITION ON DISCHARGE: Stable.\n\nDISCHARGE STATUS: Discharged to home with services.\n\nDISCHARGE MEDICATIONS: Same as on admission.\n\nFOLLOW-UP PLANS: As mentioned above, with the Trauma Clinic\nand his primary care doctor.', '\n\n\n\n\n Jacki Ahmed, M.D. 08988583\n\nDictated By:Kwan\n\nMEDQUIST36\n\nD: 2013-4-13 11:15\nT: 2002-7-17 08:56\nJOB#: Daugherty-James-1924-382278\n']
226	11369	103786.0	2203-11-12	Discharge summary	Report	Admission Date: [2203-11-3] Discharge Date: [2203-11-12] Date of Birth: [2161-11-27] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 348] Chief Complaint: Shortness of breath, chest pain Major Surgical or Invasive Procedure: Pericardiocentesis EGD with biopsy History of Present Illness: 41 y/o M w/ h/o HIV/AIDS (HIV dx 83, AIDS 92, last CD4 132, VL >100K [10/2203], RF IVDU), not currently on HAART, previous right sided bacterial endocarditis with residual 4+ TR, h/o prior MI in [2193], who presents from [Hospital ] Hospital for emergent evaluation of pericardial tamponade. Patient was recently hospitalized at [Hospital1 18] for osteomyelitis of his L-ankle s/p prior fall. Presented to ED with fevers and ankle pain. Taken to OR by ortho and found to have neg brefringent crystals c/w gout. Tissue/Bone cultures grew MSSA. Patient started on cefazolin. F/U MRI could not rule out osteomyelitis and the patient was discharged to [Hospital ] hospital for 6 weeks of IV cefazolin (to end [2203-12-5]). While at [Hospital1 ], patient had uneventful course until night prior to admission when he developed low grade temp to 100.2. The morning of admission patient felt short of breath, lethargic with some chest pain. Noted to be tachycardic by vitals, and with decreased O2 sat to 90% on RA -> 96% 2L NC. Chest CT performed showing massively enlarged cardiac silhouette. Transfered to [Hospital1 18] for emergent pericardiocentesis. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. In the ED, T98.8, HR 122, BP 147/87, RR 19, O2 97%. Patient noted to be uncomfortable, and w/ rub on exam. Pulsus not performed. Otherwise exam unremarkable. Transferred to cath lab for emergent peridcardiocentesis. In cath lab, pericardial pressure 35, RA and [Name Prefix (Prefixes) ] [Last Name (Prefixes) 1934] each 30, RV systolic 55. 1.2 L of sanguinous fluid drained from the pericardium. Pericardial pressure decreased to 5mm Hg, and RA to 18mm Hg s/p drain. Patient admitted to CCU for further management. Past Medical History: - HIV/AIDS: HIV dignosed in '[79], AIDS diagnosed in '[88], last CD4 count 132, VL 100K [2202-7-26]. Perscribed HAART but pt reports noncompliance for past 5 months (followed by Dr [Last Name (STitle) 2219] at [Hospital1 2177] and NP [Doctor Last Name ] [Telephone/Fax (1) 2218]) -- ONLY FATHER KNOWS DIAGNOSIS. - Hep C - Hep B cleared - Myocardial infarction in [2193] - h/o endocarditits with grade 4 TR - approximately 12 years ago - Recurrent epididimitis - h/o IVDU on methadone 80 mg QD (followed at Baycove [Telephone/Fax (1) 2217]) - Asthma - osteomyelitis (MSSA) on cefazolin Social History: Pt was most recently living at [Hospital1 ]. He has a girlfriend. [Name (NI) ] denies tobacco, EtOH, and current drug use/abuse. He is in a methadone program because of past IVDU. Family History: NC Physical Exam: ON ADMISSION: VS: T 99.3, BP 132/72 , HR 105 , RR 20, O2 99% 2l NC Gen: Caucasion male w/ mild bitemporal wasting resting comfortably in bed. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple. Unable to appreciate JVD as prominent carotid pulses b/l. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. +2/6 SEM at LUSB. Chest: Pericardial drain in place, clean, dry, intact, No scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Sparse basilar crackles right > left. Abd: +BS, softly distended, non-tender, liver edge palpable below the costal margin. No abdominial bruits. Ext: R-AKA. Left ankle in cast, 2+ DP pulse. No c/c/e. No femoral bruits. +line in L-groin, no bleeding, no hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit ON DISCHARGE: VS: 98.1 117/89 118 20 95% RA Exam was largely unchanged. Abdomen was mildly distended, not tender, normoactive bowel sounds. His cardiac exam was unchanged, the pericardial drain was pulled on day 2 of admission. Lungs were clear to auscultation bilaterally. Wound vac was in place, with minimal drainage. Pertinent Results: [2203-11-3] 05:00PM OTHER BODY FLUID TOT PROT-6.1 GLUCOSE-69 LD(LDH)-650 AMYLASE-56 ALBUMIN-1.9 [2203-11-3] 05:00PM OTHER BODY FLUID WBC-2122* HCT-11* POLYS-56* LYMPHS-27* MONOS-13* EOS-2* METAS-2* [2203-11-3] 03:58PM LACTATE-3.2* [2203-11-3] 03:50PM GLUCOSE-126* UREA N-38* CREAT-1.8* SODIUM-132* POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-14 [2203-11-3] 03:50PM estGFR-Using this [2203-11-3] 03:50PM CK(CPK)-29* [2203-11-3] 03:50PM cTropnT-<0.01 [2203-11-3] 03:50PM CK-MB-NotDone [2203-11-3] 03:50PM WBC-6.2 RBC-3.09* HGB-9.2* HCT-28.6* MCV-93 MCH-29.6 MCHC-32.0 RDW-19.5* [2203-11-3] 03:50PM NEUTS-77.3* LYMPHS-17.1* MONOS-5.3 EOS-0.1 BASOS-0.2 [2203-11-3] 03:50PM PLT COUNT-295# [2203-11-3] 03:50PM PT-15.1* PTT-38.2* INR(PT)-1.4* Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. . ECHO ([2203-11-3]) Pre-pericardiocentesis: The left atrium is elongated. The estimated right atrial pressure is >20 mmHg. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is moderately dilated. There is a large circumferential pericardial effusion. Stranding is visualized within the pericardial space c/w some organization. There is left atrial diastolic collapse. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of [2203-10-20], large pericardial effusion with echocardiographic signs of tamponade is new. . ECHO ([2203-11-3]) Post pericardiocentesis: The left atrium is elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is markedly dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is partial flail of a tricuspid valve leaflet. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2203-11-3], the residue pericardial effusion is minimal. . Cardiac catherization ([2203-11-3]): 1. Large circumferential pericardial effusion with tamponade physiology. 2. Successful pericardiocentesis with drainage of 1500mls of blood stained fluid. Patient left cathlab in stable condition FINAL DIAGNOSIS: 1. Severe pericardial tamponade. 2. Mild primary pulmonary hypertension. 3. Successful pericardiocentesis with drainage of 1500ml of blood stained fluid. . ECHO ([2203-11-4]): The left atrium is mildly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal [intrinsic function is likely depressed given the severity of tricuspid regurgitation.]. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened and appear shortened/remnants that do not fully coapt. A small echodensity is seen on the right atrial side of the septal leaflet - ?vegetation ?old vs. partial flail of leaflet segment. Severe [4+] tricuspid regurgitation is seen. There is a small (<1cm), circumferential, partially echo filled pericardial effusion without evidence of hemodynamic compromise. Compared with the prior study (post-pericardiocentesis, images reviewed) of [2203-11-3], the findings are similar. . ECHO ([2203-11-5]): The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened and appear shortened/remnants and fail to fully coapt. A small echodensity is again seen on the right atrial side of the septal leaflet which could be either a vegeateion or a partial leaflet segment. Severe [4+] tricuspid regurgitation is seen. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2203-11-4], the pericardial effusion is slightly smaller and may be more echo dense. The left ventricular cavity size is probably slightly larger (reflecting better filling). The small echodensity on the tricuspid leaflet has not changed in size. . ECHO ([2203-11-8]): The left atrium is mildly dilated. The right atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2203-11-5], pericardial effusion now appears slightly smaller. . ECHO ([2203-11-11]): The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The mitral valve leaflets are structurally normal. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. There is a very small, partially echo filled pericardial effusion. Compared with the prior study (images reviewed) of [2203-11-8], the findings are similar. Brief Hospital Course: 41 year old male with HIV/AIDS, previous R-sided endocarditis and severe TR, presented in cardiac tamponade from rehabilitation. CARDIAC TAMPONADE: On admission, he was transferred to the cardiac catherization lab, where over one liter of fluid was drained from his pericardial space. The fluid was sent for gram stain, culture, AFB, [Doctor First Name ], TB PCR as well as viral studies and cytology. A pericardial drain was initially left in place, but given minimal drainage over 24 hours, was pulled prior to his transfer to the floor. The etiology of the pericardial effusion is unknown. He was followed by Cardiology on the floor and the initial plan was for a pericardial window, for both tissue and to prevent reaccumulation of fluid. The patient refused the procedure at this time. He will follow up as an outpatient to re-evaluate for the procedure. The effusion was followed by serial ECHO while the patient was in the hospital. There was no evidence of re-accumulation. He is scheduled for an outpatient ECHO in several weeks to evaluate the pericardial space for reaccumlation of effusion. ATRIAL FIBRILLATION/FLUTTER: Per multiple EKGs, the patient appears to have developed new a fib/flutter. Given his guaiac positive stools, it is not advisable to start anticoagulation at this time. The patient is being rate controlled on a low dose of beta-blocker, which appears to be effective. He will be followed by outpatient Cardiology. ANEMIA: The patient had a hematocrit drop during this admission. His lab studies are consistent with anemia of chronic disease, however, the patient was found to have guaiac positive stools. GI was consulted and recommeded colonoscopy and EGD. The patient was unable to tolerate the prep and thus the colonoscopy was cancelled. His EGD demonstrated gastritis and thrush. He was started on fluconazole to treat the thrush. He was also transfused two units of packed red blood cells with an appropriate hematocrit response. HIV/AIDS: The patient had a CD4 count checked during his last admission, it was found to be 132 with a viral load >100K. Given his past noncompliance with HAART therapy and the risk of developing drug resistant HIV, HAART was not restarted. Pt is willing to restart HARRT, and the plan remains to restart medications at rehabilitation. Bactrim was continued for PCP [Name Initial (PRE) 1102]. OSTEOMYELITIS: The patient was previously admitted for left ankle pain. He was followed previously by both the orthopedic and ID services. Both services continued to follow the patient on this admission. The patient was continued on 6 weeks of IV antibiotics (last day of cefazolin [2203-12-5]), although the dose was decreased to 1g q6 because of a low white blood count. SEVERE TRICUSPID REGURGITATION: Pt with known grade 4 TR and flail leaflet which he deveoped after acute bacterial endocarditis roughly 10 years ago. We restarted his lasix and spironolactone on this admission. HCV: HCV viral load checked, and found to be 1.5 million. No further therapy initiated. ANXIETY: Pt with history of anxiety and on Klonapin at home. His home regimen was continued. ESOPHAGEAL CANDIDIASIS: Patient was found to have thrush on EGD. He was started on a course of fluconazole given his immunosupressed state. He is being discharged to complete a two week course of anti-fungal medication. Medications on Admission: cefazolin 2g IV q8 methadone 80mg PO qd (confirmed on prior admit) prednisone 10mg qd lovenox 40mg SQ prilosec 20mg PO qd ASA 81mg PO daily colace 100mg PO daily clonazepam 1mg qAM, 1mg qNoon, 2mg qhs prn sennekot 2 tabs PO BID PRN morphine sulfate IR 15mg PO q4 PRN promethazine 12.5mg PO q4h PRN Discharge Medications: 1. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q 12 NOON (). 7. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. 17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 18. Cefazolin 1 gram Recon Soln Sig: One (1) Intravenous every six (6) hours for until [2203-12-5] weeks: please continue until [2203-12-5]. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary diagnosis: Cardiac tamponade GI Bleeding Atrial flutter [Female First Name (un) 564] esophagitis Secondary diagnosis: Pancytopenia HIV/AIDS Hepatitis B and C Endocarditits with flail tricuspic valve Right heart failure. Recurrent epididymitis IVDU on methadone 80 mg QD (followed at Baycove [Telephone/Fax (1) 2217]) ?Myocardial infarction in [2193] Asthma LLE medial MSSA foot abscess/osteomyelitis. Gout Traumatic Right AKA PCP Anxiety and depression. PPD (+) treated with 6 months INH Discharge Condition: Stable without fluid reaccumulation per ECHO Discharge Instructions: You were admitted with shortness of breath. You were found to have fluid around your heart. The fluid was removed but no specific cause was identified. If you have any chest pain or shortness of breath, please alert your doctors [Name5 (PTitle) 2227]. You will need weekly labs (specifically CBC, LFTs, BUN, and Cr) faxed to Dr. [Known firstname ] [Last Name (NamePattern1) 1075] in the Infectious [Hospital 2228] clinic at [Hospital1 18] (fax [Telephone/Fax (1) 432]). You have a wound VAC on your ankle to help with healing of the tissue. This should be changed every 3 days by the nurses at your facility. You will need to be seen in the [Hospital 1957] clinic to determine how long you will need to have this in place. If you have any symptoms of worsening foot pain, foot redness, fevers, chest pain, nausea, vomiting, or any other concerning symptoms you are to go to the emergency room. Medication changes: 1. Lasix and spironalactone were restarted during this admission. 2. You HAART medication was held during this admission. These can be restarted by your ID doctors [Name5 (PTitle) 1028] [Name5 (PTitle) ] are at rehab. 3. You are being treated with an antibiotics called cefazolin. You need to continue this medication until [2203-12-5]. Followup Instructions: Please arrive at ORTHO XRAY (SCC 2) on [2203-11-15] at 7:40 AM for x-ray (Phone:[Telephone/Fax (1) 1228]). . Please follow up with your orthopedic doctor, [Name6 (MD) ] [Name8 (MD) 2229], MD on [2203-11-15] at 8:00 AM (Phone:[Telephone/Fax (1) 1228]) . Please follow up with [Known firstname ] [Name8 (MD) ], MD on [2203-11-25] 11:00AM (Phone:[Telephone/Fax (1) 457]) . You are scheduled for an ECHO on [2203-11-21] at 8 AM. Please come to the [Hospital Ward Name 23] building, [Location (un) 436] for your appointment. Please follow up with Dr. [Last Name (STitle) 2230], CT surgery on Monday, [11-21] at 1:15 pm. This appointment is at [Hospital Unit Name 2231]. You are also scheduled for a Cardiology appointment with Dr. [Last Name (STitle) 2232] on Monday, [2203-11-28] at 9:40 AM. This appointment is in the [Hospital Ward Name 23] building on the [Location (un) 436]. Please follow up with the gastroenterologists for a colonoscopy. You can call to schedule the appointment at ([Telephone/Fax (1) 2233*].	Admission Date: <Date>1943-9-4</Date> Discharge Date: <Date>1980-12-31</Date> Date of Birth: <Date>1915-12-10</Date> Sex: M Service: MEDICINE Allergies: Penicillins Attending:<Name>Aisha</Name> Chief Complaint: Shortness of breath, chest pain Major Surgical or Invasive Procedure: Pericardiocentesis EGD with biopsy History of Present Illness: 41 y/o M w/ h/o HIV/AIDS (HIV dx 83, AIDS 92, last CD4 132, VL >100K <Date>8/1911</Date>, RF IVDU), not currently on HAART, previous right sided bacterial endocarditis with residual 4+ TR, h/o prior MI in <Year>1968</Year>, who presents from <Hospital>Phillips-Tate Hospital</Hospital> Hospital for emergent evaluation of pericardial tamponade. Patient was recently hospitalized at <Hospital>Moreno, Moore and Contreras Clinic</Hospital> for osteomyelitis of his L-ankle s/p prior fall. Presented to ED with fevers and ankle pain. Taken to OR by ortho and found to have neg brefringent crystals c/w gout. Tissue/Bone cultures grew MSSA. Patient started on cefazolin. F/U MRI could not rule out osteomyelitis and the patient was discharged to <Hospital>Phillips-Tate Hospital</Hospital> hospital for 6 weeks of IV cefazolin (to end <Date>1965-7-7</Date>). While at <Hospital>Fowler, Griffin and Ingram Health System</Hospital>, patient had uneventful course until night prior to admission when he developed low grade temp to 100.2. The morning of admission patient felt short of breath, lethargic with some chest pain. Noted to be tachycardic by vitals, and with decreased O2 sat to 90% on RA -> 96% 2L NC. Chest CT performed showing massively enlarged cardiac silhouette. Transfered to <Hospital>Moreno, Moore and Contreras Clinic</Hospital> for emergent pericardiocentesis. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. In the ED, T98.8, HR 122, BP 147/87, RR 19, O2 97%. Patient noted to be uncomfortable, and w/ rub on exam. Pulsus not performed. Otherwise exam unremarkable. Transferred to cath lab for emergent peridcardiocentesis. In cath lab, pericardial pressure 35, RA and <Name>Karthik Pleasant</Name> <Name>Merino</Name> each 30, RV systolic 55. 1.2 L of sanguinous fluid drained from the pericardium. Pericardial pressure decreased to 5mm Hg, and RA to 18mm Hg s/p drain. Patient admitted to CCU for further management. Past Medical History: - HIV/AIDS: HIV dignosed in '<Digit>21</Digit>, AIDS diagnosed in '<Digit>67</Digit>, last CD4 count 132, VL 100K <Date>1920-5-22</Date>. Perscribed HAART but pt reports noncompliance for past 5 months (followed by Dr <Name>Davis</Name> at <Hospital>Spencer Group Clinic</Hospital> and NP <Doctor Name>Dr.Kuykendall</Doctor Name> <Telephone>321-745-5205</Telephone>) -- ONLY FATHER KNOWS DIAGNOSIS. - Hep C - Hep B cleared - Myocardial infarction in <Year>1968</Year> - h/o endocarditits with grade 4 TR - approximately 12 years ago - Recurrent epididimitis - h/o IVDU on methadone 80 mg QD (followed at Baycove <Telephone>944-345-8192</Telephone>) - Asthma - osteomyelitis (MSSA) on cefazolin Social History: Pt was most recently living at <Hospital>Fowler, Griffin and Ingram Health System</Hospital>. He has a girlfriend. <Name>Shannan Grier</Name> denies tobacco, EtOH, and current drug use/abuse. He is in a methadone program because of past IVDU. Family History: NC Physical Exam: ON ADMISSION: VS: T 99.3, BP 132/72 , HR 105 , RR 20, O2 99% 2l NC Gen: Caucasion male w/ mild bitemporal wasting resting comfortably in bed. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple. Unable to appreciate JVD as prominent carotid pulses b/l. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. +2/6 SEM at LUSB. Chest: Pericardial drain in place, clean, dry, intact, No scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Sparse basilar crackles right > left. Abd: +BS, softly distended, non-tender, liver edge palpable below the costal margin. No abdominial bruits. Ext: R-AKA. Left ankle in cast, 2+ DP pulse. No c/c/e. No femoral bruits. +line in L-groin, no bleeding, no hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit ON DISCHARGE: VS: 98.1 117/89 118 20 95% RA Exam was largely unchanged. Abdomen was mildly distended, not tender, normoactive bowel sounds. His cardiac exam was unchanged, the pericardial drain was pulled on day 2 of admission. Lungs were clear to auscultation bilaterally. Wound vac was in place, with minimal drainage. Pertinent Results: <Date>1943-9-4</Date> 05:00PM OTHER BODY FLUID TOT PROT-6.1 GLUCOSE-69 LD(LDH)-650 AMYLASE-56 ALBUMIN-1.9 <Date>1943-9-4</Date> 05:00PM OTHER BODY FLUID WBC-2122* HCT-11* POLYS-56* LYMPHS-27* MONOS-13* EOS-2* METAS-2* <Date>1943-9-4</Date> 03:58PM LACTATE-3.2* <Date>1943-9-4</Date> 03:50PM GLUCOSE-126* UREA N-38* CREAT-1.8* SODIUM-132* POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-14 <Date>1943-9-4</Date> 03:50PM estGFR-Using this <Date>1943-9-4</Date> 03:50PM CK(CPK)-29* <Date>1943-9-4</Date> 03:50PM cTropnT-<0.01 <Date>1943-9-4</Date> 03:50PM CK-MB-NotDone <Date>1943-9-4</Date> 03:50PM WBC-6.2 RBC-3.09* HGB-9.2* HCT-28.6* MCV-93 MCH-29.6 MCHC-32.0 RDW-19.5* <Date>1943-9-4</Date> 03:50PM NEUTS-77.3* LYMPHS-17.1* MONOS-5.3 EOS-0.1 BASOS-0.2 <Date>1943-9-4</Date> 03:50PM PLT COUNT-295# <Date>1943-9-4</Date> 03:50PM PT-15.1* PTT-38.2* INR(PT)-1.4* Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. . ECHO (<Date>1943-9-4</Date>) Pre-pericardiocentesis: The left atrium is elongated. The estimated right atrial pressure is >20 mmHg. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is moderately dilated. There is a large circumferential pericardial effusion. Stranding is visualized within the pericardial space c/w some organization. There is left atrial diastolic collapse. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of <Date>1980-2-18</Date>, large pericardial effusion with echocardiographic signs of tamponade is new. . ECHO (<Date>1943-9-4</Date>) Post pericardiocentesis: The left atrium is elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is markedly dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is partial flail of a tricuspid valve leaflet. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of <Date>1943-9-4</Date>, the residue pericardial effusion is minimal. . Cardiac catherization (<Date>1943-9-4</Date>): 1. Large circumferential pericardial effusion with tamponade physiology. 2. Successful pericardiocentesis with drainage of 1500mls of blood stained fluid. Patient left cathlab in stable condition FINAL DIAGNOSIS: 1. Severe pericardial tamponade. 2. Mild primary pulmonary hypertension. 3. Successful pericardiocentesis with drainage of 1500ml of blood stained fluid. . ECHO (<Date>1964-5-16</Date>): The left atrium is mildly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal [intrinsic function is likely depressed given the severity of tricuspid regurgitation.]. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened and appear shortened/remnants that do not fully coapt. A small echodensity is seen on the right atrial side of the septal leaflet - ?vegetation ?old vs. partial flail of leaflet segment. Severe [4+] tricuspid regurgitation is seen. There is a small (<1cm), circumferential, partially echo filled pericardial effusion without evidence of hemodynamic compromise. Compared with the prior study (post-pericardiocentesis, images reviewed) of <Date>1943-9-4</Date>, the findings are similar. . ECHO (<Date>2001-1-28</Date>): The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened and appear shortened/remnants and fail to fully coapt. A small echodensity is again seen on the right atrial side of the septal leaflet which could be either a vegeateion or a partial leaflet segment. Severe [4+] tricuspid regurgitation is seen. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of <Date>1964-5-16</Date>, the pericardial effusion is slightly smaller and may be more echo dense. The left ventricular cavity size is probably slightly larger (reflecting better filling). The small echodensity on the tricuspid leaflet has not changed in size. . ECHO (<Date>1919-4-17</Date>): The left atrium is mildly dilated. The right atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of <Date>2001-1-28</Date>, pericardial effusion now appears slightly smaller. . ECHO (<Date>1970-6-28</Date>): The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The mitral valve leaflets are structurally normal. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. There is a very small, partially echo filled pericardial effusion. Compared with the prior study (images reviewed) of <Date>1919-4-17</Date>, the findings are similar. Brief Hospital Course: 41 year old male with HIV/AIDS, previous R-sided endocarditis and severe TR, presented in cardiac tamponade from rehabilitation. CARDIAC TAMPONADE: On admission, he was transferred to the cardiac catherization lab, where over one liter of fluid was drained from his pericardial space. The fluid was sent for gram stain, culture, AFB, <Name>Raymond</Name>, TB PCR as well as viral studies and cytology. A pericardial drain was initially left in place, but given minimal drainage over 24 hours, was pulled prior to his transfer to the floor. The etiology of the pericardial effusion is unknown. He was followed by Cardiology on the floor and the initial plan was for a pericardial window, for both tissue and to prevent reaccumulation of fluid. The patient refused the procedure at this time. He will follow up as an outpatient to re-evaluate for the procedure. The effusion was followed by serial ECHO while the patient was in the hospital. There was no evidence of re-accumulation. He is scheduled for an outpatient ECHO in several weeks to evaluate the pericardial space for reaccumlation of effusion. ATRIAL FIBRILLATION/FLUTTER: Per multiple EKGs, the patient appears to have developed new a fib/flutter. Given his guaiac positive stools, it is not advisable to start anticoagulation at this time. The patient is being rate controlled on a low dose of beta-blocker, which appears to be effective. He will be followed by outpatient Cardiology. ANEMIA: The patient had a hematocrit drop during this admission. His lab studies are consistent with anemia of chronic disease, however, the patient was found to have guaiac positive stools. GI was consulted and recommeded colonoscopy and EGD. The patient was unable to tolerate the prep and thus the colonoscopy was cancelled. His EGD demonstrated gastritis and thrush. He was started on fluconazole to treat the thrush. He was also transfused two units of packed red blood cells with an appropriate hematocrit response. HIV/AIDS: The patient had a CD4 count checked during his last admission, it was found to be 132 with a viral load >100K. Given his past noncompliance with HAART therapy and the risk of developing drug resistant HIV, HAART was not restarted. Pt is willing to restart HARRT, and the plan remains to restart medications at rehabilitation. Bactrim was continued for PCP <Name>Ashley Kenner</Name>. OSTEOMYELITIS: The patient was previously admitted for left ankle pain. He was followed previously by both the orthopedic and ID services. Both services continued to follow the patient on this admission. The patient was continued on 6 weeks of IV antibiotics (last day of cefazolin <Date>1965-7-7</Date>), although the dose was decreased to 1g q6 because of a low white blood count. SEVERE TRICUSPID REGURGITATION: Pt with known grade 4 TR and flail leaflet which he deveoped after acute bacterial endocarditis roughly 10 years ago. We restarted his lasix and spironolactone on this admission. HCV: HCV viral load checked, and found to be 1.5 million. No further therapy initiated. ANXIETY: Pt with history of anxiety and on Klonapin at home. His home regimen was continued. ESOPHAGEAL CANDIDIASIS: Patient was found to have thrush on EGD. He was started on a course of fluconazole given his immunosupressed state. He is being discharged to complete a two week course of anti-fungal medication. Medications on Admission: cefazolin 2g IV q8 methadone 80mg PO qd (confirmed on prior admit) prednisone 10mg qd lovenox 40mg SQ prilosec 20mg PO qd ASA 81mg PO daily colace 100mg PO daily clonazepam 1mg qAM, 1mg qNoon, 2mg qhs prn sennekot 2 tabs PO BID PRN morphine sulfate IR 15mg PO q4 PRN promethazine 12.5mg PO q4h PRN Discharge Medications: 1. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q 12 NOON (). 7. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. 17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 18. Cefazolin 1 gram Recon Soln Sig: One (1) Intravenous every six (6) hours for until <Date>1965-7-7</Date> weeks: please continue until <Date>1965-7-7</Date>. Discharge Disposition: Extended Care Facility: <Hospital>Ingram, Moreno and Hood Hospital</Hospital> & Rehab Center - <Hospital>Stewart-Thomas Health System</Hospital> Discharge Diagnosis: Primary diagnosis: Cardiac tamponade GI Bleeding Atrial flutter <Name>Barbara</Name> esophagitis Secondary diagnosis: Pancytopenia HIV/AIDS Hepatitis B and C Endocarditits with flail tricuspic valve Right heart failure. Recurrent epididymitis IVDU on methadone 80 mg QD (followed at Baycove <Telephone>944-345-8192</Telephone>) ?Myocardial infarction in <Year>1968</Year> Asthma LLE medial MSSA foot abscess/osteomyelitis. Gout Traumatic Right AKA PCP Anxiety and depression. PPD (+) treated with 6 months INH Discharge Condition: Stable without fluid reaccumulation per ECHO Discharge Instructions: You were admitted with shortness of breath. You were found to have fluid around your heart. The fluid was removed but no specific cause was identified. If you have any chest pain or shortness of breath, please alert your doctors <Name>Eleanor Kiel</Name>. You will need weekly labs (specifically CBC, LFTs, BUN, and Cr) faxed to Dr. <Name>Kimberly</Name> <Name>Islam</Name> in the Infectious <Hospital>Tran PLC Health System</Hospital> clinic at <Hospital>Moreno, Moore and Contreras Clinic</Hospital> (fax <Telephone>685-752-8271</Telephone>). You have a wound VAC on your ankle to help with healing of the tissue. This should be changed every 3 days by the nurses at your facility. You will need to be seen in the <Hospital>Nelson-Mayer Medical Center</Hospital> clinic to determine how long you will need to have this in place. If you have any symptoms of worsening foot pain, foot redness, fevers, chest pain, nausea, vomiting, or any other concerning symptoms you are to go to the emergency room. Medication changes: 1. Lasix and spironalactone were restarted during this admission. 2. You HAART medication was held during this admission. These can be restarted by your ID doctors <Name>Jere Lofft</Name> <Name>Lauren Harris</Name> are at rehab. 3. You are being treated with an antibiotics called cefazolin. You need to continue this medication until <Date>1965-7-7</Date>. Followup Instructions: Please arrive at ORTHO XRAY (SCC 2) on <Date>2002-1-16</Date> at 7:40 AM for x-ray *(Phone:<Telephone>651-552-6218</Telephone>). . Please follow up with your orthopedic doctor, <Name>An Camargo</Name> <Name>Athanasios Pegram</Name>, MD on <Date>2002-1-16</Date> at 8:00 AM (Phone:<Telephone>651-552-6218</Telephone>) . Please follow up with <Name>Kimberly</Name> <Name>Mari Grier</Name>, MD on <Date>1918-11-16</Date> 11:00AM (Phone:<Telephone>183-507-7880</Telephone>) . You are scheduled for an ECHO on <Date>1927-12-28</Date> at 8 AM. Please come to the <Hospital>Perez Group Health System</Hospital> building, <Location>85105 Anderson Square Suite 079 Nicoleville, VT 09599</Location> for your appointment. Please follow up with Dr. <Name>Quinones</Name>, CT surgery on Monday, <Date>10-3</Date> at 1:15 pm. This appointment is at <Hospital>Schultz LLC Medical Center</Hospital>. You are also scheduled for a Cardiology appointment with Dr. <Name>Poff</Name> on Monday, <Date>1934-10-22</Date> at 9:40 AM. This appointment is in the <Hospital>Perez Group Health System</Hospital> building on the <Location>85105 Anderson Square Suite 079 Nicoleville, VT 09599</Location>. Please follow up with the gastroenterologists for a colonoscopy. You can call to schedule the appointment at (<Telephone>600-520-7831</Telephone>.	000000000000000001111111100000000000000000000000000000000111111111100000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>000001111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000001111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111000000000000000000000000000000000000000000000011111111000000000000011111111111111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111110111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001100000000000000000000011000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000011111111111111111111000000001111111111111011111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111111111000000000000000000000000111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000001111111100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Date: 1943-9-4 Discharge Date: 1980-12-31 Date of Birth: 1915-12-10 Sex: M Service: MEDICINE Allergies: Penicillins Attending:Aisha Chief Complaint: Shortness of breath, chest pain Major Surgical or Invasive Procedure: Pericardiocentesis EGD with biopsy History of Present Illness: 41 y/o M w/ h/o HIV/AIDS (HIV dx 83, AIDS 92, last CD4 132, VL >100K 8/1911, RF IVDU), not currently on HAART, previous right sided bacterial endocarditis with residual 4+ TR, h/o prior MI in 1968, who presents from Phillips-Tate Hospital Hospital for emergent evaluation of pericardial tamponade. Patient was recently hospitalized at Moreno, Moore and Contreras Clinic for osteomyelitis of his L-ankle s/p prior fall. Presented to ED with fevers and ankle pain. Taken to OR by ortho and found to have neg brefringent crystals c/w gout. Tissue/Bone cultures grew MSSA. Patient started on cefazolin. F/U MRI could not rule out osteomyelitis and the patient was discharged to Phillips-Tate Hospital hospital for 6 weeks of IV cefazolin (to end 1965-7-7). While at Fowler, Griffin and Ingram Health System, patient had uneventful course until night prior to admission when he developed low grade temp to 100.2. The morning of admission patient felt short of breath, lethargic with some chest pain. Noted to be tachycardic by vitals, and with decreased O2 sat to 90% on RA -> 96% 2L NC. Chest CT performed showing massively enlarged cardiac silhouette. Transfered to Moreno, Moore and Contreras Clinic for emergent pericardiocentesis. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. In the ED, T98.8, HR 122, BP 147/87, RR 19, O2 97%. Patient noted to be uncomfortable, and w/ rub on exam. Pulsus not performed. Otherwise exam unremarkable. Transferred to cath lab for emergent peridcardiocentesis. In cath lab, pericardial pressure 35, RA and Karthik Pleasant Merino each 30, RV systolic 55. 1.2 L of sanguinous fluid drained from the pericardium. Pericardial pressure decreased to 5mm Hg, and RA to 18mm Hg s/p drain. Patient admitted to CCU for further management. Past Medical History: - HIV/AIDS: HIV dignosed in '21, AIDS diagnosed in '67, last CD4 count 132, VL 100K 1920-5-22. Perscribed HAART but pt reports noncompliance for past 5 months (followed by Dr Davis at Spencer Group Clinic and NP Dr.Kuykendall 321-745-5205) -- ONLY FATHER KNOWS DIAGNOSIS. - Hep C - Hep B cleared - Myocardial infarction in 1968 - h/o endocarditits with grade 4 TR - approximately 12 years ago - Recurrent epididimitis - h/o IVDU on methadone 80 mg QD (followed at Baycove 944-345-8192) - Asthma - osteomyelitis (MSSA) on cefazolin Social History: Pt was most recently living at Fowler, Griffin and Ingram Health System. He has a girlfriend. Shannan Grier denies tobacco, EtOH, and current drug use/abuse. He is in a methadone program because of past IVDU. Family History: NC Physical Exam: ON ADMISSION: VS: T 99.3, BP 132/72 , HR 105 , RR 20, O2 99% 2l NC Gen: Caucasion male w/ mild bitemporal wasting resting comfortably in bed. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple. Unable to appreciate JVD as prominent carotid pulses b/l. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. +2/6 SEM at LUSB. Chest: Pericardial drain in place, clean, dry, intact, No scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Sparse basilar crackles right > left. Abd: +BS, softly distended, non-tender, liver edge palpable below the costal margin. No abdominial bruits. Ext: R-AKA. Left ankle in cast, 2+ DP pulse. No c/c/e. No femoral bruits. +line in L-groin, no bleeding, no hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit ON DISCHARGE: VS: 98.1 117/89 118 20 95% RA Exam was largely unchanged. Abdomen was mildly distended, not tender, normoactive bowel sounds. His cardiac exam was unchanged, the pericardial drain was pulled on day 2 of admission. Lungs were clear to auscultation bilaterally. Wound vac was in place, with minimal drainage. Pertinent Results: 1943-9-4 05:00PM OTHER BODY FLUID TOT PROT-6.1 GLUCOSE-69 LD(LDH)-650 AMYLASE-56 ALBUMIN-1.9 1943-9-4 05:00PM OTHER BODY FLUID WBC-2122* HCT-11* POLYS-56* LYMPHS-27* MONOS-13* EOS-2* METAS-2* 1943-9-4 03:58PM LACTATE-3.2* 1943-9-4 03:50PM GLUCOSE-126* UREA N-38* CREAT-1.8* SODIUM-132* POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-14 1943-9-4 03:50PM estGFR-Using this 1943-9-4 03:50PM CK(CPK)-29* 1943-9-4 03:50PM cTropnT-1943-9-4 03:50PM CK-MB-NotDone 1943-9-4 03:50PM WBC-6.2 RBC-3.09* HGB-9.2* HCT-28.6* MCV-93 MCH-29.6 MCHC-32.0 RDW-19.5* 1943-9-4 03:50PM NEUTS-77.3* LYMPHS-17.1* MONOS-5.3 EOS-0.1 BASOS-0.2 1943-9-4 03:50PM PLT COUNT-295# 1943-9-4 03:50PM PT-15.1* PTT-38.2* INR(PT)-1.4* Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. . ECHO (1943-9-4) Pre-pericardiocentesis: The left atrium is elongated. The estimated right atrial pressure is >20 mmHg. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is moderately dilated. There is a large circumferential pericardial effusion. Stranding is visualized within the pericardial space c/w some organization. There is left atrial diastolic collapse. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of 1980-2-18, large pericardial effusion with echocardiographic signs of tamponade is new. . ECHO (1943-9-4) Post pericardiocentesis: The left atrium is elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is markedly dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is partial flail of a tricuspid valve leaflet. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of 1943-9-4, the residue pericardial effusion is minimal. . Cardiac catherization (1943-9-4): 1. Large circumferential pericardial effusion with tamponade physiology. 2. Successful pericardiocentesis with drainage of 1500mls of blood stained fluid. Patient left cathlab in stable condition FINAL DIAGNOSIS: 1. Severe pericardial tamponade. 2. Mild primary pulmonary hypertension. 3. Successful pericardiocentesis with drainage of 1500ml of blood stained fluid. . ECHO (1964-5-16): The left atrium is mildly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP1943-9-4, the findings are similar. . ECHO (2001-1-28): The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened and appear shortened/remnants and fail to fully coapt. A small echodensity is again seen on the right atrial side of the septal leaflet which could be either a vegeateion or a partial leaflet segment. Severe [4+] tricuspid regurgitation is seen. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of 1964-5-16, the pericardial effusion is slightly smaller and may be more echo dense. The left ventricular cavity size is probably slightly larger (reflecting better filling). The small echodensity on the tricuspid leaflet has not changed in size. . ECHO (1919-4-17): The left atrium is mildly dilated. The right atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of 2001-1-28, pericardial effusion now appears slightly smaller. . ECHO (1970-6-28): The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The mitral valve leaflets are structurally normal. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. There is a very small, partially echo filled pericardial effusion. Compared with the prior study (images reviewed) of 1919-4-17, the findings are similar. Brief Hospital Course: 41 year old male with HIV/AIDS, previous R-sided endocarditis and severe TR, presented in cardiac tamponade from rehabilitation. CARDIAC TAMPONADE: On admission, he was transferred to the cardiac catherization lab, where over one liter of fluid was drained from his pericardial space. The fluid was sent for gram stain, culture, AFB, Raymond, TB PCR as well as viral studies and cytology. A pericardial drain was initially left in place, but given minimal drainage over 24 hours, was pulled prior to his transfer to the floor. The etiology of the pericardial effusion is unknown. He was followed by Cardiology on the floor and the initial plan was for a pericardial window, for both tissue and to prevent reaccumulation of fluid. The patient refused the procedure at this time. He will follow up as an outpatient to re-evaluate for the procedure. The effusion was followed by serial ECHO while the patient was in the hospital. There was no evidence of re-accumulation. He is scheduled for an outpatient ECHO in several weeks to evaluate the pericardial space for reaccumlation of effusion. ATRIAL FIBRILLATION/FLUTTER: Per multiple EKGs, the patient appears to have developed new a fib/flutter. Given his guaiac positive stools, it is not advisable to start anticoagulation at this time. The patient is being rate controlled on a low dose of beta-blocker, which appears to be effective. He will be followed by outpatient Cardiology. ANEMIA: The patient had a hematocrit drop during this admission. His lab studies are consistent with anemia of chronic disease, however, the patient was found to have guaiac positive stools. GI was consulted and recommeded colonoscopy and EGD. The patient was unable to tolerate the prep and thus the colonoscopy was cancelled. His EGD demonstrated gastritis and thrush. He was started on fluconazole to treat the thrush. He was also transfused two units of packed red blood cells with an appropriate hematocrit response. HIV/AIDS: The patient had a CD4 count checked during his last admission, it was found to be 132 with a viral load >100K. Given his past noncompliance with HAART therapy and the risk of developing drug resistant HIV, HAART was not restarted. Pt is willing to restart HARRT, and the plan remains to restart medications at rehabilitation. Bactrim was continued for PCP Ashley Kenner. OSTEOMYELITIS: The patient was previously admitted for left ankle pain. He was followed previously by both the orthopedic and ID services. Both services continued to follow the patient on this admission. The patient was continued on 6 weeks of IV antibiotics (last day of cefazolin 1965-7-7), although the dose was decreased to 1g q6 because of a low white blood count. SEVERE TRICUSPID REGURGITATION: Pt with known grade 4 TR and flail leaflet which he deveoped after acute bacterial endocarditis roughly 10 years ago. We restarted his lasix and spironolactone on this admission. HCV: HCV viral load checked, and found to be 1.5 million. No further therapy initiated. ANXIETY: Pt with history of anxiety and on Klonapin at home. His home regimen was continued. ESOPHAGEAL CANDIDIASIS: Patient was found to have thrush on EGD. He was started on a course of fluconazole given his immunosupressed state. He is being discharged to complete a two week course of anti-fungal medication. Medications on Admission: cefazolin 2g IV q8 methadone 80mg PO qd (confirmed on prior admit) prednisone 10mg qd lovenox 40mg SQ prilosec 20mg PO qd ASA 81mg PO daily colace 100mg PO daily clonazepam 1mg qAM, 1mg qNoon, 2mg qhs prn sennekot 2 tabs PO BID PRN morphine sulfate IR 15mg PO q4 PRN promethazine 12.5mg PO q4h PRN Discharge Medications: 1. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q 12 NOON (). 7. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. 17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 18. Cefazolin 1 gram Recon Soln Sig: One (1) Intravenous every six (6) hours for until 1965-7-7 weeks: please continue until 1965-7-7. Discharge Disposition: Extended Care Facility: Ingram, Moreno and Hood Hospital & Rehab Center - Stewart-Thomas Health System Discharge Diagnosis: Primary diagnosis: Cardiac tamponade GI Bleeding Atrial flutter Barbara esophagitis Secondary diagnosis: Pancytopenia HIV/AIDS Hepatitis B and C Endocarditits with flail tricuspic valve Right heart failure. Recurrent epididymitis IVDU on methadone 80 mg QD (followed at Baycove 944-345-8192) ?Myocardial infarction in 1968 Asthma LLE medial MSSA foot abscess/osteomyelitis. Gout Traumatic Right AKA PCP Anxiety and depression. PPD (+) treated with 6 months INH Discharge Condition: Stable without fluid reaccumulation per ECHO Discharge Instructions: You were admitted with shortness of breath. You were found to have fluid around your heart. The fluid was removed but no specific cause was identified. If you have any chest pain or shortness of breath, please alert your doctors Eleanor Kiel. You will need weekly labs (specifically CBC, LFTs, BUN, and Cr) faxed to Dr. Kimberly Islam in the Infectious Tran PLC Health System clinic at Moreno, Moore and Contreras Clinic (fax 685-752-8271). You have a wound VAC on your ankle to help with healing of the tissue. This should be changed every 3 days by the nurses at your facility. You will need to be seen in the Nelson-Mayer Medical Center clinic to determine how long you will need to have this in place. If you have any symptoms of worsening foot pain, foot redness, fevers, chest pain, nausea, vomiting, or any other concerning symptoms you are to go to the emergency room. Medication changes: 1. Lasix and spironalactone were restarted during this admission. 2. You HAART medication was held during this admission. These can be restarted by your ID doctors Jere Lofft Lauren Harris are at rehab. 3. You are being treated with an antibiotics called cefazolin. You need to continue this medication until 1965-7-7. Followup Instructions: Please arrive at ORTHO XRAY (SCC 2) on 2002-1-16 at 7:40 AM for x-ray *(Phone:651-552-6218). . Please follow up with your orthopedic doctor, An Camargo Athanasios Pegram, MD on 2002-1-16 at 8:00 AM (Phone:651-552-6218) . Please follow up with Kimberly Mari Grier, MD on 1918-11-16 11:00AM (Phone:183-507-7880) . You are scheduled for an ECHO on 1927-12-28 at 8 AM. Please come to the Perez Group Health System building, 85105 Anderson Square Suite 079 Nicoleville, VT 09599 for your appointment. Please follow up with Dr. Quinones, CT surgery on Monday, 10-3 at 1:15 pm. This appointment is at Schultz LLC Medical Center. You are also scheduled for a Cardiology appointment with Dr. Poff on Monday, 1934-10-22 at 9:40 AM. This appointment is in the Perez Group Health System building on the 85105 Anderson Square Suite 079 Nicoleville, VT 09599. Please follow up with the gastroenterologists for a colonoscopy. You can call to schedule the appointment at (600-520-7831.	['Admission Date: 1943-9-4 Discharge Date: 1980-12-31\n\nDate of Birth: 1915-12-10 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPenicillins\n\nAttending:Aisha\nChief Complaint:\nShortness of breath, chest pain\n\nMajor Surgical or Invasive Procedure:\nPericardiocentesis\nEGD with biopsy\n\n\nHistory of Present Illness:\n41 y/o M w/ h/o HIV/AIDS (HIV dx 83, AIDS 92, last CD4 132, VL\n>100K 8/1911, RF IVDU), not currently on HAART, previous right\nsided bacterial endocarditis with residual 4+ TR, h/o prior MI\nin 1968, who presents from Phillips-Tate Hospital Hospital for emergent\nevaluation of pericardial tamponade.\n\nPatient was recently hospitalized at Moreno, Moore and Contreras Clinic for osteomyelitis of\nhis L-ankle s/p prior fall. Presented to ED with fevers and\nankle pain. Taken to OR by ortho and found to have neg\nbrefringent crystals c/w gout.', ' Tissue/Bone cultures grew MSSA.\nPatient started on cefazolin. F/U MRI could not rule out\nosteomyelitis and the patient was discharged to Phillips-Tate Hospital\nhospital for 6 weeks of IV cefazolin (to end 1965-7-7).\n\nWhile at Fowler, Griffin and Ingram Health System, patient had uneventful course until night\nprior to admission when he developed low grade temp to 100.2.\nThe morning of admission patient felt short of breath, lethargic\nwith some chest pain. Noted to be tachycardic by vitals, and\nwith decreased O2 sat to 90% on RA -> 96% 2L NC. Chest CT\nperformed showing massively enlarged cardiac silhouette.\nTransfered to Moreno, Moore and Contreras Clinic for emergent pericardiocentesis.\n\nOn review of symptoms, he denies any prior history of stroke,\nTIA, deep venous thrombosis, pulmonary embolism, bleeding at the\ntime of surgery, myalgias, joint pains, cough, hemoptysis, black\nstools or red stools.', " He denies recent fevers, chills or rigors.\nHe denies exertional buttock or calf pain. All of the other\nreview of systems were negative.\n\nIn the ED, T98.8, HR 122, BP 147/87, RR 19, O2 97%. Patient\nnoted to be uncomfortable, and w/ rub on exam. Pulsus not\nperformed. Otherwise exam unremarkable. Transferred to cath lab\nfor emergent peridcardiocentesis.\n\nIn cath lab, pericardial pressure 35, RA and Karthik Pleasant Merino each\n30, RV systolic 55. 1.2 L of sanguinous fluid drained from the\npericardium. Pericardial pressure decreased to 5mm Hg, and RA to\n18mm Hg s/p drain. Patient admitted to CCU for further\nmanagement.\n\n\nPast Medical History:\n- HIV/AIDS: HIV dignosed in '21, AIDS diagnosed in '67, last CD4\ncount 132, VL 100K 1920-5-22. Perscribed HAART but pt reports\nnoncompliance for past 5 months (followed by Dr Davis at Spencer Group Clinic\nand NP Dr.", 'Kuykendall 321-745-5205) -- ONLY FATHER KNOWS DIAGNOSIS.\n- Hep C\n- Hep B cleared\n- Myocardial infarction in 1968\n- h/o endocarditits with grade 4 TR - approximately 12 years ago\n\n- Recurrent epididimitis\n- h/o IVDU on methadone 80 mg QD (followed at Baycove\n944-345-8192)\n- Asthma\n- osteomyelitis (MSSA) on cefazolin\n\n\nSocial History:\nPt was most recently living at Fowler, Griffin and Ingram Health System. He has a girlfriend.\nShannan Grier denies tobacco, EtOH, and current drug use/abuse. He is in a\nmethadone program because of past IVDU.\n\n\nFamily History:\nNC\n\nPhysical Exam:\nON ADMISSION:\nVS: T 99.3, BP 132/72 , HR 105 , RR 20, O2 99% 2l NC\nGen: Caucasion male w/ mild bitemporal wasting resting\ncomfortably in bed.\nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were\npink, no pallor or cyanosis of the oral mucosa.', '\nNeck: Supple. Unable to appreciate JVD as prominent carotid\npulses b/l.\nCV: PMI located in 5th intercostal space, midclavicular line.\nRR, normal S1, S2. +2/6 SEM at LUSB.\nChest: Pericardial drain in place, clean, dry, intact, No\nscoliosis or kyphosis. Resp were unlabored, no accessory muscle\nuse. Sparse basilar crackles right > left.\nAbd: +BS, softly distended, non-tender, liver edge palpable\nbelow the costal margin. No abdominial bruits.\nExt: R-AKA. Left ankle in cast, 2+ DP pulse. No c/c/e. No\nfemoral bruits. +line in L-groin, no bleeding, no hematoma.\nSkin: No stasis dermatitis, ulcers, scars, or xanthomas.\nPulses: Right: Carotid 2+ without bruit; Femoral 2+ without\nbruit; 2+ DP\nLeft: Carotid 2+ without bruit; Femoral 2+ without bruit\nON DISCHARGE:\nVS: 98.1 117/89 118 20 95% RA\nExam was largely unchanged.', ' Abdomen was mildly distended, not\ntender, normoactive bowel sounds. His cardiac exam was\nunchanged, the pericardial drain was pulled on day 2 of\nadmission. Lungs were clear to auscultation bilaterally. Wound\nvac was in place, with minimal drainage.\n\n\nPertinent Results:\n1943-9-4 05:00PM OTHER BODY FLUID TOT PROT-6.1 GLUCOSE-69\nLD(LDH)-650 AMYLASE-56 ALBUMIN-1.9\n1943-9-4 05:00PM OTHER BODY FLUID WBC-2122* HCT-11* POLYS-56\nLYMPHS-27 MONOS-13* EOS-2* METAS-2\n1943-9-4 03:58PM LACTATE-3.2\n1943-9-4 03:50PM GLUCOSE-126* UREA N-38* CREAT-1.8\nSODIUM-132 POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-14\n1943-9-4 03:50PM estGFR-Using this\n1943-9-4 03:50PM CK(CPK)-29\n1943-9-4 03:50PM cTropnT-1943-9-4 03:50PM CK-MB-NotDone\n1943-9-4 03:50PM WBC-6.2 RBC-3.09 HGB-9.2* HCT-28.6* MCV-93\nMCH-29.', '6 MCHC-32.0 RDW-19.5\n1943-9-4 03:50PM NEUTS-77.3 LYMPHS-17.1* MONOS-5.3 EOS-0.1\nBASOS-0.2\n1943-9-4 03:50PM PLT COUNT-295#\n1943-9-4 03:50PM PT-15.1* PTT-38.2* INR(PT)-1.4\n\nPericardial fluid: NEGATIVE FOR MALIGNANT CELLS.\n.\nECHO (1943-9-4) Pre-pericardiocentesis: The left atrium is\nelongated. The estimated right atrial pressure is >20 mmHg. The\nleft ventricular cavity is unusually small. Regional left\nventricular wall motion is normal. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). The right ventricular cavity\nis moderately dilated. There is a large circumferential\npericardial effusion. Stranding is visualized within the\npericardial space c/w some organization. There is left atrial\ndiastolic collapse. There is right ventricular diastolic\ncollapse, consistent with impaired fillling/tamponade\nphysiology.', ' There is significant, accentuated respiratory\nvariation in mitral/tricuspid valve inflows, consistent with\nimpaired ventricular filling.\n\nCompared with the prior study (images reviewed) of 1980-2-18,\nlarge pericardial effusion with echocardiographic signs of\ntamponade is new.\n.\nECHO (1943-9-4) Post pericardiocentesis: The left atrium is\nelongated. The right atrium is markedly dilated. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size\nand systolic function (LVEF>55%). The right ventricular cavity\nis markedly dilated. Right ventricular systolic function is\nnormal. [Intrinsic right ventricular systolic function is likely\nmore depressed given the severity of tricuspid regurgitation.]\nThere is abnormal septal motion/position consistent with right\nventricular pressure/volume overload.', ' There is no aortic valve\nstenosis. The mitral valve leaflets are mildly thickened. There\nis partial flail of a tricuspid valve leaflet. The tricuspid\nvalve leaflets fail to fully coapt. Severe [4+] tricuspid\nregurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of 1943-9-4,\nthe residue pericardial effusion is minimal.\n.\nCardiac catherization (1943-9-4):\n1. Large circumferential pericardial effusion with tamponade\nphysiology.\n2. Successful pericardiocentesis with drainage of 1500mls of\nblood\nstained fluid. Patient left cathlab in stable condition\nFINAL DIAGNOSIS:\n1. Severe pericardial tamponade.\n2. Mild primary pulmonary hypertension.\n3. Successful pericardiocentesis with drainage of 1500ml of\nblood\nstained fluid.', '\n.\nECHO (1964-5-16): The left atrium is mildly dilated. The right\natrium is markedly dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>55%). Transmitral and\ntissue Doppler imaging suggests normal diastolic function, and a\nnormal left ventricular filling pressure (PCWP1943-9-4, the findings are similar.\n.\nECHO (2001-1-28): The left atrium is mildly dilated. The right\natrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and systolic\nfunction (LVEF>55%). The right ventricular cavity is moderately\ndilated. Right ventricular systolic function is borderline\nnormal. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The tricuspid valve leaflets are\nmildly thickened and appear shortened/remnants and fail to fully\ncoapt.', ' A small echodensity is again seen on the right atrial\nside of the septal leaflet which could be either a vegeateion or\na partial leaflet segment. Severe [4+] tricuspid regurgitation\nis seen. There is a small pericardial effusion. The effusion is\necho dense, consistent with blood, inflammation or other\ncellular elements. There are no echocardiographic signs of\ntamponade.\n\nCompared with the prior study (images reviewed) of 1964-5-16,\nthe pericardial effusion is slightly smaller and may be more\necho dense. The left ventricular cavity size is probably\nslightly larger (reflecting better filling). The small\nechodensity on the tricuspid leaflet has not changed in size.\n.\nECHO (1919-4-17): The left atrium is mildly dilated. The right\natrium is dilated. There is mild symmetric left ventricular\nhypertrophy.', ' The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is normal (LVEF>55%). The\nright ventricular cavity is dilated. Right ventricular systolic\nfunction is normal. [Intrinsic right ventricular systolic\nfunction is likely more depressed given the severity of\ntricuspid regurgitation.] There is abnormal septal\nmotion/position consistent with right ventricular\npressure/volume overload. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. The mitral\nvalve appears structurally normal with trivial mitral\nregurgitation. The tricuspid valve leaflets fail to fully coapt.\nSevere [4+] tricuspid regurgitation is seen. There is a\ntrivial/physiologic pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of 2001-1-28,\npericardial effusion now appears slightly smaller.', '\n.\nECHO (1970-6-28):\nThe right atrium is markedly dilated. There is mild symmetric\nleft ventricular hypertrophy with normal cavity size and\nsystolic function (LVEF>55%). The right ventricular cavity is\nmoderately dilated. Right ventricular systolic function is\nborderline normal. The mitral valve leaflets are structurally\nnormal. The tricuspid valve leaflets are mildly thickened. The\ntricuspid valve leaflets fail to fully coapt. There is a very\nsmall, partially echo filled pericardial effusion.\n\nCompared with the prior study (images reviewed) of 1919-4-17,\nthe findings are similar.\n\n\nBrief Hospital Course:\n41 year old male with HIV/AIDS, previous R-sided endocarditis\nand severe TR, presented in cardiac tamponade from\nrehabilitation.\n\nCARDIAC TAMPONADE: On admission, he was transferred to the\ncardiac catherization lab, where over one liter of fluid was\ndrained from his pericardial space.', ' The fluid was sent for gram\nstain, culture, AFB, Raymond, TB PCR as well as viral studies and\ncytology. A pericardial drain was initially left in place, but\ngiven minimal drainage over 24 hours, was pulled prior to his\ntransfer to the floor. The etiology of the pericardial effusion\nis unknown. He was followed by Cardiology on the floor and the\ninitial plan was for a pericardial window, for both tissue and\nto prevent reaccumulation of fluid. The patient refused the\nprocedure at this time. He will follow up as an outpatient to\nre-evaluate for the procedure. The effusion was followed by\nserial ECHO while the patient was in the hospital. There was no\nevidence of re-accumulation. He is scheduled for an outpatient\nECHO in several weeks to evaluate the pericardial space for\nreaccumlation of effusion.', '\n\nATRIAL FIBRILLATION/FLUTTER: Per multiple EKGs, the patient\nappears to have developed new a fib/flutter. Given his guaiac\npositive stools, it is not advisable to start anticoagulation at\nthis time. The patient is being rate controlled on a low dose\nof beta-blocker, which appears to be effective. He will be\nfollowed by outpatient Cardiology.\n\nANEMIA: The patient had a hematocrit drop during this admission.\n His lab studies are consistent with anemia of chronic disease,\nhowever, the patient was found to have guaiac positive stools.\nGI was consulted and recommeded colonoscopy and EGD. The\npatient was unable to tolerate the prep and thus the colonoscopy\nwas cancelled. His EGD demonstrated gastritis and thrush. He\nwas started on fluconazole to treat the thrush. He was also\ntransfused two units of packed red blood cells with an\nappropriate hematocrit response.', '\n\nHIV/AIDS: The patient had a CD4 count checked during his last\nadmission, it was found to be 132 with a viral load >100K.\nGiven his past noncompliance with HAART therapy and the risk of\ndeveloping drug resistant HIV, HAART was not restarted. Pt is\nwilling to restart HARRT, and the plan remains to restart\nmedications at rehabilitation. Bactrim was continued for PCP\nAshley Kenner.\n\nOSTEOMYELITIS: The patient was previously admitted for left\nankle pain. He was followed previously by both the orthopedic\nand ID services. Both services continued to follow the patient\non this admission. The patient was continued on 6 weeks of IV\nantibiotics (last day of cefazolin 1965-7-7), although the dose\nwas decreased to 1g q6 because of a low white blood count.\n\nSEVERE TRICUSPID REGURGITATION: Pt with known grade 4 TR and\nflail leaflet which he deveoped after acute bacterial\nendocarditis roughly 10 years ago.', ' We restarted his lasix and\nspironolactone on this admission.\n\nHCV: HCV viral load checked, and found to be 1.5 million. No\nfurther therapy initiated.\n\nANXIETY: Pt with history of anxiety and on Klonapin at home.\nHis home regimen was continued.\n\nESOPHAGEAL CANDIDIASIS: Patient was found to have thrush on EGD.\n He was started on a course of fluconazole given his\nimmunosupressed state. He is being discharged to complete a two\nweek course of anti-fungal medication.\n\n\n\n\n\nMedications on Admission:\ncefazolin 2g IV q8\nmethadone 80mg PO qd (confirmed on prior admit)\nprednisone 10mg qd\nlovenox 40mg SQ\nprilosec 20mg PO qd\nASA 81mg PO daily\ncolace 100mg PO daily\nclonazepam 1mg qAM, 1mg qNoon, 2mg qhs prn\nsennekot 2 tabs PO BID PRN\nmorphine sulfate IR 15mg PO q4 PRN\npromethazine 12.5mg PO q4h PRN\n\n\nDischarge Medications:\n1.', ' Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble\nPO DAILY (Daily).\n2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)\nInjection TID (3 times a day).\n3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\n5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day\n(in the morning)).\n6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q 12 NOON ().\n7. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day\n(at bedtime)) as needed for anxiety.\n8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed.\n9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4\nhours) as needed.', '\n11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H\n(every 8 hours) as needed.\n12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).\n15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2\ntimes a day).\n16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every\n24 hours) for 14 days.\n17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN\n10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units\nheparin) each lumen Daily and PRN. Inspect site every shift.\n18. Cefazolin 1 gram Recon Soln Sig: One (1) Intravenous every\nsix (6) hours for until 1965-7-7 weeks: please continue until\n1965-7-7.', '\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nIngram, Moreno and Hood Hospital & Rehab Center - Stewart-Thomas Health System\n\nDischarge Diagnosis:\nPrimary diagnosis:\nCardiac tamponade\nGI Bleeding\nAtrial flutter\nBarbara esophagitis\n\nSecondary diagnosis:\nPancytopenia\nHIV/AIDS\nHepatitis B and C\nEndocarditits with flail tricuspic valve\nRight heart failure.\nRecurrent epididymitis\nIVDU on methadone 80 mg QD (followed at Baycove 944-345-8192)\n?Myocardial infarction in 1968\nAsthma\nLLE medial MSSA foot abscess/osteomyelitis.\nGout\nTraumatic Right AKA\nPCP\nAnxiety and depression.\nPPD (+) treated with 6 months INH\n\n\nDischarge Condition:\nStable without fluid reaccumulation per ECHO\n\n\nDischarge Instructions:\nYou were admitted with shortness of breath. You were\nfound to have fluid around your heart. The fluid was removed\nbut no specific cause was identified.', ' If you have any chest\npain or shortness of breath, please alert your doctors\nEleanor Kiel.\n\nYou will need weekly labs (specifically CBC, LFTs, BUN, and\nCr) faxed to Dr. Kimberly Islam in the Infectious Tran PLC Health System clinic at\nMoreno, Moore and Contreras Clinic (fax 685-752-8271).\n\nYou have a wound VAC on your ankle to help with healing of the\ntissue. This should be changed every 3 days by the nurses at\nyour facility. You will need to be seen in the Nelson-Mayer Medical Center clinic to\ndetermine how long you will need to have this in place.\n\nIf you have any symptoms of worsening foot pain, foot redness,\nfevers, chest pain, nausea, vomiting, or any other concerning\nsymptoms you are to go to the emergency room.\n\nMedication changes:\n1. Lasix and spironalactone were restarted during this\nadmission.', '\n2. You HAART medication was held during this admission. These\ncan be restarted by your ID doctors Jere Lofft Lauren Harris are at rehab.\n3. You are being treated with an antibiotics called cefazolin.\nYou need to continue this medication until 1965-7-7.\n\n\nFollowup Instructions:\nPlease arrive at ORTHO XRAY (SCC 2) on 2002-1-16 at 7:40 AM for\nx-ray (Phone:651-552-6218).\n.\nPlease follow up with your orthopedic doctor, An Camargo Athanasios Pegram, MD on 2002-1-16 at 8:00 AM (Phone:651-552-6218)\n.\nPlease follow up with Kimberly Mari Grier, MD on 1918-11-16 11:00AM\n(Phone:183-507-7880)\n.\nYou are scheduled for an ECHO on 1927-12-28 at 8 AM.\nPlease come to the Perez Group Health System building, 85105 Anderson Square Suite 079\nNicoleville, VT 09599 for your\nappointment.\n\nPlease follow up with Dr.', ' Quinones, CT surgery on Monday, 10-3 at 1:15 pm. This appointment is at Schultz LLC Medical Center.\n\nYou are also scheduled for a Cardiology appointment with Dr.\nPoff on Monday, 1934-10-22 at 9:40 AM. This appointment\nis in the Perez Group Health System building on the 85105 Anderson Square Suite 079\nNicoleville, VT 09599.\n\nPlease follow up with the gastroenterologists for a colonoscopy.\n You can call to schedule the appointment at (600-520-7831.\n\n\n\n']
227	10044	124073.0	2152-10-11	Discharge summary	Report	Admission Date: [2152-10-2] Discharge Date: [2152-10-11] Service: MEDICINE ONCOLOGY HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with a history of metastatic melanoma with known metastases to the liver and lung who status post resection in the 90s with recurrence in [2146] status post treatment with Taxol. She presented to the Emergency Room on [2152-10-3], with altered mental status, decreased p.o. intake, confusion and headache over several weeks, and was found to have three mass lesions in her brain on head CT. The patient was started on Decadron, as well as Dilantin. In the Emergency Room she became hypertensive and was sent to the SICU. She was maintained on Nipride GTT. In the Intensive Care Unit, the patient was weaned off Nipride and then changed to Labetalol, Hydralazine. The patient was also noted to have cellulitis on her left knee and was initially maintained on Vancomycin and later changed to Keflex. The patient was also evaluated by Radiation/Oncology, and it was decided that the patient would received a total of seven treatments of whole brain radiation therapy in conjunction with Decadron, as well as Dilantin. During her Intensive Care Unit stay, the patient had increased alertness and was more oriented, although she does have a history of baseline dementia. PAST MEDICAL HISTORY: Metastatic melanoma status post resection in [2138] with recurrence in [2146] status post treatment with Taxol. History of paroxysmal atrial fibrillation with anticoagulation in the past. Status post PCM for sinoatrial dysfunction. History of coronary artery disease status post myocardial infarction in [2143]. MIBI in [2152-6-23] showed an ejection fraction of 50%. History of hypercholesterolemia. History of hypertension, osteoarthritis, cellulitis. Status post skin graft. Peptic ulcer disease. History of bladder cancer. Chronic renal insufficiency. ALLERGIES: AMOXICILLIN, OXACILLIN AND PERCOCET, REACTIONS UNKNOWN. MEDICATIONS ON ADMISSION: Imdur 30 mg, Warfarin, Lasix 20 q.d., Calcium Carbonate 1500 q.d., Vitamin D 4000 q.d., Colace 100 mg b.i.d., Protonix 40 q.d., Dietrol 2 mg b.i.d., Labetalol 300 mg b.i.d., Lipitor 10 mg p.o. q.d. SOCIAL HISTORY: The patient is a home health aide. Husband died three months ago. She walks but recently was unable to do so. She otherwise has a very close family. FAMILY HISTORY: On maternal side there is a history of diabetes, as well as hypertension. PHYSICAL EXAMINATION: Vital signs: Temperature 96.5??????, blood pressure 161/47, pulse 74, respirations 14, oxygen saturation 98% on 2 L, 92% on room air. General: She was elderly, lying in bed. She was sometimes agitated and not following commands. She was nonverbal. HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular movements intact. Dry mucous membranes. There was poor dentition. Neck: Supple. No lymphadenopathy. Heart: Regular, rate and rhythm. There was an early systolic ejection murmur, 3 out of 6. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Good bowel sounds. Extremities: There were bilateral skin eschars. The left knee had excoriation and was erythematous. Neurological: The patient was obtunded and not following commands. She had a limited neurologic exam. Cranial nerves II, III and IV intact. She was moving both hands with appropriate strength. No lifting of left arm off bed. Right lower extremity with decreased strength, apparently chronic secondary to polio. On the left lower extremity, she moved toes and feet. LABORATORY DATA: On admission her white count was 6.4, hematocrit 37.5, platelet count 269, neutrophils 73, 22 lymphs, 3 monos; INR 1.1, PT 12.7, PTT 27.8; sodium 138, potassium 4.3, chloride 106, bicarb 22, BUN 36, creatinine 1.8, baseline 1.4-1.5; platelet count 151; calcium 10.6, magnesium 1.9, phos 3.1, CK 116, MB 5, troponin 0.04; Albumin 4.2; TSH 2.9; urinalysis with occasional bacteria, trace ketones, 30 protein. Electrocardiogram was paced, lateral T-wave inversion, inferior T-wave inversion which new consistent with [2152-6-23]. Head CT showed three moderately large-sized mass lesions in the right posterior frontal, right anterior frontal lobe and left parietal lesion with significant edema. There was a small amount of peripheral density, question of hemorrhage or calcification. Chest x-ray revealed cardiomegaly, atelectasis, but no overt failure. Knee films showed no fracture and no dislocation and degenerative changes with small right knee effusion. HOSPITAL COURSE: 1. Altered mental status: This was felt to be secondary to metastatic disease to the brain. The patient was evaluated by Radiation/Oncology, and it was decided that the patient would receive a total of seven treatments of whole-brain radiation therapy. Additionally she was maintained on Decadron, as well as Dilantin. The patient had no seizure activity while in the hospital. She tolerated her Decadron well and tolerated her whole-brain radiation therapy without any complications. The patient was discharged on a Decadron taper. Her Dilantin dose was increased to a total of 300 three times a day, given that her Dilantin level [Company 2240].i.d. was only 8. The patient will need her Dilantin level followed as an outpatient at her next appointment. 2. Hypertension: The patient's blood pressures while in the Emergency Room were noted to be 200/100; however, once she was transferred to the floor, she maintained very good control on a combination of Clonidine, Hydrochlorothiazide and Minoxidil, Hydralazine, as well as Labetalol 400 b.i.d. The patient's blood pressures were maintained in the 140s to 160s systolic, and it was decided that this was an appropriate range given that the patient needed to have adequate perfusion in the face of increased intracranial pressure. 3. Cellulitis: The patient was initially maintained on Vancomycin, and this was later changed to Keflex. The patient did not develop any rash or other complications Keflex. Her cellulitis was improved by the time of discharge. 4. Renal insufficiency: Her creatinine remained at baseline between 1.4-1.5. 5. Coronary artery disease: The patient was maintained on enteric coated Aspirin, as well as Labetalol. The patient ruled out for myocardial infarction, and her electrocardiogram remained stable without any EKG changes. 6. FEN: The patient was maintained on a soft diet, as well as thin liquids. She tolerated this without event. Additionally her electrolytes were followed daily and were repleted as needed. Her I&Os were monitored closely. 7. Paroxysmal atrial fibrillation: The patient is paced. She was rate controlled. She was held off all anticoagulation given her metastatic disease to the brain. DISPOSITION: The patient was discharged to her home because her family wanted the patient to do so. The patient has [12-27] full-time nurses that will be following her once she is discharged to home. Her mental status improved greatly while the patient was in the hospital. By the time of discharge, the patient was conversive and much more alert and oriented. Her neurologic exam was significant for intact cranial nerves and the ability to move all extremities spontaneously. She did have limited movement in her arms, given that she has a history of bursitis. Otherwise, the patient's exam neurologically was much improved. CONDITION ON DISCHARGE: Stable. She was stable on room air. She could not ambulate without assistance and does need help with all bed transfers. She was tolerating a p.o. diet without problems. [Name (NI) ] mental status had improved considerably in that she was conversant, could move her extremities spontaneously, and cranial nerves were intact. Her strength was notable for weakness throughout but was symmetric. DISCHARGE DIAGNOSIS: 1. Metastatic melanoma with metastases to the liver, lung and brain. 2. Hypertension. 3. Hypercholesterolemia. 5. Osteoarthritis. 6. Bursitis. 7. Cellulitis. 8. Chronic renal insufficiency. 9. Coronary artery disease. 10. Paroxysmal atrial fibrillation. DISCHARGE STATUS: As stated above, the patient will be discharged to home with [Hospital 2241] nursing care. Home Hospice has been discussed with the family, and they would like to avail this possibility as the need arises. DISCHARGE MEDICATIONS: Fluconazole nitrate powder to be applied b.i.d. as needed, Hydrochlorothiazide 25 mg 1 p.o. q.d., Minoxidil 10 mg 1 tab p.o. q.d., Hydralazine 25 mg 3 tab p.o. q.6 hours, Clonodine 0.1 mg 1 tab p.o. t.i.d., Aspirin 325 1 p.o. q.d., Pantoprazole 40 mg 1 p.o. q.d., Keflex 500 mg 1 p.o. q.12 hours for a total of 5 days, Docusate 100 p.o. b.i.d., Phenytoin 300 mg 1 p.o. t.i.d., Dexamethasone taper 8 mg p.o. q.8 hours for 3 days, then 4 mg p.o. t.i.d. for 3 days, then 4 mg p.o. b.i.d. for 3 days, then 2 mg p.o. b.i.d. for 4 days, then 1 mg p.o. b.i.d. for 7 days, then 0.7 mg 1 p.o. b.i.d. for 5 days, then 0.75 mg 1 p.o. b.i.d. for 5 days, then 0.5 mg 1 p.o. b.i.d., then Dexamethasone again 0.25 mg p.o. b.i.d. for 5 days, then Dexamethasone 0.25 mg 1 p.o. q.d. for 5 days, and then stop, Labetalol HCL 200 mg 2 tab b.i.d., Bactrim DS 1 tab p.o. q.d. for UTI prophylaxis. FOLLOW-UP: The patient is to see [Name8 (MD) 2242], RN, at the [Hospital Ward Name 23] Center on [2152-10-23], at 2 o'clock. She is to see Dr. [First Name4 (NamePattern1) 2243] [Last Name (NamePattern1) 284] at the [Hospital Ward Name 23] Center on [2152-10-23], at 3 o'clock. She is to see Dr. [Last Name (STitle) 2244] at the Hematology/Oncology Center at the [Hospital Ward Name 23] Building on [10-30] at 3 o'clock. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1736] Dictated By:[Name6 (MD) 2245] MEDQUIST36 D: [2152-10-11] 10:51 T: [2152-10-11] 11:02 JOB#: [Job Number 2246] cc:[Last Name (NamePattern4) 2247]	Admission Date: <Date>1911-5-15</Date> Discharge Date: <Date>2011-8-15</Date> Service: MEDICINE ONCOLOGY HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with a history of metastatic melanoma with known metastases to the liver and lung who status post resection in the 90s with recurrence in <Year>1905</Year> status post treatment with Taxol. She presented to the Emergency Room on <Date>2008-11-28</Date>, with altered mental status, decreased p.o. intake, confusion and headache over several weeks, and was found to have three mass lesions in her brain on head CT. The patient was started on Decadron, as well as Dilantin. In the Emergency Room she became hypertensive and was sent to the SICU. She was maintained on Nipride GTT. In the Intensive Care Unit, the patient was weaned off Nipride and then changed to Labetalol, Hydralazine. The patient was also noted to have cellulitis on her left knee and was initially maintained on Vancomycin and later changed to Keflex. The patient was also evaluated by Radiation/Oncology, and it was decided that the patient would received a total of seven treatments of whole brain radiation therapy in conjunction with Decadron, as well as Dilantin. During her Intensive Care Unit stay, the patient had increased alertness and was more oriented, although she does have a history of baseline dementia. PAST MEDICAL HISTORY: Metastatic melanoma status post resection in <Year>1905</Year> with recurrence in <Year>1905</Year> status post treatment with Taxol. History of paroxysmal atrial fibrillation with anticoagulation in the past. Status post PCM for sinoatrial dysfunction. History of coronary artery disease status post myocardial infarction in <Year>1905</Year>. MIBI in <Date>1900-4-24</Date> showed an ejection fraction of 50%. History of hypercholesterolemia. History of hypertension, osteoarthritis, cellulitis. Status post skin graft. Peptic ulcer disease. History of bladder cancer. Chronic renal insufficiency. ALLERGIES: AMOXICILLIN, OXACILLIN AND PERCOCET, REACTIONS UNKNOWN. MEDICATIONS ON ADMISSION: Imdur 30 mg, Warfarin, Lasix 20 q.d., Calcium Carbonate 1500 q.d., Vitamin D 4000 q.d., Colace 100 mg b.i.d., Protonix 40 q.d., Dietrol 2 mg b.i.d., Labetalol 300 mg b.i.d., Lipitor 10 mg p.o. q.d. SOCIAL HISTORY: The patient is a home health aide. Husband died three months ago. She walks but recently was unable to do so. She otherwise has a very close family. FAMILY HISTORY: On maternal side there is a history of diabetes, as well as hypertension. PHYSICAL EXAMINATION: Vital signs: Temperature 96.5??????, blood pressure 161/47, pulse 74, respirations 14, oxygen saturation 98% on 2 L, 92% on room air. General: She was elderly, lying in bed. She was sometimes agitated and not following commands. She was nonverbal. HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular movements intact. Dry mucous membranes. There was poor dentition. Neck: Supple. No lymphadenopathy. Heart: Regular, rate and rhythm. There was an early systolic ejection murmur, 3 out of 6. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Good bowel sounds. Extremities: There were bilateral skin eschars. The left knee had excoriation and was erythematous. Neurological: The patient was obtunded and not following commands. She had a limited neurologic exam. Cranial nerves II, III and IV intact. She was moving both hands with appropriate strength. No lifting of left arm off bed. Right lower extremity with decreased strength, apparently chronic secondary to polio. On the left lower extremity, she moved toes and feet. LABORATORY DATA: On admission her white count was 6.4, hematocrit 37.5, platelet count 269, neutrophils 73, 22 lymphs, 3 monos; INR 1.1, PT 12.7, PTT 27.8; sodium 138, potassium 4.3, chloride 106, bicarb 22, BUN 36, creatinine 1.8, baseline 1.4-1.5; platelet count 151; calcium 10.6, magnesium 1.9, phos 3.1, CK 116, MB 5, troponin 0.04; Albumin 4.2; TSH 2.9; urinalysis with occasional bacteria, trace ketones, 30 protein. Electrocardiogram was paced, lateral T-wave inversion, inferior T-wave inversion which new consistent with <Date>1900-4-24</Date>. Head CT showed three moderately large-sized mass lesions in the right posterior frontal, right anterior frontal lobe and left parietal lesion with significant edema. There was a small amount of peripheral density, question of hemorrhage or calcification. Chest x-ray revealed cardiomegaly, atelectasis, but no overt failure. Knee films showed no fracture and no dislocation and degenerative changes with small right knee effusion. HOSPITAL COURSE: 1. Altered mental status: This was felt to be secondary to metastatic disease to the brain. The patient was evaluated by Radiation/Oncology, and it was decided that the patient would receive a total of seven treatments of whole-brain radiation therapy. Additionally she was maintained on Decadron, as well as Dilantin. The patient had no seizure activity while in the hospital. She tolerated her Decadron well and tolerated her whole-brain radiation therapy without any complications. The patient was discharged on a Decadron taper. Her Dilantin dose was increased to a total of 300 three times a day, given that her Dilantin level <Company>Hawkins LLC</Company>.i.d. was only 8. The patient will need her Dilantin level followed as an outpatient at her next appointment. 2. Hypertension: The patient's blood pressures while in the Emergency Room were noted to be 200/100; however, once she was transferred to the floor, she maintained very good control on a combination of Clonidine, Hydrochlorothiazide and Minoxidil, Hydralazine, as well as Labetalol 400 b.i.d. The patient's blood pressures were maintained in the 140s to 160s systolic, and it was decided that this was an appropriate range given that the patient needed to have adequate perfusion in the face of increased intracranial pressure. 3. Cellulitis: The patient was initially maintained on Vancomycin, and this was later changed to Keflex. The patient did not develop any rash or other complications Keflex. Her cellulitis was improved by the time of discharge. 4. Renal insufficiency: Her creatinine remained at baseline between 1.4-1.5. 5. Coronary artery disease: The patient was maintained on enteric coated Aspirin, as well as Labetalol. The patient ruled out for myocardial infarction, and her electrocardiogram remained stable without any EKG changes. 6. FEN: The patient was maintained on a soft diet, as well as thin liquids. She tolerated this without event. Additionally her electrolytes were followed daily and were repleted as needed. Her I&Os were monitored closely. 7. Paroxysmal atrial fibrillation: The patient is paced. She was rate controlled. She was held off all anticoagulation given her metastatic disease to the brain. DISPOSITION: The patient was discharged to her home because her family wanted the patient to do so. The patient has <Date>9-8</Date> full-time nurses that will be following her once she is discharged to home. Her mental status improved greatly while the patient was in the hospital. By the time of discharge, the patient was conversive and much more alert and oriented. Her neurologic exam was significant for intact cranial nerves and the ability to move all extremities spontaneously. She did have limited movement in her arms, given that she has a history of bursitis. Otherwise, the patient's exam neurologically was much improved. CONDITION ON DISCHARGE: Stable. She was stable on room air. She could not ambulate without assistance and does need help with all bed transfers. She was tolerating a p.o. diet without problems. <Name>Marlon Merino</Name> mental status had improved considerably in that she was conversant, could move her extremities spontaneously, and cranial nerves were intact. Her strength was notable for weakness throughout but was symmetric. DISCHARGE DIAGNOSIS: 1. Metastatic melanoma with metastases to the liver, lung and brain. 2. Hypertension. 3. Hypercholesterolemia. 5. Osteoarthritis. 6. Bursitis. 7. Cellulitis. 8. Chronic renal insufficiency. 9. Coronary artery disease. 10. Paroxysmal atrial fibrillation. DISCHARGE STATUS: As stated above, the patient will be discharged to home with <Hospital>Hunter-Lopez Medical Center</Hospital> nursing care. Home Hospice has been discussed with the family, and they would like to avail this possibility as the need arises. DISCHARGE MEDICATIONS: Fluconazole nitrate powder to be applied b.i.d. as needed, Hydrochlorothiazide 25 mg 1 p.o. q.d., Minoxidil 10 mg 1 tab p.o. q.d., Hydralazine 25 mg 3 tab p.o. q.6 hours, Clonodine 0.1 mg 1 tab p.o. t.i.d., Aspirin 325 1 p.o. q.d., Pantoprazole 40 mg 1 p.o. q.d., Keflex 500 mg 1 p.o. q.12 hours for a total of 5 days, Docusate 100 p.o. b.i.d., Phenytoin 300 mg 1 p.o. t.i.d., Dexamethasone taper 8 mg p.o. q.8 hours for 3 days, then 4 mg p.o. t.i.d. for 3 days, then 4 mg p.o. b.i.d. for 3 days, then 2 mg p.o. b.i.d. for 4 days, then 1 mg p.o. b.i.d. for 7 days, then 0.7 mg 1 p.o. b.i.d. for 5 days, then 0.75 mg 1 p.o. b.i.d. for 5 days, then 0.5 mg 1 p.o. b.i.d., then Dexamethasone again 0.25 mg p.o. b.i.d. for 5 days, then Dexamethasone 0.25 mg 1 p.o. q.d. for 5 days, and then stop, Labetalol HCL 200 mg 2 tab b.i.d., Bactrim DS 1 tab p.o. q.d. for UTI prophylaxis. FOLLOW-UP: The patient is to see <Name>Emory Lockett</Name>, RN, at the <Hospital>Cervantes, Robertson and Cobb Medical Center</Hospital> Center on <Date>1961-10-22</Date>, at 2 o'clock. She is to see Dr. <Name>Amit</Name> <Name>Ignacio</Name> at the <Hospital>Cervantes, Robertson and Cobb Medical Center</Hospital> Center on <Date>1961-10-22</Date>, at 3 o'clock. She is to see Dr. <Name>Hall</Name> at the Hematology/Oncology Center at the <Hospital>Cervantes, Robertson and Cobb Medical Center</Hospital> Building on <Date>1-1</Date> at 3 o'clock. <Name>Marti</Name> <Name>Davis</Name>, M.D. <MD Number>12338912</MD Number> Dictated By:<Name>Isaias Dortch</Name> MEDQUIST36 D: <Date>2011-8-15</Date> 10:51 T: <Date>2011-8-15</Date> 11:02 JOB#: <Job Number>Jones-Gilmore-2021-852575</Job Number> 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Date: 1911-5-15 Discharge Date: 2011-8-15 Service: MEDICINE ONCOLOGY HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with a history of metastatic melanoma with known metastases to the liver and lung who status post resection in the 90s with recurrence in 1905 status post treatment with Taxol. She presented to the Emergency Room on 2008-11-28, with altered mental status, decreased p.o. intake, confusion and headache over several weeks, and was found to have three mass lesions in her brain on head CT. The patient was started on Decadron, as well as Dilantin. In the Emergency Room she became hypertensive and was sent to the SICU. She was maintained on Nipride GTT. In the Intensive Care Unit, the patient was weaned off Nipride and then changed to Labetalol, Hydralazine. The patient was also noted to have cellulitis on her left knee and was initially maintained on Vancomycin and later changed to Keflex. The patient was also evaluated by Radiation/Oncology, and it was decided that the patient would received a total of seven treatments of whole brain radiation therapy in conjunction with Decadron, as well as Dilantin. During her Intensive Care Unit stay, the patient had increased alertness and was more oriented, although she does have a history of baseline dementia. PAST MEDICAL HISTORY: Metastatic melanoma status post resection in 1905 with recurrence in 1905 status post treatment with Taxol. History of paroxysmal atrial fibrillation with anticoagulation in the past. Status post PCM for sinoatrial dysfunction. History of coronary artery disease status post myocardial infarction in 1905. MIBI in 1900-4-24 showed an ejection fraction of 50%. History of hypercholesterolemia. History of hypertension, osteoarthritis, cellulitis. Status post skin graft. Peptic ulcer disease. History of bladder cancer. Chronic renal insufficiency. ALLERGIES: AMOXICILLIN, OXACILLIN AND PERCOCET, REACTIONS UNKNOWN. MEDICATIONS ON ADMISSION: Imdur 30 mg, Warfarin, Lasix 20 q.d., Calcium Carbonate 1500 q.d., Vitamin D 4000 q.d., Colace 100 mg b.i.d., Protonix 40 q.d., Dietrol 2 mg b.i.d., Labetalol 300 mg b.i.d., Lipitor 10 mg p.o. q.d. SOCIAL HISTORY: The patient is a home health aide. Husband died three months ago. She walks but recently was unable to do so. She otherwise has a very close family. FAMILY HISTORY: On maternal side there is a history of diabetes, as well as hypertension. PHYSICAL EXAMINATION: Vital signs: Temperature 96.5??????, blood pressure 161/47, pulse 74, respirations 14, oxygen saturation 98% on 2 L, 92% on room air. General: She was elderly, lying in bed. She was sometimes agitated and not following commands. She was nonverbal. HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular movements intact. Dry mucous membranes. There was poor dentition. Neck: Supple. No lymphadenopathy. Heart: Regular, rate and rhythm. There was an early systolic ejection murmur, 3 out of 6. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Good bowel sounds. Extremities: There were bilateral skin eschars. The left knee had excoriation and was erythematous. Neurological: The patient was obtunded and not following commands. She had a limited neurologic exam. Cranial nerves II, III and IV intact. She was moving both hands with appropriate strength. No lifting of left arm off bed. Right lower extremity with decreased strength, apparently chronic secondary to polio. On the left lower extremity, she moved toes and feet. LABORATORY DATA: On admission her white count was 6.4, hematocrit 37.5, platelet count 269, neutrophils 73, 22 lymphs, 3 monos; INR 1.1, PT 12.7, PTT 27.8; sodium 138, potassium 4.3, chloride 106, bicarb 22, BUN 36, creatinine 1.8, baseline 1.4-1.5; platelet count 151; calcium 10.6, magnesium 1.9, phos 3.1, CK 116, MB 5, troponin 0.04; Albumin 4.2; TSH 2.9; urinalysis with occasional bacteria, trace ketones, 30 protein. Electrocardiogram was paced, lateral T-wave inversion, inferior T-wave inversion which new consistent with 1900-4-24. Head CT showed three moderately large-sized mass lesions in the right posterior frontal, right anterior frontal lobe and left parietal lesion with significant edema. There was a small amount of peripheral density, question of hemorrhage or calcification. Chest x-ray revealed cardiomegaly, atelectasis, but no overt failure. Knee films showed no fracture and no dislocation and degenerative changes with small right knee effusion. HOSPITAL COURSE: 1. Altered mental status: This was felt to be secondary to metastatic disease to the brain. The patient was evaluated by Radiation/Oncology, and it was decided that the patient would receive a total of seven treatments of whole-brain radiation therapy. Additionally she was maintained on Decadron, as well as Dilantin. The patient had no seizure activity while in the hospital. She tolerated her Decadron well and tolerated her whole-brain radiation therapy without any complications. The patient was discharged on a Decadron taper. Her Dilantin dose was increased to a total of 300 three times a day, given that her Dilantin level Hawkins LLC.i.d. was only 8. The patient will need her Dilantin level followed as an outpatient at her next appointment. 2. Hypertension: The patient's blood pressures while in the Emergency Room were noted to be 200/100; however, once she was transferred to the floor, she maintained very good control on a combination of Clonidine, Hydrochlorothiazide and Minoxidil, Hydralazine, as well as Labetalol 400 b.i.d. The patient's blood pressures were maintained in the 140s to 160s systolic, and it was decided that this was an appropriate range given that the patient needed to have adequate perfusion in the face of increased intracranial pressure. 3. Cellulitis: The patient was initially maintained on Vancomycin, and this was later changed to Keflex. The patient did not develop any rash or other complications Keflex. Her cellulitis was improved by the time of discharge. 4. Renal insufficiency: Her creatinine remained at baseline between 1.4-1.5. 5. Coronary artery disease: The patient was maintained on enteric coated Aspirin, as well as Labetalol. The patient ruled out for myocardial infarction, and her electrocardiogram remained stable without any EKG changes. 6. FEN: The patient was maintained on a soft diet, as well as thin liquids. She tolerated this without event. Additionally her electrolytes were followed daily and were repleted as needed. Her I&Os were monitored closely. 7. Paroxysmal atrial fibrillation: The patient is paced. She was rate controlled. She was held off all anticoagulation given her metastatic disease to the brain. DISPOSITION: The patient was discharged to her home because her family wanted the patient to do so. The patient has 9-8 full-time nurses that will be following her once she is discharged to home. Her mental status improved greatly while the patient was in the hospital. By the time of discharge, the patient was conversive and much more alert and oriented. Her neurologic exam was significant for intact cranial nerves and the ability to move all extremities spontaneously. She did have limited movement in her arms, given that she has a history of bursitis. Otherwise, the patient's exam neurologically was much improved. CONDITION ON DISCHARGE: Stable. She was stable on room air. She could not ambulate without assistance and does need help with all bed transfers. She was tolerating a p.o. diet without problems. Marlon Merino mental status had improved considerably in that she was conversant, could move her extremities spontaneously, and cranial nerves were intact. Her strength was notable for weakness throughout but was symmetric. DISCHARGE DIAGNOSIS: 1. Metastatic melanoma with metastases to the liver, lung and brain. 2. Hypertension. 3. Hypercholesterolemia. 5. Osteoarthritis. 6. Bursitis. 7. Cellulitis. 8. Chronic renal insufficiency. 9. Coronary artery disease. 10. Paroxysmal atrial fibrillation. DISCHARGE STATUS: As stated above, the patient will be discharged to home with Hunter-Lopez Medical Center nursing care. Home Hospice has been discussed with the family, and they would like to avail this possibility as the need arises. DISCHARGE MEDICATIONS: Fluconazole nitrate powder to be applied b.i.d. as needed, Hydrochlorothiazide 25 mg 1 p.o. q.d., Minoxidil 10 mg 1 tab p.o. q.d., Hydralazine 25 mg 3 tab p.o. q.6 hours, Clonodine 0.1 mg 1 tab p.o. t.i.d., Aspirin 325 1 p.o. q.d., Pantoprazole 40 mg 1 p.o. q.d., Keflex 500 mg 1 p.o. q.12 hours for a total of 5 days, Docusate 100 p.o. b.i.d., Phenytoin 300 mg 1 p.o. t.i.d., Dexamethasone taper 8 mg p.o. q.8 hours for 3 days, then 4 mg p.o. t.i.d. for 3 days, then 4 mg p.o. b.i.d. for 3 days, then 2 mg p.o. b.i.d. for 4 days, then 1 mg p.o. b.i.d. for 7 days, then 0.7 mg 1 p.o. b.i.d. for 5 days, then 0.75 mg 1 p.o. b.i.d. for 5 days, then 0.5 mg 1 p.o. b.i.d., then Dexamethasone again 0.25 mg p.o. b.i.d. for 5 days, then Dexamethasone 0.25 mg 1 p.o. q.d. for 5 days, and then stop, Labetalol HCL 200 mg 2 tab b.i.d., Bactrim DS 1 tab p.o. q.d. for UTI prophylaxis. FOLLOW-UP: The patient is to see Emory Lockett, RN, at the Cervantes, Robertson and Cobb Medical Center Center on 1961-10-22, at 2 o'clock. She is to see Dr. Amit Ignacio at the Cervantes, Robertson and Cobb Medical Center Center on 1961-10-22, at 3 o'clock. She is to see Dr. Hall at the Hematology/Oncology Center at the Cervantes, Robertson and Cobb Medical Center Building on 1-1 at 3 o'clock. Marti Davis, M.D. 12338912 Dictated By:Isaias Dortch MEDQUIST36 D: 2011-8-15 10:51 T: 2011-8-15 11:02 JOB#: Jones-Gilmore-2021-852575 cc:Deng	['Admission Date: 1911-5-15 Discharge Date: 2011-8-15\n\n\nService: MEDICINE ONCOLOGY\n\nHISTORY OF PRESENT ILLNESS: This is an 81-year-old female\nwith a history of metastatic melanoma with known metastases\nto the liver and lung who status post resection in the 90s\nwith recurrence in 1905 status post treatment with Taxol.\n\nShe presented to the Emergency Room on 2008-11-28,\nwith altered mental status, decreased p.o. intake, confusion\nand headache over several weeks, and was found to have three\nmass lesions in her brain on head CT.\n\nThe patient was started on Decadron, as well as Dilantin. In\nthe Emergency Room she became hypertensive and was sent to\nthe SICU. She was maintained on Nipride GTT.\n\nIn the Intensive Care Unit, the patient was weaned off\nNipride and then changed to Labetalol, Hydralazine.', ' The patient\nwas also noted to have cellulitis on her left knee and was\ninitially maintained on Vancomycin and later changed to Keflex.\n\nThe patient was also evaluated by Radiation/Oncology, and it\nwas decided that the patient would received a total of seven\ntreatments of whole brain radiation therapy in conjunction\nwith Decadron, as well as Dilantin.\n\nDuring her Intensive Care Unit stay, the patient had\nincreased alertness and was more oriented, although she does\nhave a history of baseline dementia.\n\nPAST MEDICAL HISTORY: Metastatic melanoma status post\nresection in 1905 with recurrence in 1905 status post\ntreatment with Taxol. History of paroxysmal atrial\nfibrillation with anticoagulation in the past. Status post\nPCM for sinoatrial dysfunction. History of coronary artery\ndisease status post myocardial infarction in 1905.', ' MIBI in\n1900-4-24 showed an ejection fraction of 50%. History of\nhypercholesterolemia. History of hypertension,\nosteoarthritis, cellulitis. Status post skin graft. Peptic\nulcer disease. History of bladder cancer. Chronic renal\ninsufficiency.\n\nALLERGIES: AMOXICILLIN, OXACILLIN AND PERCOCET, REACTIONS\nUNKNOWN.\n\nMEDICATIONS ON ADMISSION: Imdur 30 mg, Warfarin, Lasix 20\nq.d., Calcium Carbonate 1500 q.d., Vitamin D 4000 q.d.,\nColace 100 mg b.i.d., Protonix 40 q.d., Dietrol 2 mg b.i.d.,\nLabetalol 300 mg b.i.d., Lipitor 10 mg p.o. q.d.\n\nSOCIAL HISTORY: The patient is a home health aide. Husband\ndied three months ago. She walks but recently was unable to\ndo so. She otherwise has a very close family.\n\nFAMILY HISTORY: On maternal side there is a history of\ndiabetes, as well as hypertension.', '\n\nPHYSICAL EXAMINATION: Vital signs: Temperature 96.5??????, blood\npressure 161/47, pulse 74, respirations 14, oxygen saturation\n98% on 2 L, 92% on room air. General: She was elderly,\nlying in bed. She was sometimes agitated and not following\ncommands. She was nonverbal. HEENT: Normocephalic,\natraumatic. Pupils equal, round and reactive to light.\nExtraocular movements intact. Dry mucous membranes. There\nwas poor dentition. Neck: Supple. No lymphadenopathy.\nHeart: Regular, rate and rhythm. There was an early\nsystolic ejection murmur, 3 out of 6. Lungs: Clear to\nauscultation bilaterally. Abdomen: Soft, nontender,\nnondistended. Good bowel sounds. Extremities: There were\nbilateral skin eschars. The left knee had excoriation and\nwas erythematous. Neurological: The patient was obtunded\nand not following commands.', ' She had a limited neurologic\nexam. Cranial nerves II, III and IV intact. She was moving\nboth hands with appropriate strength. No lifting of left arm\noff bed. Right lower extremity with decreased strength,\napparently chronic secondary to polio. On the left lower\nextremity, she moved toes and feet.\n\nLABORATORY DATA: On admission her white count was 6.4,\nhematocrit 37.5, platelet count 269, neutrophils 73, 22\nlymphs, 3 monos; INR 1.1, PT 12.7, PTT 27.8; sodium 138,\npotassium 4.3, chloride 106, bicarb 22, BUN 36, creatinine\n1.8, baseline 1.4-1.5; platelet count 151; calcium 10.6,\nmagnesium 1.9, phos 3.1, CK 116, MB 5, troponin 0.04; Albumin\n4.2; TSH 2.9; urinalysis with occasional bacteria, trace\nketones, 30 protein.\n\nElectrocardiogram was paced, lateral T-wave inversion,\ninferior T-wave inversion which new consistent with 1900-4-24.', '\n\nHead CT showed three moderately large-sized mass lesions in\nthe right posterior frontal, right anterior frontal lobe and\nleft parietal lesion with significant edema. There was a\nsmall amount of peripheral density, question of hemorrhage or\ncalcification.\n\nChest x-ray revealed cardiomegaly, atelectasis, but no overt\nfailure.\n\nKnee films showed no fracture and no dislocation and\ndegenerative changes with small right knee effusion.\n\nHOSPITAL COURSE: 1. Altered mental status: This was felt\nto be secondary to metastatic disease to the brain. The\npatient was evaluated by Radiation/Oncology, and it was\ndecided that the patient would receive a total of seven\ntreatments of whole-brain radiation therapy.\n\nAdditionally she was maintained on Decadron, as well as\nDilantin. The patient had no seizure activity while in the\nhospital.', " She tolerated her Decadron well and tolerated her\nwhole-brain radiation therapy without any complications.\n\nThe patient was discharged on a Decadron taper. Her Dilantin\ndose was increased to a total of 300 three times a day, given\nthat her Dilantin level Hawkins LLC.i.d. was only 8. The\npatient will need her Dilantin level followed as an\noutpatient at her next appointment.\n\n2. Hypertension: The patient's blood pressures while in the\nEmergency Room were noted to be 200/100; however, once she\nwas transferred to the floor, she maintained very good\ncontrol on a combination of Clonidine, Hydrochlorothiazide\nand Minoxidil, Hydralazine, as well as Labetalol 400 b.i.d.\nThe patient's blood pressures were maintained in the 140s to\n160s systolic, and it was decided that this was an\nappropriate range given that the patient needed to have\nadequate perfusion in the face of increased\nintracranial pressure.", '\n\n3. Cellulitis: The patient was initially maintained on\nVancomycin, and this was later changed to Keflex. The\npatient did not develop any rash or other complications\nKeflex. Her cellulitis was improved by the time of\ndischarge.\n\n4. Renal insufficiency: Her creatinine remained at baseline\nbetween 1.4-1.5.\n\n5. Coronary artery disease: The patient was maintained on\nenteric coated Aspirin, as well as Labetalol. The patient\nruled out for myocardial infarction, and her\nelectrocardiogram remained stable without any EKG changes.\n\n6. FEN: The patient was maintained on a soft diet, as well\nas thin liquids. She tolerated this without event.\nAdditionally her electrolytes were followed daily and were\nrepleted as needed. Her I&Os were monitored closely.\n\n7. Paroxysmal atrial fibrillation: The patient is paced.', "\nShe was rate controlled. She was held off all\nanticoagulation given her metastatic disease to the brain.\n\nDISPOSITION: The patient was discharged to her home because\nher family wanted the patient to do so. The patient has 9-8\nfull-time nurses that will be following her once she is\ndischarged to home. Her mental status improved greatly while\nthe patient was in the hospital. By the time of discharge,\nthe patient was conversive and much more alert and oriented.\n\nHer neurologic exam was significant for intact cranial nerves\nand the ability to move all extremities spontaneously. She\ndid have limited movement in her arms, given that she has a\nhistory of bursitis. Otherwise, the patient's exam\nneurologically was much improved.\n\nCONDITION ON DISCHARGE: Stable. She was stable on room air.\nShe could not ambulate without assistance and does need help\nwith all bed transfers.", ' She was tolerating a p.o. diet\nwithout problems. Marlon Merino mental status had improved\nconsiderably in that she was conversant, could move her\nextremities spontaneously, and cranial nerves were intact.\nHer strength was notable for weakness throughout but was\nsymmetric.\n\nDISCHARGE DIAGNOSIS:\n1. Metastatic melanoma with metastases to the liver, lung\nand brain.\n2. Hypertension.\n3. Hypercholesterolemia.\n5. Osteoarthritis.\n6. Bursitis.\n7. Cellulitis.\n8. Chronic renal insufficiency.\n9. Coronary artery disease.\n10. Paroxysmal atrial fibrillation.\n\nDISCHARGE STATUS: As stated above, the patient will be\ndischarged to home with Hunter-Lopez Medical Center nursing care. Home Hospice\nhas been discussed with the family, and they would like to\navail this possibility as the need arises.\n\nDISCHARGE MEDICATIONS: Fluconazole nitrate powder to be\napplied b.', 'i.d. as needed, Hydrochlorothiazide 25 mg 1 p.o.\nq.d., Minoxidil 10 mg 1 tab p.o. q.d., Hydralazine 25 mg 3\ntab p.o. q.6 hours, Clonodine 0.1 mg 1 tab p.o. t.i.d.,\nAspirin 325 1 p.o. q.d., Pantoprazole 40 mg 1 p.o. q.d.,\nKeflex 500 mg 1 p.o. q.12 hours for a total of 5 days,\nDocusate 100 p.o. b.i.d., Phenytoin 300 mg 1 p.o. t.i.d.,\nDexamethasone taper 8 mg p.o. q.8 hours for 3 days, then 4 mg\np.o. t.i.d. for 3 days, then 4 mg p.o. b.i.d. for 3 days,\nthen 2 mg p.o. b.i.d. for 4 days, then 1 mg p.o. b.i.d. for 7\ndays, then 0.7 mg 1 p.o. b.i.d. for 5 days, then 0.75 mg 1\np.o. b.i.d. for 5 days, then 0.5 mg 1 p.o. b.i.d., then\nDexamethasone again 0.25 mg p.o. b.i.d. for 5 days, then\nDexamethasone 0.25 mg 1 p.o. q.d. for 5 days, and then stop,\nLabetalol HCL 200 mg 2 tab b.i.d., Bactrim DS 1 tab p.', "o. q.d.\nfor UTI prophylaxis.\n\nFOLLOW-UP: The patient is to see Emory Lockett, RN, at the Cervantes, Robertson and Cobb Medical Center\nCenter on 1961-10-22, at 2 o'clock. She is to see Dr.\nAmit Ignacio at the Cervantes, Robertson and Cobb Medical Center Center on 1961-10-22,\nat 3 o'clock. She is to see Dr. Hall at the\nHematology/Oncology Center at the Cervantes, Robertson and Cobb Medical Center Building on\n1-1 at 3 o'clock.\n\n\n\n\n Marti Davis, M.D. 12338912\n\nDictated By:Isaias Dortch\nMEDQUIST36\n\nD: 2011-8-15 10:51\nT: 2011-8-15 11:02\nJOB#: Jones-Gilmore-2021-852575\n\ncc:Deng"]
228	79900	120644.0	2194-07-25	Discharge summary	Report	Admission Date: [2194-7-18] Discharge Date: [2194-7-25] Date of Birth: [2123-12-24] Sex: F Service: MEDICINE Allergies: Atorvastatin / Penicillins / Codeine Attending:[First Name3 (LF) 2265] Chief Complaint: SOB, decreased urine Major Surgical or Invasive Procedure: Hemodialysis Placement of a R IJ catheter Placement of a R subclavian tunneled dialysis line History of Present Illness: Ms. [Known lastname 2251] is a 70yoF with h/o dilated cardiomyopathy [1-1] aortic outflow obstruction, AICD s/p VT, CAD, COPD (on home O2) who presented with decreased UO and SOB, now transferred from medicine service to CCU for hypotension. Pt is currently somnolent and unable to provide a detailed history, so details are obtained from OMR and Atrius records. Pt saw NP in complex care clinic on [7-10], at that time felt well overall, c/o dry cough but denied SOB, peripheral edema. At that time her weight was recorded at 185 lbs (dry weight is estimated at 184 lbs). On [7-17] she called the CCC office c/o minimal urine output ("only drops") and cough productive of yellow sputum. She reported compliance with her home diuretic regimen, but [Name8 (MD) ] NP note she had not filled her aldactone rx. . On DOA, she called EMS due to increasing SOB. When EMS arrived her SBP was 80. She received 250cc NS and was brought to ED. In ED she had SBP 90s so received another 500cc NS bolus. CXR showed no e/o infiltrate but she was treated empirically for CAP with 1g ceftriaxone given her recent productive cough. Labs were significant for Na 121 and Cr 5.4 (baseline 3.5-4.0). She was admitted to medicine service. On the floor, her BP was initially 98/65 but then decreased to SBP 70s. She was transferred to CCU for pressor support. . On transfer, vitals were T 95.7, HR 60 (v-paced), BP 110/56, RR 18, O2sat 100% on 2LNC. She was drowsy, but denied current SOB, chest pain, palpitations, LE swelling. She endorsed orthopnea (c/w baseline) cough productive of yellow sputum, nausea, RUQ discomfort, and anuria. Denied recent fevers/chills, diarrhea/constipation, melena/hematochezia, BRBPR. . Of note she was admitted 1 month ago (from [Date range (1) 2266]) for CHF exacerbation and hypervolemia. She was started on a lasix drip with metolazone but was ultimately started on ultrafiltration with a tunneled HD line which she tolerated well. She has not required outpatient HD since discharge. Past Medical History: 1. CARDIAC RISK FACTORS: +Hypertension, +HLD 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: [Company 2267] Cognis 100-D Dual chamber-ICD, implanted [2193-4-1] -CARDIOMYOPATHY, HYPERTROPHIC OBSTRUCTIVE (EF 35%) -ATRIAL FIBRILLATION on coumadin -CORONARY ARTERY DISEASE - NATIVE CORONARY ARTERY -VENTRICULAR TACHYCARDIA s/p AICD placement -HEART FAILURE - SYSTOLIC & DIASTOLIC, CHRONIC 3. OTHER PAST MEDICAL HISTORY: ?????? COPD ?????? PSORIASIS ?????? GOUT ?????? RHINITIS - ALLERGIC ?????? HYPOKALEMIA in the past ?????? ANEMIA, normocytic ?????? KIDNEY DISEASE - CHRONIC STAGE III (MODERATE) ?????? OBESITY ?????? Unspecified cataract ?????? Colon polyps ?????? Diverticulosis of colon with hemorrhage Social History: Lives alone in [Location (un) 2268], but has stayed with her sister recently [1-1] difficulty walking up stairs to her apt. Remote smoking and EtOH history, pt unable to quantify. Denies IVDU. Family History: Non-contributory. Physical Exam: ADMISSION EXAM: GENERAL: Fatigued-appearing elderly female, breathing comfortably on NC. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. NECK: Supple with JVP 12cm (to jaw). CARDIAC: Distant heart sounds, RRR, II/VI HSM at LLS border. LUNGS: Resp unlabored, no accessory muscle use. Bibasilar crackles, R>L. ABDOMEN: Soft, distended, TTP at RUQ with pulsatile liver. No abdominial bruits. EXTREMITIES: No c/c/e. +bulla on anterior LE. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ . DISCHARGE EXAM Pertinent Results: Admission Labs [2194-7-17] 11:30PM WBC-5.0 RBC-3.46* HGB-10.3* HCT-30.3* MCV-87# MCH-29.7 MCHC-34.0 RDW-18.5* [2194-7-17] 11:30PM PLT COUNT-100* [2194-7-17] 11:30PM PT-21.6* PTT-34.3 INR(PT)-2.0* [2194-7-17] 11:30PM TSH-14* [2194-7-17] 11:30PM proBNP-8699* [2194-7-17] 11:30PM UREA N-105* CREAT-5.4# SODIUM-121 POTASSIUM-3.4 CHLORIDE-77* TOTAL CO2-27 ANION GAP-20 [2194-7-17] 11:38PM LACTATE-1.5 [2194-7-18] 12:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-NEG [2194-7-18] 03:03AM URINE OSMOLAL-276 [2194-7-18] 03:03AM URINE HOURS-RANDOM UREA N-265 CREAT-152 SODIUM-LESS THAN POTASSIUM-54 CHLORIDE-17 [2194-7-18] 04:09PM CK-MB-4 cTropnT-0.17* [2194-7-18] 04:09PM CK(CPK)-66 . Pertinent Studies ECHO [5-/2194]: The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) with regional variation, the apical segments more hypokinetic than the basal segments. The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with borderline normal free wall function. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-1]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is no pericardial effusion. . CXR [2194-7-18]: There is a left-sided pacemaker/ICD with right atrial and right ventricular leads, as before. Severe cardiomegaly is not significantly changed. Pulmonary venous congestion is seen without definite interstitial pulmonary edema. No focal consolidations are seen. There are no pleural effusions. No pneumothorax is seen. There is minimal right basilar atelectasis. . HD Labs: - Iron studies: Iron Binding Capacity, Total 433 (nl 260 - 470 ug/dL) Ferritin 29 (nl 13 - 150 ng/mL) Transferrin 333 (nl 200 - 360 mg/dL) - PPD: negative . Discharge Labs: Brief Hospital Course: Primary Reason for Admission 70yoF with h/o dilated cardiomyopathy (EF 35%), AICD p/w SOB and poor urine output for several days found to have hyponatremia, now transferred from medicine to CCU due to hypotension. . Active Issues: . #Acute on chronic systolic heart failure: The patient was hypervolemic on exam with elevated JVP and increased abdominal distension at presentation. Given the patient had been refractory to diuretic therapy requiring ultrafiltration during her last hospitalization and was oliguric and hyponatremic on admission, ultrafiltration was initiated rather than diuretic therapy. She experienced significant muscle cramping and hypotension while on CVVHD requiring dopamine. CVVHD was discontinued on HD#2 and she was diuresed with IV lasix and metolazone. Pressures improved and she was weaned off of dopamine. It was noted that urine and blood pressure improved when the patient was in her native sinus rhythm with asynchronous ventricular pacing. Therefore the patients pacemaker escape rate was lowered to allow for increased native rhythm and the mode was changed to AAIR. Despite this change urine output remained poor and she was therefore started on a lasix drip ultimately requiring milrinone to augment diuresis. On HD#6 patient underwent placement of a tunneled dialysis catheter, and on HD#7 she continued HD using the tunneled line (see below). Lasix and metolazone were discontinued as patient will be HD dependent. . #Hypotension: Patient was hypotensive on admission in the setting of volume overload. Her hypotension was believed to be due to worsening cardiac output in setting of dilated cardiomyopathy. She was temporarily on a dopamine gtt, but this was weaned by HD#2. In addition, she experienced episodes of hypotension with CVVH with diuresis and antihypertensive medications, so her antihypertensive medications were held. On discharge, her BP was stable. She was asked to continue to hold her carvedilol and to follow up with her PCP about restarting as tolerated. . # Hyponatremia: Pts sodium was 119 on admission and likely cause of her AMS, thought to be hypervolemic hyponatremia with poor renal perfusion given e/o volume overload on exam and low urine Na. Her fluid intake was restricted to 1.5L daily, and she started CVVH as above with improvement in her hyponatremia as well as her mental status. At the time of discharge her sodium was 135. . # Acute on chronic renal failure: Patient was noted to have a creat of 5.4, baseline 3.5-4.0, and oliguria x 2-3 days on admission. As stated above she had previously required ultrafiltration during hospitalizations for heart failure exacerbation. Renal was consulted and felt that the patient would require chronic HD. Given her hypotension she was initally started on CVVH with dopamine gtt for pressure support. However as above she did not tolerate CVVH and it was discontinued. She was diuresed with lasix gtt and milrinone as above until she had her tunneled line placed on HD#6. She tolerated HD well, with stable BP and no muscle cramping. Outpatient dialysis was arranged with [Location (un) ] [Location (un) ] Dialysis Center for mondays, wednesdays and fridays. . # Afib: Pt has a history of atrial fibrillation on coumadin at home. On admission her coumadin was held in preparation for placement of a tunneled dialysis catheter. As stated above her pacemaker settings were changed and she was in sinus rhythm for most of her CCU course with heart rates in the 50-70s. Her mode was changed to AAIR to allow for intrinsice AV conduction and minimize ventricular pacing in an abnormal heart. Her coumadin was restarted at her home dose on HD#7. Her INR at the time of discharge was 1.4. # Stable issues: . # COPD: Patient's recent cough and SOB with h/o COPD was initially c/f COPD exacerbation, and she was initially started on prednisone and levofloxacin. However there was no wheezing on exam therefore prednisone and antibiotics were discontinued. She was continued on her home albuterol/ipratropium nebulizer treatments, and maintained O2 sats >90% on 2L NC (her baseline O2 requirement). . # CAD: Stable, no c/o chest pain during hospitalization. She was continued on her home ASA and pravastatin. . # HTN: Carvedilol was discontinued due to frequent episodes of hypotension (with SBP 70s-80s). She can resume as an outpatient if BP tolerates. . # Gout: Patient was continued on her home allopurinol and did not have any pain concerning for a gout flare. . # Transitional issues: - Patient maintained full code status throughout hospitalization. - She will continue outpatient hemodialysis at [Location (un) ] [Location (un) ] Dialysis Center - She has follow-up scheduled with her PCP and her cardiologist. She will be contact[Name (NI) ] regarding a follow-up appointment with the device clinic in 3 months. Medications on Admission: 1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Insomnia. 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): Start on [2194-7-2]. 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath. 5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 6. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain up to 3x q 5 minutes. 11. Outpatient Lab Work Please check INR and Chem 10 on [2194-7-3] and [2194-7-7]. Please fax results to: PCP [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 2253] (fax # [Telephone/Fax (1) 2254]) 12. furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 14. spironolactone 25 mg Tablet Sig: 0.25 Tablet PO EVERY OTHER DAY (Every Other Day). Disp:4 Tablet(s) Refills:0 15. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:30 Tablet, Chewable(s) Refills:2 17. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 11. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. 12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every five minutes up to 3 times as needed as needed for chest pain. 13. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 14. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID:prn as needed for constipation. Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Chronic Renal Failure Acute on Chronic systolic CHF Atrial Fibrillation Coronary Artery Disease Chronic Obstructive Pulmonary Disease Hypertension Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to the hospital for shortness of breath and not making urine. Your heart was not pumping well which caused you to have extra fluid. We gave you medication to help you to urinate out this fluid however your kidneys were not working properly and you needed dialysis to do the job of your kidneys. You got a special IV to be used for dialysis. You will need to continue going to dialysis three times a week. Your blood pressure was also so low so we did not give you your home blood pressure medications while you were in the hospital. You should continue to go to dialysis three times a week. You were also started on a medication called nephrocaps that you will need to continue. You should stop taking your carvedilol, metolazone, spironolactone and lasix unless your doctor instructs you to restart these medications. Continue your coumadin and amiodarone for your abnormal heart rhythm (atrial fibrillation). Continue your aspirin and pravastatin for your heart disease, your allopurinol for your gout, your albuterol and ipratropium for your COPD. Followup Instructions: Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2269],MD Specialty: Internal Medicine When: Thursday [7-31] at 3:30p Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 2261] Name: [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) 2271], NP Specialty: Cardiology When: Tuesday [8-5] at 2pm Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2258] Please call the Device Clinic in the cardiology department at [Hospital1 69] to schedule an appointment in 3 months. You can call [Telephone/Fax (1) 2272] to schedule. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2273]	Admission Date: <Date>1987-4-2</Date> Discharge Date: <Date>1970-9-10</Date> Date of Birth: <Date>2017-4-30</Date> Sex: F Service: MEDICINE Allergies: Atorvastatin / Penicillins / Codeine Attending:<Name>Latrice</Name> Chief Complaint: SOB, decreased urine Major Surgical or Invasive Procedure: Hemodialysis Placement of a R IJ catheter Placement of a R subclavian tunneled dialysis line History of Present Illness: Ms. <Name>Ivory</Name> is a 70yoF with h/o dilated cardiomyopathy <Date>1-15</Date> aortic outflow obstruction, AICD s/p VT, CAD, COPD (on home O2) who presented with decreased UO and SOB, now transferred from medicine service to CCU for hypotension. Pt is currently somnolent and unable to provide a detailed history, so details are obtained from OMR and Atrius records. Pt saw NP in complex care clinic on <Date>6-23</Date>, at that time felt well overall, c/o dry cough but denied SOB, peripheral edema. At that time her weight was recorded at 185 lbs (dry weight is estimated at 184 lbs). On <Date>3-21</Date> she called the CCC office c/o minimal urine output ("only drops") and cough productive of yellow sputum. She reported compliance with her home diuretic regimen, but <Name>Joyce Anderson</Name> NP note she had not filled her aldactone rx. . On DOA, she called EMS due to increasing SOB. When EMS arrived her SBP was 80. She received 250cc NS and was brought to ED. In ED she had SBP 90s so received another 500cc NS bolus. CXR showed no e/o infiltrate but she was treated empirically for CAP with 1g ceftriaxone given her recent productive cough. Labs were significant for Na 121 and Cr 5.4 (baseline 3.5-4.0). She was admitted to medicine service. On the floor, her BP was initially 98/65 but then decreased to SBP 70s. She was transferred to CCU for pressor support. . On transfer, vitals were T 95.7, HR 60 (v-paced), BP 110/56, RR 18, O2sat 100% on 2LNC. She was drowsy, but denied current SOB, chest pain, palpitations, LE swelling. She endorsed orthopnea (c/w baseline) cough productive of yellow sputum, nausea, RUQ discomfort, and anuria. Denied recent fevers/chills, diarrhea/constipation, melena/hematochezia, BRBPR. . Of note she was admitted 1 month ago (from <Date Range>1914-9-1 to 1975-10-2</Date Range>) for CHF exacerbation and hypervolemia. She was started on a lasix drip with metolazone but was ultimately started on ultrafiltration with a tunneled HD line which she tolerated well. She has not required outpatient HD since discharge. Past Medical History: 1. CARDIAC RISK FACTORS: +Hypertension, +HLD 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: <Company>Cisneros-Vega</Company> Cognis 100-D Dual chamber-ICD, implanted <Date>1966-12-1</Date> -CARDIOMYOPATHY, HYPERTROPHIC OBSTRUCTIVE (EF 35%) -ATRIAL FIBRILLATION on coumadin -CORONARY ARTERY DISEASE - NATIVE CORONARY ARTERY -VENTRICULAR TACHYCARDIA s/p AICD placement -HEART FAILURE - SYSTOLIC & DIASTOLIC, CHRONIC 3. OTHER PAST MEDICAL HISTORY: ?????? COPD ?????? PSORIASIS ?????? GOUT ?????? RHINITIS - ALLERGIC ?????? HYPOKALEMIA in the past ?????? ANEMIA, normocytic ?????? KIDNEY DISEASE - CHRONIC STAGE III (MODERATE) ?????? OBESITY ?????? Unspecified cataract ?????? Colon polyps ?????? Diverticulosis of colon with hemorrhage Social History: Lives alone in <Location>741 Jason Island South Diane, AR 46844</Location>, but has stayed with her sister recently <Date>1-15</Date> difficulty walking up stairs to her apt. Remote smoking and EtOH history, pt unable to quantify. Denies IVDU. Family History: Non-contributory. Physical Exam: ADMISSION EXAM: GENERAL: Fatigued-appearing elderly female, breathing comfortably on NC. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. NECK: Supple with JVP 12cm (to jaw). CARDIAC: Distant heart sounds, RRR, II/VI HSM at LLS border. LUNGS: Resp unlabored, no accessory muscle use. Bibasilar crackles, R>L. ABDOMEN: Soft, distended, TTP at RUQ with pulsatile liver. No abdominial bruits. EXTREMITIES: No c/c/e. +bulla on anterior LE. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ . DISCHARGE EXAM Pertinent Results: Admission Labs <Date>1942-7-27</Date> 11:30PM WBC-5.0 RBC-3.46* HGB-10.3* HCT-30.3* MCV-87# MCH-29.7 MCHC-34.0 RDW-18.5* <Date>1942-7-27</Date> 11:30PM PLT COUNT-100* <Date>1942-7-27</Date> 11:30PM PT-21.6* PTT-34.3 INR(PT)-2.0* <Date>1942-7-27</Date> 11:30PM TSH-14* <Date>1942-7-27</Date> 11:30PM proBNP-8699* <Date>1942-7-27</Date> 11:30PM UREA N-105* CREAT-5.4# SODIUM-121 POTASSIUM-3.4 CHLORIDE-77* TOTAL CO2-27 ANION GAP-20 <Date>1942-7-27</Date> 11:38PM LACTATE-1.5 <Date>1987-4-2</Date> 12:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-NEG <Date>1987-4-2</Date> 03:03AM URINE OSMOLAL-276 <Date>1987-4-2</Date> 03:03AM URINE HOURS-RANDOM UREA N-265 CREAT-152 SODIUM-LESS THAN POTASSIUM-54 CHLORIDE-17 <Date>1987-4-2</Date> 04:09PM CK-MB-4 cTropnT-0.17* <Date>1987-4-2</Date> 04:09PM CK(CPK)-66 . Pertinent Studies ECHO <Date>9-1957</Date>: The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) with regional variation, the apical segments more hypokinetic than the basal segments. The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with borderline normal free wall function. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate (<Date>3-12</Date>+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is no pericardial effusion. . CXR <Date>1987-4-2</Date>: There is a left-sided pacemaker/ICD with right atrial and right ventricular leads, as before. Severe cardiomegaly is not significantly changed. Pulmonary venous congestion is seen without definite interstitial pulmonary edema. No focal consolidations are seen. There are no pleural effusions. No pneumothorax is seen. There is minimal right basilar atelectasis. . HD Labs: - Iron studies: Iron Binding Capacity, Total 433 (nl 260 - 470 ug/dL) Ferritin 29 (nl 13 - 150 ng/mL) Transferrin 333 (nl 200 - 360 mg/dL) - PPD: negative . Discharge Labs: Brief Hospital Course: Primary Reason for Admission 70yoF with h/o dilated cardiomyopathy (EF 35%), AICD p/w SOB and poor urine output for several days found to have hyponatremia, now transferred from medicine to CCU due to hypotension. . Active Issues: . #Acute on chronic systolic heart failure: The patient was hypervolemic on exam with elevated JVP and increased abdominal distension at presentation. Given the patient had been refractory to diuretic therapy requiring ultrafiltration during her last hospitalization and was oliguric and hyponatremic on admission, ultrafiltration was initiated rather than diuretic therapy. She experienced significant muscle cramping and hypotension while on CVVHD requiring dopamine. CVVHD was discontinued on HD#2 and she was diuresed with IV lasix and metolazone. Pressures improved and she was weaned off of dopamine. It was noted that urine and blood pressure improved when the patient was in her native sinus rhythm with asynchronous ventricular pacing. Therefore the patients pacemaker escape rate was lowered to allow for increased native rhythm and the mode was changed to AAIR. Despite this change urine output remained poor and she was therefore started on a lasix drip ultimately requiring milrinone to augment diuresis. On HD#6 patient underwent placement of a tunneled dialysis catheter, and on HD#7 she continued HD using the tunneled line (see below). Lasix and metolazone were discontinued as patient will be HD dependent. . #Hypotension: Patient was hypotensive on admission in the setting of volume overload. Her hypotension was believed to be due to worsening cardiac output in setting of dilated cardiomyopathy. She was temporarily on a dopamine gtt, but this was weaned by HD#2. In addition, she experienced episodes of hypotension with CVVH with diuresis and antihypertensive medications, so her antihypertensive medications were held. On discharge, her BP was stable. She was asked to continue to hold her carvedilol and to follow up with her PCP about restarting as tolerated. . # Hyponatremia: Pts sodium was 119 on admission and likely cause of her AMS, thought to be hypervolemic hyponatremia with poor renal perfusion given e/o volume overload on exam and low urine Na. Her fluid intake was restricted to 1.5L daily, and she started CVVH as above with improvement in her hyponatremia as well as her mental status. At the time of discharge her sodium was 135. . # Acute on chronic renal failure: Patient was noted to have a creat of 5.4, baseline 3.5-4.0, and oliguria x 2-3 days on admission. As stated above she had previously required ultrafiltration during hospitalizations for heart failure exacerbation. Renal was consulted and felt that the patient would require chronic HD. Given her hypotension she was initally started on CVVH with dopamine gtt for pressure support. However as above she did not tolerate CVVH and it was discontinued. She was diuresed with lasix gtt and milrinone as above until she had her tunneled line placed on HD#6. She tolerated HD well, with stable BP and no muscle cramping. Outpatient dialysis was arranged with <Location>43902 Carrie Route Apt. 677 East Aprilport, CA 59906</Location> <Location>43902 Carrie Route Apt. 677 East Aprilport, CA 59906</Location> Dialysis Center for mondays, wednesdays and fridays. . # Afib: Pt has a history of atrial fibrillation on coumadin at home. On admission her coumadin was held in preparation for placement of a tunneled dialysis catheter. As stated above her pacemaker settings were changed and she was in sinus rhythm for most of her CCU course with heart rates in the 50-70s. Her mode was changed to AAIR to allow for intrinsice AV conduction and minimize ventricular pacing in an abnormal heart. Her coumadin was restarted at her home dose on HD#7. Her INR at the time of discharge was 1.4. # Stable issues: . # COPD: Patient's recent cough and SOB with h/o COPD was initially c/f COPD exacerbation, and she was initially started on prednisone and levofloxacin. However there was no wheezing on exam therefore prednisone and antibiotics were discontinued. She was continued on her home albuterol/ipratropium nebulizer treatments, and maintained O2 sats >90% on 2L NC (her baseline O2 requirement). . # CAD: Stable, no c/o chest pain during hospitalization. She was continued on her home ASA and pravastatin. . # HTN: Carvedilol was discontinued due to frequent episodes of hypotension (with SBP 70s-80s). She can resume as an outpatient if BP tolerates. . # Gout: Patient was continued on her home allopurinol and did not have any pain concerning for a gout flare. . # Transitional issues: - Patient maintained full code status throughout hospitalization. - She will continue outpatient hemodialysis at <Location>43902 Carrie Route Apt. 677 East Aprilport, CA 59906</Location> <Location>43902 Carrie Route Apt. 677 East Aprilport, CA 59906</Location> Dialysis Center - She has follow-up scheduled with her PCP and her cardiologist. She will be contact<Name>Judith Medrano</Name> regarding a follow-up appointment with the device clinic in 3 months. Medications on Admission: 1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Insomnia. 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): Start on <Date>1919-11-29</Date>. 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath. 5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation <Hospital>Thomas PLC Hospital</Hospital> (2 times a day). 6. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain up to 3x q 5 minutes. 11. Outpatient Lab Work Please check INR and Chem 10 on <Date>1967-5-18</Date> and <Date>1964-1-23</Date>. Please fax results to: PCP <Name>Christina</Name> <Name>Moore</Name> (fax # <Telephone>150-263-3368</Telephone>) 12. furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 14. spironolactone 25 mg Tablet Sig: 0.25 Tablet PO EVERY OTHER DAY (Every Other Day). Disp:4 Tablet(s) Refills:0 15. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:30 Tablet, Chewable(s) Refills:2 17. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 11. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. 12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every five minutes up to 3 times as needed as needed for chest pain. 13. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 14. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID:prn as needed for constipation. Discharge Disposition: Home With Service Facility: <Hospital>Quinn-Velasquez Clinic</Hospital> <Name>Lian Jones</Name> Discharge Diagnosis: Chronic Renal Failure Acute on Chronic systolic CHF Atrial Fibrillation Coronary Artery Disease Chronic Obstructive Pulmonary Disease Hypertension Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to the hospital for shortness of breath and not making urine. Your heart was not pumping well which caused you to have extra fluid. We gave you medication to help you to urinate out this fluid however your kidneys were not working properly and you needed dialysis to do the job of your kidneys. You got a special IV to be used for dialysis. You will need to continue going to dialysis three times a week. Your blood pressure was also so low so we did not give you your home blood pressure medications while you were in the hospital. You should continue to go to dialysis three times a week. You were also started on a medication called nephrocaps that you will need to continue. You should stop taking your carvedilol, metolazone, spironolactone and lasix unless your doctor instructs you to restart these medications. Continue your coumadin and amiodarone for your abnormal heart rhythm (atrial fibrillation). Continue your aspirin and pravastatin for your heart disease, your allopurinol for your gout, your albuterol and ipratropium for your COPD. Followup Instructions: Name: <Name>Julie</Name> <Name>Lyna</Name>,MD Specialty: Internal Medicine When: Thursday <Date>4-3</Date> at 3:30p Location: <Hospital>Burns Ltd Medical Center</Hospital> Address: <Location>43902 Carrie Route Apt. 677 East Aprilport, CA 59906</Location>, <Location>43902 Carrie Route Apt. 677 East Aprilport, CA 59906</Location>,<Numeric Identifier>4269609</Numeric Identifier> Phone: <Telephone>263-568-9653</Telephone> Name: <Name>Betty</Name> <Name>Lees</Name>, NP Specialty: Cardiology When: Tuesday <Date>5-6</Date> at 2pm Location: <Hospital>Burns Ltd Medical Center</Hospital> Address: <Location>43902 Carrie Route Apt. 677 East Aprilport, CA 59906</Location>, <Location>43902 Carrie Route Apt. 677 East Aprilport, CA 59906</Location>,<Numeric Identifier>9098205</Numeric Identifier> Phone: <Telephone>767-364-7569</Telephone> Please call the Device Clinic in the cardiology department at <Hospital>Mayer-Moody Hospital</Hospital> to schedule an appointment in 3 months. You can call <Telephone>550-291-5934</Telephone> to schedule. <Name>Amanda</Name> <Name>Mitra Deluna</Name> MD <MD Number>90357120</MD 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Date: 1987-4-2 Discharge Date: 1970-9-10 Date of Birth: 2017-4-30 Sex: F Service: MEDICINE Allergies: Atorvastatin / Penicillins / Codeine Attending:Latrice Chief Complaint: SOB, decreased urine Major Surgical or Invasive Procedure: Hemodialysis Placement of a R IJ catheter Placement of a R subclavian tunneled dialysis line History of Present Illness: Ms. Ivory is a 70yoF with h/o dilated cardiomyopathy 1-15 aortic outflow obstruction, AICD s/p VT, CAD, COPD (on home O2) who presented with decreased UO and SOB, now transferred from medicine service to CCU for hypotension. Pt is currently somnolent and unable to provide a detailed history, so details are obtained from OMR and Atrius records. Pt saw NP in complex care clinic on 6-23, at that time felt well overall, c/o dry cough but denied SOB, peripheral edema. At that time her weight was recorded at 185 lbs (dry weight is estimated at 184 lbs). On 3-21 she called the CCC office c/o minimal urine output ("only drops") and cough productive of yellow sputum. She reported compliance with her home diuretic regimen, but Joyce Anderson NP note she had not filled her aldactone rx. . On DOA, she called EMS due to increasing SOB. When EMS arrived her SBP was 80. She received 250cc NS and was brought to ED. In ED she had SBP 90s so received another 500cc NS bolus. CXR showed no e/o infiltrate but she was treated empirically for CAP with 1g ceftriaxone given her recent productive cough. Labs were significant for Na 121 and Cr 5.4 (baseline 3.5-4.0). She was admitted to medicine service. On the floor, her BP was initially 98/65 but then decreased to SBP 70s. She was transferred to CCU for pressor support. . On transfer, vitals were T 95.7, HR 60 (v-paced), BP 110/56, RR 18, O2sat 100% on 2LNC. She was drowsy, but denied current SOB, chest pain, palpitations, LE swelling. She endorsed orthopnea (c/w baseline) cough productive of yellow sputum, nausea, RUQ discomfort, and anuria. Denied recent fevers/chills, diarrhea/constipation, melena/hematochezia, BRBPR. . Of note she was admitted 1 month ago (from 1914-9-1 to 1975-10-2) for CHF exacerbation and hypervolemia. She was started on a lasix drip with metolazone but was ultimately started on ultrafiltration with a tunneled HD line which she tolerated well. She has not required outpatient HD since discharge. Past Medical History: 1. CARDIAC RISK FACTORS: +Hypertension, +HLD 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: Cisneros-Vega Cognis 100-D Dual chamber-ICD, implanted 1966-12-1 -CARDIOMYOPATHY, HYPERTROPHIC OBSTRUCTIVE (EF 35%) -ATRIAL FIBRILLATION on coumadin -CORONARY ARTERY DISEASE - NATIVE CORONARY ARTERY -VENTRICULAR TACHYCARDIA s/p AICD placement -HEART FAILURE - SYSTOLIC & DIASTOLIC, CHRONIC 3. OTHER PAST MEDICAL HISTORY: ?????? COPD ?????? PSORIASIS ?????? GOUT ?????? RHINITIS - ALLERGIC ?????? HYPOKALEMIA in the past ?????? ANEMIA, normocytic ?????? KIDNEY DISEASE - CHRONIC STAGE III (MODERATE) ?????? OBESITY ?????? Unspecified cataract ?????? Colon polyps ?????? Diverticulosis of colon with hemorrhage Social History: Lives alone in 741 Jason Island South Diane, AR 46844, but has stayed with her sister recently 1-15 difficulty walking up stairs to her apt. Remote smoking and EtOH history, pt unable to quantify. Denies IVDU. Family History: Non-contributory. Physical Exam: ADMISSION EXAM: GENERAL: Fatigued-appearing elderly female, breathing comfortably on NC. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. NECK: Supple with JVP 12cm (to jaw). CARDIAC: Distant heart sounds, RRR, II/VI HSM at LLS border. LUNGS: Resp unlabored, no accessory muscle use. Bibasilar crackles, R>L. ABDOMEN: Soft, distended, TTP at RUQ with pulsatile liver. No abdominial bruits. EXTREMITIES: No c/c/e. +bulla on anterior LE. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ . DISCHARGE EXAM Pertinent Results: Admission Labs 1942-7-27 11:30PM WBC-5.0 RBC-3.46* HGB-10.3* HCT-30.3* MCV-87# MCH-29.7 MCHC-34.0 RDW-18.5* 1942-7-27 11:30PM PLT COUNT-100* 1942-7-27 11:30PM PT-21.6* PTT-34.3 INR(PT)-2.0* 1942-7-27 11:30PM TSH-14* 1942-7-27 11:30PM proBNP-8699* 1942-7-27 11:30PM UREA N-105* CREAT-5.4# SODIUM-121 POTASSIUM-3.4 CHLORIDE-77* TOTAL CO2-27 ANION GAP-20 1942-7-27 11:38PM LACTATE-1.5 1987-4-2 12:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-NEG 1987-4-2 03:03AM URINE OSMOLAL-276 1987-4-2 03:03AM URINE HOURS-RANDOM UREA N-265 CREAT-152 SODIUM-LESS THAN POTASSIUM-54 CHLORIDE-17 1987-4-2 04:09PM CK-MB-4 cTropnT-0.17* 1987-4-2 04:09PM CK(CPK)-66 . Pertinent Studies ECHO 9-1957: The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) with regional variation, the apical segments more hypokinetic than the basal segments. The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with borderline normal free wall function. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate (3-12+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is no pericardial effusion. . CXR 1987-4-2: There is a left-sided pacemaker/ICD with right atrial and right ventricular leads, as before. Severe cardiomegaly is not significantly changed. Pulmonary venous congestion is seen without definite interstitial pulmonary edema. No focal consolidations are seen. There are no pleural effusions. No pneumothorax is seen. There is minimal right basilar atelectasis. . HD Labs: - Iron studies: Iron Binding Capacity, Total 433 (nl 260 - 470 ug/dL) Ferritin 29 (nl 13 - 150 ng/mL) Transferrin 333 (nl 200 - 360 mg/dL) - PPD: negative . Discharge Labs: Brief Hospital Course: Primary Reason for Admission 70yoF with h/o dilated cardiomyopathy (EF 35%), AICD p/w SOB and poor urine output for several days found to have hyponatremia, now transferred from medicine to CCU due to hypotension. . Active Issues: . #Acute on chronic systolic heart failure: The patient was hypervolemic on exam with elevated JVP and increased abdominal distension at presentation. Given the patient had been refractory to diuretic therapy requiring ultrafiltration during her last hospitalization and was oliguric and hyponatremic on admission, ultrafiltration was initiated rather than diuretic therapy. She experienced significant muscle cramping and hypotension while on CVVHD requiring dopamine. CVVHD was discontinued on HD#2 and she was diuresed with IV lasix and metolazone. Pressures improved and she was weaned off of dopamine. It was noted that urine and blood pressure improved when the patient was in her native sinus rhythm with asynchronous ventricular pacing. Therefore the patients pacemaker escape rate was lowered to allow for increased native rhythm and the mode was changed to AAIR. Despite this change urine output remained poor and she was therefore started on a lasix drip ultimately requiring milrinone to augment diuresis. On HD#6 patient underwent placement of a tunneled dialysis catheter, and on HD#7 she continued HD using the tunneled line (see below). Lasix and metolazone were discontinued as patient will be HD dependent. . #Hypotension: Patient was hypotensive on admission in the setting of volume overload. Her hypotension was believed to be due to worsening cardiac output in setting of dilated cardiomyopathy. She was temporarily on a dopamine gtt, but this was weaned by HD#2. In addition, she experienced episodes of hypotension with CVVH with diuresis and antihypertensive medications, so her antihypertensive medications were held. On discharge, her BP was stable. She was asked to continue to hold her carvedilol and to follow up with her PCP about restarting as tolerated. . # Hyponatremia: Pts sodium was 119 on admission and likely cause of her AMS, thought to be hypervolemic hyponatremia with poor renal perfusion given e/o volume overload on exam and low urine Na. Her fluid intake was restricted to 1.5L daily, and she started CVVH as above with improvement in her hyponatremia as well as her mental status. At the time of discharge her sodium was 135. . # Acute on chronic renal failure: Patient was noted to have a creat of 5.4, baseline 3.5-4.0, and oliguria x 2-3 days on admission. As stated above she had previously required ultrafiltration during hospitalizations for heart failure exacerbation. Renal was consulted and felt that the patient would require chronic HD. Given her hypotension she was initally started on CVVH with dopamine gtt for pressure support. However as above she did not tolerate CVVH and it was discontinued. She was diuresed with lasix gtt and milrinone as above until she had her tunneled line placed on HD#6. She tolerated HD well, with stable BP and no muscle cramping. Outpatient dialysis was arranged with 43902 Carrie Route Apt. 677 East Aprilport, CA 59906 43902 Carrie Route Apt. 677 East Aprilport, CA 59906 Dialysis Center for mondays, wednesdays and fridays. . # Afib: Pt has a history of atrial fibrillation on coumadin at home. On admission her coumadin was held in preparation for placement of a tunneled dialysis catheter. As stated above her pacemaker settings were changed and she was in sinus rhythm for most of her CCU course with heart rates in the 50-70s. Her mode was changed to AAIR to allow for intrinsice AV conduction and minimize ventricular pacing in an abnormal heart. Her coumadin was restarted at her home dose on HD#7. Her INR at the time of discharge was 1.4. # Stable issues: . # COPD: Patient's recent cough and SOB with h/o COPD was initially c/f COPD exacerbation, and she was initially started on prednisone and levofloxacin. However there was no wheezing on exam therefore prednisone and antibiotics were discontinued. She was continued on her home albuterol/ipratropium nebulizer treatments, and maintained O2 sats >90% on 2L NC (her baseline O2 requirement). . # CAD: Stable, no c/o chest pain during hospitalization. She was continued on her home ASA and pravastatin. . # HTN: Carvedilol was discontinued due to frequent episodes of hypotension (with SBP 70s-80s). She can resume as an outpatient if BP tolerates. . # Gout: Patient was continued on her home allopurinol and did not have any pain concerning for a gout flare. . # Transitional issues: - Patient maintained full code status throughout hospitalization. - She will continue outpatient hemodialysis at 43902 Carrie Route Apt. 677 East Aprilport, CA 59906 43902 Carrie Route Apt. 677 East Aprilport, CA 59906 Dialysis Center - She has follow-up scheduled with her PCP and her cardiologist. She will be contactJudith Medrano regarding a follow-up appointment with the device clinic in 3 months. Medications on Admission: 1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Insomnia. 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): Start on 1919-11-29. 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath. 5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Thomas PLC Hospital (2 times a day). 6. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain up to 3x q 5 minutes. 11. Outpatient Lab Work Please check INR and Chem 10 on 1967-5-18 and 1964-1-23. Please fax results to: PCP Christina Moore (fax # 150-263-3368) 12. furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 14. spironolactone 25 mg Tablet Sig: 0.25 Tablet PO EVERY OTHER DAY (Every Other Day). Disp:4 Tablet(s) Refills:0 15. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:30 Tablet, Chewable(s) Refills:2 17. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 11. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. 12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every five minutes up to 3 times as needed as needed for chest pain. 13. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 14. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID:prn as needed for constipation. Discharge Disposition: Home With Service Facility: Quinn-Velasquez Clinic Lian Jones Discharge Diagnosis: Chronic Renal Failure Acute on Chronic systolic CHF Atrial Fibrillation Coronary Artery Disease Chronic Obstructive Pulmonary Disease Hypertension Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to the hospital for shortness of breath and not making urine. Your heart was not pumping well which caused you to have extra fluid. We gave you medication to help you to urinate out this fluid however your kidneys were not working properly and you needed dialysis to do the job of your kidneys. You got a special IV to be used for dialysis. You will need to continue going to dialysis three times a week. Your blood pressure was also so low so we did not give you your home blood pressure medications while you were in the hospital. You should continue to go to dialysis three times a week. You were also started on a medication called nephrocaps that you will need to continue. You should stop taking your carvedilol, metolazone, spironolactone and lasix unless your doctor instructs you to restart these medications. Continue your coumadin and amiodarone for your abnormal heart rhythm (atrial fibrillation). Continue your aspirin and pravastatin for your heart disease, your allopurinol for your gout, your albuterol and ipratropium for your COPD. Followup Instructions: Name: Julie Lyna,MD Specialty: Internal Medicine When: Thursday 4-3 at 3:30p Location: Burns Ltd Medical Center Address: 43902 Carrie Route Apt. 677 East Aprilport, CA 59906, 43902 Carrie Route Apt. 677 East Aprilport, CA 59906,4269609 Phone: 263-568-9653 Name: Betty Lees, NP Specialty: Cardiology When: Tuesday 5-6 at 2pm Location: Burns Ltd Medical Center Address: 43902 Carrie Route Apt. 677 East Aprilport, CA 59906, 43902 Carrie Route Apt. 677 East Aprilport, CA 59906,9098205 Phone: 767-364-7569 Please call the Device Clinic in the cardiology department at Mayer-Moody Hospital to schedule an appointment in 3 months. You can call 550-291-5934 to schedule. Amanda Mitra Deluna MD 90357120	['Admission Date: 1987-4-2 Discharge Date: 1970-9-10\n\nDate of Birth: 2017-4-30 Sex: F\n\nService: MEDICINE\n\nAllergies:\nAtorvastatin / Penicillins / Codeine\n\nAttending:Latrice\nChief Complaint:\nSOB, decreased urine\n\nMajor Surgical or Invasive Procedure:\nHemodialysis\nPlacement of a R IJ catheter\nPlacement of a R subclavian tunneled dialysis line\n\n\nHistory of Present Illness:\nMs. Ivory is a 70yoF with h/o dilated cardiomyopathy 1-15\naortic outflow obstruction, AICD s/p VT, CAD, COPD (on home O2)\nwho presented with decreased UO and SOB, now transferred from\nmedicine service to CCU for hypotension. Pt is currently\nsomnolent and unable to provide a detailed history, so details\nare obtained from OMR and Atrius records. Pt saw NP in complex\ncare clinic on 6-23, at that time felt well overall, c/o dry\ncough but denied SOB, peripheral edema.', ' At that time her weight\nwas recorded at 185 lbs (dry weight is estimated at 184 lbs). On\n3-21 she called the CCC office c/o minimal urine output ("only\ndrops") and cough productive of yellow sputum. She reported\ncompliance with her home diuretic regimen, but Joyce Anderson NP note she\nhad not filled her aldactone rx.\n.\nOn DOA, she called EMS due to increasing SOB. When EMS arrived\nher SBP was 80. She received 250cc NS and was brought to ED.\nIn ED she had SBP 90s so received another 500cc NS bolus. CXR\nshowed no e/o infiltrate but she was treated empirically for CAP\nwith 1g ceftriaxone given her recent productive cough. Labs were\nsignificant for Na 121 and Cr 5.4 (baseline 3.5-4.0). She was\nadmitted to medicine service. On the floor, her BP was\ninitially 98/65 but then decreased to SBP 70s.', ' She was\ntransferred to CCU for pressor support.\n.\nOn transfer, vitals were T 95.7, HR 60 (v-paced), BP 110/56, RR\n18, O2sat 100% on 2LNC. She was drowsy, but denied current SOB,\nchest pain, palpitations, LE swelling. She endorsed orthopnea\n(c/w baseline) cough productive of yellow sputum, nausea, RUQ\ndiscomfort, and anuria. Denied recent fevers/chills,\ndiarrhea/constipation, melena/hematochezia, BRBPR.\n.\nOf note she was admitted 1 month ago (from 1914-9-1 to 1975-10-2) for CHF\nexacerbation and hypervolemia. She was started on a lasix drip\nwith metolazone but was ultimately started on ultrafiltration\nwith a tunneled HD line which she tolerated well. She has not\nrequired outpatient HD since discharge.\n\n\nPast Medical History:\n1. CARDIAC RISK FACTORS: +Hypertension, +HLD\n2. CARDIAC HISTORY:\n- CABG:\n- PERCUTANEOUS CORONARY INTERVENTIONS:\n- PACING/ICD: Cisneros-Vega Cognis 100-D Dual chamber-ICD,\nimplanted 1966-12-1\n-CARDIOMYOPATHY, HYPERTROPHIC OBSTRUCTIVE (EF 35%)\n-ATRIAL FIBRILLATION on coumadin\n-CORONARY ARTERY DISEASE - NATIVE CORONARY ARTERY\n-VENTRICULAR TACHYCARDIA s/p AICD placement\n-HEART FAILURE - SYSTOLIC & DIASTOLIC, CHRONIC\n3.', ' OTHER PAST MEDICAL HISTORY:\n?????? COPD\n?????? PSORIASIS\n?????? GOUT\n?????? RHINITIS - ALLERGIC\n?????? HYPOKALEMIA in the past\n?????? ANEMIA, normocytic\n?????? KIDNEY DISEASE - CHRONIC STAGE III (MODERATE)\n?????? OBESITY\n?????? Unspecified cataract\n?????? Colon polyps\n?????? Diverticulosis of colon with hemorrhage\n\nSocial History:\nLives alone in 741 Jason Island\nSouth Diane, AR 46844, but has stayed with her sister recently\n1-15 difficulty walking up stairs to her apt. Remote smoking and\nEtOH history, pt unable to quantify. Denies IVDU.\n\nFamily History:\nNon-contributory.\n\nPhysical Exam:\nADMISSION EXAM:\nGENERAL: Fatigued-appearing elderly female, breathing\ncomfortably on NC.\nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.\nNECK: Supple with JVP 12cm (to jaw).\nCARDIAC: Distant heart sounds, RRR, II/VI HSM at LLS border.', '\nLUNGS: Resp unlabored, no accessory muscle use. Bibasilar\ncrackles, R>L.\nABDOMEN: Soft, distended, TTP at RUQ with pulsatile liver. No\nabdominial bruits.\nEXTREMITIES: No c/c/e. +bulla on anterior LE.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES:\nRight: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+\nLeft: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+\n.\nDISCHARGE EXAM\n\n\nPertinent Results:\nAdmission Labs\n1942-7-27 11:30PM WBC-5.0 RBC-3.46* HGB-10.3* HCT-30.3* MCV-87#\nMCH-29.7 MCHC-34.0 RDW-18.5\n1942-7-27 11:30PM PLT COUNT-100\n1942-7-27 11:30PM PT-21.6* PTT-34.3 INR(PT)-2.0\n1942-7-27 11:30PM TSH-14\n1942-7-27 11:30PM proBNP-8699\n1942-7-27 11:30PM UREA N-105 CREAT-5.4# SODIUM-121\nPOTASSIUM-3.4 CHLORIDE-77* TOTAL CO2-27 ANION GAP-20\n1942-7-27 11:38PM LACTATE-1.', '5\n1987-4-2 12:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0\nLEUK-NEG\n1987-4-2 03:03AM URINE OSMOLAL-276\n1987-4-2 03:03AM URINE HOURS-RANDOM UREA N-265 CREAT-152\nSODIUM-LESS THAN POTASSIUM-54 CHLORIDE-17\n1987-4-2 04:09PM CK-MB-4 cTropnT-0.17\n1987-4-2 04:09PM CK(CPK)-66\n.\nPertinent Studies\nECHO 9-1957: The left atrium is moderately dilated. The right\natrium is markedly dilated. There is mild symmetric left\nventricular hypertrophy. Overall left ventricular systolic\nfunction is moderately depressed (LVEF= 35 %) with regional\nvariation, the apical segments more hypokinetic than the basal\nsegments. The right ventricular free wall thickness is normal.\nThe right ventricular cavity is dilated with borderline normal\nfree wall function. There are focal calcifications in the aortic\narch.', ' The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. Mild to moderate (3-12+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. Moderate [2+] tricuspid regurgitation is seen. There\nis mild pulmonary artery systolic hypertension. The main\npulmonary artery is dilated. The branch pulmonary arteries are\ndilated. There is no pericardial effusion.\n.\nCXR 1987-4-2: There is a left-sided pacemaker/ICD with right\natrial and right ventricular leads, as before. Severe\ncardiomegaly is not significantly changed. Pulmonary venous\ncongestion is seen without definite interstitial pulmonary\nedema. No focal consolidations are seen.', ' There are no pleural\neffusions. No pneumothorax is seen. There is minimal right\nbasilar atelectasis.\n.\nHD Labs:\n- Iron studies:\nIron Binding Capacity, Total 433 (nl 260 - 470 ug/dL)\nFerritin 29 (nl 13 - 150 ng/mL)\nTransferrin 333 (nl 200 - 360 mg/dL)\n\n- PPD: negative\n.\nDischarge Labs:\n\nBrief Hospital Course:\nPrimary Reason for Admission\n70yoF with h/o dilated cardiomyopathy (EF 35%), AICD p/w SOB and\npoor urine output for several days found to have hyponatremia,\nnow transferred from medicine to CCU due to hypotension.\n.\nActive Issues:\n.\n#Acute on chronic systolic heart failure: The patient was\nhypervolemic on exam with elevated JVP and increased abdominal\ndistension at presentation. Given the patient had been\nrefractory to diuretic therapy requiring ultrafiltration during\nher last hospitalization and was oliguric and hyponatremic on\nadmission, ultrafiltration was initiated rather than diuretic\ntherapy.', ' She experienced significant muscle cramping and\nhypotension while on CVVHD requiring dopamine. CVVHD was\ndiscontinued on HD#2 and she was diuresed with IV lasix and\nmetolazone. Pressures improved and she was weaned off of\ndopamine. It was noted that urine and blood pressure improved\nwhen the patient was in her native sinus rhythm with\nasynchronous ventricular pacing. Therefore the patients\npacemaker escape rate was lowered to allow for increased native\nrhythm and the mode was changed to AAIR. Despite this change\nurine output remained poor and she was therefore started on a\nlasix drip ultimately requiring milrinone to augment diuresis.\nOn HD#6 patient underwent placement of a tunneled dialysis\ncatheter, and on HD#7 she continued HD using the tunneled line\n(see below). Lasix and metolazone were discontinued as patient\nwill be HD dependent.', '\n.\n#Hypotension: Patient was hypotensive on admission in the\nsetting of volume overload. Her hypotension was believed to be\ndue to worsening cardiac output in setting of dilated\ncardiomyopathy. She was temporarily on a dopamine gtt, but this\nwas weaned by HD#2. In addition, she experienced episodes of\nhypotension with CVVH with diuresis and antihypertensive\nmedications, so her antihypertensive medications were held. On\ndischarge, her BP was stable. She was asked to continue to hold\nher carvedilol and to follow up with her PCP about restarting as\ntolerated.\n.\n# Hyponatremia: Pts sodium was 119 on admission and likely cause\nof her AMS, thought to be hypervolemic hyponatremia with poor\nrenal perfusion given e/o volume overload on exam and low urine\nNa. Her fluid intake was restricted to 1.', '5L daily, and she\nstarted CVVH as above with improvement in her hyponatremia as\nwell as her mental status. At the time of discharge her sodium\nwas 135.\n.\n# Acute on chronic renal failure: Patient was noted to have a\ncreat of 5.4, baseline 3.5-4.0, and oliguria x 2-3 days on\nadmission. As stated above she had previously required\nultrafiltration during hospitalizations for heart failure\nexacerbation. Renal was consulted and felt that the patient\nwould require chronic HD. Given her hypotension she was\ninitally started on CVVH with dopamine gtt for pressure support.\n However as above she did not tolerate CVVH and it was\ndiscontinued. She was diuresed with lasix gtt and milrinone as\nabove until she had her tunneled line placed on HD#6. She\ntolerated HD well, with stable BP and no muscle cramping.', "\nOutpatient dialysis was arranged with 43902 Carrie Route Apt. 677\nEast Aprilport, CA 59906 43902 Carrie Route Apt. 677\nEast Aprilport, CA 59906 Dialysis\nCenter for mondays, wednesdays and fridays.\n.\n# Afib: Pt has a history of atrial fibrillation on coumadin at\nhome. On admission her coumadin was held in preparation for\nplacement of a tunneled dialysis catheter. As stated above her\npacemaker settings were changed and she was in sinus rhythm for\nmost of her CCU course with heart rates in the 50-70s. Her mode\nwas changed to AAIR to allow for intrinsice AV conduction and\nminimize ventricular pacing in an abnormal heart. Her coumadin\nwas restarted at her home dose on HD#7. Her INR at the time of\ndischarge was 1.4.\n\n# Stable issues:\n.\n# COPD: Patient's recent cough and SOB with h/o COPD was\ninitially c/f COPD exacerbation, and she was initially started\non prednisone and levofloxacin.", ' However there was no wheezing on\nexam therefore prednisone and antibiotics were discontinued. She\nwas continued on her home albuterol/ipratropium nebulizer\ntreatments, and maintained O2 sats >90% on 2L NC (her baseline\nO2 requirement).\n.\n# CAD: Stable, no c/o chest pain during hospitalization. She\nwas continued on her home ASA and pravastatin.\n.\n# HTN: Carvedilol was discontinued due to frequent episodes of\nhypotension (with SBP 70s-80s). She can resume as an outpatient\nif BP tolerates.\n.\n# Gout: Patient was continued on her home allopurinol and did\nnot have any pain concerning for a gout flare.\n.\n# Transitional issues:\n- Patient maintained full code status throughout\nhospitalization.\n- She will continue outpatient hemodialysis at 43902 Carrie Route Apt. 677\nEast Aprilport, CA 59906 43902 Carrie Route Apt.', ' 677\nEast Aprilport, CA 59906\nDialysis Center\n- She has follow-up scheduled with her PCP and her cardiologist.\n She will be contactJudith Medrano regarding a follow-up appointment with\nthe device clinic in 3 months.\n\nMedications on Admission:\n1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)\nas needed for Insomnia.\n2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER\n\nDAY (Every Other Day): Start on 1919-11-29.\n3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:\nOne (1) Cap Inhalation DAILY (Daily).\n4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:\nOne (1) Puff Inhalation Q6H (every 6 hours) as needed for\nshortness of breath.\n5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff\nInhalation Thomas PLC Hospital (2 times a day).\n6. ferrous gluconate 325 mg (37.', '5 mg iron) Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.\nDisp:90 Tablet(s)* Refills:0\n8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day).\nDisp:60 Tablet(s) Refills:0\n9. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.\nDisp:30 Tablet(s) Refills:0\n10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,\n\nSublingual Sublingual PRN (as needed) as needed for chest pain\nup to 3x q 5 minutes.\n11. Outpatient Lab Work\nPlease check INR and Chem 10 on 1967-5-18 and 1964-1-23.\nPlease fax results to: PCP Christina Moore (fax # 150-263-3368)\n12. furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times\n\na day).\n13. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times\n\na day).\nDisp:60 Tablet(s) Refills:2\n14.', ' spironolactone 25 mg Tablet Sig: 0.25 Tablet PO EVERY OTHER\n\nDAY (Every Other Day).\nDisp:4 Tablet(s) Refills:0\n15. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a\nday.\n16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\n\nPO once a day.\nDisp:30 Tablet, Chewable(s) Refills:2\n17. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.\n\nDischarge Medications:\n1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).\n\n2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER\nDAY (Every Other Day).\n3. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n5. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY\n(Daily).\n6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap\nPO DAILY (Daily).', '\n7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4\nPM.\n8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:\nOne (1) capsule Inhalation once a day.\n9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:\nOne (1) puff Inhalation every six (6) hours as needed for\nshortness of breath or wheezing.\n10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs\nInhalation twice a day.\n11. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.\n\n12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet\nSublingual every five minutes up to 3 times as needed as needed\nfor chest pain.\n13. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a\nday.\n14. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.\n15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO\nBID:prn as needed for constipation.', '\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nQuinn-Velasquez Clinic Lian Jones\n\nDischarge Diagnosis:\nChronic Renal Failure\nAcute on Chronic systolic CHF\nAtrial Fibrillation\nCoronary Artery Disease\nChronic Obstructive Pulmonary Disease\nHypertension\nGout\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:\nIt was a pleasure taking care of you while you were in the\nhospital.\n\nYou were admitted to the hospital for shortness of breath and\nnot making urine. Your heart was not pumping well which caused\nyou to have extra fluid. We gave you medication to help you to\nurinate out this fluid however your kidneys were not working\nproperly and you needed dialysis to do the job of your kidneys.', '\nYou got a special IV to be used for dialysis. You will need to\ncontinue going to dialysis three times a week. Your blood\npressure was also so low so we did not give you your home blood\npressure medications while you were in the hospital.\n\nYou should continue to go to dialysis three times a week. You\nwere also started on a medication called nephrocaps that you\nwill need to continue.\n\nYou should stop taking your carvedilol, metolazone,\nspironolactone and lasix unless your doctor instructs you to\nrestart these medications.\n\nContinue your coumadin and amiodarone for your abnormal heart\nrhythm (atrial fibrillation). Continue your aspirin and\npravastatin for your heart disease, your allopurinol for your\ngout, your albuterol and ipratropium for your COPD.\n\n\nFollowup Instructions:\nName: Julie Lyna,MD\nSpecialty: Internal Medicine\nWhen: Thursday 4-3 at 3:30p\nLocation: Burns Ltd Medical Center\nAddress: 43902 Carrie Route Apt.', ' 677\nEast Aprilport, CA 59906, 43902 Carrie Route Apt. 677\nEast Aprilport, CA 59906,4269609\nPhone: 263-568-9653\n\nName: Betty Lees, NP\nSpecialty: Cardiology\nWhen: Tuesday 5-6 at 2pm\nLocation: Burns Ltd Medical Center\nAddress: 43902 Carrie Route Apt. 677\nEast Aprilport, CA 59906, 43902 Carrie Route Apt. 677\nEast Aprilport, CA 59906,9098205\nPhone: 767-364-7569\n\nPlease call the Device Clinic in the cardiology department at\nMayer-Moody Hospital to schedule an appointment\nin 3 months. You can call 550-291-5934 to schedule.\n\n\n Amanda Mitra Deluna MD 90357120\n\n']
229	79900	128319.0	2195-04-17	Discharge summary	Report	Admission Date: [2195-4-14] Discharge Date: [2195-4-17] Date of Birth: [2123-12-24] Sex: F Service: MEDICINE Allergies: Atorvastatin / Penicillins / Codeine / Oxycodone Attending:[First Name3 (LF) 2290] Chief Complaint: Left leg swelling/edema Major Surgical or Invasive Procedure: None History of Present Illness: 71F with history of CHF, CAD, afib on coumadin, ESRD on HD and COPD presenting with pain, swelling and erythema on the left leg. Patient has had chronic ulcers of the left and right leg since last [Month (only) 216] and had been on vancomycin for 2 week course completed on [2195-2-19]. Today noted increased swelling and pain in the left calf, which had changed from previous baseline as she had not had pain in the leg before No f/c. No n/v/d. No CP/SOB. The blisters on her legs occasionally drain non purulent fluid, but she reports no increased drainage over the past few days. Was given a dose of vancomycin at HD. . In the ED, initial VS were: 8 98 64 131/113 16 99%. Patient was not given any additional antibiotics given recent dose at HD. Underwent LLE ultrasound which showed no evidence of DVT, but substantial subcutaneous edema. Patient was to be admitted to floor, but repeat vitals showed BP of 80/50. Patient was asymptomatic at that time without CP/SOB, lightheadedness or visual changes. Was given a 500cc bolus and responded to 89/50. Subsequently admitted to MICU for further monitoring of vital signs. . On arrival to the MICU, patient is alert and oriented, in NAD. Notes minimal pain and swelling in the left calf. Denies f/c. Denies CP/SOB. Of note, she reports multiple week history of cough for which she was started on doxycycline by her PCP [Last Name (NamePattern4) ] [4-10]. Otherwise has no other complaints. Past Medical History: - Hypertension - Hyperlpidemia - Ventricular tachycardia s/p ICD implantation [2193-4-1] ([Company 2275] Cognis 100-D Dual chamber-ICD) - Heart failure, systolic and diastolic, EF 35% - Atrial fibrillation on warfarin - Coronary artery disease - COPD - Psoriasis - Gout - Allergic rhinitis - Hypokalemia (in past) - Anemia, normocytic - ESRD - Obesity - Cataract - Colon polyps - Diverticulosis of colon with hemorrhage Social History: -Former tobacco [12-1] pack per day x 25 years -Previous alcohol use: quit 2 years ago -Denies recreational drug use or other toxic habits -Lives alone. Is able to complete her ADLs. Family History: [Name (NI) 2280], mother with 'heart trouble' Physical Exam: Vitals: T: 97.6 BP: 91/57 P: 65 R: 26 O2: 98% General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased breathsounds diffusely, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: trace pitting edema bilaterally in lower exytremities, healed ulcers on right lower extremity without drainage, LLE with surrounding erythema blanching, minimal serosanguineous drainage from ulcers, 1+ DP pulses bilaterally Neuro: alert and oriented x 3, moving all extremities Physical Exam on Discharge: VS: 97.7, 91/68, 88, 18, 96RA General: Alert, oriented, no acute distress, sitting up in bed comfortable HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Systolic murmur heard at the RUSB, regular rate and rhythm, normal S1 + S2 Lungs: CTAB anteriorly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext:Right leg healed ulcers on right lower extremity without drainage, LLE with minimal erythema, much regressed from the border. Pt with decreased edema of the leg compared to yesterday 1+DP pulse, and still with 2+pitting edema in the thigh. Small 1mm ulcer without purulence draining out of it. Tender to palpation. Neuro: alert and oriented x 3, moving all extremities Pertinent Results: Admission Labs: [2195-4-14] 12:57PM PT-21.9* INR(PT)-2.1* [2195-4-14] 04:55PM PLT SMR-LOW PLT COUNT-85* [2195-4-14] 04:55PM NEUTS-84.1* LYMPHS-10.2* MONOS-5.3 EOS-0.3 BASOS-0.2 [2195-4-14] 04:55PM WBC-8.4# RBC-3.99* HGB-11.6* HCT-38.6 MCV-97 MCH-29.0 MCHC-29.9* RDW-17.0* [2195-4-14] 04:55PM GLUCOSE-137* UREA N-10 CREAT-2.5# SODIUM-142 POTASSIUM-3.1 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13 [2195-4-14] 05:02PM LACTATE-2.0 [2195-4-14] 08:24PM LACTATE-1.6 Discharge Labs: [2195-4-17] 06:28AM BLOOD WBC-4.4 RBC-3.99* Hgb-12.0 Hct-40.3 MCV-101* MCH-30.0 MCHC-29.7* RDW-17.4* Plt Ct-94* [2195-4-17] 06:28AM BLOOD Glucose-95 UreaN-12 Creat-3.0# Na-133 K-3.7 Cl-94 HCO3-29 AnGap-14 [2195-4-17] 06:28AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 [2195-4-16] 06:29AM BLOOD Vanco-13.0 [2195-4-14] 05:02PM BLOOD Lactate-2.0 Micro: Blood culture [2195-4-14] PENDING Imaging: [2195-4-14] LENI- IMPRESSION: Limited examination due to patient discomfort and extensive subcutaneous edema with no evidence of deep venous thrombosis in the left common femoral, superficial femoral, or popliteal veins. [2195-4-14] CXR- Severe cardiomegaly has worsened, but pulmonary edema has cleared. Pleural effusion is small if any. Right supraclavicular dual-channel [Month/Day/Year 2286] catheter ends in the region of the superior cavoatrial junction, unchanged. Transvenous right atrial pacer and right ventricular pacer defibrillator leads are in standard placements. No pneumothorax or appreciable pleural effusion. Brief Hospital Course: 71F with history of CHF, CAD, afib on coumadin, ESRD on HD and COPD presenting with LLE cellulitis. . # Cellulitis - patient with chronic ulcers on left lower extremity presented with inreased pain and erythema and elevated WBC consistent with cellulitis. She was recently treated for cellulitis in that leg with vancomycin on previous hospitalization in [2194-1-28]. After two days of vancomycin, she had marked improvement in the leg with decreased erythema in color and was dramatically receeding from the marked border below the area. There was still [12-1]+pitting edema in the left thigh, but improved compared to admission when it was harder and was obscuring the anatomical markings of the knee on extension. LENI of the leg was negative for DVT. She was seen by vascular surgery during this admission, who did not feel that surgery was indicated and agreed with the proposed medical management. -Vancomycin dosed with HD x 2 weeks (last day [4-28]) -Ciprofloxacin 500mg po qday x 2 weeks (last day [4-28]) . #Hypotension - patient hypotensive to SBPs in 80s. In the ED there was concern that she was possibly septic, so she was admited to the ICU. She received 1.5L of IV fluids and her BP repsonded well. Her baseline blood pressure is in the low 90s systolic. After being on the floor she continued to have lower blood pressures and was asymptomatic with them. -She will require monitoring of her blood pressure during [Month/Year (2) 2286] sessions . # Afib - on amiodarone and coumadin as outpatient. Stable. INR therapeutic at 2.1 on admission. Continued on home medications - cont warfarin and amiodarone . # CAD - Continued on amiodarone, pravastatin and SLNGT . # COPD - on spiriva, alubterol and fluticasone at home. Also uses 2L NC at night at home. Has had cough for the past [3-6] weeks and recently started on doxycycline on [4-10], which was continued for planned 7 day course total and will be completed on [4-16]. No worsening SOB. CXR showed no evidence of PNA . # chronic sytolic CHF - Continued on home furosemide dose. Patinet is not on ACEI prior to this admission, and this was not started given her hypotension. . # ESRD - Continued on HD schedule of T-TH-SAT. She received an extra ultrafiltration session on [4-17] (friday) to try to remove more fluid from her left leg. . Transitional Issues: Pending labs/studies: Blood cultures from [2195-4-14] Medications started: 1. Vancomycin (antibiotic) to be given with [Month/Day/Year 2286] through [4-28]. Ciprofloxacin 500mg by mouth once a day through [4-28] Medications changed: none Medications stopped: None Follow-up needed for: *You will need to have your INR checked at [Month/Year (2) ] on Saturday [4-18] as you just started ciprofloxacin which can cause changes in this* 1. Monitoring of vancomycin levels at [Month/Year (2) ] Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Medications on Admission: Senna-Gen 8.6 mg Tab 2 Tablet(s) by mouth at bedtime - Spiriva with HandiHaler 18 mcg & inhalation Caps 1 Capsule(s) inhaled once a day - cholecalciferol (vitamin D3) 1,000 unit Cap 1 Capsule(s) by mouth once a day - Calcium 500 500 mg calcium (1,250 mg) Tab - pravastatin 20 mg Tab 1 Tablet(s) by mouth DAILY - allopurinol 100 mg Tab 1 Tablet(s) by mouth EVERY OTHER DAY - doxycycline hyclate 100 mg Cap 1 Capsule(s) by mouth [Hospital1 ] - Vitamin B-1 50 mg Tab - albuterol sulfate HFA 90 mcg/Actuation Aerosol Inhaler 1 HFA(s) inhaled every six (6) hours - furosemide 80 mg Tab 1 Tablet(s) by mouth twice a day - amiodarone 200 mg Tab 1 Tablet(s) by mouth once a day - Nitrostat 0.3 mg Sublingual Tab 1 Tablet(s) sublingually every five minutes up to 3 times as needed as needed for chest pain - ferrous gluconate 325 mg (37.5 mg iron) Tab 1 Tablet(s) by mouth DAILY (Daily) - zolpidem 5 mg Tab 1 Tablet(s) by mouth HS (at bedtime) - tramadol 50 mg Tab 1 Tablet(s) by mouth for pain - docusate sodium 100 mg Cap 1 (One) Capsule(s) by mouth twice a day - warfarin 1 mg Tab 1 Tablet(s) by mouth once a day - Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 Aerosol(s) inhaled twice a day - B complex-vitamin C-folic acid 400 mcg Tab 1 Tablet(s) by mouth DAILY Discharge Medications: 1. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 3. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 4. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Vitamin B-1 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual every five minutes with chest pain, take up to 3 as needed for chest pain. 12. ferrous gluconate 325 mg (36 mg iron) Tablet Sig: One (1) Tablet PO once a day. 13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 15. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS ([Doctor First Name ],MO,TU,WE,TH,FR,SA). 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day: on [Doctor First Name 2286] days take after your [Doctor First Name 2286] session. Disp:11 Tablet(s) Refills:0 20. vancomycin 1,000 mg Recon Soln Sig: sliding scale dose Intravenous with [Doctor First Name 2286]: based on Vanc trough drawn at [Doctor First Name 2286]. To be given through [2195-4-28]. Disp:qs Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary: Cellulitis Secondary: Atrial fibrillation, Chronic systolic heart failure, End stage renal disease on [Name (NI) 2286] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 2251], It was a pleasure taking care of you here at [Hospital1 18]. You were admitted to the hospital because you were found to have an infection of the skin on your left leg. While you were in the emergency room your blood pressure was on the lower side so you were in the ICU for a night to make sure it didn't drop further and it was stable (your blood pressure at baseline runs very low and you were asymptomatic throughout your ICU stay). You were then transferred to the regular medical floor where you were stable. You received [Hospital1 2286] on your regularly scheduled timing, and received an extra session on Friday. Transitional Issues: Pending labs/studies: Blood cultures from [2195-4-14] Medications started: 1. Vancomycin (antibiotic) to be given with [Month/Day/Year 2286] through [4-28]. Ciprofloxacin 500mg by mouth once a day through [4-28] Medications changed: none Medications stopped: None Follow-up needed for: *You will need to have your INR checked at [Month/Year (2) ] on Saturday [4-18] as you just started ciprofloxacin which can cause changes in this* 1. Monitoring of vancomycin levels at [Month/Year (2) ] Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] M. Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 2261] When: Thursday, [4-30], 2:00 PM Department: VASCULAR SURGERY When: FRIDAY [2195-5-15] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	Admission Date: <Date>1933-4-27</Date> Discharge Date: <Date>1927-11-21</Date> Date of Birth: <Date>1988-10-5</Date> Sex: F Service: MEDICINE Allergies: Atorvastatin / Penicillins / Codeine / Oxycodone Attending:<Name>Teresita</Name> Chief Complaint: Left leg swelling/edema Major Surgical or Invasive Procedure: None History of Present Illness: 71F with history of CHF, CAD, afib on coumadin, ESRD on HD and COPD presenting with pain, swelling and erythema on the left leg. Patient has had chronic ulcers of the left and right leg since last <Month>September</Month> and had been on vancomycin for 2 week course completed on <Date>1912-5-5</Date>. Today noted increased swelling and pain in the left calf, which had changed from previous baseline as she had not had pain in the leg before No f/c. No n/v/d. No CP/SOB. The blisters on her legs occasionally drain non purulent fluid, but she reports no increased drainage over the past few days. Was given a dose of vancomycin at HD. . In the ED, initial VS were: 8 98 64 131/113 16 99%. Patient was not given any additional antibiotics given recent dose at HD. Underwent LLE ultrasound which showed no evidence of DVT, but substantial subcutaneous edema. Patient was to be admitted to floor, but repeat vitals showed BP of 80/50. Patient was asymptomatic at that time without CP/SOB, lightheadedness or visual changes. Was given a 500cc bolus and responded to 89/50. Subsequently admitted to MICU for further monitoring of vital signs. . On arrival to the MICU, patient is alert and oriented, in NAD. Notes minimal pain and swelling in the left calf. Denies f/c. Denies CP/SOB. Of note, she reports multiple week history of cough for which she was started on doxycycline by her PCP <Name>Brown</Name> <Date>9-12</Date>. Otherwise has no other complaints. Past Medical History: - Hypertension - Hyperlpidemia - Ventricular tachycardia s/p ICD implantation <Date>1919-8-19</Date> (<Company>Brown-Cooper</Company> Cognis 100-D Dual chamber-ICD) - Heart failure, systolic and diastolic, EF 35% - Atrial fibrillation on warfarin - Coronary artery disease - COPD - Psoriasis - Gout - Allergic rhinitis - Hypokalemia (in past) - Anemia, normocytic - ESRD - Obesity - Cataract - Colon polyps - Diverticulosis of colon with hemorrhage Social History: -Former tobacco <Date>11-20</Date> pack per day x 25 years -Previous alcohol use: quit 2 years ago -Denies recreational drug use or other toxic habits -Lives alone. Is able to complete her ADLs. Family History: <Name>Sammie Blanchar</Name>, mother with 'heart trouble' Physical Exam: Vitals: T: 97.6 BP: 91/57 P: 65 R: 26 O2: 98% General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased breathsounds diffusely, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: trace pitting edema bilaterally in lower exytremities, healed ulcers on right lower extremity without drainage, LLE with surrounding erythema blanching, minimal serosanguineous drainage from ulcers, 1+ DP pulses bilaterally Neuro: alert and oriented x 3, moving all extremities Physical Exam on Discharge: VS: 97.7, 91/68, 88, 18, 96RA General: Alert, oriented, no acute distress, sitting up in bed comfortable HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Systolic murmur heard at the RUSB, regular rate and rhythm, normal S1 + S2 Lungs: CTAB anteriorly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext:Right leg healed ulcers on right lower extremity without drainage, LLE with minimal erythema, much regressed from the border. Pt with decreased edema of the leg compared to yesterday 1+DP pulse, and still with 2+pitting edema in the thigh. Small 1mm ulcer without purulence draining out of it. Tender to palpation. Neuro: alert and oriented x 3, moving all extremities Pertinent Results: Admission Labs: <Date>1933-4-27</Date> 12:57PM PT-21.9* INR(PT)-2.1* <Date>1933-4-27</Date> 04:55PM PLT SMR-LOW PLT COUNT-85* <Date>1933-4-27</Date> 04:55PM NEUTS-84.1* LYMPHS-10.2* MONOS-5.3 EOS-0.3 BASOS-0.2 <Date>1933-4-27</Date> 04:55PM WBC-8.4# RBC-3.99* HGB-11.6* HCT-38.6 MCV-97 MCH-29.0 MCHC-29.9* RDW-17.0* <Date>1933-4-27</Date> 04:55PM GLUCOSE-137* UREA N-10 CREAT-2.5# SODIUM-142 POTASSIUM-3.1 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13 <Date>1933-4-27</Date> 05:02PM LACTATE-2.0 <Date>1933-4-27</Date> 08:24PM LACTATE-1.6 Discharge Labs: <Date>1927-11-21</Date> 06:28AM BLOOD WBC-4.4 RBC-3.99* Hgb-12.0 Hct-40.3 MCV-101* MCH-30.0 MCHC-29.7* RDW-17.4* Plt Ct-94* <Date>1927-11-21</Date> 06:28AM BLOOD Glucose-95 UreaN-12 Creat-3.0# Na-133 K-3.7 Cl-94 HCO3-29 AnGap-14 <Date>1927-11-21</Date> 06:28AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 <Date>1965-11-6</Date> 06:29AM BLOOD Vanco-13.0 <Date>1933-4-27</Date> 05:02PM BLOOD Lactate-2.0 Micro: Blood culture <Date>1933-4-27</Date> PENDING Imaging: <Date>1933-4-27</Date> LENI- IMPRESSION: Limited examination due to patient discomfort and extensive subcutaneous edema with no evidence of deep venous thrombosis in the left common femoral, superficial femoral, or popliteal veins. <Date>1933-4-27</Date> CXR- Severe cardiomegaly has worsened, but pulmonary edema has cleared. Pleural effusion is small if any. Right supraclavicular dual-channel <Month>July</Month> catheter ends in the region of the superior cavoatrial junction, unchanged. Transvenous right atrial pacer and right ventricular pacer defibrillator leads are in standard placements. No pneumothorax or appreciable pleural effusion. Brief Hospital Course: 71F with history of CHF, CAD, afib on coumadin, ESRD on HD and COPD presenting with LLE cellulitis. . # Cellulitis - patient with chronic ulcers on left lower extremity presented with inreased pain and erythema and elevated WBC consistent with cellulitis. She was recently treated for cellulitis in that leg with vancomycin on previous hospitalization in <Date>1937-10-2</Date>. After two days of vancomycin, she had marked improvement in the leg with decreased erythema in color and was dramatically receeding from the marked border below the area. There was still <Date>11-20</Date>+pitting edema in the left thigh, but improved compared to admission when it was harder and was obscuring the anatomical markings of the knee on extension. LENI of the leg was negative for DVT. She was seen by vascular surgery during this admission, who did not feel that surgery was indicated and agreed with the proposed medical management. -Vancomycin dosed with HD x 2 weeks (last day <Date>8-25</Date>) -Ciprofloxacin 500mg po qday x 2 weeks (last day <Date>8-25</Date>) . #Hypotension - patient hypotensive to SBPs in 80s. In the ED there was concern that she was possibly septic, so she was admited to the ICU. She received 1.5L of IV fluids and her BP repsonded well. Her baseline blood pressure is in the low 90s systolic. After being on the floor she continued to have lower blood pressures and was asymptomatic with them. -She will require monitoring of her blood pressure during <Month>November</Month> sessions . # Afib - on amiodarone and coumadin as outpatient. Stable. INR therapeutic at 2.1 on admission. Continued on home medications - cont warfarin and amiodarone . # CAD - Continued on amiodarone, pravastatin and SLNGT . # COPD - on spiriva, alubterol and fluticasone at home. Also uses 2L NC at night at home. Has had cough for the past <Date>12-15</Date> weeks and recently started on doxycycline on <Date>9-12</Date>, which was continued for planned 7 day course total and will be completed on <Date>10-25</Date>. No worsening SOB. CXR showed no evidence of PNA . # chronic sytolic CHF - Continued on home furosemide dose. Patinet is not on ACEI prior to this admission, and this was not started given her hypotension. . # ESRD - Continued on HD schedule of T-TH-SAT. She received an extra ultrafiltration session on <Date>6-9</Date> (friday) to try to remove more fluid from her left leg. . Transitional Issues: Pending labs/studies: Blood cultures from <Date>1933-4-27</Date> Medications started: 1. Vancomycin (antibiotic) to be given with <Month>July</Month> through <Date>8-25</Date>. Ciprofloxacin 500mg by mouth once a day through <Date>8-25</Date> Medications changed: none Medications stopped: None Follow-up needed for: *You will need to have your INR checked at <Month>October</Month> on Saturday <Date>11-9</Date> as you just started ciprofloxacin which can cause changes in this* 1. Monitoring of vancomycin levels at <Month>October</Month> Weigh yourself every morning, <Name>Zachary Caro</Name> MD if weight goes up more than 3 lbs. Medications on Admission: Senna-Gen 8.6 mg Tab 2 Tablet(s) by mouth at bedtime - Spiriva with HandiHaler 18 mcg & inhalation Caps 1 Capsule(s) inhaled once a day - cholecalciferol (vitamin D3) 1,000 unit Cap 1 Capsule(s) by mouth once a day - Calcium 500 500 mg calcium (1,250 mg) Tab - pravastatin 20 mg Tab 1 Tablet(s) by mouth DAILY - allopurinol 100 mg Tab 1 Tablet(s) by mouth EVERY OTHER DAY - doxycycline hyclate 100 mg Cap 1 Capsule(s) by mouth <Hospital>Ramirez-Miller Hospital</Hospital> - Vitamin B-1 50 mg Tab - albuterol sulfate HFA 90 mcg/Actuation Aerosol Inhaler 1 HFA(s) inhaled every six (6) hours - furosemide 80 mg Tab 1 Tablet(s) by mouth twice a day - amiodarone 200 mg Tab 1 Tablet(s) by mouth once a day - Nitrostat 0.3 mg Sublingual Tab 1 Tablet(s) sublingually every five minutes up to 3 times as needed as needed for chest pain - ferrous gluconate 325 mg (37.5 mg iron) Tab 1 Tablet(s) by mouth DAILY (Daily) - zolpidem 5 mg Tab 1 Tablet(s) by mouth HS (at bedtime) - tramadol 50 mg Tab 1 Tablet(s) by mouth for pain - docusate sodium 100 mg Cap 1 (One) Capsule(s) by mouth twice a day - warfarin 1 mg Tab 1 Tablet(s) by mouth once a day - Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 Aerosol(s) inhaled twice a day - B complex-vitamin C-folic acid 400 mcg Tab 1 Tablet(s) by mouth DAILY Discharge Medications: 1. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 3. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 4. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Vitamin B-1 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual every five minutes with chest pain, take up to 3 as needed for chest pain. 12. ferrous gluconate 325 mg (36 mg iron) Tablet Sig: One (1) Tablet PO once a day. 13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 15. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS (<Name>Aparna</Name>,MO,TU,WE,TH,FR,SA). 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day: on <Name>Brianne</Name> days take after your <Name>Brianne</Name> session. Disp:11 Tablet(s) Refills:0 20. vancomycin 1,000 mg Recon Soln Sig: sliding scale dose Intravenous with <Name>Brianne</Name>: based on Vanc trough drawn at <Name>Brianne</Name>. To be given through <Date>1993-7-22</Date>. Disp:qs Refills:0 Discharge Disposition: Home With Service Facility: <Hospital>Martin-Perez Clinic</Hospital> <Name>Michelle Bludsworth</Name> Discharge Diagnosis: Primary: Cellulitis Secondary: Atrial fibrillation, Chronic systolic heart failure, End stage renal disease on <Name>Sean Dizon</Name> Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. <Name>Negrete</Name>, It was a pleasure taking care of you here at <Hospital>Todd Group Medical Center</Hospital>. You were admitted to the hospital because you were found to have an infection of the skin on your left leg. While you were in the emergency room your blood pressure was on the lower side so you were in the ICU for a night to make sure it didn't drop further and it was stable (your blood pressure at baseline runs very low and you were asymptomatic throughout your ICU stay). You were then transferred to the regular medical floor where you were stable. You received <Hospital>Rice, Garcia and Thomas Clinic</Hospital> on your regularly scheduled timing, and received an extra session on Friday. Transitional Issues: Pending labs/studies: Blood cultures from <Date>1933-4-27</Date> Medications started: 1. Vancomycin (antibiotic) to be given with <Month>July</Month> through <Date>8-25</Date>. Ciprofloxacin 500mg by mouth once a day through <Date>8-25</Date> Medications changed: none Medications stopped: None Follow-up needed for: *You will need to have your INR checked at <Month>October</Month> on Saturday <Date>11-9</Date> as you just started ciprofloxacin which can cause changes in this* 1. Monitoring of vancomycin levels at <Month>October</Month> Weigh yourself every morning, <Name>Zachary Caro</Name> MD if weight goes up more than 3 lbs. Followup Instructions: Name: <Name>Kibler</Name>,<Name>Elijah</Name> M. Location: <Hospital>Wright and Sons Health System</Hospital> Address: <Location>15498 Johnson Avenue Suite 158 West Laurenville, FM 43989</Location>, <Location>15498 Johnson Avenue Suite 158 West Laurenville, FM 43989</Location>,<Numeric Identifier>3894925</Numeric Identifier> Phone: <Telephone>341-702-5343</Telephone> When: Thursday, <Date>3-24</Date>, 2:00 PM Department: VASCULAR SURGERY When: FRIDAY <Date>1912-10-6</Date> at 9:30 AM With: <Name>Camilo</Name> <Name>Merino</Name>, MD <Telephone>232-624-2860</Telephone> Building: LM <Hospital>Mcconnell Inc Clinic</Hospital> <Location>15498 Johnson Avenue Suite 158 West Laurenville, FM 43989</Location> Campus: WEST Best Parking: <Hospital>Wilson-Le Hospital</Hospital> 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Date: 1933-4-27 Discharge Date: 1927-11-21 Date of Birth: 1988-10-5 Sex: F Service: MEDICINE Allergies: Atorvastatin / Penicillins / Codeine / Oxycodone Attending:Teresita Chief Complaint: Left leg swelling/edema Major Surgical or Invasive Procedure: None History of Present Illness: 71F with history of CHF, CAD, afib on coumadin, ESRD on HD and COPD presenting with pain, swelling and erythema on the left leg. Patient has had chronic ulcers of the left and right leg since last September and had been on vancomycin for 2 week course completed on 1912-5-5. Today noted increased swelling and pain in the left calf, which had changed from previous baseline as she had not had pain in the leg before No f/c. No n/v/d. No CP/SOB. The blisters on her legs occasionally drain non purulent fluid, but she reports no increased drainage over the past few days. Was given a dose of vancomycin at HD. . In the ED, initial VS were: 8 98 64 131/113 16 99%. Patient was not given any additional antibiotics given recent dose at HD. Underwent LLE ultrasound which showed no evidence of DVT, but substantial subcutaneous edema. Patient was to be admitted to floor, but repeat vitals showed BP of 80/50. Patient was asymptomatic at that time without CP/SOB, lightheadedness or visual changes. Was given a 500cc bolus and responded to 89/50. Subsequently admitted to MICU for further monitoring of vital signs. . On arrival to the MICU, patient is alert and oriented, in NAD. Notes minimal pain and swelling in the left calf. Denies f/c. Denies CP/SOB. Of note, she reports multiple week history of cough for which she was started on doxycycline by her PCP Brown 9-12. Otherwise has no other complaints. Past Medical History: - Hypertension - Hyperlpidemia - Ventricular tachycardia s/p ICD implantation 1919-8-19 (Brown-Cooper Cognis 100-D Dual chamber-ICD) - Heart failure, systolic and diastolic, EF 35% - Atrial fibrillation on warfarin - Coronary artery disease - COPD - Psoriasis - Gout - Allergic rhinitis - Hypokalemia (in past) - Anemia, normocytic - ESRD - Obesity - Cataract - Colon polyps - Diverticulosis of colon with hemorrhage Social History: -Former tobacco 11-20 pack per day x 25 years -Previous alcohol use: quit 2 years ago -Denies recreational drug use or other toxic habits -Lives alone. Is able to complete her ADLs. Family History: Sammie Blanchar, mother with 'heart trouble' Physical Exam: Vitals: T: 97.6 BP: 91/57 P: 65 R: 26 O2: 98% General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased breathsounds diffusely, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: trace pitting edema bilaterally in lower exytremities, healed ulcers on right lower extremity without drainage, LLE with surrounding erythema blanching, minimal serosanguineous drainage from ulcers, 1+ DP pulses bilaterally Neuro: alert and oriented x 3, moving all extremities Physical Exam on Discharge: VS: 97.7, 91/68, 88, 18, 96RA General: Alert, oriented, no acute distress, sitting up in bed comfortable HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Systolic murmur heard at the RUSB, regular rate and rhythm, normal S1 + S2 Lungs: CTAB anteriorly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext:Right leg healed ulcers on right lower extremity without drainage, LLE with minimal erythema, much regressed from the border. Pt with decreased edema of the leg compared to yesterday 1+DP pulse, and still with 2+pitting edema in the thigh. Small 1mm ulcer without purulence draining out of it. Tender to palpation. Neuro: alert and oriented x 3, moving all extremities Pertinent Results: Admission Labs: 1933-4-27 12:57PM PT-21.9* INR(PT)-2.1* 1933-4-27 04:55PM PLT SMR-LOW PLT COUNT-85* 1933-4-27 04:55PM NEUTS-84.1* LYMPHS-10.2* MONOS-5.3 EOS-0.3 BASOS-0.2 1933-4-27 04:55PM WBC-8.4# RBC-3.99* HGB-11.6* HCT-38.6 MCV-97 MCH-29.0 MCHC-29.9* RDW-17.0* 1933-4-27 04:55PM GLUCOSE-137* UREA N-10 CREAT-2.5# SODIUM-142 POTASSIUM-3.1 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13 1933-4-27 05:02PM LACTATE-2.0 1933-4-27 08:24PM LACTATE-1.6 Discharge Labs: 1927-11-21 06:28AM BLOOD WBC-4.4 RBC-3.99* Hgb-12.0 Hct-40.3 MCV-101* MCH-30.0 MCHC-29.7* RDW-17.4* Plt Ct-94* 1927-11-21 06:28AM BLOOD Glucose-95 UreaN-12 Creat-3.0# Na-133 K-3.7 Cl-94 HCO3-29 AnGap-14 1927-11-21 06:28AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 1965-11-6 06:29AM BLOOD Vanco-13.0 1933-4-27 05:02PM BLOOD Lactate-2.0 Micro: Blood culture 1933-4-27 PENDING Imaging: 1933-4-27 LENI- IMPRESSION: Limited examination due to patient discomfort and extensive subcutaneous edema with no evidence of deep venous thrombosis in the left common femoral, superficial femoral, or popliteal veins. 1933-4-27 CXR- Severe cardiomegaly has worsened, but pulmonary edema has cleared. Pleural effusion is small if any. Right supraclavicular dual-channel July catheter ends in the region of the superior cavoatrial junction, unchanged. Transvenous right atrial pacer and right ventricular pacer defibrillator leads are in standard placements. No pneumothorax or appreciable pleural effusion. Brief Hospital Course: 71F with history of CHF, CAD, afib on coumadin, ESRD on HD and COPD presenting with LLE cellulitis. . # Cellulitis - patient with chronic ulcers on left lower extremity presented with inreased pain and erythema and elevated WBC consistent with cellulitis. She was recently treated for cellulitis in that leg with vancomycin on previous hospitalization in 1937-10-2. After two days of vancomycin, she had marked improvement in the leg with decreased erythema in color and was dramatically receeding from the marked border below the area. There was still 11-20+pitting edema in the left thigh, but improved compared to admission when it was harder and was obscuring the anatomical markings of the knee on extension. LENI of the leg was negative for DVT. She was seen by vascular surgery during this admission, who did not feel that surgery was indicated and agreed with the proposed medical management. -Vancomycin dosed with HD x 2 weeks (last day 8-25) -Ciprofloxacin 500mg po qday x 2 weeks (last day 8-25) . #Hypotension - patient hypotensive to SBPs in 80s. In the ED there was concern that she was possibly septic, so she was admited to the ICU. She received 1.5L of IV fluids and her BP repsonded well. Her baseline blood pressure is in the low 90s systolic. After being on the floor she continued to have lower blood pressures and was asymptomatic with them. -She will require monitoring of her blood pressure during November sessions . # Afib - on amiodarone and coumadin as outpatient. Stable. INR therapeutic at 2.1 on admission. Continued on home medications - cont warfarin and amiodarone . # CAD - Continued on amiodarone, pravastatin and SLNGT . # COPD - on spiriva, alubterol and fluticasone at home. Also uses 2L NC at night at home. Has had cough for the past 12-15 weeks and recently started on doxycycline on 9-12, which was continued for planned 7 day course total and will be completed on 10-25. No worsening SOB. CXR showed no evidence of PNA . # chronic sytolic CHF - Continued on home furosemide dose. Patinet is not on ACEI prior to this admission, and this was not started given her hypotension. . # ESRD - Continued on HD schedule of T-TH-SAT. She received an extra ultrafiltration session on 6-9 (friday) to try to remove more fluid from her left leg. . Transitional Issues: Pending labs/studies: Blood cultures from 1933-4-27 Medications started: 1. Vancomycin (antibiotic) to be given with July through 8-25. Ciprofloxacin 500mg by mouth once a day through 8-25 Medications changed: none Medications stopped: None Follow-up needed for: *You will need to have your INR checked at October on Saturday 11-9 as you just started ciprofloxacin which can cause changes in this* 1. Monitoring of vancomycin levels at October Weigh yourself every morning, Zachary Caro MD if weight goes up more than 3 lbs. Medications on Admission: Senna-Gen 8.6 mg Tab 2 Tablet(s) by mouth at bedtime - Spiriva with HandiHaler 18 mcg & inhalation Caps 1 Capsule(s) inhaled once a day - cholecalciferol (vitamin D3) 1,000 unit Cap 1 Capsule(s) by mouth once a day - Calcium 500 500 mg calcium (1,250 mg) Tab - pravastatin 20 mg Tab 1 Tablet(s) by mouth DAILY - allopurinol 100 mg Tab 1 Tablet(s) by mouth EVERY OTHER DAY - doxycycline hyclate 100 mg Cap 1 Capsule(s) by mouth Ramirez-Miller Hospital - Vitamin B-1 50 mg Tab - albuterol sulfate HFA 90 mcg/Actuation Aerosol Inhaler 1 HFA(s) inhaled every six (6) hours - furosemide 80 mg Tab 1 Tablet(s) by mouth twice a day - amiodarone 200 mg Tab 1 Tablet(s) by mouth once a day - Nitrostat 0.3 mg Sublingual Tab 1 Tablet(s) sublingually every five minutes up to 3 times as needed as needed for chest pain - ferrous gluconate 325 mg (37.5 mg iron) Tab 1 Tablet(s) by mouth DAILY (Daily) - zolpidem 5 mg Tab 1 Tablet(s) by mouth HS (at bedtime) - tramadol 50 mg Tab 1 Tablet(s) by mouth for pain - docusate sodium 100 mg Cap 1 (One) Capsule(s) by mouth twice a day - warfarin 1 mg Tab 1 Tablet(s) by mouth once a day - Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 Aerosol(s) inhaled twice a day - B complex-vitamin C-folic acid 400 mcg Tab 1 Tablet(s) by mouth DAILY Discharge Medications: 1. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 3. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 4. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Vitamin B-1 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual every five minutes with chest pain, take up to 3 as needed for chest pain. 12. ferrous gluconate 325 mg (36 mg iron) Tablet Sig: One (1) Tablet PO once a day. 13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 15. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS (Aparna,MO,TU,WE,TH,FR,SA). 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day: on Brianne days take after your Brianne session. Disp:11 Tablet(s) Refills:0 20. vancomycin 1,000 mg Recon Soln Sig: sliding scale dose Intravenous with Brianne: based on Vanc trough drawn at Brianne. To be given through 1993-7-22. Disp:qs Refills:0 Discharge Disposition: Home With Service Facility: Martin-Perez Clinic Michelle Bludsworth Discharge Diagnosis: Primary: Cellulitis Secondary: Atrial fibrillation, Chronic systolic heart failure, End stage renal disease on Sean Dizon Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. Negrete, It was a pleasure taking care of you here at Todd Group Medical Center. You were admitted to the hospital because you were found to have an infection of the skin on your left leg. While you were in the emergency room your blood pressure was on the lower side so you were in the ICU for a night to make sure it didn't drop further and it was stable (your blood pressure at baseline runs very low and you were asymptomatic throughout your ICU stay). You were then transferred to the regular medical floor where you were stable. You received Rice, Garcia and Thomas Clinic on your regularly scheduled timing, and received an extra session on Friday. Transitional Issues: Pending labs/studies: Blood cultures from 1933-4-27 Medications started: 1. Vancomycin (antibiotic) to be given with July through 8-25. Ciprofloxacin 500mg by mouth once a day through 8-25 Medications changed: none Medications stopped: None Follow-up needed for: *You will need to have your INR checked at October on Saturday 11-9 as you just started ciprofloxacin which can cause changes in this* 1. Monitoring of vancomycin levels at October Weigh yourself every morning, Zachary Caro MD if weight goes up more than 3 lbs. Followup Instructions: Name: Kibler,Elijah M. Location: Wright and Sons Health System Address: 15498 Johnson Avenue Suite 158 West Laurenville, FM 43989, 15498 Johnson Avenue Suite 158 West Laurenville, FM 43989,3894925 Phone: 341-702-5343 When: Thursday, 3-24, 2:00 PM Department: VASCULAR SURGERY When: FRIDAY 1912-10-6 at 9:30 AM With: Camilo Merino, MD 232-624-2860 Building: LM Mcconnell Inc Clinic 15498 Johnson Avenue Suite 158 West Laurenville, FM 43989 Campus: WEST Best Parking: Wilson-Le Hospital Garage	['Admission Date: 1933-4-27 Discharge Date: 1927-11-21\n\nDate of Birth: 1988-10-5 Sex: F\n\nService: MEDICINE\n\nAllergies:\nAtorvastatin / Penicillins / Codeine / Oxycodone\n\nAttending:Teresita\nChief Complaint:\nLeft leg swelling/edema\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\n71F with history of CHF, CAD, afib on coumadin, ESRD on HD and\nCOPD presenting with pain, swelling and erythema on the left\nleg. Patient has had chronic ulcers of the left and right leg\nsince last September and had been on vancomycin for 2 week course\ncompleted on 1912-5-5. Today noted increased swelling and pain\nin the left calf, which had changed from previous baseline as\nshe had not had pain in the leg before No f/c. No n/v/d. No\nCP/SOB. The blisters on her legs occasionally drain non\npurulent fluid, but she reports no increased drainage over the\npast few days.', ' Was given a dose of vancomycin at HD.\n.\nIn the ED, initial VS were: 8 98 64 131/113 16 99%. Patient was\nnot given any additional antibiotics given recent dose at HD.\nUnderwent LLE ultrasound which showed no evidence of DVT, but\nsubstantial subcutaneous edema. Patient was to be admitted to\nfloor, but repeat vitals showed BP of 80/50. Patient was\nasymptomatic at that time without CP/SOB, lightheadedness or\nvisual changes. Was given a 500cc bolus and responded to 89/50.\nSubsequently admitted to MICU for further monitoring of vital\nsigns.\n.\nOn arrival to the MICU, patient is alert and oriented, in NAD.\nNotes minimal pain and swelling in the left calf. Denies f/c.\nDenies CP/SOB. Of note, she reports multiple week history of\ncough for which she was started on doxycycline by her PCP Brown\n9-12.', " Otherwise has no other complaints.\n\n\nPast Medical History:\n- Hypertension\n- Hyperlpidemia\n- Ventricular tachycardia s/p ICD implantation 1919-8-19 (Brown-Cooper Cognis 100-D Dual chamber-ICD)\n- Heart failure, systolic and diastolic, EF 35%\n- Atrial fibrillation on warfarin\n- Coronary artery disease\n- COPD\n- Psoriasis\n- Gout\n- Allergic rhinitis\n- Hypokalemia (in past)\n- Anemia, normocytic\n- ESRD\n- Obesity\n- Cataract\n- Colon polyps\n- Diverticulosis of colon with hemorrhage\n\nSocial History:\n-Former tobacco 11-20 pack per day x 25 years\n-Previous alcohol use: quit 2 years ago\n-Denies recreational drug use or other toxic habits\n-Lives alone. Is able to complete her ADLs.\n\nFamily History:\n Sammie Blanchar, mother with 'heart trouble'\n\nPhysical Exam:\nVitals: T: 97.6 BP: 91/57 P: 65 R: 26 O2: 98%\nGeneral: Alert, oriented, no acute distress\nHEENT: MMM, oropharynx clear, EOMI, PERRL\nNeck: supple, JVP not elevated, no LAD\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops\nLungs: Decreased breathsounds diffusely, no wheezes, rales,\nronchi\nAbdomen: soft, non-tender, non-distended, bowel sounds present,\nno organomegaly\nGU: no foley\nExt: trace pitting edema bilaterally in lower exytremities,\nhealed ulcers on right lower extremity without drainage, LLE\nwith surrounding erythema blanching, minimal serosanguineous\ndrainage from ulcers, 1+ DP pulses bilaterally\nNeuro: alert and oriented x 3, moving all extremities\n\nPhysical Exam on Discharge:\nVS: 97.", '7, 91/68, 88, 18, 96RA\nGeneral: Alert, oriented, no acute distress, sitting up in bed\ncomfortable\nHEENT: MMM, oropharynx clear, EOMI, PERRL\nNeck: supple, no LAD\nCV: Systolic murmur heard at the RUSB, regular rate and rhythm,\nnormal S1 + S2\nLungs: CTAB anteriorly\nAbdomen: soft, non-tender, non-distended, bowel sounds present,\nno organomegaly\nGU: no foley\nExt:Right leg healed ulcers on right lower extremity without\ndrainage, LLE with minimal erythema, much regressed from the\nborder. Pt with decreased edema of the leg compared to yesterday\n1+DP pulse, and still with 2+pitting edema in the thigh. Small\n1mm ulcer without purulence draining out of it. Tender to\npalpation.\nNeuro: alert and oriented x 3, moving all extremities\n\nPertinent Results:\nAdmission Labs:\n1933-4-27 12:57PM PT-21.9* INR(PT)-2.', '1\n1933-4-27 04:55PM PLT SMR-LOW PLT COUNT-85\n1933-4-27 04:55PM NEUTS-84.1* LYMPHS-10.2* MONOS-5.3 EOS-0.3\nBASOS-0.2\n1933-4-27 04:55PM WBC-8.4# RBC-3.99* HGB-11.6* HCT-38.6 MCV-97\nMCH-29.0 MCHC-29.9* RDW-17.0\n1933-4-27 04:55PM GLUCOSE-137 UREA N-10 CREAT-2.5# SODIUM-142\nPOTASSIUM-3.1 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13\n1933-4-27 05:02PM LACTATE-2.0\n1933-4-27 08:24PM LACTATE-1.6\n\nDischarge Labs:\n1927-11-21 06:28AM BLOOD WBC-4.4 RBC-3.99* Hgb-12.0 Hct-40.3\nMCV-101* MCH-30.0 MCHC-29.7* RDW-17.4* Plt Ct-94\n1927-11-21 06:28AM BLOOD Glucose-95 UreaN-12 Creat-3.0# Na-133\nK-3.7 Cl-94* HCO3-29 AnGap-14\n1927-11-21 06:28AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8\n1965-11-6 06:29AM BLOOD Vanco-13.0\n1933-4-27 05:02PM BLOOD Lactate-2.0\n\nMicro:\nBlood culture 1933-4-27 PENDING\n\nImaging:\n1933-4-27 LENI- IMPRESSION: Limited examination due to patient\ndiscomfort and extensive subcutaneous edema with no evidence of\ndeep venous thrombosis in the left common femoral, superficial\nfemoral, or popliteal veins.', '\n\n1933-4-27 CXR- Severe cardiomegaly has worsened, but pulmonary\nedema has cleared. Pleural effusion is small if any. Right\nsupraclavicular dual-channel July catheter ends in the\nregion of the superior cavoatrial junction, unchanged.\nTransvenous right atrial pacer and right ventricular pacer\ndefibrillator leads are in standard placements. No pneumothorax\nor appreciable pleural effusion.\n\nBrief Hospital Course:\n71F with history of CHF, CAD, afib on coumadin, ESRD on HD and\nCOPD presenting with LLE cellulitis.\n.\n# Cellulitis - patient with chronic ulcers on left lower\nextremity presented with inreased pain and erythema and elevated\nWBC consistent with cellulitis. She was recently treated for\ncellulitis in that leg with vancomycin on previous\nhospitalization in 1937-10-2. After two days of vancomycin, she\nhad marked improvement in the leg with decreased erythema in\ncolor and was dramatically receeding from the marked border\nbelow the area.', ' There was still 11-20+pitting edema in the left\nthigh, but improved compared to admission when it was harder and\nwas obscuring the anatomical markings of the knee on extension.\nLENI of the leg was negative for DVT. She was seen by vascular\nsurgery during this admission, who did not feel that surgery was\nindicated and agreed with the proposed medical management.\n-Vancomycin dosed with HD x 2 weeks (last day 8-25)\n-Ciprofloxacin 500mg po qday x 2 weeks (last day 8-25)\n.\n#Hypotension - patient hypotensive to SBPs in 80s. In the ED\nthere was concern that she was possibly septic, so she was\nadmited to the ICU. She received 1.5L of IV fluids and her BP\nrepsonded well. Her baseline blood pressure is in the low 90s\nsystolic. After being on the floor she continued to have lower\nblood pressures and was asymptomatic with them.', '\n-She will require monitoring of her blood pressure during\nNovember sessions\n.\n# Afib - on amiodarone and coumadin as outpatient. Stable. INR\ntherapeutic at 2.1 on admission. Continued on home medications\n- cont warfarin and amiodarone\n.\n# CAD - Continued on amiodarone, pravastatin and SLNGT\n.\n# COPD - on spiriva, alubterol and fluticasone at home. Also\nuses 2L NC at night at home. Has had cough for the past 12-15\nweeks and recently started on doxycycline on 9-12, which was\ncontinued for planned 7 day course total and will be completed\non 10-25. No worsening SOB. CXR showed no evidence of PNA\n.\n# chronic sytolic CHF - Continued on home furosemide dose.\nPatinet is not on ACEI prior to this admission, and this was not\nstarted given her hypotension.\n.\n# ESRD - Continued on HD schedule of T-TH-SAT.', ' She received an\nextra ultrafiltration session on 6-9 (friday) to try to remove\nmore fluid from her left leg.\n.\nTransitional Issues:\nPending labs/studies: Blood cultures from 1933-4-27\nMedications started:\n1. Vancomycin (antibiotic) to be given with July through\n8-25. Ciprofloxacin 500mg by mouth once a day through 8-25\nMedications changed: none\nMedications stopped: None\nFollow-up needed for:\n*You will need to have your INR checked at October on\nSaturday 11-9 as you just started ciprofloxacin which can cause\nchanges in this\n1. Monitoring of vancomycin levels at October\n\nWeigh yourself every morning, Zachary Caro MD if weight goes up more\nthan 3 lbs.\n\n\nMedications on Admission:\n Senna-Gen 8.6 mg Tab 2 Tablet(s) by mouth at bedtime\n- Spiriva with HandiHaler 18 mcg & inhalation Caps 1 Capsule(s)\ninhaled once a day\n- cholecalciferol (vitamin D3) 1,000 unit Cap 1 Capsule(s) by\nmouth once a day\n- Calcium 500 500 mg calcium (1,250 mg) Tab\n- pravastatin 20 mg Tab 1 Tablet(s) by mouth DAILY\n- allopurinol 100 mg Tab 1 Tablet(s) by mouth EVERY OTHER DAY\n- doxycycline hyclate 100 mg Cap 1 Capsule(s) by mouth Ramirez-Miller Hospital\n- Vitamin B-1 50 mg Tab\n- albuterol sulfate HFA 90 mcg/Actuation Aerosol Inhaler 1\nHFA(s) inhaled every six (6) hours\n- furosemide 80 mg Tab 1 Tablet(s) by mouth twice a day\n- amiodarone 200 mg Tab 1 Tablet(s) by mouth once a day\n- Nitrostat 0.', '3 mg Sublingual Tab 1 Tablet(s) sublingually every\nfive minutes up to 3 times as needed as needed for chest pain\n- ferrous gluconate 325 mg (37.5 mg iron) Tab 1 Tablet(s) by\nmouth DAILY (Daily)\n- zolpidem 5 mg Tab 1 Tablet(s) by mouth HS (at bedtime)\n- tramadol 50 mg Tab 1 Tablet(s) by mouth for pain\n- docusate sodium 100 mg Cap 1 (One) Capsule(s) by mouth twice a\nday\n- warfarin 1 mg Tab 1 Tablet(s) by mouth once a day\n- Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 Aerosol(s)\ninhaled twice a day\n- B complex-vitamin C-folic acid 400 mcg Tab 1 Tablet(s) by\nmouth DAILY\n\n\nDischarge Medications:\n1. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.\n2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device\nSig: One (1) cap Inhalation once a day.\n3. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)\nCapsule PO once a day.', '\n4. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)\nTablet PO once a day.\n5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.\n6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER\nDAY (Every Other Day).\n7. Vitamin B-1 50 mg Tablet Sig: One (1) Tablet PO once a day.\n8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:\nTwo (2) puffs Inhalation every six (6) hours as needed for\nshortness of breath or wheezing.\n9. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a\nday).\n10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab\nSublingual every five minutes with chest pain, take up to 3 as\nneeded for chest pain.\n12. ferrous gluconate 325 mg (36 mg iron) Tablet Sig: One (1)\nTablet PO once a day.', '\n13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).\n\n14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\nhours) as needed for pain.\n15. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS\n(Aparna,MO,TU,WE,TH,FR,SA).\n16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice\na day.\n17. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs\nInhalation twice a day.\n18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap\nPO DAILY (Daily).\n19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a\nday: on Brianne days take after your Brianne session.\nDisp:11 Tablet(s)* Refills:0\n20. vancomycin 1,000 mg Recon Soln Sig: sliding scale dose\nIntravenous with Brianne: based on Vanc trough drawn at\nBrianne. To be given through 1993-7-22.\nDisp:qs Refills:0\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nMartin-Perez Clinic Michelle Bludsworth\n\nDischarge Diagnosis:\nPrimary: Cellulitis\nSecondary: Atrial fibrillation, Chronic systolic heart failure,\nEnd stage renal disease on Sean Dizon\n\nDischarge Condition:\nMental Status: Clear and coherent.', "\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\nDischarge Instructions:\nDear Ms. Negrete,\nIt was a pleasure taking care of you here at Todd Group Medical Center. You were\nadmitted to the hospital because you were found to have an\ninfection of the skin on your left leg. While you were in the\nemergency room your blood pressure was on the lower side so you\nwere in the ICU for a night to make sure it didn't drop further\nand it was stable (your blood pressure at baseline runs very low\nand you were asymptomatic throughout your ICU stay). You were\nthen transferred to the regular medical floor where you were\nstable.\n\nYou received Rice, Garcia and Thomas Clinic on your regularly scheduled timing, and\nreceived an extra session on Friday.\n\nTransitional Issues:\nPending labs/studies: Blood cultures from 1933-4-27\nMedications started:\n1.", ' Vancomycin (antibiotic) to be given with July through\n8-25. Ciprofloxacin 500mg by mouth once a day through 8-25\nMedications changed: none\nMedications stopped: None\nFollow-up needed for:\n*You will need to have your INR checked at October on\nSaturday 11-9 as you just started ciprofloxacin which can cause\nchanges in this*\n1. Monitoring of vancomycin levels at October\n\nWeigh yourself every morning, Zachary Caro MD if weight goes up more\nthan 3 lbs.\n\nFollowup Instructions:\nName: Kibler,Elijah M.\nLocation: Wright and Sons Health System\nAddress: 15498 Johnson Avenue Suite 158\nWest Laurenville, FM 43989, 15498 Johnson Avenue Suite 158\nWest Laurenville, FM 43989,3894925\nPhone: 341-702-5343\nWhen: Thursday, 3-24, 2:00 PM\n\nDepartment: VASCULAR SURGERY\nWhen: FRIDAY 1912-10-6 at 9:30 AM\nWith: Camilo Merino, MD 232-624-2860\nBuilding: LM Mcconnell Inc Clinic 15498 Johnson Avenue Suite 158\nWest Laurenville, FM 43989\nCampus: WEST Best Parking: Wilson-Le Hospital Garage\n\n\n\n']
230	9805	188132.0	2130-02-09	Discharge summary	Report	Admission Date: [2130-2-3] Discharge Date: [2130-2-9] Date of Birth: [2060-12-25] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 371] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: None History of Present Illness: 69 yo M presents 8 days s/p anal seton placement with a 24 hour history of bright red blood per rectum soaking his clothes. He turned the toilet water dark red approximately 15 times. Multiple large clots seen. He complains of associated dizziness and had hypotension in the ED. Denies fevers, chills, N/V, or change in appetite. Past Medical History: 1. Crohn's dz, found in [2125] on colonoscopy for anal fissure, positive [Doctor First Name ], been treated with Remicade 2. Rheumatoid arthritis 3. HTN 4. hx of renal calculus 5. s/p appendectomy 6. s/p TURP 7. s/p cholecystectomy 8. Recent pulmonary embolism- on coumadin since [2-12] 9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF 25% 10. Chronic left knee pain s/p meniscectomy, synovectomy, and debridement of left knee [2123] 11. Recent gallstone pancreatitis [2-12] 12. Afib - [2-12] rate controlled on atenolol Social History: Married for 46 years and lives with wife. 3 children who all live in area. No tobocco, h/o occasional ETOH, stopped drinking in [11-13], denies h/o ETOH abuse. No illicit drugs. Family History: Father died at 62 from MI Mother died at 52 of cirrhosis No cancer or diabetes to patient's knowledge No hisotry of clotting disorders Physical Exam: At time of discharge: A&O X 3, NAD RRR CTAB Abd soft, NT/ND, +bs, no masses Ext with 2+ pitting edema b/l Strings from seton in place from rectum Pertinent Results: [2130-2-3] 07:00 WBC-11.2* RBC-3.30* Hgb-9.2* Hct-28.2* MCV-85 MCH-27.7 MCHC-32.5 RDW-15.9* Plt Ct-571* [2130-2-3] 11:03AM Hct-22.4* PT-107.3* PTT-40.8* INR(PT)-15.1* [2130-2-3] PT-22.2* PTT-30.9 INR(PT)-2.2* Fibrino-412# Glucose-108 UreaN-19 Creat-1.4* Na-139 K-3.9 Cl-106 HCO3-23 AnGap-14 CK-MB-NotDone cTropnT-0.03* CK-MB-2 cTropnT-0.03* Phos-2.9 Mg-1.0* 03/02/06PT-15.3* PTT-30.2 INR(PT)-1.4* BLOOD Hct-28.7* Brief Hospital Course: On [2130-2-3] Mr. [Known lastname 2302] was admitted to the surgery service under the care of Dr. [Last Name (STitle) ] with the diagnosis of a lower GI bleed. His initial Hct was 28 and initial INR was 15. He was admitted to the ICU and resuscitated. He was transfused 2 units of PRBCs for a Hct of 22, and 2 units of FFP to reverse his anticoagulation. He was also given Vitamin K. The following day he was transfused 4 more units of PRBCs. The GI service was consulted and 2 attempts were made to do a colonoscopy. Both attempts were aborted due to a poor preparation. After 3 days in the ICU, Mr. [Known lastname 2303] Hct was stable at 26-27. He was transferred to the floor and given 1 more unit of PRBCs for borderline urine output. His Hct then stabilized at 28-29. Since he had no more episodes of bloody bowel movements, it was felt that there was no need to make further attempts at colonoscopy. His diet was then slowly advanced, physical therapy evaluated the patient, and he was discharged to rehab on HD 7. He will follow-up with Dr. [Last Name (STitle) 1940] from GI as well as his PCP regarding his coumadin dose and INR checks. At the time of discharge he was placed on coumadin 1mg Qhs (h/o PE and cardiac thrombus) and his INR was 1.4. His Hct was 28.7. Medications on Admission: Protonix, Lisinopril, Atenolol, Hydroxychloroquine, Lasix, Percocet, colace, lidocaine ointment, Coumadin Discharge Medications: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Follow INR with PCP. [Name Initial (NameIs) ]:30 Tablet(s) Refills:2 6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [Name Initial (NameIs) ]:20 Tablet(s) Refills:0 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Lower GI bleed Discharge Condition: Good Discharge Instructions: Please call your doctor or go to the ER if you experience any of the following: high fevers, severe pain, increasing nausea/emesis, dizziness, or increasing amount of blood in your stool. Please resume all prehospital medications and take all new ones as prescribed. Follow-up with your PCP regarding your coumadin levels. Followup Instructions: 1. Dr. [Last Name (STitle) 1940] (GI) - please call for appointment [Telephone/Fax (1) 1983] 2. [Name6 (MD) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time: [2130-3-8] 10:10 PCP [Name Initial (PRE) ] [Name10 (NameIs) ] call results of INR to your primary care physician	Admission Date: <Date>1977-8-27</Date> Discharge Date: <Date>1958-3-27</Date> Date of Birth: <Date>1961-10-29</Date> Sex: M Service: SURGERY Allergies: Penicillins Attending:<Name>Pamela</Name> Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: None History of Present Illness: 69 yo M presents 8 days s/p anal seton placement with a 24 hour history of bright red blood per rectum soaking his clothes. He turned the toilet water dark red approximately 15 times. Multiple large clots seen. He complains of associated dizziness and had hypotension in the ED. Denies fevers, chills, N/V, or change in appetite. Past Medical History: 1. Crohn's dz, found in <Year>2009</Year> on colonoscopy for anal fissure, positive <Name>Lillie</Name>, been treated with Remicade 2. Rheumatoid arthritis 3. HTN 4. hx of renal calculus 5. s/p appendectomy 6. s/p TURP 7. s/p cholecystectomy 8. Recent pulmonary embolism- on coumadin since <Date>9-24</Date> 9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF 25% 10. Chronic left knee pain s/p meniscectomy, synovectomy, and debridement of left knee <Year>2009</Year> 11. Recent gallstone pancreatitis <Date>9-24</Date> 12. Afib - <Date>9-24</Date> rate controlled on atenolol Social History: Married for 46 years and lives with wife. 3 children who all live in area. No tobocco, h/o occasional ETOH, stopped drinking in <Date>11-10</Date>, denies h/o ETOH abuse. No illicit drugs. Family History: Father died at 62 from MI Mother died at 52 of cirrhosis No cancer or diabetes to patient's knowledge No hisotry of clotting disorders Physical Exam: At time of discharge: A&O X 3, NAD RRR CTAB Abd soft, NT/ND, +bs, no masses Ext with 2+ pitting edema b/l Strings from seton in place from rectum Pertinent Results: <Date>1977-8-27</Date> 07:00 WBC-11.2* RBC-3.30* Hgb-9.2* Hct-28.2* MCV-85 MCH-27.7 MCHC-32.5 RDW-15.9* Plt Ct-571* <Date>1977-8-27</Date> 11:03AM Hct-22.4* PT-107.3* PTT-40.8* INR(PT)-15.1* <Date>1977-8-27</Date> PT-22.2* PTT-30.9 INR(PT)-2.2* Fibrino-412# Glucose-108 UreaN-19 Creat-1.4* Na-139 K-3.9 Cl-106 HCO3-23 AnGap-14 CK-MB-NotDone cTropnT-0.03* CK-MB-2 cTropnT-0.03* Phos-2.9 Mg-1.0* 03/02/06PT-15.3* PTT-30.2 INR(PT)-1.4* BLOOD Hct-28.7* Brief Hospital Course: On <Date>1977-8-27</Date> Mr. <Name>Ceja</Name> was admitted to the surgery service under the care of Dr. <Name>Naegelin</Name> with the diagnosis of a lower GI bleed. His initial Hct was 28 and initial INR was 15. He was admitted to the ICU and resuscitated. He was transfused 2 units of PRBCs for a Hct of 22, and 2 units of FFP to reverse his anticoagulation. He was also given Vitamin K. The following day he was transfused 4 more units of PRBCs. The GI service was consulted and 2 attempts were made to do a colonoscopy. Both attempts were aborted due to a poor preparation. After 3 days in the ICU, Mr. <Name>Post</Name> Hct was stable at 26-27. He was transferred to the floor and given 1 more unit of PRBCs for borderline urine output. His Hct then stabilized at 28-29. Since he had no more episodes of bloody bowel movements, it was felt that there was no need to make further attempts at colonoscopy. His diet was then slowly advanced, physical therapy evaluated the patient, and he was discharged to rehab on HD 7. He will follow-up with Dr. <Name>Loveland</Name> from GI as well as his PCP regarding his coumadin dose and INR checks. At the time of discharge he was placed on coumadin 1mg Qhs (h/o PE and cardiac thrombus) and his INR was 1.4. His Hct was 28.7. Medications on Admission: Protonix, Lisinopril, Atenolol, Hydroxychloroquine, Lasix, Percocet, colace, lidocaine ointment, Coumadin Discharge Medications: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Follow INR with PCP. <Name>Teressa Belle</Name>:30 Tablet(s) Refills:2 6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. <Name>Teressa Belle</Name>:20 Tablet(s) Refills:0 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: <Hospital>Benjamin-Wyatt Medical Center</Hospital> - <Location>971 Roy Dam Williamsview, NJ 89793</Location> Discharge Diagnosis: Lower GI bleed Discharge Condition: Good Discharge Instructions: Please call your doctor or go to the ER if you experience any of the following: high fevers, severe pain, increasing nausea/emesis, dizziness, or increasing amount of blood in your stool. Please resume all prehospital medications and take all new ones as prescribed. Follow-up with your PCP regarding your coumadin levels. Followup Instructions: 1. Dr. <Name>Loveland</Name> (GI) - please call for appointment <Telephone>428-340-8876</Telephone> 2. <Name>Zachary Turcios</Name> <Name>Rebeca Cobbs</Name>, MD Phone:<Telephone>358-652-4654</Telephone> Date/Time: <Date>1970-11-11</Date> 10:10 PCP <Name>Bo Ahmed</Name> <Name>Araceli Lockett</Name> call results of INR to your primary care 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Date: 1977-8-27 Discharge Date: 1958-3-27 Date of Birth: 1961-10-29 Sex: M Service: SURGERY Allergies: Penicillins Attending:Pamela Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: None History of Present Illness: 69 yo M presents 8 days s/p anal seton placement with a 24 hour history of bright red blood per rectum soaking his clothes. He turned the toilet water dark red approximately 15 times. Multiple large clots seen. He complains of associated dizziness and had hypotension in the ED. Denies fevers, chills, N/V, or change in appetite. Past Medical History: 1. Crohn's dz, found in 2009 on colonoscopy for anal fissure, positive Lillie, been treated with Remicade 2. Rheumatoid arthritis 3. HTN 4. hx of renal calculus 5. s/p appendectomy 6. s/p TURP 7. s/p cholecystectomy 8. Recent pulmonary embolism- on coumadin since 9-24 9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF 25% 10. Chronic left knee pain s/p meniscectomy, synovectomy, and debridement of left knee 2009 11. Recent gallstone pancreatitis 9-24 12. Afib - 9-24 rate controlled on atenolol Social History: Married for 46 years and lives with wife. 3 children who all live in area. No tobocco, h/o occasional ETOH, stopped drinking in 11-10, denies h/o ETOH abuse. No illicit drugs. Family History: Father died at 62 from MI Mother died at 52 of cirrhosis No cancer or diabetes to patient's knowledge No hisotry of clotting disorders Physical Exam: At time of discharge: A&O X 3, NAD RRR CTAB Abd soft, NT/ND, +bs, no masses Ext with 2+ pitting edema b/l Strings from seton in place from rectum Pertinent Results: 1977-8-27 07:00 WBC-11.2* RBC-3.30* Hgb-9.2* Hct-28.2* MCV-85 MCH-27.7 MCHC-32.5 RDW-15.9* Plt Ct-571* 1977-8-27 11:03AM Hct-22.4* PT-107.3* PTT-40.8* INR(PT)-15.1* 1977-8-27 PT-22.2* PTT-30.9 INR(PT)-2.2* Fibrino-412# Glucose-108 UreaN-19 Creat-1.4* Na-139 K-3.9 Cl-106 HCO3-23 AnGap-14 CK-MB-NotDone cTropnT-0.03* CK-MB-2 cTropnT-0.03* Phos-2.9 Mg-1.0* 03/02/06PT-15.3* PTT-30.2 INR(PT)-1.4* BLOOD Hct-28.7* Brief Hospital Course: On 1977-8-27 Mr. Ceja was admitted to the surgery service under the care of Dr. Naegelin with the diagnosis of a lower GI bleed. His initial Hct was 28 and initial INR was 15. He was admitted to the ICU and resuscitated. He was transfused 2 units of PRBCs for a Hct of 22, and 2 units of FFP to reverse his anticoagulation. He was also given Vitamin K. The following day he was transfused 4 more units of PRBCs. The GI service was consulted and 2 attempts were made to do a colonoscopy. Both attempts were aborted due to a poor preparation. After 3 days in the ICU, Mr. Post Hct was stable at 26-27. He was transferred to the floor and given 1 more unit of PRBCs for borderline urine output. His Hct then stabilized at 28-29. Since he had no more episodes of bloody bowel movements, it was felt that there was no need to make further attempts at colonoscopy. His diet was then slowly advanced, physical therapy evaluated the patient, and he was discharged to rehab on HD 7. He will follow-up with Dr. Loveland from GI as well as his PCP regarding his coumadin dose and INR checks. At the time of discharge he was placed on coumadin 1mg Qhs (h/o PE and cardiac thrombus) and his INR was 1.4. His Hct was 28.7. Medications on Admission: Protonix, Lisinopril, Atenolol, Hydroxychloroquine, Lasix, Percocet, colace, lidocaine ointment, Coumadin Discharge Medications: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Follow INR with PCP. Teressa Belle:30 Tablet(s) Refills:2 6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Teressa Belle:20 Tablet(s) Refills:0 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Benjamin-Wyatt Medical Center - 971 Roy Dam Williamsview, NJ 89793 Discharge Diagnosis: Lower GI bleed Discharge Condition: Good Discharge Instructions: Please call your doctor or go to the ER if you experience any of the following: high fevers, severe pain, increasing nausea/emesis, dizziness, or increasing amount of blood in your stool. Please resume all prehospital medications and take all new ones as prescribed. Follow-up with your PCP regarding your coumadin levels. Followup Instructions: 1. Dr. Loveland (GI) - please call for appointment 428-340-8876 2. Zachary Turcios Rebeca Cobbs, MD Phone:358-652-4654 Date/Time: 1970-11-11 10:10 PCP Bo Ahmed Araceli Lockett call results of INR to your primary care physician	["Admission Date: 1977-8-27 Discharge Date: 1958-3-27\n\nDate of Birth: 1961-10-29 Sex: M\n\nService: SURGERY\n\nAllergies:\nPenicillins\n\nAttending:Pamela\nChief Complaint:\nBright red blood per rectum\n\nMajor Surgical or Invasive Procedure:\nNone\n\n\nHistory of Present Illness:\n69 yo M presents 8 days s/p anal seton placement with a 24 hour\nhistory of bright red blood per rectum soaking his clothes. He\nturned the toilet water dark red approximately 15 times.\nMultiple large clots seen. He complains of associated dizziness\nand had hypotension in the ED. Denies fevers, chills, N/V, or\nchange in appetite.\n\nPast Medical History:\n1. Crohn's dz, found in 2009 on colonoscopy for anal fissure,\npositive Lillie, been treated with Remicade\n2. Rheumatoid arthritis\n3. HTN\n4. hx of renal calculus\n5.", " s/p appendectomy\n6. s/p TURP\n7. s/p cholecystectomy\n8. Recent pulmonary embolism- on coumadin since 9-24\n9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF\n25%\n10. Chronic left knee pain s/p meniscectomy, synovectomy, and\ndebridement of left knee 2009\n11. Recent gallstone pancreatitis 9-24\n12. Afib - 9-24 rate controlled on atenolol\n\n\nSocial History:\nMarried for 46 years and lives with wife. 3 children who all\nlive in area. No tobocco, h/o occasional ETOH, stopped drinking\nin 11-10, denies h/o ETOH abuse. No illicit drugs.\n\n\nFamily History:\nFather died at 62 from MI\nMother died at 52 of cirrhosis\nNo cancer or diabetes to patient's knowledge\nNo hisotry of clotting disorders\n\nPhysical Exam:\nAt time of discharge:\n\nA&O X 3, NAD\nRRR\nCTAB\nAbd soft, NT/ND, +bs, no masses\nExt with 2+ pitting edema b/l\nStrings from seton in place from rectum\n\nPertinent Results:\n1977-8-27 07:00 WBC-11.", '2* RBC-3.30* Hgb-9.2* Hct-28.2* MCV-85\nMCH-27.7 MCHC-32.5 RDW-15.9* Plt Ct-571\n1977-8-27 11:03AM Hct-22.4\nPT-107.3* PTT-40.8* INR(PT)-15.1\n1977-8-27 PT-22.2 PTT-30.9 INR(PT)-2.2* Fibrino-412#\nGlucose-108 UreaN-19 Creat-1.4* Na-139 K-3.9 Cl-106 HCO3-23\nAnGap-14\nCK-MB-NotDone cTropnT-0.03\nCK-MB-2 cTropnT-0.03\nPhos-2.9 Mg-1.0\n03/02/06PT-15.3 PTT-30.2 INR(PT)-1.4* BLOOD Hct-28.7\n\nBrief Hospital Course:\nOn 1977-8-27 Mr. Ceja was admitted to the surgery service\nunder the care of Dr. Naegelin with the diagnosis of a lower GI\nbleed. His initial Hct was 28 and initial INR was 15. He was\nadmitted to the ICU and resuscitated. He was transfused 2 units\nof PRBCs for a Hct of 22, and 2 units of FFP to reverse his\nanticoagulation. He was also given Vitamin K. The following day\nhe was transfused 4 more units of PRBCs.', ' The GI service was\nconsulted and 2 attempts were made to do a colonoscopy. Both\nattempts were aborted due to a poor preparation. After 3 days in\nthe ICU, Mr. Post Hct was stable at 26-27. He was\ntransferred to the floor and given 1 more unit of PRBCs for\nborderline urine output. His Hct then stabilized at 28-29. Since\nhe had no more episodes of bloody bowel movements, it was felt\nthat there was no need to make further attempts at colonoscopy.\nHis diet was then slowly advanced, physical therapy evaluated\nthe patient, and he was discharged to rehab on HD 7. He will\nfollow-up with Dr. Loveland from GI as well as his PCP regarding\nhis coumadin dose and INR checks. At the time of discharge he\nwas placed on coumadin 1mg Qhs (h/o PE and cardiac thrombus) and\nhis INR was 1.4. His Hct was 28.7.\n\nMedications on Admission:\nProtonix, Lisinopril, Atenolol, Hydroxychloroquine, Lasix,\nPercocet, colace, lidocaine ointment, Coumadin\n\nDischarge Medications:\n1.', ' Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO once a day.\n2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.\n3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.\n4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.\n5. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime:\nFollow INR with PCP.\nTeressa Belle:30 Tablet(s)* Refills:2\n6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.\nTeressa Belle:20 Tablet(s) Refills:0\n7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.\n8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO once\na day.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nBenjamin-Wyatt Medical Center - 971 Roy Dam\nWilliamsview, NJ 89793\n\nDischarge Diagnosis:\nLower GI bleed\n\n\nDischarge Condition:\nGood\n\n\nDischarge Instructions:\nPlease call your doctor or go to the ER if you experience any of\nthe following: high fevers, severe pain, increasing\nnausea/emesis, dizziness, or increasing amount of blood in your\nstool.', ' Please resume all prehospital medications and take all\nnew ones as prescribed. Follow-up with your PCP regarding your\ncoumadin levels.\n\nFollowup Instructions:\n1. Dr. Loveland (GI) - please call for appointment 428-340-8876\n2. Zachary Turcios Rebeca Cobbs, MD Phone:358-652-4654 Date/Time: 1970-11-11 10:10\nPCP Bo Ahmed Araceli Lockett call results of INR to your primary care physician\n\n\n\n']
231	9805	177212.0	2131-07-05	Discharge summary	Report	Admission Date: [2131-6-28] Discharge Date: [2131-7-5] Date of Birth: [2060-12-25] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 678] Chief Complaint: Mr. [Known lastname 2302] is a 70 y.o. male with hx of Crohn's disease, afib, dilated CMP and PE (on coumadin), who presents with hematochezia/BRBPR in setting of INR 7.7. Major Surgical or Invasive Procedure: Colonoscopy w/ multiple Bx History of Present Illness: Patient had felt well during the last 2 weeks prior to admission, although he had noticed slightly red/pink tinge to his stool occasionally. Three days prior to admission, pt had an INR of 2.7 at coumadin clinic. One day prior to presenation, the patient self-started asacol from previous prescription because worsening of rectal chrone's disease. On day of presentation, pt began having dark red bloody BMs, had ~15 episodes before calling EMS. Upon ED arrival, had several additional large bloody BMs. He received vitamin K SQ, 2 FFP, and 2 PRBC for stabilization of bleeding. BP was stable throughout. Past Medical History: 1. Crohn's dz, found in [2125] on colonoscopy for anal fissure, positive [Doctor First Name ], been treated with Remicade 2. Rheumatoid arthritis 3. HTN 4. hx of renal calculus 5. s/p appendectomy 6. s/p TURP 7. s/p cholecystectomy 8. Recent pulmonary embolism- on coumadin since [2-12] 9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF 25% 10. Chronic left knee pain s/p meniscectomy, synovectomy, and debridement of left knee [2123] 11. Recent gallstone pancreatitis [2-12] 12. Afib - [2-12] rate controlled on atenolol Social History: Married for 46 years and lives with wife. 3 children who all live in area. No tobocco, h/o occasional ETOH, stopped drinking in [11-13], denies h/o ETOH abuse. No illicit drugs. Family History: Father died at 62 from MI Mother died at 52 of cirrhosis No cancer or diabetes to patient's knowledge No hisotry of clotting disorders Physical Exam: Exam afebrile, BP 100s/60s, 98%RA, HR 70s NAD, alert and talkative lungs clear irreg, distant S1S2 abdomen soft rectum with significant erythema/maceration, dark red blood in vault, Pertinent Results: [2131-6-28] 10:00PM BLOOD WBC-8.0 RBC-3.50* Hgb-9.0* Hct-27.2* MCV-78* MCH-25.7# MCHC-33.1 RDW-16.1 Plt Ct-384 [2131-6-28] 10:00PM BLOOD Neuts-80.0* Lymphs-14.5* Monos-4.7 Eos-0.6 Baso-0.1 [2131-6-28] 10:00PM BLOOD PT-62.1* PTT-39.2* INR(PT)-7.7* [2131-6-28] 10:00PM BLOOD Glucose-96 UreaN-20 Creat-1.6* Na-137 K-3.8 Cl-107 HCO3-23 AnGap-11 [2131-6-28] 10:00PM BLOOD CK(CPK)-58 [2131-6-28] 10:00PM BLOOD CK-MB-NotDone cTropnT-0.06* [2131-6-29] 04:15AM BLOOD Calcium-7.7* Phos-3.5 Mg-1.6 EKG: Baseline artifact. Regular rhythm with left anterior fascicular block and right bundle-branch block configuration, probably sinus rhythm. Since the previous tracing of [2130-2-3] the QRS width is wider and R wave reversal in the lateral precordial leads is more marked, related to axis or lateral myocardial infarction. Clinical correlation is suggested. Brief Hospital Course: ## Hematochezia/Crohn's: Likely [1-12] combination of known Crohn's and overanticoagulation most likely due to drug interaction of coumadin w/ sasacol. Received 2Units FFP and 1 unit PRBC + vit K. With drop of Hct as low as 23.6, 27.0 upon d/c. INR upon d/c 1.0. Underwent colonoscopy showing ulcer in proximal ascending colon which wx bx to exclude ulcerated neoplasia, chrohn's dz which was bx, and pseudopolyps in the descending colon and sigmoid colon. . ## ARF: likely hypovolemia in setting of GIB, Cr of 1.6 from baseline of 1.0. Currently back to baseline. . ## Paroxysmal atrial fibrillation: in sinus rhythm on [Month/Day (2) 2304]. - hold anticoag for now as risks outweigh benefits. Will be restarted w/ f/u w/ PCP. [Name10 (NameIs) ] control meds because of bleeding, pt not in AF on [Last Name (LF) 2304], [First Name3 (LF) ] restart BB w/ d/c to rehab facility. ## HTN: Meds held in setting of bleed, restarting OP meds w/ d/c to rehab. Holding lasix [1-12] to continued dehydration [1-12] to poor PO intake. . ## DCM: appears euvolemic - hold furosemide in setting of GI bleed . ## h/o PE, LV thrombus: - hold anticoag in setting of GI bleed, will restart as outpatient. Medications on Admission: ASPIRIN 81 daily ATENOLOL 50 daily ATIVAN 0.5 [Hospital1 ] prn anxiety WARFARIN with goal INR [1-13] CYANOCOBALAMIN 1,000 mcg daily FUROSEMIDE 40 mg daily LISINOPRIL 10 mg daily Lidocaine-Hydrocortisone Ac 3-0.5 %--Thin film rectally daily MVI PLAQUENIL 200 mg [Hospital1 ] Tylenol #3 prn pain ASACOL 1200 mg tid PANTOPRAZOLE 40 mg daily Discharge Medications: 1. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q4-6H (every 4 to 6 hours). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 533] [Last Name (NamePattern1) ] for Extended Care - [Location 1268] Discharge Diagnosis: Lower GI Bleed Discharge Condition: Stable Discharge Instructions: You are being discharged from the hospital after an admission for a lower gastrointestinal bleed. Because of significant blood loss, you were stabilized throughout the admission with transfusion of blood products and clotting proteins. You underwent colonoscopy to evaluate for source of the bleeding. It not only showed multiple areas of sick colon consistent with your Chron's disease, but also a non-bleeding ulcer in the bowel. Multiple biopsy's were taken, results pending. The most likely cause of your bleeding is your very low ability to clot due to a reaction between your blood thinner coumadin and the asacol which you started. Both medications are being stopped, and only restarted after discussion between your PCP and your Gastroenterologist. After being evaluated by Physical Therapy, it is felt that you would benefit from a short stay in an acute rehab facility to help improve your strength after this hospitalization. Followup Instructions: Follow up w/ Dr. [First Name (STitle) 216] in [12-12] weeks ([Telephone/Fax (1) 1300] Follow up w/ Dr. [Last Name (STitle) 2305] in [12-12] weeks ([Telephone/Fax (1) 2306] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 684]	Admission Date: <Date>1928-11-20</Date> Discharge Date: <Date>1909-6-28</Date> Date of Birth: <Date>1974-11-18</Date> Sex: M Service: MEDICINE Allergies: Penicillins Attending:<Name>Lorena</Name> Chief Complaint: Mr. <Name>Lockett</Name> is a 70 y.o. male with hx of Crohn's disease, afib, dilated CMP and PE (on coumadin), who presents with hematochezia/BRBPR in setting of INR 7.7. Major Surgical or Invasive Procedure: Colonoscopy w/ multiple Bx History of Present Illness: Patient had felt well during the last 2 weeks prior to admission, although he had noticed slightly red/pink tinge to his stool occasionally. Three days prior to admission, pt had an INR of 2.7 at coumadin clinic. One day prior to presenation, the patient self-started asacol from previous prescription because worsening of rectal chrone's disease. On day of presentation, pt began having dark red bloody BMs, had ~15 episodes before calling EMS. Upon ED arrival, had several additional large bloody BMs. He received vitamin K SQ, 2 FFP, and 2 PRBC for stabilization of bleeding. BP was stable throughout. Past Medical History: 1. Crohn's dz, found in <Year>2017</Year> on colonoscopy for anal fissure, positive <Name>Sachin</Name>, been treated with Remicade 2. Rheumatoid arthritis 3. HTN 4. hx of renal calculus 5. s/p appendectomy 6. s/p TURP 7. s/p cholecystectomy 8. Recent pulmonary embolism- on coumadin since <Date>2-29</Date> 9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF 25% 10. Chronic left knee pain s/p meniscectomy, synovectomy, and debridement of left knee <Year>2017</Year> 11. Recent gallstone pancreatitis <Date>2-29</Date> 12. Afib - <Date>2-29</Date> rate controlled on atenolol Social History: Married for 46 years and lives with wife. 3 children who all live in area. No tobocco, h/o occasional ETOH, stopped drinking in <Date>12-6</Date>, denies h/o ETOH abuse. No illicit drugs. Family History: Father died at 62 from MI Mother died at 52 of cirrhosis No cancer or diabetes to patient's knowledge No hisotry of clotting disorders Physical Exam: Exam afebrile, BP 100s/60s, 98%RA, HR 70s NAD, alert and talkative lungs clear irreg, distant S1S2 abdomen soft rectum with significant erythema/maceration, dark red blood in vault, Pertinent Results: <Date>1928-11-20</Date> 10:00PM BLOOD WBC-8.0 RBC-3.50* Hgb-9.0* Hct-27.2* MCV-78* MCH-25.7# MCHC-33.1 RDW-16.1 Plt Ct-384 <Date>1928-11-20</Date> 10:00PM BLOOD Neuts-80.0* Lymphs-14.5* Monos-4.7 Eos-0.6 Baso-0.1 <Date>1928-11-20</Date> 10:00PM BLOOD PT-62.1* PTT-39.2* INR(PT)-7.7* <Date>1928-11-20</Date> 10:00PM BLOOD Glucose-96 UreaN-20 Creat-1.6* Na-137 K-3.8 Cl-107 HCO3-23 AnGap-11 <Date>1928-11-20</Date> 10:00PM BLOOD CK(CPK)-58 <Date>1928-11-20</Date> 10:00PM BLOOD CK-MB-NotDone cTropnT-0.06* <Date>1939-12-28</Date> 04:15AM BLOOD Calcium-7.7* Phos-3.5 Mg-1.6 EKG: Baseline artifact. Regular rhythm with left anterior fascicular block and right bundle-branch block configuration, probably sinus rhythm. Since the previous tracing of <Date>1999-6-29</Date> the QRS width is wider and R wave reversal in the lateral precordial leads is more marked, related to axis or lateral myocardial infarction. Clinical correlation is suggested. Brief Hospital Course: ## Hematochezia/Crohn's: Likely <Date>5-15</Date> combination of known Crohn's and overanticoagulation most likely due to drug interaction of coumadin w/ sasacol. Received 2Units FFP and 1 unit PRBC + vit K. With drop of Hct as low as 23.6, 27.0 upon d/c. INR upon d/c 1.0. Underwent colonoscopy showing ulcer in proximal ascending colon which wx bx to exclude ulcerated neoplasia, chrohn's dz which was bx, and pseudopolyps in the descending colon and sigmoid colon. . ## ARF: likely hypovolemia in setting of GIB, Cr of 1.6 from baseline of 1.0. Currently back to baseline. . ## Paroxysmal atrial fibrillation: in sinus rhythm on <Month>June</Month>. - hold anticoag for now as risks outweigh benefits. Will be restarted w/ f/u w/ PCP. <Name>Mitra Harris</Name> control meds because of bleeding, pt not in AF on <Name>Lewis</Name>, <Name>Marek</Name> restart BB w/ d/c to rehab facility. ## HTN: Meds held in setting of bleed, restarting OP meds w/ d/c to rehab. Holding lasix <Date>5-15</Date> to continued dehydration <Date>5-15</Date> to poor PO intake. . ## DCM: appears euvolemic - hold furosemide in setting of GI bleed . ## h/o PE, LV thrombus: - hold anticoag in setting of GI bleed, will restart as outpatient. Medications on Admission: ASPIRIN 81 daily ATENOLOL 50 daily ATIVAN 0.5 <Hospital>Thompson PLC Health System</Hospital> prn anxiety WARFARIN with goal INR <Date>2-8</Date> CYANOCOBALAMIN 1,000 mcg daily FUROSEMIDE 40 mg daily LISINOPRIL 10 mg daily Lidocaine-Hydrocortisone Ac 3-0.5 %--Thin film rectally daily MVI PLAQUENIL 200 mg <Hospital>Thompson PLC Health System</Hospital> Tylenol #3 prn pain ASACOL 1200 mg tid PANTOPRAZOLE 40 mg daily Discharge Medications: 1. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q4-6H (every 4 to 6 hours). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: <Name>Lorena</Name> <Name>Bludsworth</Name> for Extended Care - <Location>91490 Kenneth Dale Robertmouth, KY 14842</Location> Discharge Diagnosis: Lower GI Bleed Discharge Condition: Stable Discharge Instructions: You are being discharged from the hospital after an admission for a lower gastrointestinal bleed. Because of significant blood loss, you were stabilized throughout the admission with transfusion of blood products and clotting proteins. You underwent colonoscopy to evaluate for source of the bleeding. It not only showed multiple areas of sick colon consistent with your Chron's disease, but also a non-bleeding ulcer in the bowel. Multiple biopsy's were taken, results pending. The most likely cause of your bleeding is your very low ability to clot due to a reaction between your blood thinner coumadin and the asacol which you started. Both medications are being stopped, and only restarted after discussion between your PCP and your Gastroenterologist. After being evaluated by Physical Therapy, it is felt that you would benefit from a short stay in an acute rehab facility to help improve your strength after this hospitalization. Followup Instructions: Follow up w/ Dr. <Name>Tracy</Name> in <Date>4-22</Date> weeks (<Telephone>856-754-4014</Telephone> Follow up w/ Dr. <Name>Tamaro</Name> in <Date>4-22</Date> weeks (<Telephone>792-813-9034</Telephone> <Name>Gregory Ahmed</Name> <Name>Araceli Caro</Name> MD <MD Number>15102140</MD 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Date: 1928-11-20 Discharge Date: 1909-6-28 Date of Birth: 1974-11-18 Sex: M Service: MEDICINE Allergies: Penicillins Attending:Lorena Chief Complaint: Mr. Lockett is a 70 y.o. male with hx of Crohn's disease, afib, dilated CMP and PE (on coumadin), who presents with hematochezia/BRBPR in setting of INR 7.7. Major Surgical or Invasive Procedure: Colonoscopy w/ multiple Bx History of Present Illness: Patient had felt well during the last 2 weeks prior to admission, although he had noticed slightly red/pink tinge to his stool occasionally. Three days prior to admission, pt had an INR of 2.7 at coumadin clinic. One day prior to presenation, the patient self-started asacol from previous prescription because worsening of rectal chrone's disease. On day of presentation, pt began having dark red bloody BMs, had ~15 episodes before calling EMS. Upon ED arrival, had several additional large bloody BMs. He received vitamin K SQ, 2 FFP, and 2 PRBC for stabilization of bleeding. BP was stable throughout. Past Medical History: 1. Crohn's dz, found in 2017 on colonoscopy for anal fissure, positive Sachin, been treated with Remicade 2. Rheumatoid arthritis 3. HTN 4. hx of renal calculus 5. s/p appendectomy 6. s/p TURP 7. s/p cholecystectomy 8. Recent pulmonary embolism- on coumadin since 2-29 9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF 25% 10. Chronic left knee pain s/p meniscectomy, synovectomy, and debridement of left knee 2017 11. Recent gallstone pancreatitis 2-29 12. Afib - 2-29 rate controlled on atenolol Social History: Married for 46 years and lives with wife. 3 children who all live in area. No tobocco, h/o occasional ETOH, stopped drinking in 12-6, denies h/o ETOH abuse. No illicit drugs. Family History: Father died at 62 from MI Mother died at 52 of cirrhosis No cancer or diabetes to patient's knowledge No hisotry of clotting disorders Physical Exam: Exam afebrile, BP 100s/60s, 98%RA, HR 70s NAD, alert and talkative lungs clear irreg, distant S1S2 abdomen soft rectum with significant erythema/maceration, dark red blood in vault, Pertinent Results: 1928-11-20 10:00PM BLOOD WBC-8.0 RBC-3.50* Hgb-9.0* Hct-27.2* MCV-78* MCH-25.7# MCHC-33.1 RDW-16.1 Plt Ct-384 1928-11-20 10:00PM BLOOD Neuts-80.0* Lymphs-14.5* Monos-4.7 Eos-0.6 Baso-0.1 1928-11-20 10:00PM BLOOD PT-62.1* PTT-39.2* INR(PT)-7.7* 1928-11-20 10:00PM BLOOD Glucose-96 UreaN-20 Creat-1.6* Na-137 K-3.8 Cl-107 HCO3-23 AnGap-11 1928-11-20 10:00PM BLOOD CK(CPK)-58 1928-11-20 10:00PM BLOOD CK-MB-NotDone cTropnT-0.06* 1939-12-28 04:15AM BLOOD Calcium-7.7* Phos-3.5 Mg-1.6 EKG: Baseline artifact. Regular rhythm with left anterior fascicular block and right bundle-branch block configuration, probably sinus rhythm. Since the previous tracing of 1999-6-29 the QRS width is wider and R wave reversal in the lateral precordial leads is more marked, related to axis or lateral myocardial infarction. Clinical correlation is suggested. Brief Hospital Course: ## Hematochezia/Crohn's: Likely 5-15 combination of known Crohn's and overanticoagulation most likely due to drug interaction of coumadin w/ sasacol. Received 2Units FFP and 1 unit PRBC + vit K. With drop of Hct as low as 23.6, 27.0 upon d/c. INR upon d/c 1.0. Underwent colonoscopy showing ulcer in proximal ascending colon which wx bx to exclude ulcerated neoplasia, chrohn's dz which was bx, and pseudopolyps in the descending colon and sigmoid colon. . ## ARF: likely hypovolemia in setting of GIB, Cr of 1.6 from baseline of 1.0. Currently back to baseline. . ## Paroxysmal atrial fibrillation: in sinus rhythm on June. - hold anticoag for now as risks outweigh benefits. Will be restarted w/ f/u w/ PCP. Mitra Harris control meds because of bleeding, pt not in AF on Lewis, Marek restart BB w/ d/c to rehab facility. ## HTN: Meds held in setting of bleed, restarting OP meds w/ d/c to rehab. Holding lasix 5-15 to continued dehydration 5-15 to poor PO intake. . ## DCM: appears euvolemic - hold furosemide in setting of GI bleed . ## h/o PE, LV thrombus: - hold anticoag in setting of GI bleed, will restart as outpatient. Medications on Admission: ASPIRIN 81 daily ATENOLOL 50 daily ATIVAN 0.5 Thompson PLC Health System prn anxiety WARFARIN with goal INR 2-8 CYANOCOBALAMIN 1,000 mcg daily FUROSEMIDE 40 mg daily LISINOPRIL 10 mg daily Lidocaine-Hydrocortisone Ac 3-0.5 %--Thin film rectally daily MVI PLAQUENIL 200 mg Thompson PLC Health System Tylenol #3 prn pain ASACOL 1200 mg tid PANTOPRAZOLE 40 mg daily Discharge Medications: 1. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q4-6H (every 4 to 6 hours). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Lorena Bludsworth for Extended Care - 91490 Kenneth Dale Robertmouth, KY 14842 Discharge Diagnosis: Lower GI Bleed Discharge Condition: Stable Discharge Instructions: You are being discharged from the hospital after an admission for a lower gastrointestinal bleed. Because of significant blood loss, you were stabilized throughout the admission with transfusion of blood products and clotting proteins. You underwent colonoscopy to evaluate for source of the bleeding. It not only showed multiple areas of sick colon consistent with your Chron's disease, but also a non-bleeding ulcer in the bowel. Multiple biopsy's were taken, results pending. The most likely cause of your bleeding is your very low ability to clot due to a reaction between your blood thinner coumadin and the asacol which you started. Both medications are being stopped, and only restarted after discussion between your PCP and your Gastroenterologist. After being evaluated by Physical Therapy, it is felt that you would benefit from a short stay in an acute rehab facility to help improve your strength after this hospitalization. Followup Instructions: Follow up w/ Dr. Tracy in 4-22 weeks (856-754-4014 Follow up w/ Dr. Tamaro in 4-22 weeks (792-813-9034 Gregory Ahmed Araceli Caro MD 15102140	["Admission Date: 1928-11-20 Discharge Date: 1909-6-28\n\nDate of Birth: 1974-11-18 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPenicillins\n\nAttending:Lorena\nChief Complaint:\nMr. Lockett is a 70 y.o. male with hx of Crohn's disease, afib,\ndilated CMP and PE (on coumadin), who presents with\nhematochezia/BRBPR in setting of INR 7.7.\n\nMajor Surgical or Invasive Procedure:\nColonoscopy w/ multiple Bx\n\nHistory of Present Illness:\nPatient had felt well during the last 2 weeks prior to\nadmission, although he had noticed slightly red/pink tinge to\nhis stool occasionally. Three days prior to admission, pt had\nan INR of 2.7 at coumadin clinic. One day prior to presenation,\nthe patient self-started asacol from previous prescription\nbecause worsening of rectal chrone's disease. On day of\npresentation, pt began having dark red bloody BMs, had ~15\nepisodes before calling EMS.", " Upon ED arrival, had several\nadditional large bloody BMs. He received vitamin K SQ, 2 FFP,\nand 2 PRBC for stabilization of bleeding. BP was stable\nthroughout.\n\n\nPast Medical History:\n1. Crohn's dz, found in 2017 on colonoscopy for anal fissure,\npositive Sachin, been treated with Remicade\n2. Rheumatoid arthritis\n3. HTN\n4. hx of renal calculus\n5. s/p appendectomy\n6. s/p TURP\n7. s/p cholecystectomy\n8. Recent pulmonary embolism- on coumadin since 2-29\n9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF\n25%\n10. Chronic left knee pain s/p meniscectomy, synovectomy, and\ndebridement of left knee 2017\n11. Recent gallstone pancreatitis 2-29\n12. Afib - 2-29 rate controlled on atenolol\n\n\nSocial History:\nMarried for 46 years and lives with wife. 3 children who all\nlive in area. No tobocco, h/o occasional ETOH, stopped drinking\nin 12-6, denies h/o ETOH abuse.", " No illicit drugs.\n\n\nFamily History:\nFather died at 62 from MI\nMother died at 52 of cirrhosis\nNo cancer or diabetes to patient's knowledge\nNo hisotry of clotting disorders\n\nPhysical Exam:\nExam afebrile, BP 100s/60s, 98%RA, HR 70s\nNAD, alert and talkative\nlungs clear\nirreg, distant S1S2\nabdomen soft\nrectum with significant erythema/maceration, dark red blood in\nvault,\n\n\nPertinent Results:\n1928-11-20 10:00PM BLOOD WBC-8.0 RBC-3.50* Hgb-9.0* Hct-27.2\nMCV-78 MCH-25.7# MCHC-33.1 RDW-16.1 Plt Ct-384\n1928-11-20 10:00PM BLOOD Neuts-80.0* Lymphs-14.5* Monos-4.7\nEos-0.6 Baso-0.1\n1928-11-20 10:00PM BLOOD PT-62.1* PTT-39.2* INR(PT)-7.7\n1928-11-20 10:00PM BLOOD Glucose-96 UreaN-20 Creat-1.6 Na-137\nK-3.8 Cl-107 HCO3-23 AnGap-11\n1928-11-20 10:00PM BLOOD CK(CPK)-58\n1928-11-20 10:00PM BLOOD CK-MB-NotDone cTropnT-0.", "06\n1939-12-28 04:15AM BLOOD Calcium-7.7 Phos-3.5 Mg-1.6\n\nEKG:\nBaseline artifact. Regular rhythm with left anterior fascicular\nblock and right\nbundle-branch block configuration, probably sinus rhythm. Since\nthe previous\ntracing of 1999-6-29 the QRS width is wider and R wave reversal in\nthe lateral\nprecordial leads is more marked, related to axis or lateral\nmyocardial\ninfarction. Clinical correlation is suggested.\n\n\nBrief Hospital Course:\n## Hematochezia/Crohn's: Likely 5-15 combination of known Crohn's\nand overanticoagulation most likely due to drug interaction of\ncoumadin w/ sasacol. Received 2Units FFP and 1 unit PRBC + vit\nK. With drop of Hct as low as 23.6, 27.0 upon d/c. INR upon d/c\n1.0. Underwent colonoscopy showing ulcer in proximal ascending\ncolon which wx bx to exclude ulcerated neoplasia, chrohn's dz\nwhich was bx, and pseudopolyps in the descending colon and\nsigmoid colon.", '\n.\n## ARF: likely hypovolemia in setting of GIB, Cr of 1.6 from\nbaseline of 1.0. Currently back to baseline.\n.\n## Paroxysmal atrial fibrillation: in sinus rhythm on June.\n- hold anticoag for now as risks outweigh benefits. Will be\nrestarted w/ f/u w/ PCP. Mitra Harris control meds because of bleeding,\npt not in AF on Lewis, Marek restart BB w/ d/c to rehab facility.\n\n\n## HTN: Meds held in setting of bleed, restarting OP meds w/ d/c\nto rehab. Holding lasix 5-15 to continued dehydration 5-15 to\npoor PO intake.\n.\n## DCM: appears euvolemic\n- hold furosemide in setting of GI bleed\n.\n## h/o PE, LV thrombus:\n- hold anticoag in setting of GI bleed, will restart as\noutpatient.\n\n\nMedications on Admission:\nASPIRIN 81 daily\nATENOLOL 50 daily\nATIVAN 0.5 Thompson PLC Health System prn anxiety\nWARFARIN with goal INR 2-8\nCYANOCOBALAMIN 1,000 mcg daily\nFUROSEMIDE 40 mg daily\nLISINOPRIL 10 mg daily\nLidocaine-Hydrocortisone Ac 3-0.', '5 %--Thin film rectally daily\nMVI\nPLAQUENIL 200 mg Thompson PLC Health System\nTylenol #3 prn pain\nASACOL 1200 mg tid\nPANTOPRAZOLE 40 mg daily\n\n\nDischarge Medications:\n1. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO\nQ4H (every 4 hours) as needed for pain.\n2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q4-6H\n(every 4 to 6 hours).\n4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.\n5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nLorena Bludsworth for Extended Care - 91490 Kenneth Dale\nRobertmouth, KY 14842\n\nDischarge Diagnosis:\nLower GI Bleed\n\n\nDischarge Condition:\nStable\n\n\nDischarge Instructions:\n You are being discharged from the hospital after an admission\nfor a lower gastrointestinal bleed.', " Because of significant\nblood loss, you were stabilized throughout the admission with\ntransfusion of blood products and clotting proteins. You\nunderwent colonoscopy to evaluate for source of the bleeding.\nIt not only showed multiple areas of sick colon consistent with\nyour Chron's disease, but also a non-bleeding ulcer in the\nbowel. Multiple biopsy's were taken, results pending. The most\nlikely cause of your bleeding is your very low ability to clot\ndue to a reaction between your blood thinner coumadin and the\nasacol which you started. Both medications are being stopped,\nand only restarted after discussion between your PCP and your\nGastroenterologist.\n After being evaluated by Physical Therapy, it is felt that\nyou would benefit from a short stay in an acute rehab facility\nto help improve your strength after this hospitalization.", '\n\nFollowup Instructions:\nFollow up w/ Dr. Tracy in 4-22 weeks (856-754-4014\nFollow up w/ Dr. Tamaro in 4-22 weeks (792-813-9034\n\n\n Gregory Ahmed Araceli Caro MD 15102140\n\n']
232	9805	177212.0	2131-07-23	Discharge summary	Report	Admission Date: [2131-7-5] Discharge Date: [2131-7-24] Date of Birth: [2060-12-25] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1481] Chief Complaint: New diagnosis Colon Cancer Major Surgical or Invasive Procedure: [2131-7-11]: ERCP with sphincterotomy [2131-7-16]: laparoscopic right colectomy History of Present Illness: Mr. [Known lastname 2302] is a 70 y.o. male with hx of Crohn's disease, afib, dilated CMP, h/o PE who presents after recent discharge due to colon biopsies found positive for Colon Cancer. Pt recent admission was for bloody stools and significantly elevated INR. During this admission he had colonoscopy with multiple biopsies. He was discharged in stable condition without any IBD meds and without anticoagulation. He was called by PCP and told to come back due to positive colon biopsy and need for further staging/workup. Pt denies any grossly bloody stools at home, has not been taking any meds and has been tolerating po well with minimal rectal pain. Past Medical History: 1. Crohn's dz, found in [2125] on colonoscopy for anal fissure, positive [Doctor First Name ], been treated with Remicade 2. Rheumatoid arthritis 3. HTN 4. hx of renal calculus 5. s/p appendectomy 6. s/p TURP 7. s/p cholecystectomy 8. Recent pulmonary embolism- on coumadin since [2-12] 9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF 25% 10. Chronic left knee pain s/p meniscectomy, synovectomy, and debridement of left knee [2123] 11. Recent gallstone pancreatitis [2-12] 12. Afib - [2-12] rate controlled on atenolol Social History: Married for 46 years and lives with wife. 3 children who all live in area. No tobocco, h/o occasional ETOH, stopped drinking in [11-13], denies h/o ETOH abuse. No illicit drugs. Family History: Father died at 62 from MI Mother died at 52 of cirrhosis No cancer or diabetes to patient's knowledge No history of clotting disorders Physical Exam: T-96.8 BP-140/70 P-96 RR-20 Sats-95% on RA Gen: NAD, comfortable HEENT: NCAT, EOMI, MMM, oropharynx CV: irreg/irreg no m/r/g no JVD RESP: CTAB no w/r/crackles ABD: soft/NT/ND/NABS EXTR: no c/c/edema, +PT pulses bilaterally Pertinent Results: Admission Labs: [2131-7-4] WBC-8.7 RBC-3.87* HGB-10.5* HCT-31.9* MCV-82 MCH-27.2 MCHC-33.0 RDW-16.4* CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-1.9 GLUCOSE-84 UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11 PLT COUNT-352 CEA 1.5 [2131-7-10]: ECHO LA is normal in size. No ASD is seen by 2D or color Doppler. There is mild symmetric LV hypertrophy. LV cavity is moderately dilated. There is a sessile mural thrombus at the LV apex; the clot is mural and not mobile. Overall LV systolic function is moderately-to-severely depressed (LVEF= 30 %) secondary to severe hypokinesis of the inferior, posterior, and lateral walls, and extensive apical akinesis. There is no VSD. RV chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. AV leaflets (3) are mildly thickened but AS is not present. Mild (1+) AR is seen. MV leaflets are mildly thickened. There is no MVP. Mild (1+) MR is seen. LV inflow pattern suggests impaired relaxation. The estimated PA systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [2130-2-3], a LV apical thrombus is now present [2131-7-9] Stress Test: IMPRESSION: No significant ST-T wave changes in the setting of baseline ST-T wave abnormalities. No anginal-type symptoms. Nuclear report sent separately. [2131-7-9] PMIBI: IMPRESSION: 1. Abnormal study. 2. Severe, fixed perfusion defect involving the inferior wall and the a large region at the apex. 3. Moderately dilated LV. 4. Akinetic apex and inferior wall with LVEF 28%. [2131-7-9] MRI Abdomen IMPRESSION: 1. Hypodense flat subcapsular lesion within segment IV-B on prior CT from [2131-7-6], demonstrates a slight delayed enhancement; however gross stability since [2129-4-9] CT abdomen and pelvis suggest a benign lesion. This lesion is amenable to further evaluation by targeted ultrasound, possibly with biopsy, as clinically indicated. 2. Vague 1.3 cm lesion in segment 7 on prior CT from [2131-7-6] is not clearly visualized. However, this examination is motion limited and a small lesion within this vicinity cannot entirely be excluded. 3. Filling defect in the lower common bile duct suggests choledocholithiasis without evidence of acute obstruction. [2131-7-6] CT chest/abd/pelvis w/ w/o contrast 1) 3.7 cm irregular soft tissue mass at the lateral aspect of the ascending colon, associated with lymph nodes, corresponding to the colon cancer seen on colonoscopy. Small amount of fluid along the right paracolic gutter, probably due to biopsy. 2) Featureless appearance of the descending and sigmoid colon, with increased wall thickening and fat stranding in the descending colon, suggestive of active inflammation due to Crohn's disease. 3) Ill-defined 1.3 cm lesion in the segment 7 of the liver, for which metastasis is suspected given the colon cancer. Further evaluation by multiphasic MRI is recommended. 4) Unchanged nodular appearance of the left adrenal gland. The finding can be evaluated at the time of MRI as well. 6) New bilateral pleural effusion. 7) Increased mucosal enhancement in the perianal region, with probable perianal fistula on the right, new since prior study. 8) Multiple hypodense lesions in the kidney, unchanged since prior study. [2131-7-5] 09:55AM GLUCOSE-120* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-3.6 CHLORIDE-110* TOTAL CO2-26 ANION GAP-8 [2131-7-5] 09:55AM CALCIUM-7.7* [2131-7-5] 09:55AM WBC-7.8 RBC-3.69* HGB-9.8* HCT-30.4* MCV-83 MCH-26.7* MCHC-32.3 RDW-16.5* [2131-7-5] 09:55AM PLT COUNT-333 [2131-7-4] 07:00AM GLUCOSE-84 UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11 [2131-7-4] 07:00AM CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-1.9 [2131-7-4] 07:00AM WBC-8.7 RBC-3.87* HGB-10.5* HCT-31.9* MCV-82 MCH-27.2 MCHC-33.0 RDW-16.4* [2131-7-4] 07:00AM PLT COUNT-352 Brief Hospital Course: 70 y.o. male with hx of Crohn's disease, afib, dilated CMP, h/o PE who presents after recent discharge for LGIB in setting of supratherapeutic INR on the same day when colon biopsies were found positive for Colon Cancer. Patient was admitted for metastatic work-up and cardiology clearance prior to colonic mass resection. . ## Colon Cancer: CT abdomen with 3-4 cm mass in ascending colon with enlarged LNs, biopsies positive for Ca. Pt had CT of torso for staging, showing possible metastatic dz of a single nodule in the liver. MRI w/ liver protocol performed, without lesion suspicious for mets. Cardiology recommended addition of statin, asa, heparin gtt prior to surgery. Pt at mod-high risk for moderate risk surgery. . ## Dilated CMP/Systolic dysfuction: monitoring strict I/Os, remained euvolemic. Continue meds of Lisinopril and Atenolol. Stress w/ no significant ST-T wave changes or anginal-type pain in setting of stress on [7-9]. PMIBI with evidence of fixed profusion deficit, severe apical [Last Name (LF) 2307], [First Name3 (LF) ] 28%. Cardiology consulted. ECHO on [7-10] showed mural thrombus and apical aneurysm. Restarted ASA and started simvastatin and Heparin gtt. Pt to require long-term anticoagulation on discharge. . # Choledochololithiasis: Seen on MRI of the abdomen. Patient s/p ERCP w/ sphinctorotmy on [7-11] without complication. . ## Recent GI bleed/Anemia: Hematocrit is stable at 26-30. Pt denies any grossly bloody stools. Given mural thrombus, on IV heparin until colon resection. [ ]will send stools for guiac and monitor hct daily. . ## Crohn's Disease - Stable, primarily rectal involvement. Patient on lidocaine jelly and prn tylenol #3 for rectal pain. Currently on no treatment for Crohn's given colon ca diagnosis. . ## Paroxysmal atrial fibrillation: pt was discharged without anticoagulation on last admission after being admitted with an INR > 7. Benefits of anticoagution are outweighed by the risks at this time. To resume coumadin post-op. . ## Benign essential HTN: Controlled on Atenolol and lisinopril . ## h/o PE: anticoagulation with Heparin gtt . ## FEN: Heart healthy diet, will replete lytes prn. . ## PPX: SCDs, bowel regimen . ## FULL CODE Medications on Admission: Pt denies taking any meds at home at the time of this admission. Pt has been on in the recent past: Atenolol 50 daily Lisinopril 10mg daily Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Tablet(s) 3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis/insomnia. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Mesalamine 1,000 mg Suppository Sig: One (1) Rectal once a day. 17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 18. Lidocaine HCl 5 % Ointment Sig: One (1) Topical twice a day as needed for pain: Appl Topical twice a day as needed for pain for 2 weeks. . Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 533] [Last Name (NamePattern1) ] for Extended Care - [Location 1268] Discharge Diagnosis: Primary Diagnosis: colon CA Secondary Diagnosis: Atrial Fibrillation Dilated cardiomyopathy - EF 28%, akinetic apex, LV mural thrombus, LV aneurysm h/o PE recent Lower GI Bleed Gallstone Pancreatitis h/o renal calculi Crohn's Disease Discharge Condition: stable Tolerating a Regular diet, poor appetite. Needs encouragement Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. * Please check your weight once a day in the morning. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in 2 weeks. Call [Telephone/Fax (1) ] to schedule this appointment. Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2131-8-15] 11:10 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2308], MD Phone:[Telephone/Fax (1) 2309] Date/Time:[2131-8-16] 9:00 Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 2310], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2131-9-3] 1:00 Completed by:[2131-7-23]	Admission Date: <Date>1945-11-8</Date> Discharge Date: <Date>1935-3-18</Date> Date of Birth: <Date>1961-11-24</Date> Sex: M Service: SURGERY Allergies: Penicillins Attending:<Name>Nora</Name> Chief Complaint: New diagnosis Colon Cancer Major Surgical or Invasive Procedure: <Date>2011-4-15</Date>: ERCP with sphincterotomy <Date>1925-10-15</Date>: laparoscopic right colectomy History of Present Illness: Mr. <Name>Finateri</Name> is a 70 y.o. male with hx of Crohn's disease, afib, dilated CMP, h/o PE who presents after recent discharge due to colon biopsies found positive for Colon Cancer. Pt recent admission was for bloody stools and significantly elevated INR. During this admission he had colonoscopy with multiple biopsies. He was discharged in stable condition without any IBD meds and without anticoagulation. He was called by PCP and told to come back due to positive colon biopsy and need for further staging/workup. Pt denies any grossly bloody stools at home, has not been taking any meds and has been tolerating po well with minimal rectal pain. Past Medical History: 1. Crohn's dz, found in <Year>1940</Year> on colonoscopy for anal fissure, positive <Name>Marti</Name>, been treated with Remicade 2. Rheumatoid arthritis 3. HTN 4. hx of renal calculus 5. s/p appendectomy 6. s/p TURP 7. s/p cholecystectomy 8. Recent pulmonary embolism- on coumadin since <Date>7-30</Date> 9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF 25% 10. Chronic left knee pain s/p meniscectomy, synovectomy, and debridement of left knee <Year>1940</Year> 11. Recent gallstone pancreatitis <Date>7-30</Date> 12. Afib - <Date>7-30</Date> rate controlled on atenolol Social History: Married for 46 years and lives with wife. 3 children who all live in area. No tobocco, h/o occasional ETOH, stopped drinking in <Date>3-13</Date>, denies h/o ETOH abuse. No illicit drugs. Family History: Father died at 62 from MI Mother died at 52 of cirrhosis No cancer or diabetes to patient's knowledge No history of clotting disorders Physical Exam: T-96.8 BP-140/70 P-96 RR-20 Sats-95% on RA Gen: NAD, comfortable HEENT: NCAT, EOMI, MMM, oropharynx CV: irreg/irreg no m/r/g no JVD RESP: CTAB no w/r/crackles ABD: soft/NT/ND/NABS EXTR: no c/c/edema, +PT pulses bilaterally Pertinent Results: Admission Labs: <Date>1914-5-25</Date> WBC-8.7 RBC-3.87* HGB-10.5* HCT-31.9* MCV-82 MCH-27.2 MCHC-33.0 RDW-16.4* CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-1.9 GLUCOSE-84 UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11 PLT COUNT-352 CEA 1.5 <Date>1933-7-6</Date>: ECHO LA is normal in size. No ASD is seen by 2D or color Doppler. There is mild symmetric LV hypertrophy. LV cavity is moderately dilated. There is a sessile mural thrombus at the LV apex; the clot is mural and not mobile. Overall LV systolic function is moderately-to-severely depressed (LVEF= 30 %) secondary to severe hypokinesis of the inferior, posterior, and lateral walls, and extensive apical akinesis. There is no VSD. RV chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. AV leaflets (3) are mildly thickened but AS is not present. Mild (1+) AR is seen. MV leaflets are mildly thickened. There is no MVP. Mild (1+) MR is seen. LV inflow pattern suggests impaired relaxation. The estimated PA systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of <Date>1975-5-11</Date>, a LV apical thrombus is now present <Date>1977-10-24</Date> Stress Test: IMPRESSION: No significant ST-T wave changes in the setting of baseline ST-T wave abnormalities. No anginal-type symptoms. Nuclear report sent separately. <Date>1977-10-24</Date> PMIBI: IMPRESSION: 1. Abnormal study. 2. Severe, fixed perfusion defect involving the inferior wall and the a large region at the apex. 3. Moderately dilated LV. 4. Akinetic apex and inferior wall with LVEF 28%. <Date>1977-10-24</Date> MRI Abdomen IMPRESSION: 1. Hypodense flat subcapsular lesion within segment IV-B on prior CT from <Date>1920-5-27</Date>, demonstrates a slight delayed enhancement; however gross stability since <Date>1962-2-16</Date> CT abdomen and pelvis suggest a benign lesion. This lesion is amenable to further evaluation by targeted ultrasound, possibly with biopsy, as clinically indicated. 2. Vague 1.3 cm lesion in segment 7 on prior CT from <Date>1920-5-27</Date> is not clearly visualized. However, this examination is motion limited and a small lesion within this vicinity cannot entirely be excluded. 3. Filling defect in the lower common bile duct suggests choledocholithiasis without evidence of acute obstruction. <Date>1920-5-27</Date> CT chest/abd/pelvis w/ w/o contrast 1) 3.7 cm irregular soft tissue mass at the lateral aspect of the ascending colon, associated with lymph nodes, corresponding to the colon cancer seen on colonoscopy. Small amount of fluid along the right paracolic gutter, probably due to biopsy. 2) Featureless appearance of the descending and sigmoid colon, with increased wall thickening and fat stranding in the descending colon, suggestive of active inflammation due to Crohn's disease. 3) Ill-defined 1.3 cm lesion in the segment 7 of the liver, for which metastasis is suspected given the colon cancer. Further evaluation by multiphasic MRI is recommended. 4) Unchanged nodular appearance of the left adrenal gland. The finding can be evaluated at the time of MRI as well. 6) New bilateral pleural effusion. 7) Increased mucosal enhancement in the perianal region, with probable perianal fistula on the right, new since prior study. 8) Multiple hypodense lesions in the kidney, unchanged since prior study. <Date>1945-11-8</Date> 09:55AM GLUCOSE-120* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-3.6 CHLORIDE-110* TOTAL CO2-26 ANION GAP-8 <Date>1945-11-8</Date> 09:55AM CALCIUM-7.7* <Date>1945-11-8</Date> 09:55AM WBC-7.8 RBC-3.69* HGB-9.8* HCT-30.4* MCV-83 MCH-26.7* MCHC-32.3 RDW-16.5* <Date>1945-11-8</Date> 09:55AM PLT COUNT-333 <Date>1914-5-25</Date> 07:00AM GLUCOSE-84 UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11 <Date>1914-5-25</Date> 07:00AM CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-1.9 <Date>1914-5-25</Date> 07:00AM WBC-8.7 RBC-3.87* HGB-10.5* HCT-31.9* MCV-82 MCH-27.2 MCHC-33.0 RDW-16.4* <Date>1914-5-25</Date> 07:00AM PLT COUNT-352 Brief Hospital Course: 70 y.o. male with hx of Crohn's disease, afib, dilated CMP, h/o PE who presents after recent discharge for LGIB in setting of supratherapeutic INR on the same day when colon biopsies were found positive for Colon Cancer. Patient was admitted for metastatic work-up and cardiology clearance prior to colonic mass resection. . ## Colon Cancer: CT abdomen with 3-4 cm mass in ascending colon with enlarged LNs, biopsies positive for Ca. Pt had CT of torso for staging, showing possible metastatic dz of a single nodule in the liver. MRI w/ liver protocol performed, without lesion suspicious for mets. Cardiology recommended addition of statin, asa, heparin gtt prior to surgery. Pt at mod-high risk for moderate risk surgery. . ## Dilated CMP/Systolic dysfuction: monitoring strict I/Os, remained euvolemic. Continue meds of Lisinopril and Atenolol. Stress w/ no significant ST-T wave changes or anginal-type pain in setting of stress on <Date>12-11</Date>. PMIBI with evidence of fixed profusion deficit, severe apical <Name>Lyna</Name>, <Name>Brianna</Name> 28%. Cardiology consulted. ECHO on <Date>12-4</Date> showed mural thrombus and apical aneurysm. Restarted ASA and started simvastatin and Heparin gtt. Pt to require long-term anticoagulation on discharge. . # Choledochololithiasis: Seen on MRI of the abdomen. Patient s/p ERCP w/ sphinctorotmy on <Date>2-16</Date> without complication. . ## Recent GI bleed/Anemia: Hematocrit is stable at 26-30. Pt denies any grossly bloody stools. Given mural thrombus, on IV heparin until colon resection. [ ]will send stools for guiac and monitor hct daily. . ## Crohn's Disease - Stable, primarily rectal involvement. Patient on lidocaine jelly and prn tylenol #3 for rectal pain. Currently on no treatment for Crohn's given colon ca diagnosis. . ## Paroxysmal atrial fibrillation: pt was discharged without anticoagulation on last admission after being admitted with an INR > 7. Benefits of anticoagution are outweighed by the risks at this time. To resume coumadin post-op. . ## Benign essential HTN: Controlled on Atenolol and lisinopril . ## h/o PE: anticoagulation with Heparin gtt . ## FEN: Heart healthy diet, will replete lytes prn. . ## PPX: SCDs, bowel regimen . ## FULL CODE Medications on Admission: Pt denies taking any meds at home at the time of this admission. Pt has been on in the recent past: Atenolol 50 daily Lisinopril 10mg daily Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Tablet(s) 3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis/insomnia. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Mesalamine 1,000 mg Suppository Sig: One (1) Rectal once a day. 17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 18. Lidocaine HCl 5 % Ointment Sig: One (1) Topical twice a day as needed for pain: Appl Topical twice a day as needed for pain for 2 weeks. . Discharge Disposition: Extended Care Facility: <Name>Amit</Name> <Name>Johnson</Name> for Extended Care - <Location>3586 David Shores South Laurenmouth, KS 79532</Location> Discharge Diagnosis: Primary Diagnosis: colon CA Secondary Diagnosis: Atrial Fibrillation Dilated cardiomyopathy - EF 28%, akinetic apex, LV mural thrombus, LV aneurysm h/o PE recent Lower GI Bleed Gallstone Pancreatitis h/o renal calculi Crohn's Disease Discharge Condition: stable Tolerating a Regular diet, poor appetite. Needs encouragement Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. * Please check your weight once a day in the morning. Followup Instructions: Follow up with Dr. <Name>Quinones</Name> in 2 weeks. Call <Telephone>265-860-4378</Telephone> to schedule this appointment. Provider: <Name>Curtis Kiel</Name> <Name>Prince Benavidez</Name>, MD Phone:<Telephone>402-552-5644</Telephone> Date/Time:<Date>1908-6-30</Date> 11:10 Provider: <Name>Abigail</Name> <Name>Hasan</Name>, MD Phone:<Telephone>208-709-1439</Telephone> Date/Time:<Date>2012-9-31</Date> 9:00 Provider: <Name>Octavia</Name> <Name>Casenhiser</Name>, MD Phone:<Telephone>624-818-7464</Telephone> Date/Time:<Date>1988-8-8</Date> 1:00 Completed by:<Date>1957-8-23</Date>	000000000000000001111111110000000000000000000000000000000011111111100000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000011110000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1945-11-8 Discharge Date: 1935-3-18 Date of Birth: 1961-11-24 Sex: M Service: SURGERY Allergies: Penicillins Attending:Nora Chief Complaint: New diagnosis Colon Cancer Major Surgical or Invasive Procedure: 2011-4-15: ERCP with sphincterotomy 1925-10-15: laparoscopic right colectomy History of Present Illness: Mr. Finateri is a 70 y.o. male with hx of Crohn's disease, afib, dilated CMP, h/o PE who presents after recent discharge due to colon biopsies found positive for Colon Cancer. Pt recent admission was for bloody stools and significantly elevated INR. During this admission he had colonoscopy with multiple biopsies. He was discharged in stable condition without any IBD meds and without anticoagulation. He was called by PCP and told to come back due to positive colon biopsy and need for further staging/workup. Pt denies any grossly bloody stools at home, has not been taking any meds and has been tolerating po well with minimal rectal pain. Past Medical History: 1. Crohn's dz, found in 1940 on colonoscopy for anal fissure, positive Marti, been treated with Remicade 2. Rheumatoid arthritis 3. HTN 4. hx of renal calculus 5. s/p appendectomy 6. s/p TURP 7. s/p cholecystectomy 8. Recent pulmonary embolism- on coumadin since 7-30 9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF 25% 10. Chronic left knee pain s/p meniscectomy, synovectomy, and debridement of left knee 1940 11. Recent gallstone pancreatitis 7-30 12. Afib - 7-30 rate controlled on atenolol Social History: Married for 46 years and lives with wife. 3 children who all live in area. No tobocco, h/o occasional ETOH, stopped drinking in 3-13, denies h/o ETOH abuse. No illicit drugs. Family History: Father died at 62 from MI Mother died at 52 of cirrhosis No cancer or diabetes to patient's knowledge No history of clotting disorders Physical Exam: T-96.8 BP-140/70 P-96 RR-20 Sats-95% on RA Gen: NAD, comfortable HEENT: NCAT, EOMI, MMM, oropharynx CV: irreg/irreg no m/r/g no JVD RESP: CTAB no w/r/crackles ABD: soft/NT/ND/NABS EXTR: no c/c/edema, +PT pulses bilaterally Pertinent Results: Admission Labs: 1914-5-25 WBC-8.7 RBC-3.87* HGB-10.5* HCT-31.9* MCV-82 MCH-27.2 MCHC-33.0 RDW-16.4* CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-1.9 GLUCOSE-84 UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11 PLT COUNT-352 CEA 1.5 1933-7-6: ECHO LA is normal in size. No ASD is seen by 2D or color Doppler. There is mild symmetric LV hypertrophy. LV cavity is moderately dilated. There is a sessile mural thrombus at the LV apex; the clot is mural and not mobile. Overall LV systolic function is moderately-to-severely depressed (LVEF= 30 %) secondary to severe hypokinesis of the inferior, posterior, and lateral walls, and extensive apical akinesis. There is no VSD. RV chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. AV leaflets (3) are mildly thickened but AS is not present. Mild (1+) AR is seen. MV leaflets are mildly thickened. There is no MVP. Mild (1+) MR is seen. LV inflow pattern suggests impaired relaxation. The estimated PA systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of 1975-5-11, a LV apical thrombus is now present 1977-10-24 Stress Test: IMPRESSION: No significant ST-T wave changes in the setting of baseline ST-T wave abnormalities. No anginal-type symptoms. Nuclear report sent separately. 1977-10-24 PMIBI: IMPRESSION: 1. Abnormal study. 2. Severe, fixed perfusion defect involving the inferior wall and the a large region at the apex. 3. Moderately dilated LV. 4. Akinetic apex and inferior wall with LVEF 28%. 1977-10-24 MRI Abdomen IMPRESSION: 1. Hypodense flat subcapsular lesion within segment IV-B on prior CT from 1920-5-27, demonstrates a slight delayed enhancement; however gross stability since 1962-2-16 CT abdomen and pelvis suggest a benign lesion. This lesion is amenable to further evaluation by targeted ultrasound, possibly with biopsy, as clinically indicated. 2. Vague 1.3 cm lesion in segment 7 on prior CT from 1920-5-27 is not clearly visualized. However, this examination is motion limited and a small lesion within this vicinity cannot entirely be excluded. 3. Filling defect in the lower common bile duct suggests choledocholithiasis without evidence of acute obstruction. 1920-5-27 CT chest/abd/pelvis w/ w/o contrast 1) 3.7 cm irregular soft tissue mass at the lateral aspect of the ascending colon, associated with lymph nodes, corresponding to the colon cancer seen on colonoscopy. Small amount of fluid along the right paracolic gutter, probably due to biopsy. 2) Featureless appearance of the descending and sigmoid colon, with increased wall thickening and fat stranding in the descending colon, suggestive of active inflammation due to Crohn's disease. 3) Ill-defined 1.3 cm lesion in the segment 7 of the liver, for which metastasis is suspected given the colon cancer. Further evaluation by multiphasic MRI is recommended. 4) Unchanged nodular appearance of the left adrenal gland. The finding can be evaluated at the time of MRI as well. 6) New bilateral pleural effusion. 7) Increased mucosal enhancement in the perianal region, with probable perianal fistula on the right, new since prior study. 8) Multiple hypodense lesions in the kidney, unchanged since prior study. 1945-11-8 09:55AM GLUCOSE-120* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-3.6 CHLORIDE-110* TOTAL CO2-26 ANION GAP-8 1945-11-8 09:55AM CALCIUM-7.7* 1945-11-8 09:55AM WBC-7.8 RBC-3.69* HGB-9.8* HCT-30.4* MCV-83 MCH-26.7* MCHC-32.3 RDW-16.5* 1945-11-8 09:55AM PLT COUNT-333 1914-5-25 07:00AM GLUCOSE-84 UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11 1914-5-25 07:00AM CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-1.9 1914-5-25 07:00AM WBC-8.7 RBC-3.87* HGB-10.5* HCT-31.9* MCV-82 MCH-27.2 MCHC-33.0 RDW-16.4* 1914-5-25 07:00AM PLT COUNT-352 Brief Hospital Course: 70 y.o. male with hx of Crohn's disease, afib, dilated CMP, h/o PE who presents after recent discharge for LGIB in setting of supratherapeutic INR on the same day when colon biopsies were found positive for Colon Cancer. Patient was admitted for metastatic work-up and cardiology clearance prior to colonic mass resection. . ## Colon Cancer: CT abdomen with 3-4 cm mass in ascending colon with enlarged LNs, biopsies positive for Ca. Pt had CT of torso for staging, showing possible metastatic dz of a single nodule in the liver. MRI w/ liver protocol performed, without lesion suspicious for mets. Cardiology recommended addition of statin, asa, heparin gtt prior to surgery. Pt at mod-high risk for moderate risk surgery. . ## Dilated CMP/Systolic dysfuction: monitoring strict I/Os, remained euvolemic. Continue meds of Lisinopril and Atenolol. Stress w/ no significant ST-T wave changes or anginal-type pain in setting of stress on 12-11. PMIBI with evidence of fixed profusion deficit, severe apical Lyna, Brianna 28%. Cardiology consulted. ECHO on 12-4 showed mural thrombus and apical aneurysm. Restarted ASA and started simvastatin and Heparin gtt. Pt to require long-term anticoagulation on discharge. . # Choledochololithiasis: Seen on MRI of the abdomen. Patient s/p ERCP w/ sphinctorotmy on 2-16 without complication. . ## Recent GI bleed/Anemia: Hematocrit is stable at 26-30. Pt denies any grossly bloody stools. Given mural thrombus, on IV heparin until colon resection. [ ]will send stools for guiac and monitor hct daily. . ## Crohn's Disease - Stable, primarily rectal involvement. Patient on lidocaine jelly and prn tylenol #3 for rectal pain. Currently on no treatment for Crohn's given colon ca diagnosis. . ## Paroxysmal atrial fibrillation: pt was discharged without anticoagulation on last admission after being admitted with an INR > 7. Benefits of anticoagution are outweighed by the risks at this time. To resume coumadin post-op. . ## Benign essential HTN: Controlled on Atenolol and lisinopril . ## h/o PE: anticoagulation with Heparin gtt . ## FEN: Heart healthy diet, will replete lytes prn. . ## PPX: SCDs, bowel regimen . ## FULL CODE Medications on Admission: Pt denies taking any meds at home at the time of this admission. Pt has been on in the recent past: Atenolol 50 daily Lisinopril 10mg daily Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Tablet(s) 3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis/insomnia. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Mesalamine 1,000 mg Suppository Sig: One (1) Rectal once a day. 17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 18. Lidocaine HCl 5 % Ointment Sig: One (1) Topical twice a day as needed for pain: Appl Topical twice a day as needed for pain for 2 weeks. . Discharge Disposition: Extended Care Facility: Amit Johnson for Extended Care - 3586 David Shores South Laurenmouth, KS 79532 Discharge Diagnosis: Primary Diagnosis: colon CA Secondary Diagnosis: Atrial Fibrillation Dilated cardiomyopathy - EF 28%, akinetic apex, LV mural thrombus, LV aneurysm h/o PE recent Lower GI Bleed Gallstone Pancreatitis h/o renal calculi Crohn's Disease Discharge Condition: stable Tolerating a Regular diet, poor appetite. Needs encouragement Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. * Please check your weight once a day in the morning. Followup Instructions: Follow up with Dr. Quinones in 2 weeks. Call 265-860-4378 to schedule this appointment. Provider: Curtis Kiel Prince Benavidez, MD Phone:402-552-5644 Date/Time:1908-6-30 11:10 Provider: Abigail Hasan, MD Phone:208-709-1439 Date/Time:2012-9-31 9:00 Provider: Octavia Casenhiser, MD Phone:624-818-7464 Date/Time:1988-8-8 1:00 Completed by:1957-8-23	["Admission Date: 1945-11-8 Discharge Date: 1935-3-18\n\nDate of Birth: 1961-11-24 Sex: M\n\nService: SURGERY\n\nAllergies:\nPenicillins\n\nAttending:Nora\nChief Complaint:\nNew diagnosis Colon Cancer\n\nMajor Surgical or Invasive Procedure:\n2011-4-15: ERCP with sphincterotomy\n1925-10-15: laparoscopic right colectomy\n\n\nHistory of Present Illness:\nMr. Finateri is a 70 y.o. male with hx of Crohn's disease, afib,\ndilated CMP, h/o PE who presents after recent discharge due to\ncolon biopsies found positive for Colon Cancer. Pt recent\nadmission was for bloody stools and significantly elevated INR.\nDuring this admission he had colonoscopy with multiple biopsies.\n He was discharged in stable condition without any IBD meds and\nwithout anticoagulation. He was called by PCP and told to come\nback due to positive colon biopsy and need for further\nstaging/workup.", " Pt denies any grossly bloody stools at home,\nhas not been taking any meds and has been tolerating po well\nwith minimal rectal pain.\n\nPast Medical History:\n1. Crohn's dz, found in 1940 on colonoscopy for anal fissure,\npositive Marti, been treated with Remicade\n2. Rheumatoid arthritis\n3. HTN\n4. hx of renal calculus\n5. s/p appendectomy\n6. s/p TURP\n7. s/p cholecystectomy\n8. Recent pulmonary embolism- on coumadin since 7-30\n9. LVH, LV enlargement, apical LV aneurysm with LV thrombus, EF\n25%\n10. Chronic left knee pain s/p meniscectomy, synovectomy, and\ndebridement of left knee 1940\n11. Recent gallstone pancreatitis 7-30\n12. Afib - 7-30 rate controlled on atenolol\n\n\nSocial History:\nMarried for 46 years and lives with wife. 3 children who all\nlive in area. No tobocco, h/o occasional ETOH, stopped drinking\nin 3-13, denies h/o ETOH abuse.", " No illicit drugs.\n\n\nFamily History:\nFather died at 62 from MI\nMother died at 52 of cirrhosis\nNo cancer or diabetes to patient's knowledge\nNo history of clotting disorders\n\nPhysical Exam:\nT-96.8 BP-140/70 P-96 RR-20 Sats-95% on RA\nGen: NAD, comfortable\nHEENT: NCAT, EOMI, MMM, oropharynx\nCV: irreg/irreg no m/r/g no JVD\nRESP: CTAB no w/r/crackles\nABD: soft/NT/ND/NABS\nEXTR: no c/c/edema, +PT pulses bilaterally\n\nPertinent Results:\nAdmission Labs:\n1914-5-25 WBC-8.7 RBC-3.87* HGB-10.5* HCT-31.9* MCV-82 MCH-27.2\nMCHC-33.0 RDW-16.4* CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-1.9\nGLUCOSE-84 UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-4.2\nCHLORIDE-106 TOTAL CO2-26 ANION GAP-11 PLT COUNT-352\nCEA 1.5\n\n1933-7-6: ECHO\nLA is normal in size. No ASD is seen by 2D or color Doppler.\nThere is mild symmetric LV hypertrophy.", ' LV cavity is moderately\ndilated. There is a sessile mural thrombus at the LV apex; the\nclot is mural and not mobile. Overall LV systolic function is\nmoderately-to-severely depressed (LVEF= 30 %) secondary to\nsevere hypokinesis of the inferior, posterior, and lateral\nwalls, and extensive apical akinesis. There is no VSD. RV\nchamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level. The ascending aorta is mildly\ndilated. AV leaflets (3) are mildly thickened but AS is not\npresent. Mild (1+) AR is seen. MV leaflets are mildly thickened.\nThere is no MVP. Mild (1+) MR is seen. LV inflow pattern\nsuggests impaired relaxation. The estimated PA systolic pressure\nis normal. There is no pericardial effusion.\n\nCompared with the findings of the prior report (images\nunavailable for review) of 1975-5-11, a LV apical\nthrombus is now present\n\n1977-10-24 Stress Test:\nIMPRESSION: No significant ST-T wave changes in the setting of\nbaseline\nST-T wave abnormalities.', ' No anginal-type symptoms. Nuclear\nreport sent\nseparately.\n\n1977-10-24 PMIBI:\nIMPRESSION: 1. Abnormal study. 2. Severe, fixed perfusion defect\ninvolving the inferior wall and the a large region at the apex.\n3. Moderately dilated LV. 4. Akinetic apex and inferior wall\nwith LVEF 28%.\n\n1977-10-24 MRI Abdomen\nIMPRESSION:\n1. Hypodense flat subcapsular lesion within segment IV-B on\nprior CT from 1920-5-27, demonstrates a slight delayed\nenhancement; however gross stability since 1962-2-16 CT abdomen\nand pelvis suggest a benign lesion. This lesion is amenable to\nfurther evaluation by targeted ultrasound, possibly with biopsy,\nas clinically indicated.\n2. Vague 1.3 cm lesion in segment 7 on prior CT from 1920-5-27\nis not clearly visualized. However, this examination is motion\nlimited and a small lesion within this vicinity cannot entirely\nbe excluded.', "\n3. Filling defect in the lower common bile duct suggests\ncholedocholithiasis without evidence of acute obstruction.\n\n1920-5-27 CT chest/abd/pelvis w/ w/o contrast\n1) 3.7 cm irregular soft tissue mass at the lateral aspect of\nthe ascending colon, associated with lymph nodes, corresponding\nto the colon cancer seen on colonoscopy. Small amount of fluid\nalong the right paracolic gutter, probably due to biopsy. 2)\nFeatureless appearance of the descending and sigmoid colon, with\nincreased wall thickening and fat stranding in the descending\ncolon, suggestive of active inflammation due to Crohn's disease.\n\n3) Ill-defined 1.3 cm lesion in the segment 7 of the liver, for\nwhich metastasis is suspected given the colon cancer. Further\nevaluation by multiphasic MRI is recommended.\n4) Unchanged nodular appearance of the left adrenal gland.", ' The\nfinding can be evaluated at the time of MRI as well.\n6) New bilateral pleural effusion.\n7) Increased mucosal enhancement in the perianal region, with\nprobable perianal fistula on the right, new since prior study.\n8) Multiple hypodense lesions in the kidney, unchanged since\nprior study.\n\n1945-11-8 09:55AM GLUCOSE-120* UREA N-14 CREAT-0.9 SODIUM-140\nPOTASSIUM-3.6 CHLORIDE-110* TOTAL CO2-26 ANION GAP-8\n1945-11-8 09:55AM CALCIUM-7.7\n1945-11-8 09:55AM WBC-7.8 RBC-3.69 HGB-9.8* HCT-30.4* MCV-83\nMCH-26.7* MCHC-32.3 RDW-16.5\n1945-11-8 09:55AM PLT COUNT-333\n1914-5-25 07:00AM GLUCOSE-84 UREA N-12 CREAT-0.9 SODIUM-139\nPOTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11\n1914-5-25 07:00AM CALCIUM-8.2 PHOSPHATE-2.8 MAGNESIUM-1.9\n1914-5-25 07:00AM WBC-8.7 RBC-3.87* HGB-10.5* HCT-31.', "9* MCV-82\nMCH-27.2 MCHC-33.0 RDW-16.4\n1914-5-25 07:00AM PLT COUNT-352\n\nBrief Hospital Course:\n70 y.o. male with hx of Crohn's disease, afib, dilated CMP, h/o\nPE who presents after recent discharge for LGIB in setting of\nsupratherapeutic INR on the same day when colon biopsies were\nfound positive for Colon Cancer. Patient was admitted for\nmetastatic work-up and cardiology clearance prior to colonic\nmass resection.\n.\n## Colon Cancer: CT abdomen with 3-4 cm mass in ascending colon\nwith enlarged LNs, biopsies positive for Ca. Pt had CT of torso\nfor staging, showing possible metastatic dz of a single nodule\nin the liver. MRI w/ liver protocol performed, without lesion\nsuspicious for mets. Cardiology recommended addition of statin,\nasa, heparin gtt prior to surgery. Pt at mod-high risk for\nmoderate risk surgery.", '\n.\n## Dilated CMP/Systolic dysfuction: monitoring strict I/Os,\nremained euvolemic. Continue meds of Lisinopril and Atenolol.\nStress w/ no significant ST-T wave changes or anginal-type pain\nin setting of stress on 12-11. PMIBI with evidence of fixed\nprofusion deficit, severe apical Lyna, Brianna 28%. Cardiology\nconsulted. ECHO on 12-4 showed mural thrombus and apical\naneurysm. Restarted ASA and started simvastatin and Heparin gtt.\nPt to require long-term anticoagulation on discharge.\n.\n# Choledochololithiasis: Seen on MRI of the abdomen. Patient s/p\nERCP w/ sphinctorotmy on 2-16 without complication.\n.\n## Recent GI bleed/Anemia: Hematocrit is stable at 26-30. Pt\ndenies any grossly bloody stools. Given mural thrombus, on IV\nheparin until colon resection.\n[ ]will send stools for guiac and monitor hct daily.', "\n.\n## Crohn's Disease - Stable, primarily rectal involvement.\nPatient on lidocaine jelly and prn tylenol #3 for rectal pain.\nCurrently on no treatment for Crohn's given colon ca diagnosis.\n\n.\n## Paroxysmal atrial fibrillation: pt was discharged without\nanticoagulation on last admission after being admitted with an\nINR > 7. Benefits of anticoagution are outweighed by the risks\nat this time. To resume coumadin post-op.\n.\n## Benign essential HTN: Controlled on Atenolol and lisinopril\n.\n## h/o PE: anticoagulation with Heparin gtt\n.\n## FEN: Heart healthy diet, will replete lytes prn.\n.\n## PPX: SCDs, bowel regimen\n.\n## FULL CODE\n\n\nMedications on Admission:\nPt denies taking any meds at home at the time of this admission.\nPt has been on in the recent past:\nAtenolol 50 daily\nLisinopril 10mg daily\n\n\nDischarge Medications:\n1.", ' Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for anxiety. Tablet(s)\n3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical TID (3\ntimes a day) as needed.\n4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4\nhours) as needed for pain.\n5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1\ndoses.\n7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).\n9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n10. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\n11. Pantoprazole 40 mg Tablet, Delayed Release (E.', "C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4\ntimes a day).\n13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3\ntimes a day).\n14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO\nQ6H (every 6 hours) as needed for pruritis/insomnia.\n15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.\n16. Mesalamine 1,000 mg Suppository Sig: One (1) Rectal once a\nday.\n17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.\n18. Lidocaine HCl 5 % Ointment Sig: One (1) Topical twice a day\nas needed for pain: Appl Topical twice a day as needed for pain\nfor 2 weeks.\n.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nAmit Johnson for Extended Care - 3586 David Shores\nSouth Laurenmouth, KS 79532\n\nDischarge Diagnosis:\nPrimary Diagnosis:\ncolon CA\n\nSecondary Diagnosis:\nAtrial Fibrillation\nDilated cardiomyopathy - EF 28%, akinetic apex, LV mural\nthrombus, LV aneurysm\nh/o PE\nrecent Lower GI Bleed\nGallstone Pancreatitis\nh/o renal calculi\nCrohn's Disease\n\n\nDischarge Condition:\nstable\nTolerating a Regular diet, poor appetite.", ' Needs encouragement\nAdequate pain control with oral medication\n\n\nDischarge Instructions:\nPlease call your doctor or return to the ER for any of the\nfollowing:\n You experience new chest pain, pressure, squeezing or\ntightness.\n* New or worsening cough or wheezing.\n* If you are vomitting and cannot keep in fluids or your\nmedications.\n* You are getting dehydrated due to continued vomitting,\ndiarrhea or other reasons. Signs of dehydration include dry\nmouth, rapid heartbeat or feeling dizzy or faint when standing.\n* You see blood or dark/black material when you vomit or have a\nbowel movement.\n* Your skin, or the whites of your eyes become yellow.\n* Your pain is not improving within 8-12 hours or not gone\nwithin 24 hours. Call or return immediately if your pain is\ngetting worse or is changing location or moving to your chest or\nback.', '\n* You have shaking chills, or a fever greater than 101.5 (F)\ndegrees or 38(C) degrees.\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\nas ordered.\n* Continue to amubulate several times per day.\n* Please check your weight once a day in the morning.\n\nFollowup Instructions:\nFollow up with Dr. Quinones in 2 weeks. Call 265-860-4378 to\nschedule this appointment.\n\nProvider: Curtis Kiel Prince Benavidez, MD Phone:402-552-5644 Date/Time:1908-6-30\n11:10\nProvider: Abigail Hasan, MD Phone:208-709-1439\nDate/Time:2012-9-31 9:00\nProvider: Octavia Casenhiser, MD Phone:624-818-7464\nDate/Time:1988-8-8 1:00\n\n\n\nCompleted by:1957-8-23']
233	99091	185274.0	2190-02-24	Discharge summary	Report	Admission Date: [2190-2-11] Discharge Date: [2190-2-24] Date of Birth: [2132-12-15] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1257] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 57 yo F with PMHX of HTN who presents with shortness of breath x 7 days, worsening over the last 3 days. Patient reports that she has been feeling weak over the last 3 weeks with an unintentional 10 lb weight loss (of note over the last 2 months she has lost 20lbs). 1 week ago she started feeling SOB with exertion, and "hot and cold" but no fevers chills. Then 3 days ago she began to have a non-productive cough that left her "gasping for air", worse at night, with "belly racing", (which appears to be belly breathing when pt demonstrates this). Patient denies nausea, vomiting, chest pain, night sweats, but does endorse a poor appetite. She reports that food has been tasting bland over the last week and that she will only eat food that's "really tasty" like [Location (un) 86] Market, but most of the time she just has soup at home. Of note, patient also reports that 2 weeks ago she had burning on urination for 7 days that went away spontaneously. She also reports that over the last 3 days she has been having more watery stools than normal, but no more frequent BM's than usual. Patient attributed the loose stools to her being ill "it's what happens when I get sick." Today was seen by NP[Company 2316], found to have decreased breath sounds throughout, HR of 120, O2 sat of 70%, increased to 84% on 2L, so was sent to the ED. . In the ED, initial VS were: 110 120/80 28 86% 6L (to 100% on NRB). On exam, shallow breathing and tachypneic but mild degree of respiratory distress. Flu swab ordered. EKG showed *. CXR showed atypical pneumonia vs PCP. [Name10 (NameIs) 227] [Name11 (NameIs) 2317], ordered for azithromycin, but unclear if given. Got 1 liter IVF on way out of ED. Access is 18g and 20g PIV. Temp 97.6 96 120/70 37 99,NRB. . On the floor, patient reported feeling "much better", and when asked what had caused her improvement she reported that it was "the oxygen, definitely". . Review of systems: (+) Per HPI; otherwise she reports a small flat skin discoloration in spots on her L upper extremity (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies wheezing. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, constipation, abdominal pain. Denies frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: -HTN -Vitiligo -Uterine fibroids Social History: She works for the [Company 2318], currently as a ticket collector. She lives with her 2 daughters and her boyfriend of 4 years sleeps over often. For the last 1.5 years patient has been drinking a pint of [Doctor Last Name ]-[Doctor Last Name ] (cognac) and a 6 pack of Corona over the course of 2 days, every day. While she was drinking she would smoke 3 cigarettes per day. She abruptly quit both drinking and smoking 6 weeks PTA, and reports that "[Doctor Last Name 2319] finally gave me the strength to do it". Family History: Mother had [Name (NI) 2320], died at 74 from cancer. Father died at 62 of CAD. 1 sister with hypertension and thyroid disease. 2 brothers and 1 sister alive and healthy. Her daughters are healthy. Physical Exam: Vitals: T:98.8 BP:105/66 P: 91 R: 28 O2: 94% on 100% NRB General: AAOx3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx with some mild thrush noted at base of tongue Neck: supple, JVP not elevated, no LAD Lungs: poor air movement, coarse crackles at the bases bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, vitiligonous changes on the shins bilaterally Pertinent Results: Admission Labs: [2190-2-11*] 10:40AM BLOOD WBC-10.2# RBC-3.93 Hgb-12.5 Hct-35.9* MCV-92# MCH-31.8 MCHC-34.8 RDW-12.9 Plt Ct-527# [2190-2-11] 10:40AM BLOOD Neuts-91.5 Lymphs-5.3* Monos-2.0 Eos-0.6 Baso-0.5 [2190-2-11] 10:40AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-136 K-3.4 Cl-94* HCO3-27 AnGap-18 [2190-2-11] 10:40AM BLOOD Albumin-3.1* Immuno: [2190-2-14] 05:30AM BLOOD WBC-14.0* Lymph-4* Abs [Last Name (un) ]-560 CD3%-32 Abs CD3-179* CD4%-1 Abs CD4-8* CD8%-29 Abs CD8-165* CD4/CD8-0.1* HIV-1 Viral Load/Ultrasensitive (Final [2190-2-15]): 114,000 copies/ml. Micro: Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2190-2-12]): POSITIVE FOR PNEUMOCYSTIS JIROVECII (CARINII). CHEST (PORTABLE AP) Study Date of [2190-2-11] 10:44 AM IMPRESSION: Diffuse hazy opacities within both lungs, without evidence for volume overload. Findings are most concerning for a diffuse infectious process, likely with atypical organisms. If the patient is immunocompromised, PCP should be considered. Brief Hospital Course: On admission there was high index of suspicion for PCP given the appearance on chest x-ray and a significant amount of oropharyngeal thrush. Bronchoscopy with BAL on [2190-2-12] was positive for PCP. [Name10 (NameIs) ] was presumptively started on Bactrim and Prednisone treatment in the emergency department. She was consented for HIV testing and it came back positive with a viral load (VL) of 114,000 and a CD4 of 8. Her oxygenation was tenuous initially requiring face mask with desaturation to the high 70 with movement to the commode but she did not require intubation. Over the course of her treatment she was transition ed to face tent and eventually to 4-5 L of oxygen via nasal cannula. Her overall oxygenation minimally improved very slowly despite Bactrim with a prolonged steroid taper. She was finally discharged home with O2 supplementation of [3-2] L to keep O2 sat at 94 % at rest. Her hypoxia was related to the PCP [Name Initial (PRE) 1064]. For confirmation, she underwent CTA of the lung which was negative for pulmonary embolism. The CT did show diffuse ground glass opacities as well as lymphadenopathy without effusions consistent with the diagnosis of PCP. [Name10 (NameIs) 2321] her exertional hypoxia, she remained well with minimal symptoms (only mild dyspnea with activity but no significant cough and no fever or chest pain). Patient remained in the hospital for several extra days hoping that her hypoxia will improve. It did remain stable at the above level without any additional symptoms (4-5 L at rest with O2 sat at 94 with decrease to 87-85 with activity. Without oxygen, her O2 sat will decrease to 76 with activity). In regards to the new diagnosis of AIDS(AIDS defining illness and CD4 of 8), her toxoplasma IgG was positive. She was started on azithromycin for [Doctor First Name ] prophylaxis. ID was consulted and will follow her closely as an outpatient ( 3 days after discharge). HIV genotyping was sent and was pending at the time of discharge. The patient has a history of hypertension and was continued on home dose of Atenolol 50 mg daily. BP was well controlled despite holding amlodipine/chlorthalidone and these were NOT restarted on discharge. She did have elevation of her liver function tests on presentation. Work up included negative hepatitis serologies and RUQ ultrasound (mild fatty infiltration). LFTs abnormalities were related to PCP pneumonia, fatty liver, or both. Blood AFB culture and HCV viral loads are pending and will be followed by her ID. She was discharged home without VNA, the latter would offer little help as she had no to minimal symptoms. Total discharge time 56 minutes. Medications on Admission: amlodipine 10 mg daily atenolol-chlorthalidone 100 mg-25 mg 0.5 tablet daily calcium carbonate-vitamin D3 500 mg (1,250 mg)-400 unit [Hospital1 ] Discharge Medications: 1. Home Oxygen 4-5 L continuous oxygen for portability pulse dose system. PCP [Name Initial (PRE) ]. 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 for constipation. 4. azithromycin 600 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,FR). Disp:60 Tablet(s) Refills:2 5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 17 days. Disp:102 Tablet(s) Refills:0 6. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 14 days: take 1 tablet for 10 days followed by [11-29] tablet for 4 days. Disp:12 Tablet(s) Refills:0 8. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day. Disp:2 MDI Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: PCP Pneumonia HIV/AIDS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. (requiring supplemental O2) Discharge Instructions: You were admitted with shortness of breath and were found to have a severe pneumonia from an organism called PCP. [Name10 (NameIs) ] have been treated with antibiotics and prednisone. Your immune system is suppressed by HIV/AIDS and you will need to be followed closely by the infectious disease team. You have a very low oxygen in your blood from the severe inflammation related to the PCP [Name Initial (PRE) 1064]. This may take several days to weeks to improve. Please increase your activity as much as possible to avoid clots formation in legs or lung. You requested discharge home. . Please note the following changes to your medication regimen: Followup Instructions: Department: [Hospital3 249] When: WEDNESDAY [2190-3-3] at 10:20 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2322], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: INFECTIOUS DISEASE When: FRIDAY [2190-2-26] at 11:00 AM With: [Name6 (MD) 2323] [Name8 (MD) 2324], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	Admission Date: <Date>1978-5-9</Date> Discharge Date: <Date>1930-1-29</Date> Date of Birth: <Date>1938-2-28</Date> Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Latonya</Name> Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 57 yo F with PMHX of HTN who presents with shortness of breath x 7 days, worsening over the last 3 days. Patient reports that she has been feeling weak over the last 3 weeks with an unintentional 10 lb weight loss (of note over the last 2 months she has lost 20lbs). 1 week ago she started feeling SOB with exertion, and "hot and cold" but no fevers chills. Then 3 days ago she began to have a non-productive cough that left her "gasping for air", worse at night, with "belly racing", (which appears to be belly breathing when pt demonstrates this). Patient denies nausea, vomiting, chest pain, night sweats, but does endorse a poor appetite. She reports that food has been tasting bland over the last week and that she will only eat food that's "really tasty" like <Location>52851 Henderson Lane Suite 007 Parkerfurt, MH 06234</Location> Market, but most of the time she just has soup at home. Of note, patient also reports that 2 weeks ago she had burning on urination for 7 days that went away spontaneously. She also reports that over the last 3 days she has been having more watery stools than normal, but no more frequent BM's than usual. Patient attributed the loose stools to her being ill "it's what happens when I get sick." Today was seen by NP<Company>Alvarez, Cortez and Nielsen</Company>, found to have decreased breath sounds throughout, HR of 120, O2 sat of 70%, increased to 84% on 2L, so was sent to the ED. . In the ED, initial VS were: 110 120/80 28 86% 6L (to 100% on NRB). On exam, shallow breathing and tachypneic but mild degree of respiratory distress. Flu swab ordered. EKG showed **. CXR showed atypical pneumonia vs PCP. <Name>Joe Debelius</Name> <Name>Bernardino Ahmed</Name>, ordered for azithromycin, but unclear if given. Got 1 liter IVF on way out of ED. Access is 18g and 20g PIV. Temp 97.6 96 120/70 37 99,NRB. . On the floor, patient reported feeling "much better", and when asked what had caused her improvement she reported that it was "the oxygen, definitely". . Review of systems: (+) Per HPI; otherwise she reports a small flat skin discoloration in spots on her L upper extremity (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies wheezing. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, constipation, abdominal pain. Denies frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: -HTN -Vitiligo -Uterine fibroids Social History: She works for the <Company>Maldonado-Bradley</Company>, currently as a ticket collector. She lives with her 2 daughters and her boyfriend of 4 years sleeps over often. For the last 1.5 years patient has been drinking a pint of <Doctor Name>Dr.Conyers</Doctor Name>-<Doctor Name>Dr.Conyers</Doctor Name> (cognac) and a 6 pack of Corona over the course of 2 days, every day. While she was drinking she would smoke 3 cigarettes per day. She abruptly quit both drinking and smoking 6 weeks PTA, and reports that "<Doctor Name>Dr.Kwan</Doctor Name> finally gave me the strength to do it". Family History: Mother had <Name>Manu Hui</Name>, died at 74 from cancer. Father died at 62 of CAD. 1 sister with hypertension and thyroid disease. 2 brothers and 1 sister alive and healthy. Her daughters are healthy. Physical Exam: Vitals: T:98.8 BP:105/66 P: 91 R: 28 O2: 94% on 100% NRB General: AAOx3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx with some mild thrush noted at base of tongue Neck: supple, JVP not elevated, no LAD Lungs: poor air movement, coarse crackles at the bases bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, vitiligonous changes on the shins bilaterally Pertinent Results: Admission Labs: <Date>1978-5-9</Date> 10:40AM BLOOD WBC-10.2# RBC-3.93 Hgb-12.5 Hct-35.9* MCV-92# MCH-31.8 MCHC-34.8 RDW-12.9 Plt Ct-527# <Date>1978-5-9</Date> 10:40AM BLOOD Neuts-91.5 Lymphs-5.3* Monos-2.0 Eos-0.6 Baso-0.5 <Date>1978-5-9</Date> 10:40AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-136 K-3.4 Cl-94* HCO3-27 AnGap-18 <Date>1978-5-9</Date> 10:40AM BLOOD Albumin-3.1* Immuno: <Date>1930-11-11</Date> 05:30AM BLOOD WBC-14.0* Lymph-4* Abs <Name>Conyers</Name>-560 CD3%-32 Abs CD3-179* CD4%-1 Abs CD4-8* CD8%-29 Abs CD8-165* CD4/CD8-0.1* HIV-1 Viral Load/Ultrasensitive (Final <Date>1922-3-14</Date>): 114,000 copies/ml. Micro: Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final <Date>1968-10-21</Date>): POSITIVE FOR PNEUMOCYSTIS JIROVECII (CARINII). CHEST (PORTABLE AP) Study Date of <Date>1978-5-9</Date> 10:44 AM IMPRESSION: Diffuse hazy opacities within both lungs, without evidence for volume overload. Findings are most concerning for a diffuse infectious process, likely with atypical organisms. If the patient is immunocompromised, PCP should be considered. Brief Hospital Course: On admission there was high index of suspicion for PCP given the appearance on chest x-ray and a significant amount of oropharyngeal thrush. Bronchoscopy with BAL on <Date>1968-10-21</Date> was positive for PCP. <Name>Aparna Bludsworth</Name> was presumptively started on Bactrim and Prednisone treatment in the emergency department. She was consented for HIV testing and it came back positive with a viral load (VL) of 114,000 and a CD4 of 8. Her oxygenation was tenuous initially requiring face mask with desaturation to the high 70 with movement to the commode but she did not require intubation. Over the course of her treatment she was transition ed to face tent and eventually to 4-5 L of oxygen via nasal cannula. Her overall oxygenation minimally improved very slowly despite Bactrim with a prolonged steroid taper. She was finally discharged home with O2 supplementation of <Date>1-29</Date> L to keep O2 sat at 94 % at rest. Her hypoxia was related to the PCP <Name>Theo Lees</Name>. For confirmation, she underwent CTA of the lung which was negative for pulmonary embolism. The CT did show diffuse ground glass opacities as well as lymphadenopathy without effusions consistent with the diagnosis of PCP. <Name>Cindy Pegram</Name> her exertional hypoxia, she remained well with minimal symptoms (only mild dyspnea with activity but no significant cough and no fever or chest pain). Patient remained in the hospital for several extra days hoping that her hypoxia will improve. It did remain stable at the above level without any additional symptoms (4-5 L at rest with O2 sat at 94 with decrease to 87-85 with activity. Without oxygen, her O2 sat will decrease to 76 with activity). In regards to the new diagnosis of AIDS(AIDS defining illness and CD4 of 8), her toxoplasma IgG was positive. She was started on azithromycin for <Name>Gildardo</Name> prophylaxis. ID was consulted and will follow her closely as an outpatient ( 3 days after discharge). HIV genotyping was sent and was pending at the time of discharge. The patient has a history of hypertension and was continued on home dose of Atenolol 50 mg daily. BP was well controlled despite holding amlodipine/chlorthalidone and these were NOT restarted on discharge. She did have elevation of her liver function tests on presentation. Work up included negative hepatitis serologies and RUQ ultrasound (mild fatty infiltration). LFTs abnormalities were related to PCP pneumonia, fatty liver, or both. Blood AFB culture and HCV viral loads are pending and will be followed by her ID. She was discharged home without VNA, the latter would offer little help as she had no to minimal symptoms. Total discharge time 56 minutes. Medications on Admission: amlodipine 10 mg daily atenolol-chlorthalidone 100 mg-25 mg 0.5 tablet daily calcium carbonate-vitamin D3 500 mg (1,250 mg)-400 unit <Hospital>Howe PLC Health System</Hospital> Discharge Medications: 1. Home Oxygen 4-5 L continuous oxygen for portability pulse dose system. PCP <Name>Sandeep Bounds</Name>. 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 for constipation. 4. azithromycin 600 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,FR). Disp:60 Tablet(s) Refills:2 5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 17 days. Disp:102 Tablet(s) Refills:0 6. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 14 days: take 1 tablet for 10 days followed by <Date>4-18</Date> tablet for 4 days. Disp:12 Tablet(s) Refills:0 8. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day. Disp:2 MDI Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: PCP Pneumonia HIV/AIDS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. (requiring supplemental O2) Discharge Instructions: You were admitted with shortness of breath and were found to have a severe pneumonia from an organism called PCP. <Name>Aparna Bludsworth</Name> have been treated with antibiotics and prednisone. Your immune system is suppressed by HIV/AIDS and you will need to be followed closely by the infectious disease team. You have a very low oxygen in your blood from the severe inflammation related to the PCP <Name>Theo Lees</Name>. This may take several days to weeks to improve. Please increase your activity as much as possible to avoid clots formation in legs or lung. You requested discharge home. . Please note the following changes to your medication regimen: Followup Instructions: Department: <Hospital>Cross-Johnson Health System</Hospital> When: WEDNESDAY <Date>1989-9-13</Date> at 10:20 AM With: <Name>Latrice</Name> <Name>Archie</Name>, MD <Telephone>279-648-3115</Telephone> Building: <Hospital>Dixon, Taylor and Chung Medical Center</Hospital> <Location>Unit 0580 Box 6546 DPO AE 23229</Location> Campus: EAST Best Parking: <Hospital>Dominguez Inc Clinic</Hospital> Garage Department: INFECTIOUS DISEASE When: FRIDAY <Date>2014-3-16</Date> at 11:00 AM With: <Name>Demetrius Ignacio</Name> <Name>George Hazelwood</Name>, MD <Telephone>451-560-5336</Telephone> Building: LM <Hospital>Frazier, Parker and Rodriguez Health System</Hospital> Bldg (<Name>Belle</Name>) <Hospital>Jones, Rios and Hays Health System</Hospital> Campus: WEST Best Parking: <Hospital>Frazier, Parker and Rodriguez Health System</Hospital> 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111111100000000000000000001111111111111111101111111111111111000001111111111110000000000000011111111111111111111111111111111111111111110000000111110011111111111111111111111111111111110000000000000000000000000000000011111111111111111111111111111111111111111110000000000	Admission Date: 1978-5-9 Discharge Date: 1930-1-29 Date of Birth: 1938-2-28 Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Latonya Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 57 yo F with PMHX of HTN who presents with shortness of breath x 7 days, worsening over the last 3 days. Patient reports that she has been feeling weak over the last 3 weeks with an unintentional 10 lb weight loss (of note over the last 2 months she has lost 20lbs). 1 week ago she started feeling SOB with exertion, and "hot and cold" but no fevers chills. Then 3 days ago she began to have a non-productive cough that left her "gasping for air", worse at night, with "belly racing", (which appears to be belly breathing when pt demonstrates this). Patient denies nausea, vomiting, chest pain, night sweats, but does endorse a poor appetite. She reports that food has been tasting bland over the last week and that she will only eat food that's "really tasty" like 52851 Henderson Lane Suite 007 Parkerfurt, MH 06234 Market, but most of the time she just has soup at home. Of note, patient also reports that 2 weeks ago she had burning on urination for 7 days that went away spontaneously. She also reports that over the last 3 days she has been having more watery stools than normal, but no more frequent BM's than usual. Patient attributed the loose stools to her being ill "it's what happens when I get sick." Today was seen by NPAlvarez, Cortez and Nielsen, found to have decreased breath sounds throughout, HR of 120, O2 sat of 70%, increased to 84% on 2L, so was sent to the ED. . In the ED, initial VS were: 110 120/80 28 86% 6L (to 100% on NRB). On exam, shallow breathing and tachypneic but mild degree of respiratory distress. Flu swab ordered. EKG showed **. CXR showed atypical pneumonia vs PCP. Joe Debelius Bernardino Ahmed, ordered for azithromycin, but unclear if given. Got 1 liter IVF on way out of ED. Access is 18g and 20g PIV. Temp 97.6 96 120/70 37 99,NRB. . On the floor, patient reported feeling "much better", and when asked what had caused her improvement she reported that it was "the oxygen, definitely". . Review of systems: (+) Per HPI; otherwise she reports a small flat skin discoloration in spots on her L upper extremity (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies wheezing. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, constipation, abdominal pain. Denies frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: -HTN -Vitiligo -Uterine fibroids Social History: She works for the Maldonado-Bradley, currently as a ticket collector. She lives with her 2 daughters and her boyfriend of 4 years sleeps over often. For the last 1.5 years patient has been drinking a pint of Dr.Conyers-Dr.Conyers (cognac) and a 6 pack of Corona over the course of 2 days, every day. While she was drinking she would smoke 3 cigarettes per day. She abruptly quit both drinking and smoking 6 weeks PTA, and reports that "Dr.Kwan finally gave me the strength to do it". Family History: Mother had Manu Hui, died at 74 from cancer. Father died at 62 of CAD. 1 sister with hypertension and thyroid disease. 2 brothers and 1 sister alive and healthy. Her daughters are healthy. Physical Exam: Vitals: T:98.8 BP:105/66 P: 91 R: 28 O2: 94% on 100% NRB General: AAOx3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx with some mild thrush noted at base of tongue Neck: supple, JVP not elevated, no LAD Lungs: poor air movement, coarse crackles at the bases bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, vitiligonous changes on the shins bilaterally Pertinent Results: Admission Labs: 1978-5-9 10:40AM BLOOD WBC-10.2# RBC-3.93 Hgb-12.5 Hct-35.9* MCV-92# MCH-31.8 MCHC-34.8 RDW-12.9 Plt Ct-527# 1978-5-9 10:40AM BLOOD Neuts-91.5 Lymphs-5.3* Monos-2.0 Eos-0.6 Baso-0.5 1978-5-9 10:40AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-136 K-3.4 Cl-94* HCO3-27 AnGap-18 1978-5-9 10:40AM BLOOD Albumin-3.1* Immuno: 1930-11-11 05:30AM BLOOD WBC-14.0* Lymph-4* Abs Conyers-560 CD3%-32 Abs CD3-179* CD4%-1 Abs CD4-8* CD8%-29 Abs CD8-165* CD4/CD8-0.1* HIV-1 Viral Load/Ultrasensitive (Final 1922-3-14): 114,000 copies/ml. Micro: Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final 1968-10-21): POSITIVE FOR PNEUMOCYSTIS JIROVECII (CARINII). CHEST (PORTABLE AP) Study Date of 1978-5-9 10:44 AM IMPRESSION: Diffuse hazy opacities within both lungs, without evidence for volume overload. Findings are most concerning for a diffuse infectious process, likely with atypical organisms. If the patient is immunocompromised, PCP should be considered. Brief Hospital Course: On admission there was high index of suspicion for PCP given the appearance on chest x-ray and a significant amount of oropharyngeal thrush. Bronchoscopy with BAL on 1968-10-21 was positive for PCP. Aparna Bludsworth was presumptively started on Bactrim and Prednisone treatment in the emergency department. She was consented for HIV testing and it came back positive with a viral load (VL) of 114,000 and a CD4 of 8. Her oxygenation was tenuous initially requiring face mask with desaturation to the high 70 with movement to the commode but she did not require intubation. Over the course of her treatment she was transition ed to face tent and eventually to 4-5 L of oxygen via nasal cannula. Her overall oxygenation minimally improved very slowly despite Bactrim with a prolonged steroid taper. She was finally discharged home with O2 supplementation of 1-29 L to keep O2 sat at 94 % at rest. Her hypoxia was related to the PCP Theo Lees. For confirmation, she underwent CTA of the lung which was negative for pulmonary embolism. The CT did show diffuse ground glass opacities as well as lymphadenopathy without effusions consistent with the diagnosis of PCP. Cindy Pegram her exertional hypoxia, she remained well with minimal symptoms (only mild dyspnea with activity but no significant cough and no fever or chest pain). Patient remained in the hospital for several extra days hoping that her hypoxia will improve. It did remain stable at the above level without any additional symptoms (4-5 L at rest with O2 sat at 94 with decrease to 87-85 with activity. Without oxygen, her O2 sat will decrease to 76 with activity). In regards to the new diagnosis of AIDS(AIDS defining illness and CD4 of 8), her toxoplasma IgG was positive. She was started on azithromycin for Gildardo prophylaxis. ID was consulted and will follow her closely as an outpatient ( 3 days after discharge). HIV genotyping was sent and was pending at the time of discharge. The patient has a history of hypertension and was continued on home dose of Atenolol 50 mg daily. BP was well controlled despite holding amlodipine/chlorthalidone and these were NOT restarted on discharge. She did have elevation of her liver function tests on presentation. Work up included negative hepatitis serologies and RUQ ultrasound (mild fatty infiltration). LFTs abnormalities were related to PCP pneumonia, fatty liver, or both. Blood AFB culture and HCV viral loads are pending and will be followed by her ID. She was discharged home without VNA, the latter would offer little help as she had no to minimal symptoms. Total discharge time 56 minutes. Medications on Admission: amlodipine 10 mg daily atenolol-chlorthalidone 100 mg-25 mg 0.5 tablet daily calcium carbonate-vitamin D3 500 mg (1,250 mg)-400 unit Howe PLC Health System Discharge Medications: 1. Home Oxygen 4-5 L continuous oxygen for portability pulse dose system. PCP Sandeep Bounds. 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 for constipation. 4. azithromycin 600 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,FR). Disp:60 Tablet(s) Refills:2 5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 17 days. Disp:102 Tablet(s) Refills:0 6. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 14 days: take 1 tablet for 10 days followed by 4-18 tablet for 4 days. Disp:12 Tablet(s) Refills:0 8. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day. Disp:2 MDI Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: PCP Pneumonia HIV/AIDS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. (requiring supplemental O2) Discharge Instructions: You were admitted with shortness of breath and were found to have a severe pneumonia from an organism called PCP. Aparna Bludsworth have been treated with antibiotics and prednisone. Your immune system is suppressed by HIV/AIDS and you will need to be followed closely by the infectious disease team. You have a very low oxygen in your blood from the severe inflammation related to the PCP Theo Lees. This may take several days to weeks to improve. Please increase your activity as much as possible to avoid clots formation in legs or lung. You requested discharge home. . Please note the following changes to your medication regimen: Followup Instructions: Department: Cross-Johnson Health System When: WEDNESDAY 1989-9-13 at 10:20 AM With: Latrice Archie, MD 279-648-3115 Building: Dixon, Taylor and Chung Medical Center Unit 0580 Box 6546 DPO AE 23229 Campus: EAST Best Parking: Dominguez Inc Clinic Garage Department: INFECTIOUS DISEASE When: FRIDAY 2014-3-16 at 11:00 AM With: Demetrius Ignacio George Hazelwood, MD 451-560-5336 Building: LM Frazier, Parker and Rodriguez Health System Bldg (Belle) Jones, Rios and Hays Health System Campus: WEST Best Parking: Frazier, Parker and Rodriguez Health System Garage	['Admission Date: 1978-5-9 Discharge Date: 1930-1-29\n\nDate of Birth: 1938-2-28 Sex: F\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Latonya\nChief Complaint:\nDyspnea\n\n\nMajor Surgical or Invasive Procedure:\nBronchoscopy\n\nHistory of Present Illness:\n57 yo F with PMHX of HTN who presents with shortness of breath x\n7 days, worsening over the last 3 days. Patient reports that she\nhas been feeling weak over the last 3 weeks with an\nunintentional 10 lb weight loss (of note over the last 2 months\nshe has lost 20lbs). 1 week ago she started feeling SOB with\nexertion, and "hot and cold" but no fevers chills. Then 3 days\nago she began to have a non-productive cough that left her\n"gasping for air", worse at night, with "belly racing", (which\nappears to be belly breathing when pt demonstrates this).', '\nPatient denies nausea, vomiting, chest pain, night sweats, but\ndoes endorse a poor appetite. She reports that food has been\ntasting bland over the last week and that she will only eat food\nthat\'s "really tasty" like 52851 Henderson Lane Suite 007\nParkerfurt, MH 06234 Market, but most of the time\nshe just has soup at home. Of note, patient also reports that 2\nweeks ago she had burning on urination for 7 days that went away\nspontaneously. She also reports that over the last 3 days she\nhas been having more watery stools than normal, but no more\nfrequent BM\'s than usual. Patient attributed the loose stools\nto her being ill "it\'s what happens when I get sick."\nToday was seen by NPAlvarez, Cortez and Nielsen, found to have decreased breath\nsounds throughout, HR of 120, O2 sat of 70%, increased to 84% on\n2L, so was sent to the ED.', '\n.\nIn the ED, initial VS were: 110 120/80 28 86% 6L (to 100% on\nNRB). On exam, shallow breathing and tachypneic but mild degree\nof respiratory distress. Flu swab ordered. EKG showed **. CXR\nshowed atypical pneumonia vs PCP. Joe Debelius Bernardino Ahmed, ordered for\nazithromycin, but unclear if given. Got 1 liter IVF on way out\nof ED. Access is 18g and 20g PIV. Temp 97.6 96 120/70 37 99,NRB.\n.\nOn the floor, patient reported feeling "much better", and when\nasked what had caused her improvement she reported that it was\n"the oxygen, definitely".\n.\nReview of systems:\n(+) Per HPI; otherwise she reports a small flat skin\ndiscoloration in spots on her L upper extremity\n(-) Denies fever, chills, night sweats. Denies headache, sinus\ntenderness, rhinorrhea or congestion. Denies wheezing. Denies\nchest pain, chest pressure, palpitations.', ' Denies nausea,\nvomiting, constipation, abdominal pain. Denies frequency, or\nurgency. Denies arthralgias or myalgias.\n\n\nPast Medical History:\n-HTN\n-Vitiligo\n-Uterine fibroids\n\n\nSocial History:\nShe works for the Maldonado-Bradley, currently as a ticket collector. She\nlives with her 2 daughters and her boyfriend of 4 years sleeps\nover often. For the last 1.5 years patient has been drinking a\npint of Dr.Conyers-Dr.Conyers (cognac) and a 6 pack of Corona over the\ncourse of 2 days, every day. While she was drinking she would\nsmoke 3 cigarettes per day. She abruptly quit both drinking and\nsmoking 6 weeks PTA, and reports that "Dr.Kwan finally gave me the\nstrength to do it".\n\nFamily History:\nMother had Manu Hui, died at 74 from cancer. Father died at 62 of\nCAD. 1 sister with hypertension and thyroid disease.', ' 2 brothers\nand 1 sister alive and healthy. Her daughters are healthy.\n\n\nPhysical Exam:\nVitals: T:98.8 BP:105/66 P: 91 R: 28 O2: 94% on 100% NRB\nGeneral: AAOx3, no acute distress\nHEENT: Sclera anicteric, MMM, oropharynx with some mild thrush\nnoted at base of tongue\nNeck: supple, JVP not elevated, no LAD\nLungs: poor air movement, coarse crackles at the bases\nbilaterally\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: no foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema, vitiligonous changes on the shins bilaterally\n\n\nPertinent Results:\nAdmission Labs:\n1978-5-9 10:40AM BLOOD WBC-10.2# RBC-3.93 Hgb-12.5 Hct-35.9\nMCV-92# MCH-31.', '8 MCHC-34.8 RDW-12.9 Plt Ct-527#\n1978-5-9 10:40AM BLOOD Neuts-91.5* Lymphs-5.3* Monos-2.0 Eos-0.6\nBaso-0.5\n1978-5-9 10:40AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-136\nK-3.4 Cl-94* HCO3-27 AnGap-18\n1978-5-9 10:40AM BLOOD Albumin-3.1\n\nImmuno:\n1930-11-11 05:30AM BLOOD WBC-14.0 Lymph-4* Abs Conyers-560 CD3%-32\nAbs CD3-179* CD4%-1 Abs CD4-8* CD8%-29 Abs CD8-165* CD4/CD8-0.1\n\nHIV-1 Viral Load/Ultrasensitive (Final 1922-3-14): 114,000\ncopies/ml.\n\nMicro:\nImmunoflourescent test for Pneumocystis jirovecii (carinii)\n(Final 1968-10-21): POSITIVE FOR PNEUMOCYSTIS JIROVECII (CARINII).\n\n\nCHEST (PORTABLE AP) Study Date of 1978-5-9 10:44 AM\nIMPRESSION: Diffuse hazy opacities within both lungs, without\nevidence for volume overload. Findings are most concerning for a\ndiffuse infectious process, likely with atypical organisms.', ' If\nthe patient is immunocompromised, PCP should be considered.\n\n\nBrief Hospital Course:\nOn admission there was high index of suspicion for PCP given the\nappearance on chest x-ray and a significant amount of\noropharyngeal thrush. Bronchoscopy with BAL on 1968-10-21 was\npositive for PCP. Aparna Bludsworth was presumptively started on Bactrim and\nPrednisone treatment in the emergency department. She was\nconsented for HIV testing and it came back positive with a\nviral load (VL) of 114,000 and a CD4 of 8. Her oxygenation was\ntenuous initially requiring face mask with desaturation to the\nhigh 70 with movement to the commode but she did not require\nintubation. Over the course of her treatment she was transition\ned to face tent and eventually to 4-5 L of oxygen via nasal\ncannula. Her overall oxygenation minimally improved very slowly\ndespite Bactrim with a prolonged steroid taper.', ' She was finally\ndischarged home with O2 supplementation of 1-29 L to keep O2 sat\nat 94 % at rest. Her hypoxia was related to the PCP Theo Lees.\nFor confirmation, she underwent CTA of the lung which was\nnegative for pulmonary embolism. The CT did show diffuse ground\nglass opacities as well as lymphadenopathy without effusions\nconsistent with the diagnosis of PCP. Cindy Pegram her exertional\nhypoxia, she remained well with minimal symptoms (only mild\ndyspnea with activity but no significant cough and no fever or\nchest pain). Patient remained in the hospital for several extra\ndays hoping that her hypoxia will improve. It did remain stable\nat the above level without any additional symptoms (4-5 L at\nrest with O2 sat at 94 with decrease to 87-85 with activity.\nWithout oxygen, her O2 sat will decrease to 76 with activity).', '\nIn regards to the new diagnosis of AIDS(AIDS defining illness\nand CD4 of 8), her toxoplasma IgG was positive. She was started\non azithromycin for Gildardo prophylaxis. ID was consulted and will\nfollow her closely as an outpatient ( 3 days after discharge).\nHIV genotyping was sent and was pending at the time of\ndischarge. The patient has a history of hypertension and was\ncontinued on home dose of Atenolol 50 mg daily. BP was well\ncontrolled despite holding amlodipine/chlorthalidone and these\nwere NOT restarted on discharge. She did have elevation of her\nliver function tests on presentation. Work up included negative\nhepatitis serologies and RUQ ultrasound (mild fatty\ninfiltration). LFTs abnormalities were related to PCP pneumonia,\nfatty liver, or both. Blood AFB culture and HCV viral loads are\npending and will be followed by her ID.', ' She was discharged home\nwithout VNA, the latter would offer little help as she had no to\nminimal symptoms. Total discharge time 56 minutes.\n\nMedications on Admission:\namlodipine 10 mg daily\natenolol-chlorthalidone 100 mg-25 mg 0.5 tablet daily\ncalcium carbonate-vitamin D3 500 mg (1,250 mg)-400 unit Howe PLC Health System\n\n\nDischarge Medications:\n1. Home Oxygen\n4-5 L continuous oxygen for portability pulse dose system. PCP\nSandeep Bounds.\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 for constipation.\n4. azithromycin 600 mg Tablet Sig: One (1) Tablet PO 2X/WEEK\n(TU,FR).\nDisp:60 Tablet(s)* Refills:2\n5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)\nTablet PO TID (3 times a day) for 17 days.', '\nDisp:102 Tablet(s) Refills:0\n6. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n7. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)\nfor 14 days: take 1 tablet for 10 days followed by 4-18 tablet\nfor 4 days.\nDisp:12 Tablet(s) Refills:0\n8. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)\nInhalation four times a day.\nDisp:2 MDI Refills:2\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPrimary:\nPCP Pneumonia\nHIV/AIDS\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent. (requiring\nsupplemental O2)\n\nDischarge Instructions:\nYou were admitted with shortness of breath and were found to\nhave a severe pneumonia from an organism called PCP. Aparna Bludsworth have\nbeen treated with antibiotics and prednisone.', ' Your immune system\nis suppressed by HIV/AIDS and you will need to be followed\nclosely by the infectious disease team. You have a very low\noxygen in your blood from the severe inflammation related to the\nPCP Theo Lees. This may take several days to weeks to improve.\nPlease increase your activity as much as possible to avoid clots\nformation in legs or lung. You requested discharge home.\n.\nPlease note the following changes to your medication regimen:\n\nFollowup Instructions:\nDepartment: Cross-Johnson Health System\nWhen: WEDNESDAY 1989-9-13 at 10:20 AM\nWith: Latrice Archie, MD 279-648-3115\nBuilding: Dixon, Taylor and Chung Medical Center Unit 0580 Box 6546\nDPO AE 23229\nCampus: EAST Best Parking: Dominguez Inc Clinic Garage\n\nDepartment: INFECTIOUS DISEASE\nWhen: FRIDAY 2014-3-16 at 11:00 AM\nWith: Demetrius Ignacio George Hazelwood, MD 451-560-5336\nBuilding: LM Frazier, Parker and Rodriguez Health System Bldg (Belle) Jones, Rios and Hays Health System\nCampus: WEST Best Parking: Frazier, Parker and Rodriguez Health System Garage\n\n\n']
234	70108	186093.0	2105-04-27	Discharge summary	Report	Admission Date: [2105-4-16] Discharge Date: [2105-4-27] Date of Birth: [2044-3-8] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2344] Chief Complaint: Airway monitoring Major Surgical or Invasive Procedure: [2105-4-24]: Right video-assisted thoraoscopy with decortication History of Present Illness: 61 year old female with PMHX of HTH presented with severe sore throat for 2 days rapidly getting worse associated with difficulty swallowing liquids and neck pain. Also found to have fever and tachycardia. Unable to take meds, only took BP meds this am. Voice is hoarse and descrbed as "hot potato" by PCP. [Name10 (NameIs) 1403] as a flight attendant, travelled all over Europe recently. Sister with sore throat as well. In PCPs office, unable to open her mouth, tender thick neck unable to evaluate pharynx. Per report pts sore throat has progressed rapidly over past 2 days. Unable to swallow her secretions, no tipoding or drooling present. . In the ED, 100.8 81 125/77 16 99%RA. She was given Clindamycin, Dexamethasone, Morphine Sulfate 4mg Syringe, HYDROmorphone (Dilaudid) 1mg/1mL Syringe, Gentamicin 80mg. Labs unremarkable. CT neck showed retropharyngeal phlegmon. ENT scoped her, has epiglottis and supraglottic swelling. Symptoms improved. Fever 102 in ED. Prior to transfer 117/78 18 100% RA. . Upon arrival to the floor, patient able to phonate but voice still hoarse. No stridor or tripoding noted. Reports inability to get secretions up. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Hypertension Allergic rhinitis Social History: Lives with sister, smokes 1/2-1ppd for the past 40 years, drinks on occasion, denies drugs. She was flight attendent for US Air. Family History: Sister with [Name2 (NI) 499] cancer and thyroid cancer in 50s Physical Exam: Admission Exam: VS: 98.7 82 136/65 13 98% on RA GA: AOx3, hoarse voice HEENT: PERRLA. MMM. no LAD. no JVD. neck tender to palpation anterior and posterioly, unable to visualize pharynx Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: rhonchi heard and left base Abd: soft, NT, +BS. no g/rt. neg HSM. neg [Doctor Last Name 515] sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: wnl Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT, pain, temperature, vibration, proprioception. cerebellar fxn intact (FTN, HTS). gait WNL. . Pertinent Results: [2105-4-16] 05:02PM LACTATE-1.4 [2105-4-16] 04:23PM GLUCOSE-116* UREA N-9 CREAT-0.7 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14 [2105-4-16] 04:23PM WBC-10.1# RBC-4.27 HGB-13.6 HCT-37.9 MCV-89 MCH-31.9 MCHC-36.0* RDW-13.1 [2105-4-16] 04:23PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.8 EOS-0 BASOS-0.2 [2105-4-16] 04:23PM PLT COUNT-225 . Scope ENT (on admission): Her glottic opening is about 4mm on scope exam without symptoms including stridor or retraction. . CT neck with contrast ([2105-4-16]): Retropharyngeal fluid collection spanning from C2/3 to C5/6 with extensive surrounding edema and inflammation of the hypopharynx. The airway is narrowed to 4mm at the level of the hyoid. Patent cervical vasculature. . CXR ([2105-4-17]): As compared to the previous radiograph, there is no relevant change. No pathologic mediastinal widening. Borderline size of the cardiac silhouette. Presence of minimal pleural effusions cannot be excluded. No focal parenchymal opacity suggesting pneumonia. No pulmonary edema. . CT neck and chest w/ contrast ([2105-4-18]): 1. Interval slight decrease of the retropharyngeal fluid collection and improved airway patency. 2. No evidence of Lemierre's disease or new abscess formation. 3. No evidence of extension of the fluid collection into the mediastinum. No evidence of mediastinitis. . Chest CT ([4-22]): IMPRESSION: 1. Rapidly enlarging multiloculated right pleural effusion. This could be due to empyema considering clinical suspicion for this entity, but definitive diagnosis would require correlation with thoracentesis results. 2. Small dependent left pleural effusion has also increased in size since the prior study but does not have loculated components. 3. Slight increase in size of pre- and sub-carinal lymph nodes as well as right hilar nodes. These are likely reactive. 4. Ground-glass opacities in left upper lobe which are likely infectious or inflammatory in etiology. . TTE ([4-22]): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . [4-23] CXR REASON FOR EXAMINATION: Evaluation of the patient with complicated pleural effusion. Portable AP radiograph of the chest was reviewed in comparison to [2105-4-21]. There is interval increase in right pleural effusion, loculated, better appreciated on the prior radiograph but the change in size is significant. No pneumothorax is seen. Left pleural effusion is unchanged. Bibasal areas of atelectasis are noted. . 5/28CXR Discharge Labs . Micro. Blood Culture, Routine (Preliminary): HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. BETA- LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO AMPICILLIN. . BETA-LACTAMASE CONFIRMATION REQUESTED BY DR. [Last Name (STitle) 2345]. Aerobic Bottle Gram Stain (Final [2105-4-18]): Reported to and read back by DR. [Last Name (STitle) ] [Last Name (NamePattern4) 2346] ON [2105-4-18] AT 0720. GRAM NEGATIVE ROD(S). Brief Hospital Course: 61 yo F with PMHX of HTN presenting with sore throat, neck pain, and odynophagia found to have epiglottis and retrophargyneal phlegmon. . #Epiglottis/retropharyngenal phlegmon: Diagnosed on CT neck and by ENT scope. Symptoms consistent with this. The patient did improve clinically with steroids, Ceftriaxone and clindamycin. The patient's airway was closely monitored in the ICU and underwent repeat ENT scoping on [2105-4-18] that showed ongoing arytenoid edema but completely patent airway. Repeat CT neck and chest with contrast, in the setting of ongoing posterior neck pain and inspiration pain as well as worsening erythematous lesion (see below), did not show Lemierre's or mediastinitis. There was minimal interval improvement in the phlegmon collection, however. Blood cultures from admission were positive for GNRs, later grew out HAEMOPHILUS INFLUENZAE. Planned for 14 day course from day of first negative culture. The patient remained hemodynamically stable and re-evaluation by ENT in the ICU showed improved of supraglottic swelling so she was transfered to the floor. Repeat cultures were negative ???? HIV was sent and was negative. Patient continued to be symptom free on the floor and did not have any further airway complaints or problems. She was treated symptomatically with cepacol lozenges and was kept on a nicotine patch and received nebulizers PRN. . #Erythematous lesion: Patient developed a 3X3 inch erythematous lesion on her anterior chest, 2 inches below cricoid and poorly demarcated. The patient endorsed feeling warm and mildly tender to palpation in this area with no pruritis. No plaques/papules/bullae. The lesion was very blanching. Dermatology was consulted on [2105-4-18] given spread of this lesion to ~4X4 inches despite broadening to Vancomycin. Given the timing of her antibiotics, this lesion was not felt due to drug eruption, although a very early drug eruption can not be ruled out. The erythema was felt most consistent with a toxic exanthem, which is a vasodilation that occurs in patients with bactermia (more often staph, strep). Supportive care was provided. Derm followed patient while in house. by hospital day 4 the rash had significantly receeded. Derm did not feel compelled to biopsy - they thought it was likely due to her infectious process but did not represent a cellulitis. Her rash improved later in her hospital course. . #Pneumonia and pleural effusion: She was noted to have intermittent hypoxemia and R sided pleuritic chest pain on [4-20]. Medicine was consulted on [4-22], and in setting of new moderate pleural effusions R>L on CXR, recommended chest CT, which showed rapidly expanding and loculated effusion on R. She was then transferred to medicine, and ID was consulted. Her antibiotics were changed to ceftriaxone. Her pleural effusion was attempted to be drained by IR, but they only withdrew 30 cc of fluid, given loculation. Thoracic surgery was then involved and carried out a VATS procedure which was uncomplicated and the patient was transferred back to medicine. . #Hypertension: Blood pressures normal and intermittently high (SBPs 150s) in-house. The patient's atenolol, lipitor were held in the setting of epiglottis/retropharyngeal phlegmon but restarted once she was able to tolerate POs. Atenolol was initially started at half home dose 50mg, then back to her full dose.However due to asymp. bradycardia into the 40's atenolol was discontinued ad replaced with Chlorthalidone on [4-25]. . # Intermittent bradycardia to 40s, asymptomatic: She was monitored on telemetry with occasional intermittent bradycardia to the 40s. her EKG was otherwise normal, without AVB. TTE was done which showed no HD significant pericardial effusion, abscess, or vegetations. Her bradycardia may have been due to vagal tone in setting of pleural effusions and pleuritic pain. . # Lower extremity edema: She noted increased edema during this admission. She had some baseline edema as a flight attendant but only while standing for long durations. She had no JVD or HJR, and TTE was normal. . #PPX: Heparin sq #Full Code, confirmed. Medications on Admission: -Lipitor 20 mg Tab 1 Tablet(s) by mouth once a day -atenolol 100 mg Tab 1 Tablet(s) by mouth once a day -ProAir HFA 90 mcg/Actuation Aerosol Inhaler two puffs(s) inhaled every 4-6 hours as needed for SOB/wheezes -Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 puffs(s) twice a day -fluticasone 50 mcg/Actuation Nasal Spray, Susp 2 sprays each nostril daily Discharge Medications: 1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:2 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: Five (5) ML PO Q4H (every 4 hours) as needed for pain. Disp:250 ML(s) Refills:0 6. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs puffs Inhalation twice a day. 8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) puffs Nasal once a day: 2 sprays to nose daily. 9. Outpatient Lab Work 1. CBC with differential 2. ESR 3. CRP Please obtain this blood work on [2105-5-4] and fax results to infectious disease at ([Telephone/Fax (1) 1354] 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. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bacterial supraglottitis Bacteremia Loculated pleural effusions Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-7] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. You were admitted with a severe throat infection and bacteremia with H influenza. You also developed a rash on your chest thought to be due to this bacteria. Your rash and throat improved, but you then developed shortness of breath due to increasing pleural effusions. You were thought to have pneumonia, and your pleural effusion was treated by thoracic surgery with VATS procedure. Your antibiotic course will be levofloxacin until told to stop by the infectious disease doctors. You will be seen by them as an outpatient. . Medication changes: START Levaquin (aka Levofloxacin) for your infection STOP Atenolol (this was stopped because your heart rate was low) START Chlorthalidone (for blood pressure control) . You should take all your other medication as prescribed by your doctors. . Thoracic surgery Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough (it is normal to cough-up blood tinge sputum for a few days) or chest pain -Incision develops drainage or increased redness -Chest tube site remove dressing and cover site with a bandaid until healed -Should site drain cover with a clean dressing and change as needed Activity -Shower daily. Wash incision with mild soap and water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lifting greater than 10 pounds -No driving while taking narcotics Followup Instructions: ENT (ears nose and throat): Please follow up with Dr. [First Name (STitle) ] in 2 weeks. Her office can be reached at [Telephone/Fax (1) 2349] to make a follow-up appointment. . Infectious disease : You have an appointment on [2105-5-7] with Dr. [Last Name (STitle) 2350] @ 2:50pm. Please note that you also have a CT of your neck ordered for [2105-5-4] (You need to call [Telephone/Fax (1) 327] to confirm the time/location of this exam). Before your appointment with Dr. [Last Name (STitle) 2350], you will need to have your blood drawn and have the results faxed to ([Telephone/Fax (1) 1353]. Thoracic surgery: Follow-up with Dr. [Last Name (STitle) ] [0-0-] Date/Time:[2105-5-12] 3:00 on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center, [Location (un) ] Chest X-Ray [Location (un) 861] Radiology 30 minutes before your appointment Please also follow up with your PCP. [Name10 (NameIs) 2351] your appointment you should have your blood drawn with the following results sent to the infectious disease team (CBC with differential; ESR;CRP). The number to fax them to is ([Telephone/Fax (1) 1353]. Note that you have the following appointment scheduled: Department: [Hospital1 18] [Location (un) 2352]- ADULT MED When: MONDAY [2105-5-4] at 10:15 AM With: [First Name4 (NamePattern1) 2353] [Last Name (NamePattern1) 2354], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551*] Campus: OFF CAMPUS Best Parking: Free Parking on Site	Admission Date: <Date>1949-10-11</Date> Discharge Date: <Date>1980-10-7</Date> Date of Birth: <Date>1986-3-17</Date> Sex: F Service: MEDICINE Allergies: Penicillins Attending:<Name>Christina</Name> Chief Complaint: Airway monitoring Major Surgical or Invasive Procedure: <Date>1941-1-23</Date>: Right video-assisted thoraoscopy with decortication History of Present Illness: 61 year old female with PMHX of HTH presented with severe sore throat for 2 days rapidly getting worse associated with difficulty swallowing liquids and neck pain. Also found to have fever and tachycardia. Unable to take meds, only took BP meds this am. Voice is hoarse and descrbed as "hot potato" by PCP. <Name>Lillie Jones</Name> as a flight attendant, travelled all over Europe recently. Sister with sore throat as well. In PCPs office, unable to open her mouth, tender thick neck unable to evaluate pharynx. Per report pts sore throat has progressed rapidly over past 2 days. Unable to swallow her secretions, no tipoding or drooling present. . In the ED, 100.8 81 125/77 16 99%RA. She was given Clindamycin, Dexamethasone, Morphine Sulfate 4mg Syringe, HYDROmorphone (Dilaudid) 1mg/1mL Syringe, Gentamicin 80mg. Labs unremarkable. CT neck showed retropharyngeal phlegmon. ENT scoped her, has epiglottis and supraglottic swelling. Symptoms improved. Fever 102 in ED. Prior to transfer 117/78 18 100% RA. . Upon arrival to the floor, patient able to phonate but voice still hoarse. No stridor or tripoding noted. Reports inability to get secretions up. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Hypertension Allergic rhinitis Social History: Lives with sister, smokes 1/2-1ppd for the past 40 years, drinks on occasion, denies drugs. She was flight attendent for US Air. Family History: Sister with <Name>Lian Hui</Name> cancer and thyroid cancer in 50s Physical Exam: Admission Exam: VS: 98.7 82 136/65 13 98% on RA GA: AOx3, hoarse voice HEENT: PERRLA. MMM. no LAD. no JVD. neck tender to palpation anterior and posterioly, unable to visualize pharynx Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: rhonchi heard and left base Abd: soft, NT, +BS. no g/rt. neg HSM. neg <Doctor Name>Dr.Bounds</Doctor Name> sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: wnl Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT, pain, temperature, vibration, proprioception. cerebellar fxn intact (FTN, HTS). gait WNL. . Pertinent Results: <Date>1949-10-11</Date> 05:02PM LACTATE-1.4 <Date>1949-10-11</Date> 04:23PM GLUCOSE-116* UREA N-9 CREAT-0.7 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14 <Date>1949-10-11</Date> 04:23PM WBC-10.1# RBC-4.27 HGB-13.6 HCT-37.9 MCV-89 MCH-31.9 MCHC-36.0* RDW-13.1 <Date>1949-10-11</Date> 04:23PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.8 EOS-0 BASOS-0.2 <Date>1949-10-11</Date> 04:23PM PLT COUNT-225 . Scope ENT (on admission): Her glottic opening is about 4mm on scope exam without symptoms including stridor or retraction. . CT neck with contrast (<Date>1949-10-11</Date>): Retropharyngeal fluid collection spanning from C2/3 to C5/6 with extensive surrounding edema and inflammation of the hypopharynx. The airway is narrowed to 4mm at the level of the hyoid. Patent cervical vasculature. . CXR (<Date>2015-1-9</Date>): As compared to the previous radiograph, there is no relevant change. No pathologic mediastinal widening. Borderline size of the cardiac silhouette. Presence of minimal pleural effusions cannot be excluded. No focal parenchymal opacity suggesting pneumonia. No pulmonary edema. . CT neck and chest w/ contrast (<Date>2008-11-16</Date>): 1. Interval slight decrease of the retropharyngeal fluid collection and improved airway patency. 2. No evidence of Lemierre's disease or new abscess formation. 3. No evidence of extension of the fluid collection into the mediastinum. No evidence of mediastinitis. . Chest CT (<Date>6-31</Date>): IMPRESSION: 1. Rapidly enlarging multiloculated right pleural effusion. This could be due to empyema considering clinical suspicion for this entity, but definitive diagnosis would require correlation with thoracentesis results. 2. Small dependent left pleural effusion has also increased in size since the prior study but does not have loculated components. 3. Slight increase in size of pre- and sub-carinal lymph nodes as well as right hilar nodes. These are likely reactive. 4. Ground-glass opacities in left upper lobe which are likely infectious or inflammatory in etiology. . TTE (<Date>6-31</Date>): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . <Date>5-28</Date> CXR REASON FOR EXAMINATION: Evaluation of the patient with complicated pleural effusion. Portable AP radiograph of the chest was reviewed in comparison to <Date>2004-10-1</Date>. There is interval increase in right pleural effusion, loculated, better appreciated on the prior radiograph but the change in size is significant. No pneumothorax is seen. Left pleural effusion is unchanged. Bibasal areas of atelectasis are noted. . 5/28CXR Discharge Labs . Micro. Blood Culture, Routine (Preliminary): HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. BETA- LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO AMPICILLIN. . BETA-LACTAMASE CONFIRMATION REQUESTED BY DR. <Name>Lyna</Name>. Aerobic Bottle Gram Stain (Final <Date>2008-11-16</Date>): Reported to and read back by DR. <Name>Booker</Name> <Name>Hui</Name> ON <Date>2008-11-16</Date> AT 0720. GRAM NEGATIVE ROD(S). Brief Hospital Course: 61 yo F with PMHX of HTN presenting with sore throat, neck pain, and odynophagia found to have epiglottis and retrophargyneal phlegmon. . #Epiglottis/retropharyngenal phlegmon: Diagnosed on CT neck and by ENT scope. Symptoms consistent with this. The patient did improve clinically with steroids, Ceftriaxone and clindamycin. The patient's airway was closely monitored in the ICU and underwent repeat ENT scoping on <Date>2008-11-16</Date> that showed ongoing arytenoid edema but completely patent airway. Repeat CT neck and chest with contrast, in the setting of ongoing posterior neck pain and inspiration pain as well as worsening erythematous lesion (see below), did not show Lemierre's or mediastinitis. There was minimal interval improvement in the phlegmon collection, however. Blood cultures from admission were positive for GNRs, later grew out HAEMOPHILUS INFLUENZAE. Planned for 14 day course from day of first negative culture. The patient remained hemodynamically stable and re-evaluation by ENT in the ICU showed improved of supraglottic swelling so she was transfered to the floor. Repeat cultures were negative ???? HIV was sent and was negative. Patient continued to be symptom free on the floor and did not have any further airway complaints or problems. She was treated symptomatically with cepacol lozenges and was kept on a nicotine patch and received nebulizers PRN. . #Erythematous lesion: Patient developed a 3X3 inch erythematous lesion on her anterior chest, 2 inches below cricoid and poorly demarcated. The patient endorsed feeling warm and mildly tender to palpation in this area with no pruritis. No plaques/papules/bullae. The lesion was very blanching. Dermatology was consulted on <Date>2008-11-16</Date> given spread of this lesion to ~4X4 inches despite broadening to Vancomycin. Given the timing of her antibiotics, this lesion was not felt due to drug eruption, although a very early drug eruption can not be ruled out. The erythema was felt most consistent with a toxic exanthem, which is a vasodilation that occurs in patients with bactermia (more often staph, strep). Supportive care was provided. Derm followed patient while in house. by hospital day 4 the rash had significantly receeded. Derm did not feel compelled to biopsy - they thought it was likely due to her infectious process but did not represent a cellulitis. Her rash improved later in her hospital course. . #Pneumonia and pleural effusion: She was noted to have intermittent hypoxemia and R sided pleuritic chest pain on <Date>7-20</Date>. Medicine was consulted on <Date>6-31</Date>, and in setting of new moderate pleural effusions R>L on CXR, recommended chest CT, which showed rapidly expanding and loculated effusion on R. She was then transferred to medicine, and ID was consulted. Her antibiotics were changed to ceftriaxone. Her pleural effusion was attempted to be drained by IR, but they only withdrew 30 cc of fluid, given loculation. Thoracic surgery was then involved and carried out a VATS procedure which was uncomplicated and the patient was transferred back to medicine. . #Hypertension: Blood pressures normal and intermittently high (SBPs 150s) in-house. The patient's atenolol, lipitor were held in the setting of epiglottis/retropharyngeal phlegmon but restarted once she was able to tolerate POs. Atenolol was initially started at half home dose 50mg, then back to her full dose.However due to asymp. bradycardia into the 40's atenolol was discontinued ad replaced with Chlorthalidone on <Date>5-16</Date>. . # Intermittent bradycardia to 40s, asymptomatic: She was monitored on telemetry with occasional intermittent bradycardia to the 40s. her EKG was otherwise normal, without AVB. TTE was done which showed no HD significant pericardial effusion, abscess, or vegetations. Her bradycardia may have been due to vagal tone in setting of pleural effusions and pleuritic pain. . # Lower extremity edema: She noted increased edema during this admission. She had some baseline edema as a flight attendant but only while standing for long durations. She had no JVD or HJR, and TTE was normal. . #PPX: Heparin sq #Full Code, confirmed. Medications on Admission: -Lipitor 20 mg Tab 1 Tablet(s) by mouth once a day -atenolol 100 mg Tab 1 Tablet(s) by mouth once a day -ProAir HFA 90 mcg/Actuation Aerosol Inhaler two puffs(s) inhaled every 4-6 hours as needed for SOB/wheezes -Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 puffs(s) twice a day -fluticasone 50 mcg/Actuation Nasal Spray, Susp 2 sprays each nostril daily Discharge Medications: 1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:2 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: Five (5) ML PO Q4H (every 4 hours) as needed for pain. Disp:250 ML(s) Refills:0 6. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs puffs Inhalation twice a day. 8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) puffs Nasal once a day: 2 sprays to nose daily. 9. Outpatient Lab Work 1. CBC with differential 2. ESR 3. CRP Please obtain this blood work on <Date>1928-9-19</Date> and fax results to infectious disease at (<Telephone>280-127-8194</Telephone> 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. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bacterial supraglottitis Bacteremia Loculated pleural effusions Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than <Date>5-22</Date> lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. You were admitted with a severe throat infection and bacteremia with H influenza. You also developed a rash on your chest thought to be due to this bacteria. Your rash and throat improved, but you then developed shortness of breath due to increasing pleural effusions. You were thought to have pneumonia, and your pleural effusion was treated by thoracic surgery with VATS procedure. Your antibiotic course will be levofloxacin until told to stop by the infectious disease doctors. You will be seen by them as an outpatient. . Medication changes: START Levaquin (aka Levofloxacin) for your infection STOP Atenolol (this was stopped because your heart rate was low) START Chlorthalidone (for blood pressure control) . You should take all your other medication as prescribed by your doctors. . Thoracic surgery Call Dr.<Name>Tyler Pegram</Name> office <Telephone>863-960-3119</Telephone> if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough (it is normal to cough-up blood tinge sputum for a few days) or chest pain -Incision develops drainage or increased redness -Chest tube site remove dressing and cover site with a bandaid until healed -Should site drain cover with a clean dressing and change as needed Activity -Shower daily. Wash incision with mild soap and water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lifting greater than 10 pounds -No driving while taking narcotics Followup Instructions: ENT (ears nose and throat): Please follow up with Dr. <Name>Nikolai</Name> in 2 weeks. Her office can be reached at <Telephone>571-619-9427</Telephone> to make a follow-up appointment. . Infectious disease : You have an appointment on <Date>1976-10-13</Date> with Dr. <Name>Hang</Name> @ 2:50pm. Please note that you also have a CT of your neck ordered for <Date>1928-9-19</Date> (You need to call <Telephone>811-246-4623</Telephone> to confirm the time/location of this exam). Before your appointment with Dr. <Name>Hang</Name>, you will need to have your blood drawn and have the results faxed to (<Telephone>650-700-9639</Telephone>. Thoracic surgery: Follow-up with Dr. <Name>Booker</Name> <Date>8-1910</Date> Date/Time:<Date>1970-7-30</Date> 3:00 on the <Hospital>Miller-Stanley Medical Center</Hospital> <Hospital>Davis and Sons Health System</Hospital> Clinical Center, <Location>0198 Matthew Street Apt. 344 Baileyview, WV 29849</Location> Chest X-Ray <Location>6957 Fernandez Crescent West Brett, NH 29962</Location> Radiology 30 minutes before your appointment Please also follow up with your PCP. <Name>Hany Quinones</Name> your appointment you should have your blood drawn with the following results sent to the infectious disease team (CBC with differential; ESR;CRP). The number to fax them to is (<Telephone>650-700-9639</Telephone>. Note that you have the following appointment scheduled: Department: <Hospital>Wade Group Clinic</Hospital> <Location>4119 Samantha Village Apt. 057 South Randy, MI 15098</Location>- ADULT MED When: MONDAY <Date>1928-9-19</Date> at 10:15 AM With: <Name>Wade</Name> <Name>Blanks</Name>, MD <Telephone>366-762-8717</Telephone> Building: <Location>81851 Courtney Wells Berryburgh, IN 55247</Location> (<Location>0198 Matthew Street Apt. 344 Baileyview, WV 29849</Location>, MA) <Location>01856 Smith Station Apt. 546 Williamborough, OR 77847</Location> Campus: OFF CAMPUS Best Parking: Free Parking on 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Date: 1949-10-11 Discharge Date: 1980-10-7 Date of Birth: 1986-3-17 Sex: F Service: MEDICINE Allergies: Penicillins Attending:Christina Chief Complaint: Airway monitoring Major Surgical or Invasive Procedure: 1941-1-23: Right video-assisted thoraoscopy with decortication History of Present Illness: 61 year old female with PMHX of HTH presented with severe sore throat for 2 days rapidly getting worse associated with difficulty swallowing liquids and neck pain. Also found to have fever and tachycardia. Unable to take meds, only took BP meds this am. Voice is hoarse and descrbed as "hot potato" by PCP. Lillie Jones as a flight attendant, travelled all over Europe recently. Sister with sore throat as well. In PCPs office, unable to open her mouth, tender thick neck unable to evaluate pharynx. Per report pts sore throat has progressed rapidly over past 2 days. Unable to swallow her secretions, no tipoding or drooling present. . In the ED, 100.8 81 125/77 16 99%RA. She was given Clindamycin, Dexamethasone, Morphine Sulfate 4mg Syringe, HYDROmorphone (Dilaudid) 1mg/1mL Syringe, Gentamicin 80mg. Labs unremarkable. CT neck showed retropharyngeal phlegmon. ENT scoped her, has epiglottis and supraglottic swelling. Symptoms improved. Fever 102 in ED. Prior to transfer 117/78 18 100% RA. . Upon arrival to the floor, patient able to phonate but voice still hoarse. No stridor or tripoding noted. Reports inability to get secretions up. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Hypertension Allergic rhinitis Social History: Lives with sister, smokes 1/2-1ppd for the past 40 years, drinks on occasion, denies drugs. She was flight attendent for US Air. Family History: Sister with Lian Hui cancer and thyroid cancer in 50s Physical Exam: Admission Exam: VS: 98.7 82 136/65 13 98% on RA GA: AOx3, hoarse voice HEENT: PERRLA. MMM. no LAD. no JVD. neck tender to palpation anterior and posterioly, unable to visualize pharynx Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: rhonchi heard and left base Abd: soft, NT, +BS. no g/rt. neg HSM. neg Dr.Bounds sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: wnl Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT, pain, temperature, vibration, proprioception. cerebellar fxn intact (FTN, HTS). gait WNL. . Pertinent Results: 1949-10-11 05:02PM LACTATE-1.4 1949-10-11 04:23PM GLUCOSE-116* UREA N-9 CREAT-0.7 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14 1949-10-11 04:23PM WBC-10.1# RBC-4.27 HGB-13.6 HCT-37.9 MCV-89 MCH-31.9 MCHC-36.0* RDW-13.1 1949-10-11 04:23PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.8 EOS-0 BASOS-0.2 1949-10-11 04:23PM PLT COUNT-225 . Scope ENT (on admission): Her glottic opening is about 4mm on scope exam without symptoms including stridor or retraction. . CT neck with contrast (1949-10-11): Retropharyngeal fluid collection spanning from C2/3 to C5/6 with extensive surrounding edema and inflammation of the hypopharynx. The airway is narrowed to 4mm at the level of the hyoid. Patent cervical vasculature. . CXR (2015-1-9): As compared to the previous radiograph, there is no relevant change. No pathologic mediastinal widening. Borderline size of the cardiac silhouette. Presence of minimal pleural effusions cannot be excluded. No focal parenchymal opacity suggesting pneumonia. No pulmonary edema. . CT neck and chest w/ contrast (2008-11-16): 1. Interval slight decrease of the retropharyngeal fluid collection and improved airway patency. 2. No evidence of Lemierre's disease or new abscess formation. 3. No evidence of extension of the fluid collection into the mediastinum. No evidence of mediastinitis. . Chest CT (6-31): IMPRESSION: 1. Rapidly enlarging multiloculated right pleural effusion. This could be due to empyema considering clinical suspicion for this entity, but definitive diagnosis would require correlation with thoracentesis results. 2. Small dependent left pleural effusion has also increased in size since the prior study but does not have loculated components. 3. Slight increase in size of pre- and sub-carinal lymph nodes as well as right hilar nodes. These are likely reactive. 4. Ground-glass opacities in left upper lobe which are likely infectious or inflammatory in etiology. . TTE (6-31): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . 5-28 CXR REASON FOR EXAMINATION: Evaluation of the patient with complicated pleural effusion. Portable AP radiograph of the chest was reviewed in comparison to 2004-10-1. There is interval increase in right pleural effusion, loculated, better appreciated on the prior radiograph but the change in size is significant. No pneumothorax is seen. Left pleural effusion is unchanged. Bibasal areas of atelectasis are noted. . 5/28CXR Discharge Labs . Micro. Blood Culture, Routine (Preliminary): HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. BETA- LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO AMPICILLIN. . BETA-LACTAMASE CONFIRMATION REQUESTED BY DR. Lyna. Aerobic Bottle Gram Stain (Final 2008-11-16): Reported to and read back by DR. Booker Hui ON 2008-11-16 AT 0720. GRAM NEGATIVE ROD(S). Brief Hospital Course: 61 yo F with PMHX of HTN presenting with sore throat, neck pain, and odynophagia found to have epiglottis and retrophargyneal phlegmon. . #Epiglottis/retropharyngenal phlegmon: Diagnosed on CT neck and by ENT scope. Symptoms consistent with this. The patient did improve clinically with steroids, Ceftriaxone and clindamycin. The patient's airway was closely monitored in the ICU and underwent repeat ENT scoping on 2008-11-16 that showed ongoing arytenoid edema but completely patent airway. Repeat CT neck and chest with contrast, in the setting of ongoing posterior neck pain and inspiration pain as well as worsening erythematous lesion (see below), did not show Lemierre's or mediastinitis. There was minimal interval improvement in the phlegmon collection, however. Blood cultures from admission were positive for GNRs, later grew out HAEMOPHILUS INFLUENZAE. Planned for 14 day course from day of first negative culture. The patient remained hemodynamically stable and re-evaluation by ENT in the ICU showed improved of supraglottic swelling so she was transfered to the floor. Repeat cultures were negative ???? HIV was sent and was negative. Patient continued to be symptom free on the floor and did not have any further airway complaints or problems. She was treated symptomatically with cepacol lozenges and was kept on a nicotine patch and received nebulizers PRN. . #Erythematous lesion: Patient developed a 3X3 inch erythematous lesion on her anterior chest, 2 inches below cricoid and poorly demarcated. The patient endorsed feeling warm and mildly tender to palpation in this area with no pruritis. No plaques/papules/bullae. The lesion was very blanching. Dermatology was consulted on 2008-11-16 given spread of this lesion to ~4X4 inches despite broadening to Vancomycin. Given the timing of her antibiotics, this lesion was not felt due to drug eruption, although a very early drug eruption can not be ruled out. The erythema was felt most consistent with a toxic exanthem, which is a vasodilation that occurs in patients with bactermia (more often staph, strep). Supportive care was provided. Derm followed patient while in house. by hospital day 4 the rash had significantly receeded. Derm did not feel compelled to biopsy - they thought it was likely due to her infectious process but did not represent a cellulitis. Her rash improved later in her hospital course. . #Pneumonia and pleural effusion: She was noted to have intermittent hypoxemia and R sided pleuritic chest pain on 7-20. Medicine was consulted on 6-31, and in setting of new moderate pleural effusions R>L on CXR, recommended chest CT, which showed rapidly expanding and loculated effusion on R. She was then transferred to medicine, and ID was consulted. Her antibiotics were changed to ceftriaxone. Her pleural effusion was attempted to be drained by IR, but they only withdrew 30 cc of fluid, given loculation. Thoracic surgery was then involved and carried out a VATS procedure which was uncomplicated and the patient was transferred back to medicine. . #Hypertension: Blood pressures normal and intermittently high (SBPs 150s) in-house. The patient's atenolol, lipitor were held in the setting of epiglottis/retropharyngeal phlegmon but restarted once she was able to tolerate POs. Atenolol was initially started at half home dose 50mg, then back to her full dose.However due to asymp. bradycardia into the 40's atenolol was discontinued ad replaced with Chlorthalidone on 5-16. . # Intermittent bradycardia to 40s, asymptomatic: She was monitored on telemetry with occasional intermittent bradycardia to the 40s. her EKG was otherwise normal, without AVB. TTE was done which showed no HD significant pericardial effusion, abscess, or vegetations. Her bradycardia may have been due to vagal tone in setting of pleural effusions and pleuritic pain. . # Lower extremity edema: She noted increased edema during this admission. She had some baseline edema as a flight attendant but only while standing for long durations. She had no JVD or HJR, and TTE was normal. . #PPX: Heparin sq #Full Code, confirmed. Medications on Admission: -Lipitor 20 mg Tab 1 Tablet(s) by mouth once a day -atenolol 100 mg Tab 1 Tablet(s) by mouth once a day -ProAir HFA 90 mcg/Actuation Aerosol Inhaler two puffs(s) inhaled every 4-6 hours as needed for SOB/wheezes -Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 puffs(s) twice a day -fluticasone 50 mcg/Actuation Nasal Spray, Susp 2 sprays each nostril daily Discharge Medications: 1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:2 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: Five (5) ML PO Q4H (every 4 hours) as needed for pain. Disp:250 ML(s) Refills:0 6. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs puffs Inhalation twice a day. 8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) puffs Nasal once a day: 2 sprays to nose daily. 9. Outpatient Lab Work 1. CBC with differential 2. ESR 3. CRP Please obtain this blood work on 1928-9-19 and fax results to infectious disease at (280-127-8194 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. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bacterial supraglottitis Bacteremia Loculated pleural effusions Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than 5-22 lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. You were admitted with a severe throat infection and bacteremia with H influenza. You also developed a rash on your chest thought to be due to this bacteria. Your rash and throat improved, but you then developed shortness of breath due to increasing pleural effusions. You were thought to have pneumonia, and your pleural effusion was treated by thoracic surgery with VATS procedure. Your antibiotic course will be levofloxacin until told to stop by the infectious disease doctors. You will be seen by them as an outpatient. . Medication changes: START Levaquin (aka Levofloxacin) for your infection STOP Atenolol (this was stopped because your heart rate was low) START Chlorthalidone (for blood pressure control) . You should take all your other medication as prescribed by your doctors. . Thoracic surgery Call Dr.Tyler Pegram office 863-960-3119 if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough (it is normal to cough-up blood tinge sputum for a few days) or chest pain -Incision develops drainage or increased redness -Chest tube site remove dressing and cover site with a bandaid until healed -Should site drain cover with a clean dressing and change as needed Activity -Shower daily. Wash incision with mild soap and water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lifting greater than 10 pounds -No driving while taking narcotics Followup Instructions: ENT (ears nose and throat): Please follow up with Dr. Nikolai in 2 weeks. Her office can be reached at 571-619-9427 to make a follow-up appointment. . Infectious disease : You have an appointment on 1976-10-13 with Dr. Hang @ 2:50pm. Please note that you also have a CT of your neck ordered for 1928-9-19 (You need to call 811-246-4623 to confirm the time/location of this exam). Before your appointment with Dr. Hang, you will need to have your blood drawn and have the results faxed to (650-700-9639. Thoracic surgery: Follow-up with Dr. Booker 8-1910 Date/Time:1970-7-30 3:00 on the Miller-Stanley Medical Center Davis and Sons Health System Clinical Center, 0198 Matthew Street Apt. 344 Baileyview, WV 29849 Chest X-Ray 6957 Fernandez Crescent West Brett, NH 29962 Radiology 30 minutes before your appointment Please also follow up with your PCP. Hany Quinones your appointment you should have your blood drawn with the following results sent to the infectious disease team (CBC with differential; ESR;CRP). The number to fax them to is (650-700-9639. Note that you have the following appointment scheduled: Department: Wade Group Clinic 4119 Samantha Village Apt. 057 South Randy, MI 15098- ADULT MED When: MONDAY 1928-9-19 at 10:15 AM With: Wade Blanks, MD 366-762-8717 Building: 81851 Courtney Wells Berryburgh, IN 55247 (0198 Matthew Street Apt. 344 Baileyview, WV 29849, MA) 01856 Smith Station Apt. 546 Williamborough, OR 77847 Campus: OFF CAMPUS Best Parking: Free Parking on Site	['Admission Date: 1949-10-11 Discharge Date: 1980-10-7\n\nDate of Birth: 1986-3-17 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPenicillins\n\nAttending:Christina\nChief Complaint:\nAirway monitoring\n\nMajor Surgical or Invasive Procedure:\n1941-1-23: Right video-assisted thoraoscopy with decortication\n\n\nHistory of Present Illness:\n61 year old female with PMHX of HTH presented with severe sore\nthroat for 2 days rapidly getting worse associated with\ndifficulty swallowing liquids and neck pain. Also found to have\nfever and tachycardia. Unable to take meds, only took BP meds\nthis am. Voice is hoarse and descrbed as "hot potato" by PCP.\nLillie Jones as a flight attendant, travelled all over Europe recently.\nSister with sore throat as well. In PCPs office, unable to open\nher mouth, tender thick neck unable to evaluate pharynx.', ' Per\nreport pts sore throat has progressed rapidly over past 2 days.\nUnable to swallow her secretions, no tipoding or drooling\npresent.\n.\nIn the ED, 100.8 81 125/77 16 99%RA. She was given Clindamycin,\nDexamethasone, Morphine Sulfate 4mg Syringe, HYDROmorphone\n(Dilaudid) 1mg/1mL Syringe, Gentamicin 80mg. Labs unremarkable.\nCT neck showed retropharyngeal phlegmon. ENT scoped her, has\nepiglottis and supraglottic swelling. Symptoms improved. Fever\n102 in ED. Prior to transfer 117/78 18 100% RA.\n.\nUpon arrival to the floor, patient able to phonate but voice\nstill hoarse. No stridor or tripoding noted. Reports inability\nto get secretions up.\n.\nReview of systems:\n(+) Per HPI\n(-) Denies night sweats, recent weight loss or gain. Denies\nheadache, sinus tenderness, rhinorrhea or congestion. Denied\ncough, shortness of breath.', ' Denied chest pain or tightness,\npalpitations. Denied nausea, vomiting, diarrhea, constipation or\nabdominal pain. No recent change in bowel or bladder habits. No\ndysuria. Denied arthralgias or myalgias.\n\n\nPast Medical History:\nHypertension\nAllergic rhinitis\n\nSocial History:\nLives with sister, smokes 1/2-1ppd for the past 40 years, drinks\non occasion, denies drugs. She was flight attendent for US Air.\n\n\nFamily History:\nSister with Lian Hui cancer and thyroid cancer in 50s\n\nPhysical Exam:\nAdmission Exam:\nVS: 98.7 82 136/65 13 98% on RA\nGA: AOx3, hoarse voice\nHEENT: PERRLA. MMM. no LAD. no JVD. neck tender to palpation\nanterior and posterioly, unable to visualize pharynx\nCards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.\nno murmurs/gallops/rubs.\nPulm: rhonchi heard and left base\nAbd: soft, NT, +BS.', ' no g/rt. neg HSM. neg Dr.Bounds sign.\nExtremities: wwp, no edema. DPs, PTs 2+.\nSkin: wnl\nNeuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.\nDTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,\npain, temperature, vibration, proprioception. cerebellar fxn\nintact (FTN, HTS). gait WNL.\n.\n\n\nPertinent Results:\n1949-10-11 05:02PM LACTATE-1.4\n1949-10-11 04:23PM GLUCOSE-116* UREA N-9 CREAT-0.7 SODIUM-139\nPOTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14\n1949-10-11 04:23PM WBC-10.1# RBC-4.27 HGB-13.6 HCT-37.9 MCV-89\nMCH-31.9 MCHC-36.0* RDW-13.1\n1949-10-11 04:23PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.8 EOS-0\nBASOS-0.2\n1949-10-11 04:23PM PLT COUNT-225\n.\nScope ENT (on admission): Her glottic opening is about 4mm on\nscope exam without symptoms including stridor or retraction.', "\n.\nCT neck with contrast (1949-10-11): Retropharyngeal fluid\ncollection spanning from C2/3 to C5/6 with extensive surrounding\nedema and inflammation of the hypopharynx. The airway is\nnarrowed to 4mm at the level of the hyoid. Patent cervical\nvasculature.\n.\nCXR (2015-1-9): As compared to the previous radiograph, there\nis no relevant change. No pathologic mediastinal widening.\nBorderline size of the cardiac silhouette. Presence of minimal\npleural effusions cannot be excluded. No focal parenchymal\nopacity suggesting pneumonia. No pulmonary edema.\n.\nCT neck and chest w/ contrast (2008-11-16):\n1. Interval slight decrease of the retropharyngeal fluid\ncollection and\nimproved airway patency.\n2. No evidence of Lemierre's disease or new abscess formation.\n\n3. No evidence of extension of the fluid collection into the\nmediastinum.", ' No evidence of mediastinitis.\n.\nChest CT (6-31): IMPRESSION:\n1. Rapidly enlarging multiloculated right pleural effusion. This\ncould be due to empyema considering clinical suspicion for this\nentity, but definitive diagnosis would require correlation with\nthoracentesis results.\n2. Small dependent left pleural effusion has also increased in\nsize since the prior study but does not have loculated\ncomponents.\n3. Slight increase in size of pre- and sub-carinal lymph nodes\nas well as right hilar nodes. These are likely reactive.\n4. Ground-glass opacities in left upper lobe which are likely\ninfectious or inflammatory in etiology.\n.\nTTE (6-31): The left atrium is mildly dilated. No atrial septal\ndefect is seen by 2D or color Doppler. Left ventricular wall\nthickness, cavity size and regional/global systolic function are\nnormal (LVEF >55%).', ' There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The\ndiameters of aorta at the sinus, ascending and arch levels are\nnormal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No masses or vegetations are\nseen on the aortic valve. No aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. No mass or vegetation is seen on the mitral\nvalve. Trivial mitral regurgitation is seen. There is borderline\npulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion. There are no\nechocardiographic signs of tamponade.\n.\n5-28 CXR\nREASON FOR EXAMINATION: Evaluation of the patient with\ncomplicated pleural\neffusion.\n\nPortable AP radiograph of the chest was reviewed in comparison\nto 2004-10-1.', '\n\nThere is interval increase in right pleural effusion, loculated,\nbetter\nappreciated on the prior radiograph but the change in size is\nsignificant. No pneumothorax is seen. Left pleural effusion is\nunchanged. Bibasal areas of atelectasis are noted.\n.\n5/28CXR\n\nDischarge Labs\n.\nMicro.\n\nBlood Culture, Routine (Preliminary):\n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.\n BETA- LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO\nAMPICILLIN. .\n BETA-LACTAMASE CONFIRMATION REQUESTED BY DR. Lyna.\n\n Aerobic Bottle Gram Stain (Final 2008-11-16):\n Reported to and read back by DR. Booker Hui ON 2008-11-16 AT\n0720.\n GRAM NEGATIVE ROD(S).\n\n\nBrief Hospital Course:\n61 yo F with PMHX of HTN presenting with sore throat, neck pain,\nand odynophagia found to have epiglottis and retrophargyneal\nphlegmon.', "\n.\n#Epiglottis/retropharyngenal phlegmon: Diagnosed on CT neck and\nby ENT scope. Symptoms consistent with this. The patient did\nimprove clinically with steroids, Ceftriaxone and clindamycin.\nThe patient's airway was closely monitored in the ICU and\nunderwent repeat ENT scoping on 2008-11-16 that showed ongoing\narytenoid edema but completely patent airway. Repeat CT neck and\nchest with contrast, in the setting of ongoing posterior neck\npain and inspiration pain as well as worsening erythematous\nlesion (see below), did not show Lemierre's or mediastinitis.\nThere was minimal interval improvement in the phlegmon\ncollection, however. Blood cultures from admission were positive\nfor GNRs, later grew out HAEMOPHILUS INFLUENZAE. Planned for 14\nday course from day of first negative culture. The patient\nremained hemodynamically stable and re-evaluation by ENT in the\nICU showed improved of supraglottic swelling so she was\ntransfered to the floor.", ' Repeat cultures were negative ???? HIV\nwas sent and was negative. Patient continued to be symptom free\non the floor and did not have any further airway complaints or\nproblems. She was treated symptomatically with cepacol lozenges\nand was kept on a nicotine patch and received nebulizers PRN.\n.\n#Erythematous lesion: Patient developed a 3X3 inch erythematous\nlesion on her anterior chest, 2 inches below cricoid and poorly\ndemarcated. The patient endorsed feeling warm and mildly tender\nto palpation in this area with no pruritis. No\nplaques/papules/bullae. The lesion was very blanching.\nDermatology was consulted on 2008-11-16 given spread of this\nlesion to ~4X4 inches despite broadening to Vancomycin. Given\nthe timing of her antibiotics, this lesion was not felt due to\ndrug eruption, although a very early drug eruption can not be\nruled out.', ' The erythema was felt most consistent with a toxic\nexanthem, which is a vasodilation that occurs in patients with\nbactermia (more often staph, strep). Supportive care was\nprovided. Derm followed patient while in house. by hospital day\n4 the rash had significantly receeded. Derm did not feel\ncompelled to biopsy - they thought it was likely due to her\ninfectious process but did not represent a cellulitis. Her rash\nimproved later in her hospital course.\n.\n#Pneumonia and pleural effusion: She was noted to have\nintermittent hypoxemia and R sided pleuritic chest pain on 7-20.\nMedicine was consulted on 6-31, and in setting of new moderate\npleural effusions R>L on CXR, recommended chest CT, which showed\nrapidly expanding and loculated effusion on R. She was then\ntransferred to medicine, and ID was consulted.', " Her antibiotics\nwere changed to ceftriaxone. Her pleural effusion was attempted\nto be drained by IR, but they only withdrew 30 cc of fluid,\ngiven loculation. Thoracic surgery was then involved and carried\nout a VATS procedure which was uncomplicated and the patient was\ntransferred back to medicine.\n.\n#Hypertension: Blood pressures normal and intermittently high\n(SBPs 150s) in-house. The patient's atenolol, lipitor were held\nin the setting of epiglottis/retropharyngeal phlegmon but\nrestarted once she was able to tolerate POs. Atenolol was\ninitially started at half home dose 50mg, then back to her full\ndose.However due to asymp. bradycardia into the 40's atenolol\nwas discontinued ad replaced with Chlorthalidone on 5-16.\n.\n# Intermittent bradycardia to 40s, asymptomatic: She was\nmonitored on telemetry with occasional intermittent bradycardia\nto the 40s.", ' her EKG was otherwise normal, without AVB. TTE was\ndone which showed no HD significant pericardial effusion,\nabscess, or vegetations. Her bradycardia may have been due to\nvagal tone in setting of pleural effusions and pleuritic pain.\n.\n# Lower extremity edema: She noted increased edema during this\nadmission. She had some baseline edema as a flight attendant but\nonly while standing for long durations. She had no JVD or HJR,\nand TTE was normal.\n.\n#PPX: Heparin sq\n#Full Code, confirmed.\n\n\nMedications on Admission:\n-Lipitor 20 mg Tab 1 Tablet(s) by mouth once a day\n-atenolol 100 mg Tab 1 Tablet(s) by mouth once a day\n-ProAir HFA 90 mcg/Actuation Aerosol Inhaler\ntwo puffs(s) inhaled every 4-6 hours as needed for SOB/wheezes\n-Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 puffs(s) twice\na day\n-fluticasone 50 mcg/Actuation Nasal Spray, Susp 2 sprays each\nnostril daily\n\n\nDischarge Medications:\n1.', ' nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr\nTransdermal DAILY (Daily).\nDisp:30 Patch 24 hr(s) Refills:2\n2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime).\n3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for constipation.\n4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\nDisp:60 Capsule(s) Refills:2\n5. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)\nML PO Q4H (every 4 hours) as needed for pain.\nDisp:250 ML(s) Refills:0\n6. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)\npuffs Inhalation every 4-6 hours as needed for shortness of\nbreath or wheezing.\n7. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs\npuffs Inhalation twice a day.\n8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)\npuffs Nasal once a day: 2 sprays to nose daily.', '\n9. Outpatient Lab Work\n1. CBC with differential\n2. ESR\n3. CRP\n\nPlease obtain this blood work on 1928-9-19 and fax results\nto infectious disease at (280-127-8194\n\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. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:2\n12. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day\nfor 14 days.\nDisp:14 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nBacterial supraglottitis\nBacteremia\nLoculated pleural effusions\nPneumonia\n\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.', '\n\n\nDischarge Instructions:\nPlease call your doctor or nurse practitioner if you experience\nthe following:\nYou experience new chest pain, pressure, squeezing or\ntightness.\nNew or worsening cough, shortness of breath, or wheeze.\nIf you are vomiting and cannot keep down fluids or your\nmedications.\nYou are getting dehydrated due to continued vomiting, diarrhea,\nor other reasons. Signs of dehydration include dry mouth, rapid\nheartbeat, or feeling dizzy or faint when standing.\nYou see blood or dark/black material when you vomit or have a\nbowel movement.\nYou experience burning when you urinate, have blood in your\nurine, or experience a discharge.\nYour pain is not improving within 8-12 hours or is not gone\nwithin 24 hours. Call or return immediately if your pain is\ngetting worse or changes location or moving to your chest or\nback.', '\nYou have shaking chills, or fever greater than 101.5 degrees\nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern\nyou.\n.\nGeneral Discharge Instructions:\nPlease resume all regular home medications , unless specifically\nadvised not to take a particular medication. Also, please take\nany new medications as prescribed.\nPlease get plenty of rest, continue to ambulate several times\nper day, and drink adequate amounts of fluids. Avoid lifting\nweights greater than 5-22 lbs until you follow-up with your\nsurgeon, who will instruct you further regarding activity\nrestrictions.\nAvoid driving or operating heavy machinery while taking pain\nmedications.\nPlease follow-up with your surgeon and Primary Care Provider\n(PCP) as advised.\n\nYou were admitted with a severe throat infection and bacteremia\nwith H influenza.', ' You also developed a rash on your chest\nthought to be due to this bacteria. Your rash and throat\nimproved, but you then developed shortness of breath due to\nincreasing pleural effusions. You were thought to have\npneumonia, and your pleural effusion was treated by thoracic\nsurgery with VATS procedure. Your antibiotic course will be\nlevofloxacin until told to stop by the infectious disease\ndoctors. You will be seen by them as an outpatient.\n.\nMedication changes:\nSTART Levaquin (aka Levofloxacin) for your infection\nSTOP Atenolol (this was stopped because your heart rate was\nlow)\nSTART Chlorthalidone (for blood pressure control)\n.\nYou should take all your other medication as prescribed by your\ndoctors.\n.\nThoracic surgery\nCall Dr.Tyler Pegram office 863-960-3119 if you experience:\n-Fevers > 101 or chills\n-Increased shortness of breath, cough (it is normal to cough-up\nblood tinge sputum for a few days) or chest pain\n-Incision develops drainage or increased redness\n-Chest tube site remove dressing and cover site with a bandaid\nuntil healed\n-Should site drain cover with a clean dressing and change as\nneeded\n\nActivity\n-Shower daily.', ' Wash incision with mild soap and water, rinse,\npat dry\n-No tub bathing, swimming or hot tubs until incision healed\n-No lifting greater than 10 pounds\n-No driving while taking narcotics\n\n\nFollowup Instructions:\nENT (ears nose and throat):\nPlease follow up with Dr. Nikolai in 2 weeks. Her office can be\nreached at 571-619-9427 to make a follow-up appointment.\n.\nInfectious disease :\nYou have an appointment on 1976-10-13 with Dr. Hang @\n2:50pm. Please note that you also have a CT of your neck ordered\nfor 1928-9-19 (You need to call 811-246-4623 to confirm the\ntime/location of this exam). Before your appointment with Dr.\nHang, you will need to have your blood drawn and have the\nresults faxed to (650-700-9639.\n\nThoracic surgery:\nFollow-up with Dr. Booker 8-1910 Date/Time:1970-7-30\n3:00\non the Miller-Stanley Medical Center Davis and Sons Health System Clinical Center, 0198 Matthew Street Apt.', ' 344\nBaileyview, WV 29849\nChest X-Ray 6957 Fernandez Crescent\nWest Brett, NH 29962 Radiology 30 minutes before your\nappointment\n\nPlease also follow up with your PCP. Hany Quinones your appointment you\nshould have your blood drawn with the following results sent to\nthe infectious disease team (CBC with differential; ESR;CRP).\nThe number to fax them to is (650-700-9639.\n\nNote that you have the following appointment scheduled:\nDepartment: Wade Group Clinic 4119 Samantha Village Apt. 057\nSouth Randy, MI 15098- ADULT MED\nWhen: MONDAY 1928-9-19 at 10:15 AM\nWith: Wade Blanks, MD 366-762-8717\nBuilding: 81851 Courtney Wells\nBerryburgh, IN 55247 (0198 Matthew Street Apt. 344\nBaileyview, WV 29849, MA) 01856 Smith Station Apt. 546\nWilliamborough, OR 77847\nCampus: OFF CAMPUS Best Parking: Free Parking on Site\n\n\n\n']
235	19631	185175.0	2198-05-08	Discharge summary	Report	Admission Date: [2198-4-23] Discharge Date: [2198-5-8] Date of Birth: [2122-10-14] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: fever Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Pancreatic debridement with wide drainage. 3. Open cholecystectomy. 4. Placement of a combined G/J tube (MIC tube). 5. PICC line placement 6. ERCP with stent History of Present Illness: This is a 75 year old man who is a retired anethesiologist with h/o CAD s/p CABG and ischemic cardiomyopathy with EF of 25% who was recently discharged from [Hospital1 18] following a hospital course for gallstone pancreatitis and now re-presents from rehab for fevers. During last admission, he was transferred from OSH with with fever and pancreatitis which was thought to be from gallstones although there were no gallstones in the bile ducts, just in the gallbladder itself. CT scan done on admissionw as consistent with severe pancreatitis. ERCP was done on [2198-4-6], with sphinceterotomy and CBD stent placed. His post procedure course was complicated by fevers and repeat CT abd shows progression of severe pancreatitis with extensive peripancreatitis fluid collection. This was thought to be either from PNA or from inflammation from his pancreatitis. He finished a course of azithro/ctx and a course of flagyl/cipro and eventually he devefesced. All cultures were negative. He was discharged to rehab. . At rehab, he reports having fevers since Friday [2198-4-21], with highest at 102.0. He has no localizing pain. Denies cough, dysuria, abd pain or nausea and vomit. . ROS: Negative for headache, chest pain, shortness of breath or change in bowel habits. Past Medical History: # Coronary artery disease status post CABG x4 in [2183]. # Status post MI in [2182]. # Ischemic cardiomyopathy, EF 20-25%, echo [2194]. # Atrial flutter, currently A-paced. # Ventricular irritability. # ICD placement [2193], changed in [2195] ([Company 1543] dual- chamber system.) # CRI with a baseline creatinine of 1.2-1.5. # Gout. # Gallstones. # Kidney stones. # h/o Syncope. Social History: A retired anesthesiologist, worked in pain management. Denies tobacco, drugs. Bottle of wine per week. Family History: Father had a MI at age 70. Physical Exam: VITALS: 102.2 112/P 68 16 93%-RA GEN: A+Ox3, NAD HEENT: MMM, OP clear NECK: no LAD, no JVD CV: RRR, II/VI holosystolic murmur at LLSB PULM: crackles at bases with decreased sounds on right base, no wheeze, rhonchi ABD: soft, NT, ND, +BS EXT: [Male First Name (un) ] stockings on both legs; 1+ pitting edema to knees bilaterally Pertinent Results: 137 101 19 --------------< 105 4.3 28 1.2 Ca: 9.4 Mg: 1.9 P: 3.1 ALT: 23 AP: 135 Tbili: 0.6 Alb: 3.0 AST: 22 LDH: 169 [Doctor First Name ]: 25 Lip: 38 95 13.1 > 9.5 < 176 28.9 N:90.0 Band:0 L:5.2 M:4.5 E:0.1 Bas:0.2 Hypochr: 2+ Anisocy: 1+ Macrocy: 1+ Ovalocy: 1+ PT: 15.8 PTT: 28.3 INR: 1.4 EKG: Regular 68 PBM, apaced, low voltage in limb leads, no ST/T changes compared to [2198-4-5] CT ABD WITH IV AND ORAL CONTRAST: 1. All visualized peripancreatic collections appear slightly smaller. 2. New air bubbles within multiple collections. Correlate with history of marsupialization or attempts at drainage in the interval since [2198-4-10]. Superimposed infection in the collections cannot be excluded given the new air bubbles, although the collections are infected, they would not expect to get smaller. 3. Biliary stent in position. No evidence of worsening biliary dilatation. 4. Cholelithiasis and Phrygian cap in gallbladder. 5. Bilateral pleural effusions, right greater than left with associated bilateral lower lobe atelectasis. Effusions slightly larger than on [2198-2-8]. CXR: Small bilateral pleural effusions have increased. Moderate enlargement of the cardiac silhouette is stable. Upper lungs grossly clear. Atelectasis at the lung bases is slightly more severe today. No pneumothorax. Transvenous right atrial pacer and right ventricular pacer defibrillator leads are unchanged in their respective positions. The patient is status post median sternotomy and coronary bypass grafting. . [2198-4-30] 05:17AM BLOOD WBC-8.1 RBC-2.98* Hgb-9.3* Hct-27.9* MCV-94 MCH-31.2 MCHC-33.2 RDW-16.2* Plt Ct-197 [2198-5-3] 04:35AM BLOOD WBC-10.4 RBC-3.03* Hgb-9.0* Hct-28.2* MCV-93 MCH-29.5 MCHC-31.7 RDW-16.2* Plt Ct-277 [2198-4-23] 12:50PM BLOOD Neuts-90.0* Bands-0 Lymphs-5.2* Monos-4.5 Eos-0.1 Baso-0.2 [2198-5-3] 04:35AM BLOOD Glucose-145* UreaN-21* Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-30 AnGap-10 [2198-5-5] 05:31AM BLOOD Glucose-145* UreaN-22* Creat-0.8 Na-138 K-4.1 Cl-101 HCO3-28 AnGap-13 [2198-5-1] 04:07AM BLOOD ALT-31 AST-39 AlkPhos-160* Amylase-23 TotBili-0.7 DirBili-0.4* IndBili-0.3 [2198-5-1] 04:07AM BLOOD Lipase-41 [2198-5-5] 05:31AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0 [2198-4-30] 05:17AM BLOOD Albumin-2.4* Iron-12* [2198-4-30] 05:17AM BLOOD calTIBC-140* Ferritn-589* TRF-108* . SPECIMEN SUBMITTED: GALLBLADDER AND CONTENTS. Gallbladder, cholecystectomy (A): Acute and chronic cholecystitis. Cholelithiasis. . REPEAT, (REQUEST BY RADIOLOGIST) [2198-5-5] 6:47 PM FINDINGS: X-ray of the three surgical drains revealed no evidence of any contrast which is radiopaque within these drains. . CT PELVIS W/CONTRAST [2198-5-5] 12:07 PM IMPRESSION: 1. Heterogeneity in the region of the pancreas consistent with the patient's previous necrotizing pancreatitis. 2. Three surgical drains in situ with some high attenuation in the region of the lesser sac which may represent fistulization from the small bowel into this residual collection. 3. Loculated fluid under the anterior abdominal wall measuring 16 cm. 4. Gastrojejunostomy in situ. 5. Renal cysts. 6. Bilateral pleural effusions. 7. Enlarged prostate at 8 cm. . Brief Hospital Course: 75 year old man with CAD s/p CABD and ischemic cardiomyopathy EF 25% who was recently admitted for gallstone pancreatitis, now re-admitted from rehab for fevers. . # FEVERS: Likely source is from his pancreas. On last admission, he was febrile without an identified infectious source and was thought to be from inflammatory response to pancreatitis and peri-pancreatic fluid. Currently with leukocytosis and left shift although no localizing signs of infection. The differential at this time includes (infected) pancreatic pseudocyst, necrotizing pancreatitis and an obstructed bile duct stent. -- appreciate GI following -- keep NPO for now until CT scan and labs return -- CT scan of abdomen with oral and IV contrast -- culture blood and urine -- CXR to r/o PNA . # CAD: currenty stable without chest pain. -- continue asa + captopril + carvedilol . # CHF: currently euvolemic, and stable. -- admitted and dry weight: -- continue asa + captopril + carvedilol . # Aflutter: currently apaced -- continue to hold coumadin in case he needs surgery -- continue carvedilol . # CRI: Baseline creatinine 1.2-1.5 -- hydration and bicarb prior to contrast study -- continue to monitor creatinine . # ANEMIA: iron studies from last admission suggest iron deficiency and chronic disease -- continue iron supplements -- continue to monitor hct . # GOUT: continue allopurinol . # BPH: continue flomax [Hospital1 ] . # FEN: -- IV hydration prior to CT scan . # PPX: -- ambulating -- protonix . # CODE: full . # DISPO: pending . . = = = = = = = = = = = = = = = = = = ================================================================ Surgery was then consulted and he went to the OR on [4-24] for his Infected pancreatic necrosis, status post gallstone pancreatitis. He had 1. Exploratory laparotomy. 2. Pancreatic debridement with wide drainage. 3. Open cholecystectomy. 4. Placement of a combined G/J tube (MIC tube). Post-op he stayed in the ICU for 2 nights and was trasnfered to the floor on POD 3. GI/Abd: He was NPO with a NGT and IVF. The NGT was removed on POD 2. His G-tube was left to gravity drainage. His J-tube was capped and then trophic tubefeedings were started on POD 2. His tubefeedings were advanced to a goal of Replete with Fiber 3/4 strength at 80cc/hr. He had 3 JP drains in place and these were draining thick, dark fluid. He continued to have high output from these drains. He was started on sips on POD 5, he was advanced to clears on POD 6. JP amylase was checked on POD 7, once on a full liquid diet. His JP Amylase was 27K, 34K, and 14K. He was made NPO due to his JP amylase reported as high. He continued on the tubefeedings. A grape juice test was positive for a leak from around the JP drains. He had one small spot with minimal drainage that could be expressed from his incision. His is now having drainage around all his drains and g/j tube with mild skin irritation. He has irritation around the tube extending out from ~0.5 - 3 cm and appears at [Doctor First Name ] to develop yeast. His midline incision is c/i but has a small amount of serous drainage on the gauze. Have suggested using Criticaid anti fungal moisture barrier to protect his skin from the drainage and to prevent the formation of yeast. Continue to apply a thin layer of dressing around the drains and change as needed do not allow the gauze to become saturated with drainage. Apply the antifungal Criticaid two to three times/day. A CT was obtained on [5-5] and showed: 1. Heterogeneity in the region of the pancreas consistent with the patient's previous necrotizing pancreatitis. 2. Three surgical drains in situ with some high attenuation in the region of the lesser sac which may represent fistulization from the small bowel into this residual collection. 3. Loculated fluid under the anterior abdominal wall measuring 16 cm. 4. Gastrojejunostomy in situ. 5. Renal cysts. 6. Bilateral pleural effusions. 7. Enlarged prostate at 8 cm. . He will remain NPO with TF for 2 weeks and then return for a repeat CT. His drains will remain and the drainage will be monitored. Pain: He had good pain control with a PCA. He continued on a PCA thru POD 6. Once back on a diet, he was ordered for PO pain meds with good control. Labs: We monitored his labs and his Tbili decreased from a high of 2.6 on POD 2 to WNL by [2198-4-28]. Cards: He was being followed by his PCP/Cardiologist. He was put back on his home meds on POD5, including Lasix IV for gentle diuresis and his heart meds. Renal: He was diuresing well and continued to have negative fluid balance and losing weight appropriately. Medications on Admission: # Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). # Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). # Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). # Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). # Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY # Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. # Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for shortness of breath, edema. # Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). # Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. # Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). # Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. # Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). # Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. # Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. # Colace, senna PRN # Protein powder, 2 scoops [Hospital1 ] # Demerol PRN Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for fever or pain. 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 8. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 12. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every [3-2] hours. 17. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 18. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 2 doses: D/C on [5-9]. Disp:2 Recon Soln(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: PRIMARY: Infected pancreatic necrosis, status post gallstone pancreatitis. Post-op Pancreatic leak SECONDARY: # Coronary artery disease status post CABG x4 in [2183]. # Ischemic cardiomyopathy, EF 20-25%, echo [2194]. # Atrial flutter, currently A-paced. # Ventricular irritability. # ICD placement [2193], changed in [2195] ([Company 1543] dual- chamber system.) # CRI with a baseline creatinine of 1.2-1.5. # Gout # Gallstones Discharge Condition: hemodynamically stable, afebrile, ambulating Discharge Instructions: Please take all medication as prescribed. Keep appointments listed below. If you have chest pain or shortness of breath, get medical attention immediately. If you have fevers or any discomfort, please call your doctor or go to the emergency department. . Continue with tubefeedings. Continue with drain care and with tubefeeding care. Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2198-5-25] 9:00 Please follow-up with Dr. [Last Name (STitle) ] on [2198-5-25] at 10:15. Call ([Telephone/Fax (1) 2363] with questions. Please follow up with your PCP [Name Initial (PRE) 176] 2 weeks: PCP: [Name10 (NameIs) ],[Name11 (NameIs) 1730] [0-0-] OTHER APPOINTMENTS: Provider: [First Name4 (NamePattern1) 1386] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2198-4-30] 10:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 2359] Date/Time:[2198-4-30] 3:30 Completed by:[2198-5-8]	Admission Date: <Date>2014-5-29</Date> Discharge Date: <Date>1992-12-23</Date> Date of Birth: <Date>2004-11-22</Date> Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Nora</Name> Chief Complaint: fever Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Pancreatic debridement with wide drainage. 3. Open cholecystectomy. 4. Placement of a combined G/J tube (MIC tube). 5. PICC line placement 6. ERCP with stent History of Present Illness: This is a 75 year old man who is a retired anethesiologist with h/o CAD s/p CABG and ischemic cardiomyopathy with EF of 25% who was recently discharged from <Hospital>Murphy Ltd Health System</Hospital> following a hospital course for gallstone pancreatitis and now re-presents from rehab for fevers. During last admission, he was transferred from OSH with with fever and pancreatitis which was thought to be from gallstones although there were no gallstones in the bile ducts, just in the gallbladder itself. CT scan done on admissionw as consistent with severe pancreatitis. ERCP was done on <Date>1977-4-10</Date>, with sphinceterotomy and CBD stent placed. His post procedure course was complicated by fevers and repeat CT abd shows progression of severe pancreatitis with extensive peripancreatitis fluid collection. This was thought to be either from PNA or from inflammation from his pancreatitis. He finished a course of azithro/ctx and a course of flagyl/cipro and eventually he devefesced. All cultures were negative. He was discharged to rehab. . At rehab, he reports having fevers since Friday <Date>1997-12-13</Date>, with highest at 102.0. He has no localizing pain. Denies cough, dysuria, abd pain or nausea and vomit. . ROS: Negative for headache, chest pain, shortness of breath or change in bowel habits. Past Medical History: # Coronary artery disease status post CABG x4 in <Year>2005</Year>. # Status post MI in <Year>2005</Year>. # Ischemic cardiomyopathy, EF 20-25%, echo <Year>2005</Year>. # Atrial flutter, currently A-paced. # Ventricular irritability. # ICD placement <Year>2005</Year>, changed in <Year>2005</Year> (<Company>Moreno, Lopez and Fuller</Company> dual- chamber system.) # CRI with a baseline creatinine of 1.2-1.5. # Gout. # Gallstones. # Kidney stones. # h/o Syncope. Social History: A retired anesthesiologist, worked in pain management. Denies tobacco, drugs. Bottle of wine per week. Family History: Father had a MI at age 70. Physical Exam: VITALS: 102.2 112/P 68 16 93%-RA GEN: A+Ox3, NAD HEENT: MMM, OP clear NECK: no LAD, no JVD CV: RRR, II/VI holosystolic murmur at LLSB PULM: crackles at bases with decreased sounds on right base, no wheeze, rhonchi ABD: soft, NT, ND, +BS EXT: <Name>Uma</Name> stockings on both legs; 1+ pitting edema to knees bilaterally Pertinent Results: 137 101 19 --------------< 105 4.3 28 1.2 Ca: 9.4 Mg: 1.9 P: 3.1 ALT: 23 AP: 135 Tbili: 0.6 Alb: 3.0 AST: 22 LDH: 169 <Name>Alesha</Name>: 25 Lip: 38 95 13.1 > 9.5 < 176 28.9 N:90.0 Band:0 L:5.2 M:4.5 E:0.1 Bas:0.2 Hypochr: 2+ Anisocy: 1+ Macrocy: 1+ Ovalocy: 1+ PT: 15.8 PTT: 28.3 INR: 1.4 EKG: Regular 68 PBM, apaced, low voltage in limb leads, no ST/T changes compared to <Date>1928-8-18</Date> CT ABD WITH IV AND ORAL CONTRAST: 1. All visualized peripancreatic collections appear slightly smaller. 2. New air bubbles within multiple collections. Correlate with history of marsupialization or attempts at drainage in the interval since <Date>1922-11-3</Date>. Superimposed infection in the collections cannot be excluded given the new air bubbles, although the collections are infected, they would not expect to get smaller. 3. Biliary stent in position. No evidence of worsening biliary dilatation. 4. Cholelithiasis and Phrygian cap in gallbladder. 5. Bilateral pleural effusions, right greater than left with associated bilateral lower lobe atelectasis. Effusions slightly larger than on <Date>2008-3-16</Date>. CXR: Small bilateral pleural effusions have increased. Moderate enlargement of the cardiac silhouette is stable. Upper lungs grossly clear. Atelectasis at the lung bases is slightly more severe today. No pneumothorax. Transvenous right atrial pacer and right ventricular pacer defibrillator leads are unchanged in their respective positions. The patient is status post median sternotomy and coronary bypass grafting. . <Date>1941-2-21</Date> 05:17AM BLOOD WBC-8.1 RBC-2.98* Hgb-9.3* Hct-27.9* MCV-94 MCH-31.2 MCHC-33.2 RDW-16.2* Plt Ct-197 <Date>2001-5-27</Date> 04:35AM BLOOD WBC-10.4 RBC-3.03* Hgb-9.0* Hct-28.2* MCV-93 MCH-29.5 MCHC-31.7 RDW-16.2* Plt Ct-277 <Date>2014-5-29</Date> 12:50PM BLOOD Neuts-90.0* Bands-0 Lymphs-5.2* Monos-4.5 Eos-0.1 Baso-0.2 <Date>2001-5-27</Date> 04:35AM BLOOD Glucose-145* UreaN-21* Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-30 AnGap-10 <Date>2018-12-10</Date> 05:31AM BLOOD Glucose-145* UreaN-22* Creat-0.8 Na-138 K-4.1 Cl-101 HCO3-28 AnGap-13 <Date>1904-1-9</Date> 04:07AM BLOOD ALT-31 AST-39 AlkPhos-160* Amylase-23 TotBili-0.7 DirBili-0.4* IndBili-0.3 <Date>1904-1-9</Date> 04:07AM BLOOD Lipase-41 <Date>2018-12-10</Date> 05:31AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0 <Date>1941-2-21</Date> 05:17AM BLOOD Albumin-2.4* Iron-12* <Date>1941-2-21</Date> 05:17AM BLOOD calTIBC-140* Ferritn-589* TRF-108* . SPECIMEN SUBMITTED: GALLBLADDER AND CONTENTS. Gallbladder, cholecystectomy (A): Acute and chronic cholecystitis. Cholelithiasis. . REPEAT, (REQUEST BY RADIOLOGIST) <Date>2018-12-10</Date> 6:47 PM FINDINGS: X-ray of the three surgical drains revealed no evidence of any contrast which is radiopaque within these drains. . CT PELVIS W/CONTRAST <Date>2018-12-10</Date> 12:07 PM IMPRESSION: 1. Heterogeneity in the region of the pancreas consistent with the patient's previous necrotizing pancreatitis. 2. Three surgical drains in situ with some high attenuation in the region of the lesser sac which may represent fistulization from the small bowel into this residual collection. 3. Loculated fluid under the anterior abdominal wall measuring 16 cm. 4. Gastrojejunostomy in situ. 5. Renal cysts. 6. Bilateral pleural effusions. 7. Enlarged prostate at 8 cm. . Brief Hospital Course: 75 year old man with CAD s/p CABD and ischemic cardiomyopathy EF 25% who was recently admitted for gallstone pancreatitis, now re-admitted from rehab for fevers. . # FEVERS: Likely source is from his pancreas. On last admission, he was febrile without an identified infectious source and was thought to be from inflammatory response to pancreatitis and peri-pancreatic fluid. Currently with leukocytosis and left shift although no localizing signs of infection. The differential at this time includes (infected) pancreatic pseudocyst, necrotizing pancreatitis and an obstructed bile duct stent. -- appreciate GI following -- keep NPO for now until CT scan and labs return -- CT scan of abdomen with oral and IV contrast -- culture blood and urine -- CXR to r/o PNA . # CAD: currenty stable without chest pain. -- continue asa + captopril + carvedilol . # CHF: currently euvolemic, and stable. -- admitted and dry weight: -- continue asa + captopril + carvedilol . # Aflutter: currently apaced -- continue to hold coumadin in case he needs surgery -- continue carvedilol . # CRI: Baseline creatinine 1.2-1.5 -- hydration and bicarb prior to contrast study -- continue to monitor creatinine . # ANEMIA: iron studies from last admission suggest iron deficiency and chronic disease -- continue iron supplements -- continue to monitor hct . # GOUT: continue allopurinol . # BPH: continue flomax <Hospital>Benson-Rodriguez Clinic</Hospital> . # FEN: -- IV hydration prior to CT scan . # PPX: -- ambulating -- protonix . # CODE: full . # DISPO: pending . . = = = = = = = = = = = = = = = = = = ================================================================ Surgery was then consulted and he went to the OR on <Date>10-29</Date> for his Infected pancreatic necrosis, status post gallstone pancreatitis. He had 1. Exploratory laparotomy. 2. Pancreatic debridement with wide drainage. 3. Open cholecystectomy. 4. Placement of a combined G/J tube (MIC tube). Post-op he stayed in the ICU for 2 nights and was trasnfered to the floor on POD 3. GI/Abd: He was NPO with a NGT and IVF. The NGT was removed on POD 2. His G-tube was left to gravity drainage. His J-tube was capped and then trophic tubefeedings were started on POD 2. His tubefeedings were advanced to a goal of Replete with Fiber 3/4 strength at 80cc/hr. He had 3 JP drains in place and these were draining thick, dark fluid. He continued to have high output from these drains. He was started on sips on POD 5, he was advanced to clears on POD 6. JP amylase was checked on POD 7, once on a full liquid diet. His JP Amylase was 27K, 34K, and 14K. He was made NPO due to his JP amylase reported as high. He continued on the tubefeedings. A grape juice test was positive for a leak from around the JP drains. He had one small spot with minimal drainage that could be expressed from his incision. His is now having drainage around all his drains and g/j tube with mild skin irritation. He has irritation around the tube extending out from ~0.5 - 3 cm and appears at <Name>Alesha</Name> to develop yeast. His midline incision is c/i but has a small amount of serous drainage on the gauze. Have suggested using Criticaid anti fungal moisture barrier to protect his skin from the drainage and to prevent the formation of yeast. Continue to apply a thin layer of dressing around the drains and change as needed do not allow the gauze to become saturated with drainage. Apply the antifungal Criticaid two to three times/day. A CT was obtained on <Date>12-31</Date> and showed: 1. Heterogeneity in the region of the pancreas consistent with the patient's previous necrotizing pancreatitis. 2. Three surgical drains in situ with some high attenuation in the region of the lesser sac which may represent fistulization from the small bowel into this residual collection. 3. Loculated fluid under the anterior abdominal wall measuring 16 cm. 4. Gastrojejunostomy in situ. 5. Renal cysts. 6. Bilateral pleural effusions. 7. Enlarged prostate at 8 cm. . He will remain NPO with TF for 2 weeks and then return for a repeat CT. His drains will remain and the drainage will be monitored. Pain: He had good pain control with a PCA. He continued on a PCA thru POD 6. Once back on a diet, he was ordered for PO pain meds with good control. Labs: We monitored his labs and his Tbili decreased from a high of 2.6 on POD 2 to WNL by <Date>1930-8-9</Date>. Cards: He was being followed by his PCP/Cardiologist. He was put back on his home meds on POD5, including Lasix IV for gentle diuresis and his heart meds. Renal: He was diuresing well and continued to have negative fluid balance and losing weight appropriately. Medications on Admission: # Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). # Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). # Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). # Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). # Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY # Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. # Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for shortness of breath, edema. # Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). # Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. # Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). # Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. # Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). # Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. # Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. # Colace, senna PRN # Protein powder, 2 scoops <Hospital>Benson-Rodriguez Clinic</Hospital> # Demerol PRN Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for fever or pain. 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 8. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 12. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every <Date>11-31</Date> hours. 17. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 18. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 2 doses: D/C on <Date>7-1</Date>. Disp:2 Recon Soln(s) Refills:0 Discharge Disposition: Extended Care Facility: <Hospital>Garcia, Medina and Harper Health System</Hospital> & Rehab Center - <Hospital>Garcia-Jones Medical Center</Hospital> Discharge Diagnosis: PRIMARY: Infected pancreatic necrosis, status post gallstone pancreatitis. Post-op Pancreatic leak SECONDARY: # Coronary artery disease status post CABG x4 in <Year>2005</Year>. # Ischemic cardiomyopathy, EF 20-25%, echo <Year>2005</Year>. # Atrial flutter, currently A-paced. # Ventricular irritability. # ICD placement <Year>2005</Year>, changed in <Year>2005</Year> (<Company>Moreno, Lopez and Fuller</Company> dual- chamber system.) # CRI with a baseline creatinine of 1.2-1.5. # Gout # Gallstones Discharge Condition: hemodynamically stable, afebrile, ambulating Discharge Instructions: Please take all medication as prescribed. Keep appointments listed below. If you have chest pain or shortness of breath, get medical attention immediately. If you have fevers or any discomfort, please call your doctor or go to the emergency department. . Continue with tubefeedings. Continue with drain care and with tubefeeding care. Followup Instructions: Provider: <Name>Ted Wilson</Name> SCAN Phone:<Telephone>890-953-1027</Telephone> Date/Time:<Date>1974-9-27</Date> 9:00 Please follow-up with Dr. <Name>Merino</Name> on <Date>1974-9-27</Date> at 10:15. Call (<Telephone>563-169-6669</Telephone> with questions. Please follow up with your PCP <Name>Jeremy Lofft</Name> 2 weeks: PCP: <Name>Ted Wilson</Name>,<Name>Quincy Debelius</Name> <Date>9-1911</Date> OTHER APPOINTMENTS: Provider: <Name>Mattie</Name> <Name>Anderson</Name>, MD Phone:<Telephone>802-368-2810</Telephone> Date/Time:<Date>1941-2-21</Date> 10:20 Provider: <Name>Stacey</Name> <Name>Lyna</Name>, MD Phone:<Telephone>940-842-4052</Telephone> Date/Time:<Date>1941-2-21</Date> 3:30 Completed 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Date: 2014-5-29 Discharge Date: 1992-12-23 Date of Birth: 2004-11-22 Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Nora Chief Complaint: fever Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Pancreatic debridement with wide drainage. 3. Open cholecystectomy. 4. Placement of a combined G/J tube (MIC tube). 5. PICC line placement 6. ERCP with stent History of Present Illness: This is a 75 year old man who is a retired anethesiologist with h/o CAD s/p CABG and ischemic cardiomyopathy with EF of 25% who was recently discharged from Murphy Ltd Health System following a hospital course for gallstone pancreatitis and now re-presents from rehab for fevers. During last admission, he was transferred from OSH with with fever and pancreatitis which was thought to be from gallstones although there were no gallstones in the bile ducts, just in the gallbladder itself. CT scan done on admissionw as consistent with severe pancreatitis. ERCP was done on 1977-4-10, with sphinceterotomy and CBD stent placed. His post procedure course was complicated by fevers and repeat CT abd shows progression of severe pancreatitis with extensive peripancreatitis fluid collection. This was thought to be either from PNA or from inflammation from his pancreatitis. He finished a course of azithro/ctx and a course of flagyl/cipro and eventually he devefesced. All cultures were negative. He was discharged to rehab. . At rehab, he reports having fevers since Friday 1997-12-13, with highest at 102.0. He has no localizing pain. Denies cough, dysuria, abd pain or nausea and vomit. . ROS: Negative for headache, chest pain, shortness of breath or change in bowel habits. Past Medical History: # Coronary artery disease status post CABG x4 in 2005. # Status post MI in 2005. # Ischemic cardiomyopathy, EF 20-25%, echo 2005. # Atrial flutter, currently A-paced. # Ventricular irritability. # ICD placement 2005, changed in 2005 (Moreno, Lopez and Fuller dual- chamber system.) # CRI with a baseline creatinine of 1.2-1.5. # Gout. # Gallstones. # Kidney stones. # h/o Syncope. Social History: A retired anesthesiologist, worked in pain management. Denies tobacco, drugs. Bottle of wine per week. Family History: Father had a MI at age 70. Physical Exam: VITALS: 102.2 112/P 68 16 93%-RA GEN: A+Ox3, NAD HEENT: MMM, OP clear NECK: no LAD, no JVD CV: RRR, II/VI holosystolic murmur at LLSB PULM: crackles at bases with decreased sounds on right base, no wheeze, rhonchi ABD: soft, NT, ND, +BS EXT: Uma stockings on both legs; 1+ pitting edema to knees bilaterally Pertinent Results: 137 101 19 --------------Alesha: 25 Lip: 38 95 13.1 > 9.5 1928-8-18 CT ABD WITH IV AND ORAL CONTRAST: 1. All visualized peripancreatic collections appear slightly smaller. 2. New air bubbles within multiple collections. Correlate with history of marsupialization or attempts at drainage in the interval since 1922-11-3. Superimposed infection in the collections cannot be excluded given the new air bubbles, although the collections are infected, they would not expect to get smaller. 3. Biliary stent in position. No evidence of worsening biliary dilatation. 4. Cholelithiasis and Phrygian cap in gallbladder. 5. Bilateral pleural effusions, right greater than left with associated bilateral lower lobe atelectasis. Effusions slightly larger than on 2008-3-16. CXR: Small bilateral pleural effusions have increased. Moderate enlargement of the cardiac silhouette is stable. Upper lungs grossly clear. Atelectasis at the lung bases is slightly more severe today. No pneumothorax. Transvenous right atrial pacer and right ventricular pacer defibrillator leads are unchanged in their respective positions. The patient is status post median sternotomy and coronary bypass grafting. . 1941-2-21 05:17AM BLOOD WBC-8.1 RBC-2.98* Hgb-9.3* Hct-27.9* MCV-94 MCH-31.2 MCHC-33.2 RDW-16.2* Plt Ct-197 2001-5-27 04:35AM BLOOD WBC-10.4 RBC-3.03* Hgb-9.0* Hct-28.2* MCV-93 MCH-29.5 MCHC-31.7 RDW-16.2* Plt Ct-277 2014-5-29 12:50PM BLOOD Neuts-90.0* Bands-0 Lymphs-5.2* Monos-4.5 Eos-0.1 Baso-0.2 2001-5-27 04:35AM BLOOD Glucose-145* UreaN-21* Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-30 AnGap-10 2018-12-10 05:31AM BLOOD Glucose-145* UreaN-22* Creat-0.8 Na-138 K-4.1 Cl-101 HCO3-28 AnGap-13 1904-1-9 04:07AM BLOOD ALT-31 AST-39 AlkPhos-160* Amylase-23 TotBili-0.7 DirBili-0.4* IndBili-0.3 1904-1-9 04:07AM BLOOD Lipase-41 2018-12-10 05:31AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0 1941-2-21 05:17AM BLOOD Albumin-2.4* Iron-12* 1941-2-21 05:17AM BLOOD calTIBC-140* Ferritn-589* TRF-108* . SPECIMEN SUBMITTED: GALLBLADDER AND CONTENTS. Gallbladder, cholecystectomy (A): Acute and chronic cholecystitis. Cholelithiasis. . REPEAT, (REQUEST BY RADIOLOGIST) 2018-12-10 6:47 PM FINDINGS: X-ray of the three surgical drains revealed no evidence of any contrast which is radiopaque within these drains. . CT PELVIS W/CONTRAST 2018-12-10 12:07 PM IMPRESSION: 1. Heterogeneity in the region of the pancreas consistent with the patient's previous necrotizing pancreatitis. 2. Three surgical drains in situ with some high attenuation in the region of the lesser sac which may represent fistulization from the small bowel into this residual collection. 3. Loculated fluid under the anterior abdominal wall measuring 16 cm. 4. Gastrojejunostomy in situ. 5. Renal cysts. 6. Bilateral pleural effusions. 7. Enlarged prostate at 8 cm. . Brief Hospital Course: 75 year old man with CAD s/p CABD and ischemic cardiomyopathy EF 25% who was recently admitted for gallstone pancreatitis, now re-admitted from rehab for fevers. . # FEVERS: Likely source is from his pancreas. On last admission, he was febrile without an identified infectious source and was thought to be from inflammatory response to pancreatitis and peri-pancreatic fluid. Currently with leukocytosis and left shift although no localizing signs of infection. The differential at this time includes (infected) pancreatic pseudocyst, necrotizing pancreatitis and an obstructed bile duct stent. -- appreciate GI following -- keep NPO for now until CT scan and labs return -- CT scan of abdomen with oral and IV contrast -- culture blood and urine -- CXR to r/o PNA . # CAD: currenty stable without chest pain. -- continue asa + captopril + carvedilol . # CHF: currently euvolemic, and stable. -- admitted and dry weight: -- continue asa + captopril + carvedilol . # Aflutter: currently apaced -- continue to hold coumadin in case he needs surgery -- continue carvedilol . # CRI: Baseline creatinine 1.2-1.5 -- hydration and bicarb prior to contrast study -- continue to monitor creatinine . # ANEMIA: iron studies from last admission suggest iron deficiency and chronic disease -- continue iron supplements -- continue to monitor hct . # GOUT: continue allopurinol . # BPH: continue flomax Benson-Rodriguez Clinic . # FEN: -- IV hydration prior to CT scan . # PPX: -- ambulating -- protonix . # CODE: full . # DISPO: pending . . = = = = = = = = = = = = = = = = = = ================================================================ Surgery was then consulted and he went to the OR on 10-29 for his Infected pancreatic necrosis, status post gallstone pancreatitis. He had 1. Exploratory laparotomy. 2. Pancreatic debridement with wide drainage. 3. Open cholecystectomy. 4. Placement of a combined G/J tube (MIC tube). Post-op he stayed in the ICU for 2 nights and was trasnfered to the floor on POD 3. GI/Abd: He was NPO with a NGT and IVF. The NGT was removed on POD 2. His G-tube was left to gravity drainage. His J-tube was capped and then trophic tubefeedings were started on POD 2. His tubefeedings were advanced to a goal of Replete with Fiber 3/4 strength at 80cc/hr. He had 3 JP drains in place and these were draining thick, dark fluid. He continued to have high output from these drains. He was started on sips on POD 5, he was advanced to clears on POD 6. JP amylase was checked on POD 7, once on a full liquid diet. His JP Amylase was 27K, 34K, and 14K. He was made NPO due to his JP amylase reported as high. He continued on the tubefeedings. A grape juice test was positive for a leak from around the JP drains. He had one small spot with minimal drainage that could be expressed from his incision. His is now having drainage around all his drains and g/j tube with mild skin irritation. He has irritation around the tube extending out from ~0.5 - 3 cm and appears at Alesha to develop yeast. His midline incision is c/i but has a small amount of serous drainage on the gauze. Have suggested using Criticaid anti fungal moisture barrier to protect his skin from the drainage and to prevent the formation of yeast. Continue to apply a thin layer of dressing around the drains and change as needed do not allow the gauze to become saturated with drainage. Apply the antifungal Criticaid two to three times/day. A CT was obtained on 12-31 and showed: 1. Heterogeneity in the region of the pancreas consistent with the patient's previous necrotizing pancreatitis. 2. Three surgical drains in situ with some high attenuation in the region of the lesser sac which may represent fistulization from the small bowel into this residual collection. 3. Loculated fluid under the anterior abdominal wall measuring 16 cm. 4. Gastrojejunostomy in situ. 5. Renal cysts. 6. Bilateral pleural effusions. 7. Enlarged prostate at 8 cm. . He will remain NPO with TF for 2 weeks and then return for a repeat CT. His drains will remain and the drainage will be monitored. Pain: He had good pain control with a PCA. He continued on a PCA thru POD 6. Once back on a diet, he was ordered for PO pain meds with good control. Labs: We monitored his labs and his Tbili decreased from a high of 2.6 on POD 2 to WNL by 1930-8-9. Cards: He was being followed by his PCP/Cardiologist. He was put back on his home meds on POD5, including Lasix IV for gentle diuresis and his heart meds. Renal: He was diuresing well and continued to have negative fluid balance and losing weight appropriately. Medications on Admission: # Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). # Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). # Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). # Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). # Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY # Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. # Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for shortness of breath, edema. # Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). # Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. # Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). # Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. # Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). # Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. # Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. # Colace, senna PRN # Protein powder, 2 scoops Benson-Rodriguez Clinic # Demerol PRN Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for fever or pain. 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 8. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 12. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 11-31 hours. 17. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 18. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 2 doses: D/C on 7-1. Disp:2 Recon Soln(s) Refills:0 Discharge Disposition: Extended Care Facility: Garcia, Medina and Harper Health System & Rehab Center - Garcia-Jones Medical Center Discharge Diagnosis: PRIMARY: Infected pancreatic necrosis, status post gallstone pancreatitis. Post-op Pancreatic leak SECONDARY: # Coronary artery disease status post CABG x4 in 2005. # Ischemic cardiomyopathy, EF 20-25%, echo 2005. # Atrial flutter, currently A-paced. # Ventricular irritability. # ICD placement 2005, changed in 2005 (Moreno, Lopez and Fuller dual- chamber system.) # CRI with a baseline creatinine of 1.2-1.5. # Gout # Gallstones Discharge Condition: hemodynamically stable, afebrile, ambulating Discharge Instructions: Please take all medication as prescribed. Keep appointments listed below. If you have chest pain or shortness of breath, get medical attention immediately. If you have fevers or any discomfort, please call your doctor or go to the emergency department. . Continue with tubefeedings. Continue with drain care and with tubefeeding care. Followup Instructions: Provider: Ted Wilson SCAN Phone:890-953-1027 Date/Time:1974-9-27 9:00 Please follow-up with Dr. Merino on 1974-9-27 at 10:15. Call (563-169-6669 with questions. Please follow up with your PCP Jeremy Lofft 2 weeks: PCP: Ted Wilson,Quincy Debelius 9-1911 OTHER APPOINTMENTS: Provider: Mattie Anderson, MD Phone:802-368-2810 Date/Time:1941-2-21 10:20 Provider: Stacey Lyna, MD Phone:940-842-4052 Date/Time:1941-2-21 3:30 Completed by:1992-12-23	['Admission Date: 2014-5-29 Discharge Date: 1992-12-23\n\nDate of Birth: 2004-11-22 Sex: M\n\nService: SURGERY\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Nora\nChief Complaint:\nfever\n\nMajor Surgical or Invasive Procedure:\n1. Exploratory laparotomy.\n2. Pancreatic debridement with wide drainage.\n3. Open cholecystectomy.\n4. Placement of a combined G/J tube (MIC tube).\n5. PICC line placement\n6. ERCP with stent\n\n\nHistory of Present Illness:\nThis is a 75 year old man who is a retired anethesiologist with\nh/o CAD s/p CABG and ischemic cardiomyopathy with EF of 25% who\nwas recently discharged from Murphy Ltd Health System following a hospital course\nfor gallstone pancreatitis and now re-presents from rehab for\nfevers. During last admission, he was transferred from OSH with\nwith fever and pancreatitis which was thought to be from\ngallstones although there were no gallstones in the bile ducts,\njust in the gallbladder itself.', ' CT scan done on admissionw as\nconsistent with severe pancreatitis. ERCP was done on 1977-4-10,\nwith sphinceterotomy and CBD stent placed. His post procedure\ncourse was complicated by fevers and repeat CT abd shows\nprogression of severe pancreatitis with extensive\nperipancreatitis fluid collection. This was thought to be\neither from PNA or from inflammation from his pancreatitis. He\nfinished a course of azithro/ctx and a course of flagyl/cipro\nand eventually he devefesced. All cultures were negative. He\nwas discharged to rehab.\n.\nAt rehab, he reports having fevers since Friday 1997-12-13, with\nhighest at 102.0. He has no localizing pain. Denies cough,\ndysuria, abd pain or nausea and vomit.\n.\nROS: Negative for headache, chest pain, shortness of breath or\nchange in bowel habits.\n\nPast Medical History:\n# Coronary artery disease status post CABG x4 in 2005.', '\n# Status post MI in 2005.\n# Ischemic cardiomyopathy, EF 20-25%, echo 2005.\n# Atrial flutter, currently A-paced.\n# Ventricular irritability.\n# ICD placement 2005, changed in 2005 (Moreno, Lopez and Fuller dual- chamber\nsystem.)\n# CRI with a baseline creatinine of 1.2-1.5.\n# Gout.\n# Gallstones.\n# Kidney stones.\n# h/o Syncope.\n\nSocial History:\nA retired anesthesiologist, worked in pain management. Denies\ntobacco, drugs. Bottle of wine per week.\n\nFamily History:\nFather had a MI at age 70.\n\nPhysical Exam:\nVITALS: 102.2 112/P 68 16 93%-RA\nGEN: A+Ox3, NAD\nHEENT: MMM, OP clear\nNECK: no LAD, no JVD\nCV: RRR, II/VI holosystolic murmur at LLSB\nPULM: crackles at bases with decreased sounds on right base, no\nwheeze, rhonchi\nABD: soft, NT, ND, +BS\nEXT: Uma stockings on both legs; 1+ pitting edema to knees\nbilaterally\n\nPertinent Results:\n137 101 19\n--------------Alesha: 25 Lip: 38\n\n 95\n13.', '1 > 9.5 1928-8-18\n\nCT ABD WITH IV AND ORAL CONTRAST:\n1. All visualized peripancreatic collections appear slightly\nsmaller.\n2. New air bubbles within multiple collections. Correlate with\nhistory of marsupialization or attempts at drainage in the\ninterval since 1922-11-3. Superimposed infection in the\ncollections cannot be excluded given the new air bubbles,\nalthough the collections are infected, they would not expect to\nget smaller.\n3. Biliary stent in position. No evidence of worsening biliary\ndilatation.\n4. Cholelithiasis and Phrygian cap in gallbladder.\n5. Bilateral pleural effusions, right greater than left with\nassociated bilateral lower lobe atelectasis. Effusions slightly\nlarger than on 2008-3-16.\n\nCXR:\nSmall bilateral pleural effusions have increased. Moderate\nenlargement of the cardiac silhouette is stable.', ' Upper lungs\ngrossly clear. Atelectasis at the lung bases is slightly more\nsevere today. No pneumothorax. Transvenous right atrial pacer\nand right ventricular pacer defibrillator leads are unchanged in\ntheir respective positions. The patient is status post median\nsternotomy and coronary bypass grafting.\n.\n\n1941-2-21 05:17AM BLOOD WBC-8.1 RBC-2.98* Hgb-9.3* Hct-27.9\nMCV-94 MCH-31.2 MCHC-33.2 RDW-16.2 Plt Ct-197\n2001-5-27 04:35AM BLOOD WBC-10.4 RBC-3.03* Hgb-9.0* Hct-28.2\nMCV-93 MCH-29.5 MCHC-31.7 RDW-16.2 Plt Ct-277\n2014-5-29 12:50PM BLOOD Neuts-90.0* Bands-0 Lymphs-5.2* Monos-4.5\nEos-0.1 Baso-0.2\n2001-5-27 04:35AM BLOOD Glucose-145* UreaN-21* Creat-0.7 Na-136\nK-4.2 Cl-100 HCO3-30 AnGap-10\n2018-12-10 05:31AM BLOOD Glucose-145* UreaN-22* Creat-0.8 Na-138\nK-4.1 Cl-101 HCO3-28 AnGap-13\n1904-1-9 04:07AM BLOOD ALT-31 AST-39 AlkPhos-160* Amylase-23\nTotBili-0.', "7 DirBili-0.4* IndBili-0.3\n1904-1-9 04:07AM BLOOD Lipase-41\n2018-12-10 05:31AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0\n1941-2-21 05:17AM BLOOD Albumin-2.4* Iron-12\n1941-2-21 05:17AM BLOOD calTIBC-140 Ferritn-589* TRF-108\n.\nSPECIMEN SUBMITTED: GALLBLADDER AND CONTENTS.\nGallbladder, cholecystectomy (A):\nAcute and chronic cholecystitis.\nCholelithiasis.\n.\n\nREPEAT, (REQUEST BY RADIOLOGIST) 2018-12-10 6:47 PM\nFINDINGS: X-ray of the three surgical drains revealed no\nevidence of any contrast which is radiopaque within these\ndrains.\n.\nCT PELVIS W/CONTRAST 2018-12-10 12:07 PM\nIMPRESSION:\n1. Heterogeneity in the region of the pancreas consistent with\nthe patient's previous necrotizing pancreatitis.\n2. Three surgical drains in situ with some high attenuation in\nthe region of the lesser sac which may represent fistulization\nfrom the small bowel into this residual collection.", '\n3. Loculated fluid under the anterior abdominal wall measuring\n16 cm.\n4. Gastrojejunostomy in situ.\n5. Renal cysts.\n6. Bilateral pleural effusions.\n7. Enlarged prostate at 8 cm.\n.\n\n\nBrief Hospital Course:\n75 year old man with CAD s/p CABD and ischemic cardiomyopathy EF\n25% who was recently admitted for gallstone pancreatitis, now\nre-admitted from rehab for fevers.\n.\n# FEVERS: Likely source is from his pancreas. On last\nadmission, he was febrile without an identified infectious\nsource and was thought to be from inflammatory response to\npancreatitis and peri-pancreatic fluid. Currently with\nleukocytosis and left shift although no localizing signs of\ninfection. The differential at this time includes (infected)\npancreatic pseudocyst, necrotizing pancreatitis and an\nobstructed bile duct stent.', '\n-- appreciate GI following\n-- keep NPO for now until CT scan and labs return\n-- CT scan of abdomen with oral and IV contrast\n-- culture blood and urine\n-- CXR to r/o PNA\n.\n# CAD: currenty stable without chest pain.\n-- continue asa + captopril + carvedilol\n.\n# CHF: currently euvolemic, and stable.\n-- admitted and dry weight:\n-- continue asa + captopril + carvedilol\n.\n# Aflutter: currently apaced\n-- continue to hold coumadin in case he needs surgery\n-- continue carvedilol\n.\n# CRI: Baseline creatinine 1.2-1.5\n-- hydration and bicarb prior to contrast study\n-- continue to monitor creatinine\n.\n# ANEMIA: iron studies from last admission suggest iron\ndeficiency and chronic disease\n-- continue iron supplements\n-- continue to monitor hct\n.\n# GOUT: continue allopurinol\n.\n# BPH: continue flomax Benson-Rodriguez Clinic\n.', '\n# FEN:\n-- IV hydration prior to CT scan\n.\n# PPX:\n-- ambulating\n-- protonix\n.\n# CODE: full\n.\n# DISPO: pending\n.\n.\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\nSurgery was then consulted and he went to the OR on 10-29 for his\nInfected pancreatic necrosis, status post gallstone\npancreatitis. He had\n1. Exploratory laparotomy.\n2. Pancreatic debridement with wide drainage.\n3. Open cholecystectomy.\n4. Placement of a combined G/J tube (MIC tube).\n\nPost-op he stayed in the ICU for 2 nights and was trasnfered to\nthe floor on POD 3.\n\nGI/Abd: He was NPO with a NGT and IVF. The NGT was removed on\nPOD 2. His G-tube was left to gravity drainage.\nHis J-tube was capped and then trophic tubefeedings were started\non POD 2. His tubefeedings were advanced to a goal of Replete\nwith Fiber 3/4 strength at 80cc/hr.', '\nHe had 3 JP drains in place and these were draining thick, dark\nfluid.\nHe continued to have high output from these drains.\nHe was started on sips on POD 5, he was advanced to clears on\nPOD 6.\nJP amylase was checked on POD 7, once on a full liquid diet. His\nJP Amylase was 27K, 34K, and 14K. He was made NPO due to his JP\namylase reported as high. He continued on the tubefeedings. A\ngrape juice test was positive for a leak from around the JP\ndrains.\nHe had one small spot with minimal drainage that could be\nexpressed from his incision.\nHis is now having drainage around all his drains and g/j tube\nwith mild skin irritation. He has irritation around the tube\nextending out from ~0.5 - 3 cm and appears at Alesha to develop\nyeast. His midline incision is c/i but has a small amount of\nserous drainage on the gauze.', "\n\nHave suggested using Criticaid anti fungal moisture barrier to\nprotect his skin from the drainage and to prevent the formation\nof yeast. Continue to apply a thin layer of dressing around the\ndrains and change as needed do not allow the gauze to become\nsaturated with drainage. Apply the antifungal Criticaid two to\nthree times/day.\n\n\nA CT was obtained on 12-31 and showed:\n1. Heterogeneity in the region of the pancreas consistent with\nthe patient's previous necrotizing pancreatitis.\n2. Three surgical drains in situ with some high attenuation in\nthe region of the lesser sac which may represent fistulization\nfrom the small bowel into this residual collection.\n3. Loculated fluid under the anterior abdominal wall measuring\n16 cm.\n4. Gastrojejunostomy in situ.\n5. Renal cysts.\n6. Bilateral pleural effusions.", '\n7. Enlarged prostate at 8 cm.\n.\nHe will remain NPO with TF for 2 weeks and then return for a\nrepeat CT. His drains will remain and the drainage will be\nmonitored.\n\nPain: He had good pain control with a PCA. He continued on a PCA\nthru POD 6. Once back on a diet, he was ordered for PO pain meds\nwith good control.\n\nLabs: We monitored his labs and his Tbili decreased from a high\nof 2.6 on POD 2 to WNL by 1930-8-9.\n\nCards: He was being followed by his PCP/Cardiologist. He was put\nback on his home meds on POD5, including Lasix IV for gentle\ndiuresis and his heart meds.\n\nRenal: He was diuresing well and continued to have negative\nfluid balance and losing weight appropriately.\n\n\nMedications on Admission:\n# Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).\n# Amiodarone 200 mg Tablet Sig: 0.', '5 Tablet PO DAILY (Daily).\n# Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a\nday).\n# Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times\na day).\n# Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n# Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY\n# Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.\n# Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as\nneeded for shortness of breath, edema.\n# Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\n# Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3\ntimes a day).\n# Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed for shortness of breath or\nwheezing.\n# Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)\nCapsule, Sust. Release 24 hr PO BID (2 times a day).', '\n# Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)\nas needed for insomnia.\n# Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\n# Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO once a day.\n# Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation\nevery 4-6 hours as needed for shortness of breath or wheezing.\n# Colace, senna PRN\n# Protein powder, 2 scoops Benson-Rodriguez Clinic\n# Demerol PRN\n\n\nDischarge Medications:\n1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed.\n2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)\nInhalation Q6H (every 6 hours) as needed.\n3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)\nInjection TID (3 times a day).\n4. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale\n Injection ASDIR (AS DIRECTED).', '\n5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as\nneeded for fever or pain.\n6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.\n7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)\nCapsule, Sust. Release 24 hr PO BID (2 times a day).\n8. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a\nday).\n9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times\na day).\n10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five\n(5) ML PO Q6H (every 6 hours) as needed.\n12. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).\n\n13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)\nTablet, Chewable PO QID (4 times a day) as needed.\n14. Pantoprazole 40 mg Tablet, Delayed Release (E.', 'C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).\n15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).\n\n16. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 11-31\nhours.\n17. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)\nInjection Q8H (every 8 hours).\n18. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).\n19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID\n(2 times a day).\n20. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon\nSoln Intravenous Q8H (every 8 hours) for 2 doses: D/C on 7-1.\nDisp:2 Recon Soln(s)* Refills:0\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nGarcia, Medina and Harper Health System & Rehab Center - Garcia-Jones Medical Center\n\nDischarge Diagnosis:\nPRIMARY:\nInfected pancreatic necrosis,\nstatus post gallstone pancreatitis.', '\nPost-op Pancreatic leak\n\nSECONDARY:\n# Coronary artery disease status post CABG x4 in 2005.\n# Ischemic cardiomyopathy, EF 20-25%, echo 2005.\n# Atrial flutter, currently A-paced.\n# Ventricular irritability.\n# ICD placement 2005, changed in 2005 (Moreno, Lopez and Fuller dual- chamber\nsystem.)\n# CRI with a baseline creatinine of 1.2-1.5.\n# Gout\n# Gallstones\n\n\nDischarge Condition:\nhemodynamically stable, afebrile, ambulating\n\n\nDischarge Instructions:\nPlease take all medication as prescribed. Keep appointments\nlisted below. If you have chest pain or shortness of breath,\nget medical attention immediately. If you have fevers or any\ndiscomfort, please call your doctor or go to the emergency\ndepartment.\n.\nContinue with tubefeedings.\nContinue with drain care and with tubefeeding care.\n\nFollowup Instructions:\nProvider: Ted Wilson SCAN Phone:890-953-1027 Date/Time:1974-9-27 9:00\n\nPlease follow-up with Dr.', ' Merino on 1974-9-27 at 10:15. Call\n(563-169-6669 with questions.\n\nPlease follow up with your PCP Jeremy Lofft 2 weeks:\nPCP: Ted Wilson,Quincy Debelius 9-1911\n\nOTHER APPOINTMENTS:\nProvider: Mattie Anderson, MD Phone:802-368-2810\nDate/Time:1941-2-21 10:20\nProvider: Stacey Lyna, MD Phone:940-842-4052\nDate/Time:1941-2-21 3:30\n\n\n\nCompleted by:1992-12-23']
236	26601	116471.0	2127-07-30	Discharge summary	Report	Admission Date: [2127-7-21] Discharge Date: [2127-7-30] Service: MED Allergies: Bactrim / Amiodarone / Quinine / Codeine / Zithromax Attending:[First Name3 (LF) 898] Chief Complaint: Abdominal Discomfort Major Surgical or Invasive Procedure: ERCP x 2 Endotracheal Intubation History of Present Illness: The patient is an 85 year old woman with PMH of ESRD on HD, HTN, and DM, who presented to the [Hospital1 18] ED on [7-21] with complaint of nausea, vomiting, abdominal pain, and diarrhea x 3 days. The patient also reported recent fever and chills. In the ED, patient had a low grade temperature of 100.5 degrees. Her abdomen was slightly distended, with no rigidity or rebound. Admission laboratory data were notable for WBC 6.2, elevated transaminases, and INR 3.7. Right upper quadrant ultrasound disclosed a 5 mm gallstone in the neck of the gallbladder. There was also a 5mm gallstone in the common bile duct, without ductal dilatation. The patient was evaluated by surgery for her choledocholithiasis. The patient was also seen by the ERCP fellow. The patient was not acutely ill last night, so she was admitted to the Medicine team, with plan for ERCP today. She was kept NPO and was administered IVF overnight. This morning, she was administered 4 U FFP to reverse her INR. After receiving 2 U FFP, she became hypoxic, with O2 sats dropping to the 70s. She was placed on 100% NRB with improvement in her O2 sats to the 90s. Prior to dialysis, she was given 100 mg IV Lasix, with urine output (non measured). At 1:50 PM, she was transferred to the Hemodialysis Unit for initiation of hemodialysis. Approximately 1 L was removed, yet the patient remained in respiratory distress, with O2 sats in the low 90s on NRB. At 2:30 PM, a respiratory code was called since patient's O2 sats dropped to 70s on the NRB. The patient was emergently intubated. ABG prior to intubation was 7.21/55/55. EKG disclosed new ST segment depressions in the inferior and lateral leads. Following intubation, the patient's SBP dropped to 80s. She was administered approximately 500 cc NS bolus, and required Dopamine transiently. The patient was transferred to the MICU for further management. Past Medical History: 1. End stage renal disease, on hemodialysis via RIJ tunnelled portacath. h/o failed left arm fistula. 2. History of crescente glomerulonephritis by renal biopsy, likely related to underlying vasculitis. 3. Vasculitis, ANCA positive, treated with chronic steroids. Currently on steroid taper. 4. Chronic obstructive pulmonary disease. 5. Steroid induced diabetes mellitus. 6. Chronic anemia related to end stage renal disease. 7. History of hemorrhoids. 8. Atrial fibrillation, status post transesophageal echocardiography and cardioversion, currently on Atenolol and Coumadin with an ejection fraction of over 55 percent on echocardiogram in [2126-3-2]. 9. Gastroesophageal reflux disease with a normal EGD [2126-6-2]. 10. Hypothyroidism. 11. Hypertension. Social History: Prior tobacco history over twenty years ago. She denies any alcohol use. She lives with her daughter, [Name (NI) ] [Name (NI) 46], who is her health care proxy. The patient is full code. Primary care physician is [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683]. Family History: Non-contributory Physical Exam: General: Elderly female lying in bed, ETT in place. VS: T: 100.7 BP: 104/48 initially, 68/34 at 4 PM HR: 128 Resp: AC 550x14/100%/5 O2sat: 95% HEENT: Sclerae anicteric. PERRL. MMM. OP clear. Neck: Obese. Supple. Difficult to assess JVP. CVS: RRR. S1, S2. No m/r/g. Lungs: Crackles in bases bilaterally. Abd: Slightly distended. +BS. Ext: Cold. No clubbing, cyanosis, or edema. L AVF. Neuro: Intubated, sedated. Moving all extremities. Pertinent Results: [2127-7-21] 08:00AM WBC-6.2 RBC-4.25 HGB-12.7 HCT-40.4 MCV-95 MCH-29.9 MCHC-31.5 RDW-16.3* [2127-7-21] 08:00AM NEUTS-80.5* LYMPHS-12.4* MONOS-4.6 EOS-2.2 BASOS-0.3 [2127-7-21] 08:00AM PLT COUNT-284 [2127-7-22] 03:52AM BLOOD WBC-3.7* RBC-3.78* Hgb-11.8* Hct-35.8* MCV-95 MCH-31.2 MCHC-33.0 RDW-16.2* Plt Ct-217 [2127-7-21] 08:00AM BLOOD PT-23.5* PTT-40.1* INR(PT)-3.7 [2127-7-22] 12:15PM BLOOD PT-12.7 PTT-26.8 INR(PT)-1.1 [2127-7-21] 08:00AM BLOOD Glucose-138* UreaN-18 Creat-2.7* Na-135 K-3.3 Cl-100 HCO3-23 AnGap-15 [2127-7-22] 03:52AM BLOOD Glucose-109* UreaN-9 Creat-2.0* Na-141 K-3.4 Cl-104 HCO3-28 AnGap-12 [2127-7-21] 08:00AM BLOOD ALT-65* AST-36 AlkPhos-506* Amylase-54 TotBili-0.4 [2127-7-22] 03:52AM BLOOD ALT-41* AST-21 AlkPhos-393* Amylase-40 TotBili-0.3 [2127-7-21] 08:00AM BLOOD Lipase-43 GGT-558* [2127-7-22] 03:52AM BLOOD Lipase-23 [2127-7-22] 03:52AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.7 Mg-1.6 [2127-7-22] 01:28PM BLOOD Type-ART pO2-79* pCO2-56* pH-7.27* calHCO3-27 Base XS--1 [2127-7-22] 02:40PM BLOOD pO2-55* pCO2-55* pH-7.21* calHCO3-23 Base XS--6 [2127-7-22] 01:28PM BLOOD Lactate-2.6* EKG: (2:47 PM) Sinus tachycardia 118 bpm. Nl intervals, nl axis. ST segment depressions in II, III, avF, V3-V6. Poor R wave progression. These changes are new compared to previous EKG ([3-5]). (16:33 PM) Radiology: RADIOLOGY Final Report ABNORMAL! LIVER OR GALLBLADDER US (SINGLE ORGAN) [2127-7-21] 1:20 PM LIVER OR GALLBLADDER US (SINGL Reason: RUQ PAIN AND NAUSEA, RO CHOLECYSTITIS [Hospital 93] MEDICAL CONDITION: 85 year old woman with hx diabetes, renal failure, on tapering prednisone for ANCA-positive vasculitis with known gallstone by abd CT last month, and intermittent vomiting but no abd pain. r/o acute cholecystitis or abscess. REASON FOR THIS EXAMINATION: acute cholecystitis or abscess INDICATION: Intermittent vomiting without abdominal pain. Known gallstone by abdominal CT last month. COMPARISON: CT scan, [2127-6-23], is not available on line for comparison. FINDINGS: There is a 5-mm gallstone within the gallbladder neck, but there is no evidence of gallbladder wall edema or pericholecystic fluid to suggest acute cholecystitis. Additionally, a 5-mm flat stone is seen within the common duct, but there is no evidence of ductal dilatation. The common duct measures 3-4 mm proximally. There is no intrahepatic ductal dilatation. The portal vein is open, and flow is hepatopetal. The pancreas appears echogenic, consistent with fatty infiltration. There is no free fluid. IMPRESSION: Cholelithiasis and choledocholithiasis without evidence of acute cholecystitis. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 2368] DR. [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: MON [2127-7-21] 10:09 PM RADIOLOGY Preliminary Report CHEST (PORTABLE AP) [2127-7-22] 1:21 PM CHEST (PORTABLE AP) Reason: ?volume overload [Hospital 93] MEDICAL CONDITION: 85 year old woman with chf and decreasing sats after FFP infusion REASON FOR THIS EXAMINATION: ?volume overload INDICATION: Decreasing oxygen saturation after FFP administration. COMPARISON: [2127-7-21]. CHEST, AP PORTABLE RADIOGRAPH: There is stable cardiac enlargement. The mediastinal and hilar contours are unremarkable. There is bilateral pulmonary vascular redistribution, perihilar haziness and interstitial opacities. There is unchanged small left pleural effusion. The right internal jugular central venous catheter is again noted with tip in the proximal right atrium. The osseous structures are unremarkable. IMPRESSION: New pulmonary edema. DR. [First Name11 (Name Pattern1) 2369] [Initial (NamePattern1) ] [Last Name (NamePattern4) 2370] DR. [First Name (STitle) 2371] [Initials (NamePattern4) ] [Last Name (NamePattern4) 2372] Brief Hospital Course: 1. Respiratory Failure: On HD#2, the patient developed acute respiratory distress. The patient had recieved IVF in the ED the nigtht before and that monring had recieved 4 units of FFP for planned ERCP, the last two within one hour of respiratory distress. CXR demonstrated acute developement of bilateral pulmonary infiltrates. Ddx included cardiogenic pulmonary edema versus TRALI. The patient was taken for emergent HD; however, depspite succesful diuresis, the patient required intubation for respiratory failure. TRALI work-up is pending at the time of discharge. The patient remained intubated in the MICU and succesfully extubated on the second attempt. 2. Hypotension: After intubation, the patient became hypotensive in the MICU requiring initiation of pressors. She was found to be adrenally insufficent by cortisyn stimulation test and started on stress-dose hydrocortisone and fludircortisone. In addition, she required pressors and continued IV Unasyn for possible sepsis, though blood cultures were negative. The patient's blood pressure improved and stablized. 3. Choledocholithasis: Demonstrated on admission RUQ US on admission without transaminitis but with low-grade fever and left-shift. The patient was evaluted by Surgery and ERCP service. She was started on IV Unasyn. Patient underwent ERCP in MICU while intubated, which demonstrated dilated CBD but no stones. Patient had spinchterotomy. The patient completed a 10 day course of IV Unsyn and will be discharged on two days. Consideration should be given to possible outpatient cholecystetomy. 4. GI Bleed: Post-ERCP, the patient dropped Hct and was foudn to be guiac postitive. Patient underwent repeat ERCP which demonstrated spincterotomy bleed. This required epiniephrine injection. Hct remained relatively stable, though she had a possible rebleed several days later which stablized without repeat scope. ASA and coumadin were held [2-3] bleed and may be safely restarted on [2127-8-4]. The patient's Hct remained stable for the rest of her hospital course. The patient will continue on her PPI. 5. Coronary Artery Disease: During the patient's MICU stay, EKG was noted to have poor R wave progression. An echocardiogram was obtained which demonstrated regional LV dysfunction suggesting CAD. Cardiac enzymes demonstrated non-diagnostic elevated Tropnin T, felt either secondary to demand or ESRD. ASA was held [2-3] GI bleed and the patient's beta-blocker was continued. The patient will need an outpatient evaluation of her coronaries, likely with ETT MIBI when she is stable. Again, ASA will be started [2127-8-4*]. 6. ESRD: The patient did well on her hemodilyasis schedule. The patient's prednisone was continued for her history of renal vascultitis. 7. Hypothryoidism: Patient stable on levothyroxine. Discharge Medications: 1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day: Take four tablets on day #1, two tablets on day #2, one tablet on day #3, then resume 1 mg per day. Disp:7 Tablet(s)* Refills:0 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 4. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 5. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (once a day). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-3] Puffs Inhalation Q6H (every 6 hours) as needed. 7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 tube Refills:2 9. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:2 Tablet(s) Refills:0 10. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day: Start after higher-dose prednisone complete. Discharge Disposition: Home Discharge Diagnosis: Choledocholithasis Spinchterotomy Upper GI bleed ESRD Coronary Artery Disease Diarrhea Anemia Hypothryoidism Respiratory Failure Diabetes Mellitus Discharge Condition: Good Discharge Instructions: 1. Please follow-up with your PCP 2. Your primary doctor will obtain a medical alert braclet for you, indicating that you have adrenal insufficency. 3. You will restart your coumadin and start aspirin on [Hospital1 766] after seeing your PCP. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 1683] on [Last Name (LF) 766], [8-4] at 10:15 Completed by:[2127-8-11]	Admission Date: <Date>1999-4-11</Date> Discharge Date: <Date>1946-3-11</Date> Service: MED Allergies: Bactrim / Amiodarone / Quinine / Codeine / Zithromax Attending:<Name>Dawn</Name> Chief Complaint: Abdominal Discomfort Major Surgical or Invasive Procedure: ERCP x 2 Endotracheal Intubation History of Present Illness: The patient is an 85 year old woman with PMH of ESRD on HD, HTN, and DM, who presented to the <Hospital>Peters, Lang and Torres Clinic</Hospital> ED on <Date>12-4</Date> with complaint of nausea, vomiting, abdominal pain, and diarrhea x 3 days. The patient also reported recent fever and chills. In the ED, patient had a low grade temperature of 100.5 degrees. Her abdomen was slightly distended, with no rigidity or rebound. Admission laboratory data were notable for WBC 6.2, elevated transaminases, and INR 3.7. Right upper quadrant ultrasound disclosed a 5 mm gallstone in the neck of the gallbladder. There was also a 5mm gallstone in the common bile duct, without ductal dilatation. The patient was evaluated by surgery for her choledocholithiasis. The patient was also seen by the ERCP fellow. The patient was not acutely ill last night, so she was admitted to the Medicine team, with plan for ERCP today. She was kept NPO and was administered IVF overnight. This morning, she was administered 4 U FFP to reverse her INR. After receiving 2 U FFP, she became hypoxic, with O2 sats dropping to the 70s. She was placed on 100% NRB with improvement in her O2 sats to the 90s. Prior to dialysis, she was given 100 mg IV Lasix, with urine output (non measured). At 1:50 PM, she was transferred to the Hemodialysis Unit for initiation of hemodialysis. Approximately 1 L was removed, yet the patient remained in respiratory distress, with O2 sats in the low 90s on NRB. At 2:30 PM, a respiratory code was called since patient's O2 sats dropped to 70s on the NRB. The patient was emergently intubated. ABG prior to intubation was 7.21/55/55. EKG disclosed new ST segment depressions in the inferior and lateral leads. Following intubation, the patient's SBP dropped to 80s. She was administered approximately 500 cc NS bolus, and required Dopamine transiently. The patient was transferred to the MICU for further management. Past Medical History: 1. End stage renal disease, on hemodialysis via RIJ tunnelled portacath. h/o failed left arm fistula. 2. History of crescente glomerulonephritis by renal biopsy, likely related to underlying vasculitis. 3. Vasculitis, ANCA positive, treated with chronic steroids. Currently on steroid taper. 4. Chronic obstructive pulmonary disease. 5. Steroid induced diabetes mellitus. 6. Chronic anemia related to end stage renal disease. 7. History of hemorrhoids. 8. Atrial fibrillation, status post transesophageal echocardiography and cardioversion, currently on Atenolol and Coumadin with an ejection fraction of over 55 percent on echocardiogram in <Date>1996-3-11</Date>. 9. Gastroesophageal reflux disease with a normal EGD <Date>1972-8-8</Date>. 10. Hypothyroidism. 11. Hypertension. Social History: Prior tobacco history over twenty years ago. She denies any alcohol use. She lives with her daughter, <Name>Danilo Londrie</Name> <Name>Judy Thompson</Name>, who is her health care proxy. The patient is full code. Primary care physician is <Name>Miller</Name>. <Name>Alphonso</Name> <Name>Taylor</Name>. Family History: Non-contributory Physical Exam: General: Elderly female lying in bed, ETT in place. VS: T: 100.7 BP: 104/48 initially, 68/34 at 4 PM HR: 128 Resp: AC 550x14/100%/5 O2sat: 95% HEENT: Sclerae anicteric. PERRL. MMM. OP clear. Neck: Obese. Supple. Difficult to assess JVP. CVS: RRR. S1, S2. No m/r/g. Lungs: Crackles in bases bilaterally. Abd: Slightly distended. +BS. Ext: Cold. No clubbing, cyanosis, or edema. L AVF. Neuro: Intubated, sedated. Moving all extremities. Pertinent Results: <Date>1999-4-11</Date> 08:00AM WBC-6.2 RBC-4.25 HGB-12.7 HCT-40.4 MCV-95 MCH-29.9 MCHC-31.5 RDW-16.3* <Date>1999-4-11</Date> 08:00AM NEUTS-80.5* LYMPHS-12.4* MONOS-4.6 EOS-2.2 BASOS-0.3 <Date>1999-4-11</Date> 08:00AM PLT COUNT-284 <Date>1901-1-22</Date> 03:52AM BLOOD WBC-3.7* RBC-3.78* Hgb-11.8* Hct-35.8* MCV-95 MCH-31.2 MCHC-33.0 RDW-16.2* Plt Ct-217 <Date>1999-4-11</Date> 08:00AM BLOOD PT-23.5* PTT-40.1* INR(PT)-3.7 <Date>1901-1-22</Date> 12:15PM BLOOD PT-12.7 PTT-26.8 INR(PT)-1.1 <Date>1999-4-11</Date> 08:00AM BLOOD Glucose-138* UreaN-18 Creat-2.7* Na-135 K-3.3 Cl-100 HCO3-23 AnGap-15 <Date>1901-1-22</Date> 03:52AM BLOOD Glucose-109* UreaN-9 Creat-2.0* Na-141 K-3.4 Cl-104 HCO3-28 AnGap-12 <Date>1999-4-11</Date> 08:00AM BLOOD ALT-65* AST-36 AlkPhos-506* Amylase-54 TotBili-0.4 <Date>1901-1-22</Date> 03:52AM BLOOD ALT-41* AST-21 AlkPhos-393* Amylase-40 TotBili-0.3 <Date>1999-4-11</Date> 08:00AM BLOOD Lipase-43 GGT-558* <Date>1901-1-22</Date> 03:52AM BLOOD Lipase-23 <Date>1901-1-22</Date> 03:52AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.7 Mg-1.6 <Date>1901-1-22</Date> 01:28PM BLOOD Type-ART pO2-79* pCO2-56* pH-7.27* calHCO3-27 Base XS--1 <Date>1901-1-22</Date> 02:40PM BLOOD pO2-55* pCO2-55* pH-7.21* calHCO3-23 Base XS--6 <Date>1901-1-22</Date> 01:28PM BLOOD Lactate-2.6* EKG: (2:47 PM) Sinus tachycardia 118 bpm. Nl intervals, nl axis. ST segment depressions in II, III, avF, V3-V6. Poor R wave progression. These changes are new compared to previous EKG (<Date>7-2</Date>). (16:33 PM) Radiology: RADIOLOGY Final Report *ABNORMAL! LIVER OR GALLBLADDER US (SINGLE ORGAN) <Date>1999-4-11</Date> 1:20 PM LIVER OR GALLBLADDER US (SINGL Reason: RUQ PAIN AND NAUSEA, RO CHOLECYSTITIS <Hospital>Blake, Scott and Jackson Clinic</Hospital> MEDICAL CONDITION: 85 year old woman with hx diabetes, renal failure, on tapering prednisone for ANCA-positive vasculitis with known gallstone by abd CT last month, and intermittent vomiting but no abd pain. r/o acute cholecystitis or abscess. REASON FOR THIS EXAMINATION: acute cholecystitis or abscess INDICATION: Intermittent vomiting without abdominal pain. Known gallstone by abdominal CT last month. COMPARISON: CT scan, <Date>2005-8-4</Date>, is not available on line for comparison. FINDINGS: There is a 5-mm gallstone within the gallbladder neck, but there is no evidence of gallbladder wall edema or pericholecystic fluid to suggest acute cholecystitis. Additionally, a 5-mm flat stone is seen within the common duct, but there is no evidence of ductal dilatation. The common duct measures 3-4 mm proximally. There is no intrahepatic ductal dilatation. The portal vein is open, and flow is hepatopetal. The pancreas appears echogenic, consistent with fatty infiltration. There is no free fluid. IMPRESSION: Cholelithiasis and choledocholithiasis without evidence of acute cholecystitis. The study and the report were reviewed by the staff radiologist. DR. <Name>Zachary</Name> <Initial>JR</Initial> <Name>Loveland</Name> DR. <Name>Retha</Name> <Initial>JR</Initial> <Name>Miller</Name> Approved: MON <Date>1999-4-11</Date> 10:09 PM RADIOLOGY Preliminary Report CHEST (PORTABLE AP) <Date>1901-1-22</Date> 1:21 PM CHEST (PORTABLE AP) Reason: ?volume overload <Hospital>Blake, Scott and Jackson Clinic</Hospital> MEDICAL CONDITION: 85 year old woman with chf and decreasing sats after FFP infusion REASON FOR THIS EXAMINATION: ?volume overload INDICATION: Decreasing oxygen saturation after FFP administration. COMPARISON: <Date>1999-4-11</Date>. CHEST, AP PORTABLE RADIOGRAPH: There is stable cardiac enlargement. The mediastinal and hilar contours are unremarkable. There is bilateral pulmonary vascular redistribution, perihilar haziness and interstitial opacities. There is unchanged small left pleural effusion. The right internal jugular central venous catheter is again noted with tip in the proximal right atrium. The osseous structures are unremarkable. IMPRESSION: New pulmonary edema. DR. <Name>An</Name> <Initial>JR</Initial> <Name>Lees</Name> DR. <Name>Keiko</Name> <Initial>BN</Initial> <Name>Ornelas</Name> Brief Hospital Course: 1. Respiratory Failure: On HD#2, the patient developed acute respiratory distress. The patient had recieved IVF in the ED the nigtht before and that monring had recieved 4 units of FFP for planned ERCP, the last two within one hour of respiratory distress. CXR demonstrated acute developement of bilateral pulmonary infiltrates. Ddx included cardiogenic pulmonary edema versus TRALI. The patient was taken for emergent HD; however, depspite succesful diuresis, the patient required intubation for respiratory failure. TRALI work-up is pending at the time of discharge. The patient remained intubated in the MICU and succesfully extubated on the second attempt. 2. Hypotension: After intubation, the patient became hypotensive in the MICU requiring initiation of pressors. She was found to be adrenally insufficent by cortisyn stimulation test and started on stress-dose hydrocortisone and fludircortisone. In addition, she required pressors and continued IV Unasyn for possible sepsis, though blood cultures were negative. The patient's blood pressure improved and stablized. 3. Choledocholithasis: Demonstrated on admission RUQ US on admission without transaminitis but with low-grade fever and left-shift. The patient was evaluted by Surgery and ERCP service. She was started on IV Unasyn. Patient underwent ERCP in MICU while intubated, which demonstrated dilated CBD but no stones. Patient had spinchterotomy. The patient completed a 10 day course of IV Unsyn and will be discharged on two days. Consideration should be given to possible outpatient cholecystetomy. 4. GI Bleed: Post-ERCP, the patient dropped Hct and was foudn to be guiac postitive. Patient underwent repeat ERCP which demonstrated spincterotomy bleed. This required epiniephrine injection. Hct remained relatively stable, though she had a possible rebleed several days later which stablized without repeat scope. ASA and coumadin were held <Date>1-7</Date> bleed and may be safely restarted on <Date>1993-10-12</Date>. The patient's Hct remained stable for the rest of her hospital course. The patient will continue on her PPI. 5. Coronary Artery Disease: During the patient's MICU stay, EKG was noted to have poor R wave progression. An echocardiogram was obtained which demonstrated regional LV dysfunction suggesting CAD. Cardiac enzymes demonstrated non-diagnostic elevated Tropnin T, felt either secondary to demand or ESRD. ASA was held <Date>1-7</Date> GI bleed and the patient's beta-blocker was continued. The patient will need an outpatient evaluation of her coronaries, likely with ETT MIBI when she is stable. Again, ASA will be started <Date>1993-10-12</Date>. 6. ESRD: The patient did well on her hemodilyasis schedule. The patient's prednisone was continued for her history of renal vascultitis. 7. Hypothryoidism: Patient stable on levothyroxine. Discharge Medications: 1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day: Take four tablets on day #1, two tablets on day #2, one tablet on day #3, then resume 1 mg per day. Disp:7 Tablet(s)* Refills:0 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 4. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 5. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (once a day). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: <Date>10-25</Date> Puffs Inhalation Q6H (every 6 hours) as needed. 7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical <Hospital>Gilbert LLC Medical Center</Hospital> (2 times a day). Disp:1 tube Refills:2 9. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:2 Tablet(s) Refills:0 10. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day: Start after higher-dose prednisone complete. Discharge Disposition: Home Discharge Diagnosis: Choledocholithasis Spinchterotomy Upper GI bleed ESRD Coronary Artery Disease Diarrhea Anemia Hypothryoidism Respiratory Failure Diabetes Mellitus Discharge Condition: Good Discharge Instructions: 1. Please follow-up with your PCP 2. Your primary doctor will obtain a medical alert braclet for you, indicating that you have adrenal insufficency. 3. You will restart your coumadin and start aspirin on <Hospital>Garrett-Fox Medical Center</Hospital> after seeing your PCP. Followup Instructions: Please follow-up with Dr. <Name>Moore</Name> on <Name>Londrie</Name>, <Date>2-2</Date> at 10:15 Completed by:<Date>2007-5-27</Date>	000000000000000001111111110000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111100000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111011111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111110011111111011111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000111111111000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1999-4-11 Discharge Date: 1946-3-11 Service: MED Allergies: Bactrim / Amiodarone / Quinine / Codeine / Zithromax Attending:Dawn Chief Complaint: Abdominal Discomfort Major Surgical or Invasive Procedure: ERCP x 2 Endotracheal Intubation History of Present Illness: The patient is an 85 year old woman with PMH of ESRD on HD, HTN, and DM, who presented to the Peters, Lang and Torres Clinic ED on 12-4 with complaint of nausea, vomiting, abdominal pain, and diarrhea x 3 days. The patient also reported recent fever and chills. In the ED, patient had a low grade temperature of 100.5 degrees. Her abdomen was slightly distended, with no rigidity or rebound. Admission laboratory data were notable for WBC 6.2, elevated transaminases, and INR 3.7. Right upper quadrant ultrasound disclosed a 5 mm gallstone in the neck of the gallbladder. There was also a 5mm gallstone in the common bile duct, without ductal dilatation. The patient was evaluated by surgery for her choledocholithiasis. The patient was also seen by the ERCP fellow. The patient was not acutely ill last night, so she was admitted to the Medicine team, with plan for ERCP today. She was kept NPO and was administered IVF overnight. This morning, she was administered 4 U FFP to reverse her INR. After receiving 2 U FFP, she became hypoxic, with O2 sats dropping to the 70s. She was placed on 100% NRB with improvement in her O2 sats to the 90s. Prior to dialysis, she was given 100 mg IV Lasix, with urine output (non measured). At 1:50 PM, she was transferred to the Hemodialysis Unit for initiation of hemodialysis. Approximately 1 L was removed, yet the patient remained in respiratory distress, with O2 sats in the low 90s on NRB. At 2:30 PM, a respiratory code was called since patient's O2 sats dropped to 70s on the NRB. The patient was emergently intubated. ABG prior to intubation was 7.21/55/55. EKG disclosed new ST segment depressions in the inferior and lateral leads. Following intubation, the patient's SBP dropped to 80s. She was administered approximately 500 cc NS bolus, and required Dopamine transiently. The patient was transferred to the MICU for further management. Past Medical History: 1. End stage renal disease, on hemodialysis via RIJ tunnelled portacath. h/o failed left arm fistula. 2. History of crescente glomerulonephritis by renal biopsy, likely related to underlying vasculitis. 3. Vasculitis, ANCA positive, treated with chronic steroids. Currently on steroid taper. 4. Chronic obstructive pulmonary disease. 5. Steroid induced diabetes mellitus. 6. Chronic anemia related to end stage renal disease. 7. History of hemorrhoids. 8. Atrial fibrillation, status post transesophageal echocardiography and cardioversion, currently on Atenolol and Coumadin with an ejection fraction of over 55 percent on echocardiogram in 1996-3-11. 9. Gastroesophageal reflux disease with a normal EGD 1972-8-8. 10. Hypothyroidism. 11. Hypertension. Social History: Prior tobacco history over twenty years ago. She denies any alcohol use. She lives with her daughter, Danilo Londrie Judy Thompson, who is her health care proxy. The patient is full code. Primary care physician is Miller. Alphonso Taylor. Family History: Non-contributory Physical Exam: General: Elderly female lying in bed, ETT in place. VS: T: 100.7 BP: 104/48 initially, 68/34 at 4 PM HR: 128 Resp: AC 550x14/100%/5 O2sat: 95% HEENT: Sclerae anicteric. PERRL. MMM. OP clear. Neck: Obese. Supple. Difficult to assess JVP. CVS: RRR. S1, S2. No m/r/g. Lungs: Crackles in bases bilaterally. Abd: Slightly distended. +BS. Ext: Cold. No clubbing, cyanosis, or edema. L AVF. Neuro: Intubated, sedated. Moving all extremities. Pertinent Results: 1999-4-11 08:00AM WBC-6.2 RBC-4.25 HGB-12.7 HCT-40.4 MCV-95 MCH-29.9 MCHC-31.5 RDW-16.3* 1999-4-11 08:00AM NEUTS-80.5* LYMPHS-12.4* MONOS-4.6 EOS-2.2 BASOS-0.3 1999-4-11 08:00AM PLT COUNT-284 1901-1-22 03:52AM BLOOD WBC-3.7* RBC-3.78* Hgb-11.8* Hct-35.8* MCV-95 MCH-31.2 MCHC-33.0 RDW-16.2* Plt Ct-217 1999-4-11 08:00AM BLOOD PT-23.5* PTT-40.1* INR(PT)-3.7 1901-1-22 12:15PM BLOOD PT-12.7 PTT-26.8 INR(PT)-1.1 1999-4-11 08:00AM BLOOD Glucose-138* UreaN-18 Creat-2.7* Na-135 K-3.3 Cl-100 HCO3-23 AnGap-15 1901-1-22 03:52AM BLOOD Glucose-109* UreaN-9 Creat-2.0* Na-141 K-3.4 Cl-104 HCO3-28 AnGap-12 1999-4-11 08:00AM BLOOD ALT-65* AST-36 AlkPhos-506* Amylase-54 TotBili-0.4 1901-1-22 03:52AM BLOOD ALT-41* AST-21 AlkPhos-393* Amylase-40 TotBili-0.3 1999-4-11 08:00AM BLOOD Lipase-43 GGT-558* 1901-1-22 03:52AM BLOOD Lipase-23 1901-1-22 03:52AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.7 Mg-1.6 1901-1-22 01:28PM BLOOD Type-ART pO2-79* pCO2-56* pH-7.27* calHCO3-27 Base XS--1 1901-1-22 02:40PM BLOOD pO2-55* pCO2-55* pH-7.21* calHCO3-23 Base XS--6 1901-1-22 01:28PM BLOOD Lactate-2.6* EKG: (2:47 PM) Sinus tachycardia 118 bpm. Nl intervals, nl axis. ST segment depressions in II, III, avF, V3-V6. Poor R wave progression. These changes are new compared to previous EKG (7-2). (16:33 PM) Radiology: RADIOLOGY Final Report *ABNORMAL! LIVER OR GALLBLADDER US (SINGLE ORGAN) 1999-4-11 1:20 PM LIVER OR GALLBLADDER US (SINGL Reason: RUQ PAIN AND NAUSEA, RO CHOLECYSTITIS Blake, Scott and Jackson Clinic MEDICAL CONDITION: 85 year old woman with hx diabetes, renal failure, on tapering prednisone for ANCA-positive vasculitis with known gallstone by abd CT last month, and intermittent vomiting but no abd pain. r/o acute cholecystitis or abscess. REASON FOR THIS EXAMINATION: acute cholecystitis or abscess INDICATION: Intermittent vomiting without abdominal pain. Known gallstone by abdominal CT last month. COMPARISON: CT scan, 2005-8-4, is not available on line for comparison. FINDINGS: There is a 5-mm gallstone within the gallbladder neck, but there is no evidence of gallbladder wall edema or pericholecystic fluid to suggest acute cholecystitis. Additionally, a 5-mm flat stone is seen within the common duct, but there is no evidence of ductal dilatation. The common duct measures 3-4 mm proximally. There is no intrahepatic ductal dilatation. The portal vein is open, and flow is hepatopetal. The pancreas appears echogenic, consistent with fatty infiltration. There is no free fluid. IMPRESSION: Cholelithiasis and choledocholithiasis without evidence of acute cholecystitis. The study and the report were reviewed by the staff radiologist. DR. Zachary JR Loveland DR. Retha JR Miller Approved: MON 1999-4-11 10:09 PM RADIOLOGY Preliminary Report CHEST (PORTABLE AP) 1901-1-22 1:21 PM CHEST (PORTABLE AP) Reason: ?volume overload Blake, Scott and Jackson Clinic MEDICAL CONDITION: 85 year old woman with chf and decreasing sats after FFP infusion REASON FOR THIS EXAMINATION: ?volume overload INDICATION: Decreasing oxygen saturation after FFP administration. COMPARISON: 1999-4-11. CHEST, AP PORTABLE RADIOGRAPH: There is stable cardiac enlargement. The mediastinal and hilar contours are unremarkable. There is bilateral pulmonary vascular redistribution, perihilar haziness and interstitial opacities. There is unchanged small left pleural effusion. The right internal jugular central venous catheter is again noted with tip in the proximal right atrium. The osseous structures are unremarkable. IMPRESSION: New pulmonary edema. DR. An JR Lees DR. Keiko BN Ornelas Brief Hospital Course: 1. Respiratory Failure: On HD#2, the patient developed acute respiratory distress. The patient had recieved IVF in the ED the nigtht before and that monring had recieved 4 units of FFP for planned ERCP, the last two within one hour of respiratory distress. CXR demonstrated acute developement of bilateral pulmonary infiltrates. Ddx included cardiogenic pulmonary edema versus TRALI. The patient was taken for emergent HD; however, depspite succesful diuresis, the patient required intubation for respiratory failure. TRALI work-up is pending at the time of discharge. The patient remained intubated in the MICU and succesfully extubated on the second attempt. 2. Hypotension: After intubation, the patient became hypotensive in the MICU requiring initiation of pressors. She was found to be adrenally insufficent by cortisyn stimulation test and started on stress-dose hydrocortisone and fludircortisone. In addition, she required pressors and continued IV Unasyn for possible sepsis, though blood cultures were negative. The patient's blood pressure improved and stablized. 3. Choledocholithasis: Demonstrated on admission RUQ US on admission without transaminitis but with low-grade fever and left-shift. The patient was evaluted by Surgery and ERCP service. She was started on IV Unasyn. Patient underwent ERCP in MICU while intubated, which demonstrated dilated CBD but no stones. Patient had spinchterotomy. The patient completed a 10 day course of IV Unsyn and will be discharged on two days. Consideration should be given to possible outpatient cholecystetomy. 4. GI Bleed: Post-ERCP, the patient dropped Hct and was foudn to be guiac postitive. Patient underwent repeat ERCP which demonstrated spincterotomy bleed. This required epiniephrine injection. Hct remained relatively stable, though she had a possible rebleed several days later which stablized without repeat scope. ASA and coumadin were held 1-7 bleed and may be safely restarted on 1993-10-12. The patient's Hct remained stable for the rest of her hospital course. The patient will continue on her PPI. 5. Coronary Artery Disease: During the patient's MICU stay, EKG was noted to have poor R wave progression. An echocardiogram was obtained which demonstrated regional LV dysfunction suggesting CAD. Cardiac enzymes demonstrated non-diagnostic elevated Tropnin T, felt either secondary to demand or ESRD. ASA was held 1-7 GI bleed and the patient's beta-blocker was continued. The patient will need an outpatient evaluation of her coronaries, likely with ETT MIBI when she is stable. Again, ASA will be started 1993-10-12. 6. ESRD: The patient did well on her hemodilyasis schedule. The patient's prednisone was continued for her history of renal vascultitis. 7. Hypothryoidism: Patient stable on levothyroxine. Discharge Medications: 1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day: Take four tablets on day #1, two tablets on day #2, one tablet on day #3, then resume 1 mg per day. Disp:7 Tablet(s)* Refills:0 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 4. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 5. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (once a day). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: 10-25 Puffs Inhalation Q6H (every 6 hours) as needed. 7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical Gilbert LLC Medical Center (2 times a day). Disp:1 tube Refills:2 9. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:2 Tablet(s) Refills:0 10. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day: Start after higher-dose prednisone complete. Discharge Disposition: Home Discharge Diagnosis: Choledocholithasis Spinchterotomy Upper GI bleed ESRD Coronary Artery Disease Diarrhea Anemia Hypothryoidism Respiratory Failure Diabetes Mellitus Discharge Condition: Good Discharge Instructions: 1. Please follow-up with your PCP 2. Your primary doctor will obtain a medical alert braclet for you, indicating that you have adrenal insufficency. 3. You will restart your coumadin and start aspirin on Garrett-Fox Medical Center after seeing your PCP. Followup Instructions: Please follow-up with Dr. Moore on Londrie, 2-2 at 10:15 Completed by:2007-5-27	['Admission Date: 1999-4-11 Discharge Date: 1946-3-11\n\n\nService: MED\n\nAllergies:\nBactrim / Amiodarone / Quinine / Codeine / Zithromax\n\nAttending:Dawn\nChief Complaint:\nAbdominal Discomfort\n\nMajor Surgical or Invasive Procedure:\nERCP x 2\nEndotracheal Intubation\n\nHistory of Present Illness:\nThe patient is an 85 year old woman with PMH of ESRD on HD, HTN,\nand DM, who presented to the Peters, Lang and Torres Clinic ED on 12-4 with complaint of\nnausea, vomiting, abdominal pain, and diarrhea x 3 days. The\npatient also reported recent fever and chills. In the ED,\npatient had a low grade temperature of 100.5 degrees. Her\nabdomen was slightly distended, with no rigidity or rebound.\nAdmission laboratory data were notable for WBC 6.2, elevated\ntransaminases, and INR 3.7. Right upper quadrant ultrasound\ndisclosed a 5 mm gallstone in the neck of the gallbladder.', '\nThere was also a 5mm gallstone in the common bile duct, without\nductal dilatation. The patient was evaluated by surgery for her\ncholedocholithiasis. The patient was also seen by the ERCP\nfellow. The patient was not acutely ill last night, so she was\nadmitted to the Medicine team, with plan for ERCP today. She was\nkept NPO and was administered IVF overnight.\n This morning, she was administered 4 U FFP to reverse her INR.\n After receiving 2 U FFP, she became hypoxic, with O2 sats\ndropping to the 70s. She was placed on 100% NRB with\nimprovement in her O2 sats to the 90s. Prior to dialysis, she\nwas given 100 mg IV Lasix, with urine output (non measured). At\n1:50 PM, she was transferred to the Hemodialysis Unit for\ninitiation of hemodialysis. Approximately 1 L was removed, yet\nthe patient remained in respiratory distress, with O2 sats in\nthe low 90s on NRB.', " At 2:30 PM, a respiratory code was called\nsince patient's O2 sats dropped to 70s on the NRB. The patient\nwas emergently intubated. ABG prior to intubation was\n7.21/55/55. EKG disclosed new ST segment depressions in the\ninferior and lateral leads. Following intubation, the patient's\nSBP dropped to 80s. She was administered approximately 500 cc\nNS bolus, and required Dopamine transiently. The patient was\ntransferred to the MICU for further management.\n\n\nPast Medical History:\n1. End stage renal disease, on hemodialysis via RIJ tunnelled\nportacath. h/o failed left arm fistula.\n\n2. History of crescente glomerulonephritis by renal biopsy,\nlikely related to underlying vasculitis.\n\n3. Vasculitis, ANCA positive, treated with chronic steroids.\nCurrently on steroid taper.\n\n4. Chronic obstructive pulmonary disease.", '\n\n5. Steroid induced diabetes mellitus.\n\n6. Chronic anemia related to end stage renal disease.\n\n7. History of hemorrhoids.\n\n8. Atrial fibrillation, status post transesophageal\nechocardiography and cardioversion, currently on Atenolol and\nCoumadin with an ejection fraction of over 55 percent on\nechocardiogram in 1996-3-11.\n\n9. Gastroesophageal reflux disease with a normal EGD 1972-8-8.\n\n10. Hypothyroidism.\n\n11. Hypertension.\n\n\nSocial History:\nPrior tobacco history over twenty years ago. She denies any\nalcohol use. She\nlives with her daughter, Danilo Londrie Judy Thompson, who is her health\ncare proxy. The patient is full code. Primary care physician is\nMiller. Alphonso Taylor.\n\nFamily History:\nNon-contributory\n\nPhysical Exam:\nGeneral: Elderly female lying in bed, ETT in place.\nVS: T: 100.7 BP: 104/48 initially, 68/34 at 4 PM HR: 128\n Resp: AC 550x14/100%/5 O2sat: 95%\nHEENT: Sclerae anicteric.', ' PERRL. MMM. OP clear.\nNeck: Obese. Supple. Difficult to assess JVP.\nCVS: RRR. S1, S2. No m/r/g.\nLungs: Crackles in bases bilaterally.\nAbd: Slightly distended. +BS.\nExt: Cold. No clubbing, cyanosis, or edema. L AVF.\nNeuro: Intubated, sedated. Moving all extremities.\n\nPertinent Results:\n1999-4-11 08:00AM WBC-6.2 RBC-4.25 HGB-12.7 HCT-40.4 MCV-95\nMCH-29.9 MCHC-31.5 RDW-16.3\n1999-4-11 08:00AM NEUTS-80.5 LYMPHS-12.4* MONOS-4.6 EOS-2.2\nBASOS-0.3\n1999-4-11 08:00AM PLT COUNT-284\n1901-1-22 03:52AM BLOOD WBC-3.7* RBC-3.78* Hgb-11.8* Hct-35.8\nMCV-95 MCH-31.2 MCHC-33.0 RDW-16.2 Plt Ct-217\n1999-4-11 08:00AM BLOOD PT-23.5* PTT-40.1* INR(PT)-3.7\n1901-1-22 12:15PM BLOOD PT-12.7 PTT-26.8 INR(PT)-1.1\n1999-4-11 08:00AM BLOOD Glucose-138* UreaN-18 Creat-2.7* Na-135\nK-3.3 Cl-100 HCO3-23 AnGap-15\n1901-1-22 03:52AM BLOOD Glucose-109* UreaN-9 Creat-2.', '0* Na-141\nK-3.4 Cl-104 HCO3-28 AnGap-12\n1999-4-11 08:00AM BLOOD ALT-65* AST-36 AlkPhos-506* Amylase-54\nTotBili-0.4\n1901-1-22 03:52AM BLOOD ALT-41* AST-21 AlkPhos-393* Amylase-40\nTotBili-0.3\n1999-4-11 08:00AM BLOOD Lipase-43 GGT-558\n1901-1-22 03:52AM BLOOD Lipase-23\n1901-1-22 03:52AM BLOOD Albumin-3.2 Calcium-8.1* Phos-2.7 Mg-1.6\n1901-1-22 01:28PM BLOOD Type-ART pO2-79* pCO2-56* pH-7.27\ncalHCO3-27 Base XS--1\n1901-1-22 02:40PM BLOOD pO2-55 pCO2-55* pH-7.21* calHCO3-23 Base\nXS--6 1901-1-22 01:28PM BLOOD Lactate-2.6\n\nEKG:\n(2:47 PM) Sinus tachycardia 118 bpm. Nl intervals, nl axis. ST\nsegment depressions in II, III, avF, V3-V6. Poor R wave\nprogression. These changes are new compared to previous EKG\n(7-2).\n\n(16:33 PM)\n\nRadiology:\n RADIOLOGY Final Report ABNORMAL!\n\nLIVER OR GALLBLADDER US (SINGLE ORGAN) 1999-4-11 1:20 PM\n\nLIVER OR GALLBLADDER US (SINGL\n\nReason: RUQ PAIN AND NAUSEA, RO CHOLECYSTITIS\n\nBlake, Scott and Jackson Clinic MEDICAL CONDITION:\n85 year old woman with hx diabetes, renal failure, on tapering\nprednisone for ANCA-positive vasculitis with known gallstone by\nabd CT last month, and intermittent vomiting but no abd pain.', '\nr/o acute cholecystitis or abscess.\nREASON FOR THIS EXAMINATION:\nacute cholecystitis or abscess\nINDICATION: Intermittent vomiting without abdominal pain. Known\ngallstone by abdominal CT last month.\n\nCOMPARISON: CT scan, 2005-8-4, is not available on line for\ncomparison.\n\nFINDINGS: There is a 5-mm gallstone within the gallbladder neck,\nbut there is no evidence of gallbladder wall edema or\npericholecystic fluid to suggest acute cholecystitis.\nAdditionally, a 5-mm flat stone is seen within the common duct,\nbut there is no evidence of ductal dilatation. The common duct\nmeasures 3-4 mm proximally. There is no intrahepatic ductal\ndilatation. The portal vein is open, and flow is hepatopetal.\nThe pancreas appears echogenic, consistent with fatty\ninfiltration. There is no free fluid.\n\nIMPRESSION: Cholelithiasis and choledocholithiasis without\nevidence of acute cholecystitis.', '\nThe study and the report were reviewed by the staff radiologist.\nDR. Zachary JR Loveland\nDR. Retha JR Miller\nApproved: MON 1999-4-11 10:09 PM\n\n RADIOLOGY Preliminary Report\n\nCHEST (PORTABLE AP) 1901-1-22 1:21 PM\n\nCHEST (PORTABLE AP)\n\nReason: ?volume overload\n\nBlake, Scott and Jackson Clinic MEDICAL CONDITION:\n85 year old woman with chf and decreasing sats after FFP\ninfusion\nREASON FOR THIS EXAMINATION:\n?volume overload\nINDICATION: Decreasing oxygen saturation after FFP\nadministration.\n\nCOMPARISON: 1999-4-11.\n\nCHEST, AP PORTABLE RADIOGRAPH: There is stable cardiac\nenlargement. The mediastinal and hilar contours are\nunremarkable. There is bilateral pulmonary vascular\nredistribution, perihilar haziness and interstitial opacities.\nThere is unchanged small left pleural effusion. The right\ninternal jugular central venous catheter is again noted with tip\nin the proximal right atrium.', ' The osseous structures are\nunremarkable.\n\nIMPRESSION: New pulmonary edema.\nDR. An JR Lees\nDR. Keiko BN Ornelas\n\n\nBrief Hospital Course:\n1. Respiratory Failure: On HD#2, the patient developed acute\nrespiratory distress. The patient had recieved IVF in the ED\nthe nigtht before and that monring had recieved 4 units of FFP\nfor planned ERCP, the last two within one hour of respiratory\ndistress. CXR demonstrated acute developement of bilateral\npulmonary infiltrates. Ddx included cardiogenic pulmonary edema\nversus TRALI. The patient was taken for emergent HD; however,\ndepspite succesful diuresis, the patient required intubation for\nrespiratory failure. TRALI work-up is pending at the time of\ndischarge. The patient remained intubated in the MICU and\nsuccesfully extubated on the second attempt.', "\n\n2. Hypotension: After intubation, the patient became hypotensive\nin the MICU requiring initiation of pressors. She was found to\nbe adrenally insufficent by cortisyn stimulation test and\nstarted on stress-dose hydrocortisone and fludircortisone. In\naddition, she required pressors and continued IV Unasyn for\npossible sepsis, though blood cultures were negative. The\npatient's blood pressure improved and stablized.\n\n3. Choledocholithasis: Demonstrated on admission RUQ US on\nadmission without transaminitis but with low-grade fever and\nleft-shift. The patient was evaluted by Surgery and ERCP\nservice. She was started on IV Unasyn. Patient underwent ERCP\nin MICU while intubated, which demonstrated dilated CBD but no\nstones. Patient had spinchterotomy. The patient completed a 10\nday course of IV Unsyn and will be discharged on two days.", "\nConsideration should be given to possible outpatient\ncholecystetomy.\n\n4. GI Bleed: Post-ERCP, the patient dropped Hct and was foudn to\nbe guiac postitive. Patient underwent repeat ERCP which\ndemonstrated spincterotomy bleed. This required epiniephrine\ninjection. Hct remained relatively stable, though she had a\npossible rebleed several days later which stablized without\nrepeat scope. ASA and coumadin were held 1-7 bleed and may be\nsafely restarted on 1993-10-12. The patient's Hct remained stable\nfor the rest of her hospital course. The patient will continue\non her PPI.\n\n5. Coronary Artery Disease: During the patient's MICU stay, EKG\nwas noted to have\npoor R wave progression. An echocardiogram was obtained which\ndemonstrated regional LV dysfunction suggesting CAD. Cardiac\nenzymes demonstrated non-diagnostic elevated Tropnin T, felt\neither secondary to demand or ESRD.", " ASA was held 1-7 GI bleed\nand the patient's beta-blocker was continued. The patient will\nneed an outpatient evaluation of her coronaries, likely with ETT\nMIBI when she is stable. Again, ASA will be started 1993-10-12.\n\n6. ESRD: The patient did well on her hemodilyasis schedule. The\npatient's prednisone was continued for her history of renal\nvascultitis.\n\n7. Hypothryoidism: Patient stable on levothyroxine.\n\nDischarge Medications:\n1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD\n(once a day).\n2. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day:\nTake four tablets on day #1, two tablets on day #2, one tablet\non day #3, then resume 1 mg per day.\nDisp:7 Tablet(s)* Refills:0\n3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:\nOne (1) Tablet, Delayed Release (E.", 'C.) PO twice a day.\n4. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)\nTablet Sustained Release 24HR PO once a day.\n5. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive\nPatch, Medicated Topical QD (once a day).\n6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: 10-25\nPuffs Inhalation Q6H (every 6 hours) as needed.\n7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.\n8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical Gilbert LLC Medical Center\n(2 times a day).\nDisp:1 tube Refills:2\n9. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO once a day\nfor 2 days.\nDisp:2 Tablet(s) Refills:0\n10. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day:\nStart after higher-dose prednisone complete.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nCholedocholithasis\nSpinchterotomy\nUpper GI bleed\nESRD\nCoronary Artery Disease\nDiarrhea\nAnemia\nHypothryoidism\nRespiratory Failure\nDiabetes Mellitus\n\n\nDischarge Condition:\nGood\n\nDischarge Instructions:\n1.', ' Please follow-up with your PCP\n2. Your primary doctor will obtain a medical alert braclet for\nyou, indicating that you have adrenal insufficency.\n3. You will restart your coumadin and start aspirin on Garrett-Fox Medical Center\nafter seeing your PCP.\n\nFollowup Instructions:\nPlease follow-up with Dr. Moore on Londrie, 2-2 at 10:15\n\n\n\nCompleted by:2007-5-27']
237	26601	155131.0	2131-12-29	Discharge summary	Report	Admission Date: [2131-12-23] Discharge Date: [2131-12-29] Service: MEDICINE Allergies: Bactrim / Amiodarone / Quinine / Codeine / Zithromax / Lisinopril / Citalopram / Ciprofloxacin / Hydralazine Attending:[First Name3 (LF) 898] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation PICC line placement Hemodialysis Transfusion of one unit packed red blood cells History of Present Illness: A [Age over 90 ] year-old female with past medical history of chronic obstructive pulmonary disease, Wegener's granulomatosis, recent admission [Date range (1) 2374] for acute on chronic renal failure with decision to initiate hemodialysis at that time and hospital stay complicated by left lower lobe Moraxella pneumonia presenting with altered mental status. Per her daughter, the patient was home this past week and accidentally took trazodone 50 mg two days prior to admission, which had been discontinued due to confusion. Her confusion/visual hallucinations improved the day prior to admission. She complained of increased productive cough and oxygen requirement (previously intermittent 2L NC, now continuous) over the past two days, responding to an increase in nebulizer treatments. The patient was noted to be lethargic this afternoon, responsive to sternal rub. When aroused, she was oriented x 3 and moving all extremities well, however. The patient was noted to be "cold." She has not complained of recent fevers, chills, chest pain, abdominal pain, nausea, vomiting, diarrhea, erythema around line. . In the ED, initial VS T 96, HR 63, BP 77/55, RR 18 SaO2 98% (oxygen not documented). Per report, patient had poor respiratory effort, became apneic, and was subsequently intubated. Chest x-ray showed bilateral effusions and left lower lobe pneumonia. Head CT negative for acute process. A right femoral line was placed for access. She was given etomidate and roccuronium for intubation, vancomycin 1 gm IV x 1, zosyn 4.5 gm IV x 1, 1L NS. The patient was started on levophed for hypotension peri-intubation, off within half an hour. . On arrival to the MICU, she is responsive to tactile stimuli. Past Medical History: - Chronic obstructive pulmonary disease: No pulmonary function testing in our system; currently managed with Duonebs - Wegener's granulomatosis: Complicated by renal failure requiring HD - End-stage renal disease on hemodialysis: Started on hemodialysis last admission, was previously on two years prior - Atrial fibrillation: Rate-controlled; on coumadin - Transient ischemic attack: Occurred during prior hospitalization when her anticoagulation was held - Hard of hearing: Bilateral hearing aids Social History: The patient lives with her daughter. She is able to perform most of her ADLs on her own. 60 py smoking history but quit 20 yrs ago. She has a caretaker/friend who comes to the house to help once a week. Family History: Non-contributory Physical Exam: General Appearance: Well nourished Head, Ears, Nose, Throat: Normocephalic, PERRL Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Rhonchorous: L > R) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent, failed AV fistula in left upper extremity Skin: Warm Neurologic: Responds to: Verbal stimuli, Movement: Non -purposeful, Sedated, Tone: Normal Pertinent Results: Labs on Admission: [2131-12-23] 04:50PM WBC-9.6# RBC-3.22* HGB-8.6* HCT-27.8* MCV-86 MCH-26.6* MCHC-30.8* RDW-15.6* [2131-12-23] 04:50PM NEUTS-73* BANDS-2 LYMPHS-18 MONOS-2 EOS-1 BASOS-0 ATYPS-0 METAS-4* MYELOS-0 [2131-12-23] 04:50PM PLT SMR-NORMAL PLT COUNT-330# [2131-12-23] 04:50PM PT-21.4* PTT-57.4* INR(PT)-2.0* [2131-12-23] 04:50PM GLUCOSE-135* UREA N-45* CREAT-6.3* SODIUM-131* POTASSIUM-5.6* CHLORIDE-94* TOTAL CO2-28 ANION GAP-15 [2131-12-23] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2131-12-23] 09:22PM CK(CPK)-22* [2131-12-23] 09:22PM CK-MB-NotDone cTropnT-0.03* Labs on Discharge: [2131-12-29] 06:07AM BLOOD WBC-6.4 RBC-3.18* Hgb-8.8* Hct-26.9* MCV-85 MCH-27.6 MCHC-32.7 RDW-18.2* Plt Ct-250 [2131-12-29] 06:07AM BLOOD Glucose-139* UreaN-11 Creat-3.5* Na-142 K-3.6 Cl-104 HCO3-30 AnGap-12 MICRO: [2131-12-24] Sputum Culture: MORAXELLA CATARRHALIS. MODERATE GROWTH. Studies: [2131-12-28] CT CHEST: 1. Simple bilateral pleural effusions are moderate on the left and small on the right. No definite underlying consolidation is seen. 2. Recommend three-month followup for right apex lesion with internal calcification, which may represent scarring, although underlying neoplastic process cannot be excluded. 3. Moderate-to-severe coronary artery atherosclerosis is most prominent in the left anterior descending artery. 4. Small pericardial effusion causes no mass effect. 5. Splenic hypodensity is not well characterized and ultrasound may be obtained for evaluation if clinically indicated. 6. Moderate emphysema. [2131-12-23] CXR: Bibasal effusions with a pneumonic consolidation in the left lower lobe. Please ensure followup to clearance. [2131-12-23] CT HEAD: 1. No evidence of acute intracranial hemorrhage. 2. Left frontal encephalomalacia with probable slight further involution. 3. Left maxillary sinus disease. Brief Hospital Course: Mrs. [Known lastname 46] is a [Age over 90 ] yo F with past medical history of COPD, Wegener's granulomatosis with resulting chronic kidney disease, recent admission [Date range (3) 2374] for acute on chronic renal failure, started on hemodialysis w/hospital stay c/b left lower lobe Moraxella pneumonia admitted with recurrant moraxella pneumonia and sepsis. 1)Moraxella pneumonia: Most likely explanation for respiratory failure/hypotension in ED requiring intubation. She was successfully extubated on [12-25] and maintaining O2 sats on O2 via NC without e/o respiratory distress. Her sputum culture from [2131-12-24] is again growing Moraxella, no other new organisms. CXR continues to show same LLL infiltrate concerning for partially treated pneumonia. Concerning for endobronchial lesion with postobstructive pneumonia however chest CT did not show any underlying structural cause for recurrance of pneumonia. She did have bilateral pleural effusions which appeared simple and did not appear to be parapneumonic. She was initially treated with vancomycin and zosyn however this was changed to ceftriaxone once culture data returned with moraxella. She improved daily from a repiratory standpoint and was on minimal to no oxygen on discharge. She was changed to cefpodoxime on discharge to be given only on hemodialysis days, after dialysis as this antibiotic is renally cleared. 2)Altered mental status: Likely delirium in the setting of infection, sedating meds, ICU stay especially in setting of advanced age. In addition, daughter reports that she took trazodone two days prior to admission, which has caused confusion in the past. She had a CT head on admission without acute process. Her mental status cleared during her hospital stay and treatment of pneumonia. 3)Coagulopathy: Her INR was 2 on admission, however climbed to peak of 5.3 likley due to poor nutrition and antibiotics. Her coumadin was stopped [12-25] and held throughout the remainder of her admission. She was restarted on 1mg coumdain on discharge with INR checks with dialysis. Her INR was 2.9 on the day of discharge. 4)Chronic renal failure: Secondary to ANCA vasculitis. Decision made to initiate HD last admission. She was dialysed for volume overload in the hospital and was dishcarged with plan for dialysis at FMC - West Suburban Dialysis Center. She was continued on epogen with dialysis, nephrocaps, calcitriol, calcium. 5)Anemia: Baseline mid-20s as of most recent [12-10] admission; prior to that was in the low 30s. No signs or symptoms of active bleeding, guaiac negative. She was transfused one unit PRBC with dialysis on [12-26] with stable hematocrit around 26 throughout the remainder of her hospitalization. She should be continued on epogen with dialysis. 6)Diarrhea - patient has developed diarrhea in setting of multiple admissions and antibiotics. She had one stool that was negative for C. diff and was started on loperamide to decrease stool output given skin breakdown. She was also advised to eat yogurt three times daily. Diarrhea is most likely antibiotic associated due to alteration of normal bowel flora, however she will require two additional stool samples to rule out C.diff. She will require monitoring of in's and out's and encouragement for oral intake to prevent dehydration. 7)Skin Breakdown: During her admission she began developing skin breakdown on her gluteal cleft likely due to a combination of immobility due to acute illness and diarrhea as discussed above. She will require close monitoring of her skin and frequent personal care to keep her buttocks clean and protected. 8)Paroxysmal Atrial fibrillation: Her metoprolol was initially held in the ICU given sinus bradycardia and sepsis. It was resumed at home dose on [12-26] however given borderline blood pressures, it was decreased to 75mg [Hospital1 ] on [12-27]. 9) Spiculated lesion on CT chest: as discussed in radiology report, will need repeat CT in 3 months to reassess this lesion for stability. 10)Hypothyroidism: Continue levothyroxine 11)Code: Full 12) Comm: [Name (NI) ] [First Name8 (NamePattern2) ] [Name (NI) 46] [Telephone/Fax (1) 2373], daughter/HCP Medications on Admission: Medications: 1. Coumadin 1 mg PO DAILY 2. Nephrocaps 1 mg PO DAILY 3. Metoprolol Tartrate 100 mg PO BID 4. Levothyroxine 125 mcg PO DAILY 5. Fluticasone 50 mcg Spray [1-3] Sprays Nasal [Hospital1 ]:PRN nasal symptoms 6. Albuterol Sulfate Nebulization Q4H:PRN 7. Ipratropium Bromide Inhalation Q6H 8. Pantoprazole 40 mg PO BID 9. Fexofenadine 30 mg PO BID:PRN allergies 10. Calcitriol 0.25 mcg PO DAILY 11. Guaifenesin 100 mg/5 mL Syrup 5-10 MLs PO Q6H:PRN cough 12. Miconazole Nitrate 2 % Powder Appl Topical TID 13. Fluocinolone 0.01 % Cream Topical [Hospital1 ]:PRN eczema 14. Cefpodoxime 200 mg 3x/week for 12 days Discharge Medications: 1. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: please have your INR checked at dialysis and dose adjusted . 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal twice a day as needed for rhinorrhea. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Epoetin Alfa 10,000 unit/mL Solution Sig: according to protocol Injection ASDIR (AS DIRECTED): at dialysis. 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 5 days. 14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO QHD (each hemodialysis): please give only on HD days, please give after HD complete Day 1 =[2131-12-24] Last Day=[2131-1-6]. 16. Outpatient Lab Work Please send stool two stool samples for C.difficile 17. Outpatient Lab Work Please check INR with hemodialysis and adjust coumadin accordingly. Discharge Disposition: Extended Care Facility: st. [Doctor Last Name 2375] manor Discharge Diagnosis: Chronic Kidney disease on hemodialysis Wegener's granulomatosis Paroxysmal atrial fibrillation COPD Non-infectious diarrhea Secondary Diagnoses: Anemia Discharge Condition: fair O2 saturation 95% on 0.5L NC Discharge Instructions: You were admitted to the hospital with confusion, low blood pressure and low oxygen most likely due to a serious pneumonia. You were intubated and sent to the ICU for care. You improved and were able to be extubated the following day. You were treated with antibiotics for pneumonia and your breathing improved. You had blood cultures, urine cultures and stool cultures which did not show any evidence of infection. You had dialysis with fluid removal as you were given a large amount of IV fluids on admission for your infection which caused swelling in your arms and fluid around your lungs. You developed diarrhea during your admission which is most likely due to antibiotics. You were started on loperamide to attempt to decrease the diarrhea and to prevent further skin breakdown. Medications: 1)You will be discharged on cefpodoxime to complete a 2 week course of antibiotics. This should be taken only on dialysis days, after your dialysis. 2)You can take loperamide as needed to decrease your diarrhea. 3)Your coumadin was held during your admission but can be restarted on discharge as your INR was down to 2.9. 4)Your metoprolol was decreased to 75mg twice daily as your blood pressure was borderline low. No other changes were made to your medications. Please follow up as below. Please call your doctor or return to the hospital if you have any concerning symptoms including fevers, confusion, chest pain, trouble breathing, low blood pressure or other worrisome symptoms. Followup Instructions: Provider: [Name10 (NameIs) ],[First Name8 (NamePattern2) 2352] [Last Name (NamePattern1) 2352] - ADULT MEDICINE (SB) Phone:[Telephone/Fax (1) 1144] Date/Time:[2132-1-23] 11:15 . Dialysis: FMC - West Suburban Dialysis Center [Last Name (NamePattern1) 2376]. [Location (un) 47] [Telephone/Fax (1) 2377] Due to the upcoming holiday the pt. will be on special holiday schedule, which will be [Telephone/Fax (1) 766], Wednesday and Saturday at 11:00am. Her confirmed dialysis schedule will be every Tues., Thurs. and Saturday at 11:00am. . Please call the radiology departement at [Telephone/Fax (1) 250] #1 to schedule an appointment for an ultrasound of your left arm. Please call Dr. [Last Name (STitle) 1683] or Dr. [First Name (STitle) 805] after you have this study so they know to look for the results. Please call Dr. [Last Name (STitle) 1683] at [Telephone/Fax (1) 1144] and schedule an appointment to follow up within one to two weeks of discharge. Please discuss with Dr. [Last Name (STitle) 1683] schedule a CT scan of your chest in 3 months to further evaluate a nodule seen on chest CT during your admission. Please call Dr. [First Name (STitle) 805] at [Telephone/Fax (1) 2378] and schedule an appointment to follow up.	Admission Date: <Date>1921-12-10</Date> Discharge Date: <Date>2013-5-15</Date> Service: MEDICINE Allergies: Bactrim / Amiodarone / Quinine / Codeine / Zithromax / Lisinopril / Citalopram / Ciprofloxacin / Hydralazine Attending:<Name>Teressa</Name> Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation PICC line placement Hemodialysis Transfusion of one unit packed red blood cells History of Present Illness: A <Age>72</Age> year-old female with past medical history of chronic obstructive pulmonary disease, Wegener's granulomatosis, recent admission <Date Range>1981-1-2 to 2008-2-14</Date Range> for acute on chronic renal failure with decision to initiate hemodialysis at that time and hospital stay complicated by left lower lobe Moraxella pneumonia presenting with altered mental status. Per her daughter, the patient was home this past week and accidentally took trazodone 50 mg two days prior to admission, which had been discontinued due to confusion. Her confusion/visual hallucinations improved the day prior to admission. She complained of increased productive cough and oxygen requirement (previously intermittent 2L NC, now continuous) over the past two days, responding to an increase in nebulizer treatments. The patient was noted to be lethargic this afternoon, responsive to sternal rub. When aroused, she was oriented x 3 and moving all extremities well, however. The patient was noted to be "cold." She has not complained of recent fevers, chills, chest pain, abdominal pain, nausea, vomiting, diarrhea, erythema around line. . In the ED, initial VS T 96, HR 63, BP 77/55, RR 18 SaO2 98% (oxygen not documented). Per report, patient had poor respiratory effort, became apneic, and was subsequently intubated. Chest x-ray showed bilateral effusions and left lower lobe pneumonia. Head CT negative for acute process. A right femoral line was placed for access. She was given etomidate and roccuronium for intubation, vancomycin 1 gm IV x 1, zosyn 4.5 gm IV x 1, 1L NS. The patient was started on levophed for hypotension peri-intubation, off within half an hour. . On arrival to the MICU, she is responsive to tactile stimuli. Past Medical History: - Chronic obstructive pulmonary disease: No pulmonary function testing in our system; currently managed with Duonebs - Wegener's granulomatosis: Complicated by renal failure requiring HD - End-stage renal disease on hemodialysis: Started on hemodialysis last admission, was previously on two years prior - Atrial fibrillation: Rate-controlled; on coumadin - Transient ischemic attack: Occurred during prior hospitalization when her anticoagulation was held - Hard of hearing: Bilateral hearing aids Social History: The patient lives with her daughter. She is able to perform most of her ADLs on her own. 60 py smoking history but quit 20 yrs ago. She has a caretaker/friend who comes to the house to help once a week. Family History: Non-contributory Physical Exam: General Appearance: Well nourished Head, Ears, Nose, Throat: Normocephalic, PERRL Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Rhonchorous: L > R) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent, failed AV fistula in left upper extremity Skin: Warm Neurologic: Responds to: Verbal stimuli, Movement: Non -purposeful, Sedated, Tone: Normal Pertinent Results: Labs on Admission: <Date>1921-12-10</Date> 04:50PM WBC-9.6# RBC-3.22* HGB-8.6* HCT-27.8* MCV-86 MCH-26.6* MCHC-30.8* RDW-15.6* <Date>1921-12-10</Date> 04:50PM NEUTS-73* BANDS-2 LYMPHS-18 MONOS-2 EOS-1 BASOS-0 ATYPS-0 METAS-4* MYELOS-0 <Date>1921-12-10</Date> 04:50PM PLT SMR-NORMAL PLT COUNT-330# <Date>1921-12-10</Date> 04:50PM PT-21.4* PTT-57.4* INR(PT)-2.0* <Date>1921-12-10</Date> 04:50PM GLUCOSE-135* UREA N-45* CREAT-6.3* SODIUM-131* POTASSIUM-5.6* CHLORIDE-94* TOTAL CO2-28 ANION GAP-15 <Date>1921-12-10</Date> 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR <Date>1921-12-10</Date> 09:22PM CK(CPK)-22* <Date>1921-12-10</Date> 09:22PM CK-MB-NotDone cTropnT-0.03* Labs on Discharge: <Date>2013-5-15</Date> 06:07AM BLOOD WBC-6.4 RBC-3.18* Hgb-8.8* Hct-26.9* MCV-85 MCH-27.6 MCHC-32.7 RDW-18.2* Plt Ct-250 <Date>2013-5-15</Date> 06:07AM BLOOD Glucose-139* UreaN-11 Creat-3.5* Na-142 K-3.6 Cl-104 HCO3-30 AnGap-12 MICRO: <Date>1997-8-30</Date> Sputum Culture: MORAXELLA CATARRHALIS. MODERATE GROWTH. Studies: <Date>1933-3-18</Date> CT CHEST: 1. Simple bilateral pleural effusions are moderate on the left and small on the right. No definite underlying consolidation is seen. 2. Recommend three-month followup for right apex lesion with internal calcification, which may represent scarring, although underlying neoplastic process cannot be excluded. 3. Moderate-to-severe coronary artery atherosclerosis is most prominent in the left anterior descending artery. 4. Small pericardial effusion causes no mass effect. 5. Splenic hypodensity is not well characterized and ultrasound may be obtained for evaluation if clinically indicated. 6. Moderate emphysema. <Date>1921-12-10</Date> CXR: Bibasal effusions with a pneumonic consolidation in the left lower lobe. Please ensure followup to clearance. <Date>1921-12-10</Date> CT HEAD: 1. No evidence of acute intracranial hemorrhage. 2. Left frontal encephalomalacia with probable slight further involution. 3. Left maxillary sinus disease. Brief Hospital Course: Mrs. <Name>Londrie</Name> is a <Age>72</Age> yo F with past medical history of COPD, Wegener's granulomatosis with resulting chronic kidney disease, recent admission <Date Range>1959-3-10 to 2021-9-4</Date Range> for acute on chronic renal failure, started on hemodialysis w/hospital stay c/b left lower lobe Moraxella pneumonia admitted with recurrant moraxella pneumonia and sepsis. 1)Moraxella pneumonia: Most likely explanation for respiratory failure/hypotension in ED requiring intubation. She was successfully extubated on <Date>2-30</Date> and maintaining O2 sats on O2 via NC without e/o respiratory distress. Her sputum culture from <Date>1997-8-30</Date> is again growing Moraxella, no other new organisms. CXR continues to show same LLL infiltrate concerning for partially treated pneumonia. Concerning for endobronchial lesion with postobstructive pneumonia however chest CT did not show any underlying structural cause for recurrance of pneumonia. She did have bilateral pleural effusions which appeared simple and did not appear to be parapneumonic. She was initially treated with vancomycin and zosyn however this was changed to ceftriaxone once culture data returned with moraxella. She improved daily from a repiratory standpoint and was on minimal to no oxygen on discharge. She was changed to cefpodoxime on discharge to be given only on hemodialysis days, after dialysis as this antibiotic is renally cleared. 2)Altered mental status: Likely delirium in the setting of infection, sedating meds, ICU stay especially in setting of advanced age. In addition, daughter reports that she took trazodone two days prior to admission, which has caused confusion in the past. She had a CT head on admission without acute process. Her mental status cleared during her hospital stay and treatment of pneumonia. 3)Coagulopathy: Her INR was 2 on admission, however climbed to peak of 5.3 likley due to poor nutrition and antibiotics. Her coumadin was stopped <Date>2-30</Date> and held throughout the remainder of her admission. She was restarted on 1mg coumdain on discharge with INR checks with dialysis. Her INR was 2.9 on the day of discharge. 4)Chronic renal failure: Secondary to ANCA vasculitis. Decision made to initiate HD last admission. She was dialysed for volume overload in the hospital and was dishcarged with plan for dialysis at FMC - West Suburban Dialysis Center. She was continued on epogen with dialysis, nephrocaps, calcitriol, calcium. 5)Anemia: Baseline mid-20s as of most recent <Date>2-23</Date> admission; prior to that was in the low 30s. No signs or symptoms of active bleeding, guaiac negative. She was transfused one unit PRBC with dialysis on <Date>9-6</Date> with stable hematocrit around 26 throughout the remainder of her hospitalization. She should be continued on epogen with dialysis. 6)Diarrhea - patient has developed diarrhea in setting of multiple admissions and antibiotics. She had one stool that was negative for C. diff and was started on loperamide to decrease stool output given skin breakdown. She was also advised to eat yogurt three times daily. Diarrhea is most likely antibiotic associated due to alteration of normal bowel flora, however she will require two additional stool samples to rule out C.diff. She will require monitoring of in's and out's and encouragement for oral intake to prevent dehydration. 7)Skin Breakdown: During her admission she began developing skin breakdown on her gluteal cleft likely due to a combination of immobility due to acute illness and diarrhea as discussed above. She will require close monitoring of her skin and frequent personal care to keep her buttocks clean and protected. 8)Paroxysmal Atrial fibrillation: Her metoprolol was initially held in the ICU given sinus bradycardia and sepsis. It was resumed at home dose on <Date>9-6</Date> however given borderline blood pressures, it was decreased to 75mg <Hospital>Francis, Murray and Williamson Hospital</Hospital> on <Date>7-6</Date>. 9) Spiculated lesion on CT chest: as discussed in radiology report, will need repeat CT in 3 months to reassess this lesion for stability. 10)Hypothyroidism: Continue levothyroxine 11)Code: Full 12) Comm: <Name>Kamran Wilson</Name> <Name>Jacob</Name> <Name>Diane Waldon</Name> <Telephone>150-966-1961</Telephone>, daughter/HCP Medications on Admission: Medications: 1. Coumadin 1 mg PO DAILY 2. Nephrocaps 1 mg PO DAILY 3. Metoprolol Tartrate 100 mg PO BID 4. Levothyroxine 125 mcg PO DAILY 5. Fluticasone 50 mcg Spray <Date>10-13</Date> Sprays Nasal <Hospital>Francis, Murray and Williamson Hospital</Hospital>:PRN nasal symptoms 6. Albuterol Sulfate Nebulization Q4H:PRN 7. Ipratropium Bromide Inhalation Q6H 8. Pantoprazole 40 mg PO BID 9. Fexofenadine 30 mg PO BID:PRN allergies 10. Calcitriol 0.25 mcg PO DAILY 11. Guaifenesin 100 mg/5 mL Syrup 5-10 MLs PO Q6H:PRN cough 12. Miconazole Nitrate 2 % Powder Appl Topical TID 13. Fluocinolone 0.01 % Cream Topical <Hospital>Francis, Murray and Williamson Hospital</Hospital>:PRN eczema 14. Cefpodoxime 200 mg 3x/week for 12 days Discharge Medications: 1. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: please have your INR checked at dialysis and dose adjusted . 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal twice a day as needed for rhinorrhea. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Epoetin Alfa 10,000 unit/mL Solution Sig: according to protocol Injection ASDIR (AS DIRECTED): at dialysis. 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 5 days. 14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical <Hospital>Francis, Murray and Williamson Hospital</Hospital> (2 times a day). 15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO QHD (each hemodialysis): please give only on HD days, please give after HD complete Day 1 =<Date>1997-8-30</Date> Last Day=<Date>1947-1-7</Date>. 16. Outpatient Lab Work Please send stool two stool samples for C.difficile 17. Outpatient Lab Work Please check INR with hemodialysis and adjust coumadin accordingly. Discharge Disposition: Extended Care Facility: st. <Doctor Name>Dr.Recinos</Doctor Name> manor Discharge Diagnosis: Chronic Kidney disease on hemodialysis Wegener's granulomatosis Paroxysmal atrial fibrillation COPD Non-infectious diarrhea Secondary Diagnoses: Anemia Discharge Condition: fair O2 saturation 95% on 0.5L NC Discharge Instructions: You were admitted to the hospital with confusion, low blood pressure and low oxygen most likely due to a serious pneumonia. You were intubated and sent to the ICU for care. You improved and were able to be extubated the following day. You were treated with antibiotics for pneumonia and your breathing improved. You had blood cultures, urine cultures and stool cultures which did not show any evidence of infection. You had dialysis with fluid removal as you were given a large amount of IV fluids on admission for your infection which caused swelling in your arms and fluid around your lungs. You developed diarrhea during your admission which is most likely due to antibiotics. You were started on loperamide to attempt to decrease the diarrhea and to prevent further skin breakdown. Medications: 1)You will be discharged on cefpodoxime to complete a 2 week course of antibiotics. This should be taken only on dialysis days, after your dialysis. 2)You can take loperamide as needed to decrease your diarrhea. 3)Your coumadin was held during your admission but can be restarted on discharge as your INR was down to 2.9. 4)Your metoprolol was decreased to 75mg twice daily as your blood pressure was borderline low. No other changes were made to your medications. Please follow up as below. Please call your doctor or return to the hospital if you have any concerning symptoms including fevers, confusion, chest pain, trouble breathing, low blood pressure or other worrisome symptoms. Followup Instructions: Provider: <Name>Karthik Dizon</Name>,<Name>Stacey</Name> <Name>Caro</Name> - ADULT MEDICINE (SB) Phone:<Telephone>137-276-6047</Telephone> Date/Time:<Date>2009-3-18</Date> 11:15 . Dialysis: FMC - West Suburban Dialysis Center <Name>Harris</Name>. <Location>8127 Wright Pines Suite 366 Chavezburgh, ID 07275</Location> <Telephone>827-872-2868</Telephone> Due to the upcoming holiday the pt. will be on special holiday schedule, which will be <Telephone>256-351-4048</Telephone>, Wednesday and Saturday at 11:00am. Her confirmed dialysis schedule will be every Tues., Thurs. and Saturday at 11:00am. . Please call the radiology departement at <Telephone>680-344-3253</Telephone> #1 to schedule an appointment for an ultrasound of your left arm. Please call Dr. <Name>Poff</Name> or Dr. <Name>Kathi</Name> after you have this study so they know to look for the results. Please call Dr. <Name>Poff</Name> at <Telephone>137-276-6047</Telephone> and schedule an appointment to follow up within one to two weeks of discharge. Please discuss with Dr. <Name>Poff</Name> schedule a CT scan of your chest in 3 months to further evaluate a nodule seen on chest CT during your admission. Please call Dr. <Name>Kathi</Name> at <Telephone>978-191-9385</Telephone> and schedule an appointment to follow 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Date: 1921-12-10 Discharge Date: 2013-5-15 Service: MEDICINE Allergies: Bactrim / Amiodarone / Quinine / Codeine / Zithromax / Lisinopril / Citalopram / Ciprofloxacin / Hydralazine Attending:Teressa Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation PICC line placement Hemodialysis Transfusion of one unit packed red blood cells History of Present Illness: A 72 year-old female with past medical history of chronic obstructive pulmonary disease, Wegener's granulomatosis, recent admission 1981-1-2 to 2008-2-14 for acute on chronic renal failure with decision to initiate hemodialysis at that time and hospital stay complicated by left lower lobe Moraxella pneumonia presenting with altered mental status. Per her daughter, the patient was home this past week and accidentally took trazodone 50 mg two days prior to admission, which had been discontinued due to confusion. Her confusion/visual hallucinations improved the day prior to admission. She complained of increased productive cough and oxygen requirement (previously intermittent 2L NC, now continuous) over the past two days, responding to an increase in nebulizer treatments. The patient was noted to be lethargic this afternoon, responsive to sternal rub. When aroused, she was oriented x 3 and moving all extremities well, however. The patient was noted to be "cold." She has not complained of recent fevers, chills, chest pain, abdominal pain, nausea, vomiting, diarrhea, erythema around line. . In the ED, initial VS T 96, HR 63, BP 77/55, RR 18 SaO2 98% (oxygen not documented). Per report, patient had poor respiratory effort, became apneic, and was subsequently intubated. Chest x-ray showed bilateral effusions and left lower lobe pneumonia. Head CT negative for acute process. A right femoral line was placed for access. She was given etomidate and roccuronium for intubation, vancomycin 1 gm IV x 1, zosyn 4.5 gm IV x 1, 1L NS. The patient was started on levophed for hypotension peri-intubation, off within half an hour. . On arrival to the MICU, she is responsive to tactile stimuli. Past Medical History: - Chronic obstructive pulmonary disease: No pulmonary function testing in our system; currently managed with Duonebs - Wegener's granulomatosis: Complicated by renal failure requiring HD - End-stage renal disease on hemodialysis: Started on hemodialysis last admission, was previously on two years prior - Atrial fibrillation: Rate-controlled; on coumadin - Transient ischemic attack: Occurred during prior hospitalization when her anticoagulation was held - Hard of hearing: Bilateral hearing aids Social History: The patient lives with her daughter. She is able to perform most of her ADLs on her own. 60 py smoking history but quit 20 yrs ago. She has a caretaker/friend who comes to the house to help once a week. Family History: Non-contributory Physical Exam: General Appearance: Well nourished Head, Ears, Nose, Throat: Normocephalic, PERRL Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Rhonchorous: L > R) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent, failed AV fistula in left upper extremity Skin: Warm Neurologic: Responds to: Verbal stimuli, Movement: Non -purposeful, Sedated, Tone: Normal Pertinent Results: Labs on Admission: 1921-12-10 04:50PM WBC-9.6# RBC-3.22* HGB-8.6* HCT-27.8* MCV-86 MCH-26.6* MCHC-30.8* RDW-15.6* 1921-12-10 04:50PM NEUTS-73* BANDS-2 LYMPHS-18 MONOS-2 EOS-1 BASOS-0 ATYPS-0 METAS-4* MYELOS-0 1921-12-10 04:50PM PLT SMR-NORMAL PLT COUNT-330# 1921-12-10 04:50PM PT-21.4* PTT-57.4* INR(PT)-2.0* 1921-12-10 04:50PM GLUCOSE-135* UREA N-45* CREAT-6.3* SODIUM-131* POTASSIUM-5.6* CHLORIDE-94* TOTAL CO2-28 ANION GAP-15 1921-12-10 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR 1921-12-10 09:22PM CK(CPK)-22* 1921-12-10 09:22PM CK-MB-NotDone cTropnT-0.03* Labs on Discharge: 2013-5-15 06:07AM BLOOD WBC-6.4 RBC-3.18* Hgb-8.8* Hct-26.9* MCV-85 MCH-27.6 MCHC-32.7 RDW-18.2* Plt Ct-250 2013-5-15 06:07AM BLOOD Glucose-139* UreaN-11 Creat-3.5* Na-142 K-3.6 Cl-104 HCO3-30 AnGap-12 MICRO: 1997-8-30 Sputum Culture: MORAXELLA CATARRHALIS. MODERATE GROWTH. Studies: 1933-3-18 CT CHEST: 1. Simple bilateral pleural effusions are moderate on the left and small on the right. No definite underlying consolidation is seen. 2. Recommend three-month followup for right apex lesion with internal calcification, which may represent scarring, although underlying neoplastic process cannot be excluded. 3. Moderate-to-severe coronary artery atherosclerosis is most prominent in the left anterior descending artery. 4. Small pericardial effusion causes no mass effect. 5. Splenic hypodensity is not well characterized and ultrasound may be obtained for evaluation if clinically indicated. 6. Moderate emphysema. 1921-12-10 CXR: Bibasal effusions with a pneumonic consolidation in the left lower lobe. Please ensure followup to clearance. 1921-12-10 CT HEAD: 1. No evidence of acute intracranial hemorrhage. 2. Left frontal encephalomalacia with probable slight further involution. 3. Left maxillary sinus disease. Brief Hospital Course: Mrs. Londrie is a 72 yo F with past medical history of COPD, Wegener's granulomatosis with resulting chronic kidney disease, recent admission 1959-3-10 to 2021-9-4 for acute on chronic renal failure, started on hemodialysis w/hospital stay c/b left lower lobe Moraxella pneumonia admitted with recurrant moraxella pneumonia and sepsis. 1)Moraxella pneumonia: Most likely explanation for respiratory failure/hypotension in ED requiring intubation. She was successfully extubated on 2-30 and maintaining O2 sats on O2 via NC without e/o respiratory distress. Her sputum culture from 1997-8-30 is again growing Moraxella, no other new organisms. CXR continues to show same LLL infiltrate concerning for partially treated pneumonia. Concerning for endobronchial lesion with postobstructive pneumonia however chest CT did not show any underlying structural cause for recurrance of pneumonia. She did have bilateral pleural effusions which appeared simple and did not appear to be parapneumonic. She was initially treated with vancomycin and zosyn however this was changed to ceftriaxone once culture data returned with moraxella. She improved daily from a repiratory standpoint and was on minimal to no oxygen on discharge. She was changed to cefpodoxime on discharge to be given only on hemodialysis days, after dialysis as this antibiotic is renally cleared. 2)Altered mental status: Likely delirium in the setting of infection, sedating meds, ICU stay especially in setting of advanced age. In addition, daughter reports that she took trazodone two days prior to admission, which has caused confusion in the past. She had a CT head on admission without acute process. Her mental status cleared during her hospital stay and treatment of pneumonia. 3)Coagulopathy: Her INR was 2 on admission, however climbed to peak of 5.3 likley due to poor nutrition and antibiotics. Her coumadin was stopped 2-30 and held throughout the remainder of her admission. She was restarted on 1mg coumdain on discharge with INR checks with dialysis. Her INR was 2.9 on the day of discharge. 4)Chronic renal failure: Secondary to ANCA vasculitis. Decision made to initiate HD last admission. She was dialysed for volume overload in the hospital and was dishcarged with plan for dialysis at FMC - West Suburban Dialysis Center. She was continued on epogen with dialysis, nephrocaps, calcitriol, calcium. 5)Anemia: Baseline mid-20s as of most recent 2-23 admission; prior to that was in the low 30s. No signs or symptoms of active bleeding, guaiac negative. She was transfused one unit PRBC with dialysis on 9-6 with stable hematocrit around 26 throughout the remainder of her hospitalization. She should be continued on epogen with dialysis. 6)Diarrhea - patient has developed diarrhea in setting of multiple admissions and antibiotics. She had one stool that was negative for C. diff and was started on loperamide to decrease stool output given skin breakdown. She was also advised to eat yogurt three times daily. Diarrhea is most likely antibiotic associated due to alteration of normal bowel flora, however she will require two additional stool samples to rule out C.diff. She will require monitoring of in's and out's and encouragement for oral intake to prevent dehydration. 7)Skin Breakdown: During her admission she began developing skin breakdown on her gluteal cleft likely due to a combination of immobility due to acute illness and diarrhea as discussed above. She will require close monitoring of her skin and frequent personal care to keep her buttocks clean and protected. 8)Paroxysmal Atrial fibrillation: Her metoprolol was initially held in the ICU given sinus bradycardia and sepsis. It was resumed at home dose on 9-6 however given borderline blood pressures, it was decreased to 75mg Francis, Murray and Williamson Hospital on 7-6. 9) Spiculated lesion on CT chest: as discussed in radiology report, will need repeat CT in 3 months to reassess this lesion for stability. 10)Hypothyroidism: Continue levothyroxine 11)Code: Full 12) Comm: Kamran Wilson Jacob Diane Waldon 150-966-1961, daughter/HCP Medications on Admission: Medications: 1. Coumadin 1 mg PO DAILY 2. Nephrocaps 1 mg PO DAILY 3. Metoprolol Tartrate 100 mg PO BID 4. Levothyroxine 125 mcg PO DAILY 5. Fluticasone 50 mcg Spray 10-13 Sprays Nasal Francis, Murray and Williamson Hospital:PRN nasal symptoms 6. Albuterol Sulfate Nebulization Q4H:PRN 7. Ipratropium Bromide Inhalation Q6H 8. Pantoprazole 40 mg PO BID 9. Fexofenadine 30 mg PO BID:PRN allergies 10. Calcitriol 0.25 mcg PO DAILY 11. Guaifenesin 100 mg/5 mL Syrup 5-10 MLs PO Q6H:PRN cough 12. Miconazole Nitrate 2 % Powder Appl Topical TID 13. Fluocinolone 0.01 % Cream Topical Francis, Murray and Williamson Hospital:PRN eczema 14. Cefpodoxime 200 mg 3x/week for 12 days Discharge Medications: 1. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: please have your INR checked at dialysis and dose adjusted . 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal twice a day as needed for rhinorrhea. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Epoetin Alfa 10,000 unit/mL Solution Sig: according to protocol Injection ASDIR (AS DIRECTED): at dialysis. 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 5 days. 14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical Francis, Murray and Williamson Hospital (2 times a day). 15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO QHD (each hemodialysis): please give only on HD days, please give after HD complete Day 1 =1997-8-30 Last Day=1947-1-7. 16. Outpatient Lab Work Please send stool two stool samples for C.difficile 17. Outpatient Lab Work Please check INR with hemodialysis and adjust coumadin accordingly. Discharge Disposition: Extended Care Facility: st. Dr.Recinos manor Discharge Diagnosis: Chronic Kidney disease on hemodialysis Wegener's granulomatosis Paroxysmal atrial fibrillation COPD Non-infectious diarrhea Secondary Diagnoses: Anemia Discharge Condition: fair O2 saturation 95% on 0.5L NC Discharge Instructions: You were admitted to the hospital with confusion, low blood pressure and low oxygen most likely due to a serious pneumonia. You were intubated and sent to the ICU for care. You improved and were able to be extubated the following day. You were treated with antibiotics for pneumonia and your breathing improved. You had blood cultures, urine cultures and stool cultures which did not show any evidence of infection. You had dialysis with fluid removal as you were given a large amount of IV fluids on admission for your infection which caused swelling in your arms and fluid around your lungs. You developed diarrhea during your admission which is most likely due to antibiotics. You were started on loperamide to attempt to decrease the diarrhea and to prevent further skin breakdown. Medications: 1)You will be discharged on cefpodoxime to complete a 2 week course of antibiotics. This should be taken only on dialysis days, after your dialysis. 2)You can take loperamide as needed to decrease your diarrhea. 3)Your coumadin was held during your admission but can be restarted on discharge as your INR was down to 2.9. 4)Your metoprolol was decreased to 75mg twice daily as your blood pressure was borderline low. No other changes were made to your medications. Please follow up as below. Please call your doctor or return to the hospital if you have any concerning symptoms including fevers, confusion, chest pain, trouble breathing, low blood pressure or other worrisome symptoms. Followup Instructions: Provider: Karthik Dizon,Stacey Caro - ADULT MEDICINE (SB) Phone:137-276-6047 Date/Time:2009-3-18 11:15 . Dialysis: FMC - West Suburban Dialysis Center Harris. 8127 Wright Pines Suite 366 Chavezburgh, ID 07275 827-872-2868 Due to the upcoming holiday the pt. will be on special holiday schedule, which will be 256-351-4048, Wednesday and Saturday at 11:00am. Her confirmed dialysis schedule will be every Tues., Thurs. and Saturday at 11:00am. . Please call the radiology departement at 680-344-3253 #1 to schedule an appointment for an ultrasound of your left arm. Please call Dr. Poff or Dr. Kathi after you have this study so they know to look for the results. Please call Dr. Poff at 137-276-6047 and schedule an appointment to follow up within one to two weeks of discharge. Please discuss with Dr. Poff schedule a CT scan of your chest in 3 months to further evaluate a nodule seen on chest CT during your admission. Please call Dr. Kathi at 978-191-9385 and schedule an appointment to follow up.	["Admission Date: 1921-12-10 Discharge Date: 2013-5-15\n\n\nService: MEDICINE\n\nAllergies:\nBactrim / Amiodarone / Quinine / Codeine / Zithromax /\nLisinopril / Citalopram / Ciprofloxacin / Hydralazine\n\nAttending:Teressa\nChief Complaint:\nAltered mental status\n\nMajor Surgical or Invasive Procedure:\nIntubation\nPICC line placement\nHemodialysis\nTransfusion of one unit packed red blood cells\n\n\nHistory of Present Illness:\nA 72 year-old female with past medical history of chronic\nobstructive pulmonary disease, Wegener's granulomatosis, recent\nadmission 1981-1-2 to 2008-2-14 for acute on chronic renal failure\nwith decision to initiate hemodialysis at that time and hospital\nstay complicated by left lower lobe Moraxella pneumonia\npresenting with altered mental status. Per her daughter, the\npatient was home this past week and accidentally took trazodone\n50 mg two days prior to admission, which had been discontinued\ndue to confusion.", ' Her confusion/visual hallucinations improved\nthe day prior to admission. She complained of increased\nproductive cough and oxygen requirement (previously intermittent\n2L NC, now continuous) over the past two days, responding to an\nincrease in nebulizer treatments. The patient was noted to be\nlethargic this afternoon, responsive to sternal rub. When\naroused, she was oriented x 3 and moving all extremities well,\nhowever. The patient was noted to be "cold." She has not\ncomplained of recent fevers, chills, chest pain, abdominal pain,\nnausea, vomiting, diarrhea, erythema around line.\n.\nIn the ED, initial VS T 96, HR 63, BP 77/55, RR 18 SaO2 98%\n(oxygen not documented). Per report, patient had poor\nrespiratory effort, became apneic, and was subsequently\nintubated. Chest x-ray showed bilateral effusions and left\nlower lobe pneumonia.', " Head CT negative for acute process. A\nright femoral line was placed for access. She was given\netomidate and roccuronium for intubation, vancomycin 1 gm IV x\n1, zosyn 4.5 gm IV x 1, 1L NS. The patient was started on\nlevophed for hypotension peri-intubation, off within half an\nhour.\n.\nOn arrival to the MICU, she is responsive to tactile stimuli.\n\nPast Medical History:\n- Chronic obstructive pulmonary disease: No pulmonary function\ntesting in our system; currently managed with Duonebs\n- Wegener's granulomatosis: Complicated by renal failure\nrequiring HD\n- End-stage renal disease on hemodialysis: Started on\nhemodialysis last admission, was previously on two years prior\n- Atrial fibrillation: Rate-controlled; on coumadin\n- Transient ischemic attack: Occurred during prior\nhospitalization when her anticoagulation was held\n- Hard of hearing: Bilateral hearing aids\n\nSocial History:\nThe patient lives with her daughter.", ' She is able to perform\nmost of her ADLs on her own. 60 py smoking history but quit 20\nyrs ago. She has a caretaker/friend who comes to the house to\nhelp once a week.\n\n\nFamily History:\nNon-contributory\n\nPhysical Exam:\nGeneral Appearance: Well nourished\n\nHead, Ears, Nose, Throat: Normocephalic, PERRL\n\nLymphatic: Cervical WNL\n\nCardiovascular: (S1: Normal), (S2: Normal)\n\nPeripheral Vascular: (Right radial pulse: Present), (Left radial\npulse: Present), (Right DP pulse: Present), (Left DP pulse:\nPresent)\n\nRespiratory / Chest: (Breath Sounds: Rhonchorous: L > R)\n\nAbdominal: Soft, Non-tender, Bowel sounds present\n\nExtremities: Right: Absent, Left: Absent, failed AV fistula in\nleft upper extremity\n\nSkin: Warm\n\nNeurologic: Responds to: Verbal stimuli, Movement: Non\n-purposeful, Sedated, Tone: Normal\n\nPertinent Results:\nLabs on Admission:\n1921-12-10 04:50PM WBC-9.', '6# RBC-3.22* HGB-8.6* HCT-27.8* MCV-86\nMCH-26.6* MCHC-30.8* RDW-15.6\n1921-12-10 04:50PM NEUTS-73 BANDS-2 LYMPHS-18 MONOS-2 EOS-1\nBASOS-0 ATYPS-0 METAS-4* MYELOS-0\n1921-12-10 04:50PM PLT SMR-NORMAL PLT COUNT-330#\n1921-12-10 04:50PM PT-21.4* PTT-57.4* INR(PT)-2.0\n1921-12-10 04:50PM GLUCOSE-135 UREA N-45* CREAT-6.3\nSODIUM-131 POTASSIUM-5.6* CHLORIDE-94* TOTAL CO2-28 ANION\nGAP-15\n1921-12-10 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500\nGLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR\n1921-12-10 09:22PM CK(CPK)-22\n1921-12-10 09:22PM CK-MB-NotDone cTropnT-0.03\n\nLabs on Discharge:\n2013-5-15 06:07AM BLOOD WBC-6.4 RBC-3.18* Hgb-8.8* Hct-26.9\nMCV-85 MCH-27.6 MCHC-32.7 RDW-18.2 Plt Ct-250\n2013-5-15 06:07AM BLOOD Glucose-139* UreaN-11 Creat-3.5* Na-142\nK-3.6 Cl-104 HCO3-30 AnGap-12\n\nMICRO:\n1997-8-30 Sputum Culture: MORAXELLA CATARRHALIS.', ' MODERATE\nGROWTH.\n\nStudies:\n1933-3-18 CT CHEST:\n1. Simple bilateral pleural effusions are moderate on the left\nand small on the right. No definite underlying consolidation is\nseen.\n2. Recommend three-month followup for right apex lesion with\ninternal\ncalcification, which may represent scarring, although underlying\nneoplastic process cannot be excluded.\n3. Moderate-to-severe coronary artery atherosclerosis is most\nprominent in\nthe left anterior descending artery.\n4. Small pericardial effusion causes no mass effect.\n5. Splenic hypodensity is not well characterized and ultrasound\nmay be\nobtained for evaluation if clinically indicated.\n6. Moderate emphysema.\n\n1921-12-10 CXR: Bibasal effusions with a pneumonic consolidation\nin the left lower lobe. Please ensure followup to clearance.\n\n1921-12-10 CT HEAD:\n1.', " No evidence of acute intracranial hemorrhage.\n2. Left frontal encephalomalacia with probable slight further\ninvolution.\n3. Left maxillary sinus disease.\n\n\nBrief Hospital Course:\nMrs. Londrie is a 72 yo F with past medical history of COPD,\nWegener's granulomatosis with resulting chronic kidney disease,\nrecent admission 1959-3-10 to 2021-9-4 for acute on chronic renal\nfailure, started on hemodialysis w/hospital stay c/b left lower\nlobe Moraxella pneumonia admitted with recurrant moraxella\npneumonia and sepsis.\n\n1)Moraxella pneumonia: Most likely explanation for respiratory\nfailure/hypotension in ED requiring intubation. She was\nsuccessfully extubated on 2-30 and maintaining O2 sats on O2\nvia NC without e/o respiratory distress. Her sputum culture\nfrom 1997-8-30 is again growing Moraxella, no other new\norganisms.", ' CXR continues to show same LLL infiltrate concerning\nfor partially treated pneumonia. Concerning for endobronchial\nlesion with postobstructive pneumonia however chest CT did not\nshow any underlying structural cause for recurrance of\npneumonia. She did have bilateral pleural effusions which\nappeared simple and did not appear to be parapneumonic. She was\ninitially treated with vancomycin and zosyn however this was\nchanged to ceftriaxone once culture data returned with\nmoraxella. She improved daily from a repiratory standpoint and\nwas on minimal to no oxygen on discharge. She was changed to\ncefpodoxime on discharge to be given only on hemodialysis days,\nafter dialysis as this antibiotic is renally cleared.\n\n2)Altered mental status: Likely delirium in the setting of\ninfection, sedating meds, ICU stay especially in setting of\nadvanced age.', ' In addition, daughter reports that she took\ntrazodone two days prior to admission, which has caused\nconfusion in the past. She had a CT head on admission without\nacute process. Her mental status cleared during her hospital\nstay and treatment of pneumonia.\n\n3)Coagulopathy: Her INR was 2 on admission, however climbed to\npeak of 5.3 likley due to poor nutrition and antibiotics. Her\ncoumadin was stopped 2-30 and held throughout the remainder of\nher admission. She was restarted on 1mg coumdain on discharge\nwith INR checks with dialysis. Her INR was 2.9 on the day of\ndischarge.\n\n4)Chronic renal failure: Secondary to ANCA vasculitis. Decision\nmade to initiate HD last admission. She was dialysed for volume\noverload in the hospital and was dishcarged with plan for\ndialysis at FMC - West Suburban Dialysis Center.', ' She was\ncontinued on epogen with dialysis, nephrocaps, calcitriol,\ncalcium.\n\n5)Anemia: Baseline mid-20s as of most recent 2-23 admission;\nprior to that was in the low 30s. No signs or symptoms of active\nbleeding, guaiac negative. She was transfused one unit PRBC\nwith dialysis on 9-6 with stable hematocrit around 26\nthroughout the remainder of her hospitalization. She should be\ncontinued on epogen with dialysis.\n\n6)Diarrhea - patient has developed diarrhea in setting of\nmultiple admissions and antibiotics. She had one stool that was\nnegative for C. diff and was started on loperamide to decrease\nstool output given skin breakdown. She was also advised to eat\nyogurt three times daily. Diarrhea is most likely antibiotic\nassociated due to alteration of normal bowel flora, however she\nwill require two additional stool samples to rule out C.', "diff.\nShe will require monitoring of in's and out's and encouragement\nfor oral intake to prevent dehydration.\n\n7)Skin Breakdown: During her admission she began developing skin\nbreakdown on her gluteal cleft likely due to a combination of\nimmobility due to acute illness and diarrhea as discussed above.\n She will require close monitoring of her skin and frequent\npersonal care to keep her buttocks clean and protected.\n\n8)Paroxysmal Atrial fibrillation: Her metoprolol was initially\nheld in the ICU given sinus bradycardia and sepsis. It was\nresumed at home dose on 9-6 however given borderline blood\npressures, it was decreased to 75mg Francis, Murray and Williamson Hospital on 7-6.\n\n9) Spiculated lesion on CT chest: as discussed in radiology\nreport, will need repeat CT in 3 months to reassess this lesion\nfor stability.", '\n\n10)Hypothyroidism: Continue levothyroxine\n\n11)Code: Full\n\n12) Comm: Kamran Wilson Jacob Diane Waldon 150-966-1961, daughter/HCP\n\nMedications on Admission:\nMedications:\n1. Coumadin 1 mg PO DAILY\n2. Nephrocaps 1 mg PO DAILY\n3. Metoprolol Tartrate 100 mg PO BID\n4. Levothyroxine 125 mcg PO DAILY\n5. Fluticasone 50 mcg Spray 10-13 Sprays Nasal Francis, Murray and Williamson Hospital:PRN nasal\nsymptoms\n6. Albuterol Sulfate Nebulization Q4H:PRN\n7. Ipratropium Bromide Inhalation Q6H\n8. Pantoprazole 40 mg PO BID\n9. Fexofenadine 30 mg PO BID:PRN allergies\n10. Calcitriol 0.25 mcg PO DAILY\n11. Guaifenesin 100 mg/5 mL Syrup 5-10 MLs PO Q6H:PRN cough\n12. Miconazole Nitrate 2 % Powder Appl Topical TID\n13. Fluocinolone 0.01 % Cream Topical Francis, Murray and Williamson Hospital:PRN eczema\n14. Cefpodoxime 200 mg 3x/week for 12 days\n\n\nDischarge Medications:\n1.', ' Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:\nplease have your INR checked at dialysis and dose adjusted .\n2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap\nPO DAILY (Daily).\n3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID\n(2 times a day).\n4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n5. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray\nNasal twice a day as needed for rhinorrhea.\n6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as\nneeded.\n7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours).\n8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n9.', ' Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times\na day) as needed for diarrhea.\n10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\nhours) as needed for fever, pain.\n11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\n12. Epoetin Alfa 10,000 unit/mL Solution Sig: according to\nprotocol Injection ASDIR (AS DIRECTED): at dialysis.\n13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID\n(4 times a day) for 5 days.\n14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical Francis, Murray and Williamson Hospital (2\ntimes a day).\n15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO QHD (each\nhemodialysis): please give only on HD days, please give after HD\ncomplete\nDay 1 =1997-8-30\nLast Day=1947-1-7.\n16. Outpatient Lab Work\nPlease send stool two stool samples for C.', "difficile\n17. Outpatient Lab Work\nPlease check INR with hemodialysis and adjust coumadin\naccordingly.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nst. Dr.Recinos manor\n\nDischarge Diagnosis:\nChronic Kidney disease on hemodialysis\nWegener's granulomatosis\nParoxysmal atrial fibrillation\nCOPD\nNon-infectious diarrhea\n\nSecondary Diagnoses:\nAnemia\n\n\nDischarge Condition:\nfair\nO2 saturation 95% on 0.5L NC\n\n\nDischarge Instructions:\nYou were admitted to the hospital with confusion, low blood\npressure and low oxygen most likely due to a serious pneumonia.\nYou were intubated and sent to the ICU for care. You improved\nand were able to be extubated the following day. You were\ntreated with antibiotics for pneumonia and your breathing\nimproved. You had blood cultures, urine cultures and stool\ncultures which did not show any evidence of infection.", '\n\nYou had dialysis with fluid removal as you were given a large\namount of IV fluids on admission for your infection which caused\nswelling in your arms and fluid around your lungs.\n\nYou developed diarrhea during your admission which is most\nlikely due to antibiotics. You were started on loperamide to\nattempt to decrease the diarrhea and to prevent further skin\nbreakdown.\n\nMedications:\n1)You will be discharged on cefpodoxime to complete a 2 week\ncourse of antibiotics. This should be taken only on dialysis\ndays, after your dialysis.\n2)You can take loperamide as needed to decrease your diarrhea.\n3)Your coumadin was held during your admission but can be\nrestarted on discharge as your INR was down to 2.9.\n4)Your metoprolol was decreased to 75mg twice daily as your\nblood pressure was borderline low.', '\nNo other changes were made to your medications.\n\nPlease follow up as below.\n\nPlease call your doctor or return to the hospital if you have\nany concerning symptoms including fevers, confusion, chest pain,\ntrouble breathing, low blood pressure or other worrisome\nsymptoms.\n\nFollowup Instructions:\nProvider: Karthik Dizon,Stacey Caro - ADULT MEDICINE (SB)\nPhone:137-276-6047 Date/Time:2009-3-18 11:15\n.\nDialysis:\nFMC - West Suburban Dialysis Center\nHarris.\n8127 Wright Pines Suite 366\nChavezburgh, ID 07275 827-872-2868\nDue to the upcoming holiday the pt. will be on special holiday\nschedule, which will be 256-351-4048, Wednesday and Saturday at\n11:00am. Her confirmed dialysis schedule will be every Tues.,\nThurs. and Saturday at 11:00am.\n.\nPlease call the radiology departement at 680-344-3253 #1 to\nschedule an appointment for an ultrasound of your left arm.', '\nPlease call Dr. Poff or Dr. Kathi after you have this study\nso they know to look for the results.\n\nPlease call Dr. Poff at 137-276-6047 and schedule an\nappointment to follow up within one to two weeks of discharge.\n\nPlease discuss with Dr. Poff schedule a CT scan of your chest\nin 3 months to further evaluate a nodule seen on chest CT during\nyour admission.\n\nPlease call Dr. Kathi at 978-191-9385 and schedule an\nappointment to follow up.\n\n\n\n']
238	5136	151912.0	2189-12-10	Discharge summary	Report	Admission Date: [2189-12-1] Discharge Date: [2189-12-11] Date of Birth: [2123-2-13] Sex: M Service: VSU CHIEF COMPLAINT: Chronic right ankle infection with unstable joint. HISTORY OF PRESENT ILLNESS: This is a 66-year-old male with a nonhealing right malleolar wound and fracture for the last 2 years who underwent a right ankle traction and open reduction internal fixation. The patient has had multiple admissions for wound infections and multiple IV antibiotic courses. Most recent admission was [2189-9-28], for a wound infection. The patient recently complained of a temperature elevation on [2189-11-30], and now is to be admitted to Dr.[Name (NI) 1392] service for continued IV antibiotics. The patient initially was discharged on daptomycin and followed by VNA. PAST MEDICAL HISTORY: Type 2 diabetes with triopathy, endstage renal disease secondary to diabetes, status post cadaver transplant in [2182], history of coronary artery disease, status post CABG in [2178], history of peripheral vascular disease, right ankle fracture in [2188-6-6], with an open reduction internal fixation, status post hardware removal, chronic osteomyelitis. ALLERGIES: No known drug allergies. MEDICATIONS: Percocet, dicloxacillin 100 mg twice a day, gabapentin 1600 mg twice a day, Lasix 20 mg twice a day, Sensipar 30 mg daily, metoprolol 25 mg daily, ranitidine 150 mg daily. There are two other medications that the patient is on, of which the handwriting is not decipherable at this time. SOCIAL HISTORY: The patient is a nonsmoker, is married and lives with his spouse. PHYSICAL EXAMINATION: Vital signs 94.6, 94, 18, blood pressure 144/88, oxygen saturation 93% in room air. Blood sugar fingerstick was 291 on admission. General appearance: Alert, cooperative white male in no acute distress. HEENT exam: Mild right eye ptosis. Neck is supple without lymphadenopathy or carotid bruits. Lungs are clear to auscultation bilaterally. Chest is with a well healed median sternotomy incision. Heart is a regular rate and rhythm with a systolic ejection murmur II/VI, nonradiating. Abdomen is soft, nontender, obese. Extremities: Right malleolus with punctate lesion with draining and surrounding erythema. Pulse exam shows palpable radial pulses, femoral pulses bilaterally. The right DP and PT are dopplerable signals. The left DP and PT are dopplerable signs. Neurological exam is nonfocal. HOSPITAL COURSE: The patient was admitted to the vascular service. His dicloxacillin was continued. Vancomycin and Flagyl were instituted. He was continued on his preadmission medications. He was seen by Dr. [Last Name (STitle) 1391] and advisement was made for him to undergo a below the knee amputation. The patient accepted the recommendation. Transplant nephrology was consulted to follow the patient during his hospitalization. [Last Name (un) ] was consulted for hyperglycemic management. Daily SK5 levels were obtained. He required minimal adjustment in his immunosuppression. He continued on his Lantus with a Humalog sliding scale with improvement in his glycemic control. On [2189-12-3], he underwent a right BKA without incident. He was transferred to the PACU in stable condition. At the end of his surgical procedure intraoperatively, the patient became hypotensive with systolic blood pressure in the 60s and he was given Neo 200 mcg x2 and epinephrine 5 mg x2. The patient went into a monomorphic VT 4 minutes at a rate of 130. He was given lidocaine 100 mg IV bolus and amiodarone 125 mg over 15 minutes. The patient converted to sinus rhythm. An intraoperative TEE showed severe biventricular failure. Dopamine was started at 5 mcg/kg/minute. Blood pressure improved. He was transferred to the PACU and then to the ICU for continued care. Serial enzymes were obtained. Repeat echo was obtained on the 28th which demonstrated left ventricular wall thickness and cavity dimensions were obtained by 2-D images. He has severely depressed left ventricular ejection fraction. He had multiple regional wall motion abnormalities. His aortic valve was moderately thickened leaflets. There were no masses or vegetations on the aortic valve. No aortic insufficiency. The mitral valve, tricuspid valve were normal with trivial MR [First Name (Titles) ] [Last Name (Titles) ]. The pulmonic valve and artery were unremarkable. The pericardium showed no pleural effusion. Aortic valve area was calculated at 1.3 cm squared, normal is 3 cm squared. Gradient peak was 32 mm. There was no intracardiac thrombus noted on the primary or the secondary echo. The ejection fraction was calculated at 30% to 40%. IV heparin was begun to maintain a goal PTT between 40 and 60. The patient's Dobutamine was weaned with hopes to extubate. Pulse exam remained unchanged. The right amputation site was clean dry dressing. He remained on bedrest in the SICU. Cardiac enzymes: Base was 20, peaked at 96 for the CK. CK MBs were not obtained. His troponins were 0.01 and 0.03. The patient's Swan was converted to a CVL on [2189-12-4]. The patient continued on heparin, was extubated and transferred to the VICU for continued monitoring and care on [2189-12-5]. Cardiology was requested to see the patient on [2189-12-6], who felt the patient was hemodynamically stable and his atrial fibrillation was rate controlled. We should continue the heparin while his INR is less than 2 and his goal INR should be [1-9], and recommend metoprolol tartrate twice a day versus single dosing. They recommended aspirin 81 mg and simvastatin 20 mg daily. Hyperglycemia control remained relatively good. He did not require adjustment in his Lantus. His premeal coverage was adjusted. Vancomycin, ciprofloxacin and Flagyl were discontinued on [2189-12-7]. The patient remained afebrile. Foley was discontinued. Peripheral line was placed and the central line was discontinued. The patient had been advanced to a regular diet and ambulation to chair was begun. On [2189-12-8], postoperative day 5, the patient continues on IV heparin/Coumadinization conversion. Serial coags were monitored. Physical therapy will see the patient and make recommendations regarding disposition planning, being a new amputation if he will go to rehabilitation. Will talk to infectious disease, Dr. [Last Name (STitle) 2379], regarding discontinue the doxycycline. The remaining hospital course, the patient will be discharged when medically stable and bed available at rehabilitation. At the time of discharge, discharge medication instructions will be dictated. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2189-12-8] 11:23:20 T: [2189-12-8] 14:38:59 Job#: [Job Number 2383]	Admission Date: <Date>2006-12-3</Date> Discharge Date: <Date>1999-10-4</Date> Date of Birth: <Date>1921-4-14</Date> Sex: M Service: VSU CHIEF COMPLAINT: Chronic right ankle infection with unstable joint. HISTORY OF PRESENT ILLNESS: This is a 66-year-old male with a nonhealing right malleolar wound and fracture for the last 2 years who underwent a right ankle traction and open reduction internal fixation. The patient has had multiple admissions for wound infections and multiple IV antibiotic courses. Most recent admission was <Date>1912-11-8</Date>, for a wound infection. The patient recently complained of a temperature elevation on <Date>1948-1-7</Date>, and now is to be admitted to Dr.<Name>Raymundo Kiel</Name> service for continued IV antibiotics. The patient initially was discharged on daptomycin and followed by VNA. PAST MEDICAL HISTORY: Type 2 diabetes with triopathy, endstage renal disease secondary to diabetes, status post cadaver transplant in <Year>1985</Year>, history of coronary artery disease, status post CABG in <Year>1985</Year>, history of peripheral vascular disease, right ankle fracture in <Date>1979-2-9</Date>, with an open reduction internal fixation, status post hardware removal, chronic osteomyelitis. ALLERGIES: No known drug allergies. MEDICATIONS: Percocet, dicloxacillin 100 mg twice a day, gabapentin 1600 mg twice a day, Lasix 20 mg twice a day, Sensipar 30 mg daily, metoprolol 25 mg daily, ranitidine 150 mg daily. There are two other medications that the patient is on, of which the handwriting is not decipherable at this time. SOCIAL HISTORY: The patient is a nonsmoker, is married and lives with his spouse. PHYSICAL EXAMINATION: Vital signs 94.6, 94, 18, blood pressure 144/88, oxygen saturation 93% in room air. Blood sugar fingerstick was 291 on admission. General appearance: Alert, cooperative white male in no acute distress. HEENT exam: Mild right eye ptosis. Neck is supple without lymphadenopathy or carotid bruits. Lungs are clear to auscultation bilaterally. Chest is with a well healed median sternotomy incision. Heart is a regular rate and rhythm with a systolic ejection murmur II/VI, nonradiating. Abdomen is soft, nontender, obese. Extremities: Right malleolus with punctate lesion with draining and surrounding erythema. Pulse exam shows palpable radial pulses, femoral pulses bilaterally. The right DP and PT are dopplerable signals. The left DP and PT are dopplerable signs. Neurological exam is nonfocal. HOSPITAL COURSE: The patient was admitted to the vascular service. His dicloxacillin was continued. Vancomycin and Flagyl were instituted. He was continued on his preadmission medications. He was seen by Dr. <Name>Moore</Name> and advisement was made for him to undergo a below the knee amputation. The patient accepted the recommendation. Transplant nephrology was consulted to follow the patient during his hospitalization. <Name>Tamaro</Name> was consulted for hyperglycemic management. Daily SK5 levels were obtained. He required minimal adjustment in his immunosuppression. He continued on his Lantus with a Humalog sliding scale with improvement in his glycemic control. On <Date>1944-7-5</Date>, he underwent a right BKA without incident. He was transferred to the PACU in stable condition. At the end of his surgical procedure intraoperatively, the patient became hypotensive with systolic blood pressure in the 60s and he was given Neo 200 mcg x2 and epinephrine 5 mg x2. The patient went into a monomorphic VT 4 minutes at a rate of 130. He was given lidocaine 100 mg IV bolus and amiodarone 125 mg over 15 minutes. The patient converted to sinus rhythm. An intraoperative TEE showed severe biventricular failure. Dopamine was started at 5 mcg/kg/minute. Blood pressure improved. He was transferred to the PACU and then to the ICU for continued care. Serial enzymes were obtained. Repeat echo was obtained on the 28th which demonstrated left ventricular wall thickness and cavity dimensions were obtained by 2-D images. He has severely depressed left ventricular ejection fraction. He had multiple regional wall motion abnormalities. His aortic valve was moderately thickened leaflets. There were no masses or vegetations on the aortic valve. No aortic insufficiency. The mitral valve, tricuspid valve were normal with trivial MR <Name>Theo</Name> <Name>Finateri</Name>. The pulmonic valve and artery were unremarkable. The pericardium showed no pleural effusion. Aortic valve area was calculated at 1.3 cm squared, normal is 3 cm squared. Gradient peak was 32 mm. There was no intracardiac thrombus noted on the primary or the secondary echo. The ejection fraction was calculated at 30% to 40%. IV heparin was begun to maintain a goal PTT between 40 and 60. The patient's Dobutamine was weaned with hopes to extubate. Pulse exam remained unchanged. The right amputation site was clean dry dressing. He remained on bedrest in the SICU. Cardiac enzymes: Base was 20, peaked at 96 for the CK. CK MBs were not obtained. His troponins were 0.01 and 0.03. The patient's Swan was converted to a CVL on <Date>1978-2-2</Date>. The patient continued on heparin, was extubated and transferred to the VICU for continued monitoring and care on <Date>1944-9-29</Date>. Cardiology was requested to see the patient on <Date>1962-4-19</Date>, who felt the patient was hemodynamically stable and his atrial fibrillation was rate controlled. We should continue the heparin while his INR is less than 2 and his goal INR should be <Date>9-19</Date>, and recommend metoprolol tartrate twice a day versus single dosing. They recommended aspirin 81 mg and simvastatin 20 mg daily. Hyperglycemia control remained relatively good. He did not require adjustment in his Lantus. His premeal coverage was adjusted. Vancomycin, ciprofloxacin and Flagyl were discontinued on <Date>1913-3-26</Date>. The patient remained afebrile. Foley was discontinued. Peripheral line was placed and the central line was discontinued. The patient had been advanced to a regular diet and ambulation to chair was begun. On <Date>1999-6-3</Date>, postoperative day 5, the patient continues on IV heparin/Coumadinization conversion. Serial coags were monitored. Physical therapy will see the patient and make recommendations regarding disposition planning, being a new amputation if he will go to rehabilitation. Will talk to infectious disease, Dr. <Name>Thompson</Name>, regarding discontinue the doxycycline. The remaining hospital course, the patient will be discharged when medically stable and bed available at rehabilitation. At the time of discharge, discharge medication instructions will be dictated. <Name>Janice</Name> <Name>Kobayashi</Name>, <MD Number>46355283</MD Number> Dictated By:<Name>Ahmed</Name> MEDQUIST36 D: <Date>1999-6-3</Date> 11:23:20 T: <Date>1999-6-3</Date> 14:38:59 Job#: <Job Number>Collins-James-1906-126589</Job 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Date: 2006-12-3 Discharge Date: 1999-10-4 Date of Birth: 1921-4-14 Sex: M Service: VSU CHIEF COMPLAINT: Chronic right ankle infection with unstable joint. HISTORY OF PRESENT ILLNESS: This is a 66-year-old male with a nonhealing right malleolar wound and fracture for the last 2 years who underwent a right ankle traction and open reduction internal fixation. The patient has had multiple admissions for wound infections and multiple IV antibiotic courses. Most recent admission was 1912-11-8, for a wound infection. The patient recently complained of a temperature elevation on 1948-1-7, and now is to be admitted to Dr.Raymundo Kiel service for continued IV antibiotics. The patient initially was discharged on daptomycin and followed by VNA. PAST MEDICAL HISTORY: Type 2 diabetes with triopathy, endstage renal disease secondary to diabetes, status post cadaver transplant in 1985, history of coronary artery disease, status post CABG in 1985, history of peripheral vascular disease, right ankle fracture in 1979-2-9, with an open reduction internal fixation, status post hardware removal, chronic osteomyelitis. ALLERGIES: No known drug allergies. MEDICATIONS: Percocet, dicloxacillin 100 mg twice a day, gabapentin 1600 mg twice a day, Lasix 20 mg twice a day, Sensipar 30 mg daily, metoprolol 25 mg daily, ranitidine 150 mg daily. There are two other medications that the patient is on, of which the handwriting is not decipherable at this time. SOCIAL HISTORY: The patient is a nonsmoker, is married and lives with his spouse. PHYSICAL EXAMINATION: Vital signs 94.6, 94, 18, blood pressure 144/88, oxygen saturation 93% in room air. Blood sugar fingerstick was 291 on admission. General appearance: Alert, cooperative white male in no acute distress. HEENT exam: Mild right eye ptosis. Neck is supple without lymphadenopathy or carotid bruits. Lungs are clear to auscultation bilaterally. Chest is with a well healed median sternotomy incision. Heart is a regular rate and rhythm with a systolic ejection murmur II/VI, nonradiating. Abdomen is soft, nontender, obese. Extremities: Right malleolus with punctate lesion with draining and surrounding erythema. Pulse exam shows palpable radial pulses, femoral pulses bilaterally. The right DP and PT are dopplerable signals. The left DP and PT are dopplerable signs. Neurological exam is nonfocal. HOSPITAL COURSE: The patient was admitted to the vascular service. His dicloxacillin was continued. Vancomycin and Flagyl were instituted. He was continued on his preadmission medications. He was seen by Dr. Moore and advisement was made for him to undergo a below the knee amputation. The patient accepted the recommendation. Transplant nephrology was consulted to follow the patient during his hospitalization. Tamaro was consulted for hyperglycemic management. Daily SK5 levels were obtained. He required minimal adjustment in his immunosuppression. He continued on his Lantus with a Humalog sliding scale with improvement in his glycemic control. On 1944-7-5, he underwent a right BKA without incident. He was transferred to the PACU in stable condition. At the end of his surgical procedure intraoperatively, the patient became hypotensive with systolic blood pressure in the 60s and he was given Neo 200 mcg x2 and epinephrine 5 mg x2. The patient went into a monomorphic VT 4 minutes at a rate of 130. He was given lidocaine 100 mg IV bolus and amiodarone 125 mg over 15 minutes. The patient converted to sinus rhythm. An intraoperative TEE showed severe biventricular failure. Dopamine was started at 5 mcg/kg/minute. Blood pressure improved. He was transferred to the PACU and then to the ICU for continued care. Serial enzymes were obtained. Repeat echo was obtained on the 28th which demonstrated left ventricular wall thickness and cavity dimensions were obtained by 2-D images. He has severely depressed left ventricular ejection fraction. He had multiple regional wall motion abnormalities. His aortic valve was moderately thickened leaflets. There were no masses or vegetations on the aortic valve. No aortic insufficiency. The mitral valve, tricuspid valve were normal with trivial MR Theo Finateri. The pulmonic valve and artery were unremarkable. The pericardium showed no pleural effusion. Aortic valve area was calculated at 1.3 cm squared, normal is 3 cm squared. Gradient peak was 32 mm. There was no intracardiac thrombus noted on the primary or the secondary echo. The ejection fraction was calculated at 30% to 40%. IV heparin was begun to maintain a goal PTT between 40 and 60. The patient's Dobutamine was weaned with hopes to extubate. Pulse exam remained unchanged. The right amputation site was clean dry dressing. He remained on bedrest in the SICU. Cardiac enzymes: Base was 20, peaked at 96 for the CK. CK MBs were not obtained. His troponins were 0.01 and 0.03. The patient's Swan was converted to a CVL on 1978-2-2. The patient continued on heparin, was extubated and transferred to the VICU for continued monitoring and care on 1944-9-29. Cardiology was requested to see the patient on 1962-4-19, who felt the patient was hemodynamically stable and his atrial fibrillation was rate controlled. We should continue the heparin while his INR is less than 2 and his goal INR should be 9-19, and recommend metoprolol tartrate twice a day versus single dosing. They recommended aspirin 81 mg and simvastatin 20 mg daily. Hyperglycemia control remained relatively good. He did not require adjustment in his Lantus. His premeal coverage was adjusted. Vancomycin, ciprofloxacin and Flagyl were discontinued on 1913-3-26. The patient remained afebrile. Foley was discontinued. Peripheral line was placed and the central line was discontinued. The patient had been advanced to a regular diet and ambulation to chair was begun. On 1999-6-3, postoperative day 5, the patient continues on IV heparin/Coumadinization conversion. Serial coags were monitored. Physical therapy will see the patient and make recommendations regarding disposition planning, being a new amputation if he will go to rehabilitation. Will talk to infectious disease, Dr. Thompson, regarding discontinue the doxycycline. The remaining hospital course, the patient will be discharged when medically stable and bed available at rehabilitation. At the time of discharge, discharge medication instructions will be dictated. Janice Kobayashi, 46355283 Dictated By:Ahmed MEDQUIST36 D: 1999-6-3 11:23:20 T: 1999-6-3 14:38:59 Job#: Collins-James-1906-126589	['Admission Date: 2006-12-3 Discharge Date: 1999-10-4\n\nDate of Birth: 1921-4-14 Sex: M\n\nService: VSU\n\n\nCHIEF COMPLAINT: Chronic right ankle infection with unstable\njoint.\n\nHISTORY OF PRESENT ILLNESS: This is a 66-year-old male with\na nonhealing right malleolar wound and fracture for the last\n2 years who underwent a right ankle traction and open\nreduction internal fixation. The patient has had multiple\nadmissions for wound infections and multiple IV antibiotic\ncourses. Most recent admission was 1912-11-8, for a\nwound infection. The patient recently complained of a\ntemperature elevation on 1948-1-7, and now is to be\nadmitted to Dr.Raymundo Kiel service for continued IV\nantibiotics. The patient initially was discharged on\ndaptomycin and followed by VNA.\n\nPAST MEDICAL HISTORY: Type 2 diabetes with triopathy,\nendstage renal disease secondary to diabetes, status post\ncadaver transplant in 1985, history of coronary artery\ndisease, status post CABG in 1985, history of peripheral\nvascular disease, right ankle fracture in 1979-2-9, with an\nopen reduction internal fixation, status post hardware\nremoval, chronic osteomyelitis.', '\n\nALLERGIES: No known drug allergies.\n\nMEDICATIONS: Percocet, dicloxacillin 100 mg twice a day,\ngabapentin 1600 mg twice a day, Lasix 20 mg twice a day,\nSensipar 30 mg daily, metoprolol 25 mg daily, ranitidine 150\nmg daily. There are two other medications that the patient is\non, of which the handwriting is not decipherable at this\ntime.\n\nSOCIAL HISTORY: The patient is a nonsmoker, is married and\nlives with his spouse.\n\nPHYSICAL EXAMINATION: Vital signs 94.6, 94, 18, blood\npressure 144/88, oxygen saturation 93% in room air. Blood\nsugar fingerstick was 291 on admission. General appearance:\nAlert, cooperative white male in no acute distress. HEENT\nexam: Mild right eye ptosis. Neck is supple without\nlymphadenopathy or carotid bruits. Lungs are clear to\nauscultation bilaterally. Chest is with a well healed median\nsternotomy incision.', ' Heart is a regular rate and rhythm with\na systolic ejection murmur II/VI, nonradiating. Abdomen is\nsoft, nontender, obese. Extremities: Right malleolus with\npunctate lesion with draining and surrounding erythema. Pulse\nexam shows palpable radial pulses, femoral pulses\nbilaterally. The right DP and PT are dopplerable signals. The\nleft DP and PT are dopplerable signs. Neurological exam is\nnonfocal.\n\nHOSPITAL COURSE: The patient was admitted to the vascular\nservice. His dicloxacillin was continued. Vancomycin and\nFlagyl were instituted. He was continued on his preadmission\nmedications. He was seen by Dr. Moore and advisement was\nmade for him to undergo a below the knee amputation. The\npatient accepted the recommendation. Transplant nephrology\nwas consulted to follow the patient during his\nhospitalization.', ' Tamaro was consulted for hyperglycemic\nmanagement. Daily SK5 levels were obtained. He required\nminimal adjustment in his immunosuppression. He continued on\nhis Lantus with a Humalog sliding scale with improvement in\nhis glycemic control. On 1944-7-5, he underwent a\nright BKA without incident. He was transferred to the PACU in\nstable condition. At the end of his surgical procedure\nintraoperatively, the patient became hypotensive with\nsystolic blood pressure in the 60s and he was given Neo 200\nmcg x2 and epinephrine 5 mg x2. The patient went into a\nmonomorphic VT 4 minutes at a rate of 130. He was given\nlidocaine 100 mg IV bolus and amiodarone 125 mg over 15\nminutes. The patient converted to sinus rhythm. An\nintraoperative TEE showed severe biventricular failure.\nDopamine was started at 5 mcg/kg/minute.', ' Blood pressure\nimproved. He was transferred to the PACU and then to the ICU\nfor continued care. Serial enzymes were obtained. Repeat echo\nwas obtained on the 28th which demonstrated left ventricular\nwall thickness and cavity dimensions were obtained by 2-D\nimages. He has severely depressed left ventricular ejection\nfraction. He had multiple regional wall motion abnormalities.\nHis aortic valve was moderately thickened leaflets. There\nwere no masses or vegetations on the aortic valve. No aortic\ninsufficiency. The mitral valve, tricuspid valve were normal\nwith trivial MR Theo Finateri. The pulmonic valve and artery were\nunremarkable. The pericardium showed no pleural effusion.\nAortic valve area was calculated at 1.3 cm squared, normal is\n3 cm squared. Gradient peak was 32 mm. There was no\nintracardiac thrombus noted on the primary or the secondary\necho.', " The ejection fraction was calculated at 30% to 40%. IV\nheparin was begun to maintain a goal PTT between 40 and 60.\nThe patient's Dobutamine was weaned with hopes to extubate.\nPulse exam remained unchanged. The right amputation site was\nclean dry dressing. He remained on bedrest in the SICU.\nCardiac enzymes: Base was 20, peaked at 96 for the CK. CK MBs\nwere not obtained. His troponins were 0.01 and 0.03. The\npatient's Swan was converted to a CVL on 1978-2-2.\nThe patient continued on heparin, was extubated and\ntransferred to the VICU for continued monitoring and care on\n1944-9-29. Cardiology was requested to see the\npatient on 1962-4-19, who felt the patient was\nhemodynamically stable and his atrial fibrillation was rate\ncontrolled. We should continue the heparin while his INR is\nless than 2 and his goal INR should be 9-19, and recommend\nmetoprolol tartrate twice a day versus single dosing.", ' They\nrecommended aspirin 81 mg and simvastatin 20 mg daily.\nHyperglycemia control remained relatively good. He did not\nrequire adjustment in his Lantus. His premeal coverage was\nadjusted. Vancomycin, ciprofloxacin and Flagyl were\ndiscontinued on 1913-3-26. The patient remained\nafebrile. Foley was discontinued. Peripheral line was placed\nand the central line was discontinued. The patient had been\nadvanced to a regular diet and ambulation to chair was begun.\nOn 1999-6-3, postoperative day 5, the patient\ncontinues on IV heparin/Coumadinization conversion. Serial\ncoags were monitored. Physical therapy will see the patient\nand make recommendations regarding disposition planning,\nbeing a new amputation if he will go to rehabilitation. Will\ntalk to infectious disease, Dr. Thompson, regarding discontinue\nthe doxycycline.', ' The remaining hospital course, the patient\nwill be discharged when medically stable and bed available at\nrehabilitation. At the time of discharge, discharge\nmedication instructions will be dictated.\n\n\n\n Janice Kobayashi, 46355283\n\nDictated By:Ahmed\nMEDQUIST36\nD: 1999-6-3 11:23:20\nT: 1999-6-3 14:38:59\nJob#: Collins-James-1906-126589\n']
239	24424	146533.0	2188-05-14	Discharge summary	Report	Admission Date: [2188-5-9] Discharge Date: [2188-5-14] Date of Birth: [2121-7-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2074] Chief Complaint: Direct transfer from [Hospital3 417] Hospital for STEMI, cath and now stablized hct and transfered out of CCU Major Surgical or Invasive Procedure: Cardiac catheterization Blood transfusion History of Present Illness: Mr. [Known lastname 2391] is a 66-year-old male with hx HIV on HAART, lymphoma, LUL lung adenocarcinoma s/p resection, hx CAD s/p PCI with DES in [5-17] to proximal circumflex artery. In [11-16] he had elective cath showing 90% restenosis at proximal edge of previously placed stent, treated with overlapping Cyper stent. Mid-RCA was 80% occluded and treated with DES as well. In [2-18] pt had a left femoral artery to dorsalis pedis artery bypass graft with an in situ greater saphenous vein graft. His plavix was discontinued at that time. He was recently admitted on [2188-4-30] w/ STEMI over III, F, taken to cath, where he had a DES placed in the LCX for the vessel being occluded by a thrombus proximally. Of note, at cath [4-30], he had a totally occluded right external iliac artery. The pt was discharged home [2188-5-3]. Since that time, per the pt, he felt at baseline, with the exception of intermittent left leg pain (s/p vascular surgery, bypass) that would occasionally awaken him at night. He stated he was up this morning at 4am b/c of this left leg pain, when he developed a "cold rough" feeling in his esophagus similar to his pain that he had with all of his prior MIs. He states it was a [5-24] in severity. He took 1 nitro, and it resolved. He reports he did not take his plavix yesterday and today. He noted intermittent right sided chest pain as well last night, which felt like "gas pain", + SOB, no diaphoresis, + nausea, no vomiting. He states the feeling returned and then persisted, took a 2nd nitro but it only decreased the pain to a [2192-2-16]. He called 911. . In the ambulance, the pt's pain decr to [1-25] and he received ASA, another nitro en route. His pain, however, only resolved completely on nitro gtt at OSH where he was given ASA, IV integrillin, IV heparin, started on nitro drip with full resolution of pain, transferred to [Hospital1 18] for emergent cath. His initial BP at OSH 130/75, down to 93/63 after nitro. Outside labs with CK 60, other ezymes pending at time of transfer, BNP 17. . At [Hospital1 18], he was given plavix 600mg load prior to cath. In the cath lab: LCX was totally occluded within proximal stents. A wire was passed and flow was reestablished (likely development of blood clots). 1 additional bare metal stent (no DES since he had questionable compliance w/ plavix) placed distal to last stent. Some non-occluding stenosis in the distal branches. Cath was performed via radial artery (per lower ext arterial disease). His right groin (femoral vein) developed a hematoma. His left groin was not accessed given his c/o left leg pain post surgery 2 months ago. He was subsequently transferred to the floor. He then had BP drop to 90s/40s-50s and a pm HCT was found to be 27.7 (6 point drop from pre-cath HCT). He is being transferred to the CCU for unstable HCT and hematoma with labile BP s/p catheterization today. . Brief CCU event: CT scan of abd neg for RP bleed. Neg groin for psuedoaneurysm. Stable hct. Received total of 3 units of blood. 2 unit pRBC for hct 27 ([5-9]) -> 31.6 ([5-10] Am)-> 29.5-> 28.2 ([5-10] 1pm)->32.3 ([5-10] 12pm)-> 31.8 ([5-11] 4am) Past Medical History: S/p left VATS and wedge biopsy of the left upper lobe [4-18] for adenocarcinoma. Non-hodgkins lung lymphoma HIV CAD Bladder Ca, s/p resection S/p bowel resection Claudication Social History: Pt lives alone, formed smoker 1ppd has cut down significantly since lung operations, but smoked for 40 years 1ppd, still smokes a cigarette ocasionally, no EtOH. No IVDA. Family History: N/C Physical Exam: T: 98.2 BP: 111/67 P: 100 RR: 18 O2sat: 100% 2L NC Gen: WNWD man in NAD. Breathing comfortably on RA lying flat. Speaking in full sentences. Pleasant and cooperative. HEENT: PERRL, no scleral icterus. MM dry. OP clear Neck: JVD to mid neck lying flat Resp: CTAB anteriorly (lying flat) CV: RRR S1 and S2 audible w/o m/r/g Abd: Soft, NT, ND, No hepatomegaly. no masses. Extr: 1+ DP pulses bilaterally. No edema. Groin: R sided hematoma well circumscribed with some ecchymosis, site c/d/i R Wrist: Site of cath with pressure band over insertion site and some leaking of blood on gauze. Good cap refill on right hand. Warm. Pertinent Results: CATH [2188-5-9] LMCA: nl LAD: 50% mid disease LCX: Total occlusion within proximal stents RCA: not injected Abdominal aortography: mild left common femoral disease. femoral graft patent with no signficant disease seen in graft or native vessels to above the knee. Intervention: Successful treatment of IPMI with BMS. Using right radial approach, LCA engaged with AL2 guide. Stent occlusion crossed with wire and bballoon with restoration of flow showing progressed diesase to 80% just distal to stents. PTCA with suboptimal result so 2.5X18 minivision stent placed into larger upper pole which had multiple moderate lesions. prior stents redilated with 3.0 balloon. No residual, normal flow in all branches. . 92 7.0 \ 9.4 / 325 ----- 27.7 . 136 103 23 / 199 AGap=16 ------------- 4.3 21 0.8 \ CK: 60 91 5.7 \ 11.4 / 338 -------- 33.6 N:63.7 L:30.4 M:3.6 E:1.8 Bas:0.5 PT: 18.1 PTT: 150 INR: 1.7 Brief Hospital Course: 66 year old male with HIV, CAD, recently admitted for STEMI found to have 100% LCX lesion and stented w/ DES, who presented with STEMI to OSH, and found to have total occlusion of proximal LCX stent, now s/p bare metal stent placement. Pt was then found to have a hematocrit drop and hypotension necessitating transfuse to CCU, now stabilized. . Blood loss: Pt was s/p catheterization with R wrist for arterial access and R groin for venous access. CT scan was performed, and ruled out RP bleed and U/S ruled out AV fistula and pseudoaneurysm. He received a total of 3 units PRBCs in CCU, and his hct has been stable. Pt likely had blood loss during cath, and in groin hematoma. After being transferred back to the floor from the CCU, his Hct was stable. Low-dose metoprolol was started the night before discharge, and he tolerated this with SBP in the 100s to 110s. . Cardiac. Patient was admitted with a repeat STEMI secondary to instent thrombosis. He had placement of a bare metal stent, and was started on higher doses of plavix at 150 mg daily. He was continued on aspirin and a high dose statin as well. His antihypertensives were held due to hypotension, and restarted prior to discharge. He was not diuresed further, despite an elevated PCWP of 28 at catheterization, due to hypotension. He remained in normal sinus rhythm. . Hyperbilirubinemia: the pt was noted to have mild jaundice and scleral icterus on [5-12]. LFTs were checked and his total bilirubin was 6.6, direct bili was 0.2. His other LFTs were normal. His hemolysis labs were normal. The hyperbilirubinemia was felt to be most likely due to either reabsorption of the large hematoma or a side effect from one of his HIV meds, most likely atazanavir. His bilirubin continued to climb but he was otherwise asymptomatic. A RUQ U/S showed small gallstones but no evidence of cholecystitis or obstruction. His statin and HIV meds were stopped on discharge. . HIV: Patient was continued on his outpatient HIV medications. He was continued on prophylactic bactrim. He was continued on his antidepressants. . Dispo. Patient was discharged to home with a stable hematocrit. Medications on Admission: Aspirin 325 mg Tablet daily Plavix 75 mg daily Toprol XL 25 mg daily Atorvastatin 80 mg daily Trimethoprim-Sulfamethoxazole 80-400 mg daily Fluoxetine 20 mg daily Oxycodone 5-10 mg q6h prn Viread 300 mg daily Trizivir 300-150-300 mg [Hospital1 ] REYATAZ 300 mg daily Norvir 100 mg daily Gabapentin 300 mg Q12H Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: 1. STEMI with in stent thrombosis 2. Hypotension 3. Groin hematoma 4. Acute blood loss anemia 5. Medication noncompliance 6. hyperbilirubinemia from hematoma reabsorption vs. HAART Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet You were admitted because you had another heart attack, from a clot in the stent in your blood vessel. This happens when you do not take your medications regularly. It is very important to take all your medications. Your dose of Plavix was increased to 150 mg daily. If you develop chest pain, nausea, vomiting, throat tightness, clamminess or shortness of breath, call your PCP or go to the emergency room. If the bruise in your groin gets larger or more tender, or if you become lightheaded on standing, you should call your doctor and let him know. Do not take your anti-retroviral medications until directed by your PCP. [Name10 (NameIs) ] medications you should not be taking are abacavir, ritonavir, atazanavir, tenofovir, and Combivir. Keep taking your Bactrim. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 2392] on Thursday [2188-5-13] at 10:20am; at that time you will have your blood drawn to check your liver function tests. You may call his office at [Telephone/Fax (1) 2393] with any questions. Please follow up with Dr. [Last Name (STitle) ] on [2188-5-28] at 10:30am. He will adjust your blood pressure medications as necessary. You may call his office at [Telephone/Fax (1) 2394] with any questions. Follow up with Dr. [Last Name (STitle) ] (vascular surgery) as scheduled on [2188-5-28] at 2:30pm. You may call her office at [Telephone/Fax (1) 2395] with any questions. Provider: [First Name11 (Name Pattern1) 2389] [Last Name (NamePattern1) 2390], MD Phone:[0-0-] Date/Time:[2188-8-14] 2:00 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2188-8-14] 1:00 Completed by:[2188-5-16]	Admission Date: <Date>2003-11-26</Date> Discharge Date: <Date>1915-7-12</Date> Date of Birth: <Date>1923-3-16</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Betty</Name> Chief Complaint: Direct transfer from <Hospital>Pena-Gonzales Hospital</Hospital> Hospital for STEMI, cath and now stablized hct and transfered out of CCU Major Surgical or Invasive Procedure: Cardiac catheterization Blood transfusion History of Present Illness: Mr. <Name>Kenner</Name> is a 66-year-old male with hx HIV on HAART, lymphoma, LUL lung adenocarcinoma s/p resection, hx CAD s/p PCI with DES in <Date>1-11</Date> to proximal circumflex artery. In <Date>9-12</Date> he had elective cath showing 90% restenosis at proximal edge of previously placed stent, treated with overlapping Cyper stent. Mid-RCA was 80% occluded and treated with DES as well. In <Date>9-11</Date> pt had a left femoral artery to dorsalis pedis artery bypass graft with an in situ greater saphenous vein graft. His plavix was discontinued at that time. He was recently admitted on <Date>1986-9-11</Date> w/ STEMI over III, F, taken to cath, where he had a DES placed in the LCX for the vessel being occluded by a thrombus proximally. Of note, at cath <Date>4-9</Date>, he had a totally occluded right external iliac artery. The pt was discharged home <Date>1911-10-6</Date>. Since that time, per the pt, he felt at baseline, with the exception of intermittent left leg pain (s/p vascular surgery, bypass) that would occasionally awaken him at night. He stated he was up this morning at 4am b/c of this left leg pain, when he developed a "cold rough" feeling in his esophagus similar to his pain that he had with all of his prior MIs. He states it was a <Date>10-19</Date> in severity. He took 1 nitro, and it resolved. He reports he did not take his plavix yesterday and today. He noted intermittent right sided chest pain as well last night, which felt like "gas pain", + SOB, no diaphoresis, + nausea, no vomiting. He states the feeling returned and then persisted, took a 2nd nitro but it only decreased the pain to a <Date>1925-7-7</Date>. He called 911. . In the ambulance, the pt's pain decr to <Date>4-31</Date> and he received ASA, another nitro en route. His pain, however, only resolved completely on nitro gtt at OSH where he was given ASA, IV integrillin, IV heparin, started on nitro drip with full resolution of pain, transferred to <Hospital>Griffin-Sanders Hospital</Hospital> for emergent cath. His initial BP at OSH 130/75, down to 93/63 after nitro. Outside labs with CK 60, other ezymes pending at time of transfer, BNP 17. . At <Hospital>Griffin-Sanders Hospital</Hospital>, he was given plavix 600mg load prior to cath. In the cath lab: LCX was totally occluded within proximal stents. A wire was passed and flow was reestablished (likely development of blood clots). 1 additional bare metal stent (no DES since he had questionable compliance w/ plavix) placed distal to last stent. Some non-occluding stenosis in the distal branches. Cath was performed via radial artery (per lower ext arterial disease). His right groin (femoral vein) developed a hematoma. His left groin was not accessed given his c/o left leg pain post surgery 2 months ago. He was subsequently transferred to the floor. He then had BP drop to 90s/40s-50s and a pm HCT was found to be 27.7 (6 point drop from pre-cath HCT). He is being transferred to the CCU for unstable HCT and hematoma with labile BP s/p catheterization today. . Brief CCU event: CT scan of abd neg for RP bleed. Neg groin for psuedoaneurysm. Stable hct. Received total of 3 units of blood. 2 unit pRBC for hct 27 (<Date>1-23</Date>) -> 31.6 (<Date>12-18</Date> Am)-> 29.5-> 28.2 (<Date>12-18</Date> 1pm)->32.3 (<Date>12-18</Date> 12pm)-> 31.8 (<Date>5-31</Date> 4am) Past Medical History: S/p left VATS and wedge biopsy of the left upper lobe <Date>11-20</Date> for adenocarcinoma. Non-hodgkins lung lymphoma HIV CAD Bladder Ca, s/p resection S/p bowel resection Claudication Social History: Pt lives alone, formed smoker 1ppd has cut down significantly since lung operations, but smoked for 40 years 1ppd, still smokes a cigarette ocasionally, no EtOH. No IVDA. Family History: N/C Physical Exam: T: 98.2 BP: 111/67 P: 100 RR: 18 O2sat: 100% 2L NC Gen: WNWD man in NAD. Breathing comfortably on RA lying flat. Speaking in full sentences. Pleasant and cooperative. HEENT: PERRL, no scleral icterus. MM dry. OP clear Neck: JVD to mid neck lying flat Resp: CTAB anteriorly (lying flat) CV: RRR S1 and S2 audible w/o m/r/g Abd: Soft, NT, ND, No hepatomegaly. no masses. Extr: 1+ DP pulses bilaterally. No edema. Groin: R sided hematoma well circumscribed with some ecchymosis, site c/d/i R Wrist: Site of cath with pressure band over insertion site and some leaking of blood on gauze. Good cap refill on right hand. Warm. Pertinent Results: CATH <Date>2003-11-26</Date> LMCA: nl LAD: 50% mid disease LCX: Total occlusion within proximal stents RCA: not injected Abdominal aortography: mild left common femoral disease. femoral graft patent with no signficant disease seen in graft or native vessels to above the knee. Intervention: Successful treatment of IPMI with BMS. Using right radial approach, LCA engaged with AL2 guide. Stent occlusion crossed with wire and bballoon with restoration of flow showing progressed diesase to 80% just distal to stents. PTCA with suboptimal result so 2.5X18 minivision stent placed into larger upper pole which had multiple moderate lesions. prior stents redilated with 3.0 balloon. No residual, normal flow in all branches. . 92 7.0 \ 9.4 / 325 ----- 27.7 . 136 103 23 / 199 AGap=16 ------------- 4.3 21 0.8 \ CK: 60 91 5.7 \ 11.4 / 338 -------- 33.6 N:63.7 L:30.4 M:3.6 E:1.8 Bas:0.5 PT: 18.1 PTT: 150 INR: 1.7 Brief Hospital Course: 66 year old male with HIV, CAD, recently admitted for STEMI found to have 100% LCX lesion and stented w/ DES, who presented with STEMI to OSH, and found to have total occlusion of proximal LCX stent, now s/p bare metal stent placement. Pt was then found to have a hematocrit drop and hypotension necessitating transfuse to CCU, now stabilized. . Blood loss: Pt was s/p catheterization with R wrist for arterial access and R groin for venous access. CT scan was performed, and ruled out RP bleed and U/S ruled out AV fistula and pseudoaneurysm. He received a total of 3 units PRBCs in CCU, and his hct has been stable. Pt likely had blood loss during cath, and in groin hematoma. After being transferred back to the floor from the CCU, his Hct was stable. Low-dose metoprolol was started the night before discharge, and he tolerated this with SBP in the 100s to 110s. . Cardiac. Patient was admitted with a repeat STEMI secondary to instent thrombosis. He had placement of a bare metal stent, and was started on higher doses of plavix at 150 mg daily. He was continued on aspirin and a high dose statin as well. His antihypertensives were held due to hypotension, and restarted prior to discharge. He was not diuresed further, despite an elevated PCWP of 28 at catheterization, due to hypotension. He remained in normal sinus rhythm. . Hyperbilirubinemia: the pt was noted to have mild jaundice and scleral icterus on <Date>10-26</Date>. LFTs were checked and his total bilirubin was 6.6, direct bili was 0.2. His other LFTs were normal. His hemolysis labs were normal. The hyperbilirubinemia was felt to be most likely due to either reabsorption of the large hematoma or a side effect from one of his HIV meds, most likely atazanavir. His bilirubin continued to climb but he was otherwise asymptomatic. A RUQ U/S showed small gallstones but no evidence of cholecystitis or obstruction. His statin and HIV meds were stopped on discharge. . HIV: Patient was continued on his outpatient HIV medications. He was continued on prophylactic bactrim. He was continued on his antidepressants. . Dispo. Patient was discharged to home with a stable hematocrit. Medications on Admission: Aspirin 325 mg Tablet daily Plavix 75 mg daily Toprol XL 25 mg daily Atorvastatin 80 mg daily Trimethoprim-Sulfamethoxazole 80-400 mg daily Fluoxetine 20 mg daily Oxycodone 5-10 mg q6h prn Viread 300 mg daily Trizivir 300-150-300 mg <Hospital>Young Inc Clinic</Hospital> REYATAZ 300 mg daily Norvir 100 mg daily Gabapentin 300 mg Q12H Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: <Hospital>Shaw-Munoz Hospital</Hospital> VNA Discharge Diagnosis: 1. STEMI with in stent thrombosis 2. Hypotension 3. Groin hematoma 4. Acute blood loss anemia 5. Medication noncompliance 6. hyperbilirubinemia from hematoma reabsorption vs. HAART Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, <Name>Raymond Lees</Name> MD if weight > 3 lbs. Adhere to 2 gm sodium diet You were admitted because you had another heart attack, from a clot in the stent in your blood vessel. This happens when you do not take your medications regularly. It is very important to take all your medications. Your dose of Plavix was increased to 150 mg daily. If you develop chest pain, nausea, vomiting, throat tightness, clamminess or shortness of breath, call your PCP or go to the emergency room. If the bruise in your groin gets larger or more tender, or if you become lightheaded on standing, you should call your doctor and let him know. Do not take your anti-retroviral medications until directed by your PCP. <Name>Jamila Sakkas</Name> medications you should not be taking are abacavir, ritonavir, atazanavir, tenofovir, and Combivir. Keep taking your Bactrim. Followup Instructions: Please follow up with Dr. <Name>Hui</Name> on Thursday <Date>1933-11-24</Date> at 10:20am; at that time you will have your blood drawn to check your liver function tests. You may call his office at <Telephone>895-807-9022</Telephone> with any questions. Please follow up with Dr. <Name>Caro</Name> on <Date>1968-4-22</Date> at 10:30am. He will adjust your blood pressure medications as necessary. You may call his office at <Telephone>709-912-5211</Telephone> with any questions. Follow up with Dr. <Name>Caro</Name> (vascular surgery) as scheduled on <Date>1968-4-22</Date> at 2:30pm. You may call her office at <Telephone>362-636-8580</Telephone> with any questions. Provider: <Name>Norine</Name> <Name>Camargo</Name>, MD Phone:<Date>12-2016</Date> Date/Time:<Date>1951-6-7</Date> 2:00 Provider: <Name>Jamila Sakkas</Name> SCAN Phone:<Telephone>767-965-6077</Telephone> Date/Time:<Date>1951-6-7</Date> 1:00 Completed 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Date: 2003-11-26 Discharge Date: 1915-7-12 Date of Birth: 1923-3-16 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Betty Chief Complaint: Direct transfer from Pena-Gonzales Hospital Hospital for STEMI, cath and now stablized hct and transfered out of CCU Major Surgical or Invasive Procedure: Cardiac catheterization Blood transfusion History of Present Illness: Mr. Kenner is a 66-year-old male with hx HIV on HAART, lymphoma, LUL lung adenocarcinoma s/p resection, hx CAD s/p PCI with DES in 1-11 to proximal circumflex artery. In 9-12 he had elective cath showing 90% restenosis at proximal edge of previously placed stent, treated with overlapping Cyper stent. Mid-RCA was 80% occluded and treated with DES as well. In 9-11 pt had a left femoral artery to dorsalis pedis artery bypass graft with an in situ greater saphenous vein graft. His plavix was discontinued at that time. He was recently admitted on 1986-9-11 w/ STEMI over III, F, taken to cath, where he had a DES placed in the LCX for the vessel being occluded by a thrombus proximally. Of note, at cath 4-9, he had a totally occluded right external iliac artery. The pt was discharged home 1911-10-6. Since that time, per the pt, he felt at baseline, with the exception of intermittent left leg pain (s/p vascular surgery, bypass) that would occasionally awaken him at night. He stated he was up this morning at 4am b/c of this left leg pain, when he developed a "cold rough" feeling in his esophagus similar to his pain that he had with all of his prior MIs. He states it was a 10-19 in severity. He took 1 nitro, and it resolved. He reports he did not take his plavix yesterday and today. He noted intermittent right sided chest pain as well last night, which felt like "gas pain", + SOB, no diaphoresis, + nausea, no vomiting. He states the feeling returned and then persisted, took a 2nd nitro but it only decreased the pain to a 1925-7-7. He called 911. . In the ambulance, the pt's pain decr to 4-31 and he received ASA, another nitro en route. His pain, however, only resolved completely on nitro gtt at OSH where he was given ASA, IV integrillin, IV heparin, started on nitro drip with full resolution of pain, transferred to Griffin-Sanders Hospital for emergent cath. His initial BP at OSH 130/75, down to 93/63 after nitro. Outside labs with CK 60, other ezymes pending at time of transfer, BNP 17. . At Griffin-Sanders Hospital, he was given plavix 600mg load prior to cath. In the cath lab: LCX was totally occluded within proximal stents. A wire was passed and flow was reestablished (likely development of blood clots). 1 additional bare metal stent (no DES since he had questionable compliance w/ plavix) placed distal to last stent. Some non-occluding stenosis in the distal branches. Cath was performed via radial artery (per lower ext arterial disease). His right groin (femoral vein) developed a hematoma. His left groin was not accessed given his c/o left leg pain post surgery 2 months ago. He was subsequently transferred to the floor. He then had BP drop to 90s/40s-50s and a pm HCT was found to be 27.7 (6 point drop from pre-cath HCT). He is being transferred to the CCU for unstable HCT and hematoma with labile BP s/p catheterization today. . Brief CCU event: CT scan of abd neg for RP bleed. Neg groin for psuedoaneurysm. Stable hct. Received total of 3 units of blood. 2 unit pRBC for hct 27 (1-23) -> 31.6 (12-18 Am)-> 29.5-> 28.2 (12-18 1pm)->32.3 (12-18 12pm)-> 31.8 (5-31 4am) Past Medical History: S/p left VATS and wedge biopsy of the left upper lobe 11-20 for adenocarcinoma. Non-hodgkins lung lymphoma HIV CAD Bladder Ca, s/p resection S/p bowel resection Claudication Social History: Pt lives alone, formed smoker 1ppd has cut down significantly since lung operations, but smoked for 40 years 1ppd, still smokes a cigarette ocasionally, no EtOH. No IVDA. Family History: N/C Physical Exam: T: 98.2 BP: 111/67 P: 100 RR: 18 O2sat: 100% 2L NC Gen: WNWD man in NAD. Breathing comfortably on RA lying flat. Speaking in full sentences. Pleasant and cooperative. HEENT: PERRL, no scleral icterus. MM dry. OP clear Neck: JVD to mid neck lying flat Resp: CTAB anteriorly (lying flat) CV: RRR S1 and S2 audible w/o m/r/g Abd: Soft, NT, ND, No hepatomegaly. no masses. Extr: 1+ DP pulses bilaterally. No edema. Groin: R sided hematoma well circumscribed with some ecchymosis, site c/d/i R Wrist: Site of cath with pressure band over insertion site and some leaking of blood on gauze. Good cap refill on right hand. Warm. Pertinent Results: CATH 2003-11-26 LMCA: nl LAD: 50% mid disease LCX: Total occlusion within proximal stents RCA: not injected Abdominal aortography: mild left common femoral disease. femoral graft patent with no signficant disease seen in graft or native vessels to above the knee. Intervention: Successful treatment of IPMI with BMS. Using right radial approach, LCA engaged with AL2 guide. Stent occlusion crossed with wire and bballoon with restoration of flow showing progressed diesase to 80% just distal to stents. PTCA with suboptimal result so 2.5X18 minivision stent placed into larger upper pole which had multiple moderate lesions. prior stents redilated with 3.0 balloon. No residual, normal flow in all branches. . 92 7.0 \ 9.4 / 325 ----- 27.7 . 136 103 23 / 199 AGap=16 ------------- 4.3 21 0.8 \ CK: 60 91 5.7 \ 11.4 / 338 -------- 33.6 N:63.7 L:30.4 M:3.6 E:1.8 Bas:0.5 PT: 18.1 PTT: 150 INR: 1.7 Brief Hospital Course: 66 year old male with HIV, CAD, recently admitted for STEMI found to have 100% LCX lesion and stented w/ DES, who presented with STEMI to OSH, and found to have total occlusion of proximal LCX stent, now s/p bare metal stent placement. Pt was then found to have a hematocrit drop and hypotension necessitating transfuse to CCU, now stabilized. . Blood loss: Pt was s/p catheterization with R wrist for arterial access and R groin for venous access. CT scan was performed, and ruled out RP bleed and U/S ruled out AV fistula and pseudoaneurysm. He received a total of 3 units PRBCs in CCU, and his hct has been stable. Pt likely had blood loss during cath, and in groin hematoma. After being transferred back to the floor from the CCU, his Hct was stable. Low-dose metoprolol was started the night before discharge, and he tolerated this with SBP in the 100s to 110s. . Cardiac. Patient was admitted with a repeat STEMI secondary to instent thrombosis. He had placement of a bare metal stent, and was started on higher doses of plavix at 150 mg daily. He was continued on aspirin and a high dose statin as well. His antihypertensives were held due to hypotension, and restarted prior to discharge. He was not diuresed further, despite an elevated PCWP of 28 at catheterization, due to hypotension. He remained in normal sinus rhythm. . Hyperbilirubinemia: the pt was noted to have mild jaundice and scleral icterus on 10-26. LFTs were checked and his total bilirubin was 6.6, direct bili was 0.2. His other LFTs were normal. His hemolysis labs were normal. The hyperbilirubinemia was felt to be most likely due to either reabsorption of the large hematoma or a side effect from one of his HIV meds, most likely atazanavir. His bilirubin continued to climb but he was otherwise asymptomatic. A RUQ U/S showed small gallstones but no evidence of cholecystitis or obstruction. His statin and HIV meds were stopped on discharge. . HIV: Patient was continued on his outpatient HIV medications. He was continued on prophylactic bactrim. He was continued on his antidepressants. . Dispo. Patient was discharged to home with a stable hematocrit. Medications on Admission: Aspirin 325 mg Tablet daily Plavix 75 mg daily Toprol XL 25 mg daily Atorvastatin 80 mg daily Trimethoprim-Sulfamethoxazole 80-400 mg daily Fluoxetine 20 mg daily Oxycodone 5-10 mg q6h prn Viread 300 mg daily Trizivir 300-150-300 mg Young Inc Clinic REYATAZ 300 mg daily Norvir 100 mg daily Gabapentin 300 mg Q12H Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Shaw-Munoz Hospital VNA Discharge Diagnosis: 1. STEMI with in stent thrombosis 2. Hypotension 3. Groin hematoma 4. Acute blood loss anemia 5. Medication noncompliance 6. hyperbilirubinemia from hematoma reabsorption vs. HAART Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, Raymond Lees MD if weight > 3 lbs. Adhere to 2 gm sodium diet You were admitted because you had another heart attack, from a clot in the stent in your blood vessel. This happens when you do not take your medications regularly. It is very important to take all your medications. Your dose of Plavix was increased to 150 mg daily. If you develop chest pain, nausea, vomiting, throat tightness, clamminess or shortness of breath, call your PCP or go to the emergency room. If the bruise in your groin gets larger or more tender, or if you become lightheaded on standing, you should call your doctor and let him know. Do not take your anti-retroviral medications until directed by your PCP. Jamila Sakkas medications you should not be taking are abacavir, ritonavir, atazanavir, tenofovir, and Combivir. Keep taking your Bactrim. Followup Instructions: Please follow up with Dr. Hui on Thursday 1933-11-24 at 10:20am; at that time you will have your blood drawn to check your liver function tests. You may call his office at 895-807-9022 with any questions. Please follow up with Dr. Caro on 1968-4-22 at 10:30am. He will adjust your blood pressure medications as necessary. You may call his office at 709-912-5211 with any questions. Follow up with Dr. Caro (vascular surgery) as scheduled on 1968-4-22 at 2:30pm. You may call her office at 362-636-8580 with any questions. Provider: Norine Camargo, MD Phone:12-2016 Date/Time:1951-6-7 2:00 Provider: Jamila Sakkas SCAN Phone:767-965-6077 Date/Time:1951-6-7 1:00 Completed by:1971-5-14	['Admission Date: 2003-11-26 Discharge Date: 1915-7-12\n\nDate of Birth: 1923-3-16 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Betty\nChief Complaint:\nDirect transfer from Pena-Gonzales Hospital Hospital for STEMI, cath and\nnow stablized hct and transfered out of CCU\n\nMajor Surgical or Invasive Procedure:\nCardiac catheterization\nBlood transfusion\n\nHistory of Present Illness:\nMr. Kenner is a 66-year-old male with hx HIV on HAART,\nlymphoma, LUL lung adenocarcinoma s/p resection, hx CAD s/p PCI\nwith DES in 1-11 to proximal circumflex artery. In 9-12 he had\nelective cath showing 90% restenosis at proximal edge of\npreviously placed stent, treated with overlapping Cyper stent.\nMid-RCA was 80% occluded and treated with DES as well.', ' In 9-11\npt had a left femoral artery to dorsalis pedis artery bypass\ngraft with an in situ greater saphenous vein graft. His plavix\nwas discontinued at that time. He was recently admitted on\n1986-9-11 w/ STEMI over III, F, taken to cath, where he had a DES\nplaced in the LCX for the vessel being occluded by a thrombus\nproximally. Of note, at cath 4-9, he had a totally occluded\nright external iliac artery. The pt was discharged home 1911-10-6.\nSince that time, per the pt, he felt at baseline, with the\nexception of intermittent left leg pain (s/p vascular surgery,\nbypass) that would occasionally awaken him at night. He stated\nhe was up this morning at 4am b/c of this left leg pain, when he\ndeveloped a "cold rough" feeling in his esophagus similar to his\npain that he had with all of his prior MIs.', ' He states it was a\n10-19 in severity. He took 1 nitro, and it resolved. He reports\nhe did not take his plavix yesterday and today. He noted\nintermittent right sided chest pain as well last night, which\nfelt like "gas pain", + SOB, no diaphoresis, + nausea, no\nvomiting. He states the feeling returned and then persisted,\ntook a 2nd nitro but it only decreased the pain to a 1925-7-7. He\ncalled 911.\n.\nIn the ambulance, the pt\'s pain decr to 4-31 and he received\nASA, another nitro en route. His pain, however, only resolved\ncompletely on nitro gtt at OSH where he was given ASA, IV\nintegrillin, IV heparin, started on nitro drip with full\nresolution of pain, transferred to Griffin-Sanders Hospital for emergent cath. His\ninitial BP at OSH 130/75, down to 93/63 after nitro. Outside\nlabs with CK 60, other ezymes pending at time of transfer, BNP\n17.', '\n.\nAt Griffin-Sanders Hospital, he was given plavix 600mg load prior to cath. In the\ncath lab: LCX was totally occluded within proximal stents. A\nwire was passed and flow was reestablished (likely development\nof blood clots). 1 additional bare metal stent (no DES since he\nhad questionable compliance w/ plavix) placed distal to last\nstent. Some non-occluding stenosis in the distal branches. Cath\nwas performed via radial artery (per lower ext arterial\ndisease). His right groin (femoral vein) developed a hematoma.\nHis left groin was not accessed given his c/o left leg pain post\nsurgery 2 months ago. He was subsequently transferred to the\nfloor. He then had BP drop to 90s/40s-50s and a pm HCT was found\nto be 27.7 (6 point drop from pre-cath HCT). He is being\ntransferred to the CCU for unstable HCT and hematoma with labile\nBP s/p catheterization today.', '\n.\nBrief CCU event: CT scan of abd neg for RP bleed. Neg groin for\npsuedoaneurysm. Stable hct. Received total of 3 units of blood.\n2 unit pRBC for hct 27 (1-23) -> 31.6 (12-18 Am)-> 29.5-> 28.2\n(12-18 1pm)->32.3 (12-18 12pm)-> 31.8 (5-31 4am)\n\n\nPast Medical History:\nS/p left VATS and wedge biopsy of the left upper\nlobe 11-20 for adenocarcinoma.\nNon-hodgkins lung lymphoma\nHIV\nCAD\nBladder Ca, s/p resection\nS/p bowel resection\nClaudication\n\nSocial History:\nPt lives alone, formed smoker 1ppd has cut down significantly\nsince lung operations, but smoked for 40 years 1ppd, still\nsmokes a cigarette ocasionally, no EtOH. No IVDA.\n\nFamily History:\nN/C\n\nPhysical Exam:\nT: 98.2 BP: 111/67 P: 100 RR: 18 O2sat: 100% 2L NC\nGen: WNWD man in NAD. Breathing comfortably on RA lying flat.\nSpeaking in full sentences.', ' Pleasant and cooperative.\nHEENT: PERRL, no scleral icterus. MM dry. OP clear\nNeck: JVD to mid neck lying flat\nResp: CTAB anteriorly (lying flat)\nCV: RRR S1 and S2 audible w/o m/r/g\nAbd: Soft, NT, ND, No hepatomegaly. no masses.\nExtr: 1+ DP pulses bilaterally. No edema.\nGroin: R sided hematoma well circumscribed with some ecchymosis,\nsite c/d/i\nR Wrist: Site of cath with pressure band over insertion site and\nsome leaking of blood on gauze. Good cap refill on right hand.\nWarm.\n\n\nPertinent Results:\nCATH 2003-11-26\nLMCA: nl\nLAD: 50% mid disease\nLCX: Total occlusion within proximal stents\nRCA: not injected\nAbdominal aortography: mild left common femoral disease. femoral\ngraft patent with no signficant disease seen in graft or native\nvessels to above the knee.\nIntervention: Successful treatment of IPMI with BMS.', ' Using right\nradial approach, LCA engaged with AL2 guide. Stent occlusion\ncrossed with wire and bballoon with restoration of flow showing\nprogressed diesase to 80% just distal to stents. PTCA with\nsuboptimal result so 2.5X18 minivision stent placed into larger\nupper pole which had multiple moderate lesions. prior stents\nredilated with 3.0 balloon. No residual, normal flow in all\nbranches.\n.\n 92\n7.0 \\ 9.4 / 325\n -----\n 27.7\n.\n136 103 23 / 199 AGap=16\n-------------\n4.3 21 0.8 \\\nCK: 60\n 91\n5.7 \\ 11.4 / 338\n --------\n 33.6\n N:63.7 L:30.4 M:3.6 E:1.8 Bas:0.5\nPT: 18.1 PTT: 150 INR: 1.7\n\n\n\nBrief Hospital Course:\n66 year old male with HIV, CAD, recently admitted for STEMI\nfound to have 100% LCX lesion and stented w/ DES, who presented\nwith STEMI to OSH, and found to have total occlusion of proximal\nLCX stent, now s/p bare metal stent placement.', ' Pt was then found\nto have a hematocrit drop and hypotension necessitating\ntransfuse to CCU, now stabilized.\n.\nBlood loss: Pt was s/p catheterization with R wrist for arterial\naccess and R groin for venous access. CT scan was performed, and\nruled out RP bleed and U/S ruled out AV fistula and\npseudoaneurysm. He received a total of 3 units PRBCs in CCU, and\nhis hct has been stable. Pt likely had blood loss during cath,\nand in groin hematoma. After being transferred back to the floor\nfrom the CCU, his Hct was stable. Low-dose metoprolol was\nstarted the night before discharge, and he tolerated this with\nSBP in the 100s to 110s.\n.\nCardiac. Patient was admitted with a repeat STEMI secondary to\ninstent thrombosis. He had placement of a bare metal stent, and\nwas started on higher doses of plavix at 150 mg daily.', ' He was\ncontinued on aspirin and a high dose statin as well. His\nantihypertensives were held due to hypotension, and restarted\nprior to discharge.\nHe was not diuresed further, despite an elevated PCWP of 28 at\ncatheterization, due to hypotension. He remained in normal sinus\nrhythm.\n.\nHyperbilirubinemia: the pt was noted to have mild jaundice and\nscleral icterus on 10-26. LFTs were checked and his total\nbilirubin was 6.6, direct bili was 0.2. His other LFTs were\nnormal. His hemolysis labs were normal. The hyperbilirubinemia\nwas felt to be most likely due to either reabsorption of the\nlarge hematoma or a side effect from one of his HIV meds, most\nlikely atazanavir. His bilirubin continued to climb but he was\notherwise asymptomatic. A RUQ U/S showed small gallstones but no\nevidence of cholecystitis or obstruction.', ' His statin and HIV\nmeds were stopped on discharge.\n.\nHIV: Patient was continued on his outpatient HIV medications. He\nwas continued on prophylactic bactrim. He was continued on his\nantidepressants.\n.\nDispo. Patient was discharged to home with a stable hematocrit.\n\nMedications on Admission:\nAspirin 325 mg Tablet daily\nPlavix 75 mg daily\nToprol XL 25 mg daily\nAtorvastatin 80 mg daily\nTrimethoprim-Sulfamethoxazole 80-400 mg daily\nFluoxetine 20 mg daily\nOxycodone 5-10 mg q6h prn\nViread 300 mg daily\nTrizivir 300-150-300 mg Young Inc Clinic\nREYATAZ 300 mg daily\nNorvir 100 mg daily\nGabapentin 300 mg Q12H\n\n\nDischarge Medications:\n1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\n2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).', '\n3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n5. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\nDisp:60 Tablet(s) Refills:2\n6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2\ntimes a day).\nDisp:30 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nShaw-Munoz Hospital VNA\n\nDischarge Diagnosis:\n1. STEMI with in stent thrombosis\n2. Hypotension\n3. Groin hematoma\n4. Acute blood loss anemia\n5. Medication noncompliance\n6. hyperbilirubinemia from hematoma reabsorption vs. HAART\n\n\nDischarge Condition:\nStable\n\n\nDischarge Instructions:\nWeigh yourself every morning, Raymond Lees MD if weight > 3 lbs.', '\nAdhere to 2 gm sodium diet\nYou were admitted because you had another heart attack, from a\nclot in the stent in your blood vessel. This happens when you do\nnot take your medications regularly.\nIt is very important to take all your medications. Your dose of\nPlavix was increased to 150 mg daily.\nIf you develop chest pain, nausea, vomiting, throat tightness,\nclamminess or shortness of breath, call your PCP or go to the\nemergency room.\nIf the bruise in your groin gets larger or more tender, or if\nyou become lightheaded on standing, you should call your doctor\nand let him know.\nDo not take your anti-retroviral medications until directed by\nyour PCP. Jamila Sakkas medications you should not be taking are abacavir,\nritonavir, atazanavir, tenofovir, and Combivir. Keep taking your\nBactrim.\n\nFollowup Instructions:\nPlease follow up with Dr.', ' Hui on Thursday 1933-11-24 at\n10:20am; at that time you will have your blood drawn to check\nyour liver function tests. You may call his office at\n895-807-9022 with any questions.\nPlease follow up with Dr. Caro on 1968-4-22 at 10:30am. He will\nadjust your blood pressure medications as necessary. You may\ncall his office at 709-912-5211 with any questions.\nFollow up with Dr. Caro (vascular surgery) as scheduled on\n1968-4-22 at 2:30pm. You may call her office at 362-636-8580\nwith any questions.\nProvider: Norine Camargo, MD Phone:12-2016\nDate/Time:1951-6-7 2:00\nProvider: Jamila Sakkas SCAN Phone:767-965-6077 Date/Time:1951-6-7 1:00\n\n\n\nCompleted by:1971-5-14']
240	27051	113012.0	2194-02-02	Discharge summary	Report	Admission Date: [2194-1-7] Discharge Date: [2194-2-2] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Altered Mental Status and hypotension Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ]F Russian-speaking h/o refractory nodular sclerosing Hodgkins Lymphoma was brought in by EMS and admitted after her home health care aide noted she was hypotensive to 88/40 and confused. In the ED, T 98.4 (rectal), HR 101, BP 102/53, RR 20, O2Sat 98% on 3L. Incontinant of guaiac-positive stool. Treated with 4 L NS, vanco 1g IV, ceftazadime 1g IV, and flagyl 500mg IV. Received 0.5 mg ativan and 2mg IV morphine for agitation. Pt was admitted to [Hospital Unit Name 153] where she completed a 10-day course of ceftazadime and vancomycin for urosepsis. A 7-day course of metronidazole was also completed for empiric treatment of C. Diff given loose stools in the setting of an elevated WBC count, although all C. Diff assays were negative. Pt was stabilized and was transferred to the floor for further care. At the time of transfer, active issues were poor nutritional status, thrombocytopenia and anemia. On the floor, however, pt experienced an episode of new Afib with RVR to 160s and hypotension to SBP 90-100s, as well as respiratory distress after she received fluid resuscitation. There was also a concern for tachy-brady syndrome because she had pauses up to 4 sec on telemetry; EP curbside, however, felt digoxin was not recommended. Pt was therefore readmitted to the MICU. While in the MICU, she was started on vancomycin and piperacillin-tazobactam as she had (1) sites of possible infection at the erosions under her breasts and on her right hip, as well as question of PNA, (2) rising WBC, reaching a high of nearly 17. MICU course was also marked by (1) hypotension, which responded to gentle NS boluses; (2) low UOP believed to be [2-22] both hypovolemia and a low baseline nitrogenous load/obligate urine output; and (3) recurrent Afib, for which she was transitioned to amiodarone 400mg PO daily, to run for 7 days before titrating downward. Past Medical History: # Nodular sclerosing Hodgkins Lymphoma ([3-/2188]) --Presentation: Inguinal lymphadenopathy, treated with local radiotherapy initially with good results. --CT [8-23]: Progression, treated with Cytoxan, Velban and Prednisone with a good response --Eroding mass at sacrum, treated with radiation therapy --[3-/2191]: Severe hypoxemia, somnolence, and generalized edema, with anasarca responsive to diuresis and oxygen supplements, and discharged on constant oxygen --[3-/2191]: CVVP trial, stopped in [10-28] because of low blood counts --Low-dose modified regimen: Chlorambucil 4mg daily for days [1-27], Procarbazine 50mg daily for days [1-27], Velban 10 mg IV on day 1 only, Neulasta 6mg on day 8. --[9-/2192]: Chemotherapy discontinued given poor response --[1-/2193]: L sided chest pain with lytic lesions in the thoracic vertebrae; received radiation therapy to T6-T8 including the right 7th rib --CT [8-/2193]: Interval decrease in vertebral lesions. # Lower extremity cellulitis # GERD # Arthritis # Chronic BLE edema # Hypothyroidism # Hypertension # Constipation Social History: Lives at home with health care aide. Son [Name (NI) ] very involved in her care. Three children. No tobacco, alcohol, and illicit drug use. Family History: Noncontributory Physical Exam: Initial Physical Exam GENERAL: Elderly female in no acute distress. Minimally reponsive to verbal stimuli but very responsive to tactile stimulation. VITALS: T 98.8 Rectal HR 79 BP 104/67 RR 15 SAT 97%4L NC HEENT: Sclera anicteric. Moist mucous membranes. NECK: 2+ carotid pulses. No LAD.No JVP elevation. CHEST: Lungs Clear Anteriorly and laterally. No axillary LAD. HEART: Regular. No murmurs. ABD: Soft, non distended, quiet bowel sounds, non tender to percussion. EXT: Pitting edema of feet bilaterally. Nonpalpable pulses. Feet cool. Reasonable capillary refill bilaterally. NEURO: Sleepy but arousable. Pupils 1-2mm bilaterally. Withdraws from painful stimuli. Good strength. Increased Tone. Mute reflexes bilaterally. Toes mute bilaterally. Physical Exam at Time of Transfer to Medical Floor VITALS: T 97.1 P 96 R 24 100/60 94% 2L NC GENERAL: Elderly female in no acute distress. Minimally reponsive to verbal stimuli but arousable with tactile stimulation. HEENT: Sclera anicteric. Dry mucous membranes. NECK: 2+ carotid pulses. No LAD. No JVP elevation. CHEST: Diminished breath sounds at bases bilaterally. No axillary LAD. HEART: Regular. No murmurs. ABD: Soft, distended, active bowel sounds, non tender to percussion. EXT: Pitting edema of all extremities bilaterally. Nonpalpable pulses. Feet cool. Reasonable capillary refill bilaterally. NEURO: Sleepy but arousable. Pupils 3-4mm bilaterally. Withdraws from painful stimuli. Diminished reflexes bilaterally throughout. Physical Exam upon transfer to MICU: VS: Temp: 98.1 BP: 87/35 HR: 102 RR: 31 O2sat 94% 2 LNC GEN: pleasant, comfortable, NAD, somewhat somnolent (falling asleep during the exam) HEENT: PERRL, EOMI, anicteric, tachy MM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd RESP: occ. crackle at bases, though difficult to assess b/c patient not cooperative during the exam CV: RR, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: warm, + anasarca with involvement of upper limbs SKIN: no rashes, no jaundice NEURO: somewhat somnolent. Cn II-XII grossly intact. Difficult to complete full neuro exam given somnolence Pertinent Results: [1-8] - CXR - IMPRESSION: Persistent right-sided effusion. No definite consolidation. Routine PA and lateral films are recommended for evaluation when feasible. [1-10]. Echo. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (probably 3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Based on [2193] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Compared with the report of the prior study (images unavailable for review) of [2190-12-22], there is no definite change. Brief Hospital Course: [Age over 90 ]F with Nodular Sclerosing Hodgkin's Lymphoma initially admitted for urosepsis, and who was transferred to the ICU with hypotension and AFib with RVR. # Goals of Care: The patient had a long hospital course with many family meetings reagarding goals of care. On [2194-1-21] the patient was made DNR/DNI but the family continued to want ICU transfers and pressors if needed, regardless of comfort to the patient. The patient was tranferred to the unit on [2194-1-30]. She was started on levophed for hypotension but eventually a decision was made that it was medically futile to escalate care. Care was not escalated and she expired at 14:26 on [2194-2-2]. The family declined autopsy. # Afib with RVR: Pt experienced transient episodes of Afib to 150's controlled with diltiazem and metoprolol, with spontaneous conversion but with multiple episodes of up to 4 second pauses and bradycardia to 40, likely junctional escape. Digoxin considered unfavorable in this patient. In the MICU, pt was started on amiodarone gtt, and converted to amiodarone PO. When the patient was readmitted to the ICU on [2194-1-30], she was having increased pauses up to 20 seconds. Her amiodarone was stopped. # Thrombocytopenia/Anemia: The patient was anemia and thrombocytopenic throughout the admission thought to be secondary to marrow infiltration of lymphoma. Was transfused total of 3 units PLT (1 unit each on [1-14] and [1-19]) with a transfusion threshold of 10. Will continue to trend platelets, transfuse for bleeding or platelet count < 10. Transfused 1 unit platelets with good bump on [1-25]. Also, the patient has been receiving pRBC transfusions for HCT <24 (total of four units since [2194-1-12]). # Hypotension: Early on in the admission, she was having hypotensive episodes after furosemide but was responsive to fluid blosues of 250 cc. ECHO demonstrated impaired LV relaxation and given elevated WBC, there was concern for distributive shock. Once no longer fluid responsive, she was started on phenylephrine gtt, which was weaned off. She was again hypotension later in her admission thought to be secondary to systemic vasodilation. She was started on levophed but a decision was then made to not escalate care. # Infection: WBC elevated with multiple possible infectious sources which could contribute to hypotension (ie, skin erosions under breasts, course breath sounds with ?PNA). Vanc and piptaz started on [1-22]; cultures of blood and urine pending; sputum not obtainable at this point. CDiff repeated with toxin B. C Diff neg, thus D/C flagyl [1-24]. Now with GNR from skin swab. # Hypernatremia: Noted to be periodically hypernatremic since admission (Na 148-150), due to free water defecit. She has been getting slow infusions of D5W as she has poor po intake and have not been able to keep up her free water intake. # Altered Mental Status: Increased lethargy compared to baseline on admission most likely [2-22] metabolic encephalopathy due to infection and acute renal failure, with slight improvement after resolution of urosepsis. Head CT negative for acute process. Thyroid studies show elevated TSH but this may be c/w sick euthyroid syndrome. # Respiratory Distress: Early in her admission, the patient developed labored breathing after receiving 1 L NS for hypotension c/w flash pulmonary edema. Diuresis with furosemide gtt lead to hypotension; albumin resuscitation lead to repeated respiratory distress. On [2194-1-30] she was on the floor and had a witnessed aspiration event and needed 100% Hi Flow mask. While in the ICU her O2 was weaned but again aspirated and had increasing O2 requirements. # Acute renal failure: Pt noted to have Cr up to 1.7 on admission from presumed baseline of 1.0, returned to baseline of 0.9. Likely was pre-renal due to dehydration and hypotension due to sepsis. Later in her hospital course, the patient was hypotensive and her creatinine again began to rise thought secondary to ATN. # Hypothyroidism: Initially treated with levothyroxine 12.5 mcg IV daily (half home dose). T3 low. TSH elevated. Resumed home dose 1/4. # Anasarca: Pt has diffuse edema and large bilateral pleural effusions likely third-spacing from malnutrition given low albumin (2.8 on admission, then 2.2) and poor po intake. Diuresis has been difficult due to hypotension as detailed above. Continue to monitor. # Urosepsis: Admitted with hypotension due to urosepsis requiring pressor support. Urine cultures from [1-9] were positive for E.coli, and pt completed treated with vancomycin and ceftazidime x10 days. Repeat UCx [2194-1-19] grew out yeast, which was not treated. Another repeat UCx [1-22] final again grew out yeast. # Right Hip pain: Pain due to destruction of the right acetabulum consistent with progressive lymphoma on CT scan. There is dramatic medial displacement of the right femoral head secondary to lack of remaining osseous support. Stable destruction of the right posterior sacroiliac joint and surrounding right sacral ala and iliac bone. The patient's pain is being controlled with fentanyl and lidocaine patches. # Bilateral pleural effusion: R>L, thought most likely due to agressive hydration in the setting of sepsis and hypoalbuminemia. Was difficult to effect a significant diurese in MICU due to development of hypotension in response to furosemide. Appears slightly improved on CXR from [2194-1-17], unchanged on [1-20] CXR. # Nodular Sclerosing Hodgkin's Lymphoma: Seen by oncology, no interventions at this time. Likely with bone marrow infiltration causing anemia and thrombocytopenia above, as pt with low retic count and no evidence of hemolysis. No further treatment per oncology. # Coagulopathy: Mild, likely due to nutritional deficiency. Encourage PO intake and trend LFTs, coags. Medications on Admission: Medications on Admission: 1. Levothyroxine 25 mcg daily 2. Docusate Sodium 100 mg [Hospital1 ] 3. Omeprazole 20 mg daily 4. Oxycodone-Acetaminophen 5-325 mg Q4H PRN 5. Ferrous Sulfate 325mg daily 6. Tylenol-Codeine #3 300-30 mg QID PRN 7. Ultram 50 mg every 4-6 hours 8. Lasix 20 mg daily 9. Senna 8.6 mg [Hospital1 ] prn 10. Aspirin 81 mg daily 11. Potassium Chloride 12. Multivitamin . Medications on Transfer 1. Acetaminophen 325-650 mg PO/PR Q6H:PRN 2. Miconazole Powder 2% 1 Appl TP TID apply to affected area 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 CAP PO DAILY 5. Ipratropium Bromide Neb 1 NEB IH Q6H 6. Bisacodyl 10 mg PO/PR DAILY:PRN 7. Senna 1 TAB PO BID constipation 8. Docusate Sodium 100 mg PO BID 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/cough 10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 11. Fentanyl Patch 25 mcg/hr TP Q72H 12. Lidocaine 5% Patch 1 PTCH TD QD apply to right hip. One per day, on for 12 hours then remove 13. Sarna Lotion 1 Appl TP TID:PRN 14. Levothyroxine Sodium 12.5 mcg IV DAILY 15. Pantoprazole 40 mg IV Q24H Discharge Medications: The patient expired at 14:26pm on [2194-2-2] Discharge Disposition: Extended Care Discharge Diagnosis: Urosepsis Aspiration Pneumonitis Atrial Fibrillation with RVR Lymphoma Discharge Condition: The patient expired at 14:26pm on [2194-2-2] Discharge Instructions: The patient expired at 14:26pm on [2194-2-2] Followup Instructions: The patient expired at 14:26pm on [2194-2-2] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	Admission Date: <Date>1912-12-23</Date> Discharge Date: <Date>1917-7-30</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Son</Name> Chief Complaint: Altered Mental Status and hypotension Major Surgical or Invasive Procedure: None History of Present Illness: <Age>62</Age>F Russian-speaking h/o refractory nodular sclerosing Hodgkins Lymphoma was brought in by EMS and admitted after her home health care aide noted she was hypotensive to 88/40 and confused. In the ED, T 98.4 (rectal), HR 101, BP 102/53, RR 20, O2Sat 98% on 3L. Incontinant of guaiac-positive stool. Treated with 4 L NS, vanco 1g IV, ceftazadime 1g IV, and flagyl 500mg IV. Received 0.5 mg ativan and 2mg IV morphine for agitation. Pt was admitted to <Hospital>Kelly, Brown and Leonard Health System</Hospital> where she completed a 10-day course of ceftazadime and vancomycin for urosepsis. A 7-day course of metronidazole was also completed for empiric treatment of C. Diff given loose stools in the setting of an elevated WBC count, although all C. Diff assays were negative. Pt was stabilized and was transferred to the floor for further care. At the time of transfer, active issues were poor nutritional status, thrombocytopenia and anemia. On the floor, however, pt experienced an episode of new Afib with RVR to 160s and hypotension to SBP 90-100s, as well as respiratory distress after she received fluid resuscitation. There was also a concern for tachy-brady syndrome because she had pauses up to 4 sec on telemetry; EP curbside, however, felt digoxin was not recommended. Pt was therefore readmitted to the MICU. While in the MICU, she was started on vancomycin and piperacillin-tazobactam as she had (1) sites of possible infection at the erosions under her breasts and on her right hip, as well as question of PNA, (2) rising WBC, reaching a high of nearly 17. MICU course was also marked by (1) hypotension, which responded to gentle NS boluses; (2) low UOP believed to be <Date>1-6</Date> both hypovolemia and a low baseline nitrogenous load/obligate urine output; and (3) recurrent Afib, for which she was transitioned to amiodarone 400mg PO daily, to run for 7 days before titrating downward. Past Medical History: # Nodular sclerosing Hodgkins Lymphoma (<Date>6-1994</Date>) --Presentation: Inguinal lymphadenopathy, treated with local radiotherapy initially with good results. --CT <Date>2-31</Date>: Progression, treated with Cytoxan, Velban and Prednisone with a good response --Eroding mass at sacrum, treated with radiation therapy --<Date>2-1937</Date>: Severe hypoxemia, somnolence, and generalized edema, with anasarca responsive to diuresis and oxygen supplements, and discharged on constant oxygen --<Date>2-1937</Date>: CVVP trial, stopped in <Date>9-7</Date> because of low blood counts --Low-dose modified regimen: Chlorambucil 4mg daily for days <Date>11-25</Date>, Procarbazine 50mg daily for days <Date>11-25</Date>, Velban 10 mg IV on day 1 only, Neulasta 6mg on day 8. --<Date>8-1930</Date>: Chemotherapy discontinued given poor response --<Date>3-1992</Date>: L sided chest pain with lytic lesions in the thoracic vertebrae; received radiation therapy to T6-T8 including the right 7th rib --CT <Date>6-1953</Date>: Interval decrease in vertebral lesions. # Lower extremity cellulitis # GERD # Arthritis # Chronic BLE edema # Hypothyroidism # Hypertension # Constipation Social History: Lives at home with health care aide. Son <Name>Cedric Naegelin</Name> very involved in her care. Three children. No tobacco, alcohol, and illicit drug use. Family History: Noncontributory Physical Exam: Initial Physical Exam GENERAL: Elderly female in no acute distress. Minimally reponsive to verbal stimuli but very responsive to tactile stimulation. VITALS: T 98.8 Rectal HR 79 BP 104/67 RR 15 SAT 97%4L NC HEENT: Sclera anicteric. Moist mucous membranes. NECK: 2+ carotid pulses. No LAD.No JVP elevation. CHEST: Lungs Clear Anteriorly and laterally. No axillary LAD. HEART: Regular. No murmurs. ABD: Soft, non distended, quiet bowel sounds, non tender to percussion. EXT: Pitting edema of feet bilaterally. Nonpalpable pulses. Feet cool. Reasonable capillary refill bilaterally. NEURO: Sleepy but arousable. Pupils 1-2mm bilaterally. Withdraws from painful stimuli. Good strength. Increased Tone. Mute reflexes bilaterally. Toes mute bilaterally. Physical Exam at Time of Transfer to Medical Floor VITALS: T 97.1 P 96 R 24 100/60 94% 2L NC GENERAL: Elderly female in no acute distress. Minimally reponsive to verbal stimuli but arousable with tactile stimulation. HEENT: Sclera anicteric. Dry mucous membranes. NECK: 2+ carotid pulses. No LAD. No JVP elevation. CHEST: Diminished breath sounds at bases bilaterally. No axillary LAD. HEART: Regular. No murmurs. ABD: Soft, distended, active bowel sounds, non tender to percussion. EXT: Pitting edema of all extremities bilaterally. Nonpalpable pulses. Feet cool. Reasonable capillary refill bilaterally. NEURO: Sleepy but arousable. Pupils 3-4mm bilaterally. Withdraws from painful stimuli. Diminished reflexes bilaterally throughout. Physical Exam upon transfer to MICU: VS: Temp: 98.1 BP: 87/35 HR: 102 RR: 31 O2sat 94% 2 LNC GEN: pleasant, comfortable, NAD, somewhat somnolent (falling asleep during the exam) HEENT: PERRL, EOMI, anicteric, tachy MM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd RESP: occ. crackle at bases, though difficult to assess b/c patient not cooperative during the exam CV: RR, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: warm, + anasarca with involvement of upper limbs SKIN: no rashes, no jaundice NEURO: somewhat somnolent. Cn II-XII grossly intact. Difficult to complete full neuro exam given somnolence Pertinent Results: <Date>5-28</Date> - CXR - IMPRESSION: Persistent right-sided effusion. No definite consolidation. Routine PA and lateral films are recommended for evaluation when feasible. <Date>4-2</Date>. Echo. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (probably 3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Based on <Year>2011</Year> AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Compared with the report of the prior study (images unavailable for review) of <Date>1933-1-6</Date>, there is no definite change. Brief Hospital Course: <Age>62</Age>F with Nodular Sclerosing Hodgkin's Lymphoma initially admitted for urosepsis, and who was transferred to the ICU with hypotension and AFib with RVR. # Goals of Care: The patient had a long hospital course with many family meetings reagarding goals of care. On <Date>1965-2-23</Date> the patient was made DNR/DNI but the family continued to want ICU transfers and pressors if needed, regardless of comfort to the patient. The patient was tranferred to the unit on <Date>1910-11-14</Date>. She was started on levophed for hypotension but eventually a decision was made that it was medically futile to escalate care. Care was not escalated and she expired at 14:26 on <Date>1917-7-30</Date>. The family declined autopsy. # Afib with RVR: Pt experienced transient episodes of Afib to 150's controlled with diltiazem and metoprolol, with spontaneous conversion but with multiple episodes of up to 4 second pauses and bradycardia to 40, likely junctional escape. Digoxin considered unfavorable in this patient. In the MICU, pt was started on amiodarone gtt, and converted to amiodarone PO. When the patient was readmitted to the ICU on <Date>1910-11-14</Date>, she was having increased pauses up to 20 seconds. Her amiodarone was stopped. # Thrombocytopenia/Anemia: The patient was anemia and thrombocytopenic throughout the admission thought to be secondary to marrow infiltration of lymphoma. Was transfused total of 3 units PLT (1 unit each on <Date>6-6</Date> and <Date>5-13</Date>) with a transfusion threshold of 10. Will continue to trend platelets, transfuse for bleeding or platelet count < 10. Transfused 1 unit platelets with good bump on <Date>4-21</Date>. Also, the patient has been receiving pRBC transfusions for HCT <24 (total of four units since <Date>1938-6-16</Date>). # Hypotension: Early on in the admission, she was having hypotensive episodes after furosemide but was responsive to fluid blosues of 250 cc. ECHO demonstrated impaired LV relaxation and given elevated WBC, there was concern for distributive shock. Once no longer fluid responsive, she was started on phenylephrine gtt, which was weaned off. She was again hypotension later in her admission thought to be secondary to systemic vasodilation. She was started on levophed but a decision was then made to not escalate care. # Infection: WBC elevated with multiple possible infectious sources which could contribute to hypotension (ie, skin erosions under breasts, course breath sounds with ?PNA). Vanc and piptaz started on <Date>4-30</Date>; cultures of blood and urine pending; sputum not obtainable at this point. CDiff repeated with toxin B. C Diff neg, thus D/C flagyl <Date>3-9</Date>. Now with GNR from skin swab. # Hypernatremia: Noted to be periodically hypernatremic since admission (Na 148-150), due to free water defecit. She has been getting slow infusions of D5W as she has poor po intake and have not been able to keep up her free water intake. # Altered Mental Status: Increased lethargy compared to baseline on admission most likely <Date>1-6</Date> metabolic encephalopathy due to infection and acute renal failure, with slight improvement after resolution of urosepsis. Head CT negative for acute process. Thyroid studies show elevated TSH but this may be c/w sick euthyroid syndrome. # Respiratory Distress: Early in her admission, the patient developed labored breathing after receiving 1 L NS for hypotension c/w flash pulmonary edema. Diuresis with furosemide gtt lead to hypotension; albumin resuscitation lead to repeated respiratory distress. On <Date>1910-11-14</Date> she was on the floor and had a witnessed aspiration event and needed 100% Hi Flow mask. While in the ICU her O2 was weaned but again aspirated and had increasing O2 requirements. # Acute renal failure: Pt noted to have Cr up to 1.7 on admission from presumed baseline of 1.0, returned to baseline of 0.9. Likely was pre-renal due to dehydration and hypotension due to sepsis. Later in her hospital course, the patient was hypotensive and her creatinine again began to rise thought secondary to ATN. # Hypothyroidism: Initially treated with levothyroxine 12.5 mcg IV daily (half home dose). T3 low. TSH elevated. Resumed home dose 1/4. # Anasarca: Pt has diffuse edema and large bilateral pleural effusions likely third-spacing from malnutrition given low albumin (2.8 on admission, then 2.2) and poor po intake. Diuresis has been difficult due to hypotension as detailed above. Continue to monitor. # Urosepsis: Admitted with hypotension due to urosepsis requiring pressor support. Urine cultures from <Date>1-12</Date> were positive for E.coli, and pt completed treated with vancomycin and ceftazidime x10 days. Repeat UCx <Date>1909-8-25</Date> grew out yeast, which was not treated. Another repeat UCx <Date>4-30</Date> final again grew out yeast. # Right Hip pain: Pain due to destruction of the right acetabulum consistent with progressive lymphoma on CT scan. There is dramatic medial displacement of the right femoral head secondary to lack of remaining osseous support. Stable destruction of the right posterior sacroiliac joint and surrounding right sacral ala and iliac bone. The patient's pain is being controlled with fentanyl and lidocaine patches. # Bilateral pleural effusion: R>L, thought most likely due to agressive hydration in the setting of sepsis and hypoalbuminemia. Was difficult to effect a significant diurese in MICU due to development of hypotension in response to furosemide. Appears slightly improved on CXR from <Date>1901-2-3</Date>, unchanged on <Date>9-22</Date> CXR. # Nodular Sclerosing Hodgkin's Lymphoma: Seen by oncology, no interventions at this time. Likely with bone marrow infiltration causing anemia and thrombocytopenia above, as pt with low retic count and no evidence of hemolysis. No further treatment per oncology. # Coagulopathy: Mild, likely due to nutritional deficiency. Encourage PO intake and trend LFTs, coags. Medications on Admission: Medications on Admission: 1. Levothyroxine 25 mcg daily 2. Docusate Sodium 100 mg <Hospital>Holmes-James Clinic</Hospital> 3. Omeprazole 20 mg daily 4. Oxycodone-Acetaminophen 5-325 mg Q4H PRN 5. Ferrous Sulfate 325mg daily 6. Tylenol-Codeine #3 300-30 mg QID PRN 7. Ultram 50 mg every 4-6 hours 8. Lasix 20 mg daily 9. Senna 8.6 mg <Hospital>Holmes-James Clinic</Hospital> prn 10. Aspirin 81 mg daily 11. Potassium Chloride 12. Multivitamin . Medications on Transfer 1. Acetaminophen 325-650 mg PO/PR Q6H:PRN 2. Miconazole Powder 2% 1 Appl TP TID apply to affected area 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 CAP PO DAILY 5. Ipratropium Bromide Neb 1 NEB IH Q6H 6. Bisacodyl 10 mg PO/PR DAILY:PRN 7. Senna 1 TAB PO BID constipation 8. Docusate Sodium 100 mg PO BID 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/cough 10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 11. Fentanyl Patch 25 mcg/hr TP Q72H 12. Lidocaine 5% Patch 1 PTCH TD QD apply to right hip. One per day, on for 12 hours then remove 13. Sarna Lotion 1 Appl TP TID:PRN 14. Levothyroxine Sodium 12.5 mcg IV DAILY 15. Pantoprazole 40 mg IV Q24H Discharge Medications: The patient expired at 14:26pm on <Date>1917-7-30</Date> Discharge Disposition: Extended Care Discharge Diagnosis: Urosepsis Aspiration Pneumonitis Atrial Fibrillation with RVR Lymphoma Discharge Condition: The patient expired at 14:26pm on <Date>1917-7-30</Date> Discharge Instructions: The patient expired at 14:26pm on <Date>1917-7-30</Date> Followup Instructions: The patient expired at 14:26pm on <Date>1917-7-30</Date> <Initial>PG</Initial> <Name>Ngo</Name> <Name>Gregory Waldon</Name> MD <MD Number>08465759</MD 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Date: 1912-12-23 Discharge Date: 1917-7-30 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Son Chief Complaint: Altered Mental Status and hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 62F Russian-speaking h/o refractory nodular sclerosing Hodgkins Lymphoma was brought in by EMS and admitted after her home health care aide noted she was hypotensive to 88/40 and confused. In the ED, T 98.4 (rectal), HR 101, BP 102/53, RR 20, O2Sat 98% on 3L. Incontinant of guaiac-positive stool. Treated with 4 L NS, vanco 1g IV, ceftazadime 1g IV, and flagyl 500mg IV. Received 0.5 mg ativan and 2mg IV morphine for agitation. Pt was admitted to Kelly, Brown and Leonard Health System where she completed a 10-day course of ceftazadime and vancomycin for urosepsis. A 7-day course of metronidazole was also completed for empiric treatment of C. Diff given loose stools in the setting of an elevated WBC count, although all C. Diff assays were negative. Pt was stabilized and was transferred to the floor for further care. At the time of transfer, active issues were poor nutritional status, thrombocytopenia and anemia. On the floor, however, pt experienced an episode of new Afib with RVR to 160s and hypotension to SBP 90-100s, as well as respiratory distress after she received fluid resuscitation. There was also a concern for tachy-brady syndrome because she had pauses up to 4 sec on telemetry; EP curbside, however, felt digoxin was not recommended. Pt was therefore readmitted to the MICU. While in the MICU, she was started on vancomycin and piperacillin-tazobactam as she had (1) sites of possible infection at the erosions under her breasts and on her right hip, as well as question of PNA, (2) rising WBC, reaching a high of nearly 17. MICU course was also marked by (1) hypotension, which responded to gentle NS boluses; (2) low UOP believed to be 1-6 both hypovolemia and a low baseline nitrogenous load/obligate urine output; and (3) recurrent Afib, for which she was transitioned to amiodarone 400mg PO daily, to run for 7 days before titrating downward. Past Medical History: # Nodular sclerosing Hodgkins Lymphoma (6-1994) --Presentation: Inguinal lymphadenopathy, treated with local radiotherapy initially with good results. --CT 2-31: Progression, treated with Cytoxan, Velban and Prednisone with a good response --Eroding mass at sacrum, treated with radiation therapy --2-1937: Severe hypoxemia, somnolence, and generalized edema, with anasarca responsive to diuresis and oxygen supplements, and discharged on constant oxygen --2-1937: CVVP trial, stopped in 9-7 because of low blood counts --Low-dose modified regimen: Chlorambucil 4mg daily for days 11-25, Procarbazine 50mg daily for days 11-25, Velban 10 mg IV on day 1 only, Neulasta 6mg on day 8. --8-1930: Chemotherapy discontinued given poor response --3-1992: L sided chest pain with lytic lesions in the thoracic vertebrae; received radiation therapy to T6-T8 including the right 7th rib --CT 6-1953: Interval decrease in vertebral lesions. # Lower extremity cellulitis # GERD # Arthritis # Chronic BLE edema # Hypothyroidism # Hypertension # Constipation Social History: Lives at home with health care aide. Son Cedric Naegelin very involved in her care. Three children. No tobacco, alcohol, and illicit drug use. Family History: Noncontributory Physical Exam: Initial Physical Exam GENERAL: Elderly female in no acute distress. Minimally reponsive to verbal stimuli but very responsive to tactile stimulation. VITALS: T 98.8 Rectal HR 79 BP 104/67 RR 15 SAT 97%4L NC HEENT: Sclera anicteric. Moist mucous membranes. NECK: 2+ carotid pulses. No LAD.No JVP elevation. CHEST: Lungs Clear Anteriorly and laterally. No axillary LAD. HEART: Regular. No murmurs. ABD: Soft, non distended, quiet bowel sounds, non tender to percussion. EXT: Pitting edema of feet bilaterally. Nonpalpable pulses. Feet cool. Reasonable capillary refill bilaterally. NEURO: Sleepy but arousable. Pupils 1-2mm bilaterally. Withdraws from painful stimuli. Good strength. Increased Tone. Mute reflexes bilaterally. Toes mute bilaterally. Physical Exam at Time of Transfer to Medical Floor VITALS: T 97.1 P 96 R 24 100/60 94% 2L NC GENERAL: Elderly female in no acute distress. Minimally reponsive to verbal stimuli but arousable with tactile stimulation. HEENT: Sclera anicteric. Dry mucous membranes. NECK: 2+ carotid pulses. No LAD. No JVP elevation. CHEST: Diminished breath sounds at bases bilaterally. No axillary LAD. HEART: Regular. No murmurs. ABD: Soft, distended, active bowel sounds, non tender to percussion. EXT: Pitting edema of all extremities bilaterally. Nonpalpable pulses. Feet cool. Reasonable capillary refill bilaterally. NEURO: Sleepy but arousable. Pupils 3-4mm bilaterally. Withdraws from painful stimuli. Diminished reflexes bilaterally throughout. Physical Exam upon transfer to MICU: VS: Temp: 98.1 BP: 87/35 HR: 102 RR: 31 O2sat 94% 2 LNC GEN: pleasant, comfortable, NAD, somewhat somnolent (falling asleep during the exam) HEENT: PERRL, EOMI, anicteric, tachy MM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd RESP: occ. crackle at bases, though difficult to assess b/c patient not cooperative during the exam CV: RR, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: warm, + anasarca with involvement of upper limbs SKIN: no rashes, no jaundice NEURO: somewhat somnolent. Cn II-XII grossly intact. Difficult to complete full neuro exam given somnolence Pertinent Results: 5-28 - CXR - IMPRESSION: Persistent right-sided effusion. No definite consolidation. Routine PA and lateral films are recommended for evaluation when feasible. 4-2. Echo. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (probably 3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Based on 2011 AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Compared with the report of the prior study (images unavailable for review) of 1933-1-6, there is no definite change. Brief Hospital Course: 62F with Nodular Sclerosing Hodgkin's Lymphoma initially admitted for urosepsis, and who was transferred to the ICU with hypotension and AFib with RVR. # Goals of Care: The patient had a long hospital course with many family meetings reagarding goals of care. On 1965-2-23 the patient was made DNR/DNI but the family continued to want ICU transfers and pressors if needed, regardless of comfort to the patient. The patient was tranferred to the unit on 1910-11-14. She was started on levophed for hypotension but eventually a decision was made that it was medically futile to escalate care. Care was not escalated and she expired at 14:26 on 1917-7-30. The family declined autopsy. # Afib with RVR: Pt experienced transient episodes of Afib to 150's controlled with diltiazem and metoprolol, with spontaneous conversion but with multiple episodes of up to 4 second pauses and bradycardia to 40, likely junctional escape. Digoxin considered unfavorable in this patient. In the MICU, pt was started on amiodarone gtt, and converted to amiodarone PO. When the patient was readmitted to the ICU on 1910-11-14, she was having increased pauses up to 20 seconds. Her amiodarone was stopped. # Thrombocytopenia/Anemia: The patient was anemia and thrombocytopenic throughout the admission thought to be secondary to marrow infiltration of lymphoma. Was transfused total of 3 units PLT (1 unit each on 6-6 and 5-13) with a transfusion threshold of 10. Will continue to trend platelets, transfuse for bleeding or platelet count 4-21. Also, the patient has been receiving pRBC transfusions for HCT 1938-6-16). # Hypotension: Early on in the admission, she was having hypotensive episodes after furosemide but was responsive to fluid blosues of 250 cc. ECHO demonstrated impaired LV relaxation and given elevated WBC, there was concern for distributive shock. Once no longer fluid responsive, she was started on phenylephrine gtt, which was weaned off. She was again hypotension later in her admission thought to be secondary to systemic vasodilation. She was started on levophed but a decision was then made to not escalate care. # Infection: WBC elevated with multiple possible infectious sources which could contribute to hypotension (ie, skin erosions under breasts, course breath sounds with ?PNA). Vanc and piptaz started on 4-30; cultures of blood and urine pending; sputum not obtainable at this point. CDiff repeated with toxin B. C Diff neg, thus D/C flagyl 3-9. Now with GNR from skin swab. # Hypernatremia: Noted to be periodically hypernatremic since admission (Na 148-150), due to free water defecit. She has been getting slow infusions of D5W as she has poor po intake and have not been able to keep up her free water intake. # Altered Mental Status: Increased lethargy compared to baseline on admission most likely 1-6 metabolic encephalopathy due to infection and acute renal failure, with slight improvement after resolution of urosepsis. Head CT negative for acute process. Thyroid studies show elevated TSH but this may be c/w sick euthyroid syndrome. # Respiratory Distress: Early in her admission, the patient developed labored breathing after receiving 1 L NS for hypotension c/w flash pulmonary edema. Diuresis with furosemide gtt lead to hypotension; albumin resuscitation lead to repeated respiratory distress. On 1910-11-14 she was on the floor and had a witnessed aspiration event and needed 100% Hi Flow mask. While in the ICU her O2 was weaned but again aspirated and had increasing O2 requirements. # Acute renal failure: Pt noted to have Cr up to 1.7 on admission from presumed baseline of 1.0, returned to baseline of 0.9. Likely was pre-renal due to dehydration and hypotension due to sepsis. Later in her hospital course, the patient was hypotensive and her creatinine again began to rise thought secondary to ATN. # Hypothyroidism: Initially treated with levothyroxine 12.5 mcg IV daily (half home dose). T3 low. TSH elevated. Resumed home dose 1/4. # Anasarca: Pt has diffuse edema and large bilateral pleural effusions likely third-spacing from malnutrition given low albumin (2.8 on admission, then 2.2) and poor po intake. Diuresis has been difficult due to hypotension as detailed above. Continue to monitor. # Urosepsis: Admitted with hypotension due to urosepsis requiring pressor support. Urine cultures from 1-12 were positive for E.coli, and pt completed treated with vancomycin and ceftazidime x10 days. Repeat UCx 1909-8-25 grew out yeast, which was not treated. Another repeat UCx 4-30 final again grew out yeast. # Right Hip pain: Pain due to destruction of the right acetabulum consistent with progressive lymphoma on CT scan. There is dramatic medial displacement of the right femoral head secondary to lack of remaining osseous support. Stable destruction of the right posterior sacroiliac joint and surrounding right sacral ala and iliac bone. The patient's pain is being controlled with fentanyl and lidocaine patches. # Bilateral pleural effusion: R>L, thought most likely due to agressive hydration in the setting of sepsis and hypoalbuminemia. Was difficult to effect a significant diurese in MICU due to development of hypotension in response to furosemide. Appears slightly improved on CXR from 1901-2-3, unchanged on 9-22 CXR. # Nodular Sclerosing Hodgkin's Lymphoma: Seen by oncology, no interventions at this time. Likely with bone marrow infiltration causing anemia and thrombocytopenia above, as pt with low retic count and no evidence of hemolysis. No further treatment per oncology. # Coagulopathy: Mild, likely due to nutritional deficiency. Encourage PO intake and trend LFTs, coags. Medications on Admission: Medications on Admission: 1. Levothyroxine 25 mcg daily 2. Docusate Sodium 100 mg Holmes-James Clinic 3. Omeprazole 20 mg daily 4. Oxycodone-Acetaminophen 5-325 mg Q4H PRN 5. Ferrous Sulfate 325mg daily 6. Tylenol-Codeine #3 300-30 mg QID PRN 7. Ultram 50 mg every 4-6 hours 8. Lasix 20 mg daily 9. Senna 8.6 mg Holmes-James Clinic prn 10. Aspirin 81 mg daily 11. Potassium Chloride 12. Multivitamin . Medications on Transfer 1. Acetaminophen 325-650 mg PO/PR Q6H:PRN 2. Miconazole Powder 2% 1 Appl TP TID apply to affected area 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 CAP PO DAILY 5. Ipratropium Bromide Neb 1 NEB IH Q6H 6. Bisacodyl 10 mg PO/PR DAILY:PRN 7. Senna 1 TAB PO BID constipation 8. Docusate Sodium 100 mg PO BID 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/cough 10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 11. Fentanyl Patch 25 mcg/hr TP Q72H 12. Lidocaine 5% Patch 1 PTCH TD QD apply to right hip. One per day, on for 12 hours then remove 13. Sarna Lotion 1 Appl TP TID:PRN 14. Levothyroxine Sodium 12.5 mcg IV DAILY 15. Pantoprazole 40 mg IV Q24H Discharge Medications: The patient expired at 14:26pm on 1917-7-30 Discharge Disposition: Extended Care Discharge Diagnosis: Urosepsis Aspiration Pneumonitis Atrial Fibrillation with RVR Lymphoma Discharge Condition: The patient expired at 14:26pm on 1917-7-30 Discharge Instructions: The patient expired at 14:26pm on 1917-7-30 Followup Instructions: The patient expired at 14:26pm on 1917-7-30 PG Ngo Gregory Waldon MD 08465759	['Admission Date: 1912-12-23 Discharge Date: 1917-7-30\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Son\nChief Complaint:\nAltered Mental Status and hypotension\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\n62F Russian-speaking h/o refractory nodular sclerosing Hodgkins\nLymphoma was brought in by EMS and admitted after her home\nhealth care aide noted she was hypotensive to 88/40 and\nconfused.\n\nIn the ED, T 98.4 (rectal), HR 101, BP 102/53, RR 20, O2Sat 98%\non 3L. Incontinant of guaiac-positive stool. Treated with 4 L\nNS, vanco 1g IV, ceftazadime 1g IV, and flagyl 500mg IV.\nReceived 0.5 mg ativan and 2mg IV morphine for agitation.\n\nPt was admitted to Kelly, Brown and Leonard Health System where she completed a 10-day course of\nceftazadime and vancomycin for urosepsis.', ' A 7-day course of\nmetronidazole was also completed for empiric treatment of C.\nDiff given loose stools in the setting of an elevated WBC count,\nalthough all C. Diff assays were negative. Pt was stabilized and\nwas transferred to the floor for further care. At the time of\ntransfer, active issues were poor nutritional status,\nthrombocytopenia and anemia.\n\nOn the floor, however, pt experienced an episode of new Afib\nwith RVR to 160s and hypotension to SBP 90-100s, as well as\nrespiratory distress after she received fluid resuscitation.\nThere was also a concern for tachy-brady syndrome because she\nhad pauses up to 4 sec on telemetry; EP curbside, however, felt\ndigoxin was not recommended.\n\nPt was therefore readmitted to the MICU. While in the MICU, she\nwas started on vancomycin and piperacillin-tazobactam as she had\n(1) sites of possible infection at the erosions under her\nbreasts and on her right hip, as well as question of PNA, (2)\nrising WBC, reaching a high of nearly 17.', ' MICU course was also\nmarked by (1) hypotension, which responded to gentle NS boluses;\n(2) low UOP believed to be 1-6 both hypovolemia and a low\nbaseline nitrogenous load/obligate urine output; and (3)\nrecurrent Afib, for which she was transitioned to amiodarone\n400mg PO daily, to run for 7 days before titrating downward.\n\nPast Medical History:\n# Nodular sclerosing Hodgkins Lymphoma (6-1994)\n--Presentation: Inguinal lymphadenopathy, treated with local\nradiotherapy initially with good results.\n--CT 2-31: Progression, treated with Cytoxan, Velban and\nPrednisone with a good response\n--Eroding mass at sacrum, treated with radiation therapy\n--2-1937: Severe hypoxemia, somnolence, and generalized edema,\nwith anasarca responsive to diuresis and oxygen supplements, and\ndischarged on constant oxygen\n--2-1937: CVVP trial, stopped in 9-7 because of low blood\ncounts\n--Low-dose modified regimen: Chlorambucil 4mg daily for days\n11-25, Procarbazine 50mg daily for days 11-25, Velban 10 mg IV on\nday 1 only, Neulasta 6mg on day 8.', '\n--8-1930: Chemotherapy discontinued given poor response\n--3-1992: L sided chest pain with lytic lesions in the thoracic\nvertebrae; received radiation therapy to T6-T8 including the\nright 7th rib\n--CT 6-1953: Interval decrease in vertebral lesions.\n\n# Lower extremity cellulitis\n# GERD\n# Arthritis\n# Chronic BLE edema\n# Hypothyroidism\n# Hypertension\n# Constipation\n\nSocial History:\nLives at home with health care aide. Son Cedric Naegelin very involved in\nher care. Three children. No tobacco, alcohol, and illicit drug\nuse.\n\n\nFamily History:\nNoncontributory\n\nPhysical Exam:\nInitial Physical Exam\nGENERAL: Elderly female in no acute distress. Minimally\nreponsive to verbal stimuli but very responsive to tactile\nstimulation.\nVITALS: T 98.8 Rectal HR 79 BP 104/67 RR 15 SAT 97%4L NC\nHEENT: Sclera anicteric.', ' Moist mucous membranes.\nNECK: 2+ carotid pulses. No LAD.No JVP elevation.\nCHEST: Lungs Clear Anteriorly and laterally. No axillary LAD.\nHEART: Regular. No murmurs.\nABD: Soft, non distended, quiet bowel sounds, non tender to\npercussion.\nEXT: Pitting edema of feet bilaterally. Nonpalpable pulses. Feet\ncool. Reasonable capillary refill bilaterally.\nNEURO: Sleepy but arousable. Pupils 1-2mm bilaterally. Withdraws\nfrom painful stimuli. Good strength. Increased Tone. Mute\nreflexes bilaterally. Toes mute bilaterally.\n\nPhysical Exam at Time of Transfer to Medical Floor\nVITALS: T 97.1 P 96 R 24 100/60 94% 2L NC\nGENERAL: Elderly female in no acute distress. Minimally\nreponsive to verbal stimuli but arousable with tactile\nstimulation.\nHEENT: Sclera anicteric. Dry mucous membranes.\nNECK: 2+ carotid pulses.', ' No LAD. No JVP elevation.\nCHEST: Diminished breath sounds at bases bilaterally. No\naxillary LAD.\nHEART: Regular. No murmurs.\nABD: Soft, distended, active bowel sounds, non tender to\npercussion.\nEXT: Pitting edema of all extremities bilaterally. Nonpalpable\npulses. Feet cool. Reasonable capillary refill bilaterally.\nNEURO: Sleepy but arousable. Pupils 3-4mm bilaterally. Withdraws\nfrom painful stimuli. Diminished reflexes bilaterally\nthroughout.\n\nPhysical Exam upon transfer to MICU:\nVS: Temp: 98.1 BP: 87/35 HR: 102 RR: 31 O2sat 94% 2 LNC\nGEN: pleasant, comfortable, NAD, somewhat somnolent (falling\nasleep during the exam)\nHEENT: PERRL, EOMI, anicteric, tachy MM, op without lesions\nNECK: no supraclavicular or cervical lymphadenopathy, no jvd\nRESP: occ. crackle at bases, though difficult to assess b/c\npatient not cooperative during the exam\nCV: RR, no m/r/g\nABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly\nEXT: warm, + anasarca with involvement of upper limbs\nSKIN: no rashes, no jaundice\nNEURO: somewhat somnolent.', ' Cn II-XII grossly intact. Difficult\nto complete full neuro exam given somnolence\n\nPertinent Results:\n5-28 - CXR - IMPRESSION: Persistent right-sided effusion. No\ndefinite consolidation. Routine PA and lateral films are\nrecommended for evaluation when feasible.\n\n4-2. Echo.\nThe left atrium is normal in size. No atrial septal defect is\nseen by 2D or color Doppler. Left ventricular wall thicknesses\nare normal. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The\naortic valve leaflets (probably 3) are mildly thickened. There\nis no aortic valve stenosis. Trace aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Physiologic\nmitral regurgitation is seen (within normal limits).', " There is\nmoderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nBased on 2011 AHA endocarditis prophylaxis recommendations, the\necho findings indicate prophylaxis is NOT recommended. Clinical\ndecisions regarding the need for prophylaxis should be based on\nclinical and echocardiographic data.\n\nCompared with the report of the prior study (images unavailable\nfor review) of 1933-1-6, there is no definite change.\n\nBrief Hospital Course:\n62F with Nodular Sclerosing Hodgkin's Lymphoma initially\nadmitted for urosepsis, and who was transferred to the ICU with\nhypotension and AFib with RVR.\n\n# Goals of Care: The patient had a long hospital course with\nmany family meetings reagarding goals of care. On 1965-2-23 the\npatient was made DNR/DNI but the family continued to want ICU\ntransfers and pressors if needed, regardless of comfort to the\npatient.", " The patient was tranferred to the unit on 1910-11-14.\nShe was started on levophed for hypotension but eventually a\ndecision was made that it was medically futile to escalate care.\n Care was not escalated and she expired at 14:26 on 1917-7-30.\nThe family declined autopsy.\n\n# Afib with RVR: Pt experienced transient episodes of Afib to\n150's controlled with diltiazem and metoprolol, with spontaneous\nconversion but with multiple episodes of up to 4 second pauses\nand bradycardia to 40, likely junctional escape. Digoxin\nconsidered unfavorable in this patient. In the MICU, pt was\nstarted on amiodarone gtt, and converted to amiodarone PO. When\nthe patient was readmitted to the ICU on 1910-11-14, she was having\nincreased pauses up to 20 seconds. Her amiodarone was stopped.\n\n\n# Thrombocytopenia/Anemia: The patient was anemia and\nthrombocytopenic throughout the admission thought to be\nsecondary to marrow infiltration of lymphoma.", ' Was transfused\ntotal of 3 units PLT (1 unit each on 6-6 and 5-13)\nwith a transfusion threshold of 10. Will continue to trend\nplatelets, transfuse for bleeding or platelet count 4-21. Also, the\npatient has been receiving pRBC transfusions for HCT 1938-6-16).\n\n# Hypotension: Early on in the admission, she was having\nhypotensive episodes after furosemide but was responsive to\nfluid blosues of 250 cc. ECHO demonstrated impaired LV\nrelaxation and given elevated WBC, there was concern for\ndistributive shock. Once no longer fluid responsive, she was\nstarted on phenylephrine gtt, which was weaned off. She was\nagain hypotension later in her admission thought to be secondary\nto systemic vasodilation. She was started on levophed but a\ndecision was then made to not escalate care.\n\n# Infection: WBC elevated with multiple possible infectious\nsources which could contribute to hypotension (ie, skin erosions\nunder breasts, course breath sounds with ?PNA).', ' Vanc and piptaz\nstarted on 4-30; cultures of blood and urine pending; sputum not\nobtainable at this point. CDiff repeated with toxin B. C Diff\nneg, thus D/C flagyl 3-9. Now with GNR from skin swab.\n\n# Hypernatremia: Noted to be periodically hypernatremic since\nadmission (Na 148-150), due to free water defecit. She has been\ngetting slow infusions of D5W as she has poor po intake and have\nnot been able to keep up her free water intake.\n\n# Altered Mental Status: Increased lethargy compared to baseline\non admission most likely 1-6 metabolic encephalopathy due to\ninfection and acute renal failure, with slight improvement after\nresolution of urosepsis. Head CT negative for acute process.\nThyroid studies show elevated TSH but this may be c/w sick\neuthyroid syndrome.\n\n# Respiratory Distress: Early in her admission, the patient\ndeveloped labored breathing after receiving 1 L NS for\nhypotension c/w flash pulmonary edema.', ' Diuresis with furosemide\ngtt lead to hypotension; albumin resuscitation lead to repeated\nrespiratory distress. On 1910-11-14 she was on the floor and had a\nwitnessed aspiration event and needed 100% Hi Flow mask. While\nin the ICU her O2 was weaned but again aspirated and had\nincreasing O2 requirements.\n\n# Acute renal failure: Pt noted to have Cr up to 1.7 on\nadmission from presumed baseline of 1.0, returned to baseline of\n0.9. Likely was pre-renal due to dehydration and hypotension due\nto sepsis. Later in her hospital course, the patient was\nhypotensive and her creatinine again began to rise thought\nsecondary to ATN.\n\n# Hypothyroidism: Initially treated with levothyroxine 12.5 mcg\nIV daily (half home dose). T3 low. TSH elevated. Resumed home\ndose 1/4.\n\n# Anasarca: Pt has diffuse edema and large bilateral pleural\neffusions likely third-spacing from malnutrition given low\nalbumin (2.', "8 on admission, then 2.2) and poor po intake.\nDiuresis has been difficult due to hypotension as detailed\nabove. Continue to monitor.\n\n# Urosepsis: Admitted with hypotension due to urosepsis\nrequiring pressor support. Urine cultures from 1-12 were\npositive for E.coli, and pt completed treated with vancomycin\nand ceftazidime x10 days. Repeat UCx 1909-8-25 grew out yeast,\nwhich was not treated. Another repeat UCx 4-30 final again grew\nout yeast.\n\n# Right Hip pain: Pain due to destruction of the right\nacetabulum consistent with progressive lymphoma on CT scan.\nThere is dramatic medial displacement of the right femoral head\nsecondary to lack of remaining osseous support. Stable\ndestruction of the right posterior sacroiliac joint and\nsurrounding right sacral ala and iliac bone. The patient's pain\nis being controlled with fentanyl and lidocaine patches.", "\n\n# Bilateral pleural effusion: R>L, thought most likely due to\nagressive hydration in the setting of sepsis and\nhypoalbuminemia. Was difficult to effect a significant diurese\nin MICU due to development of hypotension in response to\nfurosemide. Appears slightly improved on CXR from 1901-2-3,\nunchanged on 9-22 CXR.\n\n# Nodular Sclerosing Hodgkin's Lymphoma: Seen by oncology, no\ninterventions at this time. Likely with bone marrow infiltration\ncausing anemia and thrombocytopenia above, as pt with low retic\ncount and no evidence of hemolysis. No further treatment per\noncology.\n\n# Coagulopathy: Mild, likely due to nutritional deficiency.\nEncourage PO intake and trend LFTs, coags.\n\n\n\nMedications on Admission:\nMedications on Admission:\n1. Levothyroxine 25 mcg daily\n2. Docusate Sodium 100 mg Holmes-James Clinic\n3.", ' Omeprazole 20 mg daily\n4. Oxycodone-Acetaminophen 5-325 mg Q4H PRN\n5. Ferrous Sulfate 325mg daily\n6. Tylenol-Codeine #3 300-30 mg QID PRN\n7. Ultram 50 mg every 4-6 hours\n8. Lasix 20 mg daily\n9. Senna 8.6 mg Holmes-James Clinic prn\n10. Aspirin 81 mg daily\n11. Potassium Chloride\n12. Multivitamin\n.\nMedications on Transfer\n1. Acetaminophen 325-650 mg PO/PR Q6H:PRN\n2. Miconazole Powder 2% 1 Appl TP TID apply to affected area\n3. FoLIC Acid 1 mg PO DAILY\n4. Multivitamins 1 CAP PO DAILY\n5. Ipratropium Bromide Neb 1 NEB IH Q6H\n6. Bisacodyl 10 mg PO/PR DAILY:PRN\n7. Senna 1 TAB PO BID constipation\n8. Docusate Sodium 100 mg PO BID\n9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/cough\n10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n11. Fentanyl Patch 25 mcg/hr TP Q72H\n12. Lidocaine 5% Patch 1 PTCH TD QD apply to right hip.', ' One per\nday, on for 12 hours then remove\n13. Sarna Lotion 1 Appl TP TID:PRN\n14. Levothyroxine Sodium 12.5 mcg IV DAILY\n15. Pantoprazole 40 mg IV Q24H\n\nDischarge Medications:\nThe patient expired at 14:26pm on 1917-7-30\n\nDischarge Disposition:\nExtended Care\n\nDischarge Diagnosis:\nUrosepsis\nAspiration Pneumonitis\nAtrial Fibrillation with RVR\nLymphoma\n\nDischarge Condition:\nThe patient expired at 14:26pm on 1917-7-30\n\nDischarge Instructions:\nThe patient expired at 14:26pm on 1917-7-30\n\nFollowup Instructions:\nThe patient expired at 14:26pm on 1917-7-30\n\n PG Ngo Gregory Waldon MD 08465759\n\n']
241	22663	187885.0	2165-09-28	Discharge summary	Report	Admission Date: [2165-9-23] Discharge Date: [2165-9-28] Date of Birth: [2114-1-13] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 51-year-old African-American female with an extensive history of alcohol abuse, class B child cirrhosis, abstinent from alcohol since [2165-3-26]. She saw her primary care physician on [9-20] with complaints of a 5-day history of general malaise, abdominal pain, and found to have white count of 26. Not notified until three days thereafter when she was told to go to the Emergency Room. She presented to the Emergency Department with abdominal pain, hypotensive to 60/30, baseline systolic pressure of 90, not responsive to intravenous fluids, so started on dopamine and sent to the unit. On presentation her white count was 42, total bilirubin was 7.2. Urinalysis positive for pan-sensitive Escherichia coli. A subsequent abdomen ultrasound showed no ascites. A right upper quadrant ultrasound showed gallbladder inflammation consistent with cholecystitis. Started on ceftriaxone, vancomycin, and Flagyl. She had an endoscopic retrograde cholangiopancreatography on the [Hospital Ward Name ] with a common bile duct stent, transient elevation of amylase and lipase status post stent. They were falling at the time of transfer. She was weaned off pressors. Followed by Gastroenterology and General Surgery. On the evening of transfer to the Medicine Service, she was tolerating solids without nausea and vomiting. No nausea or vomiting since admission. Guaiac-positive, but hematocrit was stable. Review of systems was negative. A history of esophageal varices. A 3-grade II, one grade 3 on esophagogastroduodenoscopy in [2165-6-26]. History of upper gastrointestinal bleed, hemodynamically stable off pressors to floor without problem. PAST MEDICAL HISTORY: 1. Alcoholic hepatitis cirrhosis; child class B. 2. Alcohol abuse until [2165-3-26]. 3. A history of upper gastrointestinal bleed. 4. Cholelithiasis. 5. Gastroesophageal reflux disease. 6. Anemia. 7. Urinary tract infection. 8. Hypercholesterolemia. 9. Gastritis. 10. Hip fracture in [2164-7-27]. SOCIAL HISTORY: She lives with her sister in [Location (un) 686]. Three sons. A half pack per day of smoking. Absent from alcohol since [2165-3-26]. MEDICATIONS ON TRANSFER: Neurontin 100 mg p.o. t.i.d., ursodiol 300 mg p.o. t.i.d., multivitamin, thiamine, folate, ceftriaxone, Protonix, Toradol as needed. ALLERGIES: Allergy to PENICILLIN, LEVOFLOXACIN, and CODEINE. MEDICATIONS AT HOME: Medications at home include K-Dur, Lasix, thiamine, folate, multivitamin, spironolactone 100, Neurontin 100 mg p.o. t.i.d., propranolol 10 mg p.o. b.i.d., ursodiol. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature of 97.2, blood pressure was 100/40, heart rate was 81, respiratory rate was 15, oxygen saturation was 96% on room air. In no acute distress. Mild scleral icterus. Neck was supple without lymphadenopathy. Lungs were clear. Heart revealed first heart sound and second heart sound. The abdomen was soft, mildly tender. No guarding. No rebound. Positive bowel sounds. The liver was not enlarged. Extremities showed no edema. Dorsalis pedis pulses and radial pulses were 2+ bilaterally. RADIOLOGY/IMAGING: A right upper quadrant ultrasound showed gallbladder wall thickening, common bile duct 7 mm, no stones. A CT of the abdomen without contrast showed no diverticula, no dilated bowel loops, no inflammation changes, moderate ascites, multiple subcentimeter mesenteric retroperitoneal lymphadenopathy, nonspecific. HOSPITAL COURSE BY SYSTEM: 1. GASTROINTESTINAL: Status post endoscopic retrograde cholangiopancreatography with common bile duct stent, stable at the time of transfer to the Medicine Service. She remained stable throughout the admission. Liver function tests and total bilirubin were still mildly evaluated at the time of discharge. She was to follow up with endoscopic retrograde cholangiopancreatography fellow for stent removal in two to three weeks status post discharge. 2. INFECTIOUS DISEASE: She was treated with ceftriaxone for pan-sensitive Escherichia coli with negative cultures otherwise. She was treated for a total of 14 days given complicated urinary tract infection. She was treated with Bactrim. DISCHARGE DIAGNOSES: 1. Urinary tract infection complicated by sepsis. 2. Cholecystitis. 3. Class B cirrhosis. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-AAD Dictated By:[Last Name (NamePattern1) 2396] MEDQUIST36 D: [2166-6-23] 09:20 T: [2166-6-28] 07:34 JOB#: [Job Number 2397]	Admission Date: <Date>1968-10-1</Date> Discharge Date: <Date>1902-6-17</Date> Date of Birth: <Date>1910-3-21</Date> Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 51-year-old African-American female with an extensive history of alcohol abuse, class B child cirrhosis, abstinent from alcohol since <Date>1955-11-13</Date>. She saw her primary care physician on <Date>9-11</Date> with complaints of a 5-day history of general malaise, abdominal pain, and found to have white count of 26. Not notified until three days thereafter when she was told to go to the Emergency Room. She presented to the Emergency Department with abdominal pain, hypotensive to 60/30, baseline systolic pressure of 90, not responsive to intravenous fluids, so started on dopamine and sent to the unit. On presentation her white count was 42, total bilirubin was 7.2. Urinalysis positive for pan-sensitive Escherichia coli. A subsequent abdomen ultrasound showed no ascites. A right upper quadrant ultrasound showed gallbladder inflammation consistent with cholecystitis. Started on ceftriaxone, vancomycin, and Flagyl. She had an endoscopic retrograde cholangiopancreatography on the <Hospital>Curtis, Singleton and Parker Medical Center</Hospital> with a common bile duct stent, transient elevation of amylase and lipase status post stent. They were falling at the time of transfer. She was weaned off pressors. Followed by Gastroenterology and General Surgery. On the evening of transfer to the Medicine Service, she was tolerating solids without nausea and vomiting. No nausea or vomiting since admission. Guaiac-positive, but hematocrit was stable. Review of systems was negative. A history of esophageal varices. A 3-grade II, one grade 3 on esophagogastroduodenoscopy in <Date>1961-2-6</Date>. History of upper gastrointestinal bleed, hemodynamically stable off pressors to floor without problem. PAST MEDICAL HISTORY: 1. Alcoholic hepatitis cirrhosis; child class B. 2. Alcohol abuse until <Date>1955-11-13</Date>. 3. A history of upper gastrointestinal bleed. 4. Cholelithiasis. 5. Gastroesophageal reflux disease. 6. Anemia. 7. Urinary tract infection. 8. Hypercholesterolemia. 9. Gastritis. 10. Hip fracture in <Date>2004-4-29</Date>. SOCIAL HISTORY: She lives with her sister in <Location>807 Peter Common Carlamouth, VT 21036</Location>. Three sons. A half pack per day of smoking. Absent from alcohol since <Date>1955-11-13</Date>. MEDICATIONS ON TRANSFER: Neurontin 100 mg p.o. t.i.d., ursodiol 300 mg p.o. t.i.d., multivitamin, thiamine, folate, ceftriaxone, Protonix, Toradol as needed. ALLERGIES: Allergy to PENICILLIN, LEVOFLOXACIN, and CODEINE. MEDICATIONS AT HOME: Medications at home include K-Dur, Lasix, thiamine, folate, multivitamin, spironolactone 100, Neurontin 100 mg p.o. t.i.d., propranolol 10 mg p.o. b.i.d., ursodiol. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature of 97.2, blood pressure was 100/40, heart rate was 81, respiratory rate was 15, oxygen saturation was 96% on room air. In no acute distress. Mild scleral icterus. Neck was supple without lymphadenopathy. Lungs were clear. Heart revealed first heart sound and second heart sound. The abdomen was soft, mildly tender. No guarding. No rebound. Positive bowel sounds. The liver was not enlarged. Extremities showed no edema. Dorsalis pedis pulses and radial pulses were 2+ bilaterally. RADIOLOGY/IMAGING: A right upper quadrant ultrasound showed gallbladder wall thickening, common bile duct 7 mm, no stones. A CT of the abdomen without contrast showed no diverticula, no dilated bowel loops, no inflammation changes, moderate ascites, multiple subcentimeter mesenteric retroperitoneal lymphadenopathy, nonspecific. HOSPITAL COURSE BY SYSTEM: 1. GASTROINTESTINAL: Status post endoscopic retrograde cholangiopancreatography with common bile duct stent, stable at the time of transfer to the Medicine Service. She remained stable throughout the admission. Liver function tests and total bilirubin were still mildly evaluated at the time of discharge. She was to follow up with endoscopic retrograde cholangiopancreatography fellow for stent removal in two to three weeks status post discharge. 2. INFECTIOUS DISEASE: She was treated with ceftriaxone for pan-sensitive Escherichia coli with negative cultures otherwise. She was treated for a total of 14 days given complicated urinary tract infection. She was treated with Bactrim. DISCHARGE DIAGNOSES: 1. Urinary tract infection complicated by sepsis. 2. Cholecystitis. 3. Class B cirrhosis. DR.<Name>Pettway</Name>,<Name>Retha</Name> 12-AAD Dictated By:<Name>Anderson</Name> MEDQUIST36 D: <Date>1999-1-17</Date> 09:20 T: <Date>1936-10-12</Date> 07:34 JOB#: <Job Number>Simmons-Rogers-2019-379908</Job 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Date: 1968-10-1 Discharge Date: 1902-6-17 Date of Birth: 1910-3-21 Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 51-year-old African-American female with an extensive history of alcohol abuse, class B child cirrhosis, abstinent from alcohol since 1955-11-13. She saw her primary care physician on 9-11 with complaints of a 5-day history of general malaise, abdominal pain, and found to have white count of 26. Not notified until three days thereafter when she was told to go to the Emergency Room. She presented to the Emergency Department with abdominal pain, hypotensive to 60/30, baseline systolic pressure of 90, not responsive to intravenous fluids, so started on dopamine and sent to the unit. On presentation her white count was 42, total bilirubin was 7.2. Urinalysis positive for pan-sensitive Escherichia coli. A subsequent abdomen ultrasound showed no ascites. A right upper quadrant ultrasound showed gallbladder inflammation consistent with cholecystitis. Started on ceftriaxone, vancomycin, and Flagyl. She had an endoscopic retrograde cholangiopancreatography on the Curtis, Singleton and Parker Medical Center with a common bile duct stent, transient elevation of amylase and lipase status post stent. They were falling at the time of transfer. She was weaned off pressors. Followed by Gastroenterology and General Surgery. On the evening of transfer to the Medicine Service, she was tolerating solids without nausea and vomiting. No nausea or vomiting since admission. Guaiac-positive, but hematocrit was stable. Review of systems was negative. A history of esophageal varices. A 3-grade II, one grade 3 on esophagogastroduodenoscopy in 1961-2-6. History of upper gastrointestinal bleed, hemodynamically stable off pressors to floor without problem. PAST MEDICAL HISTORY: 1. Alcoholic hepatitis cirrhosis; child class B. 2. Alcohol abuse until 1955-11-13. 3. A history of upper gastrointestinal bleed. 4. Cholelithiasis. 5. Gastroesophageal reflux disease. 6. Anemia. 7. Urinary tract infection. 8. Hypercholesterolemia. 9. Gastritis. 10. Hip fracture in 2004-4-29. SOCIAL HISTORY: She lives with her sister in 807 Peter Common Carlamouth, VT 21036. Three sons. A half pack per day of smoking. Absent from alcohol since 1955-11-13. MEDICATIONS ON TRANSFER: Neurontin 100 mg p.o. t.i.d., ursodiol 300 mg p.o. t.i.d., multivitamin, thiamine, folate, ceftriaxone, Protonix, Toradol as needed. ALLERGIES: Allergy to PENICILLIN, LEVOFLOXACIN, and CODEINE. MEDICATIONS AT HOME: Medications at home include K-Dur, Lasix, thiamine, folate, multivitamin, spironolactone 100, Neurontin 100 mg p.o. t.i.d., propranolol 10 mg p.o. b.i.d., ursodiol. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature of 97.2, blood pressure was 100/40, heart rate was 81, respiratory rate was 15, oxygen saturation was 96% on room air. In no acute distress. Mild scleral icterus. Neck was supple without lymphadenopathy. Lungs were clear. Heart revealed first heart sound and second heart sound. The abdomen was soft, mildly tender. No guarding. No rebound. Positive bowel sounds. The liver was not enlarged. Extremities showed no edema. Dorsalis pedis pulses and radial pulses were 2+ bilaterally. RADIOLOGY/IMAGING: A right upper quadrant ultrasound showed gallbladder wall thickening, common bile duct 7 mm, no stones. A CT of the abdomen without contrast showed no diverticula, no dilated bowel loops, no inflammation changes, moderate ascites, multiple subcentimeter mesenteric retroperitoneal lymphadenopathy, nonspecific. HOSPITAL COURSE BY SYSTEM: 1. GASTROINTESTINAL: Status post endoscopic retrograde cholangiopancreatography with common bile duct stent, stable at the time of transfer to the Medicine Service. She remained stable throughout the admission. Liver function tests and total bilirubin were still mildly evaluated at the time of discharge. She was to follow up with endoscopic retrograde cholangiopancreatography fellow for stent removal in two to three weeks status post discharge. 2. INFECTIOUS DISEASE: She was treated with ceftriaxone for pan-sensitive Escherichia coli with negative cultures otherwise. She was treated for a total of 14 days given complicated urinary tract infection. She was treated with Bactrim. DISCHARGE DIAGNOSES: 1. Urinary tract infection complicated by sepsis. 2. Cholecystitis. 3. Class B cirrhosis. DR.Pettway,Retha 12-AAD Dictated By:Anderson MEDQUIST36 D: 1999-1-17 09:20 T: 1936-10-12 07:34 JOB#: Simmons-Rogers-2019-379908	['Admission Date: 1968-10-1 Discharge Date: 1902-6-17\n\nDate of Birth: 1910-3-21 Sex: F\n\nService: Medicine\nHISTORY OF PRESENT ILLNESS: This is a 51-year-old\nAfrican-American female with an extensive history of alcohol\nabuse, class B child cirrhosis, abstinent from alcohol since\n1955-11-13. She saw her primary care physician on 9-11\nwith complaints of a 5-day history of general malaise, abdominal\npain, and found to have white count of 26. Not notified until\nthree days thereafter when she was told to go to the Emergency\nRoom.\n\nShe presented to the Emergency Department with abdominal\npain, hypotensive to 60/30, baseline systolic pressure of 90,\nnot responsive to intravenous fluids, so started on dopamine\nand sent to the unit.\nOn presentation her white count was 42, total bilirubin\nwas 7.', '2. Urinalysis positive for pan-sensitive Escherichia\ncoli. A subsequent abdomen ultrasound showed no ascites. A\nright upper quadrant ultrasound showed gallbladder inflammation\nconsistent with cholecystitis. Started on ceftriaxone,\nvancomycin, and Flagyl. She had an endoscopic retrograde\ncholangiopancreatography on the Curtis, Singleton and Parker Medical Center with a common bile\nduct stent, transient elevation of amylase and lipase status post\nstent. They were falling at the time of transfer. She was\nweaned off pressors. Followed by Gastroenterology and General\nSurgery.\n\nOn the evening of transfer to the Medicine Service, she was\ntolerating solids without nausea and vomiting. No nausea or\nvomiting since admission. Guaiac-positive, but hematocrit was\nstable. Review of systems was negative.', ' A history of\nesophageal varices. A 3-grade II, one grade 3 on\nesophagogastroduodenoscopy in 1961-2-6. History of upper\ngastrointestinal bleed, hemodynamically stable off pressors to\nfloor without problem.\n\nPAST MEDICAL HISTORY:\n 1. Alcoholic hepatitis cirrhosis; child class B.\n 2. Alcohol abuse until 1955-11-13.\n 3. A history of upper gastrointestinal bleed.\n 4. Cholelithiasis.\n 5. Gastroesophageal reflux disease.\n 6. Anemia.\n 7. Urinary tract infection.\n 8. Hypercholesterolemia.\n 9. Gastritis.\n10. Hip fracture in 2004-4-29.\n\nSOCIAL HISTORY: She lives with her sister in 807 Peter Common\nCarlamouth, VT 21036.\nThree sons. A half pack per day of smoking. Absent from\nalcohol since 1955-11-13.\n\nMEDICATIONS ON TRANSFER: Neurontin 100 mg p.o. t.i.d.,\nursodiol 300 mg p.o. t.i.d., multivitamin, thiamine, folate,\nceftriaxone, Protonix, Toradol as needed.', '\n\nALLERGIES: Allergy to PENICILLIN, LEVOFLOXACIN, and CODEINE.\n\nMEDICATIONS AT HOME: Medications at home include K-Dur,\nLasix, thiamine, folate, multivitamin, spironolactone 100,\nNeurontin 100 mg p.o. t.i.d., propranolol 10 mg p.o. b.i.d.,\nursodiol.\n\nPHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed\ntemperature of 97.2, blood pressure was 100/40, heart rate\nwas 81, respiratory rate was 15, oxygen saturation was 96% on\nroom air. In no acute distress. Mild scleral icterus. Neck\nwas supple without lymphadenopathy. Lungs were clear. Heart\nrevealed first heart sound and second heart sound. The\nabdomen was soft, mildly tender. No guarding. No rebound.\nPositive bowel sounds. The liver was not enlarged.\nExtremities showed no edema. Dorsalis pedis pulses and\nradial pulses were 2+ bilaterally.', '\n\nRADIOLOGY/IMAGING: A right upper quadrant ultrasound showed\ngallbladder wall thickening, common bile duct 7 mm, no\nstones.\n\nA CT of the abdomen without contrast showed no diverticula,\nno dilated bowel loops, no inflammation changes, moderate\nascites, multiple subcentimeter mesenteric retroperitoneal\nlymphadenopathy, nonspecific.\n\nHOSPITAL COURSE BY SYSTEM:\n\n1. GASTROINTESTINAL: Status post endoscopic retrograde\ncholangiopancreatography with common bile duct stent, stable\nat the time of transfer to the Medicine Service. She\nremained stable throughout the admission. Liver function\ntests and total bilirubin were still mildly evaluated at the\ntime of discharge. She was to follow up with endoscopic\nretrograde cholangiopancreatography fellow for stent removal\nin two to three weeks status post discharge.', '\n\n2. INFECTIOUS DISEASE: She was treated with ceftriaxone for\npan-sensitive Escherichia coli with negative cultures\notherwise. She was treated for a total of 14 days given\ncomplicated urinary tract infection. She was treated with\nBactrim.\n\nDISCHARGE DIAGNOSES:\n1. Urinary tract infection complicated by sepsis.\n2. Cholecystitis.\n3. Class B cirrhosis.\n\n\n DR.Pettway,Retha 12-AAD\n\n\n\nDictated By:Anderson\n\nMEDQUIST36\n\nD: 1999-1-17 09:20\nT: 1936-10-12 07:34\nJOB#: Simmons-Rogers-2019-379908\n\n']
242	22663	140246.0	2170-09-05	Discharge summary	Report	Admission Date: [2170-9-1] Discharge Date: [2170-9-5] Date of Birth: [2114-1-13] Sex: F Service: MEDICINE Allergies: Penicillins / Levofloxacin / Codeine / Bactrim Ds Attending:[First Name3 (LF) 1580] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 56F with EtOH cirrhosis initially found unresponsive in AM 3d ago. FSBGs 200s, no e/o sz, and initially intubated on arrival to the ED for airway protection. CT head was negative, LP deferred [12-28] coagulopathy. Pt. with h/o of poor compliance with encephalopathy meds and mutliple admissions in past for AMS, though pt. reports compliance with meds and [12-29] BMS/day. Pt. was extubated yesterday without complication and has had no e/o withdrawal on this admission (per pt. last ETOH in [Month (only) ]). Pt. with dirty U/A on admit and sputum cx. growing G+ cocci, and was placed on meropenem as has allergies to penicillins/levo. Past Medical History: 1. EtOH cirrhosis- dx [2162], pt of Dr. [Last Name (STitle) ], esophageal varices grade II in [2166], h/o encephalopathy on lactulose and rifaximin with multiple admissions for altered mental status due to med noncompliance, h/o ascites now on diuretics, not a transplant candidate given active EtOH use 2. EtOH abuse- for ~40 years, + h/o DTs 3. GERD 4. HTN 5. Depression 6. Hypokalemia 7. ?upper GI bleed hx Social History: lives with uncle and sister, on disability for cirrhosis, used to work as nurse's aide; drinks [11-27] pint gin per day x40y, even heavier EtOH use in the past, last in [Month (only) ]; 20 pack-yr history of tobacco abuse; denies IVDU Family History: non-contributory Physical Exam: Vitals: T 97.3, BP 108/65, HR 73, 20, O2sat 99% on 4L General: elderly AA woman, NAD HEENT: PERRL, EOMI, OP clear, sl. dry MM Neck: supple, no JVD, no [Doctor First Name ] Pulm: Crackles at L base, sl. coarse at R base, otherwise clear CV: RRR, nl S1S2, no MRGs Abd- distended but soft, dullness to percussion laterally, non tender Extrem- Trace LE edema Neuro- AA&O X 3, CN II-XII frossly intact. motor/sensory exam wnl Pertinent Results: [2170-9-1] 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-TR [2170-9-1] 01:15PM URINE RBC-[1-28]* WBC-[5-5]* BACTERIA-MANY YEAST-NONE EPI-[1-28] [2170-9-1] 09:41AM TYPE-ART TIDAL VOL-450 O2-100 PO2-354* PCO2-31* PH-7.47* TOTAL CO2-23 BASE XS-0 AADO2-357 REQ O2-62 INTUBATED-INTUBATED [2170-9-1] 09:30AM AMMONIA-226* [2170-9-1] 08:50AM GLUCOSE-207* UREA N-11 CREAT-0.7 SODIUM-138 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-20* ANION GAP-14 [2170-9-1] 08:50AM ALT(SGPT)-19 AST(SGOT)-35 ALK PHOS-298* AMYLASE-91 TOT BILI-2.9* [2170-9-1] 08:50AM LIPASE-53 [2170-9-1] 08:50AM ALBUMIN-2.8* [2170-9-1] 08:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2170-9-1] 08:50AM WBC-6.7 RBC-3.21* HGB-11.8* HCT-35.1* MCV-109* MCH-36.8* MCHC-33.7 RDW-14.9 [2170-9-1] 08:50AM PT-17.4* PTT-43.3* INR(PT)-1.6* [2170-9-1] 08:20AM GLUCOSE-199* UREA N-12 CREAT-0.9 SODIUM-136 POTASSIUM-6.9* CHLORIDE-108 TOTAL CO2-20* ANION GAP-15 [2170-9-5] 04:50AM BLOOD WBC-6.8 RBC-2.60* Hgb-9.7* Hct-28.3* MCV-109* MCH-37.4* MCHC-34.5 RDW-14.8 Plt Ct-76* [2170-9-5] 04:50AM BLOOD Plt Ct-76* [2170-9-5] 04:50AM BLOOD PT-19.2* PTT-46.8* INR(PT)-1.8* [2170-9-5] 04:50AM BLOOD Glucose-112* UreaN-12 Creat-0.8 Na-144 K-3.9 Cl-117* HCO3-21* AnGap-10 [2170-9-5] 04:50AM BLOOD ALT-19 AST-37 AlkPhos-141* TotBili-3.0* [2170-9-5] 04:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.4* [2170-9-2] 03:12AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE PA AND LATERAL CHEST ON [2170-9-3] AT 19:50 INDICATION: Positive sputum Gram stain and increasing O2 requirement. IMPRESSION: There is no definite evidence for pneumonia, and there is a slightly improved appearance to the pulmonary vasculature compared to prior study suggesting improved fluid status. Brief Hospital Course: A/P: 56F with decompensated EtOH cirrhosis w/ encephalopathy and esophageal varices, admitted to ICU after being found down, intubated. . # Altered mental status: Likely [12-28] hepatic encephalopathy, PA lateral CXR negative, sputum cx. negative. Has had multiple admissions for encephalopathy [12-28] med noncompliance, though pt. and family report compliance with meds and 2-3 times daily BMs. No leukocytosis or abd. pain, with minimal ascites, so unlikely SBP. Sputum gram stain with G+ cocci, but cultures negative and no e/o PNA on CXR. Tox screen negative on admission. CT head negative. - continued lactulose q6h with PRN lactulose enemas - continued rifaximin, ursodiol at outpatient dose - MVI/thiamine/folate Pt.'s mental status cleared quickly and pt. was sent home on increased lactulose/rifaxamin to prevent encephalopathy. . # Respiratory failure: intubated for airway protection, as initially unresponsive, MS quickly improved with lactulose, and pt. was extubated. . # EtOH cirrhosis: Decompensated with encephalopathy, ascites, and varices. Currently with minimal ascites. Last EGD [4-28], no known h/o melena or BRBPR, guaiac negative on exam. MELD 16. Thrombocytopenia within baseline. Tbili trended down during admission. Guaiacs negative during admission. . # Anemia: baseline wanders from 25-->36, hct stable during admit. . Medications on Admission: CALCIUM CARBONATE 500 mg tid FLUOXETINE 20 MG qd FOLIC ACID 1 MG qd IBUPROFEN 800 MG tid prn K-DUR 20 mEq [Hospital1 ] MAGNESIUM OXIDE 400 mg [Hospital1 ] MULTIVITAMIN qd PREVACID 30 mg qd RIFAXIMIN 400 mg tid SPIRONOLACTONE 50 mg qd THIAMINE HCL 100MG qd URSODIOL 300 mg tid VITAMIN D 800 unit qd LACTULOSE 2 TB qid Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours). Disp:3 qs Refills:2 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 13. K-Dur 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:2 14. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: hepatic encephalopathy alcoholic cirrhosis Secondary: hypertension anemia gastroesophageal reflux disease Discharge Condition: Good. The patient's mental status has returned to baseline. Taking POs, ambulating, satting >94% on room air Discharge Instructions: Please take all medications as prescribed. It is especially important to take your lactulose and rifaxamin so that you have at least 3 loose bowel movements a day. Please follow-up with your appointments as below. Please contact your doctor or go to the emergency room if you experience: --confusion --stomach pain --nausea or vomiting --fevers or chills --shortness of breath --chest pain Followup Instructions: Liver physician: [Name Initial (NameIs) 2169]: [Name10 (NameIs) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2170-9-27] 10:15 Primary care physician: [Name Initial (NameIs) 2169]: [First Name4 (NamePattern1) 2428] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2170-10-16] 1:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1583] MD, MSC, MPH[MD Number(3) 1584]	Admission Date: <Date>1924-10-25</Date> Discharge Date: <Date>1971-10-28</Date> Date of Birth: <Date>1991-7-19</Date> Sex: F Service: MEDICINE Allergies: Penicillins / Levofloxacin / Codeine / Bactrim Ds Attending:<Name>Athanasios</Name> Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 56F with EtOH cirrhosis initially found unresponsive in AM 3d ago. FSBGs 200s, no e/o sz, and initially intubated on arrival to the ED for airway protection. CT head was negative, LP deferred <Date>3-22</Date> coagulopathy. Pt. with h/o of poor compliance with encephalopathy meds and mutliple admissions in past for AMS, though pt. reports compliance with meds and <Date>2-31</Date> BMS/day. Pt. was extubated yesterday without complication and has had no e/o withdrawal on this admission (per pt. last ETOH in <Month>May</Month>). Pt. with dirty U/A on admit and sputum cx. growing G+ cocci, and was placed on meropenem as has allergies to penicillins/levo. Past Medical History: 1. EtOH cirrhosis- dx <Year>2008</Year>, pt of Dr. <Name>Broadnax</Name>, esophageal varices grade II in <Year>2008</Year>, h/o encephalopathy on lactulose and rifaximin with multiple admissions for altered mental status due to med noncompliance, h/o ascites now on diuretics, not a transplant candidate given active EtOH use 2. EtOH abuse- for ~40 years, + h/o DTs 3. GERD 4. HTN 5. Depression 6. Hypokalemia 7. ?upper GI bleed hx Social History: lives with uncle and sister, on disability for cirrhosis, used to work as nurse's aide; drinks <Date>10-14</Date> pint gin per day x40y, even heavier EtOH use in the past, last in <Month>May</Month>; 20 pack-yr history of tobacco abuse; denies IVDU Family History: non-contributory Physical Exam: Vitals: T 97.3, BP 108/65, HR 73, 20, O2sat 99% on 4L General: elderly AA woman, NAD HEENT: PERRL, EOMI, OP clear, sl. dry MM Neck: supple, no JVD, no <Name>Dat</Name> Pulm: Crackles at L base, sl. coarse at R base, otherwise clear CV: RRR, nl S1S2, no MRGs Abd- distended but soft, dullness to percussion laterally, non tender Extrem- Trace LE edema Neuro- AA&O X 3, CN II-XII frossly intact. motor/sensory exam wnl Pertinent Results: <Date>1924-10-25</Date> 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-TR <Date>1924-10-25</Date> 01:15PM URINE RBC-<Date>12-8</Date>* WBC-<Date>12-22</Date>* BACTERIA-MANY YEAST-NONE EPI-<Date>12-8</Date> <Date>1924-10-25</Date> 09:41AM TYPE-ART TIDAL VOL-450 O2-100 PO2-354* PCO2-31* PH-7.47* TOTAL CO2-23 BASE XS-0 AADO2-357 REQ O2-62 INTUBATED-INTUBATED <Date>1924-10-25</Date> 09:30AM AMMONIA-226* <Date>1924-10-25</Date> 08:50AM GLUCOSE-207* UREA N-11 CREAT-0.7 SODIUM-138 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-20* ANION GAP-14 <Date>1924-10-25</Date> 08:50AM ALT(SGPT)-19 AST(SGOT)-35 ALK PHOS-298* AMYLASE-91 TOT BILI-2.9* <Date>1924-10-25</Date> 08:50AM LIPASE-53 <Date>1924-10-25</Date> 08:50AM ALBUMIN-2.8* <Date>1924-10-25</Date> 08:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG <Date>1924-10-25</Date> 08:50AM WBC-6.7 RBC-3.21* HGB-11.8* HCT-35.1* MCV-109* MCH-36.8* MCHC-33.7 RDW-14.9 <Date>1924-10-25</Date> 08:50AM PT-17.4* PTT-43.3* INR(PT)-1.6* <Date>1924-10-25</Date> 08:20AM GLUCOSE-199* UREA N-12 CREAT-0.9 SODIUM-136 POTASSIUM-6.9* CHLORIDE-108 TOTAL CO2-20* ANION GAP-15 <Date>1971-10-28</Date> 04:50AM BLOOD WBC-6.8 RBC-2.60* Hgb-9.7* Hct-28.3* MCV-109* MCH-37.4* MCHC-34.5 RDW-14.8 Plt Ct-76* <Date>1971-10-28</Date> 04:50AM BLOOD Plt Ct-76* <Date>1971-10-28</Date> 04:50AM BLOOD PT-19.2* PTT-46.8* INR(PT)-1.8* <Date>1971-10-28</Date> 04:50AM BLOOD Glucose-112* UreaN-12 Creat-0.8 Na-144 K-3.9 Cl-117* HCO3-21* AnGap-10 <Date>1971-10-28</Date> 04:50AM BLOOD ALT-19 AST-37 AlkPhos-141* TotBili-3.0* <Date>1971-10-28</Date> 04:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.4* <Date>1957-9-9</Date> 03:12AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE PA AND LATERAL CHEST ON <Date>1959-4-28</Date> AT 19:50 INDICATION: Positive sputum Gram stain and increasing O2 requirement. IMPRESSION: There is no definite evidence for pneumonia, and there is a slightly improved appearance to the pulmonary vasculature compared to prior study suggesting improved fluid status. Brief Hospital Course: A/P: 56F with decompensated EtOH cirrhosis w/ encephalopathy and esophageal varices, admitted to ICU after being found down, intubated. . # Altered mental status: Likely <Date>3-22</Date> hepatic encephalopathy, PA lateral CXR negative, sputum cx. negative. Has had multiple admissions for encephalopathy <Date>3-22</Date> med noncompliance, though pt. and family report compliance with meds and 2-3 times daily BMs. No leukocytosis or abd. pain, with minimal ascites, so unlikely SBP. Sputum gram stain with G+ cocci, but cultures negative and no e/o PNA on CXR. Tox screen negative on admission. CT head negative. - continued lactulose q6h with PRN lactulose enemas - continued rifaximin, ursodiol at outpatient dose - MVI/thiamine/folate Pt.'s mental status cleared quickly and pt. was sent home on increased lactulose/rifaxamin to prevent encephalopathy. . # Respiratory failure: intubated for airway protection, as initially unresponsive, MS quickly improved with lactulose, and pt. was extubated. . # EtOH cirrhosis: Decompensated with encephalopathy, ascites, and varices. Currently with minimal ascites. Last EGD <Date>12-26</Date>, no known h/o melena or BRBPR, guaiac negative on exam. MELD 16. Thrombocytopenia within baseline. Tbili trended down during admission. Guaiacs negative during admission. . # Anemia: baseline wanders from 25-->36, hct stable during admit. . Medications on Admission: CALCIUM CARBONATE 500 mg tid FLUOXETINE 20 MG qd FOLIC ACID 1 MG qd IBUPROFEN 800 MG tid prn K-DUR 20 mEq <Hospital>Smith and Sons Medical Center</Hospital> MAGNESIUM OXIDE 400 mg <Hospital>Smith and Sons Medical Center</Hospital> MULTIVITAMIN qd PREVACID 30 mg qd RIFAXIMIN 400 mg tid SPIRONOLACTONE 50 mg qd THIAMINE HCL 100MG qd URSODIOL 300 mg tid VITAMIN D 800 unit qd LACTULOSE 2 TB qid Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours). Disp:3 qs Refills:2 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 13. K-Dur 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:2 14. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: <Location>65197 Lee Locks Apt. 036 Timothyton, WY 26712</Location> VNA Discharge Diagnosis: Primary: hepatic encephalopathy alcoholic cirrhosis Secondary: hypertension anemia gastroesophageal reflux disease Discharge Condition: Good. The patient's mental status has returned to baseline. Taking POs, ambulating, satting >94% on room air Discharge Instructions: Please take all medications as prescribed. It is especially important to take your lactulose and rifaxamin so that you have at least 3 loose bowel movements a day. Please follow-up with your appointments as below. Please contact your doctor or go to the emergency room if you experience: --confusion --stomach pain --nausea or vomiting --fevers or chills --shortness of breath --chest pain Followup Instructions: Liver physician: <Name>Angela Lenling</Name>: <Name>Creighton Shipley</Name> <Name>Lewis</Name>, MD Phone:<Telephone>161-293-2817</Telephone> Date/Time:<Date>1907-9-11</Date> 10:15 Primary care physician: <Name>Angela Lenling</Name>: <Name>Natividad</Name> <Name>Chin</Name>, MD Phone:<Telephone>427-697-1693</Telephone> Date/Time:<Date>1931-10-15</Date> 1:30 <Name>Quincy</Name> <Name>Lees</Name> MD, MSC, MPH<MD Number>92311667</MD 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Date: 1924-10-25 Discharge Date: 1971-10-28 Date of Birth: 1991-7-19 Sex: F Service: MEDICINE Allergies: Penicillins / Levofloxacin / Codeine / Bactrim Ds Attending:Athanasios Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 56F with EtOH cirrhosis initially found unresponsive in AM 3d ago. FSBGs 200s, no e/o sz, and initially intubated on arrival to the ED for airway protection. CT head was negative, LP deferred 3-22 coagulopathy. Pt. with h/o of poor compliance with encephalopathy meds and mutliple admissions in past for AMS, though pt. reports compliance with meds and 2-31 BMS/day. Pt. was extubated yesterday without complication and has had no e/o withdrawal on this admission (per pt. last ETOH in May). Pt. with dirty U/A on admit and sputum cx. growing G+ cocci, and was placed on meropenem as has allergies to penicillins/levo. Past Medical History: 1. EtOH cirrhosis- dx 2008, pt of Dr. Broadnax, esophageal varices grade II in 2008, h/o encephalopathy on lactulose and rifaximin with multiple admissions for altered mental status due to med noncompliance, h/o ascites now on diuretics, not a transplant candidate given active EtOH use 2. EtOH abuse- for ~40 years, + h/o DTs 3. GERD 4. HTN 5. Depression 6. Hypokalemia 7. ?upper GI bleed hx Social History: lives with uncle and sister, on disability for cirrhosis, used to work as nurse's aide; drinks 10-14 pint gin per day x40y, even heavier EtOH use in the past, last in May; 20 pack-yr history of tobacco abuse; denies IVDU Family History: non-contributory Physical Exam: Vitals: T 97.3, BP 108/65, HR 73, 20, O2sat 99% on 4L General: elderly AA woman, NAD HEENT: PERRL, EOMI, OP clear, sl. dry MM Neck: supple, no JVD, no Dat Pulm: Crackles at L base, sl. coarse at R base, otherwise clear CV: RRR, nl S1S2, no MRGs Abd- distended but soft, dullness to percussion laterally, non tender Extrem- Trace LE edema Neuro- AA&O X 3, CN II-XII frossly intact. motor/sensory exam wnl Pertinent Results: 1924-10-25 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-TR 1924-10-25 01:15PM URINE RBC-12-8* WBC-12-22* BACTERIA-MANY YEAST-NONE EPI-12-8 1924-10-25 09:41AM TYPE-ART TIDAL VOL-450 O2-100 PO2-354* PCO2-31* PH-7.47* TOTAL CO2-23 BASE XS-0 AADO2-357 REQ O2-62 INTUBATED-INTUBATED 1924-10-25 09:30AM AMMONIA-226* 1924-10-25 08:50AM GLUCOSE-207* UREA N-11 CREAT-0.7 SODIUM-138 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-20* ANION GAP-14 1924-10-25 08:50AM ALT(SGPT)-19 AST(SGOT)-35 ALK PHOS-298* AMYLASE-91 TOT BILI-2.9* 1924-10-25 08:50AM LIPASE-53 1924-10-25 08:50AM ALBUMIN-2.8* 1924-10-25 08:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG 1924-10-25 08:50AM WBC-6.7 RBC-3.21* HGB-11.8* HCT-35.1* MCV-109* MCH-36.8* MCHC-33.7 RDW-14.9 1924-10-25 08:50AM PT-17.4* PTT-43.3* INR(PT)-1.6* 1924-10-25 08:20AM GLUCOSE-199* UREA N-12 CREAT-0.9 SODIUM-136 POTASSIUM-6.9* CHLORIDE-108 TOTAL CO2-20* ANION GAP-15 1971-10-28 04:50AM BLOOD WBC-6.8 RBC-2.60* Hgb-9.7* Hct-28.3* MCV-109* MCH-37.4* MCHC-34.5 RDW-14.8 Plt Ct-76* 1971-10-28 04:50AM BLOOD Plt Ct-76* 1971-10-28 04:50AM BLOOD PT-19.2* PTT-46.8* INR(PT)-1.8* 1971-10-28 04:50AM BLOOD Glucose-112* UreaN-12 Creat-0.8 Na-144 K-3.9 Cl-117* HCO3-21* AnGap-10 1971-10-28 04:50AM BLOOD ALT-19 AST-37 AlkPhos-141* TotBili-3.0* 1971-10-28 04:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.4* 1957-9-9 03:12AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE PA AND LATERAL CHEST ON 1959-4-28 AT 19:50 INDICATION: Positive sputum Gram stain and increasing O2 requirement. IMPRESSION: There is no definite evidence for pneumonia, and there is a slightly improved appearance to the pulmonary vasculature compared to prior study suggesting improved fluid status. Brief Hospital Course: A/P: 56F with decompensated EtOH cirrhosis w/ encephalopathy and esophageal varices, admitted to ICU after being found down, intubated. . # Altered mental status: Likely 3-22 hepatic encephalopathy, PA lateral CXR negative, sputum cx. negative. Has had multiple admissions for encephalopathy 3-22 med noncompliance, though pt. and family report compliance with meds and 2-3 times daily BMs. No leukocytosis or abd. pain, with minimal ascites, so unlikely SBP. Sputum gram stain with G+ cocci, but cultures negative and no e/o PNA on CXR. Tox screen negative on admission. CT head negative. - continued lactulose q6h with PRN lactulose enemas - continued rifaximin, ursodiol at outpatient dose - MVI/thiamine/folate Pt.'s mental status cleared quickly and pt. was sent home on increased lactulose/rifaxamin to prevent encephalopathy. . # Respiratory failure: intubated for airway protection, as initially unresponsive, MS quickly improved with lactulose, and pt. was extubated. . # EtOH cirrhosis: Decompensated with encephalopathy, ascites, and varices. Currently with minimal ascites. Last EGD 12-26, no known h/o melena or BRBPR, guaiac negative on exam. MELD 16. Thrombocytopenia within baseline. Tbili trended down during admission. Guaiacs negative during admission. . # Anemia: baseline wanders from 25-->36, hct stable during admit. . Medications on Admission: CALCIUM CARBONATE 500 mg tid FLUOXETINE 20 MG qd FOLIC ACID 1 MG qd IBUPROFEN 800 MG tid prn K-DUR 20 mEq Smith and Sons Medical Center MAGNESIUM OXIDE 400 mg Smith and Sons Medical Center MULTIVITAMIN qd PREVACID 30 mg qd RIFAXIMIN 400 mg tid SPIRONOLACTONE 50 mg qd THIAMINE HCL 100MG qd URSODIOL 300 mg tid VITAMIN D 800 unit qd LACTULOSE 2 TB qid Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours). Disp:3 qs Refills:2 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 13. K-Dur 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:2 14. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: 65197 Lee Locks Apt. 036 Timothyton, WY 26712 VNA Discharge Diagnosis: Primary: hepatic encephalopathy alcoholic cirrhosis Secondary: hypertension anemia gastroesophageal reflux disease Discharge Condition: Good. The patient's mental status has returned to baseline. Taking POs, ambulating, satting >94% on room air Discharge Instructions: Please take all medications as prescribed. It is especially important to take your lactulose and rifaxamin so that you have at least 3 loose bowel movements a day. Please follow-up with your appointments as below. Please contact your doctor or go to the emergency room if you experience: --confusion --stomach pain --nausea or vomiting --fevers or chills --shortness of breath --chest pain Followup Instructions: Liver physician: Angela Lenling: Creighton Shipley Lewis, MD Phone:161-293-2817 Date/Time:1907-9-11 10:15 Primary care physician: Angela Lenling: Natividad Chin, MD Phone:427-697-1693 Date/Time:1931-10-15 1:30 Quincy Lees MD, MSC, MPH92311667	['Admission Date: 1924-10-25 Discharge Date: 1971-10-28\n\nDate of Birth: 1991-7-19 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPenicillins / Levofloxacin / Codeine / Bactrim Ds\n\nAttending:Athanasios\nChief Complaint:\naltered mental status\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\n56F with EtOH cirrhosis initially found unresponsive in AM 3d\nago. FSBGs 200s, no e/o sz, and initially intubated on arrival\nto the ED for airway protection. CT head was negative, LP\ndeferred 3-22 coagulopathy. Pt. with h/o of poor compliance with\nencephalopathy meds and mutliple admissions in past for AMS,\nthough pt. reports compliance with meds and 2-31 BMS/day. Pt. was\nextubated yesterday without complication and has had no e/o\nwithdrawal on this admission (per pt.', " last ETOH in May). Pt.\nwith dirty U/A on admit and sputum cx. growing G+ cocci, and was\nplaced on meropenem as has allergies to penicillins/levo.\n\nPast Medical History:\n1. EtOH cirrhosis- dx 2008, pt of Dr. Broadnax, esophageal varices\ngrade II in 2008, h/o encephalopathy on lactulose and rifaximin\nwith multiple admissions for altered mental status due to med\nnoncompliance, h/o ascites now on diuretics, not a transplant\ncandidate given active EtOH use\n2. EtOH abuse- for ~40 years, + h/o DTs\n3. GERD\n4. HTN\n5. Depression\n6. Hypokalemia\n7. ?upper GI bleed hx\n\n\nSocial History:\nlives with uncle and sister, on disability for cirrhosis, used\nto work as nurse's aide; drinks 10-14 pint gin per day x40y, even\nheavier EtOH use in the past, last in May; 20 pack-yr history\nof tobacco abuse; denies IVDU\n\nFamily History:\nnon-contributory\n\nPhysical Exam:\nVitals: T 97.", '3, BP 108/65, HR 73, 20, O2sat 99% on 4L\nGeneral: elderly AA woman, NAD\nHEENT: PERRL, EOMI, OP clear, sl. dry MM\nNeck: supple, no JVD, no Dat\nPulm: Crackles at L base, sl. coarse at R base, otherwise clear\n\nCV: RRR, nl S1S2, no MRGs\nAbd- distended but soft, dullness to percussion laterally, non\ntender\nExtrem- Trace LE edema\nNeuro- AA&O X 3, CN II-XII frossly intact. motor/sensory exam\nwnl\n\n\nPertinent Results:\n1924-10-25 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG\nGLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-TR\n1924-10-25 01:15PM URINE RBC-12-8* WBC-12-22* BACTERIA-MANY\nYEAST-NONE EPI-12-8\n1924-10-25 09:41AM TYPE-ART TIDAL VOL-450 O2-100 PO2-354\nPCO2-31 PH-7.47* TOTAL CO2-23 BASE XS-0 AADO2-357 REQ O2-62\nINTUBATED-INTUBATED\n1924-10-25 09:30AM AMMONIA-226\n1924-10-25 08:50AM GLUCOSE-207 UREA N-11 CREAT-0.', '7 SODIUM-138\nPOTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-20* ANION GAP-14\n1924-10-25 08:50AM ALT(SGPT)-19 AST(SGOT)-35 ALK PHOS-298\nAMYLASE-91 TOT BILI-2.9\n1924-10-25 08:50AM LIPASE-53\n1924-10-25 08:50AM ALBUMIN-2.8\n1924-10-25 08:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG\nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n1924-10-25 08:50AM WBC-6.7 RBC-3.21 HGB-11.8* HCT-35.1\nMCV-109 MCH-36.8* MCHC-33.7 RDW-14.9\n1924-10-25 08:50AM PT-17.4* PTT-43.3* INR(PT)-1.6\n1924-10-25 08:20AM GLUCOSE-199 UREA N-12 CREAT-0.9 SODIUM-136\nPOTASSIUM-6.9* CHLORIDE-108 TOTAL CO2-20* ANION GAP-15\n\n1971-10-28 04:50AM BLOOD WBC-6.8 RBC-2.60* Hgb-9.7* Hct-28.3\nMCV-109 MCH-37.4* MCHC-34.5 RDW-14.8 Plt Ct-76\n1971-10-28 04:50AM BLOOD Plt Ct-76\n1971-10-28 04:50AM BLOOD PT-19.2* PTT-46.8* INR(PT)-1.8\n1971-10-28 04:50AM BLOOD Glucose-112 UreaN-12 Creat-0.', '8 Na-144\nK-3.9 Cl-117* HCO3-21* AnGap-10\n1971-10-28 04:50AM BLOOD ALT-19 AST-37 AlkPhos-141* TotBili-3.0\n1971-10-28 04:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.4\n1957-9-9 03:12AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE\n\nPA AND LATERAL CHEST ON 1959-4-28 AT 19:50\n\nINDICATION: Positive sputum Gram stain and increasing O2\nrequirement.\n\nIMPRESSION: There is no definite evidence for pneumonia, and\nthere is a slightly improved appearance to the pulmonary\nvasculature compared to prior study suggesting improved fluid\nstatus.\n\n\nBrief Hospital Course:\nA/P: 56F with decompensated EtOH cirrhosis w/ encephalopathy and\nesophageal varices, admitted to ICU after being found down,\nintubated.\n.\n# Altered mental status: Likely 3-22 hepatic encephalopathy, PA\nlateral CXR negative, sputum cx. negative. Has had multiple\nadmissions for encephalopathy 3-22 med noncompliance, though pt.', "\nand family report compliance with meds and 2-3 times daily BMs.\nNo leukocytosis or abd. pain, with minimal ascites, so unlikely\nSBP. Sputum gram stain with G+ cocci, but cultures negative and\nno e/o PNA on CXR. Tox screen negative on admission. CT head\nnegative.\n- continued lactulose q6h with PRN lactulose enemas\n- continued rifaximin, ursodiol at outpatient dose\n- MVI/thiamine/folate\nPt.'s mental status cleared quickly and pt. was sent home on\nincreased lactulose/rifaxamin to prevent encephalopathy.\n.\n# Respiratory failure: intubated for airway protection, as\ninitially unresponsive, MS quickly improved with lactulose, and\npt. was extubated.\n.\n# EtOH cirrhosis: Decompensated with encephalopathy, ascites,\nand varices. Currently with minimal ascites. Last EGD 12-26, no\nknown h/o melena or BRBPR, guaiac negative on exam.", ' MELD 16.\nThrombocytopenia within baseline. Tbili trended down during\nadmission. Guaiacs negative during admission.\n.\n# Anemia: baseline wanders from 25-->36, hct stable during\nadmit.\n.\n\n\nMedications on Admission:\nCALCIUM CARBONATE 500 mg tid\nFLUOXETINE 20 MG qd\nFOLIC ACID 1 MG qd\nIBUPROFEN 800 MG tid prn\nK-DUR 20 mEq Smith and Sons Medical Center\nMAGNESIUM OXIDE 400 mg Smith and Sons Medical Center\nMULTIVITAMIN qd\nPREVACID 30 mg qd\nRIFAXIMIN 400 mg tid\nSPIRONOLACTONE 50 mg qd\nTHIAMINE HCL 100MG qd\nURSODIOL 300 mg tid\nVITAMIN D 800 unit qd\nLACTULOSE 2 TB qid\n\n\nDischarge Medications:\n1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a\nday).\nDisp:180 Tablet(s) Refills:2\n2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times\na day).\nDisp:90 Capsule(s) Refills:2\n3.', ' Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One\n(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).\nDisp:30 Capsule, Delayed Release(E.C.)(s) Refills:2\n4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY\n(Daily).\nDisp:30 Cap(s) Refills:2\n5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\nDisp:30 Tablet(s) Refills:2\n6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\nDisp:30 Capsule(s) Refills:2\n7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\nDisp:60 Tablet(s) Refills:2\n8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day).\nDisp:60 Tablet(s) Refills:2\n9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every\n4 hours).\nDisp:3 qs Refills:2\n10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)\nTablet PO DAILY (Daily).', '\nDisp:60 Tablet(s) Refills:2\n11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:2\n12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)\nTablet, Chewable PO TID (3 times a day).\nDisp:90 Tablet, Chewable(s) Refills:2\n13. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab\nSust.Rel. Particle/Crystal PO once a day.\nDisp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:2\n14. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\nDisp:30 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n65197 Lee Locks Apt. 036\nTimothyton, WY 26712 VNA\n\nDischarge Diagnosis:\nPrimary: hepatic encephalopathy\n alcoholic cirrhosis\nSecondary: hypertension\n anemia\n gastroesophageal reflux disease\n\n\nDischarge Condition:\nGood.', " The patient's mental status has returned to baseline.\nTaking POs, ambulating, satting >94% on room air\n\n\nDischarge Instructions:\nPlease take all medications as prescribed. It is especially\nimportant to take your lactulose and rifaxamin so that you have\nat least 3 loose bowel movements a day.\n\nPlease follow-up with your appointments as below.\n\nPlease contact your doctor or go to the emergency room if you\nexperience:\n--confusion\n--stomach pain\n--nausea or vomiting\n--fevers or chills\n--shortness of breath\n--chest pain\n\nFollowup Instructions:\nLiver physician: Angela Lenling: Creighton Shipley Lewis, MD\nPhone:161-293-2817 Date/Time:1907-9-11 10:15\nPrimary care physician: Angela Lenling: Natividad Chin, MD\nPhone:427-697-1693 Date/Time:1931-10-15 1:30\n\n\n Quincy Lees MD, MSC, MPH92311667\n\n"]
243	2414	106238.0	2186-06-11	Discharge summary	Report	Admission Date: [2186-6-7] Discharge Date: [2186-6-11] Date of Birth: [2124-11-5] Sex: M Service: [Hospital Ward Name ] ICU CHIEF COMPLAINT: "Black stools" x one day. HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old male with a history of ischemic cardiomyopathy with an EF of 30 to 35%, status post left anterior descending coronary artery stent [2182], history of colonic polyps in [2177] status post resection, history of recurrent left lower extremity deep venous thrombosis on chronic anticoagulation who was in his usual state of health until two days prior when he noted onset of fatigue, nausea, loss of appetite. Yesterday one day prior to admission he had one episode of black stool. He denies any abdominal pain. He denies any vomiting or bright red blood per rectum. Of note, he had a light bowel movement on the day prior. He denies any history of heavy alcohol use or non-steroidal anti-inflammatory drugs use. No prior retching. No back pain. He does have a history of abdominal aortic aneurysm repair. He denies any changes in his Coumadin dosing. No lightheadedness. No loss of consciousness. The patient came to the clinic for a scheduled phlebotomy for his hemochromatosis at which time his systolic blood pressure was 88. He reported having black stool and was sent to the Emergency Room. In the Emergency Room he was OB positive. Nasogastric lavage was performed, which returned clear fluid. He was given 2 liters of saline intravenous with no improvement in systolics. His hematocrit was 31 initially and dropped to 24. INR was 2.3. He was given 2 mg of po vitamin K and sent to the [Hospital Ward Name 332] Intensive Care Unit. REVIEW OF SYSTEMS: He denies any fevers or chills. He denies any abdominal pain. He does admit to taking Dilantin 200 mg in [Doctor Last Name 2434] of his usual 300 dose of one to two weeks. He also admits to persistent reflux symptoms for several years, but it has been untreated. He uses Rolaids prn. PAST MEDICAL HISTORY: 1. Coronary artery disease status post non Q wave myocardial infarction in [2180] with left anterior descending coronary artery [Last Name (un) 2435]. Status post myocardial infarction in [2182] with percutaneous transluminal coronary angioplasty to left anterior descending coronary artery stent. 2. History of congestive heart failure with an EF of 30 to 35%. 3. Hemochromatosis with early cirrhosis requiring q 3 month phlebotomies. 4. Noninsulin dependent diabetes mellitus. 5. Status post abdominal aortic aneurysm repair in [2178]. 6. History of recurrent left lower extremity deep venous thrombosis now on anticoagulation. 7. History of seizure disorder. 8. Status post L4-L5 discectomy in [2181]. 9. History of benign colonic polyp resection in [2177]. MEDICATIONS AT HOME: 1. Aspirin 81. 2. Atenolol 50. 3. Zestril 10. 4. Lipitor 10. 5. Coumadin 5 Tuesday to Sunday, 7.5 on Monday. 6. Metformin 1000 twice a day. 7. Glyburide 20 twice a day. 8. Folate one. 9. Dilantin 300. ALLERGIES: The patient admits to an allergy to intravenous dye many years ago. The reaction was some bumps on his hand. No shortness of breath or choking. SOCIAL HISTORY: The patient lives with his wife in [Name (NI) 2436]. He is retired from the furniture upholstery business. He smoked 35 years times half a pack a day. Quit in [2182]. Very rare alcohol. No non-steroidal anti-inflammatory drugs or Ibuprofen use. PHYSICAL EXAMINATION: The patient's temperature was 98.4. Heart rate 76 to 79. Blood pressure 90/50. Respirations 15. Sat 94 to 99% on 2 liters. In general, well appearing and in no acute distress. Pupils are equal, round and reactive to light. No scleral icterus. Oropharynx is clear. Conjunctiva were slightly pale. No lymphadenopathy. No bruits. JVP approximately 8 cm. Chest rales at the right base. Cardiac regular. S1 and S2. No murmurs. Abdomen was benign, soft, nontender. Good bowel sounds. He had a midline ventral hernia, which was soft. Liver was palpated 2 cm below the costal margin. The patient was OB positive in the Emergency Department. Extremities revealed 1+ pedal edema with venostasis changes bilaterally. Skin examination had no rashes. The patient s alert and oriented times three with a chronic left foot drop. INITIAL LABORATORIES: White blood cell count 6.3, hematocrit 31.4, which then dropped to 24.3, baseline is 41. Platelets 138. SMA 7 notable for a sodium of 136, K of 4.7, bicarb 24, BUN 32, creatinine 0.5, glucose 158, INR 2.3. Dilantin level was 3.0. ALT 35, AST 51, alkaline phosphatase 203. Total bilirubin .5, LDH 215, albumin 3.0. Enzymes were cycled, which were negative. The patient's electrocardiogram revealed normal sinus rhythm, PR prolongation at 206. Left axis deviation, inferior Qs, all of which were old. There were some new T wave flattening in V2 to V6. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient was admitted with melena likely an upper gastrointestinal bleed given history of abdominal aortic aneurysm, question of enteric fistula. Given history of hemochromatosis and early cirrhosis, question of varices, given history of reflux symptoms, question of esophagitis, gastritis. The patient was again admitted with gastrointestinal bleed and was typed and crossed. He was initially transfused 2 units for a hematocrit of 24. He had two peripheral intravenouses in place. INR was corrected with vitamin K 2 mg and 4 units of fresh frozen platelets and hematocrit revealed a change from 24 up to 26 after 4 units. INR corrected to 1.7. The patient was also started on Protonix 40 intravenous b.i.d. Aspirin and Coumadin were held. The patient underwent an esophagogastroduodenoscopy on the following morning, which revealed grade 1 esophageal varices and mild gastritis esophagitis as well as portal gastropathy. There was no active bleeding at any site. The patient then underwent an abdominal CT, which was negative for aortic enteric fistula. On the following day the patient underwent a colonoscopy, which was normal up until the ascending colon. However, they were not able to go all the way to the cecum and recommended virtual colonoscopy in the future and the patient had then underwent a repeat esophagogastroduodenoscopy with banding times four to the esophageal varices. The patient will need a repeat banding procedure in ten days. After the banding the patient was started on Sucralfate 1 gram q.i.d. and was continued on Protonix. Again aspirin and Coumadin were held throughout. After 4 units hematocrit stabilized from 24 up to 32 and remained stable at 32 upon discharge. 2. Hypotension: The patient was initially in the systolics in the 90s likely hypovolemic in the setting of a gastrointestinal bleed. However, given the history of cardiac disease the patient's enzymes were cycled times three, which were negative. He was resuscitated with fluid, fresh frozen platelets and packed red cells and blood pressure remained stable throughout. After the esophagogastroduodenoscopy the Atenolol was switched to Nadolol given the history of cirrhosis and varices and Zestril was held up until discharge due to low blood pressures. 3. Coronary artery disease: Patient with a history of myocardial infarction in [2180] and [2182] and is status post stent of the percutaneous transluminal coronary angioplasty in [2182]. Enzymes were cycled, which were negative. Aspirin and Coumadin were held due to gastrointestinal bleed. Beta blocker and ace were initially held due to low blood pressures. Lipitor was held secondary to new cirrhosis. The patient was restarted on Nadolol upon discharge, however, aspirin, Coumadin, Zestril and Lipitor were held prior to discharge to be restarted by primary care physician at his or her discretion. 4. Deep venous thrombosis: Patient with recurrent left lower extremity deep venous thrombosis, but admitted with gastrointestinal bleed. INR 2.3, Coumadin was held due to multiple procedures and held upon discharge. The patient will undergo repeat banding in ten days after which time the patient may or may not resume anticoagulation per primary care physician. 5. Hemachromatosis: The patient with hemachromatosis for long standing, now with evidence of cirrhosis on examination. The patient will continue with further phlebotomies as per Dr. [Last Name (STitle) ] and may need further workup for cirrhosis. 6. History of abdominal aortic aneurysm: Patient ruled out enteric fistula with negative abdominal CT. 7. Seizure disorder: The patient was given additional dose of Dilantin 400 times one and then restarted on his regular does of 300 and will continue on his regular dose. No further seizure activity. 8. Diabetes: The patient was initially held NPO diabetic medications due to NPO status. Was covered with a sliding scale. Sugars remained stable and can restart Glyburide upon discharge. Metformin held secondary to cirrhosis. DISCHARGE DIAGNOSES: 1. Esophageal varices s/p banding. 2. Portal gastropathy. 3. Gastritis esophagitis. 4. Hemachromatosis with early cirrhosis. 5. Coronary disease. 6. Recurrent deep venous thrombosis. 7. Congestive heart failure. 8. Diabetes. 9. s/p abdominal aortic aneurysm repair. 10. Seizure disorder. MEDICATIONS ON DISCHARGE: 1. Nadolol 20 q.d. 2. Sucralfate one q.i.d. times seven days. 3. Protonix 40 po q.d. 4. Dilantin 300. 5. Folate 1. MEDICATIONS HELD: 1. Aspirin. 2. Coumadin. 3. Lipitor. 4. Zestril. 5. Atenolol switched to Nadolol. FOLLOW UP: The patient will follow up with primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 410]. Follow up with hematologist [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and follow up with liver specialist [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for repeat banding in ten days. At the time of follow up, the timing for resuming anticoagulation should be addressed. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437], M.D. [MD Number(1) 2438] Dictated By:[Name8 (MD) 2439] MEDQUIST36 D: [2186-6-12] 03:36 T: [2186-6-19] 08:59 JOB#: [Job Number 2440] cc:[Last Name (NamePattern4) 2441]	Admission Date: <Date>1938-5-12</Date> Discharge Date: <Date>1938-1-24</Date> Date of Birth: <Date>1904-1-27</Date> Sex: M Service: <Hospital>Blankenship, Weeks and Murray Hospital</Hospital> ICU CHIEF COMPLAINT: "Black stools" x one day. HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old male with a history of ischemic cardiomyopathy with an EF of 30 to 35%, status post left anterior descending coronary artery stent <Year>1965</Year>, history of colonic polyps in <Year>1965</Year> status post resection, history of recurrent left lower extremity deep venous thrombosis on chronic anticoagulation who was in his usual state of health until two days prior when he noted onset of fatigue, nausea, loss of appetite. Yesterday one day prior to admission he had one episode of black stool. He denies any abdominal pain. He denies any vomiting or bright red blood per rectum. Of note, he had a light bowel movement on the day prior. He denies any history of heavy alcohol use or non-steroidal anti-inflammatory drugs use. No prior retching. No back pain. He does have a history of abdominal aortic aneurysm repair. He denies any changes in his Coumadin dosing. No lightheadedness. No loss of consciousness. The patient came to the clinic for a scheduled phlebotomy for his hemochromatosis at which time his systolic blood pressure was 88. He reported having black stool and was sent to the Emergency Room. In the Emergency Room he was OB positive. Nasogastric lavage was performed, which returned clear fluid. He was given 2 liters of saline intravenous with no improvement in systolics. His hematocrit was 31 initially and dropped to 24. INR was 2.3. He was given 2 mg of po vitamin K and sent to the <Hospital>Kennedy Inc Medical Center</Hospital> Intensive Care Unit. REVIEW OF SYSTEMS: He denies any fevers or chills. He denies any abdominal pain. He does admit to taking Dilantin 200 mg in <Doctor Name>Dr.Recinos</Doctor Name> of his usual 300 dose of one to two weeks. He also admits to persistent reflux symptoms for several years, but it has been untreated. He uses Rolaids prn. PAST MEDICAL HISTORY: 1. Coronary artery disease status post non Q wave myocardial infarction in <Year>1965</Year> with left anterior descending coronary artery <Name>Deng</Name>. Status post myocardial infarction in <Year>1965</Year> with percutaneous transluminal coronary angioplasty to left anterior descending coronary artery stent. 2. History of congestive heart failure with an EF of 30 to 35%. 3. Hemochromatosis with early cirrhosis requiring q 3 month phlebotomies. 4. Noninsulin dependent diabetes mellitus. 5. Status post abdominal aortic aneurysm repair in <Year>1965</Year>. 6. History of recurrent left lower extremity deep venous thrombosis now on anticoagulation. 7. History of seizure disorder. 8. Status post L4-L5 discectomy in <Year>1965</Year>. 9. History of benign colonic polyp resection in <Year>1965</Year>. MEDICATIONS AT HOME: 1. Aspirin 81. 2. Atenolol 50. 3. Zestril 10. 4. Lipitor 10. 5. Coumadin 5 Tuesday to Sunday, 7.5 on Monday. 6. Metformin 1000 twice a day. 7. Glyburide 20 twice a day. 8. Folate one. 9. Dilantin 300. ALLERGIES: The patient admits to an allergy to intravenous dye many years ago. The reaction was some bumps on his hand. No shortness of breath or choking. SOCIAL HISTORY: The patient lives with his wife in <Name>Jerry Casenhiser</Name>. He is retired from the furniture upholstery business. He smoked 35 years times half a pack a day. Quit in <Year>1965</Year>. Very rare alcohol. No non-steroidal anti-inflammatory drugs or Ibuprofen use. PHYSICAL EXAMINATION: The patient's temperature was 98.4. Heart rate 76 to 79. Blood pressure 90/50. Respirations 15. Sat 94 to 99% on 2 liters. In general, well appearing and in no acute distress. Pupils are equal, round and reactive to light. No scleral icterus. Oropharynx is clear. Conjunctiva were slightly pale. No lymphadenopathy. No bruits. JVP approximately 8 cm. Chest rales at the right base. Cardiac regular. S1 and S2. No murmurs. Abdomen was benign, soft, nontender. Good bowel sounds. He had a midline ventral hernia, which was soft. Liver was palpated 2 cm below the costal margin. The patient was OB positive in the Emergency Department. Extremities revealed 1+ pedal edema with venostasis changes bilaterally. Skin examination had no rashes. The patient s alert and oriented times three with a chronic left foot drop. INITIAL LABORATORIES: White blood cell count 6.3, hematocrit 31.4, which then dropped to 24.3, baseline is 41. Platelets 138. SMA 7 notable for a sodium of 136, K of 4.7, bicarb 24, BUN 32, creatinine 0.5, glucose 158, INR 2.3. Dilantin level was 3.0. ALT 35, AST 51, alkaline phosphatase 203. Total bilirubin .5, LDH 215, albumin 3.0. Enzymes were cycled, which were negative. The patient's electrocardiogram revealed normal sinus rhythm, PR prolongation at 206. Left axis deviation, inferior Qs, all of which were old. There were some new T wave flattening in V2 to V6. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient was admitted with melena likely an upper gastrointestinal bleed given history of abdominal aortic aneurysm, question of enteric fistula. Given history of hemochromatosis and early cirrhosis, question of varices, given history of reflux symptoms, question of esophagitis, gastritis. The patient was again admitted with gastrointestinal bleed and was typed and crossed. He was initially transfused 2 units for a hematocrit of 24. He had two peripheral intravenouses in place. INR was corrected with vitamin K 2 mg and 4 units of fresh frozen platelets and hematocrit revealed a change from 24 up to 26 after 4 units. INR corrected to 1.7. The patient was also started on Protonix 40 intravenous b.i.d. Aspirin and Coumadin were held. The patient underwent an esophagogastroduodenoscopy on the following morning, which revealed grade 1 esophageal varices and mild gastritis esophagitis as well as portal gastropathy. There was no active bleeding at any site. The patient then underwent an abdominal CT, which was negative for aortic enteric fistula. On the following day the patient underwent a colonoscopy, which was normal up until the ascending colon. However, they were not able to go all the way to the cecum and recommended virtual colonoscopy in the future and the patient had then underwent a repeat esophagogastroduodenoscopy with banding times four to the esophageal varices. The patient will need a repeat banding procedure in ten days. After the banding the patient was started on Sucralfate 1 gram q.i.d. and was continued on Protonix. Again aspirin and Coumadin were held throughout. After 4 units hematocrit stabilized from 24 up to 32 and remained stable at 32 upon discharge. 2. Hypotension: The patient was initially in the systolics in the 90s likely hypovolemic in the setting of a gastrointestinal bleed. However, given the history of cardiac disease the patient's enzymes were cycled times three, which were negative. He was resuscitated with fluid, fresh frozen platelets and packed red cells and blood pressure remained stable throughout. After the esophagogastroduodenoscopy the Atenolol was switched to Nadolol given the history of cirrhosis and varices and Zestril was held up until discharge due to low blood pressures. 3. Coronary artery disease: Patient with a history of myocardial infarction in <Year>1965</Year> and <Year>1965</Year> and is status post stent of the percutaneous transluminal coronary angioplasty in <Year>1965</Year>. Enzymes were cycled, which were negative. Aspirin and Coumadin were held due to gastrointestinal bleed. Beta blocker and ace were initially held due to low blood pressures. Lipitor was held secondary to new cirrhosis. The patient was restarted on Nadolol upon discharge, however, aspirin, Coumadin, Zestril and Lipitor were held prior to discharge to be restarted by primary care physician at his or her discretion. 4. Deep venous thrombosis: Patient with recurrent left lower extremity deep venous thrombosis, but admitted with gastrointestinal bleed. INR 2.3, Coumadin was held due to multiple procedures and held upon discharge. The patient will undergo repeat banding in ten days after which time the patient may or may not resume anticoagulation per primary care physician. 5. Hemachromatosis: The patient with hemachromatosis for long standing, now with evidence of cirrhosis on examination. The patient will continue with further phlebotomies as per Dr. <Name>Bludsworth</Name> and may need further workup for cirrhosis. 6. History of abdominal aortic aneurysm: Patient ruled out enteric fistula with negative abdominal CT. 7. Seizure disorder: The patient was given additional dose of Dilantin 400 times one and then restarted on his regular does of 300 and will continue on his regular dose. No further seizure activity. 8. Diabetes: The patient was initially held NPO diabetic medications due to NPO status. Was covered with a sliding scale. Sugars remained stable and can restart Glyburide upon discharge. Metformin held secondary to cirrhosis. DISCHARGE DIAGNOSES: 1. Esophageal varices s/p banding. 2. Portal gastropathy. 3. Gastritis esophagitis. 4. Hemachromatosis with early cirrhosis. 5. Coronary disease. 6. Recurrent deep venous thrombosis. 7. Congestive heart failure. 8. Diabetes. 9. s/p abdominal aortic aneurysm repair. 10. Seizure disorder. MEDICATIONS ON DISCHARGE: 1. Nadolol 20 q.d. 2. Sucralfate one q.i.d. times seven days. 3. Protonix 40 po q.d. 4. Dilantin 300. 5. Folate 1. MEDICATIONS HELD: 1. Aspirin. 2. Coumadin. 3. Lipitor. 4. Zestril. 5. Atenolol switched to Nadolol. FOLLOW UP: The patient will follow up with primary care physician <Name>Yuen</Name>. <Name>Reinaldo</Name> <Name>Ahmed</Name>. Follow up with hematologist <Name>Prince</Name> <Name>Bounds</Name> and follow up with liver specialist <Name>Brianne</Name> <Name>Bounds</Name> for repeat banding in ten days. At the time of follow up, the timing for resuming anticoagulation should be addressed. <Name>Prince</Name> <Name>Grier</Name>, M.D. <MD Number>41050462</MD Number> Dictated By:<Name>Jessie Walker</Name> MEDQUIST36 D: <Date>1957-5-22</Date> 03:36 T: <Date>1918-3-7</Date> 08:59 JOB#: <Job Number>Bryant PLC-1962-447555</Job Number> 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111111111111111111110000011111111	Admission Date: 1938-5-12 Discharge Date: 1938-1-24 Date of Birth: 1904-1-27 Sex: M Service: Blankenship, Weeks and Murray Hospital ICU CHIEF COMPLAINT: "Black stools" x one day. HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old male with a history of ischemic cardiomyopathy with an EF of 30 to 35%, status post left anterior descending coronary artery stent 1965, history of colonic polyps in 1965 status post resection, history of recurrent left lower extremity deep venous thrombosis on chronic anticoagulation who was in his usual state of health until two days prior when he noted onset of fatigue, nausea, loss of appetite. Yesterday one day prior to admission he had one episode of black stool. He denies any abdominal pain. He denies any vomiting or bright red blood per rectum. Of note, he had a light bowel movement on the day prior. He denies any history of heavy alcohol use or non-steroidal anti-inflammatory drugs use. No prior retching. No back pain. He does have a history of abdominal aortic aneurysm repair. He denies any changes in his Coumadin dosing. No lightheadedness. No loss of consciousness. The patient came to the clinic for a scheduled phlebotomy for his hemochromatosis at which time his systolic blood pressure was 88. He reported having black stool and was sent to the Emergency Room. In the Emergency Room he was OB positive. Nasogastric lavage was performed, which returned clear fluid. He was given 2 liters of saline intravenous with no improvement in systolics. His hematocrit was 31 initially and dropped to 24. INR was 2.3. He was given 2 mg of po vitamin K and sent to the Kennedy Inc Medical Center Intensive Care Unit. REVIEW OF SYSTEMS: He denies any fevers or chills. He denies any abdominal pain. He does admit to taking Dilantin 200 mg in Dr.Recinos of his usual 300 dose of one to two weeks. He also admits to persistent reflux symptoms for several years, but it has been untreated. He uses Rolaids prn. PAST MEDICAL HISTORY: 1. Coronary artery disease status post non Q wave myocardial infarction in 1965 with left anterior descending coronary artery Deng. Status post myocardial infarction in 1965 with percutaneous transluminal coronary angioplasty to left anterior descending coronary artery stent. 2. History of congestive heart failure with an EF of 30 to 35%. 3. Hemochromatosis with early cirrhosis requiring q 3 month phlebotomies. 4. Noninsulin dependent diabetes mellitus. 5. Status post abdominal aortic aneurysm repair in 1965. 6. History of recurrent left lower extremity deep venous thrombosis now on anticoagulation. 7. History of seizure disorder. 8. Status post L4-L5 discectomy in 1965. 9. History of benign colonic polyp resection in 1965. MEDICATIONS AT HOME: 1. Aspirin 81. 2. Atenolol 50. 3. Zestril 10. 4. Lipitor 10. 5. Coumadin 5 Tuesday to Sunday, 7.5 on Monday. 6. Metformin 1000 twice a day. 7. Glyburide 20 twice a day. 8. Folate one. 9. Dilantin 300. ALLERGIES: The patient admits to an allergy to intravenous dye many years ago. The reaction was some bumps on his hand. No shortness of breath or choking. SOCIAL HISTORY: The patient lives with his wife in Jerry Casenhiser. He is retired from the furniture upholstery business. He smoked 35 years times half a pack a day. Quit in 1965. Very rare alcohol. No non-steroidal anti-inflammatory drugs or Ibuprofen use. PHYSICAL EXAMINATION: The patient's temperature was 98.4. Heart rate 76 to 79. Blood pressure 90/50. Respirations 15. Sat 94 to 99% on 2 liters. In general, well appearing and in no acute distress. Pupils are equal, round and reactive to light. No scleral icterus. Oropharynx is clear. Conjunctiva were slightly pale. No lymphadenopathy. No bruits. JVP approximately 8 cm. Chest rales at the right base. Cardiac regular. S1 and S2. No murmurs. Abdomen was benign, soft, nontender. Good bowel sounds. He had a midline ventral hernia, which was soft. Liver was palpated 2 cm below the costal margin. The patient was OB positive in the Emergency Department. Extremities revealed 1+ pedal edema with venostasis changes bilaterally. Skin examination had no rashes. The patient s alert and oriented times three with a chronic left foot drop. INITIAL LABORATORIES: White blood cell count 6.3, hematocrit 31.4, which then dropped to 24.3, baseline is 41. Platelets 138. SMA 7 notable for a sodium of 136, K of 4.7, bicarb 24, BUN 32, creatinine 0.5, glucose 158, INR 2.3. Dilantin level was 3.0. ALT 35, AST 51, alkaline phosphatase 203. Total bilirubin .5, LDH 215, albumin 3.0. Enzymes were cycled, which were negative. The patient's electrocardiogram revealed normal sinus rhythm, PR prolongation at 206. Left axis deviation, inferior Qs, all of which were old. There were some new T wave flattening in V2 to V6. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient was admitted with melena likely an upper gastrointestinal bleed given history of abdominal aortic aneurysm, question of enteric fistula. Given history of hemochromatosis and early cirrhosis, question of varices, given history of reflux symptoms, question of esophagitis, gastritis. The patient was again admitted with gastrointestinal bleed and was typed and crossed. He was initially transfused 2 units for a hematocrit of 24. He had two peripheral intravenouses in place. INR was corrected with vitamin K 2 mg and 4 units of fresh frozen platelets and hematocrit revealed a change from 24 up to 26 after 4 units. INR corrected to 1.7. The patient was also started on Protonix 40 intravenous b.i.d. Aspirin and Coumadin were held. The patient underwent an esophagogastroduodenoscopy on the following morning, which revealed grade 1 esophageal varices and mild gastritis esophagitis as well as portal gastropathy. There was no active bleeding at any site. The patient then underwent an abdominal CT, which was negative for aortic enteric fistula. On the following day the patient underwent a colonoscopy, which was normal up until the ascending colon. However, they were not able to go all the way to the cecum and recommended virtual colonoscopy in the future and the patient had then underwent a repeat esophagogastroduodenoscopy with banding times four to the esophageal varices. The patient will need a repeat banding procedure in ten days. After the banding the patient was started on Sucralfate 1 gram q.i.d. and was continued on Protonix. Again aspirin and Coumadin were held throughout. After 4 units hematocrit stabilized from 24 up to 32 and remained stable at 32 upon discharge. 2. Hypotension: The patient was initially in the systolics in the 90s likely hypovolemic in the setting of a gastrointestinal bleed. However, given the history of cardiac disease the patient's enzymes were cycled times three, which were negative. He was resuscitated with fluid, fresh frozen platelets and packed red cells and blood pressure remained stable throughout. After the esophagogastroduodenoscopy the Atenolol was switched to Nadolol given the history of cirrhosis and varices and Zestril was held up until discharge due to low blood pressures. 3. Coronary artery disease: Patient with a history of myocardial infarction in 1965 and 1965 and is status post stent of the percutaneous transluminal coronary angioplasty in 1965. Enzymes were cycled, which were negative. Aspirin and Coumadin were held due to gastrointestinal bleed. Beta blocker and ace were initially held due to low blood pressures. Lipitor was held secondary to new cirrhosis. The patient was restarted on Nadolol upon discharge, however, aspirin, Coumadin, Zestril and Lipitor were held prior to discharge to be restarted by primary care physician at his or her discretion. 4. Deep venous thrombosis: Patient with recurrent left lower extremity deep venous thrombosis, but admitted with gastrointestinal bleed. INR 2.3, Coumadin was held due to multiple procedures and held upon discharge. The patient will undergo repeat banding in ten days after which time the patient may or may not resume anticoagulation per primary care physician. 5. Hemachromatosis: The patient with hemachromatosis for long standing, now with evidence of cirrhosis on examination. The patient will continue with further phlebotomies as per Dr. Bludsworth and may need further workup for cirrhosis. 6. History of abdominal aortic aneurysm: Patient ruled out enteric fistula with negative abdominal CT. 7. Seizure disorder: The patient was given additional dose of Dilantin 400 times one and then restarted on his regular does of 300 and will continue on his regular dose. No further seizure activity. 8. Diabetes: The patient was initially held NPO diabetic medications due to NPO status. Was covered with a sliding scale. Sugars remained stable and can restart Glyburide upon discharge. Metformin held secondary to cirrhosis. DISCHARGE DIAGNOSES: 1. Esophageal varices s/p banding. 2. Portal gastropathy. 3. Gastritis esophagitis. 4. Hemachromatosis with early cirrhosis. 5. Coronary disease. 6. Recurrent deep venous thrombosis. 7. Congestive heart failure. 8. Diabetes. 9. s/p abdominal aortic aneurysm repair. 10. Seizure disorder. MEDICATIONS ON DISCHARGE: 1. Nadolol 20 q.d. 2. Sucralfate one q.i.d. times seven days. 3. Protonix 40 po q.d. 4. Dilantin 300. 5. Folate 1. MEDICATIONS HELD: 1. Aspirin. 2. Coumadin. 3. Lipitor. 4. Zestril. 5. Atenolol switched to Nadolol. FOLLOW UP: The patient will follow up with primary care physician Yuen. Reinaldo Ahmed. Follow up with hematologist Prince Bounds and follow up with liver specialist Brianne Bounds for repeat banding in ten days. At the time of follow up, the timing for resuming anticoagulation should be addressed. Prince Grier, M.D. 41050462 Dictated By:Jessie Walker MEDQUIST36 D: 1957-5-22 03:36 T: 1918-3-7 08:59 JOB#: Bryant PLC-1962-447555 cc:Debelius	['Admission Date: 1938-5-12 Discharge Date: 1938-1-24\n\nDate of Birth: 1904-1-27 Sex: M\n\nService: Blankenship, Weeks and Murray Hospital ICU\n\nCHIEF COMPLAINT: "Black stools" x one day.\n\nHISTORY OF PRESENT ILLNESS: The patient is a 61 year-old\nmale with a history of ischemic cardiomyopathy with an EF of\n30 to 35%, status post left anterior descending coronary\nartery stent 1965, history of colonic polyps in 1965 status\npost resection, history of recurrent left lower extremity\ndeep venous thrombosis on chronic anticoagulation who was in\nhis usual state of health until two days prior when he noted\nonset of fatigue, nausea, loss of appetite. Yesterday one\nday prior to admission he had one episode of black stool. He\ndenies any abdominal pain. He denies any vomiting or bright\nred blood per rectum.', ' Of note, he had a light bowel movement\non the day prior. He denies any history of heavy alcohol use\nor non-steroidal anti-inflammatory drugs use. No prior\nretching. No back pain. He does have a history of abdominal\naortic aneurysm repair. He denies any changes in his\nCoumadin dosing. No lightheadedness. No loss of\nconsciousness. The patient came to the clinic for a\nscheduled phlebotomy for his hemochromatosis at which time\nhis systolic blood pressure was 88. He reported having black\nstool and was sent to the Emergency Room. In the Emergency\nRoom he was OB positive. Nasogastric lavage was performed,\nwhich returned clear fluid. He was given 2 liters of saline\nintravenous with no improvement in systolics. His hematocrit\nwas 31 initially and dropped to 24. INR was 2.3. He was\ngiven 2 mg of po vitamin K and sent to the Kennedy Inc Medical Center Intensive\nCare Unit.', '\n\nREVIEW OF SYSTEMS: He denies any fevers or chills. He\ndenies any abdominal pain. He does admit to taking Dilantin\n200 mg in Dr.Recinos of his usual 300 dose of one to two weeks.\nHe also admits to persistent reflux symptoms for several\nyears, but it has been untreated. He uses Rolaids prn.\n\nPAST MEDICAL HISTORY:\n1. Coronary artery disease status post non Q wave myocardial\ninfarction in 1965 with left anterior descending coronary\nartery Deng. Status post myocardial infarction in 1965 with\npercutaneous transluminal coronary angioplasty to left\nanterior descending coronary artery stent.\n2. History of congestive heart failure with an EF of 30 to\n35%.\n3. Hemochromatosis with early cirrhosis requiring q 3 month\nphlebotomies.\n4. Noninsulin dependent diabetes mellitus.\n5. Status post abdominal aortic aneurysm repair in 1965.', '\n6. History of recurrent left lower extremity deep venous\nthrombosis now on anticoagulation.\n7. History of seizure disorder.\n8. Status post L4-L5 discectomy in 1965.\n9. History of benign colonic polyp resection in 1965.\n\nMEDICATIONS AT HOME:\n1. Aspirin 81.\n2. Atenolol 50.\n3. Zestril 10.\n4. Lipitor 10.\n5. Coumadin 5 Tuesday to Sunday, 7.5 on Monday.\n6. Metformin 1000 twice a day.\n7. Glyburide 20 twice a day.\n8. Folate one.\n9. Dilantin 300.\n\nALLERGIES: The patient admits to an allergy to intravenous\ndye many years ago. The reaction was some bumps on his hand.\nNo shortness of breath or choking.\n\nSOCIAL HISTORY: The patient lives with his wife in\nJerry Casenhiser. He is retired from the furniture upholstery\nbusiness. He smoked 35 years times half a pack a day. Quit\nin 1965. Very rare alcohol.', " No non-steroidal\nanti-inflammatory drugs or Ibuprofen use.\n\nPHYSICAL EXAMINATION: The patient's temperature was 98.4.\nHeart rate 76 to 79. Blood pressure 90/50. Respirations 15.\nSat 94 to 99% on 2 liters. In general, well appearing and in\nno acute distress. Pupils are equal, round and reactive to\nlight. No scleral icterus. Oropharynx is clear.\nConjunctiva were slightly pale. No lymphadenopathy. No\nbruits. JVP approximately 8 cm. Chest rales at the right\nbase. Cardiac regular. S1 and S2. No murmurs. Abdomen was\nbenign, soft, nontender. Good bowel sounds. He had a\nmidline ventral hernia, which was soft. Liver was palpated 2\ncm below the costal margin. The patient was OB positive in\nthe Emergency Department. Extremities revealed 1+ pedal\nedema with venostasis changes bilaterally.", " Skin examination\nhad no rashes. The patient s alert and oriented times three\nwith a chronic left foot drop.\n\nINITIAL LABORATORIES: White blood cell count 6.3, hematocrit\n31.4, which then dropped to 24.3, baseline is 41. Platelets\n138. SMA 7 notable for a sodium of 136, K of 4.7, bicarb 24,\nBUN 32, creatinine 0.5, glucose 158, INR 2.3. Dilantin level\nwas 3.0. ALT 35, AST 51, alkaline phosphatase 203. Total\nbilirubin .5, LDH 215, albumin 3.0. Enzymes were cycled,\nwhich were negative. The patient's electrocardiogram\nrevealed normal sinus rhythm, PR prolongation at 206. Left\naxis deviation, inferior Qs, all of which were old. There\nwere some new T wave flattening in V2 to V6.\n\nHOSPITAL COURSE: 1. Gastrointestinal bleed: The patient\nwas admitted with melena likely an upper gastrointestinal\nbleed given history of abdominal aortic aneurysm, question of\nenteric fistula.", ' Given history of hemochromatosis and early\ncirrhosis, question of varices, given history of reflux\nsymptoms, question of esophagitis, gastritis. The patient\nwas again admitted with gastrointestinal bleed and was typed\nand crossed. He was initially transfused 2 units for a\nhematocrit of 24. He had two peripheral intravenouses in\nplace. INR was corrected with vitamin K 2 mg and 4 units of\nfresh frozen platelets and hematocrit revealed a change from\n24 up to 26 after 4 units. INR corrected to 1.7. The\npatient was also started on Protonix 40 intravenous b.i.d.\nAspirin and Coumadin were held. The patient underwent an\nesophagogastroduodenoscopy on the following morning, which\nrevealed grade 1 esophageal varices and mild gastritis\nesophagitis as well as portal gastropathy. There was no\nactive bleeding at any site.', ' The patient then underwent an\nabdominal CT, which was negative for aortic enteric fistula.\nOn the following day the patient underwent a colonoscopy,\nwhich was normal up until the ascending colon. However, they\nwere not able to go all the way to the cecum and recommended\nvirtual colonoscopy in the future and the patient had then\nunderwent a repeat esophagogastroduodenoscopy with banding\ntimes four to the esophageal varices. The patient will need\na repeat banding procedure in ten days. After the banding\nthe patient was started on Sucralfate 1 gram q.i.d. and was\ncontinued on Protonix. Again aspirin and Coumadin were held\nthroughout. After 4 units hematocrit stabilized from 24 up\nto 32 and remained stable at 32 upon discharge.\n\n2. Hypotension: The patient was initially in the systolics\nin the 90s likely hypovolemic in the setting of a\ngastrointestinal bleed.', " However, given the history of\ncardiac disease the patient's enzymes were cycled times\nthree, which were negative. He was resuscitated with fluid,\nfresh frozen platelets and packed red cells and blood\npressure remained stable throughout. After the\nesophagogastroduodenoscopy the Atenolol was switched to\nNadolol given the history of cirrhosis and varices and\nZestril was held up until discharge due to low blood\npressures.\n\n3. Coronary artery disease: Patient with a history of\nmyocardial infarction in 1965 and 1965 and is status post\nstent of the percutaneous transluminal coronary angioplasty\nin 1965. Enzymes were cycled, which were negative. Aspirin\nand Coumadin were held due to gastrointestinal bleed. Beta\nblocker and ace were initially held due to low blood\npressures. Lipitor was held secondary to new cirrhosis.", ' The\npatient was restarted on Nadolol upon discharge, however,\naspirin, Coumadin, Zestril and Lipitor were held prior to\ndischarge to be restarted by primary care physician at his or\nher discretion.\n\n4. Deep venous thrombosis: Patient with recurrent left\nlower extremity deep venous thrombosis, but admitted with\ngastrointestinal bleed. INR 2.3, Coumadin was held due to\nmultiple procedures and held upon discharge. The patient\nwill undergo repeat banding in ten days after which time the\npatient may or may not resume anticoagulation per primary\ncare physician.\n\n5. Hemachromatosis: The patient with hemachromatosis for\nlong standing, now with evidence of cirrhosis on examination.\nThe patient will continue with further phlebotomies as per\nDr. Bludsworth and may need further workup for cirrhosis.', '\n\n6. History of abdominal aortic aneurysm: Patient ruled out\nenteric fistula with negative abdominal CT.\n\n7. Seizure disorder: The patient was given additional dose\nof Dilantin 400 times one and then restarted on his regular\ndoes of 300 and will continue on his regular dose. No\nfurther seizure activity.\n\n8. Diabetes: The patient was initially held NPO diabetic\nmedications due to NPO status. Was covered with a sliding\nscale. Sugars remained stable and can restart Glyburide upon\ndischarge. Metformin held secondary to cirrhosis.\n\nDISCHARGE DIAGNOSES:\n1. Esophageal varices s/p banding.\n2. Portal gastropathy.\n3. Gastritis esophagitis.\n4. Hemachromatosis with early cirrhosis.\n5. Coronary disease.\n6. Recurrent deep venous thrombosis.\n7. Congestive heart failure.\n8. Diabetes.\n9. s/p abdominal aortic aneurysm repair.', '\n10. Seizure disorder.\n\nMEDICATIONS ON DISCHARGE:\n1. Nadolol 20 q.d.\n2. Sucralfate one q.i.d. times seven days.\n3. Protonix 40 po q.d.\n4. Dilantin 300.\n5. Folate 1.\n\nMEDICATIONS HELD:\n1. Aspirin.\n2. Coumadin.\n3. Lipitor.\n4. Zestril.\n5. Atenolol switched to Nadolol.\n\nFOLLOW UP: The patient will follow up with primary care\nphysician Yuen. Reinaldo Ahmed. Follow up with hematologist Prince\nBounds and follow up with liver specialist Brianne Bounds for repeat\nbanding in ten days. At the time of follow up, the timing for\nresuming anticoagulation should be addressed.\n\n\n\n\n\n Prince Grier, M.D. 41050462\n\nDictated By:Jessie Walker\n\nMEDQUIST36\n\nD: 1957-5-22 03:36\nT: 1918-3-7 08:59\nJOB#: Bryant PLC-1962-447555\n\ncc:Debelius']
244	19183	145164.0	2141-07-13	Discharge summary	Report	Admission Date: [2141-7-9] Discharge Date: [2141-7-13] Date of Birth: [2095-12-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: overdose Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [Known lastname 2445] is a 45 year old man who presented to the [Hospital1 18] via [Location (un) 86] EMS. Pt was found by EMS at his home at 10:21pm [2141-7-8]. The patient was supine, pt was noted to by awake and alert, BP 120/88, pulse 72. He was noted to have overdosed taking "35 pills" - bottles at the scene included citalopram, risperdal, doxazosin, and doxepin. A note was found with him saying "I don't want to do time." He was brought to [Hospital1 18] where his VS were T 98.7 BP 126/79 RR 18 99% RA. Pt was noted to have altered mental status and a GCS of 12. A foley was placed and 150cc of urine was obtained. By report, he said he had taken "a bunch of vicodin" so narcan 5mg was given 5mg given at 12:20am with little response. At 1:13 am the patient was intubated for airway protection, but the intubation was difficult and anaesthesia needed to perform the intubation fiberoptically. In total, the patient was given 2L NS and 1L D5W with 150meq bicarb. Activated charcoal was also given. An EKG was performed and was RBB with a QRS of 136. Tox screen was also positive for cocaine, TCAs and acetaminophen Past Medical History: History of hepatitis B exposure History of head trauma History of witdrawal seizure Social History: He has a history of polysubstance abuse, abusing both intravenous and intranasal heroin, as well as cocaine. He has been on a methadone maintenance program. He has a history of multiple suicide attempts, including an overdose of zyprexa. He has been incarcereated twice. He has a history of alcohol abuse and marijuana and tobacco use. Family History: Noncontributory . Physical Exam: VS: T 97 HR 81 BP 110/67 RR 13 Sat 100% Vent: AC Tv 600 RR 12 PEEP 5 FiO2 0.4 pulling: Mv 6.8 PIP 31 Plat 17 MaP 10 Gen: AA man intubated and sedated. +ETT +foley +PIV x2 HEENT: pupils constricted but reactive, sclerae anicteric Neck: supple, no masses, trachea midline CV: Normal s1/s2, RRR, no m/r/g Pul: CTA bilaterally Abd: Soft, NT, ND Ext: No edema, warm, dry, DP 2+ bilaterally, RP 2+ bilaterally. Neuro: Sedated, withdraws to pain Pertinent Results: [2141-7-8] 11:45PM BLOOD WBC-11.5* RBC-5.63# Hgb-17.4# Hct-49.3 MCV-88 MCH-30.8 MCHC-35.2* RDW-13.6 Plt Ct-207 [2141-7-8] 11:45PM BLOOD Neuts-71.2* Lymphs-23.8 Monos-4.5 Eos-0.3 Baso-0.3 [2141-7-8] 11:45PM BLOOD Plt Ct-207 [2141-7-8] 11:45PM BLOOD Glucose-83 UreaN-16 Creat-1.3* Na-134 K-8.23* Cl-99 HCO3-25 AnGap-18 [2141-7-8] 11:45PM BLOOD ALT-184* AST-688* CK(CPK)-[Numeric Identifier 2446]* AlkPhos-85 Amylase-62 TotBili-1.4 [2141-7-11] 02:00AM BLOOD CK-MB-4 cTropnT-<0.01 [2141-7-10] 10:19AM BLOOD CK-MB-10 MB Indx-0.1 cTropnT-<0.01 [2141-7-8] 11:45PM BLOOD Calcium-9.3 Phos-4.6* Mg-2.3 [2141-7-8] 11:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.1 Bnzodzp-NEG Barbitr-NEG Tricycl-POS [2141-7-9] 04:34AM BLOOD Acetmnp-NEG [2141-7-9] 01:00AM BLOOD K-4.3 [2141-7-13] 03:02AM BLOOD WBC-8.1 RBC-4.35* Hgb-13.4* Hct-38.5* MCV-88 MCH-30.9 MCHC-35.0 RDW-13.5 Plt Ct-188 [2141-7-13] 03:02AM BLOOD ALT-106* AST-223* LD(LDH)-356* CK(CPK)-6223* AlkPhos-65 TotBili-1.0 Brief Hospital Course: 45M w/ history of depression, polysubstance abuse, presenting after a suicide attempt, overdosing on tricyclics (doxepin) and also with cocaine intoxication who was sucessfully extubated with a closing QRS and decreasing CK. Patient's renal function remained good with excellent urine output. Pt medically cleared for psych admission. 1. TCA: QRS closed, monitored on tele. 2. Rhabdo: decreasing CK with IV hydration and excellent urine output. 3. SI: 1:1 sitter and psych consult, pt upset that he did not succeed with suicide attempt, admit to psych, all TCAs and sedatives held. 4. left arm swelling: no evidence of compartment syndrome, PIV pulled from left hand, seen by ortho for possible ulnar neuropraxia, improving upon discharge. US showed no DVT. Transferred to psych on section 12 for further eval and readjust of medications. Medications on Admission: BENADRYL 25MG--Take 2 by mouth at bedtime BENZAMYCINPAK 3-5%--Apply twice a day to face for acne CELEXA 20MG--Take one by mouth at bedtime COLACE 100MG--1-2 tabs by mouth every day as needed DOXEPIN HCL 25MG--One capsule(s) by mouth at bedtime Doxazosin 1MG--2 tablet(s) by mouth at bedtime RISPERDAL 0.25MG--Take two tablets before sleep TRETINOIN 0.025%--Pea sized amt to face and rub in for acne VIAGRA 50 mg--0.5-1 tablet(s) by mouth once a day as needed for for sexual activity take 30-60 minutes prior to sexual activity WESTCORT 0.2%--Twice a day to face for 7 days, then d/c ZANTAC 150MG--One tablet by mouth twice Discharge Medications: 1. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO at bedtime as needed for insomnia for 10 days. 2. Colace 100 mg Capsule Sig: [11-21] Capsules PO once a day as needed for constipation for 10 days. 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime for 30 days. 4. Risperdal 0.25 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for insomnia for 10 days. 5. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day for 30 days. 6. BenzamycinPak [1-22] % Gel Sig: One (1) Topical twice a day for 10 days. Discharge Disposition: Extended Care Facility: [Hospital1 69] - [Location (un) 86] Discharge Diagnosis: TCA overdose, suicide attempt, depression, h/o withdrawal seizures, h/o head trauma, h/o cocaine use, h/o hep B exposure Discharge Condition: Improved Discharge Instructions: Discharge to pyschiatry service, keep your scheduled appointments, hold your anti-depressant medications until you see psychiatry. Followup Instructions: Please follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) 2447] within 2-3 days	Admission Date: <Date>1908-8-21</Date> Discharge Date: <Date>1989-11-26</Date> Date of Birth: <Date>2019-8-9</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Curtis</Name> Chief Complaint: overdose Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. <Name>White</Name> is a 45 year old man who presented to the <Hospital>Haynes Inc Clinic</Hospital> via <Location>96803 Larry Estate Apt. 080 East Michellebury, WI 64939</Location> EMS. Pt was found by EMS at his home at 10:21pm <Date>1915-7-5</Date>. The patient was supine, pt was noted to by awake and alert, BP 120/88, pulse 72. He was noted to have overdosed taking "35 pills" - bottles at the scene included citalopram, risperdal, doxazosin, and doxepin. A note was found with him saying "I don't want to do time." He was brought to <Hospital>Haynes Inc Clinic</Hospital> where his VS were T 98.7 BP 126/79 RR 18 99% RA. Pt was noted to have altered mental status and a GCS of 12. A foley was placed and 150cc of urine was obtained. By report, he said he had taken "a bunch of vicodin" so narcan 5mg was given 5mg given at 12:20am with little response. At 1:13 am the patient was intubated for airway protection, but the intubation was difficult and anaesthesia needed to perform the intubation fiberoptically. In total, the patient was given 2L NS and 1L D5W with 150meq bicarb. Activated charcoal was also given. An EKG was performed and was RBB with a QRS of 136. Tox screen was also positive for cocaine, TCAs and acetaminophen Past Medical History: History of hepatitis B exposure History of head trauma History of witdrawal seizure Social History: He has a history of polysubstance abuse, abusing both intravenous and intranasal heroin, as well as cocaine. He has been on a methadone maintenance program. He has a history of multiple suicide attempts, including an overdose of zyprexa. He has been incarcereated twice. He has a history of alcohol abuse and marijuana and tobacco use. Family History: Noncontributory . Physical Exam: VS: T 97 HR 81 BP 110/67 RR 13 Sat 100% Vent: AC Tv 600 RR 12 PEEP 5 FiO2 0.4 pulling: Mv 6.8 PIP 31 Plat 17 MaP 10 Gen: AA man intubated and sedated. +ETT +foley +PIV x2 HEENT: pupils constricted but reactive, sclerae anicteric Neck: supple, no masses, trachea midline CV: Normal s1/s2, RRR, no m/r/g Pul: CTA bilaterally Abd: Soft, NT, ND Ext: No edema, warm, dry, DP 2+ bilaterally, RP 2+ bilaterally. Neuro: Sedated, withdraws to pain Pertinent Results: <Date>1915-7-5</Date> 11:45PM BLOOD WBC-11.5* RBC-5.63# Hgb-17.4# Hct-49.3 MCV-88 MCH-30.8 MCHC-35.2* RDW-13.6 Plt Ct-207 <Date>1915-7-5</Date> 11:45PM BLOOD Neuts-71.2* Lymphs-23.8 Monos-4.5 Eos-0.3 Baso-0.3 <Date>1915-7-5</Date> 11:45PM BLOOD Plt Ct-207 <Date>1915-7-5</Date> 11:45PM BLOOD Glucose-83 UreaN-16 Creat-1.3* Na-134 K-8.23* Cl-99 HCO3-25 AnGap-18 <Date>1915-7-5</Date> 11:45PM BLOOD ALT-184* AST-688* CK(CPK)-<Numeric Identifier>9087910</Numeric Identifier>* AlkPhos-85 Amylase-62 TotBili-1.4 <Date>1925-11-15</Date> 02:00AM BLOOD CK-MB-4 cTropnT-<0.01 <Date>1959-1-9</Date> 10:19AM BLOOD CK-MB-10 MB Indx-0.1 cTropnT-<0.01 <Date>1915-7-5</Date> 11:45PM BLOOD Calcium-9.3 Phos-4.6* Mg-2.3 <Date>1915-7-5</Date> 11:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.1 Bnzodzp-NEG Barbitr-NEG Tricycl-POS <Date>1908-8-21</Date> 04:34AM BLOOD Acetmnp-NEG <Date>1908-8-21</Date> 01:00AM BLOOD K-4.3 <Date>1989-11-26</Date> 03:02AM BLOOD WBC-8.1 RBC-4.35* Hgb-13.4* Hct-38.5* MCV-88 MCH-30.9 MCHC-35.0 RDW-13.5 Plt Ct-188 <Date>1989-11-26</Date> 03:02AM BLOOD ALT-106* AST-223* LD(LDH)-356* CK(CPK)-6223* AlkPhos-65 TotBili-1.0 Brief Hospital Course: 45M w/ history of depression, polysubstance abuse, presenting after a suicide attempt, overdosing on tricyclics (doxepin) and also with cocaine intoxication who was sucessfully extubated with a closing QRS and decreasing CK. Patient's renal function remained good with excellent urine output. Pt medically cleared for psych admission. 1. TCA: QRS closed, monitored on tele. 2. Rhabdo: decreasing CK with IV hydration and excellent urine output. 3. SI: 1:1 sitter and psych consult, pt upset that he did not succeed with suicide attempt, admit to psych, all TCAs and sedatives held. 4. left arm swelling: no evidence of compartment syndrome, PIV pulled from left hand, seen by ortho for possible ulnar neuropraxia, improving upon discharge. US showed no DVT. Transferred to psych on section 12 for further eval and readjust of medications. Medications on Admission: BENADRYL 25MG--Take 2 by mouth at bedtime BENZAMYCINPAK 3-5%--Apply twice a day to face for acne CELEXA 20MG--Take one by mouth at bedtime COLACE 100MG--1-2 tabs by mouth every day as needed DOXEPIN HCL 25MG--One capsule(s) by mouth at bedtime Doxazosin 1MG--2 tablet(s) by mouth at bedtime RISPERDAL 0.25MG--Take two tablets before sleep TRETINOIN 0.025%--Pea sized amt to face and rub in for acne VIAGRA 50 mg--0.5-1 tablet(s) by mouth once a day as needed for for sexual activity take 30-60 minutes prior to sexual activity WESTCORT 0.2%--Twice a day to face for 7 days, then d/c ZANTAC 150MG--One tablet by mouth twice Discharge Medications: 1. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO at bedtime as needed for insomnia for 10 days. 2. Colace 100 mg Capsule Sig: <Date>1-25</Date> Capsules PO once a day as needed for constipation for 10 days. 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime for 30 days. 4. Risperdal 0.25 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for insomnia for 10 days. 5. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day for 30 days. 6. BenzamycinPak <Date>3-29</Date> % Gel Sig: One (1) Topical twice a day for 10 days. Discharge Disposition: Extended Care Facility: <Hospital>Wilson, Glover and Clark Medical Center</Hospital> - <Location>96803 Larry Estate Apt. 080 East Michellebury, WI 64939</Location> Discharge Diagnosis: TCA overdose, suicide attempt, depression, h/o withdrawal seizures, h/o head trauma, h/o cocaine use, h/o hep B exposure Discharge Condition: Improved Discharge Instructions: Discharge to pyschiatry service, keep your scheduled appointments, hold your anti-depressant medications until you see psychiatry. Followup Instructions: Please follow up with your primary care doctor <Name>Bruce</Name> <Name>Son</Name> within 2-3 days	000000000000000001111111110000000000000000000000000000000011111111110000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000111111111111111110000011111111111111111111111111111111111111111111111111111110000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000111111100000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000011111111100000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1908-8-21 Discharge Date: 1989-11-26 Date of Birth: 2019-8-9 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Curtis Chief Complaint: overdose Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. White is a 45 year old man who presented to the Haynes Inc Clinic via 96803 Larry Estate Apt. 080 East Michellebury, WI 64939 EMS. Pt was found by EMS at his home at 10:21pm 1915-7-5. The patient was supine, pt was noted to by awake and alert, BP 120/88, pulse 72. He was noted to have overdosed taking "35 pills" - bottles at the scene included citalopram, risperdal, doxazosin, and doxepin. A note was found with him saying "I don't want to do time." He was brought to Haynes Inc Clinic where his VS were T 98.7 BP 126/79 RR 18 99% RA. Pt was noted to have altered mental status and a GCS of 12. A foley was placed and 150cc of urine was obtained. By report, he said he had taken "a bunch of vicodin" so narcan 5mg was given 5mg given at 12:20am with little response. At 1:13 am the patient was intubated for airway protection, but the intubation was difficult and anaesthesia needed to perform the intubation fiberoptically. In total, the patient was given 2L NS and 1L D5W with 150meq bicarb. Activated charcoal was also given. An EKG was performed and was RBB with a QRS of 136. Tox screen was also positive for cocaine, TCAs and acetaminophen Past Medical History: History of hepatitis B exposure History of head trauma History of witdrawal seizure Social History: He has a history of polysubstance abuse, abusing both intravenous and intranasal heroin, as well as cocaine. He has been on a methadone maintenance program. He has a history of multiple suicide attempts, including an overdose of zyprexa. He has been incarcereated twice. He has a history of alcohol abuse and marijuana and tobacco use. Family History: Noncontributory . Physical Exam: VS: T 97 HR 81 BP 110/67 RR 13 Sat 100% Vent: AC Tv 600 RR 12 PEEP 5 FiO2 0.4 pulling: Mv 6.8 PIP 31 Plat 17 MaP 10 Gen: AA man intubated and sedated. +ETT +foley +PIV x2 HEENT: pupils constricted but reactive, sclerae anicteric Neck: supple, no masses, trachea midline CV: Normal s1/s2, RRR, no m/r/g Pul: CTA bilaterally Abd: Soft, NT, ND Ext: No edema, warm, dry, DP 2+ bilaterally, RP 2+ bilaterally. Neuro: Sedated, withdraws to pain Pertinent Results: 1915-7-5 11:45PM BLOOD WBC-11.5* RBC-5.63# Hgb-17.4# Hct-49.3 MCV-88 MCH-30.8 MCHC-35.2* RDW-13.6 Plt Ct-207 1915-7-5 11:45PM BLOOD Neuts-71.2* Lymphs-23.8 Monos-4.5 Eos-0.3 Baso-0.3 1915-7-5 11:45PM BLOOD Plt Ct-207 1915-7-5 11:45PM BLOOD Glucose-83 UreaN-16 Creat-1.3* Na-134 K-8.23* Cl-99 HCO3-25 AnGap-18 1915-7-5 11:45PM BLOOD ALT-184* AST-688* CK(CPK)-9087910* AlkPhos-85 Amylase-62 TotBili-1.4 1925-11-15 02:00AM BLOOD CK-MB-4 cTropnT-1959-1-9 10:19AM BLOOD CK-MB-10 MB Indx-0.1 cTropnT-1915-7-5 11:45PM BLOOD Calcium-9.3 Phos-4.6* Mg-2.3 1915-7-5 11:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.1 Bnzodzp-NEG Barbitr-NEG Tricycl-POS 1908-8-21 04:34AM BLOOD Acetmnp-NEG 1908-8-21 01:00AM BLOOD K-4.3 1989-11-26 03:02AM BLOOD WBC-8.1 RBC-4.35* Hgb-13.4* Hct-38.5* MCV-88 MCH-30.9 MCHC-35.0 RDW-13.5 Plt Ct-188 1989-11-26 03:02AM BLOOD ALT-106* AST-223* LD(LDH)-356* CK(CPK)-6223* AlkPhos-65 TotBili-1.0 Brief Hospital Course: 45M w/ history of depression, polysubstance abuse, presenting after a suicide attempt, overdosing on tricyclics (doxepin) and also with cocaine intoxication who was sucessfully extubated with a closing QRS and decreasing CK. Patient's renal function remained good with excellent urine output. Pt medically cleared for psych admission. 1. TCA: QRS closed, monitored on tele. 2. Rhabdo: decreasing CK with IV hydration and excellent urine output. 3. SI: 1:1 sitter and psych consult, pt upset that he did not succeed with suicide attempt, admit to psych, all TCAs and sedatives held. 4. left arm swelling: no evidence of compartment syndrome, PIV pulled from left hand, seen by ortho for possible ulnar neuropraxia, improving upon discharge. US showed no DVT. Transferred to psych on section 12 for further eval and readjust of medications. Medications on Admission: BENADRYL 25MG--Take 2 by mouth at bedtime BENZAMYCINPAK 3-5%--Apply twice a day to face for acne CELEXA 20MG--Take one by mouth at bedtime COLACE 100MG--1-2 tabs by mouth every day as needed DOXEPIN HCL 25MG--One capsule(s) by mouth at bedtime Doxazosin 1MG--2 tablet(s) by mouth at bedtime RISPERDAL 0.25MG--Take two tablets before sleep TRETINOIN 0.025%--Pea sized amt to face and rub in for acne VIAGRA 50 mg--0.5-1 tablet(s) by mouth once a day as needed for for sexual activity take 30-60 minutes prior to sexual activity WESTCORT 0.2%--Twice a day to face for 7 days, then d/c ZANTAC 150MG--One tablet by mouth twice Discharge Medications: 1. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO at bedtime as needed for insomnia for 10 days. 2. Colace 100 mg Capsule Sig: 1-25 Capsules PO once a day as needed for constipation for 10 days. 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime for 30 days. 4. Risperdal 0.25 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for insomnia for 10 days. 5. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day for 30 days. 6. BenzamycinPak 3-29 % Gel Sig: One (1) Topical twice a day for 10 days. Discharge Disposition: Extended Care Facility: Wilson, Glover and Clark Medical Center - 96803 Larry Estate Apt. 080 East Michellebury, WI 64939 Discharge Diagnosis: TCA overdose, suicide attempt, depression, h/o withdrawal seizures, h/o head trauma, h/o cocaine use, h/o hep B exposure Discharge Condition: Improved Discharge Instructions: Discharge to pyschiatry service, keep your scheduled appointments, hold your anti-depressant medications until you see psychiatry. Followup Instructions: Please follow up with your primary care doctor Bruce Son within 2-3 days	['Admission Date: 1908-8-21 Discharge Date: 1989-11-26\n\nDate of Birth: 2019-8-9 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Curtis\nChief Complaint:\noverdose\n\nMajor Surgical or Invasive Procedure:\nIntubation\n\n\nHistory of Present Illness:\nMr. White is a 45 year old man who presented to the Haynes Inc Clinic via\n96803 Larry Estate Apt. 080\nEast Michellebury, WI 64939 EMS. Pt was found by EMS at his home at 10:21pm 1915-7-5.\nThe patient was supine, pt was noted to by awake and alert, BP\n120/88, pulse 72. He was noted to have overdosed taking "35\npills" - bottles at the scene included citalopram, risperdal,\ndoxazosin, and doxepin. A note was found with him saying "I\ndon\'t want to do time." He was brought to Haynes Inc Clinic where his VS\nwere T 98.', '7 BP 126/79 RR 18 99% RA. Pt was noted to have altered\nmental status and a GCS of 12. A foley was placed and 150cc of\nurine was obtained. By report, he said he had taken "a bunch of\nvicodin" so narcan 5mg was given 5mg given at 12:20am with\nlittle response. At 1:13 am the patient was intubated for airway\nprotection, but the intubation was difficult and anaesthesia\nneeded to perform the intubation fiberoptically. In total, the\npatient was given 2L NS and 1L D5W with 150meq bicarb. Activated\ncharcoal was also given. An EKG was performed and was RBB with a\nQRS of 136. Tox screen was also positive for cocaine, TCAs and\nacetaminophen\n\nPast Medical History:\nHistory of hepatitis B exposure\nHistory of head trauma\nHistory of witdrawal seizure\n\n\nSocial History:\nHe has a history of polysubstance abuse, abusing both\nintravenous and intranasal heroin, as well as cocaine.', ' He has\nbeen on a methadone maintenance program. He has a history of\nmultiple suicide attempts, including an overdose of zyprexa. He\nhas been incarcereated twice. He has a history of alcohol abuse\nand marijuana and tobacco use.\n\nFamily History:\nNoncontributory\n.\n\n\nPhysical Exam:\nVS: T 97 HR 81 BP 110/67 RR 13 Sat 100%\nVent: AC Tv 600 RR 12 PEEP 5 FiO2 0.4 pulling: Mv 6.8 PIP 31\nPlat 17 MaP 10\nGen: AA man intubated and sedated. +ETT +foley +PIV x2\nHEENT: pupils constricted but reactive, sclerae anicteric\nNeck: supple, no masses, trachea midline\nCV: Normal s1/s2, RRR, no m/r/g\nPul: CTA bilaterally\nAbd: Soft, NT, ND\nExt: No edema, warm, dry, DP 2+ bilaterally, RP 2+ bilaterally.\n\nNeuro: Sedated, withdraws to pain\n\n\nPertinent Results:\n1915-7-5 11:45PM BLOOD WBC-11.5* RBC-5.63# Hgb-17.4# Hct-49.', '3\nMCV-88 MCH-30.8 MCHC-35.2* RDW-13.6 Plt Ct-207\n1915-7-5 11:45PM BLOOD Neuts-71.2* Lymphs-23.8 Monos-4.5 Eos-0.3\nBaso-0.3\n1915-7-5 11:45PM BLOOD Plt Ct-207\n1915-7-5 11:45PM BLOOD Glucose-83 UreaN-16 Creat-1.3* Na-134\nK-8.23* Cl-99 HCO3-25 AnGap-18\n1915-7-5 11:45PM BLOOD ALT-184* AST-688* CK(CPK)-9087910\nAlkPhos-85 Amylase-62 TotBili-1.4\n1925-11-15 02:00AM BLOOD CK-MB-4 cTropnT-1959-1-9 10:19AM BLOOD CK-MB-10 MB Indx-0.1 cTropnT-1915-7-5 11:45PM BLOOD Calcium-9.3 Phos-4.6 Mg-2.3\n1915-7-5 11:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.1\nBnzodzp-NEG Barbitr-NEG Tricycl-POS\n1908-8-21 04:34AM BLOOD Acetmnp-NEG\n1908-8-21 01:00AM BLOOD K-4.3\n1989-11-26 03:02AM BLOOD WBC-8.1 RBC-4.35* Hgb-13.4* Hct-38.5\nMCV-88 MCH-30.9 MCHC-35.0 RDW-13.5 Plt Ct-188\n1989-11-26 03:02AM BLOOD ALT-106 AST-223* LD(LDH)-356\nCK(CPK)-6223 AlkPhos-65 TotBili-1.', "0\n\nBrief Hospital Course:\n45M w/ history of depression, polysubstance abuse, presenting\nafter a suicide attempt, overdosing on tricyclics (doxepin) and\nalso with cocaine intoxication who was sucessfully extubated\nwith a closing QRS and decreasing CK. Patient's renal function\nremained good with excellent urine output. Pt medically cleared\nfor psych admission.\n1. TCA: QRS closed, monitored on tele.\n2. Rhabdo: decreasing CK with IV hydration and excellent urine\noutput.\n3. SI: 1:1 sitter and psych consult, pt upset that he did not\nsucceed with suicide attempt, admit to psych, all TCAs and\nsedatives held.\n4. left arm swelling: no evidence of compartment syndrome, PIV\npulled from left hand, seen by ortho for possible ulnar\nneuropraxia, improving upon discharge. US showed no DVT.\n\nTransferred to psych on section 12 for further eval and readjust\nof medications.", '\n\nMedications on Admission:\nBENADRYL 25MG--Take 2 by mouth at bedtime\nBENZAMYCINPAK 3-5%--Apply twice a day to face for acne\nCELEXA 20MG--Take one by mouth at bedtime\nCOLACE 100MG--1-2 tabs by mouth every day as needed\nDOXEPIN HCL 25MG--One capsule(s) by mouth at bedtime\nDoxazosin 1MG--2 tablet(s) by mouth at bedtime\nRISPERDAL 0.25MG--Take two tablets before sleep\nTRETINOIN 0.025%--Pea sized amt to face and rub in for acne\nVIAGRA 50 mg--0.5-1 tablet(s) by mouth once a day as needed for\n\nfor sexual activity take 30-60 minutes prior to sexual activity\n\nWESTCORT 0.2%--Twice a day to face for 7 days, then d/c\nZANTAC 150MG--One tablet by mouth twice\n\n\nDischarge Medications:\n1. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO at bedtime as\nneeded for insomnia for 10 days.\n2. Colace 100 mg Capsule Sig: 1-25 Capsules PO once a day as\nneeded for constipation for 10 days.', '\n3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime for\n30 days.\n4. Risperdal 0.25 mg Tablet Sig: Two (2) Tablet PO at bedtime as\nneeded for insomnia for 10 days.\n5. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day for\n30 days.\n6. BenzamycinPak 3-29 % Gel Sig: One (1) Topical twice a day\nfor 10 days.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nWilson, Glover and Clark Medical Center - 96803 Larry Estate Apt. 080\nEast Michellebury, WI 64939\n\nDischarge Diagnosis:\nTCA overdose, suicide attempt, depression, h/o withdrawal\nseizures, h/o head trauma, h/o cocaine use, h/o hep B exposure\n\n\nDischarge Condition:\nImproved\n\n\nDischarge Instructions:\nDischarge to pyschiatry service, keep your scheduled\nappointments, hold your anti-depressant medications until you\nsee psychiatry.\n\nFollowup Instructions:\nPlease follow up with your primary care doctor Bruce Son\nwithin 2-3 days\n\n\n\n']
245	710	114242.0	2182-02-28	Discharge summary	Report	Admission Date: [2182-2-18] Discharge Date: [2182-2-28] Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old female with a complex medical history who was admitted after a cardiac arrest on [2182-2-18]. She was initially taken to the CCU, thought to be in congestive heart failure. Subsequently developed sepsis, acute ARDS, respiratory-cardiopulmonary failure. On [2182-2-28], at 3:15 p.m., the patient was pronounced dead. Family was at bedside. Date of death [2182-2-28]. Time of death 3:15 p.m. [First Name11 (Name Pattern1) 122] [Last Name (NamePattern4) 2462], [MD Number(1) 2463] Dictated By:[Last Name (NamePattern4) 2464] MEDQUIST36 D: [2182-5-20] 16:12:18 T: [2182-5-21] 01:55:14 Job#: [Job Number 2465]	Admission Date: <Date>2011-8-10</Date> Discharge Date: <Date>1964-3-13</Date> Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old female with a complex medical history who was admitted after a cardiac arrest on <Date>2011-8-10</Date>. She was initially taken to the CCU, thought to be in congestive heart failure. Subsequently developed sepsis, acute ARDS, respiratory-cardiopulmonary failure. On <Date>1964-3-13</Date>, at 3:15 p.m., the patient was pronounced dead. Family was at bedside. Date of death <Date>1964-3-13</Date>. Time of death 3:15 p.m. <Name>Heather</Name> <Name>Sakkas</Name>, <MD Number>92982904</MD Number> Dictated By:<Name>Tamaro</Name> MEDQUIST36 D: <Date>1953-11-15</Date> 16:12:18 T: <Date>1944-9-12</Date> 01:55:14 Job#: <Job Number>Rivera-Russell-2010-370488</Job Number>	000000000000000011111111100000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000011111110111111001111111100000000000000111111000000000000000011111111110000000000000011111111100000000000000000111111111111111111111111110	Admission Date: 2011-8-10 Discharge Date: 1964-3-13 Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old female with a complex medical history who was admitted after a cardiac arrest on 2011-8-10. She was initially taken to the CCU, thought to be in congestive heart failure. Subsequently developed sepsis, acute ARDS, respiratory-cardiopulmonary failure. On 1964-3-13, at 3:15 p.m., the patient was pronounced dead. Family was at bedside. Date of death 1964-3-13. Time of death 3:15 p.m. Heather Sakkas, 92982904 Dictated By:Tamaro MEDQUIST36 D: 1953-11-15 16:12:18 T: 1944-9-12 01:55:14 Job#: Rivera-Russell-2010-370488	['Admission Date: 2011-8-10 Discharge Date: 1964-3-13\n\nDate of Birth: Sex: F\n\nService:\n\n\nHISTORY OF PRESENT ILLNESS: The patient is a 70-year-old\nfemale with a complex medical history who was admitted after\na cardiac arrest on 2011-8-10. She was initially taken to the\nCCU, thought to be in congestive heart failure. Subsequently\ndeveloped sepsis, acute ARDS, respiratory-cardiopulmonary\nfailure. On 1964-3-13, at 3:15 p.m., the patient was\npronounced dead. Family was at bedside.\n\nDate of death 1964-3-13. Time of death 3:15 p.m.\n\n\n\n Heather Sakkas, 92982904\n\nDictated By:Tamaro\nMEDQUIST36\nD: 1953-11-15 16:12:18\nT: 1944-9-12 01:55:14\nJob#: Rivera-Russell-2010-370488\n']
246	710	114242.0	2182-02-28	Discharge summary	Report	Admission Date: [2182-2-18] Discharge Date: [2182-2-28] Date of Birth: [2109-8-28] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient was a 73-year-old female admitted to the CCU on [2182-2-18] with hyperkalemia and bradycardia. The patient had a past medical history significant for hypertension, glaucoma, and breast cancer treated with lumpectomy, XRT in [2176]. She was in her usual state of health until [12-2] when she began to note shortness of breath. She saw her PCP and performed [Name Initial (PRE) ] chest x-ray, which revealed a right upper lobe density. This was followed up with a CT scan, which revealed a lobulated mass of 2.3 cm in the posterior segment of the right lower lobe and bilateral lobe interstitial fibrosis. Follow-up PET scan was nondiagnostic. The patient had a mediastinoscopy, which showed no evidence of malignancy or lymph nodes. Lung biopsy was performed, which revealed pulmonary fibrosis. Subsequent spirometry revealed a mild restrictive defect. The entire picture was thought to represent UIP. On [2182-2-18], she presented to the [Hospital1 ] [First Name (Titles) 2142] [Last Name (Titles) ] with a complaint of nausea, vomiting, and diarrhea times several days. In the waiting room, she developed presyncope. She was urgently brought to the trauma bay, there her heart rate was in the 30s with the EKG revealing a junctional rhythm. Her SBP was in the 80s. Attempts made to place a temporary pacing wire but during the procedure the patient suffered respiratory arrest. She was intubated and resuscitated, and a line was successfully placed. Subsequent labs revealed a potassium of 9.8. The patient was treated with calcium bicarb, insulin, and glucose and admitted to CCU. In the CCU, the patient was started on Levophed and dopamine for hypotension. Swan-Ganz catheter was placed to evaluate her hypotension and revealed an SVR of 2473 with a cardiac output of 2.2. Two hours later, the cardiac output was 6.5 and SVR was 898 after pressors were weaned down. Urgent TTE revealed normal systolic function, no pericardial effusion. Potassium dropped to 4.3 after 1 day. The patient was empirically treated with vancomycin, levofloxacin, and Flagyl for hypotension, which was thought possibly due to sepsis. By hospital day 3, she was off pressors, her white blood count was 16.1. She was successfully extubated, and her potassium remained normal. By hospital day 4, she continued to have mild respiratory distress despite being extubated. She was thought to be in mild CHF. She was diuresed. Levofloxacin and vancomycin were continued for possible pneumonia. By hospital day 5, she developed worsening respiratory distress, and the patient agreed to elective intubation. She was then transferred to the MICU for further workup and care. PAST MEDICAL HISTORY: Hypertension. Glaucoma. Breast cancer. UIP. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Verapamil. 2. Propranolol. 3. Tamoxifen. 4. Xalatan eye drops. 5. Betoptic eye drops. 6. Calcium carbonate. 7. Aspirin. 8. Folate. 9. Vitamin E. PHYSICAL EXAMINATION: On admission to the MICU, temperature 98.9 degrees, blood pressure 126/61, and pulse 108. The patient was sedated and intubated. Her lungs revealed diffuse crackles bilaterally. Cardiac exam was within normal limits. Abdomen was benign. Lower extremity revealed no edema. PERTINENT LABORATORY DATA: On admission to the MICU included a white count of 21.9, hematocrit of 29.3, and platelets of 85. Chest x-ray on admission to MICU revealed persistent bilateral upper lobe patchy opacities, may represent interstitial edema plus aspiration. Continued patchy atelectasis within the left lower lobe and small left pleural effusion. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit with presumed diagnosis of sepsis. Subsequently, she developed a picture consistent with ARDS and required multiple pressors. After several days in the CCU, she was on 3 different pressors and was unable to maintain her blood pressure. She was requiring increasing ventilatory support. A discussion was held with the family who decided that the patient will be made DNI/DNR due to the fact that CPR was likely to be unhelpful if the patient arrested. On [2182-2-28] at 03:15 p.m., the patient was pronounced dead. The family was at the bedside. CONDITION ON DISCHARGE: Expired. DISCHARGE STATUS: Expired. DISCHARGE MEDICATIONS: None. FOLLOW UP PLAN: None. DISCHARGE DIAGNOSES: Septic shock. Respiratory failure. Hyperkalemia causing cardiopulmonary arrest. DR.[Last Name (STitle) 2466],[First Name3 (LF) 2467] 12-746 Dictated By:[Last Name (NamePattern4) 2464] MEDQUIST36 D: [2182-6-21] 16:34:53 T: [2182-6-21] 19:31:08 Job#: [Job Number 2468]	Admission Date: <Date>1907-8-30</Date> Discharge Date: <Date>1904-4-29</Date> Date of Birth: <Date>1932-10-22</Date> Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient was a 73-year-old female admitted to the CCU on <Date>1907-8-30</Date> with hyperkalemia and bradycardia. The patient had a past medical history significant for hypertension, glaucoma, and breast cancer treated with lumpectomy, XRT in <Year>1978</Year>. She was in her usual state of health until <Date>7-29</Date> when she began to note shortness of breath. She saw her PCP and performed <Name>Frank Ngo</Name> chest x-ray, which revealed a right upper lobe density. This was followed up with a CT scan, which revealed a lobulated mass of 2.3 cm in the posterior segment of the right lower lobe and bilateral lobe interstitial fibrosis. Follow-up PET scan was nondiagnostic. The patient had a mediastinoscopy, which showed no evidence of malignancy or lymph nodes. Lung biopsy was performed, which revealed pulmonary fibrosis. Subsequent spirometry revealed a mild restrictive defect. The entire picture was thought to represent UIP. On <Date>1907-8-30</Date>, she presented to the <Hospital>Simpson and Sons Hospital</Hospital> <Name>Jordan</Name> <Name>Mao</Name> with a complaint of nausea, vomiting, and diarrhea times several days. In the waiting room, she developed presyncope. She was urgently brought to the trauma bay, there her heart rate was in the 30s with the EKG revealing a junctional rhythm. Her SBP was in the 80s. Attempts made to place a temporary pacing wire but during the procedure the patient suffered respiratory arrest. She was intubated and resuscitated, and a line was successfully placed. Subsequent labs revealed a potassium of 9.8. The patient was treated with calcium bicarb, insulin, and glucose and admitted to CCU. In the CCU, the patient was started on Levophed and dopamine for hypotension. Swan-Ganz catheter was placed to evaluate her hypotension and revealed an SVR of 2473 with a cardiac output of 2.2. Two hours later, the cardiac output was 6.5 and SVR was 898 after pressors were weaned down. Urgent TTE revealed normal systolic function, no pericardial effusion. Potassium dropped to 4.3 after 1 day. The patient was empirically treated with vancomycin, levofloxacin, and Flagyl for hypotension, which was thought possibly due to sepsis. By hospital day 3, she was off pressors, her white blood count was 16.1. She was successfully extubated, and her potassium remained normal. By hospital day 4, she continued to have mild respiratory distress despite being extubated. She was thought to be in mild CHF. She was diuresed. Levofloxacin and vancomycin were continued for possible pneumonia. By hospital day 5, she developed worsening respiratory distress, and the patient agreed to elective intubation. She was then transferred to the MICU for further workup and care. PAST MEDICAL HISTORY: Hypertension. Glaucoma. Breast cancer. UIP. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Verapamil. 2. Propranolol. 3. Tamoxifen. 4. Xalatan eye drops. 5. Betoptic eye drops. 6. Calcium carbonate. 7. Aspirin. 8. Folate. 9. Vitamin E. PHYSICAL EXAMINATION: On admission to the MICU, temperature 98.9 degrees, blood pressure 126/61, and pulse 108. The patient was sedated and intubated. Her lungs revealed diffuse crackles bilaterally. Cardiac exam was within normal limits. Abdomen was benign. Lower extremity revealed no edema. PERTINENT LABORATORY DATA: On admission to the MICU included a white count of 21.9, hematocrit of 29.3, and platelets of 85. Chest x-ray on admission to MICU revealed persistent bilateral upper lobe patchy opacities, may represent interstitial edema plus aspiration. Continued patchy atelectasis within the left lower lobe and small left pleural effusion. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit with presumed diagnosis of sepsis. Subsequently, she developed a picture consistent with ARDS and required multiple pressors. After several days in the CCU, she was on 3 different pressors and was unable to maintain her blood pressure. She was requiring increasing ventilatory support. A discussion was held with the family who decided that the patient will be made DNI/DNR due to the fact that CPR was likely to be unhelpful if the patient arrested. On <Date>1904-4-29</Date> at 03:15 p.m., the patient was pronounced dead. The family was at the bedside. CONDITION ON DISCHARGE: Expired. DISCHARGE STATUS: Expired. DISCHARGE MEDICATIONS: None. FOLLOW UP PLAN: None. DISCHARGE DIAGNOSES: Septic shock. Respiratory failure. Hyperkalemia causing cardiopulmonary arrest. DR.<Name>Clapp</Name>,<Name>Hany</Name> 12-746 Dictated By:<Name>Deluna</Name> MEDQUIST36 D: <Date>1947-10-13</Date> 16:34:53 T: <Date>1947-10-13</Date> 19:31:08 Job#: <Job Number>Cannon Inc-1916-118949</Job Number>	0000000000000000111111111000000000000000000000000111111111000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000001111111111111111111111111011111101110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111101111000000000000000000000111111000000000000000011111111110000000000000011111111110000000000000000011111111111111111111110	Admission Date: 1907-8-30 Discharge Date: 1904-4-29 Date of Birth: 1932-10-22 Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient was a 73-year-old female admitted to the CCU on 1907-8-30 with hyperkalemia and bradycardia. The patient had a past medical history significant for hypertension, glaucoma, and breast cancer treated with lumpectomy, XRT in 1978. She was in her usual state of health until 7-29 when she began to note shortness of breath. She saw her PCP and performed Frank Ngo chest x-ray, which revealed a right upper lobe density. This was followed up with a CT scan, which revealed a lobulated mass of 2.3 cm in the posterior segment of the right lower lobe and bilateral lobe interstitial fibrosis. Follow-up PET scan was nondiagnostic. The patient had a mediastinoscopy, which showed no evidence of malignancy or lymph nodes. Lung biopsy was performed, which revealed pulmonary fibrosis. Subsequent spirometry revealed a mild restrictive defect. The entire picture was thought to represent UIP. On 1907-8-30, she presented to the Simpson and Sons Hospital Jordan Mao with a complaint of nausea, vomiting, and diarrhea times several days. In the waiting room, she developed presyncope. She was urgently brought to the trauma bay, there her heart rate was in the 30s with the EKG revealing a junctional rhythm. Her SBP was in the 80s. Attempts made to place a temporary pacing wire but during the procedure the patient suffered respiratory arrest. She was intubated and resuscitated, and a line was successfully placed. Subsequent labs revealed a potassium of 9.8. The patient was treated with calcium bicarb, insulin, and glucose and admitted to CCU. In the CCU, the patient was started on Levophed and dopamine for hypotension. Swan-Ganz catheter was placed to evaluate her hypotension and revealed an SVR of 2473 with a cardiac output of 2.2. Two hours later, the cardiac output was 6.5 and SVR was 898 after pressors were weaned down. Urgent TTE revealed normal systolic function, no pericardial effusion. Potassium dropped to 4.3 after 1 day. The patient was empirically treated with vancomycin, levofloxacin, and Flagyl for hypotension, which was thought possibly due to sepsis. By hospital day 3, she was off pressors, her white blood count was 16.1. She was successfully extubated, and her potassium remained normal. By hospital day 4, she continued to have mild respiratory distress despite being extubated. She was thought to be in mild CHF. She was diuresed. Levofloxacin and vancomycin were continued for possible pneumonia. By hospital day 5, she developed worsening respiratory distress, and the patient agreed to elective intubation. She was then transferred to the MICU for further workup and care. PAST MEDICAL HISTORY: Hypertension. Glaucoma. Breast cancer. UIP. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Verapamil. 2. Propranolol. 3. Tamoxifen. 4. Xalatan eye drops. 5. Betoptic eye drops. 6. Calcium carbonate. 7. Aspirin. 8. Folate. 9. Vitamin E. PHYSICAL EXAMINATION: On admission to the MICU, temperature 98.9 degrees, blood pressure 126/61, and pulse 108. The patient was sedated and intubated. Her lungs revealed diffuse crackles bilaterally. Cardiac exam was within normal limits. Abdomen was benign. Lower extremity revealed no edema. PERTINENT LABORATORY DATA: On admission to the MICU included a white count of 21.9, hematocrit of 29.3, and platelets of 85. Chest x-ray on admission to MICU revealed persistent bilateral upper lobe patchy opacities, may represent interstitial edema plus aspiration. Continued patchy atelectasis within the left lower lobe and small left pleural effusion. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit with presumed diagnosis of sepsis. Subsequently, she developed a picture consistent with ARDS and required multiple pressors. After several days in the CCU, she was on 3 different pressors and was unable to maintain her blood pressure. She was requiring increasing ventilatory support. A discussion was held with the family who decided that the patient will be made DNI/DNR due to the fact that CPR was likely to be unhelpful if the patient arrested. On 1904-4-29 at 03:15 p.m., the patient was pronounced dead. The family was at the bedside. CONDITION ON DISCHARGE: Expired. DISCHARGE STATUS: Expired. DISCHARGE MEDICATIONS: None. FOLLOW UP PLAN: None. DISCHARGE DIAGNOSES: Septic shock. Respiratory failure. Hyperkalemia causing cardiopulmonary arrest. DR.Clapp,Hany 12-746 Dictated By:Deluna MEDQUIST36 D: 1947-10-13 16:34:53 T: 1947-10-13 19:31:08 Job#: Cannon Inc-1916-118949	['Admission Date: 1907-8-30 Discharge Date: 1904-4-29\n\nDate of Birth: 1932-10-22 Sex: F\n\nService:\n\n\nHISTORY OF PRESENT ILLNESS: The patient was a 73-year-old\nfemale admitted to the CCU on 1907-8-30 with hyperkalemia and\nbradycardia. The patient had a past medical history\nsignificant for hypertension, glaucoma, and breast cancer\ntreated with lumpectomy, XRT in 1978. She was in her usual\nstate of health until 7-29 when she began to note shortness\nof breath. She saw her PCP and performed Frank Ngo chest x-ray,\nwhich revealed a right upper lobe density. This was followed\nup with a CT scan, which revealed a lobulated mass of 2.3 cm\nin the posterior segment of the right lower lobe and\nbilateral lobe interstitial fibrosis. Follow-up PET scan was\nnondiagnostic. The patient had a mediastinoscopy, which\nshowed no evidence of malignancy or lymph nodes.', ' Lung biopsy\nwas performed, which revealed pulmonary fibrosis. Subsequent\nspirometry revealed a mild restrictive defect. The entire\npicture was thought to represent UIP.\n\nOn 1907-8-30, she presented to the Simpson and Sons Hospital\nJordan Mao with a complaint of nausea, vomiting, and\ndiarrhea times several days. In the waiting room, she\ndeveloped presyncope. She was urgently brought to the trauma\nbay, there her heart rate was in the 30s with the EKG\nrevealing a junctional rhythm. Her SBP was in the 80s.\nAttempts made to place a temporary pacing wire but during the\nprocedure the patient suffered respiratory arrest. She was\nintubated and resuscitated, and a line was successfully\nplaced. Subsequent labs revealed a potassium of 9.8. The\npatient was treated with calcium bicarb, insulin, and glucose\nand admitted to CCU.', '\n\nIn the CCU, the patient was started on Levophed and dopamine\nfor hypotension. Swan-Ganz catheter was placed to evaluate\nher hypotension and revealed an SVR of 2473 with a cardiac\noutput of 2.2. Two hours later, the cardiac output was 6.5\nand SVR was 898 after pressors were weaned down. Urgent TTE\nrevealed normal systolic function, no pericardial effusion.\nPotassium dropped to 4.3 after 1 day. The patient was\nempirically treated with vancomycin, levofloxacin, and Flagyl\nfor hypotension, which was thought possibly due to sepsis.\nBy hospital day 3, she was off pressors, her white blood\ncount was 16.1. She was successfully extubated, and her\npotassium remained normal. By hospital day 4, she continued\nto have mild respiratory distress despite being extubated.\nShe was thought to be in mild CHF.', ' She was diuresed.\nLevofloxacin and vancomycin were continued for possible\npneumonia. By hospital day 5, she developed worsening\nrespiratory distress, and the patient agreed to elective\nintubation. She was then transferred to the MICU for further\nworkup and care.\n\nPAST MEDICAL HISTORY: Hypertension.\n\nGlaucoma.\n\nBreast cancer.\n\nUIP.\n\nALLERGIES: No known drug allergies.\n\nMEDICATIONS ON ADMISSION:\n1. Verapamil.\n2. Propranolol.\n3. Tamoxifen.\n4. Xalatan eye drops.\n5. Betoptic eye drops.\n6. Calcium carbonate.\n7. Aspirin.\n8. Folate.\n9. Vitamin E.\n\n\nPHYSICAL EXAMINATION: On admission to the MICU, temperature\n98.9 degrees, blood pressure 126/61, and pulse 108. The\npatient was sedated and intubated. Her lungs revealed\ndiffuse crackles bilaterally. Cardiac exam was within normal\nlimits. Abdomen was benign.', ' Lower extremity revealed no\nedema.\n\nPERTINENT LABORATORY DATA: On admission to the MICU included\na white count of 21.9, hematocrit of 29.3, and platelets of\n85.\n\nChest x-ray on admission to MICU revealed persistent\nbilateral upper lobe patchy opacities, may represent\ninterstitial edema plus aspiration. Continued patchy\natelectasis within the left lower lobe and small left pleural\neffusion.\n\nCONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted\nto the Medical Intensive Care Unit with presumed diagnosis of\nsepsis. Subsequently, she developed a picture consistent\nwith ARDS and required multiple pressors. After several days\nin the CCU, she was on 3 different pressors and was unable to\nmaintain her blood pressure. She was requiring increasing\nventilatory support. A discussion was held with the family\nwho decided that the patient will be made DNI/DNR due to the\nfact that CPR was likely to be unhelpful if the patient\narrested.', ' On 1904-4-29 at 03:15 p.m., the patient was\npronounced dead. The family was at the bedside.\n\nCONDITION ON DISCHARGE: Expired.\n\nDISCHARGE STATUS: Expired.\n\nDISCHARGE MEDICATIONS: None.\n\nFOLLOW UP PLAN: None.\n\nDISCHARGE DIAGNOSES: Septic shock.\n\nRespiratory failure.\n\nHyperkalemia causing cardiopulmonary arrest.\n\n\n\n DR.Clapp,Hany 12-746\n\nDictated By:Deluna\nMEDQUIST36\nD: 1947-10-13 16:34:53\nT: 1947-10-13 19:31:08\nJob#: Cannon Inc-1916-118949\n']
247	30812	112678.0	2143-11-25	Discharge summary	Report	Admission Date: [2143-11-22] Discharge Date: [2143-11-25] Date of Birth: [2075-10-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Reason for ICU admission: ROMI, coffee ground emesis Major Surgical or Invasive Procedure: endoscopy History of Present Illness: HPI: 68 y.o. man with HTN presented to PCP for routine visit on day of admission, c/o 2 months of worsening DOE and chest pressure with exertion. He reports having a stress test 1 year ago which was stopped after 3 minutes for hypertension (SBP in the 230s). He had no symptoms and no ST wave changes. In addition, he complains of severe heartburn (different than his chest pressure) intermittently every few days x 3 months, along with violent coughing fits which cause him to vomit dark brown liquid. He denies frank blood in his emesis. The heartburn is worse at night with lying flat. He denies NSAID use, but does admit to drinking at least [2-9] drinks of burbon daily. . He was referred to the ED for concern of ACS. In the ED, he was afebrile, HR 70s, BP 116/73m RR 16, and 97% RA. Hct was 41. His trop was negative but ECG showed TWI in V1-V3 which were new. He was given ASA 325, Lopressor, and started on nitroglycerin and heparin gtt. Became hypotensive with nitro to SBP 80s, BP responded to 2L NS. He then started to vomit brown colored, guiac positive emesis. The heparin and nitro drips were stopped. He was given IV protonix and Reglan. He was admitted to MICU for further monitoring/ROMI. . ROS: Denies fever, chills. No h/o blood clot or recent travel. . Past Medical History: PMH: HTN ETOH abuse h/o perianal abscess CKD, baseline Cr 1.3-1.4 Glaucoma . Social History: Social hx: Lives with his partner (male). Retired budjet analyst for park service. Has history of alchoholism, quit for 20 yrs, then starting drinking again when he retired, but much less. Drinks 2-3 glasses burbon daily, more when with friends. Starts drinking around 5pm. Former smoker, >50 pack years, quit 1.5 years ago. No illicits . Family History: . Family hx: Father died age 51 of melanoma, but had "silent MI" in late 40s. Mother had MI in her 70s. Physical Exam: PE: VS: T 97.8, BP 160/61, RR 16, HR 79, 96% 2L Gen: shaky, no apparent distress HEENT: eomi, moist mucous membranes Neck: supple, no appreciable JVD Lungs: CTA b/l Heart: RRR nl S1S2, no M/R/G Abd: +BS, soft, ND/NT Ext: no edema, +PP b/l Neuro: intention tremor. No asterixis. No pronator drift. +dysmetria with FNF. Strength 5/5 b/l upper and lower. CN II-XII intact . Pertinent Results: ECG: NSR @ 81. TWI V1-V3, new since [8-/2140] . CXR [2143-11-22]: AP upright chest radiograph is obtained. A small amount of left basilar atelectasis is noted. There is no evidence of pneumonia, CHF. There is no pneumothorax. Cardiomediastinal silhouette is unremarkable. Mildly unfolded thoracic aorta noted. Visualized osseous structures are intact. IMPRESSION: No evidence of pneumonia or CHF . [2143-11-22]. The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([1-8]+) 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 no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2142-12-6], the findings are similar. . [2143-11-25]. EGD. Severe esophagitis in the middle third of the esophagus and lower third of the esophagus compatible with severe reflux esophagitis (biopsy) Erythema in the antrum compatible with gastritis (biopsy, biopsy) Erythema and congestion in the second part of the duodenum compatible with duodenitis (biopsy) Otherwise normal EGD to second part of the duodenum Brief Hospital Course: In summary, Mr. [Name14 (STitle) 2469] is a 68 y.o. man with PMH significant for HTN and alcohol abuse, admitted for DOE and chest pressure. Patient was ruled out for MI, but developed coffee ground emesis while on heparin drip. EGD showed severe esophagitis and gastritis. . Upper GI bleed. Patient developed coffee-ground emesis in ED in setting of chronic heartburn and alcohol abuse while on heparin drip. EGD showed severe esophagitis and gastritis, likely due to chronic alcohol use. Hct fell to 32 from 42 on admission, but patient did not require transfusions. He was sent home on PPI [Hospital1 ]. Gastric biopsies for H. pylori were pending at time of discharge. . Chest pressure/ SOB. Patient presented with CP and SOB on exertion. He has no history of CAD. He had a stress test one year ago which was terminated early due to hypertension. Cardiac enzymes were negative. He was initally started on a heparin drip in the ED due to concern for unstable angina, but this was stopped when patient developed coffee ground emesis. His antihypertensives were intially held, but resumed on hospital day 2. A lipid panel was checked and his LDL was in the 40s. He was advised to get outpatient stress test and PFTs. Patient has a significant smoking history and CSR showed hyperinflation, suggesting that his DOE may be pulmonary in origin. . Alcohol abuse. Patient has history of alcoholism and quit drinking for 20 years and now drinks daily. He denies history of DTs or seizure. He was tremulous and required a CIWA scale. He was given thiamine, folate, and multivitamin during his hospitalization. . Transaminitis. Patient had mildly elevated LFTs that were thought to be due to alcohol hepatitis. Hepatitis serologies were sent, but were pending at time of discharge. . Contact: patient and his partner [Name (NI) ] [Name (NI) 2470] [Telephone/Fax (1) 2471] Medications on Admission: Home Meds: Toprol XL 25mg daily Lisinopril 40mg daily Amlodipine 10mg daily Xalatan oph drops, 1 drop each eye QHS Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pantoprazole 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 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Upper GI bleed GERD . Secondary diagnosis: Hypertension Alcohol abuse Chronic kidney disease Glaucoma Discharge Condition: good Discharge Instructions: You were admitted for chest pain. You were coughing up blood in the emergency department, so you went to the intensive care unit for monitoring. You had an endoscopy on [11-25] which showed severe inflammation in the esophagus and stomach due to acid reflux. . Please resume all medications as you were taking prior to admission. In addition, please take pantoprazole twice daily for acid reflux. You should avoid alcohol use and avoid using over the counter anti-inflammatory medications like Aleive or Advil. . You should follow up with Dr. [Last Name (STitle) 2472] in [1-8] weeks and schedule pulmonary function tests and a stress test. . Please call your physician or come to the emergency department for shortness of breath, chest pain, chest pressure, fevers, chills, leg swelling, coughing up blood, blood in stool, or any other concerning symptoms. Followup Instructions: Please schedule a follow up appointment with Dr. [Last Name (STitle) 2472] in [1-8] weeks. You will likely need a stress test and pulmonary function tests, but you should discuss this with your Dr. [Last Name (STitle) 2472] first. Ph. [Telephone/Fax (1) 133]. The results of the gastric biopsy were pending at the time of discharge, so Dr. [Last Name (STitle) 2472] will check the results for you. . You will need a repeat endoscopy in [6-14] weeks. Please call [Telephone/Fax (1) 463] to schedule it. . You will need a follow up appointment in [Hospital ] clinic with Dr. [Last Name (STitle) 2473] in 4 weeks. Please call [Telephone/Fax (1) 463] to schedule appointment.	Admission Date: <Date>1928-7-16</Date> Discharge Date: <Date>1961-2-3</Date> Date of Birth: <Date>1994-10-22</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Nancy</Name> Chief Complaint: Reason for ICU admission: ROMI, coffee ground emesis Major Surgical or Invasive Procedure: endoscopy History of Present Illness: HPI: 68 y.o. man with HTN presented to PCP for routine visit on day of admission, c/o 2 months of worsening DOE and chest pressure with exertion. He reports having a stress test 1 year ago which was stopped after 3 minutes for hypertension (SBP in the 230s). He had no symptoms and no ST wave changes. In addition, he complains of severe heartburn (different than his chest pressure) intermittently every few days x 3 months, along with violent coughing fits which cause him to vomit dark brown liquid. He denies frank blood in his emesis. The heartburn is worse at night with lying flat. He denies NSAID use, but does admit to drinking at least <Date>10-17</Date> drinks of burbon daily. . He was referred to the ED for concern of ACS. In the ED, he was afebrile, HR 70s, BP 116/73m RR 16, and 97% RA. Hct was 41. His trop was negative but ECG showed TWI in V1-V3 which were new. He was given ASA 325, Lopressor, and started on nitroglycerin and heparin gtt. Became hypotensive with nitro to SBP 80s, BP responded to 2L NS. He then started to vomit brown colored, guiac positive emesis. The heparin and nitro drips were stopped. He was given IV protonix and Reglan. He was admitted to MICU for further monitoring/ROMI. . ROS: Denies fever, chills. No h/o blood clot or recent travel. . Past Medical History: PMH: HTN ETOH abuse h/o perianal abscess CKD, baseline Cr 1.3-1.4 Glaucoma . Social History: Social hx: Lives with his partner (male). Retired budjet analyst for park service. Has history of alchoholism, quit for 20 yrs, then starting drinking again when he retired, but much less. Drinks 2-3 glasses burbon daily, more when with friends. Starts drinking around 5pm. Former smoker, >50 pack years, quit 1.5 years ago. No illicits . Family History: . Family hx: Father died age 51 of melanoma, but had "silent MI" in late 40s. Mother had MI in her 70s. Physical Exam: PE: VS: T 97.8, BP 160/61, RR 16, HR 79, 96% 2L Gen: shaky, no apparent distress HEENT: eomi, moist mucous membranes Neck: supple, no appreciable JVD Lungs: CTA b/l Heart: RRR nl S1S2, no M/R/G Abd: +BS, soft, ND/NT Ext: no edema, +PP b/l Neuro: intention tremor. No asterixis. No pronator drift. +dysmetria with FNF. Strength 5/5 b/l upper and lower. CN II-XII intact . Pertinent Results: ECG: NSR @ 81. TWI V1-V3, new since <Date>11-1922</Date> . CXR <Date>1928-7-16</Date>: AP upright chest radiograph is obtained. A small amount of left basilar atelectasis is noted. There is no evidence of pneumonia, CHF. There is no pneumothorax. Cardiomediastinal silhouette is unremarkable. Mildly unfolded thoracic aorta noted. Visualized osseous structures are intact. IMPRESSION: No evidence of pneumonia or CHF . <Date>1928-7-16</Date>. The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate (<Date>5-3</Date>+) 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 no pericardial effusion. Compared with the findings of the prior study (images reviewed) of <Date>1949-7-5</Date>, the findings are similar. . <Date>1961-2-3</Date>. EGD. Severe esophagitis in the middle third of the esophagus and lower third of the esophagus compatible with severe reflux esophagitis (biopsy) Erythema in the antrum compatible with gastritis (biopsy, biopsy) Erythema and congestion in the second part of the duodenum compatible with duodenitis (biopsy) Otherwise normal EGD to second part of the duodenum Brief Hospital Course: In summary, Mr. <Name>Tyler Kibler</Name> is a 68 y.o. man with PMH significant for HTN and alcohol abuse, admitted for DOE and chest pressure. Patient was ruled out for MI, but developed coffee ground emesis while on heparin drip. EGD showed severe esophagitis and gastritis. . Upper GI bleed. Patient developed coffee-ground emesis in ED in setting of chronic heartburn and alcohol abuse while on heparin drip. EGD showed severe esophagitis and gastritis, likely due to chronic alcohol use. Hct fell to 32 from 42 on admission, but patient did not require transfusions. He was sent home on PPI <Hospital>Hawkins-Boyd Medical Center</Hospital>. Gastric biopsies for H. pylori were pending at time of discharge. . Chest pressure/ SOB. Patient presented with CP and SOB on exertion. He has no history of CAD. He had a stress test one year ago which was terminated early due to hypertension. Cardiac enzymes were negative. He was initally started on a heparin drip in the ED due to concern for unstable angina, but this was stopped when patient developed coffee ground emesis. His antihypertensives were intially held, but resumed on hospital day 2. A lipid panel was checked and his LDL was in the 40s. He was advised to get outpatient stress test and PFTs. Patient has a significant smoking history and CSR showed hyperinflation, suggesting that his DOE may be pulmonary in origin. . Alcohol abuse. Patient has history of alcoholism and quit drinking for 20 years and now drinks daily. He denies history of DTs or seizure. He was tremulous and required a CIWA scale. He was given thiamine, folate, and multivitamin during his hospitalization. . Transaminitis. Patient had mildly elevated LFTs that were thought to be due to alcohol hepatitis. Hepatitis serologies were sent, but were pending at time of discharge. . Contact: patient and his partner <Name>Isaias Chau</Name> <Name>Mattie Lees</Name> <Telephone>889-580-8266</Telephone> Medications on Admission: Home Meds: Toprol XL 25mg daily Lisinopril 40mg daily Amlodipine 10mg daily Xalatan oph drops, 1 drop each eye QHS Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pantoprazole 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 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Upper GI bleed GERD . Secondary diagnosis: Hypertension Alcohol abuse Chronic kidney disease Glaucoma Discharge Condition: good Discharge Instructions: You were admitted for chest pain. You were coughing up blood in the emergency department, so you went to the intensive care unit for monitoring. You had an endoscopy on <Date>11-2</Date> which showed severe inflammation in the esophagus and stomach due to acid reflux. . Please resume all medications as you were taking prior to admission. In addition, please take pantoprazole twice daily for acid reflux. You should avoid alcohol use and avoid using over the counter anti-inflammatory medications like Aleive or Advil. . You should follow up with Dr. <Name>Martin</Name> in <Date>5-3</Date> weeks and schedule pulmonary function tests and a stress test. . Please call your physician or come to the emergency department for shortness of breath, chest pain, chest pressure, fevers, chills, leg swelling, coughing up blood, blood in stool, or any other concerning symptoms. Followup Instructions: Please schedule a follow up appointment with Dr. <Name>Martin</Name> in <Date>5-3</Date> weeks. You will likely need a stress test and pulmonary function tests, but you should discuss this with your Dr. <Name>Martin</Name> first. Ph. <Telephone>139-981-7456</Telephone>. The results of the gastric biopsy were pending at the time of discharge, so Dr. <Name>Martin</Name> will check the results for you. . You will need a repeat endoscopy in <Date>11-4</Date> weeks. Please call <Telephone>956-375-5468</Telephone> to schedule it. . You will need a follow up appointment in <Hospital>Diaz-Montoya Medical Center</Hospital> clinic with Dr. <Name>Chowdhury</Name> in 4 weeks. Please call <Telephone>956-375-5468</Telephone> to schedule appointment.	00000000000000000111111111000000000000000000000000000000001111111100000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111110000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111110000000000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Date: 1928-7-16 Discharge Date: 1961-2-3 Date of Birth: 1994-10-22 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Nancy Chief Complaint: Reason for ICU admission: ROMI, coffee ground emesis Major Surgical or Invasive Procedure: endoscopy History of Present Illness: HPI: 68 y.o. man with HTN presented to PCP for routine visit on day of admission, c/o 2 months of worsening DOE and chest pressure with exertion. He reports having a stress test 1 year ago which was stopped after 3 minutes for hypertension (SBP in the 230s). He had no symptoms and no ST wave changes. In addition, he complains of severe heartburn (different than his chest pressure) intermittently every few days x 3 months, along with violent coughing fits which cause him to vomit dark brown liquid. He denies frank blood in his emesis. The heartburn is worse at night with lying flat. He denies NSAID use, but does admit to drinking at least 10-17 drinks of burbon daily. . He was referred to the ED for concern of ACS. In the ED, he was afebrile, HR 70s, BP 116/73m RR 16, and 97% RA. Hct was 41. His trop was negative but ECG showed TWI in V1-V3 which were new. He was given ASA 325, Lopressor, and started on nitroglycerin and heparin gtt. Became hypotensive with nitro to SBP 80s, BP responded to 2L NS. He then started to vomit brown colored, guiac positive emesis. The heparin and nitro drips were stopped. He was given IV protonix and Reglan. He was admitted to MICU for further monitoring/ROMI. . ROS: Denies fever, chills. No h/o blood clot or recent travel. . Past Medical History: PMH: HTN ETOH abuse h/o perianal abscess CKD, baseline Cr 1.3-1.4 Glaucoma . Social History: Social hx: Lives with his partner (male). Retired budjet analyst for park service. Has history of alchoholism, quit for 20 yrs, then starting drinking again when he retired, but much less. Drinks 2-3 glasses burbon daily, more when with friends. Starts drinking around 5pm. Former smoker, >50 pack years, quit 1.5 years ago. No illicits . Family History: . Family hx: Father died age 51 of melanoma, but had "silent MI" in late 40s. Mother had MI in her 70s. Physical Exam: PE: VS: T 97.8, BP 160/61, RR 16, HR 79, 96% 2L Gen: shaky, no apparent distress HEENT: eomi, moist mucous membranes Neck: supple, no appreciable JVD Lungs: CTA b/l Heart: RRR nl S1S2, no M/R/G Abd: +BS, soft, ND/NT Ext: no edema, +PP b/l Neuro: intention tremor. No asterixis. No pronator drift. +dysmetria with FNF. Strength 5/5 b/l upper and lower. CN II-XII intact . Pertinent Results: ECG: NSR @ 81. TWI V1-V3, new since 11-1922 . CXR 1928-7-16: AP upright chest radiograph is obtained. A small amount of left basilar atelectasis is noted. There is no evidence of pneumonia, CHF. There is no pneumothorax. Cardiomediastinal silhouette is unremarkable. Mildly unfolded thoracic aorta noted. Visualized osseous structures are intact. IMPRESSION: No evidence of pneumonia or CHF . 1928-7-16. The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate (5-3+) 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 no pericardial effusion. Compared with the findings of the prior study (images reviewed) of 1949-7-5, the findings are similar. . 1961-2-3. EGD. Severe esophagitis in the middle third of the esophagus and lower third of the esophagus compatible with severe reflux esophagitis (biopsy) Erythema in the antrum compatible with gastritis (biopsy, biopsy) Erythema and congestion in the second part of the duodenum compatible with duodenitis (biopsy) Otherwise normal EGD to second part of the duodenum Brief Hospital Course: In summary, Mr. Tyler Kibler is a 68 y.o. man with PMH significant for HTN and alcohol abuse, admitted for DOE and chest pressure. Patient was ruled out for MI, but developed coffee ground emesis while on heparin drip. EGD showed severe esophagitis and gastritis. . Upper GI bleed. Patient developed coffee-ground emesis in ED in setting of chronic heartburn and alcohol abuse while on heparin drip. EGD showed severe esophagitis and gastritis, likely due to chronic alcohol use. Hct fell to 32 from 42 on admission, but patient did not require transfusions. He was sent home on PPI Hawkins-Boyd Medical Center. Gastric biopsies for H. pylori were pending at time of discharge. . Chest pressure/ SOB. Patient presented with CP and SOB on exertion. He has no history of CAD. He had a stress test one year ago which was terminated early due to hypertension. Cardiac enzymes were negative. He was initally started on a heparin drip in the ED due to concern for unstable angina, but this was stopped when patient developed coffee ground emesis. His antihypertensives were intially held, but resumed on hospital day 2. A lipid panel was checked and his LDL was in the 40s. He was advised to get outpatient stress test and PFTs. Patient has a significant smoking history and CSR showed hyperinflation, suggesting that his DOE may be pulmonary in origin. . Alcohol abuse. Patient has history of alcoholism and quit drinking for 20 years and now drinks daily. He denies history of DTs or seizure. He was tremulous and required a CIWA scale. He was given thiamine, folate, and multivitamin during his hospitalization. . Transaminitis. Patient had mildly elevated LFTs that were thought to be due to alcohol hepatitis. Hepatitis serologies were sent, but were pending at time of discharge. . Contact: patient and his partner Isaias Chau Mattie Lees 889-580-8266 Medications on Admission: Home Meds: Toprol XL 25mg daily Lisinopril 40mg daily Amlodipine 10mg daily Xalatan oph drops, 1 drop each eye QHS Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pantoprazole 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 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Upper GI bleed GERD . Secondary diagnosis: Hypertension Alcohol abuse Chronic kidney disease Glaucoma Discharge Condition: good Discharge Instructions: You were admitted for chest pain. You were coughing up blood in the emergency department, so you went to the intensive care unit for monitoring. You had an endoscopy on 11-2 which showed severe inflammation in the esophagus and stomach due to acid reflux. . Please resume all medications as you were taking prior to admission. In addition, please take pantoprazole twice daily for acid reflux. You should avoid alcohol use and avoid using over the counter anti-inflammatory medications like Aleive or Advil. . You should follow up with Dr. Martin in 5-3 weeks and schedule pulmonary function tests and a stress test. . Please call your physician or come to the emergency department for shortness of breath, chest pain, chest pressure, fevers, chills, leg swelling, coughing up blood, blood in stool, or any other concerning symptoms. Followup Instructions: Please schedule a follow up appointment with Dr. Martin in 5-3 weeks. You will likely need a stress test and pulmonary function tests, but you should discuss this with your Dr. Martin first. Ph. 139-981-7456. The results of the gastric biopsy were pending at the time of discharge, so Dr. Martin will check the results for you. . You will need a repeat endoscopy in 11-4 weeks. Please call 956-375-5468 to schedule it. . You will need a follow up appointment in Diaz-Montoya Medical Center clinic with Dr. Chowdhury in 4 weeks. Please call 956-375-5468 to schedule appointment.	['Admission Date: 1928-7-16 Discharge Date: 1961-2-3\n\nDate of Birth: 1994-10-22 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Nancy\nChief Complaint:\nReason for ICU admission: ROMI, coffee ground emesis\n\nMajor Surgical or Invasive Procedure:\nendoscopy\n\nHistory of Present Illness:\nHPI:\n68 y.o. man with HTN presented to PCP for routine visit on day\nof admission, c/o 2 months of worsening DOE and chest pressure\nwith exertion. He reports having a stress test 1 year ago which\nwas stopped after 3 minutes for hypertension (SBP in the 230s).\nHe had no symptoms and no ST wave changes. In addition, he\ncomplains of severe heartburn (different than his chest\npressure) intermittently every few days x 3 months, along with\nviolent coughing fits which cause him to vomit dark brown\nliquid.', ' He denies frank blood in his emesis. The heartburn is\nworse at night with lying flat. He denies NSAID use, but does\nadmit to drinking at least 10-17 drinks of burbon daily.\n.\nHe was referred to the ED for concern of ACS. In the ED, he was\nafebrile, HR 70s, BP 116/73m RR 16, and 97% RA. Hct was 41. His\ntrop was negative but ECG showed TWI in V1-V3 which were new. He\nwas given ASA 325, Lopressor, and started on nitroglycerin and\nheparin gtt. Became hypotensive with nitro to SBP 80s, BP\nresponded to 2L NS. He then started to vomit brown colored,\nguiac positive emesis. The heparin and nitro drips were stopped.\nHe was given IV protonix and Reglan. He was admitted to MICU for\nfurther monitoring/ROMI.\n.\nROS: Denies fever, chills. No h/o blood clot or recent travel.\n.\n\n\nPast Medical History:\n\nPMH:\nHTN\nETOH abuse\nh/o perianal abscess\nCKD, baseline Cr 1.', '3-1.4\nGlaucoma\n.\n\n\nSocial History:\n\nSocial hx: Lives with his partner (male). Retired budjet analyst\nfor park service. Has history of alchoholism, quit for 20 yrs,\nthen starting drinking again when he retired, but much less.\nDrinks 2-3 glasses burbon daily, more when with friends. Starts\ndrinking around 5pm. Former smoker, >50 pack years, quit 1.5\nyears ago. No illicits\n.\n\n\nFamily History:\n\n.\nFamily hx: Father died age 51 of melanoma, but had "silent MI"\nin late 40s. Mother had MI in her 70s.\n\n\nPhysical Exam:\nPE:\nVS: T 97.8, BP 160/61, RR 16, HR 79, 96% 2L\nGen: shaky, no apparent distress\nHEENT: eomi, moist mucous membranes\nNeck: supple, no appreciable JVD\nLungs: CTA b/l\nHeart: RRR nl S1S2, no M/R/G\nAbd: +BS, soft, ND/NT\nExt: no edema, +PP b/l\nNeuro: intention tremor. No asterixis. No pronator drift.', '\n+dysmetria with FNF. Strength 5/5 b/l upper and lower. CN II-XII\nintact\n.\n\n\nPertinent Results:\nECG: NSR @ 81. TWI V1-V3, new since 11-1922\n.\nCXR 1928-7-16:\nAP upright chest radiograph is obtained. A small amount of left\n\nbasilar atelectasis is noted. There is no evidence of pneumonia,\nCHF. There is no pneumothorax. Cardiomediastinal silhouette is\nunremarkable. Mildly unfolded thoracic aorta noted. Visualized\nosseous structures are intact.\nIMPRESSION: No evidence of pneumonia or CHF\n.\n1928-7-16.\nThe left atrium is moderately dilated. Left ventricular wall\nthickness, cavity size and regional/global systolic function are\nnormal (LVEF 70%) The right ventricular free wall is\nhypertrophied. Right ventricular chamber size is normal. Right\nventricular systolic function is normal. The aortic root is\nmoderately dilated at the sinus level.', ' The ascending aorta is\nmoderately dilated. The aortic arch is mildly dilated. There are\nfocal calcifications in the aortic arch. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not\npresent. Mild to moderate (5-3+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. Trivial mitral regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There\nis no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed)\nof 1949-7-5, the findings are similar.\n.\n1961-2-3. EGD.\nSevere esophagitis in the middle third of the esophagus and\nlower third of the esophagus compatible with severe reflux\nesophagitis (biopsy)\nErythema in the antrum compatible with gastritis (biopsy,\nbiopsy)\nErythema and congestion in the second part of the duodenum\ncompatible with duodenitis (biopsy)\nOtherwise normal EGD to second part of the duodenum\n\nBrief Hospital Course:\nIn summary, Mr.', ' Tyler Kibler is a 68 y.o. man with PMH significant\nfor HTN and alcohol abuse, admitted for DOE and chest pressure.\nPatient was ruled out for MI, but developed coffee ground emesis\nwhile on heparin drip. EGD showed severe esophagitis and\ngastritis.\n.\nUpper GI bleed. Patient developed coffee-ground emesis in ED in\nsetting of chronic heartburn and alcohol abuse while on heparin\ndrip. EGD showed severe esophagitis and gastritis, likely due\nto chronic alcohol use. Hct fell to 32 from 42 on admission,\nbut patient did not require transfusions. He was sent home on\nPPI Hawkins-Boyd Medical Center. Gastric biopsies for H. pylori were pending at time of\ndischarge.\n.\nChest pressure/ SOB. Patient presented with CP and SOB on\nexertion. He has no history of CAD. He had a stress test one\nyear ago which was terminated early due to hypertension.', '\nCardiac enzymes were negative. He was initally started on a\nheparin drip in the ED due to concern for unstable angina, but\nthis was stopped when patient developed coffee ground emesis.\nHis antihypertensives were intially held, but resumed on\nhospital day 2. A lipid panel was checked and his LDL was in\nthe 40s. He was advised to get outpatient stress test and PFTs.\n Patient has a significant smoking history and CSR showed\nhyperinflation, suggesting that his DOE may be pulmonary in\norigin.\n.\nAlcohol abuse. Patient has history of alcoholism and quit\ndrinking for 20 years and now drinks daily. He denies history\nof DTs or seizure. He was tremulous and required a CIWA scale.\nHe was given thiamine, folate, and multivitamin during his\nhospitalization.\n.\nTransaminitis. Patient had mildly elevated LFTs that were\nthought to be due to alcohol hepatitis.', ' Hepatitis serologies\nwere sent, but were pending at time of discharge.\n.\nContact: patient and his partner Isaias Chau Mattie Lees 889-580-8266\n\n\nMedications on Admission:\nHome Meds:\nToprol XL 25mg daily\nLisinopril 40mg daily\nAmlodipine 10mg daily\nXalatan oph drops, 1 drop each eye QHS\n\nDischarge Medications:\n1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at\nbedtime).\n2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).\n3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO twice a day.\nDisp:60 Tablet, Delayed Release (E.C.)(s) Refills:2\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPrimary diagnosis:\nUpper GI bleed\nGERD\n.', '\nSecondary diagnosis:\nHypertension\nAlcohol abuse\nChronic kidney disease\nGlaucoma\n\n\nDischarge Condition:\ngood\n\n\nDischarge Instructions:\nYou were admitted for chest pain. You were coughing up blood in\nthe emergency department, so you went to the intensive care unit\nfor monitoring. You had an endoscopy on 11-2 which showed\nsevere inflammation in the esophagus and stomach due to acid\nreflux.\n.\nPlease resume all medications as you were taking prior to\nadmission. In addition, please take pantoprazole twice daily\nfor acid reflux. You should avoid alcohol use and avoid using\nover the counter anti-inflammatory medications like Aleive or\nAdvil.\n.\nYou should follow up with Dr. Martin in 5-3 weeks and schedule\npulmonary function tests and a stress test.\n.\nPlease call your physician or come to the emergency department\nfor shortness of breath, chest pain, chest pressure, fevers,\nchills, leg swelling, coughing up blood, blood in stool, or any\nother concerning symptoms.', '\n\n\nFollowup Instructions:\nPlease schedule a follow up appointment with Dr. Martin in 5-3\nweeks. You will likely need a stress test and pulmonary\nfunction tests, but you should discuss this with your Dr.\nMartin first. Ph. 139-981-7456. The results of the gastric\nbiopsy were pending at the time of discharge, so Dr. Martin\nwill check the results for you.\n.\nYou will need a repeat endoscopy in 11-4 weeks. Please call\n956-375-5468 to schedule it.\n.\nYou will need a follow up appointment in Diaz-Montoya Medical Center clinic with Dr.\nChowdhury in 4 weeks. Please call 956-375-5468 to schedule\nappointment.\n\n\n\n']
248	96774	129414.0	2174-02-14	Discharge summary	Report	Admission Date: [2174-2-12] Discharge Date: [2174-2-14] Date of Birth: [2122-4-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2474] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 51 yo M with h/o asthma and right lung volume loss of unclear etiology (?congenital hypoplasia), recurrent bronchitis in winter, OSA, obesity, HTN who presented with 1 week of productive cough, progresssive SOB, and over the past 2 days weakness and fatigue to the point he was falling asleep at work. He tried increasing his albuterol use but this did not help so he came to the emergency room. In the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA on presentation, 100% on NRB. The ED resident noted that he was not particularly wheezy on exam. Labs notable for WBC of 5, HCT 34.5, sodium of 131 and creatinine of 1.0. Patient was given ceftriaxone and azithromycin, nebs and 125 IV methylprednisone. He had a CXR which was inconclusive, possible RML pneumonia. Also be very tachycardic, EKG shows sinus tach. Got a CTA for concern of PE-but no PE, but some increased interstitial markings in RUL and RLL, more likely chronic process vs. pneumonia. Tried to wean him down on 02, as soon as he would fall asleep would desat. Right now, 40% venti mask and he is [Age over 90 ]%. Vitals on transfer, 99/5, HR 106, 127/87, 23. On the floor, the patient notes that he feels fine while lying still, but worse with movement. Denies sick contacts, recent travel, new pets. Only recent med change is stopping zoloft 1 month ago. He worked previously in the printing business and thinks he could have been exposed to some chemicals. Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Asthma Hypertension Hyperkalemia: intermittent elevations of his potassium. Obesity Glucose intolerance Obstructive sleep apnea: declined CPAP therapy. Anxiety Vitamin B12 deficiency Social History: Married, no children. He works for [Company 2475]. Previously he worked in a printing company where he reports that he was exposed to fumes and did not wear a mask. Tobacco: Quit. Alcohol: Two glasses of wine per night and 3 bottles over the weekend. Drugs: None. Family History: Grandmother with diabetes. Father with Alzheimer's. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds at R base, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2167-8-31] Actual Pred %Pred Actual %Pred %chg FVC 2.77 4.22 66 3.46 82 +25 FEV1 1.41 3.25 43 1.79 55 +27 MMF 0.59 3.53 17 0.62 18 +5 FEV1/FVC 51 77 66 51 66 +0 There is a moderate obstructive ventilatory defect with significant bronchdilator response. Admission labs [2174-2-12]: WBC-5.5 RBC-3.81* Hgb-11.7* Hct-34.8* MCV-91 MCH-30.8 MCHC-33.7 RDW-15.2 Plt Ct-336 PT-13.2 PTT-28.2 INR(PT)-1.1 Glucose-90 UreaN-18 Creat-1.0 Na-131* K-4.9 Cl-98 HCO3-21* AnGap-17 Phos-5.0* Mg-1.9 Iron-34* calTIBC-274 VitB12-405 Folate-10.2 Ferritn-249 TRF-211 Lactate-1.6 Discharge labs [2174-2-14]: WBC-4.5 RBC-3.49* Hgb-10.9* Hct-33.4* MCV-96 MCH-31.1 MCHC-32.5 RDW-15.1 Plt Ct-307 Glucose-86 UreaN-22* Creat-1.1 Na-137 K-4.5 Cl-105 HCO3-23 AnGap-14 Micro: [2-12] Blood cultures- pending at time of discharge (negative to date) [2-12] MRSA screen pending [2-12] Urine culture and legionella- negative [2-12] RSV screen negative Imaging: [2-12] EKG: Sinus tachycardia. Right bundle-branch block. No previous tracing available for comparison. [2-12] CXR: SINGLE FRONTAL PORTABLE VIEW OF THE CHEST: As compared to prior study there is minimal increase in right mid - lower lung opacity . Right lower lobe pleural thickening is grossly stable. Bullous changes denoted by relative lucency in the right upper lobe are again noted and unchanged. Prominent right mediastinal - paratracheal soft tissue remains unchanged. Left lung is clear. Heart is not enlarged. The aortic contour is grossly unremarkable. IMPRESSION: Minimal interval increase in opacification of the right mid - lower lung is better evaluated on subsequent CT from same day. [2-12] CTA Chest: 1. No pulmonary embolus. 2. Right lung volume loss could be due to a congenital anomaly or pulmonary infection early in life. 3. Persistent area of round atelectasis in the right lower lobe with increased size slightly since [2166]. 4. New subpleural septal thickening in the left upper lobe and medial basal left lower lobe, new since [2166] and suggestive of an interstitial fibrosis. 5. Mildly enlarged 13-mm prevascular lymph node. Given the pulmonary interstitial findings and mildly enlarged lymph node, followup high-resolution CT is suggested, preferrably in 3 months if not needed earlier. [2-14] Transthoracic echocardiogram: The left atrium and right atrium are normal in cavity size. The right atrial pressure is indeterminate. Mild symmetric left ventricular hypertrophy with normal cavity size, and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Right ventricular cavity enlargement with free wall hypokinesis and moderate pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function. This constellation of findings is suggestive of a primary pulmonary process, e.g., pulmonary embolism. Brief Hospital Course: In the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA on presentation, 100% on NRB. Labs notable for WBC of 5, HCT 34.5, sodium of 131 and creatinine of 1.0. Patient was given ceftriaxone and azithromycin, nebs, and methylprednisone. He had a CXR which was possibly suggestive of RML pneumonia, and a CTA that showed no signs of PE but did reveal some increased interstitial markings in the RUL and RLL, more consistent with a chronic process vs. pneumonia. the patient was admitted to the ICU for monitoring on [2-12]. He had in past refused CPAP for his OSA but accepted it and reported he had an unusually restful night. He was transferred to the medicine floor on [2-13]. # Hypoxia: His increased cough and the CT and chest Xray imaging were most consistent with a right middle lobe pneumonia with underlying chronic pneumonic process, and he will need another high-resolution chest CT in 3 months to evaluate progression of these findings. In the ICU, he continued antibiotic treatment for CAP. He did not receive further steroids. He had an Echo that showed RV enlargement, free wall hypokinesis & moderate elevation of PASP. Although these findings were consistent with possible pulmonary embolism, he had a CTA on admission that was negative for PE. Pulmonary was consulted and felt his right heart findings could be related to his underlying known chronic lung disease and sleep apnea rather than PE. After discussion with his PCP and pulmonologist, he was discharged to have a repeat sleep study performed and follow-up TTE in 1 month. Patient was encouraged to start using home CPAP. # Hyponatremia: He was noted to be mildly hyponatremic at admission, possibly due to salt-wasting from his HCTZ use. This mild hyponatremia resolved with a liter of normal saline. # Obstructive sleep apnea: He is now agreeable to trialing CPAP. He was told he should have an outpatient sleep study as above. # Normocytic Anemia: His hematocrit was slightly lower than recent baseline, and iron studies were consistent with chronic inflammation. This will be further worked up as an outpatient. Medications on Admission: # Albuterol Sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler 2 puffs inhaled every 4 hr as needed for asthma # Amlodipine 5 mg Tablet 1 (One) Tablet(s) by mouth once a day # Fluticasone-Salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose Disk with Device 1 (One) puff twice a day # Hydrochlorothiazide 25 mg Tablet 1 Tablet(s) by mouth daily # Lisinopril 40 mg Tablet 1 Tablet(s) by mouth once a day # Tiotropium Bromide [Spiriva with HandiHaler] 18 mcg Capsule, w/Inhalation Device one diskus inhaled once a day Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation every twelve (12) hours. 5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) diskus Inhalation once a day. 7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:4 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypoxia Community acquired pneumonia Obstructive sleep apnea Secondary: Asthma Hypertension Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You came to the hospital with shortness of breath and fatigue. You were briefly in the intensive care unit for close monitoring and your breathing improved with antibiotics and steroids. You were found to have pneumonia and are being treated with antibiotics. You had an echocardiogram of your heart that showed some strain on the right side of your heart, and this is likely due to your lung disease. Please follow-up with your PCP [Last Name (NamePattern4) ]. [First Name (STitle) 1022] and your pulmonologist Dr. [Last Name (STitle) ] as below. You have also been scheduled to see Dr. [First Name (STitle) 437] in sleep medicine to discuss your sleep apnea. The following changes were made to your medications: Started levofloxacin, an antibiotic, once daily. You should take this for 4 more days. Followup Instructions: Please follow-up with your PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 1022], on [2-21] at 4:20pm. You should have another echocardiogram done in 1 month to evaluate your heart function. You have an appointment to see Dr. [First Name (STitle) 437], a sleep physician, [Name10 (NameIs) ] [2-22] at 8 AM, [Hospital Ward Name 23] building [Location (un) ] to discuss your sleep apnea. You should be fitted for a CPAP machine at home to treat your obstructive sleep apnea. If you need to reschedule, you can call [Telephone/Fax (1) 612]. Please follow-up with Pulmonary (Dr. [Last Name (STitle) ] on [3-22] at 8:45 AM on the [Location (un) 436] of the [Hospital Ward Name 23] building, [Location (un) 2476]. If an earlier appointment is available, they will contact you. If you need to reschedule your appointment, please call [Telephone/Fax (1) 612]. A CT of the chest showed subpleural septal thickening in the left upper and medial basal lower lobes, new since [2166], and a mildly enlarged 13-mm prevascular lymph node. Given these findings, you should have a second high-resolution CT in the next 3 months to determine whether these changes resolve on their own. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477] MD, [MD Number(3) 2478]	Admission Date: <Date>2010-7-6</Date> Discharge Date: <Date>1964-11-27</Date> Date of Birth: <Date>1995-10-29</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Nancy</Name> Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 51 yo M with h/o asthma and right lung volume loss of unclear etiology (?congenital hypoplasia), recurrent bronchitis in winter, OSA, obesity, HTN who presented with 1 week of productive cough, progresssive SOB, and over the past 2 days weakness and fatigue to the point he was falling asleep at work. He tried increasing his albuterol use but this did not help so he came to the emergency room. In the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA on presentation, 100% on NRB. The ED resident noted that he was not particularly wheezy on exam. Labs notable for WBC of 5, HCT 34.5, sodium of 131 and creatinine of 1.0. Patient was given ceftriaxone and azithromycin, nebs and 125 IV methylprednisone. He had a CXR which was inconclusive, possible RML pneumonia. Also be very tachycardic, EKG shows sinus tach. Got a CTA for concern of PE-but no PE, but some increased interstitial markings in RUL and RLL, more likely chronic process vs. pneumonia. Tried to wean him down on 02, as soon as he would fall asleep would desat. Right now, 40% venti mask and he is <Age>80</Age>%. Vitals on transfer, 99/5, HR 106, 127/87, 23. On the floor, the patient notes that he feels fine while lying still, but worse with movement. Denies sick contacts, recent travel, new pets. Only recent med change is stopping zoloft 1 month ago. He worked previously in the printing business and thinks he could have been exposed to some chemicals. Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Asthma Hypertension Hyperkalemia: intermittent elevations of his potassium. Obesity Glucose intolerance Obstructive sleep apnea: declined CPAP therapy. Anxiety Vitamin B12 deficiency Social History: Married, no children. He works for <Company>Heath LLC</Company>. Previously he worked in a printing company where he reports that he was exposed to fumes and did not wear a mask. Tobacco: Quit. Alcohol: Two glasses of wine per night and 3 bottles over the weekend. Drugs: None. Family History: Grandmother with diabetes. Father with Alzheimer's. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds at R base, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: <Date>1927-7-21</Date> Actual Pred %Pred Actual %Pred %chg FVC 2.77 4.22 66 3.46 82 +25 FEV1 1.41 3.25 43 1.79 55 +27 MMF 0.59 3.53 17 0.62 18 +5 FEV1/FVC 51 77 66 51 66 +0 There is a moderate obstructive ventilatory defect with significant bronchdilator response. Admission labs <Date>2010-7-6</Date>: WBC-5.5 RBC-3.81* Hgb-11.7* Hct-34.8* MCV-91 MCH-30.8 MCHC-33.7 RDW-15.2 Plt Ct-336 PT-13.2 PTT-28.2 INR(PT)-1.1 Glucose-90 UreaN-18 Creat-1.0 Na-131* K-4.9 Cl-98 HCO3-21* AnGap-17 Phos-5.0* Mg-1.9 Iron-34* calTIBC-274 VitB12-405 Folate-10.2 Ferritn-249 TRF-211 Lactate-1.6 Discharge labs <Date>1964-11-27</Date>: WBC-4.5 RBC-3.49* Hgb-10.9* Hct-33.4* MCV-96 MCH-31.1 MCHC-32.5 RDW-15.1 Plt Ct-307 Glucose-86 UreaN-22* Creat-1.1 Na-137 K-4.5 Cl-105 HCO3-23 AnGap-14 Micro: <Date>11-6</Date> Blood cultures- pending at time of discharge (negative to date) <Date>11-6</Date> MRSA screen pending <Date>11-6</Date> Urine culture and legionella- negative <Date>11-6</Date> RSV screen negative Imaging: <Date>11-6</Date> EKG: Sinus tachycardia. Right bundle-branch block. No previous tracing available for comparison. <Date>11-6</Date> CXR: SINGLE FRONTAL PORTABLE VIEW OF THE CHEST: As compared to prior study there is minimal increase in right mid - lower lung opacity . Right lower lobe pleural thickening is grossly stable. Bullous changes denoted by relative lucency in the right upper lobe are again noted and unchanged. Prominent right mediastinal - paratracheal soft tissue remains unchanged. Left lung is clear. Heart is not enlarged. The aortic contour is grossly unremarkable. IMPRESSION: Minimal interval increase in opacification of the right mid - lower lung is better evaluated on subsequent CT from same day. <Date>11-6</Date> CTA Chest: 1. No pulmonary embolus. 2. Right lung volume loss could be due to a congenital anomaly or pulmonary infection early in life. 3. Persistent area of round atelectasis in the right lower lobe with increased size slightly since <Year>1960</Year>. 4. New subpleural septal thickening in the left upper lobe and medial basal left lower lobe, new since <Year>1960</Year> and suggestive of an interstitial fibrosis. 5. Mildly enlarged 13-mm prevascular lymph node. Given the pulmonary interstitial findings and mildly enlarged lymph node, followup high-resolution CT is suggested, preferrably in 3 months if not needed earlier. <Date>9-15</Date> Transthoracic echocardiogram: The left atrium and right atrium are normal in cavity size. The right atrial pressure is indeterminate. Mild symmetric left ventricular hypertrophy with normal cavity size, and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Right ventricular cavity enlargement with free wall hypokinesis and moderate pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function. This constellation of findings is suggestive of a primary pulmonary process, e.g., pulmonary embolism. Brief Hospital Course: In the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA on presentation, 100% on NRB. Labs notable for WBC of 5, HCT 34.5, sodium of 131 and creatinine of 1.0. Patient was given ceftriaxone and azithromycin, nebs, and methylprednisone. He had a CXR which was possibly suggestive of RML pneumonia, and a CTA that showed no signs of PE but did reveal some increased interstitial markings in the RUL and RLL, more consistent with a chronic process vs. pneumonia. the patient was admitted to the ICU for monitoring on <Date>11-6</Date>. He had in past refused CPAP for his OSA but accepted it and reported he had an unusually restful night. He was transferred to the medicine floor on <Date>7-2</Date>. # Hypoxia: His increased cough and the CT and chest Xray imaging were most consistent with a right middle lobe pneumonia with underlying chronic pneumonic process, and he will need another high-resolution chest CT in 3 months to evaluate progression of these findings. In the ICU, he continued antibiotic treatment for CAP. He did not receive further steroids. He had an Echo that showed RV enlargement, free wall hypokinesis & moderate elevation of PASP. Although these findings were consistent with possible pulmonary embolism, he had a CTA on admission that was negative for PE. Pulmonary was consulted and felt his right heart findings could be related to his underlying known chronic lung disease and sleep apnea rather than PE. After discussion with his PCP and pulmonologist, he was discharged to have a repeat sleep study performed and follow-up TTE in 1 month. Patient was encouraged to start using home CPAP. # Hyponatremia: He was noted to be mildly hyponatremic at admission, possibly due to salt-wasting from his HCTZ use. This mild hyponatremia resolved with a liter of normal saline. # Obstructive sleep apnea: He is now agreeable to trialing CPAP. He was told he should have an outpatient sleep study as above. # Normocytic Anemia: His hematocrit was slightly lower than recent baseline, and iron studies were consistent with chronic inflammation. This will be further worked up as an outpatient. Medications on Admission: # Albuterol Sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler 2 puffs inhaled every 4 hr as needed for asthma # Amlodipine 5 mg Tablet 1 (One) Tablet(s) by mouth once a day # Fluticasone-Salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose Disk with Device 1 (One) puff twice a day # Hydrochlorothiazide 25 mg Tablet 1 Tablet(s) by mouth daily # Lisinopril 40 mg Tablet 1 Tablet(s) by mouth once a day # Tiotropium Bromide [Spiriva with HandiHaler] 18 mcg Capsule, w/Inhalation Device one diskus inhaled once a day Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation every twelve (12) hours. 5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) diskus Inhalation once a day. 7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:4 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypoxia Community acquired pneumonia Obstructive sleep apnea Secondary: Asthma Hypertension Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You came to the hospital with shortness of breath and fatigue. You were briefly in the intensive care unit for close monitoring and your breathing improved with antibiotics and steroids. You were found to have pneumonia and are being treated with antibiotics. You had an echocardiogram of your heart that showed some strain on the right side of your heart, and this is likely due to your lung disease. Please follow-up with your PCP <Name>Conyers</Name>. <Name>Franklin</Name> and your pulmonologist Dr. <Name>Bludsworth</Name> as below. You have also been scheduled to see Dr. <Name>Kayla</Name> in sleep medicine to discuss your sleep apnea. The following changes were made to your medications: Started levofloxacin, an antibiotic, once daily. You should take this for 4 more days. Followup Instructions: Please follow-up with your PCP, <Name>Conyers</Name>. <Name>Franklin</Name>, on <Date>8-31</Date> at 4:20pm. You should have another echocardiogram done in 1 month to evaluate your heart function. You have an appointment to see Dr. <Name>Kayla</Name>, a sleep physician, <Name>Timothy Debelius</Name> <Date>12-9</Date> at 8 AM, <Hospital>Dorsey, Brown and Villanueva Clinic</Hospital> building <Location>04520 Anderson Crossroad Apt. 160 Christianstad, OH 67261</Location> to discuss your sleep apnea. You should be fitted for a CPAP machine at home to treat your obstructive sleep apnea. If you need to reschedule, you can call <Telephone>999-510-9412</Telephone>. Please follow-up with Pulmonary (Dr. <Name>Bludsworth</Name> on <Date>11-25</Date> at 8:45 AM on the <Location>66974 Boone Gateway Lake Daniel, NV 21433</Location> of the <Hospital>Dorsey, Brown and Villanueva Clinic</Hospital> building, <Location>9841 Nelson Pine Lake Kenneth, IA 78770</Location>. If an earlier appointment is available, they will contact you. If you need to reschedule your appointment, please call <Telephone>999-510-9412</Telephone>. A CT of the chest showed subpleural septal thickening in the left upper and medial basal lower lobes, new since <Year>1960</Year>, and a mildly enlarged 13-mm prevascular lymph node. Given these findings, you should have a second high-resolution CT in the next 3 months to determine whether these changes resolve on their own. <Name>Tan</Name> <Name>Young</Name> MD, <MD Number>77341587</MD 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Date: 2010-7-6 Discharge Date: 1964-11-27 Date of Birth: 1995-10-29 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Nancy Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 51 yo M with h/o asthma and right lung volume loss of unclear etiology (?congenital hypoplasia), recurrent bronchitis in winter, OSA, obesity, HTN who presented with 1 week of productive cough, progresssive SOB, and over the past 2 days weakness and fatigue to the point he was falling asleep at work. He tried increasing his albuterol use but this did not help so he came to the emergency room. In the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA on presentation, 100% on NRB. The ED resident noted that he was not particularly wheezy on exam. Labs notable for WBC of 5, HCT 34.5, sodium of 131 and creatinine of 1.0. Patient was given ceftriaxone and azithromycin, nebs and 125 IV methylprednisone. He had a CXR which was inconclusive, possible RML pneumonia. Also be very tachycardic, EKG shows sinus tach. Got a CTA for concern of PE-but no PE, but some increased interstitial markings in RUL and RLL, more likely chronic process vs. pneumonia. Tried to wean him down on 02, as soon as he would fall asleep would desat. Right now, 40% venti mask and he is 80%. Vitals on transfer, 99/5, HR 106, 127/87, 23. On the floor, the patient notes that he feels fine while lying still, but worse with movement. Denies sick contacts, recent travel, new pets. Only recent med change is stopping zoloft 1 month ago. He worked previously in the printing business and thinks he could have been exposed to some chemicals. Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Asthma Hypertension Hyperkalemia: intermittent elevations of his potassium. Obesity Glucose intolerance Obstructive sleep apnea: declined CPAP therapy. Anxiety Vitamin B12 deficiency Social History: Married, no children. He works for Heath LLC. Previously he worked in a printing company where he reports that he was exposed to fumes and did not wear a mask. Tobacco: Quit. Alcohol: Two glasses of wine per night and 3 bottles over the weekend. Drugs: None. Family History: Grandmother with diabetes. Father with Alzheimer's. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds at R base, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: 1927-7-21 Actual Pred %Pred Actual %Pred %chg FVC 2.77 4.22 66 3.46 82 +25 FEV1 1.41 3.25 43 1.79 55 +27 MMF 0.59 3.53 17 0.62 18 +5 FEV1/FVC 51 77 66 51 66 +0 There is a moderate obstructive ventilatory defect with significant bronchdilator response. Admission labs 2010-7-6: WBC-5.5 RBC-3.81* Hgb-11.7* Hct-34.8* MCV-91 MCH-30.8 MCHC-33.7 RDW-15.2 Plt Ct-336 PT-13.2 PTT-28.2 INR(PT)-1.1 Glucose-90 UreaN-18 Creat-1.0 Na-131* K-4.9 Cl-98 HCO3-21* AnGap-17 Phos-5.0* Mg-1.9 Iron-34* calTIBC-274 VitB12-405 Folate-10.2 Ferritn-249 TRF-211 Lactate-1.6 Discharge labs 1964-11-27: WBC-4.5 RBC-3.49* Hgb-10.9* Hct-33.4* MCV-96 MCH-31.1 MCHC-32.5 RDW-15.1 Plt Ct-307 Glucose-86 UreaN-22* Creat-1.1 Na-137 K-4.5 Cl-105 HCO3-23 AnGap-14 Micro: 11-6 Blood cultures- pending at time of discharge (negative to date) 11-6 MRSA screen pending 11-6 Urine culture and legionella- negative 11-6 RSV screen negative Imaging: 11-6 EKG: Sinus tachycardia. Right bundle-branch block. No previous tracing available for comparison. 11-6 CXR: SINGLE FRONTAL PORTABLE VIEW OF THE CHEST: As compared to prior study there is minimal increase in right mid - lower lung opacity . Right lower lobe pleural thickening is grossly stable. Bullous changes denoted by relative lucency in the right upper lobe are again noted and unchanged. Prominent right mediastinal - paratracheal soft tissue remains unchanged. Left lung is clear. Heart is not enlarged. The aortic contour is grossly unremarkable. IMPRESSION: Minimal interval increase in opacification of the right mid - lower lung is better evaluated on subsequent CT from same day. 11-6 CTA Chest: 1. No pulmonary embolus. 2. Right lung volume loss could be due to a congenital anomaly or pulmonary infection early in life. 3. Persistent area of round atelectasis in the right lower lobe with increased size slightly since 1960. 4. New subpleural septal thickening in the left upper lobe and medial basal left lower lobe, new since 1960 and suggestive of an interstitial fibrosis. 5. Mildly enlarged 13-mm prevascular lymph node. Given the pulmonary interstitial findings and mildly enlarged lymph node, followup high-resolution CT is suggested, preferrably in 3 months if not needed earlier. 9-15 Transthoracic echocardiogram: The left atrium and right atrium are normal in cavity size. The right atrial pressure is indeterminate. Mild symmetric left ventricular hypertrophy with normal cavity size, and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Right ventricular cavity enlargement with free wall hypokinesis and moderate pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function. This constellation of findings is suggestive of a primary pulmonary process, e.g., pulmonary embolism. Brief Hospital Course: In the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA on presentation, 100% on NRB. Labs notable for WBC of 5, HCT 34.5, sodium of 131 and creatinine of 1.0. Patient was given ceftriaxone and azithromycin, nebs, and methylprednisone. He had a CXR which was possibly suggestive of RML pneumonia, and a CTA that showed no signs of PE but did reveal some increased interstitial markings in the RUL and RLL, more consistent with a chronic process vs. pneumonia. the patient was admitted to the ICU for monitoring on 11-6. He had in past refused CPAP for his OSA but accepted it and reported he had an unusually restful night. He was transferred to the medicine floor on 7-2. # Hypoxia: His increased cough and the CT and chest Xray imaging were most consistent with a right middle lobe pneumonia with underlying chronic pneumonic process, and he will need another high-resolution chest CT in 3 months to evaluate progression of these findings. In the ICU, he continued antibiotic treatment for CAP. He did not receive further steroids. He had an Echo that showed RV enlargement, free wall hypokinesis & moderate elevation of PASP. Although these findings were consistent with possible pulmonary embolism, he had a CTA on admission that was negative for PE. Pulmonary was consulted and felt his right heart findings could be related to his underlying known chronic lung disease and sleep apnea rather than PE. After discussion with his PCP and pulmonologist, he was discharged to have a repeat sleep study performed and follow-up TTE in 1 month. Patient was encouraged to start using home CPAP. # Hyponatremia: He was noted to be mildly hyponatremic at admission, possibly due to salt-wasting from his HCTZ use. This mild hyponatremia resolved with a liter of normal saline. # Obstructive sleep apnea: He is now agreeable to trialing CPAP. He was told he should have an outpatient sleep study as above. # Normocytic Anemia: His hematocrit was slightly lower than recent baseline, and iron studies were consistent with chronic inflammation. This will be further worked up as an outpatient. Medications on Admission: # Albuterol Sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler 2 puffs inhaled every 4 hr as needed for asthma # Amlodipine 5 mg Tablet 1 (One) Tablet(s) by mouth once a day # Fluticasone-Salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose Disk with Device 1 (One) puff twice a day # Hydrochlorothiazide 25 mg Tablet 1 Tablet(s) by mouth daily # Lisinopril 40 mg Tablet 1 Tablet(s) by mouth once a day # Tiotropium Bromide [Spiriva with HandiHaler] 18 mcg Capsule, w/Inhalation Device one diskus inhaled once a day Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation every twelve (12) hours. 5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) diskus Inhalation once a day. 7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:4 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypoxia Community acquired pneumonia Obstructive sleep apnea Secondary: Asthma Hypertension Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You came to the hospital with shortness of breath and fatigue. You were briefly in the intensive care unit for close monitoring and your breathing improved with antibiotics and steroids. You were found to have pneumonia and are being treated with antibiotics. You had an echocardiogram of your heart that showed some strain on the right side of your heart, and this is likely due to your lung disease. Please follow-up with your PCP Conyers. Franklin and your pulmonologist Dr. Bludsworth as below. You have also been scheduled to see Dr. Kayla in sleep medicine to discuss your sleep apnea. The following changes were made to your medications: Started levofloxacin, an antibiotic, once daily. You should take this for 4 more days. Followup Instructions: Please follow-up with your PCP, Conyers. Franklin, on 8-31 at 4:20pm. You should have another echocardiogram done in 1 month to evaluate your heart function. You have an appointment to see Dr. Kayla, a sleep physician, Timothy Debelius 12-9 at 8 AM, Dorsey, Brown and Villanueva Clinic building 04520 Anderson Crossroad Apt. 160 Christianstad, OH 67261 to discuss your sleep apnea. You should be fitted for a CPAP machine at home to treat your obstructive sleep apnea. If you need to reschedule, you can call 999-510-9412. Please follow-up with Pulmonary (Dr. Bludsworth on 11-25 at 8:45 AM on the 66974 Boone Gateway Lake Daniel, NV 21433 of the Dorsey, Brown and Villanueva Clinic building, 9841 Nelson Pine Lake Kenneth, IA 78770. If an earlier appointment is available, they will contact you. If you need to reschedule your appointment, please call 999-510-9412. A CT of the chest showed subpleural septal thickening in the left upper and medial basal lower lobes, new since 1960, and a mildly enlarged 13-mm prevascular lymph node. Given these findings, you should have a second high-resolution CT in the next 3 months to determine whether these changes resolve on their own. Tan Young MD, 77341587	['Admission Date: 2010-7-6 Discharge Date: 1964-11-27\n\nDate of Birth: 1995-10-29 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Nancy\nChief Complaint:\nshortness of breath\n\nMajor Surgical or Invasive Procedure:\nNone\n\n\nHistory of Present Illness:\n51 yo M with h/o asthma and right lung volume loss of unclear\netiology (?congenital hypoplasia), recurrent bronchitis in\nwinter, OSA, obesity, HTN who presented with 1 week of\nproductive cough, progresssive SOB, and over the past 2 days\nweakness and fatigue to the point he was falling asleep at work.\nHe tried increasing his albuterol use but this did not help so\nhe came to the emergency room.\n\nIn the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA\non presentation, 100% on NRB.', ' The ED resident noted that he was\nnot particularly wheezy on exam. Labs notable for WBC of 5, HCT\n34.5, sodium of 131 and creatinine of 1.0. Patient was given\nceftriaxone and azithromycin, nebs and 125 IV methylprednisone.\nHe had a CXR which was inconclusive, possible RML pneumonia.\nAlso be very tachycardic, EKG shows sinus tach. Got a CTA for\nconcern of PE-but no PE, but some increased interstitial\nmarkings in RUL and RLL, more likely chronic process vs.\npneumonia. Tried to wean him down on 02, as soon as he would\nfall asleep would desat. Right now, 40% venti mask and he is\n80%. Vitals on transfer, 99/5, HR 106, 127/87, 23.\n\nOn the floor, the patient notes that he feels fine while lying\nstill, but worse with movement. Denies sick contacts, recent\ntravel, new pets. Only recent med change is stopping zoloft 1\nmonth ago.', ' He worked previously in the printing business and\nthinks he could have been exposed to some chemicals.\n\nReview of systems:\n(+) Per HPI\n(-) Denies fever, night sweats, recent weight loss or gain.\nDenies headache, sinus tenderness, rhinorrhea or congestion.\nDenies chest pain, chest pressure, palpitations, or weakness.\nDenies nausea, vomiting, diarrhea, constipation, abdominal pain,\nor changes in bowel habits. Denies dysuria, frequency, or\nurgency. Denies arthralgias or myalgias. Denies rashes or skin\nchanges.\n\n\nPast Medical History:\nAsthma\nHypertension\nHyperkalemia: intermittent elevations of his potassium.\nObesity\nGlucose intolerance\nObstructive sleep apnea: declined CPAP therapy.\nAnxiety\nVitamin B12 deficiency\n\nSocial History:\nMarried, no children. He works for Heath LLC. Previously he worked\nin a printing company where he reports that he was exposed to\nfumes and did not wear a mask.', "\nTobacco: Quit.\nAlcohol: Two glasses of wine per night and 3 bottles over the\nweekend.\nDrugs: None.\n\nFamily History:\nGrandmother with diabetes. Father with Alzheimer's.\n\n\nPhysical Exam:\nGeneral: Alert, oriented, no acute distress\nHEENT: Sclera anicteric, MMM, oropharynx clear\nNeck: supple, JVP not elevated, no LAD\nLungs: Decreased breath sounds at R base, no wheezes, rales,\nrhonchi\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: no foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema\n\nPertinent Results:\n1927-7-21\n Actual Pred %Pred Actual %Pred %chg\nFVC 2.77 4.22 66 3.46 82 +25\nFEV1 1.41 3.25 43 1.79 55 +27\nMMF 0.", '59 3.53 17 0.62 18 +5\nFEV1/FVC 51 77 66 51 66 +0\nThere is a moderate obstructive ventilatory defect with\n significant bronchdilator response.\n\nAdmission labs 2010-7-6:\n\nWBC-5.5 RBC-3.81* Hgb-11.7* Hct-34.8* MCV-91 MCH-30.8 MCHC-33.7\nRDW-15.2 Plt Ct-336\nPT-13.2 PTT-28.2 INR(PT)-1.1\nGlucose-90 UreaN-18 Creat-1.0 Na-131* K-4.9 Cl-98 HCO3-21\nAnGap-17\nPhos-5.0 Mg-1.9 Iron-34\ncalTIBC-274 VitB12-405 Folate-10.2 Ferritn-249 TRF-211\nLactate-1.6\n\nDischarge labs 1964-11-27:\n\nWBC-4.5 RBC-3.49 Hgb-10.9* Hct-33.4* MCV-96 MCH-31.1 MCHC-32.5\nRDW-15.1 Plt Ct-307\nGlucose-86 UreaN-22* Creat-1.1 Na-137 K-4.5 Cl-105 HCO3-23\nAnGap-14\n\nMicro:\n11-6 Blood cultures- pending at time of discharge (negative to\ndate)\n11-6 MRSA screen pending\n11-6 Urine culture and legionella- negative\n11-6 RSV screen negative\n\nImaging:\n11-6 EKG: Sinus tachycardia.', ' Right bundle-branch block. No\nprevious tracing available for comparison.\n\n11-6 CXR:\nSINGLE FRONTAL PORTABLE VIEW OF THE CHEST: As compared to prior\nstudy there is minimal increase in right mid - lower lung\nopacity . Right lower lobe pleural thickening is grossly stable.\nBullous changes denoted by relative lucency in the right upper\nlobe are again noted and unchanged. Prominent right mediastinal\n- paratracheal soft tissue remains unchanged. Left lung is\nclear. Heart is not enlarged. The aortic contour is grossly\nunremarkable.\n\nIMPRESSION: Minimal interval increase in opacification of the\nright mid -\nlower lung is better evaluated on subsequent CT from same day.\n\n11-6 CTA Chest:\n1. No pulmonary embolus.\n2. Right lung volume loss could be due to a congenital anomaly\nor pulmonary infection early in life.', '\n3. Persistent area of round atelectasis in the right lower lobe\nwith\nincreased size slightly since 1960.\n4. New subpleural septal thickening in the left upper lobe and\nmedial basal left lower lobe, new since 1960 and suggestive of\nan interstitial fibrosis.\n5. Mildly enlarged 13-mm prevascular lymph node.\n\nGiven the pulmonary interstitial findings and mildly enlarged\nlymph node,\nfollowup high-resolution CT is suggested, preferrably in 3\nmonths if not\nneeded earlier.\n\n9-15 Transthoracic echocardiogram:\nThe left atrium and right atrium are normal in cavity size. The\nright atrial pressure is indeterminate. Mild symmetric left\nventricular hypertrophy with normal cavity size, and global\nsystolic function (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully\nexcluded.', ' The right ventricular cavity is moderately dilated\nwith moderate global free wall hypokinesis. There is abnormal\nsystolic septal motion/position consistent with right\nventricular pressure overload. The aortic valve leaflets are\nmildly thickened (?#). There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is\nmoderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Right ventricular cavity\nenlargement with free wall hypokinesis and moderate pulmonary\nartery systolic hypertension. Mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic\nfunction.\nThis constellation of findings is suggestive of a primary\npulmonary process, e.', 'g., pulmonary embolism.\n\nBrief Hospital Course:\nIn the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA\non presentation, 100% on NRB. Labs notable for WBC of 5, HCT\n34.5, sodium of 131 and creatinine of 1.0. Patient was given\nceftriaxone and azithromycin, nebs, and methylprednisone. He\nhad a CXR which was possibly suggestive of RML pneumonia, and a\nCTA that showed no signs of PE but did reveal some increased\ninterstitial markings in the RUL and RLL, more consistent with a\nchronic process vs. pneumonia. the patient was admitted to the\nICU for monitoring on 11-6. He had in past refused CPAP for his\nOSA but accepted it and reported he had an unusually restful\nnight. He was transferred to the medicine floor on 7-2.\n\n# Hypoxia: His increased cough and the CT and chest Xray\nimaging were most consistent with a right middle lobe pneumonia\nwith underlying chronic pneumonic process, and he will need\nanother high-resolution chest CT in 3 months to evaluate\nprogression of these findings.', ' In the ICU, he continued\nantibiotic treatment for CAP. He did not receive further\nsteroids. He had an Echo that showed RV enlargement, free wall\nhypokinesis & moderate elevation of PASP. Although these\nfindings were consistent with possible pulmonary embolism, he\nhad a CTA on admission that was negative for PE. Pulmonary was\nconsulted and felt his right heart findings could be related to\nhis underlying known chronic lung disease and sleep apnea rather\nthan PE. After discussion with his PCP and pulmonologist, he was\ndischarged to have a repeat sleep study performed and follow-up\nTTE in 1 month. Patient was encouraged to start using home\nCPAP.\n\n# Hyponatremia: He was noted to be mildly hyponatremic at\nadmission, possibly due to salt-wasting from his HCTZ use. This\nmild hyponatremia resolved with a liter of normal saline.', '\n\n# Obstructive sleep apnea: He is now agreeable to trialing CPAP.\nHe was told he should have an outpatient sleep study as above.\n\n# Normocytic Anemia: His hematocrit was slightly lower than\nrecent baseline, and iron studies were consistent with chronic\ninflammation. This will be further worked up as an outpatient.\n\nMedications on Admission:\n# Albuterol Sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler 2\npuffs inhaled every 4 hr as needed for asthma\n# Amlodipine 5 mg Tablet 1 (One) Tablet(s) by mouth once a day\n# Fluticasone-Salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose\nDisk with Device 1 (One) puff twice a day\n# Hydrochlorothiazide 25 mg Tablet 1 Tablet(s) by mouth daily\n\n# Lisinopril 40 mg Tablet 1 Tablet(s) by mouth once a day\n# Tiotropium Bromide [Spiriva with HandiHaler] 18 mcg Capsule,\nw/Inhalation Device one diskus inhaled once a day\n\nDischarge Medications:\n1.', ' Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:\nTwo (2) puffs Inhalation every four (4) hours as needed for\nshortness of breath or wheezing.\n2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once\na day.\n3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n4. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)\npuff Inhalation every twelve (12) hours.\n5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.\n6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device\nSig: One (1) diskus Inhalation once a day.\n7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day\nfor 4 days.\nDisp:4 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPrimary:\nHypoxia\nCommunity acquired pneumonia\nObstructive sleep apnea\n\nSecondary:\nAsthma\nHypertension\n\n\nDischarge Condition:\nMental Status: Clear and coherent\nLevel of Consciousness: Alert and interactive\nActivity Status: Ambulatory - Independent\n\n\nDischarge Instructions:\nYou came to the hospital with shortness of breath and fatigue.', '\nYou were briefly in the intensive care unit for close monitoring\nand your breathing improved with antibiotics and steroids. You\nwere found to have pneumonia and are being treated with\nantibiotics. You had an echocardiogram of your heart that\nshowed some strain on the right side of your heart, and this is\nlikely due to your lung disease. Please follow-up with your PCP\nConyers. Franklin and your pulmonologist Dr. Bludsworth as below. You have\nalso been scheduled to see Dr. Kayla in sleep medicine to\ndiscuss your sleep apnea.\n\nThe following changes were made to your medications:\nStarted levofloxacin, an antibiotic, once daily. You should\ntake this for 4 more days.\n\nFollowup Instructions:\nPlease follow-up with your PCP, Conyers. Franklin, on 8-31 at 4:20pm. You\nshould have another echocardiogram done in 1 month to evaluate\nyour heart function.', '\n\nYou have an appointment to see Dr. Kayla, a sleep physician, Timothy Debelius\n12-9 at 8 AM, Dorsey, Brown and Villanueva Clinic building 04520 Anderson Crossroad Apt. 160\nChristianstad, OH 67261 to discuss your\nsleep apnea. You should be fitted for a CPAP machine at home to\ntreat your obstructive sleep apnea. If you need to reschedule,\nyou can call 999-510-9412.\n\nPlease follow-up with Pulmonary (Dr. Bludsworth on 11-25 at\n8:45 AM on the 66974 Boone Gateway\nLake Daniel, NV 21433 of the Dorsey, Brown and Villanueva Clinic building, 9841 Nelson Pine\nLake Kenneth, IA 78770. If an earlier appointment is available, they will contact\nyou. If you need to reschedule your appointment, please call\n999-510-9412.\n\nA CT of the chest showed subpleural septal thickening in the\nleft upper and medial basal lower lobes, new since 1960, and a\nmildly enlarged 13-mm prevascular lymph node.', ' Given these\nfindings, you should have a second high-resolution CT in the\nnext 3 months to determine whether these changes resolve on\ntheir own.\n\n\n Tan Young MD, 77341587\n\n']
249	62745	133623.0	2145-12-01	Discharge summary	Report	Admission Date: [2145-11-30] Discharge Date: [2145-12-1] Date of Birth: [2091-4-13] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2485] Chief Complaint: Afib with RVR Major Surgical or Invasive Procedure: None History of Present Illness: 54M with hx of ETOH abuse, HCV, presented to the ED this evening intoxicated. Upon arrival the pt was noted to have slurred speech and decreased responsiveness. The patient states that today he invited a friend over to his house where he shared 1L of vodka. The pt reports that while drinking he experienced left sided chest pain that led his friend to call EMS for him. The pt states he drinks heavily [2-3]/month. He denies history of seizure, loss of urine or stool. No loss of consciousness, no known trauma. The pt describes his chest pain as left sided [8-12], with radiation to the left arm. No known CAD. +Reproducibility with palpation. . In the emergency department initial vitals 98.2 100 116/71 20 100%RA Exam was notable for an intoxicated male with clear lungs and without signs of aspiration on CXR. Upon assessment the pt reportedly became combative with a HR revealing AF with RVR with rates in 160-170s. Pt has received a total of 100mg of Valium during his ED course, Diltiazem 30mg IV of dilt x3, Dilt 30mg PO and subsequently placed on a Diltiazem drip at 15mg/hr. Lactate of 3.2->2.6->1.8 following 4L of NS. . The pt subsequently re-developed chest pain while in the ED. Received ASA 325mg and Nitro 0.4mg x3. Repeat ECG unchanged. Cardiology evaluated pt and felt his pain was unlikely cardiac. Recommended Metoprolol. Chest Pain improved with a total of Morphine 12mg IV and Dilaudid 1mg IV. . Upon arrival to the unit the patient states his chest pain remains a [8-12] with radiation to left arm. Denies headache, visual changes, sweats, hallucination, fevers, chills, cough, BRBPR, melena, emesis, abdominal pain. Past Medical History: 1. ETOH abuse as above 2. Hepatitis C: He has never been treated and is followed by his PCP. 3. s/p cholecystectomy in [2121] 4. s/p bariatric surgery in [2110] 5. h/o PUD in [2121] 6. h/o C. diff in [2132] Social History: Pt lives alone. His only child is the son who died in the war. He is [Initials (NamePattern4) ] [Last Name (NamePattern4) ] at [Company 2486]. . Tobacco: quit 4 years ago, 10 year pack history ETOH: as above Recreational drugs: denied use, inc. IVDA Family History: Colorectal cancer in uncle (45yo), uncle (37yo), grandmother (92) Physical Exam: VITAL SIGNS: T=97.5 BP=154/76 HR 90 RR=16 94RA PHYSICAL EXAM GENERAL: Pleasant, mildly discheveled male in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Irregularly irregular, tachycardic. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP flat LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: No nystagmus. No asterxis. A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [12-4]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: CXR [11-30]: UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette is top normal in size. The mediastinal and hilar contours are stable. Pulmonary vascularity is normal. The lungs are clear. No pleural effusion or pneumothorax is visualized. Left acromioclavicular joint separation is redemonstrated, unchanged. IMPRESSION: No acute cardiopulmonary abnormality. . [2145-11-30] 01:30PM WBC-5.5# RBC-3.97* HGB-9.0* HCT-30.3* MCV-76# MCH-22.7# MCHC-29.8* RDW-18.9* [2145-11-30] 01:30PM NEUTS-59.4 LYMPHS-34.1 MONOS-4.1 EOS-1.5 BASOS-0.8 [2145-11-30] 01:30PM PLT COUNT-309 [2145-11-30] 01:30PM GLUCOSE-111* UREA N-15 CREAT-0.8 SODIUM-144 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15 [2145-11-30] 09:30PM CK-MB-7 cTropnT-<0.01 [2145-11-30] 09:30PM CK(CPK)-547* [2145-11-30] 09:35PM LACTATE-2.6* [2145-11-30] 01:30PM BLOOD ASA-NEG Ethanol-412* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2145-12-1] 01:54AM BLOOD Lactate-1.8 Brief Hospital Course: ASSESSMENT AND PLAN: 54M with hx of ETOH abuse, HCV, presenting with AF with RVR, Chest Pain in the setting of ETOH intoxication. . #: AF with RVR: Pt was in AF with RVR at presentation, which was a new finding from prior EKGs. EKG showed no evidence of ischemia. Pt was started on dilt gtt in ED and was transitioned to PO metoprolol after arriving the ICU. HR was stable in 90s at rest. Patient left AMA without waiting to receive his prescriptions or cardiology follow-up. He was instructed to return to the ED for palpitations, chest pain, SOB or any other symptoms. He was instructed to follow up with his PCP. . # ETOH Intoxication: Pt presented with ETOH level of 412 and was intoxicated. Lactate elevated but quickly trended down. He received banana bag, and PO folate and thiamine. Electrolytes were normal. Patient was monitored on CIWA scale in the ICU and received Valium prn. SW was consulted. However, patient left AMA. He stated he planned to take his home dose Campral and continue attending AA meetings. He lives in a recovery home and was instructed to have EMS notified if he experiences shaking, confusion or any other symptoms. . #. Chest pain: Pt presented with atypical chest pain in the setting of intoxication that was reproducible on palpation. He denies trauma but had been lifting heavy boxes recently. Pt evaluated by Cards while in ED who felt that pain was non-cardiac. ASA 325mg and Nitroglycerin x1. One set of CE was significant for elevated CK but normal troponin. DDx includes muscluoskeletal, no evidence of PNA or ACS. PE unlikely given reproducibility. . # Anemia: Hct 30 on arrival. Near prior baseline. No evidence of GI Bleed, no known prior hx of varies. . # HCV: Currently not receiving treatment. [Hospital6 1597], records confirmed that Hep C antibody was confirmed to be positive [2143-6-2]. HCV genotype was type IB, and RNA viral load was 996,000 copies at that time. Medications on Admission: None Discharge Medications: Patient left against medical advice. Discharge Disposition: Home Discharge Diagnosis: Patient left against medical advice. Discharge Condition: Patient left against medical advice. Discharge Instructions: Patient left against medical advice. Followup Instructions: Patient left against medical advice.	Admission Date: <Date>2021-5-6</Date> Discharge Date: <Date>1932-10-16</Date> Date of Birth: <Date>1926-7-2</Date> Sex: M Service: MEDICINE Allergies: Penicillins Attending:<Name>Ethan</Name> Chief Complaint: Afib with RVR Major Surgical or Invasive Procedure: None History of Present Illness: 54M with hx of ETOH abuse, HCV, presented to the ED this evening intoxicated. Upon arrival the pt was noted to have slurred speech and decreased responsiveness. The patient states that today he invited a friend over to his house where he shared 1L of vodka. The pt reports that while drinking he experienced left sided chest pain that led his friend to call EMS for him. The pt states he drinks heavily <Date>10-6</Date>/month. He denies history of seizure, loss of urine or stool. No loss of consciousness, no known trauma. The pt describes his chest pain as left sided <Date>11-15</Date>, with radiation to the left arm. No known CAD. +Reproducibility with palpation. . In the emergency department initial vitals 98.2 100 116/71 20 100%RA Exam was notable for an intoxicated male with clear lungs and without signs of aspiration on CXR. Upon assessment the pt reportedly became combative with a HR revealing AF with RVR with rates in 160-170s. Pt has received a total of 100mg of Valium during his ED course, Diltiazem 30mg IV of dilt x3, Dilt 30mg PO and subsequently placed on a Diltiazem drip at 15mg/hr. Lactate of 3.2->2.6->1.8 following 4L of NS. . The pt subsequently re-developed chest pain while in the ED. Received ASA 325mg and Nitro 0.4mg x3. Repeat ECG unchanged. Cardiology evaluated pt and felt his pain was unlikely cardiac. Recommended Metoprolol. Chest Pain improved with a total of Morphine 12mg IV and Dilaudid 1mg IV. . Upon arrival to the unit the patient states his chest pain remains a <Date>11-15</Date> with radiation to left arm. Denies headache, visual changes, sweats, hallucination, fevers, chills, cough, BRBPR, melena, emesis, abdominal pain. Past Medical History: 1. ETOH abuse as above 2. Hepatitis C: He has never been treated and is followed by his PCP. 3. s/p cholecystectomy in <Year>1932</Year> 4. s/p bariatric surgery in <Year>1932</Year> 5. h/o PUD in <Year>1932</Year> 6. h/o C. diff in <Year>1932</Year> Social History: Pt lives alone. His only child is the son who died in the war. He is <Initial>TM</Initial> <Name>Camargo</Name> at <Company>Williams PLC</Company>. . Tobacco: quit 4 years ago, 10 year pack history ETOH: as above Recreational drugs: denied use, inc. IVDA Family History: Colorectal cancer in uncle (45yo), uncle (37yo), grandmother (92) Physical Exam: VITAL SIGNS: T=97.5 BP=154/76 HR 90 RR=16 94RA PHYSICAL EXAM GENERAL: Pleasant, mildly discheveled male in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Irregularly irregular, tachycardic. Normal S1, S2. No murmurs, rubs or <Name>Spikes</Name>. JVP flat LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: No nystagmus. No asterxis. A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. <Date>2-4</Date>+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: CXR <Date>4-18</Date>: UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette is top normal in size. The mediastinal and hilar contours are stable. Pulmonary vascularity is normal. The lungs are clear. No pleural effusion or pneumothorax is visualized. Left acromioclavicular joint separation is redemonstrated, unchanged. IMPRESSION: No acute cardiopulmonary abnormality. . <Date>2021-5-6</Date> 01:30PM WBC-5.5# RBC-3.97* HGB-9.0* HCT-30.3* MCV-76# MCH-22.7# MCHC-29.8* RDW-18.9* <Date>2021-5-6</Date> 01:30PM NEUTS-59.4 LYMPHS-34.1 MONOS-4.1 EOS-1.5 BASOS-0.8 <Date>2021-5-6</Date> 01:30PM PLT COUNT-309 <Date>2021-5-6</Date> 01:30PM GLUCOSE-111* UREA N-15 CREAT-0.8 SODIUM-144 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15 <Date>2021-5-6</Date> 09:30PM CK-MB-7 cTropnT-<0.01 <Date>2021-5-6</Date> 09:30PM CK(CPK)-547* <Date>2021-5-6</Date> 09:35PM LACTATE-2.6* <Date>2021-5-6</Date> 01:30PM BLOOD ASA-NEG Ethanol-412* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG <Date>1932-10-16</Date> 01:54AM BLOOD Lactate-1.8 Brief Hospital Course: ASSESSMENT AND PLAN: 54M with hx of ETOH abuse, HCV, presenting with AF with RVR, Chest Pain in the setting of ETOH intoxication. . #: AF with RVR: Pt was in AF with RVR at presentation, which was a new finding from prior EKGs. EKG showed no evidence of ischemia. Pt was started on dilt gtt in ED and was transitioned to PO metoprolol after arriving the ICU. HR was stable in 90s at rest. Patient left AMA without waiting to receive his prescriptions or cardiology follow-up. He was instructed to return to the ED for palpitations, chest pain, SOB or any other symptoms. He was instructed to follow up with his PCP. . # ETOH Intoxication: Pt presented with ETOH level of 412 and was intoxicated. Lactate elevated but quickly trended down. He received banana bag, and PO folate and thiamine. Electrolytes were normal. Patient was monitored on CIWA scale in the ICU and received Valium prn. SW was consulted. However, patient left AMA. He stated he planned to take his home dose Campral and continue attending AA meetings. He lives in a recovery home and was instructed to have EMS notified if he experiences shaking, confusion or any other symptoms. . #. Chest pain: Pt presented with atypical chest pain in the setting of intoxication that was reproducible on palpation. He denies trauma but had been lifting heavy boxes recently. Pt evaluated by Cards while in ED who felt that pain was non-cardiac. ASA 325mg and Nitroglycerin x1. One set of CE was significant for elevated CK but normal troponin. DDx includes muscluoskeletal, no evidence of PNA or ACS. PE unlikely given reproducibility. . # Anemia: Hct 30 on arrival. Near prior baseline. No evidence of GI Bleed, no known prior hx of varies. . # HCV: Currently not receiving treatment. <Hospital>Chambers, Brandt and Jackson Clinic</Hospital>, records confirmed that Hep C antibody was confirmed to be positive <Date>1955-8-7</Date>. HCV genotype was type IB, and RNA viral load was 996,000 copies at that time. Medications on Admission: None Discharge Medications: Patient left against medical advice. Discharge Disposition: Home Discharge Diagnosis: Patient left against medical advice. Discharge Condition: Patient left against medical advice. Discharge Instructions: Patient left against medical advice. Followup Instructions: Patient left against medical advice.	0000000000000000011111111000000000000000000000000000000001111111111000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>0000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000111100000000000000001111000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011011111110000111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 2021-5-6 Discharge Date: 1932-10-16 Date of Birth: 1926-7-2 Sex: M Service: MEDICINE Allergies: Penicillins Attending:Ethan Chief Complaint: Afib with RVR Major Surgical or Invasive Procedure: None History of Present Illness: 54M with hx of ETOH abuse, HCV, presented to the ED this evening intoxicated. Upon arrival the pt was noted to have slurred speech and decreased responsiveness. The patient states that today he invited a friend over to his house where he shared 1L of vodka. The pt reports that while drinking he experienced left sided chest pain that led his friend to call EMS for him. The pt states he drinks heavily 10-6/month. He denies history of seizure, loss of urine or stool. No loss of consciousness, no known trauma. The pt describes his chest pain as left sided 11-15, with radiation to the left arm. No known CAD. +Reproducibility with palpation. . In the emergency department initial vitals 98.2 100 116/71 20 100%RA Exam was notable for an intoxicated male with clear lungs and without signs of aspiration on CXR. Upon assessment the pt reportedly became combative with a HR revealing AF with RVR with rates in 160-170s. Pt has received a total of 100mg of Valium during his ED course, Diltiazem 30mg IV of dilt x3, Dilt 30mg PO and subsequently placed on a Diltiazem drip at 15mg/hr. Lactate of 3.2->2.6->1.8 following 4L of NS. . The pt subsequently re-developed chest pain while in the ED. Received ASA 325mg and Nitro 0.4mg x3. Repeat ECG unchanged. Cardiology evaluated pt and felt his pain was unlikely cardiac. Recommended Metoprolol. Chest Pain improved with a total of Morphine 12mg IV and Dilaudid 1mg IV. . Upon arrival to the unit the patient states his chest pain remains a 11-15 with radiation to left arm. Denies headache, visual changes, sweats, hallucination, fevers, chills, cough, BRBPR, melena, emesis, abdominal pain. Past Medical History: 1. ETOH abuse as above 2. Hepatitis C: He has never been treated and is followed by his PCP. 3. s/p cholecystectomy in 1932 4. s/p bariatric surgery in 1932 5. h/o PUD in 1932 6. h/o C. diff in 1932 Social History: Pt lives alone. His only child is the son who died in the war. He is TM Camargo at Williams PLC. . Tobacco: quit 4 years ago, 10 year pack history ETOH: as above Recreational drugs: denied use, inc. IVDA Family History: Colorectal cancer in uncle (45yo), uncle (37yo), grandmother (92) Physical Exam: VITAL SIGNS: T=97.5 BP=154/76 HR 90 RR=16 94RA PHYSICAL EXAM GENERAL: Pleasant, mildly discheveled male in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Irregularly irregular, tachycardic. Normal S1, S2. No murmurs, rubs or Spikes. JVP flat LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: No nystagmus. No asterxis. A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. 2-4+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: CXR 4-18: UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette is top normal in size. The mediastinal and hilar contours are stable. Pulmonary vascularity is normal. The lungs are clear. No pleural effusion or pneumothorax is visualized. Left acromioclavicular joint separation is redemonstrated, unchanged. IMPRESSION: No acute cardiopulmonary abnormality. . 2021-5-6 01:30PM WBC-5.5# RBC-3.97* HGB-9.0* HCT-30.3* MCV-76# MCH-22.7# MCHC-29.8* RDW-18.9* 2021-5-6 01:30PM NEUTS-59.4 LYMPHS-34.1 MONOS-4.1 EOS-1.5 BASOS-0.8 2021-5-6 01:30PM PLT COUNT-309 2021-5-6 01:30PM GLUCOSE-111* UREA N-15 CREAT-0.8 SODIUM-144 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15 2021-5-6 09:30PM CK-MB-7 cTropnT-2021-5-6 09:30PM CK(CPK)-547* 2021-5-6 09:35PM LACTATE-2.6* 2021-5-6 01:30PM BLOOD ASA-NEG Ethanol-412* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG 1932-10-16 01:54AM BLOOD Lactate-1.8 Brief Hospital Course: ASSESSMENT AND PLAN: 54M with hx of ETOH abuse, HCV, presenting with AF with RVR, Chest Pain in the setting of ETOH intoxication. . #: AF with RVR: Pt was in AF with RVR at presentation, which was a new finding from prior EKGs. EKG showed no evidence of ischemia. Pt was started on dilt gtt in ED and was transitioned to PO metoprolol after arriving the ICU. HR was stable in 90s at rest. Patient left AMA without waiting to receive his prescriptions or cardiology follow-up. He was instructed to return to the ED for palpitations, chest pain, SOB or any other symptoms. He was instructed to follow up with his PCP. . # ETOH Intoxication: Pt presented with ETOH level of 412 and was intoxicated. Lactate elevated but quickly trended down. He received banana bag, and PO folate and thiamine. Electrolytes were normal. Patient was monitored on CIWA scale in the ICU and received Valium prn. SW was consulted. However, patient left AMA. He stated he planned to take his home dose Campral and continue attending AA meetings. He lives in a recovery home and was instructed to have EMS notified if he experiences shaking, confusion or any other symptoms. . #. Chest pain: Pt presented with atypical chest pain in the setting of intoxication that was reproducible on palpation. He denies trauma but had been lifting heavy boxes recently. Pt evaluated by Cards while in ED who felt that pain was non-cardiac. ASA 325mg and Nitroglycerin x1. One set of CE was significant for elevated CK but normal troponin. DDx includes muscluoskeletal, no evidence of PNA or ACS. PE unlikely given reproducibility. . # Anemia: Hct 30 on arrival. Near prior baseline. No evidence of GI Bleed, no known prior hx of varies. . # HCV: Currently not receiving treatment. Chambers, Brandt and Jackson Clinic, records confirmed that Hep C antibody was confirmed to be positive 1955-8-7. HCV genotype was type IB, and RNA viral load was 996,000 copies at that time. Medications on Admission: None Discharge Medications: Patient left against medical advice. Discharge Disposition: Home Discharge Diagnosis: Patient left against medical advice. Discharge Condition: Patient left against medical advice. Discharge Instructions: Patient left against medical advice. Followup Instructions: Patient left against medical advice.	['Admission Date: 2021-5-6 Discharge Date: 1932-10-16\n\nDate of Birth: 1926-7-2 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPenicillins\n\nAttending:Ethan\nChief Complaint:\nAfib with RVR\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\n54M with hx of ETOH abuse, HCV, presented to the ED this evening\nintoxicated. Upon arrival the pt was noted to have slurred\nspeech and decreased responsiveness. The patient states that\ntoday he invited a friend over to his house where he shared 1L\nof vodka. The pt reports that while drinking he experienced left\nsided chest pain that led his friend to call EMS for him. The pt\nstates he drinks heavily 10-6/month. He denies history of\nseizure, loss of urine or stool. No loss of consciousness, no\nknown trauma. The pt describes his chest pain as left sided\n11-15, with radiation to the left arm.', ' No known CAD.\n+Reproducibility with palpation.\n.\nIn the emergency department initial vitals 98.2 100 116/71 20\n100%RA\nExam was notable for an intoxicated male with clear lungs and\nwithout signs of aspiration on CXR. Upon assessment the pt\nreportedly became combative with a HR revealing AF with RVR with\nrates in 160-170s. Pt has received a total of 100mg of Valium\nduring his ED course, Diltiazem 30mg IV of dilt x3, Dilt 30mg PO\nand subsequently placed on a Diltiazem drip at 15mg/hr. Lactate\nof 3.2->2.6->1.8 following 4L of NS.\n.\nThe pt subsequently re-developed chest pain while in the ED.\nReceived ASA 325mg and Nitro 0.4mg x3. Repeat ECG unchanged.\nCardiology evaluated pt and felt his pain was unlikely cardiac.\nRecommended Metoprolol. Chest Pain improved with a total of\nMorphine 12mg IV and Dilaudid 1mg IV.', '\n.\nUpon arrival to the unit the patient states his chest pain\nremains a 11-15 with radiation to left arm. Denies headache,\nvisual changes, sweats, hallucination, fevers, chills, cough,\nBRBPR, melena, emesis, abdominal pain.\n\nPast Medical History:\n1. ETOH abuse as above\n2. Hepatitis C: He has never been treated and is followed by\nhis PCP.\n3. s/p cholecystectomy in 1932\n4. s/p bariatric surgery in 1932\n5. h/o PUD in 1932\n6. h/o C. diff in 1932\n\nSocial History:\nPt lives alone. His only child is the son who died in the war.\nHe is TM Camargo at Williams PLC.\n.\nTobacco: quit 4 years ago, 10 year pack history\nETOH: as above\nRecreational drugs: denied use, inc. IVDA\n\n\nFamily History:\nColorectal cancer in uncle (45yo), uncle (37yo), grandmother\n(92)\n\nPhysical Exam:\nVITAL SIGNS:\nT=97.5 BP=154/76 HR 90 RR=16 94RA\nPHYSICAL EXAM\nGENERAL: Pleasant, mildly discheveled male in NAD\nHEENT: Normocephalic, atraumatic.', ' No conjunctival pallor. No\nscleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No\nLAD, No thyromegaly.\nCARDIAC: Irregularly irregular, tachycardic. Normal S1, S2. No\nmurmurs, rubs or Spikes. JVP flat\nLUNGS: CTAB, good air movement biaterally.\nABDOMEN: NABS. Soft, NT, ND. No HSM\nEXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior\ntibial pulses.\nSKIN: No rashes/lesions, ecchymoses.\nNEURO: No nystagmus. No asterxis. A&Ox3. Appropriate. CN 2-12\ngrossly intact. Preserved sensation throughout. 5/5 strength\nthroughout. 2-4+ reflexes, equal BL. Normal coordination. Gait\nassessment deferred\nPSYCH: Listens and responds to questions appropriately, pleasant\n\nPertinent Results:\nCXR 4-18:\nUPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette is top\nnormal in size. The mediastinal and hilar contours are stable.', '\nPulmonary vascularity is normal. The lungs are clear. No pleural\neffusion or pneumothorax is visualized. Left acromioclavicular\njoint separation is redemonstrated, unchanged.\nIMPRESSION: No acute cardiopulmonary abnormality.\n.\n2021-5-6 01:30PM WBC-5.5# RBC-3.97* HGB-9.0* HCT-30.3\nMCV-76# MCH-22.7# MCHC-29.8 RDW-18.9\n2021-5-6 01:30PM NEUTS-59.4 LYMPHS-34.1 MONOS-4.1 EOS-1.5\nBASOS-0.8\n2021-5-6 01:30PM PLT COUNT-309\n2021-5-6 01:30PM GLUCOSE-111 UREA N-15 CREAT-0.8 SODIUM-144\nPOTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15\n2021-5-6 09:30PM CK-MB-7 cTropnT-2021-5-6 09:30PM CK(CPK)-547\n2021-5-6 09:35PM LACTATE-2.6\n2021-5-6 01:30PM BLOOD ASA-NEG Ethanol-412* Acetmnp-NEG\nBnzodzp-POS Barbitr-NEG Tricycl-NEG\n1932-10-16 01:54AM BLOOD Lactate-1.8\n\nBrief Hospital Course:\nASSESSMENT AND PLAN: 54M with hx of ETOH abuse, HCV, presenting\nwith AF with RVR, Chest Pain in the setting of ETOH\nintoxication.', '\n.\n#: AF with RVR: Pt was in AF with RVR at presentation, which was\na new finding from prior EKGs. EKG showed no evidence of\nischemia. Pt was started on dilt gtt in ED and was transitioned\nto PO metoprolol after arriving the ICU. HR was stable in 90s at\nrest. Patient left AMA without waiting to receive his\nprescriptions or cardiology follow-up. He was instructed to\nreturn to the ED for palpitations, chest pain, SOB or any other\nsymptoms. He was instructed to follow up with his PCP.\n.\n# ETOH Intoxication: Pt presented with ETOH level of 412 and was\nintoxicated. Lactate elevated but quickly trended down. He\nreceived banana bag, and PO folate and thiamine. Electrolytes\nwere normal. Patient was monitored on CIWA scale in the ICU and\nreceived Valium prn. SW was consulted. However, patient left\nAMA.', ' He stated he planned to take his home dose Campral and\ncontinue attending AA meetings. He lives in a recovery home and\nwas instructed to have EMS notified if he experiences shaking,\nconfusion or any other symptoms.\n.\n#. Chest pain:\nPt presented with atypical chest pain in the setting of\nintoxication that was reproducible on palpation. He denies\ntrauma but had been lifting heavy boxes recently. Pt evaluated\nby Cards while in ED who felt that pain was non-cardiac. ASA\n325mg and Nitroglycerin x1. One set of CE was significant for\nelevated CK but normal troponin. DDx includes muscluoskeletal,\nno evidence of PNA or ACS. PE unlikely given reproducibility.\n.\n# Anemia: Hct 30 on arrival. Near prior baseline. No evidence of\nGI Bleed, no known prior hx of varies.\n.\n# HCV: Currently not receiving treatment.', ' Chambers, Brandt and Jackson Clinic,\nrecords confirmed that Hep C antibody was confirmed to be\npositive 1955-8-7. HCV genotype was type IB, and RNA viral load\nwas\n996,000 copies at that time.\n\n\nMedications on Admission:\nNone\n\nDischarge Medications:\nPatient left against medical advice.\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPatient left against medical advice.\n\nDischarge Condition:\nPatient left against medical advice.\n\nDischarge Instructions:\nPatient left against medical advice.\n\nFollowup Instructions:\nPatient left against medical advice.\n\n\n']
186	1136	186931.0	2194-05-14	Discharge summary	Report	Admission Date: [2194-5-8] Discharge Date: [2194-5-14] Service: MEDICINE Allergies: Lisinopril / Nsaids / Nesiritide Attending:[First Name3 (LF) 1865] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: * interview conducted with the aid of Ms. [Known lastname 1862] daughter . History of Present Illness: Ms. [Known lastname ] is an 86 y/o F with history of nephrotic CRI, renal artery stenosis, and CHF, who presented with hypertensive emergency and heart failure. The patient reports that she was in her usual state of health until 3 days prior to admission. At that time, her BP was 220 systolic @ home and she noticed mild SOB. On the night prior to admission, she developed increasing SOB. Per the patient's daughter, she had been taking her medications as prescribed. She denies chest pain throughout this time. She was brought in by daughter to [Name (NI) ] for evaluation and was found to have BP 202/40 with a K of 5.9. She was treated with kayexalate 30, lasix 40 IV, clonidine 0.3 mg PO X 1, and levoflox 750 mg IV x 1. . The patient was initially admitted to the floor, where she was found to have the following vitals: 98.3 226/68 68 90% 5LNC (mid 80s on 2LNC), 96% on face tent, RR > 40. As she was acutely dyspneic and in acute failure, she was given 100mg IV lasix and Diuril (on the advice of Renal consultants), w/ good effect-> UOP 350cc in ~1hour. She did not receive any nitrates or morphine at the time. On MICU evaluation was 99% on shovel mask, but still RR>40. Appeared comfortable, JVP ~9 cm. At that time, she denied HA, visual changes, CP, urinary changes, no abd pain, N/V/D. In the MICU, she was aggressively diuresed and placed on her usual blood pressure regimen. Overnight [Date range (1) 1873], she did not receive all of her blood pressures meds as her BPs were in the 110s/120s overnight. She did receive all doses of clonidine and hydralazine on [5-9]. . Her daughter tells me that her edema is less than usual, but that her right leg is chronically larger than the left. She has been using several pillows to sleep at home. She denies PND. She is not on supplemental O2 at home. Generally BP at home is 170s (per PCP 160s in office at baseline). . Pt was diagnosed with w/ RLL PNA by her PCP and tx [Name Initial (PRE) ]/ levofloxacin X 10 days about 4 weeks ago. Since that time, the daughter has been living with the pt X 3 weeks. Her cough has persisted per the daughter, but the patient did improve greatly following antibiotics. . At the present time, the patient says she is comfortable. She denies chest pain. She continues to make adequate urine. Past Medical History: - Renal artery stenosis: MRI [2185] atrophic R kidney, mod stenosis of R renal artery, L renal artery normal - CRI/nephrotic range proteinuria, renal artery stenosis, followed by Dr. [Last Name (STitle) 1860] (Nephrology) (recent baseline Cr 7.9-9.1) - PVD/Claudication - Congestive heart failure w/ EF 50-55%, known WMA ([9-1]) - h/o R cephalic vein DVT ([7-2]) - Colon cancer dx [2-/2192] s/p resection - GERD - Hypertension - Hyperlipidemia - h/o Rheumatic Fever - RBBB - Anemia baseline Hct low 30s - Osteoarthritis - Osteopenia - Glaucoma Social History: Russian-speaking. Living alone independently prior to hospitalization in 2/[2192]. Several children and grandchildren in the area are involved in her care. denies alcohol or tobacco use. Family History: mother- HTN Physical Exam: VS afebrile HR 62 BP 178/46 RR 26 O2 93% 4L NC GENERAL: NAD, lying @30 degrees and comfortable HEENT: EOMI, OMMM, pupils small but reactive NECK: JVP at 8 cm, supple, no LAD, no carotid bruits CARDIOVASCULAR: S1, S2, reg, II/VI systolic throughout precordium LUNGS: crackles halfway up bilaterally, no wheezes, good air movement ABDOMEN: Soft, NT, ND, no masses, foley catheter in place EXTREMITIES: Warm, trace edema bilaterally, right leg slightly larger than left NEURO: A/O X3, russian speaking, pleasant, strength 5/5 bilateral grip, biceps, triceps, ankle dorsi- & plantarflexion, sensation intact bilateral upper & lower extremities Pertinent Results: Studies: [2194-5-8] CXR: IMPRESSION: Moderate congestive heart failure, worse since the exam of one month ago. . [2194-5-8] ECHO: TTE Conclusions: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF 60%). . There is mild aortic valve stenosis (area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is seen. . There is severe mitral annular calcification. There is a minimally increased gradient consistent with minimal mitral stenosis. Mild to moderate ([1-28]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] . The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. . There is severe pulmonary artery systolic hypertension. There is a small pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2193-9-19], borderline mitral stenosis is now evident. The mitral regurgitation, which is almost certainly underestimated on this study, is probably increased. . [2194-5-11] CXR TWO VIEWS: Comparison with the previous study done [2194-5-9]. There is interval improvement in interstitial pulmonary edema. The mild pulmonary vascular congestion persists. Streaky density at the lung bases is consistent with subsegmental atelectasis. There is a moderate right pleural effusion and small left pleural effusion. An underlying right basilar consolidation cannot be excluded. The heart and mediastinal structures are unchanged. IMPRESSION: Interval improvement in congestive heart failure. . . Labs: ProBNP greater than 70,000 . Cardiac enzymes: [2194-5-8] 12:10PM BLOOD CK(CPK)-24* [2194-5-8] 06:30PM BLOOD CK(CPK)-20* [2194-5-9] 02:50AM BLOOD CK(CPK)-22* [2194-5-8] 04:49AM BLOOD CK-MB-NotDone cTropnT-0.13* [2194-5-8] 12:10PM BLOOD CK-MB-NotDone cTropnT-0.13* [2194-5-8] 06:30PM BLOOD CK-MB-NotDone cTropnT-0.14* [2194-5-9] 02:50AM BLOOD CK-MB-NotDone [2194-5-9] 02:50AM BLOOD cTropnT-0.15* . Her lab values remained fairly constant throughout her admission and her discharge labs are given here. . WBC-6.6 RBC-3.46* Hgb-9.5* Hct-29.0* MCV-84 MCH-27.4 MCHC-32.6 RDW-17.7* Plt Ct-211 . Glucose-89 UreaN-107* Creat-8.6* Na-130* K-5.0 Cl-100 HCO3-17* Calcium-8.9 Phos-7.1* Mg-2.5 . . . Micro: [2194-5-12] BLOOD CULTURE x2 bottles No growth [2194-5-10] BLOOD CULTURE x4 bottles No growth [2194-5-10] URINE No growth [2194-5-10] BLOOD CULTURE x2 bottles No growth [2194-5-8] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE} EMERGENCY [Hospital1 ] [2194-5-8] BLOOD CULTURE x2 bottles No growth Brief Hospital Course: Ms. [Known lastname ] is an 86 year old female with probable endstage renal failure not on HD, who presented with hypertensive emergency and congestive heart failure. She was admitted to the medical floor but immediately was sent to the MICU for respiratory distress. There she was agressively diuresed and then returned to the medical floor. . * Hypertensive Emergency: Her HTN is likely secondary to her ESRD. The elevated blood pressures caused flash pulmonary edema and congestive heart failure. She was given blood pressure medications to help control her BP within the range of 130-160 as she probably is dependent on some hypertension for perfusion. Her baseline BP is reportedly 160 at home. Ultimately she was placed on clonidine 0.2 mg TID, hydralazine 100mg TID, norvasc 10mg qday, metoprolol 12.5mg TID, lasix 40mg [Hospital1 ]. . * ? SVT: During her initally presentation, she did have some runs of SVT noted on telemetry. Once she was diuresed no further episodes were noted. She was continued on metoprolol 12.5 mg TID for given episodes of ? SVT. . * Congestive Heart Failure: Likely from worsening renal failure and hypertensive urgency. She was agressively diuresed in the MICU with IV furosemide overnight and then with PO furosemide on the medical floor. She was also continued on hydralazine for afterload reduction. . * Renal Failure: A renal consult was obtained. They felt that there was no acute needs for dialysis at present although they have been discussing starting HD with the patient and her family for a while now. This discussion was continued throughout the admission and the patient and her family were resistent to starting. They agreed to meet with Dr. [Last Name (STitle) 1366] in the next two weeks to discuss getting a tunnelled cath and starting HD. Throughout admission, her electrolytes were monitored closely as she had boughts of hyperkalemia, hyperphosphatemia and acidosis. These were controlled with standard measures. . * Hyperkalemia: Received Kayexalate in ED. Usually takes kayexalate twice a week as outpatient, so this was restarted as an inpatient. . * Anemia: Baseline Hct appears to be 29-33 and now 25. Iron 45, ferritin 149, TIBC 269 in [3-5]. Per renal recommendation, she was transfused 1 unit PRBC on [2194-5-12] without complications. . * Bacteremia: WBC count 10 on admission and down to 6.4 today. Has been afebrile but blood cultures showed 2/4 bottles with staph coag negative- likely contaminant. Before speciation returned, she was treated with vancomycin dosed by level. Once it was found to be coag negative staph, the vancomycin was discontinued. All subsequent surveillence cultures were negative. . * Code status: Full - discussed w/ patient's daughter. . * COMM: Dtr [Name2 (NI) 1874] [Telephone/Fax (1) 1875]; Son [Name (NI) ] [Telephone/Fax (1) 1876] Medications on Admission: Albuterol 2 4X/day Baking soda [3-30] tsp Clonidine 0.3 mg @ AM, 0.2 mg @ Noon, 0.3 mg @ PM Epogen 10K 2X/week Hydralazine 75 TID Imdur 30 once daily Lasix 20 once daily (daughter states patient taking only 20 at home) Lipitor 10 once daily Toprol 25 once daily Amlodipine 10 once daily Phoslo 1334 TID Renagel 800 TID Vit D 50K q month Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. Disp:120 Tablet(s) Refills:2 5. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:270 Tablet(s) Refills:2 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 7. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:270 Capsule(s) Refills:2 8. Baking Soda [3-30] teaspoon by mouth daily 9. Kayexalate Powder Sig: One (1) teaspoon PO Twice a week. 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 11. Albuterol Inhalation 12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Epoetin Alfa Injection Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: hypertensive emergency Diastolic congestive heart failure stage V chronic kidney disease Anemia GERD Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L daily . You were admitted with very high blood pressure and fluid overload in your lungs. You were given medications to help lower your blood pressure and get the fluid off. . Some of your medication doses have been changed. Please see the medication list for those different doses. . As you know, your kidneys do not function very well. It has been recommended that you start dialysis to help remove the toxins in your blood which your kidneys can no longer remove. You have decided to hold off on this for now (despite knowing the risks of sudden death, fluid overload), but you should follow up with Dr. [Last Name (STitle) 1366] to have this started soon. . You should continue to take your medications as prescribed. . You should contact your PCP or go to the emergency room if you have fevers>101, chills, shortness of breath, chest pain, weight gain more than 3 lbs, or any other symptoms which are concerning to you. Followup Instructions: Provider: [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878], M.D. Phone:[Telephone/Fax (1) 435] Date/Time:[2194-5-22] 5:00PM . . Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 250] Call to schedule appointment . . Primary care: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1879], M.D. Date/Time:[2194-6-17] 2:30PM Phone [Telephone/Fax (1) 250] Completed by:[2194-5-25]	Admission Date: <Date>2012-11-5</Date> Discharge Date: <Date>1972-12-8</Date> Service: MEDICINE Allergies: Lisinopril / Nsaids / Nesiritide Attending:<Name>Lissette</Name> Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: * interview conducted with the aid of Ms. <Name>Demong</Name> daughter . History of Present Illness: Ms. <Name>White</Name> is an 86 y/o F with history of nephrotic CRI, renal artery stenosis, and CHF, who presented with hypertensive emergency and heart failure. The patient reports that she was in her usual state of health until 3 days prior to admission. At that time, her BP was 220 systolic @ home and she noticed mild SOB. On the night prior to admission, she developed increasing SOB. Per the patient's daughter, she had been taking her medications as prescribed. She denies chest pain throughout this time. She was brought in by daughter to <Name>Lyle Demong</Name> for evaluation and was found to have BP 202/40 with a K of 5.9. She was treated with kayexalate 30, lasix 40 IV, clonidine 0.3 mg PO X 1, and levoflox 750 mg IV x 1. . The patient was initially admitted to the floor, where she was found to have the following vitals: 98.3 226/68 68 90% 5LNC (mid 80s on 2LNC), 96% on face tent, RR > 40. As she was acutely dyspneic and in acute failure, she was given 100mg IV lasix and Diuril (on the advice of Renal consultants), w/ good effect-> UOP 350cc in ~1hour. She did not receive any nitrates or morphine at the time. On MICU evaluation was 99% on shovel mask, but still RR>40. Appeared comfortable, JVP ~9 cm. At that time, she denied HA, visual changes, CP, urinary changes, no abd pain, N/V/D. In the MICU, she was aggressively diuresed and placed on her usual blood pressure regimen. Overnight <Date Range>1987-3-10 to 2019-8-19</Date Range>, she did not receive all of her blood pressures meds as her BPs were in the 110s/120s overnight. She did receive all doses of clonidine and hydralazine on <Date>10-28</Date>. . Her daughter tells me that her edema is less than usual, but that her right leg is chronically larger than the left. She has been using several pillows to sleep at home. She denies PND. She is not on supplemental O2 at home. Generally BP at home is 170s (per PCP 160s in office at baseline). . Pt was diagnosed with w/ RLL PNA by her PCP and tx <Name>Jackson Dortch</Name>/ levofloxacin X 10 days about 4 weeks ago. Since that time, the daughter has been living with the pt X 3 weeks. Her cough has persisted per the daughter, but the patient did improve greatly following antibiotics. . At the present time, the patient says she is comfortable. She denies chest pain. She continues to make adequate urine. Past Medical History: - Renal artery stenosis: MRI <Year>1967</Year> atrophic R kidney, mod stenosis of R renal artery, L renal artery normal - CRI/nephrotic range proteinuria, renal artery stenosis, followed by Dr. <Name>Meraz</Name> (Nephrology) (recent baseline Cr 7.9-9.1) - PVD/Claudication - Congestive heart failure w/ EF 50-55%, known WMA (<Date>8-14</Date>) - h/o R cephalic vein DVT (<Date>7-2</Date>) - Colon cancer dx <Date>9-1973</Date> s/p resection - GERD - Hypertension - Hyperlipidemia - h/o Rheumatic Fever - RBBB - Anemia baseline Hct low 30s - Osteoarthritis - Osteopenia - Glaucoma Social History: Russian-speaking. Living alone independently prior to hospitalization in 2/<Year>1967</Year>. Several children and grandchildren in the area are involved in her care. denies alcohol or tobacco use. Family History: mother- HTN Physical Exam: VS afebrile HR 62 BP 178/46 RR 26 O2 93% 4L NC GENERAL: NAD, lying @30 degrees and comfortable HEENT: EOMI, OMMM, pupils small but reactive NECK: JVP at 8 cm, supple, no LAD, no carotid bruits CARDIOVASCULAR: S1, S2, reg, II/VI systolic throughout precordium LUNGS: crackles halfway up bilaterally, no wheezes, good air movement ABDOMEN: Soft, NT, ND, no masses, foley catheter in place EXTREMITIES: Warm, trace edema bilaterally, right leg slightly larger than left NEURO: A/O X3, russian speaking, pleasant, strength 5/5 bilateral grip, biceps, triceps, ankle dorsi- & plantarflexion, sensation intact bilateral upper & lower extremities Pertinent Results: Studies: <Date>2012-11-5</Date> CXR: IMPRESSION: Moderate congestive heart failure, worse since the exam of one month ago. . <Date>2012-11-5</Date> ECHO: TTE Conclusions: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF 60%). . There is mild aortic valve stenosis (area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is seen. . There is severe mitral annular calcification. There is a minimally increased gradient consistent with minimal mitral stenosis. Mild to moderate (<Date>12-30</Date>+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] . The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. . There is severe pulmonary artery systolic hypertension. There is a small pericardial effusion. Compared with the findings of the prior study (images reviewed) of <Date>1928-2-13</Date>, borderline mitral stenosis is now evident. The mitral regurgitation, which is almost certainly underestimated on this study, is probably increased. . <Date>1978-9-4</Date> CXR TWO VIEWS: Comparison with the previous study done <Date>1940-4-7</Date>. There is interval improvement in interstitial pulmonary edema. The mild pulmonary vascular congestion persists. Streaky density at the lung bases is consistent with subsegmental atelectasis. There is a moderate right pleural effusion and small left pleural effusion. An underlying right basilar consolidation cannot be excluded. The heart and mediastinal structures are unchanged. IMPRESSION: Interval improvement in congestive heart failure. . . Labs: ProBNP greater than 70,000 . Cardiac enzymes: <Date>2012-11-5</Date> 12:10PM BLOOD CK(CPK)-24* <Date>2012-11-5</Date> 06:30PM BLOOD CK(CPK)-20* <Date>1940-4-7</Date> 02:50AM BLOOD CK(CPK)-22* <Date>2012-11-5</Date> 04:49AM BLOOD CK-MB-NotDone cTropnT-0.13* <Date>2012-11-5</Date> 12:10PM BLOOD CK-MB-NotDone cTropnT-0.13* <Date>2012-11-5</Date> 06:30PM BLOOD CK-MB-NotDone cTropnT-0.14* <Date>1940-4-7</Date> 02:50AM BLOOD CK-MB-NotDone <Date>1940-4-7</Date> 02:50AM BLOOD cTropnT-0.15* . Her lab values remained fairly constant throughout her admission and her discharge labs are given here. . WBC-6.6 RBC-3.46* Hgb-9.5* Hct-29.0* MCV-84 MCH-27.4 MCHC-32.6 RDW-17.7* Plt Ct-211 . Glucose-89 UreaN-107* Creat-8.6* Na-130* K-5.0 Cl-100 HCO3-17* Calcium-8.9 Phos-7.1* Mg-2.5 . . . Micro: <Date>1946-11-16</Date> BLOOD CULTURE x2 bottles No growth <Date>1958-8-21</Date> BLOOD CULTURE x4 bottles No growth <Date>1958-8-21</Date> URINE No growth <Date>1958-8-21</Date> BLOOD CULTURE x2 bottles No growth <Date>2012-11-5</Date> BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE} EMERGENCY <Hospital>Watson Inc Health System</Hospital> <Date>2012-11-5</Date> BLOOD CULTURE x2 bottles No growth Brief Hospital Course: Ms. <Name>White</Name> is an 86 year old female with probable endstage renal failure not on HD, who presented with hypertensive emergency and congestive heart failure. She was admitted to the medical floor but immediately was sent to the MICU for respiratory distress. There she was agressively diuresed and then returned to the medical floor. . * Hypertensive Emergency: Her HTN is likely secondary to her ESRD. The elevated blood pressures caused flash pulmonary edema and congestive heart failure. She was given blood pressure medications to help control her BP within the range of 130-160 as she probably is dependent on some hypertension for perfusion. Her baseline BP is reportedly 160 at home. Ultimately she was placed on clonidine 0.2 mg TID, hydralazine 100mg TID, norvasc 10mg qday, metoprolol 12.5mg TID, lasix 40mg <Hospital>Watson Inc Health System</Hospital>. . * ? SVT: During her initally presentation, she did have some runs of SVT noted on telemetry. Once she was diuresed no further episodes were noted. She was continued on metoprolol 12.5 mg TID for given episodes of ? SVT. . * Congestive Heart Failure: Likely from worsening renal failure and hypertensive urgency. She was agressively diuresed in the MICU with IV furosemide overnight and then with PO furosemide on the medical floor. She was also continued on hydralazine for afterload reduction. . * Renal Failure: A renal consult was obtained. They felt that there was no acute needs for dialysis at present although they have been discussing starting HD with the patient and her family for a while now. This discussion was continued throughout the admission and the patient and her family were resistent to starting. They agreed to meet with Dr. <Name>Grose</Name> in the next two weeks to discuss getting a tunnelled cath and starting HD. Throughout admission, her electrolytes were monitored closely as she had boughts of hyperkalemia, hyperphosphatemia and acidosis. These were controlled with standard measures. . * Hyperkalemia: Received Kayexalate in ED. Usually takes kayexalate twice a week as outpatient, so this was restarted as an inpatient. . * Anemia: Baseline Hct appears to be 29-33 and now 25. Iron 45, ferritin 149, TIBC 269 in <Date>2-24</Date>. Per renal recommendation, she was transfused 1 unit PRBC on <Date>1946-11-16</Date> without complications. . * Bacteremia: WBC count 10 on admission and down to 6.4 today. Has been afebrile but blood cultures showed 2/4 bottles with staph coag negative- likely contaminant. Before speciation returned, she was treated with vancomycin dosed by level. Once it was found to be coag negative staph, the vancomycin was discontinued. All subsequent surveillence cultures were negative. . * Code status: Full - discussed w/ patient's daughter. . * COMM: Dtr <Name>Julie Luu</Name> <Telephone>239-729-3529</Telephone>; Son <Name>Lyle Demong</Name> <Telephone>235-555-2632</Telephone> Medications on Admission: Albuterol 2 4X/day Baking soda <Date>12-17</Date> tsp Clonidine 0.3 mg @ AM, 0.2 mg @ Noon, 0.3 mg @ PM Epogen 10K 2X/week Hydralazine 75 TID Imdur 30 once daily Lasix 20 once daily (daughter states patient taking only 20 at home) Lipitor 10 once daily Toprol 25 once daily Amlodipine 10 once daily Phoslo 1334 TID Renagel 800 TID Vit D 50K q month Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. Disp:120 Tablet(s) Refills:2 5. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:270 Tablet(s) Refills:2 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 7. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:270 Capsule(s) Refills:2 8. Baking Soda <Date>12-17</Date> teaspoon by mouth daily 9. Kayexalate Powder Sig: One (1) teaspoon PO Twice a week. 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 11. Albuterol Inhalation 12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Epoetin Alfa Injection Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: hypertensive emergency Diastolic congestive heart failure stage V chronic kidney disease Anemia GERD Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, <Name>Latrice Demong</Name> MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L daily . You were admitted with very high blood pressure and fluid overload in your lungs. You were given medications to help lower your blood pressure and get the fluid off. . Some of your medication doses have been changed. Please see the medication list for those different doses. . As you know, your kidneys do not function very well. It has been recommended that you start dialysis to help remove the toxins in your blood which your kidneys can no longer remove. You have decided to hold off on this for now (despite knowing the risks of sudden death, fluid overload), but you should follow up with Dr. <Name>Grose</Name> to have this started soon. . You should continue to take your medications as prescribed. . You should contact your PCP or go to the emergency room if you have fevers>101, chills, shortness of breath, chest pain, weight gain more than 3 lbs, or any other symptoms which are concerning to you. Followup Instructions: Provider: <Name>Indira</Name> <Name>Moore</Name>, M.D. Phone:<Telephone>276-735-7855</Telephone> Date/Time:<Date>2013-1-21</Date> 5:00PM . . Provider: <Name>Alexis Gauthier</Name>,<Name>Orville Lyna</Name> <Name>Fannie Clark</Name>. <Telephone>729-838-1001</Telephone> Call to schedule appointment . . Primary care: <Name>Travis</Name> <Name>Bogle</Name>, M.D. Date/Time:<Date>1988-2-22</Date> 2:30PM Phone <Telephone>729-838-1001</Telephone> Completed 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Date: 2012-11-5 Discharge Date: 1972-12-8 Service: MEDICINE Allergies: Lisinopril / Nsaids / Nesiritide Attending:Lissette Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: * interview conducted with the aid of Ms. Demong daughter . History of Present Illness: Ms. White is an 86 y/o F with history of nephrotic CRI, renal artery stenosis, and CHF, who presented with hypertensive emergency and heart failure. The patient reports that she was in her usual state of health until 3 days prior to admission. At that time, her BP was 220 systolic @ home and she noticed mild SOB. On the night prior to admission, she developed increasing SOB. Per the patient's daughter, she had been taking her medications as prescribed. She denies chest pain throughout this time. She was brought in by daughter to Lyle Demong for evaluation and was found to have BP 202/40 with a K of 5.9. She was treated with kayexalate 30, lasix 40 IV, clonidine 0.3 mg PO X 1, and levoflox 750 mg IV x 1. . The patient was initially admitted to the floor, where she was found to have the following vitals: 98.3 226/68 68 90% 5LNC (mid 80s on 2LNC), 96% on face tent, RR > 40. As she was acutely dyspneic and in acute failure, she was given 100mg IV lasix and Diuril (on the advice of Renal consultants), w/ good effect-> UOP 350cc in ~1hour. She did not receive any nitrates or morphine at the time. On MICU evaluation was 99% on shovel mask, but still RR>40. Appeared comfortable, JVP ~9 cm. At that time, she denied HA, visual changes, CP, urinary changes, no abd pain, N/V/D. In the MICU, she was aggressively diuresed and placed on her usual blood pressure regimen. Overnight 1987-3-10 to 2019-8-19, she did not receive all of her blood pressures meds as her BPs were in the 110s/120s overnight. She did receive all doses of clonidine and hydralazine on 10-28. . Her daughter tells me that her edema is less than usual, but that her right leg is chronically larger than the left. She has been using several pillows to sleep at home. She denies PND. She is not on supplemental O2 at home. Generally BP at home is 170s (per PCP 160s in office at baseline). . Pt was diagnosed with w/ RLL PNA by her PCP and tx Jackson Dortch/ levofloxacin X 10 days about 4 weeks ago. Since that time, the daughter has been living with the pt X 3 weeks. Her cough has persisted per the daughter, but the patient did improve greatly following antibiotics. . At the present time, the patient says she is comfortable. She denies chest pain. She continues to make adequate urine. Past Medical History: - Renal artery stenosis: MRI 1967 atrophic R kidney, mod stenosis of R renal artery, L renal artery normal - CRI/nephrotic range proteinuria, renal artery stenosis, followed by Dr. Meraz (Nephrology) (recent baseline Cr 7.9-9.1) - PVD/Claudication - Congestive heart failure w/ EF 50-55%, known WMA (8-14) - h/o R cephalic vein DVT (7-2) - Colon cancer dx 9-1973 s/p resection - GERD - Hypertension - Hyperlipidemia - h/o Rheumatic Fever - RBBB - Anemia baseline Hct low 30s - Osteoarthritis - Osteopenia - Glaucoma Social History: Russian-speaking. Living alone independently prior to hospitalization in 2/1967. Several children and grandchildren in the area are involved in her care. denies alcohol or tobacco use. Family History: mother- HTN Physical Exam: VS afebrile HR 62 BP 178/46 RR 26 O2 93% 4L NC GENERAL: NAD, lying @30 degrees and comfortable HEENT: EOMI, OMMM, pupils small but reactive NECK: JVP at 8 cm, supple, no LAD, no carotid bruits CARDIOVASCULAR: S1, S2, reg, II/VI systolic throughout precordium LUNGS: crackles halfway up bilaterally, no wheezes, good air movement ABDOMEN: Soft, NT, ND, no masses, foley catheter in place EXTREMITIES: Warm, trace edema bilaterally, right leg slightly larger than left NEURO: A/O X3, russian speaking, pleasant, strength 5/5 bilateral grip, biceps, triceps, ankle dorsi- & plantarflexion, sensation intact bilateral upper & lower extremities Pertinent Results: Studies: 2012-11-5 CXR: IMPRESSION: Moderate congestive heart failure, worse since the exam of one month ago. . 2012-11-5 ECHO: TTE Conclusions: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF 60%). . There is mild aortic valve stenosis (area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is seen. . There is severe mitral annular calcification. There is a minimally increased gradient consistent with minimal mitral stenosis. Mild to moderate (12-30+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] . The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. . There is severe pulmonary artery systolic hypertension. There is a small pericardial effusion. Compared with the findings of the prior study (images reviewed) of 1928-2-13, borderline mitral stenosis is now evident. The mitral regurgitation, which is almost certainly underestimated on this study, is probably increased. . 1978-9-4 CXR TWO VIEWS: Comparison with the previous study done 1940-4-7. There is interval improvement in interstitial pulmonary edema. The mild pulmonary vascular congestion persists. Streaky density at the lung bases is consistent with subsegmental atelectasis. There is a moderate right pleural effusion and small left pleural effusion. An underlying right basilar consolidation cannot be excluded. The heart and mediastinal structures are unchanged. IMPRESSION: Interval improvement in congestive heart failure. . . Labs: ProBNP greater than 70,000 . Cardiac enzymes: 2012-11-5 12:10PM BLOOD CK(CPK)-24* 2012-11-5 06:30PM BLOOD CK(CPK)-20* 1940-4-7 02:50AM BLOOD CK(CPK)-22* 2012-11-5 04:49AM BLOOD CK-MB-NotDone cTropnT-0.13* 2012-11-5 12:10PM BLOOD CK-MB-NotDone cTropnT-0.13* 2012-11-5 06:30PM BLOOD CK-MB-NotDone cTropnT-0.14* 1940-4-7 02:50AM BLOOD CK-MB-NotDone 1940-4-7 02:50AM BLOOD cTropnT-0.15* . Her lab values remained fairly constant throughout her admission and her discharge labs are given here. . WBC-6.6 RBC-3.46* Hgb-9.5* Hct-29.0* MCV-84 MCH-27.4 MCHC-32.6 RDW-17.7* Plt Ct-211 . Glucose-89 UreaN-107* Creat-8.6* Na-130* K-5.0 Cl-100 HCO3-17* Calcium-8.9 Phos-7.1* Mg-2.5 . . . Micro: 1946-11-16 BLOOD CULTURE x2 bottles No growth 1958-8-21 BLOOD CULTURE x4 bottles No growth 1958-8-21 URINE No growth 1958-8-21 BLOOD CULTURE x2 bottles No growth 2012-11-5 BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE} EMERGENCY Watson Inc Health System 2012-11-5 BLOOD CULTURE x2 bottles No growth Brief Hospital Course: Ms. White is an 86 year old female with probable endstage renal failure not on HD, who presented with hypertensive emergency and congestive heart failure. She was admitted to the medical floor but immediately was sent to the MICU for respiratory distress. There she was agressively diuresed and then returned to the medical floor. . * Hypertensive Emergency: Her HTN is likely secondary to her ESRD. The elevated blood pressures caused flash pulmonary edema and congestive heart failure. She was given blood pressure medications to help control her BP within the range of 130-160 as she probably is dependent on some hypertension for perfusion. Her baseline BP is reportedly 160 at home. Ultimately she was placed on clonidine 0.2 mg TID, hydralazine 100mg TID, norvasc 10mg qday, metoprolol 12.5mg TID, lasix 40mg Watson Inc Health System. . * ? SVT: During her initally presentation, she did have some runs of SVT noted on telemetry. Once she was diuresed no further episodes were noted. She was continued on metoprolol 12.5 mg TID for given episodes of ? SVT. . * Congestive Heart Failure: Likely from worsening renal failure and hypertensive urgency. She was agressively diuresed in the MICU with IV furosemide overnight and then with PO furosemide on the medical floor. She was also continued on hydralazine for afterload reduction. . * Renal Failure: A renal consult was obtained. They felt that there was no acute needs for dialysis at present although they have been discussing starting HD with the patient and her family for a while now. This discussion was continued throughout the admission and the patient and her family were resistent to starting. They agreed to meet with Dr. Grose in the next two weeks to discuss getting a tunnelled cath and starting HD. Throughout admission, her electrolytes were monitored closely as she had boughts of hyperkalemia, hyperphosphatemia and acidosis. These were controlled with standard measures. . * Hyperkalemia: Received Kayexalate in ED. Usually takes kayexalate twice a week as outpatient, so this was restarted as an inpatient. . * Anemia: Baseline Hct appears to be 29-33 and now 25. Iron 45, ferritin 149, TIBC 269 in 2-24. Per renal recommendation, she was transfused 1 unit PRBC on 1946-11-16 without complications. . * Bacteremia: WBC count 10 on admission and down to 6.4 today. Has been afebrile but blood cultures showed 2/4 bottles with staph coag negative- likely contaminant. Before speciation returned, she was treated with vancomycin dosed by level. Once it was found to be coag negative staph, the vancomycin was discontinued. All subsequent surveillence cultures were negative. . * Code status: Full - discussed w/ patient's daughter. . * COMM: Dtr Julie Luu 239-729-3529; Son Lyle Demong 235-555-2632 Medications on Admission: Albuterol 2 4X/day Baking soda 12-17 tsp Clonidine 0.3 mg @ AM, 0.2 mg @ Noon, 0.3 mg @ PM Epogen 10K 2X/week Hydralazine 75 TID Imdur 30 once daily Lasix 20 once daily (daughter states patient taking only 20 at home) Lipitor 10 once daily Toprol 25 once daily Amlodipine 10 once daily Phoslo 1334 TID Renagel 800 TID Vit D 50K q month Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. Disp:120 Tablet(s) Refills:2 5. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:270 Tablet(s) Refills:2 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 7. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:270 Capsule(s) Refills:2 8. Baking Soda 12-17 teaspoon by mouth daily 9. Kayexalate Powder Sig: One (1) teaspoon PO Twice a week. 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 11. Albuterol Inhalation 12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Epoetin Alfa Injection Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: hypertensive emergency Diastolic congestive heart failure stage V chronic kidney disease Anemia GERD Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, Latrice Demong MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L daily . You were admitted with very high blood pressure and fluid overload in your lungs. You were given medications to help lower your blood pressure and get the fluid off. . Some of your medication doses have been changed. Please see the medication list for those different doses. . As you know, your kidneys do not function very well. It has been recommended that you start dialysis to help remove the toxins in your blood which your kidneys can no longer remove. You have decided to hold off on this for now (despite knowing the risks of sudden death, fluid overload), but you should follow up with Dr. Grose to have this started soon. . You should continue to take your medications as prescribed. . You should contact your PCP or go to the emergency room if you have fevers>101, chills, shortness of breath, chest pain, weight gain more than 3 lbs, or any other symptoms which are concerning to you. Followup Instructions: Provider: Indira Moore, M.D. Phone:276-735-7855 Date/Time:2013-1-21 5:00PM . . Provider: Alexis Gauthier,Orville Lyna Fannie Clark. 729-838-1001 Call to schedule appointment . . Primary care: Travis Bogle, M.D. Date/Time:1988-2-22 2:30PM Phone 729-838-1001 Completed by:1903-3-5	["Admission Date: 2012-11-5 Discharge Date: 1972-12-8\n\n\nService: MEDICINE\n\nAllergies:\nLisinopril / Nsaids / Nesiritide\n\nAttending:Lissette\nChief Complaint:\n Shortness of breath\n\nMajor Surgical or Invasive Procedure:\nnone\n\n\nHistory of Present Illness:\n* interview conducted with the aid of Ms. Demong daughter\n.\nHistory of Present Illness: Ms. White is an 86 y/o F with\nhistory of nephrotic CRI, renal artery stenosis, and CHF, who\npresented with hypertensive emergency and heart failure. The\npatient reports that she was in her usual state of health until\n3 days prior to admission. At that time, her BP was 220 systolic\n@ home and she noticed mild SOB. On the night prior to\nadmission, she developed increasing SOB. Per the patient's\ndaughter, she had been taking her medications as prescribed.", ' She\ndenies chest pain throughout this time. She was brought in by\ndaughter to Lyle Demong for evaluation and was found to have BP 202/40\nwith a K of 5.9. She was treated with kayexalate 30, lasix 40\nIV, clonidine 0.3 mg PO X 1, and levoflox 750 mg IV x 1.\n.\nThe patient was initially admitted to the floor, where she was\nfound to have the following vitals: 98.3 226/68 68 90% 5LNC (mid\n80s on 2LNC), 96% on face tent, RR > 40. As she was acutely\ndyspneic and in acute failure, she was given 100mg IV lasix and\nDiuril (on the advice of Renal consultants), w/ good effect->\nUOP 350cc in ~1hour. She did not receive any nitrates or\nmorphine at the time. On MICU evaluation was 99% on shovel mask,\nbut still RR>40. Appeared comfortable, JVP ~9 cm. At that time,\nshe denied HA, visual changes, CP, urinary changes, no abd pain,\nN/V/D.', ' In the MICU, she was aggressively diuresed and placed on\nher usual blood pressure regimen. Overnight 1987-3-10 to 2019-8-19, she did\nnot receive all of her blood pressures meds as her BPs were in\nthe 110s/120s overnight. She did receive all doses of clonidine\nand hydralazine on 10-28.\n.\nHer daughter tells me that her edema is less than usual, but\nthat her right leg is chronically larger than the left. She has\nbeen using several pillows to sleep at home. She denies PND. She\nis not on supplemental O2 at home. Generally BP at home is 170s\n(per PCP 160s in office at baseline).\n.\nPt was diagnosed with w/ RLL PNA by her PCP and tx Jackson Dortch/\nlevofloxacin X 10 days about 4 weeks ago. Since that time, the\ndaughter has been living with the pt X 3 weeks. Her cough has\npersisted per the daughter, but the patient did improve greatly\nfollowing antibiotics.', '\n.\nAt the present time, the patient says she is comfortable. She\ndenies chest pain. She continues to make adequate urine.\n\nPast Medical History:\n- Renal artery stenosis: MRI 1967 atrophic R kidney, mod\nstenosis of R renal artery, L renal artery normal\n- CRI/nephrotic range proteinuria, renal artery stenosis,\nfollowed by Dr. Meraz (Nephrology) (recent baseline Cr 7.9-9.1)\n- PVD/Claudication\n- Congestive heart failure w/ EF 50-55%, known WMA (8-14)\n- h/o R cephalic vein DVT (7-2)\n- Colon cancer dx 9-1973 s/p resection\n- GERD\n- Hypertension\n- Hyperlipidemia\n- h/o Rheumatic Fever\n- RBBB\n- Anemia baseline Hct low 30s\n- Osteoarthritis\n- Osteopenia\n- Glaucoma\n\nSocial History:\nRussian-speaking. Living alone independently prior to\nhospitalization in 2/1967. Several children and grandchildren\nin the area are involved in her care.', '\ndenies alcohol or tobacco use.\n\n\nFamily History:\nmother- HTN\n\nPhysical Exam:\nVS afebrile HR 62 BP 178/46 RR 26 O2 93% 4L NC\nGENERAL: NAD, lying @30 degrees and comfortable\nHEENT: EOMI, OMMM, pupils small but reactive\nNECK: JVP at 8 cm, supple, no LAD, no carotid bruits\nCARDIOVASCULAR: S1, S2, reg, II/VI systolic throughout\nprecordium\nLUNGS: crackles halfway up bilaterally, no wheezes, good air\nmovement\nABDOMEN: Soft, NT, ND, no masses, foley catheter in place\nEXTREMITIES: Warm, trace edema bilaterally, right leg slightly\nlarger than left\nNEURO: A/O X3, russian speaking, pleasant, strength 5/5\nbilateral grip, biceps, triceps, ankle dorsi- & plantarflexion,\nsensation intact bilateral upper & lower extremities\n\nPertinent Results:\nStudies:\n2012-11-5 CXR: IMPRESSION: Moderate congestive heart failure,\nworse since the exam of one month ago.', '\n.\n2012-11-5 ECHO: TTE Conclusions:\nThe left atrium is moderately dilated. There is moderate\nsymmetric left\nventricular hypertrophy. Overall left ventricular systolic\nfunction is normal (LVEF 60%).\n.\nThere is mild aortic valve stenosis (area 1.2-1.9cm2). Moderate\n(2+) aortic\nregurgitation is seen.\n.\nThere is severe mitral annular calcification. There is a\nminimally increased gradient consistent with minimal mitral\nstenosis. Mild to moderate (12-30+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation\nmay be significantly UNDERestimated.]\n.\nThe tricuspid valve leaflets are mildly thickened. The\nsupporting structures of the tricuspid valve are\nthickened/fibrotic.\n.\nThere is severe pulmonary artery systolic hypertension. There is\na small pericardial effusion.', '\n\nCompared with the findings of the prior study (images reviewed)\nof 1928-2-13, borderline mitral stenosis is now evident.\nThe mitral regurgitation, which is almost certainly\nunderestimated on this study, is probably increased.\n.\n1978-9-4 CXR TWO VIEWS: Comparison with the previous study done\n1940-4-7. There is interval improvement in interstitial pulmonary\nedema. The mild pulmonary vascular congestion persists. Streaky\ndensity at the lung bases is consistent with subsegmental\natelectasis. There is a moderate right pleural effusion and\nsmall left pleural effusion. An underlying right basilar\nconsolidation cannot be excluded. The heart and mediastinal\nstructures are unchanged.\n\nIMPRESSION: Interval improvement in congestive heart failure.\n.\n.\nLabs:\nProBNP greater than 70,000\n.\nCardiac enzymes:\n2012-11-5 12:10PM BLOOD CK(CPK)-24\n2012-11-5 06:30PM BLOOD CK(CPK)-20\n1940-4-7 02:50AM BLOOD CK(CPK)-22\n2012-11-5 04:49AM BLOOD CK-MB-NotDone cTropnT-0.', '13\n2012-11-5 12:10PM BLOOD CK-MB-NotDone cTropnT-0.13\n2012-11-5 06:30PM BLOOD CK-MB-NotDone cTropnT-0.14\n1940-4-7 02:50AM BLOOD CK-MB-NotDone\n1940-4-7 02:50AM BLOOD cTropnT-0.15\n.\nHer lab values remained fairly constant throughout her admission\nand her discharge labs are given here.\n.\nWBC-6.6 RBC-3.46 Hgb-9.5* Hct-29.0* MCV-84 MCH-27.4 MCHC-32.6\nRDW-17.7* Plt Ct-211\n.\nGlucose-89 UreaN-107* Creat-8.6* Na-130* K-5.0 Cl-100 HCO3-17\nCalcium-8.9 Phos-7.1 Mg-2.5\n\n.\n.\n.\nMicro:\n1946-11-16 BLOOD CULTURE \tx2 bottles No growth\n1958-8-21 \tBLOOD CULTURE \tx4 bottles No growth\n1958-8-21 \tURINE \tNo growth\n1958-8-21 \tBLOOD CULTURE \tx2 bottles No growth\n2012-11-5 \tBLOOD CULTURE \tAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,\nCOAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,\nCOAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE}\n\tEMERGENCY Watson Inc Health System\n2012-11-5 \tBLOOD CULTURE \tx2 bottles No growth\n\nBrief Hospital Course:\nMs.', ' White is an 86 year old female with probable endstage\nrenal failure not on HD, who presented with hypertensive\nemergency and congestive heart failure. She was admitted to the\nmedical floor but immediately was sent to the MICU for\nrespiratory distress. There she was agressively diuresed and\nthen returned to the medical floor.\n.\n* Hypertensive Emergency: Her HTN is likely secondary to her\nESRD. The elevated blood pressures caused flash pulmonary edema\nand congestive heart failure. She was given blood pressure\nmedications to help control her BP within the range of 130-160\nas she probably is dependent on some hypertension for perfusion.\n Her baseline BP is reportedly 160 at home. Ultimately she was\nplaced on clonidine 0.2 mg TID, hydralazine 100mg TID, norvasc\n10mg qday, metoprolol 12.5mg TID, lasix 40mg Watson Inc Health System.', '\n.\n* ? SVT: During her initally presentation, she did have some\nruns of SVT noted on telemetry. Once she was diuresed no\nfurther episodes were noted. She was continued on metoprolol\n12.5 mg TID for given episodes of ? SVT.\n.\n* Congestive Heart Failure: Likely from worsening renal failure\nand hypertensive urgency. She was agressively diuresed in the\nMICU with IV furosemide overnight and then with PO furosemide on\nthe medical floor. She was also continued on hydralazine for\nafterload reduction.\n.\n* Renal Failure: A renal consult was obtained. They felt that\nthere was no acute needs for dialysis at present although they\nhave been discussing starting HD with the patient and her family\nfor a while now. This discussion was continued throughout the\nadmission and the patient and her family were resistent to\nstarting.', ' They agreed to meet with Dr. Grose in the next two\nweeks to discuss getting a tunnelled cath and starting HD.\nThroughout admission, her electrolytes were monitored closely as\nshe had boughts of hyperkalemia, hyperphosphatemia and acidosis.\n These were controlled with standard measures.\n.\n* Hyperkalemia: Received Kayexalate in ED. Usually takes\nkayexalate twice a week as outpatient, so this was restarted as\nan inpatient.\n.\n* Anemia: Baseline Hct appears to be 29-33 and now 25. Iron 45,\nferritin 149, TIBC 269 in 2-24. Per renal recommendation, she\nwas transfused 1 unit PRBC on 1946-11-16 without complications.\n.\n* Bacteremia: WBC count 10 on admission and down to 6.4 today.\nHas been afebrile but blood cultures showed 2/4 bottles with\nstaph coag negative- likely contaminant. Before speciation\nreturned, she was treated with vancomycin dosed by level.', " Once\nit was found to be coag negative staph, the vancomycin was\ndiscontinued. All subsequent surveillence cultures were\nnegative.\n.\n* Code status: Full - discussed w/ patient's daughter.\n.\n* COMM: Dtr Julie Luu 239-729-3529; Son Lyle Demong 235-555-2632\n\nMedications on Admission:\nAlbuterol 2 4X/day\nBaking soda 12-17 tsp\nClonidine 0.3 mg @ AM, 0.2 mg @ Noon, 0.3 mg @ PM\nEpogen 10K 2X/week\nHydralazine 75 TID\nImdur 30 once daily\nLasix 20 once daily (daughter states patient taking only 20 at\nhome)\nLipitor 10 once daily\nToprol 25 once daily\nAmlodipine 10 once daily\nPhoslo 1334 TID\nRenagel 800 TID\nVit D 50K q month\n\nDischarge Medications:\n1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a\nday).\n3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.", '\n4. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO every eight\n(8) hours.\nDisp:120 Tablet(s) Refills:2\n5. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO three times\na day.\nDisp:270 Tablet(s) Refills:2\n6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.\nDisp:60 Tablet(s) Refills:2\n7. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID\nW/MEALS (3 TIMES A DAY WITH MEALS).\nDisp:270 Capsule(s) Refills:2\n8. Baking Soda\n12-17 teaspoon by mouth daily\n9. Kayexalate Powder Sig: One (1) teaspoon PO Twice a week.\n\n10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO once a day.\nDisp:45 Tablet Sustained Release 24 hr(s) Refills:2\n11. Albuterol Inhalation\n12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO once a day.', '\n13. Epoetin Alfa Injection\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPrimary diagnosis:\nhypertensive emergency\nDiastolic congestive heart failure\nstage V chronic kidney disease\nAnemia\nGERD\n\n\nDischarge Condition:\nstable\n\n\nDischarge Instructions:\nWeigh yourself every morning, Latrice Demong MD if weight > 3 lbs.\nAdhere to 2 gm sodium diet\nFluid Restriction: 1.5L daily\n.\nYou were admitted with very high blood pressure and fluid\noverload in your lungs. You were given medications to help lower\nyour blood pressure and get the fluid off.\n.\nSome of your medication doses have been changed. Please see the\nmedication list for those different doses.\n.\nAs you know, your kidneys do not function very well. It has been\nrecommended that you start dialysis to help remove the toxins in\nyour blood which your kidneys can no longer remove.', ' You have\ndecided to hold off on this for now (despite knowing the risks\nof sudden death, fluid overload), but you should follow up with\nDr. Grose to have this started soon.\n.\nYou should continue to take your medications as prescribed.\n.\nYou should contact your PCP or go to the emergency room if you\nhave fevers>101, chills, shortness of breath, chest pain, weight\ngain more than 3 lbs, or any other symptoms which are concerning\nto you.\n\nFollowup Instructions:\nProvider: Indira Moore, M.D. Phone:276-735-7855\nDate/Time:2013-1-21 5:00PM\n.\n.\nProvider: Alexis Gauthier,Orville Lyna Fannie Clark. 729-838-1001 Call to schedule\nappointment\n.\n.\nPrimary care: Travis Bogle, M.D. Date/Time:1988-2-22 2:30PM\nPhone 729-838-1001\n\n\n\nCompleted by:1903-3-5']
187	1136	136706.0	2194-08-16	Discharge summary	Report	Admission Date: [2194-8-15] Discharge Date: [2194-8-16] Service: MEDICINE Allergies: Lisinopril / Nsaids / Nesiritide Attending:[First Name3 (LF) 1881] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [Known lastname ] is a 86F with h/o colon cancer, ESRD on hemodialysis, diastolic CHF, pulmonary hypertension, and prior cephalic vein thrombosis who presented to the ED on [8-15] with dyspnea. The patient's dialysis catheter became dislodged [8-12]. Consequently she missed her normal dialysis session [8-13]. On [8-14] she had a new tunneled catheter placed, but was not dialyzed. The afternoon of [8-14] her daughter noticed that the patient seemed increasingly dyspneic and was hypertensive to 200's. She was given hydralazine and clonidine and the BP improved to 160's. She called her daughter ~3am on [8-15] due to worsening dyspnea. The patient denies any accompanying headache, vision changes, chest discomfort, palpitations, nausea, vomiting, cough, weakness or loss of sensation. EMS was called, and she was given CPAP with some relief of her dyspnea. Per her daughter, similar symptoms have occurred 3 times in the past. In the ED her vitals were BP 258/61 RR 28 O2 100% on CPAP, 89% on room air (temperature was not recorded). She was started on a nitroglycerin drip, and given calcium and bicarbonate for a potassium of 7.1. She was weaned off NIPPV, with O2 saturation of 97% on 3L NC. She was subsequently transferred to the ICU for further monitoring and dialysis. Past Medical History: 1) Hypertension 2) Stage V chronic kidney disease, followed by Dr. [Last Name (STitle) 1366]. 3) Diastolic CHF (EF 60% on TTE in [5-3]), likely volume related in the setting of her renal disease. 4) Rheumatic fever, with the following valvular abnormalities: Mild aortic stenosis, moderate aortic regurgitation, mild mitral stenosis, mild to moderate MR, mild TR. 5) Severe PA systolic hypertension 6) Renal artery stenosis: MRI [2185] atrophic R kidney, moderate stenosis of R renal artery, L renal artery normal. 7) Peripheral vascular disease: Has claudication. 8) Right cephalic vein DVT in [6-/2193] 9) Colon cancer in [2-/2192], status post resection. 10) Hyperlipidemia 11) Right bundle branch block 12) Anemia of renal failure 13) Osteoarthritis 14) Osteopenia 15) Glaucoma Social History: Lives at home, usually alone, but recently the daughter has moved in with her. She does not smoke, drink alcohol, or use IV drugs. Family History: mother- HTN Physical Exam: T 98.2 P 50 BP 196/76 O2 97% on 2L RR 24 General: Pleasant elderly woman in no acute distress CV: Regular rate S1 S2 II/VI SEM at RUSB with I/VI diastolic decrescendo murmur as well at RUSB Pulm: Lungs with crackles at bases bilaterally, no wheezes or rhonchi. R chest with tunneled catheter. Abd: Soft, nontender, +BS Extrem: Warm and well perfused, no edema Neuro: Alert and answering questions appropriately, moving all extremities Pertinent Results: [2194-8-14] 07:45AM BLOOD WBC-8.1 RBC-3.86* Hgb-11.7* Hct-34.8* MCV-90 MCH-30.3 MCHC-33.6 RDW-18.6* Plt Ct-180 [2194-8-15] 05:00AM BLOOD Neuts-91.0* Bands-0 Lymphs-5.1* Monos-2.7 Eos-1.0 Baso-0.2 [2194-8-14] 07:45AM BLOOD PT-11.5 INR(PT)-1.0 [2194-8-14] 07:45AM BLOOD Glucose-106* UreaN-82* Creat-6.2# Na-141 K-5.8 Cl-106 HCO3-23 AnGap-18 [2194-8-15] 05:00AM BLOOD cTropnT-0.09* [2194-8-15] 05:13AM BLOOD Type-ART pO2-440* pCO2-35 pH-7.38 calTCO2-22 Base XS--3 [2194-8-15] 05:00AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.009 [2194-8-15] 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2194-8-15] 05:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [8-15] CXR FINDINGS: AP view of the chest on upright position. The cardiac silhouette cannot be evaluated on this AP view. The right-sided central venous catheter is unchanged. The left costophrenic angle is blunted consistent with pleural effusions. Left lung base atelectasis are noted. There is no evidence of pneumothorax. There is a right lung base opacity obscuring the right-side cardiac border which may represent right middle lobe atelectasis vs. pneumonia. Pprominence of the pulmonary vasculature is noted, consistent with mild CHF. The osseous structures are unchanged. IMPRESSION: 1. Right middle lobe atelectasis vs. pneumonia. 2. Mild CHF with small left- sided pleural effusion. [8-15] EKG Sinus bradycardia at 56bpm, left axis, old RBBB, peaked T's that are new compared to [2194-6-24] EKG. Inverted T in V3 on [6-2] EKG has flipped to positive. No signs of acute ischemia. Brief Hospital Course: 1. Dyspnea - The patient's dyspnea was thought to be secondary from volume overload, occuring in the context of ESRD and a missed hemodialysis session, as well as hypertension leading to flash pulmonary edema. Her dyspnea following hemodialysis. 2. Hypertension - The patient's hypertension is also likely related to volume overload. Her blood pressures improved following dialysis and resumption of her home course of toprol, clonidine, amlodipine, and hydralazine. 3. Hyperkalemia - The patient's potassium normalized following dialysis. 4. ESRD - Renal following, on dialysis MWF. 5. FEN - Continue sevelemer, nephrocaps. Medications on Admission: 1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: CARETENDERS Discharge Diagnosis: Primary: hyptertensive emergency Secondary: diastolic CHF ESRD Discharge Condition: stable, shortness of breath relieved Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1879], M.D. Date/Time:[2194-8-25] 8:30 -cont HD on MWF [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882] MD, [MD Number(3) 1883]	Admission Date: <Date>1998-10-22</Date> Discharge Date: <Date>1984-9-29</Date> Service: MEDICINE Allergies: Lisinopril / Nsaids / Nesiritide Attending:<Name>Sandeep</Name> Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. <Name>Deluna</Name> is a 86F with h/o colon cancer, ESRD on hemodialysis, diastolic CHF, pulmonary hypertension, and prior cephalic vein thrombosis who presented to the ED on <Date>3-16</Date> with dyspnea. The patient's dialysis catheter became dislodged <Date>11-7</Date>. Consequently she missed her normal dialysis session <Date>4-11</Date>. On <Date>4-9</Date> she had a new tunneled catheter placed, but was not dialyzed. The afternoon of <Date>4-9</Date> her daughter noticed that the patient seemed increasingly dyspneic and was hypertensive to 200's. She was given hydralazine and clonidine and the BP improved to 160's. She called her daughter ~3am on <Date>3-16</Date> due to worsening dyspnea. The patient denies any accompanying headache, vision changes, chest discomfort, palpitations, nausea, vomiting, cough, weakness or loss of sensation. EMS was called, and she was given CPAP with some relief of her dyspnea. Per her daughter, similar symptoms have occurred 3 times in the past. In the ED her vitals were BP 258/61 RR 28 O2 100% on CPAP, 89% on room air (temperature was not recorded). She was started on a nitroglycerin drip, and given calcium and bicarbonate for a potassium of 7.1. She was weaned off NIPPV, with O2 saturation of 97% on 3L NC. She was subsequently transferred to the ICU for further monitoring and dialysis. Past Medical History: 1) Hypertension 2) Stage V chronic kidney disease, followed by Dr. <Name>Ivory</Name>. 3) Diastolic CHF (EF 60% on TTE in <Date>6-9</Date>), likely volume related in the setting of her renal disease. 4) Rheumatic fever, with the following valvular abnormalities: Mild aortic stenosis, moderate aortic regurgitation, mild mitral stenosis, mild to moderate MR, mild TR. 5) Severe PA systolic hypertension 6) Renal artery stenosis: MRI <Year>1991</Year> atrophic R kidney, moderate stenosis of R renal artery, L renal artery normal. 7) Peripheral vascular disease: Has claudication. 8) Right cephalic vein DVT in <Date>4-1955</Date> 9) Colon cancer in <Date>4-2015</Date>, status post resection. 10) Hyperlipidemia 11) Right bundle branch block 12) Anemia of renal failure 13) Osteoarthritis 14) Osteopenia 15) Glaucoma Social History: Lives at home, usually alone, but recently the daughter has moved in with her. She does not smoke, drink alcohol, or use IV drugs. Family History: mother- HTN Physical Exam: T 98.2 P 50 BP 196/76 O2 97% on 2L RR 24 General: Pleasant elderly woman in no acute distress CV: Regular rate S1 S2 II/VI SEM at RUSB with I/VI diastolic decrescendo murmur as well at RUSB Pulm: Lungs with crackles at bases bilaterally, no wheezes or rhonchi. R chest with tunneled catheter. Abd: Soft, nontender, +BS Extrem: Warm and well perfused, no edema Neuro: Alert and answering questions appropriately, moving all extremities Pertinent Results: <Date>1906-8-28</Date> 07:45AM BLOOD WBC-8.1 RBC-3.86* Hgb-11.7* Hct-34.8* MCV-90 MCH-30.3 MCHC-33.6 RDW-18.6* Plt Ct-180 <Date>1998-10-22</Date> 05:00AM BLOOD Neuts-91.0* Bands-0 Lymphs-5.1* Monos-2.7 Eos-1.0 Baso-0.2 <Date>1906-8-28</Date> 07:45AM BLOOD PT-11.5 INR(PT)-1.0 <Date>1906-8-28</Date> 07:45AM BLOOD Glucose-106* UreaN-82* Creat-6.2# Na-141 K-5.8 Cl-106 HCO3-23 AnGap-18 <Date>1998-10-22</Date> 05:00AM BLOOD cTropnT-0.09* <Date>1998-10-22</Date> 05:13AM BLOOD Type-ART pO2-440* pCO2-35 pH-7.38 calTCO2-22 Base XS--3 <Date>1998-10-22</Date> 05:00AM URINE COLOR-Yellow APPEAR-Clear SP <Name>Pichardo</Name>-1.009 <Date>1998-10-22</Date> 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG <Date>1998-10-22</Date> 05:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 <Date>3-16</Date> CXR FINDINGS: AP view of the chest on upright position. The cardiac silhouette cannot be evaluated on this AP view. The right-sided central venous catheter is unchanged. The left costophrenic angle is blunted consistent with pleural effusions. Left lung base atelectasis are noted. There is no evidence of pneumothorax. There is a right lung base opacity obscuring the right-side cardiac border which may represent right middle lobe atelectasis vs. pneumonia. Pprominence of the pulmonary vasculature is noted, consistent with mild CHF. The osseous structures are unchanged. IMPRESSION: 1. Right middle lobe atelectasis vs. pneumonia. 2. Mild CHF with small left- sided pleural effusion. <Date>3-16</Date> EKG Sinus bradycardia at 56bpm, left axis, old RBBB, peaked T's that are new compared to <Date>1951-7-24</Date> EKG. Inverted T in V3 on <Date>10-12</Date> EKG has flipped to positive. No signs of acute ischemia. Brief Hospital Course: 1. Dyspnea - The patient's dyspnea was thought to be secondary from volume overload, occuring in the context of ESRD and a missed hemodialysis session, as well as hypertension leading to flash pulmonary edema. Her dyspnea following hemodialysis. 2. Hypertension - The patient's hypertension is also likely related to volume overload. Her blood pressures improved following dialysis and resumption of her home course of toprol, clonidine, amlodipine, and hydralazine. 3. Hyperkalemia - The patient's potassium normalized following dialysis. 4. ESRD - Renal following, on dialysis MWF. 5. FEN - Continue sevelemer, nephrocaps. Medications on Admission: 1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: CARETENDERS Discharge Diagnosis: Primary: hyptertensive emergency Secondary: diastolic CHF ESRD Discharge Condition: stable, shortness of breath relieved Discharge Instructions: Weigh yourself every morning, <Name>Latonya Ngo</Name> MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Provider: <Name>Nisha</Name> <Name>Olles</Name>, M.D. Date/Time:<Date>1993-12-2</Date> 8:30 -cont HD on MWF <Name>Nisha</Name> <Name>Amaro</Name> MD, <MD Number>63699911</MD 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Date: 1998-10-22 Discharge Date: 1984-9-29 Service: MEDICINE Allergies: Lisinopril / Nsaids / Nesiritide Attending:Sandeep Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. Deluna is a 86F with h/o colon cancer, ESRD on hemodialysis, diastolic CHF, pulmonary hypertension, and prior cephalic vein thrombosis who presented to the ED on 3-16 with dyspnea. The patient's dialysis catheter became dislodged 11-7. Consequently she missed her normal dialysis session 4-11. On 4-9 she had a new tunneled catheter placed, but was not dialyzed. The afternoon of 4-9 her daughter noticed that the patient seemed increasingly dyspneic and was hypertensive to 200's. She was given hydralazine and clonidine and the BP improved to 160's. She called her daughter ~3am on 3-16 due to worsening dyspnea. The patient denies any accompanying headache, vision changes, chest discomfort, palpitations, nausea, vomiting, cough, weakness or loss of sensation. EMS was called, and she was given CPAP with some relief of her dyspnea. Per her daughter, similar symptoms have occurred 3 times in the past. In the ED her vitals were BP 258/61 RR 28 O2 100% on CPAP, 89% on room air (temperature was not recorded). She was started on a nitroglycerin drip, and given calcium and bicarbonate for a potassium of 7.1. She was weaned off NIPPV, with O2 saturation of 97% on 3L NC. She was subsequently transferred to the ICU for further monitoring and dialysis. Past Medical History: 1) Hypertension 2) Stage V chronic kidney disease, followed by Dr. Ivory. 3) Diastolic CHF (EF 60% on TTE in 6-9), likely volume related in the setting of her renal disease. 4) Rheumatic fever, with the following valvular abnormalities: Mild aortic stenosis, moderate aortic regurgitation, mild mitral stenosis, mild to moderate MR, mild TR. 5) Severe PA systolic hypertension 6) Renal artery stenosis: MRI 1991 atrophic R kidney, moderate stenosis of R renal artery, L renal artery normal. 7) Peripheral vascular disease: Has claudication. 8) Right cephalic vein DVT in 4-1955 9) Colon cancer in 4-2015, status post resection. 10) Hyperlipidemia 11) Right bundle branch block 12) Anemia of renal failure 13) Osteoarthritis 14) Osteopenia 15) Glaucoma Social History: Lives at home, usually alone, but recently the daughter has moved in with her. She does not smoke, drink alcohol, or use IV drugs. Family History: mother- HTN Physical Exam: T 98.2 P 50 BP 196/76 O2 97% on 2L RR 24 General: Pleasant elderly woman in no acute distress CV: Regular rate S1 S2 II/VI SEM at RUSB with I/VI diastolic decrescendo murmur as well at RUSB Pulm: Lungs with crackles at bases bilaterally, no wheezes or rhonchi. R chest with tunneled catheter. Abd: Soft, nontender, +BS Extrem: Warm and well perfused, no edema Neuro: Alert and answering questions appropriately, moving all extremities Pertinent Results: 1906-8-28 07:45AM BLOOD WBC-8.1 RBC-3.86* Hgb-11.7* Hct-34.8* MCV-90 MCH-30.3 MCHC-33.6 RDW-18.6* Plt Ct-180 1998-10-22 05:00AM BLOOD Neuts-91.0* Bands-0 Lymphs-5.1* Monos-2.7 Eos-1.0 Baso-0.2 1906-8-28 07:45AM BLOOD PT-11.5 INR(PT)-1.0 1906-8-28 07:45AM BLOOD Glucose-106* UreaN-82* Creat-6.2# Na-141 K-5.8 Cl-106 HCO3-23 AnGap-18 1998-10-22 05:00AM BLOOD cTropnT-0.09* 1998-10-22 05:13AM BLOOD Type-ART pO2-440* pCO2-35 pH-7.38 calTCO2-22 Base XS--3 1998-10-22 05:00AM URINE COLOR-Yellow APPEAR-Clear SP Pichardo-1.009 1998-10-22 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG 1998-10-22 05:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 3-16 CXR FINDINGS: AP view of the chest on upright position. The cardiac silhouette cannot be evaluated on this AP view. The right-sided central venous catheter is unchanged. The left costophrenic angle is blunted consistent with pleural effusions. Left lung base atelectasis are noted. There is no evidence of pneumothorax. There is a right lung base opacity obscuring the right-side cardiac border which may represent right middle lobe atelectasis vs. pneumonia. Pprominence of the pulmonary vasculature is noted, consistent with mild CHF. The osseous structures are unchanged. IMPRESSION: 1. Right middle lobe atelectasis vs. pneumonia. 2. Mild CHF with small left- sided pleural effusion. 3-16 EKG Sinus bradycardia at 56bpm, left axis, old RBBB, peaked T's that are new compared to 1951-7-24 EKG. Inverted T in V3 on 10-12 EKG has flipped to positive. No signs of acute ischemia. Brief Hospital Course: 1. Dyspnea - The patient's dyspnea was thought to be secondary from volume overload, occuring in the context of ESRD and a missed hemodialysis session, as well as hypertension leading to flash pulmonary edema. Her dyspnea following hemodialysis. 2. Hypertension - The patient's hypertension is also likely related to volume overload. Her blood pressures improved following dialysis and resumption of her home course of toprol, clonidine, amlodipine, and hydralazine. 3. Hyperkalemia - The patient's potassium normalized following dialysis. 4. ESRD - Renal following, on dialysis MWF. 5. FEN - Continue sevelemer, nephrocaps. Medications on Admission: 1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: CARETENDERS Discharge Diagnosis: Primary: hyptertensive emergency Secondary: diastolic CHF ESRD Discharge Condition: stable, shortness of breath relieved Discharge Instructions: Weigh yourself every morning, Latonya Ngo MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Provider: Nisha Olles, M.D. Date/Time:1993-12-2 8:30 -cont HD on MWF Nisha Amaro MD, 63699911	["Admission Date: 1998-10-22 Discharge Date: 1984-9-29\n\n\nService: MEDICINE\n\nAllergies:\nLisinopril / Nsaids / Nesiritide\n\nAttending:Sandeep\nChief Complaint:\nshortness of breath\n\nMajor Surgical or Invasive Procedure:\nHD\n\nHistory of Present Illness:\nMs. Deluna is a 86F with h/o colon cancer, ESRD on\nhemodialysis, diastolic CHF, pulmonary hypertension, and prior\ncephalic vein thrombosis who presented to the ED on 3-16 with\ndyspnea.\n\nThe patient's dialysis catheter became dislodged 11-7.\nConsequently she missed her normal dialysis session 4-11. On\n4-9 she had a new tunneled catheter placed, but was not\ndialyzed. The afternoon of 4-9 her daughter noticed that the\npatient seemed increasingly dyspneic and was hypertensive to\n200's. She was given hydralazine and clonidine and the BP\nimproved to 160's.", ' She called her daughter ~3am on 3-16 due to\nworsening dyspnea. The patient denies any accompanying headache,\nvision changes, chest discomfort, palpitations, nausea,\nvomiting, cough, weakness or loss of sensation. EMS was called,\nand she was given CPAP with some relief of her dyspnea. Per her\ndaughter, similar symptoms have occurred 3 times in the past.\n\nIn the ED her vitals were BP 258/61 RR 28 O2 100% on CPAP, 89%\non room air (temperature was not recorded). She was started on a\nnitroglycerin drip, and given calcium and bicarbonate for a\npotassium of 7.1. She was weaned off NIPPV, with O2 saturation\nof 97% on 3L NC. She was subsequently transferred to the ICU for\nfurther monitoring and dialysis.\n\nPast Medical History:\n1) Hypertension\n2) Stage V chronic kidney disease, followed by Dr. Ivory.', '\n3) Diastolic CHF (EF 60% on TTE in 6-9), likely volume related\nin the setting of her renal disease.\n4) Rheumatic fever, with the following valvular abnormalities:\nMild aortic stenosis, moderate aortic regurgitation, mild mitral\nstenosis, mild to moderate MR, mild TR.\n5) Severe PA systolic hypertension\n6) Renal artery stenosis: MRI 1991 atrophic R kidney, moderate\nstenosis of R renal artery, L renal artery normal.\n7) Peripheral vascular disease: Has claudication.\n8) Right cephalic vein DVT in 4-1955\n9) Colon cancer in 4-2015, status post resection.\n10) Hyperlipidemia\n11) Right bundle branch block\n12) Anemia of renal failure\n13) Osteoarthritis\n14) Osteopenia\n15) Glaucoma\n\n\nSocial History:\nLives at home, usually alone, but recently the daughter has\nmoved in with her. She does not smoke, drink alcohol, or use IV\ndrugs.', '\n\n\nFamily History:\nmother- HTN\n\nPhysical Exam:\nT 98.2 P 50 BP 196/76 O2 97% on 2L RR 24\n\nGeneral: Pleasant elderly woman in no acute distress\nCV: Regular rate S1 S2 II/VI SEM at RUSB with I/VI diastolic\ndecrescendo murmur as well at RUSB\nPulm: Lungs with crackles at bases bilaterally, no wheezes or\nrhonchi. R chest with tunneled catheter.\nAbd: Soft, nontender, +BS\nExtrem: Warm and well perfused, no edema\nNeuro: Alert and answering questions appropriately, moving all\nextremities\n\nPertinent Results:\n1906-8-28 07:45AM BLOOD WBC-8.1 RBC-3.86* Hgb-11.7* Hct-34.8\nMCV-90 MCH-30.3 MCHC-33.6 RDW-18.6 Plt Ct-180\n1998-10-22 05:00AM BLOOD Neuts-91.0* Bands-0 Lymphs-5.1* Monos-2.7\nEos-1.0 Baso-0.2\n1906-8-28 07:45AM BLOOD PT-11.5 INR(PT)-1.0\n1906-8-28 07:45AM BLOOD Glucose-106* UreaN-82* Creat-6.2# Na-141\nK-5.', '8 Cl-106 HCO3-23 AnGap-18\n1998-10-22 05:00AM BLOOD cTropnT-0.09\n1998-10-22 05:13AM BLOOD Type-ART pO2-440 pCO2-35 pH-7.38\ncalTCO2-22 Base XS--3\n1998-10-22 05:00AM URINE COLOR-Yellow APPEAR-Clear SP Pichardo-1.009\n1998-10-22 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100\nGLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0\nLEUK-NEG\n1998-10-22 05:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE\nEPI-0-2\n\n3-16 CXR\nFINDINGS: AP view of the chest on upright position. The\ncardiac silhouette cannot be evaluated on this AP view. The\nright-sided central venous catheter is unchanged. The left\ncostophrenic angle is blunted consistent with pleural effusions.\n Left lung base atelectasis are noted. There is no evidence of\npneumothorax. There is a right lung base opacity obscuring the\nright-side cardiac border which may represent right middle lobe\natelectasis vs.', " pneumonia. Pprominence of the pulmonary\nvasculature is noted, consistent with mild CHF. The osseous\nstructures are unchanged.\n IMPRESSION:\n1. Right middle lobe atelectasis vs. pneumonia.\n2. Mild CHF with small left- sided pleural effusion.\n\n3-16 EKG\nSinus bradycardia at 56bpm, left axis, old RBBB, peaked T's that\nare new compared to 1951-7-24 EKG. Inverted T in V3 on 10-12 EKG\nhas flipped to positive. No signs of acute ischemia.\n\nBrief Hospital Course:\n1. Dyspnea - The patient's dyspnea was thought to be secondary\nfrom volume overload, occuring in the context of ESRD and a\nmissed hemodialysis session, as well as hypertension leading to\nflash pulmonary edema. Her dyspnea following hemodialysis.\n\n2. Hypertension - The patient's hypertension is also likely\nrelated to volume overload. Her blood pressures improved\nfollowing dialysis and resumption of her home course of toprol,\nclonidine, amlodipine, and hydralazine.", "\n\n3. Hyperkalemia - The patient's potassium normalized following\ndialysis.\n\n4. ESRD - Renal following, on dialysis MWF.\n\n5. FEN - Continue sevelemer, nephrocaps.\n\nMedications on Admission:\n1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times\na day).\nDisp:180 Tablet(s) Refills:2\n2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a\nday).\n4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID\nW/MEALS (3 TIMES A DAY WITH MEALS).\n5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times\na day).\n6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).\n7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).", '\n8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap\nPO DAILY (Daily).\n9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times\na day).\n10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n\n\nDischarge Medications:\n1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times\na day).\nDisp:180 Tablet(s) Refills:2\n2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a\nday).\n4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID\nW/MEALS (3 TIMES A DAY WITH MEALS).\n5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times\na day).\n6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).\n7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr\nSig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).', '\n8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap\nPO DAILY (Daily).\n9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times\na day).\n10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nCARETENDERS\n\nDischarge Diagnosis:\nPrimary: hyptertensive emergency\n\nSecondary: diastolic CHF\nESRD\n\n\nDischarge Condition:\nstable, shortness of breath relieved\n\n\nDischarge Instructions:\nWeigh yourself every morning, Latonya Ngo MD if weight > 3 lbs.\nAdhere to 2 gm sodium diet\nFluid Restriction:\n\nFollowup Instructions:\nProvider: Nisha Olles, M.D. Date/Time:1993-12-2 8:30\n-cont HD on MWF\n\n\n Nisha Amaro MD, 63699911\n\n']
188	98046	139402.0	2198-08-04	Discharge summary	Report	Admission Date: [2198-7-17] Discharge Date: [2198-8-4] Date of Birth: [2132-6-25] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1406] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [2198-7-25] 1. Left atrial appendage resection. 2. Coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery, and reverse saphenous vein graft to the posterior descending artery and obtuse marginal artery. 3. Aortic valve replacement with a 25-mm St. [Male First Name (un) 923] Epic tissue valve, model #EFT100-25- 00. History of Present Illness: 66 year old male who presented with worsening shortness of breath and hypotension. He presented to his PCP's office for follow up and was noted to be short of breath and hypotensive with SBP's in the 80's. His symptoms started approximately 2-3 weeks prior to presentation. He mainly had difficulty with shortness of breath. This shortness of breath would prevent him from sleeping comfortably. He describes symptoms consistent with orthopnea and PND. He notes that he saw Dr. [Last Name (STitle) ] a couple of weeks ago and was started on lasix and aldactone. He was also noted to be in atrial fibrillation at that time as well. He is now being referred to cardiac surgery for evaluation of revascularization and possible aortic valve replacement. Past Medical History: Atrial fibrillation Coronary Artery Disease Aortic Stenosis PMH: Diastolic and Systolic CHF (EF 30-35%) Type 2 diabetes Hypertension Hypercholesterolemia Chronic Back Pain degenerative neurological disease ? MS Bilateral drop foot Social History: Lives with his wife. Retired for 30 years, used to own a bagel shop and was a landlord. Able to ambulate around the home with assistance and/or walker. Uses a wheelchair outside of the home. -Tobacco: smoked 1 ppd for 40 yrs, quit about 6 months ago -EtOH: drinks 3-4 glasses of scotch or wine daily -Drugs: marijuana ~once weekly Family History: Father died of an MI at age 73. Mother died at 78 of unknown causes. Physical Exam: Pulse:94 Resp:18 O2 sat:98/RA B/P Right:117/84 Left:116/78 Height:73" Weight:97.2 kgs General: Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [xx] bowel sounds + [] Extremities: Warm [x], well-perfused [] Edema [x] +1 edema ankles/feet,mild purplish discolouration to balateral feet_____ Varicosities: None [x] Neuro: Grossly intact []upper extremity hand grasps week bilaterally, lower ext bilateral weakness, can raise both legs off bed but poor resistence, bilaterl foot drop, thought process slow Pulses: Femoral Right:cath site Left:+1 DP Right:trace Left:trace PT [Name (NI) 167]: trace Left:trace Radial Right: +2 Left:+2 Carotid Bruit Right: +1 Left:+1 Pertinent Results: ADMISSION LABS: [2198-7-17] 06:30PM BLOOD WBC-15.1* RBC-4.56* Hgb-14.7 Hct-41.4 MCV-91 MCH-32.2* MCHC-35.5* RDW-12.8 Plt Ct-176 [2198-7-17] 06:30PM BLOOD PT-13.8* PTT-26.5 INR(PT)-1.2* [2198-7-17] 06:30PM BLOOD Glucose-126* UreaN-31* Creat-2.1* Na-130* K-5.7* Cl-95* HCO3-23 AnGap-18 [2198-7-18] 06:25AM BLOOD ALT-21 AST-24 LD(LDH)-277* CK(CPK)-73 AlkPhos-129 TotBili-0.5 [2198-7-17] 06:30PM BLOOD proBNP-7438* [2198-7-17] 06:30PM BLOOD cTropnT-0.07* [2198-7-18] 06:25AM BLOOD CK-MB-3 cTropnT-0.07* [2198-7-18] 06:15PM BLOOD CK-MB-3 cTropnT-0.05* CXR [2198-7-17]: Semi-upright portable AP view of the chest obtained. Moderate-to-severe cardiomegaly with diffuse ground-glass haziness throughout the lungs compatible with pulmonary edema. The right hemidiaphragm remains somewhat elevated and overall low lung volumes are noted which somewhat limit the evaluation. There are no large pleural effusions and no sign of pneumothorax. Hilar engorgement is compatible with congestive heart failure. Bony structures appear intact. IMPRESSION: Cardiomegaly, pulmonary edema. LHC [2198-7-23]: 1) Selective coronary angiography of this right-dominant system demonstrated severe three vessel CAD. The LMCA was normal without any angiographically-apparent flow-limiting lesions. The stent in the proximal LAD had diffuse 60% in-stent restenosis. There was 80% stenosis throuhgout the proximal LCX, with a 60-70% stenosis at the origin of the OMB. The RCA had a 100% proximal stenosis with prominent left-to-right collaterals. 2) Resting hemodynamics showed elevated right and left-sided filling pressures with an RVEDP of 17 mmHg and an LVEDP of 27 mmHg. The peak gradient over the aortic valve was 14 mmHg. Using the Gorlin equation, the [Location (un) 109] was calculated to be 1.1 cm2, indicating moderate aortic stenosis. 3) Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate aortic stenosis. 3. Atrial fibrillation with rapid ventricular response. 4. Needs diuresis prior to cardioversion. 5. Consideration for AVR-CABG. LENI [2198-7-24]: negative for DVT Carotid U/S [2198-7-24]: Panorex [2198-7-24]: Brief Hospital Course: The patient underwent the usual preoperative work-up. Dental examined the patient and recommended extraction of one tooth. The patient refused. The patient was brought to the operating room on [2198-7-25] where the patient underwent AVR (tissue), CABG x 3, resection of left atrial appendage with Dr. [Last Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He does have a history of heart failure with an EF of 30% and initially required multiple inotropes and vasopressors. He remained intubated due to pulmonary congestion, which improved with diuresis. Rapid a-fib developed and amiodarone drip was initiated. This was discontinued when rate was controlled. He failed a trial of Precedex. He self-extubated and was re-intubated without incident. He developed a leukocytosis and was started on cipro for a positive urinalysis. There was no growth on culture, and cipro was discontinued. Tube feeds were started on POD 3. He was extubated on POD 4. By this time, all vasoactive drips had been weaned. Coumadin was resumed for chronic a-fib. Chest tubes and pacing wires were discontinued without complication. Beta-blocker was initiated and the patient was gently diuresed toward the pre-operative weight. ACE Inhibitor was not initiated due to a rise in Creatinine, which would start to trend down prior to discharge. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #10 the patient was ambulating freely, and pain was controlled with oral analgesics. Due to upper and lower pole serosanguinous sternal drainage, Mr.[Known lastname 1884] was placed on prophylactic antibiotics x 1 week per Dr.[Last Name (STitle) ]. The patient was discharged to [Hospital 100] Rehab in good condition with appropriate follow up instructions. Medications on Admission: DILTIAZEM HCL [CARDIZEM CD] - 240 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth every day FUROSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day HOME OXYGEN - - use as directed by nasal cannula once a day ( 1-2 liters by nasal cannula) LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - 850 mg Tablet - 1 (One) Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once a day MUPIROCIN - 2 % Ointment - apply to affected area (s) twice a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s) sublingually PRN for CP OVERNIGHT OXIMETRY ON ROOM AIR - - As Directed Dx: CAD, Dyspnea PHYSICAL CONDITIONING AND STRENGTHENING - - for diabetic neuropathy, gait instability and general weakness; 1-3 visits weekly; evaluation and treatment PREGABALIN [LYRICA] - 50 mg Capsule - 2 Capsule(s) by mouth three times a day for painful diabetic neuropathy SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth no more than every day as directed SIMVASTATIN [ZOCOR] - 10 mg Tablet - 1 Tablet(s) by mouth every day SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day PROPECIA Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or temp>38.4. 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) for 7 days. 15. warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 16. warfarin 1 mg Tablet Sig: MD to dose daily Tablet PO once a day: indication:Atrial Fibrillation/ INR goal=2-2.5. 17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for dry skin. 18. furosemide 10 mg/mL Solution Sig: Eight (8) Injection [Hospital1 ] (2 times a day): total=80 mg [Hospital1 ]. 19. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Atrial fibrillation Coronary Artery Disease Aortic Stenosis PMH: Diastolic and Systolic CHF (EF 30-35%) Type 2 diabetes Hypertension Hypercholesterolemia Chronic Back Pain degenerative neurological disease ? MS Bilateral drop foot Discharge Condition: Alert and oriented x3 nonfocal Max Assist Sternal pain managed with oral analgesics Sternal Incision - scant serosanguinous drainage from upper and lower pole. Sternum stable. Mild erythema-evaluated by Dr.[Last Name (STitle) ] prior to Dc. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [Last Name (STitle) ] on [8-30] at 1:30pm ([Telephone/Fax (1) 170]) Cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [8-21] at 3:15pm Please call to schedule the following: Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] J. [Telephone/Fax (1) 250] in [2-27] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR Coumadin for A-Fib Goal INR 2-2.5 Please arrange for coumadin follow-up on discharge from rehab Completed by:[2198-8-4]	Admission Date: <Date>1938-12-14</Date> Discharge Date: <Date>1941-7-4</Date> Date of Birth: <Date>1955-8-5</Date> Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Henry</Name> Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: <Date>1953-1-31</Date> 1. Left atrial appendage resection. 2. Coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery, and reverse saphenous vein graft to the posterior descending artery and obtuse marginal artery. 3. Aortic valve replacement with a 25-mm St. <Name>Jacob</Name> Epic tissue valve, model #EFT100-25- 00. History of Present Illness: 66 year old male who presented with worsening shortness of breath and hypotension. He presented to his PCP's office for follow up and was noted to be short of breath and hypotensive with SBP's in the 80's. His symptoms started approximately 2-3 weeks prior to presentation. He mainly had difficulty with shortness of breath. This shortness of breath would prevent him from sleeping comfortably. He describes symptoms consistent with orthopnea and PND. He notes that he saw Dr. <Name>Ivory</Name> a couple of weeks ago and was started on lasix and aldactone. He was also noted to be in atrial fibrillation at that time as well. He is now being referred to cardiac surgery for evaluation of revascularization and possible aortic valve replacement. Past Medical History: Atrial fibrillation Coronary Artery Disease Aortic Stenosis PMH: Diastolic and Systolic CHF (EF 30-35%) Type 2 diabetes Hypertension Hypercholesterolemia Chronic Back Pain degenerative neurological disease ? MS Bilateral drop foot Social History: Lives with his wife. Retired for 30 years, used to own a bagel shop and was a landlord. Able to ambulate around the home with assistance and/or walker. Uses a wheelchair outside of the home. -Tobacco: smoked 1 ppd for 40 yrs, quit about 6 months ago -EtOH: drinks 3-4 glasses of scotch or wine daily -Drugs: marijuana ~once weekly Family History: Father died of an MI at age 73. Mother died at 78 of unknown causes. Physical Exam: Pulse:94 Resp:18 O2 sat:98/RA B/P Right:117/84 Left:116/78 Height:73" Weight:97.2 kgs General: Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [xx] bowel sounds + [] Extremities: Warm [x], well-perfused [] Edema [x] +1 edema ankles/feet,mild purplish discolouration to balateral feet_____ Varicosities: None [x] Neuro: Grossly intact []upper extremity hand grasps week bilaterally, lower ext bilateral weakness, can raise both legs off bed but poor resistence, bilaterl foot drop, thought process slow Pulses: Femoral Right:cath site Left:+1 DP Right:trace Left:trace PT <Name>Lisa Feguson</Name>: trace Left:trace Radial Right: +2 Left:+2 Carotid Bruit Right: +1 Left:+1 Pertinent Results: ADMISSION LABS: <Date>1938-12-14</Date> 06:30PM BLOOD WBC-15.1* RBC-4.56* Hgb-14.7 Hct-41.4 MCV-91 MCH-32.2* MCHC-35.5* RDW-12.8 Plt Ct-176 <Date>1938-12-14</Date> 06:30PM BLOOD PT-13.8* PTT-26.5 INR(PT)-1.2* <Date>1938-12-14</Date> 06:30PM BLOOD Glucose-126* UreaN-31* Creat-2.1* Na-130* K-5.7* Cl-95* HCO3-23 AnGap-18 <Date>1933-8-25</Date> 06:25AM BLOOD ALT-21 AST-24 LD(LDH)-277* CK(CPK)-73 AlkPhos-129 TotBili-0.5 <Date>1938-12-14</Date> 06:30PM BLOOD proBNP-7438* <Date>1938-12-14</Date> 06:30PM BLOOD cTropnT-0.07* <Date>1933-8-25</Date> 06:25AM BLOOD CK-MB-3 cTropnT-0.07* <Date>1933-8-25</Date> 06:15PM BLOOD CK-MB-3 cTropnT-0.05* CXR <Date>1938-12-14</Date>: Semi-upright portable AP view of the chest obtained. Moderate-to-severe cardiomegaly with diffuse ground-glass haziness throughout the lungs compatible with pulmonary edema. The right hemidiaphragm remains somewhat elevated and overall low lung volumes are noted which somewhat limit the evaluation. There are no large pleural effusions and no sign of pneumothorax. Hilar engorgement is compatible with congestive heart failure. Bony structures appear intact. IMPRESSION: Cardiomegaly, pulmonary edema. LHC <Date>1917-3-7</Date>: 1) Selective coronary angiography of this right-dominant system demonstrated severe three vessel CAD. The LMCA was normal without any angiographically-apparent flow-limiting lesions. The stent in the proximal LAD had diffuse 60% in-stent restenosis. There was 80% stenosis throuhgout the proximal LCX, with a 60-70% stenosis at the origin of the OMB. The RCA had a 100% proximal stenosis with prominent left-to-right collaterals. 2) Resting hemodynamics showed elevated right and left-sided filling pressures with an RVEDP of 17 mmHg and an LVEDP of 27 mmHg. The peak gradient over the aortic valve was 14 mmHg. Using the Gorlin equation, the <Location>165 Amy Shores Apt. 673 North Mathewfurt, NH 67854</Location> was calculated to be 1.1 cm2, indicating moderate aortic stenosis. 3) Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate aortic stenosis. 3. Atrial fibrillation with rapid ventricular response. 4. Needs diuresis prior to cardioversion. 5. Consideration for AVR-CABG. LENI <Date>1918-4-20</Date>: negative for DVT Carotid U/S <Date>1918-4-20</Date>: Panorex <Date>1918-4-20</Date>: Brief Hospital Course: The patient underwent the usual preoperative work-up. Dental examined the patient and recommended extraction of one tooth. The patient refused. The patient was brought to the operating room on <Date>1953-1-31</Date> where the patient underwent AVR (tissue), CABG x 3, resection of left atrial appendage with Dr. <Name>Ivory</Name>. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He does have a history of heart failure with an EF of 30% and initially required multiple inotropes and vasopressors. He remained intubated due to pulmonary congestion, which improved with diuresis. Rapid a-fib developed and amiodarone drip was initiated. This was discontinued when rate was controlled. He failed a trial of Precedex. He self-extubated and was re-intubated without incident. He developed a leukocytosis and was started on cipro for a positive urinalysis. There was no growth on culture, and cipro was discontinued. Tube feeds were started on POD 3. He was extubated on POD 4. By this time, all vasoactive drips had been weaned. Coumadin was resumed for chronic a-fib. Chest tubes and pacing wires were discontinued without complication. Beta-blocker was initiated and the patient was gently diuresed toward the pre-operative weight. ACE Inhibitor was not initiated due to a rise in Creatinine, which would start to trend down prior to discharge. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #10 the patient was ambulating freely, and pain was controlled with oral analgesics. Due to upper and lower pole serosanguinous sternal drainage, Mr.<Name>Turcios</Name> was placed on prophylactic antibiotics x 1 week per Dr.<Name>Ivory</Name>. The patient was discharged to <Hospital>Maynard-Davis Clinic</Hospital> Rehab in good condition with appropriate follow up instructions. Medications on Admission: DILTIAZEM HCL [CARDIZEM CD] - 240 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth every day FUROSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day HOME OXYGEN - - use as directed by nasal cannula once a day ( 1-2 liters by nasal cannula) LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - 850 mg Tablet - 1 (One) Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once a day MUPIROCIN - 2 % Ointment - apply to affected area (s) twice a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s) sublingually PRN for CP OVERNIGHT OXIMETRY ON ROOM AIR - - As Directed Dx: CAD, Dyspnea PHYSICAL CONDITIONING AND STRENGTHENING - - for diabetic neuropathy, gait instability and general weakness; 1-3 visits weekly; evaluation and treatment PREGABALIN [LYRICA] - 50 mg Capsule - 2 Capsule(s) by mouth three times a day for painful diabetic neuropathy SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth no more than every day as directed SIMVASTATIN [ZOCOR] - 10 mg Tablet - 1 Tablet(s) by mouth every day SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day PROPECIA Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or temp>38.4. 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) for 7 days. 15. warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 16. warfarin 1 mg Tablet Sig: MD to dose daily Tablet PO once a day: indication:Atrial Fibrillation/ INR goal=2-2.5. 17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical <Hospital>Warren-Miller Medical Center</Hospital> (2 times a day) as needed for dry skin. 18. furosemide 10 mg/mL Solution Sig: Eight (8) Injection <Hospital>Warren-Miller Medical Center</Hospital> (2 times a day): total=80 mg <Hospital>Warren-Miller Medical Center</Hospital>. 19. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID (2 times a day). Discharge Disposition: Extended Care Facility: <Hospital>Clark and Sons Hospital</Hospital> for the Aged - MACU Discharge Diagnosis: Atrial fibrillation Coronary Artery Disease Aortic Stenosis PMH: Diastolic and Systolic CHF (EF 30-35%) Type 2 diabetes Hypertension Hypercholesterolemia Chronic Back Pain degenerative neurological disease ? MS Bilateral drop foot Discharge Condition: Alert and oriented x3 nonfocal Max Assist Sternal pain managed with oral analgesics Sternal Incision - scant serosanguinous drainage from upper and lower pole. Sternum stable. Mild erythema-evaluated by Dr.<Name>Ivory</Name> prior to Dc. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns <Telephone>429-667-9529</Telephone> Please call cardiac surgery office with any questions or concerns <Telephone>429-667-9529</Telephone>. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. <Name>Ivory</Name> on <Date>9-4</Date> at 1:30pm (<Telephone>429-667-9529</Telephone>) Cardiologist Dr. <Name>Caleb</Name> <Name>Camargo</Name> <Date>10-9</Date> at 3:15pm Please call to schedule the following: Primary Care Dr. <Name>Ivory</Name>,<Name>Evan</Name> J. <Telephone>613-376-5867</Telephone> in <Date>4-21</Date> weeks Please call cardiac surgery office with any questions or concerns <Telephone>429-667-9529</Telephone>. Answering service will contact on call person during off hours Labs: PT/INR Coumadin for A-Fib Goal INR 2-2.5 Please arrange for coumadin follow-up on discharge from rehab Completed by:<Date>1941-7-4</Date>	0000000000000000011111111110000000000000000000000000000000011111111000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000001111111111000000000000000000000000000001111111110000000000000000000000000000000000000111111111000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1938-12-14 Discharge Date: 1941-7-4 Date of Birth: 1955-8-5 Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:Henry Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: 1953-1-31 1. Left atrial appendage resection. 2. Coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery, and reverse saphenous vein graft to the posterior descending artery and obtuse marginal artery. 3. Aortic valve replacement with a 25-mm St. Jacob Epic tissue valve, model #EFT100-25- 00. History of Present Illness: 66 year old male who presented with worsening shortness of breath and hypotension. He presented to his PCP's office for follow up and was noted to be short of breath and hypotensive with SBP's in the 80's. His symptoms started approximately 2-3 weeks prior to presentation. He mainly had difficulty with shortness of breath. This shortness of breath would prevent him from sleeping comfortably. He describes symptoms consistent with orthopnea and PND. He notes that he saw Dr. Ivory a couple of weeks ago and was started on lasix and aldactone. He was also noted to be in atrial fibrillation at that time as well. He is now being referred to cardiac surgery for evaluation of revascularization and possible aortic valve replacement. Past Medical History: Atrial fibrillation Coronary Artery Disease Aortic Stenosis PMH: Diastolic and Systolic CHF (EF 30-35%) Type 2 diabetes Hypertension Hypercholesterolemia Chronic Back Pain degenerative neurological disease ? MS Bilateral drop foot Social History: Lives with his wife. Retired for 30 years, used to own a bagel shop and was a landlord. Able to ambulate around the home with assistance and/or walker. Uses a wheelchair outside of the home. -Tobacco: smoked 1 ppd for 40 yrs, quit about 6 months ago -EtOH: drinks 3-4 glasses of scotch or wine daily -Drugs: marijuana ~once weekly Family History: Father died of an MI at age 73. Mother died at 78 of unknown causes. Physical Exam: Pulse:94 Resp:18 O2 sat:98/RA B/P Right:117/84 Left:116/78 Height:73" Weight:97.2 kgs General: Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [xx] bowel sounds + [] Extremities: Warm [x], well-perfused [] Edema [x] +1 edema ankles/feet,mild purplish discolouration to balateral feet_____ Varicosities: None [x] Neuro: Grossly intact []upper extremity hand grasps week bilaterally, lower ext bilateral weakness, can raise both legs off bed but poor resistence, bilaterl foot drop, thought process slow Pulses: Femoral Right:cath site Left:+1 DP Right:trace Left:trace PT Lisa Feguson: trace Left:trace Radial Right: +2 Left:+2 Carotid Bruit Right: +1 Left:+1 Pertinent Results: ADMISSION LABS: 1938-12-14 06:30PM BLOOD WBC-15.1* RBC-4.56* Hgb-14.7 Hct-41.4 MCV-91 MCH-32.2* MCHC-35.5* RDW-12.8 Plt Ct-176 1938-12-14 06:30PM BLOOD PT-13.8* PTT-26.5 INR(PT)-1.2* 1938-12-14 06:30PM BLOOD Glucose-126* UreaN-31* Creat-2.1* Na-130* K-5.7* Cl-95* HCO3-23 AnGap-18 1933-8-25 06:25AM BLOOD ALT-21 AST-24 LD(LDH)-277* CK(CPK)-73 AlkPhos-129 TotBili-0.5 1938-12-14 06:30PM BLOOD proBNP-7438* 1938-12-14 06:30PM BLOOD cTropnT-0.07* 1933-8-25 06:25AM BLOOD CK-MB-3 cTropnT-0.07* 1933-8-25 06:15PM BLOOD CK-MB-3 cTropnT-0.05* CXR 1938-12-14: Semi-upright portable AP view of the chest obtained. Moderate-to-severe cardiomegaly with diffuse ground-glass haziness throughout the lungs compatible with pulmonary edema. The right hemidiaphragm remains somewhat elevated and overall low lung volumes are noted which somewhat limit the evaluation. There are no large pleural effusions and no sign of pneumothorax. Hilar engorgement is compatible with congestive heart failure. Bony structures appear intact. IMPRESSION: Cardiomegaly, pulmonary edema. LHC 1917-3-7: 1) Selective coronary angiography of this right-dominant system demonstrated severe three vessel CAD. The LMCA was normal without any angiographically-apparent flow-limiting lesions. The stent in the proximal LAD had diffuse 60% in-stent restenosis. There was 80% stenosis throuhgout the proximal LCX, with a 60-70% stenosis at the origin of the OMB. The RCA had a 100% proximal stenosis with prominent left-to-right collaterals. 2) Resting hemodynamics showed elevated right and left-sided filling pressures with an RVEDP of 17 mmHg and an LVEDP of 27 mmHg. The peak gradient over the aortic valve was 14 mmHg. Using the Gorlin equation, the 165 Amy Shores Apt. 673 North Mathewfurt, NH 67854 was calculated to be 1.1 cm2, indicating moderate aortic stenosis. 3) Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate aortic stenosis. 3. Atrial fibrillation with rapid ventricular response. 4. Needs diuresis prior to cardioversion. 5. Consideration for AVR-CABG. LENI 1918-4-20: negative for DVT Carotid U/S 1918-4-20: Panorex 1918-4-20: Brief Hospital Course: The patient underwent the usual preoperative work-up. Dental examined the patient and recommended extraction of one tooth. The patient refused. The patient was brought to the operating room on 1953-1-31 where the patient underwent AVR (tissue), CABG x 3, resection of left atrial appendage with Dr. Ivory. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He does have a history of heart failure with an EF of 30% and initially required multiple inotropes and vasopressors. He remained intubated due to pulmonary congestion, which improved with diuresis. Rapid a-fib developed and amiodarone drip was initiated. This was discontinued when rate was controlled. He failed a trial of Precedex. He self-extubated and was re-intubated without incident. He developed a leukocytosis and was started on cipro for a positive urinalysis. There was no growth on culture, and cipro was discontinued. Tube feeds were started on POD 3. He was extubated on POD 4. By this time, all vasoactive drips had been weaned. Coumadin was resumed for chronic a-fib. Chest tubes and pacing wires were discontinued without complication. Beta-blocker was initiated and the patient was gently diuresed toward the pre-operative weight. ACE Inhibitor was not initiated due to a rise in Creatinine, which would start to trend down prior to discharge. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #10 the patient was ambulating freely, and pain was controlled with oral analgesics. Due to upper and lower pole serosanguinous sternal drainage, Mr.Turcios was placed on prophylactic antibiotics x 1 week per Dr.Ivory. The patient was discharged to Maynard-Davis Clinic Rehab in good condition with appropriate follow up instructions. Medications on Admission: DILTIAZEM HCL [CARDIZEM CD] - 240 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth every day FUROSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day HOME OXYGEN - - use as directed by nasal cannula once a day ( 1-2 liters by nasal cannula) LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - 850 mg Tablet - 1 (One) Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once a day MUPIROCIN - 2 % Ointment - apply to affected area (s) twice a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s) sublingually PRN for CP OVERNIGHT OXIMETRY ON ROOM AIR - - As Directed Dx: CAD, Dyspnea PHYSICAL CONDITIONING AND STRENGTHENING - - for diabetic neuropathy, gait instability and general weakness; 1-3 visits weekly; evaluation and treatment PREGABALIN [LYRICA] - 50 mg Capsule - 2 Capsule(s) by mouth three times a day for painful diabetic neuropathy SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth no more than every day as directed SIMVASTATIN [ZOCOR] - 10 mg Tablet - 1 Tablet(s) by mouth every day SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day PROPECIA Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or temp>38.4. 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) for 7 days. 15. warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 16. warfarin 1 mg Tablet Sig: MD to dose daily Tablet PO once a day: indication:Atrial Fibrillation/ INR goal=2-2.5. 17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical Warren-Miller Medical Center (2 times a day) as needed for dry skin. 18. furosemide 10 mg/mL Solution Sig: Eight (8) Injection Warren-Miller Medical Center (2 times a day): total=80 mg Warren-Miller Medical Center. 19. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Clark and Sons Hospital for the Aged - MACU Discharge Diagnosis: Atrial fibrillation Coronary Artery Disease Aortic Stenosis PMH: Diastolic and Systolic CHF (EF 30-35%) Type 2 diabetes Hypertension Hypercholesterolemia Chronic Back Pain degenerative neurological disease ? MS Bilateral drop foot Discharge Condition: Alert and oriented x3 nonfocal Max Assist Sternal pain managed with oral analgesics Sternal Incision - scant serosanguinous drainage from upper and lower pole. Sternum stable. Mild erythema-evaluated by Dr.Ivory prior to Dc. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns 429-667-9529 Please call cardiac surgery office with any questions or concerns 429-667-9529. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. Ivory on 9-4 at 1:30pm (429-667-9529) Cardiologist Dr. Caleb Camargo 10-9 at 3:15pm Please call to schedule the following: Primary Care Dr. Ivory,Evan J. 613-376-5867 in 4-21 weeks Please call cardiac surgery office with any questions or concerns 429-667-9529. Answering service will contact on call person during off hours Labs: PT/INR Coumadin for A-Fib Goal INR 2-2.5 Please arrange for coumadin follow-up on discharge from rehab Completed by:1941-7-4	["Admission Date: 1938-12-14 Discharge Date: 1941-7-4\n\nDate of Birth: 1955-8-5 Sex: M\n\nService: CARDIOTHORACIC\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Henry\nChief Complaint:\nDyspnea\n\nMajor Surgical or Invasive Procedure:\n1953-1-31\n1. Left atrial appendage resection.\n2. Coronary artery bypass grafting x3: Left internal\n mammary artery to left anterior descending artery, and\n reverse saphenous vein graft to the posterior descending\n artery and obtuse marginal artery.\n3. Aortic valve replacement with a 25-mm St. Jacob Epic\n tissue valve, model #EFT100-25- 00.\n\n\nHistory of Present Illness:\n66 year old male who presented with worsening shortness of\nbreath and hypotension. He presented to his PCP's office for\nfollow up and was noted to be short of breath and hypotensive\nwith SBP's in the 80's.", ' His symptoms\nstarted approximately 2-3 weeks prior to presentation. He mainly\nhad difficulty with shortness of breath. This shortness of\nbreath\nwould prevent him from sleeping comfortably. He describes\nsymptoms consistent with orthopnea and PND. He notes that he saw\nDr. Ivory a couple of weeks ago and was started on lasix and\naldactone. He was also noted to be in atrial fibrillation at\nthat\ntime as well. He is now being referred to cardiac surgery for\nevaluation of revascularization and possible aortic valve\nreplacement.\n\n\nPast Medical History:\nAtrial fibrillation\nCoronary Artery Disease\nAortic Stenosis\nPMH:\nDiastolic and Systolic CHF (EF 30-35%)\nType 2 diabetes\nHypertension\nHypercholesterolemia\nChronic Back Pain\ndegenerative neurological disease ? MS\nBilateral drop foot\n\n\nSocial History:\nLives with his wife.', ' Retired for 30 years, used to own a bagel\nshop and was a landlord. Able to ambulate around the home with\nassistance and/or walker. Uses a wheelchair outside of the home.\n-Tobacco: smoked 1 ppd for 40 yrs, quit about 6 months ago\n-EtOH: drinks 3-4 glasses of scotch or wine daily\n-Drugs: marijuana ~once weekly\n\nFamily History:\nFather died of an MI at age 73. Mother died at 78 of unknown\ncauses.\n\nPhysical Exam:\nPulse:94 Resp:18 O2 sat:98/RA\nB/P Right:117/84 Left:116/78\nHeight:73" Weight:97.2 kgs\n\nGeneral:\nSkin: Dry [] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [] grade ______\nAbdomen: Soft [x] non-distended [x] non-tender [xx] bowel\nsounds\n+ []\nExtremities: Warm [x], well-perfused [] Edema [x] +1 edema\nankles/feet,mild purplish discolouration to balateral feet_____\nVaricosities: None [x]\nNeuro: Grossly intact []upper extremity hand grasps week\nbilaterally, lower ext bilateral weakness, can raise both legs\noff bed but poor resistence, bilaterl foot drop, thought process\nslow\nPulses:\nFemoral Right:cath site Left:+1\nDP Right:trace Left:trace\nPT Lisa Feguson: trace Left:trace\nRadial Right: +2 Left:+2\n\nCarotid Bruit Right: +1 Left:+1\n\n\nPertinent Results:\nADMISSION LABS:\n1938-12-14 06:30PM BLOOD WBC-15.', '1* RBC-4.56* Hgb-14.7 Hct-41.4\nMCV-91 MCH-32.2* MCHC-35.5* RDW-12.8 Plt Ct-176\n1938-12-14 06:30PM BLOOD PT-13.8* PTT-26.5 INR(PT)-1.2\n1938-12-14 06:30PM BLOOD Glucose-126 UreaN-31* Creat-2.1* Na-130\nK-5.7 Cl-95* HCO3-23 AnGap-18\n1933-8-25 06:25AM BLOOD ALT-21 AST-24 LD(LDH)-277* CK(CPK)-73\nAlkPhos-129 TotBili-0.5\n1938-12-14 06:30PM BLOOD proBNP-7438\n1938-12-14 06:30PM BLOOD cTropnT-0.07\n1933-8-25 06:25AM BLOOD CK-MB-3 cTropnT-0.07\n1933-8-25 06:15PM BLOOD CK-MB-3 cTropnT-0.05\n\nCXR 1938-12-14:\nSemi-upright portable AP view of the chest obtained.\nModerate-to-severe cardiomegaly with diffuse ground-glass\nhaziness throughout the lungs compatible with pulmonary edema.\nThe right hemidiaphragm remains somewhat elevated and overall\nlow lung volumes are noted which somewhat limit the evaluation.', '\nThere are no large pleural effusions and no sign of\npneumothorax. Hilar engorgement is compatible with congestive\nheart failure. Bony structures appear intact.\nIMPRESSION: Cardiomegaly, pulmonary edema.\n\nLHC 1917-3-7:\n1) Selective coronary angiography of this right-dominant system\ndemonstrated severe three vessel CAD. The LMCA was normal\nwithout any\nangiographically-apparent flow-limiting lesions. The stent in\nthe\nproximal LAD had diffuse 60% in-stent restenosis. There was 80%\nstenosis\nthrouhgout the proximal LCX, with a 60-70% stenosis at the\norigin of the\nOMB. The RCA had a 100% proximal stenosis with prominent\nleft-to-right\ncollaterals.\n2) Resting hemodynamics showed elevated right and left-sided\nfilling\npressures with an RVEDP of 17 mmHg and an LVEDP of 27 mmHg. The\npeak\ngradient over the aortic valve was 14 mmHg.', ' Using the Gorlin\nequation,\nthe 165 Amy Shores Apt. 673\nNorth Mathewfurt, NH 67854 was calculated to be 1.1 cm2, indicating moderate aortic\n\nstenosis.\n3) Left ventriculography was deferred.\n\nFINAL DIAGNOSIS:\n1. Three vessel coronary artery disease.\n2. Moderate aortic stenosis.\n3. Atrial fibrillation with rapid ventricular response.\n4. Needs diuresis prior to cardioversion.\n5. Consideration for AVR-CABG.\n\nLENI 1918-4-20: negative for DVT\n\nCarotid U/S 1918-4-20:\n\nPanorex 1918-4-20:\n\n\nBrief Hospital Course:\nThe patient underwent the usual preoperative work-up. Dental\nexamined the patient and recommended extraction of one tooth.\nThe patient refused.\nThe patient was brought to the operating room on 1953-1-31 where\nthe patient underwent AVR (tissue), CABG x 3, resection of left\natrial appendage with Dr.', ' Ivory. Overall the patient tolerated\nthe procedure well and post-operatively was transferred to the\nCVICU in stable condition for recovery and invasive monitoring.\nHe does have a history of heart failure with an EF of 30% and\ninitially required multiple inotropes and vasopressors. He\nremained intubated due to pulmonary congestion, which improved\nwith diuresis. Rapid a-fib developed and amiodarone drip was\ninitiated. This was discontinued when rate was controlled. He\nfailed a trial of Precedex. He self-extubated and was\nre-intubated without incident. He developed a leukocytosis and\nwas started on cipro for a positive urinalysis. There was no\ngrowth on culture, and cipro was discontinued. Tube feeds were\nstarted on POD 3. He was extubated on POD 4. By this time, all\nvasoactive drips had been weaned.', ' Coumadin was resumed for\nchronic a-fib. Chest tubes and pacing wires were discontinued\nwithout complication. Beta-blocker was initiated and the\npatient was gently diuresed toward the pre-operative weight.\nACE Inhibitor was not initiated due to a rise in Creatinine,\nwhich would start to trend down prior to discharge. The patient\nwas evaluated by the physical therapy service for assistance\nwith strength and mobility. By the time of discharge on POD #10\nthe patient was ambulating freely, and pain was controlled with\noral analgesics. Due to upper and lower pole serosanguinous\nsternal drainage, Mr.Turcios was placed on prophylactic\nantibiotics x 1 week per Dr.Ivory. The patient was discharged to\nMaynard-Davis Clinic Rehab in good condition with appropriate follow up\ninstructions.\n\nMedications on Admission:\nDILTIAZEM HCL [CARDIZEM CD] - 240 mg Capsule, Ext Release 24 hr\n- 1 Capsule(s) by mouth every day\nFUROSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day\nHOME OXYGEN - - use as directed by nasal cannula once a day (\n1-2 liters by nasal cannula)\nLISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day\nMETFORMIN - 850 mg Tablet - 1 (One) Tablet(s) by mouth twice a\nday\nMETOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1\n(One) Tablet(s) by mouth once a day\nMUPIROCIN - 2 % Ointment - apply to affected area (s) twice a\nday\nNITROGLYCERIN - 0.', '4 mg Tablet, Sublingual - one Tablet(s)\nsublingually PRN for CP\nOVERNIGHT OXIMETRY ON ROOM AIR - - As Directed Dx: CAD, Dyspnea\n\nPHYSICAL CONDITIONING AND STRENGTHENING - - for diabetic\nneuropathy, gait instability and general weakness; 1-3 visits\nweekly; evaluation and treatment\nPREGABALIN [LYRICA] - 50 mg Capsule - 2 Capsule(s) by mouth\nthree times a day for painful diabetic neuropathy\nSILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth no\nmore than every day as directed\nSIMVASTATIN [ZOCOR] - 10 mg Tablet - 1 Tablet(s) by mouth every\nday\nSPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day\n\nPROPECIA\n\nDischarge Medications:\n1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\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 pain or temp>38.4.\n4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal\nDAILY (Daily) as needed for constipation.\n5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO\nQ4H (every 4 hours) as needed for pain.\n6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n7. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4\ntimes a day).\n8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times\na day).\n9. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times\na day).\n10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)\nInjection TID (3 times a day).\n12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).', '\n13. insulin regular human 100 unit/mL Solution Sig: One (1)\nInjection ASDIR (AS DIRECTED).\n14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO QID (4\ntimes a day) for 7 days.\n15. warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for\n1 doses.\n16. warfarin 1 mg Tablet Sig: MD to dose daily Tablet PO once a\nday: indication:Atrial Fibrillation/ INR goal=2-2.5.\n17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical\nWarren-Miller Medical Center (2 times a day) as needed for dry skin.\n18. furosemide 10 mg/mL Solution Sig: Eight (8) Injection Warren-Miller Medical Center\n(2 times a day): total=80 mg Warren-Miller Medical Center.\n19. potassium chloride 10 mEq Tablet Extended Release Sig: Two\n(2) Tablet Extended Release PO BID (2 times a day).\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nClark and Sons Hospital for the Aged - MACU\n\nDischarge Diagnosis:\nAtrial fibrillation\nCoronary Artery Disease\nAortic Stenosis\nPMH:\nDiastolic and Systolic CHF (EF 30-35%)\nType 2 diabetes\nHypertension\nHypercholesterolemia\nChronic Back Pain\ndegenerative neurological disease ? MS\nBilateral drop foot\n\n\nDischarge Condition:\nAlert and oriented x3 nonfocal\nMax Assist\nSternal pain managed with oral analgesics\nSternal Incision - scant serosanguinous drainage from upper and\nlower pole.', ' Sternum stable. Mild erythema-evaluated by Dr.Ivory\nprior to Dc.\nEdema 1+\n\n\nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild\nsoap, no baths or swimming, and look at your incisions\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\nNo driving for approximately one month and while taking\nnarcotics, will be discussed at follow up appointment with\nsurgeon when you will be able to drive\nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns 429-667-9529\nPlease call cardiac surgery office with any questions or\nconcerns 429-667-9529. Answering service will contact on call\nperson during off hours\nFemales: Please wear bra to reduce pulling on incision, avoid\nrubbing on lower edge\n\n\nFollowup Instructions:\nYou are scheduled for the following appointments:\nSurgeon Dr.', ' Ivory on 9-4 at 1:30pm (429-667-9529)\nCardiologist Dr. Caleb Camargo 10-9 at 3:15pm\n\nPlease call to schedule the following:\nPrimary Care Dr. Ivory,Evan J. 613-376-5867 in 4-21 weeks\n\nPlease call cardiac surgery office with any questions or\nconcerns 429-667-9529. Answering service will contact on call\nperson during off hours\n\nLabs: PT/INR\nCoumadin for A-Fib\nGoal INR 2-2.5\nPlease arrange for coumadin follow-up on discharge from\nrehab\n\n\n\nCompleted by:1941-7-4']
189	17483	189331.0	2147-07-01	Discharge summary	Report	Admission Date: [2147-6-24] Discharge Date: [2147-7-1] Service: ICU HISTORY OF PRESENT ILLNESS: The patient is an 84 year-old female admitted with mental status changes. She is an elderly woman who was institutionalized at a nursing home for the past two months with a history of Crohn's disease who was admitted with a Crohn's flare and diarrhea on [2147-6-24]. Additionally, she was noted to be more lethargic then usual. PAST MEDICAL HISTORY: Crohn's disease, hypertension, diverticulitis, osteoarthritis, palpable deep venous thrombosis, urinary tract infection. MEDICATIONS: Celexa, folate, Pentasa, Ritalin, Nadolol. ALLERGIES: Penicillin. FAMILY HISTORY: No history of IBD. SOCIAL HISTORY: Nursing home resident. PHYSICAL EXAMINATION: Blood pressure 109/52. Chest clear to auscultation. Abdomen guaiac negative, diffusely firm abdomen. HOSPITAL COURSE: The patient is an 84 year-old woman with inflammatory bowel disease admitted with hypotension, dehydration, acute renal failure and urinary tract infection. The patient was treated aggressively for the above issues. Specifically for sepsis and Crohn's flare. She continued to have a low blood pressure during her hospital stay and was put on blood pressure supporting medication. She was treated on antibiotics for her sepsis and she was treated with Methylamine and Protonix for her Crohn's flare. Despite these efforts the patient continued to deteriorate clinically and family meetings were held to keep the family aware of her poor prognosis. On [2147-7-1] at 6:01 a.m. the patient expired despite aggressive fluid and pressor support. Her niece [Name (NI) 1894] [Name (NI) 805] was notified. FINAL DIAGNOSES: 1. Crohn's flare. 2. Sepsis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1895], M.D. [MD Number(1) 1896] Dictated By:[Last Name (NamePattern1) 1897] MEDQUIST36 D: [2147-8-28] 17:02 T: [2147-9-5] 06:59 JOB#: [Job Number 1898]	Admission Date: <Date>1940-3-2</Date> Discharge Date: <Date>2002-5-2</Date> Service: ICU HISTORY OF PRESENT ILLNESS: The patient is an 84 year-old female admitted with mental status changes. She is an elderly woman who was institutionalized at a nursing home for the past two months with a history of Crohn's disease who was admitted with a Crohn's flare and diarrhea on <Date>1940-3-2</Date>. Additionally, she was noted to be more lethargic then usual. PAST MEDICAL HISTORY: Crohn's disease, hypertension, diverticulitis, osteoarthritis, palpable deep venous thrombosis, urinary tract infection. MEDICATIONS: Celexa, folate, Pentasa, Ritalin, Nadolol. ALLERGIES: Penicillin. FAMILY HISTORY: No history of IBD. SOCIAL HISTORY: Nursing home resident. PHYSICAL EXAMINATION: Blood pressure 109/52. Chest clear to auscultation. Abdomen guaiac negative, diffusely firm abdomen. HOSPITAL COURSE: The patient is an 84 year-old woman with inflammatory bowel disease admitted with hypotension, dehydration, acute renal failure and urinary tract infection. The patient was treated aggressively for the above issues. Specifically for sepsis and Crohn's flare. She continued to have a low blood pressure during her hospital stay and was put on blood pressure supporting medication. She was treated on antibiotics for her sepsis and she was treated with Methylamine and Protonix for her Crohn's flare. Despite these efforts the patient continued to deteriorate clinically and family meetings were held to keep the family aware of her poor prognosis. On <Date>2002-5-2</Date> at 6:01 a.m. the patient expired despite aggressive fluid and pressor support. Her niece <Name>Natividad Cobbs</Name> <Name>Ubaldo Lofft</Name> was notified. FINAL DIAGNOSES: 1. Crohn's flare. 2. Sepsis. <Name>Diane</Name> <Name>Feudner</Name>, M.D. <MD Number>36990548</MD Number> Dictated By:<Name>Dizon</Name> MEDQUIST36 D: <Date>1960-4-17</Date> 17:02 T: <Date>1976-11-21</Date> 06:59 JOB#: <Job Number>Richardson, Frazier and Martinez-1996-700361</Job Number>	00000000000000000111111110000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111101111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111101111111000000001111111100000000000000111110000000000000000001111111110000000000001111111111000000000000000111111111111111111111111111111111111111111110	Admission Date: 1940-3-2 Discharge Date: 2002-5-2 Service: ICU HISTORY OF PRESENT ILLNESS: The patient is an 84 year-old female admitted with mental status changes. She is an elderly woman who was institutionalized at a nursing home for the past two months with a history of Crohn's disease who was admitted with a Crohn's flare and diarrhea on 1940-3-2. Additionally, she was noted to be more lethargic then usual. PAST MEDICAL HISTORY: Crohn's disease, hypertension, diverticulitis, osteoarthritis, palpable deep venous thrombosis, urinary tract infection. MEDICATIONS: Celexa, folate, Pentasa, Ritalin, Nadolol. ALLERGIES: Penicillin. FAMILY HISTORY: No history of IBD. SOCIAL HISTORY: Nursing home resident. PHYSICAL EXAMINATION: Blood pressure 109/52. Chest clear to auscultation. Abdomen guaiac negative, diffusely firm abdomen. HOSPITAL COURSE: The patient is an 84 year-old woman with inflammatory bowel disease admitted with hypotension, dehydration, acute renal failure and urinary tract infection. The patient was treated aggressively for the above issues. Specifically for sepsis and Crohn's flare. She continued to have a low blood pressure during her hospital stay and was put on blood pressure supporting medication. She was treated on antibiotics for her sepsis and she was treated with Methylamine and Protonix for her Crohn's flare. Despite these efforts the patient continued to deteriorate clinically and family meetings were held to keep the family aware of her poor prognosis. On 2002-5-2 at 6:01 a.m. the patient expired despite aggressive fluid and pressor support. Her niece Natividad Cobbs Ubaldo Lofft was notified. FINAL DIAGNOSES: 1. Crohn's flare. 2. Sepsis. Diane Feudner, M.D. 36990548 Dictated By:Dizon MEDQUIST36 D: 1960-4-17 17:02 T: 1976-11-21 06:59 JOB#: Richardson, Frazier and Martinez-1996-700361	["Admission Date: 1940-3-2 Discharge Date: 2002-5-2\n\n\nService: ICU\n\nHISTORY OF PRESENT ILLNESS: The patient is an 84 year-old\nfemale admitted with mental status changes. She is an elderly\nwoman who was institutionalized at a nursing home for the\npast two months with a history of Crohn's disease who was\nadmitted with a Crohn's flare and diarrhea on 1940-3-2.\nAdditionally, she was noted to be more lethargic then usual.\n\nPAST MEDICAL HISTORY: Crohn's disease, hypertension,\ndiverticulitis, osteoarthritis, palpable deep venous\nthrombosis, urinary tract infection.\n\nMEDICATIONS: Celexa, folate, Pentasa, Ritalin, Nadolol.\n\nALLERGIES: Penicillin.\n\nFAMILY HISTORY: No history of IBD.\n\nSOCIAL HISTORY: Nursing home resident.\n\nPHYSICAL EXAMINATION: Blood pressure 109/52. Chest clear to\nauscultation.", " Abdomen guaiac negative, diffusely firm\nabdomen.\n\nHOSPITAL COURSE: The patient is an 84 year-old woman with\ninflammatory bowel disease admitted with hypotension,\ndehydration, acute renal failure and urinary tract infection.\nThe patient was treated aggressively for the above issues.\nSpecifically for sepsis and Crohn's flare. She continued to\nhave a low blood pressure during her hospital stay and was\nput on blood pressure supporting medication. She was treated\non antibiotics for her sepsis and she was treated with\nMethylamine and Protonix for her Crohn's flare. Despite\nthese efforts the patient continued to deteriorate clinically\nand family meetings were held to keep the family aware of her\npoor prognosis. On 2002-5-2 at 6:01 a.m. the patient\nexpired despite aggressive fluid and pressor support.", " Her\nniece Natividad Cobbs Ubaldo Lofft was notified.\n\nFINAL DIAGNOSES:\n1. Crohn's flare.\n2. Sepsis.\n\n\n\n\n\n\n Diane Feudner, M.D. 36990548\n\nDictated By:Dizon\n\nMEDQUIST36\n\nD: 1960-4-17 17:02\nT: 1976-11-21 06:59\nJOB#: Richardson, Frazier and Martinez-1996-700361\n"]
190	9590	132347.0	2102-03-10	Discharge summary	Report	Admission Date: [2102-2-19] Discharge Date: [2102-3-9] Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 79-year-old female with a history of atrial fibrillation on Coumadin, hypertension, and cerebellar cerebrovascular accident, who presented to the Emergency Department complaining of nausea, no vomiting, and headache since one night prior to admission. When the patient woke up this morning the patient had progressive dysarthria. The patient denied any visual or auditory changes. The patient also denied any fevers, chills, changes in bowel habits, chest pain, shortness of breath, melena, bright red blood per rectum, and hematemesis. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Cerebrovascular accident. MEDICATIONS AT HOME: 1. Atenolol. 2. Coumadin. 3. Plendil. 4. Lipitor. 5. Avapro. 6. Neurontin. 7. Hydralazine. ALLERGIES: 1. Codeine. 2. Macrodantin. PHYSICAL EXAMINATION: The patient's temperature was 96.8, pulse 71, blood pressure 206/110, respiratory rate 16, oxygen saturation was 94% on room air. The patient was alert and oriented x 3 in no acute distress. The patient's speech was dysarthric. The patient's pupils were equal, round and reactive to light. The patient's extraocular movements were intact. The patient had symmetric eyebrow lift, and symmetric smile. The patient had no tongue deviation, no pronator drift. The patient had 5+ strength in the shoulders and hands. The patient's heart rate was irregularly irregular. Lungs were clear to auscultation bilaterally. The patient was moving all extremities and had 5+ strength. The patient's cranial nerves two through 12 were intact. LABORATORY STUDIES: White blood cell count was 13.3, hematocrit 46.6, platelet count 305. The patient's PT was 23.4, PTT 44.5 and INR was 3.6. The patient's chemistries were normal. CT scan done on [2-19] showed left cerebellar intraparenchymal hemorrhage. HOSPITAL COURSE: The patient was admitted to the neurosurgery service for management. The patient was started on fresh frozen plasma to reverse her INR down to less than 1.3. The patient was started on a Nipride drip to decrease blood pressure. The patient was put on q. 1 hour neurological checks and was admitted to the intensive care unit. The patient was taken to the operating room on [2102-2-20] for posterior fossa craniotomy for evacuation of cerebellar hemorrhage. The patient also underwent placement of right frontal ventriculostomy drain. Postoperatively the patient had tolerated the procedure well and an ENT consultation was obtained for evaluation of dysarthria and dysphasia. The patient was gradually weaned off the ventilator. The ventriculostomy drain pressures gradually increased to 20 cm of water. The patient's intracranial pressure did not increase with the increasing drain pressure. The ventriculostomy drain was taken out on [2102-3-8]. The patient was reevaluated by [Hospital1 ] for rehabilitation screening. The patient was accepted by [Hospital1 ] and was ready for transfer to [Hospital1 ] for rehabilitation on [2102-3-9]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. DISCHARGE MEDICATIONS: 1. Metoprolol 100 mg p.o. t.i.d. 2. Glutamine 5 mg p.o. b.i.d. 3. Coumadin 0.1 mg p.o. t.i.d. 4. Multivitamins 1 capsule p.o. q.d. 5. Amlodipine 10 mg p.o. q.d. 6. Hydralazine 50 mg p.o. q. 6. 7. Colace 100 mg p.o. b.i.d. 8. Albuterol nebulizer 1 neb q. 6 hours. 9. Atrovent nebulizer 1 neb q. 6 hours. 10. Losartan 50 mg p.o. b.i.d. 11. Lansoprazole 50 mg p.o. q.d. 12. Insulin sliding scale. FOLLOW UP: The patient should follow up with Dr. [Last Name (STitle) 1906] from neurosurgery. Please call Dr.[Name (NI) 1907] office for an appointment. [First Name8 (NamePattern2) 900] [Last Name (NamePattern1) ], MD [MD Number(1) 1908] Dictated By:[Last Name (NamePattern1) 1909] MEDQUIST36 D: [2102-3-9] 06:05 T: [2102-3-9] 07:43 JOB#: [Job Number 1910]	Admission Date: <Date>1914-8-19</Date> Discharge Date: <Date>1959-10-24</Date> Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 79-year-old female with a history of atrial fibrillation on Coumadin, hypertension, and cerebellar cerebrovascular accident, who presented to the Emergency Department complaining of nausea, no vomiting, and headache since one night prior to admission. When the patient woke up this morning the patient had progressive dysarthria. The patient denied any visual or auditory changes. The patient also denied any fevers, chills, changes in bowel habits, chest pain, shortness of breath, melena, bright red blood per rectum, and hematemesis. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Cerebrovascular accident. MEDICATIONS AT HOME: 1. Atenolol. 2. Coumadin. 3. Plendil. 4. Lipitor. 5. Avapro. 6. Neurontin. 7. Hydralazine. ALLERGIES: 1. Codeine. 2. Macrodantin. PHYSICAL EXAMINATION: The patient's temperature was 96.8, pulse 71, blood pressure 206/110, respiratory rate 16, oxygen saturation was 94% on room air. The patient was alert and oriented x 3 in no acute distress. The patient's speech was dysarthric. The patient's pupils were equal, round and reactive to light. The patient's extraocular movements were intact. The patient had symmetric eyebrow lift, and symmetric smile. The patient had no tongue deviation, no pronator drift. The patient had 5+ strength in the shoulders and hands. The patient's heart rate was irregularly irregular. Lungs were clear to auscultation bilaterally. The patient was moving all extremities and had 5+ strength. The patient's cranial nerves two through 12 were intact. LABORATORY STUDIES: White blood cell count was 13.3, hematocrit 46.6, platelet count 305. The patient's PT was 23.4, PTT 44.5 and INR was 3.6. The patient's chemistries were normal. CT scan done on <Date>12-12</Date> showed left cerebellar intraparenchymal hemorrhage. HOSPITAL COURSE: The patient was admitted to the neurosurgery service for management. The patient was started on fresh frozen plasma to reverse her INR down to less than 1.3. The patient was started on a Nipride drip to decrease blood pressure. The patient was put on q. 1 hour neurological checks and was admitted to the intensive care unit. The patient was taken to the operating room on <Date>1920-1-19</Date> for posterior fossa craniotomy for evacuation of cerebellar hemorrhage. The patient also underwent placement of right frontal ventriculostomy drain. Postoperatively the patient had tolerated the procedure well and an ENT consultation was obtained for evaluation of dysarthria and dysphasia. The patient was gradually weaned off the ventilator. The ventriculostomy drain pressures gradually increased to 20 cm of water. The patient's intracranial pressure did not increase with the increasing drain pressure. The ventriculostomy drain was taken out on <Date>1990-10-2</Date>. The patient was reevaluated by <Hospital>Erickson Ltd Health System</Hospital> for rehabilitation screening. The patient was accepted by <Hospital>Erickson Ltd Health System</Hospital> and was ready for transfer to <Hospital>Erickson Ltd Health System</Hospital> for rehabilitation on <Date>1959-10-24</Date>. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. DISCHARGE MEDICATIONS: 1. Metoprolol 100 mg p.o. t.i.d. 2. Glutamine 5 mg p.o. b.i.d. 3. Coumadin 0.1 mg p.o. t.i.d. 4. Multivitamins 1 capsule p.o. q.d. 5. Amlodipine 10 mg p.o. q.d. 6. Hydralazine 50 mg p.o. q. 6. 7. Colace 100 mg p.o. b.i.d. 8. Albuterol nebulizer 1 neb q. 6 hours. 9. Atrovent nebulizer 1 neb q. 6 hours. 10. Losartan 50 mg p.o. b.i.d. 11. Lansoprazole 50 mg p.o. q.d. 12. Insulin sliding scale. FOLLOW UP: The patient should follow up with Dr. <Name>Young</Name> from neurosurgery. Please call Dr.<Name>Guadalupe Ivory</Name> office for an appointment. <Name>Arnaldo</Name> <Name>Smith</Name>, MD <MD Number>74244968</MD Number> Dictated By:<Name>Conyers</Name> MEDQUIST36 D: <Date>1959-10-24</Date> 06:05 T: <Date>1959-10-24</Date> 07:43 JOB#: <Job Number>Hall, Edwards and Parker-1981-945799</Job Number>	000000000000000001111111110000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000111111111111111111111111110000000000000000000000000000000000000000000000000000000000001111111111111111111111111100000000000000000000000000000001111111111111111111111111100000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000011111111111111100000000000000000000000000000000000000000000000000000000000011111110111110000001111111100000000000000111111100000000000000000111111111100000000000011111111110000000000000001111111111111111111111111111111111110	Admission Date: 1914-8-19 Discharge Date: 1959-10-24 Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 79-year-old female with a history of atrial fibrillation on Coumadin, hypertension, and cerebellar cerebrovascular accident, who presented to the Emergency Department complaining of nausea, no vomiting, and headache since one night prior to admission. When the patient woke up this morning the patient had progressive dysarthria. The patient denied any visual or auditory changes. The patient also denied any fevers, chills, changes in bowel habits, chest pain, shortness of breath, melena, bright red blood per rectum, and hematemesis. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Cerebrovascular accident. MEDICATIONS AT HOME: 1. Atenolol. 2. Coumadin. 3. Plendil. 4. Lipitor. 5. Avapro. 6. Neurontin. 7. Hydralazine. ALLERGIES: 1. Codeine. 2. Macrodantin. PHYSICAL EXAMINATION: The patient's temperature was 96.8, pulse 71, blood pressure 206/110, respiratory rate 16, oxygen saturation was 94% on room air. The patient was alert and oriented x 3 in no acute distress. The patient's speech was dysarthric. The patient's pupils were equal, round and reactive to light. The patient's extraocular movements were intact. The patient had symmetric eyebrow lift, and symmetric smile. The patient had no tongue deviation, no pronator drift. The patient had 5+ strength in the shoulders and hands. The patient's heart rate was irregularly irregular. Lungs were clear to auscultation bilaterally. The patient was moving all extremities and had 5+ strength. The patient's cranial nerves two through 12 were intact. LABORATORY STUDIES: White blood cell count was 13.3, hematocrit 46.6, platelet count 305. The patient's PT was 23.4, PTT 44.5 and INR was 3.6. The patient's chemistries were normal. CT scan done on 12-12 showed left cerebellar intraparenchymal hemorrhage. HOSPITAL COURSE: The patient was admitted to the neurosurgery service for management. The patient was started on fresh frozen plasma to reverse her INR down to less than 1.3. The patient was started on a Nipride drip to decrease blood pressure. The patient was put on q. 1 hour neurological checks and was admitted to the intensive care unit. The patient was taken to the operating room on 1920-1-19 for posterior fossa craniotomy for evacuation of cerebellar hemorrhage. The patient also underwent placement of right frontal ventriculostomy drain. Postoperatively the patient had tolerated the procedure well and an ENT consultation was obtained for evaluation of dysarthria and dysphasia. The patient was gradually weaned off the ventilator. The ventriculostomy drain pressures gradually increased to 20 cm of water. The patient's intracranial pressure did not increase with the increasing drain pressure. The ventriculostomy drain was taken out on 1990-10-2. The patient was reevaluated by Erickson Ltd Health System for rehabilitation screening. The patient was accepted by Erickson Ltd Health System and was ready for transfer to Erickson Ltd Health System for rehabilitation on 1959-10-24. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. DISCHARGE MEDICATIONS: 1. Metoprolol 100 mg p.o. t.i.d. 2. Glutamine 5 mg p.o. b.i.d. 3. Coumadin 0.1 mg p.o. t.i.d. 4. Multivitamins 1 capsule p.o. q.d. 5. Amlodipine 10 mg p.o. q.d. 6. Hydralazine 50 mg p.o. q. 6. 7. Colace 100 mg p.o. b.i.d. 8. Albuterol nebulizer 1 neb q. 6 hours. 9. Atrovent nebulizer 1 neb q. 6 hours. 10. Losartan 50 mg p.o. b.i.d. 11. Lansoprazole 50 mg p.o. q.d. 12. Insulin sliding scale. FOLLOW UP: The patient should follow up with Dr. Young from neurosurgery. Please call Dr.Guadalupe Ivory office for an appointment. Arnaldo Smith, MD 74244968 Dictated By:Conyers MEDQUIST36 D: 1959-10-24 06:05 T: 1959-10-24 07:43 JOB#: Hall, Edwards and Parker-1981-945799	['Admission Date: 1914-8-19 Discharge Date: 1959-10-24\n\n\nService: Neurosurgery\n\nHISTORY OF PRESENT ILLNESS: This is a 79-year-old female\nwith a history of atrial fibrillation on Coumadin,\nhypertension, and cerebellar cerebrovascular accident, who\npresented to the Emergency Department complaining of nausea,\nno vomiting, and headache since one night prior to admission.\nWhen the patient woke up this morning the patient had\nprogressive dysarthria. The patient denied any visual or\nauditory changes. The patient also denied any fevers,\nchills, changes in bowel habits, chest pain, shortness of\nbreath, melena, bright red blood per rectum, and hematemesis.\n\nPAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial\nfibrillation. 3. Cerebrovascular accident.\n\nMEDICATIONS AT HOME: 1. Atenolol. 2. Coumadin.', " 3. Plendil.\n4. Lipitor. 5. Avapro. 6. Neurontin. 7. Hydralazine.\n\nALLERGIES: 1. Codeine. 2. Macrodantin.\n\nPHYSICAL EXAMINATION: The patient's temperature was 96.8,\npulse 71, blood pressure 206/110, respiratory rate 16, oxygen\nsaturation was 94% on room air. The patient was alert and\noriented x 3 in no acute distress. The patient's speech was\ndysarthric. The patient's pupils were equal, round and\nreactive to light. The patient's extraocular movements were\nintact. The patient had symmetric eyebrow lift, and\nsymmetric smile. The patient had no tongue deviation, no\npronator drift. The patient had 5+ strength in the shoulders\nand hands. The patient's heart rate was irregularly\nirregular. Lungs were clear to auscultation bilaterally.\nThe patient was moving all extremities and had 5+ strength.", "\nThe patient's cranial nerves two through 12 were intact.\n\nLABORATORY STUDIES: White blood cell count was 13.3,\nhematocrit 46.6, platelet count 305. The patient's PT was\n23.4, PTT 44.5 and INR was 3.6. The patient's chemistries\nwere normal.\n\nCT scan done on 12-12 showed left cerebellar\nintraparenchymal hemorrhage.\n\nHOSPITAL COURSE: The patient was admitted to the\nneurosurgery service for management. The patient was started\non fresh frozen plasma to reverse her INR down to less than\n1.3. The patient was started on a Nipride drip to decrease\nblood pressure. The patient was put on q. 1 hour\nneurological checks and was admitted to the intensive care\nunit. The patient was taken to the operating room on 1920-1-19 for posterior fossa craniotomy for evacuation of\ncerebellar hemorrhage. The patient also underwent placement\nof right frontal ventriculostomy drain.", "\n\nPostoperatively the patient had tolerated the procedure well\nand an ENT consultation was obtained for evaluation of\ndysarthria and dysphasia. The patient was gradually weaned\noff the ventilator. The ventriculostomy drain pressures\ngradually increased to 20 cm of water. The patient's\nintracranial pressure did not increase with the increasing\ndrain pressure. The ventriculostomy drain was taken out on\n1990-10-2. The patient was reevaluated by Erickson Ltd Health System for\nrehabilitation screening. The patient was accepted by\nErickson Ltd Health System and was ready for transfer to Erickson Ltd Health System for\nrehabilitation on 1959-10-24.\n\nCONDITION ON DISCHARGE: Stable.\n\nDISCHARGE STATUS: To rehabilitation.\n\nDISCHARGE MEDICATIONS:\n1. Metoprolol 100 mg p.o. t.i.d.\n2. Glutamine 5 mg p.", 'o. b.i.d.\n3. Coumadin 0.1 mg p.o. t.i.d.\n4. Multivitamins 1 capsule p.o. q.d.\n5. Amlodipine 10 mg p.o. q.d.\n6. Hydralazine 50 mg p.o. q. 6.\n7. Colace 100 mg p.o. b.i.d.\n8. Albuterol nebulizer 1 neb q. 6 hours.\n9. Atrovent nebulizer 1 neb q. 6 hours.\n10. Losartan 50 mg p.o. b.i.d.\n11. Lansoprazole 50 mg p.o. q.d.\n12. Insulin sliding scale.\n\nFOLLOW UP: The patient should follow up with Dr. Young\nfrom neurosurgery. Please call Dr.Guadalupe Ivory office for an\nappointment.\n\n\n\n\n Arnaldo Smith, MD 74244968\n\nDictated By:Conyers\nMEDQUIST36\n\nD: 1959-10-24 06:05\nT: 1959-10-24 07:43\nJOB#: Hall, Edwards and Parker-1981-945799\n']
191	26175	156154.0	2112-05-05	Discharge summary	Report	Admission Date: [2112-4-22] Discharge Date: [2112-5-5] Date of Birth: [2035-10-21] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation History of Present Illness: 76yo F with PAF s/p recent TEE-DCCV on [4-21], HTN, admitted with hypoxic respiratory failure. She was recently hospitalized from [Date range (1) 1919] for a supratherapeutic INR of 16. She was in AF with a ventricular rate of 110s-140s, asymptomatic. Medical management of her AF was initially tried. She was maintained on her atenolol and propafenone, and diltiazem was added. The decision was then made to pursue cardioversion instead. TEE-DCCV was performed on [2112-4-21]. She was in sinus rhythm after the procedure and had a HR in the 50s on atenolol and propafenone upon discharge. The diltiazem had been discontinued secondary to bradycardia post-procedure. She was also discharged on Coumadin 1mg qhs. Her family states her symptoms began just prior to discharge, when she began to feel short of breath and fatigued. Her symptoms progressively worsened at home. She was seen in [Company 191] the next morning and was found to have O2 sats in the 80s, so she was sent to the ED. . In the ED, her T was 100.6, HR 70s in NSR, and she was 84% on 4L. Her CXR showed bilateral pleural effusions and vascular engorgement, and her INR was 9. She received a Combivent neb, Lasix 20mg IV, levofloxacin 500mg IV, and vitamin K 5mg SC. She was intubated for hypoxia. Repeat CXR showed improvement in pulmonary edema after Lasix. She was admitted to the CCU for further management of hypoxia due to possible CHF. Past Medical History: 1. Atrial fibrillation: diagnosed [2102], on propafenone x several years, started Coumadin [4-11], s/p TEE-DCCV on [4-21] 2. Hypertension: on enalapril and atenolol Social History: No EtOH, no past or present smoking hx, no illicit drug use. Lives with her husband in [Name (NI) 86], has 1 daughter. Used to work in [Country 532] as an engineer. Moved to US from [Country 532] in [2098]. Family History: Noncontributory. Physical Exam: vitals- T 98.7, HR 57, RR 13, BP 118/55, O2sat 100% vent- AC 450/14, PEEP 5, FiO2 100% General- sedated and intubated HEENT- PERRL, ETT Neck- JVP 9cm Lungs- diffuse rhonchi, decreased breath sounds bilaterally Heart- RRR, normal S1/S2, no murmur/rub/gallop Abd- soft, NT, ND, NABS Ext- 2+ pitting edema to knee b/l, DP/PT pulses 2+ b/l Neuro- sedated and intubated Pertinent Results: [2112-4-22] 12:50PM WBC-18.5# RBC-4.10 HGB-12.5 HCT-36.0 MCV-88 MCH-30.6 MCHC-34.8 RDW-14.2 [2112-4-22] 12:50PM NEUTS-81.2* LYMPHS-14.3* MONOS-3.7 EOS-0.4 BASOS-0.5 [2112-4-22] 12:50PM PLT COUNT-369 [2112-4-22] 12:50PM PT-71.7* PTT-34.3 INR(PT)-9.2* [2112-4-22] 12:50PM CK(CPK)-98 [2112-4-22] 12:50PM cTropnT-<0.01 [2112-4-22] 12:50PM GLUCOSE-149* UREA N-25* CREAT-1.1 SODIUM-135 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-20* ANION GAP-17 [2112-4-22] 12:50PM ALT(SGPT)-86* AST(SGOT)-69* LD(LDH)-314* ALK PHOS-101 TOT BILI-0.4 [2112-4-22] 02:20PM LACTATE-1.8 [2112-4-22] 04:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [2112-4-22] 04:45PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 . EKG: NSR at 72, normal axis and intervals, T wave flattening in aVL, peaked Ts on V3-V6, no ST segment changes . CXR: continued moderate-to-severe pulmonary interstitial edema with bilateral pleural effusions, no evidence of pneumothorax . TEE ([4-21]): The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular cavity size, and systolic function are normal. There are complex (>4mm) atheroma in the aortic arch and simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-25]+) mitral regurgitation is seen. There is no pericardial effusion. . Stress echo ([9-25]): Good functional exercise capacity. No ECG or 2D echocardiographic evidence of inducible ischemia to achieved workload. Mildly blunted hemodynamic response to exercise. Mild mitral regurgitation. Limited study. Target HR not achieved. Brief Hospital Course: . # Dyspnea: Her shortness of breath and respiratory failure were thought secondary to pulmonary edema. The pulmonary edema likely followed an indolent course, with her rapid atrial fibrillation and diastolic dysfunction causing progressive volume overload. Her acute exacerbation was likely due to post-cardioversion pulmonary edema. She initially had a low-grade fever, but pneumonia was thought less likely, and her chest x-ray was without infiltrate. She had normal cardiac enzymes, so ischemia was not a contributing factor. She was maintained on a beta blocker and ACE-inhibitor. After aggressive diuresis, she was weaned off mechanical ventilation quickly. Diuresis was continued with prn IV Lasix, and she had resolution of her dyspnea and oxygen requirement. . # Atrial fibrillation: She was in sinus rhythm on admission, and was initially maintained on propafenone and metoprolol. On [4-23], she converted to atrial fibrillation and had a rapid ventricular response in the 140s. She underwent DC cardioversion, after which she became hypotensive and bradycardic, requiring transient treatment with dopamine. She was continued on propafenone after the DCCV. On the morning of [4-26], she converted into atrial fibrillation again, with rates of 140s. She had a normal blood pressure and some mild palpitations. She was initially loaded with po amiodarone, with slowing of her heart rates to the 100s to 110s. When her heart rate began to trend up again, she was loaded with IV amiodarone and started on a drip. Her rates remained in the 100s to 110s. She was transitioned to po amiodarone on the night of [4-26]. She experienced nausea and vomiting on po amiodarone. She underwent another cardioversion on [4-29] but reverted back to atrial fibrillation the next day. She was continued on amiodarone but remained in atrial fibrillation. She went into rapid ventricular response in the 150s on [5-1], requiring IV diltiazem to bring her rate down. She was started on po diltiazem, which was quickly titrated up with her heart rate decreasing to the 80s. The diltiazem was stopped the morning of [5-3], just before she underwent another cardioversion. She remained in sinus rhythm for the rest of her stay. She was discharged on amiodarone 200mg po three times daily, with a follow up appointment with Dr. [Last Name (STitle) 1911]. Anticoagulation as below. . # Elevated INR: INR went from 4 on [4-21] to 9 on [4-22] with only 1 mg of Coumadin. Last admission was for INR of 16 on Coumadin 4mg qhs. Received 5mg vitamin K SC in the ED. Repeat coags on the floor showed INR of 11, would have expected some decline with SC vitamin K. Her INR decreased to 4.5 with FFP. Her INR then decreased to normal. Hematology was consulted and felt she could potentially have a partial clotting factor deficiency causing her severe sensitivity to Coumadin. Her Coumadin was held throughout most of her stay, and she was maintained on IV heparin. Coumadin was restarted at 0.5mg on [5-3] after her cardioversion. Her INR remained subtherapeutic after 2 doses. She was discharged on Coumadin 0.5mg qhs with a Lovenox bridge, with an INR check 4 days after discharge. She is to follow up with her PCP to consider Hematology follow up. . # Code status: FULL CODE. . Medications on Admission: Atenolol 25mg qd Propafenone 150mg tid Coumadin 1mg qhs Discharge Medications: 1. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 3. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed: Apply to affected area as needed. Disp:qs gm Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Lovenox 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous once a day for 7 days. Disp:qs mg Refills:0 7. Outpatient Lab Work Please check INR on [Month/Year (2) 766], [2112-5-9]. Please call in results to Dr.[Name (NI) 1912] office at ([Telephone/Fax (1) 1920]. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: atrial fibrillation pulmonary edema Discharge Condition: sinus rhythm, ambulating with good O2 sats on RA Discharge Instructions: Please take all of your medications as prescribed. Please use your heart monitor as instructed, with daily recordings. If you experience shortness of breath, palpitations, dizziness, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: 1) Cardiology: Dr. [Last Name (STitle) ] [Name (STitle) 1911], ([Telephone/Fax (1) 1920], [2112-5-12] at 9:30am. The nurses at Dr.[Name (NI) 1912] clinic will be managing your Coumadin. 2) PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ], ([Telephone/Fax (1) 1921], [2112-5-31] at 1:50pm. Completed by:[2112-5-22]	Admission Date: <Date>1948-2-17</Date> Discharge Date: <Date>1990-7-29</Date> Date of Birth: <Date>1957-12-11</Date> Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Jere</Name> Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation History of Present Illness: 76yo F with PAF s/p recent TEE-DCCV on <Date>12-5</Date>, HTN, admitted with hypoxic respiratory failure. She was recently hospitalized from <Date Range>1931-7-9 to 1945-4-3</Date Range> for a supratherapeutic INR of 16. She was in AF with a ventricular rate of 110s-140s, asymptomatic. Medical management of her AF was initially tried. She was maintained on her atenolol and propafenone, and diltiazem was added. The decision was then made to pursue cardioversion instead. TEE-DCCV was performed on <Date>2020-1-3</Date>. She was in sinus rhythm after the procedure and had a HR in the 50s on atenolol and propafenone upon discharge. The diltiazem had been discontinued secondary to bradycardia post-procedure. She was also discharged on Coumadin 1mg qhs. Her family states her symptoms began just prior to discharge, when she began to feel short of breath and fatigued. Her symptoms progressively worsened at home. She was seen in <Company>Fox, David and Wilkinson</Company> the next morning and was found to have O2 sats in the 80s, so she was sent to the ED. . In the ED, her T was 100.6, HR 70s in NSR, and she was 84% on 4L. Her CXR showed bilateral pleural effusions and vascular engorgement, and her INR was 9. She received a Combivent neb, Lasix 20mg IV, levofloxacin 500mg IV, and vitamin K 5mg SC. She was intubated for hypoxia. Repeat CXR showed improvement in pulmonary edema after Lasix. She was admitted to the CCU for further management of hypoxia due to possible CHF. Past Medical History: 1. Atrial fibrillation: diagnosed <Year>1969</Year>, on propafenone x several years, started Coumadin <Date>5-12</Date>, s/p TEE-DCCV on <Date>12-5</Date> 2. Hypertension: on enalapril and atenolol Social History: No EtOH, no past or present smoking hx, no illicit drug use. Lives with her husband in <Name>Noah Deng</Name>, has 1 daughter. Used to work in <Country>Bolivia</Country> as an engineer. Moved to US from <Country>Bolivia</Country> in <Year>1969</Year>. Family History: Noncontributory. Physical Exam: vitals- T 98.7, HR 57, RR 13, BP 118/55, O2sat 100% vent- AC 450/14, PEEP 5, FiO2 100% General- sedated and intubated HEENT- PERRL, ETT Neck- JVP 9cm Lungs- diffuse rhonchi, decreased breath sounds bilaterally Heart- RRR, normal S1/S2, no murmur/rub/gallop Abd- soft, NT, ND, NABS Ext- 2+ pitting edema to knee b/l, DP/PT pulses 2+ b/l Neuro- sedated and intubated Pertinent Results: <Date>1948-2-17</Date> 12:50PM WBC-18.5# RBC-4.10 HGB-12.5 HCT-36.0 MCV-88 MCH-30.6 MCHC-34.8 RDW-14.2 <Date>1948-2-17</Date> 12:50PM NEUTS-81.2* LYMPHS-14.3* MONOS-3.7 EOS-0.4 BASOS-0.5 <Date>1948-2-17</Date> 12:50PM PLT COUNT-369 <Date>1948-2-17</Date> 12:50PM PT-71.7* PTT-34.3 INR(PT)-9.2* <Date>1948-2-17</Date> 12:50PM CK(CPK)-98 <Date>1948-2-17</Date> 12:50PM cTropnT-<0.01 <Date>1948-2-17</Date> 12:50PM GLUCOSE-149* UREA N-25* CREAT-1.1 SODIUM-135 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-20* ANION GAP-17 <Date>1948-2-17</Date> 12:50PM ALT(SGPT)-86* AST(SGOT)-69* LD(LDH)-314* ALK PHOS-101 TOT BILI-0.4 <Date>1948-2-17</Date> 02:20PM LACTATE-1.8 <Date>1948-2-17</Date> 04:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG <Date>1948-2-17</Date> 04:45PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 . EKG: NSR at 72, normal axis and intervals, T wave flattening in aVL, peaked Ts on V3-V6, no ST segment changes . CXR: continued moderate-to-severe pulmonary interstitial edema with bilateral pleural effusions, no evidence of pneumothorax . TEE (<Date>12-5</Date>): The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular cavity size, and systolic function are normal. There are complex (>4mm) atheroma in the aortic arch and simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (<Date>8-9</Date>+) mitral regurgitation is seen. There is no pericardial effusion. . Stress echo (<Date>7-15</Date>): Good functional exercise capacity. No ECG or 2D echocardiographic evidence of inducible ischemia to achieved workload. Mildly blunted hemodynamic response to exercise. Mild mitral regurgitation. Limited study. Target HR not achieved. Brief Hospital Course: . # Dyspnea: Her shortness of breath and respiratory failure were thought secondary to pulmonary edema. The pulmonary edema likely followed an indolent course, with her rapid atrial fibrillation and diastolic dysfunction causing progressive volume overload. Her acute exacerbation was likely due to post-cardioversion pulmonary edema. She initially had a low-grade fever, but pneumonia was thought less likely, and her chest x-ray was without infiltrate. She had normal cardiac enzymes, so ischemia was not a contributing factor. She was maintained on a beta blocker and ACE-inhibitor. After aggressive diuresis, she was weaned off mechanical ventilation quickly. Diuresis was continued with prn IV Lasix, and she had resolution of her dyspnea and oxygen requirement. . # Atrial fibrillation: She was in sinus rhythm on admission, and was initially maintained on propafenone and metoprolol. On <Date>11-24</Date>, she converted to atrial fibrillation and had a rapid ventricular response in the 140s. She underwent DC cardioversion, after which she became hypotensive and bradycardic, requiring transient treatment with dopamine. She was continued on propafenone after the DCCV. On the morning of <Date>2-9</Date>, she converted into atrial fibrillation again, with rates of 140s. She had a normal blood pressure and some mild palpitations. She was initially loaded with po amiodarone, with slowing of her heart rates to the 100s to 110s. When her heart rate began to trend up again, she was loaded with IV amiodarone and started on a drip. Her rates remained in the 100s to 110s. She was transitioned to po amiodarone on the night of <Date>2-9</Date>. She experienced nausea and vomiting on po amiodarone. She underwent another cardioversion on <Date>3-10</Date> but reverted back to atrial fibrillation the next day. She was continued on amiodarone but remained in atrial fibrillation. She went into rapid ventricular response in the 150s on <Date>10-7</Date>, requiring IV diltiazem to bring her rate down. She was started on po diltiazem, which was quickly titrated up with her heart rate decreasing to the 80s. The diltiazem was stopped the morning of <Date>7-31</Date>, just before she underwent another cardioversion. She remained in sinus rhythm for the rest of her stay. She was discharged on amiodarone 200mg po three times daily, with a follow up appointment with Dr. <Name>Mao</Name>. Anticoagulation as below. . # Elevated INR: INR went from 4 on <Date>12-5</Date> to 9 on <Date>6-8</Date> with only 1 mg of Coumadin. Last admission was for INR of 16 on Coumadin 4mg qhs. Received 5mg vitamin K SC in the ED. Repeat coags on the floor showed INR of 11, would have expected some decline with SC vitamin K. Her INR decreased to 4.5 with FFP. Her INR then decreased to normal. Hematology was consulted and felt she could potentially have a partial clotting factor deficiency causing her severe sensitivity to Coumadin. Her Coumadin was held throughout most of her stay, and she was maintained on IV heparin. Coumadin was restarted at 0.5mg on <Date>7-31</Date> after her cardioversion. Her INR remained subtherapeutic after 2 doses. She was discharged on Coumadin 0.5mg qhs with a Lovenox bridge, with an INR check 4 days after discharge. She is to follow up with her PCP to consider Hematology follow up. . # Code status: FULL CODE. . Medications on Admission: Atenolol 25mg qd Propafenone 150mg tid Coumadin 1mg qhs Discharge Medications: 1. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 3. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed: Apply to affected area as needed. Disp:qs gm Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Lovenox 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous once a day for 7 days. Disp:qs mg Refills:0 7. Outpatient Lab Work Please check INR on <Month>August</Month>, <Date>1942-5-21</Date>. Please call in results to Dr.<Name>Shirley Chowdhury</Name> office at (<Telephone>694-324-8218</Telephone>. Discharge Disposition: Home With Service Facility: <Hospital>Strong, Ward and Lewis Medical Center</Hospital> Homecare Discharge Diagnosis: atrial fibrillation pulmonary edema Discharge Condition: sinus rhythm, ambulating with good O2 sats on RA Discharge Instructions: Please take all of your medications as prescribed. Please use your heart monitor as instructed, with daily recordings. If you experience shortness of breath, palpitations, dizziness, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: 1) Cardiology: Dr. <Name>Beamon</Name> <Name>Donna Hui</Name>, (<Telephone>694-324-8218</Telephone>, <Date>1990-11-16</Date> at 9:30am. The nurses at Dr.<Name>Shirley Chowdhury</Name> clinic will be managing your Coumadin. 2) PCP: <Name>Brown</Name>. <Name>Joe</Name> <Name>Broadnax</Name>, (<Telephone>735-193-2396</Telephone>, <Date>1905-3-2</Date> at 1:50pm. Completed 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Date: 1948-2-17 Discharge Date: 1990-7-29 Date of Birth: 1957-12-11 Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Jere Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation History of Present Illness: 76yo F with PAF s/p recent TEE-DCCV on 12-5, HTN, admitted with hypoxic respiratory failure. She was recently hospitalized from 1931-7-9 to 1945-4-3 for a supratherapeutic INR of 16. She was in AF with a ventricular rate of 110s-140s, asymptomatic. Medical management of her AF was initially tried. She was maintained on her atenolol and propafenone, and diltiazem was added. The decision was then made to pursue cardioversion instead. TEE-DCCV was performed on 2020-1-3. She was in sinus rhythm after the procedure and had a HR in the 50s on atenolol and propafenone upon discharge. The diltiazem had been discontinued secondary to bradycardia post-procedure. She was also discharged on Coumadin 1mg qhs. Her family states her symptoms began just prior to discharge, when she began to feel short of breath and fatigued. Her symptoms progressively worsened at home. She was seen in Fox, David and Wilkinson the next morning and was found to have O2 sats in the 80s, so she was sent to the ED. . In the ED, her T was 100.6, HR 70s in NSR, and she was 84% on 4L. Her CXR showed bilateral pleural effusions and vascular engorgement, and her INR was 9. She received a Combivent neb, Lasix 20mg IV, levofloxacin 500mg IV, and vitamin K 5mg SC. She was intubated for hypoxia. Repeat CXR showed improvement in pulmonary edema after Lasix. She was admitted to the CCU for further management of hypoxia due to possible CHF. Past Medical History: 1. Atrial fibrillation: diagnosed 1969, on propafenone x several years, started Coumadin 5-12, s/p TEE-DCCV on 12-5 2. Hypertension: on enalapril and atenolol Social History: No EtOH, no past or present smoking hx, no illicit drug use. Lives with her husband in Noah Deng, has 1 daughter. Used to work in Bolivia as an engineer. Moved to US from Bolivia in 1969. Family History: Noncontributory. Physical Exam: vitals- T 98.7, HR 57, RR 13, BP 118/55, O2sat 100% vent- AC 450/14, PEEP 5, FiO2 100% General- sedated and intubated HEENT- PERRL, ETT Neck- JVP 9cm Lungs- diffuse rhonchi, decreased breath sounds bilaterally Heart- RRR, normal S1/S2, no murmur/rub/gallop Abd- soft, NT, ND, NABS Ext- 2+ pitting edema to knee b/l, DP/PT pulses 2+ b/l Neuro- sedated and intubated Pertinent Results: 1948-2-17 12:50PM WBC-18.5# RBC-4.10 HGB-12.5 HCT-36.0 MCV-88 MCH-30.6 MCHC-34.8 RDW-14.2 1948-2-17 12:50PM NEUTS-81.2* LYMPHS-14.3* MONOS-3.7 EOS-0.4 BASOS-0.5 1948-2-17 12:50PM PLT COUNT-369 1948-2-17 12:50PM PT-71.7* PTT-34.3 INR(PT)-9.2* 1948-2-17 12:50PM CK(CPK)-98 1948-2-17 12:50PM cTropnT-1948-2-17 12:50PM GLUCOSE-149* UREA N-25* CREAT-1.1 SODIUM-135 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-20* ANION GAP-17 1948-2-17 12:50PM ALT(SGPT)-86* AST(SGOT)-69* LD(LDH)-314* ALK PHOS-101 TOT BILI-0.4 1948-2-17 02:20PM LACTATE-1.8 1948-2-17 04:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG 1948-2-17 04:45PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 . EKG: NSR at 72, normal axis and intervals, T wave flattening in aVL, peaked Ts on V3-V6, no ST segment changes . CXR: continued moderate-to-severe pulmonary interstitial edema with bilateral pleural effusions, no evidence of pneumothorax . TEE (12-5): The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular cavity size, and systolic function are normal. There are complex (>4mm) atheroma in the aortic arch and simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (8-9+) mitral regurgitation is seen. There is no pericardial effusion. . Stress echo (7-15): Good functional exercise capacity. No ECG or 2D echocardiographic evidence of inducible ischemia to achieved workload. Mildly blunted hemodynamic response to exercise. Mild mitral regurgitation. Limited study. Target HR not achieved. Brief Hospital Course: . # Dyspnea: Her shortness of breath and respiratory failure were thought secondary to pulmonary edema. The pulmonary edema likely followed an indolent course, with her rapid atrial fibrillation and diastolic dysfunction causing progressive volume overload. Her acute exacerbation was likely due to post-cardioversion pulmonary edema. She initially had a low-grade fever, but pneumonia was thought less likely, and her chest x-ray was without infiltrate. She had normal cardiac enzymes, so ischemia was not a contributing factor. She was maintained on a beta blocker and ACE-inhibitor. After aggressive diuresis, she was weaned off mechanical ventilation quickly. Diuresis was continued with prn IV Lasix, and she had resolution of her dyspnea and oxygen requirement. . # Atrial fibrillation: She was in sinus rhythm on admission, and was initially maintained on propafenone and metoprolol. On 11-24, she converted to atrial fibrillation and had a rapid ventricular response in the 140s. She underwent DC cardioversion, after which she became hypotensive and bradycardic, requiring transient treatment with dopamine. She was continued on propafenone after the DCCV. On the morning of 2-9, she converted into atrial fibrillation again, with rates of 140s. She had a normal blood pressure and some mild palpitations. She was initially loaded with po amiodarone, with slowing of her heart rates to the 100s to 110s. When her heart rate began to trend up again, she was loaded with IV amiodarone and started on a drip. Her rates remained in the 100s to 110s. She was transitioned to po amiodarone on the night of 2-9. She experienced nausea and vomiting on po amiodarone. She underwent another cardioversion on 3-10 but reverted back to atrial fibrillation the next day. She was continued on amiodarone but remained in atrial fibrillation. She went into rapid ventricular response in the 150s on 10-7, requiring IV diltiazem to bring her rate down. She was started on po diltiazem, which was quickly titrated up with her heart rate decreasing to the 80s. The diltiazem was stopped the morning of 7-31, just before she underwent another cardioversion. She remained in sinus rhythm for the rest of her stay. She was discharged on amiodarone 200mg po three times daily, with a follow up appointment with Dr. Mao. Anticoagulation as below. . # Elevated INR: INR went from 4 on 12-5 to 9 on 6-8 with only 1 mg of Coumadin. Last admission was for INR of 16 on Coumadin 4mg qhs. Received 5mg vitamin K SC in the ED. Repeat coags on the floor showed INR of 11, would have expected some decline with SC vitamin K. Her INR decreased to 4.5 with FFP. Her INR then decreased to normal. Hematology was consulted and felt she could potentially have a partial clotting factor deficiency causing her severe sensitivity to Coumadin. Her Coumadin was held throughout most of her stay, and she was maintained on IV heparin. Coumadin was restarted at 0.5mg on 7-31 after her cardioversion. Her INR remained subtherapeutic after 2 doses. She was discharged on Coumadin 0.5mg qhs with a Lovenox bridge, with an INR check 4 days after discharge. She is to follow up with her PCP to consider Hematology follow up. . # Code status: FULL CODE. . Medications on Admission: Atenolol 25mg qd Propafenone 150mg tid Coumadin 1mg qhs Discharge Medications: 1. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 3. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed: Apply to affected area as needed. Disp:qs gm Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Lovenox 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous once a day for 7 days. Disp:qs mg Refills:0 7. Outpatient Lab Work Please check INR on August, 1942-5-21. Please call in results to Dr.Shirley Chowdhury office at (694-324-8218. Discharge Disposition: Home With Service Facility: Strong, Ward and Lewis Medical Center Homecare Discharge Diagnosis: atrial fibrillation pulmonary edema Discharge Condition: sinus rhythm, ambulating with good O2 sats on RA Discharge Instructions: Please take all of your medications as prescribed. Please use your heart monitor as instructed, with daily recordings. If you experience shortness of breath, palpitations, dizziness, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: 1) Cardiology: Dr. Beamon Donna Hui, (694-324-8218, 1990-11-16 at 9:30am. The nurses at Dr.Shirley Chowdhury clinic will be managing your Coumadin. 2) PCP: Brown. Joe Broadnax, (735-193-2396, 1905-3-2 at 1:50pm. Completed by:2005-10-16	['Admission Date: 1948-2-17 Discharge Date: 1990-7-29\n\nDate of Birth: 1957-12-11 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Jere\nChief Complaint:\nshortness of breath\n\nMajor Surgical or Invasive Procedure:\nintubation\n\nHistory of Present Illness:\n76yo F with PAF s/p recent TEE-DCCV on 12-5, HTN, admitted with\nhypoxic respiratory failure. She was recently hospitalized from\n1931-7-9 to 1945-4-3 for a supratherapeutic INR of 16. She was in AF with\na ventricular rate of 110s-140s, asymptomatic. Medical\nmanagement of her AF was initially tried. She was maintained on\nher atenolol and propafenone, and diltiazem was added. The\ndecision was then made to pursue cardioversion instead.\nTEE-DCCV was performed on 2020-1-3.', ' She was in sinus rhythm\nafter the procedure and had a HR in the 50s on atenolol and\npropafenone upon discharge. The diltiazem had been discontinued\nsecondary to bradycardia post-procedure. She was also\ndischarged on Coumadin 1mg qhs. Her family states her symptoms\nbegan just prior to discharge, when she began to feel short of\nbreath and fatigued. Her symptoms progressively worsened at\nhome. She was seen in Fox, David and Wilkinson the next morning and was found to\nhave O2 sats in the 80s, so she was sent to the ED.\n.\nIn the ED, her T was 100.6, HR 70s in NSR, and she was 84% on\n4L. Her CXR showed bilateral pleural effusions and vascular\nengorgement, and her INR was 9. She received a Combivent neb,\nLasix 20mg IV, levofloxacin 500mg IV, and vitamin K 5mg SC. She\nwas intubated for hypoxia.', ' Repeat CXR showed improvement in\npulmonary edema after Lasix. She was admitted to the CCU for\nfurther management of hypoxia due to possible CHF.\n\nPast Medical History:\n1. Atrial fibrillation: diagnosed 1969, on propafenone x several\nyears, started Coumadin 5-12, s/p TEE-DCCV on 12-5\n2. Hypertension: on enalapril and atenolol\n\nSocial History:\nNo EtOH, no past or present smoking hx, no illicit drug use.\nLives with her husband in Noah Deng, has 1 daughter. Used to work\nin Bolivia as an engineer. Moved to US from Bolivia in 1969.\n\nFamily History:\nNoncontributory.\n\nPhysical Exam:\nvitals- T 98.7, HR 57, RR 13, BP 118/55, O2sat 100%\nvent- AC 450/14, PEEP 5, FiO2 100%\nGeneral- sedated and intubated\nHEENT- PERRL, ETT\nNeck- JVP 9cm\nLungs- diffuse rhonchi, decreased breath sounds bilaterally\nHeart- RRR, normal S1/S2, no murmur/rub/gallop\nAbd- soft, NT, ND, NABS\nExt- 2+ pitting edema to knee b/l, DP/PT pulses 2+ b/l\nNeuro- sedated and intubated\n\nPertinent Results:\n1948-2-17 12:50PM WBC-18.', '5# RBC-4.10 HGB-12.5 HCT-36.0 MCV-88\nMCH-30.6 MCHC-34.8 RDW-14.2\n1948-2-17 12:50PM NEUTS-81.2* LYMPHS-14.3* MONOS-3.7 EOS-0.4\nBASOS-0.5\n1948-2-17 12:50PM PLT COUNT-369\n1948-2-17 12:50PM PT-71.7* PTT-34.3 INR(PT)-9.2\n1948-2-17 12:50PM CK(CPK)-98\n1948-2-17 12:50PM cTropnT-1948-2-17 12:50PM GLUCOSE-149 UREA N-25* CREAT-1.1 SODIUM-135\nPOTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-20* ANION GAP-17\n1948-2-17 12:50PM ALT(SGPT)-86* AST(SGOT)-69* LD(LDH)-314* ALK\nPHOS-101 TOT BILI-0.4\n1948-2-17 02:20PM LACTATE-1.8\n1948-2-17 04:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0\nLEUK-NEG\n1948-2-17 04:45PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE\nEPI-0\n.\nEKG: NSR at 72, normal axis and intervals, T wave flattening in\naVL, peaked Ts on V3-V6, no ST segment changes\n.', '\nCXR: continued moderate-to-severe pulmonary interstitial edema\nwith bilateral pleural effusions, no evidence of pneumothorax\n.\nTEE (12-5): The left atrium is dilated. No spontaneous echo\ncontrast or thrombus is seen in the body of the left atrium/left\natrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular cavity size, and systolic function are\nnormal. There are complex (>4mm) atheroma in the aortic arch and\nsimple atheroma in the descending thoracic aorta. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet\nexcursion. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Mild to moderate (8-9+) mitral\nregurgitation is seen. There is no pericardial effusion.', '\n.\nStress echo (7-15): Good functional exercise capacity. No ECG or\n2D echocardiographic evidence of inducible ischemia to achieved\nworkload. Mildly blunted hemodynamic response to exercise. Mild\nmitral regurgitation. Limited study. Target HR not achieved.\n\nBrief Hospital Course:\n.\n# Dyspnea: Her shortness of breath and respiratory failure were\nthought secondary to pulmonary edema. The pulmonary edema\nlikely followed an indolent course, with her rapid atrial\nfibrillation and diastolic dysfunction causing progressive\nvolume overload. Her acute exacerbation was likely due to\npost-cardioversion pulmonary edema. She initially had a\nlow-grade fever, but pneumonia was thought less likely, and her\nchest x-ray was without infiltrate. She had normal cardiac\nenzymes, so ischemia was not a contributing factor.', ' She was\nmaintained on a beta blocker and ACE-inhibitor. After\naggressive diuresis, she was weaned off mechanical ventilation\nquickly. Diuresis was continued with prn IV Lasix, and she had\nresolution of her dyspnea and oxygen requirement.\n.\n# Atrial fibrillation: She was in sinus rhythm on admission, and\nwas initially maintained on propafenone and metoprolol. On 11-24,\nshe converted to atrial fibrillation and had a rapid ventricular\nresponse in the 140s. She underwent DC cardioversion, after\nwhich she became hypotensive and bradycardic, requiring\ntransient treatment with dopamine. She was continued on\npropafenone after the DCCV. On the morning of 2-9, she\nconverted into atrial fibrillation again, with rates of 140s.\nShe had a normal blood pressure and some mild palpitations. She\nwas initially loaded with po amiodarone, with slowing of her\nheart rates to the 100s to 110s.', ' When her heart rate began to\ntrend up again, she was loaded with IV amiodarone and started on\na drip. Her rates remained in the 100s to 110s. She was\ntransitioned to po amiodarone on the night of 2-9. She\nexperienced nausea and vomiting on po amiodarone. She underwent\nanother cardioversion on 3-10 but reverted back to atrial\nfibrillation the next day. She was continued on amiodarone but\nremained in atrial fibrillation. She went into rapid\nventricular response in the 150s on 10-7, requiring IV diltiazem\nto bring her rate down. She was started on po diltiazem, which\nwas quickly titrated up with her heart rate decreasing to the\n80s. The diltiazem was stopped the morning of 7-31, just before\nshe underwent another cardioversion. She remained in sinus\nrhythm for the rest of her stay. She was discharged on\namiodarone 200mg po three times daily, with a follow up\nappointment with Dr.', ' Mao. Anticoagulation as below.\n.\n# Elevated INR: INR went from 4 on 12-5 to 9 on 6-8 with only\n1 mg of Coumadin. Last admission was for INR of 16 on Coumadin\n4mg qhs. Received 5mg vitamin K SC in the ED. Repeat coags on\nthe floor showed INR of 11, would have expected some decline\nwith SC vitamin K. Her INR decreased to 4.5 with FFP. Her INR\nthen decreased to normal. Hematology was consulted and felt she\ncould potentially have a partial clotting factor deficiency\ncausing her severe sensitivity to Coumadin. Her Coumadin was\nheld throughout most of her stay, and she was maintained on IV\nheparin. Coumadin was restarted at 0.5mg on 7-31 after her\ncardioversion. Her INR remained subtherapeutic after 2 doses.\nShe was discharged on Coumadin 0.5mg qhs with a Lovenox bridge,\nwith an INR check 4 days after discharge.', ' She is to follow up\nwith her PCP to consider Hematology follow up.\n.\n# Code status: FULL CODE.\n.\n\nMedications on Admission:\nAtenolol 25mg qd\nPropafenone 150mg tid\nCoumadin 1mg qhs\n\nDischarge Medications:\n1. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\nDisp:30 Tablet(s) Refills:2\n2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times\na day).\nDisp:90 Tablet(s) Refills:2\n3. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).\nDisp:30 Tablet(s) Refills:2\n4. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl\nTopical TID (3 times a day) as needed: Apply to affected area\nas needed.\nDisp:qs gm Refills:0\n5. 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\n6. Lovenox 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous\nonce a day for 7 days.\nDisp:qs mg Refills:0\n7. Outpatient Lab Work\nPlease check INR on August, 1942-5-21. Please call in results to\nDr.Shirley Chowdhury office at (694-324-8218.\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nStrong, Ward and Lewis Medical Center Homecare\n\nDischarge Diagnosis:\natrial fibrillation\npulmonary edema\n\n\nDischarge Condition:\nsinus rhythm, ambulating with good O2 sats on RA\n\n\nDischarge Instructions:\nPlease take all of your medications as prescribed.\n\nPlease use your heart monitor as instructed, with daily\nrecordings.\n\nIf you experience shortness of breath, palpitations, dizziness,\nor other concerning symptoms, please call your doctor or go to\nthe ER.\n\nFollowup Instructions:\n1) Cardiology: Dr.', ' Beamon Donna Hui, (694-324-8218, 1990-11-16 at\n9:30am. The nurses at Dr.Shirley Chowdhury clinic will be\nmanaging your Coumadin.\n\n2) PCP: Brown. Joe Broadnax, (735-193-2396, 1905-3-2 at 1:50pm.\n\n\n\nCompleted by:2005-10-16']
192	82559	197325.0	2157-02-08	Discharge summary	Report	Admission Date: [2157-2-1] Discharge Date: [2157-2-8] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1928] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy and biliary stent placement on [2157-2-1] History of Present Illness: Mrs. [Known firstname 1929] [Known lastname 1930] is a very nice 85 year-old woman with a history of cholecystectomy and ampullar stenosis who presents with RUQ abdominal pain. She states her pain started 2 days prior to admission, was constant and radiated towards the back. She had nausea, vomit, malaise. Denies fever, chills, changes in her bowel movements, hematochezia or melena. Unable able to tolerate oral intake. Presenting vitals were T 101.5, HR 68, BP 152/76, RR 16, SpO2 95% RA. In ED, Unasyn 3gm given and a right IJ central line was placed. She underwent ERCP that showed 1-cm stone in the common bile duct. Patient became hypoxic from the conscious sedation, so the stone was not removed to expedite the procedure. A plastic biliary stent was successfully placed. Post-ERCP, she was admitted to the ICU with a diagnosis of cholangitis. ICU course: In the ICU, the patient was continued on Zosyn, her RUQ pain significantly improved, and she began to tolerate fluids. On [2-3], she developed shortness of breath that improved with administration of furosemide. Nebulizer treatments also given. At time of transfer to floor, O2 sat was 95% on 2L nasal canula. Lisinopril restarted, but Atenolol and Nifedipine held for concern of lower heart rate. She was transferred to the floor and felt improvement in her abdominal pain. Denied shortness of breath, chest pain. Past Medical History: 1. Hypertension 2. Ampullary stenosis 3. Status post cholecystectomy for gallstones 4. History of sphincterotomy (as described above) 5. Osteoporosis 6. Gastroesophageal reflux disease 7. External hemorrhoids 8. Cerebrovascular accident in [2145] (right pontine) 9. Parkinson's diseae 10. Chronic low back pain with sciatica 11. Urinary frequency and urge incontinence 12. Diverticulosis 13. Chronic pancreatitis Social History: She lives by herself. She came the US in [2138] from [Country 1931] and is Russian-speaking. Denies alcohol, tobacco, and no drugs. Family History: No family of MI, stroke, son prostate cancer. Daughter with [Name2 (NI) 1932]. Physical Exam: Admission Exam: VS: Temp 97.8 F, BP 108/30 mmHg, HR 78 BPM, RR 14 , O2-sat 93% RA GEN: Well-appearing woman in NAD, comfortable, jaundiced (skin, mouth, conjuntiva) HEENT: NC/AT, PERRLA, EOMI, sclerae icteric, MMM, OP clear NECK: Supple, no thyromegaly, no JVD, no carotid bruits LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN: No rashes or lesions LYMPH: No cervical, axillary, or inguinal LAD NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [3-23] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Exam on transfer to floor on [2157-2-3]: VS: 98.9, 154/56, 80, 18, 97% on 2L GEN: NAD HEENT: EOMI, MMM, anicteric sclerae, no oral lesions NECK: Supple, R IJ s/p removal with bandage CHEST: CTAB CV: RRR, normal s1 and s2, no murmurs ABD: Soft, nondistended, bowel sounds present, mild tenderness in right upper/lower quadrants and midepigastrum, no rebound tenderness, no guarding EXT: No lower extremity edema SKIN: No rash NEURO: Awake, alert, oriented x3, CN 2-12 intact, strength 5/5 BUE/BLE, sensory intact throughout, fluent speech PSYCH: Calm, appropriate Pertinent Results: Admission Labs: WBC-13.8# RBC-4.09 Hgb-12.9 Hct-39.2 MCV-96 Plt Ct-182 Neuts-77* Bands-14* Lymphs-6* Monos-3 Eos-0 Baso-0 PT-12.1 INR(PT)-1.0 Glucose-216* UreaN-23* Creat-1.1 Na-138 K-5.8* Cl-98 HCO3-26 AnGap-20 ALT-723* AST-979* LD(LDH)-1269* CK(CPK)-99 AlkPhos-120* TotBili-3.5* Lipase-44 HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE Labs on transfer from ICU to floor [2157-2-3]: WBC-8.6 RBC-3.12* Hgb-10.0* Hct-30.2* MCV-97 Plt Ct-83* Glucose-193* UreaN-18 Creat-1.0 Na-138 K-3.0* Cl-103 HCO3-25 AnGap-13 ALT-51* AST-120* LD(LDH)-170 AlkPhos-65 Amylase-44 TotBili-1.5 Lipase-14 Calcium-8.0* Phos-2.2* Mg-1.6 Lactate-1.6 MICRO: Blood Culture [2157-2-1]: +Ecoli and Enterococcus, susceptible to ampicillin Urine Culture [2157-2-1]: No growth Blood cultures 3/17 x 2: Gram negative rods Blood Culture [2-3]: No growth to date Stool C-diff: Pending collection Imaging: CT Abdomen and Pelvis [2157-2-1]: 1. Stable pneumobilia and proximal biliary dilatation. 2. Left adnexal lesion, 2.6 cm. Recommend ultrasound for further characterization, and to exclude a solid lesion/cyst with mural nodule in this postmenopausal woman. ERCP [2157-2-1]: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Evidence of a previous wide open sphincterotomy was noted in the major papilla. Pus was noted at the ampulla. Cannulation: Cannulation of the biliary duct was successful and deep using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree: A single 15 mm stone that was causing partial obstruction was seen at the lower third of the common bile duct. The bile duct was dilated to 15 mm. The rest of the biliary tree was normal. Detailed cholangiogram was not obtained due to suspicion of cholangitis. Procedures: A 5cm by 10FR Double pig-tail biliary stent was placed successfully. Impression: S/P sphincterotomy - this was widely patent. Pus noted at the ampulla. Stone at the lower third of the common bile duct, dilation of bile duct to 15 mm, other normal biliary tree. A double pig-tail stent was placed in the bile duct. Otherwise normal ercp to third part of the duodenum TTE [2-8] The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Discharge labs: [2157-2-8] 06:37AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.4* Hct-31.5* MCV-96 MCH-31.5 MCHC-32.8 RDW-13.8 Plt Ct-225 [2157-2-8] 06:37AM BLOOD Glucose-100 UreaN-14 Creat-0.9 Na-141 K-3.7 Cl-104 HCO3-30 AnGap-11 [2157-2-8] 06:37AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8 Brief Hospital Course: 85 year-old woman presents with cholangitis [12-21] choledocholithiasis s/p ERCP with biliary stent placement. Gallstone was not removed because of the patient's tenous condition. The plan will be to repeat the ERCP in one month to remove the stone. Patient was also with bacteremia with E. Coli and Enterococcus likely [12-21] biliary source. Patient initially on Zosyn, but because of thrombocytopenia was changed over to Vanco and Cipro. This was finally changed to ampicillin when susceptibilities resulted. # Cholangitis: RUQ pain, fever, leukocytosis with bandemia, AST 979, ALT 723, AP 120, TB 3.5 and direct of 2.4. ERCP was performed and a double pigtail plastic stent was placed. Her hemodynamics remained stable. Blood cultures were positive for gram negative rods, and she was treated with IV Zosyn. Hepatitis serologies demonstrated previous hepatitis A exposure. She developed bacteremia (see below) and will continue antibiotics until [2-16]. She will need ERCP follow up in 1 month for repeat ERCP and stent placement. # E. Coli and Enterococcus bacteremia both susceptible to Ampicillin. Pt initially on Zosyn, then changed to Vanco and Ciprofloxacin given thrombocytopenia. ID was consulted and did not recommend cardiac imaging given that the likely source was the biliary tree and surveillance cultures were negative. She was converted to ampicillin and should continue a 14 day course since last negative culture ([Date range (3) 1933]). # Shortness of breath likely [12-21] fluid overload: Patient was intermittently tachypneic and wheezing and was treated with albuterol nebs and lasix with improvement. ECHO ordered to evaluate for systolic or diastolic dysfunction. She was found to have restrictive filling pressures and elevated [Name Prefix (Prefixes) ] [Last Name (Prefixes) 1934]. She will be discharged on lasix 10mg daily until she sees her PMD. She will need cardiology follow up given her disease. # Thrombocytopenia: PLTs decreased to 83 ([2-3]) from 182 on admission. Pt not on heparin, thought to be [12-21] sepsis at admission. Hemolysis labs not concerning for DIC, and less likely thought to be due to ITP or TTP. After discontinuation of Zosyn, the platelets increased and remained stable. On discharge, her platelets were 252. # Hypertension: Lisinopril restarted in ICU. Atenolol and Nifedipine restarted on the floor. Blood pressures were well controlled on the floor. # GERD: Pantoprazole was started. # Parkinson's disease: Continued Carbidopa-Levodopa # Diverticulosis: Stable. Guaiac negative stools. # DVT prophylaxis: mechanical # Code status: Full Code Medications on Admission: Atenolol 75 mg PO Daily Carbidopa-Levodopa 25/100 1 tab TID Lidocaine 5% patch Creon 10 249 mg EC 2 capsules with meals Lisinopril 40 mg PO Daily Nifedipine SR 60 mg PO Daily Omeprazole 40 mg PO Daily Detrol LA 2 mg PO Daily Tramadol 50 mg PO BID Zmbien 5 mg PO QHS Aspirin 81 mg PO Daily Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 9 days. Disp:27 Capsule(s) Refills:0 9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO every other day. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: PRIMARY DIAGNOSES: - Cholangitis - Choledocholithiasis - Bacteremia with E. Coli and Enterococcus - Thrombocytopenia, possibly from Zosyn - Hypoxia SECONDARY DIAGNOSES: - Hypertension - Gastroesophageal reflux disease - Parkinson's disease - Chronic urinary incontinence - Osteoporosis - Diverticulosis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Ambulatory and independent Discharge Instructions: You were admitted with abdominal pain. An ERCP was performed which showed gallstones obstructing your bile ducts. A stent was placed which improved the flow of bile. Blood tests showed a blood infection, and you are being treated with antibiotics. MEDICATION CHANGES: 1. START: Ampicillin 500mg one tablet three times daily until [2157-2-16] to complete 14-day course of antibiotics (renally dosed) 2. CHANGE: Omeprazole to Pantoprazole 40mg one tablet daily (your preference) 3. Start lasix 10mg daily. 4. Do NOT take aspirin for 5 days after your ERCP. Followup Instructions: Appointment #1 Department: [Hospital3 249] When: FRIDAY [2157-2-11] at 12:10 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 544], M.D. [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Appointment #2 Department: OPTHALMOLOGY When: MONDAY [2157-2-28] at 1 PM [Telephone/Fax (1) 253] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Appointment #3 Department: [Hospital3 1935] CENTER When: TUESDAY [2157-3-1] at 9:30 AM With: [Name6 (MD) 251] [Last Name (NamePattern4) 252], M.D. [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Appointment #4 ERCP: You will be contact[Name (NI) ] by the Gastroenterology service to schedule your biliary stent removal and gallstone extraction. This will be in about one month.	Admission Date: <Date>1940-5-27</Date> Discharge Date: <Date>1939-2-16</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Billy</Name> Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy and biliary stent placement on <Date>1940-5-27</Date> History of Present Illness: Mrs. <Name>Peter</Name> <Name>Clark</Name> is a very nice 85 year-old woman with a history of cholecystectomy and ampullar stenosis who presents with RUQ abdominal pain. She states her pain started 2 days prior to admission, was constant and radiated towards the back. She had nausea, vomit, malaise. Denies fever, chills, changes in her bowel movements, hematochezia or melena. Unable able to tolerate oral intake. Presenting vitals were T 101.5, HR 68, BP 152/76, RR 16, SpO2 95% RA. In ED, Unasyn 3gm given and a right IJ central line was placed. She underwent ERCP that showed 1-cm stone in the common bile duct. Patient became hypoxic from the conscious sedation, so the stone was not removed to expedite the procedure. A plastic biliary stent was successfully placed. Post-ERCP, she was admitted to the ICU with a diagnosis of cholangitis. ICU course: In the ICU, the patient was continued on Zosyn, her RUQ pain significantly improved, and she began to tolerate fluids. On <Date>9-25</Date>, she developed shortness of breath that improved with administration of furosemide. Nebulizer treatments also given. At time of transfer to floor, O2 sat was 95% on 2L nasal canula. Lisinopril restarted, but Atenolol and Nifedipine held for concern of lower heart rate. She was transferred to the floor and felt improvement in her abdominal pain. Denied shortness of breath, chest pain. Past Medical History: 1. Hypertension 2. Ampullary stenosis 3. Status post cholecystectomy for gallstones 4. History of sphincterotomy (as described above) 5. Osteoporosis 6. Gastroesophageal reflux disease 7. External hemorrhoids 8. Cerebrovascular accident in <Year>1981</Year> (right pontine) 9. Parkinson's diseae 10. Chronic low back pain with sciatica 11. Urinary frequency and urge incontinence 12. Diverticulosis 13. Chronic pancreatitis Social History: She lives by herself. She came the US in <Year>1981</Year> from <Country>Angola</Country> and is Russian-speaking. Denies alcohol, tobacco, and no drugs. Family History: No family of MI, stroke, son prostate cancer. Daughter with <Name>Sonny Heflin</Name>. Physical Exam: Admission Exam: VS: Temp 97.8 F, BP 108/30 mmHg, HR 78 BPM, RR 14 , O2-sat 93% RA GEN: Well-appearing woman in NAD, comfortable, jaundiced (skin, mouth, conjuntiva) HEENT: NC/AT, PERRLA, EOMI, sclerae icteric, MMM, OP clear NECK: Supple, no thyromegaly, no JVD, no carotid bruits LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN: No rashes or lesions LYMPH: No cervical, axillary, or inguinal LAD NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength <Date>1-13</Date> throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Exam on transfer to floor on <Date>2013-2-24</Date>: VS: 98.9, 154/56, 80, 18, 97% on 2L GEN: NAD HEENT: EOMI, MMM, anicteric sclerae, no oral lesions NECK: Supple, R IJ s/p removal with bandage CHEST: CTAB CV: RRR, normal s1 and s2, no murmurs ABD: Soft, nondistended, bowel sounds present, mild tenderness in right upper/lower quadrants and midepigastrum, no rebound tenderness, no guarding EXT: No lower extremity edema SKIN: No rash NEURO: Awake, alert, oriented x3, CN 2-12 intact, strength 5/5 BUE/BLE, sensory intact throughout, fluent speech PSYCH: Calm, appropriate Pertinent Results: Admission Labs: WBC-13.8# RBC-4.09 Hgb-12.9 Hct-39.2 MCV-96 Plt Ct-182 Neuts-77* Bands-14* Lymphs-6* Monos-3 Eos-0 Baso-0 PT-12.1 INR(PT)-1.0 Glucose-216* UreaN-23* Creat-1.1 Na-138 K-5.8* Cl-98 HCO3-26 AnGap-20 ALT-723* AST-979* LD(LDH)-1269* CK(CPK)-99 AlkPhos-120* TotBili-3.5* Lipase-44 HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE Labs on transfer from ICU to floor <Date>2013-2-24</Date>: WBC-8.6 RBC-3.12* Hgb-10.0* Hct-30.2* MCV-97 Plt Ct-83* Glucose-193* UreaN-18 Creat-1.0 Na-138 K-3.0* Cl-103 HCO3-25 AnGap-13 ALT-51* AST-120* LD(LDH)-170 AlkPhos-65 Amylase-44 TotBili-1.5 Lipase-14 Calcium-8.0* Phos-2.2* Mg-1.6 Lactate-1.6 MICRO: Blood Culture <Date>1940-5-27</Date>: +Ecoli and Enterococcus, susceptible to ampicillin Urine Culture <Date>1940-5-27</Date>: No growth Blood cultures 3/17 x 2: Gram negative rods Blood Culture <Date>9-25</Date>: No growth to date Stool C-diff: Pending collection Imaging: CT Abdomen and Pelvis <Date>1940-5-27</Date>: 1. Stable pneumobilia and proximal biliary dilatation. 2. Left adnexal lesion, 2.6 cm. Recommend ultrasound for further characterization, and to exclude a solid lesion/cyst with mural nodule in this postmenopausal woman. ERCP <Date>1940-5-27</Date>: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Evidence of a previous wide open sphincterotomy was noted in the major papilla. Pus was noted at the ampulla. Cannulation: Cannulation of the biliary duct was successful and deep using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree: A single 15 mm stone that was causing partial obstruction was seen at the lower third of the common bile duct. The bile duct was dilated to 15 mm. The rest of the biliary tree was normal. Detailed cholangiogram was not obtained due to suspicion of cholangitis. Procedures: A 5cm by 10FR Double pig-tail biliary stent was placed successfully. Impression: S/P sphincterotomy - this was widely patent. Pus noted at the ampulla. Stone at the lower third of the common bile duct, dilation of bile duct to 15 mm, other normal biliary tree. A double pig-tail stent was placed in the bile duct. Otherwise normal ercp to third part of the duodenum TTE <Date>8-30</Date> The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Discharge labs: <Date>1939-2-16</Date> 06:37AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.4* Hct-31.5* MCV-96 MCH-31.5 MCHC-32.8 RDW-13.8 Plt Ct-225 <Date>1939-2-16</Date> 06:37AM BLOOD Glucose-100 UreaN-14 Creat-0.9 Na-141 K-3.7 Cl-104 HCO3-30 AnGap-11 <Date>1939-2-16</Date> 06:37AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8 Brief Hospital Course: 85 year-old woman presents with cholangitis <Date>3-12</Date> choledocholithiasis s/p ERCP with biliary stent placement. Gallstone was not removed because of the patient's tenous condition. The plan will be to repeat the ERCP in one month to remove the stone. Patient was also with bacteremia with E. Coli and Enterococcus likely <Date>3-12</Date> biliary source. Patient initially on Zosyn, but because of thrombocytopenia was changed over to Vanco and Cipro. This was finally changed to ampicillin when susceptibilities resulted. # Cholangitis: RUQ pain, fever, leukocytosis with bandemia, AST 979, ALT 723, AP 120, TB 3.5 and direct of 2.4. ERCP was performed and a double pigtail plastic stent was placed. Her hemodynamics remained stable. Blood cultures were positive for gram negative rods, and she was treated with IV Zosyn. Hepatitis serologies demonstrated previous hepatitis A exposure. She developed bacteremia (see below) and will continue antibiotics until <Date>2-2</Date>. She will need ERCP follow up in 1 month for repeat ERCP and stent placement. # E. Coli and Enterococcus bacteremia both susceptible to Ampicillin. Pt initially on Zosyn, then changed to Vanco and Ciprofloxacin given thrombocytopenia. ID was consulted and did not recommend cardiac imaging given that the likely source was the biliary tree and surveillance cultures were negative. She was converted to ampicillin and should continue a 14 day course since last negative culture (<Date Range>1972-1-2 to 1988-7-7</Date Range>). # Shortness of breath likely <Date>3-12</Date> fluid overload: Patient was intermittently tachypneic and wheezing and was treated with albuterol nebs and lasix with improvement. ECHO ordered to evaluate for systolic or diastolic dysfunction. She was found to have restrictive filling pressures and elevated <Name>Karthik Lockett</Name> <Name>Moblo</Name>. She will be discharged on lasix 10mg daily until she sees her PMD. She will need cardiology follow up given her disease. # Thrombocytopenia: PLTs decreased to 83 (<Date>9-25</Date>) from 182 on admission. Pt not on heparin, thought to be <Date>3-12</Date> sepsis at admission. Hemolysis labs not concerning for DIC, and less likely thought to be due to ITP or TTP. After discontinuation of Zosyn, the platelets increased and remained stable. On discharge, her platelets were 252. # Hypertension: Lisinopril restarted in ICU. Atenolol and Nifedipine restarted on the floor. Blood pressures were well controlled on the floor. # GERD: Pantoprazole was started. # Parkinson's disease: Continued Carbidopa-Levodopa # Diverticulosis: Stable. Guaiac negative stools. # DVT prophylaxis: mechanical # Code status: Full Code Medications on Admission: Atenolol 75 mg PO Daily Carbidopa-Levodopa 25/100 1 tab TID Lidocaine 5% patch Creon 10 249 mg EC 2 capsules with meals Lisinopril 40 mg PO Daily Nifedipine SR 60 mg PO Daily Omeprazole 40 mg PO Daily Detrol LA 2 mg PO Daily Tramadol 50 mg PO BID Zmbien 5 mg PO QHS Aspirin 81 mg PO Daily Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 9 days. Disp:27 Capsule(s) Refills:0 9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO every other day. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: <Hospital>Wong-Marshall Clinic</Hospital> Family & <Hospital>Campbell, Brown and Crawford Hospital</Hospital> Services Discharge Diagnosis: PRIMARY DIAGNOSES: - Cholangitis - Choledocholithiasis - Bacteremia with E. Coli and Enterococcus - Thrombocytopenia, possibly from Zosyn - Hypoxia SECONDARY DIAGNOSES: - Hypertension - Gastroesophageal reflux disease - Parkinson's disease - Chronic urinary incontinence - Osteoporosis - Diverticulosis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Ambulatory and independent Discharge Instructions: You were admitted with abdominal pain. An ERCP was performed which showed gallstones obstructing your bile ducts. A stent was placed which improved the flow of bile. Blood tests showed a blood infection, and you are being treated with antibiotics. MEDICATION CHANGES: 1. START: Ampicillin 500mg one tablet three times daily until <Date>1994-2-26</Date> to complete 14-day course of antibiotics (renally dosed) 2. CHANGE: Omeprazole to Pantoprazole 40mg one tablet daily (your preference) 3. Start lasix 10mg daily. 4. Do NOT take aspirin for 5 days after your ERCP. Followup Instructions: Appointment #1 Department: <Hospital>Edwards, Marsh and Gonzalez Clinic</Hospital> When: FRIDAY <Date>1948-5-4</Date> at 12:10 PM With: <Name>Darnell</Name> <Name>Pichardo</Name>, M.D. <Telephone>140-878-7962</Telephone> Building: SC <Hospital>Young Inc Health System</Hospital> Clinical Ctr <Location>Unit 7943 Box 6246 DPO AA 74122</Location> Campus: EAST Best Parking: <Hospital>Young Inc Health System</Hospital> Garage Appointment #2 Department: OPTHALMOLOGY When: MONDAY <Date>2010-6-26</Date> at 1 PM <Telephone>323-952-1450</Telephone> Campus: EAST Best Parking: <Hospital>Young Inc Health System</Hospital> Garage Appointment #3 Department: <Hospital>Tanner, Munoz and Phillips Hospital</Hospital> CENTER When: TUESDAY <Date>1960-1-21</Date> at 9:30 AM With: <Name>Sharon Harris</Name> <Name>Hazelwood</Name>, M.D. <Telephone>323-952-1450</Telephone> Building: SC <Hospital>Young Inc Health System</Hospital> Clinical Ctr <Location>779 Brian Union Apt. 197 Allenberg, PR 08105</Location> Campus: EAST Best Parking: <Hospital>Young Inc Health System</Hospital> Garage Appointment #4 ERCP: You will be contact<Name>Jian Kiel</Name> by the Gastroenterology service to schedule your biliary stent removal and gallstone extraction. This will be in about one month.	0000000000000000011111111100000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000111110111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000001111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1940-5-27 Discharge Date: 1939-2-16 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Billy Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy and biliary stent placement on 1940-5-27 History of Present Illness: Mrs. Peter Clark is a very nice 85 year-old woman with a history of cholecystectomy and ampullar stenosis who presents with RUQ abdominal pain. She states her pain started 2 days prior to admission, was constant and radiated towards the back. She had nausea, vomit, malaise. Denies fever, chills, changes in her bowel movements, hematochezia or melena. Unable able to tolerate oral intake. Presenting vitals were T 101.5, HR 68, BP 152/76, RR 16, SpO2 95% RA. In ED, Unasyn 3gm given and a right IJ central line was placed. She underwent ERCP that showed 1-cm stone in the common bile duct. Patient became hypoxic from the conscious sedation, so the stone was not removed to expedite the procedure. A plastic biliary stent was successfully placed. Post-ERCP, she was admitted to the ICU with a diagnosis of cholangitis. ICU course: In the ICU, the patient was continued on Zosyn, her RUQ pain significantly improved, and she began to tolerate fluids. On 9-25, she developed shortness of breath that improved with administration of furosemide. Nebulizer treatments also given. At time of transfer to floor, O2 sat was 95% on 2L nasal canula. Lisinopril restarted, but Atenolol and Nifedipine held for concern of lower heart rate. She was transferred to the floor and felt improvement in her abdominal pain. Denied shortness of breath, chest pain. Past Medical History: 1. Hypertension 2. Ampullary stenosis 3. Status post cholecystectomy for gallstones 4. History of sphincterotomy (as described above) 5. Osteoporosis 6. Gastroesophageal reflux disease 7. External hemorrhoids 8. Cerebrovascular accident in 1981 (right pontine) 9. Parkinson's diseae 10. Chronic low back pain with sciatica 11. Urinary frequency and urge incontinence 12. Diverticulosis 13. Chronic pancreatitis Social History: She lives by herself. She came the US in 1981 from Angola and is Russian-speaking. Denies alcohol, tobacco, and no drugs. Family History: No family of MI, stroke, son prostate cancer. Daughter with Sonny Heflin. Physical Exam: Admission Exam: VS: Temp 97.8 F, BP 108/30 mmHg, HR 78 BPM, RR 14 , O2-sat 93% RA GEN: Well-appearing woman in NAD, comfortable, jaundiced (skin, mouth, conjuntiva) HEENT: NC/AT, PERRLA, EOMI, sclerae icteric, MMM, OP clear NECK: Supple, no thyromegaly, no JVD, no carotid bruits LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN: No rashes or lesions LYMPH: No cervical, axillary, or inguinal LAD NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength 1-13 throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Exam on transfer to floor on 2013-2-24: VS: 98.9, 154/56, 80, 18, 97% on 2L GEN: NAD HEENT: EOMI, MMM, anicteric sclerae, no oral lesions NECK: Supple, R IJ s/p removal with bandage CHEST: CTAB CV: RRR, normal s1 and s2, no murmurs ABD: Soft, nondistended, bowel sounds present, mild tenderness in right upper/lower quadrants and midepigastrum, no rebound tenderness, no guarding EXT: No lower extremity edema SKIN: No rash NEURO: Awake, alert, oriented x3, CN 2-12 intact, strength 5/5 BUE/BLE, sensory intact throughout, fluent speech PSYCH: Calm, appropriate Pertinent Results: Admission Labs: WBC-13.8# RBC-4.09 Hgb-12.9 Hct-39.2 MCV-96 Plt Ct-182 Neuts-77* Bands-14* Lymphs-6* Monos-3 Eos-0 Baso-0 PT-12.1 INR(PT)-1.0 Glucose-216* UreaN-23* Creat-1.1 Na-138 K-5.8* Cl-98 HCO3-26 AnGap-20 ALT-723* AST-979* LD(LDH)-1269* CK(CPK)-99 AlkPhos-120* TotBili-3.5* Lipase-44 HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE Labs on transfer from ICU to floor 2013-2-24: WBC-8.6 RBC-3.12* Hgb-10.0* Hct-30.2* MCV-97 Plt Ct-83* Glucose-193* UreaN-18 Creat-1.0 Na-138 K-3.0* Cl-103 HCO3-25 AnGap-13 ALT-51* AST-120* LD(LDH)-170 AlkPhos-65 Amylase-44 TotBili-1.5 Lipase-14 Calcium-8.0* Phos-2.2* Mg-1.6 Lactate-1.6 MICRO: Blood Culture 1940-5-27: +Ecoli and Enterococcus, susceptible to ampicillin Urine Culture 1940-5-27: No growth Blood cultures 3/17 x 2: Gram negative rods Blood Culture 9-25: No growth to date Stool C-diff: Pending collection Imaging: CT Abdomen and Pelvis 1940-5-27: 1. Stable pneumobilia and proximal biliary dilatation. 2. Left adnexal lesion, 2.6 cm. Recommend ultrasound for further characterization, and to exclude a solid lesion/cyst with mural nodule in this postmenopausal woman. ERCP 1940-5-27: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Evidence of a previous wide open sphincterotomy was noted in the major papilla. Pus was noted at the ampulla. Cannulation: Cannulation of the biliary duct was successful and deep using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree: A single 15 mm stone that was causing partial obstruction was seen at the lower third of the common bile duct. The bile duct was dilated to 15 mm. The rest of the biliary tree was normal. Detailed cholangiogram was not obtained due to suspicion of cholangitis. Procedures: A 5cm by 10FR Double pig-tail biliary stent was placed successfully. Impression: S/P sphincterotomy - this was widely patent. Pus noted at the ampulla. Stone at the lower third of the common bile duct, dilation of bile duct to 15 mm, other normal biliary tree. A double pig-tail stent was placed in the bile duct. Otherwise normal ercp to third part of the duodenum TTE 8-30 The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Discharge labs: 1939-2-16 06:37AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.4* Hct-31.5* MCV-96 MCH-31.5 MCHC-32.8 RDW-13.8 Plt Ct-225 1939-2-16 06:37AM BLOOD Glucose-100 UreaN-14 Creat-0.9 Na-141 K-3.7 Cl-104 HCO3-30 AnGap-11 1939-2-16 06:37AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8 Brief Hospital Course: 85 year-old woman presents with cholangitis 3-12 choledocholithiasis s/p ERCP with biliary stent placement. Gallstone was not removed because of the patient's tenous condition. The plan will be to repeat the ERCP in one month to remove the stone. Patient was also with bacteremia with E. Coli and Enterococcus likely 3-12 biliary source. Patient initially on Zosyn, but because of thrombocytopenia was changed over to Vanco and Cipro. This was finally changed to ampicillin when susceptibilities resulted. # Cholangitis: RUQ pain, fever, leukocytosis with bandemia, AST 979, ALT 723, AP 120, TB 3.5 and direct of 2.4. ERCP was performed and a double pigtail plastic stent was placed. Her hemodynamics remained stable. Blood cultures were positive for gram negative rods, and she was treated with IV Zosyn. Hepatitis serologies demonstrated previous hepatitis A exposure. She developed bacteremia (see below) and will continue antibiotics until 2-2. She will need ERCP follow up in 1 month for repeat ERCP and stent placement. # E. Coli and Enterococcus bacteremia both susceptible to Ampicillin. Pt initially on Zosyn, then changed to Vanco and Ciprofloxacin given thrombocytopenia. ID was consulted and did not recommend cardiac imaging given that the likely source was the biliary tree and surveillance cultures were negative. She was converted to ampicillin and should continue a 14 day course since last negative culture (1972-1-2 to 1988-7-7). # Shortness of breath likely 3-12 fluid overload: Patient was intermittently tachypneic and wheezing and was treated with albuterol nebs and lasix with improvement. ECHO ordered to evaluate for systolic or diastolic dysfunction. She was found to have restrictive filling pressures and elevated Karthik Lockett Moblo. She will be discharged on lasix 10mg daily until she sees her PMD. She will need cardiology follow up given her disease. # Thrombocytopenia: PLTs decreased to 83 (9-25) from 182 on admission. Pt not on heparin, thought to be 3-12 sepsis at admission. Hemolysis labs not concerning for DIC, and less likely thought to be due to ITP or TTP. After discontinuation of Zosyn, the platelets increased and remained stable. On discharge, her platelets were 252. # Hypertension: Lisinopril restarted in ICU. Atenolol and Nifedipine restarted on the floor. Blood pressures were well controlled on the floor. # GERD: Pantoprazole was started. # Parkinson's disease: Continued Carbidopa-Levodopa # Diverticulosis: Stable. Guaiac negative stools. # DVT prophylaxis: mechanical # Code status: Full Code Medications on Admission: Atenolol 75 mg PO Daily Carbidopa-Levodopa 25/100 1 tab TID Lidocaine 5% patch Creon 10 249 mg EC 2 capsules with meals Lisinopril 40 mg PO Daily Nifedipine SR 60 mg PO Daily Omeprazole 40 mg PO Daily Detrol LA 2 mg PO Daily Tramadol 50 mg PO BID Zmbien 5 mg PO QHS Aspirin 81 mg PO Daily Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 9 days. Disp:27 Capsule(s) Refills:0 9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO every other day. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Wong-Marshall Clinic Family & Campbell, Brown and Crawford Hospital Services Discharge Diagnosis: PRIMARY DIAGNOSES: - Cholangitis - Choledocholithiasis - Bacteremia with E. Coli and Enterococcus - Thrombocytopenia, possibly from Zosyn - Hypoxia SECONDARY DIAGNOSES: - Hypertension - Gastroesophageal reflux disease - Parkinson's disease - Chronic urinary incontinence - Osteoporosis - Diverticulosis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Ambulatory and independent Discharge Instructions: You were admitted with abdominal pain. An ERCP was performed which showed gallstones obstructing your bile ducts. A stent was placed which improved the flow of bile. Blood tests showed a blood infection, and you are being treated with antibiotics. MEDICATION CHANGES: 1. START: Ampicillin 500mg one tablet three times daily until 1994-2-26 to complete 14-day course of antibiotics (renally dosed) 2. CHANGE: Omeprazole to Pantoprazole 40mg one tablet daily (your preference) 3. Start lasix 10mg daily. 4. Do NOT take aspirin for 5 days after your ERCP. Followup Instructions: Appointment #1 Department: Edwards, Marsh and Gonzalez Clinic When: FRIDAY 1948-5-4 at 12:10 PM With: Darnell Pichardo, M.D. 140-878-7962 Building: SC Young Inc Health System Clinical Ctr Unit 7943 Box 6246 DPO AA 74122 Campus: EAST Best Parking: Young Inc Health System Garage Appointment #2 Department: OPTHALMOLOGY When: MONDAY 2010-6-26 at 1 PM 323-952-1450 Campus: EAST Best Parking: Young Inc Health System Garage Appointment #3 Department: Tanner, Munoz and Phillips Hospital CENTER When: TUESDAY 1960-1-21 at 9:30 AM With: Sharon Harris Hazelwood, M.D. 323-952-1450 Building: SC Young Inc Health System Clinical Ctr 779 Brian Union Apt. 197 Allenberg, PR 08105 Campus: EAST Best Parking: Young Inc Health System Garage Appointment #4 ERCP: You will be contactJian Kiel by the Gastroenterology service to schedule your biliary stent removal and gallstone extraction. This will be in about one month.	['Admission Date: 1940-5-27 Discharge Date: 1939-2-16\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Billy\nChief Complaint:\nAbdominal pain\n\nMajor Surgical or Invasive Procedure:\nERCP with sphincterotomy and biliary stent placement on 1940-5-27\n\nHistory of Present Illness:\nMrs. Peter Clark is a very nice 85 year-old woman with a\nhistory of cholecystectomy and ampullar stenosis who presents\nwith RUQ abdominal pain. She states her pain started 2 days\nprior to admission, was constant and radiated towards the back.\nShe had nausea, vomit, malaise. Denies fever, chills, changes\nin her bowel movements, hematochezia or melena. Unable able to\ntolerate oral intake.\n\nPresenting vitals were T 101.5, HR 68, BP 152/76, RR 16, SpO2\n95% RA. In ED, Unasyn 3gm given and a right IJ central line was\nplaced.', ' She underwent ERCP that showed 1-cm stone in the common\nbile duct. Patient became hypoxic from the conscious sedation,\nso the stone was not removed to expedite the procedure. A\nplastic biliary stent was successfully placed. Post-ERCP, she\nwas admitted to the ICU with a diagnosis of cholangitis.\n\nICU course: In the ICU, the patient was continued on Zosyn, her\nRUQ pain significantly improved, and she began to tolerate\nfluids. On 9-25, she developed shortness of breath that\nimproved with administration of furosemide. Nebulizer\ntreatments also given. At time of transfer to floor, O2 sat was\n95% on 2L nasal canula. Lisinopril restarted, but Atenolol and\nNifedipine held for concern of lower heart rate.\n\nShe was transferred to the floor and felt improvement in her\nabdominal pain. Denied shortness of breath, chest pain.', "\n\nPast Medical History:\n1. Hypertension\n2. Ampullary stenosis\n3. Status post cholecystectomy for gallstones\n4. History of sphincterotomy (as described above)\n5. Osteoporosis\n6. Gastroesophageal reflux disease\n7. External hemorrhoids\n8. Cerebrovascular accident in 1981 (right pontine)\n9. Parkinson's diseae\n10. Chronic low back pain with sciatica\n11. Urinary frequency and urge incontinence\n12. Diverticulosis\n13. Chronic pancreatitis\n\nSocial History:\nShe lives by herself. She came the US in 1981 from Angola and\nis Russian-speaking. Denies alcohol, tobacco, and no drugs.\n\nFamily History:\nNo family of MI, stroke, son prostate cancer. Daughter with\nSonny Heflin.\n\nPhysical Exam:\nAdmission Exam:\nVS: Temp 97.8 F, BP 108/30 mmHg, HR 78 BPM, RR 14 , O2-sat 93%\nRA\nGEN: Well-appearing woman in NAD, comfortable, jaundiced (skin,\nmouth, conjuntiva)\nHEENT: NC/AT, PERRLA, EOMI, sclerae icteric, MMM, OP clear\nNECK: Supple, no thyromegaly, no JVD, no carotid bruits\nLUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,\nno accessory muscle use\nHEART: PMI non-displaced, RRR, no MRG, nl S1-S2\nABDOMEN: NABS, soft/NT/ND, no masses or HSM, no\nrebound/guarding.", '\nEXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)\n\nSKIN: No rashes or lesions\nLYMPH: No cervical, axillary, or inguinal LAD\nNEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength\n1-13 throughout, sensation grossly intact throughout, DTRs 2+ and\nsymmetric, cerebellar exam intact, steady gait\nPULSES:\nRight: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\nLeft: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n\nExam on transfer to floor on 2013-2-24:\nVS: 98.9, 154/56, 80, 18, 97% on 2L\nGEN: NAD\nHEENT: EOMI, MMM, anicteric sclerae, no oral lesions\nNECK: Supple, R IJ s/p removal with bandage\nCHEST: CTAB\nCV: RRR, normal s1 and s2, no murmurs\nABD: Soft, nondistended, bowel sounds present, mild tenderness\nin right upper/lower quadrants and midepigastrum, no rebound\ntenderness, no guarding\nEXT: No lower extremity edema\nSKIN: No rash\nNEURO: Awake, alert, oriented x3, CN 2-12 intact, strength 5/5\nBUE/BLE, sensory intact throughout, fluent speech\nPSYCH: Calm, appropriate\n\nPertinent Results:\nAdmission Labs:\nWBC-13.', '8# RBC-4.09 Hgb-12.9 Hct-39.2 MCV-96 Plt Ct-182\nNeuts-77* Bands-14* Lymphs-6* Monos-3 Eos-0 Baso-0\nPT-12.1 INR(PT)-1.0\nGlucose-216* UreaN-23* Creat-1.1 Na-138 K-5.8* Cl-98 HCO3-26\nAnGap-20\nALT-723* AST-979* LD(LDH)-1269* CK(CPK)-99 AlkPhos-120\nTotBili-3.5\nLipase-44\nHBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE\n\nLabs on transfer from ICU to floor 2013-2-24:\nWBC-8.6 RBC-3.12* Hgb-10.0* Hct-30.2* MCV-97 Plt Ct-83\nGlucose-193 UreaN-18 Creat-1.0 Na-138 K-3.0* Cl-103 HCO3-25\nAnGap-13\nALT-51* AST-120* LD(LDH)-170 AlkPhos-65 Amylase-44 TotBili-1.5\nLipase-14\nCalcium-8.0* Phos-2.2* Mg-1.6\nLactate-1.6\n\nMICRO:\nBlood Culture 1940-5-27: +Ecoli and Enterococcus, susceptible to\nampicillin\nUrine Culture 1940-5-27: No growth\nBlood cultures 3/17 x 2: Gram negative rods\nBlood Culture 9-25: No growth to date\nStool C-diff: Pending collection\n\nImaging:\nCT Abdomen and Pelvis 1940-5-27:\n1.', ' Stable pneumobilia and proximal biliary dilatation.\n2. Left adnexal lesion, 2.6 cm. Recommend ultrasound for further\n\ncharacterization, and to exclude a solid lesion/cyst with mural\nnodule in this postmenopausal woman.\n\nERCP 1940-5-27:\nFindings: Esophagus: Limited exam of the esophagus was normal\nStomach: Limited exam of the stomach was normal\nDuodenum: Limited exam of the duodenum was normal\nMajor Papilla: Evidence of a previous wide open sphincterotomy\nwas noted in the major papilla. Pus was noted at the ampulla.\nCannulation: Cannulation of the biliary duct was successful and\ndeep using a free-hand technique. Contrast medium was injected\nresulting in complete opacification.\n\nBiliary Tree: A single 15 mm stone that was causing partial\nobstruction was seen at the lower third of the common bile duct.', '\nThe bile duct was dilated to 15 mm. The rest of the biliary tree\nwas normal. Detailed cholangiogram was not obtained due to\nsuspicion of cholangitis.\nProcedures: A 5cm by 10FR Double pig-tail biliary stent was\nplaced successfully.\n\nImpression: S/P sphincterotomy - this was widely patent.\nPus noted at the ampulla.\nStone at the lower third of the common bile duct, dilation of\nbile duct to 15 mm, other normal biliary tree.\nA double pig-tail stent was placed in the bile duct.\n\nOtherwise normal ercp to third part of the duodenum\n\nTTE 8-30\nThe left atrium is mildly dilated. The right atrial pressure is\nindeterminate. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The\ndiameters of aorta at the sinus, ascending and arch levels are\nnormal.', ' The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No masses or vegetations are\nseen on the aortic valve. Mild (1+) aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is\nno mitral valve prolapse. No mass or vegetation is seen on the\nmitral valve. Moderate (2+) mitral regurgitation is seen. The\nleft ventricular inflow pattern suggests a restrictive filling\nabnormality, with elevated left atrial pressure. The tricuspid\nvalve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. Significant pulmonic regurgitation\nis seen. The end-diastolic pulmonic regurgitation velocity is\nincreased suggesting pulmonary artery diastolic hypertension.\nThere is a trivial/physiologic pericardial effusion.\n\nDischarge labs:\n\n1939-2-16 06:37AM BLOOD WBC-6.', "8 RBC-3.29* Hgb-10.4* Hct-31.5\nMCV-96 MCH-31.5 MCHC-32.8 RDW-13.8 Plt Ct-225\n1939-2-16 06:37AM BLOOD Glucose-100 UreaN-14 Creat-0.9 Na-141\nK-3.7 Cl-104 HCO3-30 AnGap-11\n1939-2-16 06:37AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8\n\nBrief Hospital Course:\n85 year-old woman presents with cholangitis 3-12\ncholedocholithiasis s/p ERCP with biliary stent placement.\nGallstone was not removed because of the patient's tenous\ncondition. The plan will be to repeat the ERCP in one month to\nremove the stone. Patient was also with bacteremia with E. Coli\nand Enterococcus likely 3-12 biliary source. Patient initially\non Zosyn, but because of thrombocytopenia was changed over to\nVanco and Cipro. This was finally changed to ampicillin when\nsusceptibilities resulted.\n\n# Cholangitis: RUQ pain, fever, leukocytosis with bandemia, AST\n979, ALT 723, AP 120, TB 3.", '5 and direct of 2.4. ERCP was\nperformed and a double pigtail plastic stent was placed. Her\nhemodynamics remained stable. Blood cultures were positive for\ngram negative rods, and she was treated with IV Zosyn.\nHepatitis serologies demonstrated previous hepatitis A exposure.\n She developed bacteremia (see below) and will continue\nantibiotics until 2-2. She will need ERCP follow up in 1 month\nfor repeat ERCP and stent placement.\n\n# E. Coli and Enterococcus bacteremia both susceptible to\nAmpicillin. Pt initially on Zosyn, then changed to Vanco and\nCiprofloxacin given thrombocytopenia. ID was consulted and did\nnot recommend cardiac imaging given that the likely source was\nthe biliary tree and surveillance cultures were negative. She\nwas converted to ampicillin and should continue a 14 day course\nsince last negative culture (1972-1-2 to 1988-7-7).', '\n\n# Shortness of breath likely 3-12 fluid overload: Patient was\nintermittently tachypneic and wheezing and was treated with\nalbuterol nebs and lasix with improvement. ECHO ordered to\nevaluate for systolic or diastolic dysfunction. She was found\nto have restrictive filling pressures and elevated Karthik Lockett Moblo.\n She will be discharged on lasix 10mg daily until she sees her\nPMD. She will need cardiology follow up given her disease.\n\n# Thrombocytopenia: PLTs decreased to 83 (9-25) from 182 on\nadmission. Pt not on heparin, thought to be 3-12 sepsis at\nadmission. Hemolysis labs not concerning for DIC, and less\nlikely thought to be due to ITP or TTP. After discontinuation of\nZosyn, the platelets increased and remained stable. On\ndischarge, her platelets were 252.\n\n# Hypertension: Lisinopril restarted in ICU.', " Atenolol and\nNifedipine restarted on the floor. Blood pressures were well\ncontrolled on the floor.\n\n# GERD: Pantoprazole was started.\n\n# Parkinson's disease: Continued Carbidopa-Levodopa\n\n# Diverticulosis: Stable. Guaiac negative stools.\n\n# DVT prophylaxis: mechanical\n\n# Code status: Full Code\n\nMedications on Admission:\nAtenolol 75 mg PO Daily\nCarbidopa-Levodopa 25/100 1 tab TID\nLidocaine 5% patch\nCreon 10 249 mg EC 2 capsules with meals\nLisinopril 40 mg PO Daily\nNifedipine SR 60 mg PO Daily\nOmeprazole 40 mg PO Daily\nDetrol LA 2 mg PO Daily\nTramadol 50 mg PO BID\nZmbien 5 mg PO QHS\nAspirin 81 mg PO Daily\n\nDischarge Medications:\n1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO\nTID (3 times a day).\n2. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,\nDelayed Release(E.", 'C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A\nDAY WITH MEALS).\n3. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n4. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).\n5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet\nSustained Release PO DAILY (Daily).\n7. 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:0\n8. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every\n8 hours) for 9 days.\nDisp:27 Capsule(s) Refills:0\n9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO every other day.\nDisp:15 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nWong-Marshall Clinic Family & Campbell, Brown and Crawford Hospital Services\n\nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n- Cholangitis\n- Choledocholithiasis\n- Bacteremia with E.', " Coli and Enterococcus\n- Thrombocytopenia, possibly from Zosyn\n- Hypoxia\n\nSECONDARY DIAGNOSES:\n- Hypertension\n- Gastroesophageal reflux disease\n- Parkinson's disease\n- Chronic urinary incontinence\n- Osteoporosis\n- Diverticulosis\n\n\nDischarge Condition:\nMental Status: Clear and coherent\nLevel of Consciousness: Alert and interactive\nAmbulatory and independent\n\nDischarge Instructions:\nYou were admitted with abdominal pain. An ERCP was performed\nwhich showed gallstones obstructing your bile ducts. A stent\nwas placed which improved the flow of bile. Blood tests showed\na blood infection, and you are being treated with antibiotics.\n\nMEDICATION CHANGES:\n1. START: Ampicillin 500mg one tablet three times daily until\n1994-2-26 to complete 14-day course of antibiotics (renally dosed)\n2. CHANGE: Omeprazole to Pantoprazole 40mg one tablet daily\n(your preference)\n3.", ' Start lasix 10mg daily.\n4. Do NOT take aspirin for 5 days after your ERCP.\n\nFollowup Instructions:\nAppointment #1\nDepartment: Edwards, Marsh and Gonzalez Clinic\nWhen: FRIDAY 1948-5-4 at 12:10 PM\nWith: Darnell Pichardo, M.D. 140-878-7962\nBuilding: SC Young Inc Health System Clinical Ctr Unit 7943 Box 6246\nDPO AA 74122\nCampus: EAST Best Parking: Young Inc Health System Garage\n\nAppointment #2\nDepartment: OPTHALMOLOGY\nWhen: MONDAY 2010-6-26 at 1 PM 323-952-1450\nCampus: EAST Best Parking: Young Inc Health System Garage\n\nAppointment #3\nDepartment: Tanner, Munoz and Phillips Hospital CENTER\nWhen: TUESDAY 1960-1-21 at 9:30 AM\nWith: Sharon Harris Hazelwood, M.D. 323-952-1450\nBuilding: SC Young Inc Health System Clinical Ctr 779 Brian Union Apt. 197\nAllenberg, PR 08105\nCampus: EAST Best Parking: Young Inc Health System Garage\n\nAppointment #4\nERCP: You will be contactJian Kiel by the Gastroenterology service to\nschedule your biliary stent removal and gallstone extraction.', '\nThis will be in about one month.\n\n\n\n']
193	53151	150192.0	2182-11-03	Discharge summary	Report	Admission Date: [2182-10-17] Discharge Date: [2182-11-3] Date of Birth: [2104-4-10] Sex: F Service: MEDICINE Allergies: Penicillins / Milk Attending:[First Name3 (LF) 1253] Chief Complaint: s/p ERCP with acute mental status changes/aspiration PNA Major Surgical or Invasive Procedure: ERCP with sphincteroplasty PEG tube placement (via Interventional Radiology) History of Present Illness: 77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and Mirizzi syndrome who presented today for elective ERCP. Pt was felt to be functionning at baseline prior to procedure with mild agitation, pulling at PIVs but interacting with staff. She was given fent/midaz for ERCP with stent placement and was transferred to the post-ERCP suite in stable condition. She had elevated BPs during the procedure requiring labetalol and metoprolol. She was found mildly tachypneic/wheezing with emesis on her gown. It was felt likely that she had an aspiration event with low grade temp However, she was still moving all four extremities and responding appropriately to questions though mildly sedated prior to transfer to the floor. . On arrival to the floor, pt was minimally responsive to sternal rub and did not withdraw to focal stimuli. She was notably tachypneic and eyes were deviated to right side. She was able to track to left with stimuli and would intermittently open eyes to command. Pt had an ABG 7.4/36/92 with lactate of 3.5 and CXR showed a right lower lobe infiltrate. Due to concern for acute intracranial hemmorrhage, she was taken down for a stat CT head. On return to the floor, pt was given narcan without any significant change in mental status. Neuro was consulted for possible acute stroke and within a few minutes, she became more responsive, opening eyes spontaneously. By the time neuro came to bedside, pt was able to verbalize her name and was noted to be using the right arm and had left sided deficit. A CODE stroke was called and pt was taken for urgent CTA head which did not show any vessel obstruction and TPA was felt unlikely to be helpful. Perfusion images confirmed right temporal hypoperfusion consistent with clinical exam and likely right MCA infarct. ICU consult was initiated and pt's guardian was notified. Pt was given Vanc/Cefepime and Aspirin 300mg PR while awaiting ICU transfer. She was lying flat per neuro recs and was noted to be spitting up bilious emesis. Head of bed was elevated and pt was suctionned prior to transferred to the ICU for closer monitoring of airway and management of acute pneumonia. Past Medical History: Hypertension Developmental Delay Mirizzi Syndrome COPD Social History: At baseline, pt lives at a nursing home and is able to feed herself, undress and can transfer from chair to bed but is otherwise wheelchair bound. No smoking/ETOH history documented. Family History: none relevant to this hospitalization. Physical Exam: Admission: T 101 BP 152/86 HR 86 RR 30 Sats 94% RA GEN: somnolent, open eyes to vigorous stimulous HEENT: Eyes deviated to right, tracks to left with startle CV: RRR no apprec m RESP: diffuse expiratory wheezes, moving air well ABD: soft, [Month (only) ] BS, no rebound/guarding GU: foley in place EXTR: warm, minimal edema, toes upgoing NEURO: minimally responsive, eyes deviated, no withdrawal to painful stimuli Pertinent Results: [2182-10-17] 04:02PM BLOOD WBC-24.8# RBC-6.40 Hgb-13.9 Hct-43.8 MCV-68* MCH-21.6* MCHC-31.6 RDW-14.3 Plt Ct-273 [2182-11-2] 05:55AM BLOOD WBC-8.1 RBC-5.33 Hgb-11.8* Hct-38.1 MCV-72* MCH-22.2* MCHC-31.0 RDW-14.8 Plt Ct-399 [2182-11-1] 06:05AM BLOOD Glucose-113* UreaN-4* Creat-0.5 Na-141 K-3.5 Cl-106 HCO3-27 AnGap-12 [2182-10-28] 06:05AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.9 [2182-10-17] 04:02PM BLOOD ALT-92* AST-118* AlkPhos-247* TotBili-1.4 [2182-10-18] 04:42AM BLOOD ALT-145* AST-277* AlkPhos-136* Amylase-101* TotBili-0.5 [2182-10-28] 06:05AM BLOOD ALT-50* AST-46* LD(LDH)-170 AlkPhos-144* TotBili-0.3 [2182-10-21] 06:36AM BLOOD Triglyc-143 HDL-44 CHOL/HD-3.8 LDLcalc-93 [2182-10-21] 06:36AM BLOOD %HbA1c-9.4* eAG-223* . ERCP [2182-10-17] Procedures: A plastic stent was removed. Impression: 2 balloon sweeps were performed with a small stone, sludge and debris removed. A 1.5 cm biliary stricture in mid-CBD compatible with known cystic duct stone and mirrizi syndrome was visualized. A 10 F 5cm double pigtailed catheter was placed. Otherwise normal ercp to third part of the duodenum. CXR [2182-10-17] IMPRESSION: Right lower lobe pneumonia with atelectasis or pneumonia at the left base. . CTA HEAD W&W/O C & RECONS IMPRESSION: Moderate-to-severe intracranial atherosclerotic disease with findings suggestive of decreased perfusion to the right MCA/PCA watershed region. The findings may represent cerebral ischemia in the setting of hypovolemia, hypotension or other causes of decreased cardiac output. . Cardiac Echo: IMPRESSION: Small LV cavity size with mild symmetric LVH and hyperdynamic LV systolic function. Consequently, there is a mild to moderate LV outflow tract gradient. No pathologic valvular abnormality seen. . RUE LENI IMPRESSION: Partially occlusive thrombus in the right basilic and axillary veins at site of PICC line. Clot does not extend more centrally. . ABDOMEN (SUPINE ONLY) PORT IMPRESSION: Limited view of the abdomen demonstrating no evidence for obstruction. Bladder stone. Coags: [2182-11-1] 06:05AM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1 [2182-11-2] 05:55AM BLOOD PT-14.0* INR(PT)-1.2* (Started Warfarin 5 mg) Brief Hospital Course: 77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and Mirizzi syndrome who presented on [10-17] for elective ERCP. Pt was noted to have emesis on her gown in the post procedure suite with diffuse wheezes and low grade temp. It was thought likely that she had an aspiration event and when she was arrived on the floor, she had a profoundly depressed mental status, tachypnea and fever to 101.9. Further stat work up revealed evidence of aspiration PNA, leukocytosis and elevated lactate. Initial head imaging was unrevealing. However, she became more alert and was noted to have an acute left sided deficit. CODE STROKE was called and CTA/perfusion images confirmed right sided hypoperfusion likely consistent with right MCA stroke. Neuro felt there was no indication for TPA given patent intracranial vessels and on return to the floor, pt was noted to have bilious secretions that she was having difficulty clearing. She was transferred to the ICU for airway monitoring overnight. Pt was called out to the floor when she was able to cough and spit up secretions. She was noted to have a waxing and [Doctor Last Name 688] mental status, sometimes will respond to commands and other times will not. BP was allowed to autoregulate for the first 72 hrs post event and pt was continued on Aspirin 300mg daily. She was noted to have recovery of left arm function and was answering yes/no to questions. She was seen by PT/OT who recommended ongoing therapy upon return to NH. After discussion with HCP/guardian, decision was made to avoid follow up MRI as it was not likely to change care plan and pt was unlikely to tolerate the procedure. Echo was performed to rule out cardioembolic source which did not show any thrombus. Lipid panel showed LDL in the 93, and Hgb A1c 9.4. She was hyperglycemic during the hospitalization, and she was started on Lantus and sliding scale insulin. . Aspiration PNA: Pt was noted to have aspiration event s/p procedure and was monitored in the ICU for 24hrs given concern for her ability to protect airway . Leukocytosis, lactate and fevers resolved after initiation of Vanc/Cefepime/Flagyl. Respiratory status improved and pt had a PICC placed and she completed a course of antibiotics. Upper Extremity DVT- Patient was subsequently developed a DVT associated with the PICC line. The PICC line was discontinued and she was started on Lovenox. Once a PEG tube was placed, she was started on Warfarin for a goal INR of [2-6]. Please follow INR closely and titrate prn. She received her first dose of Warfarin 5 mg on [11-2]. Aspiration - Pt was seen by speach/swallow on multiple occasions, which she grossly failed with aspiration. She was kept strictly NPO, and she was maintained with IV medications and hydration. A dobhoff was placed for initiation of tube feeds, while waiting to see if she would regain her swallow function. It is/was hoped that her swallow function would improve, especially considering her significant recovery in her left arm movement, however, she did not show significant improvement on serial exams. In discussion with Speech and Swallow, however, there is some hope that she may recover her swallow on a long term basis, and Swallow therapy may help with this recovery. They suggested an approximate 50% chance of recovery to the point of safe oral intake in the long-term. . Diabetes-Pt with uncontrolled hyperglycemia after the initiation of tube feeds. Her lantus and insulin sliding scales were agressively increased. She is being discharged on 70 units of lantus, and a sliding scale. . Mirizzi Syndrome s/p ERCP: Pt with abnormal biliary anatomy who underwent stent and sphincteroplastyon [10-17] for recurrent abd pain. She was noted to have an acute rise in transaminases post procedure and these trended down with normal Tbili. Pt was followed by ERCP team while in house. . Developmental Delay: baseline confirmed with her guardian/mother and nursing home. . HTN: held BP meds to allow autoregulation s/p stroke. She was subsequently treated with IV metoprolol, clonidine patch, and IV lasix, with benefit. After obtaining access via PEG, a blood pressure medication regimen via PEG was begun. I expect that she will benefit from further titration of medications as an outpatient. Please note that she was also started on Lisinopril; please follow up lytes in 1 week to ensure she tolerates. . Hyperlipidemia: Patient's simvastatin was held while patient was NPO. This was resumed after obtaining access via PEG. This medication dose was increased to 40 mg for goal LDL <70 considering diabetes and stroke. Please follow up LFT's to ensure tolerating, and lipid profile to ensure she meets her targets. . CODE: DNR/DNI confirmed with guardian Medications on Admission: Aspirin 81mg daily Alendronate 70mg weekly Multivitamin Colace 100mg [Hospital1 ] Calcium/Vit D Metoprolol 50mg [Hospital1 ] Bisacodyl prn Simvastatin 20mg daily Vicodin/tylenol prn Discharge Medications: 1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Inj Subcutaneous Q12H (every 12 hours): Please continue until INR [2-6] x 48 hrs, then discontinue. 2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily): [Month (only) 116] hold for loose stools. 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for no bm x 2 days. 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please follow INR closely, and titrate prn for INR goal [2-6]. Please continue lovenox until INR >2 x 48 hrs. 5. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): Please titrate prn. Started [11-2]. 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please titrate prn. Started [11-2]. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 650 mg/20.3 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q 8H (Every 8 Hours): would schedule q 8hr x 1 week, to treat for probable post-PEG procedure pain. (then prn). 11. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 12. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. insulin glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous once a day: titrate prn. 15. Humalog 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous four times a day: as per sliding scale provided. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) 86] Discharge Diagnosis: Primary: Biliary obstruction s/p sphincteroplasty Middle cerebral artery stroke Aspiration Pneumonia Dysphagia due to stroke . Secondary: Developmental Delay Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted for an ERCP and had a aspiration event after the procedure. It was discovered that you had a stroke on [10-17] and you will need to continue working with occupational therapy to continue recovering function. You were treated for an aspiration PNA with antibiotics, which you finished in the hospital. Your blood sugars were very elevated for this your insulin doses were increased. . Please note that there were many changes to your medications as a result of this hospitalization. Please follow your new medication list. Followup Instructions: Department: NEUROLOGY When: MONDAY [2182-11-11] at 4:30 PM With: DRS. [Name5 (PTitle) 162] & [Hospital1 ] [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ENDO SUITES When: THURSDAY [2183-4-17] at 8:00 AM Department: DIGESTIVE DISEASE CENTER When: THURSDAY [2183-4-17] at 8:00 AM With: [Name6 (MD) 1948] [Last Name (NamePattern4) 1949], MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 1951] Campus: EAST Best Parking: Main Garage	Admission Date: <Date>2018-8-3</Date> Discharge Date: <Date>1931-11-11</Date> Date of Birth: <Date>1984-11-7</Date> Sex: F Service: MEDICINE Allergies: Penicillins / Milk Attending:<Name>Everardo</Name> Chief Complaint: s/p ERCP with acute mental status changes/aspiration PNA Major Surgical or Invasive Procedure: ERCP with sphincteroplasty PEG tube placement (via Interventional Radiology) History of Present Illness: 77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and Mirizzi syndrome who presented today for elective ERCP. Pt was felt to be functionning at baseline prior to procedure with mild agitation, pulling at PIVs but interacting with staff. She was given fent/midaz for ERCP with stent placement and was transferred to the post-ERCP suite in stable condition. She had elevated BPs during the procedure requiring labetalol and metoprolol. She was found mildly tachypneic/wheezing with emesis on her gown. It was felt likely that she had an aspiration event with low grade temp However, she was still moving all four extremities and responding appropriately to questions though mildly sedated prior to transfer to the floor. . On arrival to the floor, pt was minimally responsive to sternal rub and did not withdraw to focal stimuli. She was notably tachypneic and eyes were deviated to right side. She was able to track to left with stimuli and would intermittently open eyes to command. Pt had an ABG 7.4/36/92 with lactate of 3.5 and CXR showed a right lower lobe infiltrate. Due to concern for acute intracranial hemmorrhage, she was taken down for a stat CT head. On return to the floor, pt was given narcan without any significant change in mental status. Neuro was consulted for possible acute stroke and within a few minutes, she became more responsive, opening eyes spontaneously. By the time neuro came to bedside, pt was able to verbalize her name and was noted to be using the right arm and had left sided deficit. A CODE stroke was called and pt was taken for urgent CTA head which did not show any vessel obstruction and TPA was felt unlikely to be helpful. Perfusion images confirmed right temporal hypoperfusion consistent with clinical exam and likely right MCA infarct. ICU consult was initiated and pt's guardian was notified. Pt was given Vanc/Cefepime and Aspirin 300mg PR while awaiting ICU transfer. She was lying flat per neuro recs and was noted to be spitting up bilious emesis. Head of bed was elevated and pt was suctionned prior to transferred to the ICU for closer monitoring of airway and management of acute pneumonia. Past Medical History: Hypertension Developmental Delay Mirizzi Syndrome COPD Social History: At baseline, pt lives at a nursing home and is able to feed herself, undress and can transfer from chair to bed but is otherwise wheelchair bound. No smoking/ETOH history documented. Family History: none relevant to this hospitalization. Physical Exam: Admission: T 101 BP 152/86 HR 86 RR 30 Sats 94% RA GEN: somnolent, open eyes to vigorous stimulous HEENT: Eyes deviated to right, tracks to left with startle CV: RRR no apprec m RESP: diffuse expiratory wheezes, moving air well ABD: soft, <Month>July</Month> BS, no rebound/guarding GU: foley in place EXTR: warm, minimal edema, toes upgoing NEURO: minimally responsive, eyes deviated, no withdrawal to painful stimuli Pertinent Results: <Date>2018-8-3</Date> 04:02PM BLOOD WBC-24.8# RBC-6.40 Hgb-13.9 Hct-43.8 MCV-68* MCH-21.6* MCHC-31.6 RDW-14.3 Plt Ct-273 <Date>1999-10-23</Date> 05:55AM BLOOD WBC-8.1 RBC-5.33 Hgb-11.8* Hct-38.1 MCV-72* MCH-22.2* MCHC-31.0 RDW-14.8 Plt Ct-399 <Date>2008-10-17</Date> 06:05AM BLOOD Glucose-113* UreaN-4* Creat-0.5 Na-141 K-3.5 Cl-106 HCO3-27 AnGap-12 <Date>1944-2-27</Date> 06:05AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.9 <Date>2018-8-3</Date> 04:02PM BLOOD ALT-92* AST-118* AlkPhos-247* TotBili-1.4 <Date>1999-5-28</Date> 04:42AM BLOOD ALT-145* AST-277* AlkPhos-136* Amylase-101* TotBili-0.5 <Date>1944-2-27</Date> 06:05AM BLOOD ALT-50* AST-46* LD(LDH)-170 AlkPhos-144* TotBili-0.3 <Date>1948-3-30</Date> 06:36AM BLOOD Triglyc-143 HDL-44 CHOL/HD-3.8 LDLcalc-93 <Date>1948-3-30</Date> 06:36AM BLOOD %HbA1c-9.4* eAG-223* . ERCP <Date>2018-8-3</Date> Procedures: A plastic stent was removed. Impression: 2 balloon sweeps were performed with a small stone, sludge and debris removed. A 1.5 cm biliary stricture in mid-CBD compatible with known cystic duct stone and mirrizi syndrome was visualized. A 10 F 5cm double pigtailed catheter was placed. Otherwise normal ercp to third part of the duodenum. CXR <Date>2018-8-3</Date> IMPRESSION: Right lower lobe pneumonia with atelectasis or pneumonia at the left base. . CTA HEAD W&W/O C & RECONS IMPRESSION: Moderate-to-severe intracranial atherosclerotic disease with findings suggestive of decreased perfusion to the right MCA/PCA watershed region. The findings may represent cerebral ischemia in the setting of hypovolemia, hypotension or other causes of decreased cardiac output. . Cardiac Echo: IMPRESSION: Small LV cavity size with mild symmetric LVH and hyperdynamic LV systolic function. Consequently, there is a mild to moderate LV outflow tract gradient. No pathologic valvular abnormality seen. . RUE LENI IMPRESSION: Partially occlusive thrombus in the right basilic and axillary veins at site of PICC line. Clot does not extend more centrally. . ABDOMEN (SUPINE ONLY) PORT IMPRESSION: Limited view of the abdomen demonstrating no evidence for obstruction. Bladder stone. Coags: <Date>2008-10-17</Date> 06:05AM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1 <Date>1999-10-23</Date> 05:55AM BLOOD PT-14.0* INR(PT)-1.2* (Started Warfarin 5 mg) Brief Hospital Course: 77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and Mirizzi syndrome who presented on <Date>2-23</Date> for elective ERCP. Pt was noted to have emesis on her gown in the post procedure suite with diffuse wheezes and low grade temp. It was thought likely that she had an aspiration event and when she was arrived on the floor, she had a profoundly depressed mental status, tachypnea and fever to 101.9. Further stat work up revealed evidence of aspiration PNA, leukocytosis and elevated lactate. Initial head imaging was unrevealing. However, she became more alert and was noted to have an acute left sided deficit. CODE STROKE was called and CTA/perfusion images confirmed right sided hypoperfusion likely consistent with right MCA stroke. Neuro felt there was no indication for TPA given patent intracranial vessels and on return to the floor, pt was noted to have bilious secretions that she was having difficulty clearing. She was transferred to the ICU for airway monitoring overnight. Pt was called out to the floor when she was able to cough and spit up secretions. She was noted to have a waxing and <Doctor Name>Dr.Salgado</Doctor Name> mental status, sometimes will respond to commands and other times will not. BP was allowed to autoregulate for the first 72 hrs post event and pt was continued on Aspirin 300mg daily. She was noted to have recovery of left arm function and was answering yes/no to questions. She was seen by PT/OT who recommended ongoing therapy upon return to NH. After discussion with HCP/guardian, decision was made to avoid follow up MRI as it was not likely to change care plan and pt was unlikely to tolerate the procedure. Echo was performed to rule out cardioembolic source which did not show any thrombus. Lipid panel showed LDL in the 93, and Hgb A1c 9.4. She was hyperglycemic during the hospitalization, and she was started on Lantus and sliding scale insulin. . Aspiration PNA: Pt was noted to have aspiration event s/p procedure and was monitored in the ICU for 24hrs given concern for her ability to protect airway . Leukocytosis, lactate and fevers resolved after initiation of Vanc/Cefepime/Flagyl. Respiratory status improved and pt had a PICC placed and she completed a course of antibiotics. Upper Extremity DVT- Patient was subsequently developed a DVT associated with the PICC line. The PICC line was discontinued and she was started on Lovenox. Once a PEG tube was placed, she was started on Warfarin for a goal INR of <Date>11-28</Date>. Please follow INR closely and titrate prn. She received her first dose of Warfarin 5 mg on <Date>5-18</Date>. Aspiration - Pt was seen by speach/swallow on multiple occasions, which she grossly failed with aspiration. She was kept strictly NPO, and she was maintained with IV medications and hydration. A dobhoff was placed for initiation of tube feeds, while waiting to see if she would regain her swallow function. It is/was hoped that her swallow function would improve, especially considering her significant recovery in her left arm movement, however, she did not show significant improvement on serial exams. In discussion with Speech and Swallow, however, there is some hope that she may recover her swallow on a long term basis, and Swallow therapy may help with this recovery. They suggested an approximate 50% chance of recovery to the point of safe oral intake in the long-term. . Diabetes-Pt with uncontrolled hyperglycemia after the initiation of tube feeds. Her lantus and insulin sliding scales were agressively increased. She is being discharged on 70 units of lantus, and a sliding scale. . Mirizzi Syndrome s/p ERCP: Pt with abnormal biliary anatomy who underwent stent and sphincteroplastyon <Date>2-23</Date> for recurrent abd pain. She was noted to have an acute rise in transaminases post procedure and these trended down with normal Tbili. Pt was followed by ERCP team while in house. . Developmental Delay: baseline confirmed with her guardian/mother and nursing home. . HTN: held BP meds to allow autoregulation s/p stroke. She was subsequently treated with IV metoprolol, clonidine patch, and IV lasix, with benefit. After obtaining access via PEG, a blood pressure medication regimen via PEG was begun. I expect that she will benefit from further titration of medications as an outpatient. Please note that she was also started on Lisinopril; please follow up lytes in 1 week to ensure she tolerates. . Hyperlipidemia: Patient's simvastatin was held while patient was NPO. This was resumed after obtaining access via PEG. This medication dose was increased to 40 mg for goal LDL <70 considering diabetes and stroke. Please follow up LFT's to ensure tolerating, and lipid profile to ensure she meets her targets. . CODE: DNR/DNI confirmed with guardian Medications on Admission: Aspirin 81mg daily Alendronate 70mg weekly Multivitamin Colace 100mg <Hospital>Brown, Pitts and Christian Health System</Hospital> Calcium/Vit D Metoprolol 50mg <Hospital>Brown, Pitts and Christian Health System</Hospital> Bisacodyl prn Simvastatin 20mg daily Vicodin/tylenol prn Discharge Medications: 1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Inj Subcutaneous Q12H (every 12 hours): Please continue until INR <Date>11-28</Date> x 48 hrs, then discontinue. 2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily): <Month>June</Month> hold for loose stools. 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for no bm x 2 days. 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please follow INR closely, and titrate prn for INR goal <Date>11-28</Date>. Please continue lovenox until INR >2 x 48 hrs. 5. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): Please titrate prn. Started <Date>5-18</Date>. 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please titrate prn. Started <Date>5-18</Date>. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 650 mg/20.3 mL Solution Sig: Six <Age>75</Age>y (650) mg PO Q 8H (Every 8 Hours): would schedule q 8hr x 1 week, to treat for probable post-PEG procedure pain. (then prn). 11. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 12. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. insulin glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous once a day: titrate prn. 15. Humalog 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous four times a day: as per sliding scale provided. Discharge Disposition: Extended Care Facility: <Hospital>Carpenter LLC Health System</Hospital> Healthcare Center - <Location>263 Randy Lake Ricardoland, MN 70708</Location> Discharge Diagnosis: Primary: Biliary obstruction s/p sphincteroplasty Middle cerebral artery stroke Aspiration Pneumonia Dysphagia due to stroke . Secondary: Developmental Delay Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted for an ERCP and had a aspiration event after the procedure. It was discovered that you had a stroke on <Date>2-23</Date> and you will need to continue working with occupational therapy to continue recovering function. You were treated for an aspiration PNA with antibiotics, which you finished in the hospital. Your blood sugars were very elevated for this your insulin doses were increased. . Please note that there were many changes to your medications as a result of this hospitalization. Please follow your new medication list. Followup Instructions: Department: NEUROLOGY When: MONDAY <Date>1977-4-9</Date> at 4:30 PM With: DRS. <Name>Kraig Gauthier</Name> & <Hospital>Brown, Pitts and Christian Health System</Hospital> <Telephone>837-252-3110</Telephone> Building: SC <Hospital>Arnold-Curry Hospital</Hospital> Clinical Ctr <Location>768 Washington Track Suite 490 Barnetttown, PW 89180</Location> Campus: EAST Best Parking: <Hospital>Arnold-Curry Hospital</Hospital> Garage Department: ENDO SUITES When: THURSDAY <Date>1914-7-29</Date> at 8:00 AM Department: DIGESTIVE DISEASE CENTER When: THURSDAY <Date>1914-7-29</Date> at 8:00 AM With: <Name>Brianne Hui</Name> <Name>Negrete</Name>, MD <Telephone>834-896-8276</Telephone> Building: <Name>Araceli</Name> <Hospital>Mills, Tanner and Lane Medical Center</Hospital> Building (<Hospital>Nelson Inc Medical Center</Hospital>/<Hospital>Payne-Olson Medical Center</Hospital> Complex) <Location>88293 Gonzalez Bridge Suite 583 South Coreychester, IL 17647</Location> Campus: EAST Best Parking: Main 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Date: 2018-8-3 Discharge Date: 1931-11-11 Date of Birth: 1984-11-7 Sex: F Service: MEDICINE Allergies: Penicillins / Milk Attending:Everardo Chief Complaint: s/p ERCP with acute mental status changes/aspiration PNA Major Surgical or Invasive Procedure: ERCP with sphincteroplasty PEG tube placement (via Interventional Radiology) History of Present Illness: 77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and Mirizzi syndrome who presented today for elective ERCP. Pt was felt to be functionning at baseline prior to procedure with mild agitation, pulling at PIVs but interacting with staff. She was given fent/midaz for ERCP with stent placement and was transferred to the post-ERCP suite in stable condition. She had elevated BPs during the procedure requiring labetalol and metoprolol. She was found mildly tachypneic/wheezing with emesis on her gown. It was felt likely that she had an aspiration event with low grade temp However, she was still moving all four extremities and responding appropriately to questions though mildly sedated prior to transfer to the floor. . On arrival to the floor, pt was minimally responsive to sternal rub and did not withdraw to focal stimuli. She was notably tachypneic and eyes were deviated to right side. She was able to track to left with stimuli and would intermittently open eyes to command. Pt had an ABG 7.4/36/92 with lactate of 3.5 and CXR showed a right lower lobe infiltrate. Due to concern for acute intracranial hemmorrhage, she was taken down for a stat CT head. On return to the floor, pt was given narcan without any significant change in mental status. Neuro was consulted for possible acute stroke and within a few minutes, she became more responsive, opening eyes spontaneously. By the time neuro came to bedside, pt was able to verbalize her name and was noted to be using the right arm and had left sided deficit. A CODE stroke was called and pt was taken for urgent CTA head which did not show any vessel obstruction and TPA was felt unlikely to be helpful. Perfusion images confirmed right temporal hypoperfusion consistent with clinical exam and likely right MCA infarct. ICU consult was initiated and pt's guardian was notified. Pt was given Vanc/Cefepime and Aspirin 300mg PR while awaiting ICU transfer. She was lying flat per neuro recs and was noted to be spitting up bilious emesis. Head of bed was elevated and pt was suctionned prior to transferred to the ICU for closer monitoring of airway and management of acute pneumonia. Past Medical History: Hypertension Developmental Delay Mirizzi Syndrome COPD Social History: At baseline, pt lives at a nursing home and is able to feed herself, undress and can transfer from chair to bed but is otherwise wheelchair bound. No smoking/ETOH history documented. Family History: none relevant to this hospitalization. Physical Exam: Admission: T 101 BP 152/86 HR 86 RR 30 Sats 94% RA GEN: somnolent, open eyes to vigorous stimulous HEENT: Eyes deviated to right, tracks to left with startle CV: RRR no apprec m RESP: diffuse expiratory wheezes, moving air well ABD: soft, July BS, no rebound/guarding GU: foley in place EXTR: warm, minimal edema, toes upgoing NEURO: minimally responsive, eyes deviated, no withdrawal to painful stimuli Pertinent Results: 2018-8-3 04:02PM BLOOD WBC-24.8# RBC-6.40 Hgb-13.9 Hct-43.8 MCV-68* MCH-21.6* MCHC-31.6 RDW-14.3 Plt Ct-273 1999-10-23 05:55AM BLOOD WBC-8.1 RBC-5.33 Hgb-11.8* Hct-38.1 MCV-72* MCH-22.2* MCHC-31.0 RDW-14.8 Plt Ct-399 2008-10-17 06:05AM BLOOD Glucose-113* UreaN-4* Creat-0.5 Na-141 K-3.5 Cl-106 HCO3-27 AnGap-12 1944-2-27 06:05AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.9 2018-8-3 04:02PM BLOOD ALT-92* AST-118* AlkPhos-247* TotBili-1.4 1999-5-28 04:42AM BLOOD ALT-145* AST-277* AlkPhos-136* Amylase-101* TotBili-0.5 1944-2-27 06:05AM BLOOD ALT-50* AST-46* LD(LDH)-170 AlkPhos-144* TotBili-0.3 1948-3-30 06:36AM BLOOD Triglyc-143 HDL-44 CHOL/HD-3.8 LDLcalc-93 1948-3-30 06:36AM BLOOD %HbA1c-9.4* eAG-223* . ERCP 2018-8-3 Procedures: A plastic stent was removed. Impression: 2 balloon sweeps were performed with a small stone, sludge and debris removed. A 1.5 cm biliary stricture in mid-CBD compatible with known cystic duct stone and mirrizi syndrome was visualized. A 10 F 5cm double pigtailed catheter was placed. Otherwise normal ercp to third part of the duodenum. CXR 2018-8-3 IMPRESSION: Right lower lobe pneumonia with atelectasis or pneumonia at the left base. . CTA HEAD W&W/O C & RECONS IMPRESSION: Moderate-to-severe intracranial atherosclerotic disease with findings suggestive of decreased perfusion to the right MCA/PCA watershed region. The findings may represent cerebral ischemia in the setting of hypovolemia, hypotension or other causes of decreased cardiac output. . Cardiac Echo: IMPRESSION: Small LV cavity size with mild symmetric LVH and hyperdynamic LV systolic function. Consequently, there is a mild to moderate LV outflow tract gradient. No pathologic valvular abnormality seen. . RUE LENI IMPRESSION: Partially occlusive thrombus in the right basilic and axillary veins at site of PICC line. Clot does not extend more centrally. . ABDOMEN (SUPINE ONLY) PORT IMPRESSION: Limited view of the abdomen demonstrating no evidence for obstruction. Bladder stone. Coags: 2008-10-17 06:05AM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1 1999-10-23 05:55AM BLOOD PT-14.0* INR(PT)-1.2* (Started Warfarin 5 mg) Brief Hospital Course: 77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and Mirizzi syndrome who presented on 2-23 for elective ERCP. Pt was noted to have emesis on her gown in the post procedure suite with diffuse wheezes and low grade temp. It was thought likely that she had an aspiration event and when she was arrived on the floor, she had a profoundly depressed mental status, tachypnea and fever to 101.9. Further stat work up revealed evidence of aspiration PNA, leukocytosis and elevated lactate. Initial head imaging was unrevealing. However, she became more alert and was noted to have an acute left sided deficit. CODE STROKE was called and CTA/perfusion images confirmed right sided hypoperfusion likely consistent with right MCA stroke. Neuro felt there was no indication for TPA given patent intracranial vessels and on return to the floor, pt was noted to have bilious secretions that she was having difficulty clearing. She was transferred to the ICU for airway monitoring overnight. Pt was called out to the floor when she was able to cough and spit up secretions. She was noted to have a waxing and Dr.Salgado mental status, sometimes will respond to commands and other times will not. BP was allowed to autoregulate for the first 72 hrs post event and pt was continued on Aspirin 300mg daily. She was noted to have recovery of left arm function and was answering yes/no to questions. She was seen by PT/OT who recommended ongoing therapy upon return to NH. After discussion with HCP/guardian, decision was made to avoid follow up MRI as it was not likely to change care plan and pt was unlikely to tolerate the procedure. Echo was performed to rule out cardioembolic source which did not show any thrombus. Lipid panel showed LDL in the 93, and Hgb A1c 9.4. She was hyperglycemic during the hospitalization, and she was started on Lantus and sliding scale insulin. . Aspiration PNA: Pt was noted to have aspiration event s/p procedure and was monitored in the ICU for 24hrs given concern for her ability to protect airway . Leukocytosis, lactate and fevers resolved after initiation of Vanc/Cefepime/Flagyl. Respiratory status improved and pt had a PICC placed and she completed a course of antibiotics. Upper Extremity DVT- Patient was subsequently developed a DVT associated with the PICC line. The PICC line was discontinued and she was started on Lovenox. Once a PEG tube was placed, she was started on Warfarin for a goal INR of 11-28. Please follow INR closely and titrate prn. She received her first dose of Warfarin 5 mg on 5-18. Aspiration - Pt was seen by speach/swallow on multiple occasions, which she grossly failed with aspiration. She was kept strictly NPO, and she was maintained with IV medications and hydration. A dobhoff was placed for initiation of tube feeds, while waiting to see if she would regain her swallow function. It is/was hoped that her swallow function would improve, especially considering her significant recovery in her left arm movement, however, she did not show significant improvement on serial exams. In discussion with Speech and Swallow, however, there is some hope that she may recover her swallow on a long term basis, and Swallow therapy may help with this recovery. They suggested an approximate 50% chance of recovery to the point of safe oral intake in the long-term. . Diabetes-Pt with uncontrolled hyperglycemia after the initiation of tube feeds. Her lantus and insulin sliding scales were agressively increased. She is being discharged on 70 units of lantus, and a sliding scale. . Mirizzi Syndrome s/p ERCP: Pt with abnormal biliary anatomy who underwent stent and sphincteroplastyon 2-23 for recurrent abd pain. She was noted to have an acute rise in transaminases post procedure and these trended down with normal Tbili. Pt was followed by ERCP team while in house. . Developmental Delay: baseline confirmed with her guardian/mother and nursing home. . HTN: held BP meds to allow autoregulation s/p stroke. She was subsequently treated with IV metoprolol, clonidine patch, and IV lasix, with benefit. After obtaining access via PEG, a blood pressure medication regimen via PEG was begun. I expect that she will benefit from further titration of medications as an outpatient. Please note that she was also started on Lisinopril; please follow up lytes in 1 week to ensure she tolerates. . Hyperlipidemia: Patient's simvastatin was held while patient was NPO. This was resumed after obtaining access via PEG. This medication dose was increased to 40 mg for goal LDL Brown, Pitts and Christian Health System Calcium/Vit D Metoprolol 50mg Brown, Pitts and Christian Health System Bisacodyl prn Simvastatin 20mg daily Vicodin/tylenol prn Discharge Medications: 1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Inj Subcutaneous Q12H (every 12 hours): Please continue until INR 11-28 x 48 hrs, then discontinue. 2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily): June hold for loose stools. 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for no bm x 2 days. 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please follow INR closely, and titrate prn for INR goal 11-28. Please continue lovenox until INR >2 x 48 hrs. 5. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): Please titrate prn. Started 5-18. 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please titrate prn. Started 5-18. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 650 mg/20.3 mL Solution Sig: Six 75y (650) mg PO Q 8H (Every 8 Hours): would schedule q 8hr x 1 week, to treat for probable post-PEG procedure pain. (then prn). 11. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 12. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. insulin glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous once a day: titrate prn. 15. Humalog 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous four times a day: as per sliding scale provided. Discharge Disposition: Extended Care Facility: Carpenter LLC Health System Healthcare Center - 263 Randy Lake Ricardoland, MN 70708 Discharge Diagnosis: Primary: Biliary obstruction s/p sphincteroplasty Middle cerebral artery stroke Aspiration Pneumonia Dysphagia due to stroke . Secondary: Developmental Delay Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted for an ERCP and had a aspiration event after the procedure. It was discovered that you had a stroke on 2-23 and you will need to continue working with occupational therapy to continue recovering function. You were treated for an aspiration PNA with antibiotics, which you finished in the hospital. Your blood sugars were very elevated for this your insulin doses were increased. . Please note that there were many changes to your medications as a result of this hospitalization. Please follow your new medication list. Followup Instructions: Department: NEUROLOGY When: MONDAY 1977-4-9 at 4:30 PM With: DRS. Kraig Gauthier & Brown, Pitts and Christian Health System 837-252-3110 Building: SC Arnold-Curry Hospital Clinical Ctr 768 Washington Track Suite 490 Barnetttown, PW 89180 Campus: EAST Best Parking: Arnold-Curry Hospital Garage Department: ENDO SUITES When: THURSDAY 1914-7-29 at 8:00 AM Department: DIGESTIVE DISEASE CENTER When: THURSDAY 1914-7-29 at 8:00 AM With: Brianne Hui Negrete, MD 834-896-8276 Building: Araceli Mills, Tanner and Lane Medical Center Building (Nelson Inc Medical Center/Payne-Olson Medical Center Complex) 88293 Gonzalez Bridge Suite 583 South Coreychester, IL 17647 Campus: EAST Best Parking: Main Garage	['Admission Date: 2018-8-3 Discharge Date: 1931-11-11\n\nDate of Birth: 1984-11-7 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPenicillins / Milk\n\nAttending:Everardo\nChief Complaint:\ns/p ERCP with acute mental status changes/aspiration PNA\n\nMajor Surgical or Invasive Procedure:\nERCP with sphincteroplasty\nPEG tube placement (via Interventional Radiology)\n\n\nHistory of Present Illness:\n77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and\nMirizzi syndrome who presented today for elective ERCP. Pt was\nfelt to be functionning at baseline prior to procedure with mild\nagitation, pulling at PIVs but interacting with staff. She was\ngiven fent/midaz for ERCP with stent placement and was\ntransferred to the post-ERCP suite in stable condition. She had\nelevated BPs during the procedure requiring labetalol and\nmetoprolol.', ' She was found mildly tachypneic/wheezing with emesis\non her gown. It was felt likely that she had an aspiration event\nwith low grade temp However, she was still moving all four\nextremities and responding appropriately to questions though\nmildly sedated prior to transfer to the floor.\n.\nOn arrival to the floor, pt was minimally responsive to sternal\nrub and did not withdraw to focal stimuli. She was notably\ntachypneic and eyes were deviated to right side. She was able\nto track to left with stimuli and would intermittently open eyes\nto command. Pt had an ABG 7.4/36/92 with lactate of 3.5 and\nCXR showed a right lower lobe infiltrate. Due to concern for\nacute intracranial hemmorrhage, she was taken down for a stat CT\nhead. On return to the floor, pt was given narcan without any\nsignificant change in mental status.', " Neuro was consulted for\npossible acute stroke and within a few minutes, she became more\nresponsive, opening eyes spontaneously. By the time neuro came\nto bedside, pt was able to verbalize her name and was noted to\nbe using the right arm and had left sided deficit. A CODE\nstroke was called and pt was taken for urgent CTA head which did\nnot show any vessel obstruction and TPA was felt unlikely to be\nhelpful. Perfusion images confirmed right temporal\nhypoperfusion consistent with clinical exam and likely right MCA\ninfarct. ICU consult was initiated and pt's guardian was\nnotified. Pt was given Vanc/Cefepime and Aspirin 300mg PR while\nawaiting ICU transfer. She was lying flat per neuro recs and\nwas noted to be spitting up bilious emesis. Head of bed was\nelevated and pt was suctionned prior to transferred to the ICU\nfor closer monitoring of airway and management of acute\npneumonia.", '\n\nPast Medical History:\nHypertension\nDevelopmental Delay\nMirizzi Syndrome\nCOPD\n\n\nSocial History:\nAt baseline, pt lives at a nursing home and is able to feed\nherself, undress and can transfer from chair to bed but is\notherwise wheelchair bound. No smoking/ETOH history documented.\n\nFamily History:\nnone relevant to this hospitalization.\n\nPhysical Exam:\nAdmission:\nT 101 BP 152/86 HR 86 RR 30 Sats 94% RA\nGEN: somnolent, open eyes to vigorous stimulous\nHEENT: Eyes deviated to right, tracks to left with startle\nCV: RRR no apprec m\nRESP: diffuse expiratory wheezes, moving air well\nABD: soft, July BS, no rebound/guarding\nGU: foley in place\nEXTR: warm, minimal edema, toes upgoing\nNEURO: minimally responsive, eyes deviated, no withdrawal to\npainful stimuli\n\nPertinent Results:\n2018-8-3 04:02PM BLOOD WBC-24.', '8# RBC-6.40 Hgb-13.9 Hct-43.8\nMCV-68* MCH-21.6* MCHC-31.6 RDW-14.3 Plt Ct-273\n1999-10-23 05:55AM BLOOD WBC-8.1 RBC-5.33 Hgb-11.8* Hct-38.1\nMCV-72* MCH-22.2* MCHC-31.0 RDW-14.8 Plt Ct-399\n2008-10-17 06:05AM BLOOD Glucose-113* UreaN-4* Creat-0.5 Na-141\nK-3.5 Cl-106 HCO3-27 AnGap-12\n1944-2-27 06:05AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.9\n2018-8-3 04:02PM BLOOD ALT-92* AST-118* AlkPhos-247* TotBili-1.4\n1999-5-28 04:42AM BLOOD ALT-145* AST-277* AlkPhos-136\nAmylase-101 TotBili-0.5\n1944-2-27 06:05AM BLOOD ALT-50* AST-46* LD(LDH)-170 AlkPhos-144\nTotBili-0.3\n1948-3-30 06:36AM BLOOD Triglyc-143 HDL-44 CHOL/HD-3.8 LDLcalc-93\n1948-3-30 06:36AM BLOOD %HbA1c-9.4 eAG-223\n.\nERCP 2018-8-3\nProcedures: A plastic stent was removed.\nImpression: 2 balloon sweeps were performed with a small stone,\nsludge and debris removed.', ' A 1.5 cm biliary stricture in mid-CBD\ncompatible with known cystic duct stone and mirrizi syndrome was\nvisualized. A 10 F 5cm double pigtailed catheter was placed.\nOtherwise normal ercp to third part of the duodenum.\n\nCXR 2018-8-3 IMPRESSION: Right lower lobe pneumonia with\natelectasis or pneumonia at the left base.\n.\nCTA HEAD W&W/O C & RECONS IMPRESSION: Moderate-to-severe\nintracranial atherosclerotic disease with findings suggestive of\ndecreased perfusion to the right MCA/PCA watershed region. The\nfindings may represent cerebral ischemia in the setting of\nhypovolemia, hypotension or other causes of decreased cardiac\noutput.\n.\nCardiac Echo: IMPRESSION: Small LV cavity size with mild\nsymmetric LVH and hyperdynamic LV systolic function.\nConsequently, there is a mild to moderate LV outflow tract\ngradient.', ' No pathologic valvular abnormality seen.\n.\nRUE LENI IMPRESSION: Partially occlusive thrombus in the right\nbasilic and axillary veins at site of PICC line. Clot does not\nextend more centrally.\n.\nABDOMEN (SUPINE ONLY) PORT IMPRESSION: Limited view of the\nabdomen demonstrating no evidence for obstruction. Bladder\nstone.\n\nCoags:\n2008-10-17 06:05AM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1\n1999-10-23 05:55AM BLOOD PT-14.0 INR(PT)-1.2* (Started Warfarin\n5 mg)\n\nBrief Hospital Course:\n77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and\nMirizzi syndrome who presented on 2-23 for elective ERCP. Pt\nwas noted to have emesis on her gown in the post procedure suite\nwith diffuse wheezes and low grade temp. It was thought likely\nthat she had an aspiration event and when she was arrived on the\nfloor, she had a profoundly depressed mental status, tachypnea\nand fever to 101.', '9. Further stat work up revealed evidence of\naspiration PNA, leukocytosis and elevated lactate. Initial head\nimaging was unrevealing. However, she became more alert and was\nnoted to have an acute left sided deficit. CODE STROKE was\ncalled and CTA/perfusion images confirmed right sided\nhypoperfusion likely consistent with right MCA stroke. Neuro\nfelt there was no indication for TPA given patent intracranial\nvessels and on return to the floor, pt was noted to have bilious\nsecretions that she was having difficulty clearing. She was\ntransferred to the ICU for airway monitoring overnight. Pt was\ncalled out to the floor when she was able to cough and spit up\nsecretions. She was noted to have a waxing and Dr.Salgado mental\nstatus, sometimes will respond to commands and other times will\nnot. BP was allowed to autoregulate for the first 72 hrs post\nevent and pt was continued on Aspirin 300mg daily.', ' She was\nnoted to have recovery of left arm function and was answering\nyes/no to questions.\n\nShe was seen by PT/OT who recommended ongoing therapy upon\nreturn to NH.\nAfter discussion with HCP/guardian, decision was made to avoid\nfollow up MRI as it was not likely to change care plan and pt\nwas unlikely to tolerate the procedure. Echo was performed to\nrule out cardioembolic source which did not show any thrombus.\nLipid panel showed LDL in the 93, and Hgb A1c 9.4. She was\nhyperglycemic during the hospitalization, and she was started on\nLantus and sliding scale insulin.\n.\nAspiration PNA: Pt was noted to have aspiration event s/p\nprocedure and was monitored in the ICU for 24hrs given concern\nfor her ability to protect airway . Leukocytosis, lactate and\nfevers resolved after initiation of Vanc/Cefepime/Flagyl.', '\nRespiratory status improved and pt had a PICC placed and she\ncompleted a course of antibiotics.\n\nUpper Extremity DVT- Patient was subsequently developed a DVT\nassociated with the PICC line. The PICC line was discontinued\nand she was started on Lovenox. Once a PEG tube was placed, she\nwas started on Warfarin for a goal INR of 11-28. Please follow\nINR closely and titrate prn. She received her first dose of\nWarfarin 5 mg on 5-18.\n\nAspiration - Pt was seen by speach/swallow on multiple\noccasions, which she grossly failed with aspiration. She was\nkept strictly NPO, and she was maintained with IV medications\nand hydration. A dobhoff was placed for initiation of tube\nfeeds, while waiting to see if she would regain her swallow\nfunction. It is/was hoped that her swallow function would\nimprove, especially considering her significant recovery in her\nleft arm movement, however, she did not show significant\nimprovement on serial exams.', ' In discussion with Speech and\nSwallow, however, there is some hope that she may recover her\nswallow on a long term basis, and Swallow therapy may help with\nthis recovery. They suggested an approximate 50% chance of\nrecovery to the point of safe oral intake in the long-term.\n.\nDiabetes-Pt with uncontrolled hyperglycemia after the initiation\nof tube feeds. Her lantus and insulin sliding scales were\nagressively increased. She is being discharged on 70 units of\nlantus, and a sliding scale.\n.\nMirizzi Syndrome s/p ERCP: Pt with abnormal biliary anatomy who\nunderwent stent and sphincteroplastyon 2-23 for recurrent abd\npain. She was noted to have an acute rise in transaminases post\nprocedure and these trended down with normal Tbili. Pt was\nfollowed by ERCP team while in house.\n.\nDevelopmental Delay: baseline confirmed with her guardian/mother\nand nursing home.', "\n.\nHTN: held BP meds to allow autoregulation s/p stroke. She was\nsubsequently treated with IV metoprolol, clonidine patch, and IV\nlasix, with benefit. After obtaining access via PEG, a blood\npressure medication regimen via PEG was begun. I expect that she\nwill benefit from further titration of medications as an\noutpatient. Please note that she was also started on\nLisinopril; please follow up lytes in 1 week to ensure she\ntolerates.\n.\nHyperlipidemia: Patient's simvastatin was held while patient was\nNPO. This was resumed after obtaining access via PEG. This\nmedication dose was increased to 40 mg for goal LDL Brown, Pitts and Christian Health System\nCalcium/Vit D\nMetoprolol 50mg Brown, Pitts and Christian Health System\nBisacodyl prn\nSimvastatin 20mg daily\nVicodin/tylenol prn\n\nDischarge Medications:\n1.", ' enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Inj Subcutaneous\nQ12H (every 12 hours): Please continue until INR 11-28 x 48 hrs,\nthen discontinue.\n2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)\npacket PO DAILY (Daily): June hold for loose stools.\n3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal\nHS (at bedtime) as needed for no bm x 2 days.\n4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4\nPM: Please follow INR closely, and titrate prn for INR goal 11-28.\nPlease continue lovenox until INR >2 x 48 hrs.\n5. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly\nTransdermal QMON (every Monday).\n6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\n7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO\nDAILY (Daily): Please titrate prn.', ' Started 5-18.\n8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):\nPlease titrate prn. Started 5-18.\n9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n10. acetaminophen 650 mg/20.3 mL Solution Sig: Six 75y\n(650) mg PO Q 8H (Every 8 Hours): would schedule q 8hr x 1 week,\nto treat for probable post-PEG procedure pain. (then prn).\n11. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.\n\n12. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,\nChewable PO once a day.\n13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.\n\n14. insulin glargine 100 unit/mL Solution Sig: Seventy (70)\nunits Subcutaneous once a day: titrate prn.\n15. Humalog 100 unit/mL Solution Sig: as per sliding scale units\nSubcutaneous four times a day: as per sliding scale provided.', '\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nCarpenter LLC Health System Healthcare Center - 263 Randy Lake\nRicardoland, MN 70708\n\nDischarge Diagnosis:\nPrimary:\nBiliary obstruction s/p sphincteroplasty\nMiddle cerebral artery stroke\nAspiration Pneumonia\nDysphagia due to stroke\n.\nSecondary:\nDevelopmental Delay\nHypertension\n\n\nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Bedbound.\n\n\nDischarge Instructions:\nYou were admitted for an ERCP and had a aspiration event after\nthe procedure. It was discovered that you had a stroke on 2-23\nand you will need to continue working with occupational therapy\nto continue recovering function. You were treated for an\naspiration PNA with antibiotics, which you finished in the\nhospital.', ' Your blood sugars were very elevated for this your\ninsulin doses were increased.\n.\nPlease note that there were many changes to your medications as\na result of this hospitalization. Please follow your new\nmedication list.\n\nFollowup Instructions:\nDepartment: NEUROLOGY\nWhen: MONDAY 1977-4-9 at 4:30 PM\nWith: DRS. Kraig Gauthier & Brown, Pitts and Christian Health System 837-252-3110\nBuilding: SC Arnold-Curry Hospital Clinical Ctr 768 Washington Track Suite 490\nBarnetttown, PW 89180\nCampus: EAST Best Parking: Arnold-Curry Hospital Garage\n\nDepartment: ENDO SUITES\nWhen: THURSDAY 1914-7-29 at 8:00 AM\n\nDepartment: DIGESTIVE DISEASE CENTER\nWhen: THURSDAY 1914-7-29 at 8:00 AM\nWith: Brianne Hui Negrete, MD 834-896-8276\nBuilding: Araceli Mills, Tanner and Lane Medical Center Building (Nelson Inc Medical Center/Payne-Olson Medical Center Complex) 88293 Gonzalez Bridge Suite 583\nSouth Coreychester, IL 17647\nCampus: EAST Best Parking: Main Garage\n\n\n\n']
194	22180	116189.0	2132-09-09	Discharge summary	Report	Admission Date: [2132-9-4] Discharge Date: [2132-9-9] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1055] Chief Complaint: 1. SOB x 1 week 2. intermittent black stool for 6 months Major Surgical or Invasive Procedure: Upper Endoscopy Colonoscopy History of Present Illness: This is an 80 yo F who presents to the ED with SOB and LE edema x1 week. On arrival to the ED, she was unable to speak in full sentences and was wheezing. On further questioning, she claims that she had not been taking her usual dose of lasix for one week. Her presciption had ran out. She also notes a 6 month history of intermittent black stool. She has discussed this with her PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Her most recent occult blood in [2132-8-20] was negative and according to Dr. [Last Name (STitle) ], the stool was brown, not black as she describes it. Patient also claims that she has occasional BRBPR on straining with BMs, with a history of hemorrhoids. She is on a daily ASA, and denies other NSAID use. She has no history of alcohol consumption. Denies abd pain/nausea/vomitting/hemetemesis. On ROS, she denies chest pain/fever/ chills/changes in bowel habit/headache/hemeturia/changes in diet. Past Medical History: 1. DM II 2. HTN 3. pulmonary hypertension 4. increased cholesterol 5. chroninc low back pain and sciatica Social History: Denies ETOH, IVDA, or tob use. Physical Exam: BP 150/58 P70 Gen: comfortable, pale elderly Russian speaking female lying in bed in NAD. HEENT: PERRL. Anicteric. MMM. Pale conjunctiva Neck: Supple. No masses or LAD. JVD 8-10 cm. Lungs: diffuse crackles. Cardiac: RRR. S1/S2. II/VI systolic M heard best at apex. Abd: Soft, obese, NT, ND, +NABS. No rebound or guarding. Extrem: 3+ pitting edema b/l, palpable DP pulses Neuro: CN II-VII intact, [4-30] musc strength UE/LE Pertinent Results: [2132-9-4] 08:14PM HGB-5.7* calcHCT-17 [2132-9-4] 04:22PM URINE HOURS-RANDOM [2132-9-4] 04:22PM URINE GR HOLD-HOLD [2132-9-4] 04:22PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2132-9-4] 04:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2132-9-4] 04:22PM URINE RBC-<1 WBC-<1 BACTERIA-RARE YEAST-NONE EPI-0-2 [2132-9-4] 04:18PM PT-13.3 PTT-29.5 INR(PT)-1.1 [2132-9-4] 03:21PM GLUCOSE-169* UREA N-86* CREAT-1.1 SODIUM-142 POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-20 [2132-9-4] 03:21PM CK(CPK)-38 [2132-9-4] 03:21PM CK-MB-NotDone cTropnT-<0.01 [2132-9-4] 03:21PM VIT B12-182* [2132-9-4] 03:21PM WBC-10.2# RBC-1.92# HGB-5.4# HCT-17.0# MCV-88 MCH-27.9 MCHC-31.6 RDW-17.2 [2132-9-4] 03:21PM NEUTS-77.8* LYMPHS-18.0 MONOS-3.0 EOS-0.7 BASOS-0.5 [2132-9-4] 03:21PM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-1+ [2132-9-4] 03:21PM PLT COUNT-362# Brief Hospital Course: 80 yo F w/ DM2, HTN, PA HTN p/w SOB and LE edema x1 week, now with severe anemia (hct of 17 noted by her PCP) thought to be secondary to UGIB, hemodynamically stable s/p 6 Units of bld w/ increase of hct to 30. serial hcts q 6 hrs remained stable at 30. Pt had EGD in ED ([2132-9-5]) which revealed granularity, friability and erythema in the stomach body, fundus and antrum compatible with acute gastritis (biopsy obtained). Erythema in the duodenal bulb compatible with duodenitis. Ulcer in the distal bulb. Otherwise normal EGD to second part of the duodenum. Echo:([2132-8-23]) 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. Compared with the findings of the prior study (tape reviewed) of [2128-8-18], there has been no significant change. 1. GIB with increased BUN, likely UGIB, however LGIB initially considered as well. Pt had 2 large bore IV's placed. NG lavage was positive as well as stool guiacs. EGD as above. No active bleed noted however ulcer and gastritis likely source of anemia. Ulcer thought to be secondary to NSAID use vs H. pylori. Will treat for H.Pylori if indicated. Pt will follow up with GI. ASA was held secondary to bleed. Losartan was initially held, then restarted at half normal dose. NSAIDs were avoided. Initially given IV PPI [Hospital1 ] which was then changed to po. Colonoscopy performed was reported to be normal. 2. Cardiac. EKG changes (NSR at 84, Nl axis and intervals, TWI III, TWI V1-V4). Pt was ruled out for MI with three sets of neg cardiac enzymes. She denied CP. ECG changes likely secondary to demand ischemia from severe anemia. She was initially monitored on tele with no events. An echo done on [2132-8-23], as above (LVEF>55%). SOB most likely due to discontinuation of lasix for one week in setting of diastolic CHF. Treated with 40 of lasix IV (held off on diuresis intially secondary to concern for GI bld). 3. Resp. CXR done on [2132-9-5] without overt evidence of CHF or pneumonia. Findings suggestive of pulmonary artery hypertension. She required O2 supplementation during her stay and was noted to have RA sats in the 80's with ambulation likely secondary to PA HTN. She was sent home on supplemental O2. A Repeat cxr was suggestive of pulm congestion. Lasix given as above. 4. DM2. Initially bld sugars controlled with RISS, oral hyperglycemics were restarted prior to discharge. 5. Anemia secondary to gastritis and PUD, as well as Fe/Vit B12 def. She was transfused a total of 6 Units of PRBC's and her hct was monitored q 6 hrs. She was started on Vit B12 supplementation. She was continued on Niferex. Medications on Admission: 1. Niferex 150 [Hospital1 ] 2. metformin 850 TID 3. Losartan 50 4. Rosiglitazone 8 QD 5. Lipitor 20 6. ASA 81 7. lasix 40 [Hospital1 ] 8. Paxil 20 Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:60 Tablet(s) Refills:2 8. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO once a day. 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Supplemental Oxygen Please use supplemental Oxygen with exerction. Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: Upper GI Bleed secondary to Gastritits Secondary Diagnoses: DM HTN Vitmain B12 deficiency Discharge Condition: Good. Discharge Instructions: Please call your primary care physician or return to the hospital if you experience further bleeding, shortness of breath, or any other problems arise. Please use supplemental oxygen with exerction. DO NOT TAKE ASPIRIN. Followup Instructions: 1. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1953], [Name12 (NameIs) 280] Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2132-9-17] 10:40 2. Provider: [Name10 (NameIs) ] Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 1954] Date/Time:[2132-9-30] 2:20 3. Provider: [Name Initial (NameIs) ] PAIN MANAGEMENT CENTER Where: PAIN MANAGEMENT CENTER Date/Time:[2132-9-17] 3:00 4. Provider: [First Name11 (Name Pattern1) 1955] [Last Name (NamePattern4) 1956], M.D. Where: [Hospital6 29] [Hospital3 1935] CENTER Phone:[Telephone/Fax (1) 253] Date/Time:[2132-10-31] 1:00	Admission Date: <Date>2015-2-7</Date> Discharge Date: <Date>2007-4-1</Date> Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Quincy</Name> Chief Complaint: 1. SOB x 1 week 2. intermittent black stool for 6 months Major Surgical or Invasive Procedure: Upper Endoscopy Colonoscopy History of Present Illness: This is an 80 yo F who presents to the ED with SOB and LE edema x1 week. On arrival to the ED, she was unable to speak in full sentences and was wheezing. On further questioning, she claims that she had not been taking her usual dose of lasix for one week. Her presciption had ran out. She also notes a 6 month history of intermittent black stool. She has discussed this with her PCP, <Name>Ivory</Name>. <Name>Londrie</Name>. Her most recent occult blood in <Date>1947-8-28</Date> was negative and according to Dr. <Name>Londrie</Name>, the stool was brown, not black as she describes it. Patient also claims that she has occasional BRBPR on straining with BMs, with a history of hemorrhoids. She is on a daily ASA, and denies other NSAID use. She has no history of alcohol consumption. Denies abd pain/nausea/vomitting/hemetemesis. On ROS, she denies chest pain/fever/ chills/changes in bowel habit/headache/hemeturia/changes in diet. Past Medical History: 1. DM II 2. HTN 3. pulmonary hypertension 4. increased cholesterol 5. chroninc low back pain and sciatica Social History: Denies ETOH, IVDA, or tob use. Physical Exam: BP 150/58 P70 Gen: comfortable, pale elderly Russian speaking female lying in bed in NAD. HEENT: PERRL. Anicteric. MMM. Pale conjunctiva Neck: Supple. No masses or LAD. JVD 8-10 cm. Lungs: diffuse crackles. Cardiac: RRR. S1/S2. II/VI systolic M heard best at apex. Abd: Soft, obese, NT, ND, +NABS. No rebound or guarding. Extrem: 3+ pitting edema b/l, palpable DP pulses Neuro: CN II-VII intact, <Date>9-7</Date> musc strength UE/LE Pertinent Results: <Date>2015-2-7</Date> 08:14PM HGB-5.7* calcHCT-17 <Date>2015-2-7</Date> 04:22PM URINE HOURS-RANDOM <Date>2015-2-7</Date> 04:22PM URINE GR HOLD-HOLD <Date>2015-2-7</Date> 04:22PM URINE COLOR-Straw APPEAR-Clear SP <Name>Olles</Name>-1.009 <Date>2015-2-7</Date> 04:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG <Date>2015-2-7</Date> 04:22PM URINE RBC-<1 WBC-<1 BACTERIA-RARE YEAST-NONE EPI-0-2 <Date>2015-2-7</Date> 04:18PM PT-13.3 PTT-29.5 INR(PT)-1.1 <Date>2015-2-7</Date> 03:21PM GLUCOSE-169* UREA N-86* CREAT-1.1 SODIUM-142 POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-20 <Date>2015-2-7</Date> 03:21PM CK(CPK)-38 <Date>2015-2-7</Date> 03:21PM CK-MB-NotDone cTropnT-<0.01 <Date>2015-2-7</Date> 03:21PM VIT B12-182* <Date>2015-2-7</Date> 03:21PM WBC-10.2# RBC-1.92# HGB-5.4# HCT-17.0# MCV-88 MCH-27.9 MCHC-31.6 RDW-17.2 <Date>2015-2-7</Date> 03:21PM NEUTS-77.8* LYMPHS-18.0 MONOS-3.0 EOS-0.7 BASOS-0.5 <Date>2015-2-7</Date> 03:21PM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-1+ <Date>2015-2-7</Date> 03:21PM PLT COUNT-362# Brief Hospital Course: 80 yo F w/ DM2, HTN, PA HTN p/w SOB and LE edema x1 week, now with severe anemia (hct of 17 noted by her PCP) thought to be secondary to UGIB, hemodynamically stable s/p 6 Units of bld w/ increase of hct to 30. serial hcts q 6 hrs remained stable at 30. Pt had EGD in ED (<Date>1908-5-7</Date>) which revealed granularity, friability and erythema in the stomach body, fundus and antrum compatible with acute gastritis (biopsy obtained). Erythema in the duodenal bulb compatible with duodenitis. Ulcer in the distal bulb. Otherwise normal EGD to second part of the duodenum. Echo:(<Date>1985-6-30</Date>) 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. Compared with the findings of the prior study (tape reviewed) of <Date>1943-7-28</Date>, there has been no significant change. 1. GIB with increased BUN, likely UGIB, however LGIB initially considered as well. Pt had 2 large bore IV's placed. NG lavage was positive as well as stool guiacs. EGD as above. No active bleed noted however ulcer and gastritis likely source of anemia. Ulcer thought to be secondary to NSAID use vs H. pylori. Will treat for H.Pylori if indicated. Pt will follow up with GI. ASA was held secondary to bleed. Losartan was initially held, then restarted at half normal dose. NSAIDs were avoided. Initially given IV PPI <Hospital>Barber LLC Hospital</Hospital> which was then changed to po. Colonoscopy performed was reported to be normal. 2. Cardiac. EKG changes (NSR at 84, Nl axis and intervals, TWI III, TWI V1-V4). Pt was ruled out for MI with three sets of neg cardiac enzymes. She denied CP. ECG changes likely secondary to demand ischemia from severe anemia. She was initially monitored on tele with no events. An echo done on <Date>1985-6-30</Date>, as above (LVEF>55%). SOB most likely due to discontinuation of lasix for one week in setting of diastolic CHF. Treated with 40 of lasix IV (held off on diuresis intially secondary to concern for GI bld). 3. Resp. CXR done on <Date>1908-5-7</Date> without overt evidence of CHF or pneumonia. Findings suggestive of pulmonary artery hypertension. She required O2 supplementation during her stay and was noted to have RA sats in the 80's with ambulation likely secondary to PA HTN. She was sent home on supplemental O2. A Repeat cxr was suggestive of pulm congestion. Lasix given as above. 4. DM2. Initially bld sugars controlled with RISS, oral hyperglycemics were restarted prior to discharge. 5. Anemia secondary to gastritis and PUD, as well as Fe/Vit B12 def. She was transfused a total of 6 Units of PRBC's and her hct was monitored q 6 hrs. She was started on Vit B12 supplementation. She was continued on Niferex. Medications on Admission: 1. Niferex 150 <Hospital>Barber LLC Hospital</Hospital> 2. metformin 850 TID 3. Losartan 50 4. Rosiglitazone 8 QD 5. Lipitor 20 6. ASA 81 7. lasix 40 <Hospital>Barber LLC Hospital</Hospital> 8. Paxil 20 Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:60 Tablet(s) Refills:2 8. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO once a day. 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Supplemental Oxygen Please use supplemental Oxygen with exerction. Discharge Disposition: Home With Service Facility: <Hospital>Elliott, Abbott and Barron Hospital</Hospital>, <Location>48715 Fowler Hills Suite 602 West Jocelyn, WY 97024</Location> Discharge Diagnosis: Upper GI Bleed secondary to Gastritits Secondary Diagnoses: DM HTN Vitmain B12 deficiency Discharge Condition: Good. Discharge Instructions: Please call your primary care physician or return to the hospital if you experience further bleeding, shortness of breath, or any other problems arise. Please use supplemental oxygen with exerction. DO NOT TAKE ASPIRIN. Followup Instructions: 1. Provider: <Name>Charlotte</Name> <Name>Debelius</Name>, <Name>Creighton Heflin</Name> Where: <Hospital>Barron and Sons Hospital</Hospital> <Hospital>Rhodes, Kelley and Gibson Medical Center</Hospital> Phone:<Telephone>192-820-7011</Telephone> Date/Time:<Date>1913-4-4</Date> 10:40 2. Provider: <Name>Dorothy Lyna</Name> Where: <Hospital>Barron and Sons Hospital</Hospital> MEDICAL SPECIALTIES Phone:<Telephone>426-439-5480</Telephone> Date/Time:<Date>1902-12-3</Date> 2:20 3. Provider: <Name>Percy Casenhiser</Name> PAIN MANAGEMENT CENTER Where: PAIN MANAGEMENT CENTER Date/Time:<Date>1913-4-4</Date> 3:00 4. Provider: <Name>Emory</Name> <Name>Kenner</Name>, M.D. Where: <Hospital>Barron and Sons Hospital</Hospital> <Hospital>Brown-Boone Medical Center</Hospital> CENTER Phone:<Telephone>534-724-3404</Telephone> Date/Time:<Date>1904-11-30</Date> 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Date: 2015-2-7 Discharge Date: 2007-4-1 Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Quincy Chief Complaint: 1. SOB x 1 week 2. intermittent black stool for 6 months Major Surgical or Invasive Procedure: Upper Endoscopy Colonoscopy History of Present Illness: This is an 80 yo F who presents to the ED with SOB and LE edema x1 week. On arrival to the ED, she was unable to speak in full sentences and was wheezing. On further questioning, she claims that she had not been taking her usual dose of lasix for one week. Her presciption had ran out. She also notes a 6 month history of intermittent black stool. She has discussed this with her PCP, Ivory. Londrie. Her most recent occult blood in 1947-8-28 was negative and according to Dr. Londrie, the stool was brown, not black as she describes it. Patient also claims that she has occasional BRBPR on straining with BMs, with a history of hemorrhoids. She is on a daily ASA, and denies other NSAID use. She has no history of alcohol consumption. Denies abd pain/nausea/vomitting/hemetemesis. On ROS, she denies chest pain/fever/ chills/changes in bowel habit/headache/hemeturia/changes in diet. Past Medical History: 1. DM II 2. HTN 3. pulmonary hypertension 4. increased cholesterol 5. chroninc low back pain and sciatica Social History: Denies ETOH, IVDA, or tob use. Physical Exam: BP 150/58 P70 Gen: comfortable, pale elderly Russian speaking female lying in bed in NAD. HEENT: PERRL. Anicteric. MMM. Pale conjunctiva Neck: Supple. No masses or LAD. JVD 8-10 cm. Lungs: diffuse crackles. Cardiac: RRR. S1/S2. II/VI systolic M heard best at apex. Abd: Soft, obese, NT, ND, +NABS. No rebound or guarding. Extrem: 3+ pitting edema b/l, palpable DP pulses Neuro: CN II-VII intact, 9-7 musc strength UE/LE Pertinent Results: 2015-2-7 08:14PM HGB-5.7* calcHCT-17 2015-2-7 04:22PM URINE HOURS-RANDOM 2015-2-7 04:22PM URINE GR HOLD-HOLD 2015-2-7 04:22PM URINE COLOR-Straw APPEAR-Clear SP Olles-1.009 2015-2-7 04:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 2015-2-7 04:22PM URINE RBC-2015-2-7 04:18PM PT-13.3 PTT-29.5 INR(PT)-1.1 2015-2-7 03:21PM GLUCOSE-169* UREA N-86* CREAT-1.1 SODIUM-142 POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-20 2015-2-7 03:21PM CK(CPK)-38 2015-2-7 03:21PM CK-MB-NotDone cTropnT-2015-2-7 03:21PM VIT B12-182* 2015-2-7 03:21PM WBC-10.2# RBC-1.92# HGB-5.4# HCT-17.0# MCV-88 MCH-27.9 MCHC-31.6 RDW-17.2 2015-2-7 03:21PM NEUTS-77.8* LYMPHS-18.0 MONOS-3.0 EOS-0.7 BASOS-0.5 2015-2-7 03:21PM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-1+ 2015-2-7 03:21PM PLT COUNT-362# Brief Hospital Course: 80 yo F w/ DM2, HTN, PA HTN p/w SOB and LE edema x1 week, now with severe anemia (hct of 17 noted by her PCP) thought to be secondary to UGIB, hemodynamically stable s/p 6 Units of bld w/ increase of hct to 30. serial hcts q 6 hrs remained stable at 30. Pt had EGD in ED (1908-5-7) which revealed granularity, friability and erythema in the stomach body, fundus and antrum compatible with acute gastritis (biopsy obtained). Erythema in the duodenal bulb compatible with duodenitis. Ulcer in the distal bulb. Otherwise normal EGD to second part of the duodenum. Echo:(1985-6-30) 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. Compared with the findings of the prior study (tape reviewed) of 1943-7-28, there has been no significant change. 1. GIB with increased BUN, likely UGIB, however LGIB initially considered as well. Pt had 2 large bore IV's placed. NG lavage was positive as well as stool guiacs. EGD as above. No active bleed noted however ulcer and gastritis likely source of anemia. Ulcer thought to be secondary to NSAID use vs H. pylori. Will treat for H.Pylori if indicated. Pt will follow up with GI. ASA was held secondary to bleed. Losartan was initially held, then restarted at half normal dose. NSAIDs were avoided. Initially given IV PPI Barber LLC Hospital which was then changed to po. Colonoscopy performed was reported to be normal. 2. Cardiac. EKG changes (NSR at 84, Nl axis and intervals, TWI III, TWI V1-V4). Pt was ruled out for MI with three sets of neg cardiac enzymes. She denied CP. ECG changes likely secondary to demand ischemia from severe anemia. She was initially monitored on tele with no events. An echo done on 1985-6-30, as above (LVEF>55%). SOB most likely due to discontinuation of lasix for one week in setting of diastolic CHF. Treated with 40 of lasix IV (held off on diuresis intially secondary to concern for GI bld). 3. Resp. CXR done on 1908-5-7 without overt evidence of CHF or pneumonia. Findings suggestive of pulmonary artery hypertension. She required O2 supplementation during her stay and was noted to have RA sats in the 80's with ambulation likely secondary to PA HTN. She was sent home on supplemental O2. A Repeat cxr was suggestive of pulm congestion. Lasix given as above. 4. DM2. Initially bld sugars controlled with RISS, oral hyperglycemics were restarted prior to discharge. 5. Anemia secondary to gastritis and PUD, as well as Fe/Vit B12 def. She was transfused a total of 6 Units of PRBC's and her hct was monitored q 6 hrs. She was started on Vit B12 supplementation. She was continued on Niferex. Medications on Admission: 1. Niferex 150 Barber LLC Hospital 2. metformin 850 TID 3. Losartan 50 4. Rosiglitazone 8 QD 5. Lipitor 20 6. ASA 81 7. lasix 40 Barber LLC Hospital 8. Paxil 20 Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:60 Tablet(s) Refills:2 8. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO once a day. 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Supplemental Oxygen Please use supplemental Oxygen with exerction. Discharge Disposition: Home With Service Facility: Elliott, Abbott and Barron Hospital, 48715 Fowler Hills Suite 602 West Jocelyn, WY 97024 Discharge Diagnosis: Upper GI Bleed secondary to Gastritits Secondary Diagnoses: DM HTN Vitmain B12 deficiency Discharge Condition: Good. Discharge Instructions: Please call your primary care physician or return to the hospital if you experience further bleeding, shortness of breath, or any other problems arise. Please use supplemental oxygen with exerction. DO NOT TAKE ASPIRIN. Followup Instructions: 1. Provider: Charlotte Debelius, Creighton Heflin Where: Barron and Sons Hospital Rhodes, Kelley and Gibson Medical Center Phone:192-820-7011 Date/Time:1913-4-4 10:40 2. Provider: Dorothy Lyna Where: Barron and Sons Hospital MEDICAL SPECIALTIES Phone:426-439-5480 Date/Time:1902-12-3 2:20 3. Provider: Percy Casenhiser PAIN MANAGEMENT CENTER Where: PAIN MANAGEMENT CENTER Date/Time:1913-4-4 3:00 4. Provider: Emory Kenner, M.D. Where: Barron and Sons Hospital Brown-Boone Medical Center CENTER Phone:534-724-3404 Date/Time:1904-11-30 1:00	['Admission Date: 2015-2-7 Discharge Date: 2007-4-1\n\n\nService: MED\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Quincy\nChief Complaint:\n1. SOB x 1 week\n2. intermittent black stool for 6 months\n\nMajor Surgical or Invasive Procedure:\nUpper Endoscopy\nColonoscopy\n\n\nHistory of Present Illness:\nThis is an 80 yo F who presents to the ED with SOB and LE edema\nx1 week. On arrival to the ED, she was unable to speak in full\nsentences and was wheezing. On further questioning, she claims\nthat she had not been taking her usual dose of lasix for one\nweek. Her presciption had ran out.\nShe also notes a 6 month history of intermittent black stool.\nShe has discussed this with her PCP, Ivory. Londrie. Her most recent\noccult blood in 1947-8-28 was negative and according to Dr.', ' Londrie,\nthe stool was brown, not black as she describes it. Patient also\nclaims that she has occasional BRBPR on straining with BMs, with\na history of hemorrhoids. She is on a daily ASA, and denies\nother NSAID use. She has no history of alcohol consumption.\nDenies abd pain/nausea/vomitting/hemetemesis.\nOn ROS, she denies chest pain/fever/ chills/changes in bowel\nhabit/headache/hemeturia/changes in diet.\n\n\nPast Medical History:\n1. DM II\n2. HTN\n3. pulmonary hypertension\n4. increased cholesterol\n5. chroninc low back pain and sciatica\n\n\nSocial History:\nDenies ETOH, IVDA, or tob use.\n\nPhysical Exam:\nBP 150/58 P70\nGen: comfortable, pale elderly Russian speaking female lying in\nbed in NAD.\nHEENT: PERRL. Anicteric. MMM. Pale conjunctiva\nNeck: Supple. No masses or LAD. JVD 8-10 cm.\nLungs: diffuse crackles.', '\nCardiac: RRR. S1/S2. II/VI systolic M heard best at apex.\nAbd: Soft, obese, NT, ND, +NABS. No rebound or guarding.\nExtrem: 3+ pitting edema b/l, palpable DP pulses\nNeuro: CN II-VII intact, 9-7 musc strength UE/LE\n\n\n\nPertinent Results:\n2015-2-7 08:14PM HGB-5.7* calcHCT-17\n2015-2-7 04:22PM URINE HOURS-RANDOM\n2015-2-7 04:22PM URINE GR HOLD-HOLD\n2015-2-7 04:22PM URINE COLOR-Straw APPEAR-Clear SP Olles-1.009\n2015-2-7 04:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0\nLEUK-NEG\n2015-2-7 04:22PM URINE RBC-2015-2-7 04:18PM PT-13.3 PTT-29.5 INR(PT)-1.1\n2015-2-7 03:21PM GLUCOSE-169* UREA N-86* CREAT-1.1 SODIUM-142\nPOTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-20\n2015-2-7 03:21PM CK(CPK)-38\n2015-2-7 03:21PM CK-MB-NotDone cTropnT-2015-2-7 03:21PM VIT B12-182\n2015-2-7 03:21PM WBC-10.', '2# RBC-1.92# HGB-5.4# HCT-17.0#\nMCV-88 MCH-27.9 MCHC-31.6 RDW-17.2\n2015-2-7 03:21PM NEUTS-77.8 LYMPHS-18.0 MONOS-3.0 EOS-0.7\nBASOS-0.5\n2015-2-7 03:21PM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-1+\n2015-2-7 03:21PM PLT COUNT-362#\n\nBrief Hospital Course:\n80 yo F w/ DM2, HTN, PA HTN p/w SOB and LE edema x1 week, now\nwith severe anemia\n(hct of 17 noted by her PCP) thought to be secondary to UGIB,\nhemodynamically stable s/p 6 Units of bld w/ increase of hct to\n30. serial hcts q 6 hrs remained stable at 30.\n\nPt had EGD in ED (1908-5-7) which revealed granularity,\nfriability and erythema in the stomach body, fundus and antrum\ncompatible with acute gastritis (biopsy obtained). Erythema in\nthe duodenal bulb compatible with duodenitis. Ulcer in the\ndistal bulb. Otherwise normal EGD to second part of the\nduodenum.', "\n\nEcho:(1985-6-30)\n1. The left atrium is mildly dilated.\n2. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is\nnormal (LVEF>55%).\n3. The aortic valve leaflets are mildly thickened. Mild (1+)\naortic regurgitation is seen.\n4. The mitral valve leaflets are mildly thickened. Mild (1+)\nmitral regurgitation is seen.\n5. Compared with the findings of the prior study (tape reviewed)\nof 1943-7-28, there has been no significant change.\n\n1. GIB with increased BUN, likely UGIB, however LGIB initially\nconsidered as well.\nPt had 2 large bore IV's placed. NG lavage was positive as well\nas stool guiacs. EGD as above. No active bleed noted however\nulcer and gastritis likely source of anemia.", ' Ulcer thought to be\nsecondary to NSAID use vs H. pylori. Will treat for H.Pylori if\nindicated. Pt will follow up with GI. ASA was held secondary to\nbleed. Losartan was initially held, then restarted at half\nnormal dose. NSAIDs were avoided. Initially given IV PPI Barber LLC Hospital\nwhich was then changed to po. Colonoscopy performed was reported\nto be normal.\n\n2. Cardiac. EKG changes (NSR at 84, Nl axis and intervals, TWI\nIII, TWI V1-V4). Pt was ruled out for MI with three sets of neg\ncardiac enzymes. She denied CP. ECG changes likely secondary to\ndemand ischemia from severe anemia. She was initially monitored\non tele with no events. An echo done on 1985-6-30, as above\n(LVEF>55%). SOB most likely due to discontinuation of lasix for\none week in setting of diastolic CHF. Treated with 40 of lasix\nIV (held off on diuresis intially secondary to concern for GI\nbld).', "\n\n3. Resp. CXR done on 1908-5-7 without overt evidence of CHF or\npneumonia. Findings suggestive of pulmonary artery hypertension.\n She required O2 supplementation during her stay and was noted\nto have RA sats in the 80's with ambulation likely secondary to\nPA HTN. She was sent home on supplemental O2. A Repeat cxr was\nsuggestive of pulm congestion. Lasix given as above.\n\n4. DM2. Initially bld sugars controlled with RISS, oral\nhyperglycemics were restarted prior to discharge.\n\n5. Anemia secondary to gastritis and PUD, as well as Fe/Vit B12\ndef. She was transfused a total of 6 Units of PRBC's and her hct\nwas monitored q 6 hrs. She was started on Vit B12\nsupplementation. She was continued on Niferex.\n\nMedications on Admission:\n1. Niferex 150 Barber LLC Hospital\n2. metformin 850 TID\n3. Losartan 50\n4.", ' Rosiglitazone 8 QD\n5. Lipitor 20\n6. ASA 81\n7. lasix 40 Barber LLC Hospital\n8. Paxil 20\n\n\nDischarge Medications:\n1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD\n(once a day).\n2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO QD (once a\nday).\n3. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO TID (3\ntimes a day).\n4. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO QD\n(once a day).\n5. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)\nCapsule PO BID (2 times a day).\n6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:\nOne (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).\nDisp:60 Tablet, Delayed Release (E.C.)(s) Refills:2\n7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO QD (once\na day).\nDisp:60 Tablet(s) Refills:2\n8. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO once a\nday.', '\n9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n10. Supplemental Oxygen\nPlease use supplemental Oxygen with exerction.\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nElliott, Abbott and Barron Hospital, 48715 Fowler Hills Suite 602\nWest Jocelyn, WY 97024\n\nDischarge Diagnosis:\nUpper GI Bleed secondary to Gastritits\n\nSecondary Diagnoses:\nDM\nHTN\nVitmain B12 deficiency\n\n\nDischarge Condition:\nGood.\n\nDischarge Instructions:\nPlease call your primary care physician or return to the\nhospital if you experience further bleeding, shortness of\nbreath, or any other problems arise. Please use supplemental\noxygen with exerction.\nDO NOT TAKE ASPIRIN.\n\nFollowup Instructions:\n1. Provider: Charlotte Debelius, Creighton Heflin Where: Barron and Sons Hospital\nRhodes, Kelley and Gibson Medical Center Phone:192-820-7011 Date/Time:1913-4-4\n10:40\n\n2.', ' Provider: Dorothy Lyna Where: Barron and Sons Hospital MEDICAL\nSPECIALTIES Phone:426-439-5480 Date/Time:1902-12-3 2:20\n\n3. Provider: Percy Casenhiser PAIN MANAGEMENT CENTER Where: PAIN\nMANAGEMENT CENTER Date/Time:1913-4-4 3:00\n\n4. Provider: Emory Kenner, M.D. Where: Barron and Sons Hospital\nBrown-Boone Medical Center CENTER Phone:534-724-3404 Date/Time:1904-11-30 1:00\n\n\n\n']
195	22180	162436.0	2134-03-09	Discharge summary	Report	Admission Date: [2134-2-16] Discharge Date: [2134-3-9] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: syncope Major Surgical or Invasive Procedure: R humeral ORIF Cervical laminectomy History of Present Illness: This is a 81 year old Russian speaking only woman brought from home after a syncopal episode on day of admission. Through Russian interpreter, patient states that she had an episode of chest pain and shortness of breath after lunch and then thinks she passed out. Patient woke up with a forehead laceration and right forearm swelling. . In ED, GCS 15, AOx4, FS 130. Patient denied chest pain or shortness of breath. EKG showed coarse afib vs atach with 2:1 block without no acute ischemic changes. Head CT was negative for intracranial hemorrhage and no new c-spine fracture on C-spine. Hip films show no definite fracture. Right arm x-ray negative for fracture. CTA to rule out PE in setting CP and syncope. [First Name3 (LF) 1957] was consulted. Patient rec'd IV morphine and a tetanus shot in ED. Past Medical History: 1. DM II 2. HTN 3. pulmonary hypertension 4. increased cholesterol 5. chronic low back pain and sciatica Social History: Patient lives alone. She does not have any stairs at home and is not able to do stairs and does find that the symptoms are somewhat worse with prolonged sitting. Patient wears a back support corset(belt), compression stocking and uses a walker. Family History: NC Physical Exam: INITIAL EXAM ON MEDICINE SERVICE 97.0 139/58 57 19 96% room air GEN: mild distress, lying on back in hard collar HEENT: 2cm laceration on forehead, PERRL, EOMI, tongue no bite marks laterally slight bruise on tip CV: irregular rate, nl S1 S2, II/VI holosystolic murmur at LLSB, no gallops PULM: CTA anteriorly/laterally, wheeze ABD: obese, soft, nontender, nondistended, +BS, no HSM EXT: nonedematous LE, pain and swelling of right wrist NEURO: alert awake, otherwise difficult to assess without interpreter, able to wiggle toes bilaterally, moving all extremities equally except painful right arm . EXAM BY NEURO CONSULT: PHYSICAL EXAM: VITALS: 99.2, 136/56, 86, 20, 97%2LNC, FS 144 GEN: pleasant obese elderly woman HEENT: racoon eyes, lac with stitching over forehead, anicteric sclera, mmm NECK: supple, quite limited ROM, no pain to palpation CHEST: normal respiratory pattern, CTA bilat CV: regular rate and rhythm with holosystolic murmur ABD: soft, nontender, softly distended, +BS, a bit tympanic EXTREM: no edema, distal dry skin legs, radial and DP pulses 2+, bruises over right arm, no evidence of compartment syndrome in the right arm. NEURO: Mental status: Patient is alert, awake, pleasant affect. Oriented to person, place, time. Good attention - tells a coherent story per Russian interpret or. Language is fluent with good comprehension, and naming. No apraxia (brushes teeth), no neglect (looks about the room). No left/right mismatch. Cranial Nerves: I: deferred II: Visual fields: full to left/right/upper/lower fields. Fundoscopic exam: unable to see discs (small pupils) but no hemorrhages in the fundi. Pupils: 2->1 mm, consensual constriction to light. III, IV, VI: EOMS full, gaze conjugate. No nystagmus. + raccoon eyes. + ptosis/swelling of the right eyelid. V: facial sensation intact over V1/2/3 to light touch and pin prick. VII: symmetric face VIII: hearing intact to finger rubs on the pillows IX, X: Symmetric elevation of palate. [Doctor First Name 81]: SCM and trapezius [4-30] bilaterally XII: tongue midline without atrophy or fasciculations. Sensory: Sensory level to pin anteriorly on the left side only at around C4/T3 (above the breast). Decreased proprioception on the right arm/leg, intact on the left hand and only mildly abnormal left toe. Sensation intact to LT bilaterally. Decreased vibratory sense bilaterally distally (intact at the ankles). No extinction to double simultaneous stimulation. Motor: Normal bulk, increased tone lower extremities, right arm is flacid. No fasciculations. Unable to test drift. No adventitious movements. Dropping the phone while attempting to hold the phone to her face with the left hand. Strength: Delt Tri [Hospital1 ] WE FE FF IP QD Ham DF PF Toe RT: 0 0 0 0 0 1 4 5 4- 4 5 4 LEFT: 4+ 4 5 4+ 4- 5 4+ 5 4 4 5 4 Reflexes: No [Doctor Last Name ], no Jaw jerk. [Hospital1 ] BR Tri Pat Ach Toes RT: 2 1 2 3 0 up LEFT: 3 3 3 3 0 down Coordination: Abnormal finger to nose on the left (not out of proportion to weakness), normal heel-to-shin, slowed RAMs and FFM on the left (right not testable). Gait: not tested, patient refused. Pertinent Results: REPORTS: . C-SPINE NON-TRAUMA W/FLEX & EXT 4 VIEWS [2134-3-8] 3:46 PM IMPRESSION: Limited evaluation of the c-spine, with limited range of motion. No listhesis seen on these views. . MR L SPINE SCAN [2134-2-27] 10:09 PM IMPRESSION: Spinal stenosis noted at the level of L3-4 and L4-5 as discussed above. . MR BRACHIAL PLEXUS; MR CONTRAST GADOLIN IMPRESSION: 1. Thickening and ill-definition of the right brachial plexus just lateral to the superior ribs and inferior to the subscapularis muscle immediately below the coracoid process, likely secondary to trauma. No mass or hematoma impinging upon the nerves within the axilla or medially. The appearance of the nerves as they course by the proximal humeral shaft fracture is not well evaluated on this study as it is too peripheral. 2. Humeral shaft fracture and hemorrhage within the subcoracoid bursa not completely evaluated on this study. 3. Cervical spine disc degeneration seen on cervical spine MR. [Name13 (STitle) ] thoracic injury seen on prior imaging of uncertain cause. . HAND (AP, LAT & OBLIQUE) RIGHT [2134-2-16] 5:46 PM THREE VIEWS OF THE RIGHT HAND: There is diffuse osseous demineralization. There are degenerative changes with no definite fracture. Joint spaces are preserved. THREE VIEWS OF THE RIGHT WRIST: Alignment is normal. No fractures are identified. There are multiple rounded calcific bodies in the dorsal soft tissues that do not appear to be fracture fragments. THREE VIEWS OF THE RIGHT ELBOW: Alignment is normal. No fractures are identified. There is an enthesophyte at the posterior olecranon. . C-spine CT: There is no evidence of cervical spine fracture. Bulky calcifications of the posterior longitudinal ligament are identified at the C2-4 levels, likely resulting in moderate spinal stenosis. Multilevel degenerative changes are identified with disc space and osteophyte formation. Bridging osteophytes are identified at C7-T2. The T1-3 processes appear fused. There is marked irregularity of the inferior endplate of T3 and superior endplate of T4 with impaction of these vertebral bodies onto each other and acute kyphotic angulation at this level. These findings are likely chronic. There is no prevertebral soft tissue swelling. The lung apices are clear. IMPRESSION: No acute cervical spine fracture. Extensive degenerative changes as described above. . Head CT: FINDINGS: There is hyperdensity along the left frontal vertex that is likely secondary to volume averaging. There is no evidence of intracranial hemorrhage, mass effect, hydrocephalus, shift of normally midline structures or major vascular territorial infarction. Hypodensity in the periventricular cerebral white matter is consistent with chronic microvascular ischemia. Small prior infarcts are identified in the right internal capsule basal ganglia and left external capsule. Surrounding osseous and soft tissue structures are unremarkable. IMPRESSION: No acute intracranial hemorrhage or mass effect. . Bilateral Hip films: Degenerative changes with no definite fracture. . CTA: Impression: 1. no PE 2. enlarged pulmonary arteries 3. lymphadenopathy in mediastinum some of which are calcified 4. calcified hilar lymph nodes 5. pulm lymph nodes along major and minor fissures bilaterally 6. fat density structures in liver and stomach . EKG: afib/atach with no ST-T changes. new TWI in III. . TTE [2134-2-17] Conclusions: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion appears normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . LABS (on admission): . [2134-2-16] 05:14PM LACTATE-3.0* K+-4.0 [2134-2-16] 05:00PM GLUCOSE-135* UREA N-31* CREAT-1.5* SODIUM-144 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-29 ANION GAP-17 [2134-2-16] 05:00PM ALT(SGPT)-16 AST(SGOT)-22 CK(CPK)-106 ALK PHOS-115 AMYLASE-69 TOT BILI-0.3 [2134-2-16] 05:00PM LIPASE-55 [2134-2-16] 05:00PM CK-MB-5 cTropnT-<0.01 [2134-2-16] 05:00PM WBC-9.6# RBC-4.33 HGB-12.6 HCT-37.6 MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 [2134-2-16] 05:00PM NEUTS-83.3* LYMPHS-13.6* MONOS-1.7* EOS-1.2 BASOS-0.3 [2134-2-16] 05:00PM PLT COUNT-209 [2134-2-16] 05:00PM PT-11.2 PTT-26.5 INR(PT)-0.9 . MICRO: . [2134-2-27] 2:39 pm URINE FINAL REPORT [2134-3-3] URINE CULTURE (Final [2134-3-3]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S 1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 2 S . [2134-3-8] 12:44 pm BLOOD CULTURE CENTRAL. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . [2134-3-8] 2:55 pm URINE URINE CULTURE (Pending): . [2134-3-8] 1:17 pm CATHETER TIP-IV Source: L SC. WOUND CULTURE (Pending): Brief Hospital Course: Summary: Briefly, this is a 81 year old Russian speaking woman who presented status post fall. No intracranial bleed. No hip fracture. + R humerus fracture. CT of c-spine showed severe stenosis. She was initially admitted to the medicine service for workup of syncope; neurology was consulted for a weak right arm following R humeral fracture and she was found to have a mixed central cord and Brown-Sequard syndrome and transferred to the neurology service for closer exam monitoring. She underwent R humerus ORIF and C2-C6 laminectomy and fusion on [2134-3-2]. A med consult was obtained on [2134-3-4] for persistent hypoxia. She was gently diuresed, and had serial ABG's which showed persistent hypercarbia. During the admission, she was also treated with Cipro for a UTI. . Neuro: The patient could not recall the events surrounding the fall and sustained a spiral fracture to the right proximal humerus, displaced, and had bilateral arm weakness and numbness distally in all 4 extremities. On exam she initially was found to have evidence of a central cord syndrome with weakness affecting arms more so than legs. She also had evidence of a brown sequard given that weakness and proprioception are down on the right with an upgoing toe, and pin sensation is down on the left, sensory level of C4/T3 anteriorly on the left (where the two dermatomes meet at the top of the breast). She was complaining of neck pain, and had had trouble voiding so a foley was placed. . MRI of the C-spine was performed for the likelihood of acute spinal cord injury with above findings. Read of MRI was: "Bulky ossification of the posterior longitudinal ligament at C2/3, C3/4, and C4/5 levels, more than the right, causing severe spinal canal stenosis.The cervical cord at those levels is deformed and compressed, demonstrating intrinsic T2 hyperintense signal. There is also a fracture at the inferior endplate of C3 anteriorly." She was placed in a hard cervical collar and pain was controlled with morphine and ibuprofen initially. She was seen by both neurosurgery and orthopedics for the injury as both services had been alternately covering the spine service in the hospital. Orthopedics also followed her for the broken right humerus, and neurosurgery had initially been consulted in the ED when a head ct showed the question of a subdural hematoma (later proven to be artifactual). . Both [Date Range ] and neurosurgery agreed that it was safest for the patient to hold off on the spine surgery for at least a week to allow cord swelling to heal before operating. She remained in a hard collar during this time and her exam improved over the next week; the pinprick sensory level retracted to the T12 region for days, then finally seemed to vanish altogether; the proprioceptive changes on the right also resolved. Although the right arm remained weak and flaccid with just [2-28] finger flexors and trapezius/shoulder shrug [2-28] (initially thought just limited by pain versus multiple nerve injury), the left arm strength improved to deltoid [3-31], [Hospital1 ]/tri both 4+ to 5-/5, and wrist and finger extensors 4+/5; finger flexors were also 4+/5. On [4-9]: there were no changes in exam. For neuropathic pain, neurontin had been initiated (patient later requested d/c to simplify med regimen). . The weekend of [2-27] on morning rounds, a mild right Horner's syndrome was noted which had not been picked up before on daily rounds. This, along with the flaccid arm, was suggestive of root avulsion on the right (and associated plexopathy). Her neurologic symptoms all gradually resolved during hospitalization. . [Date Range 1957]: Pt underwent R humerus ORIF and cervical laminectomy (report below), however pt post-op, the medicine service was consulted for hypoxia (pt required 50% shovel mask) and hypercarbia (pCO2 in high 50's). She has a follow up appointment on [3-18] with [Month/Year (2) ] to evaluate her fracture and decide whether her C-collar can be removed. . Hypoxia/hypercarbia: Pt had hx of severe pulm HTM, likely [1-28] PDA. ABG showed mild CO2 retention, ? if this was close to her baseline. Also likely had component of fluid overload, given recent surgery. Pt was gently diuresed with IV Lasix. Narcotics were d/c'd as pt appeared somnolent. O2 was successfully weaned down to 2L NC (pt apparently had been on 2L O2 at home). CTA on admission was negative for PE, and the suspicion for PE was fairly low post-op given that the pt was not tachycardic and her oxygen requirement improved. Therefore, repeat CTA was not done. She was also noted to be hypercarbic during admission, but her respiratory status remained stable while on the medicine service. . Status post fall: The original fall was of unclear etiology. The differential included vasovagal syncope versus new onset afib/atach versus mechanical given loss of consciousness. Less likely include myocardial infarction/ischemia versus pulmonary embolism versus seizure. Also less likely hypoglycemia given timing after meal although patinet on glyburide which is renally cleared in setting of increased creatinine. The patient ruled out for MI by cardiac enzymes, echo showed no obvious severe valvular disease to explain ?syncopal event, though telemetry showed periodic tachyarrhythmia ?sinus tach vs afib. She had no other significant tele events while in the hospital. . Elevated WBC and lactate at admission: unclear etiology, afebrile with negative UA and infectious workup at admission. This cleared on its own. Later in hospitalization ([2-27]) she had a UTI treated with course of ciprofloxacin. Urine cxlood cx, and cath tip cx were sent prior to d/c to workup somnolence, however pt's somnolence cleared and cx's were pending on d/c. These should be followed at her follow up appointments. . Musculoskeletal: initially, radiographic imaging was negative for fracture or bleed including right UE, hips bilaterally, c-spine and head. Patient with known chronic low back pain and sciatica. . Hypertension/pulmonary hypertension: continued ASA, held valsartan. lasix initially held for renal failure but was restarted once she was clinically stable. . Hypercholesterolemia: continued home dose of lipitor . Renal: She has slight renal insufficiency at admission and was given gentle IVF. Her electrolytes were followed and repleted as needed, MVI and continued niferex. ARF improved. She should have her potassium and BUN/creatinine followed at regular intervals starting 2-3 days post discharge, as she was discharged on her home dose of [Last Name (un) ] and new dose of lasix. Prophylaxis: The patient was maintained on TEDS, SQ heparin, PPI, bowel regimen. She complained of RLE pain one day, and u/s was ordered to r/o dvt - this study was negative. . Communication: son [Telephone/Fax (1) 1958] [Last Name (un) 1959] . OPERATIVE REPORT [Last Name (LF) 1960],[First Name3 (LF) ] T. Signed Electronically by [Last Name (LF) 1960],[First Name3 (LF) ] on [Doctor First Name ] [2134-3-4] 1:18 PM Name: [Known lastname 1961], [Known firstname 1962] Unit No: [Numeric Identifier 1963] Service: NME Date: [2134-3-2] Surgeon: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1964] PROCEDURE: IM nail right humerus. ASSISTANT: [Last Name (un) 1965]. INDICATIONS FOR PROCEDURE: Ms. [Known lastname ] is an 81-year-old woman who sustained a fall and has a displaced right proximal humerus fracture. She also has a spine injury and this has been operated on by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1966]. Given the displacement of her fracture and that she is having pain and not tolerating nonoperative treatment, we decided to proceed with intramedullary nailing. DESCRIPTION OF PROCEDURE: After informed consent was obtained and Dr. [Last Name (STitle) 1967] had completed his spinal portion of the case, the patient was placed in the supine position. The right arm was prepped and draped in normal sterile fashion. A 3 cm incision was made over the proximal humerus and the deltoid was split. Eentry point was established in the proximal humerus and the guide wire placed. The fracture was held reduced and the guide wire passed into the distal humerus. The proximal part of the humerus was reamed and then the canal was reamed up to a size 10 mm. Next a 230 by 10 mm [Doctor Last Name 1968] and Nephew nail was placed and interlocked with 2 screws proximally. The distal locking screw was placed under image intensification. Wounds were irrigated and closed with 0 Vicryl, 2-0 and a subcuticular 3-0. Postoperatively, she was brought back to the recovery room in stable condition. COMPLICATIONS: None. As the attending surgeon I was present for and performed the entire procedure. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(2) 1969] Medications on Admission: 1. aspirin 81mg QD 2. glyburide 5mg QD 3. lasix 40mg QD 4. lipitor 20mg QD 5. niferex 150mg [Hospital1 ] 6. paroxetine 20mg QD 7. losartan potassium 100mg QD (?) Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB, . 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-28] Sprays Nasal QID (4 times a day) as needed. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection SC Injection TID (3 times a day). 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 18. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 19. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 21. Outpatient Lab Work please check chem 7 in [1-29] days. Adjust Lasix and losartan if needed. 22. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) unit Subcutaneous four times a day: Regular insulin sliding scale to keep blood sugar 80-140. Give 2 units insulin for each 40 glucose units above 120 up to 400, [Name8 (MD) 138] MD if over 400. . Discharge Disposition: Extended Care Facility: [Hospital6 1970] - [Hospital1 1559] Discharge Diagnosis: Primary diagnoses: R humeral fracture C-spine stenosis Brown sequard syndrome Urinary tract infection s/p fall Secondary diagnoses: Type 2 diabetes Hypertension Pulm hypertension right sided heart failure Discharge Condition: Stable. Afebrile. Oriented to person, place. Primarily russian speaking. Discharge Instructions: Please keep your cervical collar on until your [Hospital1 ] follow-up appointment on [3-18]. Please seek medical attention immediately if you experience fevers, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, or dizziness. Please take all medications as prescribed. Your paxil is being held, but may be restarted in the future. Your glyburide is being held, but may be restarted in the future once your are eating more consistently. You were started on a lower dose of lasix, however this can be increased in the future as needed. You will need to have your electrolytes checked in the next [12-28] days, and your lasix and losartan could be adjusted based on those results. Please attend all follow-up appointments. Please see a dermatologist regarding the lesion on your left knee. The phone numuber for dermatology clinic is [Telephone/Fax (1) 1971]. Followup Instructions: Please see a dermatologist regarding the lesion on your left knee. The phone numuber for dermatology clinic is [Telephone/Fax (1) 1971]. Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2134-3-18] 8:00. Please ensure patient has BLS ambulance booked for this appointment. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1972], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2134-3-18] 8:20. Please provide transportation to this appointment for this patient. Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 1228] Date/Time:[2134-3-18] 10:20. Please provide transportation for the patient to this appointment. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1953], [Name12 (NameIs) 280] Date/Time:[2134-3-23] 9:00	Admission Date: <Date>1980-10-29</Date> Discharge Date: <Date>1933-8-11</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>German</Name> Chief Complaint: syncope Major Surgical or Invasive Procedure: R humeral ORIF Cervical laminectomy History of Present Illness: This is a 81 year old Russian speaking only woman brought from home after a syncopal episode on day of admission. Through Russian interpreter, patient states that she had an episode of chest pain and shortness of breath after lunch and then thinks she passed out. Patient woke up with a forehead laceration and right forearm swelling. . In ED, GCS 15, AOx4, FS 130. Patient denied chest pain or shortness of breath. EKG showed coarse afib vs atach with 2:1 block without no acute ischemic changes. Head CT was negative for intracranial hemorrhage and no new c-spine fracture on C-spine. Hip films show no definite fracture. Right arm x-ray negative for fracture. CTA to rule out PE in setting CP and syncope. <Name>Quan</Name> was consulted. Patient rec'd IV morphine and a tetanus shot in ED. Past Medical History: 1. DM II 2. HTN 3. pulmonary hypertension 4. increased cholesterol 5. chronic low back pain and sciatica Social History: Patient lives alone. She does not have any stairs at home and is not able to do stairs and does find that the symptoms are somewhat worse with prolonged sitting. Patient wears a back support corset(belt), compression stocking and uses a walker. Family History: NC Physical Exam: INITIAL EXAM ON MEDICINE SERVICE 97.0 139/58 57 19 96% room air GEN: mild distress, lying on back in hard collar HEENT: 2cm laceration on forehead, PERRL, EOMI, tongue no bite marks laterally slight bruise on tip CV: irregular rate, nl S1 S2, II/VI holosystolic murmur at LLSB, no gallops PULM: CTA anteriorly/laterally, wheeze ABD: obese, soft, nontender, nondistended, +BS, no HSM EXT: nonedematous LE, pain and swelling of right wrist NEURO: alert awake, otherwise difficult to assess without interpreter, able to wiggle toes bilaterally, moving all extremities equally except painful right arm . EXAM BY NEURO CONSULT: PHYSICAL EXAM: VITALS: 99.2, 136/56, 86, 20, 97%2LNC, FS 144 GEN: pleasant obese elderly woman HEENT: racoon eyes, lac with stitching over forehead, anicteric sclera, mmm NECK: supple, quite limited ROM, no pain to palpation CHEST: normal respiratory pattern, CTA bilat CV: regular rate and rhythm with holosystolic murmur ABD: soft, nontender, softly distended, +BS, a bit tympanic EXTREM: no edema, distal dry skin legs, radial and DP pulses 2+, bruises over right arm, no evidence of compartment syndrome in the right arm. NEURO: Mental status: Patient is alert, awake, pleasant affect. Oriented to person, place, time. Good attention - tells a coherent story per Russian interpret or. Language is fluent with good comprehension, and naming. No apraxia (brushes teeth), no neglect (looks about the room). No left/right mismatch. Cranial Nerves: I: deferred II: Visual fields: full to left/right/upper/lower fields. Fundoscopic exam: unable to see discs (small pupils) but no hemorrhages in the fundi. Pupils: 2->1 mm, consensual constriction to light. III, IV, VI: EOMS full, gaze conjugate. No nystagmus. + raccoon eyes. + ptosis/swelling of the right eyelid. V: facial sensation intact over V1/2/3 to light touch and pin prick. VII: symmetric face VIII: hearing intact to finger rubs on the pillows IX, X: Symmetric elevation of palate. <Name>Kimberly</Name>: SCM and trapezius <Date>2-26</Date> bilaterally XII: tongue midline without atrophy or fasciculations. Sensory: Sensory level to pin anteriorly on the left side only at around C4/T3 (above the breast). Decreased proprioception on the right arm/leg, intact on the left hand and only mildly abnormal left toe. Sensation intact to LT bilaterally. Decreased vibratory sense bilaterally distally (intact at the ankles). No extinction to double simultaneous stimulation. Motor: Normal bulk, increased tone lower extremities, right arm is flacid. No fasciculations. Unable to test drift. No adventitious movements. Dropping the phone while attempting to hold the phone to her face with the left hand. Strength: Delt Tri <Hospital>Porter-Mcmahon Hospital</Hospital> WE FE FF IP QD Ham DF PF Toe RT: 0 0 0 0 0 1 4 5 4- 4 5 4 LEFT: 4+ 4 5 4+ 4- 5 4+ 5 4 4 5 4 Reflexes: No <Doctor Name>Dr.Loveland</Doctor Name>, no Jaw jerk. <Hospital>Porter-Mcmahon Hospital</Hospital> BR Tri Pat Ach Toes RT: 2 1 2 3 0 up LEFT: 3 3 3 3 0 down Coordination: Abnormal finger to nose on the left (not out of proportion to weakness), normal heel-to-shin, slowed RAMs and FFM on the left (right not testable). Gait: not tested, patient refused. Pertinent Results: REPORTS: . C-SPINE NON-TRAUMA W/FLEX & EXT 4 VIEWS <Date>2016-7-5</Date> 3:46 PM IMPRESSION: Limited evaluation of the c-spine, with limited range of motion. No listhesis seen on these views. . MR L SPINE SCAN <Date>1940-6-8</Date> 10:09 PM IMPRESSION: Spinal stenosis noted at the level of L3-4 and L4-5 as discussed above. . MR BRACHIAL PLEXUS; MR CONTRAST GADOLIN IMPRESSION: 1. Thickening and ill-definition of the right brachial plexus just lateral to the superior ribs and inferior to the subscapularis muscle immediately below the coracoid process, likely secondary to trauma. No mass or hematoma impinging upon the nerves within the axilla or medially. The appearance of the nerves as they course by the proximal humeral shaft fracture is not well evaluated on this study as it is too peripheral. 2. Humeral shaft fracture and hemorrhage within the subcoracoid bursa not completely evaluated on this study. 3. Cervical spine disc degeneration seen on cervical spine MR. <Name>Tammy Chowdhury</Name> thoracic injury seen on prior imaging of uncertain cause. . HAND (AP, LAT & OBLIQUE) RIGHT <Date>1980-10-29</Date> 5:46 PM THREE VIEWS OF THE RIGHT HAND: There is diffuse osseous demineralization. There are degenerative changes with no definite fracture. Joint spaces are preserved. THREE VIEWS OF THE RIGHT WRIST: Alignment is normal. No fractures are identified. There are multiple rounded calcific bodies in the dorsal soft tissues that do not appear to be fracture fragments. THREE VIEWS OF THE RIGHT ELBOW: Alignment is normal. No fractures are identified. There is an enthesophyte at the posterior olecranon. . C-spine CT: There is no evidence of cervical spine fracture. Bulky calcifications of the posterior longitudinal ligament are identified at the C2-4 levels, likely resulting in moderate spinal stenosis. Multilevel degenerative changes are identified with disc space and osteophyte formation. Bridging osteophytes are identified at C7-T2. The T1-3 processes appear fused. There is marked irregularity of the inferior endplate of T3 and superior endplate of T4 with impaction of these vertebral bodies onto each other and acute kyphotic angulation at this level. These findings are likely chronic. There is no prevertebral soft tissue swelling. The lung apices are clear. IMPRESSION: No acute cervical spine fracture. Extensive degenerative changes as described above. . Head CT: FINDINGS: There is hyperdensity along the left frontal vertex that is likely secondary to volume averaging. There is no evidence of intracranial hemorrhage, mass effect, hydrocephalus, shift of normally midline structures or major vascular territorial infarction. Hypodensity in the periventricular cerebral white matter is consistent with chronic microvascular ischemia. Small prior infarcts are identified in the right internal capsule basal ganglia and left external capsule. Surrounding osseous and soft tissue structures are unremarkable. IMPRESSION: No acute intracranial hemorrhage or mass effect. . Bilateral Hip films: Degenerative changes with no definite fracture. . CTA: Impression: 1. no PE 2. enlarged pulmonary arteries 3. lymphadenopathy in mediastinum some of which are calcified 4. calcified hilar lymph nodes 5. pulm lymph nodes along major and minor fissures bilaterally 6. fat density structures in liver and stomach . EKG: afib/atach with no ST-T changes. new TWI in III. . TTE <Date>1946-5-22</Date> Conclusions: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion appears normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . LABS (on admission): . <Date>1980-10-29</Date> 05:14PM LACTATE-3.0* K+-4.0 <Date>1980-10-29</Date> 05:00PM GLUCOSE-135* UREA N-31* CREAT-1.5* SODIUM-144 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-29 ANION GAP-17 <Date>1980-10-29</Date> 05:00PM ALT(SGPT)-16 AST(SGOT)-22 CK(CPK)-106 ALK PHOS-115 AMYLASE-69 TOT BILI-0.3 <Date>1980-10-29</Date> 05:00PM LIPASE-55 <Date>1980-10-29</Date> 05:00PM CK-MB-5 cTropnT-<0.01 <Date>1980-10-29</Date> 05:00PM WBC-9.6# RBC-4.33 HGB-12.6 HCT-37.6 MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 <Date>1980-10-29</Date> 05:00PM NEUTS-83.3* LYMPHS-13.6* MONOS-1.7* EOS-1.2 BASOS-0.3 <Date>1980-10-29</Date> 05:00PM PLT COUNT-209 <Date>1980-10-29</Date> 05:00PM PT-11.2 PTT-26.5 INR(PT)-0.9 . MICRO: . <Date>1940-6-8</Date> 2:39 pm URINE FINAL REPORT <Date>1943-10-6</Date> URINE CULTURE (Final <Date>1943-10-6</Date>): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S 1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 2 S . <Date>2016-7-5</Date> 12:44 pm BLOOD CULTURE CENTRAL. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . <Date>2016-7-5</Date> 2:55 pm URINE URINE CULTURE (Pending): . <Date>2016-7-5</Date> 1:17 pm CATHETER TIP-IV Source: L SC. WOUND CULTURE (Pending): Brief Hospital Course: Summary: Briefly, this is a 81 year old Russian speaking woman who presented status post fall. No intracranial bleed. No hip fracture. + R humerus fracture. CT of c-spine showed severe stenosis. She was initially admitted to the medicine service for workup of syncope; neurology was consulted for a weak right arm following R humeral fracture and she was found to have a mixed central cord and Brown-Sequard syndrome and transferred to the neurology service for closer exam monitoring. She underwent R humerus ORIF and C2-C6 laminectomy and fusion on <Date>2016-7-10</Date>. A med consult was obtained on <Date>2006-6-31</Date> for persistent hypoxia. She was gently diuresed, and had serial ABG's which showed persistent hypercarbia. During the admission, she was also treated with Cipro for a UTI. . Neuro: The patient could not recall the events surrounding the fall and sustained a spiral fracture to the right proximal humerus, displaced, and had bilateral arm weakness and numbness distally in all 4 extremities. On exam she initially was found to have evidence of a central cord syndrome with weakness affecting arms more so than legs. She also had evidence of a brown sequard given that weakness and proprioception are down on the right with an upgoing toe, and pin sensation is down on the left, sensory level of C4/T3 anteriorly on the left (where the two dermatomes meet at the top of the breast). She was complaining of neck pain, and had had trouble voiding so a foley was placed. . MRI of the C-spine was performed for the likelihood of acute spinal cord injury with above findings. Read of MRI was: "Bulky ossification of the posterior longitudinal ligament at C2/3, C3/4, and C4/5 levels, more than the right, causing severe spinal canal stenosis.The cervical cord at those levels is deformed and compressed, demonstrating intrinsic T2 hyperintense signal. There is also a fracture at the inferior endplate of C3 anteriorly." She was placed in a hard cervical collar and pain was controlled with morphine and ibuprofen initially. She was seen by both neurosurgery and orthopedics for the injury as both services had been alternately covering the spine service in the hospital. Orthopedics also followed her for the broken right humerus, and neurosurgery had initially been consulted in the ED when a head ct showed the question of a subdural hematoma (later proven to be artifactual). . Both <Date Range>1934-10-19 to 1968-7-14</Date Range> and neurosurgery agreed that it was safest for the patient to hold off on the spine surgery for at least a week to allow cord swelling to heal before operating. She remained in a hard collar during this time and her exam improved over the next week; the pinprick sensory level retracted to the T12 region for days, then finally seemed to vanish altogether; the proprioceptive changes on the right also resolved. Although the right arm remained weak and flaccid with just <Date>7-22</Date> finger flexors and trapezius/shoulder shrug <Date>7-22</Date> (initially thought just limited by pain versus multiple nerve injury), the left arm strength improved to deltoid <Date>10-14</Date>, <Hospital>Porter-Mcmahon Hospital</Hospital>/tri both 4+ to 5-/5, and wrist and finger extensors 4+/5; finger flexors were also 4+/5. On <Date>9-28</Date>: there were no changes in exam. For neuropathic pain, neurontin had been initiated (patient later requested d/c to simplify med regimen). . The weekend of <Date>3-2</Date> on morning rounds, a mild right Horner's syndrome was noted which had not been picked up before on daily rounds. This, along with the flaccid arm, was suggestive of root avulsion on the right (and associated plexopathy). Her neurologic symptoms all gradually resolved during hospitalization. . <Date Range>1962-7-27 to 1963-11-16</Date Range>: Pt underwent R humerus ORIF and cervical laminectomy (report below), however pt post-op, the medicine service was consulted for hypoxia (pt required 50% shovel mask) and hypercarbia (pCO2 in high 50's). She has a follow up appointment on <Date>9-19</Date> with <Month>July</Month> to evaluate her fracture and decide whether her C-collar can be removed. . Hypoxia/hypercarbia: Pt had hx of severe pulm HTM, likely <Date>1-26</Date> PDA. ABG showed mild CO2 retention, ? if this was close to her baseline. Also likely had component of fluid overload, given recent surgery. Pt was gently diuresed with IV Lasix. Narcotics were d/c'd as pt appeared somnolent. O2 was successfully weaned down to 2L NC (pt apparently had been on 2L O2 at home). CTA on admission was negative for PE, and the suspicion for PE was fairly low post-op given that the pt was not tachycardic and her oxygen requirement improved. Therefore, repeat CTA was not done. She was also noted to be hypercarbic during admission, but her respiratory status remained stable while on the medicine service. . Status post fall: The original fall was of unclear etiology. The differential included vasovagal syncope versus new onset afib/atach versus mechanical given loss of consciousness. Less likely include myocardial infarction/ischemia versus pulmonary embolism versus seizure. Also less likely hypoglycemia given timing after meal although patinet on glyburide which is renally cleared in setting of increased creatinine. The patient ruled out for MI by cardiac enzymes, echo showed no obvious severe valvular disease to explain ?syncopal event, though telemetry showed periodic tachyarrhythmia ?sinus tach vs afib. She had no other significant tele events while in the hospital. . Elevated WBC and lactate at admission: unclear etiology, afebrile with negative UA and infectious workup at admission. This cleared on its own. Later in hospitalization (<Date>3-2</Date>) she had a UTI treated with course of ciprofloxacin. Urine cxlood cx, and cath tip cx were sent prior to d/c to workup somnolence, however pt's somnolence cleared and cx's were pending on d/c. These should be followed at her follow up appointments. . Musculoskeletal: initially, radiographic imaging was negative for fracture or bleed including right UE, hips bilaterally, c-spine and head. Patient with known chronic low back pain and sciatica. . Hypertension/pulmonary hypertension: continued ASA, held valsartan. lasix initially held for renal failure but was restarted once she was clinically stable. . Hypercholesterolemia: continued home dose of lipitor . Renal: She has slight renal insufficiency at admission and was given gentle IVF. Her electrolytes were followed and repleted as needed, MVI and continued niferex. ARF improved. She should have her potassium and BUN/creatinine followed at regular intervals starting 2-3 days post discharge, as she was discharged on her home dose of <Name>Deng</Name> and new dose of lasix. Prophylaxis: The patient was maintained on TEDS, SQ heparin, PPI, bowel regimen. She complained of RLE pain one day, and u/s was ordered to r/o dvt - this study was negative. . Communication: son <Telephone>876-848-6335</Telephone> <Name>Luu</Name> . OPERATIVE REPORT <Name>Ceja</Name>,<Name>Sandhya</Name> T. Signed Electronically by <Name>Caleb</Name> <Date>2006-6-31</Date> 1:18 PM Name: <Name>Whitehead</Name>, <Name>Sammie</Name> Unit No: <Numeric Identifier>0693049</Numeric Identifier> Service: NME Date: <Date>2016-7-10</Date> Surgeon: <Name>Harold</Name> <Name>Edward</Name>, M.D. <MD Number>47779070</MD Number> PROCEDURE: IM nail right humerus. ASSISTANT: <Name>Olles</Name>. INDICATIONS FOR PROCEDURE: Ms. <Name>Olles</Name> is an 81-year-old woman who sustained a fall and has a displaced right proximal humerus fracture. She also has a spine injury and this has been operated on by Dr. <Name>Rosalinda</Name> <Name>Lofft</Name>. Given the displacement of her fracture and that she is having pain and not tolerating nonoperative treatment, we decided to proceed with intramedullary nailing. DESCRIPTION OF PROCEDURE: After informed consent was obtained and Dr. <Name>Caro</Name> had completed his spinal portion of the case, the patient was placed in the supine position. The right arm was prepped and draped in normal sterile fashion. A 3 cm incision was made over the proximal humerus and the deltoid was split. Eentry point was established in the proximal humerus and the guide wire placed. The fracture was held reduced and the guide wire passed into the distal humerus. The proximal part of the humerus was reamed and then the canal was reamed up to a size 10 mm. Next a 230 by 10 mm <Doctor Name>Dr.Deng</Doctor Name> and Nephew nail was placed and interlocked with 2 screws proximally. The distal locking screw was placed under image intensification. Wounds were irrigated and closed with 0 Vicryl, 2-0 and a subcuticular 3-0. Postoperatively, she was brought back to the recovery room in stable condition. COMPLICATIONS: None. As the attending surgeon I was present for and performed the entire procedure. <Name>Harold</Name> <Name>Edward</Name>, M.D. <MD Number>14552559</MD Number> Medications on Admission: 1. aspirin 81mg QD 2. glyburide 5mg QD 3. lasix 40mg QD 4. lipitor 20mg QD 5. niferex 150mg <Hospital>Porter-Mcmahon Hospital</Hospital> 6. paroxetine 20mg QD 7. losartan potassium 100mg QD (?) Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB, . 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: <Date>9-15</Date> Sprays Nasal QID (4 times a day) as needed. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection SC Injection TID (3 times a day). 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 18. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 19. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 21. Outpatient Lab Work please check chem 7 in <Date>6-5</Date> days. Adjust Lasix and losartan if needed. 22. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) unit Subcutaneous four times a day: Regular insulin sliding scale to keep blood sugar 80-140. Give 2 units insulin for each 40 glucose units above 120 up to 400, <Name>Leslee Lockett</Name> MD if over 400. . Discharge Disposition: Extended Care Facility: <Hospital>Nguyen-Cook Health System</Hospital> - <Hospital>Bowen, Berger and Edwards Medical Center</Hospital> Discharge Diagnosis: Primary diagnoses: R humeral fracture C-spine stenosis Brown sequard syndrome Urinary tract infection s/p fall Secondary diagnoses: Type 2 diabetes Hypertension Pulm hypertension right sided heart failure Discharge Condition: Stable. Afebrile. Oriented to person, place. Primarily russian speaking. Discharge Instructions: Please keep your cervical collar on until your <Hospital>Porter-Mcmahon Hospital</Hospital> follow-up appointment on <Date>9-19</Date>. Please seek medical attention immediately if you experience fevers, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, or dizziness. Please take all medications as prescribed. Your paxil is being held, but may be restarted in the future. Your glyburide is being held, but may be restarted in the future once your are eating more consistently. You were started on a lower dose of lasix, however this can be increased in the future as needed. You will need to have your electrolytes checked in the next <Date>9-15</Date> days, and your lasix and losartan could be adjusted based on those results. Please attend all follow-up appointments. Please see a dermatologist regarding the lesion on your left knee. The phone numuber for dermatology clinic is <Telephone>679-916-3767</Telephone>. Followup Instructions: Please see a dermatologist regarding the lesion on your left knee. The phone numuber for dermatology clinic is <Telephone>679-916-3767</Telephone>. Provider: <Name>Patrick Chau</Name> XRAY (SCC 2) Phone:<Telephone>724-505-6276</Telephone> Date/Time:<Date>1998-2-31</Date> 8:00. Please ensure patient has BLS ambulance booked for this appointment. Provider: <Name>Rosalinda</Name> <Name>Taylor</Name>, MD Phone:<Telephone>724-505-6276</Telephone> Date/Time:<Date>1998-2-31</Date> 8:20. Please provide transportation to this appointment for this patient. Provider: <Name>Londrie</Name>. <Name>Ahmed</Name> Phone:<Telephone>724-505-6276</Telephone> Date/Time:<Date>1998-2-31</Date> 10:20. Please provide transportation for the patient to this appointment. Provider: <Name>Harold</Name> <Name>Benhamou</Name>, <Name>Orville Cobbs</Name> Date/Time:<Date>2003-9-24</Date> 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Date: 1980-10-29 Discharge Date: 1933-8-11 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:German Chief Complaint: syncope Major Surgical or Invasive Procedure: R humeral ORIF Cervical laminectomy History of Present Illness: This is a 81 year old Russian speaking only woman brought from home after a syncopal episode on day of admission. Through Russian interpreter, patient states that she had an episode of chest pain and shortness of breath after lunch and then thinks she passed out. Patient woke up with a forehead laceration and right forearm swelling. . In ED, GCS 15, AOx4, FS 130. Patient denied chest pain or shortness of breath. EKG showed coarse afib vs atach with 2:1 block without no acute ischemic changes. Head CT was negative for intracranial hemorrhage and no new c-spine fracture on C-spine. Hip films show no definite fracture. Right arm x-ray negative for fracture. CTA to rule out PE in setting CP and syncope. Quan was consulted. Patient rec'd IV morphine and a tetanus shot in ED. Past Medical History: 1. DM II 2. HTN 3. pulmonary hypertension 4. increased cholesterol 5. chronic low back pain and sciatica Social History: Patient lives alone. She does not have any stairs at home and is not able to do stairs and does find that the symptoms are somewhat worse with prolonged sitting. Patient wears a back support corset(belt), compression stocking and uses a walker. Family History: NC Physical Exam: INITIAL EXAM ON MEDICINE SERVICE 97.0 139/58 57 19 96% room air GEN: mild distress, lying on back in hard collar HEENT: 2cm laceration on forehead, PERRL, EOMI, tongue no bite marks laterally slight bruise on tip CV: irregular rate, nl S1 S2, II/VI holosystolic murmur at LLSB, no gallops PULM: CTA anteriorly/laterally, wheeze ABD: obese, soft, nontender, nondistended, +BS, no HSM EXT: nonedematous LE, pain and swelling of right wrist NEURO: alert awake, otherwise difficult to assess without interpreter, able to wiggle toes bilaterally, moving all extremities equally except painful right arm . EXAM BY NEURO CONSULT: PHYSICAL EXAM: VITALS: 99.2, 136/56, 86, 20, 97%2LNC, FS 144 GEN: pleasant obese elderly woman HEENT: racoon eyes, lac with stitching over forehead, anicteric sclera, mmm NECK: supple, quite limited ROM, no pain to palpation CHEST: normal respiratory pattern, CTA bilat CV: regular rate and rhythm with holosystolic murmur ABD: soft, nontender, softly distended, +BS, a bit tympanic EXTREM: no edema, distal dry skin legs, radial and DP pulses 2+, bruises over right arm, no evidence of compartment syndrome in the right arm. NEURO: Mental status: Patient is alert, awake, pleasant affect. Oriented to person, place, time. Good attention - tells a coherent story per Russian interpret or. Language is fluent with good comprehension, and naming. No apraxia (brushes teeth), no neglect (looks about the room). No left/right mismatch. Cranial Nerves: I: deferred II: Visual fields: full to left/right/upper/lower fields. Fundoscopic exam: unable to see discs (small pupils) but no hemorrhages in the fundi. Pupils: 2->1 mm, consensual constriction to light. III, IV, VI: EOMS full, gaze conjugate. No nystagmus. + raccoon eyes. + ptosis/swelling of the right eyelid. V: facial sensation intact over V1/2/3 to light touch and pin prick. VII: symmetric face VIII: hearing intact to finger rubs on the pillows IX, X: Symmetric elevation of palate. Kimberly: SCM and trapezius 2-26 bilaterally XII: tongue midline without atrophy or fasciculations. Sensory: Sensory level to pin anteriorly on the left side only at around C4/T3 (above the breast). Decreased proprioception on the right arm/leg, intact on the left hand and only mildly abnormal left toe. Sensation intact to LT bilaterally. Decreased vibratory sense bilaterally distally (intact at the ankles). No extinction to double simultaneous stimulation. Motor: Normal bulk, increased tone lower extremities, right arm is flacid. No fasciculations. Unable to test drift. No adventitious movements. Dropping the phone while attempting to hold the phone to her face with the left hand. Strength: Delt Tri Porter-Mcmahon Hospital WE FE FF IP QD Ham DF PF Toe RT: 0 0 0 0 0 1 4 5 4- 4 5 4 LEFT: 4+ 4 5 4+ 4- 5 4+ 5 4 4 5 4 Reflexes: No Dr.Loveland, no Jaw jerk. Porter-Mcmahon Hospital BR Tri Pat Ach Toes RT: 2 1 2 3 0 up LEFT: 3 3 3 3 0 down Coordination: Abnormal finger to nose on the left (not out of proportion to weakness), normal heel-to-shin, slowed RAMs and FFM on the left (right not testable). Gait: not tested, patient refused. Pertinent Results: REPORTS: . C-SPINE NON-TRAUMA W/FLEX & EXT 4 VIEWS 2016-7-5 3:46 PM IMPRESSION: Limited evaluation of the c-spine, with limited range of motion. No listhesis seen on these views. . MR L SPINE SCAN 1940-6-8 10:09 PM IMPRESSION: Spinal stenosis noted at the level of L3-4 and L4-5 as discussed above. . MR BRACHIAL PLEXUS; MR CONTRAST GADOLIN IMPRESSION: 1. Thickening and ill-definition of the right brachial plexus just lateral to the superior ribs and inferior to the subscapularis muscle immediately below the coracoid process, likely secondary to trauma. No mass or hematoma impinging upon the nerves within the axilla or medially. The appearance of the nerves as they course by the proximal humeral shaft fracture is not well evaluated on this study as it is too peripheral. 2. Humeral shaft fracture and hemorrhage within the subcoracoid bursa not completely evaluated on this study. 3. Cervical spine disc degeneration seen on cervical spine MR. Tammy Chowdhury thoracic injury seen on prior imaging of uncertain cause. . HAND (AP, LAT & OBLIQUE) RIGHT 1980-10-29 5:46 PM THREE VIEWS OF THE RIGHT HAND: There is diffuse osseous demineralization. There are degenerative changes with no definite fracture. Joint spaces are preserved. THREE VIEWS OF THE RIGHT WRIST: Alignment is normal. No fractures are identified. There are multiple rounded calcific bodies in the dorsal soft tissues that do not appear to be fracture fragments. THREE VIEWS OF THE RIGHT ELBOW: Alignment is normal. No fractures are identified. There is an enthesophyte at the posterior olecranon. . C-spine CT: There is no evidence of cervical spine fracture. Bulky calcifications of the posterior longitudinal ligament are identified at the C2-4 levels, likely resulting in moderate spinal stenosis. Multilevel degenerative changes are identified with disc space and osteophyte formation. Bridging osteophytes are identified at C7-T2. The T1-3 processes appear fused. There is marked irregularity of the inferior endplate of T3 and superior endplate of T4 with impaction of these vertebral bodies onto each other and acute kyphotic angulation at this level. These findings are likely chronic. There is no prevertebral soft tissue swelling. The lung apices are clear. IMPRESSION: No acute cervical spine fracture. Extensive degenerative changes as described above. . Head CT: FINDINGS: There is hyperdensity along the left frontal vertex that is likely secondary to volume averaging. There is no evidence of intracranial hemorrhage, mass effect, hydrocephalus, shift of normally midline structures or major vascular territorial infarction. Hypodensity in the periventricular cerebral white matter is consistent with chronic microvascular ischemia. Small prior infarcts are identified in the right internal capsule basal ganglia and left external capsule. Surrounding osseous and soft tissue structures are unremarkable. IMPRESSION: No acute intracranial hemorrhage or mass effect. . Bilateral Hip films: Degenerative changes with no definite fracture. . CTA: Impression: 1. no PE 2. enlarged pulmonary arteries 3. lymphadenopathy in mediastinum some of which are calcified 4. calcified hilar lymph nodes 5. pulm lymph nodes along major and minor fissures bilaterally 6. fat density structures in liver and stomach . EKG: afib/atach with no ST-T changes. new TWI in III. . TTE 1946-5-22 Conclusions: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion appears normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . LABS (on admission): . 1980-10-29 05:14PM LACTATE-3.0* K+-4.0 1980-10-29 05:00PM GLUCOSE-135* UREA N-31* CREAT-1.5* SODIUM-144 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-29 ANION GAP-17 1980-10-29 05:00PM ALT(SGPT)-16 AST(SGOT)-22 CK(CPK)-106 ALK PHOS-115 AMYLASE-69 TOT BILI-0.3 1980-10-29 05:00PM LIPASE-55 1980-10-29 05:00PM CK-MB-5 cTropnT-1980-10-29 05:00PM WBC-9.6# RBC-4.33 HGB-12.6 HCT-37.6 MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 1980-10-29 05:00PM NEUTS-83.3* LYMPHS-13.6* MONOS-1.7* EOS-1.2 BASOS-0.3 1980-10-29 05:00PM PLT COUNT-209 1980-10-29 05:00PM PT-11.2 PTT-26.5 INR(PT)-0.9 . MICRO: . 1940-6-8 2:39 pm URINE FINAL REPORT 1943-10-6 URINE CULTURE (Final 1943-10-6): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ 2016-7-5 12:44 pm BLOOD CULTURE CENTRAL. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . 2016-7-5 2:55 pm URINE URINE CULTURE (Pending): . 2016-7-5 1:17 pm CATHETER TIP-IV Source: L SC. WOUND CULTURE (Pending): Brief Hospital Course: Summary: Briefly, this is a 81 year old Russian speaking woman who presented status post fall. No intracranial bleed. No hip fracture. + R humerus fracture. CT of c-spine showed severe stenosis. She was initially admitted to the medicine service for workup of syncope; neurology was consulted for a weak right arm following R humeral fracture and she was found to have a mixed central cord and Brown-Sequard syndrome and transferred to the neurology service for closer exam monitoring. She underwent R humerus ORIF and C2-C6 laminectomy and fusion on 2016-7-10. A med consult was obtained on 2006-6-31 for persistent hypoxia. She was gently diuresed, and had serial ABG's which showed persistent hypercarbia. During the admission, she was also treated with Cipro for a UTI. . Neuro: The patient could not recall the events surrounding the fall and sustained a spiral fracture to the right proximal humerus, displaced, and had bilateral arm weakness and numbness distally in all 4 extremities. On exam she initially was found to have evidence of a central cord syndrome with weakness affecting arms more so than legs. She also had evidence of a brown sequard given that weakness and proprioception are down on the right with an upgoing toe, and pin sensation is down on the left, sensory level of C4/T3 anteriorly on the left (where the two dermatomes meet at the top of the breast). She was complaining of neck pain, and had had trouble voiding so a foley was placed. . MRI of the C-spine was performed for the likelihood of acute spinal cord injury with above findings. Read of MRI was: "Bulky ossification of the posterior longitudinal ligament at C2/3, C3/4, and C4/5 levels, more than the right, causing severe spinal canal stenosis.The cervical cord at those levels is deformed and compressed, demonstrating intrinsic T2 hyperintense signal. There is also a fracture at the inferior endplate of C3 anteriorly." She was placed in a hard cervical collar and pain was controlled with morphine and ibuprofen initially. She was seen by both neurosurgery and orthopedics for the injury as both services had been alternately covering the spine service in the hospital. Orthopedics also followed her for the broken right humerus, and neurosurgery had initially been consulted in the ED when a head ct showed the question of a subdural hematoma (later proven to be artifactual). . Both 1934-10-19 to 1968-7-14 and neurosurgery agreed that it was safest for the patient to hold off on the spine surgery for at least a week to allow cord swelling to heal before operating. She remained in a hard collar during this time and her exam improved over the next week; the pinprick sensory level retracted to the T12 region for days, then finally seemed to vanish altogether; the proprioceptive changes on the right also resolved. Although the right arm remained weak and flaccid with just 7-22 finger flexors and trapezius/shoulder shrug 7-22 (initially thought just limited by pain versus multiple nerve injury), the left arm strength improved to deltoid 10-14, Porter-Mcmahon Hospital/tri both 4+ to 5-/5, and wrist and finger extensors 4+/5; finger flexors were also 4+/5. On 9-28: there were no changes in exam. For neuropathic pain, neurontin had been initiated (patient later requested d/c to simplify med regimen). . The weekend of 3-2 on morning rounds, a mild right Horner's syndrome was noted which had not been picked up before on daily rounds. This, along with the flaccid arm, was suggestive of root avulsion on the right (and associated plexopathy). Her neurologic symptoms all gradually resolved during hospitalization. . 1962-7-27 to 1963-11-16: Pt underwent R humerus ORIF and cervical laminectomy (report below), however pt post-op, the medicine service was consulted for hypoxia (pt required 50% shovel mask) and hypercarbia (pCO2 in high 50's). She has a follow up appointment on 9-19 with July to evaluate her fracture and decide whether her C-collar can be removed. . Hypoxia/hypercarbia: Pt had hx of severe pulm HTM, likely 1-26 PDA. ABG showed mild CO2 retention, ? if this was close to her baseline. Also likely had component of fluid overload, given recent surgery. Pt was gently diuresed with IV Lasix. Narcotics were d/c'd as pt appeared somnolent. O2 was successfully weaned down to 2L NC (pt apparently had been on 2L O2 at home). CTA on admission was negative for PE, and the suspicion for PE was fairly low post-op given that the pt was not tachycardic and her oxygen requirement improved. Therefore, repeat CTA was not done. She was also noted to be hypercarbic during admission, but her respiratory status remained stable while on the medicine service. . Status post fall: The original fall was of unclear etiology. The differential included vasovagal syncope versus new onset afib/atach versus mechanical given loss of consciousness. Less likely include myocardial infarction/ischemia versus pulmonary embolism versus seizure. Also less likely hypoglycemia given timing after meal although patinet on glyburide which is renally cleared in setting of increased creatinine. The patient ruled out for MI by cardiac enzymes, echo showed no obvious severe valvular disease to explain ?syncopal event, though telemetry showed periodic tachyarrhythmia ?sinus tach vs afib. She had no other significant tele events while in the hospital. . Elevated WBC and lactate at admission: unclear etiology, afebrile with negative UA and infectious workup at admission. This cleared on its own. Later in hospitalization (3-2) she had a UTI treated with course of ciprofloxacin. Urine cxlood cx, and cath tip cx were sent prior to d/c to workup somnolence, however pt's somnolence cleared and cx's were pending on d/c. These should be followed at her follow up appointments. . Musculoskeletal: initially, radiographic imaging was negative for fracture or bleed including right UE, hips bilaterally, c-spine and head. Patient with known chronic low back pain and sciatica. . Hypertension/pulmonary hypertension: continued ASA, held valsartan. lasix initially held for renal failure but was restarted once she was clinically stable. . Hypercholesterolemia: continued home dose of lipitor . Renal: She has slight renal insufficiency at admission and was given gentle IVF. Her electrolytes were followed and repleted as needed, MVI and continued niferex. ARF improved. She should have her potassium and BUN/creatinine followed at regular intervals starting 2-3 days post discharge, as she was discharged on her home dose of Deng and new dose of lasix. Prophylaxis: The patient was maintained on TEDS, SQ heparin, PPI, bowel regimen. She complained of RLE pain one day, and u/s was ordered to r/o dvt - this study was negative. . Communication: son 876-848-6335 Luu . OPERATIVE REPORT Ceja,Sandhya T. Signed Electronically by Caleb 2006-6-31 1:18 PM Name: Whitehead, Sammie Unit No: 0693049 Service: NME Date: 2016-7-10 Surgeon: Harold Edward, M.D. 47779070 PROCEDURE: IM nail right humerus. ASSISTANT: Olles. INDICATIONS FOR PROCEDURE: Ms. Olles is an 81-year-old woman who sustained a fall and has a displaced right proximal humerus fracture. She also has a spine injury and this has been operated on by Dr. Rosalinda Lofft. Given the displacement of her fracture and that she is having pain and not tolerating nonoperative treatment, we decided to proceed with intramedullary nailing. DESCRIPTION OF PROCEDURE: After informed consent was obtained and Dr. Caro had completed his spinal portion of the case, the patient was placed in the supine position. The right arm was prepped and draped in normal sterile fashion. A 3 cm incision was made over the proximal humerus and the deltoid was split. Eentry point was established in the proximal humerus and the guide wire placed. The fracture was held reduced and the guide wire passed into the distal humerus. The proximal part of the humerus was reamed and then the canal was reamed up to a size 10 mm. Next a 230 by 10 mm Dr.Deng and Nephew nail was placed and interlocked with 2 screws proximally. The distal locking screw was placed under image intensification. Wounds were irrigated and closed with 0 Vicryl, 2-0 and a subcuticular 3-0. Postoperatively, she was brought back to the recovery room in stable condition. COMPLICATIONS: None. As the attending surgeon I was present for and performed the entire procedure. Harold Edward, M.D. 14552559 Medications on Admission: 1. aspirin 81mg QD 2. glyburide 5mg QD 3. lasix 40mg QD 4. lipitor 20mg QD 5. niferex 150mg Porter-Mcmahon Hospital 6. paroxetine 20mg QD 7. losartan potassium 100mg QD (?) Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB, . 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: 9-15 Sprays Nasal QID (4 times a day) as needed. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection SC Injection TID (3 times a day). 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 18. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 19. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 21. Outpatient Lab Work please check chem 7 in 6-5 days. Adjust Lasix and losartan if needed. 22. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) unit Subcutaneous four times a day: Regular insulin sliding scale to keep blood sugar 80-140. Give 2 units insulin for each 40 glucose units above 120 up to 400, Leslee Lockett MD if over 400. . Discharge Disposition: Extended Care Facility: Nguyen-Cook Health System - Bowen, Berger and Edwards Medical Center Discharge Diagnosis: Primary diagnoses: R humeral fracture C-spine stenosis Brown sequard syndrome Urinary tract infection s/p fall Secondary diagnoses: Type 2 diabetes Hypertension Pulm hypertension right sided heart failure Discharge Condition: Stable. Afebrile. Oriented to person, place. Primarily russian speaking. Discharge Instructions: Please keep your cervical collar on until your Porter-Mcmahon Hospital follow-up appointment on 9-19. Please seek medical attention immediately if you experience fevers, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, or dizziness. Please take all medications as prescribed. Your paxil is being held, but may be restarted in the future. Your glyburide is being held, but may be restarted in the future once your are eating more consistently. You were started on a lower dose of lasix, however this can be increased in the future as needed. You will need to have your electrolytes checked in the next 9-15 days, and your lasix and losartan could be adjusted based on those results. Please attend all follow-up appointments. Please see a dermatologist regarding the lesion on your left knee. The phone numuber for dermatology clinic is 679-916-3767. Followup Instructions: Please see a dermatologist regarding the lesion on your left knee. The phone numuber for dermatology clinic is 679-916-3767. Provider: Patrick Chau XRAY (SCC 2) Phone:724-505-6276 Date/Time:1998-2-31 8:00. Please ensure patient has BLS ambulance booked for this appointment. Provider: Rosalinda Taylor, MD Phone:724-505-6276 Date/Time:1998-2-31 8:20. Please provide transportation to this appointment for this patient. Provider: Londrie. Ahmed Phone:724-505-6276 Date/Time:1998-2-31 10:20. Please provide transportation for the patient to this appointment. Provider: Harold Benhamou, Orville Cobbs Date/Time:2003-9-24 9:00	['Admission Date: 1980-10-29 Discharge Date: 1933-8-11\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:German\nChief Complaint:\nsyncope\n\nMajor Surgical or Invasive Procedure:\nR humeral ORIF\nCervical laminectomy\n\n\nHistory of Present Illness:\nThis is a 81 year old Russian speaking only woman brought from\nhome after a syncopal episode on day of admission. Through\nRussian interpreter, patient states that she had an episode of\nchest pain and shortness of breath after lunch and then thinks\nshe passed out. Patient woke up with a forehead laceration and\nright forearm swelling.\n.\nIn ED, GCS 15, AOx4, FS 130. Patient denied chest pain or\nshortness of breath. EKG showed coarse afib vs atach with 2:1\nblock without no acute ischemic changes.', " Head CT was negative\nfor intracranial hemorrhage and no new c-spine fracture on\nC-spine. Hip films show no definite fracture. Right arm x-ray\nnegative for fracture. CTA to rule out PE in setting CP and\nsyncope. Quan was consulted. Patient rec'd IV morphine and a\ntetanus shot in ED.\n\n\nPast Medical History:\n1. DM II\n2. HTN\n3. pulmonary hypertension\n4. increased cholesterol\n5. chronic low back pain and sciatica\n\n\nSocial History:\nPatient lives alone. She does not have any stairs at home and is\nnot able to do stairs and does find that the symptoms are\nsomewhat worse with prolonged sitting. Patient wears a back\nsupport corset(belt), compression stocking and uses a walker.\n\nFamily History:\nNC\n\nPhysical Exam:\nINITIAL EXAM ON MEDICINE SERVICE\n 97.0 139/58 57 19 96% room air\nGEN: mild distress, lying on back in hard collar\nHEENT: 2cm laceration on forehead, PERRL, EOMI, tongue no bite\nmarks laterally slight bruise on tip\nCV: irregular rate, nl S1 S2, II/VI holosystolic murmur at LLSB,\nno gallops\nPULM: CTA anteriorly/laterally, wheeze\nABD: obese, soft, nontender, nondistended, +BS, no HSM\nEXT: nonedematous LE, pain and swelling of right wrist\nNEURO: alert awake, otherwise difficult to assess without\ninterpreter, able to wiggle toes bilaterally, moving all\nextremities equally except painful right arm\n.", '\nEXAM BY NEURO CONSULT:\nPHYSICAL EXAM:\nVITALS: 99.2, 136/56, 86, 20, 97%2LNC, FS 144\nGEN: pleasant obese elderly woman\nHEENT: racoon eyes, lac with stitching over forehead, anicteric\nsclera, mmm\nNECK: supple, quite limited ROM, no pain to palpation\nCHEST: normal respiratory pattern, CTA bilat\nCV: regular rate and rhythm with holosystolic murmur\nABD: soft, nontender, softly distended, +BS, a bit tympanic\nEXTREM: no edema, distal dry skin legs, radial and DP pulses\n2+,\nbruises over right arm, no evidence of compartment syndrome in\nthe right arm.\n\nNEURO:\nMental status:\nPatient is alert, awake, pleasant affect. Oriented to person,\nplace, time. Good attention - tells a coherent story per Russian\ninterpret or. Language is fluent with good comprehension, and\nnaming. No apraxia (brushes teeth), no neglect (looks about the\nroom).', ' No left/right mismatch.\n\nCranial Nerves:\nI: deferred\nII: Visual fields: full to left/right/upper/lower fields.\nFundoscopic exam: unable to see discs (small pupils) but no\nhemorrhages in the fundi. Pupils: 2->1 mm, consensual\nconstriction to light.\nIII, IV, VI: EOMS full, gaze conjugate. No nystagmus. +\nraccoon eyes. + ptosis/swelling of the right eyelid.\nV: facial sensation intact over V1/2/3 to light touch and pin\nprick.\nVII: symmetric face\nVIII: hearing intact to finger rubs on the pillows\nIX, X: Symmetric elevation of palate.\nKimberly: SCM and trapezius 2-26 bilaterally\nXII: tongue midline without atrophy or fasciculations.\n\nSensory:\nSensory level to pin anteriorly on the left side only at around\nC4/T3 (above the breast). Decreased proprioception on the right\narm/leg, intact on the left hand and only mildly abnormal left\ntoe.', ' Sensation intact to LT bilaterally. Decreased vibratory\nsense bilaterally distally (intact at the ankles). No extinction\nto double simultaneous stimulation.\n\nMotor:\nNormal bulk, increased tone lower extremities, right arm is\nflacid. No fasciculations. Unable to test drift. No\nadventitious movements. Dropping the phone while attempting to\nhold the phone to her face with the left hand.\nStrength:\n Delt Tri Porter-Mcmahon Hospital WE FE FF IP QD Ham DF PF Toe\nRT: 0 0 0 0 0 1 4 5 4- 4 5 4\nLEFT: 4+ 4 5 4+ 4- 5 4+ 5 4 4 5 4\n\nReflexes: No Dr.Loveland, no Jaw jerk.\n Porter-Mcmahon Hospital BR Tri Pat Ach Toes\nRT: 2 1 2 3 0 up\nLEFT: 3 3 3 3 0 down\n\nCoordination:\nAbnormal finger to nose on the left (not out of proportion to\nweakness), normal heel-to-shin, slowed RAMs and FFM on the left\n(right not testable).', '\n\nGait: not tested, patient refused.\n\nPertinent Results:\nREPORTS:\n.\nC-SPINE NON-TRAUMA W/FLEX & EXT 4 VIEWS 2016-7-5 3:46 PM\nIMPRESSION: Limited evaluation of the c-spine, with limited\nrange of motion. No listhesis seen on these views.\n.\nMR L SPINE SCAN 1940-6-8 10:09 PM\nIMPRESSION:\nSpinal stenosis noted at the level of L3-4 and L4-5 as discussed\nabove.\n.\nMR BRACHIAL PLEXUS; MR CONTRAST GADOLIN\nIMPRESSION:\n1. Thickening and ill-definition of the right brachial plexus\njust lateral to the superior ribs and inferior to the\nsubscapularis muscle immediately below the coracoid process,\nlikely secondary to trauma. No mass or hematoma impinging upon\nthe nerves within the axilla or medially. The appearance of the\nnerves as they course by the proximal humeral shaft fracture is\nnot well evaluated on this study as it is too peripheral.', '\n2. Humeral shaft fracture and hemorrhage within the subcoracoid\nbursa not completely evaluated on this study.\n3. Cervical spine disc degeneration seen on cervical spine MR.\nTammy Chowdhury thoracic injury seen on prior imaging of uncertain cause.\n.\nHAND (AP, LAT & OBLIQUE) RIGHT 1980-10-29 5:46 PM\nTHREE VIEWS OF THE RIGHT HAND: There is diffuse osseous\ndemineralization. There are degenerative changes with no\ndefinite fracture. Joint spaces are preserved.\nTHREE VIEWS OF THE RIGHT WRIST: Alignment is normal. No\nfractures are identified. There are multiple rounded calcific\nbodies in the dorsal soft tissues that do not appear to be\nfracture fragments.\nTHREE VIEWS OF THE RIGHT ELBOW: Alignment is normal. No\nfractures are identified. There is an enthesophyte at the\nposterior olecranon.\n.\nC-spine CT: There is no evidence of cervical spine fracture.', '\nBulky\ncalcifications of the posterior longitudinal ligament are\nidentified at the C2-4 levels, likely resulting in moderate\nspinal stenosis. Multilevel degenerative changes are identified\nwith disc space and osteophyte formation. Bridging osteophytes\nare identified at C7-T2. The T1-3 processes appear fused.\nThere is marked irregularity of the inferior endplate of T3 and\nsuperior endplate of T4 with impaction of these vertebral bodies\nonto each other and acute kyphotic angulation at this level.\nThese findings are likely chronic. There is no prevertebral\nsoft tissue swelling. The lung apices are clear.\nIMPRESSION: No acute cervical spine fracture. Extensive\ndegenerative changes as described above.\n.\nHead CT: FINDINGS: There is hyperdensity along the left frontal\nvertex that is likely secondary to volume averaging.', ' There is\nno evidence of intracranial hemorrhage, mass effect,\nhydrocephalus, shift of normally midline structures or major\nvascular territorial infarction. Hypodensity in the\nperiventricular cerebral white matter is consistent with chronic\nmicrovascular ischemia. Small prior infarcts are identified in\nthe right internal capsule basal ganglia and left external\ncapsule. Surrounding osseous and soft tissue structures are\nunremarkable.\nIMPRESSION: No acute intracranial hemorrhage or mass effect.\n.\nBilateral Hip films: Degenerative changes with no definite\nfracture.\n.\nCTA: Impression:\n1. no PE\n2. enlarged pulmonary arteries\n3. lymphadenopathy in mediastinum some of which are calcified\n4. calcified hilar lymph nodes\n5. pulm lymph nodes along major and minor fissures bilaterally\n6. fat density structures in liver and stomach\n.', '\nEKG: afib/atach with no ST-T changes. new TWI in III.\n.\nTTE 1946-5-22\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by\n2D or color\nDoppler. Left ventricular wall thickness, cavity size, and\nsystolic function\nare normal (LVEF>55%). Regional left ventricular wall motion\nappears normal.\nThe aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not\npresent. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are\nmildly thickened. Trivial mitral regurgitation is seen. The\nestimated\npulmonary artery systolic pressure is normal. There is no\npericardial\neffusion.\n.\nLABS (on admission):\n.\n1980-10-29 05:14PM LACTATE-3.0* K+-4.0\n1980-10-29 05:00PM GLUCOSE-135* UREA N-31* CREAT-1.5* SODIUM-144\nPOTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-29 ANION GAP-17\n1980-10-29 05:00PM ALT(SGPT)-16 AST(SGOT)-22 CK(CPK)-106 ALK\nPHOS-115 AMYLASE-69 TOT BILI-0.', '3\n1980-10-29 05:00PM LIPASE-55\n1980-10-29 05:00PM CK-MB-5 cTropnT-1980-10-29 05:00PM WBC-9.6# RBC-4.33 HGB-12.6 HCT-37.6 MCV-87\nMCH-29.2 MCHC-33.6 RDW-15.2\n1980-10-29 05:00PM NEUTS-83.3* LYMPHS-13.6* MONOS-1.7* EOS-1.2\nBASOS-0.3\n1980-10-29 05:00PM PLT COUNT-209\n1980-10-29 05:00PM PT-11.2 PTT-26.5 INR(PT)-0.9\n.\nMICRO:\n.\n1940-6-8 2:39 pm URINE\n\n FINAL REPORT 1943-10-6\n\n URINE CULTURE (Final 1943-10-6):\n ESCHERICHIA COLI. >100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..\n\n SENSITIVITIES: MIC expressed in\nMCG/ML\n\n_________________________________________________________\n ESCHERICHIA COLI\n \| ENTEROCOCCUS SP.', '\n \| \|\nAMPICILLIN------------ 2016-7-5 12:44 pm BLOOD CULTURE CENTRAL.\n\n AEROBIC BOTTLE (Pending):\n\n ANAEROBIC BOTTLE (Pending):\n.\n2016-7-5 2:55 pm URINE\n\n URINE CULTURE (Pending):\n.\n2016-7-5 1:17 pm CATHETER TIP-IV Source: L SC.\n\n WOUND CULTURE (Pending):\n\n\nBrief Hospital Course:\nSummary:\nBriefly, this is a 81 year old Russian speaking woman who\npresented status post fall. No intracranial bleed. No hip\nfracture. + R humerus fracture. CT of c-spine showed severe\nstenosis. She was initially admitted to the medicine service for\nworkup of syncope; neurology was consulted for a weak right arm\nfollowing R humeral fracture and she was found to have a mixed\ncentral cord and Brown-Sequard syndrome and transferred to the\nneurology service for closer exam monitoring.', " She underwent R\nhumerus ORIF and C2-C6 laminectomy and fusion on 2016-7-10. A med\nconsult was obtained on 2006-6-31 for persistent hypoxia. She was\ngently diuresed, and had serial ABG's which showed persistent\nhypercarbia. During the admission, she was also treated with\nCipro for a UTI.\n.\nNeuro: The patient could not recall the events surrounding the\nfall and sustained a spiral fracture to the right proximal\nhumerus, displaced, and had bilateral arm weakness and numbness\ndistally in all 4 extremities. On exam she initially was found\nto have evidence of a central cord syndrome with weakness\naffecting arms more so than legs. She also had evidence of a\nbrown sequard given that weakness and proprioception are down on\nthe right with an upgoing toe, and pin sensation is down on the\nleft, sensory level of C4/T3 anteriorly on the left (where the\ntwo dermatomes meet at the top of the breast).", ' She was\ncomplaining of neck pain, and had had trouble voiding so a foley\nwas placed.\n.\nMRI of the C-spine was performed for the likelihood of acute\nspinal cord injury with above findings. Read of MRI was: "Bulky\nossification of the posterior longitudinal ligament at C2/3,\nC3/4, and C4/5 levels, more than the right, causing severe\nspinal canal stenosis.The cervical cord at those levels is\ndeformed and compressed, demonstrating intrinsic T2 hyperintense\nsignal. There is also a fracture at the inferior endplate of C3\nanteriorly." She was placed in a hard cervical collar and pain\nwas controlled with morphine and ibuprofen initially. She was\nseen by both neurosurgery and orthopedics for the injury as both\nservices had been alternately covering the spine service in the\nhospital. Orthopedics also followed her for the broken right\nhumerus, and neurosurgery had initially been consulted in the ED\nwhen a head ct showed the question of a subdural hematoma (later\nproven to be artifactual).', '\n.\nBoth 1934-10-19 to 1968-7-14 and neurosurgery agreed that it was safest for the\npatient to hold off on the spine surgery for at least a week to\nallow cord swelling to heal before operating. She remained in a\nhard collar during this time and her exam improved over the next\nweek; the pinprick sensory level retracted to the T12 region for\ndays, then finally seemed to vanish altogether; the\nproprioceptive changes on the right also resolved. Although the\nright arm remained weak and flaccid with just 7-22 finger flexors\nand trapezius/shoulder shrug 7-22 (initially thought just limited\nby pain versus multiple nerve injury), the left arm strength\nimproved to deltoid 10-14, Porter-Mcmahon Hospital/tri both 4+ to 5-/5, and wrist and\nfinger extensors 4+/5; finger flexors were also 4+/5. On 9-28: there were no changes in exam.', " For neuropathic pain,\nneurontin had been initiated (patient later requested d/c to\nsimplify med regimen).\n.\nThe weekend of 3-2 on morning rounds, a mild right Horner's\nsyndrome was noted which had not been picked up before on daily\nrounds. This, along with the flaccid arm, was suggestive of\nroot avulsion on the right (and associated plexopathy).\nHer neurologic symptoms all gradually resolved during\nhospitalization.\n.\n1962-7-27 to 1963-11-16:\nPt underwent R humerus ORIF and cervical laminectomy (report\nbelow), however pt post-op, the medicine service was consulted\nfor hypoxia (pt required 50% shovel mask) and hypercarbia (pCO2\nin high 50's). She has a follow up appointment on 9-19 with\nJuly to evaluate her fracture and decide whether her C-collar\ncan be removed.\n.\nHypoxia/hypercarbia:\nPt had hx of severe pulm HTM, likely 1-26 PDA.", " ABG showed mild\nCO2 retention, ? if this was close to her baseline. Also likely\nhad component of fluid overload, given recent surgery. Pt was\ngently diuresed with IV Lasix. Narcotics were d/c'd as pt\nappeared somnolent. O2 was successfully weaned down to 2L NC (pt\napparently had been on 2L O2 at home). CTA on admission was\nnegative for PE, and the suspicion for PE was fairly low post-op\ngiven that the pt was not tachycardic and her oxygen requirement\nimproved. Therefore, repeat CTA was not done. She was also\nnoted to be hypercarbic during admission, but her respiratory\nstatus remained stable while on the medicine service.\n.\nStatus post fall: The original fall was of unclear etiology. The\ndifferential included vasovagal syncope versus new onset\nafib/atach versus mechanical given loss of consciousness.", " Less\nlikely include myocardial infarction/ischemia versus pulmonary\nembolism versus seizure. Also less likely hypoglycemia given\ntiming after meal although patinet on glyburide which is renally\ncleared in setting of increased creatinine. The patient ruled\nout for MI by cardiac enzymes, echo showed no obvious severe\nvalvular disease to explain ?syncopal event, though telemetry\nshowed periodic tachyarrhythmia ?sinus tach vs afib. She had no\nother significant tele events while in the hospital.\n.\nElevated WBC and lactate at admission: unclear etiology,\nafebrile with negative UA and infectious workup at admission.\nThis cleared on its own. Later in hospitalization (3-2) she had\na UTI treated with course of ciprofloxacin. Urine cxlood cx, and\ncath tip cx were sent prior to d/c to workup somnolence, however\npt's somnolence cleared and cx's were pending on d/c.", ' These\nshould be followed at her follow up appointments.\n.\nMusculoskeletal: initially, radiographic imaging was negative\nfor fracture or bleed including right UE, hips bilaterally,\nc-spine and head. Patient with known chronic low back pain and\nsciatica.\n.\nHypertension/pulmonary hypertension: continued ASA, held\nvalsartan. lasix initially held for renal failure but was\nrestarted once she was clinically stable.\n.\nHypercholesterolemia: continued home dose of lipitor\n.\nRenal: She has slight renal insufficiency at admission and was\ngiven gentle IVF. Her electrolytes were followed and repleted as\nneeded, MVI and continued niferex. ARF improved. She should\nhave her potassium and BUN/creatinine followed at regular\nintervals starting 2-3 days post discharge, as she was\ndischarged on her home dose of Deng and new dose of lasix.', '\n\nProphylaxis: The patient was maintained on TEDS, SQ heparin,\nPPI, bowel regimen. She complained of RLE pain one day, and u/s\nwas ordered to r/o dvt - this study was negative.\n.\nCommunication: son 876-848-6335 Luu\n.\n\nOPERATIVE REPORT\n\nCeja,Sandhya T.\nSigned Electronically by Caleb 2006-6-31 1:18 PM\n\nName: Whitehead, Sammie Unit No: 0693049\n\nService: NME Date: 2016-7-10\n\n\nSurgeon: Harold Edward, M.D. 47779070\n\nPROCEDURE: IM nail right humerus.\n\nASSISTANT: Olles.\n\nINDICATIONS FOR PROCEDURE: Ms. Olles is an 81-year-old\nwoman who sustained a fall and has a displaced right proximal\nhumerus fracture. She also has a spine injury and this has\nbeen operated on by Dr. Rosalinda Lofft. Given the displacement of\nher fracture and that she is having pain and not tolerating\nnonoperative treatment, we decided to proceed with\nintramedullary nailing.', '\n\nDESCRIPTION OF PROCEDURE: After informed consent was\nobtained and Dr. Caro had completed his spinal portion\nof the case, the patient was placed in the supine position.\nThe right arm was prepped and draped in normal sterile\nfashion.\n\nA 3 cm incision was made over the proximal humerus and the\ndeltoid was split. Eentry point was established in the\nproximal humerus and the guide wire placed. The fracture was\nheld reduced and the guide wire passed into the distal\nhumerus. The proximal part of the humerus was reamed and\nthen the canal was reamed up to a size 10 mm. Next a 230 by\n10 mm Dr.Deng and Nephew nail was placed and interlocked with 2\nscrews proximally. The distal locking screw was placed under\nimage intensification. Wounds were irrigated and closed with\n0 Vicryl, 2-0 and a subcuticular 3-0.', ' Postoperatively, she\nwas brought back to the recovery room in stable condition.\n\nCOMPLICATIONS: None.\n\nAs the attending surgeon I was present for and performed the\nentire procedure.\n\n Harold Edward, M.D. 14552559\n\n\nMedications on Admission:\n1. aspirin 81mg QD\n2. glyburide 5mg QD\n3. lasix 40mg QD\n4. lipitor 20mg QD\n5. niferex 150mg Porter-Mcmahon Hospital\n6. paroxetine 20mg QD\n7. losartan potassium 100mg QD (?)\n\n\nDischarge Medications:\n1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).\n2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a\nday) as needed for constipation.', '\n6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2\ntimes a day).\n7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\nML PO Q6H (every 6 hours) as needed.\n8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb\nInhalation Q4H (every 4 hours) as needed.\n9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours) as needed for SOB, .\n10. Sodium Chloride 0.65 % Aerosol, Spray Sig: 9-15 Sprays Nasal\nQID (4 times a day) as needed.\n11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\n12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)\ninjection SC Injection TID (3 times a day).\n14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H\n(every 6 hours).', '\n15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)\nTablet, Chewable PO TID (3 times a day).\n16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)\nTablet PO DAILY (Daily).\n17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for\nconstipation.\n18. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3\ntimes a day) as needed for constipation.\n19. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.\n21. Outpatient Lab Work\nplease check chem 7 in 6-5 days. Adjust Lasix and losartan if\nneeded.\n22. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)\nunit Subcutaneous four times a day: Regular insulin sliding\nscale to keep blood sugar 80-140.', ' Give 2 units insulin for each\n40 glucose units above 120 up to 400, Leslee Lockett MD if over 400. .\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nNguyen-Cook Health System - Bowen, Berger and Edwards Medical Center\n\nDischarge Diagnosis:\nPrimary diagnoses:\nR humeral fracture\nC-spine stenosis\nBrown sequard syndrome\nUrinary tract infection\ns/p fall\n\nSecondary diagnoses:\nType 2 diabetes\nHypertension\nPulm hypertension\nright sided heart failure\n\n\nDischarge Condition:\nStable. Afebrile. Oriented to person, place. Primarily russian\nspeaking.\n\nDischarge Instructions:\nPlease keep your cervical collar on until your Porter-Mcmahon Hospital follow-up\nappointment on 9-19.\n\nPlease seek medical attention immediately if you experience\nfevers, chills, chest pain, shortness of breath, nausea,\nvomiting, diarrhea, or dizziness.', '\n\nPlease take all medications as prescribed. Your paxil is being\nheld, but may be restarted in the future. Your glyburide is\nbeing held, but may be restarted in the future once your are\neating more consistently. You were started on a lower dose of\nlasix, however this can be increased in the future as needed.\nYou will need to have your electrolytes checked in the next 9-15\ndays, and your lasix and losartan could be adjusted based on\nthose results.\n\nPlease attend all follow-up appointments.\n\nPlease see a dermatologist regarding the lesion on your left\nknee. The phone numuber for dermatology clinic is 679-916-3767.\n\nFollowup Instructions:\nPlease see a dermatologist regarding the lesion on your left\nknee. The phone numuber for dermatology clinic is 679-916-3767.\n\nProvider: Patrick Chau XRAY (SCC 2) Phone:724-505-6276\nDate/Time:1998-2-31 8:00.', ' Please ensure patient has BLS ambulance\nbooked for this appointment.\n\nProvider: Rosalinda Taylor, MD Phone:724-505-6276\nDate/Time:1998-2-31 8:20. Please provide transportation to this\nappointment for this patient.\n\nProvider: Londrie. Ahmed Phone:724-505-6276 Date/Time:1998-2-31\n10:20. Please provide transportation for the patient to this\nappointment.\n\nProvider: Harold Benhamou, Orville Cobbs Date/Time:2003-9-24 9:00\n\n\n']
196	22180	186367.0	2134-08-20	Discharge summary	Report	Admission Date: [2134-8-12] Discharge Date: [2134-8-20] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1974] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation History of Present Illness: 82yo Russian speaking F with a PMH of type II DM, HTN, hyperlipidemia, obesity, pulmonary HTN and anemia, who presented to the ED this AM with worsening SOB x 2 weeks. Per the ED resident, the patient noted that she had had worsening SOB x 2 weeks (documented as 2 days [Name8 (MD) ] RN note) and also complained of orthopnea and increasing lower extremity swelling and weeping from a venous stasis ulcer on her L shin. The patient was able to communicate this verbally to ER resident (RN notes she was only able to speak in 4 word sentences). Her VNA stated that she was only 94% on 2L O2 at home and had rales [12-28] way up bilaterally. On initial assessment in the [Hospital1 18] ER, her vital signs were T 98.2, BP 167/60, HR 61, RR 23, sats 100% on RA. On next assessment (2 hrs later), pt was felt to be very SOB while attempting to use the bed pan. RN noted her to be dusky, diaphoretic. HR 72, RR 28, sats 90% on RA. She was placed on a NRB with improvement in her O2 sats to 98%. BP rose to 210/74, then 215/93. CXR was taken and read as c/w pneumonia. Blood cx were obtained and ceftriaxone was administtered. 90 mins later, she was felt to be diaphoretic again, with increased work of breathing. Her O2 sats dropped to 90% by NRB and she was prepped for intubation. She was given 2mg versed and was intubated. SBP 210 -> 178 -> 130. She was taken to CT scan for CTA. On return from CT scan, she was felt to be bucking the vent. She was given fentanyl 100mcg, with resultant drop in her SBP to 77. She was then bolused 1L of NS with improvement in her SBP to 96. She was also given vecuronium 10mg IV and ativan 1mg IV because of inability to ventilate and biting at the tube. . On review, she was given: 1gm CTX IV x1, ? azithromcyin 500mg IV x1, lasix 20mg x1, 120mg succinylcholine IV, etomidate 20mg IV, 12.5mg versed IV, and fentanyl 100mcg x1. She was also given 1 dose of mucomyst prior to her CT scan. Past Medical History: # Type II DM - last HgbA1C was 5.9% on [2134-7-30] - not currently on any oral antihyperglycemics due to hypoglycemia # HTN - per OMR note [2134-8-6], was 170/80 at home # Hyperlipidemia - in [2-28], total chol 179, HDL 86, LDL 70, TG 114 # Low back pain # Obesity - BMI 40.8 in [11-30] # h/o heart murmur - ? PDA # Anemia - Fe 38, TIBC 282, fer 86, TRF 217, B12 594, fol 18.5 on [2134-7-30] - SPEP low total protein/UPEP + only for albumin in [2-1] # Pulmonary HTN - h/o R sided heart failure - main pulmonary artery >4cm per ECHO [7-/2128] # Urinary incontinence # Syncope - neg w/u in [3-1] - sustained a fall -> s/p humerus fx + ORIF, cervical laminectomy Social History: Patient lives alone. She does not have any stairs at home and is not able to do stairs and does find that the symptoms are somewhat worse with prolonged sitting. Patient wears a back support corset(belt), compression stocking and uses a walker. Family History: NC Physical Exam: VS - T 98.2, BP 145/91, HR 60s, RR 16, sats 100% AC 10 x 450, PEEP 5, FiO2 100% Gen: Sedated, intubated. HEENT: NCAT. PERRL (5mm ->4mm). Sclera anicteric. MM moist. No cervical LAD, no axillary LAD. Neck: JVP not appreciated. CV: RR. IV/VI holosystolic murmur heard throughout the precordium. ? S2 click. Resp: Crackles [12-29] way up bilaterally, no wheezes or rhonchi. Abd: Soft, NTND. + BS. No HSM. Ext: 2+ pitting edema up to her knees bilaterally. Ext cool. No rashes. No clubbing or cyanosis. L shin has evidence of trauma, mild skin tear w/ weeping. Bandage c/d/i. Neuro: Sedated. Moves all 4 extremities to pain. Pertinent Results: CTA [8-12] 1. No pulmonary embolism. 2. Stable enlargement of the pulmonary arteries indicates chronic pulmonary hypertension. 3. Small bilateral pleural effusions and diffuse ground-glass opacity indicate congestive failure. 4. Multifocal pneumonia. 5. Interval progression of right apical pleural thickening. 6. No change in calcified nodules along the right major fissure. . . EKG ([8-13]): SR at 63. [Last Name (un) ]. Incomplete RBBB. No obvious ischemic changes. [2134-8-12] 05:40PM WBC-7.3 RBC-3.35* HGB-9.9* HCT-30.4* MCV-91 MCH-29.5 MCHC-32.4 RDW-16.5* [2134-8-12] 05:40PM NEUTS-80.2* LYMPHS-12.7* MONOS-5.0 EOS-2.0 BASOS-0.1 [2134-8-12] 05:40PM PLT COUNT-217 [2134-8-12] 05:40PM PT-13.1 PTT-28.5 INR(PT)-1.1 [2134-8-12] 05:40PM GLUCOSE-266* UREA N-28* CREAT-1.3* SODIUM-141 POTASSIUM-6.5* CHLORIDE-100 TOTAL CO2-35* ANION GAP-13 [2134-8-12] 05:40PM proBNP-5956* [2134-8-12] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2134-8-12] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2134-8-12] 08:00PM URINE RBC-0-2 WBC-[11-15]* BACTERIA-FEW YEAST-RARE EPI-0-2 Brief Hospital Course: 1) RESPIRATORY FAILURE: Most likely explanation is acute diastolic CHF ("flash" pulmonary edema) given acute onset and associated HTN. No evidence of structural heart disease on echo. ? findings of PNA, and unclear what to make of other findings on CTA--lymphoma vs TB. Pt does have an elevated LDH, but it was felt these were unlikely possibilities. Pt was treated for CHF with diuresis and improved. She was extubated and respiratory status continued to improve fitting with CHF as the etiology. She should have a repeat CT to evaluate the lymphadenopathy. She was also empirically treated with pneumonia with azithro but she was afebrile with nml WBC. She was continued on losartan, beta blockade. . 2) CV: As above. Continued on aspirin. No evidence of acute ischemia. . 3) ANEMIA, iron deficiency: Baseline Hct 28-30, at baseline on discharge. On niferex as an outpatient. Iron studies checked at last visit--Fe/TIBC ~15%. Continued on iron for iron deficieny. . 4) HTN: Contine Metoprolol, [Last Name (un) ] . 5) HYPERLIPIDEMIA: Continue home dose of lipitor. . 6) DM TYPE II: Placed on sliding scale insulin. BG relatively well controlled. . . CODE: Full . COMM: son, [Name (NI) 1975] [Name (NI) ] [Telephone/Fax (1) 1976]. Updated [8-13] Medications on Admission: ASPIRIN 81MG PO QD COLACE 100mg PO BID ERGOCALCIFEROL [Numeric Identifier 1871] UNIT PO Q WEEK GABAPENTIN 100mg PO QHS GLUCOPHAGE 850MG 1 tab PO TID recently d/c GLYBURIDE 5MG PO BID recently d/c LASIX 60mg PO QD LIPITOR 20MG PO QD LOSARTAN POTASSIUM 100MG PO QD METOPROLOL TARTRATE 25 mg PO BID NIFEREX-150 150MG PO BID OMEPRAZOLE 20 mg PO QD PAROXETINE 20MG PO QD SENNA 8.6mg PO BID Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One [Age over 90 1230]y (150) mg PO BID (2 times a day). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) unit Injection TID (3 times a day): until pt ambulating. 10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO at bedtime. 11. Niferex-150 150-50 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 1970] - [Hospital1 1559] Discharge Diagnosis: Congestive heart failure Community acquired pneumonia Type 2 diabetes mellitus Pulmonary hypertension Discharge Condition: Good. Discharge Instructions: Please take medications as prescribed. Followup Instructions: You will be seen by the doctor at rehab. Once you leave there, please follow up with Dr. [Last Name (STitle) ] -- call [Telephone/Fax (1) 250].	Admission Date: <Date>1928-2-3</Date> Discharge Date: <Date>1985-10-3</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Luisa</Name> Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation History of Present Illness: 82yo Russian speaking F with a PMH of type II DM, HTN, hyperlipidemia, obesity, pulmonary HTN and anemia, who presented to the ED this AM with worsening SOB x 2 weeks. Per the ED resident, the patient noted that she had had worsening SOB x 2 weeks (documented as 2 days <Name>Babette Luu</Name> RN note) and also complained of orthopnea and increasing lower extremity swelling and weeping from a venous stasis ulcer on her L shin. The patient was able to communicate this verbally to ER resident (RN notes she was only able to speak in 4 word sentences). Her VNA stated that she was only 94% on 2L O2 at home and had rales <Date>1-29</Date> way up bilaterally. On initial assessment in the <Hospital>Lopez PLC Hospital</Hospital> ER, her vital signs were T 98.2, BP 167/60, HR 61, RR 23, sats 100% on RA. On next assessment (2 hrs later), pt was felt to be very SOB while attempting to use the bed pan. RN noted her to be dusky, diaphoretic. HR 72, RR 28, sats 90% on RA. She was placed on a NRB with improvement in her O2 sats to 98%. BP rose to 210/74, then 215/93. CXR was taken and read as c/w pneumonia. Blood cx were obtained and ceftriaxone was administtered. 90 mins later, she was felt to be diaphoretic again, with increased work of breathing. Her O2 sats dropped to 90% by NRB and she was prepped for intubation. She was given 2mg versed and was intubated. SBP 210 -> 178 -> 130. She was taken to CT scan for CTA. On return from CT scan, she was felt to be bucking the vent. She was given fentanyl 100mcg, with resultant drop in her SBP to 77. She was then bolused 1L of NS with improvement in her SBP to 96. She was also given vecuronium 10mg IV and ativan 1mg IV because of inability to ventilate and biting at the tube. . On review, she was given: 1gm CTX IV x1, ? azithromcyin 500mg IV x1, lasix 20mg x1, 120mg succinylcholine IV, etomidate 20mg IV, 12.5mg versed IV, and fentanyl 100mcg x1. She was also given 1 dose of mucomyst prior to her CT scan. Past Medical History: # Type II DM - last HgbA1C was 5.9% on <Date>1937-8-1</Date> - not currently on any oral antihyperglycemics due to hypoglycemia # HTN - per OMR note <Date>1917-2-12</Date>, was 170/80 at home # Hyperlipidemia - in <Date>3-9</Date>, total chol 179, HDL 86, LDL 70, TG 114 # Low back pain # Obesity - BMI 40.8 in <Date>9-31</Date> # h/o heart murmur - ? PDA # Anemia - Fe 38, TIBC 282, fer 86, TRF 217, B12 594, fol 18.5 on <Date>1937-8-1</Date> - SPEP low total protein/UPEP + only for albumin in <Date>10-21</Date> # Pulmonary HTN - h/o R sided heart failure - main pulmonary artery >4cm per ECHO <Date>8-1965</Date> # Urinary incontinence # Syncope - neg w/u in <Date>10-31</Date> - sustained a fall -> s/p humerus fx + ORIF, cervical laminectomy Social History: Patient lives alone. She does not have any stairs at home and is not able to do stairs and does find that the symptoms are somewhat worse with prolonged sitting. Patient wears a back support corset(belt), compression stocking and uses a walker. Family History: NC Physical Exam: VS - T 98.2, BP 145/91, HR 60s, RR 16, sats 100% AC 10 x 450, PEEP 5, FiO2 100% Gen: Sedated, intubated. HEENT: NCAT. PERRL (5mm ->4mm). Sclera anicteric. MM moist. No cervical LAD, no axillary LAD. Neck: JVP not appreciated. CV: RR. IV/VI holosystolic murmur heard throughout the precordium. ? S2 click. Resp: Crackles <Date>10-10</Date> way up bilaterally, no wheezes or rhonchi. Abd: Soft, NTND. + BS. No HSM. Ext: 2+ pitting edema up to her knees bilaterally. Ext cool. No rashes. No clubbing or cyanosis. L shin has evidence of trauma, mild skin tear w/ weeping. Bandage c/d/i. Neuro: Sedated. Moves all 4 extremities to pain. Pertinent Results: CTA <Date>10-13</Date> 1. No pulmonary embolism. 2. Stable enlargement of the pulmonary arteries indicates chronic pulmonary hypertension. 3. Small bilateral pleural effusions and diffuse ground-glass opacity indicate congestive failure. 4. Multifocal pneumonia. 5. Interval progression of right apical pleural thickening. 6. No change in calcified nodules along the right major fissure. . . EKG (<Date>1-25</Date>): SR at 63. <Name>Scheet</Name>. Incomplete RBBB. No obvious ischemic changes. <Date>1928-2-3</Date> 05:40PM WBC-7.3 RBC-3.35* HGB-9.9* HCT-30.4* MCV-91 MCH-29.5 MCHC-32.4 RDW-16.5* <Date>1928-2-3</Date> 05:40PM NEUTS-80.2* LYMPHS-12.7* MONOS-5.0 EOS-2.0 BASOS-0.1 <Date>1928-2-3</Date> 05:40PM PLT COUNT-217 <Date>1928-2-3</Date> 05:40PM PT-13.1 PTT-28.5 INR(PT)-1.1 <Date>1928-2-3</Date> 05:40PM GLUCOSE-266* UREA N-28* CREAT-1.3* SODIUM-141 POTASSIUM-6.5* CHLORIDE-100 TOTAL CO2-35* ANION GAP-13 <Date>1928-2-3</Date> 05:40PM proBNP-5956* <Date>1928-2-3</Date> 08:00PM URINE COLOR-Yellow APPEAR-Clear SP <Name>William</Name>-1.013 <Date>1928-2-3</Date> 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR <Date>1928-2-3</Date> 08:00PM URINE RBC-0-2 WBC-<Date>4-26</Date>* BACTERIA-FEW YEAST-RARE EPI-0-2 Brief Hospital Course: 1) RESPIRATORY FAILURE: Most likely explanation is acute diastolic CHF ("flash" pulmonary edema) given acute onset and associated HTN. No evidence of structural heart disease on echo. ? findings of PNA, and unclear what to make of other findings on CTA--lymphoma vs TB. Pt does have an elevated LDH, but it was felt these were unlikely possibilities. Pt was treated for CHF with diuresis and improved. She was extubated and respiratory status continued to improve fitting with CHF as the etiology. She should have a repeat CT to evaluate the lymphadenopathy. She was also empirically treated with pneumonia with azithro but she was afebrile with nml WBC. She was continued on losartan, beta blockade. . 2) CV: As above. Continued on aspirin. No evidence of acute ischemia. . 3) ANEMIA, iron deficiency: Baseline Hct 28-30, at baseline on discharge. On niferex as an outpatient. Iron studies checked at last visit--Fe/TIBC ~15%. Continued on iron for iron deficieny. . 4) HTN: Contine Metoprolol, <Name>Scheet</Name> . 5) HYPERLIPIDEMIA: Continue home dose of lipitor. . 6) DM TYPE II: Placed on sliding scale insulin. BG relatively well controlled. . . CODE: Full . COMM: son, <Name>Joyce Pettway</Name> <Name>Henry Ngo</Name> <Telephone>480-752-5035</Telephone>. Updated <Date>1-25</Date> Medications on Admission: ASPIRIN 81MG PO QD COLACE 100mg PO BID ERGOCALCIFEROL <Numeric Identifier>1833024</Numeric Identifier> UNIT PO Q WEEK GABAPENTIN 100mg PO QHS GLUCOPHAGE 850MG 1 tab PO TID recently d/c GLYBURIDE 5MG PO BID recently d/c LASIX 60mg PO QD LIPITOR 20MG PO QD LOSARTAN POTASSIUM 100MG PO QD METOPROLOL TARTRATE 25 mg PO BID NIFEREX-150 150MG PO BID OMEPRAZOLE 20 mg PO QD PAROXETINE 20MG PO QD SENNA 8.6mg PO BID Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One <Age>87</Age>y (150) mg PO BID (2 times a day). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) unit Injection TID (3 times a day): until pt ambulating. 10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO at bedtime. 11. Niferex-150 150-50 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: <Hospital>Brown and Sons Health System</Hospital> - <Hospital>Powell, Lyons and Beck Clinic</Hospital> Discharge Diagnosis: Congestive heart failure Community acquired pneumonia Type 2 diabetes mellitus Pulmonary hypertension Discharge Condition: Good. Discharge Instructions: Please take medications as prescribed. Followup Instructions: You will be seen by the doctor at rehab. Once you leave there, please follow up with Dr. <Name>Brown</Name> -- call <Telephone>982-360-9615</Telephone>.	000000000000000001111111100000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>000000>00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000>00000000000001111110000000000000000000000000000000000000000000000011111000000000000000000000>0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000001111110000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000001111111100000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000111111110000000000000000000000000000000000000000000001111111000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1928-2-3 Discharge Date: 1985-10-3 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Luisa Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation History of Present Illness: 82yo Russian speaking F with a PMH of type II DM, HTN, hyperlipidemia, obesity, pulmonary HTN and anemia, who presented to the ED this AM with worsening SOB x 2 weeks. Per the ED resident, the patient noted that she had had worsening SOB x 2 weeks (documented as 2 days Babette Luu RN note) and also complained of orthopnea and increasing lower extremity swelling and weeping from a venous stasis ulcer on her L shin. The patient was able to communicate this verbally to ER resident (RN notes she was only able to speak in 4 word sentences). Her VNA stated that she was only 94% on 2L O2 at home and had rales 1-29 way up bilaterally. On initial assessment in the Lopez PLC Hospital ER, her vital signs were T 98.2, BP 167/60, HR 61, RR 23, sats 100% on RA. On next assessment (2 hrs later), pt was felt to be very SOB while attempting to use the bed pan. RN noted her to be dusky, diaphoretic. HR 72, RR 28, sats 90% on RA. She was placed on a NRB with improvement in her O2 sats to 98%. BP rose to 210/74, then 215/93. CXR was taken and read as c/w pneumonia. Blood cx were obtained and ceftriaxone was administtered. 90 mins later, she was felt to be diaphoretic again, with increased work of breathing. Her O2 sats dropped to 90% by NRB and she was prepped for intubation. She was given 2mg versed and was intubated. SBP 210 -> 178 -> 130. She was taken to CT scan for CTA. On return from CT scan, she was felt to be bucking the vent. She was given fentanyl 100mcg, with resultant drop in her SBP to 77. She was then bolused 1L of NS with improvement in her SBP to 96. She was also given vecuronium 10mg IV and ativan 1mg IV because of inability to ventilate and biting at the tube. . On review, she was given: 1gm CTX IV x1, ? azithromcyin 500mg IV x1, lasix 20mg x1, 120mg succinylcholine IV, etomidate 20mg IV, 12.5mg versed IV, and fentanyl 100mcg x1. She was also given 1 dose of mucomyst prior to her CT scan. Past Medical History: # Type II DM - last HgbA1C was 5.9% on 1937-8-1 - not currently on any oral antihyperglycemics due to hypoglycemia # HTN - per OMR note 1917-2-12, was 170/80 at home # Hyperlipidemia - in 3-9, total chol 179, HDL 86, LDL 70, TG 114 # Low back pain # Obesity - BMI 40.8 in 9-31 # h/o heart murmur - ? PDA # Anemia - Fe 38, TIBC 282, fer 86, TRF 217, B12 594, fol 18.5 on 1937-8-1 - SPEP low total protein/UPEP + only for albumin in 10-21 # Pulmonary HTN - h/o R sided heart failure - main pulmonary artery >4cm per ECHO 8-1965 # Urinary incontinence # Syncope - neg w/u in 10-31 - sustained a fall -> s/p humerus fx + ORIF, cervical laminectomy Social History: Patient lives alone. She does not have any stairs at home and is not able to do stairs and does find that the symptoms are somewhat worse with prolonged sitting. Patient wears a back support corset(belt), compression stocking and uses a walker. Family History: NC Physical Exam: VS - T 98.2, BP 145/91, HR 60s, RR 16, sats 100% AC 10 x 450, PEEP 5, FiO2 100% Gen: Sedated, intubated. HEENT: NCAT. PERRL (5mm ->4mm). Sclera anicteric. MM moist. No cervical LAD, no axillary LAD. Neck: JVP not appreciated. CV: RR. IV/VI holosystolic murmur heard throughout the precordium. ? S2 click. Resp: Crackles 10-10 way up bilaterally, no wheezes or rhonchi. Abd: Soft, NTND. + BS. No HSM. Ext: 2+ pitting edema up to her knees bilaterally. Ext cool. No rashes. No clubbing or cyanosis. L shin has evidence of trauma, mild skin tear w/ weeping. Bandage c/d/i. Neuro: Sedated. Moves all 4 extremities to pain. Pertinent Results: CTA 10-13 1. No pulmonary embolism. 2. Stable enlargement of the pulmonary arteries indicates chronic pulmonary hypertension. 3. Small bilateral pleural effusions and diffuse ground-glass opacity indicate congestive failure. 4. Multifocal pneumonia. 5. Interval progression of right apical pleural thickening. 6. No change in calcified nodules along the right major fissure. . . EKG (1-25): SR at 63. Scheet. Incomplete RBBB. No obvious ischemic changes. 1928-2-3 05:40PM WBC-7.3 RBC-3.35* HGB-9.9* HCT-30.4* MCV-91 MCH-29.5 MCHC-32.4 RDW-16.5* 1928-2-3 05:40PM NEUTS-80.2* LYMPHS-12.7* MONOS-5.0 EOS-2.0 BASOS-0.1 1928-2-3 05:40PM PLT COUNT-217 1928-2-3 05:40PM PT-13.1 PTT-28.5 INR(PT)-1.1 1928-2-3 05:40PM GLUCOSE-266* UREA N-28* CREAT-1.3* SODIUM-141 POTASSIUM-6.5* CHLORIDE-100 TOTAL CO2-35* ANION GAP-13 1928-2-3 05:40PM proBNP-5956* 1928-2-3 08:00PM URINE COLOR-Yellow APPEAR-Clear SP William-1.013 1928-2-3 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR 1928-2-3 08:00PM URINE RBC-0-2 WBC-4-26* BACTERIA-FEW YEAST-RARE EPI-0-2 Brief Hospital Course: 1) RESPIRATORY FAILURE: Most likely explanation is acute diastolic CHF ("flash" pulmonary edema) given acute onset and associated HTN. No evidence of structural heart disease on echo. ? findings of PNA, and unclear what to make of other findings on CTA--lymphoma vs TB. Pt does have an elevated LDH, but it was felt these were unlikely possibilities. Pt was treated for CHF with diuresis and improved. She was extubated and respiratory status continued to improve fitting with CHF as the etiology. She should have a repeat CT to evaluate the lymphadenopathy. She was also empirically treated with pneumonia with azithro but she was afebrile with nml WBC. She was continued on losartan, beta blockade. . 2) CV: As above. Continued on aspirin. No evidence of acute ischemia. . 3) ANEMIA, iron deficiency: Baseline Hct 28-30, at baseline on discharge. On niferex as an outpatient. Iron studies checked at last visit--Fe/TIBC ~15%. Continued on iron for iron deficieny. . 4) HTN: Contine Metoprolol, Scheet . 5) HYPERLIPIDEMIA: Continue home dose of lipitor. . 6) DM TYPE II: Placed on sliding scale insulin. BG relatively well controlled. . . CODE: Full . COMM: son, Joyce Pettway Henry Ngo 480-752-5035. Updated 1-25 Medications on Admission: ASPIRIN 81MG PO QD COLACE 100mg PO BID ERGOCALCIFEROL 1833024 UNIT PO Q WEEK GABAPENTIN 100mg PO QHS GLUCOPHAGE 850MG 1 tab PO TID recently d/c GLYBURIDE 5MG PO BID recently d/c LASIX 60mg PO QD LIPITOR 20MG PO QD LOSARTAN POTASSIUM 100MG PO QD METOPROLOL TARTRATE 25 mg PO BID NIFEREX-150 150MG PO BID OMEPRAZOLE 20 mg PO QD PAROXETINE 20MG PO QD SENNA 8.6mg PO BID Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One 87y (150) mg PO BID (2 times a day). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) unit Injection TID (3 times a day): until pt ambulating. 10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO at bedtime. 11. Niferex-150 150-50 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Brown and Sons Health System - Powell, Lyons and Beck Clinic Discharge Diagnosis: Congestive heart failure Community acquired pneumonia Type 2 diabetes mellitus Pulmonary hypertension Discharge Condition: Good. Discharge Instructions: Please take medications as prescribed. Followup Instructions: You will be seen by the doctor at rehab. Once you leave there, please follow up with Dr. Brown -- call 982-360-9615.	['Admission Date: 1928-2-3 Discharge Date: 1985-10-3\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Luisa\nChief Complaint:\nDyspnea\n\nMajor Surgical or Invasive Procedure:\nIntubation\n\nHistory of Present Illness:\n82yo Russian speaking F with a PMH of type II DM, HTN,\nhyperlipidemia, obesity, pulmonary HTN and anemia, who presented\nto the ED this AM with worsening SOB x 2 weeks. Per the ED\nresident, the patient noted that she had had worsening SOB x 2\nweeks (documented as 2 days Babette Luu RN note) and also complained of\northopnea and increasing lower extremity swelling and weeping\nfrom a venous stasis ulcer on her L shin. The patient was able\nto communicate this verbally to ER resident (RN notes she was\nonly able to speak in 4 word sentences).', ' Her VNA stated that she\nwas only 94% on 2L O2 at home and had rales 1-29 way up\nbilaterally. On initial assessment in the Lopez PLC Hospital ER, her vital\nsigns were T 98.2, BP 167/60, HR 61, RR 23, sats 100% on RA. On\nnext assessment (2 hrs later), pt was felt to be very SOB while\nattempting to use the bed pan. RN noted her to be dusky,\ndiaphoretic. HR 72, RR 28, sats 90% on RA. She was placed on a\nNRB with improvement in her O2 sats to 98%. BP rose to 210/74,\nthen 215/93. CXR was taken and read as c/w pneumonia. Blood cx\nwere obtained and ceftriaxone was administtered. 90 mins later,\nshe was felt to be diaphoretic again, with increased work of\nbreathing. Her O2 sats dropped to 90% by NRB and she was prepped\nfor intubation. She was given 2mg versed and was intubated. SBP\n210 -> 178 -> 130.', ' She was taken to CT scan for CTA. On return\nfrom CT scan, she was felt to be bucking the vent. She was given\nfentanyl 100mcg, with resultant drop in her SBP to 77. She was\nthen bolused 1L of NS with improvement in her SBP to 96. She was\nalso given vecuronium 10mg IV and ativan 1mg IV because of\ninability to ventilate and biting at the tube.\n.\nOn review, she was given: 1gm CTX IV x1, ? azithromcyin 500mg IV\nx1, lasix 20mg x1, 120mg succinylcholine IV, etomidate 20mg IV,\n12.5mg versed IV, and fentanyl 100mcg x1. She was also given 1\ndose of mucomyst prior to her CT scan.\n\n\nPast Medical History:\n# Type II DM\n- last HgbA1C was 5.9% on 1937-8-1\n- not currently on any oral antihyperglycemics due to\nhypoglycemia\n# HTN\n- per OMR note 1917-2-12, was 170/80 at home\n# Hyperlipidemia\n- in 3-9, total chol 179, HDL 86, LDL 70, TG 114\n# Low back pain\n# Obesity\n- BMI 40.', '8 in 9-31\n# h/o heart murmur - ? PDA\n# Anemia\n- Fe 38, TIBC 282, fer 86, TRF 217, B12 594, fol 18.5 on 1937-8-1\n\n- SPEP low total protein/UPEP + only for albumin in 10-21\n# Pulmonary HTN\n- h/o R sided heart failure\n- main pulmonary artery >4cm per ECHO 8-1965\n# Urinary incontinence\n# Syncope\n- neg w/u in 10-31\n- sustained a fall -> s/p humerus fx + ORIF, cervical\nlaminectomy\n\n\nSocial History:\nPatient lives alone. She does not have any stairs at home and is\nnot able to do stairs and does find that the symptoms are\nsomewhat worse with prolonged sitting. Patient wears a back\nsupport corset(belt), compression stocking and uses a walker.\n\n\nFamily History:\nNC\n\nPhysical Exam:\nVS - T 98.2, BP 145/91, HR 60s, RR 16, sats 100%\nAC 10 x 450, PEEP 5, FiO2 100%\nGen: Sedated, intubated.\nHEENT: NCAT. PERRL (5mm ->4mm).', ' Sclera anicteric. MM moist. No\ncervical LAD, no axillary LAD.\nNeck: JVP not appreciated.\nCV: RR. IV/VI holosystolic murmur heard throughout the\nprecordium. ? S2 click.\nResp: Crackles 10-10 way up bilaterally, no wheezes or rhonchi.\nAbd: Soft, NTND. + BS. No HSM.\nExt: 2+ pitting edema up to her knees bilaterally. Ext cool. No\nrashes. No clubbing or cyanosis. L shin has evidence of trauma,\nmild skin tear w/ weeping. Bandage c/d/i.\nNeuro: Sedated. Moves all 4 extremities to pain.\n\n\nPertinent Results:\nCTA 10-13\n1. No pulmonary embolism.\n2. Stable enlargement of the pulmonary arteries indicates\nchronic pulmonary hypertension.\n3. Small bilateral pleural effusions and diffuse ground-glass\nopacity indicate congestive failure.\n4. Multifocal pneumonia.\n5. Interval progression of right apical pleural thickening.', '\n6. No change in calcified nodules along the right major fissure.\n\n.\n.\nEKG (1-25): SR at 63. Scheet. Incomplete RBBB. No obvious ischemic\nchanges.\n\n1928-2-3 05:40PM WBC-7.3 RBC-3.35* HGB-9.9* HCT-30.4* MCV-91\nMCH-29.5 MCHC-32.4 RDW-16.5\n1928-2-3 05:40PM NEUTS-80.2 LYMPHS-12.7* MONOS-5.0 EOS-2.0\nBASOS-0.1\n1928-2-3 05:40PM PLT COUNT-217\n1928-2-3 05:40PM PT-13.1 PTT-28.5 INR(PT)-1.1\n\n1928-2-3 05:40PM GLUCOSE-266* UREA N-28* CREAT-1.3* SODIUM-141\nPOTASSIUM-6.5* CHLORIDE-100 TOTAL CO2-35* ANION GAP-13\n1928-2-3 05:40PM proBNP-5956\n\n1928-2-3 08:00PM URINE COLOR-Yellow APPEAR-Clear SP William-1.013\n1928-2-3 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR\nGLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR\n1928-2-3 08:00PM URINE RBC-0-2 WBC-4-26 BACTERIA-FEW\nYEAST-RARE EPI-0-2\n\nBrief Hospital Course:\n1) RESPIRATORY FAILURE:\nMost likely explanation is acute diastolic CHF ("flash"\npulmonary edema) given acute onset and associated HTN.', ' No\nevidence of structural heart disease on echo. ? findings of PNA,\nand unclear what to make of other findings on CTA--lymphoma vs\nTB. Pt does have an elevated LDH, but it was felt these were\nunlikely possibilities. Pt was treated for CHF with diuresis\nand improved. She was extubated and respiratory status\ncontinued to improve fitting with CHF as the etiology. She\nshould have a repeat CT to evaluate the lymphadenopathy. She\nwas also empirically treated with pneumonia with azithro but she\nwas afebrile with nml WBC. She was continued on losartan, beta\nblockade.\n.\n2) CV: As above. Continued on aspirin. No evidence of acute\nischemia.\n.\n3) ANEMIA, iron deficiency:\nBaseline Hct 28-30, at baseline on discharge. On niferex as an\noutpatient. Iron studies checked at last visit--Fe/TIBC ~15%.', '\nContinued on iron for iron deficieny.\n.\n4) HTN: Contine Metoprolol, Scheet\n.\n5) HYPERLIPIDEMIA: Continue home dose of lipitor.\n.\n6) DM TYPE II: Placed on sliding scale insulin. BG relatively\nwell controlled.\n.\n.\nCODE: Full\n.\nCOMM: son, Joyce Pettway Henry Ngo 480-752-5035. Updated 1-25\n\n\nMedications on Admission:\nASPIRIN 81MG PO QD\nCOLACE 100mg PO BID\nERGOCALCIFEROL 1833024 UNIT PO Q WEEK\nGABAPENTIN 100mg PO QHS\nGLUCOPHAGE 850MG 1 tab PO TID recently d/c\nGLYBURIDE 5MG PO BID recently d/c\nLASIX 60mg PO QD\nLIPITOR 20MG PO QD\nLOSARTAN POTASSIUM 100MG PO QD\nMETOPROLOL TARTRATE 25 mg PO BID\nNIFEREX-150 150MG PO BID\nOMEPRAZOLE 20 mg PO QD\nPAROXETINE 20MG PO QD\nSENNA 8.6mg PO BID\n\n\nDischarge Medications:\n1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.', 'C.) PO DAILY (Daily).\n2. Docusate Sodium 150 mg/15 mL Liquid Sig: One 87y\n(150) mg PO BID (2 times a day).\n3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\nCapsule, Delayed Release(E.C.) PO once a day.\n5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\n7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed.\n9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)\nunit Injection TID (3 times a day): until pt ambulating.\n10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO at\nbedtime.\n11. Niferex-150 150-50 mg Capsule Sig: One (1) Capsule PO twice\na day.', '\n12. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nBrown and Sons Health System - Powell, Lyons and Beck Clinic\n\nDischarge Diagnosis:\nCongestive heart failure\nCommunity acquired pneumonia\nType 2 diabetes mellitus\nPulmonary hypertension\n\n\nDischarge Condition:\nGood.\n\n\nDischarge Instructions:\nPlease take medications as prescribed.\n\n\nFollowup Instructions:\nYou will be seen by the doctor at rehab.\n\nOnce you leave there, please follow up with Dr. Brown -- call\n982-360-9615.\n\n\n\n']
197	22180	183067.0	2136-04-09	Discharge summary	Report	Admission Date: [2136-4-4] Discharge Date: [2136-4-9] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: fatigue Major Surgical or Invasive Procedure: R IJ placement History of Present Illness: This is a 84 year-old Russian speaking female with a history of systemic hypertension, pulmonary arterial hypertension, chronic diastolic CHF, who presents with hypotension, drop in hematocrit and guaiac positive stools. She reportedly collapsed 3 times today. Per son, patient felt lightheaded every time she stood up and had to sit back down to the floor. She has never had a problem like this in the past. Denies any NSAID or alcohol use. Denies hematemesis. Occasional blood-tinged stool when she strains, but denies hematochezia. Denies any fevers. Denies black or bloody stools, but stool always black because of iron. Of note, patient was recently admitted and discharged on [2136-4-2] with multifocal pneumonia. In the ED, initial vitals were T:98.3, BP:81/20, HR:79, O2 Sat 100% on 4L. NG lavage was negative. Patient received 2 units PRBC and right IJ placed for persistent hypotension. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, diarrhea, constipation, chest pain, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: #. Pulmonary HTN on 2 litres home O2 #. CHF - last echo [8-1]: ef > 55% with Symmetric LVH with preserved global and regional biventricular systolic function. No pulmonary hypertension seen. #. HTN #. Type II DM #. Hyperlipidemia #. Low back pain #. Obesity #. h/o heart murmur - ? PDA #. Anemia (baseline ~ 26-30) #. Urinary incontinence #. Syncope Social History: The patient lives alone and has VNA help. She denies etoh and smoking, and for ambulation wears a back support corset(belt), compression stocking and uses a walker. She is on 2L home oxygen Family History: NC Physical Exam: Vitals: T:97.3 BP:105/37 HR:88 RR:21 O2Sat:96% on RA GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, pale conjunctiva, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, 3/6 systolic murmur, normal S1 S2, radial pulses +2 PULM: Lungs CTAB ABD: Soft, Superficial subcutaneous firm area, NT, ND, +BS, no HSM, EXT: No peripheral oedema. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: Pale Pertinent Results: Laboratories: Notable for Hematocrit of 22 down from baseline 30, WBC 22.5, and creatinine 3.9 up from baseline 1.4. See below for rest. . ECG: Sinus rhythm at 76 bpm with evidence of RVH, normal axis and intervals, no ST-T changes. . Imaging: [2136-4-4] Chest x-ray: FINDINGS: Portable AP upright chest radiograph is obtained. Evaluation is somewhat limited by underpenetrated technique. There is no definite evidence of pneumonia. Heart size is stable. Pulmonary arterial prominence is noted compatible with patient's given history of pulmonary hypertension. Atherosclerotic calcification at the aorta is noted. There is no pneumothorax. Diffuse demineralized bone is noted with post-surgical changes of the right proximal humerus. . Abdominal CT:Large right rectus muscle hematoma approximately 10.1x4.4x15.2 cm. . Echocardiogram on [2136-3-26]: The left atrial volume is markedly increased (>32ml/m2). The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. 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. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: This is a 84 year-old female with a history of pulmonary hypertension, diastolic CHF, who presented with weakness, hypotension, Guaiac positive stools. . # Hypotension - Her hypotension and anemia were felt to be due to blood loss from rectus sheath hematoma. Unknown exactly how the hematoma occurred (?secondary to heparin injection while recently hospitalized)but was well visualized on the abdominal CT that she had in the ER. She was evaluated by GI (due to anemia and guaiac positive stools), who found external hemorrhoids on exam and stated there was little or no concern regarding duodenal angioectasia as source of hematocrit drop. They followed and plans for c-scope if she started bleeding again. Her Hct was 22 on admission, microcytic. She received 3 units of blood in total and her hematocrit stablized at 29-30 for several days. Her blood pressure was 80/40 on admission and she was admitted to the MICU, but did not require pressors, her BP increased with blood and fluids (2L). In the ICU she was on a po PPI, had two large bore IVs, as well as central access. Her Hct was checked q6 hours and transfusion parameter was 26. Her aspirin was held. Her BP increased to teens over 80's and she was transferred to the medical floor after one day in the MICU. On the medical floor her blood pressure remained in the 120's/80's initially but then increased to 140's. Her lisinopril, valsartan, metoprolol and furosemide were held initially due to her relatively low blood pressure and increased creatinine (see below). Her furosemide was restarted on the last day of hospitalization due to blood pressure that would tolerate it and signs of hypervolemia. In addition she had several bowel movements on the day prior to admission, likely due to many laxatives she was receiving. She did not have a leukocytosis, fever. The stool was guiaic negative. Her laxatives were discontinued except docusate. . # Acute renal failure - Pre-renal secondary to hypotension/hypovolemia. C Her electrolytes and volume status were stable. Her lisinopril, lasix and valsartan were held and continue to be held as her blood pressure is in the 130's. Her creatinine was 3.4 on admission with a baseline of 1.6. Her creatinine decreased to 1.4 after hydration and her lasix was restarted at her home dose of 80mg po bid. . # Leukocytosis - WBC on admission was very high, likely reactive, given hypotension, and acute blood loss. Blood and urine cultures were negative and she had no diarrhea. Her CXR was unremarkable and antibiotics were deferred as there was no source of infection, she was afebrile and her leukocytosis resolved (WBC was 7 for the last two days of admission). . # Hyperlipidemia - She continued to take atorvastatin . # Chronic pain - She continued to take gabapentin . # Diabetes mellitus - insulin sliding scale while in house, once creatinine normalized glipizide 2.5mg q daily was re-started. . # Psych - Continued paroxetine . # PPx: She had pneumoboots . # Code: Full code . # Comm: [Name (NI) 1961],[Name (NI) ] (Son) [Telephone/Fax (1) 1976] Medications on Admission: #. Atorvastatin 20mg #. Aspirin 81mg #. Docusate 200mg [Hospital1 ] #. Gabapentin 300mg qHS #. Paroxetine 20mg daily #. Prilosec 20mg daily #. Diovan 160mg daily #. Glipizide 2.5mg SR daily #. Lisinopril 20mg daily #. Niferex-150 Forte 150-25-1 mg-mcg-mg [Hospital1 ] #. Metoprolol Tartrate 12.5mg [Hospital1 ] #. Senna 8.6mg [Hospital1 ] #. Clindamycin 300mg q6H x 4 days #. Lasix 80mg [Hospital1 ] #. Albuterol q4-6 hours Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 Discharge Disposition: Extended Care Facility: [Location (un) 582] of [Location (un) 583] Discharge Diagnosis: Primary: - Acute blood loss anemia - Acute renal failure - Hypovolemic shock - Rectus sheath hematoma - GI bleed NOS - Acute on chronic renal failure - Acute on chronic diastolic heart failure - Pulmonary hypertension on home O2 Secondary: - Hypertension - Diabetes mellitus type II - Chronic pain - Upper GI bleed - Depression Discharge Condition: stable, ambulatory, afebrile, good po intake, stable hematocrit Discharge Instructions: You were admitted with low blood pressure, anemia. You were treated in the medical intensive care unit. You received blood transfusions and IV fluids. You were evaluated by the gastroenterologists that felt that your low blood count was due to the collection of blood in your abdominal wall and possibly some bleeding from your small intestine. You blood counts remained stable and your blood pressure improved. You were transferred to the medical floor where you remained stable. Physical therapy evaluated you, worked with you. . Please continue to take your medication as prescribed. You should call your doctor if you feel weak, dizzy, have abdominal pain, nausea, vomiting, black or red stool. . It is important that you follow up as outlined below. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 544], M.D. Date/Time:[2136-5-4] 11:10 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2136-9-5] 10:00 Completed by:[2136-4-10]	Admission Date: <Date>1999-3-16</Date> Discharge Date: <Date>1963-3-22</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Amy</Name> Chief Complaint: fatigue Major Surgical or Invasive Procedure: R IJ placement History of Present Illness: This is a 84 year-old Russian speaking female with a history of systemic hypertension, pulmonary arterial hypertension, chronic diastolic CHF, who presents with hypotension, drop in hematocrit and guaiac positive stools. She reportedly collapsed 3 times today. Per son, patient felt lightheaded every time she stood up and had to sit back down to the floor. She has never had a problem like this in the past. Denies any NSAID or alcohol use. Denies hematemesis. Occasional blood-tinged stool when she strains, but denies hematochezia. Denies any fevers. Denies black or bloody stools, but stool always black because of iron. Of note, patient was recently admitted and discharged on <Date>1908-6-20</Date> with multifocal pneumonia. In the ED, initial vitals were T:98.3, BP:81/20, HR:79, O2 Sat 100% on 4L. NG lavage was negative. Patient received 2 units PRBC and right IJ placed for persistent hypotension. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, diarrhea, constipation, chest pain, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: #. Pulmonary HTN on 2 litres home O2 #. CHF - last echo <Date>3-1</Date>: ef > 55% with Symmetric LVH with preserved global and regional biventricular systolic function. No pulmonary hypertension seen. #. HTN #. Type II DM #. Hyperlipidemia #. Low back pain #. Obesity #. h/o heart murmur - ? PDA #. Anemia (baseline ~ 26-30) #. Urinary incontinence #. Syncope Social History: The patient lives alone and has VNA help. She denies etoh and smoking, and for ambulation wears a back support corset(belt), compression stocking and uses a walker. She is on 2L home oxygen Family History: NC Physical Exam: Vitals: T:97.3 BP:105/37 HR:88 RR:21 O2Sat:96% on RA GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, pale conjunctiva, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, 3/6 systolic murmur, normal S1 S2, radial pulses +2 PULM: Lungs CTAB ABD: Soft, Superficial subcutaneous firm area, NT, ND, +BS, no HSM, EXT: No peripheral oedema. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: Pale Pertinent Results: Laboratories: Notable for Hematocrit of 22 down from baseline 30, WBC 22.5, and creatinine 3.9 up from baseline 1.4. See below for rest. . ECG: Sinus rhythm at 76 bpm with evidence of RVH, normal axis and intervals, no ST-T changes. . Imaging: <Date>1999-3-16</Date> Chest x-ray: FINDINGS: Portable AP upright chest radiograph is obtained. Evaluation is somewhat limited by underpenetrated technique. There is no definite evidence of pneumonia. Heart size is stable. Pulmonary arterial prominence is noted compatible with patient's given history of pulmonary hypertension. Atherosclerotic calcification at the aorta is noted. There is no pneumothorax. Diffuse demineralized bone is noted with post-surgical changes of the right proximal humerus. . Abdominal CT:Large right rectus muscle hematoma approximately 10.1x4.4x15.2 cm. . Echocardiogram on <Date>1950-6-9</Date>: The left atrial volume is markedly increased (>32ml/m2). The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. 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. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: This is a 84 year-old female with a history of pulmonary hypertension, diastolic CHF, who presented with weakness, hypotension, Guaiac positive stools. . # Hypotension - Her hypotension and anemia were felt to be due to blood loss from rectus sheath hematoma. Unknown exactly how the hematoma occurred (?secondary to heparin injection while recently hospitalized)but was well visualized on the abdominal CT that she had in the ER. She was evaluated by GI (due to anemia and guaiac positive stools), who found external hemorrhoids on exam and stated there was little or no concern regarding duodenal angioectasia as source of hematocrit drop. They followed and plans for c-scope if she started bleeding again. Her Hct was 22 on admission, microcytic. She received 3 units of blood in total and her hematocrit stablized at 29-30 for several days. Her blood pressure was 80/40 on admission and she was admitted to the MICU, but did not require pressors, her BP increased with blood and fluids (2L). In the ICU she was on a po PPI, had two large bore IVs, as well as central access. Her Hct was checked q6 hours and transfusion parameter was 26. Her aspirin was held. Her BP increased to teens over 80's and she was transferred to the medical floor after one day in the MICU. On the medical floor her blood pressure remained in the 120's/80's initially but then increased to 140's. Her lisinopril, valsartan, metoprolol and furosemide were held initially due to her relatively low blood pressure and increased creatinine (see below). Her furosemide was restarted on the last day of hospitalization due to blood pressure that would tolerate it and signs of hypervolemia. In addition she had several bowel movements on the day prior to admission, likely due to many laxatives she was receiving. She did not have a leukocytosis, fever. The stool was guiaic negative. Her laxatives were discontinued except docusate. . # Acute renal failure - Pre-renal secondary to hypotension/hypovolemia. C Her electrolytes and volume status were stable. Her lisinopril, lasix and valsartan were held and continue to be held as her blood pressure is in the 130's. Her creatinine was 3.4 on admission with a baseline of 1.6. Her creatinine decreased to 1.4 after hydration and her lasix was restarted at her home dose of 80mg po bid. . # Leukocytosis - WBC on admission was very high, likely reactive, given hypotension, and acute blood loss. Blood and urine cultures were negative and she had no diarrhea. Her CXR was unremarkable and antibiotics were deferred as there was no source of infection, she was afebrile and her leukocytosis resolved (WBC was 7 for the last two days of admission). . # Hyperlipidemia - She continued to take atorvastatin . # Chronic pain - She continued to take gabapentin . # Diabetes mellitus - insulin sliding scale while in house, once creatinine normalized glipizide 2.5mg q daily was re-started. . # Psych - Continued paroxetine . # PPx: She had pneumoboots . # Code: Full code . # Comm: <Name>George Son</Name>,<Name>Wade Edward</Name> (Son) <Telephone>980-596-1960</Telephone> Medications on Admission: #. Atorvastatin 20mg #. Aspirin 81mg #. Docusate 200mg <Hospital>Jennings Inc Hospital</Hospital> #. Gabapentin 300mg qHS #. Paroxetine 20mg daily #. Prilosec 20mg daily #. Diovan 160mg daily #. Glipizide 2.5mg SR daily #. Lisinopril 20mg daily #. Niferex-150 Forte 150-25-1 mg-mcg-mg <Hospital>Jennings Inc Hospital</Hospital> #. Metoprolol Tartrate 12.5mg <Hospital>Jennings Inc Hospital</Hospital> #. Senna 8.6mg <Hospital>Jennings Inc Hospital</Hospital> #. Clindamycin 300mg q6H x 4 days #. Lasix 80mg <Hospital>Jennings Inc Hospital</Hospital> #. Albuterol q4-6 hours Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 Discharge Disposition: Extended Care Facility: <Location>054 Matthew River Suite 564 Sherryfurt, MP 60721</Location> of <Location>Unit 1054 Box 8730 DPO AA 63982</Location> Discharge Diagnosis: Primary: - Acute blood loss anemia - Acute renal failure - Hypovolemic shock - Rectus sheath hematoma - GI bleed NOS - Acute on chronic renal failure - Acute on chronic diastolic heart failure - Pulmonary hypertension on home O2 Secondary: - Hypertension - Diabetes mellitus type II - Chronic pain - Upper GI bleed - Depression Discharge Condition: stable, ambulatory, afebrile, good po intake, stable hematocrit Discharge Instructions: You were admitted with low blood pressure, anemia. You were treated in the medical intensive care unit. You received blood transfusions and IV fluids. You were evaluated by the gastroenterologists that felt that your low blood count was due to the collection of blood in your abdominal wall and possibly some bleeding from your small intestine. You blood counts remained stable and your blood pressure improved. You were transferred to the medical floor where you remained stable. Physical therapy evaluated you, worked with you. . Please continue to take your medication as prescribed. You should call your doctor if you feel weak, dizzy, have abdominal pain, nausea, vomiting, black or red stool. . It is important that you follow up as outlined below. Followup Instructions: Provider: <Name>Rocio</Name> <Name>Bounds</Name>, M.D. Date/Time:<Date>2001-9-15</Date> 11:10 Provider: <Name>Eldon</Name> <Name>Jones</Name>, MD Phone:<Telephone>136-898-6133</Telephone> Date/Time:<Date>1941-9-21</Date> 10:00 Completed 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0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111011111100000000000000000111111111000000000000000001111101111100000000000111111111111000000000001111111110000000000000000000000011111111	Admission Date: 1999-3-16 Discharge Date: 1963-3-22 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Amy Chief Complaint: fatigue Major Surgical or Invasive Procedure: R IJ placement History of Present Illness: This is a 84 year-old Russian speaking female with a history of systemic hypertension, pulmonary arterial hypertension, chronic diastolic CHF, who presents with hypotension, drop in hematocrit and guaiac positive stools. She reportedly collapsed 3 times today. Per son, patient felt lightheaded every time she stood up and had to sit back down to the floor. She has never had a problem like this in the past. Denies any NSAID or alcohol use. Denies hematemesis. Occasional blood-tinged stool when she strains, but denies hematochezia. Denies any fevers. Denies black or bloody stools, but stool always black because of iron. Of note, patient was recently admitted and discharged on 1908-6-20 with multifocal pneumonia. In the ED, initial vitals were T:98.3, BP:81/20, HR:79, O2 Sat 100% on 4L. NG lavage was negative. Patient received 2 units PRBC and right IJ placed for persistent hypotension. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, diarrhea, constipation, chest pain, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: #. Pulmonary HTN on 2 litres home O2 #. CHF - last echo 3-1: ef > 55% with Symmetric LVH with preserved global and regional biventricular systolic function. No pulmonary hypertension seen. #. HTN #. Type II DM #. Hyperlipidemia #. Low back pain #. Obesity #. h/o heart murmur - ? PDA #. Anemia (baseline ~ 26-30) #. Urinary incontinence #. Syncope Social History: The patient lives alone and has VNA help. She denies etoh and smoking, and for ambulation wears a back support corset(belt), compression stocking and uses a walker. She is on 2L home oxygen Family History: NC Physical Exam: Vitals: T:97.3 BP:105/37 HR:88 RR:21 O2Sat:96% on RA GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, pale conjunctiva, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, 3/6 systolic murmur, normal S1 S2, radial pulses +2 PULM: Lungs CTAB ABD: Soft, Superficial subcutaneous firm area, NT, ND, +BS, no HSM, EXT: No peripheral oedema. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: Pale Pertinent Results: Laboratories: Notable for Hematocrit of 22 down from baseline 30, WBC 22.5, and creatinine 3.9 up from baseline 1.4. See below for rest. . ECG: Sinus rhythm at 76 bpm with evidence of RVH, normal axis and intervals, no ST-T changes. . Imaging: 1999-3-16 Chest x-ray: FINDINGS: Portable AP upright chest radiograph is obtained. Evaluation is somewhat limited by underpenetrated technique. There is no definite evidence of pneumonia. Heart size is stable. Pulmonary arterial prominence is noted compatible with patient's given history of pulmonary hypertension. Atherosclerotic calcification at the aorta is noted. There is no pneumothorax. Diffuse demineralized bone is noted with post-surgical changes of the right proximal humerus. . Abdominal CT:Large right rectus muscle hematoma approximately 10.1x4.4x15.2 cm. . Echocardiogram on 1950-6-9: The left atrial volume is markedly increased (>32ml/m2). The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. 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. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: This is a 84 year-old female with a history of pulmonary hypertension, diastolic CHF, who presented with weakness, hypotension, Guaiac positive stools. . # Hypotension - Her hypotension and anemia were felt to be due to blood loss from rectus sheath hematoma. Unknown exactly how the hematoma occurred (?secondary to heparin injection while recently hospitalized)but was well visualized on the abdominal CT that she had in the ER. She was evaluated by GI (due to anemia and guaiac positive stools), who found external hemorrhoids on exam and stated there was little or no concern regarding duodenal angioectasia as source of hematocrit drop. They followed and plans for c-scope if she started bleeding again. Her Hct was 22 on admission, microcytic. She received 3 units of blood in total and her hematocrit stablized at 29-30 for several days. Her blood pressure was 80/40 on admission and she was admitted to the MICU, but did not require pressors, her BP increased with blood and fluids (2L). In the ICU she was on a po PPI, had two large bore IVs, as well as central access. Her Hct was checked q6 hours and transfusion parameter was 26. Her aspirin was held. Her BP increased to teens over 80's and she was transferred to the medical floor after one day in the MICU. On the medical floor her blood pressure remained in the 120's/80's initially but then increased to 140's. Her lisinopril, valsartan, metoprolol and furosemide were held initially due to her relatively low blood pressure and increased creatinine (see below). Her furosemide was restarted on the last day of hospitalization due to blood pressure that would tolerate it and signs of hypervolemia. In addition she had several bowel movements on the day prior to admission, likely due to many laxatives she was receiving. She did not have a leukocytosis, fever. The stool was guiaic negative. Her laxatives were discontinued except docusate. . # Acute renal failure - Pre-renal secondary to hypotension/hypovolemia. C Her electrolytes and volume status were stable. Her lisinopril, lasix and valsartan were held and continue to be held as her blood pressure is in the 130's. Her creatinine was 3.4 on admission with a baseline of 1.6. Her creatinine decreased to 1.4 after hydration and her lasix was restarted at her home dose of 80mg po bid. . # Leukocytosis - WBC on admission was very high, likely reactive, given hypotension, and acute blood loss. Blood and urine cultures were negative and she had no diarrhea. Her CXR was unremarkable and antibiotics were deferred as there was no source of infection, she was afebrile and her leukocytosis resolved (WBC was 7 for the last two days of admission). . # Hyperlipidemia - She continued to take atorvastatin . # Chronic pain - She continued to take gabapentin . # Diabetes mellitus - insulin sliding scale while in house, once creatinine normalized glipizide 2.5mg q daily was re-started. . # Psych - Continued paroxetine . # PPx: She had pneumoboots . # Code: Full code . # Comm: George Son,Wade Edward (Son) 980-596-1960 Medications on Admission: #. Atorvastatin 20mg #. Aspirin 81mg #. Docusate 200mg Jennings Inc Hospital #. Gabapentin 300mg qHS #. Paroxetine 20mg daily #. Prilosec 20mg daily #. Diovan 160mg daily #. Glipizide 2.5mg SR daily #. Lisinopril 20mg daily #. Niferex-150 Forte 150-25-1 mg-mcg-mg Jennings Inc Hospital #. Metoprolol Tartrate 12.5mg Jennings Inc Hospital #. Senna 8.6mg Jennings Inc Hospital #. Clindamycin 300mg q6H x 4 days #. Lasix 80mg Jennings Inc Hospital #. Albuterol q4-6 hours Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 Discharge Disposition: Extended Care Facility: 054 Matthew River Suite 564 Sherryfurt, MP 60721 of Unit 1054 Box 8730 DPO AA 63982 Discharge Diagnosis: Primary: - Acute blood loss anemia - Acute renal failure - Hypovolemic shock - Rectus sheath hematoma - GI bleed NOS - Acute on chronic renal failure - Acute on chronic diastolic heart failure - Pulmonary hypertension on home O2 Secondary: - Hypertension - Diabetes mellitus type II - Chronic pain - Upper GI bleed - Depression Discharge Condition: stable, ambulatory, afebrile, good po intake, stable hematocrit Discharge Instructions: You were admitted with low blood pressure, anemia. You were treated in the medical intensive care unit. You received blood transfusions and IV fluids. You were evaluated by the gastroenterologists that felt that your low blood count was due to the collection of blood in your abdominal wall and possibly some bleeding from your small intestine. You blood counts remained stable and your blood pressure improved. You were transferred to the medical floor where you remained stable. Physical therapy evaluated you, worked with you. . Please continue to take your medication as prescribed. You should call your doctor if you feel weak, dizzy, have abdominal pain, nausea, vomiting, black or red stool. . It is important that you follow up as outlined below. Followup Instructions: Provider: Rocio Bounds, M.D. Date/Time:2001-9-15 11:10 Provider: Eldon Jones, MD Phone:136-898-6133 Date/Time:1941-9-21 10:00 Completed by:2000-6-9	['Admission Date: 1999-3-16 Discharge Date: 1963-3-22\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Amy\nChief Complaint:\nfatigue\n\nMajor Surgical or Invasive Procedure:\nR IJ placement\n\nHistory of Present Illness:\nThis is a 84 year-old Russian speaking female with a history of\nsystemic hypertension, pulmonary arterial hypertension, chronic\ndiastolic CHF, who presents with hypotension, drop in hematocrit\nand guaiac positive stools. She reportedly collapsed 3 times\ntoday. Per son, patient felt lightheaded every time she stood\nup and had to sit back down to the floor. She has never had a\nproblem like this in the past. Denies any NSAID or alcohol use.\n Denies hematemesis. Occasional blood-tinged stool when she\nstrains, but denies hematochezia.', ' Denies any fevers. Denies\nblack or bloody stools, but stool always black because of iron.\nOf note, patient was recently admitted and discharged on\n1908-6-20 with multifocal pneumonia.\n\nIn the ED, initial vitals were T:98.3, BP:81/20, HR:79, O2 Sat\n100% on 4L. NG lavage was negative. Patient received 2 units\nPRBC and right IJ placed for persistent hypotension.\n.\nROS: The patient denies any fevers, chills, weight change,\nnausea, vomiting, diarrhea, constipation, chest pain, orthopnea,\nPND, lower extremity oedema, cough, urinary frequency, urgency,\ndysuria, lightheadedness, gait unsteadiness, focal weakness,\nvision changes, headache, rash or skin changes.\n\n\nPast Medical History:\n#. Pulmonary HTN on 2 litres home O2\n#. CHF - last echo 3-1: ef > 55% with Symmetric LVH with\npreserved global and regional biventricular systolic function.', '\nNo pulmonary hypertension seen.\n#. HTN\n#. Type II DM\n#. Hyperlipidemia\n#. Low back pain\n#. Obesity\n#. h/o heart murmur - ? PDA\n#. Anemia (baseline ~ 26-30)\n#. Urinary incontinence\n#. Syncope\n\n\nSocial History:\nThe patient lives alone and has VNA help. She denies etoh and\nsmoking, and for ambulation wears a back support corset(belt),\ncompression stocking and uses a walker. She is on 2L home\noxygen\n\n\nFamily History:\nNC\n\nPhysical Exam:\nVitals: T:97.3 BP:105/37 HR:88 RR:21 O2Sat:96% on RA\nGEN: Well-appearing, well-nourished, no acute distress\nHEENT: EOMI, pale conjunctiva, no epistaxis or rhinorrhea, dry\nMM, OP Clear\nNECK: No JVD, carotid pulses brisk, no bruits, no cervical\nlymphadenopathy, trachea midline\nCOR: RRR, 3/6 systolic murmur, normal S1 S2, radial pulses +2\nPULM: Lungs CTAB\nABD: Soft, Superficial subcutaneous firm area, NT, ND, +BS, no\nHSM,\nEXT: No peripheral oedema.', "\nNEURO: alert, oriented to person, place, and time. CN II ?????? XII\ngrossly intact. Moves all 4 extremities.\nSKIN: Pale\n\n\nPertinent Results:\nLaboratories: Notable for Hematocrit of 22 down from baseline\n30, WBC 22.5, and creatinine 3.9 up from baseline 1.4. See below\nfor rest.\n.\nECG: Sinus rhythm at 76 bpm with evidence of RVH, normal axis\nand intervals, no ST-T changes.\n.\nImaging:\n1999-3-16 Chest x-ray:\nFINDINGS: Portable AP upright chest radiograph is obtained.\nEvaluation is somewhat limited by underpenetrated technique.\nThere is no definite evidence of pneumonia. Heart size is\nstable. Pulmonary arterial prominence is noted compatible with\npatient's given history of pulmonary hypertension.\nAtherosclerotic calcification at the aorta is noted. There is no\npneumothorax. Diffuse demineralized bone is noted with\npost-surgical changes of the right proximal humerus.", '\n.\nAbdominal CT:Large right rectus muscle hematoma approximately\n10.1x4.4x15.2 cm.\n.\nEchocardiogram on 1950-6-9:\nThe left atrial volume is markedly increased (>32ml/m2). The\nleft atrium is dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic\nfunction (LVEF>55%). Transmitral Doppler and tissue velocity\nimaging are consistent with Grade I (mild) LV diastolic\ndysfunction. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The\nnumber of aortic valve leaflets cannot be determined. There is\nno 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.\nThe left ventricular inflow pattern suggests impaired\nrelaxation.', ' The pulmonary artery systolic pressure could not be\ndetermined. There is no pericardial effusion.\n\nBrief Hospital Course:\nThis is a 84 year-old female with a history of pulmonary\nhypertension, diastolic CHF, who presented with weakness,\nhypotension, Guaiac positive stools.\n.\n\n# Hypotension - Her hypotension and anemia were felt to be due\nto blood loss from rectus sheath hematoma. Unknown exactly how\nthe hematoma occurred (?secondary to heparin injection while\nrecently hospitalized)but was well visualized on the abdominal\nCT that she had in the ER. She was evaluated by GI (due to\nanemia and guaiac positive stools), who found external\nhemorrhoids on exam and stated there was little or no concern\nregarding duodenal angioectasia as source of hematocrit drop.\nThey followed and plans for c-scope if she started bleeding\nagain.', " Her Hct was 22 on admission, microcytic. She received\n3 units of blood in total and her hematocrit stablized at 29-30\nfor several days. Her blood pressure was 80/40 on admission and\nshe was admitted to the MICU, but did not require pressors, her\nBP increased with blood and fluids (2L). In the ICU she was on\na po PPI, had two large bore IVs, as well as central access.\nHer Hct was checked q6 hours and transfusion parameter was 26.\nHer aspirin was held. Her BP increased to teens over 80's and\nshe was transferred to the medical floor after one day in the\nMICU. On the medical floor her blood pressure remained in the\n120's/80's initially but then increased to 140's. Her\nlisinopril, valsartan, metoprolol and furosemide were held\ninitially due to her relatively low blood pressure and increased\ncreatinine (see below).", " Her furosemide was restarted on the last\nday of hospitalization due to blood pressure that would tolerate\nit and signs of hypervolemia.\nIn addition she had several bowel movements on the day prior to\nadmission, likely due to many laxatives she was receiving. She\ndid not have a leukocytosis, fever. The stool was guiaic\nnegative. Her laxatives were discontinued except docusate.\n.\n# Acute renal failure - Pre-renal secondary to\nhypotension/hypovolemia. C Her electrolytes and volume status\nwere stable. Her lisinopril, lasix and valsartan were held and\ncontinue to be held as her blood pressure is in the 130's. Her\ncreatinine was 3.4 on admission with a baseline of 1.6. Her\ncreatinine decreased to 1.4 after hydration and her lasix was\nrestarted at her home dose of 80mg po bid.\n.\n# Leukocytosis - WBC on admission was very high, likely\nreactive, given hypotension, and acute blood loss.", ' Blood and\nurine cultures were negative and she had no diarrhea. Her CXR\nwas unremarkable and antibiotics were deferred as there was no\nsource of infection, she was afebrile and her leukocytosis\nresolved (WBC was 7 for the last two days of admission).\n.\n# Hyperlipidemia - She continued to take atorvastatin\n.\n# Chronic pain - She continued to take gabapentin\n.\n# Diabetes mellitus - insulin sliding scale while in house, once\ncreatinine normalized glipizide 2.5mg q daily was re-started.\n.\n# Psych - Continued paroxetine\n.\n# PPx: She had pneumoboots\n.\n# Code: Full code\n.\n# Comm: George Son,Wade Edward (Son) 980-596-1960\n\n\nMedications on Admission:\n#. Atorvastatin 20mg\n#. Aspirin 81mg\n#. Docusate 200mg Jennings Inc Hospital\n#. Gabapentin 300mg qHS\n#. Paroxetine 20mg daily\n#. Prilosec 20mg daily\n#.', ' Diovan 160mg daily\n#. Glipizide 2.5mg SR daily\n#. Lisinopril 20mg daily\n#. Niferex-150 Forte 150-25-1 mg-mcg-mg Jennings Inc Hospital\n#. Metoprolol Tartrate 12.5mg Jennings Inc Hospital\n#. Senna 8.6mg Jennings Inc Hospital\n#. Clindamycin 300mg q6H x 4 days\n#. Lasix 80mg Jennings Inc Hospital\n#. Albuterol q4-6 hours\n\nDischarge Medications:\n1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2\ntimes a day).\n3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at\nbedtime).\n4. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n5. Insulin Regular Human 100 unit/mL Solution Sig: as directed\nInjection ASDIR (AS DIRECTED).\n6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:\nOne (1) Inhalation Q6H (every 6 hours) as needed.', '\n7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours).\n9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: Two (2)\nCapsule PO DAILY (Daily).\nDisp:60 Capsule(s) Refills:2\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\n054 Matthew River Suite 564\nSherryfurt, MP 60721 of Unit 1054 Box 8730\nDPO AA 63982\n\nDischarge Diagnosis:\nPrimary:\n- Acute blood loss anemia\n- Acute renal failure\n- Hypovolemic shock\n- Rectus sheath hematoma\n- GI bleed NOS\n- Acute on chronic renal failure\n- Acute on chronic diastolic heart failure\n- Pulmonary hypertension on home O2\n\nSecondary:\n- Hypertension\n- Diabetes mellitus type II\n- Chronic pain\n- Upper GI bleed\n- Depression\n\n\nDischarge Condition:\nstable, ambulatory, afebrile, good po intake, stable hematocrit\n\n\nDischarge Instructions:\nYou were admitted with low blood pressure, anemia.', ' You were\ntreated in the medical intensive care unit. You received blood\ntransfusions and IV fluids. You were evaluated by the\ngastroenterologists that felt that your low blood count was due\nto the collection of blood in your abdominal wall and possibly\nsome bleeding from your small intestine. You blood counts\nremained stable and your blood pressure improved. You were\ntransferred to the medical floor where you remained stable.\nPhysical therapy evaluated you, worked with you.\n.\nPlease continue to take your medication as prescribed. You\nshould call your doctor if you feel weak, dizzy, have abdominal\npain, nausea, vomiting, black or red stool.\n.\nIt is important that you follow up as outlined below.\n\nFollowup Instructions:\nProvider: Rocio Bounds, M.D. Date/Time:2001-9-15 11:10\nProvider: Eldon Jones, MD Phone:136-898-6133 Date/Time:1941-9-21\n10:00\n\n\n\nCompleted by:2000-6-9']
198	22180	190828.0	2139-12-04	Discharge summary	Report	Admission Date: [2139-11-24] Discharge Date: [2139-12-4] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 602] Chief Complaint: somnolence Major Surgical or Invasive Procedure: none History of Present Illness: This is an 87 year old lady with a PMH of diastolic heart failure (EF>75%), severe lung disease and resultant pulmonary hypertension, T2DM, obesity, who presents from home with hypoxia and worsening somnolence. Patient reports that since discharge from the hospital on Saturday [11-21], she has had persistent increased sputum which she has difficulty coughing up. She feels like the sputum gets caught in her throat. It is white-clear. She denies fever or chills. She denies worsening dyspnea, but has only ambulated in her house as she hasn't been feeling well. She endorses mild orthopnea. She denies worsening lower extremity edema. Of note, patient was recently admitted for hypoxia with CXR findings of a LUL. She had presented to her cardiologist one week prior to initial admission with complaints of worsening dyspnea and increased sputum production, without fever or leukocytosis. At that time, cardiologist felt that patient was having an acute flare of her chronic bronchitis, and placed her on a one week course of levofloxacin. A CXR was performed at the time to rule out pneumonia which was negative for consolidation. She followed up with the cardiologist NP one week later, and was found to have O2Sats ranging from 68-80% on 3L NC (baseline, home oxygen). She continued to be afebrile without leukocytosis but reported no improvement in sputum production or dyspnea. She was sent to the ER where a repeat CXR showed bilateral upper lobe opacities concerning for pneumonia. She was given ceftriaxone and azithromycin and admitted to the medicine service. Antibiotics were not continued as patient was afebrile, without cough or leukocytosis. Right lower extremity ultrasound was negative for DVT. Patient was discharged home as her oxygen saturations returned to baseline on home 3L NC. [Name (NI) ] son reports that patient had BCG vaccination in [Country 532]. He does not know if she was ever exposed to tuberculosis. He does not know of anyone in his family who was exposed to tuberculosis. In the ED inital vitals were 97.4 70 141/47 18 100% Non-Rebreather. ABG 7.35/91/105/46. She was given vanc/cefepime x1. Lung exam c/w decreased breath sounds, tachypneic to low 30s. She was transferred to the [Hospital Unit Name 153] for further management. On arrival to the ICU, vital signs were 97.6, 69, 132/56, 18 and 96% on 3LNC. Patient was comfortable and denied any pain. Past Medical History: 1. Falls, multiple noted in OMR & D/C summaries 2. Pulmonary HTN, on 2L/nc @ home, PDA per echo [2120-11-5] 3. h/o exudative pleural effusion, treated with talc for pleuredesis ([2128-2-17]) 4. CHF per Echo ([2136-3-26]) - Grade I (mild) LV diastolic dysfunction, LV inflow pattern suggests impaired relaxation, - LVEF>55% 5. Mild (1+) AR, trivial MR, trivial TR (Echo [2136-3-26]) 6. HTN 7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7 8. Type II DM, %HbA1c 6.3 ([2136-2-3]) 9. Hyperlipidemia 10. Chronic low back pain, 12. Spinal stenosis, L3-4 & L4-5, per MRI ([2134-2-27]) 13. Compression fracture of the T3-T4, per CT ([2136-5-22]) 14. h/o Left knee medial meniscus [Last Name (LF) 1994], [First Name3 (LF) ] MRI ([2129-10-26]) 15. Obesity 16. Anemia (baseline ~ 26-30) 17. h/o Rectus sheath hematoma 18. h/o Hemorrhoids 19. h/o UGI Bleed 20. Urinary incontinence 21. Syncope 22. Gallstones, per CT ([2136-4-4]) 23. Depression . <b>PSHx:</b> - s/p IM nail right humerus ([2134-3-2]), secondary to fall - s/p Open posterior treatment of cervical fractures at C3, cervical laminectomy at C2-C4, posterior arthrodesis, C3-C4 ([2134-3-2]), seconadary to fall - s/p EGD([2129]) gastritis/duodenitis and HP, rx recommended but no documentation of eradication - s/p MVA ([12/2127]) - s/p Colonoscopy [2124] (two small adenomas) & [8-28] (2 sessile sigmoid polyps, path: mucosal prolapse) - s/p TAH for fibroids. Social History: Russian-speaking widow (husband [Name (NI) 1995] died of sudden cardiac death [10/2127]) who lives alone. Has lived in the United States since ~[2116]. She worked as a bookkeeper in [Country 532]. Son [First Name8 (NamePattern2) 1975] [Name (NI) ], [Telephone/Fax (1) 1958]) in area & assists. Son is only relative as daughter died ~[2114] of sarcoma. She does not drink or smoke. Ambulates with rolling walker, housing has elevator/no steps. VNA has been involved with HM/HHA [Hospital1 ]: [Hospital6 1952] Care, Inc. [Phone: ([Telephone/Fax (1) 1996]; Fax: ([Telephone/Fax (1) 1997]] & [Hospital1 ] Family & Children??????s Service [[Telephone/Fax (1) 1998]]. Denies tobacco use (ever). Denies ETOH use. Family History: Negative for diabetes, cardiac disease, hypertension and cancer with the exception of her daughter who died of a sarcoma. Family history is notable for longevity. Physical Exam: Admission Exam: Vitals: 97.6, 69, 132/56, 18 and 96% on 3LNC General: Alert, oriented, no acute distress, speaking in full sentences without accessory muscle use HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse rales in all lung fields with good air movement bilaterally, no prolonged expiratory phase, no wheezes, no egophany CV: Regular rate and rhythm, fixed split S1 with prominent S2, holosystolic murmur best heard at RUSB radiating to bilateral carotids. Abdomen: +BS, soft, obese, non-tender, no hepatosplenomegaly GU: foley draining clear urine Ext: Warm, well perfused, 2+ DP/PT and radial pulses, 2+ pedal edema bilaterally, no clubbing or cyanosis. Neuro: A+O x3, strength 4/5 bilaterally in upper/lower extremities Discharge exam: unchanged with the exception of: Lungs: CTAB, faint expiratory wheezes in right base Extremeties: 3cm tender compressible lump on left medial wrist Pertinent Results: Admission labs: [2139-11-24] 11:59AM BLOOD WBC-5.7 RBC-3.49* Hgb-10.1* Hct-32.1* MCV-92 MCH-28.8 MCHC-31.4 RDW-14.4 Plt Ct-188 [2139-11-24] 11:59AM BLOOD Neuts-81.5* Lymphs-12.3* Monos-4.2 Eos-1.7 Baso-0.3 [2139-11-24] 11:59AM BLOOD Glucose-185* UreaN-42* Creat-1.4* Na-143 K-4.4 Cl-92* HCO3-46* AnGap-9 [2139-11-24] 01:42PM BLOOD pO2-105 pCO2-91* pH-7.35 calTCO2-52* Base XS-19 [2139-11-24] 08:51PM BLOOD Type-ART pO2-81* pCO2-101* pH-7.32* calTCO2-54* Base XS-19 MICROBIOLOGY: Blood culture x2 ([2139-11-24])- no growth, pending final Urine culture ([2139-11-24])- no growth, final. Sputum ([2139-11-25])- no acif fast bacilli seen on smear, no legionella isolated. Acid fast culture pending Sputum ([2139-11-26])- pending [2139-11-24] CXR: IMPRESSION: 1. Worsening multifocal opacification. Recommend clinical correlation for infection, and in the absence of concern for infection, CT of the chest is recommended to exclude the possibility of malignancy. 2. Pulmonary artery enlargement compatible with pulmonary arterial hypertension. [2139-11-30] CXR: IMPRESSION: 1. Cardiomegaly and enlargement of the pulmonary arteries consistent with pulmonary hypertension. 2. No consolidation. No pulmonary edema. [2139-11-24] CT chest w/o contrast: IMPRESSION: 1. Three discrete new irregularly-shaped focal opacities demonstrated within the left upper lobe that, given multiplicity and configuration, are likely related to an active infectious or inflammatory proces, much less likely to be synchronous bronchogenic carcinoma. Differential also includes organizing pneumonia or pseudolymphoma. Recommend followup to resolution with conventional radiographs in six weeks. 2. Moderate cardiomegaly and severe pulmonary hypertension have progressed since [2135]. 3. Findings compatible with the sequelae of prior granulomatous exposure Discharge Labs: [2139-12-4] 07:20AM BLOOD WBC-4.0 RBC-3.36* Hgb-9.6* Hct-31.2* MCV-93 MCH-28.6 MCHC-30.9* RDW-15.1 Plt Ct-197 [2139-12-4] 07:20AM BLOOD Glucose-182* UreaN-49* Creat-1.3* Na-141 K-5.0 Cl-94* HCO3-44* AnGap-8 Studies pending at discharge: None Brief Hospital Course: 87 yo F with a history of diastolic heart failure, pulmonary hypertension, chronic kidney disease, and chronic bronchitis admitted with hypercarbic respiratory failure. Hospital course notable for acute renal failure. #Hypoxia/Atypical Pneumonia/Pulmonary hypertension/Chronic Obstructive Pulmonary Disease/Acute on chronic diastolic heart failure/Hypercarbic respiratory failure/Obstructive Sleep Apnea: Patient was initially admitted to the Intensive Care Unit with hypercarbic respiratory which was felt to be due to over oxygenation, and most likely worsening pulmonary hypertension from volume overload and atypical pneumonia. She was diuresed and treated with azithromycin with improvement in her symptoms. She was also seen by the Pulmonary service for evaluation of her pulmonary hypertension and episodes of apnea and they recommended an outpatient sleep study. The patient did well and was transferred from the Intensive Care Unit to the medical floor and improved with antibiotics and further diuresis and was discharged on home oxygen of 2-3L NC. Given that over-ventilation and over-oxygenation was felt to contribute to the patient's hypercarbic respiratory failure and somnolence, the patient should have oxygen for a target oxygen saturation of 89-93%. #Pulmonary nodules: Patient had sputum production and a chest CT which showed 3 left uppe lobe lung nodules that were most likely felt to be infectious. She was ruled out for TB with 3 negative sputa for AFB and patient received course of azithromycin. She should have a follow up CXR in 6 weeks. Patient and son were made aware of this and the importance of follow up. #Acute on chronic diastolic Heart Failure: As above patient was admitted in volume overload. Hospital course was notable for improvement in symptoms with diuresis, but complicated by acute renal failure (see below). Patient was ultimately discharged euvolemic on regimen of Lasix 80mg once daily to keep her euvolemic and TBB even. #Acute on Chronic renal Failure: During diuresis for acute heart failure, patient developed acute renal failure with probable contraction alkalosis. At this point diuresis was stopped, gentle fluids were given, and diuretics were stared when renal function had returned to [Location 213]. Lisinopril was held and should be started 3 days after discharge at 2.5mg po daily. # Hypertension: Blood pressure was well controlled on home regimen. Diltiazem was continued but Lisinopril was held during acute renal failure. # Diabetes mellitus: HgbA1c 6.5 in 7/[2138]. On glipizide at home. Patient was covered with sliding scale insulin in the hospital. Glipizide can be restarted once renal function stabilizes. # Transitional issues: AFB cultures will need to be followed-up She will need close pulmonary follow-up for repeat imaging in several weeks (fu of pulmonary nodules as well as follow up of her likely COPD, severe pulmonary hypertension, and probable sleep apnea . #Disposition: Patient was discharged to rehab. Medications on Admission: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever or pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Solaraze 3 % Gel Sig: One (1) application Topical twice weekly: apply to affected areas and rub in well twice weekly. 14. iron aspgly&ps-C-B12-FA-Ca-suc [Medical Record Number 2001]-1 mg-mg-mcg-mg Capsule Sig: One (1) Capsule PO twice a day. 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 17. Motrin IB 200 mg Tablet Sig: 1-2 Tablets PO 2x/day for 2 weeks as needed for pain. Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever/pain. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for sputum production/cough. Disp:200 cc Refills:0 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for wheezing/shortness of breath. Disp:30 bullets Refills:0 16. iron aspgly&ps-C-B12-FA-Ca-suc [Medical Record Number 2001]-1 mg-mg-mcg-mg Capsule Sig: One (1) Capsule PO twice a day. 17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 18. sodium chloride 0.65 % Aerosol, Spray Sig: [12-28] Sprays Nasal QID (4 times a day) as needed for nasal dryness. 19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice weekly. Disp:1 Refills:2 Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Hospital1 1559] Discharge Diagnosis: Primary: 1) Acute on Chronic Congestive Heart Failure 2) COPD 3) Pulmonary Hypertension Secondary: 1) Obstructive Sleep Apnea 2) Diabetes Mellitus, Type 2 3) Chronic Kidney Disease 4) Pulmonary nodules/Atypical pneumonia 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 Mrs [Known lastname ]: It was a pleasure taking care of you in the hospital during your stay; You were taken care of by a critical care team during your ICU stay and a medicine primary team during your inpatient hospitalization. During your stay you received treatment for congestive heart failure and continued treatment for a possible pneumonia. You will need to continue to restrict your salt intake in order to prevent exacerbations of your heart failure. Additionally, there was significant concern that you have obstructive sleep apnea. You have appointments to see a sleep medicine specialist and a pulmonologist. The following changes were made to your medication regimen: 1) START guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for sputum production/cough 2) START albuterol 0.083% neb solution, 1 nebulizer every 4 hours as needed for shortness of breath or wheezing 3) You may use saline nasal spray as needed for nasal dryness. 4) Your lasix dose was decreased to 80mg once daily (instead of twice per day). . Please try to avoid ibuprofen and other NSAIDs orally if possible because these could further damage your kidneys. Please be sure to weigh yourself every morning and call your primary care doctor if weight is increasing by more than 3 lbs. You may need to have your lasix increased again. Please be sure to keep all of your followup appointments as listed below, including your followup with the cardiologist next week. . No other changes were made to your medications and you should continue to take all your other medications as originally prescribed. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [2139-12-8] at 3:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2003], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES/SLEEP MEDICINE When: FRIDAY [2139-12-25] at 2:00 PM With: DR [Last Name (STitle) 2004] / DR [First Name (STitle) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PULMONARY FUNCTION LAB When: WEDNESDAY [2140-2-10] at 7:40 AM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES/PULMONARY When: WEDNESDAY [2140-2-10] at 8:00 AM With: DR. [Last Name (STitle) 91] & DR. [Last Name (STitle) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST [Hospital 2002] CLINIC When: WEDNESDAY [2139-12-30] at 10:00 AM With: [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878], M.D. [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: [Hospital3 249] When: FRIDAY [2140-3-11] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 544], M.D. [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: WEDNESDAY [2140-5-11] at 2:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2139-12-4]	Admission Date: <Date>1958-1-29</Date> Discharge Date: <Date>1955-8-23</Date> Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Jian</Name> Chief Complaint: somnolence Major Surgical or Invasive Procedure: none History of Present Illness: This is an 87 year old lady with a PMH of diastolic heart failure (EF>75%), severe lung disease and resultant pulmonary hypertension, T2DM, obesity, who presents from home with hypoxia and worsening somnolence. Patient reports that since discharge from the hospital on Saturday <Date>2-7</Date>, she has had persistent increased sputum which she has difficulty coughing up. She feels like the sputum gets caught in her throat. It is white-clear. She denies fever or chills. She denies worsening dyspnea, but has only ambulated in her house as she hasn't been feeling well. She endorses mild orthopnea. She denies worsening lower extremity edema. Of note, patient was recently admitted for hypoxia with CXR findings of a LUL. She had presented to her cardiologist one week prior to initial admission with complaints of worsening dyspnea and increased sputum production, without fever or leukocytosis. At that time, cardiologist felt that patient was having an acute flare of her chronic bronchitis, and placed her on a one week course of levofloxacin. A CXR was performed at the time to rule out pneumonia which was negative for consolidation. She followed up with the cardiologist NP one week later, and was found to have O2Sats ranging from 68-80% on 3L NC (baseline, home oxygen). She continued to be afebrile without leukocytosis but reported no improvement in sputum production or dyspnea. She was sent to the ER where a repeat CXR showed bilateral upper lobe opacities concerning for pneumonia. She was given ceftriaxone and azithromycin and admitted to the medicine service. Antibiotics were not continued as patient was afebrile, without cough or leukocytosis. Right lower extremity ultrasound was negative for DVT. Patient was discharged home as her oxygen saturations returned to baseline on home 3L NC. <Name>Keisha Olles</Name> son reports that patient had BCG vaccination in <Country>Mexico</Country>. He does not know if she was ever exposed to tuberculosis. He does not know of anyone in his family who was exposed to tuberculosis. In the ED inital vitals were 97.4 70 141/47 18 100% Non-Rebreather. ABG 7.35/91/105/46. She was given vanc/cefepime x1. Lung exam c/w decreased breath sounds, tachypneic to low 30s. She was transferred to the <Hospital>Buck and Sons Medical Center</Hospital> for further management. On arrival to the ICU, vital signs were 97.6, 69, 132/56, 18 and 96% on 3LNC. Patient was comfortable and denied any pain. Past Medical History: 1. Falls, multiple noted in OMR & D/C summaries 2. Pulmonary HTN, on 2L/nc @ home, PDA per echo <Date>1958-7-23</Date> 3. h/o exudative pleural effusion, treated with talc for pleuredesis (<Date>1949-1-8</Date>) 4. CHF per Echo (<Date>1959-6-1</Date>) - Grade I (mild) LV diastolic dysfunction, LV inflow pattern suggests impaired relaxation, - LVEF>55% 5. Mild (1+) AR, trivial MR, trivial TR (Echo <Date>1959-6-1</Date>) 6. HTN 7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7 8. Type II DM, %HbA1c 6.3 (<Date>2010-4-14</Date>) 9. Hyperlipidemia 10. Chronic low back pain, 12. Spinal stenosis, L3-4 & L4-5, per MRI (<Date>1987-3-30</Date>) 13. Compression fracture of the T3-T4, per CT (<Date>1939-11-3</Date>) 14. h/o Left knee medial meniscus <Name>Hall</Name>, <Name>Luisa</Name> MRI (<Date>1968-10-4</Date>) 15. Obesity 16. Anemia (baseline ~ 26-30) 17. h/o Rectus sheath hematoma 18. h/o Hemorrhoids 19. h/o UGI Bleed 20. Urinary incontinence 21. Syncope 22. Gallstones, per CT (<Date>1970-4-12</Date>) 23. Depression . <b>PSHx:</b> - s/p IM nail right humerus (<Date>2013-7-8</Date>), secondary to fall - s/p Open posterior treatment of cervical fractures at C3, cervical laminectomy at C2-C4, posterior arthrodesis, C3-C4 (<Date>2013-7-8</Date>), seconadary to fall - s/p EGD(<Year>1973</Year>) gastritis/duodenitis and HP, rx recommended but no documentation of eradication - s/p MVA (<Date>5/1989</Date>) - s/p Colonoscopy <Year>1973</Year> (two small adenomas) & <Date>4-4</Date> (2 sessile sigmoid polyps, path: mucosal prolapse) - s/p TAH for fibroids. Social History: Russian-speaking widow (husband <Name>An Prieto</Name> died of sudden cardiac death <Date>5/1953</Date>) who lives alone. Has lived in the United States since ~<Year>1973</Year>. She worked as a bookkeeper in <Country>Mexico</Country>. Son <Name>Amanda</Name> <Name>Keisha Olles</Name>, <Telephone>280-320-4968</Telephone>) in area & assists. Son is only relative as daughter died ~<Year>1973</Year> of sarcoma. She does not drink or smoke. Ambulates with rolling walker, housing has elevator/no steps. VNA has been involved with HM/HHA <Hospital>Alvarado-Harrington Health System</Hospital>: <Hospital>Sparks, Mcgrath and Conway Clinic</Hospital> Care, Inc. [Phone: (<Telephone>241-721-8268</Telephone>; Fax: (<Telephone>153-376-4810</Telephone>] & <Hospital>Alvarado-Harrington Health System</Hospital> Family & Children??????s Service [<Telephone>382-342-8692</Telephone>]. Denies tobacco use (ever). Denies ETOH use. Family History: Negative for diabetes, cardiac disease, hypertension and cancer with the exception of her daughter who died of a sarcoma. Family history is notable for longevity. Physical Exam: Admission Exam: Vitals: 97.6, 69, 132/56, 18 and 96% on 3LNC General: Alert, oriented, no acute distress, speaking in full sentences without accessory muscle use HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse rales in all lung fields with good air movement bilaterally, no prolonged expiratory phase, no wheezes, no egophany CV: Regular rate and rhythm, fixed split S1 with prominent S2, holosystolic murmur best heard at RUSB radiating to bilateral carotids. Abdomen: +BS, soft, obese, non-tender, no hepatosplenomegaly GU: foley draining clear urine Ext: Warm, well perfused, 2+ DP/PT and radial pulses, 2+ pedal edema bilaterally, no clubbing or cyanosis. Neuro: A+O x3, strength 4/5 bilaterally in upper/lower extremities Discharge exam: unchanged with the exception of: Lungs: CTAB, faint expiratory wheezes in right base Extremeties: 3cm tender compressible lump on left medial wrist Pertinent Results: Admission labs: <Date>1958-1-29</Date> 11:59AM BLOOD WBC-5.7 RBC-3.49* Hgb-10.1* Hct-32.1* MCV-92 MCH-28.8 MCHC-31.4 RDW-14.4 Plt Ct-188 <Date>1958-1-29</Date> 11:59AM BLOOD Neuts-81.5* Lymphs-12.3* Monos-4.2 Eos-1.7 Baso-0.3 <Date>1958-1-29</Date> 11:59AM BLOOD Glucose-185* UreaN-42* Creat-1.4* Na-143 K-4.4 Cl-92* HCO3-46* AnGap-9 <Date>1958-1-29</Date> 01:42PM BLOOD pO2-105 pCO2-91* pH-7.35 calTCO2-52* Base XS-19 <Date>1958-1-29</Date> 08:51PM BLOOD Type-ART pO2-81* pCO2-101* pH-7.32* calTCO2-54* Base XS-19 MICROBIOLOGY: Blood culture x2 (<Date>1958-1-29</Date>)- no growth, pending final Urine culture (<Date>1958-1-29</Date>)- no growth, final. Sputum (<Date>1981-1-17</Date>)- no acif fast bacilli seen on smear, no legionella isolated. Acid fast culture pending Sputum (<Date>1949-12-23</Date>)- pending <Date>1958-1-29</Date> CXR: IMPRESSION: 1. Worsening multifocal opacification. Recommend clinical correlation for infection, and in the absence of concern for infection, CT of the chest is recommended to exclude the possibility of malignancy. 2. Pulmonary artery enlargement compatible with pulmonary arterial hypertension. <Date>1914-11-17</Date> CXR: IMPRESSION: 1. Cardiomegaly and enlargement of the pulmonary arteries consistent with pulmonary hypertension. 2. No consolidation. No pulmonary edema. <Date>1958-1-29</Date> CT chest w/o contrast: IMPRESSION: 1. Three discrete new irregularly-shaped focal opacities demonstrated within the left upper lobe that, given multiplicity and configuration, are likely related to an active infectious or inflammatory proces, much less likely to be synchronous bronchogenic carcinoma. Differential also includes organizing pneumonia or pseudolymphoma. Recommend followup to resolution with conventional radiographs in six weeks. 2. Moderate cardiomegaly and severe pulmonary hypertension have progressed since <Year>1973</Year>. 3. Findings compatible with the sequelae of prior granulomatous exposure Discharge Labs: <Date>1955-8-23</Date> 07:20AM BLOOD WBC-4.0 RBC-3.36* Hgb-9.6* Hct-31.2* MCV-93 MCH-28.6 MCHC-30.9* RDW-15.1 Plt Ct-197 <Date>1955-8-23</Date> 07:20AM BLOOD Glucose-182* UreaN-49* Creat-1.3* Na-141 K-5.0 Cl-94* HCO3-44* AnGap-8 Studies pending at discharge: None Brief Hospital Course: 87 yo F with a history of diastolic heart failure, pulmonary hypertension, chronic kidney disease, and chronic bronchitis admitted with hypercarbic respiratory failure. Hospital course notable for acute renal failure. #Hypoxia/Atypical Pneumonia/Pulmonary hypertension/Chronic Obstructive Pulmonary Disease/Acute on chronic diastolic heart failure/Hypercarbic respiratory failure/Obstructive Sleep Apnea: Patient was initially admitted to the Intensive Care Unit with hypercarbic respiratory which was felt to be due to over oxygenation, and most likely worsening pulmonary hypertension from volume overload and atypical pneumonia. She was diuresed and treated with azithromycin with improvement in her symptoms. She was also seen by the Pulmonary service for evaluation of her pulmonary hypertension and episodes of apnea and they recommended an outpatient sleep study. The patient did well and was transferred from the Intensive Care Unit to the medical floor and improved with antibiotics and further diuresis and was discharged on home oxygen of 2-3L NC. Given that over-ventilation and over-oxygenation was felt to contribute to the patient's hypercarbic respiratory failure and somnolence, the patient should have oxygen for a target oxygen saturation of 89-93%. #Pulmonary nodules: Patient had sputum production and a chest CT which showed 3 left uppe lobe lung nodules that were most likely felt to be infectious. She was ruled out for TB with 3 negative sputa for AFB and patient received course of azithromycin. She should have a follow up CXR in 6 weeks. Patient and son were made aware of this and the importance of follow up. #Acute on chronic diastolic Heart Failure: As above patient was admitted in volume overload. Hospital course was notable for improvement in symptoms with diuresis, but complicated by acute renal failure (see below). Patient was ultimately discharged euvolemic on regimen of Lasix 80mg once daily to keep her euvolemic and TBB even. #Acute on Chronic renal Failure: During diuresis for acute heart failure, patient developed acute renal failure with probable contraction alkalosis. At this point diuresis was stopped, gentle fluids were given, and diuretics were stared when renal function had returned to <Location>69875 Richard Well Apt. 542 New Anthony, FL 27736</Location>. Lisinopril was held and should be started 3 days after discharge at 2.5mg po daily. # Hypertension: Blood pressure was well controlled on home regimen. Diltiazem was continued but Lisinopril was held during acute renal failure. # Diabetes mellitus: HgbA1c 6.5 in 7/<Year>1973</Year>. On glipizide at home. Patient was covered with sliding scale insulin in the hospital. Glipizide can be restarted once renal function stabilizes. # Transitional issues: AFB cultures will need to be followed-up She will need close pulmonary follow-up for repeat imaging in several weeks (fu of pulmonary nodules as well as follow up of her likely COPD, severe pulmonary hypertension, and probable sleep apnea . #Disposition: Patient was discharged to rehab. Medications on Admission: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever or pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Solaraze 3 % Gel Sig: One (1) application Topical twice weekly: apply to affected areas and rub in well twice weekly. 14. iron aspgly&ps-C-B12-FA-Ca-suc <Medical Record Number>64027171</Medical Record Number>-1 mg-mg-mcg-mg Capsule Sig: One (1) Capsule PO twice a day. 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 17. Motrin IB 200 mg Tablet Sig: 1-2 Tablets PO 2x/day for 2 weeks as needed for pain. Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever/pain. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for sputum production/cough. Disp:200 cc Refills:0 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for wheezing/shortness of breath. Disp:30 bullets Refills:0 16. iron aspgly&ps-C-B12-FA-Ca-suc <Medical Record Number>64027171</Medical Record Number>-1 mg-mg-mcg-mg Capsule Sig: One (1) Capsule PO twice a day. 17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 18. sodium chloride 0.65 % Aerosol, Spray Sig: <Date>1-29</Date> Sprays Nasal QID (4 times a day) as needed for nasal dryness. 19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice weekly. Disp:1 Refills:2 Discharge Disposition: Extended Care Facility: <Hospital>Bauer Group Clinic</Hospital> Healthcare Center - <Hospital>Morales, Kemp and Delgado Hospital</Hospital> Discharge Diagnosis: Primary: 1) Acute on Chronic Congestive Heart Failure 2) COPD 3) Pulmonary Hypertension Secondary: 1) Obstructive Sleep Apnea 2) Diabetes Mellitus, Type 2 3) Chronic Kidney Disease 4) Pulmonary nodules/Atypical pneumonia 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 Mrs <Name>Pichardo</Name>: It was a pleasure taking care of you in the hospital during your stay; You were taken care of by a critical care team during your ICU stay and a medicine primary team during your inpatient hospitalization. During your stay you received treatment for congestive heart failure and continued treatment for a possible pneumonia. You will need to continue to restrict your salt intake in order to prevent exacerbations of your heart failure. Additionally, there was significant concern that you have obstructive sleep apnea. You have appointments to see a sleep medicine specialist and a pulmonologist. The following changes were made to your medication regimen: 1) START guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for sputum production/cough 2) START albuterol 0.083% neb solution, 1 nebulizer every 4 hours as needed for shortness of breath or wheezing 3) You may use saline nasal spray as needed for nasal dryness. 4) Your lasix dose was decreased to 80mg once daily (instead of twice per day). . Please try to avoid ibuprofen and other NSAIDs orally if possible because these could further damage your kidneys. Please be sure to weigh yourself every morning and call your primary care doctor if weight is increasing by more than 3 lbs. You may need to have your lasix increased again. Please be sure to keep all of your followup appointments as listed below, including your followup with the cardiologist next week. . No other changes were made to your medications and you should continue to take all your other medications as originally prescribed. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY <Date>1960-12-22</Date> at 3:00 PM With: <Name>Margaret</Name> <Name>Anderson</Name>, NP <Telephone>522-126-1312</Telephone> Building: SC <Hospital>Freeman PLC Health System</Hospital> Clinical Ctr <Location>USCGC Cunningham FPO AA 14691</Location> Campus: EAST Best Parking: <Hospital>Freeman PLC Health System</Hospital> Garage Department: MEDICAL SPECIALTIES/SLEEP MEDICINE When: FRIDAY <Date>1955-10-3</Date> at 2:00 PM With: DR <Name>Kibler</Name> / DR <Name>Miriam</Name> <Telephone>447-973-9274</Telephone> Building: SC <Hospital>Freeman PLC Health System</Hospital> Clinical Ctr <Location>USCGC Cunningham FPO AA 14691</Location> Campus: EAST Best Parking: <Hospital>Freeman PLC Health System</Hospital> Garage Department: PULMONARY FUNCTION LAB When: WEDNESDAY <Date>1918-7-25</Date> at 7:40 AM With: PULMONARY FUNCTION LAB <Telephone>348-826-1564</Telephone> Building: <Hospital>Wilson-Choi Hospital</Hospital> <Location>USCGC Cunningham FPO AA 14691</Location> Campus: EAST Best Parking: <Hospital>Freeman PLC Health System</Hospital> Garage Department: MEDICAL SPECIALTIES/PULMONARY When: WEDNESDAY <Date>1918-7-25</Date> at 8:00 AM With: DR. <Name>Casenhiser</Name> & DR. <Name>Moore</Name> <Telephone>447-973-9274</Telephone> Building: SC <Hospital>Freeman PLC Health System</Hospital> Clinical Ctr <Location>USCGC Cunningham FPO AA 14691</Location> Campus: EAST Best Parking: <Hospital>Freeman PLC Health System</Hospital> Garage Department: WEST <Hospital>Guzman Ltd Medical Center</Hospital> CLINIC When: WEDNESDAY <Date>1932-3-3</Date> at 10:00 AM With: <Name>Odell</Name> <Name>Spikes</Name>, M.D. <Telephone>869-705-4872</Telephone> Building: De <Hospital>Alvarado-Harrington Health System</Hospital> Building (<Hospital>Norton, Patel and Owens Medical Center</Hospital> Complex) <Location>USCGC Cunningham FPO AA 14691</Location> Campus: WEST Best Parking: <Location>PSC 5555, Box 1372 APO AE 04251</Location> Garage Department: <Hospital>Vargas-Robertson Hospital</Hospital> When: FRIDAY <Date>2001-6-30</Date> at 9:30 AM With: <Name>Lorena</Name> <Name>William</Name>, M.D. <Telephone>795-960-1139</Telephone> Building: SC <Hospital>Freeman PLC Health System</Hospital> Clinical Ctr <Location>241 Benjamin Spurs Lanceberg, HI 06134</Location> Campus: EAST Best Parking: <Hospital>Freeman PLC Health System</Hospital> Garage Department: CARDIAC SERVICES When: WEDNESDAY <Date>1961-6-24</Date> at 2:00 PM With: <Name>Margaret</Name> <Name>Cobbs</Name>, MD <Telephone>522-126-1312</Telephone> Building: <Hospital>Wilson-Choi Hospital</Hospital> <Location>USCGC Cunningham FPO AA 14691</Location> Campus: EAST Best Parking: <Hospital>Freeman PLC Health System</Hospital> Garage Completed by:<Date>1955-8-23</Date>	000000000000000001111111110000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111110000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000001111001111100000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000001111100000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000001111000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000111111000000011111101111111111110011111111111100000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111110011111111111111111111111111111111100000000000000000000011111111111100000000111111111111000011111111111111111111111111111111100000000000000000000000000000000000111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1958-1-29 Discharge Date: 1955-8-23 Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Jian Chief Complaint: somnolence Major Surgical or Invasive Procedure: none History of Present Illness: This is an 87 year old lady with a PMH of diastolic heart failure (EF>75%), severe lung disease and resultant pulmonary hypertension, T2DM, obesity, who presents from home with hypoxia and worsening somnolence. Patient reports that since discharge from the hospital on Saturday 2-7, she has had persistent increased sputum which she has difficulty coughing up. She feels like the sputum gets caught in her throat. It is white-clear. She denies fever or chills. She denies worsening dyspnea, but has only ambulated in her house as she hasn't been feeling well. She endorses mild orthopnea. She denies worsening lower extremity edema. Of note, patient was recently admitted for hypoxia with CXR findings of a LUL. She had presented to her cardiologist one week prior to initial admission with complaints of worsening dyspnea and increased sputum production, without fever or leukocytosis. At that time, cardiologist felt that patient was having an acute flare of her chronic bronchitis, and placed her on a one week course of levofloxacin. A CXR was performed at the time to rule out pneumonia which was negative for consolidation. She followed up with the cardiologist NP one week later, and was found to have O2Sats ranging from 68-80% on 3L NC (baseline, home oxygen). She continued to be afebrile without leukocytosis but reported no improvement in sputum production or dyspnea. She was sent to the ER where a repeat CXR showed bilateral upper lobe opacities concerning for pneumonia. She was given ceftriaxone and azithromycin and admitted to the medicine service. Antibiotics were not continued as patient was afebrile, without cough or leukocytosis. Right lower extremity ultrasound was negative for DVT. Patient was discharged home as her oxygen saturations returned to baseline on home 3L NC. Keisha Olles son reports that patient had BCG vaccination in Mexico. He does not know if she was ever exposed to tuberculosis. He does not know of anyone in his family who was exposed to tuberculosis. In the ED inital vitals were 97.4 70 141/47 18 100% Non-Rebreather. ABG 7.35/91/105/46. She was given vanc/cefepime x1. Lung exam c/w decreased breath sounds, tachypneic to low 30s. She was transferred to the Buck and Sons Medical Center for further management. On arrival to the ICU, vital signs were 97.6, 69, 132/56, 18 and 96% on 3LNC. Patient was comfortable and denied any pain. Past Medical History: 1. Falls, multiple noted in OMR & D/C summaries 2. Pulmonary HTN, on 2L/nc @ home, PDA per echo 1958-7-23 3. h/o exudative pleural effusion, treated with talc for pleuredesis (1949-1-8) 4. CHF per Echo (1959-6-1) - Grade I (mild) LV diastolic dysfunction, LV inflow pattern suggests impaired relaxation, - LVEF>55% 5. Mild (1+) AR, trivial MR, trivial TR (Echo 1959-6-1) 6. HTN 7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7 8. Type II DM, %HbA1c 6.3 (2010-4-14) 9. Hyperlipidemia 10. Chronic low back pain, 12. Spinal stenosis, L3-4 & L4-5, per MRI (1987-3-30) 13. Compression fracture of the T3-T4, per CT (1939-11-3) 14. h/o Left knee medial meniscus Hall, Luisa MRI (1968-10-4) 15. Obesity 16. Anemia (baseline ~ 26-30) 17. h/o Rectus sheath hematoma 18. h/o Hemorrhoids 19. h/o UGI Bleed 20. Urinary incontinence 21. Syncope 22. Gallstones, per CT (1970-4-12) 23. Depression . PSHx: - s/p IM nail right humerus (2013-7-8), secondary to fall - s/p Open posterior treatment of cervical fractures at C3, cervical laminectomy at C2-C4, posterior arthrodesis, C3-C4 (2013-7-8), seconadary to fall - s/p EGD(1973) gastritis/duodenitis and HP, rx recommended but no documentation of eradication - s/p MVA (5/1989) - s/p Colonoscopy 1973 (two small adenomas) & 4-4 (2 sessile sigmoid polyps, path: mucosal prolapse) - s/p TAH for fibroids. Social History: Russian-speaking widow (husband An Prieto died of sudden cardiac death 5/1953) who lives alone. Has lived in the United States since ~1973. She worked as a bookkeeper in Mexico. Son Amanda Keisha Olles, 280-320-4968) in area & assists. Son is only relative as daughter died ~1973 of sarcoma. She does not drink or smoke. Ambulates with rolling walker, housing has elevator/no steps. VNA has been involved with HM/HHA Alvarado-Harrington Health System: Sparks, Mcgrath and Conway Clinic Care, Inc. [Phone: (241-721-8268; Fax: (153-376-4810] & Alvarado-Harrington Health System Family & Children??????s Service [382-342-8692]. Denies tobacco use (ever). Denies ETOH use. Family History: Negative for diabetes, cardiac disease, hypertension and cancer with the exception of her daughter who died of a sarcoma. Family history is notable for longevity. Physical Exam: Admission Exam: Vitals: 97.6, 69, 132/56, 18 and 96% on 3LNC General: Alert, oriented, no acute distress, speaking in full sentences without accessory muscle use HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse rales in all lung fields with good air movement bilaterally, no prolonged expiratory phase, no wheezes, no egophany CV: Regular rate and rhythm, fixed split S1 with prominent S2, holosystolic murmur best heard at RUSB radiating to bilateral carotids. Abdomen: +BS, soft, obese, non-tender, no hepatosplenomegaly GU: foley draining clear urine Ext: Warm, well perfused, 2+ DP/PT and radial pulses, 2+ pedal edema bilaterally, no clubbing or cyanosis. Neuro: A+O x3, strength 4/5 bilaterally in upper/lower extremities Discharge exam: unchanged with the exception of: Lungs: CTAB, faint expiratory wheezes in right base Extremeties: 3cm tender compressible lump on left medial wrist Pertinent Results: Admission labs: 1958-1-29 11:59AM BLOOD WBC-5.7 RBC-3.49* Hgb-10.1* Hct-32.1* MCV-92 MCH-28.8 MCHC-31.4 RDW-14.4 Plt Ct-188 1958-1-29 11:59AM BLOOD Neuts-81.5* Lymphs-12.3* Monos-4.2 Eos-1.7 Baso-0.3 1958-1-29 11:59AM BLOOD Glucose-185* UreaN-42* Creat-1.4* Na-143 K-4.4 Cl-92* HCO3-46* AnGap-9 1958-1-29 01:42PM BLOOD pO2-105 pCO2-91* pH-7.35 calTCO2-52* Base XS-19 1958-1-29 08:51PM BLOOD Type-ART pO2-81* pCO2-101* pH-7.32* calTCO2-54* Base XS-19 MICROBIOLOGY: Blood culture x2 (1958-1-29)- no growth, pending final Urine culture (1958-1-29)- no growth, final. Sputum (1981-1-17)- no acif fast bacilli seen on smear, no legionella isolated. Acid fast culture pending Sputum (1949-12-23)- pending 1958-1-29 CXR: IMPRESSION: 1. Worsening multifocal opacification. Recommend clinical correlation for infection, and in the absence of concern for infection, CT of the chest is recommended to exclude the possibility of malignancy. 2. Pulmonary artery enlargement compatible with pulmonary arterial hypertension. 1914-11-17 CXR: IMPRESSION: 1. Cardiomegaly and enlargement of the pulmonary arteries consistent with pulmonary hypertension. 2. No consolidation. No pulmonary edema. 1958-1-29 CT chest w/o contrast: IMPRESSION: 1. Three discrete new irregularly-shaped focal opacities demonstrated within the left upper lobe that, given multiplicity and configuration, are likely related to an active infectious or inflammatory proces, much less likely to be synchronous bronchogenic carcinoma. Differential also includes organizing pneumonia or pseudolymphoma. Recommend followup to resolution with conventional radiographs in six weeks. 2. Moderate cardiomegaly and severe pulmonary hypertension have progressed since 1973. 3. Findings compatible with the sequelae of prior granulomatous exposure Discharge Labs: 1955-8-23 07:20AM BLOOD WBC-4.0 RBC-3.36* Hgb-9.6* Hct-31.2* MCV-93 MCH-28.6 MCHC-30.9* RDW-15.1 Plt Ct-197 1955-8-23 07:20AM BLOOD Glucose-182* UreaN-49* Creat-1.3* Na-141 K-5.0 Cl-94* HCO3-44* AnGap-8 Studies pending at discharge: None Brief Hospital Course: 87 yo F with a history of diastolic heart failure, pulmonary hypertension, chronic kidney disease, and chronic bronchitis admitted with hypercarbic respiratory failure. Hospital course notable for acute renal failure. #Hypoxia/Atypical Pneumonia/Pulmonary hypertension/Chronic Obstructive Pulmonary Disease/Acute on chronic diastolic heart failure/Hypercarbic respiratory failure/Obstructive Sleep Apnea: Patient was initially admitted to the Intensive Care Unit with hypercarbic respiratory which was felt to be due to over oxygenation, and most likely worsening pulmonary hypertension from volume overload and atypical pneumonia. She was diuresed and treated with azithromycin with improvement in her symptoms. She was also seen by the Pulmonary service for evaluation of her pulmonary hypertension and episodes of apnea and they recommended an outpatient sleep study. The patient did well and was transferred from the Intensive Care Unit to the medical floor and improved with antibiotics and further diuresis and was discharged on home oxygen of 2-3L NC. Given that over-ventilation and over-oxygenation was felt to contribute to the patient's hypercarbic respiratory failure and somnolence, the patient should have oxygen for a target oxygen saturation of 89-93%. #Pulmonary nodules: Patient had sputum production and a chest CT which showed 3 left uppe lobe lung nodules that were most likely felt to be infectious. She was ruled out for TB with 3 negative sputa for AFB and patient received course of azithromycin. She should have a follow up CXR in 6 weeks. Patient and son were made aware of this and the importance of follow up. #Acute on chronic diastolic Heart Failure: As above patient was admitted in volume overload. Hospital course was notable for improvement in symptoms with diuresis, but complicated by acute renal failure (see below). Patient was ultimately discharged euvolemic on regimen of Lasix 80mg once daily to keep her euvolemic and TBB even. #Acute on Chronic renal Failure: During diuresis for acute heart failure, patient developed acute renal failure with probable contraction alkalosis. At this point diuresis was stopped, gentle fluids were given, and diuretics were stared when renal function had returned to 69875 Richard Well Apt. 542 New Anthony, FL 27736. Lisinopril was held and should be started 3 days after discharge at 2.5mg po daily. # Hypertension: Blood pressure was well controlled on home regimen. Diltiazem was continued but Lisinopril was held during acute renal failure. # Diabetes mellitus: HgbA1c 6.5 in 7/1973. On glipizide at home. Patient was covered with sliding scale insulin in the hospital. Glipizide can be restarted once renal function stabilizes. # Transitional issues: AFB cultures will need to be followed-up She will need close pulmonary follow-up for repeat imaging in several weeks (fu of pulmonary nodules as well as follow up of her likely COPD, severe pulmonary hypertension, and probable sleep apnea . #Disposition: Patient was discharged to rehab. Medications on Admission: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever or pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Solaraze 3 % Gel Sig: One (1) application Topical twice weekly: apply to affected areas and rub in well twice weekly. 14. iron aspgly&ps-C-B12-FA-Ca-suc 64027171-1 mg-mg-mcg-mg Capsule Sig: One (1) Capsule PO twice a day. 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 17. Motrin IB 200 mg Tablet Sig: 1-2 Tablets PO 2x/day for 2 weeks as needed for pain. Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever/pain. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for sputum production/cough. Disp:200 cc Refills:0 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for wheezing/shortness of breath. Disp:30 bullets Refills:0 16. iron aspgly&ps-C-B12-FA-Ca-suc 64027171-1 mg-mg-mcg-mg Capsule Sig: One (1) Capsule PO twice a day. 17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 18. sodium chloride 0.65 % Aerosol, Spray Sig: 1-29 Sprays Nasal QID (4 times a day) as needed for nasal dryness. 19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice weekly. Disp:1 Refills:2 Discharge Disposition: Extended Care Facility: Bauer Group Clinic Healthcare Center - Morales, Kemp and Delgado Hospital Discharge Diagnosis: Primary: 1) Acute on Chronic Congestive Heart Failure 2) COPD 3) Pulmonary Hypertension Secondary: 1) Obstructive Sleep Apnea 2) Diabetes Mellitus, Type 2 3) Chronic Kidney Disease 4) Pulmonary nodules/Atypical pneumonia 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 Mrs Pichardo: It was a pleasure taking care of you in the hospital during your stay; You were taken care of by a critical care team during your ICU stay and a medicine primary team during your inpatient hospitalization. During your stay you received treatment for congestive heart failure and continued treatment for a possible pneumonia. You will need to continue to restrict your salt intake in order to prevent exacerbations of your heart failure. Additionally, there was significant concern that you have obstructive sleep apnea. You have appointments to see a sleep medicine specialist and a pulmonologist. The following changes were made to your medication regimen: 1) START guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for sputum production/cough 2) START albuterol 0.083% neb solution, 1 nebulizer every 4 hours as needed for shortness of breath or wheezing 3) You may use saline nasal spray as needed for nasal dryness. 4) Your lasix dose was decreased to 80mg once daily (instead of twice per day). . Please try to avoid ibuprofen and other NSAIDs orally if possible because these could further damage your kidneys. Please be sure to weigh yourself every morning and call your primary care doctor if weight is increasing by more than 3 lbs. You may need to have your lasix increased again. Please be sure to keep all of your followup appointments as listed below, including your followup with the cardiologist next week. . No other changes were made to your medications and you should continue to take all your other medications as originally prescribed. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY 1960-12-22 at 3:00 PM With: Margaret Anderson, NP 522-126-1312 Building: SC Freeman PLC Health System Clinical Ctr USCGC Cunningham FPO AA 14691 Campus: EAST Best Parking: Freeman PLC Health System Garage Department: MEDICAL SPECIALTIES/SLEEP MEDICINE When: FRIDAY 1955-10-3 at 2:00 PM With: DR Kibler / DR Miriam 447-973-9274 Building: SC Freeman PLC Health System Clinical Ctr USCGC Cunningham FPO AA 14691 Campus: EAST Best Parking: Freeman PLC Health System Garage Department: PULMONARY FUNCTION LAB When: WEDNESDAY 1918-7-25 at 7:40 AM With: PULMONARY FUNCTION LAB 348-826-1564 Building: Wilson-Choi Hospital USCGC Cunningham FPO AA 14691 Campus: EAST Best Parking: Freeman PLC Health System Garage Department: MEDICAL SPECIALTIES/PULMONARY When: WEDNESDAY 1918-7-25 at 8:00 AM With: DR. Casenhiser & DR. Moore 447-973-9274 Building: SC Freeman PLC Health System Clinical Ctr USCGC Cunningham FPO AA 14691 Campus: EAST Best Parking: Freeman PLC Health System Garage Department: WEST Guzman Ltd Medical Center CLINIC When: WEDNESDAY 1932-3-3 at 10:00 AM With: Odell Spikes, M.D. 869-705-4872 Building: De Alvarado-Harrington Health System Building (Norton, Patel and Owens Medical Center Complex) USCGC Cunningham FPO AA 14691 Campus: WEST Best Parking: PSC 5555, Box 1372 APO AE 04251 Garage Department: Vargas-Robertson Hospital When: FRIDAY 2001-6-30 at 9:30 AM With: Lorena William, M.D. 795-960-1139 Building: SC Freeman PLC Health System Clinical Ctr 241 Benjamin Spurs Lanceberg, HI 06134 Campus: EAST Best Parking: Freeman PLC Health System Garage Department: CARDIAC SERVICES When: WEDNESDAY 1961-6-24 at 2:00 PM With: Margaret Cobbs, MD 522-126-1312 Building: Wilson-Choi Hospital USCGC Cunningham FPO AA 14691 Campus: EAST Best Parking: Freeman PLC Health System Garage Completed by:1955-8-23	["Admission Date: 1958-1-29 Discharge Date: 1955-8-23\n\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Jian\nChief Complaint:\nsomnolence\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\nThis is an 87 year old lady with a PMH of diastolic heart\nfailure (EF>75%), severe lung disease and resultant pulmonary\nhypertension, T2DM, obesity, who presents from home with hypoxia\nand worsening somnolence.\n\nPatient reports that since discharge from the hospital on\nSaturday 2-7, she has had persistent increased sputum which\nshe has difficulty coughing up. She feels like the sputum gets\ncaught in her throat. It is white-clear. She denies fever or\nchills. She denies worsening dyspnea, but has only ambulated in\nher house as she hasn't been feeling well.", ' She endorses mild\northopnea. She denies worsening lower extremity edema.\n\nOf note, patient was recently admitted for hypoxia with CXR\nfindings of a LUL. She had presented to her cardiologist one\nweek prior to initial admission with complaints of worsening\ndyspnea and increased sputum production, without fever or\nleukocytosis. At that time, cardiologist felt that patient was\nhaving an acute flare of her chronic bronchitis, and placed her\non a one week course of levofloxacin. A CXR was performed at\nthe time to rule out pneumonia which was negative for\nconsolidation. She followed up with the cardiologist NP one\nweek later, and was found to have O2Sats ranging from 68-80% on\n3L NC (baseline, home oxygen). She continued to be afebrile\nwithout leukocytosis but reported no improvement in sputum\nproduction or dyspnea.', ' She was sent to the ER where a repeat\nCXR showed bilateral upper lobe opacities concerning for\npneumonia. She was given ceftriaxone and azithromycin and\nadmitted to the medicine service. Antibiotics were not\ncontinued as patient was afebrile, without cough or\nleukocytosis. Right lower extremity ultrasound was negative for\nDVT. Patient was discharged home as her oxygen saturations\nreturned to baseline on home 3L NC.\n\nKeisha Olles son reports that patient had BCG vaccination in\nMexico. He does not know if she was ever exposed to\ntuberculosis. He does not know of anyone in his family who was\nexposed to tuberculosis.\n\nIn the ED inital vitals were 97.4 70 141/47 18 100%\nNon-Rebreather.\nABG 7.35/91/105/46. She was given vanc/cefepime x1. Lung exam\nc/w decreased breath sounds, tachypneic to low 30s.', ' She was\ntransferred to the Buck and Sons Medical Center for further management.\n\nOn arrival to the ICU, vital signs were 97.6, 69, 132/56, 18 and\n96% on 3LNC. Patient was comfortable and denied any pain.\n\nPast Medical History:\n1. Falls, multiple noted in OMR & D/C summaries\n2. Pulmonary HTN, on 2L/nc @ home, PDA per echo 1958-7-23\n3. h/o exudative pleural effusion, treated with talc for\npleuredesis (1949-1-8)\n4. CHF per Echo (1959-6-1) - Grade I (mild) LV diastolic\ndysfunction, LV inflow pattern suggests impaired relaxation, -\nLVEF>55%\n5. Mild (1+) AR, trivial MR, trivial TR (Echo 1959-6-1)\n6. HTN\n7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7\n8. Type II DM, %HbA1c 6.3 (2010-4-14)\n9. Hyperlipidemia\n10. Chronic low back pain,\n12. Spinal stenosis, L3-4 & L4-5, per MRI (1987-3-30)\n13.', ' Compression fracture of the T3-T4, per CT (1939-11-3)\n14. h/o Left knee medial meniscus Hall, Luisa MRI (1968-10-4)\n15. Obesity\n16. Anemia (baseline ~ 26-30)\n17. h/o Rectus sheath hematoma\n18. h/o Hemorrhoids\n19. h/o UGI Bleed\n20. Urinary incontinence\n21. Syncope\n22. Gallstones, per CT (1970-4-12)\n23. Depression\n.\nPSHx:\n- s/p IM nail right humerus (2013-7-8), secondary to fall\n- s/p Open posterior treatment of cervical fractures at C3,\ncervical laminectomy at C2-C4, posterior arthrodesis, C3-C4\n(2013-7-8), seconadary to fall\n- s/p EGD(1973) gastritis/duodenitis and HP, rx recommended but\nno documentation of eradication\n- s/p MVA (5/1989)\n- s/p Colonoscopy 1973 (two small adenomas) & 4-4 (2 sessile\nsigmoid polyps, path: mucosal prolapse)\n- s/p TAH for fibroids.\n\n\nSocial History:\nRussian-speaking widow (husband An Prieto died of sudden cardiac\ndeath 5/1953) who\nlives alone.', ' Has lived in the United States since ~1973. She\nworked as a bookkeeper in Mexico. Son Amanda Keisha Olles,\n280-320-4968) in area & assists. Son is only relative as\ndaughter died ~1973 of sarcoma. She does not drink or smoke.\nAmbulates with rolling walker, housing has elevator/no steps.\nVNA has been involved with HM/HHA Alvarado-Harrington Health System: Sparks, Mcgrath and Conway Clinic\nCare, Inc. [Phone: (241-721-8268; Fax: (153-376-4810] & Alvarado-Harrington Health System\nFamily & Children??????s Service [382-342-8692].\n\nDenies tobacco use (ever). Denies ETOH use.\n\nFamily History:\nNegative for diabetes, cardiac disease, hypertension and cancer\nwith the exception of her daughter who died of a sarcoma.\nFamily history is notable for longevity.\n\n\nPhysical Exam:\nAdmission Exam:\nVitals: 97.', '6, 69, 132/56, 18 and 96% on 3LNC\nGeneral: Alert, oriented, no acute distress, speaking in full\nsentences without accessory muscle use\nHEENT: Sclera anicteric, MMM, oropharynx clear\nNeck: supple, JVP not elevated, no LAD\nLungs: Diffuse rales in all lung fields with good air movement\nbilaterally, no prolonged expiratory phase, no wheezes, no\negophany\nCV: Regular rate and rhythm, fixed split S1 with prominent S2,\nholosystolic murmur best heard at RUSB radiating to bilateral\ncarotids.\nAbdomen: +BS, soft, obese, non-tender, no hepatosplenomegaly\nGU: foley draining clear urine\nExt: Warm, well perfused, 2+ DP/PT and radial pulses, 2+ pedal\nedema bilaterally, no clubbing or cyanosis.\nNeuro: A+O x3, strength 4/5 bilaterally in upper/lower\nextremities\n\nDischarge exam: unchanged with the exception of:\nLungs: CTAB, faint expiratory wheezes in right base\nExtremeties: 3cm tender compressible lump on left medial wrist\n\n\nPertinent Results:\nAdmission labs:\n1958-1-29 11:59AM BLOOD WBC-5.', '7 RBC-3.49* Hgb-10.1* Hct-32.1\nMCV-92 MCH-28.8 MCHC-31.4 RDW-14.4 Plt Ct-188\n1958-1-29 11:59AM BLOOD Neuts-81.5 Lymphs-12.3* Monos-4.2\nEos-1.7 Baso-0.3\n1958-1-29 11:59AM BLOOD Glucose-185* UreaN-42* Creat-1.4* Na-143\nK-4.4 Cl-92* HCO3-46* AnGap-9\n1958-1-29 01:42PM BLOOD pO2-105 pCO2-91* pH-7.35 calTCO2-52* Base\nXS-19\n1958-1-29 08:51PM BLOOD Type-ART pO2-81* pCO2-101* pH-7.32\ncalTCO2-54 Base XS-19\n\nMICROBIOLOGY:\nBlood culture x2 (1958-1-29)- no growth, pending final\nUrine culture (1958-1-29)- no growth, final.\nSputum (1981-1-17)- no acif fast bacilli seen on smear, no\nlegionella isolated. Acid fast culture pending\nSputum (1949-12-23)- pending\n\n1958-1-29 CXR:\nIMPRESSION:\n1. Worsening multifocal opacification. Recommend clinical\ncorrelation for\ninfection, and in the absence of concern for infection, CT of\nthe chest is\nrecommended to exclude the possibility of malignancy.', '\n2. Pulmonary artery enlargement compatible with pulmonary\narterial\nhypertension.\n\n1914-11-17 CXR:\nIMPRESSION:\n1. Cardiomegaly and enlargement of the pulmonary arteries\nconsistent with\npulmonary hypertension.\n2. No consolidation. No pulmonary edema.\n\n1958-1-29 CT chest w/o contrast:\nIMPRESSION:\n1. Three discrete new irregularly-shaped focal opacities\ndemonstrated within the left upper lobe that, given multiplicity\nand configuration, are likely related to an active infectious or\ninflammatory proces, much less likely to be synchronous\nbronchogenic carcinoma. Differential also includes organizing\npneumonia or pseudolymphoma. Recommend followup to resolution\nwith conventional radiographs in six weeks.\n2. Moderate cardiomegaly and severe pulmonary hypertension have\nprogressed\nsince 1973.\n3. Findings compatible with the sequelae of prior granulomatous\nexposure\n\nDischarge Labs:\n1955-8-23 07:20AM BLOOD WBC-4.', '0 RBC-3.36* Hgb-9.6* Hct-31.2\nMCV-93 MCH-28.6 MCHC-30.9 RDW-15.1 Plt Ct-197\n1955-8-23 07:20AM BLOOD Glucose-182* UreaN-49* Creat-1.3* Na-141\nK-5.0 Cl-94* HCO3-44* AnGap-8\n\nStudies pending at discharge:\nNone\n\nBrief Hospital Course:\n87 yo F with a history of diastolic heart failure, pulmonary\nhypertension, chronic kidney disease, and chronic bronchitis\nadmitted with hypercarbic respiratory failure. Hospital course\nnotable for acute renal failure.\n\n#Hypoxia/Atypical Pneumonia/Pulmonary hypertension/Chronic\nObstructive Pulmonary Disease/Acute on chronic diastolic heart\nfailure/Hypercarbic respiratory failure/Obstructive Sleep Apnea:\nPatient was initially admitted to the Intensive Care Unit with\nhypercarbic respiratory which was felt to be due to over\noxygenation, and most likely worsening pulmonary hypertension\nfrom volume overload and atypical pneumonia.', " She was diuresed\nand treated with azithromycin with improvement in her symptoms.\nShe was also seen by the Pulmonary service for evaluation of her\npulmonary hypertension and episodes of apnea and they\nrecommended an outpatient sleep study. The patient did well and\nwas transferred from the Intensive Care Unit to the medical\nfloor and improved with antibiotics and further diuresis and was\ndischarged on home oxygen of 2-3L NC. Given that\nover-ventilation and over-oxygenation was felt to contribute to\nthe patient's hypercarbic respiratory failure and somnolence,\nthe patient should have oxygen for a target oxygen saturation of\n89-93%.\n\n#Pulmonary nodules:\nPatient had sputum production and a chest CT which showed 3 left\nuppe lobe lung nodules that were most likely felt to be\ninfectious. She was ruled out for TB with 3 negative sputa for\nAFB and patient received course of azithromycin.", ' She should have\na follow up CXR in 6 weeks. Patient and son were made aware of\nthis and the importance of follow up.\n\n#Acute on chronic diastolic Heart Failure:\nAs above patient was admitted in volume overload. Hospital\ncourse was notable for improvement in symptoms with diuresis,\nbut complicated by acute renal failure (see below). Patient was\nultimately discharged euvolemic on regimen of Lasix 80mg once\ndaily to keep her euvolemic and TBB even.\n\n#Acute on Chronic renal Failure:\nDuring diuresis for acute heart failure, patient developed acute\nrenal failure with probable contraction alkalosis. At this point\ndiuresis was stopped, gentle fluids were given, and diuretics\nwere stared when renal function had returned to 69875 Richard Well Apt. 542\nNew Anthony, FL 27736.\nLisinopril was held and should be started 3 days after discharge\nat 2.', '5mg po daily.\n\n# Hypertension: Blood pressure was well controlled on home\nregimen. Diltiazem was continued but Lisinopril was held during\nacute renal failure.\n\n# Diabetes mellitus: HgbA1c 6.5 in 7/1973. On glipizide at\nhome. Patient was covered with sliding scale insulin in the\nhospital. Glipizide can be restarted once renal function\nstabilizes.\n\n# Transitional issues:\nAFB cultures will need to be followed-up\nShe will need close pulmonary follow-up for repeat imaging in\nseveral weeks (fu of pulmonary nodules as well as follow up of\nher likely COPD, severe pulmonary hypertension, and probable\nsleep apnea\n.\n#Disposition: Patient was discharged to rehab.\n\n\nMedications on Admission:\n1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a\nday as needed for fever or pain.\n2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\n\ntimes a day).', '\n3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\n4. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)\nCapsule, Extended Release PO DAILY (Daily).\n5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)\nSig: One (1) Capsule, Delayed Release(E.C.) PO once a day.\n6. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.\n7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at\nbedtime).\n8. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)\nTablet Extended Rel 24 hr PO DAILY (Daily).\n9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.\n10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for constipation.\n11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n12. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).', '\n13. Solaraze 3 % Gel Sig: One (1) application Topical twice\nweekly: apply to affected areas and rub in well twice weekly.\n14. iron aspgly&ps-C-B12-FA-Ca-suc 64027171-1 mg-mg-mcg-mg\nCapsule Sig: One (1) Capsule PO twice a day.\n15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\n\nPO DAILY (Daily).\n16. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2)\nCapsule PO once a day.\n17. Motrin IB 200 mg Tablet Sig: 1-2 Tablets PO 2x/day for 2\nweeks as needed for pain.\n\nDischarge Medications:\n1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed for Constipation.\n2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)\nCapsule, Extended Release PO DAILY (Daily).\n4. lisinopril 2.', '5 mg Tablet Sig: One (1) Tablet PO once a day.\n5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)\nSig: One (1) Capsule, Delayed Release(E.C.) PO once a day.\n6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.\n7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at\nbedtime).\n8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a\nday as needed for fever/pain.\n10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)\nTablet Extended Rel 24 hr PO once a day.\n13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a\nday.\n14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every\n6 hours) as needed for sputum production/cough.', '\nDisp:200 cc Refills:0\n15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) neb Inhalation every four (4) hours as\nneeded for wheezing/shortness of breath.\nDisp:30 bullets Refills:0\n16. iron aspgly&ps-C-B12-FA-Ca-suc 64027171-1 mg-mg-mcg-mg\nCapsule Sig: One (1) Capsule PO twice a day.\n17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2)\nCapsule PO once a day.\n18. sodium chloride 0.65 % Aerosol, Spray Sig: 1-29 Sprays Nasal\nQID (4 times a day) as needed for nasal dryness.\n19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice\nweekly.\nDisp:1 Refills:2\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nBauer Group Clinic Healthcare Center - Morales, Kemp and Delgado Hospital\n\nDischarge Diagnosis:\nPrimary:\n1) Acute on Chronic Congestive Heart Failure\n2) COPD\n3) Pulmonary Hypertension\nSecondary:\n1) Obstructive Sleep Apnea\n2) Diabetes Mellitus, Type 2\n3) Chronic Kidney Disease\n4) Pulmonary nodules/Atypical pneumonia\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 Mrs Pichardo:\n\nIt was a pleasure taking care of you in the hospital during your\nstay; You were taken care of by a critical care team during your\nICU stay and a medicine primary team during your inpatient\nhospitalization. During your stay you received treatment for\ncongestive heart failure and continued treatment for a possible\npneumonia. You will need to continue to restrict your salt\nintake in order to prevent exacerbations of your heart failure.\n\nAdditionally, there was significant concern that you have\nobstructive sleep apnea. You have appointments to see a sleep\nmedicine specialist and a pulmonologist.\n\nThe following changes were made to your medication regimen:\n1) START guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO\nQ6H (every 6 hours) as needed for sputum production/cough\n2) START albuterol 0.', '083% neb solution, 1 nebulizer every 4\nhours as needed for shortness of breath or wheezing\n3) You may use saline nasal spray as needed for nasal dryness.\n4) Your lasix dose was decreased to 80mg once daily (instead of\ntwice per day).\n.\nPlease try to avoid ibuprofen and other NSAIDs orally if\npossible because these could further damage your kidneys.\nPlease be sure to weigh yourself every morning and call your\nprimary care doctor if weight is increasing by more than 3 lbs.\nYou may need to have your lasix increased again.\n\nPlease be sure to keep all of your followup appointments as\nlisted below, including your followup with the cardiologist next\nweek.\n.\nNo other changes were made to your medications and you should\ncontinue to take all your other medications as originally\nprescribed.\n\nFollowup Instructions:\nDepartment: CARDIAC SERVICES\nWhen: TUESDAY 1960-12-22 at 3:00 PM\nWith: Margaret Anderson, NP 522-126-1312\nBuilding: SC Freeman PLC Health System Clinical Ctr USCGC Cunningham\nFPO AA 14691\nCampus: EAST Best Parking: Freeman PLC Health System Garage\n\nDepartment: MEDICAL SPECIALTIES/SLEEP MEDICINE\nWhen: FRIDAY 1955-10-3 at 2:00 PM\nWith: DR Kibler / DR Miriam 447-973-9274\nBuilding: SC Freeman PLC Health System Clinical Ctr USCGC Cunningham\nFPO AA 14691\nCampus: EAST Best Parking: Freeman PLC Health System Garage\n\nDepartment: PULMONARY FUNCTION LAB\nWhen: WEDNESDAY 1918-7-25 at 7:40 AM\nWith: PULMONARY FUNCTION LAB 348-826-1564\nBuilding: Wilson-Choi Hospital USCGC Cunningham\nFPO AA 14691\nCampus: EAST Best Parking: Freeman PLC Health System Garage\n\nDepartment: MEDICAL SPECIALTIES/PULMONARY\nWhen: WEDNESDAY 1918-7-25 at 8:00 AM\nWith: DR.', ' Casenhiser & DR. Moore 447-973-9274\nBuilding: SC Freeman PLC Health System Clinical Ctr USCGC Cunningham\nFPO AA 14691\nCampus: EAST Best Parking: Freeman PLC Health System Garage\n\nDepartment: WEST Guzman Ltd Medical Center CLINIC\nWhen: WEDNESDAY 1932-3-3 at 10:00 AM\nWith: Odell Spikes, M.D. 869-705-4872\nBuilding: De Alvarado-Harrington Health System Building (Norton, Patel and Owens Medical Center Complex) USCGC Cunningham\nFPO AA 14691\nCampus: WEST Best Parking: PSC 5555, Box 1372\nAPO AE 04251 Garage\n\nDepartment: Vargas-Robertson Hospital\nWhen: FRIDAY 2001-6-30 at 9:30 AM\nWith: Lorena William, M.D. 795-960-1139\nBuilding: SC Freeman PLC Health System Clinical Ctr 241 Benjamin Spurs\nLanceberg, HI 06134\nCampus: EAST Best Parking: Freeman PLC Health System Garage\n\nDepartment: CARDIAC SERVICES\nWhen: WEDNESDAY 1961-6-24 at 2:00 PM\nWith: Margaret Cobbs, MD 522-126-1312\nBuilding: Wilson-Choi Hospital USCGC Cunningham\nFPO AA 14691\nCampus: EAST Best Parking: Freeman PLC Health System Garage\n\n\n\nCompleted by:1955-8-23']
199	22180	133797.0	2139-12-31	Discharge summary	Report	Admission Date: [2139-12-25] Discharge Date: [2139-12-31] Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name8 (NamePattern2) 1103] Chief Complaint: Right subtrochanteric femur fracture Major Surgical or Invasive Procedure: [2139-12-26] - Trochanteric femoral nail for right subtrochanteric femur fracture History of Present Illness: 87F s/p fall this AM, transferred here from [Hospital3 2005] for R subtrochanteric femoral fx. She states she currently doesn't have any pain. She does not know how she fell. She was found by her aid at home on the floor by her bed. She denies HA, CP, neck pain. She was recently admitted to the MICU for CHF exacerbation from [2139-11-24] to [2139-12-4] Past Medical History: 1. Falls, multiple noted in OMR & D/C summaries 2. Pulmonary HTN, on 2L/nc @ home, PDA per echo [2120-11-5] 3. h/o exudative pleural effusion, treated with talc for pleuredesis ([2128-2-17]) 4. CHF per Echo ([2136-3-26]) - Grade I (mild) LV diastolic dysfunction, LV inflow pattern suggests impaired relaxation, - LVEF>55% 5. Mild (1+) AR, trivial MR, trivial TR (Echo [2136-3-26]) 6. HTN 7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7 8. Type II DM, %HbA1c 6.3 ([2136-2-3]) 9. Hyperlipidemia 10. Chronic low back pain, 12. Spinal stenosis, L3-4 & L4-5, per MRI ([2134-2-27]) 13. Compression fracture of the T3-T4, per CT ([2136-5-22]) 14. h/o Left knee medial meniscus [Last Name (LF) 1994], [First Name3 (LF) ] MRI ([2129-10-26]) 15. Obesity 16. Anemia (baseline ~ 26-30) 17. h/o Rectus sheath hematoma 18. h/o Hemorrhoids 19. h/o UGI Bleed 20. Urinary incontinence 21. Syncope 22. Gallstones, per CT ([2136-4-4]) 23. Depression . <b>PSHx:</b> - s/p IM nail right humerus ([2134-3-2]), secondary to fall - s/p Open posterior treatment of cervical fractures at C3, cervical laminectomy at C2-C4, posterior arthrodesis, C3-C4 ([2134-3-2]), seconadary to fall - s/p EGD([2129]) gastritis/duodenitis and HP, rx recommended but no documentation of eradication - s/p MVA ([12/2127]) - s/p Colonoscopy [2124] (two small adenomas) & [8-28] (2 sessile sigmoid polyps, path: mucosal prolapse) - s/p TAH for fibroids. Social History: Russian-speaking widow (husband [Name (NI) 1995] died of sudden cardiac death [10/2127]) who lives alone. Has lived in the United States since ~[2116]. She worked as a bookkeeper in [Country 532]. Son [First Name8 (NamePattern2) 1975] [Name (NI) ], [Telephone/Fax (1) 1958]) in area & assists. Son is only relative as daughter died ~[2114] of sarcoma. She does not drink or smoke. Ambulates with rolling walker, housing has elevator/no steps. VNA has been involved with HM/HHA [Hospital1 ]: [Hospital6 1952] Care, Inc. [Phone: ([Telephone/Fax (1) 1996]; Fax: ([Telephone/Fax (1) 1997]] & [Hospital1 ] Family & Children??????s Service [[Telephone/Fax (1) 1998]]. Denies tobacco use (ever). Denies ETOH use. Family History: Negative for diabetes, cardiac disease, hypertension and cancer with the exception of her daughter who died of a sarcoma. Family history is notable for longevity. Physical Exam: v/s: 97.8 62 98/50 18 100% 3L Nasal Cannula A&O x 3 Calm and comfortable HEENT: no facial trauma, no cspine tenderness ext: RLE with swelling and firmness at anterior/lateral thigh, no laceration or bruising. 2+ DP and PT pulse. normal sensation of big toe, medial and lateral calf and posterior thigh. normal plantar and dorsiflexion of foot. Pertinent Results: [2139-12-25] 02:50PM WBC-8.4 RBC-2.74* HGB-7.9* HCT-25.7* MCV-94 MCH-28.9 MCHC-30.7* RDW-15.8* [2139-12-25] 02:50PM NEUTS-84.5* LYMPHS-10.2* MONOS-5.1 EOS-0.1 BASOS-0.2 [2139-12-25] 02:50PM GLUCOSE-200* UREA N-39* CREAT-1.7* SODIUM-145 POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-39* ANION GAP-13 [2139-12-25] 02:50PM PLT COUNT-229 Brief Hospital Course: Ms. [Known lastname ] was admitted to the Orthopedic service on [2139-12-25] for a right subtrochanteric femur fracture after being evaluated and treated with closed reduction in the emergency room. She was noted to have a Hct=25.7, with a baseline of 30-32, so she was given 2 units of packed red cells overnight. In addition, she received one dose of kayexalate for hyperkalemia to 5.7 without EKG changes. She underwent open reduction internal fixation of the fracture without complication on [2139-12-26]. Please see operative report for full details. She was extubated without difficulty and transferred to the recovery room in stable condition. In the early post-operative course Ms. [Known lastname ] developed anuria, with a creatinine bump above her baseline, and she was transferred to the TSICU for further monitoring and treatment of her volume status and worsening renal insufficiency. During this time, she was transfused an additional 2 units of packed red cells. She remained in the ICU overnight and eventually showed improvement with good urine output, and was transferred to the floor in stable condition. On hospital day 3 she was transfused an additional 2 units of packed red cells for post-operative anemia. On hospital day 5, she received a visit from the Russian Cardiology Service who recommended restarting her home Lasix, which was done. She continued to make good urine had adequate pain management and worked with physical therapy while in the hospital. The remainder of her hospital course was uneventful and Ms. [Known lastname ] is being discharged to rehab in stable condition. She will follow with both her Cardiologist and Orthopedic trauma team in 4 and 2 weeks, respectively. Medications on Admission: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever/pain. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for sputum production/cough. Disp:200 cc Refills:0 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for wheezing/shortness of breath. Disp:30 bullets Refills:0 16. iron aspgly&ps-C-B12-FA-Ca-suc [Medical Record Number 2001]-1 mg-mg-mcg-mg Capsule Sig: One (1) Capsule PO twice a day. 17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 18. sodium chloride 0.65 % Aerosol, Spray Sig: [12-28] Sprays Nasal QID (4 times a day) as needed for nasal dryness. 19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice weekly. Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. 4. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain for 2 weeks. 5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 13. guaifenesin 100 mg/5 mL Syrup Sig: One Hundred (100) ML PO Q4H (every 4 hours). 14. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day for 4 weeks. 15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: Start 2 weeks post-fracture: [1-9]. 16. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 17. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 18. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) ] Discharge Diagnosis: Right subtrochanteric femur fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Wound Care: - Keep Incision clean and dry. - You can get the wound wet or take a shower starting from 7 days after surgery, but no baths or swimming for at least 4 weeks. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Activity: - Continue to be partial weight bearing on your right leg - You should not lift anything greater than 5 pounds. - Elevate right leg to reduce swelling and pain. Other Instructions Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. - You are being started on a Bisphosphonates to help prevent fragility fractures. Take Alendronate weekly as prescribed. Take first thing in the morning on an empty stomach. Take with at least 8 ox of water. Remain upright for at least 30 minutes. Do not eat, drink or take other medications for at least 30 minutes. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. - If you have questions, concerns or experience any of the below danger signs then please call your doctor at [Telephone/Fax (1) 1228] or go to your local emergency room. Physical Therapy: Activity: Out of bed w/ assist tid Pneumatic boots Right lower extremity: Partial weight bearing Treatments Frequency: Wound care: Site: Right Hip Type: Surgical Dressing: Gauze - dry Change dressing: qd Followup Instructions: Please call the office of Dr. [First Name (STitle) ] to schedule a follow-up appointment with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 2 weeks at [Telephone/Fax (1) 1228]. Please call ([Telephone/Fax (1) 1987] to arrange follow-up with your Cardiologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171] / NP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 1 month. Please follow-up with your primary care physician regarding this admission.	Admission Date: <Date>1900-1-31</Date> Discharge Date: <Date>1961-11-19</Date> Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Rocio</Name> Chief Complaint: Right subtrochanteric femur fracture Major Surgical or Invasive Procedure: <Date>1919-7-20</Date> - Trochanteric femoral nail for right subtrochanteric femur fracture History of Present Illness: 87F s/p fall this AM, transferred here from <Hospital>Quinn and Sons Hospital</Hospital> for R subtrochanteric femoral fx. She states she currently doesn't have any pain. She does not know how she fell. She was found by her aid at home on the floor by her bed. She denies HA, CP, neck pain. She was recently admitted to the MICU for CHF exacerbation from <Date>2003-2-13</Date> to <Date>1995-8-22</Date> Past Medical History: 1. Falls, multiple noted in OMR & D/C summaries 2. Pulmonary HTN, on 2L/nc @ home, PDA per echo <Date>2000-9-27</Date> 3. h/o exudative pleural effusion, treated with talc for pleuredesis (<Date>2014-10-19</Date>) 4. CHF per Echo (<Date>1910-10-7</Date>) - Grade I (mild) LV diastolic dysfunction, LV inflow pattern suggests impaired relaxation, - LVEF>55% 5. Mild (1+) AR, trivial MR, trivial TR (Echo <Date>1910-10-7</Date>) 6. HTN 7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7 8. Type II DM, %HbA1c 6.3 (<Date>1975-12-24</Date>) 9. Hyperlipidemia 10. Chronic low back pain, 12. Spinal stenosis, L3-4 & L4-5, per MRI (<Date>1923-1-24</Date>) 13. Compression fracture of the T3-T4, per CT (<Date>1995-8-17</Date>) 14. h/o Left knee medial meniscus <Name>Londrie</Name>, <Name>Asha</Name> MRI (<Date>1931-1-6</Date>) 15. Obesity 16. Anemia (baseline ~ 26-30) 17. h/o Rectus sheath hematoma 18. h/o Hemorrhoids 19. h/o UGI Bleed 20. Urinary incontinence 21. Syncope 22. Gallstones, per CT (<Date>1997-5-18</Date>) 23. Depression . <b>PSHx:</b> - s/p IM nail right humerus (<Date>1982-12-27</Date>), secondary to fall - s/p Open posterior treatment of cervical fractures at C3, cervical laminectomy at C2-C4, posterior arthrodesis, C3-C4 (<Date>1982-12-27</Date>), seconadary to fall - s/p EGD(<Year>2019</Year>) gastritis/duodenitis and HP, rx recommended but no documentation of eradication - s/p MVA (<Date>5/1925</Date>) - s/p Colonoscopy <Year>2019</Year> (two small adenomas) & <Date>3-30</Date> (2 sessile sigmoid polyps, path: mucosal prolapse) - s/p TAH for fibroids. Social History: Russian-speaking widow (husband <Name>Retha Chin</Name> died of sudden cardiac death <Date>4/2017</Date>) who lives alone. Has lived in the United States since ~<Year>2019</Year>. She worked as a bookkeeper in <Country>Guinea-Bissau</Country>. Son <Name>Chloe</Name> <Name>Kathleen Kobayashi</Name>, <Telephone>247-920-1040</Telephone>) in area & assists. Son is only relative as daughter died ~<Year>2019</Year> of sarcoma. She does not drink or smoke. Ambulates with rolling walker, housing has elevator/no steps. VNA has been involved with HM/HHA <Hospital>Gordon Group Medical Center</Hospital>: <Hospital>Snyder, Pearson and Chan Health System</Hospital> Care, Inc. [Phone: (<Telephone>958-783-1579</Telephone>; Fax: (<Telephone>381-809-7555</Telephone>] & <Hospital>Gordon Group Medical Center</Hospital> Family & Children??????s Service [<Telephone>263-343-7809</Telephone>]. Denies tobacco use (ever). Denies ETOH use. Family History: Negative for diabetes, cardiac disease, hypertension and cancer with the exception of her daughter who died of a sarcoma. Family history is notable for longevity. Physical Exam: v/s: 97.8 62 98/50 18 100% 3L Nasal Cannula A&O x 3 Calm and comfortable HEENT: no facial trauma, no cspine tenderness ext: RLE with swelling and firmness at anterior/lateral thigh, no laceration or bruising. 2+ DP and PT pulse. normal sensation of big toe, medial and lateral calf and posterior thigh. normal plantar and dorsiflexion of foot. Pertinent Results: <Date>1900-1-31</Date> 02:50PM WBC-8.4 RBC-2.74* HGB-7.9* HCT-25.7* MCV-94 MCH-28.9 MCHC-30.7* RDW-15.8* <Date>1900-1-31</Date> 02:50PM NEUTS-84.5* LYMPHS-10.2* MONOS-5.1 EOS-0.1 BASOS-0.2 <Date>1900-1-31</Date> 02:50PM GLUCOSE-200* UREA N-39* CREAT-1.7* SODIUM-145 POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-39* ANION GAP-13 <Date>1900-1-31</Date> 02:50PM PLT COUNT-229 Brief Hospital Course: Ms. <Name>Wilson</Name> was admitted to the Orthopedic service on <Date>1900-1-31</Date> for a right subtrochanteric femur fracture after being evaluated and treated with closed reduction in the emergency room. She was noted to have a Hct=25.7, with a baseline of 30-32, so she was given 2 units of packed red cells overnight. In addition, she received one dose of kayexalate for hyperkalemia to 5.7 without EKG changes. She underwent open reduction internal fixation of the fracture without complication on <Date>1919-7-20</Date>. Please see operative report for full details. She was extubated without difficulty and transferred to the recovery room in stable condition. In the early post-operative course Ms. <Name>Wilson</Name> developed anuria, with a creatinine bump above her baseline, and she was transferred to the TSICU for further monitoring and treatment of her volume status and worsening renal insufficiency. During this time, she was transfused an additional 2 units of packed red cells. She remained in the ICU overnight and eventually showed improvement with good urine output, and was transferred to the floor in stable condition. On hospital day 3 she was transfused an additional 2 units of packed red cells for post-operative anemia. On hospital day 5, she received a visit from the Russian Cardiology Service who recommended restarting her home Lasix, which was done. She continued to make good urine had adequate pain management and worked with physical therapy while in the hospital. The remainder of her hospital course was uneventful and Ms. <Name>Wilson</Name> is being discharged to rehab in stable condition. She will follow with both her Cardiologist and Orthopedic trauma team in 4 and 2 weeks, respectively. Medications on Admission: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever/pain. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for sputum production/cough. Disp:200 cc Refills:0 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for wheezing/shortness of breath. Disp:30 bullets Refills:0 16. iron aspgly&ps-C-B12-FA-Ca-suc <Medical Record Number>43854797</Medical Record Number>-1 mg-mg-mcg-mg Capsule Sig: One (1) Capsule PO twice a day. 17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 18. sodium chloride 0.65 % Aerosol, Spray Sig: <Date>7-12</Date> Sprays Nasal QID (4 times a day) as needed for nasal dryness. 19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice weekly. Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. 4. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain for 2 weeks. 5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 13. guaifenesin 100 mg/5 mL Syrup Sig: One Hundred (100) ML PO Q4H (every 4 hours). 14. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day for 4 weeks. 15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: Start 2 weeks post-fracture: <Date>12-4</Date>. 16. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 17. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 18. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: <Hospital>Manning-Carter Medical Center</Hospital> Healthcare Center - <Location>63597 Christine Springs Suite 052 East Rosemouth, GU 21827</Location> Discharge Diagnosis: Right subtrochanteric femur fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Wound Care: - Keep Incision clean and dry. - You can get the wound wet or take a shower starting from 7 days after surgery, but no baths or swimming for at least 4 weeks. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Activity: - Continue to be partial weight bearing on your right leg - You should not lift anything greater than 5 pounds. - Elevate right leg to reduce swelling and pain. Other Instructions Weigh yourself every morning, <Name>Christian Feudner</Name> MD if weight goes up more than 3 lbs. - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. - You are being started on a Bisphosphonates to help prevent fragility fractures. Take Alendronate weekly as prescribed. Take first thing in the morning on an empty stomach. Take with at least 8 ox of water. Remain upright for at least 30 minutes. Do not eat, drink or take other medications for at least 30 minutes. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on <Hospital>Pace, Walker and Howell Health System</Hospital> 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. - If you have questions, concerns or experience any of the below danger signs then please call your doctor at <Telephone>789-731-3713</Telephone> or go to your local emergency room. Physical Therapy: Activity: Out of bed w/ assist tid Pneumatic boots Right lower extremity: Partial weight bearing Treatments Frequency: Wound care: Site: Right Hip Type: Surgical Dressing: Gauze - dry Change dressing: qd Followup Instructions: Please call the office of Dr. <Name>Hannah</Name> to schedule a follow-up appointment with <Name>Latasha</Name> <Name>Naegelin</Name> in 2 weeks at <Telephone>789-731-3713</Telephone>. Please call (<Telephone>105-626-7392</Telephone> to arrange follow-up with your Cardiologist: Dr. <Name>Latasha</Name> <Name>Thompson</Name> / NP <Name>Latasha</Name> <Name>Naegelin</Name> in 1 month. Please follow-up with your primary care physician regarding this admission.	000000000000000001111111110000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000001111111001111000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000111110000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111110000000000000000000011110000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000011111100000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000011111111111110000000111110111111111111111111001111111111110000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111001111111111111111111111111111111111111100000000000000000000011111111111100000000111111111111000011111111111111111111111111100000000000000000000000000000000000111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1900-1-31 Discharge Date: 1961-11-19 Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:Rocio Chief Complaint: Right subtrochanteric femur fracture Major Surgical or Invasive Procedure: 1919-7-20 - Trochanteric femoral nail for right subtrochanteric femur fracture History of Present Illness: 87F s/p fall this AM, transferred here from Quinn and Sons Hospital for R subtrochanteric femoral fx. She states she currently doesn't have any pain. She does not know how she fell. She was found by her aid at home on the floor by her bed. She denies HA, CP, neck pain. She was recently admitted to the MICU for CHF exacerbation from 2003-2-13 to 1995-8-22 Past Medical History: 1. Falls, multiple noted in OMR & D/C summaries 2. Pulmonary HTN, on 2L/nc @ home, PDA per echo 2000-9-27 3. h/o exudative pleural effusion, treated with talc for pleuredesis (2014-10-19) 4. CHF per Echo (1910-10-7) - Grade I (mild) LV diastolic dysfunction, LV inflow pattern suggests impaired relaxation, - LVEF>55% 5. Mild (1+) AR, trivial MR, trivial TR (Echo 1910-10-7) 6. HTN 7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7 8. Type II DM, %HbA1c 6.3 (1975-12-24) 9. Hyperlipidemia 10. Chronic low back pain, 12. Spinal stenosis, L3-4 & L4-5, per MRI (1923-1-24) 13. Compression fracture of the T3-T4, per CT (1995-8-17) 14. h/o Left knee medial meniscus Londrie, Asha MRI (1931-1-6) 15. Obesity 16. Anemia (baseline ~ 26-30) 17. h/o Rectus sheath hematoma 18. h/o Hemorrhoids 19. h/o UGI Bleed 20. Urinary incontinence 21. Syncope 22. Gallstones, per CT (1997-5-18) 23. Depression . PSHx: - s/p IM nail right humerus (1982-12-27), secondary to fall - s/p Open posterior treatment of cervical fractures at C3, cervical laminectomy at C2-C4, posterior arthrodesis, C3-C4 (1982-12-27), seconadary to fall - s/p EGD(2019) gastritis/duodenitis and HP, rx recommended but no documentation of eradication - s/p MVA (5/1925) - s/p Colonoscopy 2019 (two small adenomas) & 3-30 (2 sessile sigmoid polyps, path: mucosal prolapse) - s/p TAH for fibroids. Social History: Russian-speaking widow (husband Retha Chin died of sudden cardiac death 4/2017) who lives alone. Has lived in the United States since ~2019. She worked as a bookkeeper in Guinea-Bissau. Son Chloe Kathleen Kobayashi, 247-920-1040) in area & assists. Son is only relative as daughter died ~2019 of sarcoma. She does not drink or smoke. Ambulates with rolling walker, housing has elevator/no steps. VNA has been involved with HM/HHA Gordon Group Medical Center: Snyder, Pearson and Chan Health System Care, Inc. [Phone: (958-783-1579; Fax: (381-809-7555] & Gordon Group Medical Center Family & Children??????s Service [263-343-7809]. Denies tobacco use (ever). Denies ETOH use. Family History: Negative for diabetes, cardiac disease, hypertension and cancer with the exception of her daughter who died of a sarcoma. Family history is notable for longevity. Physical Exam: v/s: 97.8 62 98/50 18 100% 3L Nasal Cannula A&O x 3 Calm and comfortable HEENT: no facial trauma, no cspine tenderness ext: RLE with swelling and firmness at anterior/lateral thigh, no laceration or bruising. 2+ DP and PT pulse. normal sensation of big toe, medial and lateral calf and posterior thigh. normal plantar and dorsiflexion of foot. Pertinent Results: 1900-1-31 02:50PM WBC-8.4 RBC-2.74* HGB-7.9* HCT-25.7* MCV-94 MCH-28.9 MCHC-30.7* RDW-15.8* 1900-1-31 02:50PM NEUTS-84.5* LYMPHS-10.2* MONOS-5.1 EOS-0.1 BASOS-0.2 1900-1-31 02:50PM GLUCOSE-200* UREA N-39* CREAT-1.7* SODIUM-145 POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-39* ANION GAP-13 1900-1-31 02:50PM PLT COUNT-229 Brief Hospital Course: Ms. Wilson was admitted to the Orthopedic service on 1900-1-31 for a right subtrochanteric femur fracture after being evaluated and treated with closed reduction in the emergency room. She was noted to have a Hct=25.7, with a baseline of 30-32, so she was given 2 units of packed red cells overnight. In addition, she received one dose of kayexalate for hyperkalemia to 5.7 without EKG changes. She underwent open reduction internal fixation of the fracture without complication on 1919-7-20. Please see operative report for full details. She was extubated without difficulty and transferred to the recovery room in stable condition. In the early post-operative course Ms. Wilson developed anuria, with a creatinine bump above her baseline, and she was transferred to the TSICU for further monitoring and treatment of her volume status and worsening renal insufficiency. During this time, she was transfused an additional 2 units of packed red cells. She remained in the ICU overnight and eventually showed improvement with good urine output, and was transferred to the floor in stable condition. On hospital day 3 she was transfused an additional 2 units of packed red cells for post-operative anemia. On hospital day 5, she received a visit from the Russian Cardiology Service who recommended restarting her home Lasix, which was done. She continued to make good urine had adequate pain management and worked with physical therapy while in the hospital. The remainder of her hospital course was uneventful and Ms. Wilson is being discharged to rehab in stable condition. She will follow with both her Cardiologist and Orthopedic trauma team in 4 and 2 weeks, respectively. Medications on Admission: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever/pain. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for sputum production/cough. Disp:200 cc Refills:0 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for wheezing/shortness of breath. Disp:30 bullets Refills:0 16. iron aspgly&ps-C-B12-FA-Ca-suc 43854797-1 mg-mg-mcg-mg Capsule Sig: One (1) Capsule PO twice a day. 17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 18. sodium chloride 0.65 % Aerosol, Spray Sig: 7-12 Sprays Nasal QID (4 times a day) as needed for nasal dryness. 19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice weekly. Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. 4. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain for 2 weeks. 5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 13. guaifenesin 100 mg/5 mL Syrup Sig: One Hundred (100) ML PO Q4H (every 4 hours). 14. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day for 4 weeks. 15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: Start 2 weeks post-fracture: 12-4. 16. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 17. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 18. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Manning-Carter Medical Center Healthcare Center - 63597 Christine Springs Suite 052 East Rosemouth, GU 21827 Discharge Diagnosis: Right subtrochanteric femur fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Wound Care: - Keep Incision clean and dry. - You can get the wound wet or take a shower starting from 7 days after surgery, but no baths or swimming for at least 4 weeks. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Activity: - Continue to be partial weight bearing on your right leg - You should not lift anything greater than 5 pounds. - Elevate right leg to reduce swelling and pain. Other Instructions Weigh yourself every morning, Christian Feudner MD if weight goes up more than 3 lbs. - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. - You are being started on a Bisphosphonates to help prevent fragility fractures. Take Alendronate weekly as prescribed. Take first thing in the morning on an empty stomach. Take with at least 8 ox of water. Remain upright for at least 30 minutes. Do not eat, drink or take other medications for at least 30 minutes. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on Pace, Walker and Howell Health System 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. - If you have questions, concerns or experience any of the below danger signs then please call your doctor at 789-731-3713 or go to your local emergency room. Physical Therapy: Activity: Out of bed w/ assist tid Pneumatic boots Right lower extremity: Partial weight bearing Treatments Frequency: Wound care: Site: Right Hip Type: Surgical Dressing: Gauze - dry Change dressing: qd Followup Instructions: Please call the office of Dr. Hannah to schedule a follow-up appointment with Latasha Naegelin in 2 weeks at 789-731-3713. Please call (105-626-7392 to arrange follow-up with your Cardiologist: Dr. Latasha Thompson / NP Latasha Naegelin in 1 month. Please follow-up with your primary care physician regarding this admission.	["Admission Date: 1900-1-31 Discharge Date: 1961-11-19\n\n\nService: ORTHOPAEDICS\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Rocio\nChief Complaint:\nRight subtrochanteric femur fracture\n\nMajor Surgical or Invasive Procedure:\n1919-7-20 - Trochanteric femoral nail for right subtrochanteric\nfemur fracture\n\n\nHistory of Present Illness:\n87F s/p fall this AM, transferred here from Quinn and Sons Hospital\nfor R subtrochanteric femoral fx. She states she currently\ndoesn't have any pain. She does not know how she fell. She was\nfound by her aid at home on the floor by her bed. She denies HA,\nCP, neck pain. She was recently admitted to the MICU for CHF\nexacerbation from 2003-2-13 to 1995-8-22\n\n\nPast Medical History:\n1. Falls, multiple noted in OMR & D/C summaries\n2. Pulmonary HTN, on 2L/nc @ home, PDA per echo 2000-9-27\n3.", ' h/o exudative pleural effusion, treated with talc for\npleuredesis (2014-10-19)\n4. CHF per Echo (1910-10-7) - Grade I (mild) LV diastolic\ndysfunction, LV inflow pattern suggests impaired relaxation, -\nLVEF>55%\n5. Mild (1+) AR, trivial MR, trivial TR (Echo 1910-10-7)\n6. HTN\n7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7\n8. Type II DM, %HbA1c 6.3 (1975-12-24)\n9. Hyperlipidemia\n10. Chronic low back pain,\n12. Spinal stenosis, L3-4 & L4-5, per MRI (1923-1-24)\n13. Compression fracture of the T3-T4, per CT (1995-8-17)\n14. h/o Left knee medial meniscus Londrie, Asha MRI (1931-1-6)\n15. Obesity\n16. Anemia (baseline ~ 26-30)\n17. h/o Rectus sheath hematoma\n18. h/o Hemorrhoids\n19. h/o UGI Bleed\n20. Urinary incontinence\n21. Syncope\n22. Gallstones, per CT (1997-5-18)\n23. Depression\n.\nPSHx:\n- s/p IM nail right humerus (1982-12-27), secondary to fall\n- s/p Open posterior treatment of cervical fractures at C3,\ncervical laminectomy at C2-C4, posterior arthrodesis, C3-C4\n(1982-12-27), seconadary to fall\n- s/p EGD(2019) gastritis/duodenitis and HP, rx recommended but\nno documentation of eradication\n- s/p MVA (5/1925)\n- s/p Colonoscopy 2019 (two small adenomas) & 3-30 (2 sessile\nsigmoid polyps, path: mucosal prolapse)\n- s/p TAH for fibroids.', '\n\n\nSocial History:\nRussian-speaking widow (husband Retha Chin died of sudden cardiac\ndeath 4/2017) who\nlives alone. Has lived in the United States since ~2019. She\nworked as a bookkeeper in Guinea-Bissau. Son Chloe Kathleen Kobayashi,\n247-920-1040) in area & assists. Son is only relative as\ndaughter died ~2019 of sarcoma. She does not drink or smoke.\nAmbulates with rolling walker, housing has elevator/no steps.\nVNA has been involved with HM/HHA Gordon Group Medical Center: Snyder, Pearson and Chan Health System\nCare, Inc. [Phone: (958-783-1579; Fax: (381-809-7555] & Gordon Group Medical Center\nFamily & Children??????s Service [263-343-7809].\n\nDenies tobacco use (ever). Denies ETOH use.\n\n\nFamily History:\nNegative for diabetes, cardiac disease, hypertension and cancer\nwith the exception of her daughter who died of a sarcoma.', '\nFamily history is notable for longevity.\n\n\nPhysical Exam:\nv/s: 97.8 62 98/50 18 100% 3L Nasal Cannula\nA&O x 3\nCalm and comfortable\nHEENT: no facial trauma, no cspine tenderness\next: RLE with swelling and firmness at anterior/lateral thigh,\nno\nlaceration or bruising. 2+ DP and PT pulse. normal sensation of\nbig toe, medial and lateral calf and posterior thigh. normal\nplantar and dorsiflexion of foot.\n\nPertinent Results:\n1900-1-31 02:50PM WBC-8.4 RBC-2.74* HGB-7.9* HCT-25.7* MCV-94\nMCH-28.9 MCHC-30.7* RDW-15.8\n1900-1-31 02:50PM NEUTS-84.5 LYMPHS-10.2* MONOS-5.1 EOS-0.1\nBASOS-0.2\n1900-1-31 02:50PM GLUCOSE-200* UREA N-39* CREAT-1.7* SODIUM-145\nPOTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-39* ANION GAP-13\n1900-1-31 02:50PM PLT COUNT-229\n\nBrief Hospital Course:\nMs. Wilson was admitted to the Orthopedic service on 1900-1-31\nfor a right subtrochanteric femur fracture after being evaluated\nand treated with closed reduction in the emergency room.', ' She was\nnoted to have a Hct=25.7, with a baseline of 30-32, so she was\ngiven 2 units of packed red cells overnight. In addition, she\nreceived one dose of kayexalate for hyperkalemia to 5.7 without\nEKG changes. She underwent open reduction internal fixation of\nthe fracture without complication on 1919-7-20. Please see\noperative report for full details. She was extubated without\ndifficulty and transferred to the recovery room in stable\ncondition. In the early post-operative course Ms. Wilson\ndeveloped anuria, with a creatinine bump above her baseline, and\nshe was transferred to the TSICU for further monitoring and\ntreatment of her volume status and worsening renal\ninsufficiency. During this time, she was transfused an\nadditional 2 units of packed red cells. She remained in the ICU\novernight and eventually showed improvement with good urine\noutput, and was transferred to the floor in stable condition.', '\n\nOn hospital day 3 she was transfused an additional 2 units of\npacked red cells for post-operative anemia. On hospital day 5,\nshe received a visit from the Russian Cardiology Service who\nrecommended restarting her home Lasix, which was done.\n\nShe continued to make good urine had adequate pain management\nand worked with physical therapy while in the hospital. The\nremainder of her hospital course was uneventful and Ms.\nWilson is being discharged to rehab in stable condition. She\nwill follow with both her Cardiologist and Orthopedic trauma\nteam in 4 and 2 weeks, respectively.\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. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)\nCapsule, Extended Release PO DAILY (Daily).', '\n4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.\n5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)\nSig: One (1) Capsule, Delayed Release(E.C.) PO once a day.\n6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.\n7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at\nbedtime).\n8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\n\ntimes a day).\n9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a\nday as needed for fever/pain.\n10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)\nTablet Extended Rel 24 hr PO once a day.\n13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a\nday.\n14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every\n\n6 hours) as needed for sputum production/cough.', '\nDisp:200 cc Refills:0\n15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) neb Inhalation every four (4) hours as\n\nneeded for wheezing/shortness of breath.\nDisp:30 bullets Refills:0\n16. iron aspgly&ps-C-B12-FA-Ca-suc 43854797-1 mg-mg-mcg-mg\nCapsule Sig: One (1) Capsule PO twice a day.\n17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2)\nCapsule PO once a day.\n18. sodium chloride 0.65 % Aerosol, Spray Sig: 7-12 Sprays Nasal\nQID (4 times a day) as needed for nasal dryness.\n19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice\nweekly.\n\n\nDischarge Medications:\n1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).\n2. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4\nhours) as needed for pain.', '\n3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three\ntimes a day for 2 weeks.\n4. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)\nas needed for pain for 2 weeks.\n5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at\nbedtime).\n6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n9. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\n10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)\nTablet PO DAILY (Daily).\n12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)\nas needed for constipation.\n13.', ' guaifenesin 100 mg/5 mL Syrup Sig: One Hundred (100) ML PO\nQ4H (every 4 hours).\n14. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once\na day for 4 weeks.\n15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:\nStart 2 weeks post-fracture: 12-4.\n16. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).\n17. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).\n18. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)\nCapsule, Extended Release PO DAILY (Daily).\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nManning-Carter Medical Center Healthcare Center - 63597 Christine Springs Suite 052\nEast Rosemouth, GU 21827\n\nDischarge Diagnosis:\nRight subtrochanteric femur fracture\n\n\nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic but arousable.', '\nActivity Status: Out of Bed with assistance to chair or\nwheelchair.\n\n\nDischarge Instructions:\nWound Care:\n- Keep Incision clean and dry.\n- You can get the wound wet or take a shower starting from 7\ndays after surgery, but no baths or swimming for at least 4\nweeks.\n- Dry sterile dresssing may be changed daily. No dressing is\nneeded if wound continues to be non-draining.\n- Any stitches or staples that need to be removed will be taken\nout at your 2-week follow up appointment.\nActivity:\n- Continue to be partial weight bearing on your right leg\n- You should not lift anything greater than 5 pounds.\n- Elevate right leg to reduce swelling and pain.\nOther Instructions\nWeigh yourself every morning, Christian Feudner MD if weight goes up more\nthan 3 lbs.\n- Resume your regular diet.\n- Avoid nicotine products to optimize healing.', '\n- Resume your home medications. Take all medications as\ninstructed.\n- Continue taking the Lovenox to prevent blood clots.\n- You are being started on a Bisphosphonates to help prevent\nfragility fractures. Take Alendronate weekly as prescribed. Take\nfirst thing in the morning on an empty stomach. Take with at\nleast 8 ox of water. Remain upright for at least 30 minutes. Do\nnot eat, drink or take other medications for at least 30\nminutes.\n- You have also been given Additional Medications to control\nyour pain. Please allow 72 hours for refill of narcotic\nprescriptions, so plan ahead. You can either have them mailed\nto your home or pick them up at the clinic located on Pace, Walker and Howell Health System 2.\n We are not allowed to call in narcotic (oxycontin, oxycodone,\npercocet) prescriptions to the pharmacy.', ' In addition, we are\nonly allowed to write for pain medications for 90 days from the\ndate of surgery.\n- Narcotic pain medication may cause drowsiness. Do not drink\nalcohol while taking narcotic medications. Do not operate any\nmotor vehicle or machinery while taking narcotic pain\nmedications. Taking more than recommended may cause serious\nbreathing problems.\n- If you have questions, concerns or experience any of the below\ndanger signs then please call your doctor at 789-731-3713 or go\nto your local emergency room.\n\nPhysical Therapy:\nActivity: Out of bed w/ assist tid\n Pneumatic boots\n Right lower extremity: Partial weight bearing\n\nTreatments Frequency:\n Wound care:\n Site: Right Hip\n Type: Surgical\n Dressing: Gauze - dry\n Change dressing: qd\n\n\nFollowup Instructions:\nPlease call the office of Dr.', ' Hannah to schedule a follow-up\nappointment with Latasha Naegelin in 2 weeks at 789-731-3713.\n\nPlease call (105-626-7392 to arrange follow-up with your\nCardiologist: Dr. Latasha Thompson / NP Latasha Naegelin in 1 month.\n\nPlease follow-up with your primary care physician regarding this\nadmission.\n\n\n\n']
200	9487	112385.0	2138-12-12	Discharge summary	Report	Admission Date: [2138-12-2] Discharge Date: [2138-12-12] Date of Birth: [2071-12-12] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: This is a 66-year-old man with a past medical history significant for coronary artery disease, status post coronary artery bypass grafting in [2128-10-21], at which time they performed a left internal mammary artery to the left anterior descending, saphenous vein graft to the OM-I and OM-II sequential and saphenous vein graft to the PDA. He is also status post stenting of his saphenous vein graft to the OM-I, OM-II territory in [2135-3-21], and PTCA and brachytherapy to the saphenous vein graft to the OM-I, OM-II in [2137-12-21]. The patient also has a past medical history significant for insulin-dependent diabetes mellitus, hypertension, hypercholesterolemia, depression, mild dementia, history of TIA, status post bilateral carotid endarterectomies in [2134]. The patient is a 66-year-old male with a long-standing history of coronary artery disease, who was admitted [2138-12-2] due to unstable angina with a troponin level ranging between 4.5 and 5.9. Cardiac catheterization was performed on [2138-12-2] which revealed a patent left internal mammary artery graft, occluded OM-1 and OM-2 graft, and a 90% occlusion in the in-stented segment of the PDA. The last echocardiogram was performed in [2137-5-21] which revealed a left ventricular ejection fraction of 40%. ADMISSION MEDICATIONS: 1. Atenolol 50 mg p.o. q.d. 2. Lipitor 40 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Aricept 5 mg p.o. q.d. 5. Zestril 20 mg p.o. q.d. 6. Metformin 850 mg b.i.d. 7. Terazosin 5 mg q.h.s. 8. Paxil 5 mg p.o. q.d. 9. Buspar 15 mg t.i.d. 10. Depakote 750 mg b.i.d. 11. Vitamin E. 12. Nitroglycerin patch. 13. Plavix which is being held. 14. NPH insulin 12 units q.a.m., 8 units q.p.m., regular insulin 4 units q.a.m. HOSPITAL COURSE: An off-pump redo coronary artery bypass grafting was performed on [2138-12-8]. It was a coronary artery bypass grafting times one with the saphenous vein graft to the obtuse marginal via left thoracotomy incision. The patient was transferred to the Cardiac Surgery Recovery Unit in stable condition on Neo-Synephrine at 0.6 micrograms per kilogram per minute and propofol in normal sinus rhythm at 57 beats per minute. He was extubated the same day of surgery without any incidents around 6:00 p.m. On postoperative day number one, the patient had a low-grade temperature at 100.3 in sinus rhythm at 88. The vital signs were stable. The white count was 9.1, hematocrit 31.3, platelet count 147,000 with an unremarkable physical examination. The plan was to continue to keep his blood pressure down on Nipride and to start the patient on his p.o. medications as well as his p.o. diet. If able to wean off the Nipride, the plan was to transfer the patient to the floor. On postoperative day number two, the patient was mildly disoriented, however, calm without complaints with his pain well controlled. He was still with a low-grade temperature of 100.1 in sinus rhythm at 88, mildly hypertensive at 170/88. On physical examination, he had mild crackles bilaterally, otherwise his examination was benign. The plan was just to continue monitor his mental status and pain control. On postoperative day number three, the patient was still without complaints, however, still requiring a sitter for his disorientation. Currently, afebrile. The vital signs were stable, saturating at 94% on room air. The physical examination was benign. The plan was to go for a cardiac catheterization this morning with a possible PTCA with plus or minus stenting of the stenotic area. He did undergo cardiac catheterization on [2138-12-11] which now revealed a saphenous vein graft to the obtuse marginal patent and a saphenous vein graft to the posterior descending artery with a 90% distal stenosis with a 3 by 13 mm stent with distal protection and 0% residual with normal flow. The plan was to continue the patient on aspirin and Plavix 75 mg p.o. daily for 30 days and to administer Integrelin overnight. The anticipated date of discharge is [2138-12-12]. The patient is to be discharged home on the following medications. DISCHARGE MEDICATIONS: 1. Metformin 850 mg p.o. b.i.d. 2. Lisinopril 2.5 mg p.o. q.d. 3. Sliding scale of insulin. 4. Metoprolol 50 mg p.o. b.i.d. 5. Divalproex 500 mg p.o. b.i.d. 6. Buspar 15 mg p.o. t.i.d. 7. Paxil 5 mg p.o. q.d. 8. Atrovastatin 40 mg p.o. q.d. 9. Plavix 75 mg p.o. q.d. for three months. 10. Donepezil 5 mg p.o. q.h.s. 11. Dulcolax, milk of magnesia, p.r.n. 12. Percocet 5 one to two tablets p.o. q. 4-6 hours p.r.n. pain. 13. NPH 3 units at breakfast, 4 units at bedtime. 14. Ibuprofen 400 mg q.i.d. 15. Acetaminophen 650 mg q. four hours p.r.n. 16. Aspirin 325 mg p.o. q.d. 17. Colace 100 mg p.o. b.i.d. 18. Lasix 20 mg p.o. b.i.d. 19. Potassium chloride 20 mEq p.o. q.d. PLAN: The plan is for the patient to arrange a follow-up visit with Dr. [Last Name (STitle) 1537] in one month, Dr. [Last Name (STitle) 120] in one month, and his primary care physician in two to four weeks. CONDITION AT DISCHARGE: Good. DISCHARGE DIAGNOSIS: Coronary artery disease, status post re-do off-pump coronary artery bypass grafting times one. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Doctor Last Name 2011] MEDQUIST36 D: [2138-12-12] 13:20 T: [2138-12-14] 15:05 JOB#: [Job Number 2012]	Admission Date: <Date>1906-11-5</Date> Discharge Date: <Date>1942-8-3</Date> Date of Birth: <Date>2005-7-10</Date> Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: This is a 66-year-old man with a past medical history significant for coronary artery disease, status post coronary artery bypass grafting in <Date>1991-6-10</Date>, at which time they performed a left internal mammary artery to the left anterior descending, saphenous vein graft to the OM-I and OM-II sequential and saphenous vein graft to the PDA. He is also status post stenting of his saphenous vein graft to the OM-I, OM-II territory in <Date>1979-3-2</Date>, and PTCA and brachytherapy to the saphenous vein graft to the OM-I, OM-II in <Date>2021-2-6</Date>. The patient also has a past medical history significant for insulin-dependent diabetes mellitus, hypertension, hypercholesterolemia, depression, mild dementia, history of TIA, status post bilateral carotid endarterectomies in <Year>1975</Year>. The patient is a 66-year-old male with a long-standing history of coronary artery disease, who was admitted <Date>1906-11-5</Date> due to unstable angina with a troponin level ranging between 4.5 and 5.9. Cardiac catheterization was performed on <Date>1906-11-5</Date> which revealed a patent left internal mammary artery graft, occluded OM-1 and OM-2 graft, and a 90% occlusion in the in-stented segment of the PDA. The last echocardiogram was performed in <Date>1992-10-18</Date> which revealed a left ventricular ejection fraction of 40%. ADMISSION MEDICATIONS: 1. Atenolol 50 mg p.o. q.d. 2. Lipitor 40 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Aricept 5 mg p.o. q.d. 5. Zestril 20 mg p.o. q.d. 6. Metformin 850 mg b.i.d. 7. Terazosin 5 mg q.h.s. 8. Paxil 5 mg p.o. q.d. 9. Buspar 15 mg t.i.d. 10. Depakote 750 mg b.i.d. 11. Vitamin E. 12. Nitroglycerin patch. 13. Plavix which is being held. 14. NPH insulin 12 units q.a.m., 8 units q.p.m., regular insulin 4 units q.a.m. HOSPITAL COURSE: An off-pump redo coronary artery bypass grafting was performed on <Date>2017-7-27</Date>. It was a coronary artery bypass grafting times one with the saphenous vein graft to the obtuse marginal via left thoracotomy incision. The patient was transferred to the Cardiac Surgery Recovery Unit in stable condition on Neo-Synephrine at 0.6 micrograms per kilogram per minute and propofol in normal sinus rhythm at 57 beats per minute. He was extubated the same day of surgery without any incidents around 6:00 p.m. On postoperative day number one, the patient had a low-grade temperature at 100.3 in sinus rhythm at 88. The vital signs were stable. The white count was 9.1, hematocrit 31.3, platelet count 147,000 with an unremarkable physical examination. The plan was to continue to keep his blood pressure down on Nipride and to start the patient on his p.o. medications as well as his p.o. diet. If able to wean off the Nipride, the plan was to transfer the patient to the floor. On postoperative day number two, the patient was mildly disoriented, however, calm without complaints with his pain well controlled. He was still with a low-grade temperature of 100.1 in sinus rhythm at 88, mildly hypertensive at 170/88. On physical examination, he had mild crackles bilaterally, otherwise his examination was benign. The plan was just to continue monitor his mental status and pain control. On postoperative day number three, the patient was still without complaints, however, still requiring a sitter for his disorientation. Currently, afebrile. The vital signs were stable, saturating at 94% on room air. The physical examination was benign. The plan was to go for a cardiac catheterization this morning with a possible PTCA with plus or minus stenting of the stenotic area. He did undergo cardiac catheterization on <Date>1924-7-17</Date> which now revealed a saphenous vein graft to the obtuse marginal patent and a saphenous vein graft to the posterior descending artery with a 90% distal stenosis with a 3 by 13 mm stent with distal protection and 0% residual with normal flow. The plan was to continue the patient on aspirin and Plavix 75 mg p.o. daily for 30 days and to administer Integrelin overnight. The anticipated date of discharge is <Date>1942-8-3</Date>. The patient is to be discharged home on the following medications. DISCHARGE MEDICATIONS: 1. Metformin 850 mg p.o. b.i.d. 2. Lisinopril 2.5 mg p.o. q.d. 3. Sliding scale of insulin. 4. Metoprolol 50 mg p.o. b.i.d. 5. Divalproex 500 mg p.o. b.i.d. 6. Buspar 15 mg p.o. t.i.d. 7. Paxil 5 mg p.o. q.d. 8. Atrovastatin 40 mg p.o. q.d. 9. Plavix 75 mg p.o. q.d. for three months. 10. Donepezil 5 mg p.o. q.h.s. 11. Dulcolax, milk of magnesia, p.r.n. 12. Percocet 5 one to two tablets p.o. q. 4-6 hours p.r.n. pain. 13. NPH 3 units at breakfast, 4 units at bedtime. 14. Ibuprofen 400 mg q.i.d. 15. Acetaminophen 650 mg q. four hours p.r.n. 16. Aspirin 325 mg p.o. q.d. 17. Colace 100 mg p.o. b.i.d. 18. Lasix 20 mg p.o. b.i.d. 19. Potassium chloride 20 mEq p.o. q.d. PLAN: The plan is for the patient to arrange a follow-up visit with Dr. <Name>Tamaro</Name> in one month, Dr. <Name>Bludsworth</Name> in one month, and his primary care physician in two to four weeks. CONDITION AT DISCHARGE: Good. DISCHARGE DIAGNOSIS: Coronary artery disease, status post re-do off-pump coronary artery bypass grafting times one. <Name>Danilo</Name> <Name>Deng</Name>, M.D. <MD Number>06468494</MD Number> Dictated By:<Doctor Name>Dr.Deng</Doctor Name> MEDQUIST36 D: <Date>1942-8-3</Date> 13:20 T: <Date>1982-1-25</Date> 15:05 JOB#: <Job Number>Mitchell, Salas and Jackson-2001-209022</Job 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00111111000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111011110000000011111111000000000000001111111000000000000000000111111110000000000001111111110000000000000001111111111111111111111111111111111111110	Admission Date: 1906-11-5 Discharge Date: 1942-8-3 Date of Birth: 2005-7-10 Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: This is a 66-year-old man with a past medical history significant for coronary artery disease, status post coronary artery bypass grafting in 1991-6-10, at which time they performed a left internal mammary artery to the left anterior descending, saphenous vein graft to the OM-I and OM-II sequential and saphenous vein graft to the PDA. He is also status post stenting of his saphenous vein graft to the OM-I, OM-II territory in 1979-3-2, and PTCA and brachytherapy to the saphenous vein graft to the OM-I, OM-II in 2021-2-6. The patient also has a past medical history significant for insulin-dependent diabetes mellitus, hypertension, hypercholesterolemia, depression, mild dementia, history of TIA, status post bilateral carotid endarterectomies in 1975. The patient is a 66-year-old male with a long-standing history of coronary artery disease, who was admitted 1906-11-5 due to unstable angina with a troponin level ranging between 4.5 and 5.9. Cardiac catheterization was performed on 1906-11-5 which revealed a patent left internal mammary artery graft, occluded OM-1 and OM-2 graft, and a 90% occlusion in the in-stented segment of the PDA. The last echocardiogram was performed in 1992-10-18 which revealed a left ventricular ejection fraction of 40%. ADMISSION MEDICATIONS: 1. Atenolol 50 mg p.o. q.d. 2. Lipitor 40 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Aricept 5 mg p.o. q.d. 5. Zestril 20 mg p.o. q.d. 6. Metformin 850 mg b.i.d. 7. Terazosin 5 mg q.h.s. 8. Paxil 5 mg p.o. q.d. 9. Buspar 15 mg t.i.d. 10. Depakote 750 mg b.i.d. 11. Vitamin E. 12. Nitroglycerin patch. 13. Plavix which is being held. 14. NPH insulin 12 units q.a.m., 8 units q.p.m., regular insulin 4 units q.a.m. HOSPITAL COURSE: An off-pump redo coronary artery bypass grafting was performed on 2017-7-27. It was a coronary artery bypass grafting times one with the saphenous vein graft to the obtuse marginal via left thoracotomy incision. The patient was transferred to the Cardiac Surgery Recovery Unit in stable condition on Neo-Synephrine at 0.6 micrograms per kilogram per minute and propofol in normal sinus rhythm at 57 beats per minute. He was extubated the same day of surgery without any incidents around 6:00 p.m. On postoperative day number one, the patient had a low-grade temperature at 100.3 in sinus rhythm at 88. The vital signs were stable. The white count was 9.1, hematocrit 31.3, platelet count 147,000 with an unremarkable physical examination. The plan was to continue to keep his blood pressure down on Nipride and to start the patient on his p.o. medications as well as his p.o. diet. If able to wean off the Nipride, the plan was to transfer the patient to the floor. On postoperative day number two, the patient was mildly disoriented, however, calm without complaints with his pain well controlled. He was still with a low-grade temperature of 100.1 in sinus rhythm at 88, mildly hypertensive at 170/88. On physical examination, he had mild crackles bilaterally, otherwise his examination was benign. The plan was just to continue monitor his mental status and pain control. On postoperative day number three, the patient was still without complaints, however, still requiring a sitter for his disorientation. Currently, afebrile. The vital signs were stable, saturating at 94% on room air. The physical examination was benign. The plan was to go for a cardiac catheterization this morning with a possible PTCA with plus or minus stenting of the stenotic area. He did undergo cardiac catheterization on 1924-7-17 which now revealed a saphenous vein graft to the obtuse marginal patent and a saphenous vein graft to the posterior descending artery with a 90% distal stenosis with a 3 by 13 mm stent with distal protection and 0% residual with normal flow. The plan was to continue the patient on aspirin and Plavix 75 mg p.o. daily for 30 days and to administer Integrelin overnight. The anticipated date of discharge is 1942-8-3. The patient is to be discharged home on the following medications. DISCHARGE MEDICATIONS: 1. Metformin 850 mg p.o. b.i.d. 2. Lisinopril 2.5 mg p.o. q.d. 3. Sliding scale of insulin. 4. Metoprolol 50 mg p.o. b.i.d. 5. Divalproex 500 mg p.o. b.i.d. 6. Buspar 15 mg p.o. t.i.d. 7. Paxil 5 mg p.o. q.d. 8. Atrovastatin 40 mg p.o. q.d. 9. Plavix 75 mg p.o. q.d. for three months. 10. Donepezil 5 mg p.o. q.h.s. 11. Dulcolax, milk of magnesia, p.r.n. 12. Percocet 5 one to two tablets p.o. q. 4-6 hours p.r.n. pain. 13. NPH 3 units at breakfast, 4 units at bedtime. 14. Ibuprofen 400 mg q.i.d. 15. Acetaminophen 650 mg q. four hours p.r.n. 16. Aspirin 325 mg p.o. q.d. 17. Colace 100 mg p.o. b.i.d. 18. Lasix 20 mg p.o. b.i.d. 19. Potassium chloride 20 mEq p.o. q.d. PLAN: The plan is for the patient to arrange a follow-up visit with Dr. Tamaro in one month, Dr. Bludsworth in one month, and his primary care physician in two to four weeks. CONDITION AT DISCHARGE: Good. DISCHARGE DIAGNOSIS: Coronary artery disease, status post re-do off-pump coronary artery bypass grafting times one. Danilo Deng, M.D. 06468494 Dictated By:Dr.Deng MEDQUIST36 D: 1942-8-3 13:20 T: 1982-1-25 15:05 JOB#: Mitchell, Salas and Jackson-2001-209022	['Admission Date: 1906-11-5 Discharge Date: 1942-8-3\n\nDate of Birth: 2005-7-10 Sex: M\n\nService: CARDIOTHORACIC SURGERY\n\nHISTORY OF THE PRESENT ILLNESS: This is a 66-year-old man\nwith a past medical history significant for coronary artery\ndisease, status post coronary artery bypass grafting in\n1991-6-10, at which time they performed a left internal\nmammary artery to the left anterior descending, saphenous\nvein graft to the OM-I and OM-II sequential and saphenous\nvein graft to the PDA. He is also status post stenting of\nhis saphenous vein graft to the OM-I, OM-II territory in\n1979-3-2, and PTCA and brachytherapy to the saphenous\nvein graft to the OM-I, OM-II in 2021-2-6. The\npatient also has a past medical history significant for\ninsulin-dependent diabetes mellitus, hypertension,\nhypercholesterolemia, depression, mild dementia, history of\nTIA, status post bilateral carotid endarterectomies in 1975.', '\n\nThe patient is a 66-year-old male with a long-standing\nhistory of coronary artery disease, who was admitted 1906-11-5 due to unstable angina with a troponin level ranging\nbetween 4.5 and 5.9. Cardiac catheterization was performed\non 1906-11-5 which revealed a patent left internal\nmammary artery graft, occluded OM-1 and OM-2 graft, and a 90%\nocclusion in the in-stented segment of the PDA. The last\nechocardiogram was performed in 1992-10-18 which revealed a\nleft ventricular ejection fraction of 40%.\n\nADMISSION MEDICATIONS:\n1. Atenolol 50 mg p.o. q.d.\n2. Lipitor 40 mg p.o. q.d.\n3. Aspirin 325 mg p.o. q.d.\n4. Aricept 5 mg p.o. q.d.\n5. Zestril 20 mg p.o. q.d.\n6. Metformin 850 mg b.i.d.\n7. Terazosin 5 mg q.h.s.\n8. Paxil 5 mg p.o. q.d.\n9. Buspar 15 mg t.i.d.\n10. Depakote 750 mg b.i.d.', '\n11. Vitamin E.\n12. Nitroglycerin patch.\n13. Plavix which is being held.\n14. NPH insulin 12 units q.a.m., 8 units q.p.m., regular\ninsulin 4 units q.a.m.\n\nHOSPITAL COURSE: An off-pump redo coronary artery bypass\ngrafting was performed on 2017-7-27. It was a\ncoronary artery bypass grafting times one with the saphenous\nvein graft to the obtuse marginal via left thoracotomy\nincision.\n\nThe patient was transferred to the Cardiac Surgery Recovery\nUnit in stable condition on Neo-Synephrine at 0.6 micrograms\nper kilogram per minute and propofol in normal sinus rhythm\nat 57 beats per minute. He was extubated the same day of\nsurgery without any incidents around 6:00 p.m.\n\nOn postoperative day number one, the patient had a low-grade\ntemperature at 100.3 in sinus rhythm at 88. The vital signs\nwere stable.', ' The white count was 9.1, hematocrit 31.3,\nplatelet count 147,000 with an unremarkable physical\nexamination. The plan was to continue to keep his blood\npressure down on Nipride and to start the patient on his p.o.\nmedications as well as his p.o. diet. If able to wean off\nthe Nipride, the plan was to transfer the patient to the\nfloor.\n\nOn postoperative day number two, the patient was mildly\ndisoriented, however, calm without complaints with his pain\nwell controlled. He was still with a low-grade temperature\nof 100.1 in sinus rhythm at 88, mildly hypertensive at\n170/88. On physical examination, he had mild crackles\nbilaterally, otherwise his examination was benign. The plan\nwas just to continue monitor his mental status and pain\ncontrol.\n\nOn postoperative day number three, the patient was still\nwithout complaints, however, still requiring a sitter for his\ndisorientation.', ' Currently, afebrile. The vital signs were\nstable, saturating at 94% on room air. The physical\nexamination was benign. The plan was to go for a cardiac\ncatheterization this morning with a possible PTCA with plus\nor minus stenting of the stenotic area.\n\nHe did undergo cardiac catheterization on 1924-7-17\nwhich now revealed a saphenous vein graft to the obtuse\nmarginal patent and a saphenous vein graft to the posterior\ndescending artery with a 90% distal stenosis with a 3 by 13\nmm stent with distal protection and 0% residual with normal\nflow. The plan was to continue the patient on aspirin and\nPlavix 75 mg p.o. daily for 30 days and to administer\nIntegrelin overnight.\n\nThe anticipated date of discharge is 1942-8-3. The\npatient is to be discharged home on the following\nmedications.\n\nDISCHARGE MEDICATIONS:\n1.', ' Metformin 850 mg p.o. b.i.d.\n2. Lisinopril 2.5 mg p.o. q.d.\n3. Sliding scale of insulin.\n4. Metoprolol 50 mg p.o. b.i.d.\n5. Divalproex 500 mg p.o. b.i.d.\n6. Buspar 15 mg p.o. t.i.d.\n7. Paxil 5 mg p.o. q.d.\n8. Atrovastatin 40 mg p.o. q.d.\n9. Plavix 75 mg p.o. q.d. for three months.\n10. Donepezil 5 mg p.o. q.h.s.\n11. Dulcolax, milk of magnesia, p.r.n.\n12. Percocet 5 one to two tablets p.o. q. 4-6 hours p.r.n.\npain.\n13. NPH 3 units at breakfast, 4 units at bedtime.\n14. Ibuprofen 400 mg q.i.d.\n15. Acetaminophen 650 mg q. four hours p.r.n.\n16. Aspirin 325 mg p.o. q.d.\n17. Colace 100 mg p.o. b.i.d.\n18. Lasix 20 mg p.o. b.i.d.\n19. Potassium chloride 20 mEq p.o. q.d.\n\nPLAN: The plan is for the patient to arrange a follow-up\nvisit with Dr. Tamaro in one month, Dr. Bludsworth in one month,\nand his primary care physician in two to four weeks.', '\n\nCONDITION AT DISCHARGE: Good.\n\nDISCHARGE DIAGNOSIS: Coronary artery disease, status post\nre-do off-pump coronary artery bypass grafting times one.\n\n\n\n Danilo Deng, M.D. 06468494\n\nDictated By:Dr.Deng\n\nMEDQUIST36\n\nD: 1942-8-3 13:20\nT: 1982-1-25 15:05\nJOB#: Mitchell, Salas and Jackson-2001-209022\n']
201	4127	167565.0	2193-05-31	Discharge summary	Report	Admission Date: [2193-5-30] Discharge Date: [2193-5-31] Date of Birth: [2151-9-14] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male with a longstanding history of seizure disorder and mental retardation who presented to the Emergency Room with a possible asthma exacerbation, as well as some right arm shaking. The patient has a longstanding seizure disorder, by report both GTC and complex partial. The patient's seizures have been relatively well controlled for the past year up to a few weeks ago. The patient did have an episode of unresponsiveness thought to be a postictal state. He was recently admitted on [2193-5-24] at [Hospital6 649] for asthma exacerbation. He was seen by Neurology at that time for questioned seizure activity. His Keppra was increased during that hospitalization from 5,000 b.i.d. to 2,000 b.i.d. On the morning of admission, the patient was found by EMS to have an O2 saturation in the 80s and appeared apneic. It was felt that he again was having an asthmatic exacerbation. He was intubated in the field and brought to [Hospital3 ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ]. At [Hospital6 2018], he was noted to have some right arm shaking, which was felt to be a seizure episode. He received 8 mg of Ativan and was placed on propofol. He was also noted to have some teeth chattering. PAST MEDICAL HISTORY: Seizure disorder. Anoxic brain injury. Asthma. Depression. Fetal alcohol syndrome. Cervical fracture. FAMILY HISTORY: No seizure disorders. SOCIAL HISTORY: Lives in group home with 24 hour supervision. No smoking or drinking history. MEDICATIONS ON ADMISSION: 1. Depakote 500 mg p.o. t.i.d. 2. Keppra 2,000 mg p.o. b.i.d. 3. Valium 5 mg p.o. b.i.d. 4. Neurontin 800 mg t.i.d. 5. Celexa 40 mg p.o. q d. 6. Albuterol nebulizer. 7. Colace 100 mg p.o. b.i.d. 8. Pseudoephedrine 30 mg p.o. q.i.d. ALLERGIES: Phenobarbital, phenytoin, penicillin, Haldol. PHYSICAL EXAMINATION: Vital signs: Temperature 100.0, heart rate 76, blood pressure 132/77, saturation of 100 percent on vent assist control/650/20/5 on 85 percent, not overbreathing, PIP-31. General: Intubated, sedated male, appearing slightly rigid. HEENT: Pupils were 2 cm minimally reactive to light. Lungs: Expiratory wheezes bilaterally. Cardiovascular: Regular rate and rhythm. No murmurs, rubs or gallops. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis and posterior tibial pulses bilaterally. Neurological: The patient was sedated, but would withdraw to pain. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. Respiratory: The patient was continued on q.i.d. albuterol nebulizations. His sedation was lightened and he was successfully extubated the following day. Admission arterial blood gas was 7.48/39/404. It was uncertain whether or not the patient actually had asthmatic exacerbation. He was initially given Solu-Medrol 125 mg intravenously. However, this was discontinued the following day. He appeared stable with regard to his respiratory status at the time of discharge. He did not have an AA gradient. Neurological: A Neurology consult was obtained at the time of admission. Since there were no clear jerking or rhythmic movements and since the patient's group home representatives stated that this was not his typical seizure activity, it was unclear whether or not the patient was actually having seizures. At the time of admission, he received 8 mg of Ativan. His outpatient regimen of seizure medications was continued. This included Depakote, Keppra, valium and Neurontin. The patient had no obvious seizure activity during his Medical Intensive Care Unit stay. An electroencephalogram was obtained by the Neurology service, which was consistent with encephalopathy, but did not reveal any seizure activity. Levels of valproate were measured and found to be within range. Mental Status: The patient was initially fairly somnolent. However, over the course of the day, he was able to become more alert. A representative from the patient's group home was scheduled to see the patient to decide whether or not he was at his baseline. The patient was able to eat and take his medications without difficulty during his hospitalization. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To group home. DISCHARGE DIAGNOSES: Mental retardation. Seizure disorder. Asthma. Depression. DISCHARGE MEDICATIONS: No changes were made to the patient's outpatient regimen. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 2019] Dictated By:[Doctor Last Name 2020] MEDQUIST36 D: [2193-5-31] 16:25:00 T: [2193-5-31] 17:08:11 Job#: [Job Number 2021]	Admission Date: <Date>1983-11-17</Date> Discharge Date: <Date>1918-12-13</Date> Date of Birth: <Date>2008-11-31</Date> Sex: M Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male with a longstanding history of seizure disorder and mental retardation who presented to the Emergency Room with a possible asthma exacerbation, as well as some right arm shaking. The patient has a longstanding seizure disorder, by report both GTC and complex partial. The patient's seizures have been relatively well controlled for the past year up to a few weeks ago. The patient did have an episode of unresponsiveness thought to be a postictal state. He was recently admitted on <Date>1934-4-18</Date> at <Hospital>Norman-Lopez Health System</Hospital> for asthma exacerbation. He was seen by Neurology at that time for questioned seizure activity. His Keppra was increased during that hospitalization from 5,000 b.i.d. to 2,000 b.i.d. On the morning of admission, the patient was found by EMS to have an O2 saturation in the 80s and appeared apneic. It was felt that he again was having an asthmatic exacerbation. He was intubated in the field and brought to <Hospital>Dawson-Eaton Clinic</Hospital> <Hospital>Carter, Brown and White Health System</Hospital> <Name>Lisa</Name> <Name>Whitehead</Name>. At <Hospital>Adams-Norris Clinic</Hospital>, he was noted to have some right arm shaking, which was felt to be a seizure episode. He received 8 mg of Ativan and was placed on propofol. He was also noted to have some teeth chattering. PAST MEDICAL HISTORY: Seizure disorder. Anoxic brain injury. Asthma. Depression. Fetal alcohol syndrome. Cervical fracture. FAMILY HISTORY: No seizure disorders. SOCIAL HISTORY: Lives in group home with 24 hour supervision. No smoking or drinking history. MEDICATIONS ON ADMISSION: 1. Depakote 500 mg p.o. t.i.d. 2. Keppra 2,000 mg p.o. b.i.d. 3. Valium 5 mg p.o. b.i.d. 4. Neurontin 800 mg t.i.d. 5. Celexa 40 mg p.o. q d. 6. Albuterol nebulizer. 7. Colace 100 mg p.o. b.i.d. 8. Pseudoephedrine 30 mg p.o. q.i.d. ALLERGIES: Phenobarbital, phenytoin, penicillin, Haldol. PHYSICAL EXAMINATION: Vital signs: Temperature 100.0, heart rate 76, blood pressure 132/77, saturation of 100 percent on vent assist control/650/20/5 on 85 percent, not overbreathing, PIP-31. General: Intubated, sedated male, appearing slightly rigid. HEENT: Pupils were 2 cm minimally reactive to light. Lungs: Expiratory wheezes bilaterally. Cardiovascular: Regular rate and rhythm. No murmurs, rubs or gallops. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis and posterior tibial pulses bilaterally. Neurological: The patient was sedated, but would withdraw to pain. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. Respiratory: The patient was continued on q.i.d. albuterol nebulizations. His sedation was lightened and he was successfully extubated the following day. Admission arterial blood gas was 7.48/39/404. It was uncertain whether or not the patient actually had asthmatic exacerbation. He was initially given Solu-Medrol 125 mg intravenously. However, this was discontinued the following day. He appeared stable with regard to his respiratory status at the time of discharge. He did not have an AA gradient. Neurological: A Neurology consult was obtained at the time of admission. Since there were no clear jerking or rhythmic movements and since the patient's group home representatives stated that this was not his typical seizure activity, it was unclear whether or not the patient was actually having seizures. At the time of admission, he received 8 mg of Ativan. His outpatient regimen of seizure medications was continued. This included Depakote, Keppra, valium and Neurontin. The patient had no obvious seizure activity during his Medical Intensive Care Unit stay. An electroencephalogram was obtained by the Neurology service, which was consistent with encephalopathy, but did not reveal any seizure activity. Levels of valproate were measured and found to be within range. Mental Status: The patient was initially fairly somnolent. However, over the course of the day, he was able to become more alert. A representative from the patient's group home was scheduled to see the patient to decide whether or not he was at his baseline. The patient was able to eat and take his medications without difficulty during his hospitalization. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To group home. DISCHARGE DIAGNOSES: Mental retardation. Seizure disorder. Asthma. Depression. DISCHARGE MEDICATIONS: No changes were made to the patient's outpatient regimen. <Name>Meena Naegelin</Name> <Name>Pamela Davis</Name>, <MD Number>68794347</MD Number> Dictated By:<Doctor Name>Dr.Booker</Doctor Name> MEDQUIST36 D: <Date>1918-12-13</Date> 16:25:00 T: <Date>1918-12-13</Date> 17:08:11 Job#: <Job Number>Espinoza and Sons-2003-378593</Job 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Date: 1983-11-17 Discharge Date: 1918-12-13 Date of Birth: 2008-11-31 Sex: M Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male with a longstanding history of seizure disorder and mental retardation who presented to the Emergency Room with a possible asthma exacerbation, as well as some right arm shaking. The patient has a longstanding seizure disorder, by report both GTC and complex partial. The patient's seizures have been relatively well controlled for the past year up to a few weeks ago. The patient did have an episode of unresponsiveness thought to be a postictal state. He was recently admitted on 1934-4-18 at Norman-Lopez Health System for asthma exacerbation. He was seen by Neurology at that time for questioned seizure activity. His Keppra was increased during that hospitalization from 5,000 b.i.d. to 2,000 b.i.d. On the morning of admission, the patient was found by EMS to have an O2 saturation in the 80s and appeared apneic. It was felt that he again was having an asthmatic exacerbation. He was intubated in the field and brought to Dawson-Eaton Clinic Carter, Brown and White Health System Lisa Whitehead. At Adams-Norris Clinic, he was noted to have some right arm shaking, which was felt to be a seizure episode. He received 8 mg of Ativan and was placed on propofol. He was also noted to have some teeth chattering. PAST MEDICAL HISTORY: Seizure disorder. Anoxic brain injury. Asthma. Depression. Fetal alcohol syndrome. Cervical fracture. FAMILY HISTORY: No seizure disorders. SOCIAL HISTORY: Lives in group home with 24 hour supervision. No smoking or drinking history. MEDICATIONS ON ADMISSION: 1. Depakote 500 mg p.o. t.i.d. 2. Keppra 2,000 mg p.o. b.i.d. 3. Valium 5 mg p.o. b.i.d. 4. Neurontin 800 mg t.i.d. 5. Celexa 40 mg p.o. q d. 6. Albuterol nebulizer. 7. Colace 100 mg p.o. b.i.d. 8. Pseudoephedrine 30 mg p.o. q.i.d. ALLERGIES: Phenobarbital, phenytoin, penicillin, Haldol. PHYSICAL EXAMINATION: Vital signs: Temperature 100.0, heart rate 76, blood pressure 132/77, saturation of 100 percent on vent assist control/650/20/5 on 85 percent, not overbreathing, PIP-31. General: Intubated, sedated male, appearing slightly rigid. HEENT: Pupils were 2 cm minimally reactive to light. Lungs: Expiratory wheezes bilaterally. Cardiovascular: Regular rate and rhythm. No murmurs, rubs or gallops. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis and posterior tibial pulses bilaterally. Neurological: The patient was sedated, but would withdraw to pain. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. Respiratory: The patient was continued on q.i.d. albuterol nebulizations. His sedation was lightened and he was successfully extubated the following day. Admission arterial blood gas was 7.48/39/404. It was uncertain whether or not the patient actually had asthmatic exacerbation. He was initially given Solu-Medrol 125 mg intravenously. However, this was discontinued the following day. He appeared stable with regard to his respiratory status at the time of discharge. He did not have an AA gradient. Neurological: A Neurology consult was obtained at the time of admission. Since there were no clear jerking or rhythmic movements and since the patient's group home representatives stated that this was not his typical seizure activity, it was unclear whether or not the patient was actually having seizures. At the time of admission, he received 8 mg of Ativan. His outpatient regimen of seizure medications was continued. This included Depakote, Keppra, valium and Neurontin. The patient had no obvious seizure activity during his Medical Intensive Care Unit stay. An electroencephalogram was obtained by the Neurology service, which was consistent with encephalopathy, but did not reveal any seizure activity. Levels of valproate were measured and found to be within range. Mental Status: The patient was initially fairly somnolent. However, over the course of the day, he was able to become more alert. A representative from the patient's group home was scheduled to see the patient to decide whether or not he was at his baseline. The patient was able to eat and take his medications without difficulty during his hospitalization. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To group home. DISCHARGE DIAGNOSES: Mental retardation. Seizure disorder. Asthma. Depression. DISCHARGE MEDICATIONS: No changes were made to the patient's outpatient regimen. Meena Naegelin Pamela Davis, 68794347 Dictated By:Dr.Booker MEDQUIST36 D: 1918-12-13 16:25:00 T: 1918-12-13 17:08:11 Job#: Espinoza and Sons-2003-378593	["Admission Date: 1983-11-17 Discharge Date: 1918-12-13\n\nDate of Birth: 2008-11-31 Sex: M\n\nService: MED\n\n\nHISTORY OF PRESENT ILLNESS: The patient is a 41-year-old\nmale with a longstanding history of seizure disorder and\nmental retardation who presented to the Emergency Room with a\npossible asthma exacerbation, as well as some right arm\nshaking. The patient has a longstanding seizure disorder, by\nreport both GTC and complex partial. The patient's seizures\nhave been relatively well controlled for the past year up to\na few weeks ago. The patient did have an episode of\nunresponsiveness thought to be a postictal state. He was\nrecently admitted on 1934-4-18 at Norman-Lopez Health System for asthma exacerbation. He was seen by\nNeurology at that time for questioned seizure activity.", ' His\nKeppra was increased during that hospitalization from 5,000\nb.i.d. to 2,000 b.i.d.\n\nOn the morning of admission, the patient was found by EMS to\nhave an O2 saturation in the 80s and appeared apneic. It was\nfelt that he again was having an asthmatic exacerbation. He\nwas intubated in the field and brought to Dawson-Eaton Clinic\nCarter, Brown and White Health System Lisa Whitehead. At Adams-Norris Clinic, he was noted to have some right arm shaking, which\nwas felt to be a seizure episode. He received 8 mg of Ativan\nand was placed on propofol. He was also noted to have some\nteeth chattering.\n\nPAST MEDICAL HISTORY: Seizure disorder.\n\nAnoxic brain injury.\n\nAsthma.\n\nDepression.\n\nFetal alcohol syndrome.\n\nCervical fracture.\n\nFAMILY HISTORY: No seizure disorders.\n\nSOCIAL HISTORY: Lives in group home with 24 hour\nsupervision.', ' No smoking or drinking history.\n\nMEDICATIONS ON ADMISSION:\n1. Depakote 500 mg p.o. t.i.d.\n2. Keppra 2,000 mg p.o. b.i.d.\n3. Valium 5 mg p.o. b.i.d.\n4. Neurontin 800 mg t.i.d.\n5. Celexa 40 mg p.o. q d.\n6. Albuterol nebulizer.\n7. Colace 100 mg p.o. b.i.d.\n8. Pseudoephedrine 30 mg p.o. q.i.d.\n\n\nALLERGIES: Phenobarbital, phenytoin, penicillin, Haldol.\n\nPHYSICAL EXAMINATION: Vital signs: Temperature 100.0, heart\nrate 76, blood pressure 132/77, saturation of 100 percent on\nvent assist control/650/20/5 on 85 percent, not\noverbreathing, PIP-31. General: Intubated, sedated male,\nappearing slightly rigid. HEENT: Pupils were 2 cm minimally\nreactive to light. Lungs: Expiratory wheezes bilaterally.\nCardiovascular: Regular rate and rhythm. No murmurs, rubs or\ngallops. Abdomen: Soft, nontender, nondistended, normoactive\nbowel sounds.', ' Extremities: No cyanosis, clubbing or edema,\n2+ dorsalis pedis and posterior tibial pulses bilaterally.\nNeurological: The patient was sedated, but would withdraw to\npain.\n\nHOSPITAL COURSE: The patient was admitted to the Medical\nIntensive Care Unit.\n\nRespiratory: The patient was continued on q.i.d. albuterol\nnebulizations. His sedation was lightened and he was\nsuccessfully extubated the following day. Admission arterial\nblood gas was 7.48/39/404. It was uncertain whether or not\nthe patient actually had asthmatic exacerbation. He was\ninitially given Solu-Medrol 125 mg intravenously. However,\nthis was discontinued the following day. He appeared stable\nwith regard to his respiratory status at the time of\ndischarge. He did not have an AA gradient.\n\nNeurological: A Neurology consult was obtained at the time\nof admission.', " Since there were no clear jerking or rhythmic\nmovements and since the patient's group home representatives\nstated that this was not his typical seizure activity, it was\nunclear whether or not the patient was actually having\nseizures. At the time of admission, he received 8 mg of\nAtivan. His outpatient regimen of seizure medications was\ncontinued. This included Depakote, Keppra, valium and\nNeurontin. The patient had no obvious seizure activity during\nhis Medical Intensive Care Unit stay. An electroencephalogram\nwas obtained by the Neurology service, which was consistent\nwith encephalopathy, but did not reveal any seizure activity.\nLevels of valproate were measured and found to be within\nrange.\n\nMental Status: The patient was initially fairly somnolent.\nHowever, over the course of the day, he was able to become\nmore alert.", " A representative from the patient's group home\nwas scheduled to see the patient to decide whether or not he\nwas at his baseline. The patient was able to eat and take his\nmedications without difficulty during his hospitalization.\n\nCONDITION ON DISCHARGE: Stable.\n\nDISCHARGE STATUS: To group home.\n\nDISCHARGE DIAGNOSES: Mental retardation.\n\nSeizure disorder.\n\nAsthma.\n\nDepression.\n\nDISCHARGE MEDICATIONS: No changes were made to the patient's\noutpatient regimen.\n\n\n\n Meena Naegelin Pamela Davis, 68794347\n\nDictated By:Dr.Booker\nMEDQUIST36\nD: 1918-12-13 16:25:00\nT: 1918-12-13 17:08:11\nJob#: Espinoza and Sons-2003-378593\n"]
202	4127	167565.0	2193-06-10	Discharge summary	Report	Admission Date: [2193-6-9] Discharge Date: [2193-6-10] Date of Birth: [2151-9-14] Sex: M Service: [Hospital1 139] Firm HISTORY OF PRESENT ILLNESS: The patient is with mental retardation, seizure disorder, asthma, and recurrent aspiration pneumonia, who was admitted to the Intensive Care Unit already intubated for apnea. On the day of admission, the patient was sitting bolt upright in bed in respiratory distress. He was given Albuterol neb without improvement. At that time his oxygen saturation was 88 percent, and he was intubated for apnea. An initial chest x-ray showed bilateral lower lobe opacities consistent with aspiration pneumonia. He was extubated on the day after admission. On presentation the patient was febrile and started on Levofloxacin and Flagyl for aspiration pneumonia. He was called out to the floor three days after admission. PAST MEDICAL HISTORY: Seizure disorder secondary to anoxic brain injury. Over the past three months, the patient has had increasing seizure activity from baseline according to his primary caretaker. Mental retardation. Asthma. Depression. Fetal alcohol syndrome. Recurrent aspiration pneumonia. History of positive PPD. Status post fall in [2188] with a C7 fracture. History of multiple psychiatric admissions (The patient can be combative and assaultive at times). MEDICATIONS ON ADMISSION: Depakote 500 mg p.o. t.i.d., Neurontin 100 mg p.o. t.i.d., Celexa 30 mg p.o. q.d., Albuterol nebs q.6 hours p.r.n., Colace 100 mg p.o. b.i.d., Atrovent, Keppra [2188] mg p.o. b.i.d., Valium 10 mg p.o. b.i.d., Citalopram. FAMILY HISTORY: No seizure disorder. ALLERGIES: Phenobarbital, Penicillin, Haldol. PHYSICAL EXAMINATION: Vital signs: Upon transfer to the Medical Floor, temperature was 97.9 with a T-max of 101, pulse 83, ranging from 51-126, blood pressure 110/47, respirations 21, ranging from 21-32, oxygen saturation 97 percent on 4 L nasal cannula. General: Examination was significant for a young black male in no acute distress. The patient was awake and responding to voice appropriately. HEENT: Moist mucous membranes. Pupils equal, round and reactive to light. Neck: Supple. Cardiovascular: Normal S1 and S2. Regular rate and rhythm. Lungs: Decreased breath sounds at the bases with a few audible wheezes. Abdomen: Normoactive bowel sounds. Extremities: No edema. LABORATORY DATA: White count 6.4, hematocrit 40.5; creatinine 0.9, 1.6. ASSESSMENT: This was a 41-year-old male with mental retardation, recently worsening seizure disorder, on triple medication therapy, admitted with aspiration and probable aspiration pneumonia. Aspiration pneumonia: The patient was treated with a seven- day course of Levofloxacin. He was initially treated with Flagyl; however, this was discontinued before day 7 because of his tendency to decreased seizure threshold. The patient was placed on aspiration precautions. During his hospitalization, he had multiple episodes of unresponsiveness, which were likely post ictal states. In addition, he had multiple seizure activity, and therefore was deemed to unstable to go down for a video swallow. A bed side speech and swallow evaluation recommended ground/pureed food with thickened liquids. The patient tolerated this diet well. In addition, the patient was placed on a quick steroid taper with nebs p.r.n. After starting antibiotics, the patient remained afebrile for the rest of his admission, and his lung examination normalized. He was on room air at the time of this dictation. Seizure disorder: Over the past few months, the patient's seizure disorder has been worsening. Initially on admission, his Keppra dose was decreased to 1500 b.i.d. He was continued on his home dose of Valproic Acid and Gabapentin. The patient had multiple episodes of witnessed seizures, some tonic and two short tonic clonic seizures. These responded to intravenous Ativan; however, on two episodes, he had probable seizure activity with bilateral up and out for more than 20 min. Neurology was consulted. The patient received two EEGs during his hospitalization, both of which did not demonstrate seizure activity. There was generalized swelling, likely due to medication affect. The patient was transferred to the Epilepsy Service for continuous monitoring. Psychiatric: The patient has a history of combative behavior and multiple psychiatric security codes being called. A similar code was called during this hospitalization. Psychiatry was involved and recommended p.r.n. for agitation. Prior to transfer to the Neurology Service, the patient's dose of Keppra was increased back to his home dose of [2188] mg p.o. b.i.d. The patient was maintained on seizure precautions. The patient is full code. This portion of the dictation summary was dictated by the General Medicine Team. An addendum will be dictated by the Neurology Service after the patient receives continuous EEG monitoring. DR.[First Name (STitle) ],[First Name3 (LF) 1216] 13-296 Dictated By:[Last Name (NamePattern1) 2022] MEDQUIST36 D: [2193-6-10] 08:44:54 T: [2193-6-10] 09:21:26 Job#: [Job Number 2023]	Admission Date: <Date>1977-6-11</Date> Discharge Date: <Date>1953-2-9</Date> Date of Birth: <Date>1900-7-31</Date> Sex: M Service: <Hospital>Long LLC Health System</Hospital> Firm HISTORY OF PRESENT ILLNESS: The patient is with mental retardation, seizure disorder, asthma, and recurrent aspiration pneumonia, who was admitted to the Intensive Care Unit already intubated for apnea. On the day of admission, the patient was sitting bolt upright in bed in respiratory distress. He was given Albuterol neb without improvement. At that time his oxygen saturation was 88 percent, and he was intubated for apnea. An initial chest x-ray showed bilateral lower lobe opacities consistent with aspiration pneumonia. He was extubated on the day after admission. On presentation the patient was febrile and started on Levofloxacin and Flagyl for aspiration pneumonia. He was called out to the floor three days after admission. PAST MEDICAL HISTORY: Seizure disorder secondary to anoxic brain injury. Over the past three months, the patient has had increasing seizure activity from baseline according to his primary caretaker. Mental retardation. Asthma. Depression. Fetal alcohol syndrome. Recurrent aspiration pneumonia. History of positive PPD. Status post fall in <Year>2009</Year> with a C7 fracture. History of multiple psychiatric admissions (The patient can be combative and assaultive at times). MEDICATIONS ON ADMISSION: Depakote 500 mg p.o. t.i.d., Neurontin 100 mg p.o. t.i.d., Celexa 30 mg p.o. q.d., Albuterol nebs q.6 hours p.r.n., Colace 100 mg p.o. b.i.d., Atrovent, Keppra <Year>2009</Year> mg p.o. b.i.d., Valium 10 mg p.o. b.i.d., Citalopram. FAMILY HISTORY: No seizure disorder. ALLERGIES: Phenobarbital, Penicillin, Haldol. PHYSICAL EXAMINATION: Vital signs: Upon transfer to the Medical Floor, temperature was 97.9 with a T-max of 101, pulse 83, ranging from 51-126, blood pressure 110/47, respirations 21, ranging from 21-32, oxygen saturation 97 percent on 4 L nasal cannula. General: Examination was significant for a young black male in no acute distress. The patient was awake and responding to voice appropriately. HEENT: Moist mucous membranes. Pupils equal, round and reactive to light. Neck: Supple. Cardiovascular: Normal S1 and S2. Regular rate and rhythm. Lungs: Decreased breath sounds at the bases with a few audible wheezes. Abdomen: Normoactive bowel sounds. Extremities: No edema. LABORATORY DATA: White count 6.4, hematocrit 40.5; creatinine 0.9, 1.6. ASSESSMENT: This was a 41-year-old male with mental retardation, recently worsening seizure disorder, on triple medication therapy, admitted with aspiration and probable aspiration pneumonia. Aspiration pneumonia: The patient was treated with a seven- day course of Levofloxacin. He was initially treated with Flagyl; however, this was discontinued before day 7 because of his tendency to decreased seizure threshold. The patient was placed on aspiration precautions. During his hospitalization, he had multiple episodes of unresponsiveness, which were likely post ictal states. In addition, he had multiple seizure activity, and therefore was deemed to unstable to go down for a video swallow. A bed side speech and swallow evaluation recommended ground/pureed food with thickened liquids. The patient tolerated this diet well. In addition, the patient was placed on a quick steroid taper with nebs p.r.n. After starting antibiotics, the patient remained afebrile for the rest of his admission, and his lung examination normalized. He was on room air at the time of this dictation. Seizure disorder: Over the past few months, the patient's seizure disorder has been worsening. Initially on admission, his Keppra dose was decreased to 1500 b.i.d. He was continued on his home dose of Valproic Acid and Gabapentin. The patient had multiple episodes of witnessed seizures, some tonic and two short tonic clonic seizures. These responded to intravenous Ativan; however, on two episodes, he had probable seizure activity with bilateral up and out for more than 20 min. Neurology was consulted. The patient received two EEGs during his hospitalization, both of which did not demonstrate seizure activity. There was generalized swelling, likely due to medication affect. The patient was transferred to the Epilepsy Service for continuous monitoring. Psychiatric: The patient has a history of combative behavior and multiple psychiatric security codes being called. A similar code was called during this hospitalization. Psychiatry was involved and recommended p.r.n. for agitation. Prior to transfer to the Neurology Service, the patient's dose of Keppra was increased back to his home dose of <Year>2009</Year> mg p.o. b.i.d. The patient was maintained on seizure precautions. The patient is full code. This portion of the dictation summary was dictated by the General Medicine Team. An addendum will be dictated by the Neurology Service after the patient receives continuous EEG monitoring. DR.<Name>Octavia</Name>,<Name>Cameron</Name> 13-296 Dictated By:<Name>Son</Name> MEDQUIST36 D: <Date>1953-2-9</Date> 08:44:54 T: <Date>1953-2-9</Date> 09:21:26 Job#: <Job Number>Tucker Group-1978-858748</Job 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00000000001111111011111110000000000000000000001110000000000000000111111110000000000000011111111000000000000000001111111111111111111111110	Admission Date: 1977-6-11 Discharge Date: 1953-2-9 Date of Birth: 1900-7-31 Sex: M Service: Long LLC Health System Firm HISTORY OF PRESENT ILLNESS: The patient is with mental retardation, seizure disorder, asthma, and recurrent aspiration pneumonia, who was admitted to the Intensive Care Unit already intubated for apnea. On the day of admission, the patient was sitting bolt upright in bed in respiratory distress. He was given Albuterol neb without improvement. At that time his oxygen saturation was 88 percent, and he was intubated for apnea. An initial chest x-ray showed bilateral lower lobe opacities consistent with aspiration pneumonia. He was extubated on the day after admission. On presentation the patient was febrile and started on Levofloxacin and Flagyl for aspiration pneumonia. He was called out to the floor three days after admission. PAST MEDICAL HISTORY: Seizure disorder secondary to anoxic brain injury. Over the past three months, the patient has had increasing seizure activity from baseline according to his primary caretaker. Mental retardation. Asthma. Depression. Fetal alcohol syndrome. Recurrent aspiration pneumonia. History of positive PPD. Status post fall in 2009 with a C7 fracture. History of multiple psychiatric admissions (The patient can be combative and assaultive at times). MEDICATIONS ON ADMISSION: Depakote 500 mg p.o. t.i.d., Neurontin 100 mg p.o. t.i.d., Celexa 30 mg p.o. q.d., Albuterol nebs q.6 hours p.r.n., Colace 100 mg p.o. b.i.d., Atrovent, Keppra 2009 mg p.o. b.i.d., Valium 10 mg p.o. b.i.d., Citalopram. FAMILY HISTORY: No seizure disorder. ALLERGIES: Phenobarbital, Penicillin, Haldol. PHYSICAL EXAMINATION: Vital signs: Upon transfer to the Medical Floor, temperature was 97.9 with a T-max of 101, pulse 83, ranging from 51-126, blood pressure 110/47, respirations 21, ranging from 21-32, oxygen saturation 97 percent on 4 L nasal cannula. General: Examination was significant for a young black male in no acute distress. The patient was awake and responding to voice appropriately. HEENT: Moist mucous membranes. Pupils equal, round and reactive to light. Neck: Supple. Cardiovascular: Normal S1 and S2. Regular rate and rhythm. Lungs: Decreased breath sounds at the bases with a few audible wheezes. Abdomen: Normoactive bowel sounds. Extremities: No edema. LABORATORY DATA: White count 6.4, hematocrit 40.5; creatinine 0.9, 1.6. ASSESSMENT: This was a 41-year-old male with mental retardation, recently worsening seizure disorder, on triple medication therapy, admitted with aspiration and probable aspiration pneumonia. Aspiration pneumonia: The patient was treated with a seven- day course of Levofloxacin. He was initially treated with Flagyl; however, this was discontinued before day 7 because of his tendency to decreased seizure threshold. The patient was placed on aspiration precautions. During his hospitalization, he had multiple episodes of unresponsiveness, which were likely post ictal states. In addition, he had multiple seizure activity, and therefore was deemed to unstable to go down for a video swallow. A bed side speech and swallow evaluation recommended ground/pureed food with thickened liquids. The patient tolerated this diet well. In addition, the patient was placed on a quick steroid taper with nebs p.r.n. After starting antibiotics, the patient remained afebrile for the rest of his admission, and his lung examination normalized. He was on room air at the time of this dictation. Seizure disorder: Over the past few months, the patient's seizure disorder has been worsening. Initially on admission, his Keppra dose was decreased to 1500 b.i.d. He was continued on his home dose of Valproic Acid and Gabapentin. The patient had multiple episodes of witnessed seizures, some tonic and two short tonic clonic seizures. These responded to intravenous Ativan; however, on two episodes, he had probable seizure activity with bilateral up and out for more than 20 min. Neurology was consulted. The patient received two EEGs during his hospitalization, both of which did not demonstrate seizure activity. There was generalized swelling, likely due to medication affect. The patient was transferred to the Epilepsy Service for continuous monitoring. Psychiatric: The patient has a history of combative behavior and multiple psychiatric security codes being called. A similar code was called during this hospitalization. Psychiatry was involved and recommended p.r.n. for agitation. Prior to transfer to the Neurology Service, the patient's dose of Keppra was increased back to his home dose of 2009 mg p.o. b.i.d. The patient was maintained on seizure precautions. The patient is full code. This portion of the dictation summary was dictated by the General Medicine Team. An addendum will be dictated by the Neurology Service after the patient receives continuous EEG monitoring. DR.Octavia,Cameron 13-296 Dictated By:Son MEDQUIST36 D: 1953-2-9 08:44:54 T: 1953-2-9 09:21:26 Job#: Tucker Group-1978-858748	['Admission Date: 1977-6-11 Discharge Date: 1953-2-9\n\nDate of Birth: 1900-7-31 Sex: M\n\nService: Long LLC Health System Firm\n\n\nHISTORY OF PRESENT ILLNESS: The patient is with mental\nretardation, seizure disorder, asthma, and recurrent\naspiration pneumonia, who was admitted to the Intensive Care\nUnit already intubated for apnea.\n\nOn the day of admission, the patient was sitting bolt upright\nin bed in respiratory distress. He was given Albuterol neb\nwithout improvement. At that time his oxygen saturation was\n88 percent, and he was intubated for apnea.\n\nAn initial chest x-ray showed bilateral lower lobe opacities\nconsistent with aspiration pneumonia. He was extubated on\nthe day after admission.\n\nOn presentation the patient was febrile and started on\nLevofloxacin and Flagyl for aspiration pneumonia.', ' He was\ncalled out to the floor three days after admission.\n\nPAST MEDICAL HISTORY: Seizure disorder secondary to anoxic\nbrain injury. Over the past three months, the patient has\nhad increasing seizure activity from baseline according to\nhis primary caretaker.\n\nMental retardation.\n\nAsthma.\n\nDepression.\n\nFetal alcohol syndrome.\n\nRecurrent aspiration pneumonia.\n\nHistory of positive PPD.\n\nStatus post fall in 2009 with a C7 fracture.\n\nHistory of multiple psychiatric admissions (The patient can\nbe combative and assaultive at times).\n\nMEDICATIONS ON ADMISSION: Depakote 500 mg p.o. t.i.d.,\nNeurontin 100 mg p.o. t.i.d., Celexa 30 mg p.o. q.d.,\nAlbuterol nebs q.6 hours p.r.n., Colace 100 mg p.o. b.i.d.,\nAtrovent, Keppra 2009 mg p.o. b.i.d., Valium 10 mg p.o.\nb.i.d., Citalopram.\n\nFAMILY HISTORY: No seizure disorder.', '\n\nALLERGIES: Phenobarbital, Penicillin, Haldol.\n\nPHYSICAL EXAMINATION: Vital signs: Upon transfer to the\nMedical Floor, temperature was 97.9 with a T-max of 101,\npulse 83, ranging from 51-126, blood pressure 110/47,\nrespirations 21, ranging from 21-32, oxygen saturation 97\npercent on 4 L nasal cannula. General: Examination was\nsignificant for a young black male in no acute distress. The\npatient was awake and responding to voice appropriately.\nHEENT: Moist mucous membranes. Pupils equal, round and\nreactive to light. Neck: Supple. Cardiovascular: Normal\nS1 and S2. Regular rate and rhythm. Lungs: Decreased\nbreath sounds at the bases with a few audible wheezes.\nAbdomen: Normoactive bowel sounds. Extremities: No edema.\n\nLABORATORY DATA: White count 6.4, hematocrit 40.5;\ncreatinine 0.', '9, 1.6.\n\nASSESSMENT: This was a 41-year-old male with mental\nretardation, recently worsening seizure disorder, on triple\nmedication therapy, admitted with aspiration and probable\naspiration pneumonia.\n\nAspiration pneumonia: The patient was treated with a seven-\nday course of Levofloxacin. He was initially treated with\nFlagyl; however, this was discontinued before day 7 because\nof his tendency to decreased seizure threshold. The patient\nwas placed on aspiration precautions.\n\nDuring his hospitalization, he had multiple episodes of\nunresponsiveness, which were likely post ictal states. In\naddition, he had multiple seizure activity, and therefore was\ndeemed to unstable to go down for a video swallow. A bed\nside speech and swallow evaluation recommended ground/pureed\nfood with thickened liquids.', " The patient tolerated this diet\nwell.\n\nIn addition, the patient was placed on a quick steroid taper\nwith nebs p.r.n.\n\nAfter starting antibiotics, the patient remained afebrile for\nthe rest of his admission, and his lung examination\nnormalized. He was on room air at the time of this\ndictation.\n\nSeizure disorder: Over the past few months, the patient's\nseizure disorder has been worsening. Initially on admission,\nhis Keppra dose was decreased to 1500 b.i.d. He was\ncontinued on his home dose of Valproic Acid and Gabapentin.\nThe patient had multiple episodes of witnessed seizures, some\ntonic and two short tonic clonic seizures. These responded\nto intravenous Ativan; however, on two episodes, he had\nprobable seizure activity with bilateral up and out for more\nthan 20 min.\n\nNeurology was consulted.", " The patient received two EEGs\nduring his hospitalization, both of which did not demonstrate\nseizure activity. There was generalized swelling, likely due\nto medication affect. The patient was transferred to the\nEpilepsy Service for continuous monitoring.\n\nPsychiatric: The patient has a history of combative behavior\nand multiple psychiatric security codes being called. A\nsimilar code was called during this hospitalization.\n\nPsychiatry was involved and recommended p.r.n. for\nagitation.\n\nPrior to transfer to the Neurology Service, the patient's\ndose of Keppra was increased back to his home dose of 2009 mg\np.o. b.i.d.\n\nThe patient was maintained on seizure precautions.\n\nThe patient is full code.\n\nThis portion of the dictation summary was dictated by the\nGeneral Medicine Team. An addendum will be dictated by the\nNeurology Service after the patient receives continuous EEG\nmonitoring.", '\n\n\n\n\n\n\n\n\n DR.Octavia,Cameron 13-296\n\nDictated By:Son\nMEDQUIST36\nD: 1953-2-9 08:44:54\nT: 1953-2-9 09:21:26\nJob#: Tucker Group-1978-858748\n']
203	93671	119010.0	2180-11-07	Discharge summary	Report	Admission Date: [2180-10-29] Discharge Date: [2180-11-7] Date of Birth: [2128-4-5] Sex: F Service: MEDICINE Allergies: Iodides Attending:[First Name3 (LF) 2024] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: pericardiocentesis History of Present Illness: 52 year old woman with a PMH significant for metastatic breast cancer with lung and brain mets admitted to the [Hospital Unit Name 153] for management of respiratory distress. The patient reports that she has had progressively worsening dyspnea on exertion and a cough productive of whitish sputum over the past several months, and that these symptoms prompted her CT chest in [8-4] that demonstrated her pulmonary metastasis. She states that over the past 2 days, she has had worsening shortness of breath such that she is now unable to climb [11-27] flight of stairs. She also endorses some right sided chest pain that is not pleuritic, which she states has been intermitent for several months. She denies any f/c/s, palpitaitons, n/v/d, sore throat, LBP, or myalgias. . In the [Hospital1 18] ED, initial VS 97.5 130 143/82 28 94% RA. She developed a worsening O2 requirement to 5L nc, and received vanco, levofloxacin, and ceftriaxone. She was then admitted to the [Hospital Unit Name 153] for further management. . Currently, the patient continues to complain of dyspnea and cough. Denies any CP, palpitations, or assymetric lower extremity edema. Past Medical History: BREAST CANCER: - [2170] - diagnosed with 4 cm right breast infiltrating ductal carcinoma, grade 3, LVI, ER/PR/Her-2/neu +, [9-13] positive axillary nodes. Underwent 4 cycles of Adriamycin and Cytoxan and four cycles of Taxol, followed by right total mastectomy, which revealed no residual carcinoma. - Treated at [Hospital1 2025] by Dr. [Last Name (STitle) 2026] of Rad-Onc, chest wall, supraclavicular, and axillary nodes (50 Gy). - On tamoxifen, switched to letrozole in 11/[2176]. - [2177-12-4], found to have 1 cm left breast mass. Partial mastectomy demonstrated 1.1 cm infiltrating ductal carcinoma, grade 2, LVI positive, 3 mm posterior [Last Name (un) 2027] and DCIS 2 mm from inferior margin. ER/PR +, Her-2/neu -. [11-27] positive sentinel lymph nodes. - Treated with Taxol and Cytoxan for four cycles. Genetic testing revealed her to be BRCA2 heterozygosity, so she underwent left mastectomy, which revealed no residual carcinoma. Dr. [Last Name (STitle) 2028] performed a laparoscopic TAH-BSO. - Dr. [Last Name (STitle) ] treated her to the chest wall (50.4 Gy) and the supraclavicular and axillary nodes (45 Gy), completed on [2178-8-21]. She had no evidence of recurrence at the time of her last visit with Dr. [Last Name (STitle) ] on [2180-6-5]. - [8-4], developed dry cough and frontal headaches. CTA chest on [2180-8-22] demonstrated LLL pulmonary mass (17 x 16 mm with possible lymphangitic spread), enlarged cervical nodes, and a 2.2-cm paratracheal node. - EBUS by IP on [2089-8-31], 4R/7 path. Path poorly differentiated carcinoma that was TTF-1 negative, mammoglobin positive, ER negative, and HER-2/neu equivocal. - CA27.29 was elevated at 431 on [2180-9-13], up from 270 on [2180-8-30], 45 on [2180-5-5], and 25 on [2179-10-26]. - [2180-9-13] - Brain MRI revealed a 4.3 x 4.2 mm left cerebellar lesion and two small foci in the right occipital lobe. There was no edema or mass effect around these lesions. - [2180-9-15] - started xeloda CROHN'S DISEASE - dx [2167]. Mild flare in early [2179] not requiring medication changes. L RADIAL FRACTURE: - s/p requiring surgical repair on [2178-2-3], and hardware removal on [2178-3-27]. HISTORY OF RUE CELLULITIS - s/p AxLND bilaterally, but only has had complications on the R Social History: Lives with her dog [Female First Name (un) 2029] in [Location (un) 2030]. Works at [First Name5 (NamePattern1) 2031] [Last Name (NamePattern1) 2032] [Doctor Last Name 1968] [Doctor First Name 2033] as financial advisor. EtOH - social. Tobacco - Denies. Denies IV, illicit, or herbal drug use. Family History: Her father died of leukemia at age 53 and her aunt had leukemia at age 19. Sister: died of leukemia, Brother: died from HIV/AIDS Physical Exam: Admission Exam: . VS: 97.2 112 139/74 30 93%4L nc Gen: Age appropriate female in mild respiratory distress HEENT: MMM, OP clear CV: Tachy S1+S2 Pulm: Scattered mild expiratory wheezes. Decreased breath sounds at left base. Increased dullness to percussion. Abd: S/NT/ND +bs Ext: No c/c/e. LE symmetric in circumference. Neuro: AOx3, CN II-XII intact. Pertinent Results: Admission Results: [2180-10-29] 06:30PM BLOOD WBC-8.9 RBC-3.94* Hgb-12.4 Hct-35.7* MCV-91 MCH-31.5 MCHC-34.8 RDW-15.1 Plt Ct-467* [2180-10-29] 06:30PM BLOOD Neuts-84.7* Lymphs-8.6* Monos-5.1 Eos-1.4 Baso-0.3 [2180-10-29] 06:30PM BLOOD PT-13.3 PTT-22.5 INR(PT)-1.1 [2180-10-29] 06:30PM BLOOD Glucose-120* UreaN-16 Creat-0.6 Na-140 K-3.5 Cl-105 HCO3-20* AnGap-19 [2180-10-29] 06:30PM BLOOD ALT-22 AST-26 LD(LDH)-969* AlkPhos-85 TotBili-0.4 [2180-10-29] 06:27PM BLOOD Lactate-1.6 Serum LDH ([2180-10-30]): 1068 [2180-10-30] 03:09AM BLOOD Glucose-113* UreaN-12 Creat-0.6 Na-139 K-4.6 Cl-109* HCO3-15* AnGap-20 . Pericardial Fluid [2180-10-30] WBC: 2920/uL RBC: [Numeric Identifier 2034]/uL Polys 36% ATYPICAL AGGREGATES OF EPITHELIAL CELLS WITH OVERLAPPING NUCLEAR BOUNDARIES PLEASE REFER TO CYTOLOLGY Lymphocytes 42% Monos 10% Macrophage 12% Total Protein, 4.2 g/dL Glucose 64 mg/dL LD 1036 IU/L Amylase 29 IU/L Albumin 2.8 g/dL . CYTOLOGY: DIAGNOSIS: Pericardial Fluid: POSITIVE FOR MALIGNANT CELLS, consistent with metastatic breast carcinoma. . dicharge labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2180-11-7] 07:45 17.2* 3.71* 11.5* 33.5* 90 31.0 34.4 14.5 305 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2180-11-7] 07:45 1181 14 0.5 134 3.2 96 30 11 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2180-11-7] 07:45 91* 47* 76 0.7 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2180-11-7] 07:45 8.2* 2.4* 2.1 . IMMUNOLOGY CA27.29 [2180-11-2] 12:58 5611 [2180-10-25] 11:15 7863 [2180-10-4] 12:46 5524 [2180-9-13] 09:22 4311 [2180-8-30] 12:32 2705 [2180-5-5] 09:45 454 . CXR ([2180-10-29]): Ill-defined hazy opacities in both lungs, worse within the left perihilar region, with increased size of the cardiac silhouette and small left pleural effusion. Findings most likely relate to pulmonary edema. Underlying infection or neoplasm, as noted on the prior CT within the left lung cannot be discerned on this exam. . TTE ([2180-10-30]): Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is no aortic valve stenosis. There is a moderate sized pericardial effusion. The effusion appears circumferential. There is brief right atrial diastolic collapse. There is brief right ventricular diastolic compression/collapse, consistent with impaired fillling/tamponade physiology. Moderate pericardial effusion with echo evidence of tamponade. . CT Chest With Contrast ([2180-10-30]): No evidence of pulmonary embolism. Massive progression of disease with substantial generalized severe mediastinal and hilar lymphadenopathy, newly appeared bilateral pleural effusions, newly appeared pericardial effusion, newly appeared multifocal pneumonia, and evidence of lymphangitis carcinomatosa. . TTE ([2180-10-31]): Overall left ventricular systolic function is normal (LVEF>55%). There is a very small pericardial effusion which is partially echodense. The pericardium may be thickened but is not well visualized. Compared with the prior study (images reviewed) of [2180-10-30], the pericardial effusion is now much smaller. . CXR [2180-11-2]: IMPRESSION: Further progression of metastatic breast cancer disease with pericardial effusion, extensive infiltrates in left lower lobe, and additional probably metastatic spread in other lung regions. It cannot be decided whether the described findings have any relevance to therapeutically-induced fluid overload. . ECHO [2180-11-3]: Conclusions Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. IMPRESSION: Small circumferential pericardial effusion. Bilateral pleural effusions. Brief Hospital Course: 52 year old woman with a PMH significant for metastatic breast cancer with lung and brain metastases admitted originally to the [Hospital Unit Name 153] for management of respiratory distress, then transferred to CCU after pericardiocentesis for cardiac tampoande, then transferred to [Hospital Unit Name 2035] after pt's respiratory status stabilized. . #. Hypoxic Respiratory Distress: On presentation to the ICU, the patient denied any fevers but reported a productive cough of several months duration. CXR on arrival demonstrated left peri-hilar and basilar infiltrates with concern for infectious consolidation/pneumonia, pleural effusion or progression of metastatic disease as her cancer was known to be located in the left lower lobe. A CT with contrast was performed to further evaluate the intrapulmonary process and demonstrated a multifocal pneumonia, progression of the pulmonary metastases, pleural effusions as well as a moderate-to-large pericardial effusion (see below for management of pericardial effusion) but was negative for a pulmonary embolism. Given productive cough and radiographic evidence the patient was started on Levaquin and Vancomycin for robust CAP treatment. On review of her medical chart, HCAP was considered more likely and she was started on Levoquin and Cefipime. Blood and urine cultures were performed and showed no growth as well as an Influenza DFA, which was negative. The patient was maintained on oxygen by nasal canula to maintain an oxygen saturation greater than 90%. Urine culture showed no growth though UA was positive for leukocytes, as she was already on broad spectrim antibiotics, no additional coverage was added. Antibiotics were changed to Levaquin and flagyl to cover postobstructive pneumonia, she will finish a course of 8 days on [2180-11-8]. On [10-31], patient spiked fever to 100.9 and cefipime was restarted. After arrival to [Name (NI) 2035], pt remained afebrile and cultures were negative, so Cepfepime was dc'd again. Pulmonary was consulted and per their recs, Vanc was restarted and Flagyl was dc'd after 5 days. Pt ultimately completed 8d of Levoquin and at time of discharge, Vanc was changed to Linezolid to complete the course at home. Cough was treated symptomatically. Pt was discharged with O2 suppl. . #. Pericardial Effusion: Patient was tachycardic on presentation. There was concern that it may be related to the patient's hypoxia or another underlying process such as a PE or possibly hypovolemia. Antibiotics for her pneumonia as above. Intravenous fluids were given for hypovolemia with little change in heart rate. A CT was ordered as above to evaluate further, which was negative for a pulmonary embolism but did reveal a moderate-to-large pericardial effusion. A TTE was ordered to evaluate further and revealed evidence of tamponade physiology. Moreover, the patient had a pulsus paradoxus of 16-18 mm Hg on exam. The interventional cardiology service was contact[Name (NI) ] who performed pericardiocentesis which produced 470mL serosanguanous fluid which was consistent with exudate by lites criteria. Over the next day, the drain put out another 500cc of fluid. The fluid was sent for cultures which were all negative. Cytology on pericarial fluid was positive for malignant cells. After one day, the pericardial drain was pulled, and the tip sent for culture which was also negative, and the patient was transfered out of the CCU. After arrival to [Name (NI) 2035], pt remained stable on NC, however clinically appeared still distressed. On [2180-11-3], a repeat ECHO was performed and it showed small pericardical effusion, reassuring us that the fluid had not reaccumulated. Per Cardiology recs, pt was instrusted to get another repeat ECHO on [2180-11-22] when she return for her outpt appt with oncologist, Dr. [Last Name (STitle) 2036]. Dr. [Last Name (STitle) 2036] will follow-up on the ECHO results. . # Anion Gap Metabolic Acidosis: Patient presented with a mild metabolic acidosis and an anion gap of 15. The most immediate concern was for a lactic acidosis from her respiratory distress and impaired tissue oxygenation or a possible starvation ketosis. Repeat labs the morning after admission revealed a worsening of her acidosis with a HCO3 of 15 (down from 20 on admission). An ABG revealed an appropriate respiratory compensation with a pCO2 of 31. The metabolic acidosis soon resolved and pt remained stable. . # Breast cancer: CT on admission showed dramatic progression of metastatic disease involving the lungs bilaterally. She was continued on capecitabine 1000 mg [Hospital1 ], and transfered to the oncology service. Once on [Hospital1 2035], given pt's breast cancer was progressing on current therapy (CA27-29 rising) and pt's clinical status was deteriorating, inpt attending and outpt oncologist Dr. [Last Name (STitle) 2036] discussed started a new chemotherapy regimen. Thus, pt's capecitabine was stopped and on [2180-11-3] pt was given Herceptin, Docetaxel and Carboplatin. 20 minutes into the infusion, Herceptin was stopped bc pt developed SOB and hypoxia to mid 80s. Pt's symptoms resolved with time, Ativan and Lasix. Herceptin was attempted again on [2180-11-6]. This time the infusion was stopped 60 min into the infusion bc pt developed tachycardia. Pt's symptoms resolved with time. Pt was started on Neupogen 24 hours after chemotherapy administration to prevent neutropenia. The Neupogen was discontinued on day of discharge as pt's WBC was still >15. . # Elevated LFTs: Pt had midly elevated LFTs after chemo administration, which were trending down with time. . # Diarrhea: Pt developed diarrhea during the hospitalization. C diff was negative. Likely [12-28] chemo. Diarrhea improved with Imodium. . # Anemia: Hematocrit on admission was approximately 39, at the patient's known baseline. The patient subsequently received several liters of intravenous fluids for her tachycardia and her hematocrit came down to 35. Pt's Hct remained stable in the 31-35 range. Pt did not require any transfusions. . # Crohn's: Patient was continued on her Mesalamine without event. . # Pt was on regular diet. Pt was full code. Pt was on SC Heparin for DVT ppx. Medications on Admission: - Percocet 5/325 mg p.o. q.4h. p.r.n. - Mesalamine 1 g p.o. daily - Multivitamin one tablet p.o. daily - Advil p.r.n. - Tylenol p.r.n. - Capecetabine 1000 mg PO BID C3D4 Discharge Medications: 1. Oxygen 2-4 Liters continuous pulse dose for portability, metastatic breast cancer to lung 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:15 Tablet(s) Refills:2 3. mesalamine 250 mg Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO QDAY (). 4. benzonatate 100 mg Capsule Sig: One (1) Capsule PO Q4H (every 4 hours) as needed for Cough: Do not take more than 6 capsules per day. Disp:180 Capsule(s) Refills:0 5. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:600 ML(s) Refills:0 6. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:30 Capsule(s) Refills:0 7. codeine sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for cough. Disp:30 Tablet(s) Refills:0 8. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. 9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 10. multivitamin Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: Foothills Visiting Nurse & Home Care, Inc Discharge Diagnosis: Metastatic breast cancer, pericardial effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to participate in your care Ms. [Known lastname 284]. You were admitted to the hospital with shortness of breath. We found that you had extra fluid around your heart and you had a drain placed to remove the fluid. We also found that you had worsened metastatic breast cancer that has spread to your lungs. This made it difficult for you to breathe. We started new chemotherapy, which helped to improve your symptoms. We also treated you for pneumonia during your hospitalization. You will go home with supplemental oxygen. Please make the following changes to your medications: 1. Stop xeloda 2. Please start linazolid 600 mg twice a day for three days (you will finish course on [2180-11-10] 3. Start metoprolol 12.5 mg twice a day - this medication helps to slow your heart rate 4. Start benzonatate 100 mg Capsule every 4 hours as needed for cough (Do not take more than 6 capsules per day.) 5. Start Guaifenesin 100 mg/5mL syrup - take 5 - 10 mL every 6 hours as needed for cough 6. Start loperamide 2 mg up to 4 times a day as needed for diarrhea. 7. Start codeine sulfate 15 mg (0.5 Tablet)every 6 hours as needed for cough 8. Start supplemental oxygen 2-4 L via nasal cannula You will need to have a repeat ECHO to evaluate for a pericardial effusion. Dr. [Last Name (STitle) 2036] will follow-up the results of the ECHO. Please call ([Telephone/Fax (1) 2037] to make an appointment. Followup Instructions: Repeat ECHO [2180-11-22] - please call ([Telephone/Fax (1) 2037] to make an appointment. Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2180-11-22] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2038], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital 2039] CARE CENTER When: THURSDAY [2180-11-30] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2040], NP [Telephone/Fax (1) 2041] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2180-11-12]	Admission Date: <Date>1940-1-15</Date> Discharge Date: <Date>1959-8-21</Date> Date of Birth: <Date>1919-12-12</Date> Sex: F Service: MEDICINE Allergies: Iodides Attending:<Name>Nguyen</Name> Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: pericardiocentesis History of Present Illness: 52 year old woman with a PMH significant for metastatic breast cancer with lung and brain mets admitted to the <Hospital>Rhodes-Price Health System</Hospital> for management of respiratory distress. The patient reports that she has had progressively worsening dyspnea on exertion and a cough productive of whitish sputum over the past several months, and that these symptoms prompted her CT chest in <Date>2-19</Date> that demonstrated her pulmonary metastasis. She states that over the past 2 days, she has had worsening shortness of breath such that she is now unable to climb <Date>6-14</Date> flight of stairs. She also endorses some right sided chest pain that is not pleuritic, which she states has been intermitent for several months. She denies any f/c/s, palpitaitons, n/v/d, sore throat, LBP, or myalgias. . In the <Hospital>Sparks Inc Health System</Hospital> ED, initial VS 97.5 130 143/82 28 94% RA. She developed a worsening O2 requirement to 5L nc, and received vanco, levofloxacin, and ceftriaxone. She was then admitted to the <Hospital>Rhodes-Price Health System</Hospital> for further management. . Currently, the patient continues to complain of dyspnea and cough. Denies any CP, palpitations, or assymetric lower extremity edema. Past Medical History: BREAST CANCER: - <Year>1911</Year> - diagnosed with 4 cm right breast infiltrating ductal carcinoma, grade 3, LVI, ER/PR/Her-2/neu +, <Date>3-8</Date> positive axillary nodes. Underwent 4 cycles of Adriamycin and Cytoxan and four cycles of Taxol, followed by right total mastectomy, which revealed no residual carcinoma. - Treated at <Hospital>Chavez, Rose and Washington Medical Center</Hospital> by Dr. <Name>Spikes</Name> of Rad-Onc, chest wall, supraclavicular, and axillary nodes (50 Gy). - On tamoxifen, switched to letrozole in 11/<Year>1911</Year>. - <Date>1972-2-17</Date>, found to have 1 cm left breast mass. Partial mastectomy demonstrated 1.1 cm infiltrating ductal carcinoma, grade 2, LVI positive, 3 mm posterior <Name>Broadnax</Name> and DCIS 2 mm from inferior margin. ER/PR +, Her-2/neu -. <Date>6-14</Date> positive sentinel lymph nodes. - Treated with Taxol and Cytoxan for four cycles. Genetic testing revealed her to be BRCA2 heterozygosity, so she underwent left mastectomy, which revealed no residual carcinoma. Dr. <Name>Davis</Name> performed a laparoscopic TAH-BSO. - Dr. <Name>Spikes</Name> treated her to the chest wall (50.4 Gy) and the supraclavicular and axillary nodes (45 Gy), completed on <Date>2012-10-11</Date>. She had no evidence of recurrence at the time of her last visit with Dr. <Name>Spikes</Name> on <Date>1964-9-2</Date>. - <Date>2-19</Date>, developed dry cough and frontal headaches. CTA chest on <Date>1967-10-4</Date> demonstrated LLL pulmonary mass (17 x 16 mm with possible lymphangitic spread), enlarged cervical nodes, and a 2.2-cm paratracheal node. - EBUS by IP on <Date>1913-10-25</Date>, 4R/7 path. Path poorly differentiated carcinoma that was TTF-1 negative, mammoglobin positive, ER negative, and HER-2/neu equivocal. - CA27.29 was elevated at 431 on <Date>1935-8-3</Date>, up from 270 on <Date>1977-4-4</Date>, 45 on <Date>1980-12-14</Date>, and 25 on <Date>2009-3-25</Date>. - <Date>1935-8-3</Date> - Brain MRI revealed a 4.3 x 4.2 mm left cerebellar lesion and two small foci in the right occipital lobe. There was no edema or mass effect around these lesions. - <Date>2010-7-27</Date> - started xeloda CROHN'S DISEASE - dx <Year>1911</Year>. Mild flare in early <Year>1911</Year> not requiring medication changes. L RADIAL FRACTURE: - s/p requiring surgical repair on <Date>1933-4-21</Date>, and hardware removal on <Date>1925-9-28</Date>. HISTORY OF RUE CELLULITIS - s/p AxLND bilaterally, but only has had complications on the R Social History: Lives with her dog <Name>Babette</Name> in <Location>47143 King Mall Lake Karen, CO 14109</Location>. Works at <Name>Sonny</Name> <Name>Waldon</Name> <Name>Barbara</Name> as financial advisor. EtOH - social. Tobacco - Denies. Denies IV, illicit, or herbal drug use. Family History: Her father died of leukemia at age 53 and her aunt had leukemia at age 19. Sister: died of leukemia, Brother: died from HIV/AIDS Physical Exam: Admission Exam: . VS: 97.2 112 139/74 30 93%4L nc Gen: Age appropriate female in mild respiratory distress HEENT: MMM, OP clear CV: Tachy S1+S2 Pulm: Scattered mild expiratory wheezes. Decreased breath sounds at left base. Increased dullness to percussion. Abd: S/NT/ND +bs Ext: No c/c/e. LE symmetric in circumference. Neuro: AOx3, CN II-XII intact. Pertinent Results: Admission Results: <Date>1940-1-15</Date> 06:30PM BLOOD WBC-8.9 RBC-3.94* Hgb-12.4 Hct-35.7* MCV-91 MCH-31.5 MCHC-34.8 RDW-15.1 Plt Ct-467* <Date>1940-1-15</Date> 06:30PM BLOOD Neuts-84.7* Lymphs-8.6* Monos-5.1 Eos-1.4 Baso-0.3 <Date>1940-1-15</Date> 06:30PM BLOOD PT-13.3 PTT-22.5 INR(PT)-1.1 <Date>1940-1-15</Date> 06:30PM BLOOD Glucose-120* UreaN-16 Creat-0.6 Na-140 K-3.5 Cl-105 HCO3-20* AnGap-19 <Date>1940-1-15</Date> 06:30PM BLOOD ALT-22 AST-26 LD(LDH)-969* AlkPhos-85 TotBili-0.4 <Date>1940-1-15</Date> 06:27PM BLOOD Lactate-1.6 Serum LDH (<Date>1935-4-11</Date>): 1068 <Date>1935-4-11</Date> 03:09AM BLOOD Glucose-113* UreaN-12 Creat-0.6 Na-139 K-4.6 Cl-109* HCO3-15* AnGap-20 . Pericardial Fluid <Date>1935-4-11</Date> WBC: 2920/uL RBC: <Numeric Identifier>3135343</Numeric Identifier>/uL Polys 36% ATYPICAL AGGREGATES OF EPITHELIAL CELLS WITH OVERLAPPING NUCLEAR BOUNDARIES PLEASE REFER TO CYTOLOLGY Lymphocytes 42% Monos 10% Macrophage 12% Total Protein, 4.2 g/dL Glucose 64 mg/dL LD 1036 IU/L Amylase 29 IU/L Albumin 2.8 g/dL . CYTOLOGY: DIAGNOSIS: Pericardial Fluid: POSITIVE FOR MALIGNANT CELLS, consistent with metastatic breast carcinoma. . dicharge labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct <Date>1959-8-21</Date> 07:45 17.2* 3.71* 11.5* 33.5* 90 31.0 34.4 14.5 305 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap <Date>1959-8-21</Date> 07:45 1181 14 0.5 134 3.2 96 30 11 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili <Date>1959-8-21</Date> 07:45 91* 47* 76 0.7 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron <Date>1959-8-21</Date> 07:45 8.2* 2.4* 2.1 . IMMUNOLOGY CA27.29 <Date>1963-10-28</Date> 12:58 5611 <Date>1921-1-17</Date> 11:15 7863 <Date>2008-2-22</Date> 12:46 5524 <Date>1935-8-3</Date> 09:22 4311 <Date>1977-4-4</Date> 12:32 2705 <Date>1980-12-14</Date> 09:45 454 . CXR (<Date>1940-1-15</Date>): Ill-defined hazy opacities in both lungs, worse within the left perihilar region, with increased size of the cardiac silhouette and small left pleural effusion. Findings most likely relate to pulmonary edema. Underlying infection or neoplasm, as noted on the prior CT within the left lung cannot be discerned on this exam. . TTE (<Date>1935-4-11</Date>): Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is no aortic valve stenosis. There is a moderate sized pericardial effusion. The effusion appears circumferential. There is brief right atrial diastolic collapse. There is brief right ventricular diastolic compression/collapse, consistent with impaired fillling/tamponade physiology. Moderate pericardial effusion with echo evidence of tamponade. . CT Chest With Contrast (<Date>1935-4-11</Date>): No evidence of pulmonary embolism. Massive progression of disease with substantial generalized severe mediastinal and hilar lymphadenopathy, newly appeared bilateral pleural effusions, newly appeared pericardial effusion, newly appeared multifocal pneumonia, and evidence of lymphangitis carcinomatosa. . TTE (<Date>2022-3-29</Date>): Overall left ventricular systolic function is normal (LVEF>55%). There is a very small pericardial effusion which is partially echodense. The pericardium may be thickened but is not well visualized. Compared with the prior study (images reviewed) of <Date>1935-4-11</Date>, the pericardial effusion is now much smaller. . CXR <Date>1963-10-28</Date>: IMPRESSION: Further progression of metastatic breast cancer disease with pericardial effusion, extensive infiltrates in left lower lobe, and additional probably metastatic spread in other lung regions. It cannot be decided whether the described findings have any relevance to therapeutically-induced fluid overload. . ECHO <Date>1975-9-6</Date>: Conclusions Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. IMPRESSION: Small circumferential pericardial effusion. Bilateral pleural effusions. Brief Hospital Course: 52 year old woman with a PMH significant for metastatic breast cancer with lung and brain metastases admitted originally to the <Hospital>Rhodes-Price Health System</Hospital> for management of respiratory distress, then transferred to CCU after pericardiocentesis for cardiac tampoande, then transferred to <Hospital>Gibson Ltd Clinic</Hospital> after pt's respiratory status stabilized. . #. Hypoxic Respiratory Distress: On presentation to the ICU, the patient denied any fevers but reported a productive cough of several months duration. CXR on arrival demonstrated left peri-hilar and basilar infiltrates with concern for infectious consolidation/pneumonia, pleural effusion or progression of metastatic disease as her cancer was known to be located in the left lower lobe. A CT with contrast was performed to further evaluate the intrapulmonary process and demonstrated a multifocal pneumonia, progression of the pulmonary metastases, pleural effusions as well as a moderate-to-large pericardial effusion (see below for management of pericardial effusion) but was negative for a pulmonary embolism. Given productive cough and radiographic evidence the patient was started on Levaquin and Vancomycin for robust CAP treatment. On review of her medical chart, HCAP was considered more likely and she was started on Levoquin and Cefipime. Blood and urine cultures were performed and showed no growth as well as an Influenza DFA, which was negative. The patient was maintained on oxygen by nasal canula to maintain an oxygen saturation greater than 90%. Urine culture showed no growth though UA was positive for leukocytes, as she was already on broad spectrim antibiotics, no additional coverage was added. Antibiotics were changed to Levaquin and flagyl to cover postobstructive pneumonia, she will finish a course of 8 days on <Date>1941-7-10</Date>. On <Date>4-1</Date>, patient spiked fever to 100.9 and cefipime was restarted. After arrival to <Name>Gregory Amaro</Name>, pt remained afebrile and cultures were negative, so Cepfepime was dc'd again. Pulmonary was consulted and per their recs, Vanc was restarted and Flagyl was dc'd after 5 days. Pt ultimately completed 8d of Levoquin and at time of discharge, Vanc was changed to Linezolid to complete the course at home. Cough was treated symptomatically. Pt was discharged with O2 suppl. . #. Pericardial Effusion: Patient was tachycardic on presentation. There was concern that it may be related to the patient's hypoxia or another underlying process such as a PE or possibly hypovolemia. Antibiotics for her pneumonia as above. Intravenous fluids were given for hypovolemia with little change in heart rate. A CT was ordered as above to evaluate further, which was negative for a pulmonary embolism but did reveal a moderate-to-large pericardial effusion. A TTE was ordered to evaluate further and revealed evidence of tamponade physiology. Moreover, the patient had a pulsus paradoxus of 16-18 mm Hg on exam. The interventional cardiology service was contact<Name>Logan Moore</Name> who performed pericardiocentesis which produced 470mL serosanguanous fluid which was consistent with exudate by lites criteria. Over the next day, the drain put out another 500cc of fluid. The fluid was sent for cultures which were all negative. Cytology on pericarial fluid was positive for malignant cells. After one day, the pericardial drain was pulled, and the tip sent for culture which was also negative, and the patient was transfered out of the CCU. After arrival to <Name>Gregory Amaro</Name>, pt remained stable on NC, however clinically appeared still distressed. On <Date>1975-9-6</Date>, a repeat ECHO was performed and it showed small pericardical effusion, reassuring us that the fluid had not reaccumulated. Per Cardiology recs, pt was instrusted to get another repeat ECHO on <Date>1924-2-4</Date> when she return for her outpt appt with oncologist, Dr. <Name>Thompson</Name>. Dr. <Name>Thompson</Name> will follow-up on the ECHO results. . # Anion Gap Metabolic Acidosis: Patient presented with a mild metabolic acidosis and an anion gap of 15. The most immediate concern was for a lactic acidosis from her respiratory distress and impaired tissue oxygenation or a possible starvation ketosis. Repeat labs the morning after admission revealed a worsening of her acidosis with a HCO3 of 15 (down from 20 on admission). An ABG revealed an appropriate respiratory compensation with a pCO2 of 31. The metabolic acidosis soon resolved and pt remained stable. . # Breast cancer: CT on admission showed dramatic progression of metastatic disease involving the lungs bilaterally. She was continued on capecitabine 1000 mg <Hospital>Lewis-Ferrell Medical Center</Hospital>, and transfered to the oncology service. Once on <Hospital>Everett Inc Medical Center</Hospital>, given pt's breast cancer was progressing on current therapy (CA27-29 rising) and pt's clinical status was deteriorating, inpt attending and outpt oncologist Dr. <Name>Thompson</Name> discussed started a new chemotherapy regimen. Thus, pt's capecitabine was stopped and on <Date>1975-9-6</Date> pt was given Herceptin, Docetaxel and Carboplatin. 20 minutes into the infusion, Herceptin was stopped bc pt developed SOB and hypoxia to mid 80s. Pt's symptoms resolved with time, Ativan and Lasix. Herceptin was attempted again on <Date>1914-12-11</Date>. This time the infusion was stopped 60 min into the infusion bc pt developed tachycardia. Pt's symptoms resolved with time. Pt was started on Neupogen 24 hours after chemotherapy administration to prevent neutropenia. The Neupogen was discontinued on day of discharge as pt's WBC was still >15. . # Elevated LFTs: Pt had midly elevated LFTs after chemo administration, which were trending down with time. . # Diarrhea: Pt developed diarrhea during the hospitalization. C diff was negative. Likely <Date>1-12</Date> chemo. Diarrhea improved with Imodium. . # Anemia: Hematocrit on admission was approximately 39, at the patient's known baseline. The patient subsequently received several liters of intravenous fluids for her tachycardia and her hematocrit came down to 35. Pt's Hct remained stable in the 31-35 range. Pt did not require any transfusions. . # Crohn's: Patient was continued on her Mesalamine without event. . # Pt was on regular diet. Pt was full code. Pt was on SC Heparin for DVT ppx. Medications on Admission: - Percocet 5/325 mg p.o. q.4h. p.r.n. - Mesalamine 1 g p.o. daily - Multivitamin one tablet p.o. daily - Advil p.r.n. - Tylenol p.r.n. - Capecetabine 1000 mg PO BID C3D4 Discharge Medications: 1. Oxygen 2-4 Liters continuous pulse dose for portability, metastatic breast cancer to lung 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:15 Tablet(s) Refills:2 3. mesalamine 250 mg Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO QDAY (). 4. benzonatate 100 mg Capsule Sig: One (1) Capsule PO Q4H (every 4 hours) as needed for Cough: Do not take more than 6 capsules per day. Disp:180 Capsule(s) Refills:0 5. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:600 ML(s) Refills:0 6. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:30 Capsule(s) Refills:0 7. codeine sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for cough. Disp:30 Tablet(s) Refills:0 8. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. 9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 10. multivitamin Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: Foothills Visiting Nurse & Home Care, Inc Discharge Diagnosis: Metastatic breast cancer, pericardial effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to participate in your care Ms. <Name>Belle</Name>. You were admitted to the hospital with shortness of breath. We found that you had extra fluid around your heart and you had a drain placed to remove the fluid. We also found that you had worsened metastatic breast cancer that has spread to your lungs. This made it difficult for you to breathe. We started new chemotherapy, which helped to improve your symptoms. We also treated you for pneumonia during your hospitalization. You will go home with supplemental oxygen. Please make the following changes to your medications: 1. Stop xeloda 2. Please start linazolid 600 mg twice a day for three days (you will finish course on <Date>1988-9-2</Date> 3. Start metoprolol 12.5 mg twice a day - this medication helps to slow your heart rate 4. Start benzonatate 100 mg Capsule every 4 hours as needed for cough (Do not take more than 6 capsules per day.) 5. Start Guaifenesin 100 mg/5mL syrup - take 5 - 10 mL every 6 hours as needed for cough 6. Start loperamide 2 mg up to 4 times a day as needed for diarrhea. 7. Start codeine sulfate 15 mg (0.5 Tablet)every 6 hours as needed for cough 8. Start supplemental oxygen 2-4 L via nasal cannula You will need to have a repeat ECHO to evaluate for a pericardial effusion. Dr. <Name>Thompson</Name> will follow-up the results of the ECHO. Please call (<Telephone>556-294-1098</Telephone> to make an appointment. Followup Instructions: Repeat ECHO <Date>1924-2-4</Date> - please call (<Telephone>556-294-1098</Telephone> to make an appointment. Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY <Date>1924-2-4</Date> at 10:00 AM With: <Name>Alphonso</Name> <Name>Medrano</Name>, MD <Telephone>230-184-6312</Telephone> Building: SC <Hospital>Burns-Shaw Health System</Hospital> Clinical Ctr <Location>243 Alexandra Isle Suite 801 Port Joy, TX 74137</Location> Campus: EAST Best Parking: <Hospital>Burns-Shaw Health System</Hospital> Garage Department: <Hospital>Oneill, Kent and Fowler Health System</Hospital> CARE CENTER When: THURSDAY <Date>2021-11-16</Date> at 9:00 AM With: <Name>Alphonso</Name> <Name>Thompson</Name>, NP <Telephone>883-156-5326</Telephone> Building: SC <Hospital>Burns-Shaw Health System</Hospital> Clinical Ctr <Location>7423 Sabrina Circles Suite 457 East Jason, PW 89224</Location> Campus: EAST Best Parking: <Hospital>Burns-Shaw Health System</Hospital> Garage Completed 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Date: 1940-1-15 Discharge Date: 1959-8-21 Date of Birth: 1919-12-12 Sex: F Service: MEDICINE Allergies: Iodides Attending:Nguyen Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: pericardiocentesis History of Present Illness: 52 year old woman with a PMH significant for metastatic breast cancer with lung and brain mets admitted to the Rhodes-Price Health System for management of respiratory distress. The patient reports that she has had progressively worsening dyspnea on exertion and a cough productive of whitish sputum over the past several months, and that these symptoms prompted her CT chest in 2-19 that demonstrated her pulmonary metastasis. She states that over the past 2 days, she has had worsening shortness of breath such that she is now unable to climb 6-14 flight of stairs. She also endorses some right sided chest pain that is not pleuritic, which she states has been intermitent for several months. She denies any f/c/s, palpitaitons, n/v/d, sore throat, LBP, or myalgias. . In the Sparks Inc Health System ED, initial VS 97.5 130 143/82 28 94% RA. She developed a worsening O2 requirement to 5L nc, and received vanco, levofloxacin, and ceftriaxone. She was then admitted to the Rhodes-Price Health System for further management. . Currently, the patient continues to complain of dyspnea and cough. Denies any CP, palpitations, or assymetric lower extremity edema. Past Medical History: BREAST CANCER: - 1911 - diagnosed with 4 cm right breast infiltrating ductal carcinoma, grade 3, LVI, ER/PR/Her-2/neu +, 3-8 positive axillary nodes. Underwent 4 cycles of Adriamycin and Cytoxan and four cycles of Taxol, followed by right total mastectomy, which revealed no residual carcinoma. - Treated at Chavez, Rose and Washington Medical Center by Dr. Spikes of Rad-Onc, chest wall, supraclavicular, and axillary nodes (50 Gy). - On tamoxifen, switched to letrozole in 11/1911. - 1972-2-17, found to have 1 cm left breast mass. Partial mastectomy demonstrated 1.1 cm infiltrating ductal carcinoma, grade 2, LVI positive, 3 mm posterior Broadnax and DCIS 2 mm from inferior margin. ER/PR +, Her-2/neu -. 6-14 positive sentinel lymph nodes. - Treated with Taxol and Cytoxan for four cycles. Genetic testing revealed her to be BRCA2 heterozygosity, so she underwent left mastectomy, which revealed no residual carcinoma. Dr. Davis performed a laparoscopic TAH-BSO. - Dr. Spikes treated her to the chest wall (50.4 Gy) and the supraclavicular and axillary nodes (45 Gy), completed on 2012-10-11. She had no evidence of recurrence at the time of her last visit with Dr. Spikes on 1964-9-2. - 2-19, developed dry cough and frontal headaches. CTA chest on 1967-10-4 demonstrated LLL pulmonary mass (17 x 16 mm with possible lymphangitic spread), enlarged cervical nodes, and a 2.2-cm paratracheal node. - EBUS by IP on 1913-10-25, 4R/7 path. Path poorly differentiated carcinoma that was TTF-1 negative, mammoglobin positive, ER negative, and HER-2/neu equivocal. - CA27.29 was elevated at 431 on 1935-8-3, up from 270 on 1977-4-4, 45 on 1980-12-14, and 25 on 2009-3-25. - 1935-8-3 - Brain MRI revealed a 4.3 x 4.2 mm left cerebellar lesion and two small foci in the right occipital lobe. There was no edema or mass effect around these lesions. - 2010-7-27 - started xeloda CROHN'S DISEASE - dx 1911. Mild flare in early 1911 not requiring medication changes. L RADIAL FRACTURE: - s/p requiring surgical repair on 1933-4-21, and hardware removal on 1925-9-28. HISTORY OF RUE CELLULITIS - s/p AxLND bilaterally, but only has had complications on the R Social History: Lives with her dog Babette in 47143 King Mall Lake Karen, CO 14109. Works at Sonny Waldon Barbara as financial advisor. EtOH - social. Tobacco - Denies. Denies IV, illicit, or herbal drug use. Family History: Her father died of leukemia at age 53 and her aunt had leukemia at age 19. Sister: died of leukemia, Brother: died from HIV/AIDS Physical Exam: Admission Exam: . VS: 97.2 112 139/74 30 93%4L nc Gen: Age appropriate female in mild respiratory distress HEENT: MMM, OP clear CV: Tachy S1+S2 Pulm: Scattered mild expiratory wheezes. Decreased breath sounds at left base. Increased dullness to percussion. Abd: S/NT/ND +bs Ext: No c/c/e. LE symmetric in circumference. Neuro: AOx3, CN II-XII intact. Pertinent Results: Admission Results: 1940-1-15 06:30PM BLOOD WBC-8.9 RBC-3.94* Hgb-12.4 Hct-35.7* MCV-91 MCH-31.5 MCHC-34.8 RDW-15.1 Plt Ct-467* 1940-1-15 06:30PM BLOOD Neuts-84.7* Lymphs-8.6* Monos-5.1 Eos-1.4 Baso-0.3 1940-1-15 06:30PM BLOOD PT-13.3 PTT-22.5 INR(PT)-1.1 1940-1-15 06:30PM BLOOD Glucose-120* UreaN-16 Creat-0.6 Na-140 K-3.5 Cl-105 HCO3-20* AnGap-19 1940-1-15 06:30PM BLOOD ALT-22 AST-26 LD(LDH)-969* AlkPhos-85 TotBili-0.4 1940-1-15 06:27PM BLOOD Lactate-1.6 Serum LDH (1935-4-11): 1068 1935-4-11 03:09AM BLOOD Glucose-113* UreaN-12 Creat-0.6 Na-139 K-4.6 Cl-109* HCO3-15* AnGap-20 . Pericardial Fluid 1935-4-11 WBC: 2920/uL RBC: 3135343/uL Polys 36% ATYPICAL AGGREGATES OF EPITHELIAL CELLS WITH OVERLAPPING NUCLEAR BOUNDARIES PLEASE REFER TO CYTOLOLGY Lymphocytes 42% Monos 10% Macrophage 12% Total Protein, 4.2 g/dL Glucose 64 mg/dL LD 1036 IU/L Amylase 29 IU/L Albumin 2.8 g/dL . CYTOLOGY: DIAGNOSIS: Pericardial Fluid: POSITIVE FOR MALIGNANT CELLS, consistent with metastatic breast carcinoma. . dicharge labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 1959-8-21 07:45 17.2* 3.71* 11.5* 33.5* 90 31.0 34.4 14.5 305 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap 1959-8-21 07:45 1181 14 0.5 134 3.2 96 30 11 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili 1959-8-21 07:45 91* 47* 76 0.7 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron 1959-8-21 07:45 8.2* 2.4* 2.1 . IMMUNOLOGY CA27.29 1963-10-28 12:58 5611 1921-1-17 11:15 7863 2008-2-22 12:46 5524 1935-8-3 09:22 4311 1977-4-4 12:32 2705 1980-12-14 09:45 454 . CXR (1940-1-15): Ill-defined hazy opacities in both lungs, worse within the left perihilar region, with increased size of the cardiac silhouette and small left pleural effusion. Findings most likely relate to pulmonary edema. Underlying infection or neoplasm, as noted on the prior CT within the left lung cannot be discerned on this exam. . TTE (1935-4-11): Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is no aortic valve stenosis. There is a moderate sized pericardial effusion. The effusion appears circumferential. There is brief right atrial diastolic collapse. There is brief right ventricular diastolic compression/collapse, consistent with impaired fillling/tamponade physiology. Moderate pericardial effusion with echo evidence of tamponade. . CT Chest With Contrast (1935-4-11): No evidence of pulmonary embolism. Massive progression of disease with substantial generalized severe mediastinal and hilar lymphadenopathy, newly appeared bilateral pleural effusions, newly appeared pericardial effusion, newly appeared multifocal pneumonia, and evidence of lymphangitis carcinomatosa. . TTE (2022-3-29): Overall left ventricular systolic function is normal (LVEF>55%). There is a very small pericardial effusion which is partially echodense. The pericardium may be thickened but is not well visualized. Compared with the prior study (images reviewed) of 1935-4-11, the pericardial effusion is now much smaller. . CXR 1963-10-28: IMPRESSION: Further progression of metastatic breast cancer disease with pericardial effusion, extensive infiltrates in left lower lobe, and additional probably metastatic spread in other lung regions. It cannot be decided whether the described findings have any relevance to therapeutically-induced fluid overload. . ECHO 1975-9-6: Conclusions Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. IMPRESSION: Small circumferential pericardial effusion. Bilateral pleural effusions. Brief Hospital Course: 52 year old woman with a PMH significant for metastatic breast cancer with lung and brain metastases admitted originally to the Rhodes-Price Health System for management of respiratory distress, then transferred to CCU after pericardiocentesis for cardiac tampoande, then transferred to Gibson Ltd Clinic after pt's respiratory status stabilized. . #. Hypoxic Respiratory Distress: On presentation to the ICU, the patient denied any fevers but reported a productive cough of several months duration. CXR on arrival demonstrated left peri-hilar and basilar infiltrates with concern for infectious consolidation/pneumonia, pleural effusion or progression of metastatic disease as her cancer was known to be located in the left lower lobe. A CT with contrast was performed to further evaluate the intrapulmonary process and demonstrated a multifocal pneumonia, progression of the pulmonary metastases, pleural effusions as well as a moderate-to-large pericardial effusion (see below for management of pericardial effusion) but was negative for a pulmonary embolism. Given productive cough and radiographic evidence the patient was started on Levaquin and Vancomycin for robust CAP treatment. On review of her medical chart, HCAP was considered more likely and she was started on Levoquin and Cefipime. Blood and urine cultures were performed and showed no growth as well as an Influenza DFA, which was negative. The patient was maintained on oxygen by nasal canula to maintain an oxygen saturation greater than 90%. Urine culture showed no growth though UA was positive for leukocytes, as she was already on broad spectrim antibiotics, no additional coverage was added. Antibiotics were changed to Levaquin and flagyl to cover postobstructive pneumonia, she will finish a course of 8 days on 1941-7-10. On 4-1, patient spiked fever to 100.9 and cefipime was restarted. After arrival to Gregory Amaro, pt remained afebrile and cultures were negative, so Cepfepime was dc'd again. Pulmonary was consulted and per their recs, Vanc was restarted and Flagyl was dc'd after 5 days. Pt ultimately completed 8d of Levoquin and at time of discharge, Vanc was changed to Linezolid to complete the course at home. Cough was treated symptomatically. Pt was discharged with O2 suppl. . #. Pericardial Effusion: Patient was tachycardic on presentation. There was concern that it may be related to the patient's hypoxia or another underlying process such as a PE or possibly hypovolemia. Antibiotics for her pneumonia as above. Intravenous fluids were given for hypovolemia with little change in heart rate. A CT was ordered as above to evaluate further, which was negative for a pulmonary embolism but did reveal a moderate-to-large pericardial effusion. A TTE was ordered to evaluate further and revealed evidence of tamponade physiology. Moreover, the patient had a pulsus paradoxus of 16-18 mm Hg on exam. The interventional cardiology service was contactLogan Moore who performed pericardiocentesis which produced 470mL serosanguanous fluid which was consistent with exudate by lites criteria. Over the next day, the drain put out another 500cc of fluid. The fluid was sent for cultures which were all negative. Cytology on pericarial fluid was positive for malignant cells. After one day, the pericardial drain was pulled, and the tip sent for culture which was also negative, and the patient was transfered out of the CCU. After arrival to Gregory Amaro, pt remained stable on NC, however clinically appeared still distressed. On 1975-9-6, a repeat ECHO was performed and it showed small pericardical effusion, reassuring us that the fluid had not reaccumulated. Per Cardiology recs, pt was instrusted to get another repeat ECHO on 1924-2-4 when she return for her outpt appt with oncologist, Dr. Thompson. Dr. Thompson will follow-up on the ECHO results. . # Anion Gap Metabolic Acidosis: Patient presented with a mild metabolic acidosis and an anion gap of 15. The most immediate concern was for a lactic acidosis from her respiratory distress and impaired tissue oxygenation or a possible starvation ketosis. Repeat labs the morning after admission revealed a worsening of her acidosis with a HCO3 of 15 (down from 20 on admission). An ABG revealed an appropriate respiratory compensation with a pCO2 of 31. The metabolic acidosis soon resolved and pt remained stable. . # Breast cancer: CT on admission showed dramatic progression of metastatic disease involving the lungs bilaterally. She was continued on capecitabine 1000 mg Lewis-Ferrell Medical Center, and transfered to the oncology service. Once on Everett Inc Medical Center, given pt's breast cancer was progressing on current therapy (CA27-29 rising) and pt's clinical status was deteriorating, inpt attending and outpt oncologist Dr. Thompson discussed started a new chemotherapy regimen. Thus, pt's capecitabine was stopped and on 1975-9-6 pt was given Herceptin, Docetaxel and Carboplatin. 20 minutes into the infusion, Herceptin was stopped bc pt developed SOB and hypoxia to mid 80s. Pt's symptoms resolved with time, Ativan and Lasix. Herceptin was attempted again on 1914-12-11. This time the infusion was stopped 60 min into the infusion bc pt developed tachycardia. Pt's symptoms resolved with time. Pt was started on Neupogen 24 hours after chemotherapy administration to prevent neutropenia. The Neupogen was discontinued on day of discharge as pt's WBC was still >15. . # Elevated LFTs: Pt had midly elevated LFTs after chemo administration, which were trending down with time. . # Diarrhea: Pt developed diarrhea during the hospitalization. C diff was negative. Likely 1-12 chemo. Diarrhea improved with Imodium. . # Anemia: Hematocrit on admission was approximately 39, at the patient's known baseline. The patient subsequently received several liters of intravenous fluids for her tachycardia and her hematocrit came down to 35. Pt's Hct remained stable in the 31-35 range. Pt did not require any transfusions. . # Crohn's: Patient was continued on her Mesalamine without event. . # Pt was on regular diet. Pt was full code. Pt was on SC Heparin for DVT ppx. Medications on Admission: - Percocet 5/325 mg p.o. q.4h. p.r.n. - Mesalamine 1 g p.o. daily - Multivitamin one tablet p.o. daily - Advil p.r.n. - Tylenol p.r.n. - Capecetabine 1000 mg PO BID C3D4 Discharge Medications: 1. Oxygen 2-4 Liters continuous pulse dose for portability, metastatic breast cancer to lung 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:15 Tablet(s) Refills:2 3. mesalamine 250 mg Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO QDAY (). 4. benzonatate 100 mg Capsule Sig: One (1) Capsule PO Q4H (every 4 hours) as needed for Cough: Do not take more than 6 capsules per day. Disp:180 Capsule(s) Refills:0 5. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:600 ML(s) Refills:0 6. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:30 Capsule(s) Refills:0 7. codeine sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for cough. Disp:30 Tablet(s) Refills:0 8. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. 9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 10. multivitamin Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: Foothills Visiting Nurse & Home Care, Inc Discharge Diagnosis: Metastatic breast cancer, pericardial effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to participate in your care Ms. Belle. You were admitted to the hospital with shortness of breath. We found that you had extra fluid around your heart and you had a drain placed to remove the fluid. We also found that you had worsened metastatic breast cancer that has spread to your lungs. This made it difficult for you to breathe. We started new chemotherapy, which helped to improve your symptoms. We also treated you for pneumonia during your hospitalization. You will go home with supplemental oxygen. Please make the following changes to your medications: 1. Stop xeloda 2. Please start linazolid 600 mg twice a day for three days (you will finish course on 1988-9-2 3. Start metoprolol 12.5 mg twice a day - this medication helps to slow your heart rate 4. Start benzonatate 100 mg Capsule every 4 hours as needed for cough (Do not take more than 6 capsules per day.) 5. Start Guaifenesin 100 mg/5mL syrup - take 5 - 10 mL every 6 hours as needed for cough 6. Start loperamide 2 mg up to 4 times a day as needed for diarrhea. 7. Start codeine sulfate 15 mg (0.5 Tablet)every 6 hours as needed for cough 8. Start supplemental oxygen 2-4 L via nasal cannula You will need to have a repeat ECHO to evaluate for a pericardial effusion. Dr. Thompson will follow-up the results of the ECHO. Please call (556-294-1098 to make an appointment. Followup Instructions: Repeat ECHO 1924-2-4 - please call (556-294-1098 to make an appointment. Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY 1924-2-4 at 10:00 AM With: Alphonso Medrano, MD 230-184-6312 Building: SC Burns-Shaw Health System Clinical Ctr 243 Alexandra Isle Suite 801 Port Joy, TX 74137 Campus: EAST Best Parking: Burns-Shaw Health System Garage Department: Oneill, Kent and Fowler Health System CARE CENTER When: THURSDAY 2021-11-16 at 9:00 AM With: Alphonso Thompson, NP 883-156-5326 Building: SC Burns-Shaw Health System Clinical Ctr 7423 Sabrina Circles Suite 457 East Jason, PW 89224 Campus: EAST Best Parking: Burns-Shaw Health System Garage Completed by:2003-3-24	['Admission Date: 1940-1-15 Discharge Date: 1959-8-21\n\nDate of Birth: 1919-12-12 Sex: F\n\nService: MEDICINE\n\nAllergies:\nIodides\n\nAttending:Nguyen\nChief Complaint:\nDyspnea\n\nMajor Surgical or Invasive Procedure:\npericardiocentesis\n\n\nHistory of Present Illness:\n52 year old woman with a PMH significant for metastatic breast\ncancer with lung and brain mets admitted to the Rhodes-Price Health System for\nmanagement of respiratory distress. The patient reports that\nshe has had progressively worsening dyspnea on exertion and a\ncough productive of whitish sputum over the past several months,\nand that these symptoms prompted her CT chest in 2-19 that\ndemonstrated her pulmonary metastasis. She states that over the\npast 2 days, she has had worsening shortness of breath such that\nshe is now unable to climb 6-14 flight of stairs.', ' She also\nendorses some right sided chest pain that is not pleuritic,\nwhich she states has been intermitent for several months. She\ndenies any f/c/s, palpitaitons, n/v/d, sore throat, LBP, or\nmyalgias.\n.\nIn the Sparks Inc Health System ED, initial VS 97.5 130 143/82 28 94% RA. She\ndeveloped a worsening O2 requirement to 5L nc, and received\nvanco, levofloxacin, and ceftriaxone. She was then admitted to\nthe Rhodes-Price Health System for further management.\n.\nCurrently, the patient continues to complain of dyspnea and\ncough. Denies any CP, palpitations, or assymetric lower\nextremity edema.\n\n\nPast Medical History:\nBREAST CANCER:\n- 1911 - diagnosed with 4 cm right breast infiltrating ductal\ncarcinoma, grade 3, LVI, ER/PR/Her-2/neu +, 3-8 positive\naxillary nodes. Underwent 4 cycles of Adriamycin and Cytoxan and\nfour cycles of Taxol, followed by right total mastectomy, which\nrevealed no residual carcinoma.', '\n- Treated at Chavez, Rose and Washington Medical Center by Dr. Spikes of Rad-Onc, chest wall,\nsupraclavicular, and axillary nodes (50 Gy).\n- On tamoxifen, switched to letrozole in 11/1911.\n- 1972-2-17, found to have 1 cm left breast mass. Partial\nmastectomy demonstrated 1.1 cm infiltrating ductal carcinoma,\ngrade 2, LVI positive, 3 mm posterior Broadnax and DCIS 2 mm from\ninferior margin. ER/PR +, Her-2/neu -. 6-14 positive sentinel\nlymph nodes.\n- Treated with Taxol and Cytoxan for four cycles. Genetic\ntesting revealed her to be BRCA2 heterozygosity, so she\nunderwent left mastectomy, which revealed no residual carcinoma.\nDr. Davis performed a laparoscopic TAH-BSO.\n- Dr. Spikes treated her to the chest wall (50.4 Gy) and the\nsupraclavicular and axillary nodes (45 Gy), completed on\n2012-10-11.', " She had no evidence of recurrence at the\ntime\nof her last visit with Dr. Spikes on 1964-9-2.\n- 2-19, developed dry cough and frontal headaches. CTA chest on\n1967-10-4 demonstrated LLL pulmonary mass (17 x 16 mm with\npossible lymphangitic spread), enlarged cervical nodes, and a\n2.2-cm paratracheal node.\n- EBUS by IP on 1913-10-25, 4R/7 path. Path poorly differentiated\ncarcinoma that was TTF-1 negative, mammoglobin positive, ER\nnegative, and HER-2/neu equivocal.\n- CA27.29 was elevated at 431 on 1935-8-3, up from 270\non 1977-4-4, 45 on 1980-12-14, and 25 on 2009-3-25.\n- 1935-8-3 - Brain MRI revealed a 4.3 x 4.2 mm left cerebellar\nlesion and two small foci in the right occipital lobe. There was\nno edema or mass effect around these lesions.\n- 2010-7-27 - started xeloda\nCROHN'S DISEASE\n- dx 1911.", ' Mild flare in early 1911 not requiring medication\nchanges.\nL RADIAL FRACTURE:\n- s/p requiring surgical repair on 1933-4-21, and hardware\nremoval on 1925-9-28.\nHISTORY OF RUE CELLULITIS\n- s/p AxLND bilaterally, but only has had complications on the R\n\n\nSocial History:\nLives with her dog Babette in 47143 King Mall\nLake Karen, CO 14109. Works at Sonny Waldon\nBarbara as financial advisor. EtOH - social. Tobacco -\nDenies. Denies IV, illicit, or herbal drug use.\n\n\nFamily History:\nHer father died of leukemia at age 53 and her aunt had leukemia\nat age 19. Sister: died of leukemia, Brother: died from HIV/AIDS\n\nPhysical Exam:\nAdmission Exam:\n.\nVS: 97.2 112 139/74 30 93%4L nc\nGen: Age appropriate female in mild respiratory distress\nHEENT: MMM, OP clear\nCV: Tachy S1+S2\nPulm: Scattered mild expiratory wheezes.', ' Decreased breath sounds\nat left base. Increased dullness to percussion.\nAbd: S/NT/ND +bs\nExt: No c/c/e. LE symmetric in circumference.\nNeuro: AOx3, CN II-XII intact.\n\nPertinent Results:\nAdmission Results:\n1940-1-15 06:30PM BLOOD WBC-8.9 RBC-3.94* Hgb-12.4 Hct-35.7\nMCV-91 MCH-31.5 MCHC-34.8 RDW-15.1 Plt Ct-467\n1940-1-15 06:30PM BLOOD Neuts-84.7* Lymphs-8.6* Monos-5.1 Eos-1.4\nBaso-0.3\n1940-1-15 06:30PM BLOOD PT-13.3 PTT-22.5 INR(PT)-1.1\n1940-1-15 06:30PM BLOOD Glucose-120* UreaN-16 Creat-0.6 Na-140\nK-3.5 Cl-105 HCO3-20* AnGap-19\n1940-1-15 06:30PM BLOOD ALT-22 AST-26 LD(LDH)-969* AlkPhos-85\nTotBili-0.4\n1940-1-15 06:27PM BLOOD Lactate-1.6\nSerum LDH (1935-4-11): 1068\n1935-4-11 03:09AM BLOOD Glucose-113* UreaN-12 Creat-0.6 Na-139\nK-4.6 Cl-109* HCO3-15* AnGap-20\n.\nPericardial Fluid 1935-4-11\nWBC: 2920/uL\nRBC: 3135343/uL\nPolys 36%\nATYPICAL AGGREGATES OF EPITHELIAL CELLS WITH OVERLAPPING NUCLEAR\nBOUNDARIES PLEASE REFER TO CYTOLOLGY\nLymphocytes 42%\nMonos 10%\nMacrophage 12%\nTotal Protein, 4.', '2 g/dL\nGlucose 64 mg/dL\nLD 1036 IU/L\nAmylase 29 IU/L\nAlbumin 2.8 g/dL\n.\nCYTOLOGY:\nDIAGNOSIS: Pericardial Fluid:\n POSITIVE FOR MALIGNANT CELLS,\n consistent with metastatic breast carcinoma.\n.\ndicharge labs:\n COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct\n1959-8-21 07:45 17.2* 3.71* 11.5* 33.5* 90 31.0 34.4 14.5\n305\nRENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap\n1959-8-21 07:45 1181 14 0.5 134 3.2 96 30 11\nENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase\nTotBili DirBili\n1959-8-21 07:45 91* 47* 76 0.7\nCHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron\n1959-8-21 07:45 8.2* 2.4* 2.1\n.\nIMMUNOLOGY CA27.29\n1963-10-28 12:58 5611\n1921-1-17 11:15 7863\n2008-2-22 12:46 5524\n1935-8-3 09:22 4311\n1977-4-4 12:32 2705\n1980-12-14 09:45 454\n.', '\nCXR (1940-1-15):\nIll-defined hazy opacities in both lungs, worse within the left\nperihilar\nregion, with increased size of the cardiac silhouette and small\nleft pleural effusion. Findings most likely relate to pulmonary\nedema. Underlying infection or neoplasm, as noted on the prior\nCT within the left lung cannot be discerned on this exam.\n.\nTTE (1935-4-11):\nLeft ventricular wall thickness, cavity size, and global\nsystolic function are normal (LVEF>55%). There is no aortic\nvalve stenosis. There is a moderate sized pericardial effusion.\nThe effusion appears circumferential. There is brief right\natrial diastolic collapse. There is brief right ventricular\ndiastolic compression/collapse, consistent with impaired\nfillling/tamponade physiology. Moderate pericardial effusion\nwith echo evidence of tamponade.', '\n.\nCT Chest With Contrast (1935-4-11):\nNo evidence of pulmonary embolism. Massive progression of\ndisease with substantial generalized severe mediastinal and\nhilar lymphadenopathy, newly appeared bilateral pleural\neffusions, newly appeared pericardial effusion, newly appeared\nmultifocal pneumonia, and evidence of lymphangitis\ncarcinomatosa.\n.\nTTE (2022-3-29):\nOverall left ventricular systolic function is normal (LVEF>55%).\nThere is a very small pericardial effusion which is partially\nechodense. The pericardium may be thickened but is not well\nvisualized. Compared with the prior study (images reviewed) of\n1935-4-11, the pericardial effusion is now much smaller.\n.\nCXR 1963-10-28:\nIMPRESSION: Further progression of metastatic breast cancer\ndisease with\npericardial effusion, extensive infiltrates in left lower lobe,\nand additional\nprobably metastatic spread in other lung regions.', " It cannot be\ndecided\nwhether the described findings have any relevance to\ntherapeutically-induced\nfluid overload.\n.\nECHO 1975-9-6: Conclusions\nOverall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\nThere is a small pericardial effusion. The effusion appears\ncircumferential. The effusion is echo dense, consistent with\nblood, inflammation or other cellular elements.\nIMPRESSION: Small circumferential pericardial effusion.\nBilateral pleural effusions.\n\n\nBrief Hospital Course:\n52 year old woman with a PMH significant for metastatic breast\ncancer with lung and brain metastases admitted originally to the\nRhodes-Price Health System for management of respiratory distress, then transferred to\nCCU after pericardiocentesis for cardiac tampoande, then\ntransferred to Gibson Ltd Clinic after pt's respiratory status stabilized.", '\n.\n#. Hypoxic Respiratory Distress: On presentation to the ICU, the\npatient denied any fevers but reported a productive cough of\nseveral months duration. CXR on arrival demonstrated left\nperi-hilar and basilar infiltrates with concern for infectious\nconsolidation/pneumonia, pleural effusion or progression of\nmetastatic disease as her cancer was known to be located in the\nleft lower lobe. A CT with contrast was performed to further\nevaluate the intrapulmonary process and demonstrated a\nmultifocal pneumonia, progression of the pulmonary metastases,\npleural effusions as well as a moderate-to-large pericardial\neffusion (see below for management of pericardial effusion) but\nwas negative for a pulmonary embolism. Given productive cough\nand radiographic evidence the patient was started on Levaquin\nand Vancomycin for robust CAP treatment.', " On review of her\nmedical chart, HCAP was considered more likely and she was\nstarted on Levoquin and Cefipime. Blood and urine cultures were\nperformed and showed no growth as well as an Influenza DFA,\nwhich was negative. The patient was maintained on oxygen by\nnasal canula to maintain an oxygen saturation greater than 90%.\nUrine culture showed no growth though UA was positive for\nleukocytes, as she was already on broad spectrim antibiotics, no\nadditional coverage was added. Antibiotics were changed to\nLevaquin and flagyl to cover postobstructive pneumonia, she will\nfinish a course of 8 days on 1941-7-10. On 4-1, patient spiked\nfever to 100.9 and cefipime was restarted. After arrival to\nGregory Amaro, pt remained afebrile and cultures were negative, so\nCepfepime was dc'd again. Pulmonary was consulted and per their\nrecs, Vanc was restarted and Flagyl was dc'd after 5 days.", " Pt\nultimately completed 8d of Levoquin and at time of discharge,\nVanc was changed to Linezolid to complete the course at home.\nCough was treated symptomatically. Pt was discharged with O2\nsuppl.\n.\n#. Pericardial Effusion: Patient was tachycardic on\npresentation. There was concern that it may be related to the\npatient's hypoxia or another underlying process such as a PE or\npossibly hypovolemia. Antibiotics for her pneumonia as above.\nIntravenous fluids were given for hypovolemia with little change\nin heart rate. A CT was ordered as above to evaluate further,\nwhich was negative for a pulmonary embolism but did reveal a\nmoderate-to-large pericardial effusion. A TTE was ordered to\nevaluate further and revealed evidence of tamponade physiology.\nMoreover, the patient had a pulsus paradoxus of 16-18 mm Hg on\nexam.", ' The interventional cardiology service was contactLogan Moore who\nperformed pericardiocentesis which produced 470mL serosanguanous\nfluid which was consistent with exudate by lites criteria. Over\nthe next day, the drain put out another 500cc of fluid. The\nfluid was sent for cultures which were all negative. Cytology\non pericarial fluid was positive for malignant cells. After one\nday, the pericardial drain was pulled, and the tip sent for\nculture which was also negative, and the patient was transfered\nout of the CCU. After arrival to Gregory Amaro, pt remained stable on NC,\nhowever clinically appeared still distressed. On 1975-9-6, a\nrepeat ECHO was performed and it showed small pericardical\neffusion, reassuring us that the fluid had not reaccumulated.\nPer Cardiology recs, pt was instrusted to get another repeat\nECHO on 1924-2-4 when she return for her outpt appt with\noncologist, Dr.', ' Thompson. Dr. Thompson will follow-up on the ECHO\nresults.\n.\n# Anion Gap Metabolic Acidosis: Patient presented with a mild\nmetabolic acidosis and an anion gap of 15. The most immediate\nconcern was for a lactic acidosis from her respiratory distress\nand impaired tissue oxygenation or a possible starvation\nketosis. Repeat labs the morning after admission revealed a\nworsening of her acidosis with a HCO3 of 15 (down from 20 on\nadmission). An ABG revealed an appropriate respiratory\ncompensation with a pCO2 of 31. The metabolic acidosis soon\nresolved and pt remained stable.\n.\n# Breast cancer: CT on admission showed dramatic progression of\nmetastatic disease involving the lungs bilaterally. She was\ncontinued on capecitabine 1000 mg Lewis-Ferrell Medical Center, and transfered to the\noncology service.', " Once on Everett Inc Medical Center, given pt's breast cancer was\nprogressing on current therapy (CA27-29 rising) and pt's\nclinical status was deteriorating, inpt attending and outpt\noncologist Dr. Thompson discussed started a new chemotherapy\nregimen. Thus, pt's capecitabine was stopped and on 1975-9-6 pt\nwas given Herceptin, Docetaxel and Carboplatin. 20 minutes into\nthe infusion, Herceptin was stopped bc pt developed SOB and\nhypoxia to mid 80s. Pt's symptoms resolved with time, Ativan\nand Lasix. Herceptin was attempted again on 1914-12-11. This\ntime the infusion was stopped 60 min into the infusion bc pt\ndeveloped tachycardia. Pt's symptoms resolved with time. Pt was\nstarted on Neupogen 24 hours after chemotherapy administration\nto prevent neutropenia. The Neupogen was discontinued on day of\ndischarge as pt's WBC was still >15.", "\n.\n# Elevated LFTs: Pt had midly elevated LFTs after chemo\nadministration, which were trending down with time.\n.\n# Diarrhea: Pt developed diarrhea during the hospitalization.\nC diff was negative. Likely 1-12 chemo. Diarrhea improved with\nImodium.\n.\n# Anemia: Hematocrit on admission was approximately 39, at the\npatient's known baseline. The patient subsequently received\nseveral liters of intravenous fluids for her tachycardia and her\nhematocrit came down to 35. Pt's Hct remained stable in the\n31-35 range. Pt did not require any transfusions.\n.\n# Crohn's: Patient was continued on her Mesalamine without\nevent.\n.\n# Pt was on regular diet. Pt was full code. Pt was on SC\nHeparin for DVT ppx.\n\n\nMedications on Admission:\n- Percocet 5/325 mg p.o. q.4h. p.r.n.\n- Mesalamine 1 g p.o. daily\n- Multivitamin one tablet p.", 'o. daily\n- Advil p.r.n.\n- Tylenol p.r.n.\n- Capecetabine 1000 mg PO BID C3D4\n\nDischarge Medications:\n1. Oxygen\n2-4 Liters continuous pulse dose for portability, metastatic\nbreast cancer to lung\n2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2\ntimes a day).\nDisp:15 Tablet(s) Refills:2\n3. mesalamine 250 mg Capsule, Sustained Release Sig: Four (4)\nCapsule, Sustained Release PO QDAY ().\n4. benzonatate 100 mg Capsule Sig: One (1) Capsule PO Q4H (every\n4 hours) as needed for Cough: Do not take more than 6 capsules\nper day.\nDisp:180 Capsule(s) Refills:0\n5. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6\nhours) as needed for cough.\nDisp:600 ML(s) Refills:0\n6. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times\na day) as needed for diarrhea.\nDisp:30 Capsule(s) Refills:0\n7.', ' codeine sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6\nhours) as needed for cough.\nDisp:30 Tablet(s) Refills:0\n8. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day\nfor 3 days.\n9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four\n(4) hours as needed for pain.\n10. multivitamin Capsule Sig: One (1) Capsule PO once a day.\n\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nFoothills Visiting Nurse & Home Care, Inc\n\nDischarge Diagnosis:\nMetastatic breast cancer, pericardial effusion\n\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n\nDischarge Instructions:\nIt was a pleasure to participate in your care Ms. Belle.\nYou were admitted to the hospital with shortness of breath.', ' We\nfound that you had extra fluid around your heart and you had a\ndrain placed to remove the fluid. We also found that you had\nworsened metastatic breast cancer that has spread to your lungs.\n This made it difficult for you to breathe. We started new\nchemotherapy, which helped to improve your symptoms. We also\ntreated you for pneumonia during your hospitalization. You will\ngo home with supplemental oxygen.\n\nPlease make the following changes to your medications:\n1. Stop xeloda\n2. Please start linazolid 600 mg twice a day for three days (you\nwill finish course on 1988-9-2\n3. Start metoprolol 12.5 mg twice a day - this medication helps\nto slow your heart rate\n4. Start benzonatate 100 mg Capsule every 4 hours as needed for\ncough (Do not take more than 6 capsules per day.)\n5. Start Guaifenesin 100 mg/5mL syrup - take 5 - 10 mL every 6\nhours as needed for cough\n6.', ' Start loperamide 2 mg up to 4 times a day as needed for\ndiarrhea.\n7. Start codeine sulfate 15 mg (0.5 Tablet)every 6 hours as\nneeded for cough\n8. Start supplemental oxygen 2-4 L via nasal cannula\n\nYou will need to have a repeat ECHO to evaluate for a\npericardial effusion. Dr. Thompson will follow-up the results of\nthe ECHO. Please call (556-294-1098 to make an appointment.\n\nFollowup Instructions:\nRepeat ECHO 1924-2-4 - please call (556-294-1098 to make an\nappointment.\n\nDepartment: HEMATOLOGY/ONCOLOGY\nWhen: WEDNESDAY 1924-2-4 at 10:00 AM\nWith: Alphonso Medrano, MD 230-184-6312\nBuilding: SC Burns-Shaw Health System Clinical Ctr 243 Alexandra Isle Suite 801\nPort Joy, TX 74137\nCampus: EAST Best Parking: Burns-Shaw Health System Garage\n\nDepartment: Oneill, Kent and Fowler Health System CARE CENTER\nWhen: THURSDAY 2021-11-16 at 9:00 AM\nWith: Alphonso Thompson, NP 883-156-5326\nBuilding: SC Burns-Shaw Health System Clinical Ctr 7423 Sabrina Circles Suite 457\nEast Jason, PW 89224\nCampus: EAST Best Parking: Burns-Shaw Health System Garage\n\n\n\nCompleted by:2003-3-24']
204	13289	119078.0	2103-08-09	Discharge summary	Report	Admission Date: [2103-7-26] Discharge Date: [2103-8-9] Date of Birth: [2072-5-4] Sex: F Service: [Doctor First Name 147] Allergies: Penicillins Attending:[First Name3 (LF) 1556] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Status post exploratory laparatomy status post right colectomy status post appendectomy status post abdominal closure History of Present Illness: 31 yo Female who was status post normal spontaneous vaginal delivery approximately 10 weeks ago who presented on [2103-7-25] with a chief complaint of abdominal pain. She was well until about 12 hours prior to admission when she described the acute onset of sharp right lower quadrant pain and diffuse/poorly characterized dull general abdominal pain. The pain was described as sharp, constant. The pain radiated to the back. It got worse with motion, better with motrin. The pain was associated with nausea and bilious vomiting times 1, subsequent to the onset of pain. The patient also described subjective fevers and chills. The paitent did not have any constipation, diarrhea, change in the color of her stools, dysuria, hematuria, vaginal discharge, itching, or bleeding. No history of recetn truama, travel. she has not been sexually active since her delivery Past Medical History: recurrent respiratory infections allergies Gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Social History: works in a research lab no tobacco, or alcohol travelled to [Country 2045] in [2081], bermuda in [2088] Family History: No history of bowel problems. Father had a history of hypertension Physical Exam: temperature 100.8, pulse 81, blood pressure 109/71, respirations 16, oxygen saturation 100% on room air General: patient was in moderate distress, appeared acutely ill Head and neck: head atraumatic/normocephalic. sclera anicteric. No lymphadenopathy, no jvd Card: regular rate and rhythm Lungs: clear to auscultation Abdomen: soft, mildly distended. Diffuse tenderness, RLQ>LLQ. Positive for rebound, especially in lower abdomen Back: no costovertebral angle tenderness. Pelvic exam: significantly limited secondary to discomfort, exquistite tenderness at the interoitus, unable to get in foot rests. Minimal thin white discharge, right adnexal and fundal tenderness consistent with peritonitis On discharge the patient had a well healing midline incision, as well as ostomy sites that were pink and healthy. Stool and gas were present in the ostomy bag. Her abdoment was soft and nondistended Pertinent Results: Blood cultures negative, CMV IgG positive, CMV IgM negative, CMV DNA negative, RPR negative, Fungal culture negative, Stool negative for (camplobacter, salmonella, shigella, vibrio, yersina, ecoli 0157:H7, Cdificile, virus), HSVI/II negative, Hep B SAb positive, Hep BSAg negative, Cervical cultures negative for GC and chlamidyia, Rheumatoid factor negative, HIT negative, Cystic fibrosis negative, sickle negative, lupus anticoagulant negative, cryoglobulin negative, [Doctor First Name ] 1:40, ANCA negative, HCG negative. Cardiolipin antibiodies are pending. Pelvic Ultrasound [2103-7-25]: IMPRESSION: 1. Fibroid uterus. 2. Normal appearing ovaries bilaterally. No ovarian torsion seen at the time of the exam, although clinical correlation is needed to entirely exclude this diagnosis. 3. Mild-to-moderate amount of nonspecific free pelvic fluid. Abdominal CT [2103-7-25]: ABDOMEN CT WITH IV CONTRAST: There is a trace right pleural effusion and slight atelectasis at the right lung base. The NG tube extends into the stomach, where it makes a loop in the fundus. There is a large amount of fluid in the peritoneum. The liver, spleen, pancreas, adrenal glands, kidneys, and ureters appear unremarkable. The gallbladder is distended without CT evidence of wall edema. The proximal small bowel is collapsed. The mid small bowel is distended with air-fluid levels. The distal small bowel is not distended. Rectal contrast opacifies the colon, reaching the cecum. There is severe thickening of the cecal wall. The appendix seems to be normal in caliber although surrounded by inflammatory changes and fluid . These findings are most consistent with cecitis, which could be infectious or inflammatory. Ischemic etiology is less likely. PELVIC CT WITH IV CONTRAST: The uterus is enlarged with multiple fibroids, some of which demonstrate calcified rims. The bladder and rectum are unremarkable. There is a large amount of fluid tracking down from the abdomen. BONE WINDOWS: The visualized osseous structures appear unremarkable. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in evaluating bowel anatomy. There is severe cecal wall thickening. The appendix is normal in caliber. IMPRESSION: 1) Inflammatory changes in the rigth lower quadrant most likely consistent with cecitis, which could be infectious or inflammatory. Ischemic etiology less likely. 2) Large amount of intraperitoneal fluid. 3) Dilated mid small bowel loops, likely secondary to ileus. 4) Fibroid uterus. Pathology: Appendix: Acute appendicitis with acute serositis. No evidence of vasculitis seen. Ileocecal resection specimen: 1. Ileum and proximal margin: Vascular congestion. 2. Colon: a. Severe vascular congestion, submucosal edema, and transmural acute hemorrhage. b. Areas of acute transmural ischemic infarction (slides C and D). c. Distal margin: No infarction. d. No convincing evidence of a primary vasculitis. Scattered small veins have mural acute inflammation and fibrin thrombi, but these changes are almost certainly secondary to the colonic wall injury. e. One lymph node: No diagnostic abnormalities recognized. Peritoneal fluid: NEGATIVE FOR MALIGNANT CELLS. Echocardiogram: Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Small circumferential pericardial effusion. No 2D echocardiographic evidence for endocarditis identified.+ Brief Hospital Course: The patient was initially taken emergently to the operating room for exploratory laparascopy with general surgery back up. She was placed on broad spectrum antibiotics. They observed a normal left tube and [Last Name (un) 2046], and copius greenish yellow fluid, as well as right lower quadrant adhesions and a diffusely inflammed small intestine. The General surgery team became infvolved and noted that the appendix was acutely inflamed but there was no other pathology. after completion of the exploratory laparatomy, the patient remained tachycardic, with otherwise stable vital signs, but required >15 L of resucitation. Despite this the patients Hematocrit rose from 41.3 to 52, and her WBC rose form 12.9 to 39.7. The patients urine output also began to decrease. The patient was becoming edematous and the patient had increased respiratory distress. it was believed that the patient was third spacing, and the patient was transferred to the intensive care unit for monitoring. On post op day 2, the patient was taken back for a reexploration given that the patient had the hemodynamics above, and the patients abdominal exam worsened. In the operating room they discovered a retroperitoneum that was diffulsely petichial and ecchymotic, with significant retroperitoneal edema and bowel edema. the appendages eppiplocae were hemorrhagic. There was pathc purpuring darkening concerning for ischemia of the cecum. The patient underwent a right colectomy, with an ileosotomy and right transverse colon mucous fistula. the patient could not be closed and the abdomen was left open. The patient was sent back to the intensive care unit, intubated. The infectious disease and rheumatology services were consulted and were intimately involved, and the results of the studies they suggested are listed above. The patients hemodynamic status improved, although the patient remained tachycardic and intermittently febrile, although cultures remained negative and the patient remained on broad spectrum antibiotics. She continued to recieve fluid boluses for decreased urine output on post operative days 3 and 1. TPN was started on post operative days 4 and 2. On post operative days 5 and 3, the patient had an echocardiogram to rule out an embolic source for possible mesenteric ischemia, and a HIT panel was sent for decreased platelets. On post operative days 6 and 4 the patient was brought back to the operating room for closure of her abdomen. A vent wean was started on post operative days 7,5,and 1 and continued until postoperative days 10/8/4 when she was successfully extubated. Her NG tube was also discontinued. She was transferred to the floor and on postoperative days 12/10/6 the patient was started on sips. She was seen by physical therapy, as well as continued on her TPN. Her TPN was discontinued on the following day, while the patient started taking clears. The patient was also seen by enterostomy therapy to help in teaching. She remained hemodynamically stable, was passing stool through her ostomy bag, had a well healing incision, and was tolerating a regular diet, and was ready for discharge on post operative day 14/12/8, with a 1 week course of cipro flagyl to be completed per the Infectious disease team. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:40 Tablet(s) Refills:0 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Cecitis Ischemic Right colon Acute appendicitis Status post Exploratory laparotomy with right colectomy Status post right appendectomy Respiratory failure requiring intubation Discharge Condition: Good Discharge Instructions: Please [Name8 (MD) 138] MD if you have spiking fevers, inability to tolerate food, intractable nausea or vomiting, increasing abdominal pain, bleeding, drainage or redness around your incision. You should change your ostomy bag as needed with the help of a visiting nurse. You should resume taking any medications you were taking prior to this admission You should not drive when you are taking narcotic medications for pain. No heavy lifting of objects greater than 10 pounds for the next 6 weeks. You should drink at least 1 liter of fluid day, and more if possible, because your ostomy will be putting a lot of fluid out. Followup Instructions: You should follow up with Dr. [Last Name (STitle) ] in [12-1] weeks. You can call his office for an appointment. You should follow up with your primary care physician over the next week to let him know about your situation and also to monitor your electrolytes.	Admission Date: <Date>1900-5-21</Date> Discharge Date: <Date>1987-8-1</Date> Date of Birth: <Date>1986-11-21</Date> Sex: F Service: <Name>Amit</Name> Allergies: Penicillins Attending:<Name>Fannie</Name> Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Status post exploratory laparatomy status post right colectomy status post appendectomy status post abdominal closure History of Present Illness: 31 yo Female who was status post normal spontaneous vaginal delivery approximately 10 weeks ago who presented on <Date>1981-10-18</Date> with a chief complaint of abdominal pain. She was well until about 12 hours prior to admission when she described the acute onset of sharp right lower quadrant pain and diffuse/poorly characterized dull general abdominal pain. The pain was described as sharp, constant. The pain radiated to the back. It got worse with motion, better with motrin. The pain was associated with nausea and bilious vomiting times 1, subsequent to the onset of pain. The patient also described subjective fevers and chills. The paitent did not have any constipation, diarrhea, change in the color of her stools, dysuria, hematuria, vaginal discharge, itching, or bleeding. No history of recetn truama, travel. she has not been sexually active since her delivery Past Medical History: recurrent respiratory infections allergies Gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Social History: works in a research lab no tobacco, or alcohol travelled to <Country>Christmas Island</Country> in <Year>1988</Year>, bermuda in <Year>1988</Year> Family History: No history of bowel problems. Father had a history of hypertension Physical Exam: temperature 100.8, pulse 81, blood pressure 109/71, respirations 16, oxygen saturation 100% on room air General: patient was in moderate distress, appeared acutely ill Head and neck: head atraumatic/normocephalic. sclera anicteric. No lymphadenopathy, no jvd Card: regular rate and rhythm Lungs: clear to auscultation Abdomen: soft, mildly distended. Diffuse tenderness, RLQ>LLQ. Positive for rebound, especially in lower abdomen Back: no costovertebral angle tenderness. Pelvic exam: significantly limited secondary to discomfort, exquistite tenderness at the interoitus, unable to get in foot rests. Minimal thin white discharge, right adnexal and fundal tenderness consistent with peritonitis On discharge the patient had a well healing midline incision, as well as ostomy sites that were pink and healthy. Stool and gas were present in the ostomy bag. Her abdoment was soft and nondistended Pertinent Results: Blood cultures negative, CMV IgG positive, CMV IgM negative, CMV DNA negative, RPR negative, Fungal culture negative, Stool negative for (camplobacter, salmonella, shigella, vibrio, yersina, ecoli 0157:H7, Cdificile, virus), HSVI/II negative, Hep B SAb positive, Hep BSAg negative, Cervical cultures negative for GC and chlamidyia, Rheumatoid factor negative, HIT negative, Cystic fibrosis negative, sickle negative, lupus anticoagulant negative, cryoglobulin negative, <Name>Arthur</Name> 1:40, ANCA negative, HCG negative. Cardiolipin antibiodies are pending. Pelvic Ultrasound <Date>1981-10-18</Date>: IMPRESSION: 1. Fibroid uterus. 2. Normal appearing ovaries bilaterally. No ovarian torsion seen at the time of the exam, although clinical correlation is needed to entirely exclude this diagnosis. 3. Mild-to-moderate amount of nonspecific free pelvic fluid. Abdominal CT <Date>1981-10-18</Date>: ABDOMEN CT WITH IV CONTRAST: There is a trace right pleural effusion and slight atelectasis at the right lung base. The NG tube extends into the stomach, where it makes a loop in the fundus. There is a large amount of fluid in the peritoneum. The liver, spleen, pancreas, adrenal glands, kidneys, and ureters appear unremarkable. The gallbladder is distended without CT evidence of wall edema. The proximal small bowel is collapsed. The mid small bowel is distended with air-fluid levels. The distal small bowel is not distended. Rectal contrast opacifies the colon, reaching the cecum. There is severe thickening of the cecal wall. The appendix seems to be normal in caliber although surrounded by inflammatory changes and fluid . These findings are most consistent with cecitis, which could be infectious or inflammatory. Ischemic etiology is less likely. PELVIC CT WITH IV CONTRAST: The uterus is enlarged with multiple fibroids, some of which demonstrate calcified rims. The bladder and rectum are unremarkable. There is a large amount of fluid tracking down from the abdomen. BONE WINDOWS: The visualized osseous structures appear unremarkable. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in evaluating bowel anatomy. There is severe cecal wall thickening. The appendix is normal in caliber. IMPRESSION: 1) Inflammatory changes in the rigth lower quadrant most likely consistent with cecitis, which could be infectious or inflammatory. Ischemic etiology less likely. 2) Large amount of intraperitoneal fluid. 3) Dilated mid small bowel loops, likely secondary to ileus. 4) Fibroid uterus. Pathology: Appendix: Acute appendicitis with acute serositis. No evidence of vasculitis seen. Ileocecal resection specimen: 1. Ileum and proximal margin: Vascular congestion. 2. Colon: a. Severe vascular congestion, submucosal edema, and transmural acute hemorrhage. b. Areas of acute transmural ischemic infarction (slides C and D). c. Distal margin: No infarction. d. No convincing evidence of a primary vasculitis. Scattered small veins have mural acute inflammation and fibrin thrombi, but these changes are almost certainly secondary to the colonic wall injury. e. One lymph node: No diagnostic abnormalities recognized. Peritoneal fluid: NEGATIVE FOR MALIGNANT CELLS. Echocardiogram: Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Small circumferential pericardial effusion. No 2D echocardiographic evidence for endocarditis identified.+ Brief Hospital Course: The patient was initially taken emergently to the operating room for exploratory laparascopy with general surgery back up. She was placed on broad spectrum antibiotics. They observed a normal left tube and <Name>Kibler</Name>, and copius greenish yellow fluid, as well as right lower quadrant adhesions and a diffusely inflammed small intestine. The General surgery team became infvolved and noted that the appendix was acutely inflamed but there was no other pathology. after completion of the exploratory laparatomy, the patient remained tachycardic, with otherwise stable vital signs, but required >15 L of resucitation. Despite this the patients Hematocrit rose from 41.3 to 52, and her WBC rose form 12.9 to 39.7. The patients urine output also began to decrease. The patient was becoming edematous and the patient had increased respiratory distress. it was believed that the patient was third spacing, and the patient was transferred to the intensive care unit for monitoring. On post op day 2, the patient was taken back for a reexploration given that the patient had the hemodynamics above, and the patients abdominal exam worsened. In the operating room they discovered a retroperitoneum that was diffulsely petichial and ecchymotic, with significant retroperitoneal edema and bowel edema. the appendages eppiplocae were hemorrhagic. There was pathc purpuring darkening concerning for ischemia of the cecum. The patient underwent a right colectomy, with an ileosotomy and right transverse colon mucous fistula. the patient could not be closed and the abdomen was left open. The patient was sent back to the intensive care unit, intubated. The infectious disease and rheumatology services were consulted and were intimately involved, and the results of the studies they suggested are listed above. The patients hemodynamic status improved, although the patient remained tachycardic and intermittently febrile, although cultures remained negative and the patient remained on broad spectrum antibiotics. She continued to recieve fluid boluses for decreased urine output on post operative days 3 and 1. TPN was started on post operative days 4 and 2. On post operative days 5 and 3, the patient had an echocardiogram to rule out an embolic source for possible mesenteric ischemia, and a HIT panel was sent for decreased platelets. On post operative days 6 and 4 the patient was brought back to the operating room for closure of her abdomen. A vent wean was started on post operative days 7,5,and 1 and continued until postoperative days 10/8/4 when she was successfully extubated. Her NG tube was also discontinued. She was transferred to the floor and on postoperative days 12/10/6 the patient was started on sips. She was seen by physical therapy, as well as continued on her TPN. Her TPN was discontinued on the following day, while the patient started taking clears. The patient was also seen by enterostomy therapy to help in teaching. She remained hemodynamically stable, was passing stool through her ostomy bag, had a well healing incision, and was tolerating a regular diet, and was ready for discharge on post operative day 14/12/8, with a 1 week course of cipro flagyl to be completed per the Infectious disease team. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:40 Tablet(s) Refills:0 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: <Location>30656 Tara Court Lake Kristin, PW 59878</Location> VNA Discharge Diagnosis: Cecitis Ischemic Right colon Acute appendicitis Status post Exploratory laparotomy with right colectomy Status post right appendectomy Respiratory failure requiring intubation Discharge Condition: Good Discharge Instructions: Please <Name>Timothy Negrete</Name> MD if you have spiking fevers, inability to tolerate food, intractable nausea or vomiting, increasing abdominal pain, bleeding, drainage or redness around your incision. You should change your ostomy bag as needed with the help of a visiting nurse. You should resume taking any medications you were taking prior to this admission You should not drive when you are taking narcotic medications for pain. No heavy lifting of objects greater than 10 pounds for the next 6 weeks. You should drink at least 1 liter of fluid day, and more if possible, because your ostomy will be putting a lot of fluid out. Followup Instructions: You should follow up with Dr. <Name>Broadnax</Name> in <Date>8-21</Date> weeks. You can call his office for an appointment. You should follow up with your primary care physician over the next week to let him know about your situation and also to monitor your 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Date: 1900-5-21 Discharge Date: 1987-8-1 Date of Birth: 1986-11-21 Sex: F Service: Amit Allergies: Penicillins Attending:Fannie Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Status post exploratory laparatomy status post right colectomy status post appendectomy status post abdominal closure History of Present Illness: 31 yo Female who was status post normal spontaneous vaginal delivery approximately 10 weeks ago who presented on 1981-10-18 with a chief complaint of abdominal pain. She was well until about 12 hours prior to admission when she described the acute onset of sharp right lower quadrant pain and diffuse/poorly characterized dull general abdominal pain. The pain was described as sharp, constant. The pain radiated to the back. It got worse with motion, better with motrin. The pain was associated with nausea and bilious vomiting times 1, subsequent to the onset of pain. The patient also described subjective fevers and chills. The paitent did not have any constipation, diarrhea, change in the color of her stools, dysuria, hematuria, vaginal discharge, itching, or bleeding. No history of recetn truama, travel. she has not been sexually active since her delivery Past Medical History: recurrent respiratory infections allergies Gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Social History: works in a research lab no tobacco, or alcohol travelled to Christmas Island in 1988, bermuda in 1988 Family History: No history of bowel problems. Father had a history of hypertension Physical Exam: temperature 100.8, pulse 81, blood pressure 109/71, respirations 16, oxygen saturation 100% on room air General: patient was in moderate distress, appeared acutely ill Head and neck: head atraumatic/normocephalic. sclera anicteric. No lymphadenopathy, no jvd Card: regular rate and rhythm Lungs: clear to auscultation Abdomen: soft, mildly distended. Diffuse tenderness, RLQ>LLQ. Positive for rebound, especially in lower abdomen Back: no costovertebral angle tenderness. Pelvic exam: significantly limited secondary to discomfort, exquistite tenderness at the interoitus, unable to get in foot rests. Minimal thin white discharge, right adnexal and fundal tenderness consistent with peritonitis On discharge the patient had a well healing midline incision, as well as ostomy sites that were pink and healthy. Stool and gas were present in the ostomy bag. Her abdoment was soft and nondistended Pertinent Results: Blood cultures negative, CMV IgG positive, CMV IgM negative, CMV DNA negative, RPR negative, Fungal culture negative, Stool negative for (camplobacter, salmonella, shigella, vibrio, yersina, ecoli 0157:H7, Cdificile, virus), HSVI/II negative, Hep B SAb positive, Hep BSAg negative, Cervical cultures negative for GC and chlamidyia, Rheumatoid factor negative, HIT negative, Cystic fibrosis negative, sickle negative, lupus anticoagulant negative, cryoglobulin negative, Arthur 1:40, ANCA negative, HCG negative. Cardiolipin antibiodies are pending. Pelvic Ultrasound 1981-10-18: IMPRESSION: 1. Fibroid uterus. 2. Normal appearing ovaries bilaterally. No ovarian torsion seen at the time of the exam, although clinical correlation is needed to entirely exclude this diagnosis. 3. Mild-to-moderate amount of nonspecific free pelvic fluid. Abdominal CT 1981-10-18: ABDOMEN CT WITH IV CONTRAST: There is a trace right pleural effusion and slight atelectasis at the right lung base. The NG tube extends into the stomach, where it makes a loop in the fundus. There is a large amount of fluid in the peritoneum. The liver, spleen, pancreas, adrenal glands, kidneys, and ureters appear unremarkable. The gallbladder is distended without CT evidence of wall edema. The proximal small bowel is collapsed. The mid small bowel is distended with air-fluid levels. The distal small bowel is not distended. Rectal contrast opacifies the colon, reaching the cecum. There is severe thickening of the cecal wall. The appendix seems to be normal in caliber although surrounded by inflammatory changes and fluid . These findings are most consistent with cecitis, which could be infectious or inflammatory. Ischemic etiology is less likely. PELVIC CT WITH IV CONTRAST: The uterus is enlarged with multiple fibroids, some of which demonstrate calcified rims. The bladder and rectum are unremarkable. There is a large amount of fluid tracking down from the abdomen. BONE WINDOWS: The visualized osseous structures appear unremarkable. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in evaluating bowel anatomy. There is severe cecal wall thickening. The appendix is normal in caliber. IMPRESSION: 1) Inflammatory changes in the rigth lower quadrant most likely consistent with cecitis, which could be infectious or inflammatory. Ischemic etiology less likely. 2) Large amount of intraperitoneal fluid. 3) Dilated mid small bowel loops, likely secondary to ileus. 4) Fibroid uterus. Pathology: Appendix: Acute appendicitis with acute serositis. No evidence of vasculitis seen. Ileocecal resection specimen: 1. Ileum and proximal margin: Vascular congestion. 2. Colon: a. Severe vascular congestion, submucosal edema, and transmural acute hemorrhage. b. Areas of acute transmural ischemic infarction (slides C and D). c. Distal margin: No infarction. d. No convincing evidence of a primary vasculitis. Scattered small veins have mural acute inflammation and fibrin thrombi, but these changes are almost certainly secondary to the colonic wall injury. e. One lymph node: No diagnostic abnormalities recognized. Peritoneal fluid: NEGATIVE FOR MALIGNANT CELLS. Echocardiogram: Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Small circumferential pericardial effusion. No 2D echocardiographic evidence for endocarditis identified.+ Brief Hospital Course: The patient was initially taken emergently to the operating room for exploratory laparascopy with general surgery back up. She was placed on broad spectrum antibiotics. They observed a normal left tube and Kibler, and copius greenish yellow fluid, as well as right lower quadrant adhesions and a diffusely inflammed small intestine. The General surgery team became infvolved and noted that the appendix was acutely inflamed but there was no other pathology. after completion of the exploratory laparatomy, the patient remained tachycardic, with otherwise stable vital signs, but required >15 L of resucitation. Despite this the patients Hematocrit rose from 41.3 to 52, and her WBC rose form 12.9 to 39.7. The patients urine output also began to decrease. The patient was becoming edematous and the patient had increased respiratory distress. it was believed that the patient was third spacing, and the patient was transferred to the intensive care unit for monitoring. On post op day 2, the patient was taken back for a reexploration given that the patient had the hemodynamics above, and the patients abdominal exam worsened. In the operating room they discovered a retroperitoneum that was diffulsely petichial and ecchymotic, with significant retroperitoneal edema and bowel edema. the appendages eppiplocae were hemorrhagic. There was pathc purpuring darkening concerning for ischemia of the cecum. The patient underwent a right colectomy, with an ileosotomy and right transverse colon mucous fistula. the patient could not be closed and the abdomen was left open. The patient was sent back to the intensive care unit, intubated. The infectious disease and rheumatology services were consulted and were intimately involved, and the results of the studies they suggested are listed above. The patients hemodynamic status improved, although the patient remained tachycardic and intermittently febrile, although cultures remained negative and the patient remained on broad spectrum antibiotics. She continued to recieve fluid boluses for decreased urine output on post operative days 3 and 1. TPN was started on post operative days 4 and 2. On post operative days 5 and 3, the patient had an echocardiogram to rule out an embolic source for possible mesenteric ischemia, and a HIT panel was sent for decreased platelets. On post operative days 6 and 4 the patient was brought back to the operating room for closure of her abdomen. A vent wean was started on post operative days 7,5,and 1 and continued until postoperative days 10/8/4 when she was successfully extubated. Her NG tube was also discontinued. She was transferred to the floor and on postoperative days 12/10/6 the patient was started on sips. She was seen by physical therapy, as well as continued on her TPN. Her TPN was discontinued on the following day, while the patient started taking clears. The patient was also seen by enterostomy therapy to help in teaching. She remained hemodynamically stable, was passing stool through her ostomy bag, had a well healing incision, and was tolerating a regular diet, and was ready for discharge on post operative day 14/12/8, with a 1 week course of cipro flagyl to be completed per the Infectious disease team. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:40 Tablet(s) Refills:0 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: 30656 Tara Court Lake Kristin, PW 59878 VNA Discharge Diagnosis: Cecitis Ischemic Right colon Acute appendicitis Status post Exploratory laparotomy with right colectomy Status post right appendectomy Respiratory failure requiring intubation Discharge Condition: Good Discharge Instructions: Please Timothy Negrete MD if you have spiking fevers, inability to tolerate food, intractable nausea or vomiting, increasing abdominal pain, bleeding, drainage or redness around your incision. You should change your ostomy bag as needed with the help of a visiting nurse. You should resume taking any medications you were taking prior to this admission You should not drive when you are taking narcotic medications for pain. No heavy lifting of objects greater than 10 pounds for the next 6 weeks. You should drink at least 1 liter of fluid day, and more if possible, because your ostomy will be putting a lot of fluid out. Followup Instructions: You should follow up with Dr. Broadnax in 8-21 weeks. You can call his office for an appointment. You should follow up with your primary care physician over the next week to let him know about your situation and also to monitor your electrolytes.	['Admission Date: 1900-5-21 Discharge Date: 1987-8-1\n\nDate of Birth: 1986-11-21 Sex: F\n\nService: Amit\n\nAllergies:\nPenicillins\n\nAttending:Fannie\nChief Complaint:\nabdominal pain\n\nMajor Surgical or Invasive Procedure:\nStatus post exploratory laparatomy\nstatus post right colectomy\nstatus post appendectomy\nstatus post abdominal closure\n\n\nHistory of Present Illness:\n31 yo Female who was status post normal spontaneous vaginal\ndelivery approximately 10 weeks ago who presented on 1981-10-18\nwith a chief complaint of abdominal pain. She was well until\nabout 12 hours prior to admission when she described the acute\nonset of sharp right lower quadrant pain and diffuse/poorly\ncharacterized dull general abdominal pain. The pain was\ndescribed as sharp, constant. The pain radiated to the back.', '\nIt got worse with motion, better with motrin. The pain was\nassociated with nausea and bilious vomiting times 1, subsequent\nto the onset of pain. The patient also described subjective\nfevers and chills. The paitent did not have any constipation,\ndiarrhea, change in the color of her stools, dysuria, hematuria,\nvaginal discharge, itching, or bleeding. No history of recetn\ntruama, travel. she has not been sexually active since her\ndelivery\n\nPast Medical History:\nrecurrent respiratory infections\nallergies\nGastroesophageal reflux disease\nremoval of cystic mass of breast\nremoval of labial cyst\ndegenerating fibroid during pregnancy\n\nSocial History:\nworks in a research lab\nno tobacco, or alcohol\ntravelled to Christmas Island in 1988, bermuda in 1988\n\n\nFamily History:\nNo history of bowel problems.', ' Father had a history of\nhypertension\n\nPhysical Exam:\ntemperature 100.8, pulse 81, blood pressure 109/71, respirations\n16, oxygen saturation 100% on room air\nGeneral: patient was in moderate distress, appeared acutely ill\nHead and neck: head atraumatic/normocephalic. sclera anicteric.\nNo lymphadenopathy, no jvd\nCard: regular rate and rhythm\nLungs: clear to auscultation\nAbdomen: soft, mildly distended. Diffuse tenderness, RLQ>LLQ.\nPositive for rebound, especially in lower abdomen\nBack: no costovertebral angle tenderness.\nPelvic exam: significantly limited secondary to discomfort,\nexquistite tenderness at the interoitus, unable to get in foot\nrests. Minimal thin white discharge, right adnexal and fundal\ntenderness consistent with peritonitis\n\nOn discharge the patient had a well healing midline incision, as\nwell as ostomy sites that were pink and healthy.', ' Stool and gas\nwere present in the ostomy bag.\nHer abdoment was soft and nondistended\n\nPertinent Results:\nBlood cultures negative, CMV IgG positive, CMV IgM negative, CMV\nDNA negative, RPR negative, Fungal culture negative, Stool\nnegative for (camplobacter, salmonella, shigella, vibrio,\nyersina, ecoli 0157:H7, Cdificile, virus), HSVI/II negative, Hep\nB SAb positive, Hep BSAg negative, Cervical cultures negative\nfor GC and chlamidyia, Rheumatoid factor negative, HIT negative,\nCystic fibrosis negative, sickle negative, lupus anticoagulant\nnegative, cryoglobulin negative, Arthur 1:40, ANCA negative, HCG\nnegative. Cardiolipin antibiodies are pending.\n\nPelvic Ultrasound 1981-10-18:\nIMPRESSION:\n1. Fibroid uterus.\n2. Normal appearing ovaries bilaterally. No ovarian torsion seen\nat the time of the exam, although clinical correlation is needed\nto entirely exclude this diagnosis.', '\n3. Mild-to-moderate amount of nonspecific free pelvic fluid.\n\nAbdominal CT 1981-10-18:\nABDOMEN CT WITH IV CONTRAST: There is a trace right pleural\neffusion and slight atelectasis at the right lung base. The NG\ntube extends into the stomach, where it makes a loop in the\nfundus. There is a large amount of fluid in the peritoneum. The\nliver, spleen, pancreas, adrenal glands, kidneys, and ureters\nappear unremarkable. The gallbladder is distended without CT\nevidence of wall edema.\n\nThe proximal small bowel is collapsed. The mid small bowel is\ndistended with air-fluid levels. The distal small bowel is not\ndistended. Rectal contrast opacifies the colon, reaching the\ncecum. There is severe thickening of the cecal wall. The\nappendix seems to be normal in caliber although surrounded by\ninflammatory changes and fluid .', ' These findings are most\nconsistent with cecitis, which could be infectious or\ninflammatory. Ischemic etiology is less likely.\n\nPELVIC CT WITH IV CONTRAST: The uterus is enlarged with multiple\nfibroids, some of which demonstrate calcified rims. The bladder\nand rectum are unremarkable. There is a large amount of fluid\ntracking down from the abdomen.\n\nBONE WINDOWS: The visualized osseous structures appear\nunremarkable.\n\nCT RECONSTRUCTIONS: Multiplanar reconstructions were essential\nin evaluating bowel anatomy. There is severe cecal wall\nthickening. The appendix is normal in caliber.\n\nIMPRESSION:\n1) Inflammatory changes in the rigth lower quadrant most likely\nconsistent with cecitis, which could be infectious or\ninflammatory. Ischemic etiology less likely.\n2) Large amount of intraperitoneal fluid.', '\n3) Dilated mid small bowel loops, likely secondary to ileus.\n4) Fibroid uterus.\n\nPathology:\nAppendix:\n Acute appendicitis with acute serositis.\n No evidence of vasculitis seen.\nIleocecal resection specimen:\n\n1. Ileum and proximal margin:\nVascular congestion.\n\n2. Colon:\na. Severe vascular congestion, submucosal edema, and transmural\nacute hemorrhage.\nb. Areas of acute transmural ischemic infarction (slides C and\nD).\nc. Distal margin: No infarction.\nd. No convincing evidence of a primary vasculitis. Scattered\nsmall veins have mural acute inflammation and fibrin thrombi,\nbut these changes are almost certainly secondary to the colonic\nwall injury.\ne. One lymph node: No diagnostic abnormalities recognized.\n\nPeritoneal fluid:\nNEGATIVE FOR MALIGNANT CELLS.\n\nEchocardiogram:\n Conclusions:\nThe left atrium is normal in size.', ' Left ventricular wall\nthickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to\nsuboptimal technical\nquality, a focal wall motion abnormality cannot be fully\nexcluded. Right\nventricular chamber size and free wall motion are normal. The\naortic valve\nleaflets appear structurally normal with good leaflet excursion.\nNo aortic\nregurgitation is seen. The mitral valve appears structurally\nnormal with\ntrivial mitral regurgitation. No mass or vegetation is seen on\nthe mitral\nvalve. There is mild pulmonary artery systolic hypertension.\nThere is a small\ncircumferential pericardial effusion without evidence for\nhemodynamic\ncompromise.\n\nIMPRESSION: Small circumferential pericardial effusion. No 2D\nechocardiographic evidence for endocarditis identified.+\n\n\nBrief Hospital Course:\nThe patient was initially taken emergently to the operating room\nfor exploratory laparascopy with general surgery back up.', ' She\nwas placed on broad spectrum antibiotics. They observed a\nnormal left tube and Kibler, and copius greenish yellow fluid, as\nwell as right lower quadrant adhesions and a diffusely inflammed\nsmall intestine. The General surgery team became infvolved and\nnoted that the appendix was acutely inflamed but there was no\nother pathology. after completion of the exploratory\nlaparatomy, the patient remained tachycardic, with otherwise\nstable vital signs, but required >15 L of resucitation. Despite\nthis the patients Hematocrit rose from 41.3 to 52, and her WBC\nrose form 12.9 to 39.7. The patients urine output also began to\ndecrease. The patient was becoming edematous and the patient\nhad increased respiratory distress. it was believed that the\npatient was third spacing, and the patient was transferred to\nthe intensive care unit for monitoring.', '\n\nOn post op day 2, the patient was taken back for a reexploration\ngiven that the patient had the hemodynamics above, and the\npatients abdominal exam worsened. In the operating room they\ndiscovered a retroperitoneum that was diffulsely petichial and\necchymotic, with significant retroperitoneal edema and bowel\nedema. the appendages eppiplocae were hemorrhagic. There was\npathc purpuring darkening concerning for ischemia of the cecum.\nThe patient underwent a right colectomy, with an ileosotomy and\nright transverse colon mucous fistula. the patient could not be\nclosed and the abdomen was left open. The patient was sent back\nto the intensive care unit, intubated. The infectious disease\nand rheumatology services were consulted and were intimately\ninvolved, and the results of the studies they suggested are\nlisted above.', '\n\nThe patients hemodynamic status improved, although the patient\nremained tachycardic and intermittently febrile, although\ncultures remained negative and the patient remained on broad\nspectrum antibiotics. She continued to recieve fluid boluses\nfor decreased urine output on post operative days 3 and 1. TPN\nwas started on post operative days 4 and 2. On post operative\ndays 5 and 3, the patient had an echocardiogram to rule out an\nembolic source for possible mesenteric ischemia, and a HIT panel\nwas sent for decreased platelets. On post operative days 6 and\n4 the patient was brought back to the operating room for closure\nof her abdomen. A vent wean was started on post operative days\n7,5,and 1 and continued until postoperative days 10/8/4 when she\nwas successfully extubated. Her NG tube was also discontinued.', '\nShe was transferred to the floor and on postoperative days\n12/10/6 the patient was started on sips. She was seen by\nphysical therapy, as well as continued on her TPN. Her TPN was\ndiscontinued on the following day, while the patient started\ntaking clears. The patient was also seen by enterostomy therapy\nto help in teaching. She remained hemodynamically stable, was\npassing stool through her ostomy bag, had a well healing\nincision, and was tolerating a regular diet, and was ready for\ndischarge on post operative day 14/12/8, with a 1 week course of\ncipro flagyl to be completed per the Infectious disease team.\n\n\nMedications on Admission:\nnone\n\nDischarge Medications:\n1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO\nQ4-6H (every 4 to 6 hours) as needed.\nDisp:40 Tablet(s) Refills:0\n2.', ' Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO\nevery 4-6 hours.\nDisp:40 Tablet(s) Refills:0\n3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\nDisp:60 Tablet(s) Refills:2\n4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7\ndays.\nDisp:14 Tablet(s) Refills:0\n5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)\nhours for 7 days.\nDisp:21 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n30656 Tara Court\nLake Kristin, PW 59878 VNA\n\nDischarge Diagnosis:\nCecitis\nIschemic Right colon\nAcute appendicitis\nStatus post Exploratory laparotomy with right colectomy\nStatus post right appendectomy\nRespiratory failure requiring intubation\n\n\nDischarge Condition:\nGood\n\nDischarge Instructions:\nPlease Timothy Negrete MD if you have spiking fevers, inability to tolerate\nfood, intractable nausea or vomiting, increasing abdominal pain,\nbleeding, drainage or redness around your incision.', '\n\nYou should change your ostomy bag as needed with the help of a\nvisiting nurse.\n\nYou should resume taking any medications you were taking prior\nto this admission\n\nYou should not drive when you are taking narcotic medications\nfor pain.\n\nNo heavy lifting of objects greater than 10 pounds for the next\n6 weeks.\n\nYou should drink at least 1 liter of fluid day, and more if\npossible, because your ostomy will be putting a lot of fluid\nout.\n\nFollowup Instructions:\nYou should follow up with Dr. Broadnax in 8-21 weeks. You can\ncall his office for an appointment.\n\nYou should follow up with your primary care physician over the\nnext week to let him know about your situation and also to\nmonitor your electrolytes.\n\n\n\n']
205	13289	165604.0	2103-11-22	Discharge summary	Report	Admission Date: [2103-11-12] Discharge Date: [2103-11-22] Date of Birth: [2072-5-4] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1556] Chief Complaint: ileostomy in place from [9-3] Major Surgical or Invasive Procedure: ileostomy takedown on [2103-11-12] History of Present Illness: 31F had an appendectomy with right colectomy in [8-4] with ileostomy placement. She is here now for takedown of the ileostomy. Past Medical History: recurrent respiratory infections allergies Gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Social History: works in a research labno tobacco, or alcoholtravelled to [Country 2045] in [2081], bermuda in [2088] Family History: No history of bowel problems. Father had a history of hypertension Physical Exam: temp 99.8 HR 80 BP 110/72 RR 16 oxygen 100% RA General: NAD Head and neck: head atraumatic/normocephalic, sclera anicteric No lymphadenopathy, no jvd Card: regular rate and rhythm with s1s2 Lungs: clear to auscultation b/l Abdomen: soft, non-distended, ileostomy in place Back: no costovertebral angle tenderness Extremeties: no edema, no cyanosis, no clubbing Neuro: A + O x 3 Pertinent Results: [2103-11-12] 02:11PM BLOOD Hct-37.5 [2103-11-13] 12:00PM BLOOD WBC-14.1# RBC-4.81 Hgb-14.3 Hct-41.7 MCV-87 MCH-29.8 MCHC-34.4 RDW-13.1 Plt Ct-275 [2103-11-13] 10:04PM BLOOD WBC-19.2 RBC-5.14 Hgb-15.0 Hct-44.4 MCV-86 MCH-29.2 MCHC-33.9 RDW-13.0 Plt Ct-274 [2103-11-14] 03:10AM BLOOD WBC-15.1* RBC-4.56 Hgb-13.5 Hct-40.2 MCV-88 MCH-29.7 MCHC-33.7 RDW-13.2 Plt Ct-292 [2103-11-15] 04:34AM BLOOD WBC-13.2* RBC-4.08* Hgb-11.9* Hct-36.4 MCV-89 MCH-29.2 MCHC-32.8 RDW-13.2 Plt Ct-228 [2103-11-16] 06:00AM BLOOD WBC-9.6 RBC-3.96* Hgb-11.8* Hct-34.7* MCV-88 MCH-29.7 MCHC-33.9 RDW-12.8 Plt Ct-250 [2103-11-17] 05:00AM BLOOD WBC-8.0 RBC-4.21 Hgb-12.4 Hct-37.0 MCV-88 MCH-29.4 MCHC-33.5 RDW-12.8 Plt Ct-275 [2103-11-18] 05:20AM BLOOD WBC-7.6 RBC-4.73 Hgb-13.7 Hct-41.5 MCV-88 MCH-29.0 MCHC-33.0 RDW-12.8 Plt Ct-322 [2103-11-19] 10:40AM BLOOD WBC-9.4 RBC-4.44 Hgb-12.8 Hct-38.4 MCV-87 MCH-28.8 MCHC-33.3 RDW-12.8 Plt Ct-389 [2103-11-15] 04:34AM BLOOD Neuts-80.0* Lymphs-13.9* Monos-3.0 Eos-3.0 Baso-0.1 [2103-11-19] 10:40AM BLOOD Neuts-71.3* Lymphs-18.4 Monos-6.4 Eos-3.2 Baso-0.6 [2103-11-13] 12:00PM BLOOD Plt Ct-275 [2103-11-13] 10:04PM BLOOD Plt Ct-274 [2103-11-14] 03:10AM BLOOD Plt Ct-292 [2103-11-15] 04:34AM BLOOD Plt Ct-228 [2103-11-16] 06:00AM BLOOD Plt Ct-250 [2103-11-17] 05:00AM BLOOD Plt Ct-275 [2103-11-18] 05:20AM BLOOD Plt Ct-322 [2103-11-19] 10:40AM BLOOD Plt Ct-389 [2103-11-13] 05:17PM BLOOD Glucose-116* UreaN-4* Creat-0.8 Na-136 K-4.3 Cl-101 HCO3-26 AnGap-13 [2103-11-13] 10:04PM BLOOD Glucose-107* UreaN-4* Creat-0.6 Na-139 K-4.1 Cl-103 HCO3-25 AnGap-15 [2103-11-14] 03:10AM BLOOD Glucose-128* UreaN-4* Creat-0.7 Na-141 K-3.6 Cl-106 HCO3-26 AnGap-13 [2103-11-14] 05:47PM BLOOD K-4.0 [2103-11-15] 04:34AM BLOOD Glucose-85 UreaN-5* Creat-0.6 Na-138 K-3.6 Cl-104 HCO3-28 AnGap-10 [2103-11-16] 06:00AM BLOOD Glucose-105 UreaN-4* Creat-0.5 Na-137 K-3.8 Cl-102 HCO3-28 AnGap-11 [2103-11-17] 05:00AM BLOOD Glucose-124* UreaN-4* Creat-0.5 Na-138 K-4.2 Cl-104 HCO3-30* AnGap-8 [2103-11-13] 10:04PM BLOOD ALT-11 AST-21 LD(LDH)-183 AlkPhos-62 Amylase-45 TotBili-0.5 [2103-11-14] 03:10AM BLOOD ALT-9 AST-19 AlkPhos-54 Amylase-40 TotBili-0.5 [2103-11-14] 04:11AM BLOOD LD(LDH)-336* [2103-11-15] 04:34AM BLOOD ALT-8 AST-15 LD(LDH)-142 AlkPhos-56 Amylase-59 TotBili-0.4 [2103-11-13] 10:04PM BLOOD Lipase-14 [2103-11-14] 03:10AM BLOOD Lipase-13 [2103-11-15] 04:34AM BLOOD Lipase-19 [2103-11-13] 05:17PM BLOOD Calcium-9.0 Phos-2.6* Mg-1.6 [2103-11-13] 10:04PM BLOOD Calcium-9.3 Phos-2.4* Mg-1.7 [2103-11-14] 03:10AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.7 [2103-11-15] 04:34AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.5* Mg-1.7 [2103-11-16] 06:00AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7 [2103-11-17] 05:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8 [2103-11-14] 04:11AM BLOOD TSH-4.2 [2103-11-13] 10:04PM BLOOD HoldBLu-HOLD [2103-11-13] 05:43PM BLOOD Type-ART Temp-39.1 Rates-/30 FiO2-21 pO2-87 pCO2-41 pH-7.41 calHCO3-27 Base XS-0 Intubat-NOT INTUBA [2103-11-13] 05:43PM BLOOD Lactate-0.9 [2103-11-14] 07:00AM BLOOD Lactate-0.9 Brief Hospital Course: The patient was admitted on [2103-11-12] and taken to the operating room for takedown of her ileostomy and ileocolic anastomosis. She tolerated the procedure well with minimal blood loss and was transferred to the PACU and then the floor. While on the floor she began having fevers and tachycardia on POD 1. Blood cultures were sent with one bottle out of four returning positive for MRSA. She was transferred to the ICU for closer monitoring and fluid resucitation. She recovered three days later with respect to her tachycardia and was afebrile after 3 days of vancomycin. Back on the floor she was found to have an ileus with abdominal distension. We placed an NGT for decompression and kept her NPO. On POD 7 she was started on clears and was advanced to a regular diet over the next two days. We noted that her surgical wound was draining some serosanguinous fluid, so we opened up 3-4 staples and packed the wound with a wet to dry dressing. She was discharged with VNA for care of this wound as well as her ileostomy wounds on POD 10. Medications on Admission: none Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 2 weeks. Disp:28 Capsule(s) Refills:0 3. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: s/p ileostomy takedown on [2103-11-12] unexplained post-operative fever and tachycardia s/p right colectomy s/p appendectomy recurrent respiratory infections allergies gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Take a shower immediately before dressing changes by the visiting nurse. Followup Instructions: Call to schedule a follow-up appointment in [12-1] weeks with Dr. [Last Name (STitle) ]. His phone number is ([Telephone/Fax (1) 2047]. Please make an appointment with your primary care provider, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) 2049] for approximately ten days after discharge ([2103-12-2] - [2103-12-4]). At this visit you should have a CBC and blood cultures drawn. Her phone number is ([Telephone/Fax (1) 2050].	Admission Date: <Date>2001-4-27</Date> Discharge Date: <Date>2003-2-24</Date> Date of Birth: <Date>2020-6-1</Date> Sex: F Service: SURGERY Allergies: Penicillins Attending:<Name>Bruce</Name> Chief Complaint: ileostomy in place from <Date>9-14</Date> Major Surgical or Invasive Procedure: ileostomy takedown on <Date>2001-4-27</Date> History of Present Illness: 31F had an appendectomy with right colectomy in <Date>3-7</Date> with ileostomy placement. She is here now for takedown of the ileostomy. Past Medical History: recurrent respiratory infections allergies Gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Social History: works in a research labno tobacco, or alcoholtravelled to <Country>Tokelau</Country> in <Year>2000</Year>, bermuda in <Year>2000</Year> Family History: No history of bowel problems. Father had a history of hypertension Physical Exam: temp 99.8 HR 80 BP 110/72 RR 16 oxygen 100% RA General: NAD Head and neck: head atraumatic/normocephalic, sclera anicteric No lymphadenopathy, no jvd Card: regular rate and rhythm with s1s2 Lungs: clear to auscultation b/l Abdomen: soft, non-distended, ileostomy in place Back: no costovertebral angle tenderness Extremeties: no edema, no cyanosis, no clubbing Neuro: A + O x 3 Pertinent Results: <Date>2001-4-27</Date> 02:11PM BLOOD Hct-37.5 <Date>1970-9-29</Date> 12:00PM BLOOD WBC-14.1# RBC-4.81 Hgb-14.3 Hct-41.7 MCV-87 MCH-29.8 MCHC-34.4 RDW-13.1 Plt Ct-275 <Date>1970-9-29</Date> 10:04PM BLOOD WBC-19.2 RBC-5.14 Hgb-15.0 Hct-44.4 MCV-86 MCH-29.2 MCHC-33.9 RDW-13.0 Plt Ct-274 <Date>1904-8-26</Date> 03:10AM BLOOD WBC-15.1* RBC-4.56 Hgb-13.5 Hct-40.2 MCV-88 MCH-29.7 MCHC-33.7 RDW-13.2 Plt Ct-292 <Date>1927-9-15</Date> 04:34AM BLOOD WBC-13.2* RBC-4.08* Hgb-11.9* Hct-36.4 MCV-89 MCH-29.2 MCHC-32.8 RDW-13.2 Plt Ct-228 <Date>1937-12-28</Date> 06:00AM BLOOD WBC-9.6 RBC-3.96* Hgb-11.8* Hct-34.7* MCV-88 MCH-29.7 MCHC-33.9 RDW-12.8 Plt Ct-250 <Date>1942-3-26</Date> 05:00AM BLOOD WBC-8.0 RBC-4.21 Hgb-12.4 Hct-37.0 MCV-88 MCH-29.4 MCHC-33.5 RDW-12.8 Plt Ct-275 <Date>1923-3-24</Date> 05:20AM BLOOD WBC-7.6 RBC-4.73 Hgb-13.7 Hct-41.5 MCV-88 MCH-29.0 MCHC-33.0 RDW-12.8 Plt Ct-322 <Date>1927-9-14</Date> 10:40AM BLOOD WBC-9.4 RBC-4.44 Hgb-12.8 Hct-38.4 MCV-87 MCH-28.8 MCHC-33.3 RDW-12.8 Plt Ct-389 <Date>1927-9-15</Date> 04:34AM BLOOD Neuts-80.0* Lymphs-13.9* Monos-3.0 Eos-3.0 Baso-0.1 <Date>1927-9-14</Date> 10:40AM BLOOD Neuts-71.3* Lymphs-18.4 Monos-6.4 Eos-3.2 Baso-0.6 <Date>1970-9-29</Date> 12:00PM BLOOD Plt Ct-275 <Date>1970-9-29</Date> 10:04PM BLOOD Plt Ct-274 <Date>1904-8-26</Date> 03:10AM BLOOD Plt Ct-292 <Date>1927-9-15</Date> 04:34AM BLOOD Plt Ct-228 <Date>1937-12-28</Date> 06:00AM BLOOD Plt Ct-250 <Date>1942-3-26</Date> 05:00AM BLOOD Plt Ct-275 <Date>1923-3-24</Date> 05:20AM BLOOD Plt Ct-322 <Date>1927-9-14</Date> 10:40AM BLOOD Plt Ct-389 <Date>1970-9-29</Date> 05:17PM BLOOD Glucose-116* UreaN-4* Creat-0.8 Na-136 K-4.3 Cl-101 HCO3-26 AnGap-13 <Date>1970-9-29</Date> 10:04PM BLOOD Glucose-107* UreaN-4* Creat-0.6 Na-139 K-4.1 Cl-103 HCO3-25 AnGap-15 <Date>1904-8-26</Date> 03:10AM BLOOD Glucose-128* UreaN-4* Creat-0.7 Na-141 K-3.6 Cl-106 HCO3-26 AnGap-13 <Date>1904-8-26</Date> 05:47PM BLOOD K-4.0 <Date>1927-9-15</Date> 04:34AM BLOOD Glucose-85 UreaN-5* Creat-0.6 Na-138 K-3.6 Cl-104 HCO3-28 AnGap-10 <Date>1937-12-28</Date> 06:00AM BLOOD Glucose-105 UreaN-4* Creat-0.5 Na-137 K-3.8 Cl-102 HCO3-28 AnGap-11 <Date>1942-3-26</Date> 05:00AM BLOOD Glucose-124* UreaN-4* Creat-0.5 Na-138 K-4.2 Cl-104 HCO3-30* AnGap-8 <Date>1970-9-29</Date> 10:04PM BLOOD ALT-11 AST-21 LD(LDH)-183 AlkPhos-62 Amylase-45 TotBili-0.5 <Date>1904-8-26</Date> 03:10AM BLOOD ALT-9 AST-19 AlkPhos-54 Amylase-40 TotBili-0.5 <Date>1904-8-26</Date> 04:11AM BLOOD LD(LDH)-336* <Date>1927-9-15</Date> 04:34AM BLOOD ALT-8 AST-15 LD(LDH)-142 AlkPhos-56 Amylase-59 TotBili-0.4 <Date>1970-9-29</Date> 10:04PM BLOOD Lipase-14 <Date>1904-8-26</Date> 03:10AM BLOOD Lipase-13 <Date>1927-9-15</Date> 04:34AM BLOOD Lipase-19 <Date>1970-9-29</Date> 05:17PM BLOOD Calcium-9.0 Phos-2.6* Mg-1.6 <Date>1970-9-29</Date> 10:04PM BLOOD Calcium-9.3 Phos-2.4* Mg-1.7 <Date>1904-8-26</Date> 03:10AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.7 <Date>1927-9-15</Date> 04:34AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.5* Mg-1.7 <Date>1937-12-28</Date> 06:00AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7 <Date>1942-3-26</Date> 05:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8 <Date>1904-8-26</Date> 04:11AM BLOOD TSH-4.2 <Date>1970-9-29</Date> 10:04PM BLOOD HoldBLu-HOLD <Date>1970-9-29</Date> 05:43PM BLOOD Type-ART Temp-39.1 Rates-/30 FiO2-21 pO2-87 pCO2-41 pH-7.41 calHCO3-27 Base XS-0 Intubat-NOT INTUBA <Date>1970-9-29</Date> 05:43PM BLOOD Lactate-0.9 <Date>1904-8-26</Date> 07:00AM BLOOD Lactate-0.9 Brief Hospital Course: The patient was admitted on <Date>2001-4-27</Date> and taken to the operating room for takedown of her ileostomy and ileocolic anastomosis. She tolerated the procedure well with minimal blood loss and was transferred to the PACU and then the floor. While on the floor she began having fevers and tachycardia on POD 1. Blood cultures were sent with one bottle out of four returning positive for MRSA. She was transferred to the ICU for closer monitoring and fluid resucitation. She recovered three days later with respect to her tachycardia and was afebrile after 3 days of vancomycin. Back on the floor she was found to have an ileus with abdominal distension. We placed an NGT for decompression and kept her NPO. On POD 7 she was started on clears and was advanced to a regular diet over the next two days. We noted that her surgical wound was draining some serosanguinous fluid, so we opened up 3-4 staples and packed the wound with a wet to dry dressing. She was discharged with VNA for care of this wound as well as her ileostomy wounds on POD 10. Medications on Admission: none Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 2 weeks. Disp:28 Capsule(s) Refills:0 3. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: <Location>1822 Michael Drives Apt. 708 Tiffanystad, MN 60224</Location> VNA Discharge Diagnosis: s/p ileostomy takedown on <Date>2001-4-27</Date> unexplained post-operative fever and tachycardia s/p right colectomy s/p appendectomy recurrent respiratory infections allergies gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Take a shower immediately before dressing changes by the visiting nurse. Followup Instructions: Call to schedule a follow-up appointment in <Date>4-8</Date> weeks with Dr. <Name>Braswell</Name>. His phone number is (<Telephone>193-881-9621</Telephone>. Please make an appointment with your primary care provider, <Name>Luu</Name>. <Name>Marianna</Name> <Name>Ivory</Name> for approximately ten days after discharge (<Date>2010-9-8</Date> - <Date>2019-8-21</Date>). At this visit you should have a CBC and blood cultures drawn. Her phone number is (<Telephone>978-183-3734</Telephone>.	000000000000000001111111110000000000000000000000000000000011111111100000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111100001111000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000001111111110000000000000000000000000011111111100000000000000000000000000111111111000000000000000000000000001111111111000000000000000000000000001111111110000000000000000000000000011111111100000000000000000000000000111111111000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000111111111000000000000000000000000011111111100000000000000000000000001111111110000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000001111111110000000000000000000000011111111100000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 2001-4-27 Discharge Date: 2003-2-24 Date of Birth: 2020-6-1 Sex: F Service: SURGERY Allergies: Penicillins Attending:Bruce Chief Complaint: ileostomy in place from 9-14 Major Surgical or Invasive Procedure: ileostomy takedown on 2001-4-27 History of Present Illness: 31F had an appendectomy with right colectomy in 3-7 with ileostomy placement. She is here now for takedown of the ileostomy. Past Medical History: recurrent respiratory infections allergies Gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Social History: works in a research labno tobacco, or alcoholtravelled to Tokelau in 2000, bermuda in 2000 Family History: No history of bowel problems. Father had a history of hypertension Physical Exam: temp 99.8 HR 80 BP 110/72 RR 16 oxygen 100% RA General: NAD Head and neck: head atraumatic/normocephalic, sclera anicteric No lymphadenopathy, no jvd Card: regular rate and rhythm with s1s2 Lungs: clear to auscultation b/l Abdomen: soft, non-distended, ileostomy in place Back: no costovertebral angle tenderness Extremeties: no edema, no cyanosis, no clubbing Neuro: A + O x 3 Pertinent Results: 2001-4-27 02:11PM BLOOD Hct-37.5 1970-9-29 12:00PM BLOOD WBC-14.1# RBC-4.81 Hgb-14.3 Hct-41.7 MCV-87 MCH-29.8 MCHC-34.4 RDW-13.1 Plt Ct-275 1970-9-29 10:04PM BLOOD WBC-19.2 RBC-5.14 Hgb-15.0 Hct-44.4 MCV-86 MCH-29.2 MCHC-33.9 RDW-13.0 Plt Ct-274 1904-8-26 03:10AM BLOOD WBC-15.1* RBC-4.56 Hgb-13.5 Hct-40.2 MCV-88 MCH-29.7 MCHC-33.7 RDW-13.2 Plt Ct-292 1927-9-15 04:34AM BLOOD WBC-13.2* RBC-4.08* Hgb-11.9* Hct-36.4 MCV-89 MCH-29.2 MCHC-32.8 RDW-13.2 Plt Ct-228 1937-12-28 06:00AM BLOOD WBC-9.6 RBC-3.96* Hgb-11.8* Hct-34.7* MCV-88 MCH-29.7 MCHC-33.9 RDW-12.8 Plt Ct-250 1942-3-26 05:00AM BLOOD WBC-8.0 RBC-4.21 Hgb-12.4 Hct-37.0 MCV-88 MCH-29.4 MCHC-33.5 RDW-12.8 Plt Ct-275 1923-3-24 05:20AM BLOOD WBC-7.6 RBC-4.73 Hgb-13.7 Hct-41.5 MCV-88 MCH-29.0 MCHC-33.0 RDW-12.8 Plt Ct-322 1927-9-14 10:40AM BLOOD WBC-9.4 RBC-4.44 Hgb-12.8 Hct-38.4 MCV-87 MCH-28.8 MCHC-33.3 RDW-12.8 Plt Ct-389 1927-9-15 04:34AM BLOOD Neuts-80.0* Lymphs-13.9* Monos-3.0 Eos-3.0 Baso-0.1 1927-9-14 10:40AM BLOOD Neuts-71.3* Lymphs-18.4 Monos-6.4 Eos-3.2 Baso-0.6 1970-9-29 12:00PM BLOOD Plt Ct-275 1970-9-29 10:04PM BLOOD Plt Ct-274 1904-8-26 03:10AM BLOOD Plt Ct-292 1927-9-15 04:34AM BLOOD Plt Ct-228 1937-12-28 06:00AM BLOOD Plt Ct-250 1942-3-26 05:00AM BLOOD Plt Ct-275 1923-3-24 05:20AM BLOOD Plt Ct-322 1927-9-14 10:40AM BLOOD Plt Ct-389 1970-9-29 05:17PM BLOOD Glucose-116* UreaN-4* Creat-0.8 Na-136 K-4.3 Cl-101 HCO3-26 AnGap-13 1970-9-29 10:04PM BLOOD Glucose-107* UreaN-4* Creat-0.6 Na-139 K-4.1 Cl-103 HCO3-25 AnGap-15 1904-8-26 03:10AM BLOOD Glucose-128* UreaN-4* Creat-0.7 Na-141 K-3.6 Cl-106 HCO3-26 AnGap-13 1904-8-26 05:47PM BLOOD K-4.0 1927-9-15 04:34AM BLOOD Glucose-85 UreaN-5* Creat-0.6 Na-138 K-3.6 Cl-104 HCO3-28 AnGap-10 1937-12-28 06:00AM BLOOD Glucose-105 UreaN-4* Creat-0.5 Na-137 K-3.8 Cl-102 HCO3-28 AnGap-11 1942-3-26 05:00AM BLOOD Glucose-124* UreaN-4* Creat-0.5 Na-138 K-4.2 Cl-104 HCO3-30* AnGap-8 1970-9-29 10:04PM BLOOD ALT-11 AST-21 LD(LDH)-183 AlkPhos-62 Amylase-45 TotBili-0.5 1904-8-26 03:10AM BLOOD ALT-9 AST-19 AlkPhos-54 Amylase-40 TotBili-0.5 1904-8-26 04:11AM BLOOD LD(LDH)-336* 1927-9-15 04:34AM BLOOD ALT-8 AST-15 LD(LDH)-142 AlkPhos-56 Amylase-59 TotBili-0.4 1970-9-29 10:04PM BLOOD Lipase-14 1904-8-26 03:10AM BLOOD Lipase-13 1927-9-15 04:34AM BLOOD Lipase-19 1970-9-29 05:17PM BLOOD Calcium-9.0 Phos-2.6* Mg-1.6 1970-9-29 10:04PM BLOOD Calcium-9.3 Phos-2.4* Mg-1.7 1904-8-26 03:10AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.7 1927-9-15 04:34AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.5* Mg-1.7 1937-12-28 06:00AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7 1942-3-26 05:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8 1904-8-26 04:11AM BLOOD TSH-4.2 1970-9-29 10:04PM BLOOD HoldBLu-HOLD 1970-9-29 05:43PM BLOOD Type-ART Temp-39.1 Rates-/30 FiO2-21 pO2-87 pCO2-41 pH-7.41 calHCO3-27 Base XS-0 Intubat-NOT INTUBA 1970-9-29 05:43PM BLOOD Lactate-0.9 1904-8-26 07:00AM BLOOD Lactate-0.9 Brief Hospital Course: The patient was admitted on 2001-4-27 and taken to the operating room for takedown of her ileostomy and ileocolic anastomosis. She tolerated the procedure well with minimal blood loss and was transferred to the PACU and then the floor. While on the floor she began having fevers and tachycardia on POD 1. Blood cultures were sent with one bottle out of four returning positive for MRSA. She was transferred to the ICU for closer monitoring and fluid resucitation. She recovered three days later with respect to her tachycardia and was afebrile after 3 days of vancomycin. Back on the floor she was found to have an ileus with abdominal distension. We placed an NGT for decompression and kept her NPO. On POD 7 she was started on clears and was advanced to a regular diet over the next two days. We noted that her surgical wound was draining some serosanguinous fluid, so we opened up 3-4 staples and packed the wound with a wet to dry dressing. She was discharged with VNA for care of this wound as well as her ileostomy wounds on POD 10. Medications on Admission: none Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 2 weeks. Disp:28 Capsule(s) Refills:0 3. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: 1822 Michael Drives Apt. 708 Tiffanystad, MN 60224 VNA Discharge Diagnosis: s/p ileostomy takedown on 2001-4-27 unexplained post-operative fever and tachycardia s/p right colectomy s/p appendectomy recurrent respiratory infections allergies gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Take a shower immediately before dressing changes by the visiting nurse. Followup Instructions: Call to schedule a follow-up appointment in 4-8 weeks with Dr. Braswell. His phone number is (193-881-9621. Please make an appointment with your primary care provider, Luu. Marianna Ivory for approximately ten days after discharge (2010-9-8 - 2019-8-21). At this visit you should have a CBC and blood cultures drawn. Her phone number is (978-183-3734.	['Admission Date: 2001-4-27 Discharge Date: 2003-2-24\n\nDate of Birth: 2020-6-1 Sex: F\n\nService: SURGERY\n\nAllergies:\nPenicillins\n\nAttending:Bruce\nChief Complaint:\nileostomy in place from 9-14\n\nMajor Surgical or Invasive Procedure:\nileostomy takedown on 2001-4-27\n\n\nHistory of Present Illness:\n31F had an appendectomy with right colectomy in 3-7 with\nileostomy placement. She is here now for takedown of the\nileostomy.\n\nPast Medical History:\nrecurrent respiratory infections\nallergies\nGastroesophageal reflux disease\nremoval of cystic mass of breast\nremoval of labial cyst\ndegenerating fibroid during pregnancy\n\nSocial History:\nworks in a research labno tobacco, or alcoholtravelled to Tokelau\nin 2000, bermuda in 2000\n\nFamily History:\nNo history of bowel problems. Father had a history of\nhypertension\n\nPhysical Exam:\ntemp 99.', '8 HR 80 BP 110/72 RR 16 oxygen 100% RA\nGeneral: NAD\nHead and neck: head atraumatic/normocephalic, sclera anicteric\nNo lymphadenopathy, no jvd\nCard: regular rate and rhythm with s1s2\nLungs: clear to auscultation b/l\nAbdomen: soft, non-distended, ileostomy in place\nBack: no costovertebral angle tenderness\nExtremeties: no edema, no cyanosis, no clubbing\nNeuro: A + O x 3\n\nPertinent Results:\n2001-4-27 02:11PM BLOOD Hct-37.5\n1970-9-29 12:00PM BLOOD WBC-14.1# RBC-4.81 Hgb-14.3 Hct-41.7\nMCV-87 MCH-29.8 MCHC-34.4 RDW-13.1 Plt Ct-275\n1970-9-29 10:04PM BLOOD WBC-19.2 RBC-5.14 Hgb-15.0 Hct-44.4\nMCV-86 MCH-29.2 MCHC-33.9 RDW-13.0 Plt Ct-274\n1904-8-26 03:10AM BLOOD WBC-15.1* RBC-4.56 Hgb-13.5 Hct-40.2\nMCV-88 MCH-29.7 MCHC-33.7 RDW-13.2 Plt Ct-292\n1927-9-15 04:34AM BLOOD WBC-13.2* RBC-4.08* Hgb-11.9* Hct-36.', '4\nMCV-89 MCH-29.2 MCHC-32.8 RDW-13.2 Plt Ct-228\n1937-12-28 06:00AM BLOOD WBC-9.6 RBC-3.96* Hgb-11.8* Hct-34.7\nMCV-88 MCH-29.7 MCHC-33.9 RDW-12.8 Plt Ct-250\n1942-3-26 05:00AM BLOOD WBC-8.0 RBC-4.21 Hgb-12.4 Hct-37.0 MCV-88\nMCH-29.4 MCHC-33.5 RDW-12.8 Plt Ct-275\n1923-3-24 05:20AM BLOOD WBC-7.6 RBC-4.73 Hgb-13.7 Hct-41.5 MCV-88\nMCH-29.0 MCHC-33.0 RDW-12.8 Plt Ct-322\n1927-9-14 10:40AM BLOOD WBC-9.4 RBC-4.44 Hgb-12.8 Hct-38.4 MCV-87\nMCH-28.8 MCHC-33.3 RDW-12.8 Plt Ct-389\n1927-9-15 04:34AM BLOOD Neuts-80.0 Lymphs-13.9* Monos-3.0\nEos-3.0 Baso-0.1\n1927-9-14 10:40AM BLOOD Neuts-71.3* Lymphs-18.4 Monos-6.4 Eos-3.2\nBaso-0.6\n1970-9-29 12:00PM BLOOD Plt Ct-275\n1970-9-29 10:04PM BLOOD Plt Ct-274\n1904-8-26 03:10AM BLOOD Plt Ct-292\n1927-9-15 04:34AM BLOOD Plt Ct-228\n1937-12-28 06:00AM BLOOD Plt Ct-250\n1942-3-26 05:00AM BLOOD Plt Ct-275\n1923-3-24 05:20AM BLOOD Plt Ct-322\n1927-9-14 10:40AM BLOOD Plt Ct-389\n1970-9-29 05:17PM BLOOD Glucose-116* UreaN-4* Creat-0.', '8 Na-136\nK-4.3 Cl-101 HCO3-26 AnGap-13\n1970-9-29 10:04PM BLOOD Glucose-107* UreaN-4* Creat-0.6 Na-139\nK-4.1 Cl-103 HCO3-25 AnGap-15\n1904-8-26 03:10AM BLOOD Glucose-128* UreaN-4* Creat-0.7 Na-141\nK-3.6 Cl-106 HCO3-26 AnGap-13\n1904-8-26 05:47PM BLOOD K-4.0\n1927-9-15 04:34AM BLOOD Glucose-85 UreaN-5* Creat-0.6 Na-138\nK-3.6 Cl-104 HCO3-28 AnGap-10\n1937-12-28 06:00AM BLOOD Glucose-105 UreaN-4* Creat-0.5 Na-137\nK-3.8 Cl-102 HCO3-28 AnGap-11\n1942-3-26 05:00AM BLOOD Glucose-124* UreaN-4* Creat-0.5 Na-138\nK-4.2 Cl-104 HCO3-30* AnGap-8\n1970-9-29 10:04PM BLOOD ALT-11 AST-21 LD(LDH)-183 AlkPhos-62\nAmylase-45 TotBili-0.5\n1904-8-26 03:10AM BLOOD ALT-9 AST-19 AlkPhos-54 Amylase-40\nTotBili-0.5\n1904-8-26 04:11AM BLOOD LD(LDH)-336\n1927-9-15 04:34AM BLOOD ALT-8 AST-15 LD(LDH)-142 AlkPhos-56\nAmylase-59 TotBili-0.', '4\n1970-9-29 10:04PM BLOOD Lipase-14\n1904-8-26 03:10AM BLOOD Lipase-13\n1927-9-15 04:34AM BLOOD Lipase-19\n1970-9-29 05:17PM BLOOD Calcium-9.0 Phos-2.6 Mg-1.6\n1970-9-29 10:04PM BLOOD Calcium-9.3 Phos-2.4* Mg-1.7\n1904-8-26 03:10AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.7\n1927-9-15 04:34AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.5* Mg-1.7\n1937-12-28 06:00AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7\n1942-3-26 05:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8\n1904-8-26 04:11AM BLOOD TSH-4.2\n1970-9-29 10:04PM BLOOD HoldBLu-HOLD\n1970-9-29 05:43PM BLOOD Type-ART Temp-39.1 Rates-/30 FiO2-21\npO2-87 pCO2-41 pH-7.41 calHCO3-27 Base XS-0 Intubat-NOT INTUBA\n1970-9-29 05:43PM BLOOD Lactate-0.9\n1904-8-26 07:00AM BLOOD Lactate-0.9\n\nBrief Hospital Course:\nThe patient was admitted on 2001-4-27 and taken to the operating\nroom for takedown of her ileostomy and ileocolic anastomosis.', '\nShe tolerated the procedure well with minimal blood loss and was\ntransferred to the PACU and then the floor. While on the floor\nshe began having fevers and tachycardia on POD 1. Blood\ncultures were sent with one bottle out of four returning\npositive for MRSA. She was transferred to the ICU for closer\nmonitoring and fluid resucitation. She recovered three days\nlater with respect to her tachycardia and was afebrile after 3\ndays of vancomycin. Back on the floor she was found to have an\nileus with abdominal distension. We placed an NGT for\ndecompression and kept her NPO. On POD 7 she was started on\nclears and was advanced to a regular diet over the next two\ndays. We noted that her surgical wound was draining some\nserosanguinous fluid, so we opened up 3-4 staples and packed the\nwound with a wet to dry dressing.', ' She was discharged with VNA\nfor care of this wound as well as her ileostomy wounds on POD\n10.\n\nMedications on Admission:\nnone\n\nDischarge Medications:\n1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours\nas needed for pain.\nDisp:40 Tablet(s) Refills:0\n2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for\n2 weeks.\nDisp:28 Capsule(s) Refills:0\n3. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12\nhours) for 6 days.\nDisp:12 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n1822 Michael Drives Apt. 708\nTiffanystad, MN 60224 VNA\n\nDischarge Diagnosis:\ns/p ileostomy takedown on 2001-4-27\nunexplained post-operative fever and tachycardia\ns/p right colectomy\ns/p appendectomy\nrecurrent respiratory infections\nallergies\ngastroesophageal reflux disease\nremoval of cystic mass of breast\nremoval of labial cyst\ndegenerating fibroid during pregnancy\n\n\nDischarge Condition:\ngood\n\nDischarge Instructions:\nGo to an Emergency Room if you experience new and continuing\nnausea,\nvomiting, fevers (>101.', '5 F), chills, or shortness of breath.\nAlso go to the ER if your wound becomes red, swollen, warm, or\nproduces pus.\n\nIf you experience clear drainage from your wounds, cover them\nwith a\nclean dressing and stop showering until the drainage subsides\nfor at\nleast 2 days.\n\nNo heavy lifting or exertion for at least 6 weeks.\n\nNo driving while taking pain medications.\n\nNarcotics can cause constipation. Please take an over the\ncounter stool softener such as Colace or a gentle laxative such\nas Milk of Magnesia if you experience constipation.\n\nBe sure to take your complete course of antibiotics.\n\nYou may resume your regular diet as tolerated.\n\nYou may take showers (no baths) after your dressings have been\nremoved from your wounds. Take a shower immediately before\ndressing changes by the visiting nurse.', '\n\nFollowup Instructions:\nCall to schedule a follow-up appointment in 4-8 weeks with Dr.\nBraswell. His phone number is (193-881-9621.\n\nPlease make an appointment with your primary care provider, Luu.\nMarianna Ivory for approximately ten days after discharge\n(2010-9-8 - 2019-8-21). At this visit you should have a CBC and\nblood cultures drawn. Her phone number is (978-183-3734.\n\n\n\n']
206	5239	129387.0	2189-02-25	Discharge summary	Report	Admission Date: [2189-2-18] Discharge Date: [2189-2-25] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a past medical history significant for coronary artery disease, congestive heart failure, hypertension, chronic autoimmune hemolytic anemia, and history of a gastrointestinal bleed, who presented to the Emergency Department at [Hospital1 69] at 8 A.M. with epigastric pain. The patient's pain started at approximately 7:30 A.M. on the day of admission after eating breakfast. It was described as a burning sensation. The patient took one sublingual nitroglycerin without effect. The patient reportedly denied any shortness of breath, nausea, vomiting, fevers, chills, or headache. The patient had been off her aspirin and Plavix secondary to a gastrointestinal bleed in [2188-12-26], requiring hospitalization at [Hospital3 1196]. Electrocardiogram obtained in the Emergency Department showed upsloping ST segments and was initially interpreted as J-point elevation. Subsequently at 1 P.M., the patient's systolic blood pressures decreased to the 40s and repeat electrocardiogram at that time revealed bigeminy with ST elevations of 5 mm in V2 through V4. Cardiology team was consulted, and the patient brought emergently to the catheterization laboratory with systolic blood pressures in the 80s. In the catheterization laboratory, the patient's blood pressure was marginal, with pressures between 70s and 80s systolic, and dopamine drip was started. Initial angiogram showed significant left anterior descending obstruction. Intra-aortic balloon pump was placed. The patient was then electively intubated, as oxygen saturations were decreasing on non-rebreather mask. Arterial blood gas as that time was a pH of 7.16, pCO2 of 51, and pO2 of 51. PAST MEDICAL HISTORY: 1. Coronary artery disease status post left anterior descending stent and percutaneous transluminal coronary angioplasty to diagonal I and obtuse marginal I on [2188-11-28] 2. Congestive heart failure 3. Hypertension 4. Chronic autoimmune hemolytic anemia 5. History of a gastrointestinal bleed, recently discharged from the hospital on [2189-2-10] ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: Enteric-coated aspirin 325 mg by mouth once daily held since [2-10], Plavix 75 mg by mouth once daily held since [2-14], Synthroid 25 mcg by mouth once daily, Zestril 5 mg by mouth once daily, Lopressor 50 mg by mouth twice a day, folate 1 mg by mouth once daily, Protonix 40 mg by mouth once daily, Timoptic one drop to each eye once daily, Xalatan one drop to each eye once daily, prednisone 30 mg by mouth once daily PHYSICAL EXAMINATION: Vital signs: Temperature 98.8, blood pressure 88/42, heart rate 122, respiratory rate 16, oxygen saturation 100% on 50% FIO2. In general, the patient is an elderly white female, sedated and intubated. Heart: Regular rate and rhythm, positive S1 and S2, no murmurs, gallops or rubs. Lungs: Bibasilar crackles. Abdomen: Soft, nontender, nondistended, normal active bowel sounds. Extremities: No cyanosis, clubbing or edema, right groin PA catheter and arterial line in place, left groin intra-aortic balloon pump in place. LABORATORY DATA: White blood cells 14.2, hematocrit 31.8, platelets 283. Differential: Neutrophils 97%, lymphs 3%. Sodium 142, potassium 3.4, chloride 106, bicarbonate 24, BUN 23, creatinine 0.8, glucose 101. INR 1.1, PTT 20.6, PT 12.7. CK at 10 A.M. on [2-18] of 46, at 2 P.M. 475, with an MB of 60 and an MB index of 12.6 and a troponin of 40.9. Urinalysis was benign. Chest x-ray showed heart size within normal limits, a prominent pulmonary vasculature was noted, bilateral interstitial opacities were noted. Electrocardiogram at 8:47 A.M. showed sinus at 87 beats per minute, left axis deviation with left ventricular hypertrophy, 1 to [Street Address(2) 1766] elevations in V1, upsloping ST elevations in V2 and V3, no ST depressions or Qs. Electrocardiogram at 1:05 P.M. with decreased blood pressure showed bigeminy at 96 beats per minute, [Street Address(2) 1755] elevations in V2 and V3, 2 to [Street Address(2) 2051] elevations in V4 and V5, ST depressions in II, III and AVF, Q waves developed in V2 through V5, with loss of R wave progression. Cardiac catheterization from [2189-2-18], had the following findings: Left dominant system with three vessel coronary artery disease, the left main coronary artery was normal, the left anterior descending was totally occluded at the site of the previously-placed proximal stent, the ramus intermedius branch had a long tubular 80% stenosis, the left circumflex artery had a 50% proximal stenosis, the first obtuse marginal branch was totally occluded, and the second obtuse marginal branch had a 70% origin stenosis, the left posterior descending artery had a mild luminal irregularity, the right coronary artery was a small non-dominant vessel and had an 80% proximal stenosis. Successful percutaneous transluminal coronary angioplasty of the proximal left anterior descending in-stent lesion, and successful percutaneous transluminal coronary angioplasty and stenting of the ramus intermedius branch. Hemodynamic measurements performed after the coronary intervention with the patient intubated requiring intravenous inotropic support with intra-aortic balloon pump in the left femoral artery revealed elevated left-sided filling pressures. The wedge pressure was 21 mm Hg. The cardiac index was marginally decreased at 2.1. As above, an intra-aortic balloon pump was introduced into the left femoral artery. IMPRESSION: 82-year-old female with previous coronary artery disease status post recent left anterior descending stent, Class II congestive heart failure, hypertension, history of recent gastrointestinal bleed, presents with acute ST elevation, anteroseptal and anterior wall myocardial infarction. Taken to the catheterization laboratory for intervention and admitted to the Coronary Care Unit, intubated, with an intra-aortic balloon pump in place, as well as on a dopamine drip secondary to hypotension. HOSPITAL COURSE BY SYSTEM: 1. Cardiac: a. Ischemia: As above, patient with proximal left anterior descending stent in-stent re-stenosis as well as significant occlusion to the ramus intermedius status post intervention. The patient was started on aspirin and Plavix post-intervention. Peak CK was noted to be 71 to 85, which was on [2189-2-18], which gradually trended down to a value of 113 on the day of admission. In addition, the patient was started on an ACE inhibitor and beta blocker once blood pressure could tolerate. b. Pump: As above, patient noted to be in cardiogenic shock with increased wedge and decreased systolic blood pressure. Intra-aortic balloon pump was placed in the catheterization laboratory. The patient was also given lasix x 1 in the catheterization laboratory for elevated wedge pressure, and diuresed well with this one-time dose. No additional lasix doses were given on hospital day number one, and greater attention was paid to improving hemodynamics with pressor and inotropic agents. The patient was initially transferred to the Coronary Care Unit on a dopamine drip, however, was noted to be markedly tachycardic to as high as 130s to 140s in sinus rhythm. The decision was made to discontinue the dopamine and start milrinone for inotropic effect and Levophed for pressor support. The patient's blood pressure was titrated to greater than 60, and the patient's heart rate subsequently was better controlled in the 80s to 90s. Subsequently, with improved hemodynamics, decision was made to remove the intra-aortic balloon pump on hospital day number three. In addition, on the following day, the patient's milrinone and Levophed drips were discontinued as the patient was maintaining adequate hemodynamics on her own. Lastly, a decision of whether the patient should be long-term anticoagulated in light of her recent anterior wall event was to be evaluated with an echocardiogram. Decision to anticoagulate long-term will be weighed against the possible risks in light of underlying gastrointestinal pathology and a history of a recent gastrointestinal bleed. c. Rhythm: Patient noted to have a sinus tachycardia on arrival to the Coronary Care Unit, on a dopamine drip. Subsequently was switched to milrinone and Levophed drips. The patient's sinus tachycardia improved to normal sinus rhythm with occasional episodes of nonsustained ventricular tachycardia, which was thought secondary to reperfusion. 2. Pulmonary: Patient noted to be hypercarbia and hypoxic in the catheterization laboratory on a non-rebreather, and decision for intubation was made. The patient was maintained on assist control on arrival to the Coronary Care Unit, and subsequently was weaned with successful extubation on hospital day number three. 3. Hematology: Patient with a history of chronic anemia secondary to chronic autoimmune hemolytic etiology, maintained on prednisone as an outpatient. In light of recent events, the patient was placed on stress dose steroids through the intravenous, which was subsequently changed to oral prednisone. The patient received two to three units of packed red blood cells while in the Coronary Care Unit secondary to a slightly decreased hematocrit, which was thought secondary to her underlying chronic condition as well as possibly secondary to her gastrointestinal bleed in light of some coffee-ground emesis. The patient's hematocrit remained relatively stable during her hospital stay, with a range of 28 to 33. 4. Gastrointestinal: As above, patient with a history of a gastrointestinal bleed with one to two episodes of coffee-ground emesis while in the Coronary Care Unit. Coffee grounds then cleared, and the patient was maintained on Protonix 40 mg intravenously twice a day. As above, the patient's hematocrit remained stable for the most part during her hospital stay, and she remained hemodynamically stable, and there was no need for Gastroenterology consult during this hospital stay. 5. Renal: The patient's creatinine status post cardiac catheterization remained at her baseline, and there were no acute renal issues while an inpatient at [Hospital1 346]. 6. Fluids, electrolytes and nutrition: Patient's electrolytes were monitored closely, with adequate repletion, especially in light of some ventricular ectopy noted on telemetry. Initially nothing by mouth secondary to intubation, and the patient was started on low-dose tube feeds at 10 cc/hour, ProMod with fiber. Upon extubation, tube feeds were discontinued, and the patient was advanced to an oral diet without complications. This has been a dictation detailing the hospital events from [2189-2-18], to [2189-2-22]. Addendum to follow detailing the rest of the [Hospital 228] hospital course, including a list of discharge diagnoses, discharge medications, and plan for discharge and follow up. DR.[Last Name (STitle) 2052],[First Name3 (LF) 2053] 12-462 Dictated By:[Name8 (MD) 2054] MEDQUIST36 D: [2189-2-25] 01:50 T: [2189-2-25] 01:55 JOB#: [Job Number 2055]	Admission Date: <Date>1955-12-31</Date> Discharge Date: <Date>1961-7-21</Date> Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a past medical history significant for coronary artery disease, congestive heart failure, hypertension, chronic autoimmune hemolytic anemia, and history of a gastrointestinal bleed, who presented to the Emergency Department at <Hospital>Jackson, Brown and Moore Clinic</Hospital> at 8 A.M. with epigastric pain. The patient's pain started at approximately 7:30 A.M. on the day of admission after eating breakfast. It was described as a burning sensation. The patient took one sublingual nitroglycerin without effect. The patient reportedly denied any shortness of breath, nausea, vomiting, fevers, chills, or headache. The patient had been off her aspirin and Plavix secondary to a gastrointestinal bleed in <Date>1940-9-10</Date>, requiring hospitalization at <Hospital>Mckenzie-May Medical Center</Hospital>. Electrocardiogram obtained in the Emergency Department showed upsloping ST segments and was initially interpreted as J-point elevation. Subsequently at 1 P.M., the patient's systolic blood pressures decreased to the 40s and repeat electrocardiogram at that time revealed bigeminy with ST elevations of 5 mm in V2 through V4. Cardiology team was consulted, and the patient brought emergently to the catheterization laboratory with systolic blood pressures in the 80s. In the catheterization laboratory, the patient's blood pressure was marginal, with pressures between 70s and 80s systolic, and dopamine drip was started. Initial angiogram showed significant left anterior descending obstruction. Intra-aortic balloon pump was placed. The patient was then electively intubated, as oxygen saturations were decreasing on non-rebreather mask. Arterial blood gas as that time was a pH of 7.16, pCO2 of 51, and pO2 of 51. PAST MEDICAL HISTORY: 1. Coronary artery disease status post left anterior descending stent and percutaneous transluminal coronary angioplasty to diagonal I and obtuse marginal I on <Date>1926-6-2</Date> 2. Congestive heart failure 3. Hypertension 4. Chronic autoimmune hemolytic anemia 5. History of a gastrointestinal bleed, recently discharged from the hospital on <Date>1923-4-7</Date> ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: Enteric-coated aspirin 325 mg by mouth once daily held since <Date>3-31</Date>, Plavix 75 mg by mouth once daily held since <Date>4-2</Date>, Synthroid 25 mcg by mouth once daily, Zestril 5 mg by mouth once daily, Lopressor 50 mg by mouth twice a day, folate 1 mg by mouth once daily, Protonix 40 mg by mouth once daily, Timoptic one drop to each eye once daily, Xalatan one drop to each eye once daily, prednisone 30 mg by mouth once daily PHYSICAL EXAMINATION: Vital signs: Temperature 98.8, blood pressure 88/42, heart rate 122, respiratory rate 16, oxygen saturation 100% on 50% FIO2. In general, the patient is an elderly white female, sedated and intubated. Heart: Regular rate and rhythm, positive S1 and S2, no murmurs, gallops or rubs. Lungs: Bibasilar crackles. Abdomen: Soft, nontender, nondistended, normal active bowel sounds. Extremities: No cyanosis, clubbing or edema, right groin PA catheter and arterial line in place, left groin intra-aortic balloon pump in place. LABORATORY DATA: White blood cells 14.2, hematocrit 31.8, platelets 283. Differential: Neutrophils 97%, lymphs 3%. Sodium 142, potassium 3.4, chloride 106, bicarbonate 24, BUN 23, creatinine 0.8, glucose 101. INR 1.1, PTT 20.6, PT 12.7. CK at 10 A.M. on <Date>1-14</Date> of 46, at 2 P.M. 475, with an MB of 60 and an MB index of 12.6 and a troponin of 40.9. Urinalysis was benign. Chest x-ray showed heart size within normal limits, a prominent pulmonary vasculature was noted, bilateral interstitial opacities were noted. Electrocardiogram at 8:47 A.M. showed sinus at 87 beats per minute, left axis deviation with left ventricular hypertrophy, 1 to <Location>29587 Reese Throughway Suite 555 North Christopherport, WI 81689</Location> elevations in V1, upsloping ST elevations in V2 and V3, no ST depressions or Qs. Electrocardiogram at 1:05 P.M. with decreased blood pressure showed bigeminy at 96 beats per minute, <Location>0787 Stephen Meadow West Jasontown, IL 56570</Location> elevations in V2 and V3, 2 to <Location>182 Bailey Springs North Thomasport, CA 12737</Location> elevations in V4 and V5, ST depressions in II, III and AVF, Q waves developed in V2 through V5, with loss of R wave progression. Cardiac catheterization from <Date>1955-12-31</Date>, had the following findings: Left dominant system with three vessel coronary artery disease, the left main coronary artery was normal, the left anterior descending was totally occluded at the site of the previously-placed proximal stent, the ramus intermedius branch had a long tubular 80% stenosis, the left circumflex artery had a 50% proximal stenosis, the first obtuse marginal branch was totally occluded, and the second obtuse marginal branch had a 70% origin stenosis, the left posterior descending artery had a mild luminal irregularity, the right coronary artery was a small non-dominant vessel and had an 80% proximal stenosis. Successful percutaneous transluminal coronary angioplasty of the proximal left anterior descending in-stent lesion, and successful percutaneous transluminal coronary angioplasty and stenting of the ramus intermedius branch. Hemodynamic measurements performed after the coronary intervention with the patient intubated requiring intravenous inotropic support with intra-aortic balloon pump in the left femoral artery revealed elevated left-sided filling pressures. The wedge pressure was 21 mm Hg. The cardiac index was marginally decreased at 2.1. As above, an intra-aortic balloon pump was introduced into the left femoral artery. IMPRESSION: 82-year-old female with previous coronary artery disease status post recent left anterior descending stent, Class II congestive heart failure, hypertension, history of recent gastrointestinal bleed, presents with acute ST elevation, anteroseptal and anterior wall myocardial infarction. Taken to the catheterization laboratory for intervention and admitted to the Coronary Care Unit, intubated, with an intra-aortic balloon pump in place, as well as on a dopamine drip secondary to hypotension. HOSPITAL COURSE BY SYSTEM: 1. Cardiac: a. Ischemia: As above, patient with proximal left anterior descending stent in-stent re-stenosis as well as significant occlusion to the ramus intermedius status post intervention. The patient was started on aspirin and Plavix post-intervention. Peak CK was noted to be 71 to 85, which was on <Date>1955-12-31</Date>, which gradually trended down to a value of 113 on the day of admission. In addition, the patient was started on an ACE inhibitor and beta blocker once blood pressure could tolerate. b. Pump: As above, patient noted to be in cardiogenic shock with increased wedge and decreased systolic blood pressure. Intra-aortic balloon pump was placed in the catheterization laboratory. The patient was also given lasix x 1 in the catheterization laboratory for elevated wedge pressure, and diuresed well with this one-time dose. No additional lasix doses were given on hospital day number one, and greater attention was paid to improving hemodynamics with pressor and inotropic agents. The patient was initially transferred to the Coronary Care Unit on a dopamine drip, however, was noted to be markedly tachycardic to as high as 130s to 140s in sinus rhythm. The decision was made to discontinue the dopamine and start milrinone for inotropic effect and Levophed for pressor support. The patient's blood pressure was titrated to greater than 60, and the patient's heart rate subsequently was better controlled in the 80s to 90s. Subsequently, with improved hemodynamics, decision was made to remove the intra-aortic balloon pump on hospital day number three. In addition, on the following day, the patient's milrinone and Levophed drips were discontinued as the patient was maintaining adequate hemodynamics on her own. Lastly, a decision of whether the patient should be long-term anticoagulated in light of her recent anterior wall event was to be evaluated with an echocardiogram. Decision to anticoagulate long-term will be weighed against the possible risks in light of underlying gastrointestinal pathology and a history of a recent gastrointestinal bleed. c. Rhythm: Patient noted to have a sinus tachycardia on arrival to the Coronary Care Unit, on a dopamine drip. Subsequently was switched to milrinone and Levophed drips. The patient's sinus tachycardia improved to normal sinus rhythm with occasional episodes of nonsustained ventricular tachycardia, which was thought secondary to reperfusion. 2. Pulmonary: Patient noted to be hypercarbia and hypoxic in the catheterization laboratory on a non-rebreather, and decision for intubation was made. The patient was maintained on assist control on arrival to the Coronary Care Unit, and subsequently was weaned with successful extubation on hospital day number three. 3. Hematology: Patient with a history of chronic anemia secondary to chronic autoimmune hemolytic etiology, maintained on prednisone as an outpatient. In light of recent events, the patient was placed on stress dose steroids through the intravenous, which was subsequently changed to oral prednisone. The patient received two to three units of packed red blood cells while in the Coronary Care Unit secondary to a slightly decreased hematocrit, which was thought secondary to her underlying chronic condition as well as possibly secondary to her gastrointestinal bleed in light of some coffee-ground emesis. The patient's hematocrit remained relatively stable during her hospital stay, with a range of 28 to 33. 4. Gastrointestinal: As above, patient with a history of a gastrointestinal bleed with one to two episodes of coffee-ground emesis while in the Coronary Care Unit. Coffee grounds then cleared, and the patient was maintained on Protonix 40 mg intravenously twice a day. As above, the patient's hematocrit remained stable for the most part during her hospital stay, and she remained hemodynamically stable, and there was no need for Gastroenterology consult during this hospital stay. 5. Renal: The patient's creatinine status post cardiac catheterization remained at her baseline, and there were no acute renal issues while an inpatient at <Hospital>Anderson, Navarro and Brown Clinic</Hospital>. 6. Fluids, electrolytes and nutrition: Patient's electrolytes were monitored closely, with adequate repletion, especially in light of some ventricular ectopy noted on telemetry. Initially nothing by mouth secondary to intubation, and the patient was started on low-dose tube feeds at 10 cc/hour, ProMod with fiber. Upon extubation, tube feeds were discontinued, and the patient was advanced to an oral diet without complications. This has been a dictation detailing the hospital events from <Date>1955-12-31</Date>, to <Date>1926-11-12</Date>. Addendum to follow detailing the rest of the <Hospital>Crosby, Silva and Palmer Hospital</Hospital> hospital course, including a list of discharge diagnoses, discharge medications, and plan for discharge and follow up. DR.<Name>Archie</Name>,<Name>Sonny</Name> 12-462 Dictated By:<Name>Norine Hazelwood</Name> MEDQUIST36 D: <Date>1961-7-21</Date> 01:50 T: <Date>1961-7-21</Date> 01:55 JOB#: <Job Number>Lawrence, Olson and Taylor-2018-260372</Job 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Date: 1955-12-31 Discharge Date: 1961-7-21 Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a past medical history significant for coronary artery disease, congestive heart failure, hypertension, chronic autoimmune hemolytic anemia, and history of a gastrointestinal bleed, who presented to the Emergency Department at Jackson, Brown and Moore Clinic at 8 A.M. with epigastric pain. The patient's pain started at approximately 7:30 A.M. on the day of admission after eating breakfast. It was described as a burning sensation. The patient took one sublingual nitroglycerin without effect. The patient reportedly denied any shortness of breath, nausea, vomiting, fevers, chills, or headache. The patient had been off her aspirin and Plavix secondary to a gastrointestinal bleed in 1940-9-10, requiring hospitalization at Mckenzie-May Medical Center. Electrocardiogram obtained in the Emergency Department showed upsloping ST segments and was initially interpreted as J-point elevation. Subsequently at 1 P.M., the patient's systolic blood pressures decreased to the 40s and repeat electrocardiogram at that time revealed bigeminy with ST elevations of 5 mm in V2 through V4. Cardiology team was consulted, and the patient brought emergently to the catheterization laboratory with systolic blood pressures in the 80s. In the catheterization laboratory, the patient's blood pressure was marginal, with pressures between 70s and 80s systolic, and dopamine drip was started. Initial angiogram showed significant left anterior descending obstruction. Intra-aortic balloon pump was placed. The patient was then electively intubated, as oxygen saturations were decreasing on non-rebreather mask. Arterial blood gas as that time was a pH of 7.16, pCO2 of 51, and pO2 of 51. PAST MEDICAL HISTORY: 1. Coronary artery disease status post left anterior descending stent and percutaneous transluminal coronary angioplasty to diagonal I and obtuse marginal I on 1926-6-2 2. Congestive heart failure 3. Hypertension 4. Chronic autoimmune hemolytic anemia 5. History of a gastrointestinal bleed, recently discharged from the hospital on 1923-4-7 ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: Enteric-coated aspirin 325 mg by mouth once daily held since 3-31, Plavix 75 mg by mouth once daily held since 4-2, Synthroid 25 mcg by mouth once daily, Zestril 5 mg by mouth once daily, Lopressor 50 mg by mouth twice a day, folate 1 mg by mouth once daily, Protonix 40 mg by mouth once daily, Timoptic one drop to each eye once daily, Xalatan one drop to each eye once daily, prednisone 30 mg by mouth once daily PHYSICAL EXAMINATION: Vital signs: Temperature 98.8, blood pressure 88/42, heart rate 122, respiratory rate 16, oxygen saturation 100% on 50% FIO2. In general, the patient is an elderly white female, sedated and intubated. Heart: Regular rate and rhythm, positive S1 and S2, no murmurs, gallops or rubs. Lungs: Bibasilar crackles. Abdomen: Soft, nontender, nondistended, normal active bowel sounds. Extremities: No cyanosis, clubbing or edema, right groin PA catheter and arterial line in place, left groin intra-aortic balloon pump in place. LABORATORY DATA: White blood cells 14.2, hematocrit 31.8, platelets 283. Differential: Neutrophils 97%, lymphs 3%. Sodium 142, potassium 3.4, chloride 106, bicarbonate 24, BUN 23, creatinine 0.8, glucose 101. INR 1.1, PTT 20.6, PT 12.7. CK at 10 A.M. on 1-14 of 46, at 2 P.M. 475, with an MB of 60 and an MB index of 12.6 and a troponin of 40.9. Urinalysis was benign. Chest x-ray showed heart size within normal limits, a prominent pulmonary vasculature was noted, bilateral interstitial opacities were noted. Electrocardiogram at 8:47 A.M. showed sinus at 87 beats per minute, left axis deviation with left ventricular hypertrophy, 1 to 29587 Reese Throughway Suite 555 North Christopherport, WI 81689 elevations in V1, upsloping ST elevations in V2 and V3, no ST depressions or Qs. Electrocardiogram at 1:05 P.M. with decreased blood pressure showed bigeminy at 96 beats per minute, 0787 Stephen Meadow West Jasontown, IL 56570 elevations in V2 and V3, 2 to 182 Bailey Springs North Thomasport, CA 12737 elevations in V4 and V5, ST depressions in II, III and AVF, Q waves developed in V2 through V5, with loss of R wave progression. Cardiac catheterization from 1955-12-31, had the following findings: Left dominant system with three vessel coronary artery disease, the left main coronary artery was normal, the left anterior descending was totally occluded at the site of the previously-placed proximal stent, the ramus intermedius branch had a long tubular 80% stenosis, the left circumflex artery had a 50% proximal stenosis, the first obtuse marginal branch was totally occluded, and the second obtuse marginal branch had a 70% origin stenosis, the left posterior descending artery had a mild luminal irregularity, the right coronary artery was a small non-dominant vessel and had an 80% proximal stenosis. Successful percutaneous transluminal coronary angioplasty of the proximal left anterior descending in-stent lesion, and successful percutaneous transluminal coronary angioplasty and stenting of the ramus intermedius branch. Hemodynamic measurements performed after the coronary intervention with the patient intubated requiring intravenous inotropic support with intra-aortic balloon pump in the left femoral artery revealed elevated left-sided filling pressures. The wedge pressure was 21 mm Hg. The cardiac index was marginally decreased at 2.1. As above, an intra-aortic balloon pump was introduced into the left femoral artery. IMPRESSION: 82-year-old female with previous coronary artery disease status post recent left anterior descending stent, Class II congestive heart failure, hypertension, history of recent gastrointestinal bleed, presents with acute ST elevation, anteroseptal and anterior wall myocardial infarction. Taken to the catheterization laboratory for intervention and admitted to the Coronary Care Unit, intubated, with an intra-aortic balloon pump in place, as well as on a dopamine drip secondary to hypotension. HOSPITAL COURSE BY SYSTEM: 1. Cardiac: a. Ischemia: As above, patient with proximal left anterior descending stent in-stent re-stenosis as well as significant occlusion to the ramus intermedius status post intervention. The patient was started on aspirin and Plavix post-intervention. Peak CK was noted to be 71 to 85, which was on 1955-12-31, which gradually trended down to a value of 113 on the day of admission. In addition, the patient was started on an ACE inhibitor and beta blocker once blood pressure could tolerate. b. Pump: As above, patient noted to be in cardiogenic shock with increased wedge and decreased systolic blood pressure. Intra-aortic balloon pump was placed in the catheterization laboratory. The patient was also given lasix x 1 in the catheterization laboratory for elevated wedge pressure, and diuresed well with this one-time dose. No additional lasix doses were given on hospital day number one, and greater attention was paid to improving hemodynamics with pressor and inotropic agents. The patient was initially transferred to the Coronary Care Unit on a dopamine drip, however, was noted to be markedly tachycardic to as high as 130s to 140s in sinus rhythm. The decision was made to discontinue the dopamine and start milrinone for inotropic effect and Levophed for pressor support. The patient's blood pressure was titrated to greater than 60, and the patient's heart rate subsequently was better controlled in the 80s to 90s. Subsequently, with improved hemodynamics, decision was made to remove the intra-aortic balloon pump on hospital day number three. In addition, on the following day, the patient's milrinone and Levophed drips were discontinued as the patient was maintaining adequate hemodynamics on her own. Lastly, a decision of whether the patient should be long-term anticoagulated in light of her recent anterior wall event was to be evaluated with an echocardiogram. Decision to anticoagulate long-term will be weighed against the possible risks in light of underlying gastrointestinal pathology and a history of a recent gastrointestinal bleed. c. Rhythm: Patient noted to have a sinus tachycardia on arrival to the Coronary Care Unit, on a dopamine drip. Subsequently was switched to milrinone and Levophed drips. The patient's sinus tachycardia improved to normal sinus rhythm with occasional episodes of nonsustained ventricular tachycardia, which was thought secondary to reperfusion. 2. Pulmonary: Patient noted to be hypercarbia and hypoxic in the catheterization laboratory on a non-rebreather, and decision for intubation was made. The patient was maintained on assist control on arrival to the Coronary Care Unit, and subsequently was weaned with successful extubation on hospital day number three. 3. Hematology: Patient with a history of chronic anemia secondary to chronic autoimmune hemolytic etiology, maintained on prednisone as an outpatient. In light of recent events, the patient was placed on stress dose steroids through the intravenous, which was subsequently changed to oral prednisone. The patient received two to three units of packed red blood cells while in the Coronary Care Unit secondary to a slightly decreased hematocrit, which was thought secondary to her underlying chronic condition as well as possibly secondary to her gastrointestinal bleed in light of some coffee-ground emesis. The patient's hematocrit remained relatively stable during her hospital stay, with a range of 28 to 33. 4. Gastrointestinal: As above, patient with a history of a gastrointestinal bleed with one to two episodes of coffee-ground emesis while in the Coronary Care Unit. Coffee grounds then cleared, and the patient was maintained on Protonix 40 mg intravenously twice a day. As above, the patient's hematocrit remained stable for the most part during her hospital stay, and she remained hemodynamically stable, and there was no need for Gastroenterology consult during this hospital stay. 5. Renal: The patient's creatinine status post cardiac catheterization remained at her baseline, and there were no acute renal issues while an inpatient at Anderson, Navarro and Brown Clinic. 6. Fluids, electrolytes and nutrition: Patient's electrolytes were monitored closely, with adequate repletion, especially in light of some ventricular ectopy noted on telemetry. Initially nothing by mouth secondary to intubation, and the patient was started on low-dose tube feeds at 10 cc/hour, ProMod with fiber. Upon extubation, tube feeds were discontinued, and the patient was advanced to an oral diet without complications. This has been a dictation detailing the hospital events from 1955-12-31, to 1926-11-12. Addendum to follow detailing the rest of the Crosby, Silva and Palmer Hospital hospital course, including a list of discharge diagnoses, discharge medications, and plan for discharge and follow up. DR.Archie,Sonny 12-462 Dictated By:Norine Hazelwood MEDQUIST36 D: 1961-7-21 01:50 T: 1961-7-21 01:55 JOB#: Lawrence, Olson and Taylor-2018-260372	["Admission Date: 1955-12-31 Discharge Date: 1961-7-21\n\n\nService: CCU\n\nHISTORY OF PRESENT ILLNESS: The patient is an 83-year-old\nfemale with a past medical history significant for coronary\nartery disease, congestive heart failure, hypertension,\nchronic autoimmune hemolytic anemia, and history of a\ngastrointestinal bleed, who presented to the Emergency\nDepartment at Jackson, Brown and Moore Clinic at 8 A.M.\nwith epigastric pain. The patient's pain started at\napproximately 7:30 A.M. on the day of admission after eating\nbreakfast. It was described as a burning sensation. The\npatient took one sublingual nitroglycerin without effect.\nThe patient reportedly denied any shortness of breath,\nnausea, vomiting, fevers, chills, or headache. The patient\nhad been off her aspirin and Plavix secondary to a\ngastrointestinal bleed in 1940-9-10, requiring\nhospitalization at Mckenzie-May Medical Center.", "\n\nElectrocardiogram obtained in the Emergency Department showed\nupsloping ST segments and was initially interpreted as\nJ-point elevation. Subsequently at 1 P.M., the patient's\nsystolic blood pressures decreased to the 40s and repeat\nelectrocardiogram at that time revealed bigeminy with ST\nelevations of 5 mm in V2 through V4. Cardiology team was\nconsulted, and the patient brought emergently to the\ncatheterization laboratory with systolic blood pressures in\nthe 80s.\n\nIn the catheterization laboratory, the patient's blood\npressure was marginal, with pressures between 70s and 80s\nsystolic, and dopamine drip was started. Initial angiogram\nshowed significant left anterior descending obstruction.\nIntra-aortic balloon pump was placed. The patient was then\nelectively intubated, as oxygen saturations were decreasing\non non-rebreather mask.", ' Arterial blood gas as that time was\na pH of 7.16, pCO2 of 51, and pO2 of 51.\n\nPAST MEDICAL HISTORY:\n1. Coronary artery disease status post left anterior\ndescending stent and percutaneous transluminal coronary\nangioplasty to diagonal I and obtuse marginal I on 1926-6-2\n2. Congestive heart failure\n3. Hypertension\n4. Chronic autoimmune hemolytic anemia\n5. History of a gastrointestinal bleed, recently discharged\nfrom the hospital on 1923-4-7\n\nALLERGIES: No known drug allergies.\n\nMEDICATIONS AT HOME: Enteric-coated aspirin 325 mg by mouth\nonce daily held since 3-31, Plavix 75 mg by mouth once\ndaily held since 4-2, Synthroid 25 mcg by mouth once\ndaily, Zestril 5 mg by mouth once daily, Lopressor 50 mg by\nmouth twice a day, folate 1 mg by mouth once daily, Protonix\n40 mg by mouth once daily, Timoptic one drop to each eye once\ndaily, Xalatan one drop to each eye once daily, prednisone 30\nmg by mouth once daily\n\nPHYSICAL EXAMINATION: Vital signs: Temperature 98.', '8, blood\npressure 88/42, heart rate 122, respiratory rate 16, oxygen\nsaturation 100% on 50% FIO2. In general, the patient is an\nelderly white female, sedated and intubated. Heart: Regular\nrate and rhythm, positive S1 and S2, no murmurs, gallops or\nrubs. Lungs: Bibasilar crackles. Abdomen: Soft,\nnontender, nondistended, normal active bowel sounds.\nExtremities: No cyanosis, clubbing or edema, right groin PA\ncatheter and arterial line in place, left groin intra-aortic\nballoon pump in place.\n\nLABORATORY DATA: White blood cells 14.2, hematocrit 31.8,\nplatelets 283. Differential: Neutrophils 97%, lymphs 3%.\nSodium 142, potassium 3.4, chloride 106, bicarbonate 24, BUN\n23, creatinine 0.8, glucose 101. INR 1.1, PTT 20.6, PT 12.7.\nCK at 10 A.M. on 1-14 of 46, at 2 P.M. 475, with an MB of\n60 and an MB index of 12.', '6 and a troponin of 40.9.\nUrinalysis was benign. Chest x-ray showed heart size within\nnormal limits, a prominent pulmonary vasculature was noted,\nbilateral interstitial opacities were noted.\nElectrocardiogram at 8:47 A.M. showed sinus at 87 beats per\nminute, left axis deviation with left ventricular\nhypertrophy, 1 to 29587 Reese Throughway Suite 555\nNorth Christopherport, WI 81689 elevations in V1, upsloping ST\nelevations in V2 and V3, no ST depressions or Qs.\nElectrocardiogram at 1:05 P.M. with decreased blood pressure\nshowed bigeminy at 96 beats per minute, 0787 Stephen Meadow\nWest Jasontown, IL 56570 elevations in\nV2 and V3, 2 to 182 Bailey Springs\nNorth Thomasport, CA 12737 elevations in V4 and V5, ST\ndepressions in II, III and AVF, Q waves developed in V2\nthrough V5, with loss of R wave progression.', ' Cardiac\ncatheterization from 1955-12-31, had the following\nfindings: Left dominant system with three vessel coronary\nartery disease, the left main coronary artery was normal, the\nleft anterior descending was totally occluded at the site of\nthe previously-placed proximal stent, the ramus intermedius\nbranch had a long tubular 80% stenosis, the left circumflex\nartery had a 50% proximal stenosis, the first obtuse marginal\nbranch was totally occluded, and the second obtuse marginal\nbranch had a 70% origin stenosis, the left posterior\ndescending artery had a mild luminal irregularity, the right\ncoronary artery was a small non-dominant vessel and had an\n80% proximal stenosis. Successful percutaneous transluminal\ncoronary angioplasty of the proximal left anterior descending\nin-stent lesion, and successful percutaneous transluminal\ncoronary angioplasty and stenting of the ramus intermedius\nbranch.', ' Hemodynamic measurements performed after the\ncoronary intervention with the patient intubated requiring\nintravenous inotropic support with intra-aortic balloon pump\nin the left femoral artery revealed elevated left-sided\nfilling pressures. The wedge pressure was 21 mm Hg. The\ncardiac index was marginally decreased at 2.1. As above, an\nintra-aortic balloon pump was introduced into the left\nfemoral artery.\n\nIMPRESSION: 82-year-old female with previous coronary\nartery disease status post recent left anterior descending\nstent, Class II congestive heart failure, hypertension,\nhistory of recent gastrointestinal bleed, presents with acute\nST elevation, anteroseptal and anterior wall myocardial\ninfarction. Taken to the catheterization laboratory for\nintervention and admitted to the Coronary Care Unit,\nintubated, with an intra-aortic balloon pump in place, as\nwell as on a dopamine drip secondary to hypotension.', '\n\nHOSPITAL COURSE BY SYSTEM:\n1. Cardiac:\na. Ischemia: As above, patient with proximal left anterior\ndescending stent in-stent re-stenosis as well as significant\nocclusion to the ramus intermedius status post intervention.\nThe patient was started on aspirin and Plavix\npost-intervention. Peak CK was noted to be 71 to 85, which\nwas on 1955-12-31, which gradually trended down to a\nvalue of 113 on the day of admission. In addition, the\npatient was started on an ACE inhibitor and beta blocker once\nblood pressure could tolerate.\n\nb. Pump: As above, patient noted to be in cardiogenic shock\nwith increased wedge and decreased systolic blood pressure.\nIntra-aortic balloon pump was placed in the catheterization\nlaboratory. The patient was also given lasix x 1 in the\ncatheterization laboratory for elevated wedge pressure, and\ndiuresed well with this one-time dose.', " No additional lasix\ndoses were given on hospital day number one, and greater\nattention was paid to improving hemodynamics with pressor and\ninotropic agents. The patient was initially transferred to\nthe Coronary Care Unit on a dopamine drip, however, was noted\nto be markedly tachycardic to as high as 130s to 140s in\nsinus rhythm. The decision was made to discontinue the\ndopamine and start milrinone for inotropic effect and\nLevophed for pressor support. The patient's blood pressure\nwas titrated to greater than 60, and the patient's heart rate\nsubsequently was better controlled in the 80s to 90s.\nSubsequently, with improved hemodynamics, decision was made\nto remove the intra-aortic balloon pump on hospital day\nnumber three. In addition, on the following day, the\npatient's milrinone and Levophed drips were discontinued as\nthe patient was maintaining adequate hemodynamics on her own.", "\nLastly, a decision of whether the patient should be long-term\nanticoagulated in light of her recent anterior wall event was\nto be evaluated with an echocardiogram. Decision to\nanticoagulate long-term will be weighed against the possible\nrisks in light of underlying gastrointestinal pathology and a\nhistory of a recent gastrointestinal bleed.\n\nc. Rhythm: Patient noted to have a sinus tachycardia on\narrival to the Coronary Care Unit, on a dopamine drip.\nSubsequently was switched to milrinone and Levophed drips.\nThe patient's sinus tachycardia improved to normal sinus\nrhythm with occasional episodes of nonsustained ventricular\ntachycardia, which was thought secondary to reperfusion.\n\n2. Pulmonary: Patient noted to be hypercarbia and hypoxic\nin the catheterization laboratory on a non-rebreather, and\ndecision for intubation was made.", " The patient was maintained\non assist control on arrival to the Coronary Care Unit, and\nsubsequently was weaned with successful extubation on\nhospital day number three.\n\n3. Hematology: Patient with a history of chronic anemia\nsecondary to chronic autoimmune hemolytic etiology,\nmaintained on prednisone as an outpatient. In light of\nrecent events, the patient was placed on stress dose steroids\nthrough the intravenous, which was subsequently changed to\noral prednisone. The patient received two to three units of\npacked red blood cells while in the Coronary Care Unit\nsecondary to a slightly decreased hematocrit, which was\nthought secondary to her underlying chronic condition as well\nas possibly secondary to her gastrointestinal bleed in light\nof some coffee-ground emesis. The patient's hematocrit\nremained relatively stable during her hospital stay, with a\nrange of 28 to 33.", "\n\n4. Gastrointestinal: As above, patient with a history of a\ngastrointestinal bleed with one to two episodes of\ncoffee-ground emesis while in the Coronary Care Unit. Coffee\ngrounds then cleared, and the patient was maintained on\nProtonix 40 mg intravenously twice a day. As above, the\npatient's hematocrit remained stable for the most part during\nher hospital stay, and she remained hemodynamically stable,\nand there was no need for Gastroenterology consult during\nthis hospital stay.\n\n5. Renal: The patient's creatinine status post cardiac\ncatheterization remained at her baseline, and there were no\nacute renal issues while an inpatient at Anderson, Navarro and Brown Clinic.\n\n6. Fluids, electrolytes and nutrition: Patient's\nelectrolytes were monitored closely, with adequate repletion,\nespecially in light of some ventricular ectopy noted on\ntelemetry.", ' Initially nothing by mouth secondary to\nintubation, and the patient was started on low-dose tube\nfeeds at 10 cc/hour, ProMod with fiber. Upon extubation,\ntube feeds were discontinued, and the patient was advanced to\nan oral diet without complications.\n\nThis has been a dictation detailing the hospital events from\n1955-12-31, to 1926-11-12. Addendum to follow\ndetailing the rest of the Crosby, Silva and Palmer Hospital hospital course,\nincluding a list of discharge diagnoses, discharge\nmedications, and plan for discharge and follow up.\n\n\n\n\n DR.Archie,Sonny 12-462\n\nDictated By:Norine Hazelwood\nMEDQUIST36\n\nD: 1961-7-21 01:50\nT: 1961-7-21 01:55\nJOB#: Lawrence, Olson and Taylor-2018-260372\n']
207	5239	129387.0	2189-02-26	Discharge summary	Report	Admission Date: [2189-2-18] Discharge Date: [2189-2-26] Service: CCU Please note that this interval dictation takes up on [2189-2-23], where the dictation of Dr. [First Name8 (NamePattern2) 1586] [Name (STitle) ] previously dictated left off. ADDITIONAL HOSPITAL COURSE: The patient was transferred from the Coronary Care Unit to the floor at approximately 3 A.M. on [2-23], without event. At approximately 9 A.M., the patient began to complain of shortness of breath and was found to be tachycardic to the 150s after walking a distance to the bathroom. The patient's electrocardiogram demonstrated sinus tachycardia with ST elevations in Leads V2 and V3, otherwise the electrocardiogram was unchanged. On examination, the patient had a blood pressure of 146/60, pulse of 135, pulse oxygenation 98% on 2 liters, was diffusely wheezy on respiratory examination, and was markedly diaphoretic, without jugular venous distention or edema. The patient was given several doses of intravenous Lopressor, as well as high-dose intravenous lasix. The pulse oxygenation transiently fell to 88% on 5 liters face mask, and an arterial blood gas taken was 7.37/32/56. A chest x-ray demonstrated increased congestive heart failure and the patient was given some nitro paste without effect, and then begun on nitroglycerin drip as well as additional lasix 80 mg intravenous push. The patient rapidly thereafter clinically improved, with a blood pressure falling from a high in the 170s/80s to 135/76, with a normalization of respiratory rate and a pulse oxygenation of 92 to 95% on 6 liters, as well as over a liter of urine out ultimately, and a clearing of previous wheezing on examination. The patient was again cycled with cardiac enzymes, which revealed a troponin elevated greater than the measurable range, likely from the prior cardiac events that were described in Dr.[Name (NI) 2056] dictation. However, repeated measurements of creatine kinase failed to demonstrate an elevation in that enzyme, and rather demonstrated a continued trend down. The patient was begun on standing lasix initially at 40 mg once daily, which was then increased to 40 mg twice a day, and then to 80 mg by mouth twice a day. The thought being that the patient had been approximately 4 liters positive during this admission, and that the above-described events likely represented worsening congestive heart failure/pulmonary edema in the setting of volume overload. Additionally, the patient's blood pressure was better controlled with Captopril 12.5 mg by mouth three times a day, and the patient's Lopressor dose as well was increased to 50 mg by mouth three times a day with good effect on the patient's cardiac rate. The patient's hematocrit continued to be stable for the remainder of this admission. She had no further respiratory difficulties, and was seen by Physical Therapy, who suggested inpatient therapy to improve the patient's endurance. The patient was sent for echocardiography, which demonstrated an ejection fraction between 20 and 25%, with multiple wall motion abnormalities as described. In discussion with the Cardiology team, the decision was made not to anticoagulate the patient at this time, given her recent history of significant clinical gastrointestinal bleeding. In consultation with the patient's attending cardiologist, decision was made to discharge the patient to rehabilitation on [2189-2-25]. Please note that during the sequence described for [2-23], the patient's electrocardiogram appeared to show sinus tachycardia with the above-stated ST elevations in V2 and V3, which did resolve with the patient's tachycardia. ADDITIONAL DATA: The patient was sent for echocardiography on [2-24], with the following findings: Symmetric left ventricular hypertrophy with extensive regional systolic dysfunction consistent with coronary artery disease, pulmonary artery systolic hypertension, moderate mitral regurgitation, mild aortic regurgitation. The left ventricular ejection fraction was estimated to be between 20 and 25%. Left ventricular wall motion was noted in detailed report to have abnormalities in the basal anterior portion, which was hypokinetic, mild mid-anterior which was akinetic, basilar and anteroseptal which was akinetic, mid-anteroseptal which was akinetic, basal inferoseptal which was hypokinetic, mid-inferoseptal which was hypokinetic, anterior apex which was akinetic, septal apex which was akinetic, inferior apex which was akinetic, lateral apex which was akinetic, and apex which was dyskinetic. DISCHARGE MEDICATIONS: Lasix 80 mg by mouth twice a day, Captopril 12.5 mg by mouth three times a day, Ambien 5 mg by mouth daily at bedtime as needed, Prevacid 30 mg by mouth twice a day, Timoptic 5% one drop to both eyes once daily, Xalatan one drop to both eyes once daily, NPH four units subcutaneously twice a day, regular insulin sliding scale, folate 1 mg by mouth once daily, Synthroid 25 mcg by mouth once daily, Plavix 75 mg by mouth once daily for 25 days (to complete a one month course), Lopressor 50 mg by mouth three times a day and hold for systolic blood pressure less than or equal to 100 or pulse less than or equal to 60), aspirin 81 mg by mouth once daily, levofloxacin 250 mg by mouth once daily for five days (to complete a ten day course), prednisone 50 mg by mouth once daily for four days then prednisone 40 mg by mouth once daily for four days then prednisone 30 mg by mouth once daily (this is the patient's baseline prednisone dose for her autoimmune hemolytic anemia). DISCHARGE DIAGNOSIS: 1. Status post myocardial infarction 2. Congestive heart failure 3. Hypertension 4. Chronic autoimmune hemolytic anemia 5. Gastrointestinal bleeding DISCHARGE PLAN: The patient will be discharged to rehabilitation. She is to follow up with her primary care physician and cardiologist within one week of discharge from rehabilitation, as well as with her primary hematologist/oncologist or other physician for follow up of chronic autoimmune hemolytic anemia. The patient will be continued on finger stick blood glucoses four times a day with regular insulin sliding scale as described. It is suggested that the patient's electrolytes be measured every other day and repleted as necessary. CONDITION ON DISCHARGE: Stable. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Name8 (MD) 2058] MEDQUIST36 D: [2189-2-25] 02:31 T: [2189-2-25] 02:38 JOB#: [Job Number 2059]	Admission Date: <Date>1956-12-17</Date> Discharge Date: <Date>1943-12-20</Date> Service: CCU Please note that this interval dictation takes up on <Date>2001-6-13</Date>, where the dictation of Dr. <Name>Marlon</Name> <Name>Indira Kenner</Name> previously dictated left off. ADDITIONAL HOSPITAL COURSE: The patient was transferred from the Coronary Care Unit to the floor at approximately 3 A.M. on <Date>6-27</Date>, without event. At approximately 9 A.M., the patient began to complain of shortness of breath and was found to be tachycardic to the 150s after walking a distance to the bathroom. The patient's electrocardiogram demonstrated sinus tachycardia with ST elevations in Leads V2 and V3, otherwise the electrocardiogram was unchanged. On examination, the patient had a blood pressure of 146/60, pulse of 135, pulse oxygenation 98% on 2 liters, was diffusely wheezy on respiratory examination, and was markedly diaphoretic, without jugular venous distention or edema. The patient was given several doses of intravenous Lopressor, as well as high-dose intravenous lasix. The pulse oxygenation transiently fell to 88% on 5 liters face mask, and an arterial blood gas taken was 7.37/32/56. A chest x-ray demonstrated increased congestive heart failure and the patient was given some nitro paste without effect, and then begun on nitroglycerin drip as well as additional lasix 80 mg intravenous push. The patient rapidly thereafter clinically improved, with a blood pressure falling from a high in the 170s/80s to 135/76, with a normalization of respiratory rate and a pulse oxygenation of 92 to 95% on 6 liters, as well as over a liter of urine out ultimately, and a clearing of previous wheezing on examination. The patient was again cycled with cardiac enzymes, which revealed a troponin elevated greater than the measurable range, likely from the prior cardiac events that were described in Dr.<Name>Rebecca Bludsworth</Name> dictation. However, repeated measurements of creatine kinase failed to demonstrate an elevation in that enzyme, and rather demonstrated a continued trend down. The patient was begun on standing lasix initially at 40 mg once daily, which was then increased to 40 mg twice a day, and then to 80 mg by mouth twice a day. The thought being that the patient had been approximately 4 liters positive during this admission, and that the above-described events likely represented worsening congestive heart failure/pulmonary edema in the setting of volume overload. Additionally, the patient's blood pressure was better controlled with Captopril 12.5 mg by mouth three times a day, and the patient's Lopressor dose as well was increased to 50 mg by mouth three times a day with good effect on the patient's cardiac rate. The patient's hematocrit continued to be stable for the remainder of this admission. She had no further respiratory difficulties, and was seen by Physical Therapy, who suggested inpatient therapy to improve the patient's endurance. The patient was sent for echocardiography, which demonstrated an ejection fraction between 20 and 25%, with multiple wall motion abnormalities as described. In discussion with the Cardiology team, the decision was made not to anticoagulate the patient at this time, given her recent history of significant clinical gastrointestinal bleeding. In consultation with the patient's attending cardiologist, decision was made to discharge the patient to rehabilitation on <Date>1940-11-26</Date>. Please note that during the sequence described for <Date>6-27</Date>, the patient's electrocardiogram appeared to show sinus tachycardia with the above-stated ST elevations in V2 and V3, which did resolve with the patient's tachycardia. ADDITIONAL DATA: The patient was sent for echocardiography on <Date>2-24</Date>, with the following findings: Symmetric left ventricular hypertrophy with extensive regional systolic dysfunction consistent with coronary artery disease, pulmonary artery systolic hypertension, moderate mitral regurgitation, mild aortic regurgitation. The left ventricular ejection fraction was estimated to be between 20 and 25%. Left ventricular wall motion was noted in detailed report to have abnormalities in the basal anterior portion, which was hypokinetic, mild mid-anterior which was akinetic, basilar and anteroseptal which was akinetic, mid-anteroseptal which was akinetic, basal inferoseptal which was hypokinetic, mid-inferoseptal which was hypokinetic, anterior apex which was akinetic, septal apex which was akinetic, inferior apex which was akinetic, lateral apex which was akinetic, and apex which was dyskinetic. DISCHARGE MEDICATIONS: Lasix 80 mg by mouth twice a day, Captopril 12.5 mg by mouth three times a day, Ambien 5 mg by mouth daily at bedtime as needed, Prevacid 30 mg by mouth twice a day, Timoptic 5% one drop to both eyes once daily, Xalatan one drop to both eyes once daily, NPH four units subcutaneously twice a day, regular insulin sliding scale, folate 1 mg by mouth once daily, Synthroid 25 mcg by mouth once daily, Plavix 75 mg by mouth once daily for 25 days (to complete a one month course), Lopressor 50 mg by mouth three times a day and hold for systolic blood pressure less than or equal to 100 or pulse less than or equal to 60), aspirin 81 mg by mouth once daily, levofloxacin 250 mg by mouth once daily for five days (to complete a ten day course), prednisone 50 mg by mouth once daily for four days then prednisone 40 mg by mouth once daily for four days then prednisone 30 mg by mouth once daily (this is the patient's baseline prednisone dose for her autoimmune hemolytic anemia). DISCHARGE DIAGNOSIS: 1. Status post myocardial infarction 2. Congestive heart failure 3. Hypertension 4. Chronic autoimmune hemolytic anemia 5. Gastrointestinal bleeding DISCHARGE PLAN: The patient will be discharged to rehabilitation. She is to follow up with her primary care physician and cardiologist within one week of discharge from rehabilitation, as well as with her primary hematologist/oncologist or other physician for follow up of chronic autoimmune hemolytic anemia. The patient will be continued on finger stick blood glucoses four times a day with regular insulin sliding scale as described. It is suggested that the patient's electrolytes be measured every other day and repleted as necessary. CONDITION ON DISCHARGE: Stable. <Name>Susana</Name> <Name>Edward</Name>, M.D. <MD Number>12253820</MD Number> Dictated By:<Name>Isaias Moblo</Name> MEDQUIST36 D: <Date>1940-11-26</Date> 02:31 T: <Date>1940-11-26</Date> 02:38 JOB#: <Job Number>Lewis Ltd-1945-512738</Job Number>	000000000000000001111111111000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000001111110111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1956-12-17 Discharge Date: 1943-12-20 Service: CCU Please note that this interval dictation takes up on 2001-6-13, where the dictation of Dr. Marlon Indira Kenner previously dictated left off. ADDITIONAL HOSPITAL COURSE: The patient was transferred from the Coronary Care Unit to the floor at approximately 3 A.M. on 6-27, without event. At approximately 9 A.M., the patient began to complain of shortness of breath and was found to be tachycardic to the 150s after walking a distance to the bathroom. The patient's electrocardiogram demonstrated sinus tachycardia with ST elevations in Leads V2 and V3, otherwise the electrocardiogram was unchanged. On examination, the patient had a blood pressure of 146/60, pulse of 135, pulse oxygenation 98% on 2 liters, was diffusely wheezy on respiratory examination, and was markedly diaphoretic, without jugular venous distention or edema. The patient was given several doses of intravenous Lopressor, as well as high-dose intravenous lasix. The pulse oxygenation transiently fell to 88% on 5 liters face mask, and an arterial blood gas taken was 7.37/32/56. A chest x-ray demonstrated increased congestive heart failure and the patient was given some nitro paste without effect, and then begun on nitroglycerin drip as well as additional lasix 80 mg intravenous push. The patient rapidly thereafter clinically improved, with a blood pressure falling from a high in the 170s/80s to 135/76, with a normalization of respiratory rate and a pulse oxygenation of 92 to 95% on 6 liters, as well as over a liter of urine out ultimately, and a clearing of previous wheezing on examination. The patient was again cycled with cardiac enzymes, which revealed a troponin elevated greater than the measurable range, likely from the prior cardiac events that were described in Dr.Rebecca Bludsworth dictation. However, repeated measurements of creatine kinase failed to demonstrate an elevation in that enzyme, and rather demonstrated a continued trend down. The patient was begun on standing lasix initially at 40 mg once daily, which was then increased to 40 mg twice a day, and then to 80 mg by mouth twice a day. The thought being that the patient had been approximately 4 liters positive during this admission, and that the above-described events likely represented worsening congestive heart failure/pulmonary edema in the setting of volume overload. Additionally, the patient's blood pressure was better controlled with Captopril 12.5 mg by mouth three times a day, and the patient's Lopressor dose as well was increased to 50 mg by mouth three times a day with good effect on the patient's cardiac rate. The patient's hematocrit continued to be stable for the remainder of this admission. She had no further respiratory difficulties, and was seen by Physical Therapy, who suggested inpatient therapy to improve the patient's endurance. The patient was sent for echocardiography, which demonstrated an ejection fraction between 20 and 25%, with multiple wall motion abnormalities as described. In discussion with the Cardiology team, the decision was made not to anticoagulate the patient at this time, given her recent history of significant clinical gastrointestinal bleeding. In consultation with the patient's attending cardiologist, decision was made to discharge the patient to rehabilitation on 1940-11-26. Please note that during the sequence described for 6-27, the patient's electrocardiogram appeared to show sinus tachycardia with the above-stated ST elevations in V2 and V3, which did resolve with the patient's tachycardia. ADDITIONAL DATA: The patient was sent for echocardiography on 2-24, with the following findings: Symmetric left ventricular hypertrophy with extensive regional systolic dysfunction consistent with coronary artery disease, pulmonary artery systolic hypertension, moderate mitral regurgitation, mild aortic regurgitation. The left ventricular ejection fraction was estimated to be between 20 and 25%. Left ventricular wall motion was noted in detailed report to have abnormalities in the basal anterior portion, which was hypokinetic, mild mid-anterior which was akinetic, basilar and anteroseptal which was akinetic, mid-anteroseptal which was akinetic, basal inferoseptal which was hypokinetic, mid-inferoseptal which was hypokinetic, anterior apex which was akinetic, septal apex which was akinetic, inferior apex which was akinetic, lateral apex which was akinetic, and apex which was dyskinetic. DISCHARGE MEDICATIONS: Lasix 80 mg by mouth twice a day, Captopril 12.5 mg by mouth three times a day, Ambien 5 mg by mouth daily at bedtime as needed, Prevacid 30 mg by mouth twice a day, Timoptic 5% one drop to both eyes once daily, Xalatan one drop to both eyes once daily, NPH four units subcutaneously twice a day, regular insulin sliding scale, folate 1 mg by mouth once daily, Synthroid 25 mcg by mouth once daily, Plavix 75 mg by mouth once daily for 25 days (to complete a one month course), Lopressor 50 mg by mouth three times a day and hold for systolic blood pressure less than or equal to 100 or pulse less than or equal to 60), aspirin 81 mg by mouth once daily, levofloxacin 250 mg by mouth once daily for five days (to complete a ten day course), prednisone 50 mg by mouth once daily for four days then prednisone 40 mg by mouth once daily for four days then prednisone 30 mg by mouth once daily (this is the patient's baseline prednisone dose for her autoimmune hemolytic anemia). DISCHARGE DIAGNOSIS: 1. Status post myocardial infarction 2. Congestive heart failure 3. Hypertension 4. Chronic autoimmune hemolytic anemia 5. Gastrointestinal bleeding DISCHARGE PLAN: The patient will be discharged to rehabilitation. She is to follow up with her primary care physician and cardiologist within one week of discharge from rehabilitation, as well as with her primary hematologist/oncologist or other physician for follow up of chronic autoimmune hemolytic anemia. The patient will be continued on finger stick blood glucoses four times a day with regular insulin sliding scale as described. It is suggested that the patient's electrolytes be measured every other day and repleted as necessary. CONDITION ON DISCHARGE: Stable. Susana Edward, M.D. 12253820 Dictated By:Isaias Moblo MEDQUIST36 D: 1940-11-26 02:31 T: 1940-11-26 02:38 JOB#: Lewis Ltd-1945-512738	["Admission Date: 1956-12-17 Discharge Date: 1943-12-20\n\n\nService: CCU\n\nPlease note that this interval dictation takes up on 2001-6-13, where the dictation of Dr. Marlon Indira Kenner previously\ndictated left off.\n\nADDITIONAL HOSPITAL COURSE: The patient was transferred from\nthe Coronary Care Unit to the floor at approximately 3 A.M.\non 6-27, without event. At approximately 9 A.M., the\npatient began to complain of shortness of breath and was\nfound to be tachycardic to the 150s after walking a distance\nto the bathroom. The patient's electrocardiogram\ndemonstrated sinus tachycardia with ST elevations in Leads V2\nand V3, otherwise the electrocardiogram was unchanged. On\nexamination, the patient had a blood pressure of 146/60,\npulse of 135, pulse oxygenation 98% on 2 liters, was\ndiffusely wheezy on respiratory examination, and was markedly\ndiaphoretic, without jugular venous distention or edema.", ' The\npatient was given several doses of intravenous Lopressor, as\nwell as high-dose intravenous lasix. The pulse oxygenation\ntransiently fell to 88% on 5 liters face mask, and an\narterial blood gas taken was 7.37/32/56. A chest x-ray\ndemonstrated increased congestive heart failure and the\npatient was given some nitro paste without effect, and then\nbegun on nitroglycerin drip as well as additional lasix 80 mg\nintravenous push.\n\nThe patient rapidly thereafter clinically improved, with a\nblood pressure falling from a high in the 170s/80s to 135/76,\nwith a normalization of respiratory rate and a pulse\noxygenation of 92 to 95% on 6 liters, as well as over a liter\nof urine out ultimately, and a clearing of previous wheezing\non examination.\n\nThe patient was again cycled with cardiac enzymes, which\nrevealed a troponin elevated greater than the measurable\nrange, likely from the prior cardiac events that were\ndescribed in Dr.', "Rebecca Bludsworth dictation. However, repeated\nmeasurements of creatine kinase failed to demonstrate an\nelevation in that enzyme, and rather demonstrated a continued\ntrend down. The patient was begun on standing lasix\ninitially at 40 mg once daily, which was then increased to 40\nmg twice a day, and then to 80 mg by mouth twice a day. The\nthought being that the patient had been approximately 4\nliters positive during this admission, and that the\nabove-described events likely represented worsening\ncongestive heart failure/pulmonary edema in the setting of\nvolume overload. Additionally, the patient's blood pressure\nwas better controlled with Captopril 12.5 mg by mouth three\ntimes a day, and the patient's Lopressor dose as well was\nincreased to 50 mg by mouth three times a day with good\neffect on the patient's cardiac rate.", "\n\nThe patient's hematocrit continued to be stable for the\nremainder of this admission. She had no further respiratory\ndifficulties, and was seen by Physical Therapy, who suggested\ninpatient therapy to improve the patient's endurance.\n\nThe patient was sent for echocardiography, which demonstrated\nan ejection fraction between 20 and 25%, with multiple wall\nmotion abnormalities as described. In discussion with the\nCardiology team, the decision was made not to anticoagulate\nthe patient at this time, given her recent history of\nsignificant clinical gastrointestinal bleeding. In\nconsultation with the patient's attending cardiologist,\ndecision was made to discharge the patient to rehabilitation\non 1940-11-26.\n\nPlease note that during the sequence described for 6-27,\nthe patient's electrocardiogram appeared to show sinus\ntachycardia with the above-stated ST elevations in V2 and V3,\nwhich did resolve with the patient's tachycardia.", '\n\nADDITIONAL DATA: The patient was sent for echocardiography\non 2-24, with the following findings: Symmetric left\nventricular hypertrophy with extensive regional systolic\ndysfunction consistent with coronary artery disease,\npulmonary artery systolic hypertension, moderate mitral\nregurgitation, mild aortic regurgitation. The left\nventricular ejection fraction was estimated to be between 20\nand 25%. Left ventricular wall motion was noted in detailed\nreport to have abnormalities in the basal anterior portion,\nwhich was hypokinetic, mild mid-anterior which was akinetic,\nbasilar and anteroseptal which was akinetic, mid-anteroseptal\nwhich was akinetic, basal inferoseptal which was hypokinetic,\nmid-inferoseptal which was hypokinetic, anterior apex which\nwas akinetic, septal apex which was akinetic, inferior apex\nwhich was akinetic, lateral apex which was akinetic, and apex\nwhich was dyskinetic.', "\n\nDISCHARGE MEDICATIONS: Lasix 80 mg by mouth twice a day,\nCaptopril 12.5 mg by mouth three times a day, Ambien 5 mg by\nmouth daily at bedtime as needed, Prevacid 30 mg by mouth\ntwice a day, Timoptic 5% one drop to both eyes once daily,\nXalatan one drop to both eyes once daily, NPH four units\nsubcutaneously twice a day, regular insulin sliding scale,\nfolate 1 mg by mouth once daily, Synthroid 25 mcg by mouth\nonce daily, Plavix 75 mg by mouth once daily for 25 days (to\ncomplete a one month course), Lopressor 50 mg by mouth three\ntimes a day and hold for systolic blood pressure less than or\nequal to 100 or pulse less than or equal to 60), aspirin 81\nmg by mouth once daily, levofloxacin 250 mg by mouth once\ndaily for five days (to complete a ten day course),\nprednisone 50 mg by mouth once daily for four days then\nprednisone 40 mg by mouth once daily for four days then\nprednisone 30 mg by mouth once daily (this is the patient's\nbaseline prednisone dose for her autoimmune hemolytic\nanemia).", "\n\nDISCHARGE DIAGNOSIS:\n1. Status post myocardial infarction\n2. Congestive heart failure\n3. Hypertension\n4. Chronic autoimmune hemolytic anemia\n5. Gastrointestinal bleeding\n\nDISCHARGE PLAN: The patient will be discharged to\nrehabilitation. She is to follow up with her primary care\nphysician and cardiologist within one week of discharge from\nrehabilitation, as well as with her primary\nhematologist/oncologist or other physician for follow up of\nchronic autoimmune hemolytic anemia. The patient will be\ncontinued on finger stick blood glucoses four times a day\nwith regular insulin sliding scale as described. It is\nsuggested that the patient's electrolytes be measured every\nother day and repleted as necessary.\n\nCONDITION ON DISCHARGE: Stable.\n\n\n\n\n Susana Edward, M.", 'D. 12253820\n\nDictated By:Isaias Moblo\nMEDQUIST36\n\nD: 1940-11-26 02:31\nT: 1940-11-26 02:38\nJOB#: Lewis Ltd-1945-512738\n']
208	5239	125055.0	2189-03-25	Discharge summary	Report	Admission Date: [2189-3-17] Discharge Date: [2189-3-25] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old woman with a history of coronary artery disease with recent CCU stay and autoimmune hemolytic anemia who presented again to the CCU after being admitted to the floor with a two-day history of weakness, increased shortness of breath, decreased She had stent to the left anterior descending at an outside hospital in [2188-11-25]. She then represented to [Hospital6 1760] on [2189-2-18], with her anginal equivalent (epigastric pain) and was found to have ST elevations on her electrocardiogram in leads V2-V5. She had a complicated emergent catheterization. The catheterization placed on Dopamine and intubated. On catheterization, the patient had in stent restenosis of the left anterior descending, and she received percutaneous transluminal coronary angioplasty. A lesion of the ramus intermedius was stented as well. Intra-aortic balloon pump was initiated at that time. She had a four-day stay in the CCU when she was able to be taken off the balloon pump and ventilatory support. She did have an episode of acute hypoxia after transfer to the floor that improved with diuresis and nitrates. She was discharged two weeks to this current admission to a nursing home. On presentation to the Emergency Department the patient had a heart rate of around 100, and systolic blood pressure in the 80-90s. Hematocrit was down to 24.5. Hematocrit on discharge from her prior hospitalization was 33; however, her baseline hematocrit is in the mid 20s. She was transfused 1 U of packed red blood cells in the Emergency Department. She had no electrocardiogram changes on arrival to the Emergency Department. Upon arrival to the floor, she had acute decrease in oxygen saturations to the low 80s with tachypnea and tachycardia to the 150s. She was given intravenous Nitroglycerin drip, intravenous Lasix, and intravenous Lopressor 2.5 mg, as well as IV Morphine 2 mg. Her ABG showed a pH of 7.19, and a pCO2 of 48, and a pO2 of 56. The patient was intubated and transferred to the CCU. Her electrocardiogram showed sinus tachycardia with unchanged segment elevations in V2-V4 compared with baseline. Her chest x-ray was consistent with increasing congestive heart failure compared with earlier in the day. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [2189-1-23]. Catheterization in [2188-11-25] with stent to the proximal to the left anterior descending, and PTCA to the ramus and diagonal, 80% proximal right coronary artery lesion. Catheterization in [2189-1-23] showed 100% proximal left anterior descending in stent stenosis, and PTCA was performed, as well as 100% OM1 lesion, as well as an 80% ramus lesion which was stented. Catheterization was complicated by hypotension and respiratory distress as described in the HPI. 2. Systolic dysfunction a left ventricular ejection fraction of 20-25% by echocardiogram earlier this month showing mild symmetric left ventricular hypertrophy as well. Echocardiogram also showed near akinesis of the entire septum and anterior wall of the left ventricle, as well as distal inferior and distal lateral wall akinesis. The apex was aneurysmal as well. 3. Hypertension. 4. History of GI bleed. The patient had an admission during [2189-1-23] for GI bleed. 5. Autoimmune hemolytic anemia followed by Hematology/Oncology at [Hospital6 1760] diagnosed in [2188-11-25]. 6. Diabetes mellitus thought to be steroid induced. 7. Hypothyroidism. MEDICATIONS ON ADMISSION: Lasix 80 mg p.o. b.i.d., Captopril 12.5 mg t.i.d., Ambien 5 mg q.h.s., Prevacid 30 mg b.i.d., Timoptic 0.5% eye drops, Xalatan eyedrops, NPH Insulin 4 U b.i.d., sliding scale Insulin regular, Synthroid 0.25 mg q.d., Plavix 75 mg q.d., Lopressor 50 mg t.i.d., Aspirin 81 mg q.d., Prednisone taper currently at 30 mg q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient resides at [Hospital 582] Nursing Home. Denies tobacco. Occasional alcohol. She is a retired hair dresser. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 100.0??????, heart rate 100, blood pressure 118/51, oxygen saturation 100% on 60% FIO2 on vent setting AC 12 x 550 FIO2 60% .............. to 7.5. General: The patient was intubated, awake, responsive. The patient was in no acute distress. Cardiovascular: Regular, rate and rhythm. No murmurs. Audible over breath sounds. Respirations: Diffuse anterior crackles. Extremities: Trace bilateral lower extremity edema. Abdomen: Positive bowel sounds. Soft, nontender, nondistended. Guaiac negative in the Emergency Department. Neck: There was 9 cm JVP. LABORATORY DATA: White count 12.4, hematocrit 29.4 up from 24.5 in the Emergency Department, platelet count 290; INR 1.1, PTT 23.4; potassium 3.4, BUN 28, creatinine 1.4, glucose 172, magnesium 1.7, albumin 3.1; CKs serially 41, 36, 39, troponin 1.3 on the morning of admission. ASSESSMENT: This was an 83-year-old woman with known congestive heart failure and ischemic coronary disease presenting flash pulmonary edema in the setting of blood transfusion. HOSPITAL COURSE: 1. Cardiovascular/ischemia: The patient underwent repeat cardiac catheterization while intubated. The catheterization showed instant restenosis of her left anterior descending stent at 40%; however, distal to the stent, there was an 80% focal lesion which was ballooned and stented. Her ramus stent were patent with associated ostial 40% lesion. Her known 80% right coronary artery lesion remained unchanged. Right heart catheterization showed a pulmonary wedge pressure of 30, RA pressure of 12, PA pressure of 61/34, RV pressure of 61/16. Cardiac output was 4.4 with an index of 2.9. Mixed venous saturation in the Catheterization Lab was 57.6 from the pulmonary artery. The patient did well postcatheterization and was able to be extubated. She was placed on Aspirin and Plavix for life. Beta-blocker was re-added, and Lopressor was titrated up 50 mg b.i.d. Ace inhibitor was also added. Her statin was continued as well. She remained chest-pain free and free of shortness of breath throughout the rest of her hospitalization. 2. Cardiovascular/pump: The patient's ejection fraction was known to be 20%. Heart catheterization confirmed her fluid overload and congestive heart failure physiology. She did not respond to Lasix on initially arriving in the CCU; however after catheterization, she diuresed well to Lasix with general improvement in her PA diastolics and improvement of her kidney function. She was able to be extubated without difficulty after adequate diuresis was achieved. Upon arrival to the floor from the CCU, the CHF Service was consulted. They recommended initiating Digoxin, low-dose nitrate, and standing p.o. Lasix which was done. She was discharged with plans to follow-up with the CHF Service for continued medical management of her congestive heart failure. 3. Pulmonary: The patient was able to be initially extubated on the second hospital day; however, on the day after initial extubation, her status remained tenuous with increasing Nitroglycerin drip and p.r.n. Morphine required to reduce her preload enough to maintain oxygenation. On the night after initial extubation, she required emergent reintubation due to acute hypoxia. Chest x-ray prior to intubation demonstrated white-out of the lower two-thirds of the right lung; however, film 3-4 hours postintubation showed resolution of the opacity throughout the right lung consistent with acute mucous plugging. It was therefore thought that that episode of hypoxia was not due to congestive heart failure but to mucous plugging. The patient was reextubated without difficulty status post catheterization and maintained satisfactory oxygenation throughout the remainder of her hospital stay. She was also started on Levofloxacin on admission due to suspicion of right upper lobe infiltrate. Levofloxacin was switched to Ceftriaxone and Azithromycin on the third hospital day. She remained afebrile throughout her hospital course but did however start to develop a cough toward the end of her hospital stay. She was continued on the Ceftriaxone through the hospital stay with the plan for a total 14-day course along with her Azithromycin. 4. Infectious disease: As above, the patient was treated for suspicion of pneumonia. Of note, she had an isolated positive blood culture growing gram-positive cocci in pairs and clusters from [2189-3-19]; however, she was afebrile throughout the time surrounding this culture. Repeat cultures were drawn on [2189-3-24], and were pending at the time of this dictation. 5. Heme: The patient has a history of autoimmune hemolytic anemia with a baseline hematocrit in the mid 20s. As noted in the HPI, she was transfused 1 U prior to her episode of flash pulmonary edema. Hematology Service was [Name (NI) 653], and they felt that it would be acceptable to transfuse the patient as needed. The patient was transfused with one additional unit of blood during her hospital stay. Due to her steroids and autoimmune hemolytic anemia, she was restarted on stress dose steroids as she had been on her previous admission. These were quickly tapered to a discharge dose of Prednisone 10 mg q.d. The patient had stable blood pressure and hematocrit on this dose. 6. Fluids, electrolytes, and nutrition: The patient developed hypernatremia toward the end of her hospital stay with a peak sodium of 151. It was thought that this was due to inadequate p.o. intake and free-water intake, and she was encouraged to maintain p.o. intake. A Nutrition consult was obtained as well. Follow-up labs of her sodium were pending at the time of this dictation. DISPOSITION: The patient was discharged to acute rehabilitation in stable condition. DISCHARGE MEDICATIONS: Enteric Coated Aspirin 325 mg p.o. q.d., Plavix 75 mg p.o. q.d., Timoptic 0.5% eye drops 1 drop per eye q.d., Xalatan 0.005% solution 1 drop to each eye q.d., Folate 1 mg p.o. q.d., NPH Insulin 4 U subcue b.i.d., Synthroid 250 mcg p.o. q.d., Azithromycin 250 mg p.o. q.d., Protonix 40 mg p.o. q.d., Prednisone 10 mg q.d., Ceftriaxone 1 g IV q.24 hours to be discontinued on [4-1], Lopressor 50 mg p.o. q.d., Onalopril b.i.d., Ambien 5 mg p.o. q.h.s. p.r.n., Lasix 20 mg p.o. q.d., Imdur 30 mg p.o. q.d., Digoxin 0.125 mg p.o. q.d. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post new stent to the left anterior descending. 2. Congestive heart failure complicated by flash pulmonary edema requiring intubation. 3. Pneumonia. 4. Autoimmune hemolytic anemia. DR.[First Name (STitle) ],[Last Name (un) 2060] 12-953 Dictated By:[Name8 (MD) 2061] MEDQUIST36 D: [2189-3-24] 14:52 T: [2189-3-24] 15:19 JOB#: [Job Number 2062]	Admission Date: <Date>1921-5-6</Date> Discharge Date: <Date>2005-11-26</Date> Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old woman with a history of coronary artery disease with recent CCU stay and autoimmune hemolytic anemia who presented again to the CCU after being admitted to the floor with a two-day history of weakness, increased shortness of breath, decreased She had stent to the left anterior descending at an outside hospital in <Date>1925-10-23</Date>. She then represented to <Hospital>Ware-Lynn Hospital</Hospital> on <Date>1992-9-31</Date>, with her anginal equivalent (epigastric pain) and was found to have ST elevations on her electrocardiogram in leads V2-V5. She had a complicated emergent catheterization. The catheterization placed on Dopamine and intubated. On catheterization, the patient had in stent restenosis of the left anterior descending, and she received percutaneous transluminal coronary angioplasty. A lesion of the ramus intermedius was stented as well. Intra-aortic balloon pump was initiated at that time. She had a four-day stay in the CCU when she was able to be taken off the balloon pump and ventilatory support. She did have an episode of acute hypoxia after transfer to the floor that improved with diuresis and nitrates. She was discharged two weeks to this current admission to a nursing home. On presentation to the Emergency Department the patient had a heart rate of around 100, and systolic blood pressure in the 80-90s. Hematocrit was down to 24.5. Hematocrit on discharge from her prior hospitalization was 33; however, her baseline hematocrit is in the mid 20s. She was transfused 1 U of packed red blood cells in the Emergency Department. She had no electrocardiogram changes on arrival to the Emergency Department. Upon arrival to the floor, she had acute decrease in oxygen saturations to the low 80s with tachypnea and tachycardia to the 150s. She was given intravenous Nitroglycerin drip, intravenous Lasix, and intravenous Lopressor 2.5 mg, as well as IV Morphine 2 mg. Her ABG showed a pH of 7.19, and a pCO2 of 48, and a pO2 of 56. The patient was intubated and transferred to the CCU. Her electrocardiogram showed sinus tachycardia with unchanged segment elevations in V2-V4 compared with baseline. Her chest x-ray was consistent with increasing congestive heart failure compared with earlier in the day. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in <Date>1931-7-20</Date>. Catheterization in <Date>1925-10-23</Date> with stent to the proximal to the left anterior descending, and PTCA to the ramus and diagonal, 80% proximal right coronary artery lesion. Catheterization in <Date>1931-7-20</Date> showed 100% proximal left anterior descending in stent stenosis, and PTCA was performed, as well as 100% OM1 lesion, as well as an 80% ramus lesion which was stented. Catheterization was complicated by hypotension and respiratory distress as described in the HPI. 2. Systolic dysfunction a left ventricular ejection fraction of 20-25% by echocardiogram earlier this month showing mild symmetric left ventricular hypertrophy as well. Echocardiogram also showed near akinesis of the entire septum and anterior wall of the left ventricle, as well as distal inferior and distal lateral wall akinesis. The apex was aneurysmal as well. 3. Hypertension. 4. History of GI bleed. The patient had an admission during <Date>1931-7-20</Date> for GI bleed. 5. Autoimmune hemolytic anemia followed by Hematology/Oncology at <Hospital>Ware-Lynn Hospital</Hospital> diagnosed in <Date>1925-10-23</Date>. 6. Diabetes mellitus thought to be steroid induced. 7. Hypothyroidism. MEDICATIONS ON ADMISSION: Lasix 80 mg p.o. b.i.d., Captopril 12.5 mg t.i.d., Ambien 5 mg q.h.s., Prevacid 30 mg b.i.d., Timoptic 0.5% eye drops, Xalatan eyedrops, NPH Insulin 4 U b.i.d., sliding scale Insulin regular, Synthroid 0.25 mg q.d., Plavix 75 mg q.d., Lopressor 50 mg t.i.d., Aspirin 81 mg q.d., Prednisone taper currently at 30 mg q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient resides at <Hospital>Mclaughlin Inc Medical Center</Hospital> Nursing Home. Denies tobacco. Occasional alcohol. She is a retired hair dresser. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 100.0??????, heart rate 100, blood pressure 118/51, oxygen saturation 100% on 60% FIO2 on vent setting AC 12 x 550 FIO2 60% .............. to 7.5. General: The patient was intubated, awake, responsive. The patient was in no acute distress. Cardiovascular: Regular, rate and rhythm. No murmurs. Audible over breath sounds. Respirations: Diffuse anterior crackles. Extremities: Trace bilateral lower extremity edema. Abdomen: Positive bowel sounds. Soft, nontender, nondistended. Guaiac negative in the Emergency Department. Neck: There was 9 cm JVP. LABORATORY DATA: White count 12.4, hematocrit 29.4 up from 24.5 in the Emergency Department, platelet count 290; INR 1.1, PTT 23.4; potassium 3.4, BUN 28, creatinine 1.4, glucose 172, magnesium 1.7, albumin 3.1; CKs serially 41, 36, 39, troponin 1.3 on the morning of admission. ASSESSMENT: This was an 83-year-old woman with known congestive heart failure and ischemic coronary disease presenting flash pulmonary edema in the setting of blood transfusion. HOSPITAL COURSE: 1. Cardiovascular/ischemia: The patient underwent repeat cardiac catheterization while intubated. The catheterization showed instant restenosis of her left anterior descending stent at 40%; however, distal to the stent, there was an 80% focal lesion which was ballooned and stented. Her ramus stent were patent with associated ostial 40% lesion. Her known 80% right coronary artery lesion remained unchanged. Right heart catheterization showed a pulmonary wedge pressure of 30, RA pressure of 12, PA pressure of 61/34, RV pressure of 61/16. Cardiac output was 4.4 with an index of 2.9. Mixed venous saturation in the Catheterization Lab was 57.6 from the pulmonary artery. The patient did well postcatheterization and was able to be extubated. She was placed on Aspirin and Plavix for life. Beta-blocker was re-added, and Lopressor was titrated up 50 mg b.i.d. Ace inhibitor was also added. Her statin was continued as well. She remained chest-pain free and free of shortness of breath throughout the rest of her hospitalization. 2. Cardiovascular/pump: The patient's ejection fraction was known to be 20%. Heart catheterization confirmed her fluid overload and congestive heart failure physiology. She did not respond to Lasix on initially arriving in the CCU; however after catheterization, she diuresed well to Lasix with general improvement in her PA diastolics and improvement of her kidney function. She was able to be extubated without difficulty after adequate diuresis was achieved. Upon arrival to the floor from the CCU, the CHF Service was consulted. They recommended initiating Digoxin, low-dose nitrate, and standing p.o. Lasix which was done. She was discharged with plans to follow-up with the CHF Service for continued medical management of her congestive heart failure. 3. Pulmonary: The patient was able to be initially extubated on the second hospital day; however, on the day after initial extubation, her status remained tenuous with increasing Nitroglycerin drip and p.r.n. Morphine required to reduce her preload enough to maintain oxygenation. On the night after initial extubation, she required emergent reintubation due to acute hypoxia. Chest x-ray prior to intubation demonstrated white-out of the lower two-thirds of the right lung; however, film 3-4 hours postintubation showed resolution of the opacity throughout the right lung consistent with acute mucous plugging. It was therefore thought that that episode of hypoxia was not due to congestive heart failure but to mucous plugging. The patient was reextubated without difficulty status post catheterization and maintained satisfactory oxygenation throughout the remainder of her hospital stay. She was also started on Levofloxacin on admission due to suspicion of right upper lobe infiltrate. Levofloxacin was switched to Ceftriaxone and Azithromycin on the third hospital day. She remained afebrile throughout her hospital course but did however start to develop a cough toward the end of her hospital stay. She was continued on the Ceftriaxone through the hospital stay with the plan for a total 14-day course along with her Azithromycin. 4. Infectious disease: As above, the patient was treated for suspicion of pneumonia. Of note, she had an isolated positive blood culture growing gram-positive cocci in pairs and clusters from <Date>1953-9-23</Date>; however, she was afebrile throughout the time surrounding this culture. Repeat cultures were drawn on <Date>1951-12-14</Date>, and were pending at the time of this dictation. 5. Heme: The patient has a history of autoimmune hemolytic anemia with a baseline hematocrit in the mid 20s. As noted in the HPI, she was transfused 1 U prior to her episode of flash pulmonary edema. Hematology Service was <Name>Idalia Yuen</Name>, and they felt that it would be acceptable to transfuse the patient as needed. The patient was transfused with one additional unit of blood during her hospital stay. Due to her steroids and autoimmune hemolytic anemia, she was restarted on stress dose steroids as she had been on her previous admission. These were quickly tapered to a discharge dose of Prednisone 10 mg q.d. The patient had stable blood pressure and hematocrit on this dose. 6. Fluids, electrolytes, and nutrition: The patient developed hypernatremia toward the end of her hospital stay with a peak sodium of 151. It was thought that this was due to inadequate p.o. intake and free-water intake, and she was encouraged to maintain p.o. intake. A Nutrition consult was obtained as well. Follow-up labs of her sodium were pending at the time of this dictation. DISPOSITION: The patient was discharged to acute rehabilitation in stable condition. DISCHARGE MEDICATIONS: Enteric Coated Aspirin 325 mg p.o. q.d., Plavix 75 mg p.o. q.d., Timoptic 0.5% eye drops 1 drop per eye q.d., Xalatan 0.005% solution 1 drop to each eye q.d., Folate 1 mg p.o. q.d., NPH Insulin 4 U subcue b.i.d., Synthroid 250 mcg p.o. q.d., Azithromycin 250 mg p.o. q.d., Protonix 40 mg p.o. q.d., Prednisone 10 mg q.d., Ceftriaxone 1 g IV q.24 hours to be discontinued on <Date>6-4</Date>, Lopressor 50 mg p.o. q.d., Onalopril b.i.d., Ambien 5 mg p.o. q.h.s. p.r.n., Lasix 20 mg p.o. q.d., Imdur 30 mg p.o. q.d., Digoxin 0.125 mg p.o. q.d. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post new stent to the left anterior descending. 2. Congestive heart failure complicated by flash pulmonary edema requiring intubation. 3. Pneumonia. 4. Autoimmune hemolytic anemia. DR.<Name>Stephanie</Name>,<Name>Chowdhury</Name> 12-953 Dictated By:<Name>Odell Chau</Name> MEDQUIST36 D: <Date>1951-12-14</Date> 14:52 T: <Date>1951-12-14</Date> 15:19 JOB#: <Job Number>Brown Ltd-2019-828671</Job 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Date: 1921-5-6 Discharge Date: 2005-11-26 Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old woman with a history of coronary artery disease with recent CCU stay and autoimmune hemolytic anemia who presented again to the CCU after being admitted to the floor with a two-day history of weakness, increased shortness of breath, decreased She had stent to the left anterior descending at an outside hospital in 1925-10-23. She then represented to Ware-Lynn Hospital on 1992-9-31, with her anginal equivalent (epigastric pain) and was found to have ST elevations on her electrocardiogram in leads V2-V5. She had a complicated emergent catheterization. The catheterization placed on Dopamine and intubated. On catheterization, the patient had in stent restenosis of the left anterior descending, and she received percutaneous transluminal coronary angioplasty. A lesion of the ramus intermedius was stented as well. Intra-aortic balloon pump was initiated at that time. She had a four-day stay in the CCU when she was able to be taken off the balloon pump and ventilatory support. She did have an episode of acute hypoxia after transfer to the floor that improved with diuresis and nitrates. She was discharged two weeks to this current admission to a nursing home. On presentation to the Emergency Department the patient had a heart rate of around 100, and systolic blood pressure in the 80-90s. Hematocrit was down to 24.5. Hematocrit on discharge from her prior hospitalization was 33; however, her baseline hematocrit is in the mid 20s. She was transfused 1 U of packed red blood cells in the Emergency Department. She had no electrocardiogram changes on arrival to the Emergency Department. Upon arrival to the floor, she had acute decrease in oxygen saturations to the low 80s with tachypnea and tachycardia to the 150s. She was given intravenous Nitroglycerin drip, intravenous Lasix, and intravenous Lopressor 2.5 mg, as well as IV Morphine 2 mg. Her ABG showed a pH of 7.19, and a pCO2 of 48, and a pO2 of 56. The patient was intubated and transferred to the CCU. Her electrocardiogram showed sinus tachycardia with unchanged segment elevations in V2-V4 compared with baseline. Her chest x-ray was consistent with increasing congestive heart failure compared with earlier in the day. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in 1931-7-20. Catheterization in 1925-10-23 with stent to the proximal to the left anterior descending, and PTCA to the ramus and diagonal, 80% proximal right coronary artery lesion. Catheterization in 1931-7-20 showed 100% proximal left anterior descending in stent stenosis, and PTCA was performed, as well as 100% OM1 lesion, as well as an 80% ramus lesion which was stented. Catheterization was complicated by hypotension and respiratory distress as described in the HPI. 2. Systolic dysfunction a left ventricular ejection fraction of 20-25% by echocardiogram earlier this month showing mild symmetric left ventricular hypertrophy as well. Echocardiogram also showed near akinesis of the entire septum and anterior wall of the left ventricle, as well as distal inferior and distal lateral wall akinesis. The apex was aneurysmal as well. 3. Hypertension. 4. History of GI bleed. The patient had an admission during 1931-7-20 for GI bleed. 5. Autoimmune hemolytic anemia followed by Hematology/Oncology at Ware-Lynn Hospital diagnosed in 1925-10-23. 6. Diabetes mellitus thought to be steroid induced. 7. Hypothyroidism. MEDICATIONS ON ADMISSION: Lasix 80 mg p.o. b.i.d., Captopril 12.5 mg t.i.d., Ambien 5 mg q.h.s., Prevacid 30 mg b.i.d., Timoptic 0.5% eye drops, Xalatan eyedrops, NPH Insulin 4 U b.i.d., sliding scale Insulin regular, Synthroid 0.25 mg q.d., Plavix 75 mg q.d., Lopressor 50 mg t.i.d., Aspirin 81 mg q.d., Prednisone taper currently at 30 mg q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient resides at Mclaughlin Inc Medical Center Nursing Home. Denies tobacco. Occasional alcohol. She is a retired hair dresser. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 100.0??????, heart rate 100, blood pressure 118/51, oxygen saturation 100% on 60% FIO2 on vent setting AC 12 x 550 FIO2 60% .............. to 7.5. General: The patient was intubated, awake, responsive. The patient was in no acute distress. Cardiovascular: Regular, rate and rhythm. No murmurs. Audible over breath sounds. Respirations: Diffuse anterior crackles. Extremities: Trace bilateral lower extremity edema. Abdomen: Positive bowel sounds. Soft, nontender, nondistended. Guaiac negative in the Emergency Department. Neck: There was 9 cm JVP. LABORATORY DATA: White count 12.4, hematocrit 29.4 up from 24.5 in the Emergency Department, platelet count 290; INR 1.1, PTT 23.4; potassium 3.4, BUN 28, creatinine 1.4, glucose 172, magnesium 1.7, albumin 3.1; CKs serially 41, 36, 39, troponin 1.3 on the morning of admission. ASSESSMENT: This was an 83-year-old woman with known congestive heart failure and ischemic coronary disease presenting flash pulmonary edema in the setting of blood transfusion. HOSPITAL COURSE: 1. Cardiovascular/ischemia: The patient underwent repeat cardiac catheterization while intubated. The catheterization showed instant restenosis of her left anterior descending stent at 40%; however, distal to the stent, there was an 80% focal lesion which was ballooned and stented. Her ramus stent were patent with associated ostial 40% lesion. Her known 80% right coronary artery lesion remained unchanged. Right heart catheterization showed a pulmonary wedge pressure of 30, RA pressure of 12, PA pressure of 61/34, RV pressure of 61/16. Cardiac output was 4.4 with an index of 2.9. Mixed venous saturation in the Catheterization Lab was 57.6 from the pulmonary artery. The patient did well postcatheterization and was able to be extubated. She was placed on Aspirin and Plavix for life. Beta-blocker was re-added, and Lopressor was titrated up 50 mg b.i.d. Ace inhibitor was also added. Her statin was continued as well. She remained chest-pain free and free of shortness of breath throughout the rest of her hospitalization. 2. Cardiovascular/pump: The patient's ejection fraction was known to be 20%. Heart catheterization confirmed her fluid overload and congestive heart failure physiology. She did not respond to Lasix on initially arriving in the CCU; however after catheterization, she diuresed well to Lasix with general improvement in her PA diastolics and improvement of her kidney function. She was able to be extubated without difficulty after adequate diuresis was achieved. Upon arrival to the floor from the CCU, the CHF Service was consulted. They recommended initiating Digoxin, low-dose nitrate, and standing p.o. Lasix which was done. She was discharged with plans to follow-up with the CHF Service for continued medical management of her congestive heart failure. 3. Pulmonary: The patient was able to be initially extubated on the second hospital day; however, on the day after initial extubation, her status remained tenuous with increasing Nitroglycerin drip and p.r.n. Morphine required to reduce her preload enough to maintain oxygenation. On the night after initial extubation, she required emergent reintubation due to acute hypoxia. Chest x-ray prior to intubation demonstrated white-out of the lower two-thirds of the right lung; however, film 3-4 hours postintubation showed resolution of the opacity throughout the right lung consistent with acute mucous plugging. It was therefore thought that that episode of hypoxia was not due to congestive heart failure but to mucous plugging. The patient was reextubated without difficulty status post catheterization and maintained satisfactory oxygenation throughout the remainder of her hospital stay. She was also started on Levofloxacin on admission due to suspicion of right upper lobe infiltrate. Levofloxacin was switched to Ceftriaxone and Azithromycin on the third hospital day. She remained afebrile throughout her hospital course but did however start to develop a cough toward the end of her hospital stay. She was continued on the Ceftriaxone through the hospital stay with the plan for a total 14-day course along with her Azithromycin. 4. Infectious disease: As above, the patient was treated for suspicion of pneumonia. Of note, she had an isolated positive blood culture growing gram-positive cocci in pairs and clusters from 1953-9-23; however, she was afebrile throughout the time surrounding this culture. Repeat cultures were drawn on 1951-12-14, and were pending at the time of this dictation. 5. Heme: The patient has a history of autoimmune hemolytic anemia with a baseline hematocrit in the mid 20s. As noted in the HPI, she was transfused 1 U prior to her episode of flash pulmonary edema. Hematology Service was Idalia Yuen, and they felt that it would be acceptable to transfuse the patient as needed. The patient was transfused with one additional unit of blood during her hospital stay. Due to her steroids and autoimmune hemolytic anemia, she was restarted on stress dose steroids as she had been on her previous admission. These were quickly tapered to a discharge dose of Prednisone 10 mg q.d. The patient had stable blood pressure and hematocrit on this dose. 6. Fluids, electrolytes, and nutrition: The patient developed hypernatremia toward the end of her hospital stay with a peak sodium of 151. It was thought that this was due to inadequate p.o. intake and free-water intake, and she was encouraged to maintain p.o. intake. A Nutrition consult was obtained as well. Follow-up labs of her sodium were pending at the time of this dictation. DISPOSITION: The patient was discharged to acute rehabilitation in stable condition. DISCHARGE MEDICATIONS: Enteric Coated Aspirin 325 mg p.o. q.d., Plavix 75 mg p.o. q.d., Timoptic 0.5% eye drops 1 drop per eye q.d., Xalatan 0.005% solution 1 drop to each eye q.d., Folate 1 mg p.o. q.d., NPH Insulin 4 U subcue b.i.d., Synthroid 250 mcg p.o. q.d., Azithromycin 250 mg p.o. q.d., Protonix 40 mg p.o. q.d., Prednisone 10 mg q.d., Ceftriaxone 1 g IV q.24 hours to be discontinued on 6-4, Lopressor 50 mg p.o. q.d., Onalopril b.i.d., Ambien 5 mg p.o. q.h.s. p.r.n., Lasix 20 mg p.o. q.d., Imdur 30 mg p.o. q.d., Digoxin 0.125 mg p.o. q.d. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post new stent to the left anterior descending. 2. Congestive heart failure complicated by flash pulmonary edema requiring intubation. 3. Pneumonia. 4. Autoimmune hemolytic anemia. DR.Stephanie,Chowdhury 12-953 Dictated By:Odell Chau MEDQUIST36 D: 1951-12-14 14:52 T: 1951-12-14 15:19 JOB#: Brown Ltd-2019-828671	['Admission Date: 1921-5-6 Discharge Date: 2005-11-26\n\n\nService: CCU\nHISTORY OF PRESENT ILLNESS: The patient is an 83-year-old\nwoman with a history of coronary artery disease with recent\nCCU stay and autoimmune hemolytic anemia who presented again\nto the CCU after being admitted to the floor with a two-day\nhistory of weakness, increased shortness of breath, decreased\n\nShe had stent to the left anterior descending at an outside\nhospital in 1925-10-23. She then represented to Ware-Lynn Hospital on 1992-9-31, with her\nanginal equivalent (epigastric pain) and was found to have ST\nelevations on her electrocardiogram in leads V2-V5. She had\na complicated emergent catheterization. The catheterization\nplaced on Dopamine and intubated.\n\nOn catheterization, the patient had in stent restenosis of\nthe left anterior descending, and she received percutaneous\ntransluminal coronary angioplasty.', ' A lesion of the ramus\nintermedius was stented as well. Intra-aortic balloon pump\nwas initiated at that time.\n\nShe had a four-day stay in the CCU when she was able to be\ntaken off the balloon pump and ventilatory support. She did\nhave an episode of acute hypoxia after transfer to the floor\nthat improved with diuresis and nitrates. She was discharged\ntwo weeks to this current admission to a nursing home.\n\nOn presentation to the Emergency Department the patient had a\nheart rate of around 100, and systolic blood pressure in the\n80-90s. Hematocrit was down to 24.5. Hematocrit on\ndischarge from her prior hospitalization was 33; however, her\nbaseline hematocrit is in the mid 20s. She was transfused 1\nU of packed red blood cells in the Emergency Department. She\nhad no electrocardiogram changes on arrival to the Emergency\nDepartment.', '\n\nUpon arrival to the floor, she had acute decrease in oxygen\nsaturations to the low 80s with tachypnea and tachycardia to\nthe 150s. She was given intravenous Nitroglycerin drip,\nintravenous Lasix, and intravenous Lopressor 2.5 mg, as well\nas IV Morphine 2 mg. Her ABG showed a pH of 7.19, and a pCO2\nof 48, and a pO2 of 56. The patient was intubated and\ntransferred to the CCU. Her electrocardiogram showed sinus\ntachycardia with unchanged segment elevations in V2-V4\ncompared with baseline. Her chest x-ray was consistent with\nincreasing congestive heart failure compared with earlier in\nthe day.\n\nPAST MEDICAL HISTORY: 1. Coronary artery disease status\npost myocardial infarction in 1931-7-20. Catheterization in\n1925-10-23 with stent to the proximal to the left anterior\ndescending, and PTCA to the ramus and diagonal, 80% proximal\nright coronary artery lesion.', ' Catheterization in 1931-7-20\nshowed 100% proximal left anterior descending in stent\nstenosis, and PTCA was performed, as well as 100% OM1 lesion,\nas well as an 80% ramus lesion which was stented.\nCatheterization was complicated by hypotension and\nrespiratory distress as described in the HPI. 2. Systolic\ndysfunction a left ventricular ejection fraction of 20-25% by\nechocardiogram earlier this month showing mild symmetric left\nventricular hypertrophy as well. Echocardiogram also showed\nnear akinesis of the entire septum and anterior wall of the\nleft ventricle, as well as distal inferior and distal lateral\nwall akinesis. The apex was aneurysmal as well. 3.\nHypertension. 4. History of GI bleed. The patient had an\nadmission during 1931-7-20 for GI bleed. 5. Autoimmune\nhemolytic anemia followed by Hematology/Oncology at Ware-Lynn Hospital diagnosed in 1925-10-23.', '\n6. Diabetes mellitus thought to be steroid induced. 7.\nHypothyroidism.\n\nMEDICATIONS ON ADMISSION: Lasix 80 mg p.o. b.i.d., Captopril\n12.5 mg t.i.d., Ambien 5 mg q.h.s., Prevacid 30 mg b.i.d.,\nTimoptic 0.5% eye drops, Xalatan eyedrops, NPH Insulin 4 U\nb.i.d., sliding scale Insulin regular, Synthroid 0.25 mg\nq.d., Plavix 75 mg q.d., Lopressor 50 mg t.i.d., Aspirin 81\nmg q.d., Prednisone taper currently at 30 mg q.d.\n\nALLERGIES: NO KNOWN DRUG ALLERGIES.\n\nSOCIAL HISTORY: The patient resides at Mclaughlin Inc Medical Center Nursing Home.\nDenies tobacco. Occasional alcohol. She is a retired hair\ndresser.\n\nPHYSICAL EXAMINATION: Vital signs: On admission temperature\nwas 100.0??????, heart rate 100, blood pressure 118/51, oxygen\nsaturation 100% on 60% FIO2 on vent setting AC 12 x 550 FIO2\n60% .', '............. to 7.5. General: The patient was\nintubated, awake, responsive. The patient was in no acute\ndistress. Cardiovascular: Regular, rate and rhythm. No\nmurmurs. Audible over breath sounds. Respirations: Diffuse\nanterior crackles. Extremities: Trace bilateral lower\nextremity edema. Abdomen: Positive bowel sounds. Soft,\nnontender, nondistended. Guaiac negative in the Emergency\nDepartment. Neck: There was 9 cm JVP.\n\nLABORATORY DATA: White count 12.4, hematocrit 29.4 up from\n24.5 in the Emergency Department, platelet count 290; INR\n1.1, PTT 23.4; potassium 3.4, BUN 28, creatinine 1.4, glucose\n172, magnesium 1.7, albumin 3.1; CKs serially 41, 36, 39,\ntroponin 1.3 on the morning of admission.\n\nASSESSMENT: This was an 83-year-old woman with known\ncongestive heart failure and ischemic coronary disease\npresenting flash pulmonary edema in the setting of blood\ntransfusion.', '\n\nHOSPITAL COURSE: 1. Cardiovascular/ischemia: The patient\nunderwent repeat cardiac catheterization while intubated.\nThe catheterization showed instant restenosis of her left\nanterior descending stent at 40%; however, distal to the\nstent, there was an 80% focal lesion which was ballooned and\nstented. Her ramus stent were patent with associated ostial 40%\nlesion. Her known 80% right coronary artery lesion remained\nunchanged. Right heart catheterization showed a pulmonary wedge\npressure of 30, RA pressure of 12, PA pressure of 61/34, RV\npressure of 61/16. Cardiac output was 4.4 with an index of 2.9.\nMixed venous saturation in the Catheterization Lab was 57.6 from\nthe pulmonary artery.\n\nThe patient did well postcatheterization and was able to be\nextubated. She was placed on Aspirin and Plavix for life.', "\nBeta-blocker was re-added, and Lopressor was titrated up 50\nmg b.i.d. Ace inhibitor was also added. Her statin was\ncontinued as well. She remained chest-pain free and free of\nshortness of breath throughout the rest of her\nhospitalization.\n\n2. Cardiovascular/pump: The patient's ejection fraction was\nknown to be 20%. Heart catheterization confirmed her fluid\noverload and congestive heart failure physiology. She did\nnot respond to Lasix on initially arriving in the CCU;\nhowever after catheterization, she diuresed well to Lasix\nwith general improvement in her PA diastolics and improvement\nof her kidney function. She was able to be extubated without\ndifficulty after adequate diuresis was achieved.\n\nUpon arrival to the floor from the CCU, the CHF Service was\nconsulted. They recommended initiating Digoxin, low-dose\nnitrate, and standing p.", 'o. Lasix which was done. She was\ndischarged with plans to follow-up with the CHF Service for\ncontinued medical management of her congestive heart failure.\n\n3. Pulmonary: The patient was able to be initially\nextubated on the second hospital day; however, on the day\nafter initial extubation, her status remained tenuous with\nincreasing Nitroglycerin drip and p.r.n. Morphine required to\nreduce her preload enough to maintain oxygenation. On the\nnight after initial extubation, she required emergent\nreintubation due to acute hypoxia. Chest x-ray prior to\nintubation demonstrated white-out of the lower two-thirds of\nthe right lung; however, film 3-4 hours postintubation showed\nresolution of the opacity throughout the right lung\nconsistent with acute mucous plugging. It was therefore\nthought that that episode of hypoxia was not due to\ncongestive heart failure but to mucous plugging.', ' The patient\nwas reextubated without difficulty status post\ncatheterization and maintained satisfactory oxygenation\nthroughout the remainder of her hospital stay.\n\nShe was also started on Levofloxacin on admission due to\nsuspicion of right upper lobe infiltrate. Levofloxacin was\nswitched to Ceftriaxone and Azithromycin on the third\nhospital day. She remained afebrile throughout her hospital\ncourse but did however start to develop a cough toward the\nend of her hospital stay. She was continued on the\nCeftriaxone through the hospital stay with the plan for a\ntotal 14-day course along with her Azithromycin.\n\n4. Infectious disease: As above, the patient was treated\nfor suspicion of pneumonia. Of note, she had an isolated\npositive blood culture growing gram-positive cocci in pairs\nand clusters from 1953-9-23; however, she was afebrile\nthroughout the time surrounding this culture.', ' Repeat\ncultures were drawn on 1951-12-14, and were pending at\nthe time of this dictation.\n\n5. Heme: The patient has a history of autoimmune hemolytic\nanemia with a baseline hematocrit in the mid 20s. As noted\nin the HPI, she was transfused 1 U prior to her episode of\nflash pulmonary edema. Hematology Service was Idalia Yuen, and\nthey felt that it would be acceptable to transfuse the\npatient as needed. The patient was transfused with one\nadditional unit of blood during her hospital stay. Due to\nher steroids and autoimmune hemolytic anemia, she was\nrestarted on stress dose steroids as she had been on her\nprevious admission. These were quickly tapered to a\ndischarge dose of Prednisone 10 mg q.d. The patient had\nstable blood pressure and hematocrit on this dose.\n\n6. Fluids, electrolytes, and nutrition: The patient\ndeveloped hypernatremia toward the end of her hospital stay\nwith a peak sodium of 151.', ' It was thought that this was due\nto inadequate p.o. intake and free-water intake, and she was\nencouraged to maintain p.o. intake. A Nutrition consult was\nobtained as well. Follow-up labs of her sodium were pending\nat the time of this dictation.\n\nDISPOSITION: The patient was discharged to acute\nrehabilitation in stable condition.\n\nDISCHARGE MEDICATIONS: Enteric Coated Aspirin 325 mg p.o.\nq.d., Plavix 75 mg p.o. q.d., Timoptic 0.5% eye drops 1 drop\nper eye q.d., Xalatan 0.005% solution 1 drop to each eye\nq.d., Folate 1 mg p.o. q.d., NPH Insulin 4 U subcue b.i.d.,\nSynthroid 250 mcg p.o. q.d., Azithromycin 250 mg p.o. q.d.,\nProtonix 40 mg p.o. q.d., Prednisone 10 mg q.d., Ceftriaxone\n1 g IV q.24 hours to be discontinued on 6-4, Lopressor 50\nmg p.o. q.d., Onalopril b.i.d., Ambien 5 mg p.o.', ' q.h.s.\np.r.n., Lasix 20 mg p.o. q.d., Imdur 30 mg p.o. q.d., Digoxin\n0.125 mg p.o. q.d.\n\nDISCHARGE DIAGNOSIS:\n1. Coronary artery disease status post new stent to the left\nanterior descending.\n2. Congestive heart failure complicated by flash pulmonary\nedema requiring intubation.\n3. Pneumonia.\n4. Autoimmune hemolytic anemia.\n\n\n\n\n\n\n DR.Stephanie,Chowdhury 12-953\n\nDictated By:Odell Chau\nMEDQUIST36\n\nD: 1951-12-14 14:52\nT: 1951-12-14 15:19\nJOB#: Brown Ltd-2019-828671\n']
209	5239	125055.0	2189-03-27	Discharge summary	Report	Admission Date: [2189-3-17] Discharge Date: [2189-3-27] Service: CCU ADDENDUM: DISCHARGE MEDICATIONS: 1. Enalapril 15 po b.i.d. 2. Lasix 40 po q.d. 3. Digoxin .125 po q.d. 4. Imdur 30 po q.d. 5. Prednisone 10 po q.d. 6. Tylenol prn. 7. Prevacid 30 po q.d. 8. Synthroid 250 micrograms po q day. 9. Aspirin 325 mg po q.d. 10. Plavix 75 po q.d. for life. 11. Folate 1 mg po q.d. 12. Timoptic .5 solution one drop each eye q.d. 13. Zalatan .005% solution one drop each eye q.d. 14. Lopressor 50 mg po b.i.d. 15. Ambien 5 po q.h.s. prn. 16. NPH 4 units b.i.d. and then regular insulin sliding scale. 17. K-Dur 10 mg po q.d. DISCHARGE INSTRUCTIONS: The patient should have potassium followed in a couple of days and monitored closely and her potassium dose adjusted as needed. She should have daily weights and monitored for signs of congestive heart failure. The patient should follow up with Congestive Heart Failure Clinic with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2067] in one week. The phone number is [Medical Record Number 2068]. She should also follow up with her primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216] in one week as well. [Last Name (LF) 1870],[First Name3 (LF) ] 12.953 Dictated By:[Name8 (MD) 2069] MEDQUIST36 D: [2189-3-27] 13:26 T: [2189-3-27] 13:45 JOB#: [Job Number 2070] 1 1 1 R	Admission Date: <Date>1925-9-12</Date> Discharge Date: <Date>1989-12-26</Date> Service: CCU ADDENDUM: DISCHARGE MEDICATIONS: 1. Enalapril 15 po b.i.d. 2. Lasix 40 po q.d. 3. Digoxin .125 po q.d. 4. Imdur 30 po q.d. 5. Prednisone 10 po q.d. 6. Tylenol prn. 7. Prevacid 30 po q.d. 8. Synthroid 250 micrograms po q day. 9. Aspirin 325 mg po q.d. 10. Plavix 75 po q.d. for life. 11. Folate 1 mg po q.d. 12. Timoptic .5 solution one drop each eye q.d. 13. Zalatan .005% solution one drop each eye q.d. 14. Lopressor 50 mg po b.i.d. 15. Ambien 5 po q.h.s. prn. 16. NPH 4 units b.i.d. and then regular insulin sliding scale. 17. K-Dur 10 mg po q.d. DISCHARGE INSTRUCTIONS: The patient should have potassium followed in a couple of days and monitored closely and her potassium dose adjusted as needed. She should have daily weights and monitored for signs of congestive heart failure. The patient should follow up with Congestive Heart Failure Clinic with Dr. <Name>Everardo</Name> <Name>Ahmed</Name> in one week. The phone number is <Medical Record Number>54264533</Medical Record Number>. She should also follow up with her primary care physician <Name>Ivory</Name>. <Name>Todd</Name> <Name>Clark</Name> in one week as well. <Name>Londrie</Name>,<Name>Keisha</Name> 12.953 Dictated By:<Name>Araceli Feudner</Name> MEDQUIST36 D: <Date>1989-12-26</Date> 13:26 T: <Date>1989-12-26</Date> 13:45 JOB#: <Job Number>Myers-Sanchez-1975-406764</Job Number> 1 1 1 R	0000000000000000011111111100000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111101111100000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000111110011110111110000000000000000000000000000000000000000000000000000000011111110111111000000000000000000000111111111111111000000000000000001111111111000000000000111111111100000000000000011111111111111111111111110000000000	Admission Date: 1925-9-12 Discharge Date: 1989-12-26 Service: CCU ADDENDUM: DISCHARGE MEDICATIONS: 1. Enalapril 15 po b.i.d. 2. Lasix 40 po q.d. 3. Digoxin .125 po q.d. 4. Imdur 30 po q.d. 5. Prednisone 10 po q.d. 6. Tylenol prn. 7. Prevacid 30 po q.d. 8. Synthroid 250 micrograms po q day. 9. Aspirin 325 mg po q.d. 10. Plavix 75 po q.d. for life. 11. Folate 1 mg po q.d. 12. Timoptic .5 solution one drop each eye q.d. 13. Zalatan .005% solution one drop each eye q.d. 14. Lopressor 50 mg po b.i.d. 15. Ambien 5 po q.h.s. prn. 16. NPH 4 units b.i.d. and then regular insulin sliding scale. 17. K-Dur 10 mg po q.d. DISCHARGE INSTRUCTIONS: The patient should have potassium followed in a couple of days and monitored closely and her potassium dose adjusted as needed. She should have daily weights and monitored for signs of congestive heart failure. The patient should follow up with Congestive Heart Failure Clinic with Dr. Everardo Ahmed in one week. The phone number is 54264533. She should also follow up with her primary care physician Ivory. Todd Clark in one week as well. Londrie,Keisha 12.953 Dictated By:Araceli Feudner MEDQUIST36 D: 1989-12-26 13:26 T: 1989-12-26 13:45 JOB#: Myers-Sanchez-1975-406764 1 1 1 R	['Admission Date: 1925-9-12 Discharge Date: 1989-12-26\n\n\nService: CCU\n\nADDENDUM:\n\nDISCHARGE MEDICATIONS: 1. Enalapril 15 po b.i.d. 2. Lasix\n40 po q.d. 3. Digoxin .125 po q.d. 4. Imdur 30 po q.d.\n5. Prednisone 10 po q.d. 6. Tylenol prn. 7. Prevacid 30\npo q.d. 8. Synthroid 250 micrograms po q day. 9. Aspirin\n325 mg po q.d. 10. Plavix 75 po q.d. for life. 11. Folate\n1 mg po q.d. 12. Timoptic .5 solution one drop each eye\nq.d. 13. Zalatan .005% solution one drop each eye q.d. 14.\nLopressor 50 mg po b.i.d. 15. Ambien 5 po q.h.s. prn. 16.\nNPH 4 units b.i.d. and then regular insulin sliding scale.\n17. K-Dur 10 mg po q.d.\n\nDISCHARGE INSTRUCTIONS: The patient should have potassium\nfollowed in a couple of days and monitored closely and her\npotassium dose adjusted as needed.', ' She should have daily\nweights and monitored for signs of congestive heart failure.\nThe patient should follow up with Congestive Heart Failure\nClinic with Dr. Everardo Ahmed in one week. The phone number is\n54264533. She should also follow up with her primary care\nphysician Ivory. Todd Clark in one week as well.\n\n\n\n\n\n\n Londrie,Keisha 12.953\n\nDictated By:Araceli Feudner\nMEDQUIST36\n\nD: 1989-12-26 13:26\nT: 1989-12-26 13:45\nJOB#: Myers-Sanchez-1975-406764\n1\n1\n1\nR\n\n']
210	21449	139542.0	2146-07-04	Discharge summary	Report	Admission Date: [2146-7-1] Discharge Date: [2146-7-4] Date of Birth: [2088-9-20] Sex: M Service: [Hospital Unit Name 196] Allergies: Percocet / Shellfish Attending:[First Name3 (LF) 2071] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 57M h/o HTN, hypercholesterolemia, AAA, PVD, CAD who presented to OSH with SSCP, [8-28] radiating the left arm and back starting at 4am on the morning PTA. He also had diaphoresis, vomiting, SOB w/ wheezes. At OSH, he received NTG, ativan, fentanyl and morphine without sig relief. Was also give lasix, lopressor, and started on plavix, nitro gtt and heparin gtt. CTA was neg for PE. ECG showed ST depressions in V1-V3, inferior ST elevation. Past Medical History: 1. arthritis 2. intermittent claudication 3. HTN 4. hypercholesterolemia 5. barrett's esophagus 6. renal calculi 7. CAD 8. AAA 9.s/p abodominal hernia repair 10.cholecystectomy [52]. shoulder surgery [53]. remote seizure Social History: smokes 1 pack/day since age 16 occasional ETOH lives with wive and daughter Family History: HTN, No known early MI/CAD. Physical Exam: VS - T98.3, P83, R12, BP111/68, 97%RA Gen - drowsy but arousable HEENT - anicteric, no conjunctival pallor, no oral findings, no LAD, neck supple CV - RRR, nml S1/S2, no M/G/R. No JVD. Resp- CTAB. Snoring loudly. No incr WOB. GI - Pos BS, S/NT/ND. No HSM/Masses. Neuro - Sleepy but arousable. PERRL. EOMI. Withdraws all ext. Strength V/V. Ext - No C/C/E. Pertinent Results: [2146-7-1] 11:55PM GLUCOSE-97 UREA N-16 CREAT-1.0 SODIUM-142 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-30* ANION GAP-11 [2146-7-1] 11:55PM CK(CPK)-159 [2146-7-1] 11:55PM CK-MB-8 cTropnT-0.23* [2146-7-1] 11:55PM MAGNESIUM-2.0 [2146-7-1] 11:55PM WBC-8.0 RBC-4.58* HGB-14.6 HCT-39.9* MCV-87 MCH-31.9 MCHC-36.6* RDW-13.3 [2146-7-1] 11:55PM PLT COUNT-161 [2146-7-1] 11:55PM PT-13.2 PTT-27.9 INR(PT)-1.1 [2146-7-1] 03:41PM TYPE-ART PO2-159* PCO2-49* PH-7.42 TOTAL CO2-33* BASE XS-6 [2146-7-1] 03:05PM CK(CPK)-165 [2146-7-1] 03:05PM CK-MB-8 cTropnT-0.21* [2146-7-1] 03:05PM PLT COUNT-171 Brief Hospital Course: Mr. [Known lastname 2072] was admitted to [Hospital1 18] from an OSH for ACS. 1. CAD/ACS. OSH reported ECG with ST depressions in V2-V5/Elevation in III and negative CE??????s. Admitted with ACS and sent directly to cath. TNTs drawn post cath and positive, but trended down ([12-20] PCI?). CK??????s were flat. Thus, was unclear where to place pt on spectrum of UA --> STEMI. Card Cath revealed: R dom. 3VD. LMCA widely patent. LAD 50% at ostium. LCX 70% mid lesion (before OM1. RCA long 70% lesion (before bifurcation off the PDA and posterolateral branch). RCA Drug-Eluting Stent was placed and it was deemed the patient should be evaluated for CABG at a future date. Of note, after cath, the patient was extremely sleepy and had RR of 8. He was sent to the ICU for monitoring, but was lucid and stable within 8-10 hrs. His sleepiness was attributed to the large amount of sedatives, opioids that he received at the OSH and intracath. He was not given Narcan. He was stable and CP free for the remainder of his admission. Continuous telemetry monitoring revealed SR (50s-70s). Pt was continued on Atorvastatin 80 mg PO QD (incr from 40), Clopidogrel Bisulfate 75 mg PO QD, Lisinopril 20 mg PO QD (incr from 10mg), Aspirin EC 325 mg PO QD. Diltiazem was DCed. Outpatient ECHO was recommended to eval for any HK segments. 2. HTN. SBPs 90s-120s. Continued on meds as above plus Isosorbide Mononitrate (Extended Release) 30 mg PO QD. SBPs in 90s were likely related to opioid admin. 3. GERD. Continue Pantoprazole 40 mg PO Q24H. No symptoms now. 4. FEN. Cards healthy diet. 5. PPx. Colace/Senna. SubQ Hep. 6. Dispo. DCed to home after being cleared by PT. Medications on Admission: Transfer Meds: 1. Atenolol 50 [Hospital1 ] 2. Cardizem 300mg Daily 3. Zestril 10mg PO Daily 4. Clopidogrel Bisulfate 75 mg PO Daily 5. Isosorbide Mononitrate 30 mg SR PO Daily 6. Pantoprazole Sodium D.R. 40 mg PO Daily 7. Atorvastatin 40mg PO Daily 8. Aspirin 325mg PO Daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 3. 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 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 7. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Acute Coronary Syndrome Discharge Condition: Good Discharge Instructions: If you have any chest pain, shortness of breath, nausea, vomiting, or any other concerning symptoms call your cardiologist or return to the ER. Please speak to your cardiologist about an appropriate diet and exercise program as well as how remain smoking-free. Please take your new medication Plavix as instructed. Also, we have discontinued your Diltiazem/Cardizem and have increased the dose of your Lisinipril: please take as instructed and inform your primary care physician and cardiologist of these changes. Followup Instructions: Please see your cardiologist in the next week. He will arrange an echocardiogram to evaluate your heart function. Also, please speak with your cardiologist about the possibility of coronary bypass grafting surgery in the future. Please also see your primary care physician in the next 1-2 weeks. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 2073]	Admission Date: <Date>1947-7-7</Date> Discharge Date: <Date>1915-2-5</Date> Date of Birth: <Date>1950-5-25</Date> Sex: M Service: <Hospital>Fisher Inc Health System</Hospital> Allergies: Percocet / Shellfish Attending:<Name>Gildardo</Name> Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 57M h/o HTN, hypercholesterolemia, AAA, PVD, CAD who presented to OSH with SSCP, <Date>2-31</Date> radiating the left arm and back starting at 4am on the morning PTA. He also had diaphoresis, vomiting, SOB w/ wheezes. At OSH, he received NTG, ativan, fentanyl and morphine without sig relief. Was also give lasix, lopressor, and started on plavix, nitro gtt and heparin gtt. CTA was neg for PE. ECG showed ST depressions in V1-V3, inferior ST elevation. Past Medical History: 1. arthritis 2. intermittent claudication 3. HTN 4. hypercholesterolemia 5. barrett's esophagus 6. renal calculi 7. CAD 8. AAA 9.s/p abodominal hernia repair 10.cholecystectomy <Digit>44</Digit>. shoulder surgery <Digit>55</Digit>. remote seizure Social History: smokes 1 pack/day since age 16 occasional ETOH lives with wive and daughter Family History: HTN, No known early MI/CAD. Physical Exam: VS - T98.3, P83, R12, BP111/68, 97%RA Gen - drowsy but arousable HEENT - anicteric, no conjunctival pallor, no oral findings, no LAD, neck supple CV - RRR, nml S1/S2, no M/G/R. No JVD. Resp- CTAB. Snoring loudly. No incr WOB. GI - Pos BS, S/NT/ND. No HSM/Masses. Neuro - Sleepy but arousable. PERRL. EOMI. Withdraws all ext. Strength V/V. Ext - No C/C/E. Pertinent Results: <Date>1947-7-7</Date> 11:55PM GLUCOSE-97 UREA N-16 CREAT-1.0 SODIUM-142 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-30* ANION GAP-11 <Date>1947-7-7</Date> 11:55PM CK(CPK)-159 <Date>1947-7-7</Date> 11:55PM CK-MB-8 cTropnT-0.23* <Date>1947-7-7</Date> 11:55PM MAGNESIUM-2.0 <Date>1947-7-7</Date> 11:55PM WBC-8.0 RBC-4.58* HGB-14.6 HCT-39.9* MCV-87 MCH-31.9 MCHC-36.6* RDW-13.3 <Date>1947-7-7</Date> 11:55PM PLT COUNT-161 <Date>1947-7-7</Date> 11:55PM PT-13.2 PTT-27.9 INR(PT)-1.1 <Date>1947-7-7</Date> 03:41PM TYPE-ART PO2-159* PCO2-49* PH-7.42 TOTAL CO2-33* BASE XS-6 <Date>1947-7-7</Date> 03:05PM CK(CPK)-165 <Date>1947-7-7</Date> 03:05PM CK-MB-8 cTropnT-0.21* <Date>1947-7-7</Date> 03:05PM PLT COUNT-171 Brief Hospital Course: Mr. <Name>Amaro</Name> was admitted to <Hospital>Jacobson, Hanson and Bell Hospital</Hospital> from an OSH for ACS. 1. CAD/ACS. OSH reported ECG with ST depressions in V2-V5/Elevation in III and negative CE??????s. Admitted with ACS and sent directly to cath. TNTs drawn post cath and positive, but trended down (<Date>10-10</Date> PCI?). CK??????s were flat. Thus, was unclear where to place pt on spectrum of UA --> STEMI. Card Cath revealed: R dom. 3VD. LMCA widely patent. LAD 50% at ostium. LCX 70% mid lesion (before OM1. RCA long 70% lesion (before bifurcation off the PDA and posterolateral branch). RCA Drug-Eluting Stent was placed and it was deemed the patient should be evaluated for CABG at a future date. Of note, after cath, the patient was extremely sleepy and had RR of 8. He was sent to the ICU for monitoring, but was lucid and stable within 8-10 hrs. His sleepiness was attributed to the large amount of sedatives, opioids that he received at the OSH and intracath. He was not given Narcan. He was stable and CP free for the remainder of his admission. Continuous telemetry monitoring revealed SR (50s-70s). Pt was continued on Atorvastatin 80 mg PO QD (incr from 40), Clopidogrel Bisulfate 75 mg PO QD, Lisinopril 20 mg PO QD (incr from 10mg), Aspirin EC 325 mg PO QD. Diltiazem was DCed. Outpatient ECHO was recommended to eval for any HK segments. 2. HTN. SBPs 90s-120s. Continued on meds as above plus Isosorbide Mononitrate (Extended Release) 30 mg PO QD. SBPs in 90s were likely related to opioid admin. 3. GERD. Continue Pantoprazole 40 mg PO Q24H. No symptoms now. 4. FEN. Cards healthy diet. 5. PPx. Colace/Senna. SubQ Hep. 6. Dispo. DCed to home after being cleared by PT. Medications on Admission: Transfer Meds: 1. Atenolol 50 <Hospital>Gay-Taylor Hospital</Hospital> 2. Cardizem 300mg Daily 3. Zestril 10mg PO Daily 4. Clopidogrel Bisulfate 75 mg PO Daily 5. Isosorbide Mononitrate 30 mg SR PO Daily 6. Pantoprazole Sodium D.R. 40 mg PO Daily 7. Atorvastatin 40mg PO Daily 8. Aspirin 325mg PO Daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 3. 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 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 7. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Acute Coronary Syndrome Discharge Condition: Good Discharge Instructions: If you have any chest pain, shortness of breath, nausea, vomiting, or any other concerning symptoms call your cardiologist or return to the ER. Please speak to your cardiologist about an appropriate diet and exercise program as well as how remain smoking-free. Please take your new medication Plavix as instructed. Also, we have discontinued your Diltiazem/Cardizem and have increased the dose of your Lisinipril: please take as instructed and inform your primary care physician and cardiologist of these changes. Followup Instructions: Please see your cardiologist in the next week. He will arrange an echocardiogram to evaluate your heart function. Also, please speak with your cardiologist about the possibility of coronary bypass grafting surgery in the future. Please also see your primary care physician in the next 1-2 weeks. <Name>Jordan Moblo</Name> <Name>Haydee Blanchar</Name> MD, <MD Number>03584522</MD 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Date: 1947-7-7 Discharge Date: 1915-2-5 Date of Birth: 1950-5-25 Sex: M Service: Fisher Inc Health System Allergies: Percocet / Shellfish Attending:Gildardo Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 57M h/o HTN, hypercholesterolemia, AAA, PVD, CAD who presented to OSH with SSCP, 2-31 radiating the left arm and back starting at 4am on the morning PTA. He also had diaphoresis, vomiting, SOB w/ wheezes. At OSH, he received NTG, ativan, fentanyl and morphine without sig relief. Was also give lasix, lopressor, and started on plavix, nitro gtt and heparin gtt. CTA was neg for PE. ECG showed ST depressions in V1-V3, inferior ST elevation. Past Medical History: 1. arthritis 2. intermittent claudication 3. HTN 4. hypercholesterolemia 5. barrett's esophagus 6. renal calculi 7. CAD 8. AAA 9.s/p abodominal hernia repair 10.cholecystectomy 44. shoulder surgery 55. remote seizure Social History: smokes 1 pack/day since age 16 occasional ETOH lives with wive and daughter Family History: HTN, No known early MI/CAD. Physical Exam: VS - T98.3, P83, R12, BP111/68, 97%RA Gen - drowsy but arousable HEENT - anicteric, no conjunctival pallor, no oral findings, no LAD, neck supple CV - RRR, nml S1/S2, no M/G/R. No JVD. Resp- CTAB. Snoring loudly. No incr WOB. GI - Pos BS, S/NT/ND. No HSM/Masses. Neuro - Sleepy but arousable. PERRL. EOMI. Withdraws all ext. Strength V/V. Ext - No C/C/E. Pertinent Results: 1947-7-7 11:55PM GLUCOSE-97 UREA N-16 CREAT-1.0 SODIUM-142 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-30* ANION GAP-11 1947-7-7 11:55PM CK(CPK)-159 1947-7-7 11:55PM CK-MB-8 cTropnT-0.23* 1947-7-7 11:55PM MAGNESIUM-2.0 1947-7-7 11:55PM WBC-8.0 RBC-4.58* HGB-14.6 HCT-39.9* MCV-87 MCH-31.9 MCHC-36.6* RDW-13.3 1947-7-7 11:55PM PLT COUNT-161 1947-7-7 11:55PM PT-13.2 PTT-27.9 INR(PT)-1.1 1947-7-7 03:41PM TYPE-ART PO2-159* PCO2-49* PH-7.42 TOTAL CO2-33* BASE XS-6 1947-7-7 03:05PM CK(CPK)-165 1947-7-7 03:05PM CK-MB-8 cTropnT-0.21* 1947-7-7 03:05PM PLT COUNT-171 Brief Hospital Course: Mr. Amaro was admitted to Jacobson, Hanson and Bell Hospital from an OSH for ACS. 1. CAD/ACS. OSH reported ECG with ST depressions in V2-V5/Elevation in III and negative CE??????s. Admitted with ACS and sent directly to cath. TNTs drawn post cath and positive, but trended down (10-10 PCI?). CK??????s were flat. Thus, was unclear where to place pt on spectrum of UA --> STEMI. Card Cath revealed: R dom. 3VD. LMCA widely patent. LAD 50% at ostium. LCX 70% mid lesion (before OM1. RCA long 70% lesion (before bifurcation off the PDA and posterolateral branch). RCA Drug-Eluting Stent was placed and it was deemed the patient should be evaluated for CABG at a future date. Of note, after cath, the patient was extremely sleepy and had RR of 8. He was sent to the ICU for monitoring, but was lucid and stable within 8-10 hrs. His sleepiness was attributed to the large amount of sedatives, opioids that he received at the OSH and intracath. He was not given Narcan. He was stable and CP free for the remainder of his admission. Continuous telemetry monitoring revealed SR (50s-70s). Pt was continued on Atorvastatin 80 mg PO QD (incr from 40), Clopidogrel Bisulfate 75 mg PO QD, Lisinopril 20 mg PO QD (incr from 10mg), Aspirin EC 325 mg PO QD. Diltiazem was DCed. Outpatient ECHO was recommended to eval for any HK segments. 2. HTN. SBPs 90s-120s. Continued on meds as above plus Isosorbide Mononitrate (Extended Release) 30 mg PO QD. SBPs in 90s were likely related to opioid admin. 3. GERD. Continue Pantoprazole 40 mg PO Q24H. No symptoms now. 4. FEN. Cards healthy diet. 5. PPx. Colace/Senna. SubQ Hep. 6. Dispo. DCed to home after being cleared by PT. Medications on Admission: Transfer Meds: 1. Atenolol 50 Gay-Taylor Hospital 2. Cardizem 300mg Daily 3. Zestril 10mg PO Daily 4. Clopidogrel Bisulfate 75 mg PO Daily 5. Isosorbide Mononitrate 30 mg SR PO Daily 6. Pantoprazole Sodium D.R. 40 mg PO Daily 7. Atorvastatin 40mg PO Daily 8. Aspirin 325mg PO Daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 3. 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 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 7. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Acute Coronary Syndrome Discharge Condition: Good Discharge Instructions: If you have any chest pain, shortness of breath, nausea, vomiting, or any other concerning symptoms call your cardiologist or return to the ER. Please speak to your cardiologist about an appropriate diet and exercise program as well as how remain smoking-free. Please take your new medication Plavix as instructed. Also, we have discontinued your Diltiazem/Cardizem and have increased the dose of your Lisinipril: please take as instructed and inform your primary care physician and cardiologist of these changes. Followup Instructions: Please see your cardiologist in the next week. He will arrange an echocardiogram to evaluate your heart function. Also, please speak with your cardiologist about the possibility of coronary bypass grafting surgery in the future. Please also see your primary care physician in the next 1-2 weeks. Jordan Moblo Haydee Blanchar MD, 03584522	['Admission Date: 1947-7-7 Discharge Date: 1915-2-5\n\nDate of Birth: 1950-5-25 Sex: M\n\nService: Fisher Inc Health System\n\nAllergies:\nPercocet / Shellfish\n\nAttending:Gildardo\nChief Complaint:\nChest Pain\n\nMajor Surgical or Invasive Procedure:\nCardiac Catheterization\n\nHistory of Present Illness:\n57M h/o HTN, hypercholesterolemia, AAA, PVD, CAD who presented\nto OSH with SSCP, 2-31 radiating the left arm and back starting\nat 4am on the morning PTA. He also had diaphoresis, vomiting,\nSOB w/ wheezes. At OSH, he received NTG, ativan, fentanyl and\nmorphine without sig relief. Was also give lasix, lopressor, and\nstarted on plavix, nitro gtt and heparin gtt. CTA was neg for\nPE. ECG showed ST depressions in V1-V3, inferior ST elevation.\n\nPast Medical History:\n1. arthritis\n2.', " intermittent claudication\n3. HTN\n4. hypercholesterolemia\n5. barrett's esophagus\n6. renal calculi\n7. CAD\n8. AAA\n9.s/p abodominal hernia repair\n10.cholecystectomy\n44. shoulder surgery\n55. remote seizure\n\nSocial History:\nsmokes 1 pack/day since age 16\noccasional ETOH\nlives with wive and daughter\n\nFamily History:\nHTN, No known early MI/CAD.\n\nPhysical Exam:\nVS - T98.3, P83, R12, BP111/68, 97%RA\nGen - drowsy but arousable\nHEENT - anicteric, no conjunctival pallor, no oral findings, no\nLAD, neck supple\nCV - RRR, nml S1/S2, no M/G/R. No JVD.\nResp- CTAB. Snoring loudly. No incr WOB.\nGI - Pos BS, S/NT/ND. No HSM/Masses.\nNeuro - Sleepy but arousable. PERRL. EOMI. Withdraws all ext.\nStrength V/V.\nExt - No C/C/E.\n\nPertinent Results:\n1947-7-7 11:55PM GLUCOSE-97 UREA N-16 CREAT-1.0 SODIUM-142\nPOTASSIUM-4.", '1 CHLORIDE-105 TOTAL CO2-30* ANION GAP-11\n1947-7-7 11:55PM CK(CPK)-159\n1947-7-7 11:55PM CK-MB-8 cTropnT-0.23\n1947-7-7 11:55PM MAGNESIUM-2.0\n1947-7-7 11:55PM WBC-8.0 RBC-4.58 HGB-14.6 HCT-39.9* MCV-87\nMCH-31.9 MCHC-36.6* RDW-13.3\n1947-7-7 11:55PM PLT COUNT-161\n1947-7-7 11:55PM PT-13.2 PTT-27.9 INR(PT)-1.1\n1947-7-7 03:41PM TYPE-ART PO2-159* PCO2-49* PH-7.42 TOTAL\nCO2-33* BASE XS-6\n1947-7-7 03:05PM CK(CPK)-165\n1947-7-7 03:05PM CK-MB-8 cTropnT-0.21\n1947-7-7 03:05PM PLT COUNT-171\n\nBrief Hospital Course:\nMr. Amaro was admitted to Jacobson, Hanson and Bell Hospital from an OSH for ACS.\n\n1. CAD/ACS. OSH reported ECG with ST depressions in\nV2-V5/Elevation in III and negative CE??????s. Admitted with ACS and\nsent directly to cath. TNTs drawn post cath and positive, but\ntrended down (10-10 PCI?).', ' CK??????s were flat. Thus, was unclear where\nto place pt on spectrum of UA --> STEMI. Card Cath revealed: R\ndom. 3VD. LMCA widely patent. LAD 50% at ostium. LCX 70% mid\nlesion (before OM1. RCA long 70% lesion (before bifurcation off\nthe PDA and posterolateral branch). RCA Drug-Eluting Stent was\nplaced and it was deemed the patient should be evaluated for\nCABG at a future date. Of note, after cath, the patient was\nextremely sleepy and had RR of 8. He was sent to the ICU for\nmonitoring, but was lucid and stable within 8-10 hrs. His\nsleepiness was attributed to the large amount of sedatives,\nopioids that he received at the OSH and intracath. He was not\ngiven Narcan. He was stable and CP free for the remainder of his\nadmission. Continuous telemetry monitoring revealed SR\n(50s-70s). Pt was continued on Atorvastatin 80 mg PO QD (incr\nfrom 40), Clopidogrel Bisulfate 75 mg PO QD, Lisinopril 20 mg PO\nQD (incr from 10mg), Aspirin EC 325 mg PO QD.', ' Diltiazem was\nDCed. Outpatient ECHO was recommended to eval for any HK\nsegments.\n\n2. HTN. SBPs 90s-120s. Continued on meds as above plus\nIsosorbide Mononitrate (Extended Release) 30 mg PO QD. SBPs in\n90s were likely related to opioid admin.\n\n3. GERD. Continue Pantoprazole 40 mg PO Q24H. No symptoms now.\n\n4. FEN. Cards healthy diet.\n\n5. PPx. Colace/Senna. SubQ Hep.\n\n6. Dispo. DCed to home after being cleared by PT.\n\nMedications on Admission:\nTransfer Meds:\n1. Atenolol 50 Gay-Taylor Hospital\n2. Cardizem 300mg Daily\n3. Zestril 10mg PO Daily\n4. Clopidogrel Bisulfate 75 mg PO Daily\n5. Isosorbide Mononitrate 30 mg SR PO Daily\n6. Pantoprazole Sodium D.R. 40 mg PO Daily\n7. Atorvastatin 40mg PO Daily\n8. Aspirin 325mg PO Daily\n\nDischarge Medications:\n1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.', 'C.) PO QD (once a day).\nDisp:30 Tablet, Delayed Release (E.C.)(s)* Refills:2\n2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD\n(once a day).\nDisp:30 Tablet(s) Refills:2\n3. 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\n4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR\nSig: One (1) Tablet Sustained Release 24HR PO QD (once a day).\nDisp:30 Tablet Sustained Release 24HR(s) Refills:2\n5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\nDisp:60 Tablet(s) Refills:2\n6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a\nday).\nDisp:30 Tablet(s) Refills:2\n7. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD\n(once a day).', '\nDisp:60 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nAcute Coronary Syndrome\n\n\nDischarge Condition:\nGood\n\nDischarge Instructions:\nIf you have any chest pain, shortness of breath, nausea,\nvomiting, or any other concerning symptoms call your\ncardiologist or return to the ER. Please speak to your\ncardiologist about an appropriate diet and exercise program as\nwell as how remain smoking-free. Please take your new medication\nPlavix as instructed. Also, we have discontinued your\nDiltiazem/Cardizem and have increased the dose of your\nLisinipril: please take as instructed and inform your primary\ncare physician and cardiologist of these changes.\n\nFollowup Instructions:\nPlease see your cardiologist in the next week. He will arrange\nan echocardiogram to evaluate your heart function.', ' Also, please\nspeak with your cardiologist about the possibility of coronary\nbypass grafting surgery in the future. Please also see your\nprimary care physician in the next 1-2 weeks.\n\n\n Jordan Moblo Haydee Blanchar MD, 03584522\n\n']
211	40273	124821.0	2159-04-10	Discharge summary	Report	Admission Date: [2159-4-6] Discharge Date: [2159-4-10] Date of Birth: [2120-1-29] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 2080] Chief Complaint: Blurry vision Major Surgical or Invasive Procedure: None History of Present Illness: This is a 39 year old male with a history of hypertension (on beta blockade, lasix, hydralazine, imdur, metolazone) complicated by chronic kidney disease (stage IV), EF of 25-30%, obesity, and tobacco abuse. He presented today to the emergency room after [Hospital 2081] clinic noted severe bilateral papilledema; opthomology suggested this was secondary to either elevated intracranial pressure in the setting of malignant hypertension or pseudotumor cerebri. He has been symptomatic with blurry vision over the past month in the absence of headaches or other central symptoms. He has noted some gait instability. In the ED, his blood pressure was noted to be 180/118. He took his usual dose of one of his blood pressure meds (unknown) and his BP improved to 160 systolic. He was transferred to the MICU for management of hypertensive emergency. Past Medical History: Hypertension, hypertensive chronic kidney disease stage IV, systolic heart failure, last ejection fraction from [Hospital 2082] between 25 and 30%, obesity, and tobacco abuse. Social History: The patient continues to smoke cigarettes about ten per day. He has cut down recently on the amount that he smokes, but still is precontemplative about quitting at this time. Family History: No history of hypertension, heart disease, or cancer. Physical Exam: ADMISSION EXAM: VS: HR 80 BP 170/100 RR 18 96% on RA Gen: Obese. NAD. HEENT: Dilated fundoscopic exam revealed bilateral papilledema without evidence of flame hemorrhages or distinct cotton whool spots. Mucous accumulation in canthal folds. Mild proptosis apprecaited. Otherwise MMM without any cervical LAD apprecatied. PERRLA. CV: Faint heart sounds. [1-5] pansystolic murmur best apprecaited in mitral region. No carotid bruits apprecaited. No rubs or gallops. Lungs: CTABL throughout all lung fields. Abd: Obese. Nontender throughout. NBS. No appreciable organomegaly. Ext: 1+ DPP with no appreciable edema. NeurO: AOX3. NO focal neurologic deficits appeciated on focused cranial nerve exam or on brief gross motor exam. DISCHARGE EXAM: VS: 98.0 BP 129-155/96-117 HR 75-96 RR 20 Satting 100% on RA. GENERAL - well-appearing morbidly obese man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD seen, no carotid bruits LUNGS - CTA bilat HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [5-5] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: ADMISSION LABS: [2159-4-6] 03:50PM BLOOD WBC-7.3 RBC-4.07* Hgb-12.5* Hct-37.0* MCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt Ct-219 [2159-4-6] 03:50PM BLOOD Neuts-61.7 Lymphs-29.3 Monos-5.3 Eos-2.8 Baso-0.9 [2159-4-6] 03:50PM BLOOD PT-11.5 PTT-27.2 INR(PT)-1.1 [2159-4-6] 03:50PM BLOOD Glucose-84 UreaN-41* Creat-3.8* Na-142 K-3.4 Cl-100 HCO3-27 AnGap-18 [2159-4-6] 03:50PM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8 dischcarge labs: [2159-4-10] 06:20AM BLOOD WBC-8.6 RBC-4.24* Hgb-13.4* Hct-38.8* MCV-91 MCH-31.7 MCHC-34.6 RDW-13.3 Plt Ct-195 [2159-4-10] 06:20AM BLOOD Glucose-93 UreaN-53* Creat-4.1* Na-138 K-2.9* Cl-94* HCO3-26 AnGap-21* [2159-4-10] 06:20AM BLOOD Calcium-9.5 Phos-5.9# Mg-2.0 [2159-4-10] 06:20AM BLOOD ALDOSTERONE-PND [2159-4-10] 06:20AM BLOOD RENIN-PND OTHER LABS: [2159-4-7] 01:46AM BLOOD ALT-14 AST-20 AlkPhos-42 TotBili-0.4 [2159-4-7] 01:46AM BLOOD TSH-1.1 IMAGING: CT Head w/o contrast [2159-4-6]: 1. No acute intracranial pathology. 2. Bilateral proptosis. renal u/s [2159-4-9]: Both kidneys show increased echogenicity consistent with chronic kidney disease. Two simple cysts in the right kidney, one at the upper pole and one at the lower pole. Doppler evaluation of both renal arteries and of the arcuate/segmental vessels in the renal parenchyma was within normal limits. No ultrasound/Doppler evidence for renal artery stenosis. tte [2159-4-10]: The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: #Hypertensive Emergency: Pt presented with HTN systolics >200 and blurry vision, found to have papilledema. The patient's blood pressure was markedly elevated with systolic blood pressures ranging from 160-210 during ICU stay. Review of prior notes outlines a longstanding history of poorly controlled blood pressures. His home isosorbide and carvedilol were discontinued. Labetalol was uptitrated to 200mg TID, Hydral downtitrated to 50mg TID, clonidine 0.3mg weekly patch started, and furosemide/metolazone continued as is. MAP >120 was goal. On leaving the ICU SPB was in 130s. TSH was within normal limits. It was felt that this patient needed a full workup for secondary causes of hypertension. In the meantime renal artery ultrasound done here showed no renal artery stenosis but did show chornic bilateral changes consistent with CKDD. He should likely have a workup for hyperaldosteronism (see hypokalemia below) and workup including urine metanephrines and dexamethasone suppression test, as he is quite young for this degree of hypertension and seems to be compliant with his medications. He was initially started on spironolactone given report of EF 25-30% and thought that it may help with hypokalemia, however after 3 days (3 doses) this was discontinued so that pt could ideally have a renin/aldosterone level drawn prior to discharge (which is now pending), several days after discontinuation. Would recommend restarting this medication after the appropriate studies have been done. It is more than likely this patient has sleep apnea as well; in the ICU he was noted to have desats during sleep with very loud snoring. Desats resolved instantly on waking. Pt is also smoking and quite obese both of which are likely worsening his hypertension. Would recommend outpatient sleep study as well. . #hypokalemia - pt was noted to be hypokalemic with potassium 2.9-3.2. Concern for hyperaldosterone state given concommittant resistant hypertension. Pt required >160meq potassium repletion per day while in the [Hospital Unit Name 153] and still remained with K below 4.0. Outpatient records demonstrate history of low potassium. Pt also had been started on spironolactone, and while it was low dose, it did not appear to help with potassium retention. This was also unusual in the setting of elevated creatinine/chronic renal failure, which emphasized concerns for hyperaldosterone state. Spironolactone was DCd temporarily so that he could have renin/[Male First Name (un) 2083] levels drawn. #Intracranial hypertension: Likely secondary to systmemic hypertension. Neurology evalauted patient in ED and suggested potential LP if BP controlled to assess for pseudotumor cerebrii, though this can be deferred to outpatient setting if papilledema does not improve with improved BP control. . #Chronic kidney disease: The patient's creatinine was elevated at 3.6-3.7, which is baseline. CKD likely secondary to hypertensive nephropathy. Continued sevalamer and nephrocaps. . #Chronic systolic CHF: No echo in the system, but OSH records per Dr.[Name (NI) 2084] note states TTE showed increased wall thickness, estimated LVEF 25-30% and global hypokinesis without focal wall motion abnormality, as well as increased [Name Prefix (Prefixes) ] [Last Name (Prefixes) 1934], with estimated PA systolic pressure 32mm. The patient appeared euvolemic on exam, without evidence of an acute sCHF exacerbation. His blood pressure control was adjusted as above, including the addition of spironolactone to his regimen. Despite his renal impairment, he may benefit from the addition of an ACEi/[Last Name (un) ] and should discuss this with his PCP, [Name10 (NameIs) 2085], and nephrologist. He was continued on a beta blocker (though switched from metoprolol/carvedilol to labetalol), lasix, and metolazone. His EF on the TTE here showed an EF of 55%. TRANSITIONAL ISSUES: -Has PCP, [Name10 (NameIs) 2086], and nephrology follow-up scheduled -Needs outpatient sleep study -Would benefit from work-up for secondary hypertension if not already done at another facility - follow up renin/[Male First Name (un) 2083] ratio, may draw urine metaneprhines, dex suppression testing -Patient was a Full Code during this admission -Would benefit from nutrition consult - Has Cr and K ordered as outpt on Thursday which needs f/up Medications on Admission: B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by Other Provider) - Dosage uncertain CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day FUROSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth twice a day HYDRALAZINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a day ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth Qday METOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth Qday METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice a day POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1 Tablet(s) by mouth Once a day SEVELAMER HCL - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s)* Refills:0 3. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 6. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patches Transdermal QSAT (every Saturday). Disp:4 Patch Weekly(s) Refills:2 7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day. Disp:30 Tablet, ER Particles/Crystals(s) Refills:0 9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive emergency Secondary Diagnoses: Chronic kidney disease Chronic systolic heart failure Tobacco abuse Obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 2087], You were admitted to the intensive care unit at [Hospital1 771] with very high blood pressures and blurry vision. Your blurry vision was likely caused by your high blood pressure. When your blood pressure is this high, you are at risk for serious complications including further kidney damage and possible stroke. We monitored you closely and changed some of your blood pressure medications to help better control your blood pressures. We made the following changes to your medications: STOPPED: -Carvedilol -Metoprolol -Isosorbide mononitrate DECREASED: -Hydralazine from 100 mg three times a day to 50 mg three times a day INCREASED: -Potassium chloride 20 meq chrystals increased from one dose once a day to two doses once a day STARTED: -Clonidine patch 0.3 mg once a week -Labetalol 400 mg three times a day -Lisinopril 2.5mg once a day We did not make any other changes to your medications. Please continue to take them as you have been doing. It is very important that you take your blood pressure medications and monitor your blood pressure. If your blood pressure is persistently higher than 190/110, you should contact your doctor. Also, if you develop any worsening blurry vision, headache, chest pain, shortness of breath, slurred speech, or weakness on one side of the face or body, you should seek medical attention immediately. We are concerned you may have a condition called obstructive sleep apnea, and we recommend you have a sleep study after you leave the hospital. We also recommend that you see a nutritionist and work on continuing to lose weight. Please eat a low salt diet. We also strongly encourage you to stop smoking. Please also note that you will need to get your creatinine and potassium checked on Thursday, [2159-4-12]. Followup Instructions: Department: [Hospital3 249] When: THURSDAY [2159-4-12] at 2:15 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 2010] 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 [2159-4-23] at 9:40 AM With: [Doctor First Name 900] [Name8 (MD) 901], 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: WEST [Hospital 2002] CLINIC When: WEDNESDAY [2159-5-30] at 2:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2088], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	Admission Date: <Date>1935-12-10</Date> Discharge Date: <Date>1986-11-9</Date> Date of Birth: <Date>1987-5-27</Date> Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Danilo</Name> Chief Complaint: Blurry vision Major Surgical or Invasive Procedure: None History of Present Illness: This is a 39 year old male with a history of hypertension (on beta blockade, lasix, hydralazine, imdur, metolazone) complicated by chronic kidney disease (stage IV), EF of 25-30%, obesity, and tobacco abuse. He presented today to the emergency room after <Hospital>Leblanc LLC Health System</Hospital> clinic noted severe bilateral papilledema; opthomology suggested this was secondary to either elevated intracranial pressure in the setting of malignant hypertension or pseudotumor cerebri. He has been symptomatic with blurry vision over the past month in the absence of headaches or other central symptoms. He has noted some gait instability. In the ED, his blood pressure was noted to be 180/118. He took his usual dose of one of his blood pressure meds (unknown) and his BP improved to 160 systolic. He was transferred to the MICU for management of hypertensive emergency. Past Medical History: Hypertension, hypertensive chronic kidney disease stage IV, systolic heart failure, last ejection fraction from <Hospital>Smith, Roth and Phillips Hospital</Hospital> between 25 and 30%, obesity, and tobacco abuse. Social History: The patient continues to smoke cigarettes about ten per day. He has cut down recently on the amount that he smokes, but still is precontemplative about quitting at this time. Family History: No history of hypertension, heart disease, or cancer. Physical Exam: ADMISSION EXAM: VS: HR 80 BP 170/100 RR 18 96% on RA Gen: Obese. NAD. HEENT: Dilated fundoscopic exam revealed bilateral papilledema without evidence of flame hemorrhages or distinct cotton whool spots. Mucous accumulation in canthal folds. Mild proptosis apprecaited. Otherwise MMM without any cervical LAD apprecatied. PERRLA. CV: Faint heart sounds. <Date>11-23</Date> pansystolic murmur best apprecaited in mitral region. No carotid bruits apprecaited. No rubs or gallops. Lungs: CTABL throughout all lung fields. Abd: Obese. Nontender throughout. NBS. No appreciable organomegaly. Ext: 1+ DPP with no appreciable edema. NeurO: AOX3. NO focal neurologic deficits appeciated on focused cranial nerve exam or on brief gross motor exam. DISCHARGE EXAM: VS: 98.0 BP 129-155/96-117 HR 75-96 RR 20 Satting 100% on RA. GENERAL - well-appearing morbidly obese man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD seen, no carotid bruits LUNGS - CTA bilat HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength <Date>12-31</Date> throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: ADMISSION LABS: <Date>1935-12-10</Date> 03:50PM BLOOD WBC-7.3 RBC-4.07* Hgb-12.5* Hct-37.0* MCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt Ct-219 <Date>1935-12-10</Date> 03:50PM BLOOD Neuts-61.7 Lymphs-29.3 Monos-5.3 Eos-2.8 Baso-0.9 <Date>1935-12-10</Date> 03:50PM BLOOD PT-11.5 PTT-27.2 INR(PT)-1.1 <Date>1935-12-10</Date> 03:50PM BLOOD Glucose-84 UreaN-41* Creat-3.8* Na-142 K-3.4 Cl-100 HCO3-27 AnGap-18 <Date>1935-12-10</Date> 03:50PM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8 dischcarge labs: <Date>1986-11-9</Date> 06:20AM BLOOD WBC-8.6 RBC-4.24* Hgb-13.4* Hct-38.8* MCV-91 MCH-31.7 MCHC-34.6 RDW-13.3 Plt Ct-195 <Date>1986-11-9</Date> 06:20AM BLOOD Glucose-93 UreaN-53* Creat-4.1* Na-138 K-2.9* Cl-94* HCO3-26 AnGap-21* <Date>1986-11-9</Date> 06:20AM BLOOD Calcium-9.5 Phos-5.9# Mg-2.0 <Date>1986-11-9</Date> 06:20AM BLOOD ALDOSTERONE-PND <Date>1986-11-9</Date> 06:20AM BLOOD RENIN-PND OTHER LABS: <Date>1984-9-18</Date> 01:46AM BLOOD ALT-14 AST-20 AlkPhos-42 TotBili-0.4 <Date>1984-9-18</Date> 01:46AM BLOOD TSH-1.1 IMAGING: CT Head w/o contrast <Date>1935-12-10</Date>: 1. No acute intracranial pathology. 2. Bilateral proptosis. renal u/s <Date>1985-6-6</Date>: Both kidneys show increased echogenicity consistent with chronic kidney disease. Two simple cysts in the right kidney, one at the upper pole and one at the lower pole. Doppler evaluation of both renal arteries and of the arcuate/segmental vessels in the renal parenchyma was within normal limits. No ultrasound/Doppler evidence for renal artery stenosis. tte <Date>1986-11-9</Date>: The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: #Hypertensive Emergency: Pt presented with HTN systolics >200 and blurry vision, found to have papilledema. The patient's blood pressure was markedly elevated with systolic blood pressures ranging from 160-210 during ICU stay. Review of prior notes outlines a longstanding history of poorly controlled blood pressures. His home isosorbide and carvedilol were discontinued. Labetalol was uptitrated to 200mg TID, Hydral downtitrated to 50mg TID, clonidine 0.3mg weekly patch started, and furosemide/metolazone continued as is. MAP >120 was goal. On leaving the ICU SPB was in 130s. TSH was within normal limits. It was felt that this patient needed a full workup for secondary causes of hypertension. In the meantime renal artery ultrasound done here showed no renal artery stenosis but did show chornic bilateral changes consistent with CKDD. He should likely have a workup for hyperaldosteronism (see hypokalemia below) and workup including urine metanephrines and dexamethasone suppression test, as he is quite young for this degree of hypertension and seems to be compliant with his medications. He was initially started on spironolactone given report of EF 25-30% and thought that it may help with hypokalemia, however after 3 days (3 doses) this was discontinued so that pt could ideally have a renin/aldosterone level drawn prior to discharge (which is now pending), several days after discontinuation. Would recommend restarting this medication after the appropriate studies have been done. It is more than likely this patient has sleep apnea as well; in the ICU he was noted to have desats during sleep with very loud snoring. Desats resolved instantly on waking. Pt is also smoking and quite obese both of which are likely worsening his hypertension. Would recommend outpatient sleep study as well. . #hypokalemia - pt was noted to be hypokalemic with potassium 2.9-3.2. Concern for hyperaldosterone state given concommittant resistant hypertension. Pt required >160meq potassium repletion per day while in the <Hospital>Gibson LLC Medical Center</Hospital> and still remained with K below 4.0. Outpatient records demonstrate history of low potassium. Pt also had been started on spironolactone, and while it was low dose, it did not appear to help with potassium retention. This was also unusual in the setting of elevated creatinine/chronic renal failure, which emphasized concerns for hyperaldosterone state. Spironolactone was DCd temporarily so that he could have renin/<Name>Scott</Name> levels drawn. #Intracranial hypertension: Likely secondary to systmemic hypertension. Neurology evalauted patient in ED and suggested potential LP if BP controlled to assess for pseudotumor cerebrii, though this can be deferred to outpatient setting if papilledema does not improve with improved BP control. . #Chronic kidney disease: The patient's creatinine was elevated at 3.6-3.7, which is baseline. CKD likely secondary to hypertensive nephropathy. Continued sevalamer and nephrocaps. . #Chronic systolic CHF: No echo in the system, but OSH records per Dr.<Name>Shannon Post</Name> note states TTE showed increased wall thickness, estimated LVEF 25-30% and global hypokinesis without focal wall motion abnormality, as well as increased <Name>German Londrie</Name> <Name>Lyna</Name>, with estimated PA systolic pressure 32mm. The patient appeared euvolemic on exam, without evidence of an acute sCHF exacerbation. His blood pressure control was adjusted as above, including the addition of spironolactone to his regimen. Despite his renal impairment, he may benefit from the addition of an ACEi/<Name>Deng</Name> and should discuss this with his PCP, <Name>Abigail Casenhiser</Name>, and nephrologist. He was continued on a beta blocker (though switched from metoprolol/carvedilol to labetalol), lasix, and metolazone. His EF on the TTE here showed an EF of 55%. TRANSITIONAL ISSUES: -Has PCP, <Name>Laura Smith</Name>, and nephrology follow-up scheduled -Needs outpatient sleep study -Would benefit from work-up for secondary hypertension if not already done at another facility - follow up renin/<Name>Scott</Name> ratio, may draw urine metaneprhines, dex suppression testing -Patient was a Full Code during this admission -Would benefit from nutrition consult - Has Cr and K ordered as outpt on Thursday which needs f/up Medications on Admission: B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by Other Provider) - Dosage uncertain CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day FUROSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth twice a day HYDRALAZINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a day ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth Qday METOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth Qday METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice a day POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1 Tablet(s) by mouth Once a day SEVELAMER HCL - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s)* Refills:0 3. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 6. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patches Transdermal QSAT (every Saturday). Disp:4 Patch Weekly(s) Refills:2 7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day. Disp:30 Tablet, ER Particles/Crystals(s) Refills:0 9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive emergency Secondary Diagnoses: Chronic kidney disease Chronic systolic heart failure Tobacco abuse Obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. <Name>Londrie</Name>, You were admitted to the intensive care unit at <Hospital>White-Hampton Medical Center</Hospital> with very high blood pressures and blurry vision. Your blurry vision was likely caused by your high blood pressure. When your blood pressure is this high, you are at risk for serious complications including further kidney damage and possible stroke. We monitored you closely and changed some of your blood pressure medications to help better control your blood pressures. We made the following changes to your medications: STOPPED: -Carvedilol -Metoprolol -Isosorbide mononitrate DECREASED: -Hydralazine from 100 mg three times a day to 50 mg three times a day INCREASED: -Potassium chloride 20 meq chrystals increased from one dose once a day to two doses once a day STARTED: -Clonidine patch 0.3 mg once a week -Labetalol 400 mg three times a day -Lisinopril 2.5mg once a day We did not make any other changes to your medications. Please continue to take them as you have been doing. It is very important that you take your blood pressure medications and monitor your blood pressure. If your blood pressure is persistently higher than 190/110, you should contact your doctor. Also, if you develop any worsening blurry vision, headache, chest pain, shortness of breath, slurred speech, or weakness on one side of the face or body, you should seek medical attention immediately. We are concerned you may have a condition called obstructive sleep apnea, and we recommend you have a sleep study after you leave the hospital. We also recommend that you see a nutritionist and work on continuing to lose weight. Please eat a low salt diet. We also strongly encourage you to stop smoking. Please also note that you will need to get your creatinine and potassium checked on Thursday, <Date>2012-11-11</Date>. Followup Instructions: Department: <Hospital>Peck-Smith Medical Center</Hospital> When: THURSDAY <Date>2012-11-11</Date> at 2:15 PM With: <Name>Mamie</Name> <Name>Luu</Name>, MD <Telephone>531-139-9540</Telephone> Building: SC <Hospital>Carter Ltd Clinic</Hospital> Clinical Ctr <Location>Unit 3254 Box 0261 DPO AA 02741</Location> Campus: EAST Best Parking: <Hospital>Carter Ltd Clinic</Hospital> Garage Department: CARDIAC SERVICES When: MONDAY <Date>1972-10-6</Date> at 9:40 AM With: <Name>Samantha</Name> <Name>Jeremy Negrete</Name>, M.D. <Telephone>102-378-8408</Telephone> Building: SC <Hospital>Carter Ltd Clinic</Hospital> Clinical Ctr <Location>92684 Randy Lake Apt. 988 Englishfurt, PW 48629</Location> Campus: EAST Best Parking: <Hospital>Carter Ltd Clinic</Hospital> Garage Department: WEST <Hospital>Ramsey-Miller Clinic</Hospital> CLINIC When: WEDNESDAY <Date>2010-3-15</Date> at 2:30 PM With: <Name>Kala</Name> <Name>Finateri</Name>, MD <Telephone>548-610-1387</Telephone> Building: De <Hospital>Reyes, Mendoza and Hoffman Hospital</Hospital> Building (<Hospital>Miles LLC Medical Center</Hospital> Complex) <Location>92684 Randy Lake Apt. 988 Englishfurt, PW 48629</Location> Campus: WEST Best Parking: <Location>26088 Lopez Route Apt. 183 Lake Jeremy, OR 33866</Location> 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Date: 1935-12-10 Discharge Date: 1986-11-9 Date of Birth: 1987-5-27 Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Danilo Chief Complaint: Blurry vision Major Surgical or Invasive Procedure: None History of Present Illness: This is a 39 year old male with a history of hypertension (on beta blockade, lasix, hydralazine, imdur, metolazone) complicated by chronic kidney disease (stage IV), EF of 25-30%, obesity, and tobacco abuse. He presented today to the emergency room after Leblanc LLC Health System clinic noted severe bilateral papilledema; opthomology suggested this was secondary to either elevated intracranial pressure in the setting of malignant hypertension or pseudotumor cerebri. He has been symptomatic with blurry vision over the past month in the absence of headaches or other central symptoms. He has noted some gait instability. In the ED, his blood pressure was noted to be 180/118. He took his usual dose of one of his blood pressure meds (unknown) and his BP improved to 160 systolic. He was transferred to the MICU for management of hypertensive emergency. Past Medical History: Hypertension, hypertensive chronic kidney disease stage IV, systolic heart failure, last ejection fraction from Smith, Roth and Phillips Hospital between 25 and 30%, obesity, and tobacco abuse. Social History: The patient continues to smoke cigarettes about ten per day. He has cut down recently on the amount that he smokes, but still is precontemplative about quitting at this time. Family History: No history of hypertension, heart disease, or cancer. Physical Exam: ADMISSION EXAM: VS: HR 80 BP 170/100 RR 18 96% on RA Gen: Obese. NAD. HEENT: Dilated fundoscopic exam revealed bilateral papilledema without evidence of flame hemorrhages or distinct cotton whool spots. Mucous accumulation in canthal folds. Mild proptosis apprecaited. Otherwise MMM without any cervical LAD apprecatied. PERRLA. CV: Faint heart sounds. 11-23 pansystolic murmur best apprecaited in mitral region. No carotid bruits apprecaited. No rubs or gallops. Lungs: CTABL throughout all lung fields. Abd: Obese. Nontender throughout. NBS. No appreciable organomegaly. Ext: 1+ DPP with no appreciable edema. NeurO: AOX3. NO focal neurologic deficits appeciated on focused cranial nerve exam or on brief gross motor exam. DISCHARGE EXAM: VS: 98.0 BP 129-155/96-117 HR 75-96 RR 20 Satting 100% on RA. GENERAL - well-appearing morbidly obese man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD seen, no carotid bruits LUNGS - CTA bilat HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 12-31 throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: ADMISSION LABS: 1935-12-10 03:50PM BLOOD WBC-7.3 RBC-4.07* Hgb-12.5* Hct-37.0* MCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt Ct-219 1935-12-10 03:50PM BLOOD Neuts-61.7 Lymphs-29.3 Monos-5.3 Eos-2.8 Baso-0.9 1935-12-10 03:50PM BLOOD PT-11.5 PTT-27.2 INR(PT)-1.1 1935-12-10 03:50PM BLOOD Glucose-84 UreaN-41* Creat-3.8* Na-142 K-3.4 Cl-100 HCO3-27 AnGap-18 1935-12-10 03:50PM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8 dischcarge labs: 1986-11-9 06:20AM BLOOD WBC-8.6 RBC-4.24* Hgb-13.4* Hct-38.8* MCV-91 MCH-31.7 MCHC-34.6 RDW-13.3 Plt Ct-195 1986-11-9 06:20AM BLOOD Glucose-93 UreaN-53* Creat-4.1* Na-138 K-2.9* Cl-94* HCO3-26 AnGap-21* 1986-11-9 06:20AM BLOOD Calcium-9.5 Phos-5.9# Mg-2.0 1986-11-9 06:20AM BLOOD ALDOSTERONE-PND 1986-11-9 06:20AM BLOOD RENIN-PND OTHER LABS: 1984-9-18 01:46AM BLOOD ALT-14 AST-20 AlkPhos-42 TotBili-0.4 1984-9-18 01:46AM BLOOD TSH-1.1 IMAGING: CT Head w/o contrast 1935-12-10: 1. No acute intracranial pathology. 2. Bilateral proptosis. renal u/s 1985-6-6: Both kidneys show increased echogenicity consistent with chronic kidney disease. Two simple cysts in the right kidney, one at the upper pole and one at the lower pole. Doppler evaluation of both renal arteries and of the arcuate/segmental vessels in the renal parenchyma was within normal limits. No ultrasound/Doppler evidence for renal artery stenosis. tte 1986-11-9: The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: #Hypertensive Emergency: Pt presented with HTN systolics >200 and blurry vision, found to have papilledema. The patient's blood pressure was markedly elevated with systolic blood pressures ranging from 160-210 during ICU stay. Review of prior notes outlines a longstanding history of poorly controlled blood pressures. His home isosorbide and carvedilol were discontinued. Labetalol was uptitrated to 200mg TID, Hydral downtitrated to 50mg TID, clonidine 0.3mg weekly patch started, and furosemide/metolazone continued as is. MAP >120 was goal. On leaving the ICU SPB was in 130s. TSH was within normal limits. It was felt that this patient needed a full workup for secondary causes of hypertension. In the meantime renal artery ultrasound done here showed no renal artery stenosis but did show chornic bilateral changes consistent with CKDD. He should likely have a workup for hyperaldosteronism (see hypokalemia below) and workup including urine metanephrines and dexamethasone suppression test, as he is quite young for this degree of hypertension and seems to be compliant with his medications. He was initially started on spironolactone given report of EF 25-30% and thought that it may help with hypokalemia, however after 3 days (3 doses) this was discontinued so that pt could ideally have a renin/aldosterone level drawn prior to discharge (which is now pending), several days after discontinuation. Would recommend restarting this medication after the appropriate studies have been done. It is more than likely this patient has sleep apnea as well; in the ICU he was noted to have desats during sleep with very loud snoring. Desats resolved instantly on waking. Pt is also smoking and quite obese both of which are likely worsening his hypertension. Would recommend outpatient sleep study as well. . #hypokalemia - pt was noted to be hypokalemic with potassium 2.9-3.2. Concern for hyperaldosterone state given concommittant resistant hypertension. Pt required >160meq potassium repletion per day while in the Gibson LLC Medical Center and still remained with K below 4.0. Outpatient records demonstrate history of low potassium. Pt also had been started on spironolactone, and while it was low dose, it did not appear to help with potassium retention. This was also unusual in the setting of elevated creatinine/chronic renal failure, which emphasized concerns for hyperaldosterone state. Spironolactone was DCd temporarily so that he could have renin/Scott levels drawn. #Intracranial hypertension: Likely secondary to systmemic hypertension. Neurology evalauted patient in ED and suggested potential LP if BP controlled to assess for pseudotumor cerebrii, though this can be deferred to outpatient setting if papilledema does not improve with improved BP control. . #Chronic kidney disease: The patient's creatinine was elevated at 3.6-3.7, which is baseline. CKD likely secondary to hypertensive nephropathy. Continued sevalamer and nephrocaps. . #Chronic systolic CHF: No echo in the system, but OSH records per Dr.Shannon Post note states TTE showed increased wall thickness, estimated LVEF 25-30% and global hypokinesis without focal wall motion abnormality, as well as increased German Londrie Lyna, with estimated PA systolic pressure 32mm. The patient appeared euvolemic on exam, without evidence of an acute sCHF exacerbation. His blood pressure control was adjusted as above, including the addition of spironolactone to his regimen. Despite his renal impairment, he may benefit from the addition of an ACEi/Deng and should discuss this with his PCP, Abigail Casenhiser, and nephrologist. He was continued on a beta blocker (though switched from metoprolol/carvedilol to labetalol), lasix, and metolazone. His EF on the TTE here showed an EF of 55%. TRANSITIONAL ISSUES: -Has PCP, Laura Smith, and nephrology follow-up scheduled -Needs outpatient sleep study -Would benefit from work-up for secondary hypertension if not already done at another facility - follow up renin/Scott ratio, may draw urine metaneprhines, dex suppression testing -Patient was a Full Code during this admission -Would benefit from nutrition consult - Has Cr and K ordered as outpt on Thursday which needs f/up Medications on Admission: B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by Other Provider) - Dosage uncertain CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day FUROSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth twice a day HYDRALAZINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a day ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth Qday METOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth Qday METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice a day POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1 Tablet(s) by mouth Once a day SEVELAMER HCL - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s)* Refills:0 3. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 6. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patches Transdermal QSAT (every Saturday). Disp:4 Patch Weekly(s) Refills:2 7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day. Disp:30 Tablet, ER Particles/Crystals(s) Refills:0 9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive emergency Secondary Diagnoses: Chronic kidney disease Chronic systolic heart failure Tobacco abuse Obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. Londrie, You were admitted to the intensive care unit at White-Hampton Medical Center with very high blood pressures and blurry vision. Your blurry vision was likely caused by your high blood pressure. When your blood pressure is this high, you are at risk for serious complications including further kidney damage and possible stroke. We monitored you closely and changed some of your blood pressure medications to help better control your blood pressures. We made the following changes to your medications: STOPPED: -Carvedilol -Metoprolol -Isosorbide mononitrate DECREASED: -Hydralazine from 100 mg three times a day to 50 mg three times a day INCREASED: -Potassium chloride 20 meq chrystals increased from one dose once a day to two doses once a day STARTED: -Clonidine patch 0.3 mg once a week -Labetalol 400 mg three times a day -Lisinopril 2.5mg once a day We did not make any other changes to your medications. Please continue to take them as you have been doing. It is very important that you take your blood pressure medications and monitor your blood pressure. If your blood pressure is persistently higher than 190/110, you should contact your doctor. Also, if you develop any worsening blurry vision, headache, chest pain, shortness of breath, slurred speech, or weakness on one side of the face or body, you should seek medical attention immediately. We are concerned you may have a condition called obstructive sleep apnea, and we recommend you have a sleep study after you leave the hospital. We also recommend that you see a nutritionist and work on continuing to lose weight. Please eat a low salt diet. We also strongly encourage you to stop smoking. Please also note that you will need to get your creatinine and potassium checked on Thursday, 2012-11-11. Followup Instructions: Department: Peck-Smith Medical Center When: THURSDAY 2012-11-11 at 2:15 PM With: Mamie Luu, MD 531-139-9540 Building: SC Carter Ltd Clinic Clinical Ctr Unit 3254 Box 0261 DPO AA 02741 Campus: EAST Best Parking: Carter Ltd Clinic Garage Department: CARDIAC SERVICES When: MONDAY 1972-10-6 at 9:40 AM With: Samantha Jeremy Negrete, M.D. 102-378-8408 Building: SC Carter Ltd Clinic Clinical Ctr 92684 Randy Lake Apt. 988 Englishfurt, PW 48629 Campus: EAST Best Parking: Carter Ltd Clinic Garage Department: WEST Ramsey-Miller Clinic CLINIC When: WEDNESDAY 2010-3-15 at 2:30 PM With: Kala Finateri, MD 548-610-1387 Building: De Reyes, Mendoza and Hoffman Hospital Building (Miles LLC Medical Center Complex) 92684 Randy Lake Apt. 988 Englishfurt, PW 48629 Campus: WEST Best Parking: 26088 Lopez Route Apt. 183 Lake Jeremy, OR 33866 Garage	['Admission Date: 1935-12-10 Discharge Date: 1986-11-9\n\nDate of Birth: 1987-5-27 Sex: M\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Danilo\nChief Complaint:\nBlurry vision\n\nMajor Surgical or Invasive Procedure:\nNone\n\n\nHistory of Present Illness:\nThis is a 39 year old male with a history of hypertension (on\nbeta blockade, lasix, hydralazine, imdur, metolazone)\ncomplicated by chronic kidney disease (stage IV), EF of 25-30%,\nobesity, and\ntobacco abuse. He presented today to the emergency room after\nLeblanc LLC Health System clinic noted severe bilateral papilledema; opthomology\nsuggested this was secondary to either elevated intracranial\npressure in the setting of malignant hypertension or pseudotumor\ncerebri. He has been symptomatic with blurry vision over the\npast month in the absence of headaches or other central\nsymptoms.', ' He has noted some gait instability. In the ED, his\nblood pressure was noted to be 180/118. He took his usual dose\nof one of his blood pressure meds (unknown) and his BP improved\nto 160 systolic. He was transferred to the MICU for management\nof hypertensive emergency.\n\n\nPast Medical History:\nHypertension, hypertensive chronic kidney disease stage IV,\nsystolic heart failure, last ejection fraction from Smith, Roth and Phillips Hospital between 25 and 30%, obesity, and tobacco abuse.\n\n\nSocial History:\nThe patient continues to smoke cigarettes about ten per day. He\nhas cut down recently on the amount that he smokes, but still is\nprecontemplative about quitting at this time.\n\n\nFamily History:\nNo history of hypertension, heart disease, or cancer.\n\nPhysical Exam:\nADMISSION EXAM:\nVS: HR 80 BP 170/100 RR 18 96% on RA\nGen: Obese.', ' NAD.\nHEENT: Dilated fundoscopic exam revealed bilateral papilledema\nwithout evidence of flame hemorrhages or distinct cotton whool\nspots. Mucous accumulation in canthal folds. Mild proptosis\napprecaited. Otherwise MMM without any cervical LAD apprecatied.\n PERRLA.\nCV: Faint heart sounds. 11-23 pansystolic murmur best apprecaited\nin mitral region. No carotid bruits apprecaited. No rubs or\ngallops.\nLungs: CTABL throughout all lung fields.\nAbd: Obese. Nontender throughout. NBS. No appreciable\norganomegaly.\nExt: 1+ DPP with no appreciable edema.\nNeurO: AOX3. NO focal neurologic deficits appeciated on focused\ncranial nerve exam or on brief gross motor exam.\n\nDISCHARGE EXAM:\nVS: 98.0 BP 129-155/96-117 HR 75-96 RR 20 Satting 100% on RA.\nGENERAL - well-appearing morbidly obese man in NAD, comfortable,\nappropriate\nHEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear\nNECK - supple, no thyromegaly, no JVD seen, no carotid bruits\nLUNGS - CTA bilat\nHEART - PMI non-displaced, RRR, no MRG, nl S1-S2\nABDOMEN - NABS, soft/NT/ND, no masses or HSM, no\nrebound/guarding\nEXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)\n\nSKIN - no rashes or lesions\nLYMPH - no cervical, axillary, or inguinal LAD\nNEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength\n12-31 throughout, sensation grossly intact throughout, DTRs 2+ and\nsymmetric, cerebellar exam intact, steady gait\n\nPertinent Results:\nADMISSION LABS:\n1935-12-10 03:50PM BLOOD WBC-7.', '3 RBC-4.07* Hgb-12.5* Hct-37.0\nMCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt Ct-219\n1935-12-10 03:50PM BLOOD Neuts-61.7 Lymphs-29.3 Monos-5.3 Eos-2.8\nBaso-0.9\n1935-12-10 03:50PM BLOOD PT-11.5 PTT-27.2 INR(PT)-1.1\n1935-12-10 03:50PM BLOOD Glucose-84 UreaN-41 Creat-3.8* Na-142\nK-3.4 Cl-100 HCO3-27 AnGap-18\n1935-12-10 03:50PM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8\n\ndischcarge labs:\n\n1986-11-9 06:20AM BLOOD WBC-8.6 RBC-4.24* Hgb-13.4* Hct-38.8\nMCV-91 MCH-31.7 MCHC-34.6 RDW-13.3 Plt Ct-195\n1986-11-9 06:20AM BLOOD Glucose-93 UreaN-53 Creat-4.1* Na-138\nK-2.9* Cl-94* HCO3-26 AnGap-21\n1986-11-9 06:20AM BLOOD Calcium-9.5 Phos-5.9# Mg-2.0\n1986-11-9 06:20AM BLOOD ALDOSTERONE-PND\n1986-11-9 06:20AM BLOOD RENIN-PND\n\nOTHER LABS:\n1984-9-18 01:46AM BLOOD ALT-14 AST-20 AlkPhos-42 TotBili-0.4\n1984-9-18 01:46AM BLOOD TSH-1.', '1\n\nIMAGING:\n\nCT Head w/o contrast 1935-12-10:\n1. No acute intracranial pathology.\n2. Bilateral proptosis.\n\nrenal u/s 1985-6-6:\nBoth kidneys show increased echogenicity consistent with chronic\n\nkidney disease. Two simple cysts in the right kidney, one at the\nupper pole and one at the lower pole. Doppler evaluation of both\nrenal arteries and of the arcuate/segmental vessels in the renal\nparenchyma was within normal limits. No ultrasound/Doppler\nevidence for renal artery stenosis.\n\ntte 1986-11-9:\nThe left atrium is mildly dilated. The right atrium is\nmoderately dilated. The estimated right atrial pressure is at\nleast 15 mmHg. There is severe symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is low normal (LVEF 50%).\nTissue Doppler imaging suggests an increased left ventricular\nfilling pressure (PCWP>18mmHg).', " The right ventricular free wall\nis hypertrophied. Right ventricular chamber size is normal. with\ndepressed free wall contractility. The ascending aorta is mildly\ndilated. The aortic arch is mildly dilated. The aortic valve\nleaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The\nmitral valve appears structurally normal with trivial mitral\nregurgitation. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\n\nBrief Hospital Course:\n#Hypertensive Emergency: Pt presented with HTN systolics >200\nand blurry vision, found to have papilledema. The patient's\nblood pressure was markedly elevated with systolic blood\npressures ranging from 160-210 during ICU stay. Review of prior\nnotes outlines a longstanding history of poorly controlled blood\npressures.", ' His home isosorbide and carvedilol were\ndiscontinued. Labetalol was uptitrated to 200mg TID, Hydral\ndowntitrated to 50mg TID, clonidine 0.3mg weekly patch started,\nand furosemide/metolazone continued as is. MAP >120 was goal. On\nleaving the ICU SPB was in 130s. TSH was within normal limits.\nIt was felt that this patient needed a full workup for secondary\ncauses of hypertension. In the meantime renal artery ultrasound\ndone here showed no renal artery stenosis but did show chornic\nbilateral changes consistent with CKDD. He should likely have a\nworkup for hyperaldosteronism (see hypokalemia below) and workup\nincluding urine metanephrines and dexamethasone suppression\ntest, as he is quite young for this degree of hypertension and\nseems to be compliant with his medications. He was initially\nstarted on spironolactone given report of EF 25-30% and thought\nthat it may help with hypokalemia, however after 3 days (3\ndoses) this was discontinued so that pt could ideally have a\nrenin/aldosterone level drawn prior to discharge (which is now\npending), several days after discontinuation.', ' Would recommend\nrestarting this medication after the appropriate studies have\nbeen done. It is more than likely this patient has sleep apnea\nas well; in the ICU he was noted to have desats during sleep\nwith very loud snoring. Desats resolved instantly on waking. Pt\nis also smoking and quite obese both of which are likely\nworsening his hypertension. Would recommend outpatient sleep\nstudy as well.\n.\n#hypokalemia - pt was noted to be hypokalemic with potassium\n2.9-3.2. Concern for hyperaldosterone state given concommittant\nresistant hypertension. Pt required >160meq potassium repletion\nper day while in the Gibson LLC Medical Center and still remained with K below 4.0.\nOutpatient records demonstrate history of low potassium. Pt also\nhad been started on spironolactone, and while it was low dose,\nit did not appear to help with potassium retention.', " This was\nalso unusual in the setting of elevated creatinine/chronic renal\nfailure, which emphasized concerns for hyperaldosterone state.\nSpironolactone was DCd temporarily so that he could have\nrenin/Scott levels drawn.\n\n#Intracranial hypertension: Likely secondary to systmemic\nhypertension. Neurology evalauted patient in ED and suggested\npotential LP if BP controlled to assess for pseudotumor\ncerebrii, though this can be deferred to outpatient setting if\npapilledema does not improve with improved BP control.\n.\n#Chronic kidney disease: The patient's creatinine was elevated\nat 3.6-3.7, which is baseline. CKD likely secondary to\nhypertensive nephropathy. Continued sevalamer and nephrocaps.\n.\n#Chronic systolic CHF: No echo in the system, but OSH records\nper Dr.Shannon Post note states TTE showed increased wall\nthickness, estimated LVEF 25-30% and global hypokinesis without\nfocal wall motion abnormality, as well as increased German Londrie\nLyna, with estimated PA systolic pressure 32mm.", ' The\npatient appeared euvolemic on exam, without evidence of an acute\nsCHF exacerbation. His blood pressure control was adjusted as\nabove, including the addition of spironolactone to his regimen.\nDespite his renal impairment, he may benefit from the addition\nof an ACEi/Deng and should discuss this with his PCP,\nAbigail Casenhiser, and nephrologist. He was continued on a beta\nblocker (though switched from metoprolol/carvedilol to\nlabetalol), lasix, and metolazone. His EF on the TTE here showed\nan EF of 55%.\n\nTRANSITIONAL ISSUES:\n-Has PCP, Laura Smith, and nephrology follow-up scheduled\n-Needs outpatient sleep study\n-Would benefit from work-up for secondary hypertension if not\nalready done at another facility - follow up renin/Scott ratio,\nmay draw urine metaneprhines, dex suppression testing\n-Patient was a Full Code during this admission\n-Would benefit from nutrition consult\n- Has Cr and K ordered as outpt on Thursday which needs f/up\n\nMedications on Admission:\nB COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by\nOther Provider) - Dosage uncertain\nCARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day\nFUROSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth twice a day\nHYDRALAZINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a\nday\nISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr -\n1\nTablet(s) by mouth Qday\nMETOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth Qday\nMETOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice\na day\nPOTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1\nTablet(s) by mouth Once a day\nSEVELAMER HCL - (Prescribed by Other Provider) - Dosage\nuncertain\n\n\nDischarge Medications:\n1.', ' furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times\na day).\n2. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times\na day).\nDisp:90 Tablet(s) Refills:0\n3. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n4. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID\nW/MEALS (3 TIMES A DAY WITH MEALS).\n5. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a\nday).\nDisp:90 Tablet(s) Refills:0\n6. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patches\nTransdermal QSAT (every Saturday).\nDisp:4 Patch Weekly(s) Refills:2\n7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.\n8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:\nTwo (2) Tablet, ER Particles/Crystals PO once a day.\nDisp:30 Tablet, ER Particles/Crystals(s) Refills:0\n9.', ' lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.\nDisp:30 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nPrimary Diagnosis:\nHypertensive emergency\n\nSecondary Diagnoses:\nChronic kidney disease\nChronic systolic heart failure\nTobacco abuse\nObesity\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. Londrie,\n\nYou were admitted to the intensive care unit at White-Hampton Medical Center with very high blood pressures and\nblurry vision. Your blurry vision was likely caused by your\nhigh blood pressure. When your blood pressure is this high, you\nare at risk for serious complications including further kidney\ndamage and possible stroke.', ' We monitored you closely and\nchanged some of your blood pressure medications to help better\ncontrol your blood pressures.\n\nWe made the following changes to your medications:\nSTOPPED:\n-Carvedilol\n-Metoprolol\n-Isosorbide mononitrate\n\nDECREASED:\n-Hydralazine from 100 mg three times a day to 50 mg three times\na day\n\nINCREASED:\n-Potassium chloride 20 meq chrystals increased from one dose\nonce a day to two doses once a day\n\nSTARTED:\n-Clonidine patch 0.3 mg once a week\n-Labetalol 400 mg three times a day\n-Lisinopril 2.5mg once a day\n\nWe did not make any other changes to your medications. Please\ncontinue to take them as you have been doing.\n\nIt is very important that you take your blood pressure\nmedications and monitor your blood pressure. If your blood\npressure is persistently higher than 190/110, you should contact\nyour doctor.', ' Also, if you develop any worsening blurry vision,\nheadache, chest pain, shortness of breath, slurred speech, or\nweakness on one side of the face or body, you should seek\nmedical attention immediately.\n\nWe are concerned you may have a condition called obstructive\nsleep apnea, and we recommend you have a sleep study after you\nleave the hospital.\n\nWe also recommend that you see a nutritionist and work on\ncontinuing to lose weight. Please eat a low salt diet.\n\nWe also strongly encourage you to stop smoking.\n\nPlease also note that you will need to get your creatinine and\npotassium checked on Thursday, 2012-11-11.\n\nFollowup Instructions:\nDepartment: Peck-Smith Medical Center\nWhen: THURSDAY 2012-11-11 at 2:15 PM\nWith: Mamie Luu, MD 531-139-9540\nBuilding: SC Carter Ltd Clinic Clinical Ctr Unit 3254 Box 0261\nDPO AA 02741\nCampus: EAST Best Parking: Carter Ltd Clinic Garage\n\nDepartment: CARDIAC SERVICES\nWhen: MONDAY 1972-10-6 at 9:40 AM\nWith: Samantha Jeremy Negrete, M.', 'D. 102-378-8408\nBuilding: SC Carter Ltd Clinic Clinical Ctr 92684 Randy Lake Apt. 988\nEnglishfurt, PW 48629\nCampus: EAST Best Parking: Carter Ltd Clinic Garage\n\nDepartment: WEST Ramsey-Miller Clinic CLINIC\nWhen: WEDNESDAY 2010-3-15 at 2:30 PM\nWith: Kala Finateri, MD 548-610-1387\nBuilding: De Reyes, Mendoza and Hoffman Hospital Building (Miles LLC Medical Center Complex) 92684 Randy Lake Apt. 988\nEnglishfurt, PW 48629\nCampus: WEST Best Parking: 26088 Lopez Route Apt. 183\nLake Jeremy, OR 33866 Garage\n\n\n\n']
212	76874	113329.0	2101-10-28	Discharge summary	Report	Admission Date: [2101-10-25] Discharge Date: [2101-10-28] Date of Birth: [2064-10-2] Sex: F Service: MEDICINE Allergies: Cephalosporins / Floxin / Penicillins Attending:[First Name3 (LF) 2108] Chief Complaint: Xanax, Tylenol & Klonopin Overdose Major Surgical or Invasive Procedure: None History of Present Illness: 37 yo F with history of depression and suicidal attempt in the past presented with obtundation. Of note, her prior attempt was about 15 years ago during which she OD on theophylline, requiring intubation. She has been feeling more depressed over the last few months and has been seeing a therapist, on the ECT waiting list with recent evaluation by Dr. [Last Name (STitle) 2109], [First Name3 (LF) ] her partner. [Name (NI) ] reports taking 120 mg of Xanax and 80 mg Klonopin in the afternoon of [2101-10-25] as well as at least [4-7] g of Tylenol daily over the last 2 weeks. She also admitted to taking 20 mg of Ambien. She says that she was taking the tylenol intentionally to worsen her liver function. She says that she decided to do this because she wanted to commit suicide. She also reports having had 1 glass of wine on the day of these medication ingestions. She then called one of her friends afterwards, and her therapist ([First Name8 (NamePattern2) 2110] [Last Name (NamePattern1) ]) was subsequently involved and called the EMS for patient. In the ED, her initial VS were HR 99, BP 102/56, RR 20, and 98% on RA. She arrived with her friend, very lethargic. Per report, was only responsive to sternal rub and GCS of 8 throughout. Tox screen showed positive benzos and acetaminophen only. ECG showed sinus tachycardia. UA was negative. CT head did not show ICH. Her initial Tylenol level was 40. Toxicology was consulted and recommended NAC for 21 hours until level is undetectable and LFT stabilizes. She started NAC in the ED and her repeat level was 29. VS prior to transfer were T95, HR 66, BP 121/73, RR 22, O2Sat 98% RA. She was transferred to the ICU for her poor mental status. While on the floor, appears comfortable, denies any SOB, chest pain/discomfort, abdominal pain/discomfort, urinary symptoms or URI symptoms. She does have some throat tightness and discomfort when swallowing. Her partner reports that patient's mental status seems to have improved since her initial arrival to the ED. Past Medical History: - Asthma, requiring 1x intubation in late teen (unclear if this was related to the theophylline) - GERD with severe esophagitis ([2098]) - Insomnia - Bipolar Type 2, currently severe depression, requiring hospitalization at [Doctor First Name ] in the past - Depression - Suicidal attempts (last [1-/2099] following impulsive suicide attempt in which she crashed her cars, 2 other ones with OD in her late teens) Social History: Occupation: a nurse mid-wife at [Name (NI) 2025] x 10 years Drugs: Marijuana, last used about 1 week ago Tobacco: None Alcohol: occasionally Married to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 976] [Telephone/Fax (1) 2111], live in [Location (un) 538]. Family History: - mother- depression - maternal grandmother- EtOH abuse, benzodiazepine abuse - maternal uncle- bipolar affective d/o Physical Exam: Physical Exam on Arrival to [Hospital Unit Name 2112]: Temp: 36.9 BP 116/51, HR 65, RR25, O2Sat 99% RA General: lethargic, answers questions appropriately but in whispers, follows commands, NAD HEENT: PERRL, EOMi, anicteric, Mucous membrane moist NECK: no supraclavicular or cervical LAD, no JVD, no carotid bruits, no stridor Resp: CTAB with good air movement throughout, no wheeze, crackles, or rhonchi CV: RR, S1 and S2 wnl, no m/r/g ABD: soft, ND, mildly tender in the umbilical area, no hepatosplenomegaly, no guarding. EXT: no c/c/e SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: [2101-10-25] - CT head: There is no acute intracranial hemorrhage, acute large major vascular territory infarction, discrete masses, mass effect, brain edema or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. The visualized osseous structures are unremarkable. The visualized paranasal sinuses are within normal limits. Incidentally noted is a faintly-calcified likely sebaceous cyst in the left paramedian frontovertex scalp soft tissues (2:26-27); correlate with physical examination. IMPRESSION: No acute intracranial process [2101-10-27] 06:50AM BLOOD WBC-4.7 RBC-3.78* Hgb-11.8* Hct-32.8* MCV-87 MCH-31.2 MCHC-36.0* RDW-13.5 Plt Ct-238 [2101-10-25] 03:00PM BLOOD WBC-6.0 RBC-4.03* Hgb-12.6 Hct-36.0 MCV-90 MCH-31.4 MCHC-35.1* RDW-12.8 Plt Ct-275 [2101-10-26] 05:39AM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2* [2101-10-27] 06:50AM BLOOD PT-12.4 INR(PT)-1.0 [2101-10-25] 03:00PM BLOOD Neuts-66.7 Lymphs-26.5 Monos-3.5 Eos-2.2 Baso-1.0 [2101-10-27] 06:50AM BLOOD Glucose-82 UreaN-6 Creat-0.6 Na-139 K-3.8 Cl-106 HCO3-26 AnGap-11 [2101-10-25] 03:00PM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139 K-3.8 Cl-104 HCO3-26 AnGap-13 [2101-10-27] 06:50AM BLOOD ALT-21 AST-13 [2101-10-26] 02:23AM BLOOD ALT-25 AST-24 LD(LDH)-340* AlkPhos-39 TotBili-0.3 [2101-10-25] 03:00PM BLOOD ALT-28 AST-22 LD(LDH)-161 AlkPhos-56 TotBili-0.4 [2101-10-27] 06:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9 [2101-10-25] 03:00PM BLOOD HCG-<5 [2101-10-25] 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-40* Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2101-10-25] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-29 Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2101-10-26] 02:23AM BLOOD Acetmnp-6* [2101-10-26] 07:00PM BLOOD Acetmnp-NEG Brief Hospital Course: 37 yo F with depression on ECT waiting list and remote history of suicidal attempts presents with OD of benzodiazepine and Tylenol Medicaion Overdose, an attempt to suicide. The patient was treated supportively for benzodiazepine overdose and did not require mechanical ventilation. In regards to tylenol toxicity she required a N acetylcysteine drip for a tylenol level of 40 and normal liver function tests, after stopping the NAC drip her tylenol level was negative and LFTs remained normal. She was medically cleared for discharge to a psyhiatric inpatient facility as of the a.m. of [2101-10-27], she is also medically cleared for ECT. In regards to her bipolar disorder and suicide attempt psychiatry was consulted and suggested the following medication regimen: Wellbutrin 150mg po bid, duloxetine 60mg po daily, lamotrigine 350mg po daily, risperdal 0.5mg po bid prn, and ambien 10mg po qhs prn insomnia. Asthma. Does not appear to be active currently. prn albuterol / atrovent nebs. GERD: continued home omeprazole Communication/Emergency Contact: partner [Name (NI) ] [Name (NI) 976] [Telephone/Fax (1) 2111] Medications on Admission: Meds (at home): cymbalta 60 mg PO daily wellbutrin SR 450 mg PO daily lamictal 350 mg PO daily ambien 10 mg PO QHS prilosec 20 mg PO daily and sometimes [Hospital1 ] risperdal 0.5 mg PO QAM and 1 mg PO QHS (not taking for 1 week) klonopin 1 mg PO prn was stockpiling xanax, so not taking Meds (in ICU): NAC 560 mg/h IV gtt albuterol nebs prn Wellbutrin SR 150 mg [Hospital1 ] duloxetine 60 mg PO daily heparin subQ 5000 TID lamictal 350 mg PO daily omeprazole 20 mg PO daily Discharge Medications: 1. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 6. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety/agitation. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 8. lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital1 69] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: Suicide ingestion Tylenol overdose Benzodiazepine overdose Bipolar disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a suicide attempt and treated to prevent organ damage. You were transferred to an inpatient psychiatric facility. Please take your medications as prescribed and make your follow up appointments. Followup Instructions: Please follow up with your psychiatrist within 2 weeks of your discharge from the psychiatric facility. Please follow up with your primary care physician [Name Initial (PRE) 176] 1 week of your discharge from the psychiatric facility: [Last Name (LF) 2113],[First Name3 (LF) 2114] R. [Telephone/Fax (1) 2115]	Admission Date: <Date>1919-12-3</Date> Discharge Date: <Date>1929-12-27</Date> Date of Birth: <Date>1993-11-7</Date> Sex: F Service: MEDICINE Allergies: Cephalosporins / Floxin / Penicillins Attending:<Name>Raymond</Name> Chief Complaint: Xanax, Tylenol & Klonopin Overdose Major Surgical or Invasive Procedure: None History of Present Illness: 37 yo F with history of depression and suicidal attempt in the past presented with obtundation. Of note, her prior attempt was about 15 years ago during which she OD on theophylline, requiring intubation. She has been feeling more depressed over the last few months and has been seeing a therapist, on the ECT waiting list with recent evaluation by Dr. <Name>Kobayashi</Name>, <Name>Jai</Name> her partner. <Name>Celina Camargo</Name> reports taking 120 mg of Xanax and 80 mg Klonopin in the afternoon of <Date>1919-12-3</Date> as well as at least <Date>8-18</Date> g of Tylenol daily over the last 2 weeks. She also admitted to taking 20 mg of Ambien. She says that she was taking the tylenol intentionally to worsen her liver function. She says that she decided to do this because she wanted to commit suicide. She also reports having had 1 glass of wine on the day of these medication ingestions. She then called one of her friends afterwards, and her therapist (<Name>Carl</Name> <Name>Lees</Name>) was subsequently involved and called the EMS for patient. In the ED, her initial VS were HR 99, BP 102/56, RR 20, and 98% on RA. She arrived with her friend, very lethargic. Per report, was only responsive to sternal rub and GCS of 8 throughout. Tox screen showed positive benzos and acetaminophen only. ECG showed sinus tachycardia. UA was negative. CT head did not show ICH. Her initial Tylenol level was 40. Toxicology was consulted and recommended NAC for 21 hours until level is undetectable and LFT stabilizes. She started NAC in the ED and her repeat level was 29. VS prior to transfer were T95, HR 66, BP 121/73, RR 22, O2Sat 98% RA. She was transferred to the ICU for her poor mental status. While on the floor, appears comfortable, denies any SOB, chest pain/discomfort, abdominal pain/discomfort, urinary symptoms or URI symptoms. She does have some throat tightness and discomfort when swallowing. Her partner reports that patient's mental status seems to have improved since her initial arrival to the ED. Past Medical History: - Asthma, requiring 1x intubation in late teen (unclear if this was related to the theophylline) - GERD with severe esophagitis (<Year>1968</Year>) - Insomnia - Bipolar Type 2, currently severe depression, requiring hospitalization at <Name>Bryan</Name> in the past - Depression - Suicidal attempts (last <Date>10-1953</Date> following impulsive suicide attempt in which she crashed her cars, 2 other ones with OD in her late teens) Social History: Occupation: a nurse mid-wife at <Name>Henry Mao</Name> x 10 years Drugs: Marijuana, last used about 1 week ago Tobacco: None Alcohol: occasionally Married to <Name>Emily</Name> <Name>Naegelin</Name> <Telephone>395-293-5919</Telephone>, live in <Location>779 Anthony Courts Markville, NH 43829</Location>. Family History: - mother- depression - maternal grandmother- EtOH abuse, benzodiazepine abuse - maternal uncle- bipolar affective d/o Physical Exam: Physical Exam on Arrival to <Hospital>Robinson LLC Health System</Hospital>: Temp: 36.9 BP 116/51, HR 65, RR25, O2Sat 99% RA General: lethargic, answers questions appropriately but in whispers, follows commands, NAD HEENT: PERRL, EOMi, anicteric, Mucous membrane moist NECK: no supraclavicular or cervical LAD, no JVD, no carotid bruits, no stridor Resp: CTAB with good air movement throughout, no wheeze, crackles, or rhonchi CV: RR, S1 and S2 wnl, no m/r/g ABD: soft, ND, mildly tender in the umbilical area, no hepatosplenomegaly, no guarding. EXT: no c/c/e SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: <Date>1919-12-3</Date> - CT head: There is no acute intracranial hemorrhage, acute large major vascular territory infarction, discrete masses, mass effect, brain edema or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. The visualized osseous structures are unremarkable. The visualized paranasal sinuses are within normal limits. Incidentally noted is a faintly-calcified likely sebaceous cyst in the left paramedian frontovertex scalp soft tissues (2:26-27); correlate with physical examination. IMPRESSION: No acute intracranial process <Date>1905-2-25</Date> 06:50AM BLOOD WBC-4.7 RBC-3.78* Hgb-11.8* Hct-32.8* MCV-87 MCH-31.2 MCHC-36.0* RDW-13.5 Plt Ct-238 <Date>1919-12-3</Date> 03:00PM BLOOD WBC-6.0 RBC-4.03* Hgb-12.6 Hct-36.0 MCV-90 MCH-31.4 MCHC-35.1* RDW-12.8 Plt Ct-275 <Date>1920-10-10</Date> 05:39AM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2* <Date>1905-2-25</Date> 06:50AM BLOOD PT-12.4 INR(PT)-1.0 <Date>1919-12-3</Date> 03:00PM BLOOD Neuts-66.7 Lymphs-26.5 Monos-3.5 Eos-2.2 Baso-1.0 <Date>1905-2-25</Date> 06:50AM BLOOD Glucose-82 UreaN-6 Creat-0.6 Na-139 K-3.8 Cl-106 HCO3-26 AnGap-11 <Date>1919-12-3</Date> 03:00PM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139 K-3.8 Cl-104 HCO3-26 AnGap-13 <Date>1905-2-25</Date> 06:50AM BLOOD ALT-21 AST-13 <Date>1920-10-10</Date> 02:23AM BLOOD ALT-25 AST-24 LD(LDH)-340* AlkPhos-39 TotBili-0.3 <Date>1919-12-3</Date> 03:00PM BLOOD ALT-28 AST-22 LD(LDH)-161 AlkPhos-56 TotBili-0.4 <Date>1905-2-25</Date> 06:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9 <Date>1919-12-3</Date> 03:00PM BLOOD HCG-<5 <Date>1919-12-3</Date> 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-40* Bnzodzp-POS Barbitr-NEG Tricycl-NEG <Date>1919-12-3</Date> 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-29 Bnzodzp-POS Barbitr-NEG Tricycl-NEG <Date>1920-10-10</Date> 02:23AM BLOOD Acetmnp-6* <Date>1920-10-10</Date> 07:00PM BLOOD Acetmnp-NEG Brief Hospital Course: 37 yo F with depression on ECT waiting list and remote history of suicidal attempts presents with OD of benzodiazepine and Tylenol Medicaion Overdose, an attempt to suicide. The patient was treated supportively for benzodiazepine overdose and did not require mechanical ventilation. In regards to tylenol toxicity she required a N acetylcysteine drip for a tylenol level of 40 and normal liver function tests, after stopping the NAC drip her tylenol level was negative and LFTs remained normal. She was medically cleared for discharge to a psyhiatric inpatient facility as of the a.m. of <Date>1905-2-25</Date>, she is also medically cleared for ECT. In regards to her bipolar disorder and suicide attempt psychiatry was consulted and suggested the following medication regimen: Wellbutrin 150mg po bid, duloxetine 60mg po daily, lamotrigine 350mg po daily, risperdal 0.5mg po bid prn, and ambien 10mg po qhs prn insomnia. Asthma. Does not appear to be active currently. prn albuterol / atrovent nebs. GERD: continued home omeprazole Communication/Emergency Contact: partner <Name>Celina Camargo</Name> <Name>Ebony Archie</Name> <Telephone>395-293-5919</Telephone> Medications on Admission: Meds (at home): cymbalta 60 mg PO daily wellbutrin SR 450 mg PO daily lamictal 350 mg PO daily ambien 10 mg PO QHS prilosec 20 mg PO daily and sometimes <Hospital>Davis-Buck Health System</Hospital> risperdal 0.5 mg PO QAM and 1 mg PO QHS (not taking for 1 week) klonopin 1 mg PO prn was stockpiling xanax, so not taking Meds (in ICU): NAC 560 mg/h IV gtt albuterol nebs prn Wellbutrin SR 150 mg <Hospital>Davis-Buck Health System</Hospital> duloxetine 60 mg PO daily heparin subQ 5000 TID lamictal 350 mg PO daily omeprazole 20 mg PO daily Discharge Medications: 1. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 6. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety/agitation. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 8. lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). Discharge Disposition: Extended Care Facility: <Hospital>Jackson, Gonzalez and Ali Hospital</Hospital> - <Location>Unit 3498 Box 1105 DPO AA 29613</Location> Discharge Diagnosis: Primary Diagnosis: Suicide ingestion Tylenol overdose Benzodiazepine overdose Bipolar disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a suicide attempt and treated to prevent organ damage. You were transferred to an inpatient psychiatric facility. Please take your medications as prescribed and make your follow up appointments. Followup Instructions: Please follow up with your psychiatrist within 2 weeks of your discharge from the psychiatric facility. Please follow up with your primary care physician <Name>Sean Davis</Name> 1 week of your discharge from the psychiatric facility: <Name>Shipley</Name>,<Name>Rocio</Name> R. <Telephone>443-370-5703</Telephone>	00000000000000000111111111000000000000000000000000000000001111111111000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110011100000000000000011111111111111000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000011111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110111111110111111111111000000000011111111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000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Date: 1919-12-3 Discharge Date: 1929-12-27 Date of Birth: 1993-11-7 Sex: F Service: MEDICINE Allergies: Cephalosporins / Floxin / Penicillins Attending:Raymond Chief Complaint: Xanax, Tylenol & Klonopin Overdose Major Surgical or Invasive Procedure: None History of Present Illness: 37 yo F with history of depression and suicidal attempt in the past presented with obtundation. Of note, her prior attempt was about 15 years ago during which she OD on theophylline, requiring intubation. She has been feeling more depressed over the last few months and has been seeing a therapist, on the ECT waiting list with recent evaluation by Dr. Kobayashi, Jai her partner. Celina Camargo reports taking 120 mg of Xanax and 80 mg Klonopin in the afternoon of 1919-12-3 as well as at least 8-18 g of Tylenol daily over the last 2 weeks. She also admitted to taking 20 mg of Ambien. She says that she was taking the tylenol intentionally to worsen her liver function. She says that she decided to do this because she wanted to commit suicide. She also reports having had 1 glass of wine on the day of these medication ingestions. She then called one of her friends afterwards, and her therapist (Carl Lees) was subsequently involved and called the EMS for patient. In the ED, her initial VS were HR 99, BP 102/56, RR 20, and 98% on RA. She arrived with her friend, very lethargic. Per report, was only responsive to sternal rub and GCS of 8 throughout. Tox screen showed positive benzos and acetaminophen only. ECG showed sinus tachycardia. UA was negative. CT head did not show ICH. Her initial Tylenol level was 40. Toxicology was consulted and recommended NAC for 21 hours until level is undetectable and LFT stabilizes. She started NAC in the ED and her repeat level was 29. VS prior to transfer were T95, HR 66, BP 121/73, RR 22, O2Sat 98% RA. She was transferred to the ICU for her poor mental status. While on the floor, appears comfortable, denies any SOB, chest pain/discomfort, abdominal pain/discomfort, urinary symptoms or URI symptoms. She does have some throat tightness and discomfort when swallowing. Her partner reports that patient's mental status seems to have improved since her initial arrival to the ED. Past Medical History: - Asthma, requiring 1x intubation in late teen (unclear if this was related to the theophylline) - GERD with severe esophagitis (1968) - Insomnia - Bipolar Type 2, currently severe depression, requiring hospitalization at Bryan in the past - Depression - Suicidal attempts (last 10-1953 following impulsive suicide attempt in which she crashed her cars, 2 other ones with OD in her late teens) Social History: Occupation: a nurse mid-wife at Henry Mao x 10 years Drugs: Marijuana, last used about 1 week ago Tobacco: None Alcohol: occasionally Married to Emily Naegelin 395-293-5919, live in 779 Anthony Courts Markville, NH 43829. Family History: - mother- depression - maternal grandmother- EtOH abuse, benzodiazepine abuse - maternal uncle- bipolar affective d/o Physical Exam: Physical Exam on Arrival to Robinson LLC Health System: Temp: 36.9 BP 116/51, HR 65, RR25, O2Sat 99% RA General: lethargic, answers questions appropriately but in whispers, follows commands, NAD HEENT: PERRL, EOMi, anicteric, Mucous membrane moist NECK: no supraclavicular or cervical LAD, no JVD, no carotid bruits, no stridor Resp: CTAB with good air movement throughout, no wheeze, crackles, or rhonchi CV: RR, S1 and S2 wnl, no m/r/g ABD: soft, ND, mildly tender in the umbilical area, no hepatosplenomegaly, no guarding. EXT: no c/c/e SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: 1919-12-3 - CT head: There is no acute intracranial hemorrhage, acute large major vascular territory infarction, discrete masses, mass effect, brain edema or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. The visualized osseous structures are unremarkable. The visualized paranasal sinuses are within normal limits. Incidentally noted is a faintly-calcified likely sebaceous cyst in the left paramedian frontovertex scalp soft tissues (2:26-27); correlate with physical examination. IMPRESSION: No acute intracranial process 1905-2-25 06:50AM BLOOD WBC-4.7 RBC-3.78* Hgb-11.8* Hct-32.8* MCV-87 MCH-31.2 MCHC-36.0* RDW-13.5 Plt Ct-238 1919-12-3 03:00PM BLOOD WBC-6.0 RBC-4.03* Hgb-12.6 Hct-36.0 MCV-90 MCH-31.4 MCHC-35.1* RDW-12.8 Plt Ct-275 1920-10-10 05:39AM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2* 1905-2-25 06:50AM BLOOD PT-12.4 INR(PT)-1.0 1919-12-3 03:00PM BLOOD Neuts-66.7 Lymphs-26.5 Monos-3.5 Eos-2.2 Baso-1.0 1905-2-25 06:50AM BLOOD Glucose-82 UreaN-6 Creat-0.6 Na-139 K-3.8 Cl-106 HCO3-26 AnGap-11 1919-12-3 03:00PM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139 K-3.8 Cl-104 HCO3-26 AnGap-13 1905-2-25 06:50AM BLOOD ALT-21 AST-13 1920-10-10 02:23AM BLOOD ALT-25 AST-24 LD(LDH)-340* AlkPhos-39 TotBili-0.3 1919-12-3 03:00PM BLOOD ALT-28 AST-22 LD(LDH)-161 AlkPhos-56 TotBili-0.4 1905-2-25 06:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9 1919-12-3 03:00PM BLOOD HCG-1919-12-3 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-40* Bnzodzp-POS Barbitr-NEG Tricycl-NEG 1919-12-3 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-29 Bnzodzp-POS Barbitr-NEG Tricycl-NEG 1920-10-10 02:23AM BLOOD Acetmnp-6* 1920-10-10 07:00PM BLOOD Acetmnp-NEG Brief Hospital Course: 37 yo F with depression on ECT waiting list and remote history of suicidal attempts presents with OD of benzodiazepine and Tylenol Medicaion Overdose, an attempt to suicide. The patient was treated supportively for benzodiazepine overdose and did not require mechanical ventilation. In regards to tylenol toxicity she required a N acetylcysteine drip for a tylenol level of 40 and normal liver function tests, after stopping the NAC drip her tylenol level was negative and LFTs remained normal. She was medically cleared for discharge to a psyhiatric inpatient facility as of the a.m. of 1905-2-25, she is also medically cleared for ECT. In regards to her bipolar disorder and suicide attempt psychiatry was consulted and suggested the following medication regimen: Wellbutrin 150mg po bid, duloxetine 60mg po daily, lamotrigine 350mg po daily, risperdal 0.5mg po bid prn, and ambien 10mg po qhs prn insomnia. Asthma. Does not appear to be active currently. prn albuterol / atrovent nebs. GERD: continued home omeprazole Communication/Emergency Contact: partner Celina Camargo Ebony Archie 395-293-5919 Medications on Admission: Meds (at home): cymbalta 60 mg PO daily wellbutrin SR 450 mg PO daily lamictal 350 mg PO daily ambien 10 mg PO QHS prilosec 20 mg PO daily and sometimes Davis-Buck Health System risperdal 0.5 mg PO QAM and 1 mg PO QHS (not taking for 1 week) klonopin 1 mg PO prn was stockpiling xanax, so not taking Meds (in ICU): NAC 560 mg/h IV gtt albuterol nebs prn Wellbutrin SR 150 mg Davis-Buck Health System duloxetine 60 mg PO daily heparin subQ 5000 TID lamictal 350 mg PO daily omeprazole 20 mg PO daily Discharge Medications: 1. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 6. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety/agitation. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 8. lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Jackson, Gonzalez and Ali Hospital - Unit 3498 Box 1105 DPO AA 29613 Discharge Diagnosis: Primary Diagnosis: Suicide ingestion Tylenol overdose Benzodiazepine overdose Bipolar disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a suicide attempt and treated to prevent organ damage. You were transferred to an inpatient psychiatric facility. Please take your medications as prescribed and make your follow up appointments. Followup Instructions: Please follow up with your psychiatrist within 2 weeks of your discharge from the psychiatric facility. Please follow up with your primary care physician Sean Davis 1 week of your discharge from the psychiatric facility: Shipley,Rocio R. 443-370-5703	['Admission Date: 1919-12-3 Discharge Date: 1929-12-27\n\nDate of Birth: 1993-11-7 Sex: F\n\nService: MEDICINE\n\nAllergies:\nCephalosporins / Floxin / Penicillins\n\nAttending:Raymond\nChief Complaint:\nXanax, Tylenol & Klonopin Overdose\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\n37 yo F with history of depression and suicidal attempt in the\npast presented with obtundation. Of note, her prior attempt was\nabout 15 years ago during which she OD on theophylline,\nrequiring intubation. She has been feeling more depressed over\nthe last few months and has been seeing a therapist, on the ECT\nwaiting list with recent evaluation by Dr. Kobayashi, Jai her\npartner. Celina Camargo reports taking 120 mg of Xanax and 80 mg\nKlonopin in the afternoon of 1919-12-3 as well as at least 8-18\ng of Tylenol daily over the last 2 weeks.', ' She also admitted to\ntaking 20 mg of Ambien. She says that she was taking the\ntylenol intentionally to worsen her liver function. She says\nthat she decided to do this because she wanted to commit\nsuicide. She also reports having had 1 glass of wine on the day\nof these medication ingestions. She then called one of her\nfriends afterwards, and her therapist (Carl Lees) was\nsubsequently involved and called the EMS for patient.\n\nIn the ED, her initial VS were HR 99, BP 102/56, RR 20, and 98%\non RA. She arrived with her friend, very lethargic. Per\nreport, was only responsive to sternal rub and GCS of 8\nthroughout. Tox screen showed positive benzos and acetaminophen\nonly. ECG showed sinus tachycardia. UA was negative. CT head\ndid not show ICH. Her initial Tylenol level was 40. Toxicology\nwas consulted and recommended NAC for 21 hours until level is\nundetectable and LFT stabilizes.', " She started NAC in the ED and\nher repeat level was 29. VS prior to transfer were T95, HR 66,\nBP 121/73, RR 22, O2Sat 98% RA.\n\nShe was transferred to the ICU for her poor mental status.\nWhile on the floor, appears comfortable, denies any SOB, chest\npain/discomfort, abdominal pain/discomfort, urinary symptoms or\nURI symptoms. She does have some throat tightness and\ndiscomfort when swallowing. Her partner reports that patient's\nmental status seems to have improved since her initial arrival\nto the ED.\n\n\nPast Medical History:\n- Asthma, requiring 1x intubation in late teen (unclear if this\nwas related to the theophylline)\n- GERD with severe esophagitis (1968)\n- Insomnia\n- Bipolar Type 2, currently severe depression, requiring\nhospitalization at Bryan in the past\n- Depression\n- Suicidal attempts (last 10-1953 following impulsive suicide\nattempt in which she crashed her cars, 2 other ones with OD in\nher late teens)\n\n\nSocial History:\nOccupation: a nurse mid-wife at Henry Mao x 10 years\nDrugs: Marijuana, last used about 1 week ago\nTobacco: None\nAlcohol: occasionally\nMarried to Emily Naegelin 395-293-5919, live in 779 Anthony Courts\nMarkville, NH 43829.", '\n\n\nFamily History:\n- mother- depression\n- maternal grandmother- EtOH abuse, benzodiazepine abuse\n- maternal uncle- bipolar affective d/o\n\n\nPhysical Exam:\nPhysical Exam on Arrival to Robinson LLC Health System: Temp: 36.9 BP 116/51, HR 65, RR25, O2Sat 99% RA\nGeneral: lethargic, answers questions appropriately but in\nwhispers, follows commands, NAD\nHEENT: PERRL, EOMi, anicteric, Mucous membrane moist\nNECK: no supraclavicular or cervical LAD, no JVD, no carotid\nbruits, no stridor\nResp: CTAB with good air movement throughout, no wheeze,\ncrackles, or rhonchi\nCV: RR, S1 and S2 wnl, no m/r/g\nABD: soft, ND, mildly tender in the umbilical area, no\nhepatosplenomegaly, no guarding.\nEXT: no c/c/e\nSKIN: no rashes/no jaundice\nNEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No\nsensory deficits to light touch appreciated.', '\n\nPertinent Results:\n1919-12-3\n- CT head: There is no acute intracranial hemorrhage, acute\nlarge major\nvascular territory infarction, discrete masses, mass effect,\nbrain edema or\nshift of normally midline structures. The ventricles and sulci\nare normal in size and configuration. The visualized osseous\nstructures are unremarkable. The visualized paranasal sinuses\nare within normal limits. Incidentally noted is a\nfaintly-calcified likely sebaceous cyst in the left\nparamedian frontovertex scalp soft tissues (2:26-27); correlate\nwith physical examination.\nIMPRESSION: No acute intracranial process\n1905-2-25 06:50AM BLOOD WBC-4.7 RBC-3.78* Hgb-11.8* Hct-32.8\nMCV-87 MCH-31.2 MCHC-36.0 RDW-13.5 Plt Ct-238\n1919-12-3 03:00PM BLOOD WBC-6.0 RBC-4.03* Hgb-12.6 Hct-36.0\nMCV-90 MCH-31.4 MCHC-35.1* RDW-12.', '8 Plt Ct-275\n1920-10-10 05:39AM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2\n1905-2-25 06:50AM BLOOD PT-12.4 INR(PT)-1.0\n1919-12-3 03:00PM BLOOD Neuts-66.7 Lymphs-26.5 Monos-3.5 Eos-2.2\nBaso-1.0\n1905-2-25 06:50AM BLOOD Glucose-82 UreaN-6 Creat-0.6 Na-139 K-3.8\nCl-106 HCO3-26 AnGap-11\n1919-12-3 03:00PM BLOOD Glucose-107 UreaN-7 Creat-0.8 Na-139\nK-3.8 Cl-104 HCO3-26 AnGap-13\n1905-2-25 06:50AM BLOOD ALT-21 AST-13\n1920-10-10 02:23AM BLOOD ALT-25 AST-24 LD(LDH)-340* AlkPhos-39\nTotBili-0.3\n1919-12-3 03:00PM BLOOD ALT-28 AST-22 LD(LDH)-161 AlkPhos-56\nTotBili-0.4\n1905-2-25 06:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9\n1919-12-3 03:00PM BLOOD HCG-1919-12-3 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-40\nBnzodzp-POS Barbitr-NEG Tricycl-NEG\n1919-12-3 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-29\nBnzodzp-POS Barbitr-NEG Tricycl-NEG\n1920-10-10 02:23AM BLOOD Acetmnp-6\n\n1920-10-10 07:00PM BLOOD Acetmnp-NEG\n\nBrief Hospital Course:\n37 yo F with depression on ECT waiting list and remote history\nof suicidal attempts presents with OD of benzodiazepine and\nTylenol\n\nMedicaion Overdose, an attempt to suicide.', ' The patient was\ntreated supportively for benzodiazepine overdose and did not\nrequire mechanical ventilation. In regards to tylenol toxicity\nshe required a N acetylcysteine drip for a tylenol level of 40\nand normal liver function tests, after stopping the NAC drip her\ntylenol level was negative and LFTs remained normal. She was\nmedically cleared for discharge to a psyhiatric inpatient\nfacility as of the a.m. of 1905-2-25, she is also medically\ncleared for ECT. In regards to her bipolar disorder and suicide\nattempt psychiatry was consulted and suggested the following\nmedication regimen: Wellbutrin 150mg po bid, duloxetine 60mg po\ndaily, lamotrigine 350mg po daily, risperdal 0.5mg po bid prn,\nand ambien 10mg po qhs prn insomnia.\n\nAsthma. Does not appear to be active currently. prn albuterol /\natrovent nebs.', '\n\nGERD: continued home omeprazole\n\nCommunication/Emergency Contact: partner Celina Camargo Ebony Archie\n395-293-5919\n\nMedications on Admission:\nMeds (at home):\ncymbalta 60 mg PO daily\nwellbutrin SR 450 mg PO daily\nlamictal 350 mg PO daily\nambien 10 mg PO QHS\nprilosec 20 mg PO daily and sometimes Davis-Buck Health System\nrisperdal 0.5 mg PO QAM and 1 mg PO QHS (not taking for 1 week)\nklonopin 1 mg PO prn\nwas stockpiling xanax, so not taking\n\nMeds (in ICU):\nNAC 560 mg/h IV gtt\nalbuterol nebs prn\nWellbutrin SR 150 mg Davis-Buck Health System\nduloxetine 60 mg PO daily\nheparin subQ 5000 TID\nlamictal 350 mg PO daily\nomeprazole 20 mg PO daily\n\n\nDischarge Medications:\n1. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs\nInhalation four times a day as needed for shortness of breath or\nwheezing.', '\n2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\nCapsule, Delayed Release(E.C.) PO DAILY (Daily).\n3. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)\nTablet Sustained Release PO BID (2 times a day).\n4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)\nCapsule, Delayed Release(E.C.) PO DAILY (Daily).\n5. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)\nas needed for insomnia.\n6. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times\na day) as needed for anxiety/agitation.\n7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO\nDAILY (Daily) as needed for constipation.\n8. lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).\n\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nJackson, Gonzalez and Ali Hospital - Unit 3498 Box 1105\nDPO AA 29613\n\nDischarge Diagnosis:\nPrimary Diagnosis:\nSuicide ingestion\nTylenol overdose\nBenzodiazepine overdose\nBipolar disorder\n\n\nDischarge Condition:\nMental Status: Clear and coherent.', '\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n\nDischarge Instructions:\nYou were admitted to the hospital after a suicide attempt and\ntreated to prevent organ damage. You were transferred to an\ninpatient psychiatric facility. Please take your medications as\nprescribed and make your follow up appointments.\n\nFollowup Instructions:\nPlease follow up with your psychiatrist within 2 weeks of your\ndischarge from the psychiatric facility.\n\nPlease follow up with your primary care physician Sean Davis 1 week\nof your discharge from the psychiatric facility: Shipley,Rocio R.\n443-370-5703\n\n\n\n']
213	4850	175619.0	2178-07-16	Discharge summary	Report	Admission Date: [2178-7-13] Discharge Date: [2178-7-16] Date of Birth: [2113-11-13] Sex: M Service: CARDIOTHORACIC Allergies: Bee Pollens Attending:[First Name3 (LF) 1283] Chief Complaint: decreased exercise tolerance Major Surgical or Invasive Procedure: Minimally invasive mitral valve repair w/annuloplasty band History of Present Illness: 64 y/o male w/known MVP, decreasing exercise tolerance, followed by echo. Recently with severe MR, decreased LVEF. Past Medical History: MI MR/MVP hepercholesterolemia HTN BPH s/p tonsillectomy s/p repair of deviated septum Social History: married never smoked 2 glasses wine/day no drug abuse history Family History: mother died of MI at age 55 father died of MI age 62 Physical Exam: unremarkable pre-op Pertinent Results: [2178-7-16] 07:20AM BLOOD WBC-8.1 RBC-2.91* Hgb-9.1* Hct-26.6* MCV-92 MCH-31.3 MCHC-34.2 RDW-14.1 Plt Ct-113* [2178-7-16] 07:20AM BLOOD Plt Ct-113* [2178-7-15] 06:40AM BLOOD Glucose-114* UreaN-22* Creat-0.8 Na-136 K-4.4 Cl-105 HCO3-27 AnGap-8 Brief Hospital Course: Mr. [Known lastname 2137] was admitted to the pre-op holding area on [2178-7-13] and taken to the operating room where he underwent a minimally invasive mitral valve repair w/annuloplasty band. Post-operatively he was taken to the cardiac surgery recovery unit. He was weaned from mechanical ventilation and extubated the evening of surgery. He was transferred to the telemetry floor on POD # 1. His chest tubes were removed without issue. He worked with physical therapy to improve his strength and mobility. He has remained hemodynamically stable and was discharged home on postoperative day three. He will follow-up with Dr. [Last Name (STitle) 1290], his cardiologist and his primary care physician as an outpatient. Medications on Admission: ASA 81' Lipitor 80' Lisinopril 40' Terazosin 5' Proscar 5' Zetia 10' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. 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. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 weeks: then Q 6 hours prn pain. Disp:90 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: MR s/p min inv MV Repair(#34 annuloplasty band PMH: MR, ^chol, HTN, BPH Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions take all medications as prescribed call for any fever, redness or drainage from wounds [Last Name (NamePattern4) 2138]p Instructions: with Dr. [Last Name (Prefixes) ] in 4 weeks with Dr. [First Name (STitle) ] in [12-26] weeks with Dr. [Last Name (STitle) ] in [12-26] weeks Completed by:[2178-7-31]	Admission Date: <Date>1908-1-4</Date> Discharge Date: <Date>1938-3-15</Date> Date of Birth: <Date>2021-6-15</Date> Sex: M Service: CARDIOTHORACIC Allergies: Bee Pollens Attending:<Name>Janet</Name> Chief Complaint: decreased exercise tolerance Major Surgical or Invasive Procedure: Minimally invasive mitral valve repair w/annuloplasty band History of Present Illness: 64 y/o male w/known MVP, decreasing exercise tolerance, followed by echo. Recently with severe MR, decreased LVEF. Past Medical History: MI MR/MVP hepercholesterolemia HTN BPH s/p tonsillectomy s/p repair of deviated septum Social History: married never smoked 2 glasses wine/day no drug abuse history Family History: mother died of MI at age 55 father died of MI age 62 Physical Exam: unremarkable pre-op Pertinent Results: <Date>1938-3-15</Date> 07:20AM BLOOD WBC-8.1 RBC-2.91* Hgb-9.1* Hct-26.6* MCV-92 MCH-31.3 MCHC-34.2 RDW-14.1 Plt Ct-113* <Date>1938-3-15</Date> 07:20AM BLOOD Plt Ct-113* <Date>1920-2-7</Date> 06:40AM BLOOD Glucose-114* UreaN-22* Creat-0.8 Na-136 K-4.4 Cl-105 HCO3-27 AnGap-8 Brief Hospital Course: Mr. <Name>Grier</Name> was admitted to the pre-op holding area on <Date>1908-1-4</Date> and taken to the operating room where he underwent a minimally invasive mitral valve repair w/annuloplasty band. Post-operatively he was taken to the cardiac surgery recovery unit. He was weaned from mechanical ventilation and extubated the evening of surgery. He was transferred to the telemetry floor on POD # 1. His chest tubes were removed without issue. He worked with physical therapy to improve his strength and mobility. He has remained hemodynamically stable and was discharged home on postoperative day three. He will follow-up with Dr. <Name>Debelius</Name>, his cardiologist and his primary care physician as an outpatient. Medications on Admission: ASA 81' Lipitor 80' Lisinopril 40' Terazosin 5' Proscar 5' Zetia 10' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. 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. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 weeks: then Q 6 hours prn pain. Disp:90 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: <Hospital>Reeves, Smith and Woods Health System</Hospital> VNA Discharge Diagnosis: MR s/p min inv MV Repair(#34 annuloplasty band PMH: MR, ^chol, HTN, BPH Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions take all medications as prescribed call for any fever, redness or drainage from wounds <Name>Porras</Name>p Instructions: with Dr. <Name>Kaur</Name> in 4 weeks with Dr. <Name>Noah</Name> in <Date>6-9</Date> weeks with Dr. <Name>Hall</Name> in <Date>6-9</Date> weeks Completed by:<Date>1975-12-25</Date>	0000000000000000011111111000000000000000000000000000000001111111110000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111110000000000000000000000000111100000000000000000000011110000111000000000000000011110000111000000000000000000000001111111111	Admission Date: 1908-1-4 Discharge Date: 1938-3-15 Date of Birth: 2021-6-15 Sex: M Service: CARDIOTHORACIC Allergies: Bee Pollens Attending:Janet Chief Complaint: decreased exercise tolerance Major Surgical or Invasive Procedure: Minimally invasive mitral valve repair w/annuloplasty band History of Present Illness: 64 y/o male w/known MVP, decreasing exercise tolerance, followed by echo. Recently with severe MR, decreased LVEF. Past Medical History: MI MR/MVP hepercholesterolemia HTN BPH s/p tonsillectomy s/p repair of deviated septum Social History: married never smoked 2 glasses wine/day no drug abuse history Family History: mother died of MI at age 55 father died of MI age 62 Physical Exam: unremarkable pre-op Pertinent Results: 1938-3-15 07:20AM BLOOD WBC-8.1 RBC-2.91* Hgb-9.1* Hct-26.6* MCV-92 MCH-31.3 MCHC-34.2 RDW-14.1 Plt Ct-113* 1938-3-15 07:20AM BLOOD Plt Ct-113* 1920-2-7 06:40AM BLOOD Glucose-114* UreaN-22* Creat-0.8 Na-136 K-4.4 Cl-105 HCO3-27 AnGap-8 Brief Hospital Course: Mr. Grier was admitted to the pre-op holding area on 1908-1-4 and taken to the operating room where he underwent a minimally invasive mitral valve repair w/annuloplasty band. Post-operatively he was taken to the cardiac surgery recovery unit. He was weaned from mechanical ventilation and extubated the evening of surgery. He was transferred to the telemetry floor on POD # 1. His chest tubes were removed without issue. He worked with physical therapy to improve his strength and mobility. He has remained hemodynamically stable and was discharged home on postoperative day three. He will follow-up with Dr. Debelius, his cardiologist and his primary care physician as an outpatient. Medications on Admission: ASA 81' Lipitor 80' Lisinopril 40' Terazosin 5' Proscar 5' Zetia 10' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. 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. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 weeks: then Q 6 hours prn pain. Disp:90 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Reeves, Smith and Woods Health System VNA Discharge Diagnosis: MR s/p min inv MV Repair(#34 annuloplasty band PMH: MR, ^chol, HTN, BPH Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions take all medications as prescribed call for any fever, redness or drainage from wounds Porrasp Instructions: with Dr. Kaur in 4 weeks with Dr. Noah in 6-9 weeks with Dr. Hall in 6-9 weeks Completed by:1975-12-25	['Admission Date: 1908-1-4 Discharge Date: 1938-3-15\n\nDate of Birth: 2021-6-15 Sex: M\n\nService: CARDIOTHORACIC\n\nAllergies:\nBee Pollens\n\nAttending:Janet\nChief Complaint:\ndecreased exercise tolerance\n\nMajor Surgical or Invasive Procedure:\nMinimally invasive mitral valve repair w/annuloplasty band\n\n\nHistory of Present Illness:\n64 y/o male w/known MVP, decreasing exercise tolerance, followed\nby echo. Recently with severe MR, decreased LVEF.\n\nPast Medical History:\nMI\nMR/MVP\nhepercholesterolemia\nHTN\nBPH\ns/p tonsillectomy\ns/p repair of deviated septum\n\n\nSocial History:\nmarried\nnever smoked\n2 glasses wine/day\nno drug abuse history\n\nFamily History:\nmother died of MI at age 55\nfather died of MI age 62\n\nPhysical Exam:\nunremarkable pre-op\n\nPertinent Results:\n1938-3-15 07:20AM BLOOD WBC-8.', '1 RBC-2.91* Hgb-9.1* Hct-26.6\nMCV-92 MCH-31.3 MCHC-34.2 RDW-14.1 Plt Ct-113\n1938-3-15 07:20AM BLOOD Plt Ct-113\n1920-2-7 06:40AM BLOOD Glucose-114 UreaN-22* Creat-0.8 Na-136\nK-4.4 Cl-105 HCO3-27 AnGap-8\n\nBrief Hospital Course:\nMr. Grier was admitted to the pre-op holding area on 1908-1-4\nand taken to the operating room where he underwent a minimally\ninvasive mitral valve repair w/annuloplasty band.\nPost-operatively he was taken to the cardiac surgery recovery\nunit. He was weaned from mechanical ventilation and extubated\nthe evening of surgery. He was transferred to the telemetry\nfloor on POD # 1. His chest tubes were removed without issue.\nHe worked with physical therapy to improve his strength and\nmobility. He has remained hemodynamically stable and was\ndischarged home on postoperative day three.', " He will follow-up\nwith Dr. Debelius, his cardiologist and his primary care\nphysician as an outpatient.\n\nMedications on Admission:\nASA 81'\nLipitor 80'\nLisinopril 40'\nTerazosin 5'\nProscar 5'\nZetia 10'\n\n\nDischarge Medications:\n1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\nDisp:60 Capsule(s) Refills:2\n2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day).\nDisp:60 Tablet(s) Refills:2\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. 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. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.", '\nDisp:30 Tablet(s) Refills:2\n6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\nDisp:30 Tablet(s) Refills:2\n7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\nDisp:30 Tablet(s) Refills:2\n8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\nhours) for 2 weeks: then Q 6 hours prn pain.\nDisp:90 Tablet(s) Refills:0\n9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day\nfor 7 days.\nDisp:14 Tablet(s) Refills:0\n10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:\nTwo (2) Capsule, Sustained Release PO Q12H (every 12 hours) for\n7 days.\nDisp:28 Capsule, Sustained Release(s) Refills:0\n11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at\nbedtime).\nDisp:30 Capsule(s) Refills:2\n12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).', '\nDisp:30 Tablet(s) Refills:2\n13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a\nday.\nDisp:60 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nReeves, Smith and Woods Health System VNA\n\nDischarge Diagnosis:\nMR s/p min inv MV Repair(#34 annuloplasty band\nPMH: MR, ^chol, HTN, BPH\n\n\nDischarge Condition:\ngood\n\n\nDischarge Instructions:\nmay shower, no bathing or swimming for 1 month\nno creams, lotions or powders to any incisions\ntake all medications as prescribed\ncall for any fever, redness or drainage from wounds\n\nPorrasp Instructions:\nwith Dr. Kaur in 4 weeks\nwith Dr. Noah in 6-9 weeks\nwith Dr. Hall in 6-9 weeks\n\n\n\nCompleted by:1975-12-25']
214	13723	193691.0	2182-01-22	Discharge summary	Report	Admission Date: [2182-1-19] Discharge Date: [2155-2-24] Service: HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old female with a history of coronary artery disease now with bradycardia. He had an episode of dizziness when walking today. His wife took his pulse and noticed it was "slow." The patient reportedly had some relief from his symptoms after his wife gave him a sublingual nitroglycerin. He subsequently had a second episode of dizziness at rest and went to the Emergency Department. There, he was found to have a pulse of 30 without P waves. External pacing was attempted and unsuccessful capturing. Atropine was given without effect. He was started on dopamine 10 mcg per minute and noted to revert to sinus at 50 beats per minute then hypertension to the 200s. The patient was reportedly still complaining of dizziness while in sinus. He denied chest pain, shortness of breath, abdominal pain, and palpitations. He had an exercise treadmill test on [2181-1-5] which was stopped for shortness of breath with no ST segment changes. Rhythm was sinus with rare isolated AEA and VEA with blood pressure responsive flat. Nuclear images with moderate defects, apex with ejection fraction of 65% and mild apical hypokinesis. PAST MEDICAL HISTORY: 1. Coronary artery disease; in [2179-5-27] with 20% left main coronary artery, a DV left anterior descending with noncritical stenosis and widely patent stent in the proximal segment. First obtuse marginal with critical lesion. Left circumflex with mild luminal irregularities and 40% proximal right coronary artery. Mild diastolic function with ejection fraction of 60% with a normal wall motion. 2. Hepatitis C virus. 3. Hypertension. 4. Nocturia. 5. Osteoarthritis. 6. Ventral hernia. 7. Cholelithiasis; status post endoscopic retrograde cholangiopancreatography. 8. Colon cancer; status post colectomy in [2165]. 9. Positive purified protein derivative. 10. Cervical degenerative joint disease. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Atorvastatin p.o. q.d. 4. Doxazosin p.o. q.h.s. 5. Zoloxafed 200 p.m. 6. Tolterodine 200 mg p.o. b.i.d. 7. Losartan 80 mg p.o. q.d. 8. Diphenhydramine 50 mg p.o. q.h.s. 9. Glucosamine 500 mg p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, his pulse was 35, blood pressure was 100/42, respiratory rate was 22. He was 91% on room air. In general, he was lying with the head of the bed at 20 degrees, in no acute distress. His pupils were equally round and reactive to light and accommodation. Extraocular motions were intact. Oral mucous membranes were dry. Jugular venous distention was difficult to assess secondary to constant head and oral movement. He was bradycardic with a normal S1 and S2. No murmurs, rubs, or gallops. His lungs were clear to auscultation anteriorly. His abdomen with a prominent ventral hernia was soft, nontender, and nondistended. Normal active bowel sounds. His extremities showed 2+ dorsalis pedis pulses bilaterally with no pitting edema. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 7.8, hematocrit was 42.6, and platelets were 180. Prothrombin time was 12.9, partial thromboplastin time was 24.2, INR was 1.1. Sodium was 145, potassium was 5.1, chloride was 109, bicarbonate was 27, blood urea nitrogen was 22, creatinine was 1.2, and blood glucose was 115. CK was 63. Troponin was less than 0.3. Calcium was 9.9, magnesium was 1.9, phosphate was 5.2. RADIOLOGY/IMAGING: Electrocardiogram showed junctional bradycardia at 36 beats per minute with left axis with waves in III and aVF and inverted T waves in III with no ST segment changes. Electrocardiogram after dopamine showed a normal sinus rhythm at 61 beats per minute, a left axis, high-normal P-R interval, Q waves in III and aVF, T wave flattening in III, and no ST segment changes. HOSPITAL COURSE: He was admitted to the Coronary Care Unit as a percutaneous wire was unable to capture and v-pace. His heart rate was maintained on dopamine. His rhythm was found to be an atrial exit block, likely the cause of his dizziness. He was evaluated by Electrophysiology and was sent for pacemaker placement. On the second night of admission he was complaining of insomnia and was given Ambien and became very agitated. At that time, he pulled out his right internal jugular Cordis. Two hours after replaced, he received 2 mg of intravenous haloperidol for the confusion and seemed to calm down. It was thought to be secondary to the Ambien which was discontinued. He had no further episodes of hallucinations or agitation at that time. His creatinine improved with hydration to his baseline of around 0.8. He was maintained on his outpatient medications for BPH and osteoarthritis. He received a pacemaker on [2182-1-21] without complications. His hematocrit remained stable. He had received three doses of vancomycin perioperatively. His beta blocker and angiotensin receptor blocker were resumed as they had previously been held while on dopamine and also with his tendency for bradycardia. These were resumed without issue. The only complicating factor was he was slightly nauseated with vomiting after returning from his procedure. It was thought this was likely due to the sedation. He was given antiemetics, and it resolved the following day when the sedation wore off. He was able to eat and ambulate without dizziness or concern. Therefore, he was discharged home in good condition. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Atorvastatin p.o. q.d. 4. Doxazosin p.o. q.h.s. 5. Zoloxafed 200 p.m. 6. Tolterodine 200 mg p.o. b.i.d. 7. Losartan 80 mg p.o. q.d. 8. Diphenhydramine 50 mg p.o. q.h.s. 9. Glucosamine 500 mg p.o. q.d. Of note, it should be noted that the patient should not be given Ambien as it causes agitation and delirium. DISCHARGE INSTRUCTIONS/FOLLOWUP: He was to follow up with the Electrophysiology Clinic. [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ], M.D. [MD Number(2) 2139] Dictated By:[Last Name (NamePattern1) 2140] MEDQUIST36 D: [2182-1-22] 14:14 T: [2182-1-22] 19:23 JOB#: [Job Number 2141]	Admission Date: <Date>1904-5-29</Date> Discharge Date: <Date>1902-9-23</Date> Service: HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old female with a history of coronary artery disease now with bradycardia. He had an episode of dizziness when walking today. His wife took his pulse and noticed it was "slow." The patient reportedly had some relief from his symptoms after his wife gave him a sublingual nitroglycerin. He subsequently had a second episode of dizziness at rest and went to the Emergency Department. There, he was found to have a pulse of 30 without P waves. External pacing was attempted and unsuccessful capturing. Atropine was given without effect. He was started on dopamine 10 mcg per minute and noted to revert to sinus at 50 beats per minute then hypertension to the 200s. The patient was reportedly still complaining of dizziness while in sinus. He denied chest pain, shortness of breath, abdominal pain, and palpitations. He had an exercise treadmill test on <Date>2003-8-19</Date> which was stopped for shortness of breath with no ST segment changes. Rhythm was sinus with rare isolated AEA and VEA with blood pressure responsive flat. Nuclear images with moderate defects, apex with ejection fraction of 65% and mild apical hypokinesis. PAST MEDICAL HISTORY: 1. Coronary artery disease; in <Date>1924-2-20</Date> with 20% left main coronary artery, a DV left anterior descending with noncritical stenosis and widely patent stent in the proximal segment. First obtuse marginal with critical lesion. Left circumflex with mild luminal irregularities and 40% proximal right coronary artery. Mild diastolic function with ejection fraction of 60% with a normal wall motion. 2. Hepatitis C virus. 3. Hypertension. 4. Nocturia. 5. Osteoarthritis. 6. Ventral hernia. 7. Cholelithiasis; status post endoscopic retrograde cholangiopancreatography. 8. Colon cancer; status post colectomy in <Year>1988</Year>. 9. Positive purified protein derivative. 10. Cervical degenerative joint disease. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Atorvastatin p.o. q.d. 4. Doxazosin p.o. q.h.s. 5. Zoloxafed 200 p.m. 6. Tolterodine 200 mg p.o. b.i.d. 7. Losartan 80 mg p.o. q.d. 8. Diphenhydramine 50 mg p.o. q.h.s. 9. Glucosamine 500 mg p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, his pulse was 35, blood pressure was 100/42, respiratory rate was 22. He was 91% on room air. In general, he was lying with the head of the bed at 20 degrees, in no acute distress. His pupils were equally round and reactive to light and accommodation. Extraocular motions were intact. Oral mucous membranes were dry. Jugular venous distention was difficult to assess secondary to constant head and oral movement. He was bradycardic with a normal S1 and S2. No murmurs, rubs, or gallops. His lungs were clear to auscultation anteriorly. His abdomen with a prominent ventral hernia was soft, nontender, and nondistended. Normal active bowel sounds. His extremities showed 2+ dorsalis pedis pulses bilaterally with no pitting edema. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 7.8, hematocrit was 42.6, and platelets were 180. Prothrombin time was 12.9, partial thromboplastin time was 24.2, INR was 1.1. Sodium was 145, potassium was 5.1, chloride was 109, bicarbonate was 27, blood urea nitrogen was 22, creatinine was 1.2, and blood glucose was 115. CK was 63. Troponin was less than 0.3. Calcium was 9.9, magnesium was 1.9, phosphate was 5.2. RADIOLOGY/IMAGING: Electrocardiogram showed junctional bradycardia at 36 beats per minute with left axis with waves in III and aVF and inverted T waves in III with no ST segment changes. Electrocardiogram after dopamine showed a normal sinus rhythm at 61 beats per minute, a left axis, high-normal P-R interval, Q waves in III and aVF, T wave flattening in III, and no ST segment changes. HOSPITAL COURSE: He was admitted to the Coronary Care Unit as a percutaneous wire was unable to capture and v-pace. His heart rate was maintained on dopamine. His rhythm was found to be an atrial exit block, likely the cause of his dizziness. He was evaluated by Electrophysiology and was sent for pacemaker placement. On the second night of admission he was complaining of insomnia and was given Ambien and became very agitated. At that time, he pulled out his right internal jugular Cordis. Two hours after replaced, he received 2 mg of intravenous haloperidol for the confusion and seemed to calm down. It was thought to be secondary to the Ambien which was discontinued. He had no further episodes of hallucinations or agitation at that time. His creatinine improved with hydration to his baseline of around 0.8. He was maintained on his outpatient medications for BPH and osteoarthritis. He received a pacemaker on <Date>1933-2-4</Date> without complications. His hematocrit remained stable. He had received three doses of vancomycin perioperatively. His beta blocker and angiotensin receptor blocker were resumed as they had previously been held while on dopamine and also with his tendency for bradycardia. These were resumed without issue. The only complicating factor was he was slightly nauseated with vomiting after returning from his procedure. It was thought this was likely due to the sedation. He was given antiemetics, and it resolved the following day when the sedation wore off. He was able to eat and ambulate without dizziness or concern. Therefore, he was discharged home in good condition. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Atorvastatin p.o. q.d. 4. Doxazosin p.o. q.h.s. 5. Zoloxafed 200 p.m. 6. Tolterodine 200 mg p.o. b.i.d. 7. Losartan 80 mg p.o. q.d. 8. Diphenhydramine 50 mg p.o. q.h.s. 9. Glucosamine 500 mg p.o. q.d. Of note, it should be noted that the patient should not be given Ambien as it causes agitation and delirium. DISCHARGE INSTRUCTIONS/FOLLOWUP: He was to follow up with the Electrophysiology Clinic. <Name>Jermaine</Name> <Name>Benhamou</Name>, M.D. <MD Number>65154453</MD Number> Dictated By:<Name>Ahmed</Name> MEDQUIST36 D: <Date>1995-3-28</Date> 14:14 T: <Date>1995-3-28</Date> 19:23 JOB#: <Job Number>Walker PLC-1979-526494</Job 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Date: 1904-5-29 Discharge Date: 1902-9-23 Service: HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old female with a history of coronary artery disease now with bradycardia. He had an episode of dizziness when walking today. His wife took his pulse and noticed it was "slow." The patient reportedly had some relief from his symptoms after his wife gave him a sublingual nitroglycerin. He subsequently had a second episode of dizziness at rest and went to the Emergency Department. There, he was found to have a pulse of 30 without P waves. External pacing was attempted and unsuccessful capturing. Atropine was given without effect. He was started on dopamine 10 mcg per minute and noted to revert to sinus at 50 beats per minute then hypertension to the 200s. The patient was reportedly still complaining of dizziness while in sinus. He denied chest pain, shortness of breath, abdominal pain, and palpitations. He had an exercise treadmill test on 2003-8-19 which was stopped for shortness of breath with no ST segment changes. Rhythm was sinus with rare isolated AEA and VEA with blood pressure responsive flat. Nuclear images with moderate defects, apex with ejection fraction of 65% and mild apical hypokinesis. PAST MEDICAL HISTORY: 1. Coronary artery disease; in 1924-2-20 with 20% left main coronary artery, a DV left anterior descending with noncritical stenosis and widely patent stent in the proximal segment. First obtuse marginal with critical lesion. Left circumflex with mild luminal irregularities and 40% proximal right coronary artery. Mild diastolic function with ejection fraction of 60% with a normal wall motion. 2. Hepatitis C virus. 3. Hypertension. 4. Nocturia. 5. Osteoarthritis. 6. Ventral hernia. 7. Cholelithiasis; status post endoscopic retrograde cholangiopancreatography. 8. Colon cancer; status post colectomy in 1988. 9. Positive purified protein derivative. 10. Cervical degenerative joint disease. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Atorvastatin p.o. q.d. 4. Doxazosin p.o. q.h.s. 5. Zoloxafed 200 p.m. 6. Tolterodine 200 mg p.o. b.i.d. 7. Losartan 80 mg p.o. q.d. 8. Diphenhydramine 50 mg p.o. q.h.s. 9. Glucosamine 500 mg p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, his pulse was 35, blood pressure was 100/42, respiratory rate was 22. He was 91% on room air. In general, he was lying with the head of the bed at 20 degrees, in no acute distress. His pupils were equally round and reactive to light and accommodation. Extraocular motions were intact. Oral mucous membranes were dry. Jugular venous distention was difficult to assess secondary to constant head and oral movement. He was bradycardic with a normal S1 and S2. No murmurs, rubs, or gallops. His lungs were clear to auscultation anteriorly. His abdomen with a prominent ventral hernia was soft, nontender, and nondistended. Normal active bowel sounds. His extremities showed 2+ dorsalis pedis pulses bilaterally with no pitting edema. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 7.8, hematocrit was 42.6, and platelets were 180. Prothrombin time was 12.9, partial thromboplastin time was 24.2, INR was 1.1. Sodium was 145, potassium was 5.1, chloride was 109, bicarbonate was 27, blood urea nitrogen was 22, creatinine was 1.2, and blood glucose was 115. CK was 63. Troponin was less than 0.3. Calcium was 9.9, magnesium was 1.9, phosphate was 5.2. RADIOLOGY/IMAGING: Electrocardiogram showed junctional bradycardia at 36 beats per minute with left axis with waves in III and aVF and inverted T waves in III with no ST segment changes. Electrocardiogram after dopamine showed a normal sinus rhythm at 61 beats per minute, a left axis, high-normal P-R interval, Q waves in III and aVF, T wave flattening in III, and no ST segment changes. HOSPITAL COURSE: He was admitted to the Coronary Care Unit as a percutaneous wire was unable to capture and v-pace. His heart rate was maintained on dopamine. His rhythm was found to be an atrial exit block, likely the cause of his dizziness. He was evaluated by Electrophysiology and was sent for pacemaker placement. On the second night of admission he was complaining of insomnia and was given Ambien and became very agitated. At that time, he pulled out his right internal jugular Cordis. Two hours after replaced, he received 2 mg of intravenous haloperidol for the confusion and seemed to calm down. It was thought to be secondary to the Ambien which was discontinued. He had no further episodes of hallucinations or agitation at that time. His creatinine improved with hydration to his baseline of around 0.8. He was maintained on his outpatient medications for BPH and osteoarthritis. He received a pacemaker on 1933-2-4 without complications. His hematocrit remained stable. He had received three doses of vancomycin perioperatively. His beta blocker and angiotensin receptor blocker were resumed as they had previously been held while on dopamine and also with his tendency for bradycardia. These were resumed without issue. The only complicating factor was he was slightly nauseated with vomiting after returning from his procedure. It was thought this was likely due to the sedation. He was given antiemetics, and it resolved the following day when the sedation wore off. He was able to eat and ambulate without dizziness or concern. Therefore, he was discharged home in good condition. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Atorvastatin p.o. q.d. 4. Doxazosin p.o. q.h.s. 5. Zoloxafed 200 p.m. 6. Tolterodine 200 mg p.o. b.i.d. 7. Losartan 80 mg p.o. q.d. 8. Diphenhydramine 50 mg p.o. q.h.s. 9. Glucosamine 500 mg p.o. q.d. Of note, it should be noted that the patient should not be given Ambien as it causes agitation and delirium. DISCHARGE INSTRUCTIONS/FOLLOWUP: He was to follow up with the Electrophysiology Clinic. Jermaine Benhamou, M.D. 65154453 Dictated By:Ahmed MEDQUIST36 D: 1995-3-28 14:14 T: 1995-3-28 19:23 JOB#: Walker PLC-1979-526494	['Admission Date: 1904-5-29 Discharge Date: 1902-9-23\n\n\nService:\n\nHISTORY OF PRESENT ILLNESS: The patient is an 88-year-old\nfemale with a history of coronary artery disease now with\nbradycardia. He had an episode of dizziness when walking\ntoday. His wife took his pulse and noticed it was "slow."\nThe patient reportedly had some relief from his symptoms\nafter his wife gave him a sublingual nitroglycerin. He\nsubsequently had a second episode of dizziness at rest and\nwent to the Emergency Department.\n\nThere, he was found to have a pulse of 30 without P waves.\nExternal pacing was attempted and unsuccessful capturing.\nAtropine was given without effect. He was started on\ndopamine 10 mcg per minute and noted to revert to sinus at 50\nbeats per minute then hypertension to the 200s.\n\nThe patient was reportedly still complaining of dizziness\nwhile in sinus.', ' He denied chest pain, shortness of breath,\nabdominal pain, and palpitations.\n\nHe had an exercise treadmill test on 2003-8-19 which\nwas stopped for shortness of breath with no ST segment\nchanges. Rhythm was sinus with rare isolated AEA and VEA\nwith blood pressure responsive flat. Nuclear images with\nmoderate defects, apex with ejection fraction of 65% and mild\napical hypokinesis.\n\nPAST MEDICAL HISTORY:\n 1. Coronary artery disease; in 1924-2-20 with 20% left\nmain coronary artery, a DV left anterior descending with\nnoncritical stenosis and widely patent stent in the proximal\nsegment. First obtuse marginal with critical lesion. Left\ncircumflex with mild luminal irregularities and 40% proximal\nright coronary artery. Mild diastolic function with ejection\nfraction of 60% with a normal wall motion.', '\n 2. Hepatitis C virus.\n 3. Hypertension.\n 4. Nocturia.\n 5. Osteoarthritis.\n 6. Ventral hernia.\n 7. Cholelithiasis; status post endoscopic retrograde\ncholangiopancreatography.\n 8. Colon cancer; status post colectomy in 1988.\n 9. Positive purified protein derivative.\n10. Cervical degenerative joint disease.\n\nALLERGIES: He has no known drug allergies.\n\nMEDICATIONS ON ADMISSION:\n1. Aspirin 325 mg p.o. q.d.\n2. Atenolol 50 mg p.o. q.d.\n3. Atorvastatin p.o. q.d.\n4. Doxazosin p.o. q.h.s.\n5. Zoloxafed 200 p.m.\n6. Tolterodine 200 mg p.o. b.i.d.\n7. Losartan 80 mg p.o. q.d.\n8. Diphenhydramine 50 mg p.o. q.h.s.\n9. Glucosamine 500 mg p.o. q.d.\n\nPHYSICAL EXAMINATION ON PRESENTATION: On physical\nexamination, his pulse was 35, blood pressure was 100/42,\nrespiratory rate was 22. He was 91% on room air.', ' In\ngeneral, he was lying with the head of the bed at 20 degrees,\nin no acute distress. His pupils were equally round and\nreactive to light and accommodation. Extraocular motions\nwere intact. Oral mucous membranes were dry. Jugular venous\ndistention was difficult to assess secondary to constant head\nand oral movement. He was bradycardic with a normal S1 and\nS2. No murmurs, rubs, or gallops. His lungs were clear to\nauscultation anteriorly. His abdomen with a prominent\nventral hernia was soft, nontender, and nondistended. Normal\nactive bowel sounds. His extremities showed 2+ dorsalis\npedis pulses bilaterally with no pitting edema.\n\nPERTINENT LABORATORY VALUES ON PRESENTATION: White blood\ncell count was 7.8, hematocrit was 42.6, and platelets were\n180. Prothrombin time was 12.9, partial thromboplastin time\nwas 24.', '2, INR was 1.1. Sodium was 145, potassium was 5.1,\nchloride was 109, bicarbonate was 27, blood urea nitrogen was\n22, creatinine was 1.2, and blood glucose was 115. CK was\n63. Troponin was less than 0.3. Calcium was 9.9, magnesium\nwas 1.9, phosphate was 5.2.\n\nRADIOLOGY/IMAGING: Electrocardiogram showed junctional\nbradycardia at 36 beats per minute with left axis with waves\nin III and aVF and inverted T waves in III with no ST segment\nchanges.\n\nElectrocardiogram after dopamine showed a normal sinus rhythm\nat 61 beats per minute, a left axis, high-normal P-R\ninterval, Q waves in III and aVF, T wave flattening in III,\nand no ST segment changes.\n\nHOSPITAL COURSE: He was admitted to the Coronary Care Unit\nas a percutaneous wire was unable to capture and v-pace.\n\nHis heart rate was maintained on dopamine.', ' His rhythm was\nfound to be an atrial exit block, likely the cause of his\ndizziness. He was evaluated by Electrophysiology and was\nsent for pacemaker placement.\n\nOn the second night of admission he was complaining of\ninsomnia and was given Ambien and became very agitated. At\nthat time, he pulled out his right internal jugular Cordis.\nTwo hours after replaced, he received 2 mg of intravenous\nhaloperidol for the confusion and seemed to calm down. It\nwas thought to be secondary to the Ambien which was\ndiscontinued. He had no further episodes of hallucinations\nor agitation at that time.\n\nHis creatinine improved with hydration to his baseline of\naround 0.8. He was maintained on his outpatient medications\nfor BPH and osteoarthritis.\n\nHe received a pacemaker on 1933-2-4 without\ncomplications.', ' His hematocrit remained stable. He had\nreceived three doses of vancomycin perioperatively. His beta\nblocker and angiotensin receptor blocker were resumed as they\nhad previously been held while on dopamine and also with his\ntendency for bradycardia. These were resumed without issue.\n\nThe only complicating factor was he was slightly nauseated\nwith vomiting after returning from his procedure. It was\nthought this was likely due to the sedation. He was given\nantiemetics, and it resolved the following day when the\nsedation wore off.\n\nHe was able to eat and ambulate without dizziness or concern.\nTherefore, he was discharged home in good condition.\n\nMEDICATIONS ON DISCHARGE:\n1. Aspirin 325 mg p.o. q.d.\n2. Atenolol 50 mg p.o. q.d.\n3. Atorvastatin p.o. q.d.\n4. Doxazosin p.o. q.h.s.\n5. Zoloxafed 200 p.', 'm.\n6. Tolterodine 200 mg p.o. b.i.d.\n7. Losartan 80 mg p.o. q.d.\n8. Diphenhydramine 50 mg p.o. q.h.s.\n9. Glucosamine 500 mg p.o. q.d.\n\nOf note, it should be noted that the patient should not be\ngiven Ambien as it causes agitation and delirium.\n\nDISCHARGE INSTRUCTIONS/FOLLOWUP: He was to follow up with\nthe Electrophysiology Clinic.\n\n\n\n Jermaine Benhamou, M.D. 65154453\n\nDictated By:Ahmed\n\nMEDQUIST36\n\nD: 1995-3-28 14:14\nT: 1995-3-28 19:23\nJOB#: Walker PLC-1979-526494\n']
215	11018	104650.0	2148-12-11	Discharge summary	Report	Admission Date: [2148-12-2] Discharge Date: [2148-12-11] Date of Birth: [2084-12-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2145] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: BiPAP History of Present Illness: 64 yo AA male with HIV/AIDS (VL: 570; CD4: 251 on [11-27]'[48] currently treated with Combivir and Bactrim SS Mon, Wed, Fri for ppx as well as a flu shot for [2147]-[2148]) and COPD on home oxygen (FEV1/FVC: 34%; FEV1 26%; FVC: 77%) comes in with dyspnea for 6 days. The pt reports development of sob similar to his previous episodes of COPD/PNA. 2-3days ago, he subsequently developed cough productive of yellow-green sputum along with subjective fevers, chills, and diaphoresis. He also developed some pleuritic chest pain several days ago. The chest pain was located in the left side of the chest below the nipple line and occurred with deep inspiration. The pt reports these are all similar to previous episodes of COPD exacerbation. The pt had tried nebulizers Q4hours in addition to 2L NC one day PTA without any improvement. The pt uses oxygen at home 40% of the time, mostly when he is active. The pt noted inc. DOE even with the oxygen prior to this episode. The pt does admit to one episode of vomiting in the ED, which was thought to be secondary to meds he received in the ED. The pt denies HA, abd pain, diarrhea. In the ED, the pt was febrile to 101 rectally, requiring 5liters oxygen to keep sats >96%. He was given ceftriaxone, azithromycin, bactrim and solumedrol with continuouos nebs for PNA vs. COPD flare. He had one episode of emesis in ED. The pt also received a CTA which ruled out a PE (given the concern for pleuritic chest pain). ABG in the ED was: 7.44/40/81--> 7.49/40/67. The pt reports improvement in his sob after receiving solumedrol and nebs in the ED. Past Medical History: 1. HIV/AIDS: CD4: 251; VL: 570 ([2148-11-27])- on combivir and bactrim 2. COPD: intermittently on oxygen at home, followed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2146]/[First Name8 (NamePattern2) 2147] [Last Name (NamePattern1) 496]. FVC: 77%; FEV1: 26%; FEV1/FVC: 34%. 3. GERD 4. HTN 5. CRI 6. h/o GI bleed- w/u negative [2142] 7. Leukopenia- followed by [Doctor Last Name 2148]- plan is for BM bx 8. Anemia 9. Inguinal hernia 10. Homocysteinemia 11. Chronic back pain- failed spinal cord stimulator, requires injections from pain management. MR [9-21]. Herniated discs. 12. Granulmatous disease in spleen- seen on ct scan 13. Esophagitis- egd [11-20] 14. Schatzki's ring- seen on egd [7-/2143] 15. SBO obstruction in past 16. H/o of drug use- narcotics contract PAST SURGICAL HISTORY: 1. Basilar artery clipping [2134] 2. Status post several lumbar discectomies in the past. 3. Status post right inguinal hernia repair. 4. Status post right colectomy for benign disease. Social History: Disabled. Lives in [Location 669] by himself. EtOH: former heavy etoh, quit [2135] Tob: quit tobacco in [2135], 2ppd between [2100]-93. Illicit drugs: smoked crack [2135] Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: VS in ED: 100.8, 95, 159/95, 21, 98% on neb, 150cc emesis, 200cc urine in ED VS in [Hospital Unit Name 153]: 91, 126/70, 21, 97% on FM at 7L Gen: thin, almost cachectic AA male in NAD. Conversing fluently in full sentences. No accessory muscle use HEENT: EOMI, anicteric, mmm, op clear Neck: no retractions, supple, full ROM Chest: poor air movement posteriorly, soft wheezing bilaterally, no crackles, no pain on palpation of chest. CV: RRR, S1, S2, no m/r/g Abd: soft, suprapubic tenderness, neg [Doctor Last Name 515] sign, no rebound, guarding. Ext: wwp, no c/c/e, DP +1 bilaterally Pertinent Results: EKG: NSR, nml axis, peaked and widened P waves, ?ST elevations in V3 (vs. artifact) CXR [2148-12-2]: emphysematous changes CTA [2148-12-2]: No PE, +bronchiectasis and emphysema, granulmatous disease MIBI: [11/2142]: normal ECHO: [9-21]: hyperdynamic EF>75%, trivial MR [Name13 (STitle) 2149] [11-20]: normal EGD [11-20]: esophagitis Labs on Admission [2148-12-2] 05:50AM BLOOD WBC-3.2* RBC-2.94* Hgb-11.0* Hct-31.7* MCV-108* MCH-37.3* MCHC-34.6 RDW-13.8 Plt Ct-134* [2148-12-2] 05:50AM BLOOD PT-11.7 PTT-27.3 INR(PT)-0.9 [2148-12-2] 05:50AM BLOOD Glucose-105 UreaN-14 Creat-0.9 Na-138 K-3.7 Cl-101 HCO3-29 AnGap-12 [2148-12-2] 05:50AM BLOOD CK-MB-4 [2148-12-2] 05:50AM BLOOD cTropnT-0.03* [2148-12-2] 05:50AM BLOOD LD(LDH)-222 CK(CPK)-144 [2148-12-3] 05:15AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.0 Labs on Discharge [2148-12-10] 06:15AM BLOOD WBC-5.6 RBC-2.78* Hgb-9.6* Hct-29.4* MCV-106* MCH-34.5* MCHC-32.6 RDW-13.5 Plt Ct-286 [2148-12-10] 06:15AM BLOOD Plt Ct-286 [2148-12-10] 06:15AM BLOOD Glucose-91 UreaN-32* Creat-1.1 Na-137 K-4.2 Cl-101 HCO3-28 AnGap-12 [2148-12-10] 06:15AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0 Blood Gases [2148-12-2] 06:09AM BLOOD Type-ART FiO2-40 pO2-81* pCO2-40 pH-7.44 calHCO3-28 Base XS-2 [2148-12-2] 08:44AM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-40 pH-7.49* calHCO3-31* Base XS-6 [2148-12-3] 10:43AM BLOOD Type-ART pO2-26* pCO2-55* pH-7.35 calHCO3-32* Base XS-1 [2148-12-3] 01:36PM BLOOD Type-ART pO2-99 pCO2-33* pH-7.50* calHCO3-27 Base XS-2 [2148-12-3] 11:12PM BLOOD Type-ART pO2-73* pCO2-40 pH-7.46* calHCO3-29 Base XS-4 [2148-12-4] 01:23PM BLOOD Type-ART pO2-104 pCO2-46* pH-7.43 calHCO3-32* Base XS-4 Intubat-NOT INTUBA [2148-12-6] 05:19AM BLOOD Type-[Last Name (un) ] Temp-36.6 O2 Flow-2 pO2-44* pCO2-44 pH-7.44 calHCO3-31* Base XS-4 Intubat-NOT INTUBA Brief Hospital Course: A/P: 64yo M with COPD (FEV1 of 26%), HIV/AIDS (VL: 570; CD4: 251 treated with Combivir and Bactrim ppx p/w respiratory distress. . #. Respiratory distress: The patient was originally admitted to the [Hospital Unit Name 153]. During this time he was treated for positive influenza A and COPD exacerbation. He received 5 days of tamiflu. After a 5 day course in the ICU his respiratory status improved. Respiratory status stabilzed with supprot over the course of a 5 day stay in the ICU. He was started on a prednisone taper. He was transferred to the medicine floor service. Initially per PT/OT evals the patient qualified for rehab. However he quickly improved and his O2 sats were stable on room air. The patient felt safe to go home with PT and oxygen. He was discharged on a prednisone taper. He had follow up scheduled with his PCP and pulmonology. . #. HIV: The pt has HIV/AIDS with VL of 570 and CD4 of 251. He was maintained on Combivir and Bactrim SS Mon, Wed, Fri for ppx . #. HTN: The patient was maintained on HCTZ 25 daily . #. Pain: The pt has known chronic LBP and is on a narcotics contract. He was continued on tramadol and Tylenol #3 as well as tizanidine 2mg [11-18] PRN (for spasticity). Given his end stage HIV has was treated liberally with IV morphine for respiratory comfort while in the ICU. . #. Dispo: The patient was discharged home with PT, supplemental O2 and instructed to follow up with his health care providers. . #. Code Status: DNR/DNI. confirmed by MICU resident, intern and Pulm fellow. . #. Communications: HCP #1: Son: [Name (NI) ] [Name (NI) ] [Known lastname 2150]: [Telephone/Fax (1) 2151] HCP #2: Friend: [Name (NI) 2152] [Name (NI) 2153]: [Telephone/Fax (1) 2154] HCP #3: Sister: [Name (NI) 2155] [Name (NI) 2156] (moved to VA): [Telephone/Fax (1) 2157] Medications on Admission: 1. Combivir 2. Bactrim- Mon, Wed, Friday 3. Azmacort- 10 puffs [Hospital1 ] 4. Albuterol nebs and inhaler prn 5. Atrovent nebs prn 6. HCTZ 25 daily 7. Protnix 40 daily 8. Trazadone- 50 qhs prn 9. Doxazosin 2mg qhs 10. Tizanidine 2mg- one to 2 prn 11. tramadol 50 1-2 tabs q4-6 hours prn 12. APAP #3- ONE TID- Narcotics contract 13. Vitamin B12- 2000mcg daily 14. Folic acid 15. Aspirin 16. colace, senna Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 4. Azmacort 100 mcg/Actuation Aerosol Sig: Ten (10) puffs Inhalation twice a day. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 15. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 16. Prednisone 10 mg Tablet Sig: AS DIR Tablet PO DAILY (Daily) for 4 days: [2148-12-12] 30 mg qd [2148-12-13] 20 mg qd [2148-12-14] 10 mg qd [2148-12-15] 5 mg qd. Disp:6 Tablet(s) Refills:0 17. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. COPD exaccerbation 2. Influenza Secondary: 1. HIV 2. GERD 3. HTN 4. Chronic back pain Discharge Condition: afebrile, satting well on room air Discharge Instructions: If you have fevers, chills, shortness of breath, chest pain, nausea/vomiting, please call Dr [Last Name (STitle) ] for evaluation or come to the ED. 1. Take medications as directed 2. You will be on a prednisone taper on discharge for your COPD 3. Use oxygen as needed for you shortness of breath. Followup Instructions: Already scheudled: . Provider: [First Name8 (NamePattern2) 278] [Last Name (NamePattern1) 279], [Name12 (NameIs) 280] Date/Time:[2148-12-17] 6:00 . Pulmonary: Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2149-1-3] 9:10 Provider: [Name10 (NameIs) ] [Last Name (STitle) ]/DR [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2149-1-3] 9:30 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158] Completed by:[2149-5-4]	Admission Date: <Date>2006-4-10</Date> Discharge Date: <Date>1952-4-15</Date> Date of Birth: <Date>1921-2-29</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Lawrence</Name> Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: BiPAP History of Present Illness: 64 yo AA male with HIV/AIDS (VL: 570; CD4: 251 on <Date>9-19</Date>'<Digit>40</Digit> currently treated with Combivir and Bactrim SS Mon, Wed, Fri for ppx as well as a flu shot for <Year>1985</Year>-<Year>1985</Year>) and COPD on home oxygen (FEV1/FVC: 34%; FEV1 26%; FVC: 77%) comes in with dyspnea for 6 days. The pt reports development of sob similar to his previous episodes of COPD/PNA. 2-3days ago, he subsequently developed cough productive of yellow-green sputum along with subjective fevers, chills, and diaphoresis. He also developed some pleuritic chest pain several days ago. The chest pain was located in the left side of the chest below the nipple line and occurred with deep inspiration. The pt reports these are all similar to previous episodes of COPD exacerbation. The pt had tried nebulizers Q4hours in addition to 2L NC one day PTA without any improvement. The pt uses oxygen at home 40% of the time, mostly when he is active. The pt noted inc. DOE even with the oxygen prior to this episode. The pt does admit to one episode of vomiting in the ED, which was thought to be secondary to meds he received in the ED. The pt denies HA, abd pain, diarrhea. In the ED, the pt was febrile to 101 rectally, requiring 5liters oxygen to keep sats >96%. He was given ceftriaxone, azithromycin, bactrim and solumedrol with continuouos nebs for PNA vs. COPD flare. He had one episode of emesis in ED. The pt also received a CTA which ruled out a PE (given the concern for pleuritic chest pain). ABG in the ED was: 7.44/40/81--> 7.49/40/67. The pt reports improvement in his sob after receiving solumedrol and nebs in the ED. Past Medical History: 1. HIV/AIDS: CD4: 251; VL: 570 (<Date>1984-8-13</Date>)- on combivir and bactrim 2. COPD: intermittently on oxygen at home, followed by <Name>Kenya</Name> <Name>Prieto</Name>/<Name>Logan</Name> <Name>Finateri</Name>. FVC: 77%; FEV1: 26%; FEV1/FVC: 34%. 3. GERD 4. HTN 5. CRI 6. h/o GI bleed- w/u negative <Year>1985</Year> 7. Leukopenia- followed by <Doctor Name>Dr.Poff</Doctor Name>- plan is for BM bx 8. Anemia 9. Inguinal hernia 10. Homocysteinemia 11. Chronic back pain- failed spinal cord stimulator, requires injections from pain management. MR <Date>8-25</Date>. Herniated discs. 12. Granulmatous disease in spleen- seen on ct scan 13. Esophagitis- egd <Date>4-8</Date> 14. Schatzki's ring- seen on egd <Date>9-1936</Date> 15. SBO obstruction in past 16. H/o of drug use- narcotics contract PAST SURGICAL HISTORY: 1. Basilar artery clipping <Year>1985</Year> 2. Status post several lumbar discectomies in the past. 3. Status post right inguinal hernia repair. 4. Status post right colectomy for benign disease. Social History: Disabled. Lives in <Location>5627 Fleming River Riverafurt, MA 18160</Location> by himself. EtOH: former heavy etoh, quit <Year>1985</Year> Tob: quit tobacco in <Year>1985</Year>, 2ppd between <Year>1985</Year>-93. Illicit drugs: smoked crack <Year>1985</Year> Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: VS in ED: 100.8, 95, 159/95, 21, 98% on neb, 150cc emesis, 200cc urine in ED VS in <Hospital>Carr, Vasquez and Fitzgerald Medical Center</Hospital>: 91, 126/70, 21, 97% on FM at 7L Gen: thin, almost cachectic AA male in NAD. Conversing fluently in full sentences. No accessory muscle use HEENT: EOMI, anicteric, mmm, op clear Neck: no retractions, supple, full ROM Chest: poor air movement posteriorly, soft wheezing bilaterally, no crackles, no pain on palpation of chest. CV: RRR, S1, S2, no m/r/g Abd: soft, suprapubic tenderness, neg <Doctor Name>Dr.Amaro</Doctor Name> sign, no rebound, guarding. Ext: wwp, no c/c/e, DP +1 bilaterally Pertinent Results: EKG: NSR, nml axis, peaked and widened P waves, ?ST elevations in V3 (vs. artifact) CXR <Date>2006-4-10</Date>: emphysematous changes CTA <Date>2006-4-10</Date>: No PE, +bronchiectasis and emphysema, granulmatous disease MIBI: <Date>5/1984</Date>: normal ECHO: <Date>8-25</Date>: hyperdynamic EF>75%, trivial MR <Name>Alphonso Lenling</Name> <Date>4-8</Date>: normal EGD <Date>4-8</Date>: esophagitis Labs on Admission <Date>2006-4-10</Date> 05:50AM BLOOD WBC-3.2* RBC-2.94* Hgb-11.0* Hct-31.7* MCV-108* MCH-37.3* MCHC-34.6 RDW-13.8 Plt Ct-134* <Date>2006-4-10</Date> 05:50AM BLOOD PT-11.7 PTT-27.3 INR(PT)-0.9 <Date>2006-4-10</Date> 05:50AM BLOOD Glucose-105 UreaN-14 Creat-0.9 Na-138 K-3.7 Cl-101 HCO3-29 AnGap-12 <Date>2006-4-10</Date> 05:50AM BLOOD CK-MB-4 <Date>2006-4-10</Date> 05:50AM BLOOD cTropnT-0.03* <Date>2006-4-10</Date> 05:50AM BLOOD LD(LDH)-222 CK(CPK)-144 <Date>1959-8-31</Date> 05:15AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.0 Labs on Discharge <Date>2002-4-21</Date> 06:15AM BLOOD WBC-5.6 RBC-2.78* Hgb-9.6* Hct-29.4* MCV-106* MCH-34.5* MCHC-32.6 RDW-13.5 Plt Ct-286 <Date>2002-4-21</Date> 06:15AM BLOOD Plt Ct-286 <Date>2002-4-21</Date> 06:15AM BLOOD Glucose-91 UreaN-32* Creat-1.1 Na-137 K-4.2 Cl-101 HCO3-28 AnGap-12 <Date>2002-4-21</Date> 06:15AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0 Blood Gases <Date>2006-4-10</Date> 06:09AM BLOOD Type-ART FiO2-40 pO2-81* pCO2-40 pH-7.44 calHCO3-28 Base XS-2 <Date>2006-4-10</Date> 08:44AM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-40 pH-7.49* calHCO3-31* Base XS-6 <Date>1959-8-31</Date> 10:43AM BLOOD Type-ART pO2-26* pCO2-55* pH-7.35 calHCO3-32* Base XS-1 <Date>1959-8-31</Date> 01:36PM BLOOD Type-ART pO2-99 pCO2-33* pH-7.50* calHCO3-27 Base XS-2 <Date>1959-8-31</Date> 11:12PM BLOOD Type-ART pO2-73* pCO2-40 pH-7.46* calHCO3-29 Base XS-4 <Date>1914-4-23</Date> 01:23PM BLOOD Type-ART pO2-104 pCO2-46* pH-7.43 calHCO3-32* Base XS-4 Intubat-NOT INTUBA <Date>1940-5-7</Date> 05:19AM BLOOD Type-<Name>Kwan</Name> Temp-36.6 O2 Flow-2 pO2-44* pCO2-44 pH-7.44 calHCO3-31* Base XS-4 Intubat-NOT INTUBA Brief Hospital Course: A/P: 64yo M with COPD (FEV1 of 26%), HIV/AIDS (VL: 570; CD4: 251 treated with Combivir and Bactrim ppx p/w respiratory distress. . #. Respiratory distress: The patient was originally admitted to the <Hospital>Carr, Vasquez and Fitzgerald Medical Center</Hospital>. During this time he was treated for positive influenza A and COPD exacerbation. He received 5 days of tamiflu. After a 5 day course in the ICU his respiratory status improved. Respiratory status stabilzed with supprot over the course of a 5 day stay in the ICU. He was started on a prednisone taper. He was transferred to the medicine floor service. Initially per PT/OT evals the patient qualified for rehab. However he quickly improved and his O2 sats were stable on room air. The patient felt safe to go home with PT and oxygen. He was discharged on a prednisone taper. He had follow up scheduled with his PCP and pulmonology. . #. HIV: The pt has HIV/AIDS with VL of 570 and CD4 of 251. He was maintained on Combivir and Bactrim SS Mon, Wed, Fri for ppx . #. HTN: The patient was maintained on HCTZ 25 daily . #. Pain: The pt has known chronic LBP and is on a narcotics contract. He was continued on tramadol and Tylenol #3 as well as tizanidine 2mg <Date>12-21</Date> PRN (for spasticity). Given his end stage HIV has was treated liberally with IV morphine for respiratory comfort while in the ICU. . #. Dispo: The patient was discharged home with PT, supplemental O2 and instructed to follow up with his health care providers. . #. Code Status: DNR/DNI. confirmed by MICU resident, intern and Pulm fellow. . #. Communications: HCP #1: Son: <Name>Cornell Meraz</Name> <Name>Cornell Meraz</Name> <Name>Caro</Name>: <Telephone>478-495-7808</Telephone> HCP #2: Friend: <Name>Stacey Brown</Name> <Name>Terry Whitehead</Name>: <Telephone>335-553-4358</Telephone> HCP #3: Sister: <Name>Susana Kibler</Name> <Name>Joyce Hazelwood</Name> (moved to VA): <Telephone>249-253-8821</Telephone> Medications on Admission: 1. Combivir 2. Bactrim- Mon, Wed, Friday 3. Azmacort- 10 puffs <Hospital>Jenkins, Mason and Brooks Clinic</Hospital> 4. Albuterol nebs and inhaler prn 5. Atrovent nebs prn 6. HCTZ 25 daily 7. Protnix 40 daily 8. Trazadone- 50 qhs prn 9. Doxazosin 2mg qhs 10. Tizanidine 2mg- one to 2 prn 11. tramadol 50 1-2 tabs q4-6 hours prn 12. APAP #3- ONE TID- Narcotics contract 13. Vitamin B12- 2000mcg daily 14. Folic acid 15. Aspirin 16. colace, senna Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 4. Azmacort 100 mcg/Actuation Aerosol Sig: Ten (10) puffs Inhalation twice a day. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 15. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 16. Prednisone 10 mg Tablet Sig: AS DIR Tablet PO DAILY (Daily) for 4 days: <Date>1970-1-13</Date> 30 mg qd <Date>1914-7-20</Date> 20 mg qd <Date>1941-5-22</Date> 10 mg qd <Date>1986-3-11</Date> 5 mg qd. Disp:6 Tablet(s) Refills:0 17. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Discharge Disposition: Home With Service Facility: <Hospital>Rose-Johnson Medical Center</Hospital> Homecare Discharge Diagnosis: 1. COPD exaccerbation 2. Influenza Secondary: 1. HIV 2. GERD 3. HTN 4. Chronic back pain Discharge Condition: afebrile, satting well on room air Discharge Instructions: If you have fevers, chills, shortness of breath, chest pain, nausea/vomiting, please call Dr <Name>Edward</Name> for evaluation or come to the ED. 1. Take medications as directed 2. You will be on a prednisone taper on discharge for your COPD 3. Use oxygen as needed for you shortness of breath. Followup Instructions: Already scheudled: . Provider: <Name>Heath</Name> <Name>Chau</Name>, <Name>Rhea Miller</Name> Date/Time:<Date>2002-12-7</Date> 6:00 . Pulmonary: Provider: <Name>Caleb Moore</Name> BREATHING TESTS Phone:<Telephone>904-196-3397</Telephone> Date/Time:<Date>1958-9-21</Date> 9:10 Provider: <Name>Marvin Bludsworth</Name> <Name>Edward</Name>/DR <Name>Edward</Name> Phone:<Telephone>904-196-3397</Telephone> Date/Time:<Date>1958-9-21</Date> 9:30 <Name>Roosevelt Son</Name> <Name>Mable Hang</Name> MD <MD Number>73079690</MD Number> Completed 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Date: 2006-4-10 Discharge Date: 1952-4-15 Date of Birth: 1921-2-29 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Lawrence Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: BiPAP History of Present Illness: 64 yo AA male with HIV/AIDS (VL: 570; CD4: 251 on 9-19'40 currently treated with Combivir and Bactrim SS Mon, Wed, Fri for ppx as well as a flu shot for 1985-1985) and COPD on home oxygen (FEV1/FVC: 34%; FEV1 26%; FVC: 77%) comes in with dyspnea for 6 days. The pt reports development of sob similar to his previous episodes of COPD/PNA. 2-3days ago, he subsequently developed cough productive of yellow-green sputum along with subjective fevers, chills, and diaphoresis. He also developed some pleuritic chest pain several days ago. The chest pain was located in the left side of the chest below the nipple line and occurred with deep inspiration. The pt reports these are all similar to previous episodes of COPD exacerbation. The pt had tried nebulizers Q4hours in addition to 2L NC one day PTA without any improvement. The pt uses oxygen at home 40% of the time, mostly when he is active. The pt noted inc. DOE even with the oxygen prior to this episode. The pt does admit to one episode of vomiting in the ED, which was thought to be secondary to meds he received in the ED. The pt denies HA, abd pain, diarrhea. In the ED, the pt was febrile to 101 rectally, requiring 5liters oxygen to keep sats >96%. He was given ceftriaxone, azithromycin, bactrim and solumedrol with continuouos nebs for PNA vs. COPD flare. He had one episode of emesis in ED. The pt also received a CTA which ruled out a PE (given the concern for pleuritic chest pain). ABG in the ED was: 7.44/40/81--> 7.49/40/67. The pt reports improvement in his sob after receiving solumedrol and nebs in the ED. Past Medical History: 1. HIV/AIDS: CD4: 251; VL: 570 (1984-8-13)- on combivir and bactrim 2. COPD: intermittently on oxygen at home, followed by Kenya Prieto/Logan Finateri. FVC: 77%; FEV1: 26%; FEV1/FVC: 34%. 3. GERD 4. HTN 5. CRI 6. h/o GI bleed- w/u negative 1985 7. Leukopenia- followed by Dr.Poff- plan is for BM bx 8. Anemia 9. Inguinal hernia 10. Homocysteinemia 11. Chronic back pain- failed spinal cord stimulator, requires injections from pain management. MR 8-25. Herniated discs. 12. Granulmatous disease in spleen- seen on ct scan 13. Esophagitis- egd 4-8 14. Schatzki's ring- seen on egd 9-1936 15. SBO obstruction in past 16. H/o of drug use- narcotics contract PAST SURGICAL HISTORY: 1. Basilar artery clipping 1985 2. Status post several lumbar discectomies in the past. 3. Status post right inguinal hernia repair. 4. Status post right colectomy for benign disease. Social History: Disabled. Lives in 5627 Fleming River Riverafurt, MA 18160 by himself. EtOH: former heavy etoh, quit 1985 Tob: quit tobacco in 1985, 2ppd between 1985-93. Illicit drugs: smoked crack 1985 Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: VS in ED: 100.8, 95, 159/95, 21, 98% on neb, 150cc emesis, 200cc urine in ED VS in Carr, Vasquez and Fitzgerald Medical Center: 91, 126/70, 21, 97% on FM at 7L Gen: thin, almost cachectic AA male in NAD. Conversing fluently in full sentences. No accessory muscle use HEENT: EOMI, anicteric, mmm, op clear Neck: no retractions, supple, full ROM Chest: poor air movement posteriorly, soft wheezing bilaterally, no crackles, no pain on palpation of chest. CV: RRR, S1, S2, no m/r/g Abd: soft, suprapubic tenderness, neg Dr.Amaro sign, no rebound, guarding. Ext: wwp, no c/c/e, DP +1 bilaterally Pertinent Results: EKG: NSR, nml axis, peaked and widened P waves, ?ST elevations in V3 (vs. artifact) CXR 2006-4-10: emphysematous changes CTA 2006-4-10: No PE, +bronchiectasis and emphysema, granulmatous disease MIBI: 5/1984: normal ECHO: 8-25: hyperdynamic EF>75%, trivial MR Alphonso Lenling 4-8: normal EGD 4-8: esophagitis Labs on Admission 2006-4-10 05:50AM BLOOD WBC-3.2* RBC-2.94* Hgb-11.0* Hct-31.7* MCV-108* MCH-37.3* MCHC-34.6 RDW-13.8 Plt Ct-134* 2006-4-10 05:50AM BLOOD PT-11.7 PTT-27.3 INR(PT)-0.9 2006-4-10 05:50AM BLOOD Glucose-105 UreaN-14 Creat-0.9 Na-138 K-3.7 Cl-101 HCO3-29 AnGap-12 2006-4-10 05:50AM BLOOD CK-MB-4 2006-4-10 05:50AM BLOOD cTropnT-0.03* 2006-4-10 05:50AM BLOOD LD(LDH)-222 CK(CPK)-144 1959-8-31 05:15AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.0 Labs on Discharge 2002-4-21 06:15AM BLOOD WBC-5.6 RBC-2.78* Hgb-9.6* Hct-29.4* MCV-106* MCH-34.5* MCHC-32.6 RDW-13.5 Plt Ct-286 2002-4-21 06:15AM BLOOD Plt Ct-286 2002-4-21 06:15AM BLOOD Glucose-91 UreaN-32* Creat-1.1 Na-137 K-4.2 Cl-101 HCO3-28 AnGap-12 2002-4-21 06:15AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0 Blood Gases 2006-4-10 06:09AM BLOOD Type-ART FiO2-40 pO2-81* pCO2-40 pH-7.44 calHCO3-28 Base XS-2 2006-4-10 08:44AM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-40 pH-7.49* calHCO3-31* Base XS-6 1959-8-31 10:43AM BLOOD Type-ART pO2-26* pCO2-55* pH-7.35 calHCO3-32* Base XS-1 1959-8-31 01:36PM BLOOD Type-ART pO2-99 pCO2-33* pH-7.50* calHCO3-27 Base XS-2 1959-8-31 11:12PM BLOOD Type-ART pO2-73* pCO2-40 pH-7.46* calHCO3-29 Base XS-4 1914-4-23 01:23PM BLOOD Type-ART pO2-104 pCO2-46* pH-7.43 calHCO3-32* Base XS-4 Intubat-NOT INTUBA 1940-5-7 05:19AM BLOOD Type-Kwan Temp-36.6 O2 Flow-2 pO2-44* pCO2-44 pH-7.44 calHCO3-31* Base XS-4 Intubat-NOT INTUBA Brief Hospital Course: A/P: 64yo M with COPD (FEV1 of 26%), HIV/AIDS (VL: 570; CD4: 251 treated with Combivir and Bactrim ppx p/w respiratory distress. . #. Respiratory distress: The patient was originally admitted to the Carr, Vasquez and Fitzgerald Medical Center. During this time he was treated for positive influenza A and COPD exacerbation. He received 5 days of tamiflu. After a 5 day course in the ICU his respiratory status improved. Respiratory status stabilzed with supprot over the course of a 5 day stay in the ICU. He was started on a prednisone taper. He was transferred to the medicine floor service. Initially per PT/OT evals the patient qualified for rehab. However he quickly improved and his O2 sats were stable on room air. The patient felt safe to go home with PT and oxygen. He was discharged on a prednisone taper. He had follow up scheduled with his PCP and pulmonology. . #. HIV: The pt has HIV/AIDS with VL of 570 and CD4 of 251. He was maintained on Combivir and Bactrim SS Mon, Wed, Fri for ppx . #. HTN: The patient was maintained on HCTZ 25 daily . #. Pain: The pt has known chronic LBP and is on a narcotics contract. He was continued on tramadol and Tylenol #3 as well as tizanidine 2mg 12-21 PRN (for spasticity). Given his end stage HIV has was treated liberally with IV morphine for respiratory comfort while in the ICU. . #. Dispo: The patient was discharged home with PT, supplemental O2 and instructed to follow up with his health care providers. . #. Code Status: DNR/DNI. confirmed by MICU resident, intern and Pulm fellow. . #. Communications: HCP #1: Son: Cornell Meraz Cornell Meraz Caro: 478-495-7808 HCP #2: Friend: Stacey Brown Terry Whitehead: 335-553-4358 HCP #3: Sister: Susana Kibler Joyce Hazelwood (moved to VA): 249-253-8821 Medications on Admission: 1. Combivir 2. Bactrim- Mon, Wed, Friday 3. Azmacort- 10 puffs Jenkins, Mason and Brooks Clinic 4. Albuterol nebs and inhaler prn 5. Atrovent nebs prn 6. HCTZ 25 daily 7. Protnix 40 daily 8. Trazadone- 50 qhs prn 9. Doxazosin 2mg qhs 10. Tizanidine 2mg- one to 2 prn 11. tramadol 50 1-2 tabs q4-6 hours prn 12. APAP #3- ONE TID- Narcotics contract 13. Vitamin B12- 2000mcg daily 14. Folic acid 15. Aspirin 16. colace, senna Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 4. Azmacort 100 mcg/Actuation Aerosol Sig: Ten (10) puffs Inhalation twice a day. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 15. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 16. Prednisone 10 mg Tablet Sig: AS DIR Tablet PO DAILY (Daily) for 4 days: 1970-1-13 30 mg qd 1914-7-20 20 mg qd 1941-5-22 10 mg qd 1986-3-11 5 mg qd. Disp:6 Tablet(s) Refills:0 17. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Discharge Disposition: Home With Service Facility: Rose-Johnson Medical Center Homecare Discharge Diagnosis: 1. COPD exaccerbation 2. Influenza Secondary: 1. HIV 2. GERD 3. HTN 4. Chronic back pain Discharge Condition: afebrile, satting well on room air Discharge Instructions: If you have fevers, chills, shortness of breath, chest pain, nausea/vomiting, please call Dr Edward for evaluation or come to the ED. 1. Take medications as directed 2. You will be on a prednisone taper on discharge for your COPD 3. Use oxygen as needed for you shortness of breath. Followup Instructions: Already scheudled: . Provider: Heath Chau, Rhea Miller Date/Time:2002-12-7 6:00 . Pulmonary: Provider: Caleb Moore BREATHING TESTS Phone:904-196-3397 Date/Time:1958-9-21 9:10 Provider: Marvin Bludsworth Edward/DR Edward Phone:904-196-3397 Date/Time:1958-9-21 9:30 Roosevelt Son Mable Hang MD 73079690 Completed by:1911-8-5	["Admission Date: 2006-4-10 Discharge Date: 1952-4-15\n\nDate of Birth: 1921-2-29 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Lawrence\nChief Complaint:\nrespiratory distress\n\nMajor Surgical or Invasive Procedure:\nBiPAP\n\nHistory of Present Illness:\n64 yo AA male with HIV/AIDS (VL: 570; CD4: 251 on 9-19'40\ncurrently treated with Combivir and Bactrim SS Mon, Wed, Fri for\nppx as well as a flu shot for 1985-1985) and COPD on home oxygen\n(FEV1/FVC: 34%; FEV1 26%; FVC: 77%) comes in with dyspnea for 6\ndays. The pt reports development of sob similar to his previous\nepisodes of COPD/PNA. 2-3days ago, he subsequently developed\ncough productive of yellow-green sputum along with subjective\nfevers, chills, and diaphoresis.", ' He also developed some\npleuritic chest pain several days ago. The chest pain was\nlocated in the left side of the chest below the nipple line and\noccurred with deep inspiration. The pt reports these are all\nsimilar to previous episodes of COPD exacerbation. The pt had\ntried nebulizers Q4hours in addition to 2L NC one day PTA\nwithout any improvement. The pt uses oxygen at home 40% of the\ntime, mostly when he is active. The pt noted inc. DOE even with\nthe oxygen prior to this episode. The pt does admit to one\nepisode of vomiting in the ED, which was thought to be secondary\nto meds he received in the ED. The pt denies HA, abd pain,\ndiarrhea.\n\n\nIn the ED, the pt was febrile to 101 rectally, requiring 5liters\noxygen to keep sats >96%. He was given ceftriaxone,\nazithromycin, bactrim and solumedrol with continuouos nebs for\nPNA vs.', ' COPD flare. He had one episode of emesis in ED. The pt\nalso received a CTA which ruled out a PE (given the concern for\npleuritic chest pain). ABG in the ED was: 7.44/40/81-->\n7.49/40/67. The pt reports improvement in his sob after\nreceiving solumedrol and nebs in the ED.\n\n\nPast Medical History:\n1. HIV/AIDS: CD4: 251; VL: 570 (1984-8-13)- on combivir and\nbactrim\n2. COPD: intermittently on oxygen at home, followed by Kenya\nPrieto/Logan Finateri. FVC: 77%; FEV1: 26%; FEV1/FVC: 34%.\n\n3. GERD\n4. HTN\n5. CRI\n6. h/o GI bleed- w/u negative 1985\n7. Leukopenia- followed by Dr.Poff- plan is for BM bx\n8. Anemia\n9. Inguinal hernia\n10. Homocysteinemia\n11. Chronic back pain- failed spinal cord stimulator, requires\ninjections from pain management. MR 8-25. Herniated discs.\n12. Granulmatous disease in spleen- seen on ct scan\n13.', " Esophagitis- egd 4-8\n14. Schatzki's ring- seen on egd 9-1936\n15. SBO obstruction in past\n16. H/o of drug use- narcotics contract\n\nPAST SURGICAL HISTORY:\n1. Basilar artery clipping 1985\n2. Status post several lumbar discectomies in the past.\n3. Status post right inguinal hernia repair.\n4. Status post right colectomy for benign disease.\n\n\nSocial History:\nDisabled. Lives in 5627 Fleming River\nRiverafurt, MA 18160 by himself.\nEtOH: former heavy etoh, quit 1985\nTob: quit tobacco in 1985, 2ppd between 1985-93.\nIllicit drugs: smoked crack 1985\n\n\nFamily History:\n1. Father: deceased, EtOH\n2. Mother: deceased, CVA in 60s\n3. Brother: lung cancer\n4. Sister: HTN\n5. Sister: CVA in 60s\nBrothers x7 (now only two), Sister x2 (both still alive)\n\n\nPhysical Exam:\nVS in ED: 100.8, 95, 159/95, 21, 98% on neb, 150cc emesis, 200cc\nurine in ED\nVS in Carr, Vasquez and Fitzgerald Medical Center: 91, 126/70, 21, 97% on FM at 7L\nGen: thin, almost cachectic AA male in NAD.", ' Conversing fluently\nin full sentences. No accessory muscle use\nHEENT: EOMI, anicteric, mmm, op clear\nNeck: no retractions, supple, full ROM\nChest: poor air movement posteriorly, soft wheezing bilaterally,\nno crackles, no pain on palpation of chest.\nCV: RRR, S1, S2, no m/r/g\nAbd: soft, suprapubic tenderness, neg Dr.Amaro sign, no rebound,\nguarding.\nExt: wwp, no c/c/e, DP +1 bilaterally\n\n\nPertinent Results:\nEKG: NSR, nml axis, peaked and widened P waves, ?ST elevations\nin V3 (vs. artifact)\nCXR 2006-4-10: emphysematous changes\nCTA 2006-4-10: No PE, +bronchiectasis and emphysema, granulmatous\ndisease\n\n\nMIBI: 5/1984: normal\nECHO: 8-25: hyperdynamic EF>75%, trivial MR\nAlphonso Lenling 4-8: normal\nEGD 4-8: esophagitis\n\nLabs on Admission\n2006-4-10 05:50AM BLOOD WBC-3.2* RBC-2.94* Hgb-11.0* Hct-31.', '7\nMCV-108 MCH-37.3* MCHC-34.6 RDW-13.8 Plt Ct-134\n2006-4-10 05:50AM BLOOD PT-11.7 PTT-27.3 INR(PT)-0.9\n2006-4-10 05:50AM BLOOD Glucose-105 UreaN-14 Creat-0.9 Na-138\nK-3.7 Cl-101 HCO3-29 AnGap-12\n2006-4-10 05:50AM BLOOD CK-MB-4\n2006-4-10 05:50AM BLOOD cTropnT-0.03\n2006-4-10 05:50AM BLOOD LD(LDH)-222 CK(CPK)-144\n1959-8-31 05:15AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.0\n\nLabs on Discharge\n2002-4-21 06:15AM BLOOD WBC-5.6 RBC-2.78* Hgb-9.6* Hct-29.4\nMCV-106 MCH-34.5* MCHC-32.6 RDW-13.5 Plt Ct-286\n2002-4-21 06:15AM BLOOD Plt Ct-286\n2002-4-21 06:15AM BLOOD Glucose-91 UreaN-32* Creat-1.1 Na-137\nK-4.2 Cl-101 HCO3-28 AnGap-12\n2002-4-21 06:15AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0\n\nBlood Gases\n2006-4-10 06:09AM BLOOD Type-ART FiO2-40 pO2-81* pCO2-40 pH-7.44\ncalHCO3-28 Base XS-2\n2006-4-10 08:44AM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-40\npH-7.', '49* calHCO3-31* Base XS-6\n1959-8-31 10:43AM BLOOD Type-ART pO2-26* pCO2-55* pH-7.35\ncalHCO3-32* Base XS-1\n1959-8-31 01:36PM BLOOD Type-ART pO2-99 pCO2-33* pH-7.50\ncalHCO3-27 Base XS-2\n1959-8-31 11:12PM BLOOD Type-ART pO2-73 pCO2-40 pH-7.46\ncalHCO3-29 Base XS-4\n1914-4-23 01:23PM BLOOD Type-ART pO2-104 pCO2-46 pH-7.43\ncalHCO3-32* Base XS-4 Intubat-NOT INTUBA\n1940-5-7 05:19AM BLOOD Type-Kwan Temp-36.6 O2 Flow-2 pO2-44\npCO2-44 pH-7.44 calHCO3-31 Base XS-4 Intubat-NOT INTUBA\n\nBrief Hospital Course:\nA/P: 64yo M with COPD (FEV1 of 26%), HIV/AIDS (VL: 570; CD4: 251\ntreated with Combivir and Bactrim ppx p/w respiratory distress.\n\n.\n#. Respiratory distress: The patient was originally admitted to\nthe Carr, Vasquez and Fitzgerald Medical Center. During this time he was treated for positive\ninfluenza A and COPD exacerbation.', ' He received 5 days of\ntamiflu. After a 5 day course in the ICU his respiratory status\nimproved. Respiratory status stabilzed with supprot over the\ncourse of a 5 day stay in the ICU. He was started on a\nprednisone taper.\n\nHe was transferred to the medicine floor service. Initially per\nPT/OT evals the patient qualified for rehab. However he quickly\nimproved and his O2 sats were stable on room air. The patient\nfelt safe to go home with PT and oxygen. He was discharged on a\nprednisone taper. He had follow up scheduled with his PCP and\npulmonology.\n.\n#. HIV: The pt has HIV/AIDS with VL of 570 and CD4 of 251. He\nwas maintained on Combivir and Bactrim SS Mon, Wed, Fri for ppx\n\n.\n#. HTN: The patient was maintained on HCTZ 25 daily\n.\n#. Pain: The pt has known chronic LBP and is on a narcotics\ncontract.', ' He was continued on tramadol and Tylenol #3 as well as\ntizanidine 2mg 12-21 PRN (for spasticity). Given his end stage\nHIV has was treated liberally with IV morphine for respiratory\ncomfort while in the ICU.\n.\n#. Dispo: The patient was discharged home with PT, supplemental\nO2 and instructed to follow up with his health care providers.\n.\n#. Code Status: DNR/DNI. confirmed by MICU resident, intern and\nPulm fellow.\n.\n#. Communications:\nHCP #1: Son: Cornell Meraz Cornell Meraz Caro: 478-495-7808\nHCP #2: Friend: Stacey Brown Terry Whitehead: 335-553-4358\nHCP #3: Sister: Susana Kibler Joyce Hazelwood (moved to VA): 249-253-8821\n\n\nMedications on Admission:\n1. Combivir\n2. Bactrim- Mon, Wed, Friday\n3. Azmacort- 10 puffs Jenkins, Mason and Brooks Clinic\n4. Albuterol nebs and inhaler prn\n5. Atrovent nebs prn\n6.', ' HCTZ 25 daily\n7. Protnix 40 daily\n8. Trazadone- 50 qhs prn\n9. Doxazosin 2mg qhs\n10. Tizanidine 2mg- one to 2 prn\n11. tramadol 50 1-2 tabs q4-6 hours prn\n12. APAP #3- ONE TID- Narcotics contract\n13. Vitamin B12- 2000mcg daily\n14. Folic acid\n15. Aspirin\n16. colace, senna\n\n\nDischarge Medications:\n1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet\nPO BID (2 times a day).\n3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)\nTablet PO 3X/WEEK (MO,WE,FR).\n4. Azmacort 100 mcg/Actuation Aerosol Sig: Ten (10) puffs\nInhalation twice a day.\n5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours).\n6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours).', '\n7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n8. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).\n\n9. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a\nday) as needed.\n10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4\nto 6 hours) as needed.\n11. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY\n(Daily).\n12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed.\n14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID\n(2 times a day) as needed.\n15. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\n16. Prednisone 10 mg Tablet Sig: AS DIR Tablet PO DAILY (Daily)\nfor 4 days: 1970-1-13 30 mg qd\n1914-7-20 20 mg qd\n1941-5-22 10 mg qd\n1986-3-11 5 mg qd.', '\nDisp:6 Tablet(s) Refills:0\n17. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet\nPO TID (3 times a day) as needed.\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nRose-Johnson Medical Center Homecare\n\nDischarge Diagnosis:\n1. COPD exaccerbation\n2. Influenza\n\nSecondary:\n1. HIV\n2. GERD\n3. HTN\n4. Chronic back pain\n\n\nDischarge Condition:\nafebrile, satting well on room air\n\n\nDischarge Instructions:\nIf you have fevers, chills, shortness of breath, chest pain,\nnausea/vomiting, please call Dr Edward for evaluation or come to\nthe ED.\n\n1. Take medications as directed\n2. You will be on a prednisone taper on discharge for your COPD\n3. Use oxygen as needed for you shortness of breath.\n\nFollowup Instructions:\nAlready scheudled:\n.\nProvider: Heath Chau, Rhea Miller Date/Time:2002-12-7 6:00\n.', '\nPulmonary:\nProvider: Caleb Moore BREATHING TESTS Phone:904-196-3397\nDate/Time:1958-9-21 9:10\nProvider: Marvin Bludsworth Edward/DR Edward Phone:904-196-3397\nDate/Time:1958-9-21 9:30\n\n\n Roosevelt Son Mable Hang MD 73079690\n\nCompleted by:1911-8-5']
216	11018	186291.0	2151-09-24	Discharge summary	Report	Admission Date: [2151-9-21] Discharge Date: [2151-9-24] Date of Birth: [2084-12-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2167] Chief Complaint: nausea/emesis x 2 days Major Surgical or Invasive Procedure: none History of Present Illness: This is a 66 yo M w/h/o HIV(last CD4 307 [2151-9-10], VL 187 [2151-9-15]), HTN, and severe COPD on 3L oxygen at home who presents w/nausea and emesis x 2 days. He notes that he had been feeling generally well but with constipation when he had sudden onset of nausea and emesis 2 nights ago. He does not recall what he was doing. Since then, he has been tolerating some food, but has had several episodes of NBNB emesis. He notes that he has not taken any of his medications x 2 days due to the nausea. He also notes that a few days PTA he took one dose of his new antiretroviral regimen- unsure which pill- and had nausea. He subsequently stopped that regimen and reverted back to his old regimen. He denies subjective fever/chills. Notes mild diffuse, nonfocal abdominal pain which he feels is caused by the nausea and is worse w/eating. He feels that his nausea and abdominal pain is c/w severe constipation, "I know it's my constipation." He denies diarrhea, hematochezia, melena. He notes that he last moved his bowels 2 days ago which is fairly normal for him but has been passing gas. He denies any sick contacts. In the [Name (NI) ], pt was afebrile to 101.5 and hypertensive in 170s-200s/80s-110s. A right femoral line was placed and he received Morphine Sulfate 4mg IV x 1, dilaudid 1mg IV x 3, tylenol, and zofran for nausea. He also received 1 dose of labetalol IV x 1. ROS: The patient endorses mild HA, otherwise denies weight change, chest pain, palpitations, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, rash or skin changes. Past Medical History: - HIV/AIDS: CD4: 307([2151-9-10]) VL: 187 ([2151-9-15])- recently started on Truvada and Ritonavir but d/ced due to nausea. Followed by [First Name8 (NamePattern2) 1059] [Last Name (NamePattern1) 1057] outpatient. - h/o SBO s/p Ileocectomy [2136] with lysis of adhesions, ulcer noted at the anastomosis site in 06/[2149]. - COPD: severe, on 2L oxygen at home, followed by Dr. [Last Name (STitle) 2168], last spirometry [7-26] - bronchiectasis - GERD - HTN - h/o internal hemorrhoids, grade I on colonoscopy [2149] - Leukopenia - Iron deficiency Anemia - h/o hiatal hernia - Chronic back pain- laminectomy at L3, L4, L5, and S1 - h/o Granulmatous disease in spleen- seen on ct scan - Esophagitis and gastritis, EGD [2151-4-13] - Schatzki's ring- seen on egd [7-/2143] - H/o substance abuse-cocaine - osteoporosis followed by Dr. [Last Name (STitle) ], on Reclast PAST SURGICAL HISTORY: - Basilar artery clipping [2134] - Status post several lumbar discectomies in the past. - Status post right inguinal hernia repair. - Status post right colectomy for benign disease. Social History: Disabled. Lives in [Location 669] by himself. EtOH: former heavy etoh, quit [2135] Tob: quit tobacco in [2135], 2ppd between [2100]-93. Illicit drugs: smoked crack [2135] Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: Vitals: T: 98.5 BP: 139/101 HR: 83 RR: 20 O2Sat: 98% 3LNC GEN: thin, elderly, nauseous HEENT: EOMI, 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, no M/G/R, normal S1 S2, radial pulses +2 PULM: decreased chest expansion w/decreased air movement throughout, no W/R/R ABD: thin, Soft, diffusely tender, ND, +BS, no HSM, no masses but palpable stool EXT: thin, No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2151-9-21] 12:20PM WBC-4.8 RBC-3.93* HGB-11.3* HCT-35.4* MCV-90 MCH-28.8 MCHC-31.9 RDW-14.6 [2151-9-21] 12:20PM NEUTS-82.4* LYMPHS-12.4* MONOS-3.2 EOS-1.6 BASOS-0.3 [2151-9-21] 12:20PM PLT COUNT-225 . [2151-9-21] 12:20PM PT-13.0 PTT-21.7* INR(PT)-1.1 . [2151-9-21] 12:20PM GLUCOSE-126* UREA N-17 CREAT-1.1 SODIUM-144 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-30 ANION GAP-14 [2151-9-21] 12:20PM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-71 TOT BILI-0.4 [2151-9-21] 12:20PM LIPASE-30 [2151-9-21] 12:20PM CALCIUM-9.2 PHOSPHATE-2.3* MAGNESIUM-2.2 . [2151-9-21] 07:15PM TYPE-[Last Name (un) ] PO2-38* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-3 [2151-9-21] 02:18PM LACTATE-1.2 . [2151-9-21] 10:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG . ECG: Sinus rhythm at 98bpm, poor R-wave progression, no acute ST or T-wave changes, relatively unchanged from [2151-5-9]. . Imaging: CT abdomen/pelvis(prelim read): No obstruction or acute abdominal issues to explain abdominal pain. New opacity in the left lung base in a region of scar in which 3 month f/u CT recommended to exclude malignancy. . KUB: Paucity of bowel gas, however, no radiographic evidence for bowel obstruction. No free air. . Admission CXR: Hyperinflated, tortuous aorta w/o evidence of infiltrate Brief Hospital Course: 66 yo M w/h/o HIV, HTN, and severe COPD who presents w/nausea, emesis, diffuse abdominal pain x 2 days and fever in the ED. . Nausea w/emesis: c/b mild, diffuse abdominal pain. Abdominal exam is nonfocal. He does not have lab evidence of pancreatitis, but does have h/o gastritis. CT abdomen w/o evidence of any acute abdominal process and KUB w/o evidence of SBO. Treated with antiemetics and tramadol for pain. His vitals remained stable throughout ICU course. Constipation was likely contributing. He was manually disimpacted with good releif of symptoms. He then developed constipation again on the floor, with a KUB that did not show obstruction. He was given an aggressive bowel regimen, with good relief of his symptoms. . Fever: without a clear source in HIV+ pt. Abdominal pain was concerning, possible pt has diverticulitis, colitis though no CT evidence of bowel inflammation. + relative leukocytosis. Cultures for infectious source were not revealing. He was not started on antibiotics. . HTN: hypertensive urgency in the ED; currently well controlled w/dose of labetalol he received in the ED. EKG w/o acute changes. Doxazosin was restarted. He was also started on HCTZ. . HIV: last CD4 307, VL 187; Per outpatient ID doctor recommendations, he was counseled not to start HAART for now, until he is contact[Name (NI) ] by Dr. [Last Name (STitle) 1057]. . COPD: severe, on 3 L oxygen outpt. Continued on albuterol nebs, tiotropium, and Advair. . Iron deficiency anemia: unclear baseline HCT, appears to be b/w 34-38; guiac (-). He was continued on iron supplements. . FEN: Diet advanced to regular Medications on Admission: ABACAVIR-LAMIVUDINE - 600 mg-300 mg Tablet - 1 Tablet(s) by mouth once a day ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet - one Tablet(s) by mouth three times a day as needed for pain do not take more than 3 per day ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2-3 puffs inhaled as needed ALBUTEROL SULFATE - 0.083 % (0.83 mg/mL) Solution for Nebulization - 1 ml neb three times a day ATAZANAVIR - 400 mg Capsule once a day BENZONATATE - 100 mg Capsule - 1 Capsule(s) by mouth three times a day DOXAZOSIN - 2 mg at bedtime FLUTICASONE-SALMETEROL 500 mcg-50 mcg/Dose 1 puff inhaled twice daily FOLIC ACID - 1 mg once a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s) sublingually every 5 minutes as needed for chest pain RANITIDINE HCL - 150 mg twice a day TIOTROPIUM BROMIDE - 18 mcg one puff inhaler once a day TIZANIDINE - 2 mg three times a day as needed for spasms TRAMADOL 50 mg Tablet - [11-18] Tablet(s) by mouth every six hours TRAZODONE - 50 mg by mouth at bedtime as needed for insomnia TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM DS] - 800 mg-160 mg Tablet three times a week ASPIRIN - 325 mg once a day CYANOCOBALAMIN once a day DOCUSATE SODIUM - 200 mg three times a day FERROUS GLUCONATE - 325 mg daily SENNA - 8.6 mg by mouth daily Reclast Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation once a day. 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) dose Sublingual once a day as needed for chest pain: one Tablet(s) sublingually every 5 minutes as needed for chest pain . 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Tizanidine 2 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for spasms. Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive urgency 2. Constipation 3. HIV 4. Lung nodule on CT scan 5. Pain control 6. Abdominal pain Discharge Condition: Stable Discharge Instructions: You were admitted with abdominal pain from constipation. This improved with a bowel regimen. You have been given a handout on constipation management. If you develop increasing abdominal pain, blood in your stool, fevers, chills, nausea, or vomiting, please call your primary care doctor. . You were also noted to be hypertensive, and you were started on a drug called hydrochlorothiazide for hypertension. . You SHOULD NOT restart your HIV medications until you discuss this with Dr. [Last Name (STitle) 1057]. Followup Instructions: You will need a follow up chest CT for nodule in 3 months. This can be arranged by your PCP. You have an appointment with your PCP. [Name Initial (NameIs) 2169]: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2151-9-29] 9:10 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1085], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2151-10-13] 9:00 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2152-7-31] 9:10	Admission Date: <Date>1923-9-12</Date> Discharge Date: <Date>1925-12-9</Date> Date of Birth: <Date>1978-4-27</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Roger</Name> Chief Complaint: nausea/emesis x 2 days Major Surgical or Invasive Procedure: none History of Present Illness: This is a 66 yo M w/h/o HIV(last CD4 307 <Date>1907-7-23</Date>, VL 187 <Date>2002-9-12</Date>), HTN, and severe COPD on 3L oxygen at home who presents w/nausea and emesis x 2 days. He notes that he had been feeling generally well but with constipation when he had sudden onset of nausea and emesis 2 nights ago. He does not recall what he was doing. Since then, he has been tolerating some food, but has had several episodes of NBNB emesis. He notes that he has not taken any of his medications x 2 days due to the nausea. He also notes that a few days PTA he took one dose of his new antiretroviral regimen- unsure which pill- and had nausea. He subsequently stopped that regimen and reverted back to his old regimen. He denies subjective fever/chills. Notes mild diffuse, nonfocal abdominal pain which he feels is caused by the nausea and is worse w/eating. He feels that his nausea and abdominal pain is c/w severe constipation, "I know it's my constipation." He denies diarrhea, hematochezia, melena. He notes that he last moved his bowels 2 days ago which is fairly normal for him but has been passing gas. He denies any sick contacts. In the <Name>Heather Dortch</Name>, pt was afebrile to 101.5 and hypertensive in 170s-200s/80s-110s. A right femoral line was placed and he received Morphine Sulfate 4mg IV x 1, dilaudid 1mg IV x 3, tylenol, and zofran for nausea. He also received 1 dose of labetalol IV x 1. ROS: The patient endorses mild HA, otherwise denies weight change, chest pain, palpitations, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, rash or skin changes. Past Medical History: - HIV/AIDS: CD4: 307(<Date>1907-7-23</Date>) VL: 187 (<Date>2002-9-12</Date>)- recently started on Truvada and Ritonavir but d/ced due to nausea. Followed by <Name>Sandeep</Name> <Name>Chau</Name> outpatient. - h/o SBO s/p Ileocectomy <Year>1926</Year> with lysis of adhesions, ulcer noted at the anastomosis site in 06/<Year>1926</Year>. - COPD: severe, on 2L oxygen at home, followed by Dr. <Name>Tamaro</Name>, last spirometry <Date>2-14</Date> - bronchiectasis - GERD - HTN - h/o internal hemorrhoids, grade I on colonoscopy <Year>1926</Year> - Leukopenia - Iron deficiency Anemia - h/o hiatal hernia - Chronic back pain- laminectomy at L3, L4, L5, and S1 - h/o Granulmatous disease in spleen- seen on ct scan - Esophagitis and gastritis, EGD <Date>1916-4-24</Date> - Schatzki's ring- seen on egd <Date>6-1936</Date> - H/o substance abuse-cocaine - osteoporosis followed by Dr. <Name>Olles</Name>, on Reclast PAST SURGICAL HISTORY: - Basilar artery clipping <Year>1926</Year> - Status post several lumbar discectomies in the past. - Status post right inguinal hernia repair. - Status post right colectomy for benign disease. Social History: Disabled. Lives in <Location>4989 Brown Cliffs Brandyfort, MP 80844</Location> by himself. EtOH: former heavy etoh, quit <Year>1926</Year> Tob: quit tobacco in <Year>1926</Year>, 2ppd between <Year>1926</Year>-93. Illicit drugs: smoked crack <Year>1926</Year> Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: Vitals: T: 98.5 BP: 139/101 HR: 83 RR: 20 O2Sat: 98% 3LNC GEN: thin, elderly, nauseous HEENT: EOMI, 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, no M/G/R, normal S1 S2, radial pulses +2 PULM: decreased chest expansion w/decreased air movement throughout, no W/R/R ABD: thin, Soft, diffusely tender, ND, +BS, no HSM, no masses but palpable stool EXT: thin, No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: <Date>1923-9-12</Date> 12:20PM WBC-4.8 RBC-3.93* HGB-11.3* HCT-35.4* MCV-90 MCH-28.8 MCHC-31.9 RDW-14.6 <Date>1923-9-12</Date> 12:20PM NEUTS-82.4* LYMPHS-12.4* MONOS-3.2 EOS-1.6 BASOS-0.3 <Date>1923-9-12</Date> 12:20PM PLT COUNT-225 . <Date>1923-9-12</Date> 12:20PM PT-13.0 PTT-21.7* INR(PT)-1.1 . <Date>1923-9-12</Date> 12:20PM GLUCOSE-126* UREA N-17 CREAT-1.1 SODIUM-144 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-30 ANION GAP-14 <Date>1923-9-12</Date> 12:20PM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-71 TOT BILI-0.4 <Date>1923-9-12</Date> 12:20PM LIPASE-30 <Date>1923-9-12</Date> 12:20PM CALCIUM-9.2 PHOSPHATE-2.3* MAGNESIUM-2.2 . <Date>1923-9-12</Date> 07:15PM TYPE-<Name>Thompkins</Name> PO2-38* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-3 <Date>1923-9-12</Date> 02:18PM LACTATE-1.2 . <Date>1923-9-12</Date> 10:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG . ECG: Sinus rhythm at 98bpm, poor R-wave progression, no acute ST or T-wave changes, relatively unchanged from <Date>1950-4-9</Date>. . Imaging: CT abdomen/pelvis(prelim read): No obstruction or acute abdominal issues to explain abdominal pain. New opacity in the left lung base in a region of scar in which 3 month f/u CT recommended to exclude malignancy. . KUB: Paucity of bowel gas, however, no radiographic evidence for bowel obstruction. No free air. . Admission CXR: Hyperinflated, tortuous aorta w/o evidence of infiltrate Brief Hospital Course: 66 yo M w/h/o HIV, HTN, and severe COPD who presents w/nausea, emesis, diffuse abdominal pain x 2 days and fever in the ED. . Nausea w/emesis: c/b mild, diffuse abdominal pain. Abdominal exam is nonfocal. He does not have lab evidence of pancreatitis, but does have h/o gastritis. CT abdomen w/o evidence of any acute abdominal process and KUB w/o evidence of SBO. Treated with antiemetics and tramadol for pain. His vitals remained stable throughout ICU course. Constipation was likely contributing. He was manually disimpacted with good releif of symptoms. He then developed constipation again on the floor, with a KUB that did not show obstruction. He was given an aggressive bowel regimen, with good relief of his symptoms. . Fever: without a clear source in HIV+ pt. Abdominal pain was concerning, possible pt has diverticulitis, colitis though no CT evidence of bowel inflammation. + relative leukocytosis. Cultures for infectious source were not revealing. He was not started on antibiotics. . HTN: hypertensive urgency in the ED; currently well controlled w/dose of labetalol he received in the ED. EKG w/o acute changes. Doxazosin was restarted. He was also started on HCTZ. . HIV: last CD4 307, VL 187; Per outpatient ID doctor recommendations, he was counseled not to start HAART for now, until he is contact<Name>Heather Dortch</Name> by Dr. <Name>Ngo</Name>. . COPD: severe, on 3 L oxygen outpt. Continued on albuterol nebs, tiotropium, and Advair. . Iron deficiency anemia: unclear baseline HCT, appears to be b/w 34-38; guiac (-). He was continued on iron supplements. . FEN: Diet advanced to regular Medications on Admission: ABACAVIR-LAMIVUDINE - 600 mg-300 mg Tablet - 1 Tablet(s) by mouth once a day ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet - one Tablet(s) by mouth three times a day as needed for pain do not take more than 3 per day ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2-3 puffs inhaled as needed ALBUTEROL SULFATE - 0.083 % (0.83 mg/mL) Solution for Nebulization - 1 ml neb three times a day ATAZANAVIR - 400 mg Capsule once a day BENZONATATE - 100 mg Capsule - 1 Capsule(s) by mouth three times a day DOXAZOSIN - 2 mg at bedtime FLUTICASONE-SALMETEROL 500 mcg-50 mcg/Dose 1 puff inhaled twice daily FOLIC ACID - 1 mg once a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s) sublingually every 5 minutes as needed for chest pain RANITIDINE HCL - 150 mg twice a day TIOTROPIUM BROMIDE - 18 mcg one puff inhaler once a day TIZANIDINE - 2 mg three times a day as needed for spasms TRAMADOL 50 mg Tablet - <Date>4-24</Date> Tablet(s) by mouth every six hours TRAZODONE - 50 mg by mouth at bedtime as needed for insomnia TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM DS] - 800 mg-160 mg Tablet three times a week ASPIRIN - 325 mg once a day CYANOCOBALAMIN once a day DOCUSATE SODIUM - 200 mg three times a day FERROUS GLUCONATE - 325 mg daily SENNA - 8.6 mg by mouth daily Reclast Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation once a day. 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) dose Sublingual once a day as needed for chest pain: one Tablet(s) sublingually every 5 minutes as needed for chest pain . 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Tizanidine 2 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for spasms. Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive urgency 2. Constipation 3. HIV 4. Lung nodule on CT scan 5. Pain control 6. Abdominal pain Discharge Condition: Stable Discharge Instructions: You were admitted with abdominal pain from constipation. This improved with a bowel regimen. You have been given a handout on constipation management. If you develop increasing abdominal pain, blood in your stool, fevers, chills, nausea, or vomiting, please call your primary care doctor. . You were also noted to be hypertensive, and you were started on a drug called hydrochlorothiazide for hypertension. . You SHOULD NOT restart your HIV medications until you discuss this with Dr. <Name>Ngo</Name>. Followup Instructions: You will need a follow up chest CT for nodule in 3 months. This can be arranged by your PCP. You have an appointment with your PCP. <Name>Andreas Benhamou</Name>: <Name>Jacki Chau</Name> <Name>Sean Grier</Name>, MD Phone:<Telephone>936-752-3268</Telephone> Date/Time:<Date>1964-9-18</Date> 9:10 Provider: <Name>Fannie</Name> <Name>Johnson</Name>, MD Phone:<Telephone>936-752-3268</Telephone> Date/Time:<Date>1946-12-17</Date> 9:00 Provider: <Name>Ina Edward</Name> FUNCTION LAB Phone:<Telephone>305-171-8551</Telephone> Date/Time:<Date>1996-1-6</Date> 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Date: 1923-9-12 Discharge Date: 1925-12-9 Date of Birth: 1978-4-27 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Roger Chief Complaint: nausea/emesis x 2 days Major Surgical or Invasive Procedure: none History of Present Illness: This is a 66 yo M w/h/o HIV(last CD4 307 1907-7-23, VL 187 2002-9-12), HTN, and severe COPD on 3L oxygen at home who presents w/nausea and emesis x 2 days. He notes that he had been feeling generally well but with constipation when he had sudden onset of nausea and emesis 2 nights ago. He does not recall what he was doing. Since then, he has been tolerating some food, but has had several episodes of NBNB emesis. He notes that he has not taken any of his medications x 2 days due to the nausea. He also notes that a few days PTA he took one dose of his new antiretroviral regimen- unsure which pill- and had nausea. He subsequently stopped that regimen and reverted back to his old regimen. He denies subjective fever/chills. Notes mild diffuse, nonfocal abdominal pain which he feels is caused by the nausea and is worse w/eating. He feels that his nausea and abdominal pain is c/w severe constipation, "I know it's my constipation." He denies diarrhea, hematochezia, melena. He notes that he last moved his bowels 2 days ago which is fairly normal for him but has been passing gas. He denies any sick contacts. In the Heather Dortch, pt was afebrile to 101.5 and hypertensive in 170s-200s/80s-110s. A right femoral line was placed and he received Morphine Sulfate 4mg IV x 1, dilaudid 1mg IV x 3, tylenol, and zofran for nausea. He also received 1 dose of labetalol IV x 1. ROS: The patient endorses mild HA, otherwise denies weight change, chest pain, palpitations, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, rash or skin changes. Past Medical History: - HIV/AIDS: CD4: 307(1907-7-23) VL: 187 (2002-9-12)- recently started on Truvada and Ritonavir but d/ced due to nausea. Followed by Sandeep Chau outpatient. - h/o SBO s/p Ileocectomy 1926 with lysis of adhesions, ulcer noted at the anastomosis site in 06/1926. - COPD: severe, on 2L oxygen at home, followed by Dr. Tamaro, last spirometry 2-14 - bronchiectasis - GERD - HTN - h/o internal hemorrhoids, grade I on colonoscopy 1926 - Leukopenia - Iron deficiency Anemia - h/o hiatal hernia - Chronic back pain- laminectomy at L3, L4, L5, and S1 - h/o Granulmatous disease in spleen- seen on ct scan - Esophagitis and gastritis, EGD 1916-4-24 - Schatzki's ring- seen on egd 6-1936 - H/o substance abuse-cocaine - osteoporosis followed by Dr. Olles, on Reclast PAST SURGICAL HISTORY: - Basilar artery clipping 1926 - Status post several lumbar discectomies in the past. - Status post right inguinal hernia repair. - Status post right colectomy for benign disease. Social History: Disabled. Lives in 4989 Brown Cliffs Brandyfort, MP 80844 by himself. EtOH: former heavy etoh, quit 1926 Tob: quit tobacco in 1926, 2ppd between 1926-93. Illicit drugs: smoked crack 1926 Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: Vitals: T: 98.5 BP: 139/101 HR: 83 RR: 20 O2Sat: 98% 3LNC GEN: thin, elderly, nauseous HEENT: EOMI, 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, no M/G/R, normal S1 S2, radial pulses +2 PULM: decreased chest expansion w/decreased air movement throughout, no W/R/R ABD: thin, Soft, diffusely tender, ND, +BS, no HSM, no masses but palpable stool EXT: thin, No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: 1923-9-12 12:20PM WBC-4.8 RBC-3.93* HGB-11.3* HCT-35.4* MCV-90 MCH-28.8 MCHC-31.9 RDW-14.6 1923-9-12 12:20PM NEUTS-82.4* LYMPHS-12.4* MONOS-3.2 EOS-1.6 BASOS-0.3 1923-9-12 12:20PM PLT COUNT-225 . 1923-9-12 12:20PM PT-13.0 PTT-21.7* INR(PT)-1.1 . 1923-9-12 12:20PM GLUCOSE-126* UREA N-17 CREAT-1.1 SODIUM-144 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-30 ANION GAP-14 1923-9-12 12:20PM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-71 TOT BILI-0.4 1923-9-12 12:20PM LIPASE-30 1923-9-12 12:20PM CALCIUM-9.2 PHOSPHATE-2.3* MAGNESIUM-2.2 . 1923-9-12 07:15PM TYPE-Thompkins PO2-38* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-3 1923-9-12 02:18PM LACTATE-1.2 . 1923-9-12 10:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG . ECG: Sinus rhythm at 98bpm, poor R-wave progression, no acute ST or T-wave changes, relatively unchanged from 1950-4-9. . Imaging: CT abdomen/pelvis(prelim read): No obstruction or acute abdominal issues to explain abdominal pain. New opacity in the left lung base in a region of scar in which 3 month f/u CT recommended to exclude malignancy. . KUB: Paucity of bowel gas, however, no radiographic evidence for bowel obstruction. No free air. . Admission CXR: Hyperinflated, tortuous aorta w/o evidence of infiltrate Brief Hospital Course: 66 yo M w/h/o HIV, HTN, and severe COPD who presents w/nausea, emesis, diffuse abdominal pain x 2 days and fever in the ED. . Nausea w/emesis: c/b mild, diffuse abdominal pain. Abdominal exam is nonfocal. He does not have lab evidence of pancreatitis, but does have h/o gastritis. CT abdomen w/o evidence of any acute abdominal process and KUB w/o evidence of SBO. Treated with antiemetics and tramadol for pain. His vitals remained stable throughout ICU course. Constipation was likely contributing. He was manually disimpacted with good releif of symptoms. He then developed constipation again on the floor, with a KUB that did not show obstruction. He was given an aggressive bowel regimen, with good relief of his symptoms. . Fever: without a clear source in HIV+ pt. Abdominal pain was concerning, possible pt has diverticulitis, colitis though no CT evidence of bowel inflammation. + relative leukocytosis. Cultures for infectious source were not revealing. He was not started on antibiotics. . HTN: hypertensive urgency in the ED; currently well controlled w/dose of labetalol he received in the ED. EKG w/o acute changes. Doxazosin was restarted. He was also started on HCTZ. . HIV: last CD4 307, VL 187; Per outpatient ID doctor recommendations, he was counseled not to start HAART for now, until he is contactHeather Dortch by Dr. Ngo. . COPD: severe, on 3 L oxygen outpt. Continued on albuterol nebs, tiotropium, and Advair. . Iron deficiency anemia: unclear baseline HCT, appears to be b/w 34-38; guiac (-). He was continued on iron supplements. . FEN: Diet advanced to regular Medications on Admission: ABACAVIR-LAMIVUDINE - 600 mg-300 mg Tablet - 1 Tablet(s) by mouth once a day ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet - one Tablet(s) by mouth three times a day as needed for pain do not take more than 3 per day ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2-3 puffs inhaled as needed ALBUTEROL SULFATE - 0.083 % (0.83 mg/mL) Solution for Nebulization - 1 ml neb three times a day ATAZANAVIR - 400 mg Capsule once a day BENZONATATE - 100 mg Capsule - 1 Capsule(s) by mouth three times a day DOXAZOSIN - 2 mg at bedtime FLUTICASONE-SALMETEROL 500 mcg-50 mcg/Dose 1 puff inhaled twice daily FOLIC ACID - 1 mg once a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s) sublingually every 5 minutes as needed for chest pain RANITIDINE HCL - 150 mg twice a day TIOTROPIUM BROMIDE - 18 mcg one puff inhaler once a day TIZANIDINE - 2 mg three times a day as needed for spasms TRAMADOL 50 mg Tablet - 4-24 Tablet(s) by mouth every six hours TRAZODONE - 50 mg by mouth at bedtime as needed for insomnia TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM DS] - 800 mg-160 mg Tablet three times a week ASPIRIN - 325 mg once a day CYANOCOBALAMIN once a day DOCUSATE SODIUM - 200 mg three times a day FERROUS GLUCONATE - 325 mg daily SENNA - 8.6 mg by mouth daily Reclast Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation once a day. 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) dose Sublingual once a day as needed for chest pain: one Tablet(s) sublingually every 5 minutes as needed for chest pain . 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Tizanidine 2 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for spasms. Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive urgency 2. Constipation 3. HIV 4. Lung nodule on CT scan 5. Pain control 6. Abdominal pain Discharge Condition: Stable Discharge Instructions: You were admitted with abdominal pain from constipation. This improved with a bowel regimen. You have been given a handout on constipation management. If you develop increasing abdominal pain, blood in your stool, fevers, chills, nausea, or vomiting, please call your primary care doctor. . You were also noted to be hypertensive, and you were started on a drug called hydrochlorothiazide for hypertension. . You SHOULD NOT restart your HIV medications until you discuss this with Dr. Ngo. Followup Instructions: You will need a follow up chest CT for nodule in 3 months. This can be arranged by your PCP. You have an appointment with your PCP. Andreas Benhamou: Jacki Chau Sean Grier, MD Phone:936-752-3268 Date/Time:1964-9-18 9:10 Provider: Fannie Johnson, MD Phone:936-752-3268 Date/Time:1946-12-17 9:00 Provider: Ina Edward FUNCTION LAB Phone:305-171-8551 Date/Time:1996-1-6 9:10	['Admission Date: 1923-9-12 Discharge Date: 1925-12-9\n\nDate of Birth: 1978-4-27 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Roger\nChief Complaint:\nnausea/emesis x 2 days\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\nThis is a 66 yo M w/h/o HIV(last CD4 307 1907-7-23, VL 187\n2002-9-12), HTN, and severe COPD on 3L oxygen at home who\npresents w/nausea and emesis x 2 days. He notes that he had been\nfeeling generally well but with constipation when he had sudden\nonset of nausea and emesis 2 nights ago. He does not recall what\nhe was doing. Since then, he has been tolerating some food, but\nhas had several episodes of NBNB emesis. He notes that he has\nnot taken any of his medications x 2 days due to the nausea.', ' He\nalso notes that a few days PTA he took one dose of his new\nantiretroviral regimen- unsure which pill- and had nausea. He\nsubsequently stopped that regimen and reverted back to his old\nregimen. He denies subjective fever/chills. Notes mild diffuse,\nnonfocal abdominal pain which he feels is caused by the nausea\nand is worse w/eating. He feels that his nausea and abdominal\npain is c/w severe constipation, "I know it\'s my constipation."\nHe denies diarrhea, hematochezia, melena. He notes that he last\nmoved his bowels 2 days ago which is fairly normal for him but\nhas been passing gas. He denies any sick contacts.\n\nIn the Heather Dortch, pt was afebrile to 101.5 and hypertensive in\n170s-200s/80s-110s. A right femoral line was placed and he\nreceived Morphine Sulfate 4mg IV x 1, dilaudid 1mg IV x 3,\ntylenol, and zofran for nausea.', " He also received 1 dose of\nlabetalol IV x 1.\n\nROS: The patient endorses mild HA, otherwise denies weight\nchange, chest pain, palpitations, shortness of breath,\northopnea, PND, lower extremity edema, cough, urinary frequency,\nurgency, dysuria, lightheadedness, gait unsteadiness, focal\nweakness, vision changes, rash or skin changes.\n\n\nPast Medical History:\n- HIV/AIDS: CD4: 307(1907-7-23) VL: 187 (2002-9-12)- recently\nstarted on Truvada and Ritonavir but d/ced due to nausea.\nFollowed by Sandeep Chau outpatient.\n- h/o SBO s/p Ileocectomy 1926 with lysis of adhesions, ulcer\nnoted at the anastomosis site in 06/1926.\n- COPD: severe, on 2L oxygen at home, followed by Dr. Tamaro,\nlast spirometry 2-14\n- bronchiectasis\n- GERD\n- HTN\n- h/o internal hemorrhoids, grade I on colonoscopy 1926\n- Leukopenia\n- Iron deficiency Anemia\n- h/o hiatal hernia\n- Chronic back pain- laminectomy at L3, L4, L5, and S1\n- h/o Granulmatous disease in spleen- seen on ct scan\n- Esophagitis and gastritis, EGD 1916-4-24\n- Schatzki's ring- seen on egd 6-1936\n- H/o substance abuse-cocaine\n- osteoporosis followed by Dr.", ' Olles, on Reclast\n\nPAST SURGICAL HISTORY:\n- Basilar artery clipping 1926\n- Status post several lumbar discectomies in the past.\n- Status post right inguinal hernia repair.\n- Status post right colectomy for benign disease.\n\n\nSocial History:\nDisabled. Lives in 4989 Brown Cliffs\nBrandyfort, MP 80844 by himself.\nEtOH: former heavy etoh, quit 1926\nTob: quit tobacco in 1926, 2ppd between 1926-93.\nIllicit drugs: smoked crack 1926\n\n\nFamily History:\n1. Father: deceased, EtOH\n2. Mother: deceased, CVA in 60s\n3. Brother: lung cancer\n4. Sister: HTN\n5. Sister: CVA in 60s\nBrothers x7 (now only two), Sister x2 (both still alive)\n\n\nPhysical Exam:\nVitals: T: 98.5 BP: 139/101 HR: 83 RR: 20 O2Sat: 98% 3LNC\nGEN: thin, elderly, nauseous\nHEENT: EOMI, PERRL, sclera anicteric, no epistaxis or\nrhinorrhea, MMM, OP Clear\nNECK: No JVD, carotid pulses brisk, no bruits, no cervical\nlymphadenopathy, trachea midline\nCOR: RRR, no M/G/R, normal S1 S2, radial pulses +2\nPULM: decreased chest expansion w/decreased air movement\nthroughout, no W/R/R\nABD: thin, Soft, diffusely tender, ND, +BS, no HSM, no masses\nbut palpable stool\nEXT: thin, No C/C/E, no palpable cords\nNEURO: alert, oriented to person, place, and time.', ' CN II ?????? XII\ngrossly intact. Moves all 4 extremities. Strength 5/5 in upper\nand lower extremities.\nSKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.\n\n\n\nPertinent Results:\n1923-9-12 12:20PM WBC-4.8 RBC-3.93* HGB-11.3* HCT-35.4* MCV-90\nMCH-28.8 MCHC-31.9 RDW-14.6\n1923-9-12 12:20PM NEUTS-82.4* LYMPHS-12.4* MONOS-3.2 EOS-1.6\nBASOS-0.3\n1923-9-12 12:20PM PLT COUNT-225\n.\n1923-9-12 12:20PM PT-13.0 PTT-21.7* INR(PT)-1.1\n.\n1923-9-12 12:20PM GLUCOSE-126* UREA N-17 CREAT-1.1 SODIUM-144\nPOTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-30 ANION GAP-14\n1923-9-12 12:20PM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-71 TOT\nBILI-0.4\n1923-9-12 12:20PM LIPASE-30\n1923-9-12 12:20PM CALCIUM-9.2 PHOSPHATE-2.3* MAGNESIUM-2.2\n.\n1923-9-12 07:15PM TYPE-Thompkins PO2-38* PCO2-44 PH-7.42 TOTAL CO2-30\nBASE XS-3\n1923-9-12 02:18PM LACTATE-1.', '2\n.\n1923-9-12 10:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0\nLEUK-NEG\n.\nECG: Sinus rhythm at 98bpm, poor R-wave progression, no acute\nST or T-wave changes, relatively unchanged from 1950-4-9.\n.\nImaging:\nCT abdomen/pelvis(prelim read): No obstruction or acute\nabdominal issues to explain abdominal pain. New opacity in the\nleft lung base in a region of scar in which 3 month f/u CT\nrecommended to exclude malignancy.\n.\nKUB: Paucity of bowel gas, however, no radiographic evidence for\nbowel obstruction. No free air.\n.\nAdmission CXR: Hyperinflated, tortuous aorta w/o evidence of\ninfiltrate\n\n\n\nBrief Hospital Course:\n66 yo M w/h/o HIV, HTN, and severe COPD who presents w/nausea,\nemesis, diffuse abdominal pain x 2 days and fever in the ED.\n.', '\nNausea w/emesis: c/b mild, diffuse abdominal pain. Abdominal\nexam is nonfocal. He does not have lab evidence of pancreatitis,\nbut does have h/o gastritis. CT abdomen w/o evidence of any\nacute abdominal process and KUB w/o evidence of SBO. Treated\nwith antiemetics and tramadol for pain. His vitals remained\nstable throughout ICU course. Constipation was likely\ncontributing. He was manually disimpacted with good releif of\nsymptoms. He then developed constipation again on the floor,\nwith a KUB that did not show obstruction. He was given an\naggressive bowel regimen, with good relief of his symptoms.\n.\nFever: without a clear source in HIV+ pt. Abdominal pain was\nconcerning, possible pt has diverticulitis, colitis though no CT\nevidence of bowel inflammation. + relative leukocytosis.\nCultures for infectious source were not revealing.', ' He was not\nstarted on antibiotics.\n.\nHTN: hypertensive urgency in the ED; currently well controlled\nw/dose of labetalol he received in the ED. EKG w/o acute\nchanges. Doxazosin was restarted. He was also started on HCTZ.\n.\nHIV: last CD4 307, VL 187; Per outpatient ID doctor\nrecommendations, he was counseled not to start HAART for now,\nuntil he is contactHeather Dortch by Dr. Ngo.\n.\nCOPD: severe, on 3 L oxygen outpt. Continued on albuterol nebs,\ntiotropium, and Advair.\n.\nIron deficiency anemia: unclear baseline HCT, appears to be b/w\n34-38; guiac (-). He was continued on iron supplements.\n.\nFEN: Diet advanced to regular\n\nMedications on Admission:\nABACAVIR-LAMIVUDINE - 600 mg-300 mg Tablet - 1 Tablet(s) by\nmouth\nonce a day\nACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet\n- one Tablet(s) by mouth three times a day as needed for pain do\nnot take more than 3 per day\nALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2-3 puffs\ninhaled as needed\nALBUTEROL SULFATE - 0.', '083 % (0.83 mg/mL) Solution for\nNebulization - 1 ml neb three times a day\nATAZANAVIR - 400 mg Capsule once a day\nBENZONATATE - 100 mg Capsule - 1 Capsule(s) by mouth three times\na day\nDOXAZOSIN - 2 mg at bedtime\nFLUTICASONE-SALMETEROL 500 mcg-50 mcg/Dose 1 puff inhaled twice\ndaily\nFOLIC ACID - 1 mg once a day\nNITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s)\nsublingually every 5 minutes as needed for chest pain\nRANITIDINE HCL - 150 mg twice a day\nTIOTROPIUM BROMIDE - 18 mcg one puff inhaler once a day\nTIZANIDINE - 2 mg three times a day as needed for spasms\nTRAMADOL 50 mg Tablet - 4-24 Tablet(s) by mouth every\nsix hours\nTRAZODONE - 50 mg by mouth at bedtime as needed for insomnia\nTRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM DS] - 800 mg-160 mg\nTablet\nthree times a week\nASPIRIN - 325 mg once a day\nCYANOCOBALAMIN once a day\nDOCUSATE SODIUM - 200 mg three times a day\nFERROUS GLUCONATE - 325 mg daily\nSENNA - 8.', '6 mg by mouth daily\nReclast\n\n\nDischarge Medications:\n1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every\n6 hours) as needed.\n2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:\nOne (1) Cap Inhalation DAILY (Daily).\n3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).\n\n4. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)\nas needed.\n5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once\na day.\nDisp:30 Tablet(s) Refills:2\n6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\nDisp:60 Tablet(s) Refills:2\n7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) nebulizer Inhalation Q6H (every 6\nhours) as needed for shortness of breath or wheezing.\n8. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two\n(2) puffs Inhalation once a day.', '\n9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) dose\nSublingual once a day as needed for chest pain: one Tablet(s)\nsublingually every 5 minutes as needed for chest pain .\n11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day).\n12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\nDisp:60 Tablet, Delayed Release (E.C.)(s) Refills:2\n13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID\n(2 times a day).\nDisp:60 Capsule(s) Refills:2\n14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at\nbedtime) as needed.\n15. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY\n(Daily).\n16. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)\nTablet PO DAILY (Daily).', '\n17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)\nTablet PO 3X/WEEK (MO,WE,FR).\n18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n19. Tizanidine 2 mg Capsule Sig: One (1) Capsule PO every eight\n(8) hours as needed for spasms.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\n1. Hypertensive urgency\n2. Constipation\n3. HIV\n4. Lung nodule on CT scan\n5. Pain control\n6. Abdominal pain\n\n\nDischarge Condition:\nStable\n\n\nDischarge Instructions:\nYou were admitted with abdominal pain from constipation. This\nimproved with a bowel regimen. You have been given a handout on\nconstipation management. If you develop increasing abdominal\npain, blood in your stool, fevers, chills, nausea, or vomiting,\nplease call your primary care doctor.\n.\nYou were also noted to be hypertensive, and you were started on\na drug called hydrochlorothiazide for hypertension.', '\n.\nYou SHOULD NOT restart your HIV medications until you discuss\nthis with Dr. Ngo.\n\nFollowup Instructions:\nYou will need a follow up chest CT for nodule in 3 months. This\ncan be arranged by your PCP.\n\nYou have an appointment with your PCP.\nAndreas Benhamou: Jacki Chau Sean Grier, MD Phone:936-752-3268\nDate/Time:1964-9-18 9:10\nProvider: Fannie Johnson, MD Phone:936-752-3268\nDate/Time:1946-12-17 9:00\nProvider: Ina Edward FUNCTION LAB Phone:305-171-8551\nDate/Time:1996-1-6 9:10\n\n\n\n']
217	11018	180836.0	2152-03-02	Discharge summary	Report	Admission Date: [2152-2-15] Discharge Date: [2152-3-2] Date of Birth: [2084-12-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1070] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Endotracheal Intubation Arterial line placement Internal Jugular line placement History of Present Illness: Mr. [Known lastname 2150] is a 67M with HIV (Cd4 183, VL 96 copies/mL) and end stage COPD on 3-4L home O2 with a FEV1 of 0.5 who presented to the emergency room on [2152-2-15] with increased shortness of breath. Three days prior to presentation he developed nasal congestion and rhinorrhea which made it difficult for him to use his supplemental oxygen at home. He had subjective fevers and chills but did not check his temperature. He had minimal cough productive of dark yellow sputum. He was feeling more short of breath despite increasing oxygen use. He was concerned about pneumonia and presented to the emergency room. . In the emergency room his initial vitals were T: 98.1 HR: 86 RR: 107/72 RR: 22 O2: 100% on RA. He had a chest xray which showed significant hyperinflation but no acute cardiopulmonary process. He received levofloxacin 750 mg IV x 1, duonebs, solumedrol 125 mg IV x 1 and aspirin 81 mg. He was initially admitted to the floor. . While on the floor he was started on azithromycin, solumedrol 125 mg IV TID, albuterol and ipratropium nebulizers. He did well on hospital day 1 but overnight his shortness of breath worsened. He had a repeat CXR which was similar to priors. He had an ABG on a non-rebreather which was 7.37/57/207/34. He had increased work of breathing and asked to be placed on "a machine for breathing." He is transferred to the MICU for non-invasive ventilatory support. n the MICU he was intubated an an A-line was placed due to increased WOB. Blood pressure was elevated while in respiratory distress and he was treated with hydralazine. He had one episode of hypotension responsive to IVF. A right IJ central line placed. ABG on [2-18] was 7.32/54/104. Methylprednisolone was decreased to 60mg IV BID. He was extubated on ICU day 3 and initially appeared in stress but did well after small dose IV morphine.He was transferred to the floor on ICU day 4. Prior to transfer he reviewed his code status and decided to be DNR/DNI. . On the floor, he is doing relatively well. He reports he is still somewhat short of breath but not in any distress. He reports back pain secondary to old back injury. He will be spending time with family and friends who are coming in from around the country to see him. Reports lack of appetite but no n/v. Denies F/C cough, chest pain. Past Medical History: - HIV/AIDS - most recent CD4 count 183, viral load 96 copies/ml - COPD - FVC 2.34 (63%), FEV1 0.50 (20%), FEV1/FVC 21 (31%) [7-/2151] - GERD - Hypertension - h/o GI bleed - Leukopenia - Anemia (baseline hct 36) - Inguinal hernia - Homocysteinemia - Chronic back pain - Granulmatous disease in spleen- seen on ct scan - Esophagitis- egd [11-21] - Schatzki's ring- seen on egd [7-/2143] - SBO obstruction in past requiring partial bowel resection - H/o of drug use (Cocaine) Social History: Previously a truck driver, now disabled/retired. Lives in [Location 669] by himself. EtOH: former heavy etoh, quit [2135] Tob: quit tobacco in [2135], 2ppd between [2100]-93. Illicit drugs: smoked crack [2135] Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: Vitals T: 97.0 HR: 113 BP: 153/96 RR: 19 O2: 100% on BIPAP General Thin elderly man, tachypneic, using accessory muscles for respiration HEENT sclera anicteric, conjunctiva pink, mucous membranes moist, no lymphadenopathy Neck: JVP not elevated Pulmonary: Poor air movement bilaterally, scarce wheezes bilaterally, mild inspiratory crackles at bases, hyperexpansion Cardiac: Tachycardic, normal s1 + s2, no murmurs, rubs, gallops Abdominal: Soft, non-tender, non-distended, +BS Extremities: Warm and well perfused, 2+ distal pulses, no clubbing, cyanosis or edema Pertinent Results: LABS ON ADMISSION: [2152-2-15] 09:15PM BLOOD WBC-3.5* RBC-3.98* Hgb-11.8* Hct-35.9* MCV-90 MCH-29.6 MCHC-32.8 RDW-15.6* Plt Ct-149* [2152-2-15] 09:15PM BLOOD Neuts-55.0 Lymphs-33.9 Monos-6.1 Eos-4.2* Baso-0.8 [2152-2-15] 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 [2152-2-17] 06:05AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 [2152-2-17] 08:02AM BLOOD Type-ART pO2-207* pCO2-57* pH-7.37 calTCO2-34* Base XS-6 . MICROBIOLOGY: Bl Cx ([2152-2-15]) - NGTD . RADIOLOGY: CXR ([2152-2-16]): 1. No pneumonia. 2. Unchanged severe emphysema. Stable right hilar calcified lymph node. . Other Labs: [2152-3-2] 06:36AM BLOOD WBC-6.6 RBC-2.42* Hgb-7.1* Hct-21.9* MCV-90 MCH-29.3 MCHC-32.4 RDW-15.8* Plt Ct-191 [2152-3-1] 06:26AM BLOOD WBC-6.5 RBC-2.41* Hgb-7.0* Hct-22.3* MCV-93 MCH-28.9 MCHC-31.3 RDW-16.1* Plt Ct-143* [2152-2-29] 05:19AM BLOOD WBC-10.2 RBC-2.70* Hgb-7.9* Hct-24.8* MCV-92 MCH-29.4 MCHC-31.9 RDW-15.7* Plt Ct-161 [2152-2-28] 09:06AM BLOOD WBC-10.2 RBC-2.76# Hgb-8.3# Hct-24.7# MCV-90 MCH-30.0 MCHC-33.6 RDW-16.0 Plt Ct-160 [2152-2-28] 05:00AM BLOOD WBC-7.0 RBC-2.12# Hgb-6.4# Hct-19.0# MCV-90 MCH-30.1 MCHC-33.6 RDW-15.7 Plt Ct-113* [2152-2-27] 05:34AM BLOOD WBC-9.3 RBC-2.91* Hgb-8.7* Hct-26.4* MCV-91 MCH-30.0 MCHC-33.0 RDW-15.8* Plt Ct-149* [2152-2-25] 05:09AM BLOOD WBC-15.9* RBC-3.39* Hgb-10.1* Hct-30.6* MCV-90 MCH-29.8 MCHC-33.0 RDW-16.2* Plt Ct-187 [2152-2-24] 05:09AM BLOOD WBC-13.9* RBC-3.55* Hgb-10.5* Hct-32.0* MCV-90 MCH-29.5 MCHC-32.8 RDW-16.1* Plt Ct-216 [2152-2-23] 05:29AM BLOOD WBC-9.8 RBC-3.16* Hgb-9.1* Hct-28.7* MCV-91 MCH-28.9 MCHC-31.9 RDW-16.0* Plt Ct-180 [2152-2-22] 05:44AM BLOOD WBC-10.2 RBC-3.30* Hgb-9.8* Hct-29.9* MCV-91 MCH-29.9 MCHC-33.0 RDW-15.7* Plt Ct-182 [2152-2-21] 04:36AM BLOOD WBC-8.1 RBC-3.27* Hgb-9.4* Hct-28.9* MCV-88 MCH-28.8 MCHC-32.6 RDW-15.3 Plt Ct-167 [2152-2-20] 05:39AM BLOOD WBC-8.7 RBC-3.37* Hgb-9.8* Hct-30.2* MCV-90 MCH-29.0 MCHC-32.4 RDW-15.2 Plt Ct-179 [2152-2-19] 05:52AM BLOOD WBC-6.6 RBC-3.47* Hgb-10.3* Hct-31.3* MCV-90 MCH-29.5 MCHC-32.8 RDW-15.4 Plt Ct-180 [2152-2-18] 05:06AM BLOOD WBC-6.5 RBC-3.58* Hgb-10.3* Hct-32.0* MCV-89 MCH-28.8 MCHC-32.3 RDW-15.6* Plt Ct-201 [2152-2-28] 09:06AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1 [2152-2-20] 05:39AM BLOOD PT-13.3 PTT-33.0 INR(PT)-1.1 [2152-3-2] 06:36AM BLOOD Glucose-198* UreaN-8 Creat-0.7 Na-136 K-4.3 Cl-103 HCO3-27 AnGap-10 [2152-3-1] 06:26AM BLOOD Glucose-138* UreaN-9 Creat-0.7 Na-141 K-3.3 Cl-107 HCO3-29 AnGap-8 [2152-2-29] 05:19AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-138 K-3.3 Cl-101 HCO3-31 AnGap-9 [2152-2-28] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-0.8 Na-135 K-3.4 Cl-97 HCO3-28 AnGap-13 [2152-2-27] 05:34AM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-138 K-3.7 Cl-98 HCO3-31 AnGap-13 [2152-2-25] 05:09AM BLOOD Glucose-74 UreaN-28* Creat-1.0 Na-137 K-4.6 Cl-95* HCO3-32 AnGap-15 [2152-2-24] 06:00PM BLOOD Glucose-108* UreaN-31* Creat-1.1 Na-140 K-4.8 Cl-97 HCO3-36* AnGap-12 [2152-2-24] 05:09AM BLOOD Glucose-112* UreaN-30* Creat-1.0 Na-146* K-4.7 Cl-103 HCO3-37* AnGap-11 [2152-2-23] 05:29AM BLOOD Glucose-120* UreaN-33* Creat-0.9 Na-144 K-4.7 Cl-105 HCO3-35* AnGap-9 [2152-2-22] 05:44AM BLOOD Glucose-176* UreaN-34* Creat-1.1 Na-143 K-4.5 Cl-106 HCO3-33* AnGap-9 [2152-2-21] 04:36AM BLOOD Glucose-213* UreaN-35* Creat-1.0 Na-145 K-3.7 Cl-107 HCO3-33* AnGap-9 [2152-2-20] 05:39AM BLOOD Glucose-115* UreaN-40* Creat-0.9 Na-146* K-4.2 Cl-108 HCO3-31 AnGap-11 [2152-2-18] 05:06AM BLOOD Glucose-120* UreaN-36* Creat-1.2 Na-142 K-4.8 Cl-103 HCO3-28 AnGap-16 [2152-2-17] 06:05AM BLOOD Glucose-137* UreaN-18 Creat-0.9 Na-141 K-3.8 Cl-104 HCO3-28 AnGap-13 [2152-2-15] 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 [2152-2-24] 05:09AM BLOOD ALT-25 AST-26 AlkPhos-57 TotBili-0.4 [2152-2-20] 05:39AM BLOOD ALT-21 AST-29 LD(LDH)-209 AlkPhos-56 TotBili-0.7 [2152-2-15] 09:15PM BLOOD CK(CPK)-77 [2152-2-15] 09:15PM BLOOD cTropnT-0.03* [2152-3-2] 06:36AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.7 [2152-2-29] 05:19AM BLOOD Calcium-7.9* Phos-1.5* Mg-1.7 [2152-2-28] 05:00AM BLOOD Calcium-7.4* Phos-2.0* Mg-1.9 Iron-16* [2152-2-27] 05:34AM BLOOD Calcium-7.6* Phos-2.2* Mg-1.9 [2152-2-28] 05:00AM BLOOD calTIBC-127* VitB12-GREATER TH Folate-GREATER TH Ferritn-206 TRF-98* Brief Hospital Course: In summary, Mr. [Known lastname 2150] is a 67M with HIV (on HAART) and end-stage COPD (on home O2), who presented [2152-2-15] with worsening shortness of breath in the setting of likely [Hospital 2170] transferred to MICU for worsening respiratory distress. . # End-stage COPD/Respiratory Distress: End-stage baseline COPD (FEV1 20% predicted and on home O2). Admitted w likely COPD exacerbation triggered by viral URI. Nasal complaints and absence of infiltrate go against a bacterial PNA. MI and PE also considered. Pt treated with nebulizers, steroids, azithromycin. ABG shows chronic respiratory acidosis which appears compensated. Pt oxygenated well on O2 by nasal canula, but developed respiratory distress w accessory muscle use, tachypnea and tachycardia, which required MICU transfer on [2-17] for increasing respiratory distress. He was subsequently intubated that same night as his respiratory status continued to worsen. He remained stable on the vent and was extubated without complications on [2-19]. His respiratory status continued to be stable post-extubation. He was continued on azithromycin for a three day course and continued on steroids. He was then transferred back to the medical floor the following day after extubation with stable respiratory status. Followed by Dr [Last Name (STitle) 2171]. On the floor his steroid regimen was kept as IV until patient's SBO resolved. With resolution of SBO patient was transitioned to PO steroids. Pt was discharged with a steroid taper. His last dose of Prednisone 10mg [3-6]. . On the floor his dyspnea continued and he required 4-5 L of nasal O2. He was evaluated by palliative care after he made the decision to become DNR/DNI. Based on their recommendations he was switched from ATC morphine to MS contin and ativan for dyspnea related anxiety. He was noted to have mental status changes including confusion, somnolence so MS contin was discontinued with return to normal mentation. His respiratory continued to improve with decrease in anxiety noted. Patient's pain was well controlled with liquid morphine, fentanyl patch, and tylenol #3 as needed. . # HIV/AIDS: Patient on HAART with recent decrease in CD4 count to below 200, hence on bactrim ppx. Followed by Dr [Last Name (STitle) 1057]. HAART was temporarily discontinued in the setting of SBO with nausea and vomiting. With resolution of SBO, HAART was restarted on [2152-2-29]. . #Small bowel obstruction: Patient developed acutely worsening abdominal pain on the [Hospital1 ] associated with nausea and vomiting. CT of the abdomen and pelvis demonstrated a partial SBO. He was made NPO and a nasogastric tube was placed. Patient's nausea, vomiting, and abdominal distention improved steadily. His NGT was clamped and eventually discontinued on [2-28] with advancement of his diet to a regular diet. He tolerated that well. . #Pneumonia: Patient was found to have a left lower lobe pneumonia incidentally on chest xray evaluating PICC placement. Labs at the time were remarkable for leukocytosis. He was started on Zosyn and vancomycin for presumed Hospital associated pneumonia. Patient's vancomycin was stopped on [2-27]. He was continued on Zosyn and then transitioned to PO levoquin on [2-29] and discharged on this medication to complete an 8 day course of antibiotics with last day of antibiotics to be [2152-3-4]. . # Hypertension: Normotensive on admission, mild elevation in blood pressures in the setting of respiratory distress. Patient was continued on his home dose of doxazosin while in house. . # GERD: Stable. Continued H2 blocker. . # Anemia: Hematocrit dropped slightly during hospital admission from patient's baseline of 36 to 22. Iron studies demonstrated most likely anemia of chronic disease and iron deficiency anemia coupled with dilutional effect of IV hydration and daily blood draws as reasonable explanation of drop in hematocrit. Patient was always hemodynamically stable with no signs or symptoms of active bleeding. Patient was started on PO Iron. Medications on Admission: Epzicom 600mg-300mg daily Tylenol w/codeine PRN Albuterol 0.083% nebulizers TID Albuterol Inhaler Q4H:PRN Atazanvir 400 mg daily Symbicort 2 puffs [Hospital1 ] Doxazosin 2 mg QHS Folic Acid 1 mg daily Fosamprenavir 1400 mg daily Nitroglycerin 0.4 mg PRN Ranitidine 150 mg [Hospital1 ] Spiriva 18 mcg daily Tizanidine 2 mg TID Tramadol 50 mg Q6H:PRN Trazodone 50 mg QHS:PRN Bactrim DS 800 mg-160 mg three times per week Aspirin 81 mg daily B12 250 mcg daily Colace 100 mg [Hospital1 ] Ferrous Gluconate 325 mg daily Boost TID Oxygen 2-3 L Senna PRN Discharge Medications: 1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:2 20. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day: Please take 2 tabs on [2152-3-3] Please take 1 tab, [3-4], [3-5], and [3-6] The last day of medication is [3-6]. Disp:5 Tablet(s)* Refills:0 21. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 2 days. Disp:6 Tablet(s) Refills:0 22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). Disp:20 Refills:2 23. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). Disp:30 Tablet(s) Refills:2 24. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every four (4) hours: Do not exceed 4g tylenol in 24hours. do not drink or drive while on this mediction. Disp:30 Tablet(s) Refills:0 25. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: PRIMARY * COPD * HIV * High blood sugar SECONDARY * Constipation * Chronic back pain Discharge Condition: Stable Discharge Instructions: You were admitted with shortness of breath due to exacerbation of your COPD most likely by a viral respiratory infection. It became increasingly difficult for you to breath so you were intubated and transferred to the intensive care unit. . After the breathing tube was removed and transferred to the wards you continued to experience shortness of breath and anxiety. You were seen by the palliative care doctors who recommended that we treat you receive morphine and ativan to make you more comfortable. Your pain has been well controlled with morphine, tylenol #3, and a fentanyl patch. We are also giving you steroids for your COPD exacerbation. You will continue to take the steroids until [2152-3-6]. . You also developed an pneumonia while in the hospital. We are currently giving you antibiotics for this pneumonia. Your last day of antibiotics will by [2152-3-4]. . You also developed a partial small bowel obstuction while in the hospital. You were treated with a nasogastric tube and nothing by mouth. You obstruction resolved and you are now tolerating a regular diet. . Medication changes include: * Fentanyl Patch * Prednisone * Levofloxacin Followup Instructions: Please keep the following appointments Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2152-3-8] 11:00 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2152-4-24] 9:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1085], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2152-3-8] 10:00	Admission Date: <Date>1917-6-16</Date> Discharge Date: <Date>1914-10-1</Date> Date of Birth: <Date>1910-8-24</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Nisha</Name> Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Endotracheal Intubation Arterial line placement Internal Jugular line placement History of Present Illness: Mr. <Name>Moblo</Name> is a 67M with HIV (Cd4 183, VL 96 copies/mL) and end stage COPD on 3-4L home O2 with a FEV1 of 0.5 who presented to the emergency room on <Date>1917-6-16</Date> with increased shortness of breath. Three days prior to presentation he developed nasal congestion and rhinorrhea which made it difficult for him to use his supplemental oxygen at home. He had subjective fevers and chills but did not check his temperature. He had minimal cough productive of dark yellow sputum. He was feeling more short of breath despite increasing oxygen use. He was concerned about pneumonia and presented to the emergency room. . In the emergency room his initial vitals were T: 98.1 HR: 86 RR: 107/72 RR: 22 O2: 100% on RA. He had a chest xray which showed significant hyperinflation but no acute cardiopulmonary process. He received levofloxacin 750 mg IV x 1, duonebs, solumedrol 125 mg IV x 1 and aspirin 81 mg. He was initially admitted to the floor. . While on the floor he was started on azithromycin, solumedrol 125 mg IV TID, albuterol and ipratropium nebulizers. He did well on hospital day 1 but overnight his shortness of breath worsened. He had a repeat CXR which was similar to priors. He had an ABG on a non-rebreather which was 7.37/57/207/34. He had increased work of breathing and asked to be placed on "a machine for breathing." He is transferred to the MICU for non-invasive ventilatory support. n the MICU he was intubated an an A-line was placed due to increased WOB. Blood pressure was elevated while in respiratory distress and he was treated with hydralazine. He had one episode of hypotension responsive to IVF. A right IJ central line placed. ABG on <Date>3-2</Date> was 7.32/54/104. Methylprednisolone was decreased to 60mg IV BID. He was extubated on ICU day 3 and initially appeared in stress but did well after small dose IV morphine.He was transferred to the floor on ICU day 4. Prior to transfer he reviewed his code status and decided to be DNR/DNI. . On the floor, he is doing relatively well. He reports he is still somewhat short of breath but not in any distress. He reports back pain secondary to old back injury. He will be spending time with family and friends who are coming in from around the country to see him. Reports lack of appetite but no n/v. Denies F/C cough, chest pain. Past Medical History: - HIV/AIDS - most recent CD4 count 183, viral load 96 copies/ml - COPD - FVC 2.34 (63%), FEV1 0.50 (20%), FEV1/FVC 21 (31%) <Date>3-1978</Date> - GERD - Hypertension - h/o GI bleed - Leukopenia - Anemia (baseline hct 36) - Inguinal hernia - Homocysteinemia - Chronic back pain - Granulmatous disease in spleen- seen on ct scan - Esophagitis- egd <Date>2-30</Date> - Schatzki's ring- seen on egd <Date>4-1966</Date> - SBO obstruction in past requiring partial bowel resection - H/o of drug use (Cocaine) Social History: Previously a truck driver, now disabled/retired. Lives in <Location>310 Obrien Prairie Bakerfort, HI 45217</Location> by himself. EtOH: former heavy etoh, quit <Year>1944</Year> Tob: quit tobacco in <Year>1944</Year>, 2ppd between <Year>1944</Year>-93. Illicit drugs: smoked crack <Year>1944</Year> Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: Vitals T: 97.0 HR: 113 BP: 153/96 RR: 19 O2: 100% on BIPAP General Thin elderly man, tachypneic, using accessory muscles for respiration HEENT sclera anicteric, conjunctiva pink, mucous membranes moist, no lymphadenopathy Neck: JVP not elevated Pulmonary: Poor air movement bilaterally, scarce wheezes bilaterally, mild inspiratory crackles at bases, hyperexpansion Cardiac: Tachycardic, normal s1 + s2, no murmurs, rubs, gallops Abdominal: Soft, non-tender, non-distended, +BS Extremities: Warm and well perfused, 2+ distal pulses, no clubbing, cyanosis or edema Pertinent Results: LABS ON ADMISSION: <Date>1917-6-16</Date> 09:15PM BLOOD WBC-3.5* RBC-3.98* Hgb-11.8* Hct-35.9* MCV-90 MCH-29.6 MCHC-32.8 RDW-15.6* Plt Ct-149* <Date>1917-6-16</Date> 09:15PM BLOOD Neuts-55.0 Lymphs-33.9 Monos-6.1 Eos-4.2* Baso-0.8 <Date>1917-6-16</Date> 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 <Date>1953-8-17</Date> 06:05AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 <Date>1953-8-17</Date> 08:02AM BLOOD Type-ART pO2-207* pCO2-57* pH-7.37 calTCO2-34* Base XS-6 . MICROBIOLOGY: Bl Cx (<Date>1917-6-16</Date>) - NGTD . RADIOLOGY: CXR (<Date>2018-5-17</Date>): 1. No pneumonia. 2. Unchanged severe emphysema. Stable right hilar calcified lymph node. . Other Labs: <Date>1914-10-1</Date> 06:36AM BLOOD WBC-6.6 RBC-2.42* Hgb-7.1* Hct-21.9* MCV-90 MCH-29.3 MCHC-32.4 RDW-15.8* Plt Ct-191 <Date>2001-11-26</Date> 06:26AM BLOOD WBC-6.5 RBC-2.41* Hgb-7.0* Hct-22.3* MCV-93 MCH-28.9 MCHC-31.3 RDW-16.1* Plt Ct-143* <Date>1927-2-2</Date> 05:19AM BLOOD WBC-10.2 RBC-2.70* Hgb-7.9* Hct-24.8* MCV-92 MCH-29.4 MCHC-31.9 RDW-15.7* Plt Ct-161 <Date>1973-11-24</Date> 09:06AM BLOOD WBC-10.2 RBC-2.76# Hgb-8.3# Hct-24.7# MCV-90 MCH-30.0 MCHC-33.6 RDW-16.0 Plt Ct-160 <Date>1973-11-24</Date> 05:00AM BLOOD WBC-7.0 RBC-2.12# Hgb-6.4# Hct-19.0# MCV-90 MCH-30.1 MCHC-33.6 RDW-15.7 Plt Ct-113* <Date>1983-11-31</Date> 05:34AM BLOOD WBC-9.3 RBC-2.91* Hgb-8.7* Hct-26.4* MCV-91 MCH-30.0 MCHC-33.0 RDW-15.8* Plt Ct-149* <Date>1962-12-22</Date> 05:09AM BLOOD WBC-15.9* RBC-3.39* Hgb-10.1* Hct-30.6* MCV-90 MCH-29.8 MCHC-33.0 RDW-16.2* Plt Ct-187 <Date>1953-10-9</Date> 05:09AM BLOOD WBC-13.9* RBC-3.55* Hgb-10.5* Hct-32.0* MCV-90 MCH-29.5 MCHC-32.8 RDW-16.1* Plt Ct-216 <Date>1905-8-25</Date> 05:29AM BLOOD WBC-9.8 RBC-3.16* Hgb-9.1* Hct-28.7* MCV-91 MCH-28.9 MCHC-31.9 RDW-16.0* Plt Ct-180 <Date>1968-7-4</Date> 05:44AM BLOOD WBC-10.2 RBC-3.30* Hgb-9.8* Hct-29.9* MCV-91 MCH-29.9 MCHC-33.0 RDW-15.7* Plt Ct-182 <Date>1951-12-4</Date> 04:36AM BLOOD WBC-8.1 RBC-3.27* Hgb-9.4* Hct-28.9* MCV-88 MCH-28.8 MCHC-32.6 RDW-15.3 Plt Ct-167 <Date>2016-7-17</Date> 05:39AM BLOOD WBC-8.7 RBC-3.37* Hgb-9.8* Hct-30.2* MCV-90 MCH-29.0 MCHC-32.4 RDW-15.2 Plt Ct-179 <Date>1917-10-26</Date> 05:52AM BLOOD WBC-6.6 RBC-3.47* Hgb-10.3* Hct-31.3* MCV-90 MCH-29.5 MCHC-32.8 RDW-15.4 Plt Ct-180 <Date>1950-12-31</Date> 05:06AM BLOOD WBC-6.5 RBC-3.58* Hgb-10.3* Hct-32.0* MCV-89 MCH-28.8 MCHC-32.3 RDW-15.6* Plt Ct-201 <Date>1973-11-24</Date> 09:06AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1 <Date>2016-7-17</Date> 05:39AM BLOOD PT-13.3 PTT-33.0 INR(PT)-1.1 <Date>1914-10-1</Date> 06:36AM BLOOD Glucose-198* UreaN-8 Creat-0.7 Na-136 K-4.3 Cl-103 HCO3-27 AnGap-10 <Date>2001-11-26</Date> 06:26AM BLOOD Glucose-138* UreaN-9 Creat-0.7 Na-141 K-3.3 Cl-107 HCO3-29 AnGap-8 <Date>1927-2-2</Date> 05:19AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-138 K-3.3 Cl-101 HCO3-31 AnGap-9 <Date>1973-11-24</Date> 05:00AM BLOOD Glucose-84 UreaN-15 Creat-0.8 Na-135 K-3.4 Cl-97 HCO3-28 AnGap-13 <Date>1983-11-31</Date> 05:34AM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-138 K-3.7 Cl-98 HCO3-31 AnGap-13 <Date>1962-12-22</Date> 05:09AM BLOOD Glucose-74 UreaN-28* Creat-1.0 Na-137 K-4.6 Cl-95* HCO3-32 AnGap-15 <Date>1953-10-9</Date> 06:00PM BLOOD Glucose-108* UreaN-31* Creat-1.1 Na-140 K-4.8 Cl-97 HCO3-36* AnGap-12 <Date>1953-10-9</Date> 05:09AM BLOOD Glucose-112* UreaN-30* Creat-1.0 Na-146* K-4.7 Cl-103 HCO3-37* AnGap-11 <Date>1905-8-25</Date> 05:29AM BLOOD Glucose-120* UreaN-33* Creat-0.9 Na-144 K-4.7 Cl-105 HCO3-35* AnGap-9 <Date>1968-7-4</Date> 05:44AM BLOOD Glucose-176* UreaN-34* Creat-1.1 Na-143 K-4.5 Cl-106 HCO3-33* AnGap-9 <Date>1951-12-4</Date> 04:36AM BLOOD Glucose-213* UreaN-35* Creat-1.0 Na-145 K-3.7 Cl-107 HCO3-33* AnGap-9 <Date>2016-7-17</Date> 05:39AM BLOOD Glucose-115* UreaN-40* Creat-0.9 Na-146* K-4.2 Cl-108 HCO3-31 AnGap-11 <Date>1950-12-31</Date> 05:06AM BLOOD Glucose-120* UreaN-36* Creat-1.2 Na-142 K-4.8 Cl-103 HCO3-28 AnGap-16 <Date>1953-8-17</Date> 06:05AM BLOOD Glucose-137* UreaN-18 Creat-0.9 Na-141 K-3.8 Cl-104 HCO3-28 AnGap-13 <Date>1917-6-16</Date> 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 <Date>1953-10-9</Date> 05:09AM BLOOD ALT-25 AST-26 AlkPhos-57 TotBili-0.4 <Date>2016-7-17</Date> 05:39AM BLOOD ALT-21 AST-29 LD(LDH)-209 AlkPhos-56 TotBili-0.7 <Date>1917-6-16</Date> 09:15PM BLOOD CK(CPK)-77 <Date>1917-6-16</Date> 09:15PM BLOOD cTropnT-0.03* <Date>1914-10-1</Date> 06:36AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.7 <Date>1927-2-2</Date> 05:19AM BLOOD Calcium-7.9* Phos-1.5* Mg-1.7 <Date>1973-11-24</Date> 05:00AM BLOOD Calcium-7.4* Phos-2.0* Mg-1.9 Iron-16* <Date>1983-11-31</Date> 05:34AM BLOOD Calcium-7.6* Phos-2.2* Mg-1.9 <Date>1973-11-24</Date> 05:00AM BLOOD calTIBC-127* VitB12-GREATER TH Folate-GREATER TH Ferritn-206 TRF-98* Brief Hospital Course: In summary, Mr. <Name>Moblo</Name> is a 67M with HIV (on HAART) and end-stage COPD (on home O2), who presented <Date>1917-6-16</Date> with worsening shortness of breath in the setting of likely <Hospital>Rivera-Graves Hospital</Hospital> transferred to MICU for worsening respiratory distress. . # End-stage COPD/Respiratory Distress: End-stage baseline COPD (FEV1 20% predicted and on home O2). Admitted w likely COPD exacerbation triggered by viral URI. Nasal complaints and absence of infiltrate go against a bacterial PNA. MI and PE also considered. Pt treated with nebulizers, steroids, azithromycin. ABG shows chronic respiratory acidosis which appears compensated. Pt oxygenated well on O2 by nasal canula, but developed respiratory distress w accessory muscle use, tachypnea and tachycardia, which required MICU transfer on <Date>9-23</Date> for increasing respiratory distress. He was subsequently intubated that same night as his respiratory status continued to worsen. He remained stable on the vent and was extubated without complications on <Date>1-29</Date>. His respiratory status continued to be stable post-extubation. He was continued on azithromycin for a three day course and continued on steroids. He was then transferred back to the medical floor the following day after extubation with stable respiratory status. Followed by Dr <Name>Ornelas</Name>. On the floor his steroid regimen was kept as IV until patient's SBO resolved. With resolution of SBO patient was transitioned to PO steroids. Pt was discharged with a steroid taper. His last dose of Prednisone 10mg <Date>10-27</Date>. . On the floor his dyspnea continued and he required 4-5 L of nasal O2. He was evaluated by palliative care after he made the decision to become DNR/DNI. Based on their recommendations he was switched from ATC morphine to MS contin and ativan for dyspnea related anxiety. He was noted to have mental status changes including confusion, somnolence so MS contin was discontinued with return to normal mentation. His respiratory continued to improve with decrease in anxiety noted. Patient's pain was well controlled with liquid morphine, fentanyl patch, and tylenol #3 as needed. . # HIV/AIDS: Patient on HAART with recent decrease in CD4 count to below 200, hence on bactrim ppx. Followed by Dr <Name>Pettway</Name>. HAART was temporarily discontinued in the setting of SBO with nausea and vomiting. With resolution of SBO, HAART was restarted on <Date>1927-2-2</Date>. . #Small bowel obstruction: Patient developed acutely worsening abdominal pain on the <Hospital>Phillips-Khan Clinic</Hospital> associated with nausea and vomiting. CT of the abdomen and pelvis demonstrated a partial SBO. He was made NPO and a nasogastric tube was placed. Patient's nausea, vomiting, and abdominal distention improved steadily. His NGT was clamped and eventually discontinued on <Date>10-27</Date> with advancement of his diet to a regular diet. He tolerated that well. . #Pneumonia: Patient was found to have a left lower lobe pneumonia incidentally on chest xray evaluating PICC placement. Labs at the time were remarkable for leukocytosis. He was started on Zosyn and vancomycin for presumed Hospital associated pneumonia. Patient's vancomycin was stopped on <Date>7-9</Date>. He was continued on Zosyn and then transitioned to PO levoquin on <Date>3-27</Date> and discharged on this medication to complete an 8 day course of antibiotics with last day of antibiotics to be <Date>1941-6-6</Date>. . # Hypertension: Normotensive on admission, mild elevation in blood pressures in the setting of respiratory distress. Patient was continued on his home dose of doxazosin while in house. . # GERD: Stable. Continued H2 blocker. . # Anemia: Hematocrit dropped slightly during hospital admission from patient's baseline of 36 to 22. Iron studies demonstrated most likely anemia of chronic disease and iron deficiency anemia coupled with dilutional effect of IV hydration and daily blood draws as reasonable explanation of drop in hematocrit. Patient was always hemodynamically stable with no signs or symptoms of active bleeding. Patient was started on PO Iron. Medications on Admission: Epzicom 600mg-300mg daily Tylenol w/codeine PRN Albuterol 0.083% nebulizers TID Albuterol Inhaler Q4H:PRN Atazanvir 400 mg daily Symbicort 2 puffs <Hospital>Phillips-Khan Clinic</Hospital> Doxazosin 2 mg QHS Folic Acid 1 mg daily Fosamprenavir 1400 mg daily Nitroglycerin 0.4 mg PRN Ranitidine 150 mg <Hospital>Phillips-Khan Clinic</Hospital> Spiriva 18 mcg daily Tizanidine 2 mg TID Tramadol 50 mg Q6H:PRN Trazodone 50 mg QHS:PRN Bactrim DS 800 mg-160 mg three times per week Aspirin 81 mg daily B12 250 mcg daily Colace 100 mg <Hospital>Phillips-Khan Clinic</Hospital> Ferrous Gluconate 325 mg daily Boost TID Oxygen 2-3 L Senna PRN Discharge Medications: 1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:2 20. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day: Please take 2 tabs on <Date>1983-2-15</Date> Please take 1 tab, <Date>10-14</Date>, <Date>1-28</Date>, and <Date>10-27</Date> The last day of medication is <Date>10-27</Date>. Disp:5 Tablet(s)* Refills:0 21. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 2 days. Disp:6 Tablet(s) Refills:0 22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). Disp:20 Refills:2 23. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). Disp:30 Tablet(s) Refills:2 24. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every four (4) hours: Do not exceed 4g tylenol in 24hours. do not drink or drive while on this mediction. Disp:30 Tablet(s) Refills:0 25. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: <Hospital>Patterson, Hall and Gibbs Medical Center</Hospital> Homecare Discharge Diagnosis: PRIMARY * COPD * HIV * High blood sugar SECONDARY * Constipation * Chronic back pain Discharge Condition: Stable Discharge Instructions: You were admitted with shortness of breath due to exacerbation of your COPD most likely by a viral respiratory infection. It became increasingly difficult for you to breath so you were intubated and transferred to the intensive care unit. . After the breathing tube was removed and transferred to the wards you continued to experience shortness of breath and anxiety. You were seen by the palliative care doctors who recommended that we treat you receive morphine and ativan to make you more comfortable. Your pain has been well controlled with morphine, tylenol #3, and a fentanyl patch. We are also giving you steroids for your COPD exacerbation. You will continue to take the steroids until <Date>1944-11-19</Date>. . You also developed an pneumonia while in the hospital. We are currently giving you antibiotics for this pneumonia. Your last day of antibiotics will by <Date>1941-6-6</Date>. . You also developed a partial small bowel obstuction while in the hospital. You were treated with a nasogastric tube and nothing by mouth. You obstruction resolved and you are now tolerating a regular diet. . Medication changes include: * Fentanyl Patch * Prednisone * Levofloxacin Followup Instructions: Please keep the following appointments Provider: <Name>Roger Gauthier</Name> <Name>Jermaine Shipley</Name>, MD Phone:<Telephone>309-355-3117</Telephone> Date/Time:<Date>1990-10-12</Date> 11:00 Provider: <Name>Roger Gauthier</Name> <Name>Jermaine Shipley</Name>, MD Phone:<Telephone>309-355-3117</Telephone> Date/Time:<Date>1914-6-2</Date> 9:30 Provider: <Name>Hannah</Name> <Name>Medrano</Name>, MD Phone:<Telephone>309-355-3117</Telephone> Date/Time:<Date>1990-10-12</Date> 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Date: 1917-6-16 Discharge Date: 1914-10-1 Date of Birth: 1910-8-24 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Nisha Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Endotracheal Intubation Arterial line placement Internal Jugular line placement History of Present Illness: Mr. Moblo is a 67M with HIV (Cd4 183, VL 96 copies/mL) and end stage COPD on 3-4L home O2 with a FEV1 of 0.5 who presented to the emergency room on 1917-6-16 with increased shortness of breath. Three days prior to presentation he developed nasal congestion and rhinorrhea which made it difficult for him to use his supplemental oxygen at home. He had subjective fevers and chills but did not check his temperature. He had minimal cough productive of dark yellow sputum. He was feeling more short of breath despite increasing oxygen use. He was concerned about pneumonia and presented to the emergency room. . In the emergency room his initial vitals were T: 98.1 HR: 86 RR: 107/72 RR: 22 O2: 100% on RA. He had a chest xray which showed significant hyperinflation but no acute cardiopulmonary process. He received levofloxacin 750 mg IV x 1, duonebs, solumedrol 125 mg IV x 1 and aspirin 81 mg. He was initially admitted to the floor. . While on the floor he was started on azithromycin, solumedrol 125 mg IV TID, albuterol and ipratropium nebulizers. He did well on hospital day 1 but overnight his shortness of breath worsened. He had a repeat CXR which was similar to priors. He had an ABG on a non-rebreather which was 7.37/57/207/34. He had increased work of breathing and asked to be placed on "a machine for breathing." He is transferred to the MICU for non-invasive ventilatory support. n the MICU he was intubated an an A-line was placed due to increased WOB. Blood pressure was elevated while in respiratory distress and he was treated with hydralazine. He had one episode of hypotension responsive to IVF. A right IJ central line placed. ABG on 3-2 was 7.32/54/104. Methylprednisolone was decreased to 60mg IV BID. He was extubated on ICU day 3 and initially appeared in stress but did well after small dose IV morphine.He was transferred to the floor on ICU day 4. Prior to transfer he reviewed his code status and decided to be DNR/DNI. . On the floor, he is doing relatively well. He reports he is still somewhat short of breath but not in any distress. He reports back pain secondary to old back injury. He will be spending time with family and friends who are coming in from around the country to see him. Reports lack of appetite but no n/v. Denies F/C cough, chest pain. Past Medical History: - HIV/AIDS - most recent CD4 count 183, viral load 96 copies/ml - COPD - FVC 2.34 (63%), FEV1 0.50 (20%), FEV1/FVC 21 (31%) 3-1978 - GERD - Hypertension - h/o GI bleed - Leukopenia - Anemia (baseline hct 36) - Inguinal hernia - Homocysteinemia - Chronic back pain - Granulmatous disease in spleen- seen on ct scan - Esophagitis- egd 2-30 - Schatzki's ring- seen on egd 4-1966 - SBO obstruction in past requiring partial bowel resection - H/o of drug use (Cocaine) Social History: Previously a truck driver, now disabled/retired. Lives in 310 Obrien Prairie Bakerfort, HI 45217 by himself. EtOH: former heavy etoh, quit 1944 Tob: quit tobacco in 1944, 2ppd between 1944-93. Illicit drugs: smoked crack 1944 Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: Vitals T: 97.0 HR: 113 BP: 153/96 RR: 19 O2: 100% on BIPAP General Thin elderly man, tachypneic, using accessory muscles for respiration HEENT sclera anicteric, conjunctiva pink, mucous membranes moist, no lymphadenopathy Neck: JVP not elevated Pulmonary: Poor air movement bilaterally, scarce wheezes bilaterally, mild inspiratory crackles at bases, hyperexpansion Cardiac: Tachycardic, normal s1 + s2, no murmurs, rubs, gallops Abdominal: Soft, non-tender, non-distended, +BS Extremities: Warm and well perfused, 2+ distal pulses, no clubbing, cyanosis or edema Pertinent Results: LABS ON ADMISSION: 1917-6-16 09:15PM BLOOD WBC-3.5* RBC-3.98* Hgb-11.8* Hct-35.9* MCV-90 MCH-29.6 MCHC-32.8 RDW-15.6* Plt Ct-149* 1917-6-16 09:15PM BLOOD Neuts-55.0 Lymphs-33.9 Monos-6.1 Eos-4.2* Baso-0.8 1917-6-16 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 1953-8-17 06:05AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 1953-8-17 08:02AM BLOOD Type-ART pO2-207* pCO2-57* pH-7.37 calTCO2-34* Base XS-6 . MICROBIOLOGY: Bl Cx (1917-6-16) - NGTD . RADIOLOGY: CXR (2018-5-17): 1. No pneumonia. 2. Unchanged severe emphysema. Stable right hilar calcified lymph node. . Other Labs: 1914-10-1 06:36AM BLOOD WBC-6.6 RBC-2.42* Hgb-7.1* Hct-21.9* MCV-90 MCH-29.3 MCHC-32.4 RDW-15.8* Plt Ct-191 2001-11-26 06:26AM BLOOD WBC-6.5 RBC-2.41* Hgb-7.0* Hct-22.3* MCV-93 MCH-28.9 MCHC-31.3 RDW-16.1* Plt Ct-143* 1927-2-2 05:19AM BLOOD WBC-10.2 RBC-2.70* Hgb-7.9* Hct-24.8* MCV-92 MCH-29.4 MCHC-31.9 RDW-15.7* Plt Ct-161 1973-11-24 09:06AM BLOOD WBC-10.2 RBC-2.76# Hgb-8.3# Hct-24.7# MCV-90 MCH-30.0 MCHC-33.6 RDW-16.0 Plt Ct-160 1973-11-24 05:00AM BLOOD WBC-7.0 RBC-2.12# Hgb-6.4# Hct-19.0# MCV-90 MCH-30.1 MCHC-33.6 RDW-15.7 Plt Ct-113* 1983-11-31 05:34AM BLOOD WBC-9.3 RBC-2.91* Hgb-8.7* Hct-26.4* MCV-91 MCH-30.0 MCHC-33.0 RDW-15.8* Plt Ct-149* 1962-12-22 05:09AM BLOOD WBC-15.9* RBC-3.39* Hgb-10.1* Hct-30.6* MCV-90 MCH-29.8 MCHC-33.0 RDW-16.2* Plt Ct-187 1953-10-9 05:09AM BLOOD WBC-13.9* RBC-3.55* Hgb-10.5* Hct-32.0* MCV-90 MCH-29.5 MCHC-32.8 RDW-16.1* Plt Ct-216 1905-8-25 05:29AM BLOOD WBC-9.8 RBC-3.16* Hgb-9.1* Hct-28.7* MCV-91 MCH-28.9 MCHC-31.9 RDW-16.0* Plt Ct-180 1968-7-4 05:44AM BLOOD WBC-10.2 RBC-3.30* Hgb-9.8* Hct-29.9* MCV-91 MCH-29.9 MCHC-33.0 RDW-15.7* Plt Ct-182 1951-12-4 04:36AM BLOOD WBC-8.1 RBC-3.27* Hgb-9.4* Hct-28.9* MCV-88 MCH-28.8 MCHC-32.6 RDW-15.3 Plt Ct-167 2016-7-17 05:39AM BLOOD WBC-8.7 RBC-3.37* Hgb-9.8* Hct-30.2* MCV-90 MCH-29.0 MCHC-32.4 RDW-15.2 Plt Ct-179 1917-10-26 05:52AM BLOOD WBC-6.6 RBC-3.47* Hgb-10.3* Hct-31.3* MCV-90 MCH-29.5 MCHC-32.8 RDW-15.4 Plt Ct-180 1950-12-31 05:06AM BLOOD WBC-6.5 RBC-3.58* Hgb-10.3* Hct-32.0* MCV-89 MCH-28.8 MCHC-32.3 RDW-15.6* Plt Ct-201 1973-11-24 09:06AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1 2016-7-17 05:39AM BLOOD PT-13.3 PTT-33.0 INR(PT)-1.1 1914-10-1 06:36AM BLOOD Glucose-198* UreaN-8 Creat-0.7 Na-136 K-4.3 Cl-103 HCO3-27 AnGap-10 2001-11-26 06:26AM BLOOD Glucose-138* UreaN-9 Creat-0.7 Na-141 K-3.3 Cl-107 HCO3-29 AnGap-8 1927-2-2 05:19AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-138 K-3.3 Cl-101 HCO3-31 AnGap-9 1973-11-24 05:00AM BLOOD Glucose-84 UreaN-15 Creat-0.8 Na-135 K-3.4 Cl-97 HCO3-28 AnGap-13 1983-11-31 05:34AM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-138 K-3.7 Cl-98 HCO3-31 AnGap-13 1962-12-22 05:09AM BLOOD Glucose-74 UreaN-28* Creat-1.0 Na-137 K-4.6 Cl-95* HCO3-32 AnGap-15 1953-10-9 06:00PM BLOOD Glucose-108* UreaN-31* Creat-1.1 Na-140 K-4.8 Cl-97 HCO3-36* AnGap-12 1953-10-9 05:09AM BLOOD Glucose-112* UreaN-30* Creat-1.0 Na-146* K-4.7 Cl-103 HCO3-37* AnGap-11 1905-8-25 05:29AM BLOOD Glucose-120* UreaN-33* Creat-0.9 Na-144 K-4.7 Cl-105 HCO3-35* AnGap-9 1968-7-4 05:44AM BLOOD Glucose-176* UreaN-34* Creat-1.1 Na-143 K-4.5 Cl-106 HCO3-33* AnGap-9 1951-12-4 04:36AM BLOOD Glucose-213* UreaN-35* Creat-1.0 Na-145 K-3.7 Cl-107 HCO3-33* AnGap-9 2016-7-17 05:39AM BLOOD Glucose-115* UreaN-40* Creat-0.9 Na-146* K-4.2 Cl-108 HCO3-31 AnGap-11 1950-12-31 05:06AM BLOOD Glucose-120* UreaN-36* Creat-1.2 Na-142 K-4.8 Cl-103 HCO3-28 AnGap-16 1953-8-17 06:05AM BLOOD Glucose-137* UreaN-18 Creat-0.9 Na-141 K-3.8 Cl-104 HCO3-28 AnGap-13 1917-6-16 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 1953-10-9 05:09AM BLOOD ALT-25 AST-26 AlkPhos-57 TotBili-0.4 2016-7-17 05:39AM BLOOD ALT-21 AST-29 LD(LDH)-209 AlkPhos-56 TotBili-0.7 1917-6-16 09:15PM BLOOD CK(CPK)-77 1917-6-16 09:15PM BLOOD cTropnT-0.03* 1914-10-1 06:36AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.7 1927-2-2 05:19AM BLOOD Calcium-7.9* Phos-1.5* Mg-1.7 1973-11-24 05:00AM BLOOD Calcium-7.4* Phos-2.0* Mg-1.9 Iron-16* 1983-11-31 05:34AM BLOOD Calcium-7.6* Phos-2.2* Mg-1.9 1973-11-24 05:00AM BLOOD calTIBC-127* VitB12-GREATER TH Folate-GREATER TH Ferritn-206 TRF-98* Brief Hospital Course: In summary, Mr. Moblo is a 67M with HIV (on HAART) and end-stage COPD (on home O2), who presented 1917-6-16 with worsening shortness of breath in the setting of likely Rivera-Graves Hospital transferred to MICU for worsening respiratory distress. . # End-stage COPD/Respiratory Distress: End-stage baseline COPD (FEV1 20% predicted and on home O2). Admitted w likely COPD exacerbation triggered by viral URI. Nasal complaints and absence of infiltrate go against a bacterial PNA. MI and PE also considered. Pt treated with nebulizers, steroids, azithromycin. ABG shows chronic respiratory acidosis which appears compensated. Pt oxygenated well on O2 by nasal canula, but developed respiratory distress w accessory muscle use, tachypnea and tachycardia, which required MICU transfer on 9-23 for increasing respiratory distress. He was subsequently intubated that same night as his respiratory status continued to worsen. He remained stable on the vent and was extubated without complications on 1-29. His respiratory status continued to be stable post-extubation. He was continued on azithromycin for a three day course and continued on steroids. He was then transferred back to the medical floor the following day after extubation with stable respiratory status. Followed by Dr Ornelas. On the floor his steroid regimen was kept as IV until patient's SBO resolved. With resolution of SBO patient was transitioned to PO steroids. Pt was discharged with a steroid taper. His last dose of Prednisone 10mg 10-27. . On the floor his dyspnea continued and he required 4-5 L of nasal O2. He was evaluated by palliative care after he made the decision to become DNR/DNI. Based on their recommendations he was switched from ATC morphine to MS contin and ativan for dyspnea related anxiety. He was noted to have mental status changes including confusion, somnolence so MS contin was discontinued with return to normal mentation. His respiratory continued to improve with decrease in anxiety noted. Patient's pain was well controlled with liquid morphine, fentanyl patch, and tylenol #3 as needed. . # HIV/AIDS: Patient on HAART with recent decrease in CD4 count to below 200, hence on bactrim ppx. Followed by Dr Pettway. HAART was temporarily discontinued in the setting of SBO with nausea and vomiting. With resolution of SBO, HAART was restarted on 1927-2-2. . #Small bowel obstruction: Patient developed acutely worsening abdominal pain on the Phillips-Khan Clinic associated with nausea and vomiting. CT of the abdomen and pelvis demonstrated a partial SBO. He was made NPO and a nasogastric tube was placed. Patient's nausea, vomiting, and abdominal distention improved steadily. His NGT was clamped and eventually discontinued on 10-27 with advancement of his diet to a regular diet. He tolerated that well. . #Pneumonia: Patient was found to have a left lower lobe pneumonia incidentally on chest xray evaluating PICC placement. Labs at the time were remarkable for leukocytosis. He was started on Zosyn and vancomycin for presumed Hospital associated pneumonia. Patient's vancomycin was stopped on 7-9. He was continued on Zosyn and then transitioned to PO levoquin on 3-27 and discharged on this medication to complete an 8 day course of antibiotics with last day of antibiotics to be 1941-6-6. . # Hypertension: Normotensive on admission, mild elevation in blood pressures in the setting of respiratory distress. Patient was continued on his home dose of doxazosin while in house. . # GERD: Stable. Continued H2 blocker. . # Anemia: Hematocrit dropped slightly during hospital admission from patient's baseline of 36 to 22. Iron studies demonstrated most likely anemia of chronic disease and iron deficiency anemia coupled with dilutional effect of IV hydration and daily blood draws as reasonable explanation of drop in hematocrit. Patient was always hemodynamically stable with no signs or symptoms of active bleeding. Patient was started on PO Iron. Medications on Admission: Epzicom 600mg-300mg daily Tylenol w/codeine PRN Albuterol 0.083% nebulizers TID Albuterol Inhaler Q4H:PRN Atazanvir 400 mg daily Symbicort 2 puffs Phillips-Khan Clinic Doxazosin 2 mg QHS Folic Acid 1 mg daily Fosamprenavir 1400 mg daily Nitroglycerin 0.4 mg PRN Ranitidine 150 mg Phillips-Khan Clinic Spiriva 18 mcg daily Tizanidine 2 mg TID Tramadol 50 mg Q6H:PRN Trazodone 50 mg QHS:PRN Bactrim DS 800 mg-160 mg three times per week Aspirin 81 mg daily B12 250 mcg daily Colace 100 mg Phillips-Khan Clinic Ferrous Gluconate 325 mg daily Boost TID Oxygen 2-3 L Senna PRN Discharge Medications: 1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:2 20. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day: Please take 2 tabs on 1983-2-15 Please take 1 tab, 10-14, 1-28, and 10-27 The last day of medication is 10-27. Disp:5 Tablet(s)* Refills:0 21. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 2 days. Disp:6 Tablet(s) Refills:0 22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). Disp:20 Refills:2 23. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). Disp:30 Tablet(s) Refills:2 24. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every four (4) hours: Do not exceed 4g tylenol in 24hours. do not drink or drive while on this mediction. Disp:30 Tablet(s) Refills:0 25. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Patterson, Hall and Gibbs Medical Center Homecare Discharge Diagnosis: PRIMARY * COPD * HIV * High blood sugar SECONDARY * Constipation * Chronic back pain Discharge Condition: Stable Discharge Instructions: You were admitted with shortness of breath due to exacerbation of your COPD most likely by a viral respiratory infection. It became increasingly difficult for you to breath so you were intubated and transferred to the intensive care unit. . After the breathing tube was removed and transferred to the wards you continued to experience shortness of breath and anxiety. You were seen by the palliative care doctors who recommended that we treat you receive morphine and ativan to make you more comfortable. Your pain has been well controlled with morphine, tylenol #3, and a fentanyl patch. We are also giving you steroids for your COPD exacerbation. You will continue to take the steroids until 1944-11-19. . You also developed an pneumonia while in the hospital. We are currently giving you antibiotics for this pneumonia. Your last day of antibiotics will by 1941-6-6. . You also developed a partial small bowel obstuction while in the hospital. You were treated with a nasogastric tube and nothing by mouth. You obstruction resolved and you are now tolerating a regular diet. . Medication changes include: * Fentanyl Patch * Prednisone * Levofloxacin Followup Instructions: Please keep the following appointments Provider: Roger Gauthier Jermaine Shipley, MD Phone:309-355-3117 Date/Time:1990-10-12 11:00 Provider: Roger Gauthier Jermaine Shipley, MD Phone:309-355-3117 Date/Time:1914-6-2 9:30 Provider: Hannah Medrano, MD Phone:309-355-3117 Date/Time:1990-10-12 10:00	['Admission Date: 1917-6-16 Discharge Date: 1914-10-1\n\nDate of Birth: 1910-8-24 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Nisha\nChief Complaint:\nshortness of breath\n\nMajor Surgical or Invasive Procedure:\nEndotracheal Intubation\nArterial line placement\nInternal Jugular line placement\n\n\nHistory of Present Illness:\nMr. Moblo is a 67M with HIV (Cd4 183, VL 96 copies/mL) and end\nstage COPD on 3-4L home O2 with a FEV1 of 0.5 who presented to\nthe emergency room on 1917-6-16 with increased shortness of\nbreath. Three days prior to presentation he developed nasal\ncongestion and rhinorrhea which made it difficult for him to use\nhis supplemental oxygen at home. He had subjective fevers and\nchills but did not check his temperature.', ' He had minimal cough\nproductive of dark yellow sputum. He was feeling more short of\nbreath despite increasing oxygen use. He was concerned about\npneumonia and presented to the emergency room.\n.\nIn the emergency room his initial vitals were T: 98.1 HR: 86 RR:\n107/72 RR: 22 O2: 100% on RA. He had a chest xray which showed\nsignificant hyperinflation but no acute cardiopulmonary process.\nHe received levofloxacin 750 mg IV x 1, duonebs, solumedrol 125\nmg IV x 1 and aspirin 81 mg. He was initially admitted to the\nfloor.\n.\nWhile on the floor he was started on azithromycin, solumedrol\n125 mg IV TID, albuterol and ipratropium nebulizers. He did well\non hospital day 1 but overnight his shortness of breath\nworsened. He had a repeat CXR which was similar to priors. He\nhad an ABG on a non-rebreather which was 7.', '37/57/207/34. He had\nincreased work of breathing and asked to be placed on "a machine\nfor breathing." He is transferred to the MICU for non-invasive\nventilatory support.\nn the MICU he was intubated an an A-line was placed due to\nincreased\nWOB. Blood pressure was elevated while in respiratory distress\nand he was treated with hydralazine. He had one episode of\nhypotension responsive to IVF. A right IJ central line placed.\nABG on 3-2 was 7.32/54/104. Methylprednisolone was decreased to\n60mg IV BID. He was extubated on ICU day 3 and initially\nappeared in stress but did well after small dose IV morphine.He\nwas transferred to the floor on ICU day 4. Prior to transfer he\nreviewed his code status and decided to be DNR/DNI.\n.\nOn the floor, he is doing relatively well. He reports he is\nstill somewhat short of breath but not in any distress.', " He\nreports back pain secondary to old back injury. He will be\nspending time with family and friends who are coming in from\naround the country to see him. Reports lack of appetite but no\nn/v. Denies F/C cough, chest pain.\n\n\nPast Medical History:\n- HIV/AIDS - most recent CD4 count 183, viral load 96 copies/ml\n\n- COPD - FVC 2.34 (63%), FEV1 0.50 (20%), FEV1/FVC 21 (31%)\n3-1978\n- GERD\n- Hypertension\n- h/o GI bleed\n- Leukopenia\n- Anemia (baseline hct 36)\n- Inguinal hernia\n- Homocysteinemia\n- Chronic back pain\n- Granulmatous disease in spleen- seen on ct scan\n- Esophagitis- egd 2-30\n- Schatzki's ring- seen on egd 4-1966\n- SBO obstruction in past requiring partial bowel resection\n- H/o of drug use (Cocaine)\n\n\nSocial History:\nPreviously a truck driver, now disabled/retired. Lives in\n310 Obrien Prairie\nBakerfort, HI 45217 by himself.", '\nEtOH: former heavy etoh, quit 1944\nTob: quit tobacco in 1944, 2ppd between 1944-93.\nIllicit drugs: smoked crack 1944\n\n\nFamily History:\n1. Father: deceased, EtOH\n2. Mother: deceased, CVA in 60s\n3. Brother: lung cancer\n4. Sister: HTN\n5. Sister: CVA in 60s\nBrothers x7 (now only two), Sister x2 (both still alive)\n\n\nPhysical Exam:\nVitals T: 97.0 HR: 113 BP: 153/96 RR: 19 O2: 100% on BIPAP\nGeneral Thin elderly man, tachypneic, using accessory muscles\nfor respiration\nHEENT sclera anicteric, conjunctiva pink, mucous membranes\nmoist, no lymphadenopathy\nNeck: JVP not elevated\nPulmonary: Poor air movement bilaterally, scarce wheezes\nbilaterally, mild inspiratory crackles at bases, hyperexpansion\n\nCardiac: Tachycardic, normal s1 + s2, no murmurs, rubs, gallops\n\nAbdominal: Soft, non-tender, non-distended, +BS\nExtremities: Warm and well perfused, 2+ distal pulses, no\nclubbing, cyanosis or edema\n\n\nPertinent Results:\nLABS ON ADMISSION:\n1917-6-16 09:15PM BLOOD WBC-3.', '5* RBC-3.98* Hgb-11.8* Hct-35.9\nMCV-90 MCH-29.6 MCHC-32.8 RDW-15.6 Plt Ct-149\n1917-6-16 09:15PM BLOOD Neuts-55.0 Lymphs-33.9 Monos-6.1 Eos-4.2\nBaso-0.8\n1917-6-16 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143\nK-3.8 Cl-103 HCO3-32 AnGap-12\n1953-8-17 06:05AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0\n1953-8-17 08:02AM BLOOD Type-ART pO2-207* pCO2-57* pH-7.37\ncalTCO2-34* Base XS-6\n.\nMICROBIOLOGY:\nBl Cx (1917-6-16) - NGTD\n.\nRADIOLOGY:\nCXR (2018-5-17):\n1. No pneumonia.\n2. Unchanged severe emphysema. Stable right hilar calcified\nlymph node.\n.\nOther Labs:\n\n1914-10-1 06:36AM BLOOD WBC-6.6 RBC-2.42* Hgb-7.1* Hct-21.9\nMCV-90 MCH-29.3 MCHC-32.4 RDW-15.8 Plt Ct-191\n2001-11-26 06:26AM BLOOD WBC-6.5 RBC-2.41* Hgb-7.0* Hct-22.3\nMCV-93 MCH-28.9 MCHC-31.3 RDW-16.1 Plt Ct-143\n1927-2-2 05:19AM BLOOD WBC-10.', '2 RBC-2.70 Hgb-7.9* Hct-24.8\nMCV-92 MCH-29.4 MCHC-31.9 RDW-15.7 Plt Ct-161\n1973-11-24 09:06AM BLOOD WBC-10.2 RBC-2.76# Hgb-8.3# Hct-24.7#\nMCV-90 MCH-30.0 MCHC-33.6 RDW-16.0 Plt Ct-160\n1973-11-24 05:00AM BLOOD WBC-7.0 RBC-2.12# Hgb-6.4# Hct-19.0#\nMCV-90 MCH-30.1 MCHC-33.6 RDW-15.7 Plt Ct-113\n1983-11-31 05:34AM BLOOD WBC-9.3 RBC-2.91 Hgb-8.7* Hct-26.4\nMCV-91 MCH-30.0 MCHC-33.0 RDW-15.8 Plt Ct-149\n1962-12-22 05:09AM BLOOD WBC-15.9 RBC-3.39* Hgb-10.1* Hct-30.6\nMCV-90 MCH-29.8 MCHC-33.0 RDW-16.2 Plt Ct-187\n1953-10-9 05:09AM BLOOD WBC-13.9* RBC-3.55* Hgb-10.5* Hct-32.0\nMCV-90 MCH-29.5 MCHC-32.8 RDW-16.1 Plt Ct-216\n1905-8-25 05:29AM BLOOD WBC-9.8 RBC-3.16* Hgb-9.1* Hct-28.7\nMCV-91 MCH-28.9 MCHC-31.9 RDW-16.0 Plt Ct-180\n1968-7-4 05:44AM BLOOD WBC-10.2 RBC-3.30* Hgb-9.8* Hct-29.', '9\nMCV-91 MCH-29.9 MCHC-33.0 RDW-15.7 Plt Ct-182\n1951-12-4 04:36AM BLOOD WBC-8.1 RBC-3.27* Hgb-9.4* Hct-28.9\nMCV-88 MCH-28.8 MCHC-32.6 RDW-15.3 Plt Ct-167\n2016-7-17 05:39AM BLOOD WBC-8.7 RBC-3.37 Hgb-9.8* Hct-30.2\nMCV-90 MCH-29.0 MCHC-32.4 RDW-15.2 Plt Ct-179\n1917-10-26 05:52AM BLOOD WBC-6.6 RBC-3.47 Hgb-10.3* Hct-31.3\nMCV-90 MCH-29.5 MCHC-32.8 RDW-15.4 Plt Ct-180\n1950-12-31 05:06AM BLOOD WBC-6.5 RBC-3.58 Hgb-10.3* Hct-32.0\nMCV-89 MCH-28.8 MCHC-32.3 RDW-15.6 Plt Ct-201\n1973-11-24 09:06AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1\n2016-7-17 05:39AM BLOOD PT-13.3 PTT-33.0 INR(PT)-1.1\n1914-10-1 06:36AM BLOOD Glucose-198* UreaN-8 Creat-0.7 Na-136\nK-4.3 Cl-103 HCO3-27 AnGap-10\n2001-11-26 06:26AM BLOOD Glucose-138* UreaN-9 Creat-0.7 Na-141\nK-3.3 Cl-107 HCO3-29 AnGap-8\n1927-2-2 05:19AM BLOOD Glucose-99 UreaN-12 Creat-0.', '8 Na-138\nK-3.3 Cl-101 HCO3-31 AnGap-9\n1973-11-24 05:00AM BLOOD Glucose-84 UreaN-15 Creat-0.8 Na-135\nK-3.4 Cl-97 HCO3-28 AnGap-13\n1983-11-31 05:34AM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-138\nK-3.7 Cl-98 HCO3-31 AnGap-13\n1962-12-22 05:09AM BLOOD Glucose-74 UreaN-28* Creat-1.0 Na-137\nK-4.6 Cl-95* HCO3-32 AnGap-15\n1953-10-9 06:00PM BLOOD Glucose-108* UreaN-31* Creat-1.1 Na-140\nK-4.8 Cl-97 HCO3-36* AnGap-12\n1953-10-9 05:09AM BLOOD Glucose-112* UreaN-30* Creat-1.0 Na-146\nK-4.7 Cl-103 HCO3-37 AnGap-11\n1905-8-25 05:29AM BLOOD Glucose-120* UreaN-33* Creat-0.9 Na-144\nK-4.7 Cl-105 HCO3-35* AnGap-9\n1968-7-4 05:44AM BLOOD Glucose-176* UreaN-34* Creat-1.1 Na-143\nK-4.5 Cl-106 HCO3-33* AnGap-9\n1951-12-4 04:36AM BLOOD Glucose-213* UreaN-35* Creat-1.0 Na-145\nK-3.7 Cl-107 HCO3-33* AnGap-9\n2016-7-17 05:39AM BLOOD Glucose-115* UreaN-40* Creat-0.', '9 Na-146\nK-4.2 Cl-108 HCO3-31 AnGap-11\n1950-12-31 05:06AM BLOOD Glucose-120 UreaN-36* Creat-1.2 Na-142\nK-4.8 Cl-103 HCO3-28 AnGap-16\n1953-8-17 06:05AM BLOOD Glucose-137* UreaN-18 Creat-0.9 Na-141\nK-3.8 Cl-104 HCO3-28 AnGap-13\n1917-6-16 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143\nK-3.8 Cl-103 HCO3-32 AnGap-12\n1953-10-9 05:09AM BLOOD ALT-25 AST-26 AlkPhos-57 TotBili-0.4\n2016-7-17 05:39AM BLOOD ALT-21 AST-29 LD(LDH)-209 AlkPhos-56\nTotBili-0.7\n1917-6-16 09:15PM BLOOD CK(CPK)-77\n1917-6-16 09:15PM BLOOD cTropnT-0.03\n1914-10-1 06:36AM BLOOD Calcium-8.0 Phos-1.9* Mg-1.7\n1927-2-2 05:19AM BLOOD Calcium-7.9* Phos-1.5* Mg-1.7\n1973-11-24 05:00AM BLOOD Calcium-7.4* Phos-2.0* Mg-1.9 Iron-16\n1983-11-31 05:34AM BLOOD Calcium-7.6 Phos-2.2* Mg-1.9\n1973-11-24 05:00AM BLOOD calTIBC-127* VitB12-GREATER TH\nFolate-GREATER TH Ferritn-206 TRF-98\n\nBrief Hospital Course:\nIn summary, Mr.', ' Moblo is a 67M with HIV (on HAART) and\nend-stage COPD (on home O2), who presented 1917-6-16 with\nworsening shortness of breath in the setting of likely Rivera-Graves Hospital\ntransferred to MICU for worsening respiratory distress.\n.\n# End-stage COPD/Respiratory Distress: End-stage baseline COPD\n(FEV1 20% predicted and on home O2). Admitted w likely COPD\nexacerbation triggered by viral URI. Nasal complaints and\nabsence of infiltrate go against a bacterial PNA. MI and PE also\nconsidered. Pt treated with nebulizers, steroids, azithromycin.\nABG shows chronic respiratory acidosis which appears\ncompensated. Pt oxygenated well on O2 by nasal canula, but\ndeveloped respiratory distress w accessory muscle use, tachypnea\nand tachycardia, which required MICU transfer on 9-23 for\nincreasing respiratory distress.', " He was subsequently intubated\nthat same night as his respiratory status continued to worsen.\nHe remained stable on the vent and was extubated without\ncomplications on 1-29. His respiratory status continued to be\nstable post-extubation. He was continued on azithromycin for a\nthree day course and continued on steroids. He was then\ntransferred back to the medical floor the following day after\nextubation with stable respiratory status. Followed by Dr\nOrnelas. On the floor his steroid regimen was kept as IV until\npatient's SBO resolved. With resolution of SBO patient was\ntransitioned to PO steroids. Pt was discharged with a steroid\ntaper. His last dose of Prednisone 10mg 10-27.\n.\nOn the floor his dyspnea continued and he required 4-5 L of\nnasal O2. He was evaluated by palliative care after he made the\ndecision to become DNR/DNI.", " Based on their recommendations he\nwas switched from ATC morphine to MS contin and ativan for\ndyspnea related anxiety. He was noted to have mental status\nchanges including confusion, somnolence so MS contin was\ndiscontinued with return to normal mentation. His respiratory\ncontinued to improve with decrease in anxiety noted. Patient's\npain was well controlled with liquid morphine, fentanyl patch,\nand tylenol #3 as needed.\n.\n# HIV/AIDS: Patient on HAART with recent decrease in CD4 count\nto below 200, hence on bactrim ppx. Followed by Dr Pettway. HAART\nwas temporarily discontinued in the setting of SBO with nausea\nand vomiting. With resolution of SBO, HAART was restarted on\n1927-2-2.\n.\n#Small bowel obstruction: Patient developed acutely worsening\nabdominal pain on the Phillips-Khan Clinic associated with nausea and vomiting.", "\nCT of the abdomen and pelvis demonstrated a partial SBO. He was\nmade NPO and a nasogastric tube was placed. Patient's nausea,\nvomiting, and abdominal distention improved steadily. His NGT\nwas clamped and eventually discontinued on 10-27 with advancement\nof his diet to a regular diet. He tolerated that well.\n.\n#Pneumonia: Patient was found to have a left lower lobe\npneumonia incidentally on chest xray evaluating PICC placement.\nLabs at the time were remarkable for leukocytosis. He was\nstarted on Zosyn and vancomycin for presumed Hospital associated\npneumonia. Patient's vancomycin was stopped on 7-9. He was\ncontinued on Zosyn and then transitioned to PO levoquin on 3-27\nand discharged on this medication to complete an 8 day course of\nantibiotics with last day of antibiotics to be 1941-6-6.", "\n.\n# Hypertension: Normotensive on admission, mild elevation in\nblood pressures in the setting of respiratory distress. Patient\nwas continued on his home dose of doxazosin while in house.\n.\n# GERD: Stable. Continued H2 blocker.\n.\n# Anemia: Hematocrit dropped slightly during hospital admission\nfrom patient's baseline of 36 to 22. Iron studies demonstrated\nmost likely anemia of chronic disease and iron deficiency anemia\ncoupled with dilutional effect of IV hydration and daily blood\ndraws as reasonable explanation of drop in hematocrit. Patient\nwas always hemodynamically stable with no signs or symptoms of\nactive bleeding. Patient was started on PO Iron.\n\nMedications on Admission:\nEpzicom 600mg-300mg daily\nTylenol w/codeine PRN\nAlbuterol 0.083% nebulizers TID\nAlbuterol Inhaler Q4H:PRN\nAtazanvir 400 mg daily\nSymbicort 2 puffs Phillips-Khan Clinic\nDoxazosin 2 mg QHS\nFolic Acid 1 mg daily\nFosamprenavir 1400 mg daily\nNitroglycerin 0.", '4 mg PRN\nRanitidine 150 mg Phillips-Khan Clinic\nSpiriva 18 mcg daily\nTizanidine 2 mg TID\nTramadol 50 mg Q6H:PRN\nTrazodone 50 mg QHS:PRN\nBactrim DS 800 mg-160 mg three times per week\nAspirin 81 mg daily\nB12 250 mcg daily\nColace 100 mg Phillips-Khan Clinic\nFerrous Gluconate 325 mg daily\nBoost TID\nOxygen 2-3 L\nSenna PRN\n\n\nDischarge Medications:\n1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n2. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).\n\n4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n5. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY\n(Daily).\n6. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H\n(every 12 hours).\n7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a\nday).', '\n8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\nhours) as needed for pain.\n9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)\nas needed for insomnia.\n10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)\nTablet PO MWF (Monday-Wednesday-Friday).\n11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\n12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n13. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n14. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID\n(2 times a day).\n15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) Inhalation Q2H (every 2 hours) as\nneeded.\n17. Bisacodyl 5 mg Tablet, Delayed Release (E.', 'C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.\n18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n19. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr\nTransdermal Q72H (every 72 hours).\nDisp:10 Patch 72 hr(s)* Refills:2\n20. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day:\nPlease take 2 tabs on 1983-2-15\nPlease take 1 tab, 10-14, 1-28, and 10-27\nThe last day of medication is 10-27.\nDisp:5 Tablet(s)* Refills:0\n21. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H\n(every 24 hours) for 2 days.\nDisp:6 Tablet(s) Refills:0\n22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) Inhalation Q4H (every 4 hours).\nDisp:20 Refills:2\n23. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)\nTablet PO MWF (Monday-Wednesday-Friday).', '\nDisp:30 Tablet(s) Refills:2\n24. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO\nevery four (4) hours: Do not exceed 4g tylenol in 24hours. do\nnot drink or drive while on this mediction.\nDisp:30 Tablet(s) Refills:0\n25. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)\nTablet PO DAILY (Daily).\nDisp:60 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nPatterson, Hall and Gibbs Medical Center Homecare\n\nDischarge Diagnosis:\nPRIMARY\n* COPD\n* HIV\n* High blood sugar\nSECONDARY\n* Constipation\n* Chronic back pain\n\n\nDischarge Condition:\nStable\n\n\nDischarge Instructions:\nYou were admitted with shortness of breath due to exacerbation\nof your COPD most likely by a viral respiratory infection. It\nbecame increasingly difficult for you to breath so you were\nintubated and transferred to the intensive care unit.', '\n.\nAfter the breathing tube was removed and transferred to the\nwards you continued to experience shortness of breath and\nanxiety. You were seen by the palliative care doctors who\nrecommended that we treat you receive morphine and ativan to\nmake you more comfortable. Your pain has been well controlled\nwith morphine, tylenol #3, and a fentanyl patch. We are also\ngiving you steroids for your COPD exacerbation. You will\ncontinue to take the steroids until 1944-11-19.\n.\nYou also developed an pneumonia while in the hospital. We are\ncurrently giving you antibiotics for this pneumonia. Your last\nday of antibiotics will by 1941-6-6.\n.\nYou also developed a partial small bowel obstuction while in the\nhospital. You were treated with a nasogastric tube and nothing\nby mouth. You obstruction resolved and you are now tolerating a\nregular diet.', '\n.\nMedication changes include:\n* Fentanyl Patch\n* Prednisone\n* Levofloxacin\n\n\nFollowup Instructions:\nPlease keep the following appointments\nProvider: Roger Gauthier Jermaine Shipley, MD Phone:309-355-3117\nDate/Time:1990-10-12 11:00\nProvider: Roger Gauthier Jermaine Shipley, MD Phone:309-355-3117\nDate/Time:1914-6-2 9:30\nProvider: Hannah Medrano, MD Phone:309-355-3117\nDate/Time:1990-10-12 10:00\n\n\n\n']
218	11018	131769.0	2154-03-28	Discharge summary	Report	Admission Date: [2154-3-24] Discharge Date: [2154-3-28] Date of Birth: [2084-12-30] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 69 yo M h/o HIV, COPD presenting with shortness of breath and "not feeling well." He was notably just admitted to [Hospital1 2177] for a COPD exacerbation [Date range (1) 2178]. During this admission he was noted to have a tenuous respiratory status with poor air movement and was briefly intubated for a few hours. He was started on steroids with a slow taper and azithromycin. Since his discharge he did not feel well and came to [Hospital1 18] for further evaluation. . In the ED, initial vs were: 97.9 103 170/105 27 99% 3L. He was noted to have poor air movement and given 125 mg IV solumedrol and duonebs. BiPAP started, however patient vomited, so this was stopped. He was given IV zofran and phenergan. ABG was 7.37/58/96, so once his nausea resolved, he was placed back on BiPap. He was notably tachycardic to the 180s which was felt to be afib vs. MAT. He was given 15 mg IV diltiazem and broke soon after this. He was notably also given morphine and ativan. CXR notable for hyperinflation. Vitalls prior to transfer:: 101 189/109 21 100% Bipap. . Upon arrival to the MICU, the patient was taken off of BiPAP due to significant nausea. He was given IV compazine and placed on nasal cannula with saturations near 100%. He continues to feel short of breath. Past Medical History: 1. HIV. Diagnosed in [2135], status post multiple HAART regimens, no OI history, CD4 nadir 247 [2154-2-18]. 2. COPD, on chronic O2 therapy with recent intubation at [Hospital1 2177]. Notably was DNR/DNI in past 3. DVT, left lower extremity in [2152-3-17], on Coumadin therapy due to sedentary life, although completed course of anticoagulation. 4. Rectal bleeding. 5. Chronic low back pain s/p numerous back surgeries. 6. Hypertension. 7. Basilar aneurysm in [2134]. 8. History of substance abuse with cocaine. 9. Anemia of chronic disease. 10. Osteoporosis. Social History: He denies any alcohol, smoking, or drug use since [2135] when he became clean. Previous 80 pk-yr smoker. Family History: HTN, throat cancer (brother, smoker) Physical Exam: On Admission: Vitals: AF 118 172/94 99% on 3 Liters General: Alert, oriented, chactic appearing, using accessory muscles, HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, Lungs: poor air movement. no wheeezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema On Discharge: HR 98 BP 119/73 O2 93% General: Alert, oriented, cachectic appearing, using accessory muscles, HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, Lungs: poor air movement. no wheeezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [2154-3-24] 10:50AM BLOOD WBC-7.9 RBC-3.41* Hgb-9.5* Hct-31.3* MCV-92 MCH-27.9 MCHC-30.4* RDW-15.0 Plt Ct-159 [2154-3-24] 10:50AM BLOOD Neuts-86.3* Lymphs-8.4* Monos-5.0 Eos-0.3 Baso-0.1 [2154-3-24] 11:30AM BLOOD PT-15.9* PTT-20.7* INR(PT)-1.4* [2154-3-24] 10:50AM BLOOD Glucose-133* UreaN-26* Creat-1.0 Na-148* K-3.0* Cl-104 HCO3-31 AnGap-16 [2154-3-24] 04:59PM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0 [2154-3-24] 10:26AM BLOOD Type-ART Rates-/26 O2 Flow-8 pO2-110* pCO2-50* pH-7.41 calTCO2-33* Base XS-6 Intubat-NOT INTUBA Comment-NEBULIZER Discharge labs: [2154-3-28] 03:27AM BLOOD WBC-7.8 RBC-3.18* Hgb-9.4* Hct-29.4* MCV-93 MCH-29.6 MCHC-31.9 RDW-15.1 Plt Ct-191 [2154-3-28] 03:27AM BLOOD PT-23.4* PTT-35.6* INR(PT)-2.2* [2154-3-28] 03:27AM BLOOD Glucose-116* UreaN-37* Creat-1.2 Na-146* K-4.1 Cl-104 HCO3-37* AnGap-9 [2154-3-28] 03:27AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.4 Chest X-Ray: 1. Hyperexpanded lungs consistent with known diagnosis of COPD. 2. Stable right calcified lymph node. 3. No focal consolidation or pleural effusion. ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. IMPRESSION: Mildly dilated and hypertrophied right ventricle with preserved systolic function. Small and hyperdynamic left ventricle. Mild pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of [2148-9-24], RV is now mildly dilated and appears hypertrophied. The other findings are probably similar. Brief Hospital Course: 69 yo M h/o HIV on HAART, COPD on home oxygen, and remote history of left leg DVT p/w worsening dyspnea after recent discharge from OSH for COPD. . # Dyspnea: Likely COPD exacerbation. Patient has history of severe emphysema and bronchiectasis. FEV1: 20% in spirometry [2150] c/w end stage disease. Patient was intermittently treated with BIPAP in ICU, however his oxygen saturation was good and he often requested BIPAP for only short amounts of time prior to removing BIPAP. Mr. [Known lastname 2150] was started on Methylprednisolone 125 mg IV Q6H for the first day of admission and then was transitioned to prednisone 60 mg daily. He will continue on a slow prednisone taper. He was also treated with a 5 day course of levofloxacin 750 mg. Patient was treated with duonebs and received ativan and oxycodone for dyspnea. He was started on bactrim, famotidine, and calc/vit D for prophylaxis for presumed long term steroids. . # Multifocal atrial tachycardia: Patient was noted to have multifocal atrial tachycardia ED, resolved prior to admission to ICU. Likley secondary to underlying COPD. Patient's COPD was controlled and he did not have multifocal atrial tachycardia while in ICU. Diltiazem was started at 30mg TID for HR control with HRs < 100. . # HTN: Patient with elevated SBPs. He was started on PO diltiazem as above and continued on doxazosin. . # H/O DVT: Patient was diagnosed with DVT in [2152-3-17]. Reportedly completed coumadin course per Dr.[Name (NI) 2179] note in the past, however was continued due to sedentary life. On admission, patient had sub-therpeutic INR. Patient was started on SQH and pneumoboots for DVT prophylaxis. He was continued on coumadin at home dose. He requires daily INR levels as we are initiating bactrim therapy, coumadin should be adjusted as seen fit to maintain INR between [12-20]. . # HIV: Last CD4 count 247. Continued home HAART regimen. . # Hypernatremia: On presentation to ED. Improved with IVF. . # Communication: Patient, Next of [Doctor First Name ]: Sister: #1 [Doctor First Name 2155]: [Telephone/Fax (1) 2157], Son: [Name (NI) ]: [Telephone/Fax (1) 2180] . # Code: Full (discussed with patient) Medications on Admission: Atazanavir 400 daily Epzicom 600-300 daily Lexiva 1400 [Hospital1 ] Albuterol TID prn Asa 325 daily bisacodyl 5 [Hospital1 ] Colace 100 [Hospital1 ] Ferrous gluconate 324 daily Senna prn Spiriva daily warfarin 3 mg daily, except friday, take 4 mg daily Prednisone taper (50 x 3 day-> 40 x3->30 x 3 -> 20 x 3 -> 10 x 3 -> 5 x 4 days, then stop) Azithromycin 500 mg Discharge Medications: 1. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q4H (every 4 hours). 9. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours). 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 11. warfarin 1 mg Tablet Sig: Three (3) Tablet PO 6X/WEEK ([Doctor First Name ],MO,TU,WE,TH,SA). 12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (FR). 13. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 15. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 16. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO 3 times a week MWF. 17. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day: PREDNISONE TAPER = 50mg for 4days, 40mg for 4days, 30mg for 4days, 20mg for 4days, 10mg for 4days then stop. 18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breathlessness. 19. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for anxiety. 20. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure to participate in your care Mr. [Known lastname 2150]. You were admitted to the hospital for difficulty breathing, which was caused by chronic obstructive pulmonary disease. We treated you with a breathing machine called BIPAP. We treated you with steroids, inhalers, and antibiotics. You will go to a rehab facility where you can get stronger and improve your breathing. Please make the following changes to your medications: 1. Prednisone taper 2. Start bactrim DS three times a week on MWF 3. Start famotidine while on prednisone 4. Start calcium and vitamin D 5. Start oxycodone and ativan for symptom control 6. Start diltiazem 30mg tid for MAT Followup Instructions: Department: [Hospital3 249] When: WEDNESDAY [2154-5-22] at 12:00 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [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: MEDICAL SPECIALTIES When: MONDAY [2154-6-10] at 9:30 AM With: DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 612] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	Admission Date: <Date>1989-8-30</Date> Discharge Date: <Date>1920-2-5</Date> Date of Birth: <Date>1934-10-8</Date> Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Londrie</Name> Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 69 yo M h/o HIV, COPD presenting with shortness of breath and "not feeling well." He was notably just admitted to <Hospital>Hernandez-Murphy Health System</Hospital> for a COPD exacerbation <Date Range>1967-3-17 to 1970-9-13</Date Range>. During this admission he was noted to have a tenuous respiratory status with poor air movement and was briefly intubated for a few hours. He was started on steroids with a slow taper and azithromycin. Since his discharge he did not feel well and came to <Hospital>Mason-Kramer Health System</Hospital> for further evaluation. . In the ED, initial vs were: 97.9 103 170/105 27 99% 3L. He was noted to have poor air movement and given 125 mg IV solumedrol and duonebs. BiPAP started, however patient vomited, so this was stopped. He was given IV zofran and phenergan. ABG was 7.37/58/96, so once his nausea resolved, he was placed back on BiPap. He was notably tachycardic to the 180s which was felt to be afib vs. MAT. He was given 15 mg IV diltiazem and broke soon after this. He was notably also given morphine and ativan. CXR notable for hyperinflation. Vitalls prior to transfer:: 101 189/109 21 100% Bipap. . Upon arrival to the MICU, the patient was taken off of BiPAP due to significant nausea. He was given IV compazine and placed on nasal cannula with saturations near 100%. He continues to feel short of breath. Past Medical History: 1. HIV. Diagnosed in <Year>1998</Year>, status post multiple HAART regimens, no OI history, CD4 nadir 247 <Date>1977-8-11</Date>. 2. COPD, on chronic O2 therapy with recent intubation at <Hospital>Hernandez-Murphy Health System</Hospital>. Notably was DNR/DNI in past 3. DVT, left lower extremity in <Date>1952-6-1</Date>, on Coumadin therapy due to sedentary life, although completed course of anticoagulation. 4. Rectal bleeding. 5. Chronic low back pain s/p numerous back surgeries. 6. Hypertension. 7. Basilar aneurysm in <Year>1998</Year>. 8. History of substance abuse with cocaine. 9. Anemia of chronic disease. 10. Osteoporosis. Social History: He denies any alcohol, smoking, or drug use since <Year>1998</Year> when he became clean. Previous 80 pk-yr smoker. Family History: HTN, throat cancer (brother, smoker) Physical Exam: On Admission: Vitals: AF 118 172/94 99% on 3 Liters General: Alert, oriented, chactic appearing, using accessory muscles, HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, Lungs: poor air movement. no wheeezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema On Discharge: HR 98 BP 119/73 O2 93% General: Alert, oriented, cachectic appearing, using accessory muscles, HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, Lungs: poor air movement. no wheeezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: <Date>1989-8-30</Date> 10:50AM BLOOD WBC-7.9 RBC-3.41* Hgb-9.5* Hct-31.3* MCV-92 MCH-27.9 MCHC-30.4* RDW-15.0 Plt Ct-159 <Date>1989-8-30</Date> 10:50AM BLOOD Neuts-86.3* Lymphs-8.4* Monos-5.0 Eos-0.3 Baso-0.1 <Date>1989-8-30</Date> 11:30AM BLOOD PT-15.9* PTT-20.7* INR(PT)-1.4* <Date>1989-8-30</Date> 10:50AM BLOOD Glucose-133* UreaN-26* Creat-1.0 Na-148* K-3.0* Cl-104 HCO3-31 AnGap-16 <Date>1989-8-30</Date> 04:59PM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0 <Date>1989-8-30</Date> 10:26AM BLOOD Type-ART Rates-/26 O2 Flow-8 pO2-110* pCO2-50* pH-7.41 calTCO2-33* Base XS-6 Intubat-NOT INTUBA Comment-NEBULIZER Discharge labs: <Date>1920-2-5</Date> 03:27AM BLOOD WBC-7.8 RBC-3.18* Hgb-9.4* Hct-29.4* MCV-93 MCH-29.6 MCHC-31.9 RDW-15.1 Plt Ct-191 <Date>1920-2-5</Date> 03:27AM BLOOD PT-23.4* PTT-35.6* INR(PT)-2.2* <Date>1920-2-5</Date> 03:27AM BLOOD Glucose-116* UreaN-37* Creat-1.2 Na-146* K-4.1 Cl-104 HCO3-37* AnGap-9 <Date>1920-2-5</Date> 03:27AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.4 Chest X-Ray: 1. Hyperexpanded lungs consistent with known diagnosis of COPD. 2. Stable right calcified lymph node. 3. No focal consolidation or pleural effusion. ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. IMPRESSION: Mildly dilated and hypertrophied right ventricle with preserved systolic function. Small and hyperdynamic left ventricle. Mild pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of <Date>1981-6-1</Date>, RV is now mildly dilated and appears hypertrophied. The other findings are probably similar. Brief Hospital Course: 69 yo M h/o HIV on HAART, COPD on home oxygen, and remote history of left leg DVT p/w worsening dyspnea after recent discharge from OSH for COPD. . # Dyspnea: Likely COPD exacerbation. Patient has history of severe emphysema and bronchiectasis. FEV1: 20% in spirometry <Year>1998</Year> c/w end stage disease. Patient was intermittently treated with BIPAP in ICU, however his oxygen saturation was good and he often requested BIPAP for only short amounts of time prior to removing BIPAP. Mr. <Name>Bounds</Name> was started on Methylprednisolone 125 mg IV Q6H for the first day of admission and then was transitioned to prednisone 60 mg daily. He will continue on a slow prednisone taper. He was also treated with a 5 day course of levofloxacin 750 mg. Patient was treated with duonebs and received ativan and oxycodone for dyspnea. He was started on bactrim, famotidine, and calc/vit D for prophylaxis for presumed long term steroids. . # Multifocal atrial tachycardia: Patient was noted to have multifocal atrial tachycardia ED, resolved prior to admission to ICU. Likley secondary to underlying COPD. Patient's COPD was controlled and he did not have multifocal atrial tachycardia while in ICU. Diltiazem was started at 30mg TID for HR control with HRs < 100. . # HTN: Patient with elevated SBPs. He was started on PO diltiazem as above and continued on doxazosin. . # H/O DVT: Patient was diagnosed with DVT in <Date>1952-6-1</Date>. Reportedly completed coumadin course per Dr.<Name>Gregory Dizon</Name> note in the past, however was continued due to sedentary life. On admission, patient had sub-therpeutic INR. Patient was started on SQH and pneumoboots for DVT prophylaxis. He was continued on coumadin at home dose. He requires daily INR levels as we are initiating bactrim therapy, coumadin should be adjusted as seen fit to maintain INR between <Date>11-13</Date>. . # HIV: Last CD4 count 247. Continued home HAART regimen. . # Hypernatremia: On presentation to ED. Improved with IVF. . # Communication: Patient, Next of <Name>Zhi</Name>: Sister: #1 <Name>Laura</Name>: <Telephone>197-151-2735</Telephone>, Son: <Name>Eliseo Ahmed</Name>: <Telephone>294-542-1341</Telephone> . # Code: Full (discussed with patient) Medications on Admission: Atazanavir 400 daily Epzicom 600-300 daily Lexiva 1400 <Hospital>Noble Inc Health System</Hospital> Albuterol TID prn Asa 325 daily bisacodyl 5 <Hospital>Noble Inc Health System</Hospital> Colace 100 <Hospital>Noble Inc Health System</Hospital> Ferrous gluconate 324 daily Senna prn Spiriva daily warfarin 3 mg daily, except friday, take 4 mg daily Prednisone taper (50 x 3 day-> 40 x3->30 x 3 -> 20 x 3 -> 10 x 3 -> 5 x 4 days, then stop) Azithromycin 500 mg Discharge Medications: 1. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q4H (every 4 hours). 9. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours). 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 11. warfarin 1 mg Tablet Sig: Three (3) Tablet PO 6X/WEEK (<Name>Zhi</Name>,MO,TU,WE,TH,SA). 12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (FR). 13. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 15. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 16. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO 3 times a week MWF. 17. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day: PREDNISONE TAPER = 50mg for 4days, 40mg for 4days, 30mg for 4days, 20mg for 4days, 10mg for 4days then stop. 18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breathlessness. 19. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for anxiety. 20. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Discharge Disposition: Extended Care Facility: <Hospital>Schmidt, Peterson and Thomas Clinic</Hospital> for the Aged - MACU Discharge Diagnosis: COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure to participate in your care Mr. <Name>Bounds</Name>. You were admitted to the hospital for difficulty breathing, which was caused by chronic obstructive pulmonary disease. We treated you with a breathing machine called BIPAP. We treated you with steroids, inhalers, and antibiotics. You will go to a rehab facility where you can get stronger and improve your breathing. Please make the following changes to your medications: 1. Prednisone taper 2. Start bactrim DS three times a week on MWF 3. Start famotidine while on prednisone 4. Start calcium and vitamin D 5. Start oxycodone and ativan for symptom control 6. Start diltiazem 30mg tid for MAT Followup Instructions: Department: <Hospital>Potter Ltd Health System</Hospital> When: WEDNESDAY <Date>1989-2-22</Date> at 12:00 PM With: <Name>Allison</Name> <Name>Pegram</Name> <Telephone>563-766-9407</Telephone> Building: SC <Hospital>Knight-Freeman Clinic</Hospital> Clinical Ctr <Location>7718 Anthony Pine Apt. 706 West Charles, MT 90623</Location> Campus: EAST Best Parking: <Hospital>Knight-Freeman Clinic</Hospital> Garage Department: MEDICAL SPECIALTIES When: MONDAY <Date>1925-1-15</Date> at 9:30 AM With: DR. <Name>Allison</Name> <Name>Pegram</Name> <Telephone>882-749-2870</Telephone> Building: <Hospital>Jackson-Hines Medical Center</Hospital> <Location>69974 Jerry Route Rebeccaburgh, CA 96957</Location> Campus: EAST Best Parking: <Hospital>Knight-Freeman Clinic</Hospital> Garage <Initial>UH</Initial> <Name>Meraz</Name> <Name>Leonel Pegram</Name> MD <MD Number>06640505</MD 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Date: 1989-8-30 Discharge Date: 1920-2-5 Date of Birth: 1934-10-8 Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Londrie Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 69 yo M h/o HIV, COPD presenting with shortness of breath and "not feeling well." He was notably just admitted to Hernandez-Murphy Health System for a COPD exacerbation 1967-3-17 to 1970-9-13. During this admission he was noted to have a tenuous respiratory status with poor air movement and was briefly intubated for a few hours. He was started on steroids with a slow taper and azithromycin. Since his discharge he did not feel well and came to Mason-Kramer Health System for further evaluation. . In the ED, initial vs were: 97.9 103 170/105 27 99% 3L. He was noted to have poor air movement and given 125 mg IV solumedrol and duonebs. BiPAP started, however patient vomited, so this was stopped. He was given IV zofran and phenergan. ABG was 7.37/58/96, so once his nausea resolved, he was placed back on BiPap. He was notably tachycardic to the 180s which was felt to be afib vs. MAT. He was given 15 mg IV diltiazem and broke soon after this. He was notably also given morphine and ativan. CXR notable for hyperinflation. Vitalls prior to transfer:: 101 189/109 21 100% Bipap. . Upon arrival to the MICU, the patient was taken off of BiPAP due to significant nausea. He was given IV compazine and placed on nasal cannula with saturations near 100%. He continues to feel short of breath. Past Medical History: 1. HIV. Diagnosed in 1998, status post multiple HAART regimens, no OI history, CD4 nadir 247 1977-8-11. 2. COPD, on chronic O2 therapy with recent intubation at Hernandez-Murphy Health System. Notably was DNR/DNI in past 3. DVT, left lower extremity in 1952-6-1, on Coumadin therapy due to sedentary life, although completed course of anticoagulation. 4. Rectal bleeding. 5. Chronic low back pain s/p numerous back surgeries. 6. Hypertension. 7. Basilar aneurysm in 1998. 8. History of substance abuse with cocaine. 9. Anemia of chronic disease. 10. Osteoporosis. Social History: He denies any alcohol, smoking, or drug use since 1998 when he became clean. Previous 80 pk-yr smoker. Family History: HTN, throat cancer (brother, smoker) Physical Exam: On Admission: Vitals: AF 118 172/94 99% on 3 Liters General: Alert, oriented, chactic appearing, using accessory muscles, HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, Lungs: poor air movement. no wheeezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema On Discharge: HR 98 BP 119/73 O2 93% General: Alert, oriented, cachectic appearing, using accessory muscles, HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, Lungs: poor air movement. no wheeezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: 1989-8-30 10:50AM BLOOD WBC-7.9 RBC-3.41* Hgb-9.5* Hct-31.3* MCV-92 MCH-27.9 MCHC-30.4* RDW-15.0 Plt Ct-159 1989-8-30 10:50AM BLOOD Neuts-86.3* Lymphs-8.4* Monos-5.0 Eos-0.3 Baso-0.1 1989-8-30 11:30AM BLOOD PT-15.9* PTT-20.7* INR(PT)-1.4* 1989-8-30 10:50AM BLOOD Glucose-133* UreaN-26* Creat-1.0 Na-148* K-3.0* Cl-104 HCO3-31 AnGap-16 1989-8-30 04:59PM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0 1989-8-30 10:26AM BLOOD Type-ART Rates-/26 O2 Flow-8 pO2-110* pCO2-50* pH-7.41 calTCO2-33* Base XS-6 Intubat-NOT INTUBA Comment-NEBULIZER Discharge labs: 1920-2-5 03:27AM BLOOD WBC-7.8 RBC-3.18* Hgb-9.4* Hct-29.4* MCV-93 MCH-29.6 MCHC-31.9 RDW-15.1 Plt Ct-191 1920-2-5 03:27AM BLOOD PT-23.4* PTT-35.6* INR(PT)-2.2* 1920-2-5 03:27AM BLOOD Glucose-116* UreaN-37* Creat-1.2 Na-146* K-4.1 Cl-104 HCO3-37* AnGap-9 1920-2-5 03:27AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.4 Chest X-Ray: 1. Hyperexpanded lungs consistent with known diagnosis of COPD. 2. Stable right calcified lymph node. 3. No focal consolidation or pleural effusion. ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. IMPRESSION: Mildly dilated and hypertrophied right ventricle with preserved systolic function. Small and hyperdynamic left ventricle. Mild pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of 1981-6-1, RV is now mildly dilated and appears hypertrophied. The other findings are probably similar. Brief Hospital Course: 69 yo M h/o HIV on HAART, COPD on home oxygen, and remote history of left leg DVT p/w worsening dyspnea after recent discharge from OSH for COPD. . # Dyspnea: Likely COPD exacerbation. Patient has history of severe emphysema and bronchiectasis. FEV1: 20% in spirometry 1998 c/w end stage disease. Patient was intermittently treated with BIPAP in ICU, however his oxygen saturation was good and he often requested BIPAP for only short amounts of time prior to removing BIPAP. Mr. Bounds was started on Methylprednisolone 125 mg IV Q6H for the first day of admission and then was transitioned to prednisone 60 mg daily. He will continue on a slow prednisone taper. He was also treated with a 5 day course of levofloxacin 750 mg. Patient was treated with duonebs and received ativan and oxycodone for dyspnea. He was started on bactrim, famotidine, and calc/vit D for prophylaxis for presumed long term steroids. . # Multifocal atrial tachycardia: Patient was noted to have multifocal atrial tachycardia ED, resolved prior to admission to ICU. Likley secondary to underlying COPD. Patient's COPD was controlled and he did not have multifocal atrial tachycardia while in ICU. Diltiazem was started at 30mg TID for HR control with HRs 1952-6-1. Reportedly completed coumadin course per Dr.Gregory Dizon note in the past, however was continued due to sedentary life. On admission, patient had sub-therpeutic INR. Patient was started on SQH and pneumoboots for DVT prophylaxis. He was continued on coumadin at home dose. He requires daily INR levels as we are initiating bactrim therapy, coumadin should be adjusted as seen fit to maintain INR between 11-13. . # HIV: Last CD4 count 247. Continued home HAART regimen. . # Hypernatremia: On presentation to ED. Improved with IVF. . # Communication: Patient, Next of Zhi: Sister: #1 Laura: 197-151-2735, Son: Eliseo Ahmed: 294-542-1341 . # Code: Full (discussed with patient) Medications on Admission: Atazanavir 400 daily Epzicom 600-300 daily Lexiva 1400 Noble Inc Health System Albuterol TID prn Asa 325 daily bisacodyl 5 Noble Inc Health System Colace 100 Noble Inc Health System Ferrous gluconate 324 daily Senna prn Spiriva daily warfarin 3 mg daily, except friday, take 4 mg daily Prednisone taper (50 x 3 day-> 40 x3->30 x 3 -> 20 x 3 -> 10 x 3 -> 5 x 4 days, then stop) Azithromycin 500 mg Discharge Medications: 1. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q4H (every 4 hours). 9. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours). 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 11. warfarin 1 mg Tablet Sig: Three (3) Tablet PO 6X/WEEK (Zhi,MO,TU,WE,TH,SA). 12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (FR). 13. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 15. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 16. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO 3 times a week MWF. 17. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day: PREDNISONE TAPER = 50mg for 4days, 40mg for 4days, 30mg for 4days, 20mg for 4days, 10mg for 4days then stop. 18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breathlessness. 19. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for anxiety. 20. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Discharge Disposition: Extended Care Facility: Schmidt, Peterson and Thomas Clinic for the Aged - MACU Discharge Diagnosis: COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure to participate in your care Mr. Bounds. You were admitted to the hospital for difficulty breathing, which was caused by chronic obstructive pulmonary disease. We treated you with a breathing machine called BIPAP. We treated you with steroids, inhalers, and antibiotics. You will go to a rehab facility where you can get stronger and improve your breathing. Please make the following changes to your medications: 1. Prednisone taper 2. Start bactrim DS three times a week on MWF 3. Start famotidine while on prednisone 4. Start calcium and vitamin D 5. Start oxycodone and ativan for symptom control 6. Start diltiazem 30mg tid for MAT Followup Instructions: Department: Potter Ltd Health System When: WEDNESDAY 1989-2-22 at 12:00 PM With: Allison Pegram 563-766-9407 Building: SC Knight-Freeman Clinic Clinical Ctr 7718 Anthony Pine Apt. 706 West Charles, MT 90623 Campus: EAST Best Parking: Knight-Freeman Clinic Garage Department: MEDICAL SPECIALTIES When: MONDAY 1925-1-15 at 9:30 AM With: DR. Allison Pegram 882-749-2870 Building: Jackson-Hines Medical Center 69974 Jerry Route Rebeccaburgh, CA 96957 Campus: EAST Best Parking: Knight-Freeman Clinic Garage UH Meraz Leonel Pegram MD 06640505	['Admission Date: 1989-8-30 Discharge Date: 1920-2-5\n\nDate of Birth: 1934-10-8 Sex: M\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Londrie\nChief Complaint:\nShortness of Breath\n\n\nMajor Surgical or Invasive Procedure:\nNone\n\nHistory of Present Illness:\n69 yo M h/o HIV, COPD presenting with shortness of breath and\n"not feeling well." He was notably just admitted to Hernandez-Murphy Health System for a\nCOPD exacerbation 1967-3-17 to 1970-9-13. During this admission he was noted to\nhave a tenuous respiratory status with poor air movement and was\nbriefly intubated for a few hours. He was started on steroids\nwith a slow taper and azithromycin. Since his discharge he did\nnot feel well and came to Mason-Kramer Health System for further evaluation.', '\n.\nIn the ED, initial vs were: 97.9 103 170/105 27 99% 3L. He was\nnoted to have poor air movement and given 125 mg IV solumedrol\nand duonebs. BiPAP started, however patient vomited, so this was\nstopped. He was given IV zofran and phenergan. ABG was\n7.37/58/96, so once his nausea resolved, he was placed back on\nBiPap. He was notably tachycardic to the 180s which was felt to\nbe afib vs. MAT. He was given 15 mg IV diltiazem and broke soon\nafter this. He was notably also given morphine and ativan. CXR\nnotable for hyperinflation. Vitalls prior to transfer:: 101\n189/109 21 100% Bipap.\n.\nUpon arrival to the MICU, the patient was taken off of BiPAP due\nto significant nausea. He was given IV compazine and placed on\nnasal cannula with saturations near 100%. He continues to feel\nshort of breath.\n\nPast Medical History:\n1.', ' HIV. Diagnosed in 1998, status post multiple HAART\nregimens, no OI history, CD4 nadir 247 1977-8-11.\n2. COPD, on chronic O2 therapy with recent intubation at Hernandez-Murphy Health System.\nNotably was DNR/DNI in past\n3. DVT, left lower extremity in 1952-6-1, on Coumadin therapy\ndue to sedentary life, although completed course of\nanticoagulation.\n4. Rectal bleeding.\n5. Chronic low back pain s/p numerous back surgeries.\n6. Hypertension.\n7. Basilar aneurysm in 1998.\n8. History of substance abuse with cocaine.\n9. Anemia of chronic disease.\n10. Osteoporosis.\n\nSocial History:\nHe denies any alcohol, smoking, or drug use since 1998 when he\nbecame clean. Previous 80 pk-yr smoker.\n\n\nFamily History:\nHTN, throat cancer (brother, smoker)\n\nPhysical Exam:\nOn Admission:\nVitals: AF 118 172/94 99% on 3 Liters\nGeneral: Alert, oriented, chactic appearing, using accessory\nmuscles,\nHEENT: Sclera anicteric, dry MM, oropharynx clear\nNeck: supple, JVP not elevated,\nLungs: poor air movement.', ' no wheeezes, rales, rhonchi.\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: no foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema\n\nOn Discharge: HR 98 BP 119/73 O2 93%\nGeneral: Alert, oriented, cachectic appearing, using accessory\nmuscles,\nHEENT: Sclera anicteric, dry MM, oropharynx clear\nNeck: supple, JVP not elevated,\nLungs: poor air movement. no wheeezes, rales, rhonchi.\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: no foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema\n\n\nPertinent Results:\nAdmission labs:\n1989-8-30 10:50AM BLOOD WBC-7.', '9 RBC-3.41* Hgb-9.5* Hct-31.3\nMCV-92 MCH-27.9 MCHC-30.4 RDW-15.0 Plt Ct-159\n1989-8-30 10:50AM BLOOD Neuts-86.3* Lymphs-8.4* Monos-5.0 Eos-0.3\nBaso-0.1\n1989-8-30 11:30AM BLOOD PT-15.9* PTT-20.7* INR(PT)-1.4\n1989-8-30 10:50AM BLOOD Glucose-133 UreaN-26* Creat-1.0 Na-148\nK-3.0 Cl-104 HCO3-31 AnGap-16\n1989-8-30 04:59PM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0\n1989-8-30 10:26AM BLOOD Type-ART Rates-/26 O2 Flow-8 pO2-110\npCO2-50 pH-7.41 calTCO2-33* Base XS-6 Intubat-NOT INTUBA\nComment-NEBULIZER\n\nDischarge labs:\n1920-2-5 03:27AM BLOOD WBC-7.8 RBC-3.18* Hgb-9.4* Hct-29.4\nMCV-93 MCH-29.6 MCHC-31.9 RDW-15.1 Plt Ct-191\n1920-2-5 03:27AM BLOOD PT-23.4 PTT-35.6* INR(PT)-2.2\n1920-2-5 03:27AM BLOOD Glucose-116 UreaN-37* Creat-1.2 Na-146\nK-4.1 Cl-104 HCO3-37 AnGap-9\n1920-2-5 03:27AM BLOOD Calcium-8.', '6 Phos-3.4 Mg-2.4\n\nChest X-Ray:\n1. Hyperexpanded lungs consistent with known diagnosis of COPD.\n2. Stable right calcified lymph node.\n3. No focal consolidation or pleural effusion.\n\nECHO:\nThe left atrium is normal in size. Left ventricular wall\nthickness, cavity size and regional/global systolic function are\nnormal (LVEF >55%). The right ventricular free wall is\nhypertrophied. The right ventricular cavity is mildly dilated\nwith normal free wall contractility. The ascending aorta is\nmildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic\nstenosis or aortic regurgitation. The mitral valve leaflets are\nmildly thickened. There is mild pulmonary artery systolic\nhypertension. There is a small pericardial effusion.\nIMPRESSION: Mildly dilated and hypertrophied right ventricle\nwith preserved systolic function.', ' Small and hyperdynamic left\nventricle. Mild pulmonary hypertension.\nCompared with the report of the prior study (images unavailable\nfor review) of 1981-6-1, RV is now mildly dilated and appears\nhypertrophied. The other findings are probably similar.\n\n\nBrief Hospital Course:\n69 yo M h/o HIV on HAART, COPD on home oxygen, and remote\nhistory of left leg DVT p/w worsening dyspnea after recent\ndischarge from OSH for COPD.\n.\n# Dyspnea: Likely COPD exacerbation. Patient has history of\nsevere emphysema and bronchiectasis. FEV1: 20% in spirometry\n1998 c/w end stage disease. Patient was intermittently treated\nwith BIPAP in ICU, however his oxygen saturation was good and he\noften requested BIPAP for only short amounts of time prior to\nremoving BIPAP. Mr. Bounds was started on Methylprednisolone 125\nmg IV Q6H for the first day of admission and then was\ntransitioned to prednisone 60 mg daily.', " He will continue on a\nslow prednisone taper. He was also treated with a 5 day course\nof levofloxacin 750 mg. Patient was treated with duonebs and\nreceived ativan and oxycodone for dyspnea. He was started on\nbactrim, famotidine, and calc/vit D for prophylaxis for presumed\nlong term steroids.\n.\n# Multifocal atrial tachycardia: Patient was noted to have\nmultifocal atrial tachycardia ED, resolved prior to admission to\nICU. Likley secondary to underlying COPD. Patient's COPD was\ncontrolled and he did not have multifocal atrial tachycardia\nwhile in ICU. Diltiazem was started at 30mg TID for HR control\nwith HRs 1952-6-1.\nReportedly completed coumadin course per Dr.Gregory Dizon note in\nthe past, however was continued due to sedentary life. On\nadmission, patient had sub-therpeutic INR. Patient was started\non SQH and pneumoboots for DVT prophylaxis.", ' He was continued on\ncoumadin at home dose. He requires daily INR levels as we are\ninitiating bactrim therapy, coumadin should be adjusted as seen\nfit to maintain INR between 11-13.\n.\n# HIV: Last CD4 count 247. Continued home HAART regimen.\n.\n# Hypernatremia: On presentation to ED. Improved with IVF.\n.\n# Communication: Patient, Next of Zhi: Sister: #1 Laura:\n197-151-2735, Son: Eliseo Ahmed: 294-542-1341\n.\n# Code: Full (discussed with patient)\n\n\nMedications on Admission:\nAtazanavir 400 daily\nEpzicom 600-300 daily\nLexiva 1400 Noble Inc Health System\nAlbuterol TID prn\nAsa 325 daily\nbisacodyl 5 Noble Inc Health System\nColace 100 Noble Inc Health System\nFerrous gluconate 324 daily\nSenna prn\nSpiriva daily\nwarfarin 3 mg daily, except friday, take 4 mg daily\nPrednisone taper (50 x 3 day-> 40 x3->30 x 3 -> 20 x 3 -> 10 x 3\n-> 5 x 4 days, then stop)\nAzithromycin 500 mg\n\nDischarge Medications:\n1.', ' atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY\n(Daily).\n2. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H\n(every 12 hours).\n3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n4. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n5. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n6. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: Three (3) ml Inhalation Q2H (every 2 hours) as\nneeded for shortness of breath or wheezing.\n8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: Three (3) ml Inhalation Q4H (every 4 hours).\n9. ipratropium bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q4H (every 4 hours).\n10.', ' ipratropium bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q2H (every 2 hours) as needed for shortness of breath\nor wheezing.\n11. warfarin 1 mg Tablet Sig: Three (3) Tablet PO 6X/WEEK\n(Zhi,MO,TU,WE,TH,SA).\n12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (FR).\n13. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3\ntimes a day).\n14. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at\nbedtime).\n15. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every\n12 hours).\n16. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO 3 times\na week MWF.\n17. prednisone 10 mg Tablet Sig: as directed Tablet PO once a\nday: PREDNISONE TAPER =\n50mg for 4days,\n40mg for 4days,\n30mg for 4days,\n20mg for 4days,\n10mg for 4days then stop.\n18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\nhours) as needed for breathlessness.', '\n19. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as\nneeded for anxiety.\n20. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable\nSig: One (1) Tablet, Chewable PO three times a day.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nSchmidt, Peterson and Thomas Clinic for the Aged - MACU\n\nDischarge Diagnosis:\nCOPD exacerbation\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:\nIt was a pleasure to participate in your care Mr. Bounds. You\nwere admitted to the hospital for difficulty breathing, which\nwas caused by chronic obstructive pulmonary disease. We treated\nyou with a breathing machine called BIPAP. We treated you with\nsteroids, inhalers, and antibiotics.', ' You will go to a rehab\nfacility where you can get stronger and improve your breathing.\n\nPlease make the following changes to your medications:\n1. Prednisone taper\n2. Start bactrim DS three times a week on MWF\n3. Start famotidine while on prednisone\n4. Start calcium and vitamin D\n5. Start oxycodone and ativan for symptom control\n6. Start diltiazem 30mg tid for MAT\n\nFollowup Instructions:\nDepartment: Potter Ltd Health System\nWhen: WEDNESDAY 1989-2-22 at 12:00 PM\nWith: Allison Pegram 563-766-9407\nBuilding: SC Knight-Freeman Clinic Clinical Ctr 7718 Anthony Pine Apt. 706\nWest Charles, MT 90623\nCampus: EAST Best Parking: Knight-Freeman Clinic Garage\n\nDepartment: MEDICAL SPECIALTIES\nWhen: MONDAY 1925-1-15 at 9:30 AM\nWith: DR. Allison Pegram 882-749-2870\nBuilding: Jackson-Hines Medical Center 69974 Jerry Route\nRebeccaburgh, CA 96957\nCampus: EAST Best Parking: Knight-Freeman Clinic Garage\n\n\n UH Meraz Leonel Pegram MD 06640505\n\n']
219	11018	107995.0	2154-04-18	Discharge summary	Report	Admission Date: [2154-4-9] Discharge Date: [2154-4-18] Date of Birth: [2084-12-30] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2186] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: BiPap Intubation, extubation ([2154-4-13]) History of Present Illness: 69 year old male with history of HIV (CD4 116 [2154-4-8]), COPD (2-4L at home), DVT on coumadin, hypertension, chronic lower back [Last Name (un) 2187], osteoporosis who presents with respiratory distress. The patient had been recently admitted 5/13-16/[2153] for COPD exacerbation and treated with nebs, azithromycin, prednisone (slow taper). The patient presented to the ED on [2154-4-2] for dyspnea but left AMA before admission. He was sent to the ED on [2154-4-8] but left AMA again, with prednisone and azithromycin prescriptions which he never filled. He had seen Dr. [Last Name (STitle) ] in pulmonary clinic yesterday and had been non-compliant with prednisone taper. He endorsed "exhaustion" at the appointment but was stable 93% on 3.5L nasal cannula. The patient had also been at [Hospital ] Clinic with Dr. [Last Name (STitle) 2185] prior to Pulmonary appointment. . The patient re-presented to the ED today with worsening dyspnea and was brought in by EMS in respiratory distress (enroute CO2 50). He responded to nebulizers enroute and arrived looking very uncomfortable, using accessory muscles. He was tight on pulmonary exam with minimal breath sounds and speaking few word sentences. The patient was started on BiPap (50%, PSV 15, PEEP 5), which he tolerated well. He was briefly weaned off to 4L NC but decompensated, tripoding despite Methylprednisolone 125mg IV X1, Azithromycin 500mg, more nebulizers and ativan 2mg IV. . ROS: Patient denies fevers/chills, nausea/vomiting, myalgias, changes in bowel movement or urination. Past Medical History: * HIV (diagnosed [2135], s/p multiple HAART regimens, no history of opportunistic infections, CD4 nadir [2154-4-8] 116) * COPD (chornic O2 therapy at home 2-4L PRN, intubated recently at [Hospital6 ] and was DNR/DNI in the past) * DVT (left lower extremity, [2152-3-17]; still on Coumadin therapy - for sedentary lifestyle) * h/o Rectal bleeding * Chronic lower back pain s/p numerous back surgeries * Hypertension * Basilar aneurysm s/p clipping by Dr. [Last Name (STitle) 1338] ([2134]) * h/o substance abuse with cocaine * Anemia of chronic disease * Osteoporosis * s/p ileocecetomy for ?cancer. SBO in [2136] with lysis of adhesions Social History: Denies alcohol, smoking or illicit drugs (since [2135]). Previous 80 pack year smoker. Lives alone, uses wheelchair. Family History: Hypertension and throat cancer in brother (smoker) Physical Exam: Temp: 97.0 BP: 132/80 HR: 89 RR: 18 O2sat 100% on Bipap (15/5, 50%) GEN: Pleasant, comfortable, NAD, mildly anorexic HEENT: PERRL, EOMI, anicteric, MMM, RESP: CTA b/l with good air movement throughout, ?prolonged expiratory phase, barrel chested with increased AP diameter CV: Regular rate, rhythm; S1 and S2 wnl, no murmurs/gallops/rubs ABD: Nontender, nondistended, +BS, soft EXT: No cyanosis/ecchymosis, [11-18]+ bilateral lower extremity edema (symmetric) SKIN: No rashes/no jaundice/no splinters NEURO: AAOx3. CN 2-12 intact. Strength and sensation intact. . Discharge Exam: No vitals (cmo) Gen: Cachectic in NAD, no jaundice, no palor HEENT: NCAT PERRL MMMs OP clear Neck: No JVP elevation supple Pulm: Very poor air movement wheezes throughout; no rhonci no crackles CV: RRR nml S1 S2 no m/r/g Ab: +BS NTND Ext: No edema Neuro: Grossly intact AO x 3 responding appropriately to questions Pertinent Results: [2154-4-9] 06:47PM O2-100 PO2-244* PCO2-53* PH-7.44 TOTAL CO2-37* BASE XS-10 AADO2-426 REQ O2-73 [2154-4-9] 06:13PM LACTATE-1.9 . CXR [4-9]: Patchy opacity in left lung base, similar to the prior study, which remains concerning for infection. Severe emphysema. . CXR [4-13]: An endotracheal tube lies at the level of the clavicular heads, appropriately positioned. A nasogastric tube courses into the stomach. Severe emphysema is noted. The cardiomediastinal silhouette is stable. There are small bilateral pleural effusions. The left lower lobe opacity has mildly improved and reflects resolving infection. No new focal consolidation is appreciated. . Discharge Labs: None Brief Hospital Course: 69 year old male with history of HIV (CD4 116 [2154-4-8]), COPD (2-4L at home), DVT on coumadin, hypertension, chronic lower back [Last Name (un) 2187], osteoporosis who presents with respiratory distress. . # Respiratory Distress: Most likely due to ongoing COPD exacerbation. Trigger unclear given lack of pneumonia on initial CXR, no fevers/chills, productive cough. Patient has been non-compliant with medications, however, since discharge; this includes prednisone and antibiotics. ?compliance with nebulizers and has supplemental O2 at home. The patient has had CTA recently to rule out pulmonary emboli given ongoing dyspnea despite therapy. He was treated with azithromycin for 5 days and methylprednisolone. He intermittently required BiPap. A plan was made to use bipap at night once the patient was able to leave the ICU. However on the morning of [4-13] patient was anxious, tachypneic and desatted and required intubation. The patient was extubated on [4-14]. He did well overnight but subsequently had further respiratory distress and his steroids were increased to full burst. He ultimately decided to be DNR/DNI and came to the understanding that he wasn't going to get better; the patient decided to become CMO and was discharged to home hospice after discussing with Palliative Care in-house. - Continue long steroid taper at home (Prednisone 60mg X 7 days, 40mg X 7 days, 20 mg X7 days, 10mg X 7 days, off) - Continue supplemental oxygen, albuterol and ipratropium nebs - Continue MS contin and morphine liquid PRN for air hunger, shortness of breath - Continue lorazepam PRN for air hunger, shortness of breath, anxiety . # HIV: Down trending CD4 count, ?due to acute illness. Continued abacavir, lamivudine, fosamprenavir, and atazanavir. Continued Bactrim SS daily. Patient does have history of Bactrim needing to be held in [10/2153] for bone marrow suppression. The need for ongoing HAART medication and PCP prophylaxis was discussed with the patient. It was felt that he likely will not succumb to HIV/AIDS or an opportunistic infection before he succumbs to his end-stage COPD. However, taking these medications are not a hardship for the patient and he would prefer not to risk increasing HIV viral load and chance of opportunistic infection, especially in the setting of ongoing steroids. - The patient will be discharged home on hospice with continuation of his HAART medications and Bactrim PCP [Name Initial (PRE) 1102]. . # DVT: LENI the day prior to admission as outpatient was negative for DVT. Patient has been therapeutic and followed by [Hospital3 ] here at [Company 191]. He missed several doses of Coumadin in the settting of being on Bipap and developed a subtherapeutic INR. He was bridged with Lovenox. Anticoagulation held [4-13] for concern for GIB but coumadin was resumed when hct was stable for 24 hrs. Upon discharge home with hospice, however, anticoagulation was discussed with the patient. As he had a DVT in [2152-3-17] and ultimately completed treatment but was continued given his sedentary/immobile nature, the indication for ongoing anticoagulation and risk of DVT/PE is not high. - Given this information, the patient chose to be discharged off of coumadin. His primary care provider and the [Name9 (PRE) 191] anticoagulation nurses were informed of his decision, and the fact that he no longer needs INR checks. . #GIB: Patient noted to have guaic positive stool. T+S sent, PPI started, PICC placed, transfused 1 unit of blood but did not bump appropriately, so given 2nd unit. Hct then increased appropriately and remained stable. - PPI was stopped given the absence of frank melena on discharge and to minimize medications for hospice. . # Multifocal atrial tachycardia: Seen in the ED during patient's hospitalization [2154-3-28]. Patient was started on diltiazem in this setting but did not have MAT last admission either. The patient can continue on home diltiazem on discharge to prevent discomfort from breakthrough tachycardia. . # Anemia: Slightly lower than baseline Hct close to 30. Normocytic and previously thought due to chronic disease. HAART medications may be contributing to marrow suppression. In addition, pt noted to have guaic positive stools which are discussed above. . # Hypertension: Stable, mildly hypertensive, continued [Last Name (un) ] diltiazem and doxazosin. -- doxazosin was stopped on discharge for hospice to streamline medications. . # Osteoporosis: On Calcium and Vitamin D. - These medications were stopped on discharge to streamline medications. . # GERD: Admitted on famotidine. Stable, started on PPI as above while intubated as famotidine can also interact with HIV medications; also in setting of guaiac positive stools per above. - Famotidine was stopped on discharge to streamline medications. . # Other transitional issues: - Continue home O2 as prescribed - Oral suction as prescribed - Maintain PICC with appropriate heparin flushes as a provision for morphine infusion if patient's air hunger is refractory to PO morphine elixir and he requires IV morphine Medications on Admission: * Atazanavir 400mg daily * Fosamprenavir 1400mg twice daily * Aspirin 325mg daily * Abacavir 600mg daily * Lamivudine 300mg daily * Albuterol nebs every 2 hours PRN SOB, wheezing * Ipratropium nebs every 6 hours * Warfarin 3mg daily six times weekly, 2mg on Friday * Doxazosin 2mg qHS * Diltiazem 30mg three times daily * Famotidine 20mg daily * Bactrim 400-80 daily Discharge Medications: 1. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day) as needed for constipation. 5. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours: Standing. Disp:30 nebs Refills:2 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezing, shortness of breath. 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours): standing. Disp:30 nebs Refills:2 11. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): x7days, 2 tablets daily X7d, 1 tab daily X 7d, half tab daily X 7d, then off. Disp:46 Tablet(s) Refills:0 12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for shortness of breath, air hungry, anxiety. Disp:60 Tablet(s) Refills:0 13. MS Contin 15 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO every eight (8) hours. Disp:90 Tablet Extended Release(s) Refills:2 14. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Ten (10) mg PO q2h as needed for shortness of breath, air hunger, pain. Disp:500 mL Refills:2 15. Supplemental oxygen Sig: 1-5 liters once a day: via nasal cannula, titrate to comfort PRN. Disp:1 tank Refills:2 16. Admit to [Hospital 2188] Sig: One (1) once a day. Disp:1 unit Refills:2 17. Maintain PICC at home Maintain PICC at home with hospice for use with morphine infusion if need for SOB, air hunger 18. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. Disp:30 ML(s) Refills:2 19. Oral suction As needed for secretions 20. Supplemental Home Oxygen Oxygen 5-10L as needed Discharge Disposition: Home With Service Facility: [Location (un) ] Discharge Diagnosis: Primary: COPD exacerbation Secondary: HIV, prior DVT on anticoagulation, chronic lower back pain, anemia of chronic disease, osteoporosis 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 with difficulty breathing. You were found to be having a COPD exacerbation. You were treated with steroids (oral and intravenous), antibiotics, nebulizers. You were also put on a breathing machine called BiPap to make it easier for you to breath. With your very sick lungs, you did become very tired at one point, and were intubated to use a machine to help you breath. Once you were extubated, we discussed your prognosis and the severity of your condition with you. You made the decision to change your code status to Do Not Resuscitate/Do Not Intubate. The goals of your medical care was made for comfort. . You are being discharged home with hospice, who will oversee your care going forward and address all of your symptoms with the goal of making you comfortable. . It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> Stop Coumadin and INR checks --> Stop Aspirin --> Stop Doxazosin --> Stop Famotidine --> Continue prednisone 60mg daily X 1 weeks, with a slow taper --> Start Lorazepam as needed for shortness of breath, air hunger, anxiety --> Start MS Contin 30mg three times daily for air hunger --> Start Morphine liquid 5-10mL every 2 hours as needed for air hunger --> Start Prednisone and take as directed according to the prescribed taper --> Continue Albuterol nebs every 4 hours standing --> Continue Albuterol nebs every 2 hours as needed for shortness of breath, wheeze --> Continue Ipratropium nebs every 6 hours standing . Contact your hospice organization if you need help controlling your symtoms. Followup Instructions: Please feel free to contact your hospice nurses and physicians with any questions or concerns. . Also feel free to contact Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], your new primary care doctor, at [Hospital3 ] at [Telephone/Fax (1) 250]. . Department: [Hospital3 249] When: WEDNESDAY [2154-4-24] at 10:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [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: [Hospital3 249] When: WEDNESDAY [2154-5-22] at 12:00 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	Admission Date: <Date>2018-12-1</Date> Discharge Date: <Date>1911-12-6</Date> Date of Birth: <Date>2005-7-29</Date> Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Marlon</Name> Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: BiPap Intubation, extubation (<Date>1938-2-22</Date>) History of Present Illness: 69 year old male with history of HIV (CD4 116 <Date>1961-11-11</Date>), COPD (2-4L at home), DVT on coumadin, hypertension, chronic lower back <Name>Cobbs</Name>, osteoporosis who presents with respiratory distress. The patient had been recently admitted 5/13-16/<Year>1938</Year> for COPD exacerbation and treated with nebs, azithromycin, prednisone (slow taper). The patient presented to the ED on <Date>1992-9-4</Date> for dyspnea but left AMA before admission. He was sent to the ED on <Date>1961-11-11</Date> but left AMA again, with prednisone and azithromycin prescriptions which he never filled. He had seen Dr. <Name>Pegram</Name> in pulmonary clinic yesterday and had been non-compliant with prednisone taper. He endorsed "exhaustion" at the appointment but was stable 93% on 3.5L nasal cannula. The patient had also been at <Hospital>Alexander Ltd Hospital</Hospital> Clinic with Dr. <Name>Ngo</Name> prior to Pulmonary appointment. . The patient re-presented to the ED today with worsening dyspnea and was brought in by EMS in respiratory distress (enroute CO2 50). He responded to nebulizers enroute and arrived looking very uncomfortable, using accessory muscles. He was tight on pulmonary exam with minimal breath sounds and speaking few word sentences. The patient was started on BiPap (50%, PSV 15, PEEP 5), which he tolerated well. He was briefly weaned off to 4L NC but decompensated, tripoding despite Methylprednisolone 125mg IV X1, Azithromycin 500mg, more nebulizers and ativan 2mg IV. . ROS: Patient denies fevers/chills, nausea/vomiting, myalgias, changes in bowel movement or urination. Past Medical History: * HIV (diagnosed <Year>1938</Year>, s/p multiple HAART regimens, no history of opportunistic infections, CD4 nadir <Date>1961-11-11</Date> 116) * COPD (chornic O2 therapy at home 2-4L PRN, intubated recently at <Hospital>Cannon, Morris and Vega Medical Center</Hospital> and was DNR/DNI in the past) * DVT (left lower extremity, <Date>1900-8-13</Date>; still on Coumadin therapy - for sedentary lifestyle) * h/o Rectal bleeding * Chronic lower back pain s/p numerous back surgeries * Hypertension * Basilar aneurysm s/p clipping by Dr. <Name>Grier</Name> (<Year>1938</Year>) * h/o substance abuse with cocaine * Anemia of chronic disease * Osteoporosis * s/p ileocecetomy for ?cancer. SBO in <Year>1938</Year> with lysis of adhesions Social History: Denies alcohol, smoking or illicit drugs (since <Year>1938</Year>). Previous 80 pack year smoker. Lives alone, uses wheelchair. Family History: Hypertension and throat cancer in brother (smoker) Physical Exam: Temp: 97.0 BP: 132/80 HR: 89 RR: 18 O2sat 100% on Bipap (15/5, 50%) GEN: Pleasant, comfortable, NAD, mildly anorexic HEENT: PERRL, EOMI, anicteric, MMM, RESP: CTA b/l with good air movement throughout, ?prolonged expiratory phase, barrel chested with increased AP diameter CV: Regular rate, rhythm; S1 and S2 wnl, no murmurs/gallops/rubs ABD: Nontender, nondistended, +BS, soft EXT: No cyanosis/ecchymosis, <Date>1-12</Date>+ bilateral lower extremity edema (symmetric) SKIN: No rashes/no jaundice/no splinters NEURO: AAOx3. CN 2-12 intact. Strength and sensation intact. . Discharge Exam: No vitals (cmo) Gen: Cachectic in NAD, no jaundice, no palor HEENT: NCAT PERRL MMMs OP clear Neck: No JVP elevation supple Pulm: Very poor air movement wheezes throughout; no rhonci no crackles CV: RRR nml S1 S2 no m/r/g Ab: +BS NTND Ext: No edema Neuro: Grossly intact AO x 3 responding appropriately to questions Pertinent Results: <Date>2018-12-1</Date> 06:47PM O2-100 PO2-244* PCO2-53* PH-7.44 TOTAL CO2-37* BASE XS-10 AADO2-426 REQ O2-73 <Date>2018-12-1</Date> 06:13PM LACTATE-1.9 . CXR <Date>5-23</Date>: Patchy opacity in left lung base, similar to the prior study, which remains concerning for infection. Severe emphysema. . CXR <Date>12-12</Date>: An endotracheal tube lies at the level of the clavicular heads, appropriately positioned. A nasogastric tube courses into the stomach. Severe emphysema is noted. The cardiomediastinal silhouette is stable. There are small bilateral pleural effusions. The left lower lobe opacity has mildly improved and reflects resolving infection. No new focal consolidation is appreciated. . Discharge Labs: None Brief Hospital Course: 69 year old male with history of HIV (CD4 116 <Date>1961-11-11</Date>), COPD (2-4L at home), DVT on coumadin, hypertension, chronic lower back <Name>Cobbs</Name>, osteoporosis who presents with respiratory distress. . # Respiratory Distress: Most likely due to ongoing COPD exacerbation. Trigger unclear given lack of pneumonia on initial CXR, no fevers/chills, productive cough. Patient has been non-compliant with medications, however, since discharge; this includes prednisone and antibiotics. ?compliance with nebulizers and has supplemental O2 at home. The patient has had CTA recently to rule out pulmonary emboli given ongoing dyspnea despite therapy. He was treated with azithromycin for 5 days and methylprednisolone. He intermittently required BiPap. A plan was made to use bipap at night once the patient was able to leave the ICU. However on the morning of <Date>12-12</Date> patient was anxious, tachypneic and desatted and required intubation. The patient was extubated on <Date>11-16</Date>. He did well overnight but subsequently had further respiratory distress and his steroids were increased to full burst. He ultimately decided to be DNR/DNI and came to the understanding that he wasn't going to get better; the patient decided to become CMO and was discharged to home hospice after discussing with Palliative Care in-house. - Continue long steroid taper at home (Prednisone 60mg X 7 days, 40mg X 7 days, 20 mg X7 days, 10mg X 7 days, off) - Continue supplemental oxygen, albuterol and ipratropium nebs - Continue MS contin and morphine liquid PRN for air hunger, shortness of breath - Continue lorazepam PRN for air hunger, shortness of breath, anxiety . # HIV: Down trending CD4 count, ?due to acute illness. Continued abacavir, lamivudine, fosamprenavir, and atazanavir. Continued Bactrim SS daily. Patient does have history of Bactrim needing to be held in <Date>2/1939</Date> for bone marrow suppression. The need for ongoing HAART medication and PCP prophylaxis was discussed with the patient. It was felt that he likely will not succumb to HIV/AIDS or an opportunistic infection before he succumbs to his end-stage COPD. However, taking these medications are not a hardship for the patient and he would prefer not to risk increasing HIV viral load and chance of opportunistic infection, especially in the setting of ongoing steroids. - The patient will be discharged home on hospice with continuation of his HAART medications and Bactrim PCP <Name>Brenda Blanks</Name>. . # DVT: LENI the day prior to admission as outpatient was negative for DVT. Patient has been therapeutic and followed by <Hospital>Lawrence-Trujillo Health System</Hospital> here at <Company>Monroe, Stewart and Alvarado</Company>. He missed several doses of Coumadin in the settting of being on Bipap and developed a subtherapeutic INR. He was bridged with Lovenox. Anticoagulation held <Date>12-12</Date> for concern for GIB but coumadin was resumed when hct was stable for 24 hrs. Upon discharge home with hospice, however, anticoagulation was discussed with the patient. As he had a DVT in <Date>1900-8-13</Date> and ultimately completed treatment but was continued given his sedentary/immobile nature, the indication for ongoing anticoagulation and risk of DVT/PE is not high. - Given this information, the patient chose to be discharged off of coumadin. His primary care provider and the <Name>Alexander Broadnax</Name> anticoagulation nurses were informed of his decision, and the fact that he no longer needs INR checks. . #GIB: Patient noted to have guaic positive stool. T+S sent, PPI started, PICC placed, transfused 1 unit of blood but did not bump appropriately, so given 2nd unit. Hct then increased appropriately and remained stable. - PPI was stopped given the absence of frank melena on discharge and to minimize medications for hospice. . # Multifocal atrial tachycardia: Seen in the ED during patient's hospitalization <Date>1973-4-8</Date>. Patient was started on diltiazem in this setting but did not have MAT last admission either. The patient can continue on home diltiazem on discharge to prevent discomfort from breakthrough tachycardia. . # Anemia: Slightly lower than baseline Hct close to 30. Normocytic and previously thought due to chronic disease. HAART medications may be contributing to marrow suppression. In addition, pt noted to have guaic positive stools which are discussed above. . # Hypertension: Stable, mildly hypertensive, continued <Name>Kwan</Name> diltiazem and doxazosin. -- doxazosin was stopped on discharge for hospice to streamline medications. . # Osteoporosis: On Calcium and Vitamin D. - These medications were stopped on discharge to streamline medications. . # GERD: Admitted on famotidine. Stable, started on PPI as above while intubated as famotidine can also interact with HIV medications; also in setting of guaiac positive stools per above. - Famotidine was stopped on discharge to streamline medications. . # Other transitional issues: - Continue home O2 as prescribed - Oral suction as prescribed - Maintain PICC with appropriate heparin flushes as a provision for morphine infusion if patient's air hunger is refractory to PO morphine elixir and he requires IV morphine Medications on Admission: * Atazanavir 400mg daily * Fosamprenavir 1400mg twice daily * Aspirin 325mg daily * Abacavir 600mg daily * Lamivudine 300mg daily * Albuterol nebs every 2 hours PRN SOB, wheezing * Ipratropium nebs every 6 hours * Warfarin 3mg daily six times weekly, 2mg on Friday * Doxazosin 2mg qHS * Diltiazem 30mg three times daily * Famotidine 20mg daily * Bactrim 400-80 daily Discharge Medications: 1. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day) as needed for constipation. 5. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours: Standing. Disp:30 nebs Refills:2 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezing, shortness of breath. 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours): standing. Disp:30 nebs Refills:2 11. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): x7days, 2 tablets daily X7d, 1 tab daily X 7d, half tab daily X 7d, then off. Disp:46 Tablet(s) Refills:0 12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for shortness of breath, air hungry, anxiety. Disp:60 Tablet(s) Refills:0 13. MS Contin 15 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO every eight (8) hours. Disp:90 Tablet Extended Release(s) Refills:2 14. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Ten (10) mg PO q2h as needed for shortness of breath, air hunger, pain. Disp:500 mL Refills:2 15. Supplemental oxygen Sig: 1-5 liters once a day: via nasal cannula, titrate to comfort PRN. Disp:1 tank Refills:2 16. Admit to <Hospital>Schmitt PLC Clinic</Hospital> Sig: One (1) once a day. Disp:1 unit Refills:2 17. Maintain PICC at home Maintain PICC at home with hospice for use with morphine infusion if need for SOB, air hunger 18. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. Disp:30 ML(s) Refills:2 19. Oral suction As needed for secretions 20. Supplemental Home Oxygen Oxygen 5-10L as needed Discharge Disposition: Home With Service Facility: <Location>6947 Andrew Spring Suite 109 East Marcushaven, IL 21534</Location> Discharge Diagnosis: Primary: COPD exacerbation Secondary: HIV, prior DVT on anticoagulation, chronic lower back pain, anemia of chronic disease, osteoporosis 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 with difficulty breathing. You were found to be having a COPD exacerbation. You were treated with steroids (oral and intravenous), antibiotics, nebulizers. You were also put on a breathing machine called BiPap to make it easier for you to breath. With your very sick lungs, you did become very tired at one point, and were intubated to use a machine to help you breath. Once you were extubated, we discussed your prognosis and the severity of your condition with you. You made the decision to change your code status to Do Not Resuscitate/Do Not Intubate. The goals of your medical care was made for comfort. . You are being discharged home with hospice, who will oversee your care going forward and address all of your symptoms with the goal of making you comfortable. . It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> Stop Coumadin and INR checks --> Stop Aspirin --> Stop Doxazosin --> Stop Famotidine --> Continue prednisone 60mg daily X 1 weeks, with a slow taper --> Start Lorazepam as needed for shortness of breath, air hunger, anxiety --> Start MS Contin 30mg three times daily for air hunger --> Start Morphine liquid 5-10mL every 2 hours as needed for air hunger --> Start Prednisone and take as directed according to the prescribed taper --> Continue Albuterol nebs every 4 hours standing --> Continue Albuterol nebs every 2 hours as needed for shortness of breath, wheeze --> Continue Ipratropium nebs every 6 hours standing . Contact your hospice organization if you need help controlling your symtoms. Followup Instructions: Please feel free to contact your hospice nurses and physicians with any questions or concerns. . Also feel free to contact Dr. <Name>Jessie</Name> <Name>Pleasant</Name>, your new primary care doctor, at <Hospital>Lawrence-Trujillo Health System</Hospital> at <Telephone>736-710-1647</Telephone>. . Department: <Hospital>Archer-Maxwell Clinic</Hospital> When: WEDNESDAY <Date>1905-8-28</Date> at 10:00 AM With: <Name>Keith</Name> <Name>Pleasant</Name> <Telephone>736-710-1647</Telephone> Building: SC <Hospital>Riley, Donovan and Taylor Medical Center</Hospital> Clinical Ctr <Location>03997 Timothy Fall Beckerborough, NY 17104</Location> Campus: EAST Best Parking: <Hospital>Riley, Donovan and Taylor Medical Center</Hospital> Garage Department: <Hospital>Archer-Maxwell Clinic</Hospital> When: WEDNESDAY <Date>2006-9-4</Date> at 12:00 PM With: <Name>Keith</Name> <Name>Pleasant</Name> <Telephone>736-710-1647</Telephone> Building: SC <Hospital>Riley, Donovan and Taylor Medical Center</Hospital> Clinical Ctr <Location>03997 Timothy Fall Beckerborough, NY 17104</Location> Campus: EAST Best Parking: <Hospital>Riley, Donovan and Taylor Medical Center</Hospital> 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Date: 2018-12-1 Discharge Date: 1911-12-6 Date of Birth: 2005-7-29 Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:Marlon Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: BiPap Intubation, extubation (1938-2-22) History of Present Illness: 69 year old male with history of HIV (CD4 116 1961-11-11), COPD (2-4L at home), DVT on coumadin, hypertension, chronic lower back Cobbs, osteoporosis who presents with respiratory distress. The patient had been recently admitted 5/13-16/1938 for COPD exacerbation and treated with nebs, azithromycin, prednisone (slow taper). The patient presented to the ED on 1992-9-4 for dyspnea but left AMA before admission. He was sent to the ED on 1961-11-11 but left AMA again, with prednisone and azithromycin prescriptions which he never filled. He had seen Dr. Pegram in pulmonary clinic yesterday and had been non-compliant with prednisone taper. He endorsed "exhaustion" at the appointment but was stable 93% on 3.5L nasal cannula. The patient had also been at Alexander Ltd Hospital Clinic with Dr. Ngo prior to Pulmonary appointment. . The patient re-presented to the ED today with worsening dyspnea and was brought in by EMS in respiratory distress (enroute CO2 50). He responded to nebulizers enroute and arrived looking very uncomfortable, using accessory muscles. He was tight on pulmonary exam with minimal breath sounds and speaking few word sentences. The patient was started on BiPap (50%, PSV 15, PEEP 5), which he tolerated well. He was briefly weaned off to 4L NC but decompensated, tripoding despite Methylprednisolone 125mg IV X1, Azithromycin 500mg, more nebulizers and ativan 2mg IV. . ROS: Patient denies fevers/chills, nausea/vomiting, myalgias, changes in bowel movement or urination. Past Medical History: * HIV (diagnosed 1938, s/p multiple HAART regimens, no history of opportunistic infections, CD4 nadir 1961-11-11 116) * COPD (chornic O2 therapy at home 2-4L PRN, intubated recently at Cannon, Morris and Vega Medical Center and was DNR/DNI in the past) * DVT (left lower extremity, 1900-8-13; still on Coumadin therapy - for sedentary lifestyle) * h/o Rectal bleeding * Chronic lower back pain s/p numerous back surgeries * Hypertension * Basilar aneurysm s/p clipping by Dr. Grier (1938) * h/o substance abuse with cocaine * Anemia of chronic disease * Osteoporosis * s/p ileocecetomy for ?cancer. SBO in 1938 with lysis of adhesions Social History: Denies alcohol, smoking or illicit drugs (since 1938). Previous 80 pack year smoker. Lives alone, uses wheelchair. Family History: Hypertension and throat cancer in brother (smoker) Physical Exam: Temp: 97.0 BP: 132/80 HR: 89 RR: 18 O2sat 100% on Bipap (15/5, 50%) GEN: Pleasant, comfortable, NAD, mildly anorexic HEENT: PERRL, EOMI, anicteric, MMM, RESP: CTA b/l with good air movement throughout, ?prolonged expiratory phase, barrel chested with increased AP diameter CV: Regular rate, rhythm; S1 and S2 wnl, no murmurs/gallops/rubs ABD: Nontender, nondistended, +BS, soft EXT: No cyanosis/ecchymosis, 1-12+ bilateral lower extremity edema (symmetric) SKIN: No rashes/no jaundice/no splinters NEURO: AAOx3. CN 2-12 intact. Strength and sensation intact. . Discharge Exam: No vitals (cmo) Gen: Cachectic in NAD, no jaundice, no palor HEENT: NCAT PERRL MMMs OP clear Neck: No JVP elevation supple Pulm: Very poor air movement wheezes throughout; no rhonci no crackles CV: RRR nml S1 S2 no m/r/g Ab: +BS NTND Ext: No edema Neuro: Grossly intact AO x 3 responding appropriately to questions Pertinent Results: 2018-12-1 06:47PM O2-100 PO2-244* PCO2-53* PH-7.44 TOTAL CO2-37* BASE XS-10 AADO2-426 REQ O2-73 2018-12-1 06:13PM LACTATE-1.9 . CXR 5-23: Patchy opacity in left lung base, similar to the prior study, which remains concerning for infection. Severe emphysema. . CXR 12-12: An endotracheal tube lies at the level of the clavicular heads, appropriately positioned. A nasogastric tube courses into the stomach. Severe emphysema is noted. The cardiomediastinal silhouette is stable. There are small bilateral pleural effusions. The left lower lobe opacity has mildly improved and reflects resolving infection. No new focal consolidation is appreciated. . Discharge Labs: None Brief Hospital Course: 69 year old male with history of HIV (CD4 116 1961-11-11), COPD (2-4L at home), DVT on coumadin, hypertension, chronic lower back Cobbs, osteoporosis who presents with respiratory distress. . # Respiratory Distress: Most likely due to ongoing COPD exacerbation. Trigger unclear given lack of pneumonia on initial CXR, no fevers/chills, productive cough. Patient has been non-compliant with medications, however, since discharge; this includes prednisone and antibiotics. ?compliance with nebulizers and has supplemental O2 at home. The patient has had CTA recently to rule out pulmonary emboli given ongoing dyspnea despite therapy. He was treated with azithromycin for 5 days and methylprednisolone. He intermittently required BiPap. A plan was made to use bipap at night once the patient was able to leave the ICU. However on the morning of 12-12 patient was anxious, tachypneic and desatted and required intubation. The patient was extubated on 11-16. He did well overnight but subsequently had further respiratory distress and his steroids were increased to full burst. He ultimately decided to be DNR/DNI and came to the understanding that he wasn't going to get better; the patient decided to become CMO and was discharged to home hospice after discussing with Palliative Care in-house. - Continue long steroid taper at home (Prednisone 60mg X 7 days, 40mg X 7 days, 20 mg X7 days, 10mg X 7 days, off) - Continue supplemental oxygen, albuterol and ipratropium nebs - Continue MS contin and morphine liquid PRN for air hunger, shortness of breath - Continue lorazepam PRN for air hunger, shortness of breath, anxiety . # HIV: Down trending CD4 count, ?due to acute illness. Continued abacavir, lamivudine, fosamprenavir, and atazanavir. Continued Bactrim SS daily. Patient does have history of Bactrim needing to be held in 2/1939 for bone marrow suppression. The need for ongoing HAART medication and PCP prophylaxis was discussed with the patient. It was felt that he likely will not succumb to HIV/AIDS or an opportunistic infection before he succumbs to his end-stage COPD. However, taking these medications are not a hardship for the patient and he would prefer not to risk increasing HIV viral load and chance of opportunistic infection, especially in the setting of ongoing steroids. - The patient will be discharged home on hospice with continuation of his HAART medications and Bactrim PCP Brenda Blanks. . # DVT: LENI the day prior to admission as outpatient was negative for DVT. Patient has been therapeutic and followed by Lawrence-Trujillo Health System here at Monroe, Stewart and Alvarado. He missed several doses of Coumadin in the settting of being on Bipap and developed a subtherapeutic INR. He was bridged with Lovenox. Anticoagulation held 12-12 for concern for GIB but coumadin was resumed when hct was stable for 24 hrs. Upon discharge home with hospice, however, anticoagulation was discussed with the patient. As he had a DVT in 1900-8-13 and ultimately completed treatment but was continued given his sedentary/immobile nature, the indication for ongoing anticoagulation and risk of DVT/PE is not high. - Given this information, the patient chose to be discharged off of coumadin. His primary care provider and the Alexander Broadnax anticoagulation nurses were informed of his decision, and the fact that he no longer needs INR checks. . #GIB: Patient noted to have guaic positive stool. T+S sent, PPI started, PICC placed, transfused 1 unit of blood but did not bump appropriately, so given 2nd unit. Hct then increased appropriately and remained stable. - PPI was stopped given the absence of frank melena on discharge and to minimize medications for hospice. . # Multifocal atrial tachycardia: Seen in the ED during patient's hospitalization 1973-4-8. Patient was started on diltiazem in this setting but did not have MAT last admission either. The patient can continue on home diltiazem on discharge to prevent discomfort from breakthrough tachycardia. . # Anemia: Slightly lower than baseline Hct close to 30. Normocytic and previously thought due to chronic disease. HAART medications may be contributing to marrow suppression. In addition, pt noted to have guaic positive stools which are discussed above. . # Hypertension: Stable, mildly hypertensive, continued Kwan diltiazem and doxazosin. -- doxazosin was stopped on discharge for hospice to streamline medications. . # Osteoporosis: On Calcium and Vitamin D. - These medications were stopped on discharge to streamline medications. . # GERD: Admitted on famotidine. Stable, started on PPI as above while intubated as famotidine can also interact with HIV medications; also in setting of guaiac positive stools per above. - Famotidine was stopped on discharge to streamline medications. . # Other transitional issues: - Continue home O2 as prescribed - Oral suction as prescribed - Maintain PICC with appropriate heparin flushes as a provision for morphine infusion if patient's air hunger is refractory to PO morphine elixir and he requires IV morphine Medications on Admission: * Atazanavir 400mg daily * Fosamprenavir 1400mg twice daily * Aspirin 325mg daily * Abacavir 600mg daily * Lamivudine 300mg daily * Albuterol nebs every 2 hours PRN SOB, wheezing * Ipratropium nebs every 6 hours * Warfarin 3mg daily six times weekly, 2mg on Friday * Doxazosin 2mg qHS * Diltiazem 30mg three times daily * Famotidine 20mg daily * Bactrim 400-80 daily Discharge Medications: 1. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day) as needed for constipation. 5. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours: Standing. Disp:30 nebs Refills:2 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezing, shortness of breath. 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours): standing. Disp:30 nebs Refills:2 11. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): x7days, 2 tablets daily X7d, 1 tab daily X 7d, half tab daily X 7d, then off. Disp:46 Tablet(s) Refills:0 12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for shortness of breath, air hungry, anxiety. Disp:60 Tablet(s) Refills:0 13. MS Contin 15 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO every eight (8) hours. Disp:90 Tablet Extended Release(s) Refills:2 14. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Ten (10) mg PO q2h as needed for shortness of breath, air hunger, pain. Disp:500 mL Refills:2 15. Supplemental oxygen Sig: 1-5 liters once a day: via nasal cannula, titrate to comfort PRN. Disp:1 tank Refills:2 16. Admit to Schmitt PLC Clinic Sig: One (1) once a day. Disp:1 unit Refills:2 17. Maintain PICC at home Maintain PICC at home with hospice for use with morphine infusion if need for SOB, air hunger 18. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. Disp:30 ML(s) Refills:2 19. Oral suction As needed for secretions 20. Supplemental Home Oxygen Oxygen 5-10L as needed Discharge Disposition: Home With Service Facility: 6947 Andrew Spring Suite 109 East Marcushaven, IL 21534 Discharge Diagnosis: Primary: COPD exacerbation Secondary: HIV, prior DVT on anticoagulation, chronic lower back pain, anemia of chronic disease, osteoporosis 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 with difficulty breathing. You were found to be having a COPD exacerbation. You were treated with steroids (oral and intravenous), antibiotics, nebulizers. You were also put on a breathing machine called BiPap to make it easier for you to breath. With your very sick lungs, you did become very tired at one point, and were intubated to use a machine to help you breath. Once you were extubated, we discussed your prognosis and the severity of your condition with you. You made the decision to change your code status to Do Not Resuscitate/Do Not Intubate. The goals of your medical care was made for comfort. . You are being discharged home with hospice, who will oversee your care going forward and address all of your symptoms with the goal of making you comfortable. . It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> Stop Coumadin and INR checks --> Stop Aspirin --> Stop Doxazosin --> Stop Famotidine --> Continue prednisone 60mg daily X 1 weeks, with a slow taper --> Start Lorazepam as needed for shortness of breath, air hunger, anxiety --> Start MS Contin 30mg three times daily for air hunger --> Start Morphine liquid 5-10mL every 2 hours as needed for air hunger --> Start Prednisone and take as directed according to the prescribed taper --> Continue Albuterol nebs every 4 hours standing --> Continue Albuterol nebs every 2 hours as needed for shortness of breath, wheeze --> Continue Ipratropium nebs every 6 hours standing . Contact your hospice organization if you need help controlling your symtoms. Followup Instructions: Please feel free to contact your hospice nurses and physicians with any questions or concerns. . Also feel free to contact Dr. Jessie Pleasant, your new primary care doctor, at Lawrence-Trujillo Health System at 736-710-1647. . Department: Archer-Maxwell Clinic When: WEDNESDAY 1905-8-28 at 10:00 AM With: Keith Pleasant 736-710-1647 Building: SC Riley, Donovan and Taylor Medical Center Clinical Ctr 03997 Timothy Fall Beckerborough, NY 17104 Campus: EAST Best Parking: Riley, Donovan and Taylor Medical Center Garage Department: Archer-Maxwell Clinic When: WEDNESDAY 2006-9-4 at 12:00 PM With: Keith Pleasant 736-710-1647 Building: SC Riley, Donovan and Taylor Medical Center Clinical Ctr 03997 Timothy Fall Beckerborough, NY 17104 Campus: EAST Best Parking: Riley, Donovan and Taylor Medical Center Garage	['Admission Date: 2018-12-1 Discharge Date: 1911-12-6\n\nDate of Birth: 2005-7-29 Sex: M\n\nService: MEDICINE\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Marlon\nChief Complaint:\nRespiratory distress\n\nMajor Surgical or Invasive Procedure:\nBiPap\nIntubation, extubation (1938-2-22)\n\n\nHistory of Present Illness:\n69 year old male with history of HIV (CD4 116 1961-11-11), COPD\n(2-4L at home), DVT on coumadin, hypertension, chronic lower\nback Cobbs, osteoporosis who presents with respiratory distress.\nThe patient had been recently admitted 5/13-16/1938 for COPD\nexacerbation and treated with nebs, azithromycin, prednisone\n(slow taper). The patient presented to the ED on 1992-9-4 for\ndyspnea but left AMA before admission. He was sent to the ED on\n1961-11-11 but left AMA again, with prednisone and azithromycin\nprescriptions which he never filled.', ' He had seen Dr. Pegram in\npulmonary clinic yesterday and had been non-compliant with\nprednisone taper. He endorsed "exhaustion" at the appointment\nbut was stable 93% on 3.5L nasal cannula. The patient had also\nbeen at Alexander Ltd Hospital Clinic with Dr. Ngo prior to Pulmonary\nappointment.\n.\nThe patient re-presented to the ED today with worsening dyspnea\nand was brought in by EMS in respiratory distress (enroute CO2\n50). He responded to nebulizers enroute and arrived looking very\nuncomfortable, using accessory muscles. He was tight on\npulmonary exam with minimal breath sounds and speaking few word\nsentences. The patient was started on BiPap (50%, PSV 15, PEEP\n5), which he tolerated well. He was briefly weaned off to 4L NC\nbut decompensated, tripoding despite Methylprednisolone 125mg IV\nX1, Azithromycin 500mg, more nebulizers and ativan 2mg IV.', '\n.\nROS: Patient denies fevers/chills, nausea/vomiting, myalgias,\nchanges in bowel movement or urination.\n\n\nPast Medical History:\n* HIV (diagnosed 1938, s/p multiple HAART regimens, no history\nof opportunistic infections, CD4 nadir 1961-11-11 116)\n* COPD (chornic O2 therapy at home 2-4L PRN, intubated recently\nat Cannon, Morris and Vega Medical Center and was DNR/DNI in the past)\n* DVT (left lower extremity, 1900-8-13; still on Coumadin therapy\n- for sedentary lifestyle)\n* h/o Rectal bleeding\n* Chronic lower back pain s/p numerous back surgeries\n* Hypertension\n* Basilar aneurysm s/p clipping by Dr. Grier (1938)\n* h/o substance abuse with cocaine\n* Anemia of chronic disease\n* Osteoporosis\n* s/p ileocecetomy for ?cancer. SBO in 1938 with lysis of\nadhesions\n\n\nSocial History:\nDenies alcohol, smoking or illicit drugs (since 1938).', ' Previous\n80 pack year smoker. Lives alone, uses wheelchair.\n\n\nFamily History:\nHypertension and throat cancer in brother (smoker)\n\n\nPhysical Exam:\nTemp: 97.0 BP: 132/80 HR: 89 RR: 18 O2sat 100% on Bipap (15/5,\n50%)\nGEN: Pleasant, comfortable, NAD, mildly anorexic\nHEENT: PERRL, EOMI, anicteric, MMM,\nRESP: CTA b/l with good air movement throughout, ?prolonged\nexpiratory phase, barrel chested with increased AP diameter\nCV: Regular rate, rhythm; S1 and S2 wnl, no murmurs/gallops/rubs\n\nABD: Nontender, nondistended, +BS, soft\nEXT: No cyanosis/ecchymosis, 1-12+ bilateral lower extremity\nedema (symmetric)\nSKIN: No rashes/no jaundice/no splinters\nNEURO: AAOx3. CN 2-12 intact. Strength and sensation intact.\n.\nDischarge Exam:\nNo vitals (cmo)\nGen: Cachectic in NAD, no jaundice, no palor\nHEENT: NCAT PERRL MMMs OP clear\nNeck: No JVP elevation supple\nPulm: Very poor air movement wheezes throughout; no rhonci no\ncrackles\nCV: RRR nml S1 S2 no m/r/g\nAb: +BS NTND\nExt: No edema\nNeuro: Grossly intact AO x 3 responding appropriately to\nquestions\n\nPertinent Results:\n2018-12-1 06:47PM O2-100 PO2-244* PCO2-53* PH-7.', '44 TOTAL\nCO2-37* BASE XS-10 AADO2-426 REQ O2-73\n2018-12-1 06:13PM LACTATE-1.9\n.\nCXR 5-23:\nPatchy opacity in left lung base, similar to the prior study,\nwhich remains concerning for infection. Severe emphysema.\n.\nCXR 12-12:\nAn endotracheal tube lies at the level of the\nclavicular heads, appropriately positioned. A nasogastric tube\ncourses into the stomach. Severe emphysema is noted. The\ncardiomediastinal silhouette is stable. There are small\nbilateral pleural effusions. The left lower lobe opacity has\nmildly improved and reflects resolving infection. No new focal\nconsolidation is appreciated.\n.\nDischarge Labs:\nNone\n\nBrief Hospital Course:\n69 year old male with history of HIV (CD4 116 1961-11-11), COPD\n(2-4L at home), DVT on coumadin, hypertension, chronic lower\nback Cobbs, osteoporosis who presents with respiratory distress.', '\n\n.\n# Respiratory Distress: Most likely due to ongoing COPD\nexacerbation. Trigger unclear given lack of pneumonia on initial\nCXR, no fevers/chills, productive cough. Patient has been\nnon-compliant with medications, however, since discharge; this\nincludes prednisone and antibiotics. ?compliance with nebulizers\nand has supplemental O2 at home. The patient has had CTA\nrecently to rule out pulmonary emboli given ongoing dyspnea\ndespite therapy. He was treated with azithromycin for 5 days and\nmethylprednisolone. He intermittently required BiPap. A plan was\nmade to use bipap at night once the patient was able to leave\nthe ICU. However on the morning of 12-12 patient was anxious,\ntachypneic and desatted and required intubation. The patient\nwas extubated on 11-16. He did well overnight but subsequently\nhad further respiratory distress and his steroids were increased\nto full burst.', " He ultimately decided to be DNR/DNI and came to\nthe understanding that he wasn't going to get better; the\npatient decided to become CMO and was discharged to home hospice\nafter discussing with Palliative Care in-house.\n- Continue long steroid taper at home (Prednisone 60mg X 7 days,\n40mg X 7 days, 20 mg X7 days, 10mg X 7 days, off)\n- Continue supplemental oxygen, albuterol and ipratropium nebs\n- Continue MS contin and morphine liquid PRN for air hunger,\nshortness of breath\n- Continue lorazepam PRN for air hunger, shortness of breath,\nanxiety\n.\n# HIV: Down trending CD4 count, ?due to acute illness. Continued\nabacavir, lamivudine, fosamprenavir, and atazanavir. Continued\nBactrim SS daily. Patient does have history of Bactrim needing\nto be held in 2/1939 for bone marrow suppression. The need for\nongoing HAART medication and PCP prophylaxis was discussed with\nthe patient.", ' It was felt that he likely will not succumb to\nHIV/AIDS or an opportunistic infection before he succumbs to his\nend-stage COPD. However, taking these medications are not a\nhardship for the patient and he would prefer not to risk\nincreasing HIV viral load and chance of opportunistic infection,\nespecially in the setting of ongoing steroids.\n- The patient will be discharged home on hospice with\ncontinuation of his HAART medications and Bactrim PCP\nBrenda Blanks.\n.\n# DVT: LENI the day prior to admission as outpatient was\nnegative for DVT. Patient has been therapeutic and followed by\nLawrence-Trujillo Health System here at Monroe, Stewart and Alvarado. He missed several doses of\nCoumadin in the settting of being on Bipap and developed a\nsubtherapeutic INR. He was bridged with Lovenox. Anticoagulation\nheld 12-12 for concern for GIB but coumadin was resumed when hct\nwas stable for 24 hrs.', ' Upon discharge home with hospice,\nhowever, anticoagulation was discussed with the patient. As he\nhad a DVT in 1900-8-13 and ultimately completed treatment but was\ncontinued given his sedentary/immobile nature, the indication\nfor ongoing anticoagulation and risk of DVT/PE is not high.\n- Given this information, the patient chose to be discharged off\nof coumadin. His primary care provider and the Alexander Broadnax\nanticoagulation nurses were informed of his decision, and the\nfact that he no longer needs INR checks.\n.\n#GIB: Patient noted to have guaic positive stool. T+S sent, PPI\nstarted, PICC placed, transfused 1 unit of blood but did not\nbump appropriately, so given 2nd unit. Hct then increased\nappropriately and remained stable.\n- PPI was stopped given the absence of frank melena on discharge\nand to minimize medications for hospice.', "\n.\n# Multifocal atrial tachycardia: Seen in the ED during patient's\nhospitalization 1973-4-8. Patient was started on diltiazem in\nthis setting but did not have MAT last admission either. The\npatient can continue on home diltiazem on discharge to prevent\ndiscomfort from breakthrough tachycardia.\n.\n# Anemia: Slightly lower than baseline Hct close to 30.\nNormocytic and previously thought due to chronic disease. HAART\nmedications may be contributing to marrow suppression. In\naddition, pt noted to have guaic positive stools which are\ndiscussed above.\n.\n# Hypertension: Stable, mildly hypertensive, continued Kwan\ndiltiazem and doxazosin. -- doxazosin was stopped on discharge\nfor hospice to streamline medications.\n.\n# Osteoporosis: On Calcium and Vitamin D.\n- These medications were stopped on discharge to streamline\nmedications.", "\n.\n# GERD: Admitted on famotidine. Stable, started on PPI as above\nwhile intubated as famotidine can also interact with HIV\nmedications; also in setting of guaiac positive stools per\nabove.\n- Famotidine was stopped on discharge to streamline medications.\n.\n# Other transitional issues:\n- Continue home O2 as prescribed\n- Oral suction as prescribed\n- Maintain PICC with appropriate heparin flushes as a provision\nfor morphine infusion if patient's air hunger is refractory to\nPO morphine elixir and he requires IV morphine\n\nMedications on Admission:\n* Atazanavir 400mg daily\n* Fosamprenavir 1400mg twice daily\n* Aspirin 325mg daily\n* Abacavir 600mg daily\n* Lamivudine 300mg daily\n* Albuterol nebs every 2 hours PRN SOB, wheezing\n* Ipratropium nebs every 6 hours\n* Warfarin 3mg daily six times weekly, 2mg on Friday\n* Doxazosin 2mg qHS\n* Diltiazem 30mg three times daily\n* Famotidine 20mg daily\n* Bactrim 400-80 daily\n\n\nDischarge Medications:\n1.", ' atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY\n(Daily).\n2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3\ntimes a day).\n3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2\ntimes a day) as needed for constipation.\n5. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n6. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n7. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H\n(every 12 hours).\n8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) neb Inhalation every four (4) hours:\nStanding.\nDisp:30 nebs Refills:2\n9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for\nNebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as\nneeded for wheezing, shortness of breath.', '\n10. ipratropium bromide 0.02 % Solution Sig: One (1) neb\nInhalation Q6H (every 6 hours): standing.\nDisp:30 nebs Refills:2\n11. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY\n(Daily): x7days, 2 tablets daily X7d, 1 tab daily X 7d, half tab\ndaily X 7d, then off.\nDisp:46 Tablet(s) Refills:0\n12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4)\nhours as needed for shortness of breath, air hungry, anxiety.\nDisp:60 Tablet(s) Refills:0\n13. MS Contin 15 mg Tablet Extended Release Sig: Two (2) Tablet\nExtended Release PO every eight (8) hours.\nDisp:90 Tablet Extended Release(s) Refills:2\n14. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:\nTen (10) mg PO q2h as needed for shortness of breath, air\nhunger, pain.\nDisp:500 mL Refills:2\n15. Supplemental oxygen Sig: 1-5 liters once a day: via nasal\ncannula, titrate to comfort PRN.', '\nDisp:1 tank Refills:2\n16. Admit to Schmitt PLC Clinic Sig: One (1) once a day.\nDisp:1 unit Refills:2\n17. Maintain PICC at home\nMaintain PICC at home with hospice for use with morphine\ninfusion if need for SOB, air hunger\n18. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML\nIntravenous PRN (as needed) as needed for line flush.\nDisp:30 ML(s) Refills:2\n19. Oral suction\nAs needed for secretions\n20. Supplemental Home Oxygen\nOxygen 5-10L as needed\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n6947 Andrew Spring Suite 109\nEast Marcushaven, IL 21534\n\nDischarge Diagnosis:\nPrimary: COPD exacerbation\nSecondary: HIV, prior DVT on anticoagulation, chronic lower back\npain, anemia of chronic disease, osteoporosis\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 with difficulty breathing. You were found to\nbe having a COPD exacerbation. You were treated with steroids\n(oral and intravenous), antibiotics, nebulizers. You were also\nput on a breathing machine called BiPap to make it easier for\nyou to breath. With your very sick lungs, you did become very\ntired at one point, and were intubated to use a machine to help\nyou breath. Once you were extubated, we discussed your prognosis\nand the severity of your condition with you. You made the\ndecision to change your code status to Do Not Resuscitate/Do Not\nIntubate. The goals of your medical care was made for comfort.\n.\nYou are being discharged home with hospice, who will oversee\nyour care going forward and address all of your symptoms with\nthe goal of making you comfortable.', '\n.\nIt is important that you continue to take your medications as\ndirected. We made the following changes to your medications\nduring this admission:\n--> Stop Coumadin and INR checks\n--> Stop Aspirin\n--> Stop Doxazosin\n--> Stop Famotidine\n--> Continue prednisone 60mg daily X 1 weeks, with a slow taper\n--> Start Lorazepam as needed for shortness of breath, air\nhunger, anxiety\n--> Start MS Contin 30mg three times daily for air hunger\n--> Start Morphine liquid 5-10mL every 2 hours as needed for air\nhunger\n--> Start Prednisone and take as directed according to the\nprescribed taper\n--> Continue Albuterol nebs every 4 hours standing\n--> Continue Albuterol nebs every 2 hours as needed for\nshortness of breath, wheeze\n--> Continue Ipratropium nebs every 6 hours standing\n.\nContact your hospice organization if you need help controlling\nyour symtoms.', '\n\nFollowup Instructions:\nPlease feel free to contact your hospice nurses and physicians\nwith any questions or concerns.\n.\nAlso feel free to contact Dr. Jessie Pleasant, your new primary care\ndoctor, at Lawrence-Trujillo Health System at 736-710-1647.\n.\nDepartment: Archer-Maxwell Clinic\nWhen: WEDNESDAY 1905-8-28 at 10:00 AM\nWith: Keith Pleasant 736-710-1647\nBuilding: SC Riley, Donovan and Taylor Medical Center Clinical Ctr 03997 Timothy Fall\nBeckerborough, NY 17104\nCampus: EAST Best Parking: Riley, Donovan and Taylor Medical Center Garage\n\nDepartment: Archer-Maxwell Clinic\nWhen: WEDNESDAY 2006-9-4 at 12:00 PM\nWith: Keith Pleasant 736-710-1647\nBuilding: SC Riley, Donovan and Taylor Medical Center Clinical Ctr 03997 Timothy Fall\nBeckerborough, NY 17104\nCampus: EAST Best Parking: Riley, Donovan and Taylor Medical Center Garage\n\n\n\n']
220	66479	134640.0	2148-02-07	Discharge summary	Report	Admission Date: [2148-2-3] Discharge Date: [2148-2-7] Date of Birth: [2087-6-7] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: Pedestrian struck by motor vehicle Major Surgical or Invasive Procedure: [2147-2-3]: Chest tube insertion History of Present Illness: 60 year old female pedestrian struck at ~30 mph. Per witnesses patient was lifted off her feet and thrown through the air. She was alert and oriented at the scene, taken by Fire/Rescue to [Hospital1 18] in stable condition. Upon arrival she was conversant and hemodynamically stable. Due to the mechanism of her injury she was taken to the CT scanner and underwent Head/Neck/Chest/Abdomen/Pelvis evaluation Past Medical History: PMH: hyperlipidemia, BRCA1 carrier PSH: C-section, bilateral mastectomies with implant reconstruction, TAH, BSO Social History: SH: Activity Level: community ambulator Mobility Devices: none Occupation: Tobacco: denies EtOH: denies Family History: N/C Physical Exam: On admission: PE: T-97 HR-60 BP-140/70 RR-16 SaO2-99% RA A&O x 3 Agitated RLE intact w/ large ecchymotic area about the posterior aspect of the thigh. Tenderness w/ log roll and ROM of both the hip and knee. No gross deformity. Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN [First Name9 (NamePattern2) 2189] [Last Name (un) 938] FHL GS TA PP Fire 1+ PT and DP pulses LLE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN [First Name9 (NamePattern2) 2189] [Last Name (un) 938] FHL GS TA PP Fire 1+ PT and DP pulses On discharge: Pertinent Results: [2148-2-3]: TRAUMA #3 (PORT CHEST ONLY): IMPRESSION: Known right-sided pneumothorax seen on subsequent chest CT is not clearly visualized on the current radiograph. Fractures of the right posterior 11th and 12th ribs. CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST: IMPRESSION: 1. Grade 3 liver laceration involving segment VII and hemoperitoneum, without evidence of active extravasation. 2. Small right pneumothorax. 3. 11 and 12 right rib fractures. 4. Right transverse process fractures of L2 and L3. 5. Left sacral alar and left superior pubic ramus fractures CT C-SPINE W/O CONTRAST: IMPRESSION: 1. No evidence of C-spine fracture or subluxation. 2. Tiny right apical pneumothorax. 3. Sclerotic focus in the right C7 pedicle. While this may represent a bone island, please correlate with any prior history of malignancy and consider a bone scan for further evaluation. CT HEAD W/O CONTRAST: IMPRESSION: No acute intracranial process FEMUR (AP & LAT) RIGHT: IMPRESSION: No fracture or dislocation [2148-2-4]: CHEST (PORTABLE AP): The NG tube tip is in the stomach. Right apical pneumothorax is noted, small unchaged since the prior CT torso (within the limitations of comparison between different modalities). Heart size and mediastinum are unremarkable. Bibasal atelectasis is noted. No appreciable pleural effusion is seen. Bilateral breast prostheses are noted. [2147-2-5]: CHEST (PORTABLE AP): Small right apical pneumothorax is decreasing. New opacification at the periphery of the left lung is due at least in part to breast prosthesis. There could be a new small left pleural effusion or even consolidation. Followup advised. Normal cardiomediastinal silhouette. No right pleural effusion. Brief Hospital Course: Ms. [Known lastname 2190] was admitted under the acute care surgery service on [2148-2-3] for further evaluation and management of her injuries. She was initially admitted to the trauma ICU for close monitoring given her rib fractures, and was transferred to the floor on HD#1 as she remained stable. Neuro: She remained alert and oriented throughout her hospitalization. Her pain level was routinely assessed. She was initially administered IV narcotics for pain control, and was transitioned to an oral regimen when tolerating PO's. Prior to discharge, she reported adequate pain control on an oral regimen. CV: Her vital signs were monitored routinely and she remained afebrile and hemodynamically stable. Serial hct's were checked given her liver lac, initially q6h on admission and then [Hospital1 ]. They remained stable, and she remained without evidence of blood loss. Pulm: Given the small size of her pneumothorax, no chest tube placement was necessary. Agressive pulmonary toileting and incentive spirometry were encouraged. Nebulizer treatments were administered. Her supplemental oxygen was able to be weaned. Prior to discharge, her oxygen saturation was within normal limits on room air. She remained without respiratory compromise. GI: She was initially kept NPO with IV fluids for hydration and an NG tube was placed on admission given her liver laceration. Her hematocrit remained stable and abdominal exam remained benign, so the NG tube was removed on [2-4] and she was started on clear liquids. Her diet was slowly advanced over the next 24 hours and she was tolerating a regular diet at discharge. She was started on a bowel regimen given her narcotic intake. GU: A foley catheter was placed on admission. Her intake and output were closely monitored. On [2-5] it was removed and she voided without difficulty. Musk: Orthopedics was consulted given her pelvic fractures and lumbar transverse process fractures. These injuries were determined to be stable requiring no surgical intervention. Follow up in the orthopedic clinic was scheduled for 2 weeks from discharge. Physical therapy was consulted to evaluate her mobility, given her injuries determined she was best suited going to rehab. The patient was discharged to rehab in stable condition, pain controlled on oral medication, tolerating a regular diet, and urinating without difficulty. Medications on Admission: simvastatin 40mg daily, lorazepam 0.5 mg prn, multivitamins daily Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H () as needed for pain. 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q3h as needed for pain. 10. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Polytrauma: pedestrian struck R posterior thigh hematoma R apical pneumothorax Grade 3 liver laceration R 11-12th rib fx. R L1-2 transverse fx. L sacral alar fx. L sup pubic ramus fx 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 being struck by a motor vehicle. As a result of this accident you sustained multiple injuries as listed below. Your multiple rib fractures can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [2148-2-15] at 2:40 PM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: THURSDAY [2148-2-15] at 3:00 PM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2148-2-22] at 2:30 PM With: ACUTE CARE CLINIC/ DR. [Last Name (STitle) 2194] Phone:[Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601]	Admission Date: <Date>1949-2-13</Date> Discharge Date: <Date>1984-6-27</Date> Date of Birth: <Date>1982-12-12</Date> Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Keith</Name> Chief Complaint: Pedestrian struck by motor vehicle Major Surgical or Invasive Procedure: <Date>1931-11-7</Date>: Chest tube insertion History of Present Illness: 60 year old female pedestrian struck at ~30 mph. Per witnesses patient was lifted off her feet and thrown through the air. She was alert and oriented at the scene, taken by Fire/Rescue to <Hospital>Smith, Williams and Lawrence Health System</Hospital> in stable condition. Upon arrival she was conversant and hemodynamically stable. Due to the mechanism of her injury she was taken to the CT scanner and underwent Head/Neck/Chest/Abdomen/Pelvis evaluation Past Medical History: PMH: hyperlipidemia, BRCA1 carrier PSH: C-section, bilateral mastectomies with implant reconstruction, TAH, BSO Social History: SH: Activity Level: community ambulator Mobility Devices: none Occupation: Tobacco: denies EtOH: denies Family History: N/C Physical Exam: On admission: PE: T-97 HR-60 BP-140/70 RR-16 SaO2-99% RA A&O x 3 Agitated RLE intact w/ large ecchymotic area about the posterior aspect of the thigh. Tenderness w/ log roll and ROM of both the hip and knee. No gross deformity. Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN <Name>Julie</Name> <Name>Booker</Name> FHL GS TA PP Fire 1+ PT and DP pulses LLE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN <Name>Julie</Name> <Name>Booker</Name> FHL GS TA PP Fire 1+ PT and DP pulses On discharge: Pertinent Results: <Date>1949-2-13</Date>: TRAUMA #3 (PORT CHEST ONLY): IMPRESSION: Known right-sided pneumothorax seen on subsequent chest CT is not clearly visualized on the current radiograph. Fractures of the right posterior 11th and 12th ribs. CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST: IMPRESSION: 1. Grade 3 liver laceration involving segment VII and hemoperitoneum, without evidence of active extravasation. 2. Small right pneumothorax. 3. 11 and 12 right rib fractures. 4. Right transverse process fractures of L2 and L3. 5. Left sacral alar and left superior pubic ramus fractures CT C-SPINE W/O CONTRAST: IMPRESSION: 1. No evidence of C-spine fracture or subluxation. 2. Tiny right apical pneumothorax. 3. Sclerotic focus in the right C7 pedicle. While this may represent a bone island, please correlate with any prior history of malignancy and consider a bone scan for further evaluation. CT HEAD W/O CONTRAST: IMPRESSION: No acute intracranial process FEMUR (AP & LAT) RIGHT: IMPRESSION: No fracture or dislocation <Date>1991-12-14</Date>: CHEST (PORTABLE AP): The NG tube tip is in the stomach. Right apical pneumothorax is noted, small unchaged since the prior CT torso (within the limitations of comparison between different modalities). Heart size and mediastinum are unremarkable. Bibasal atelectasis is noted. No appreciable pleural effusion is seen. Bilateral breast prostheses are noted. <Date>1991-4-17</Date>: CHEST (PORTABLE AP): Small right apical pneumothorax is decreasing. New opacification at the periphery of the left lung is due at least in part to breast prosthesis. There could be a new small left pleural effusion or even consolidation. Followup advised. Normal cardiomediastinal silhouette. No right pleural effusion. Brief Hospital Course: Ms. <Name>Quinones</Name> was admitted under the acute care surgery service on <Date>1949-2-13</Date> for further evaluation and management of her injuries. She was initially admitted to the trauma ICU for close monitoring given her rib fractures, and was transferred to the floor on HD#1 as she remained stable. Neuro: She remained alert and oriented throughout her hospitalization. Her pain level was routinely assessed. She was initially administered IV narcotics for pain control, and was transitioned to an oral regimen when tolerating PO's. Prior to discharge, she reported adequate pain control on an oral regimen. CV: Her vital signs were monitored routinely and she remained afebrile and hemodynamically stable. Serial hct's were checked given her liver lac, initially q6h on admission and then <Hospital>Gross-Weiss Health System</Hospital>. They remained stable, and she remained without evidence of blood loss. Pulm: Given the small size of her pneumothorax, no chest tube placement was necessary. Agressive pulmonary toileting and incentive spirometry were encouraged. Nebulizer treatments were administered. Her supplemental oxygen was able to be weaned. Prior to discharge, her oxygen saturation was within normal limits on room air. She remained without respiratory compromise. GI: She was initially kept NPO with IV fluids for hydration and an NG tube was placed on admission given her liver laceration. Her hematocrit remained stable and abdominal exam remained benign, so the NG tube was removed on <Date>2-13</Date> and she was started on clear liquids. Her diet was slowly advanced over the next 24 hours and she was tolerating a regular diet at discharge. She was started on a bowel regimen given her narcotic intake. GU: A foley catheter was placed on admission. Her intake and output were closely monitored. On <Date>5-22</Date> it was removed and she voided without difficulty. Musk: Orthopedics was consulted given her pelvic fractures and lumbar transverse process fractures. These injuries were determined to be stable requiring no surgical intervention. Follow up in the orthopedic clinic was scheduled for 2 weeks from discharge. Physical therapy was consulted to evaluate her mobility, given her injuries determined she was best suited going to rehab. The patient was discharged to rehab in stable condition, pain controlled on oral medication, tolerating a regular diet, and urinating without difficulty. Medications on Admission: simvastatin 40mg daily, lorazepam 0.5 mg prn, multivitamins daily Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H () as needed for pain. 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q3h as needed for pain. 10. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: <Hospital>Perez, Steele and Hicks Health System</Hospital> - <Location>17222 Smith Orchard West Jeffrey, SC 23539</Location> Discharge Diagnosis: Polytrauma: pedestrian struck R posterior thigh hematoma R apical pneumothorax Grade 3 liver laceration R 11-12th rib fx. R L1-2 transverse fx. L sacral alar fx. L sup pubic ramus fx 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 being struck by a motor vehicle. As a result of this accident you sustained multiple injuries as listed below. Your multiple rib fractures can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). Followup Instructions: Department: ORTHOPEDICS When: THURSDAY <Date>1949-12-24</Date> at 2:40 PM With: ORTHO XRAY (SCC 2) <Telephone>452-162-8855</Telephone> Building: SC <Hospital>Robinson, Harrington and Wilson Medical Center</Hospital> Clinical Ctr <Location>748 Baker Pines Suite 060 South Joshuamouth, MD 14094</Location> Campus: EAST Best Parking: <Hospital>Robinson, Harrington and Wilson Medical Center</Hospital> Garage Department: ORTHOPEDICS When: THURSDAY <Date>1949-12-24</Date> at 3:00 PM With: <Name>Bradley</Name> <Name>Heflin</Name>, NP <Telephone>452-162-8855</Telephone> Building: <Hospital>Hernandez, Nolan and Moore Medical Center</Hospital> <Location>748 Baker Pines Suite 060 South Joshuamouth, MD 14094</Location> Campus: EAST Best Parking: <Hospital>Robinson, Harrington and Wilson Medical Center</Hospital> Garage Department: GENERAL SURGERY/<Hospital>Clarke, Valencia and Bennett Health System</Hospital> When: THURSDAY <Date>1911-3-31</Date> at 2:30 PM With: ACUTE CARE CLINIC/ DR. <Name>Shipley</Name> Phone:<Telephone>839-374-2632</Telephone> Building: LM <Hospital>Sexton, Morris and Taylor Health System</Hospital> Bldg (<Name>Son</Name>) <Location>Unit 7234 Box 8907 DPO AE 10367</Location> Campus: WEST Best Parking: <Hospital>Sexton, Morris and Taylor Health System</Hospital> Garage <Name>Samantha</Name> <Name>Marianna Bounds</Name> MD <MD Number>88135676</MD 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Date: 1949-2-13 Discharge Date: 1984-6-27 Date of Birth: 1982-12-12 Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:Keith Chief Complaint: Pedestrian struck by motor vehicle Major Surgical or Invasive Procedure: 1931-11-7: Chest tube insertion History of Present Illness: 60 year old female pedestrian struck at ~30 mph. Per witnesses patient was lifted off her feet and thrown through the air. She was alert and oriented at the scene, taken by Fire/Rescue to Smith, Williams and Lawrence Health System in stable condition. Upon arrival she was conversant and hemodynamically stable. Due to the mechanism of her injury she was taken to the CT scanner and underwent Head/Neck/Chest/Abdomen/Pelvis evaluation Past Medical History: PMH: hyperlipidemia, BRCA1 carrier PSH: C-section, bilateral mastectomies with implant reconstruction, TAH, BSO Social History: SH: Activity Level: community ambulator Mobility Devices: none Occupation: Tobacco: denies EtOH: denies Family History: N/C Physical Exam: On admission: PE: T-97 HR-60 BP-140/70 RR-16 SaO2-99% RA A&O x 3 Agitated RLE intact w/ large ecchymotic area about the posterior aspect of the thigh. Tenderness w/ log roll and ROM of both the hip and knee. No gross deformity. Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN Julie Booker FHL GS TA PP Fire 1+ PT and DP pulses LLE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN Julie Booker FHL GS TA PP Fire 1+ PT and DP pulses On discharge: Pertinent Results: 1949-2-13: TRAUMA #3 (PORT CHEST ONLY): IMPRESSION: Known right-sided pneumothorax seen on subsequent chest CT is not clearly visualized on the current radiograph. Fractures of the right posterior 11th and 12th ribs. CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST: IMPRESSION: 1. Grade 3 liver laceration involving segment VII and hemoperitoneum, without evidence of active extravasation. 2. Small right pneumothorax. 3. 11 and 12 right rib fractures. 4. Right transverse process fractures of L2 and L3. 5. Left sacral alar and left superior pubic ramus fractures CT C-SPINE W/O CONTRAST: IMPRESSION: 1. No evidence of C-spine fracture or subluxation. 2. Tiny right apical pneumothorax. 3. Sclerotic focus in the right C7 pedicle. While this may represent a bone island, please correlate with any prior history of malignancy and consider a bone scan for further evaluation. CT HEAD W/O CONTRAST: IMPRESSION: No acute intracranial process FEMUR (AP & LAT) RIGHT: IMPRESSION: No fracture or dislocation 1991-12-14: CHEST (PORTABLE AP): The NG tube tip is in the stomach. Right apical pneumothorax is noted, small unchaged since the prior CT torso (within the limitations of comparison between different modalities). Heart size and mediastinum are unremarkable. Bibasal atelectasis is noted. No appreciable pleural effusion is seen. Bilateral breast prostheses are noted. 1991-4-17: CHEST (PORTABLE AP): Small right apical pneumothorax is decreasing. New opacification at the periphery of the left lung is due at least in part to breast prosthesis. There could be a new small left pleural effusion or even consolidation. Followup advised. Normal cardiomediastinal silhouette. No right pleural effusion. Brief Hospital Course: Ms. Quinones was admitted under the acute care surgery service on 1949-2-13 for further evaluation and management of her injuries. She was initially admitted to the trauma ICU for close monitoring given her rib fractures, and was transferred to the floor on HD#1 as she remained stable. Neuro: She remained alert and oriented throughout her hospitalization. Her pain level was routinely assessed. She was initially administered IV narcotics for pain control, and was transitioned to an oral regimen when tolerating PO's. Prior to discharge, she reported adequate pain control on an oral regimen. CV: Her vital signs were monitored routinely and she remained afebrile and hemodynamically stable. Serial hct's were checked given her liver lac, initially q6h on admission and then Gross-Weiss Health System. They remained stable, and she remained without evidence of blood loss. Pulm: Given the small size of her pneumothorax, no chest tube placement was necessary. Agressive pulmonary toileting and incentive spirometry were encouraged. Nebulizer treatments were administered. Her supplemental oxygen was able to be weaned. Prior to discharge, her oxygen saturation was within normal limits on room air. She remained without respiratory compromise. GI: She was initially kept NPO with IV fluids for hydration and an NG tube was placed on admission given her liver laceration. Her hematocrit remained stable and abdominal exam remained benign, so the NG tube was removed on 2-13 and she was started on clear liquids. Her diet was slowly advanced over the next 24 hours and she was tolerating a regular diet at discharge. She was started on a bowel regimen given her narcotic intake. GU: A foley catheter was placed on admission. Her intake and output were closely monitored. On 5-22 it was removed and she voided without difficulty. Musk: Orthopedics was consulted given her pelvic fractures and lumbar transverse process fractures. These injuries were determined to be stable requiring no surgical intervention. Follow up in the orthopedic clinic was scheduled for 2 weeks from discharge. Physical therapy was consulted to evaluate her mobility, given her injuries determined she was best suited going to rehab. The patient was discharged to rehab in stable condition, pain controlled on oral medication, tolerating a regular diet, and urinating without difficulty. Medications on Admission: simvastatin 40mg daily, lorazepam 0.5 mg prn, multivitamins daily Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H () as needed for pain. 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q3h as needed for pain. 10. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: Perez, Steele and Hicks Health System - 17222 Smith Orchard West Jeffrey, SC 23539 Discharge Diagnosis: Polytrauma: pedestrian struck R posterior thigh hematoma R apical pneumothorax Grade 3 liver laceration R 11-12th rib fx. R L1-2 transverse fx. L sacral alar fx. L sup pubic ramus fx 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 being struck by a motor vehicle. As a result of this accident you sustained multiple injuries as listed below. Your multiple rib fractures can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). Followup Instructions: Department: ORTHOPEDICS When: THURSDAY 1949-12-24 at 2:40 PM With: ORTHO XRAY (SCC 2) 452-162-8855 Building: SC Robinson, Harrington and Wilson Medical Center Clinical Ctr 748 Baker Pines Suite 060 South Joshuamouth, MD 14094 Campus: EAST Best Parking: Robinson, Harrington and Wilson Medical Center Garage Department: ORTHOPEDICS When: THURSDAY 1949-12-24 at 3:00 PM With: Bradley Heflin, NP 452-162-8855 Building: Hernandez, Nolan and Moore Medical Center 748 Baker Pines Suite 060 South Joshuamouth, MD 14094 Campus: EAST Best Parking: Robinson, Harrington and Wilson Medical Center Garage Department: GENERAL SURGERY/Clarke, Valencia and Bennett Health System When: THURSDAY 1911-3-31 at 2:30 PM With: ACUTE CARE CLINIC/ DR. Shipley Phone:839-374-2632 Building: LM Sexton, Morris and Taylor Health System Bldg (Son) Unit 7234 Box 8907 DPO AE 10367 Campus: WEST Best Parking: Sexton, Morris and Taylor Health System Garage Samantha Marianna Bounds MD 88135676	['Admission Date: 1949-2-13 Discharge Date: 1984-6-27\n\nDate of Birth: 1982-12-12 Sex: F\n\nService: SURGERY\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Keith\nChief Complaint:\nPedestrian struck by motor vehicle\n\nMajor Surgical or Invasive Procedure:\n1931-11-7: Chest tube insertion\n\n\nHistory of Present Illness:\n60 year old female pedestrian struck at ~30 mph. Per witnesses\npatient was lifted off her feet and thrown through the air. She\nwas alert and oriented at the scene, taken by Fire/Rescue to\nSmith, Williams and Lawrence Health System in stable condition. Upon arrival she was conversant and\nhemodynamically stable. Due to the mechanism of her injury she\nwas taken to the CT scanner and underwent\nHead/Neck/Chest/Abdomen/Pelvis evaluation\n\nPast Medical History:\nPMH: hyperlipidemia, BRCA1 carrier\n\nPSH: C-section, bilateral mastectomies with implant\nreconstruction, TAH, BSO\n\n\nSocial History:\nSH:\nActivity Level: community ambulator\nMobility Devices: none\nOccupation:\nTobacco: denies\nEtOH: denies\n\n\nFamily History:\nN/C\n\nPhysical Exam:\nOn admission:\nPE:\nT-97 HR-60 BP-140/70 RR-16 SaO2-99% RA\nA&O x 3\nAgitated\n\nRLE intact w/ large ecchymotic area about the posterior aspect\nof\nthe thigh.', ' Tenderness w/ log roll and ROM of both the hip and\nknee. No gross deformity.\n\nThighs and legs are soft\nNo pain with passive motion\nSaph Sural DPN SPN MPN LPN Julie\nBooker FHL GS TA PP Fire\n1+ PT and DP pulses\n\nLLE skin clean and intact\nNo tenderness, deformity, erythema, edema, induration or\necchymosis\nThighs and legs are soft\nNo pain with passive motion\nSaph Sural DPN SPN MPN LPN Julie\nBooker FHL GS TA PP Fire\n1+ PT and DP pulses\n\nOn discharge:\n\n\nPertinent Results:\n1949-2-13:\nTRAUMA #3 (PORT CHEST ONLY):\nIMPRESSION: Known right-sided pneumothorax seen on subsequent\nchest CT is not clearly visualized on the current radiograph.\nFractures of the right\nposterior 11th and 12th ribs.\n\nCT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST:\nIMPRESSION:\n1. Grade 3 liver laceration involving segment VII and\nhemoperitoneum, without\nevidence of active extravasation.', '\n2. Small right pneumothorax.\n3. 11 and 12 right rib fractures.\n4. Right transverse process fractures of L2 and L3.\n5. Left sacral alar and left superior pubic ramus fractures\n\nCT C-SPINE W/O CONTRAST:\nIMPRESSION:\n1. No evidence of C-spine fracture or subluxation.\n2. Tiny right apical pneumothorax.\n3. Sclerotic focus in the right C7 pedicle. While this may\nrepresent a bone island, please correlate with any prior history\nof malignancy and consider a bone scan for further evaluation.\n\nCT HEAD W/O CONTRAST:\nIMPRESSION: No acute intracranial process\n\nFEMUR (AP & LAT) RIGHT:\nIMPRESSION: No fracture or dislocation\n\n1991-12-14:\nCHEST (PORTABLE AP):\nThe NG tube tip is in the stomach. Right apical pneumothorax is\nnoted, small unchaged since the prior CT torso (within the\nlimitations of comparison between different modalities).', ' Heart\nsize and mediastinum are unremarkable. Bibasal atelectasis is\nnoted. No appreciable pleural effusion is seen. Bilateral\nbreast prostheses are noted.\n\n1991-4-17:\nCHEST (PORTABLE AP):\nSmall right apical pneumothorax is decreasing. New opacification\nat the\nperiphery of the left lung is due at least in part to breast\nprosthesis.\nThere could be a new small left pleural effusion or even\nconsolidation.\nFollowup advised. Normal cardiomediastinal silhouette. No right\npleural\neffusion.\n\n\nBrief Hospital Course:\nMs. Quinones was admitted under the acute care surgery service on\n1949-2-13 for further evaluation and management of her injuries.\nShe was initially admitted to the trauma ICU for close\nmonitoring given her rib fractures, and was transferred to the\nfloor on HD#1 as she remained stable.\n\nNeuro: She remained alert and oriented throughout her\nhospitalization.', " Her pain level was routinely assessed. She was\ninitially administered IV narcotics for pain control, and was\ntransitioned to an oral regimen when tolerating PO's. Prior to\ndischarge, she reported adequate pain control on an oral\nregimen.\n\nCV: Her vital signs were monitored routinely and she remained\nafebrile and hemodynamically stable. Serial hct's were checked\ngiven her liver lac, initially q6h on admission and then Gross-Weiss Health System.\nThey remained stable, and she remained without evidence of blood\nloss.\n\nPulm: Given the small size of her pneumothorax, no chest tube\nplacement was necessary. Agressive pulmonary toileting and\nincentive spirometry were encouraged. Nebulizer treatments were\nadministered. Her supplemental oxygen was able to be weaned.\nPrior to discharge, her oxygen saturation was within normal\nlimits on room air.", ' She remained without respiratory compromise.\n\nGI: She was initially kept NPO with IV fluids for hydration and\nan NG tube was placed on admission given her liver laceration.\nHer hematocrit remained stable and abdominal exam remained\nbenign, so the NG tube was removed on 2-13 and she was started on\nclear liquids. Her diet was slowly advanced over the next 24\nhours and she was tolerating a regular diet at discharge. She\nwas started on a bowel regimen given her narcotic intake.\n\nGU: A foley catheter was placed on admission. Her intake and\noutput were closely monitored. On 5-22 it was removed and she\nvoided without difficulty.\n\nMusk: Orthopedics was consulted given her pelvic fractures and\nlumbar transverse process fractures. These injuries were\ndetermined to be stable requiring no surgical intervention.', '\nFollow up in the orthopedic clinic was scheduled for 2 weeks\nfrom discharge.\n\nPhysical therapy was consulted to evaluate her mobility, given\nher injuries determined she was best suited going to rehab. The\npatient was discharged to rehab in stable condition, pain\ncontrolled on oral medication, tolerating a regular diet, and\nurinating without difficulty.\n\n\nMedications on Admission:\nsimvastatin 40mg daily, lorazepam 0.5 mg prn, multivitamins\ndaily\n\n\nDischarge Medications:\n1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H () as\nneeded for pain.\n4. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a\nday).\n5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable\nSig: One (1) Tablet, Chewable PO TID (3 times a day).', '\n6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)\nTablet PO DAILY (Daily).\n7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.\n8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as\nneeded for constipation.\n9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q3h as needed for\npain.\n10. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO every six (6)\nhours as needed for pain.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nPerez, Steele and Hicks Health System - 17222 Smith Orchard\nWest Jeffrey, SC 23539\n\nDischarge Diagnosis:\nPolytrauma: pedestrian struck\n\nR posterior thigh hematoma\nR apical pneumothorax\nGrade 3 liver laceration\nR 11-12th rib fx.\nR L1-2 transverse fx.\nL sacral alar fx.\nL sup pubic ramus fx\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 being struck by a motor\nvehicle. As a result of this accident you sustained multiple\ninjuries as listed below.\n\nYour multiple rib fractures can cause severe pain and\nsubsequently cause you to take shallow breaths because of the\npain.\n\n* You should take your pain medication as directed to stay\nahead of the pain otherwise you won't be able to take deep\nbreaths. If the pain medication is too sedating take half the\ndose and notify your physician.\n\n* Pneumonia is a complication of rib fractures. In order to\ndecrease your risk you must use your incentive spirometer 4\ntimes every hour while awake. This will help expand the small\nairways in your lungs and assist in coughing up secretions that\npool in the lungs.", '\n\n* You will be more comfortable if you use a cough pillow to\nhold against your chest and guard your rib cage while coughing\nand deep breathing.\n\n* Symptomatic relief with ice packs or heating pads for short\nperiods may ease the pain.\n\n* Narcotic pain medication can cause constipation therefore you\nshould take a stool softener twice daily and increase your fluid\nand fiber intake if possible.\n\n* Do NOT smoke\n\n* If your doctor allows, non steroidal antiinflammatory drugs\nare very effective in controlling pain ( ie, Ibuprofen, Motrin,\nAdvil, Aleve, Naprosyn) but they have their own set of side\neffects so make sure your doctor approves.\n\n* Return to the Emergency Room right away for any acute\nshortness of breath, increased pain or crackling sensation\naround your ribs ( crepitus ).\n\n\nFollowup Instructions:\nDepartment: ORTHOPEDICS\nWhen: THURSDAY 1949-12-24 at 2:40 PM\nWith: ORTHO XRAY (SCC 2) 452-162-8855\nBuilding: SC Robinson, Harrington and Wilson Medical Center Clinical Ctr 748 Baker Pines Suite 060\nSouth Joshuamouth, MD 14094\nCampus: EAST Best Parking: Robinson, Harrington and Wilson Medical Center Garage\n\nDepartment: ORTHOPEDICS\nWhen: THURSDAY 1949-12-24 at 3:00 PM\nWith: Bradley Heflin, NP 452-162-8855\nBuilding: Hernandez, Nolan and Moore Medical Center 748 Baker Pines Suite 060\nSouth Joshuamouth, MD 14094\nCampus: EAST Best Parking: Robinson, Harrington and Wilson Medical Center Garage\n\nDepartment: GENERAL SURGERY/Clarke, Valencia and Bennett Health System\nWhen: THURSDAY 1911-3-31 at 2:30 PM\nWith: ACUTE CARE CLINIC/ DR.', ' Shipley\nPhone:839-374-2632\nBuilding: LM Sexton, Morris and Taylor Health System Bldg (Son) Unit 7234 Box 8907\nDPO AE 10367\nCampus: WEST Best Parking: Sexton, Morris and Taylor Health System Garage\n\n\n Samantha Marianna Bounds MD 88135676\n\n']
221	75347	152030.0	2174-06-03	Discharge summary	Report	Admission Date: [2174-5-3] Discharge Date: [2174-6-3] Date of Birth: [2110-2-28] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[First Name3 (LF) 2195] Chief Complaint: found down Major Surgical or Invasive Procedure: Left craniotomy History of Present Illness: In brief, this is a 64 yo M with hx of melanoma s/p craniotomy and resection of metastatic melanoma in brain. He was initially admitted after found down on [5-3]. Had multiple intraparencymal hematomas, SAH, SDH. Underwent resection of tumor and cyst cavities on [5-6]. S/p craniotomy which was done on [5-6] he has been aphasic and had ongoing myoclonic seizures. He was monitored on EEG and last seizure was 3 days ago, thought to be in setting of sepsis and lowered sz threshhold. He is currently on max doses of dilantin and Keppra and being followed by neuro for AED recommendations. He was transferred to MICU for management of septic shock after blood cx grew enterobacter cloacae (possibly spread from urine). He was on CTX but currently on meropenem, afebrile, and no leukocytosis. He has a PICC line in place for a 14-day course of meropenem. LP was done in MICU and was normal. Throughout the MICU stay he has been tachycardic with a fib and flutter intermittently on tele. On [5-15] he was ruled out for PE with negative CTA and LENIs. He responds to fluids and HR is currently in the 90s on PO diltiazem and metoprolol. [Name (NI) ] sister is his HCP and has recently made him DNR/DNI, she would like to discuss goals of care with the primary team. Neuro-oncology has been following and he may require XRT but there has been some discussion of his current poor performance status limiting gains of further therapy. ROS: as in HPI Past Medical History: HTN, Hypercholestolemia, lung CA, Asthma, Depression Social History: He is divorced and lives alone. He is a hairdresser, on disablity for the past seven years. He is a heavy smoker. He has one brother and one sister, both are healthy. He has no children. His health care proxy is her sister, [Name (NI) ]; [Name2 (NI) 2196] daughter, [Name (NI) 2197] [Name (NI) 2198] is closely involved as well. Family History: His father died at age 60; reportedly had a benign brain tumor. His mother died at 68 of complications of a stroke suffered during carotid endarterectomy. Physical Exam: DISCHAGE PHYSICAL: Vitals: T98 BP 110/76 HR 109 RR 20 99 on RA General: resting comfortably in bed. NEURO: Oriented to self, intermittently to place (sometimes knows he's in a hospital). Sometimes able to follow simple commands (raise 2 fingers). Strength 5/5 throughout. HEENT: Cranitomy scare C/D/I, mmm CV: irregularly irregular PULM: Clear bilaterally Abd: soft with normal bowel sounds Pertinent Results: CT:( wet read) Stable large left temporal lobe intraparenchymal hematoma, with surrounding edema and mass effect on the left lateral ventricle. Stable 4 mm rightward shift of midline structures, similar. 2. Mild increas in R hemispheric SAH. Mild increase in R Temporo parietal SDH. 3. Possible mild increase in the right temporal parenchymal hematoma and surrounding edema. 4, Stable left inferior frontal hemorrhagic contusion with surrounding edema. No evidence of herniation. No intraventricular bleed. MRI Brain [5-6] Pre-op Limited post-contrast images obtained for preoperative planning of left temporal lobe lesion which may represent hemorrhage or metastasis given patient's history of lung cancer. Stable foci of hemorrhagic contusions in the left frontal lobe and right temporal lobe. Stable right subdural hematoma. MRI Brain [5-7] Post-Op Status post resection of left temporal mass with expected post-surgical changes. There may be minimal residual enhancement in the anterior aspect of the previously noted enhancing lesion. This could also be postoperative in nature. No acute infarcts are seen. No hydrocephalus. Hemorrhagic contusions and right-sided subdural collections are noted. Labs: CBC 21.1/14.6/41.5/200 Coags: 13.7/22.0/1.2 UA: WBC 15 Bact many Leuk neg [5-9] ECHO:The left atrium is elongated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [5-15] CTA CHEST: IMPRESSION: 1. No evidence of PE. 2. Moderate atherosclerosis and ulcerated plaques. 3. Emphysema. 4. Moderate hiatal hernia. 5. Right adrenal adenoma. [5-15] LENIS: IMPRESSION: No bilateral lower extremity DVT. Brief Hospital Course: 64M with h/o lung cancer in [2169] s/p resection, melanoma of left arm s/p excision in [2167], who presented with left temporal hemorrhage, secondary to metastatic melanoma, s/p craniotomy with gross resection of lesion. He initially presented after being found down and was admitted to the ICU on neurosurgery service. He underwent craintomy for resection of his lesion and patholgoy returned as melanoma. His hospital course was complicated by Afib with RVR and ultimately rate controlled with oral diltizem and lopressor. He also developed enterobacter bacteremia and was treated for 14 days with meropenem. Neuro-Oncology was contact[Name (NI) ] to discuss the possibility of XRT or other chemotherapeutic [Doctor Last Name 360] however, the patient was too agitated to tolerate mapping and sitting still long enough for XRT. Systemic chemotherapy was not considered given the patient's many co-morbidities. Several family meetings were held to discuss his prognosis. Initially the decision was made to wait to see if his mental status improved, unfortunately it did not. Another family meeting was held and the decision was made by his health care proxy to have him to go hospice and focus on comfort. He is being discharged to hospice. All non-comfort related medications were stopped prior to discharge. He should be continued on pain medication, medication for atrial fibrillation including aspirin, anti-seizure medication and GERD medication. Medications on Admission: Vicoden ES 7.5mg Q 4-6h, Xanax .5mg tid prn, MVI [Last Name (LF) ], [First Name3 (LF) ] 81mg qd, citalopram 20mg daily, ProAir HFA 90mcg 2 IH Q 6h prn, Trazodone 200mg qhs, Gabapentin 300mg [Hospital1 ], Lisinopril 5mg daily, Metoprolol ER 50mg daily,Albuterol neb Q 6h, nicoderm 7mg , symbicort 160 [Hospital1 ], HFA Aerosol INH daily, Simvastatin 40mg daily Discharge Medications: 1. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for loose stool. 3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2 times a day): hold for loose stool. 5. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 1-10 mg PO Q4H (every 4 hours) as needed for pain. 9. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 10. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) mg PO Q8H (every 8 hours). 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to lower back. Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) 2199] Discharge Diagnosis: Metastatic Melanoma Delirium Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted with bleeding in the head. Imaging showed that you had a mass and you part of it taken out. Pathology showed it was melanoma that was metastatic. Your mental status did not improve and the decision was made to focus on your comfort rather than treatment of your cancer. You are being discharged to hospice. It was a pleasure meeting you and participating in your care Followup Instructions: None	Admission Date: <Date>1910-5-15</Date> Discharge Date: <Date>1931-11-2</Date> Date of Birth: <Date>1919-11-4</Date> Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:<Name>Michelle</Name> Chief Complaint: found down Major Surgical or Invasive Procedure: Left craniotomy History of Present Illness: In brief, this is a 64 yo M with hx of melanoma s/p craniotomy and resection of metastatic melanoma in brain. He was initially admitted after found down on <Date>8-9</Date>. Had multiple intraparencymal hematomas, SAH, SDH. Underwent resection of tumor and cyst cavities on <Date>3-13</Date>. S/p craniotomy which was done on <Date>3-13</Date> he has been aphasic and had ongoing myoclonic seizures. He was monitored on EEG and last seizure was 3 days ago, thought to be in setting of sepsis and lowered sz threshhold. He is currently on max doses of dilantin and Keppra and being followed by neuro for AED recommendations. He was transferred to MICU for management of septic shock after blood cx grew enterobacter cloacae (possibly spread from urine). He was on CTX but currently on meropenem, afebrile, and no leukocytosis. He has a PICC line in place for a 14-day course of meropenem. LP was done in MICU and was normal. Throughout the MICU stay he has been tachycardic with a fib and flutter intermittently on tele. On <Date>12-21</Date> he was ruled out for PE with negative CTA and LENIs. He responds to fluids and HR is currently in the 90s on PO diltiazem and metoprolol. <Name>Noah Londrie</Name> sister is his HCP and has recently made him DNR/DNI, she would like to discuss goals of care with the primary team. Neuro-oncology has been following and he may require XRT but there has been some discussion of his current poor performance status limiting gains of further therapy. ROS: as in HPI Past Medical History: HTN, Hypercholestolemia, lung CA, Asthma, Depression Social History: He is divorced and lives alone. He is a hairdresser, on disablity for the past seven years. He is a heavy smoker. He has one brother and one sister, both are healthy. He has no children. His health care proxy is her sister, <Name>Noah Londrie</Name>; <Name>Janice Turcios</Name> daughter, <Name>Meena Heflin</Name> <Name>Tammy Olles</Name> is closely involved as well. Family History: His father died at age 60; reportedly had a benign brain tumor. His mother died at 68 of complications of a stroke suffered during carotid endarterectomy. Physical Exam: DISCHAGE PHYSICAL: Vitals: T98 BP 110/76 HR 109 RR 20 99 on RA General: resting comfortably in bed. NEURO: Oriented to self, intermittently to place (sometimes knows he's in a hospital). Sometimes able to follow simple commands (raise 2 fingers). Strength 5/5 throughout. HEENT: Cranitomy scare C/D/I, mmm CV: irregularly irregular PULM: Clear bilaterally Abd: soft with normal bowel sounds Pertinent Results: CT:( wet read) Stable large left temporal lobe intraparenchymal hematoma, with surrounding edema and mass effect on the left lateral ventricle. Stable 4 mm rightward shift of midline structures, similar. 2. Mild increas in R hemispheric SAH. Mild increase in R Temporo parietal SDH. 3. Possible mild increase in the right temporal parenchymal hematoma and surrounding edema. 4, Stable left inferior frontal hemorrhagic contusion with surrounding edema. No evidence of herniation. No intraventricular bleed. MRI Brain <Date>3-13</Date> Pre-op Limited post-contrast images obtained for preoperative planning of left temporal lobe lesion which may represent hemorrhage or metastasis given patient's history of lung cancer. Stable foci of hemorrhagic contusions in the left frontal lobe and right temporal lobe. Stable right subdural hematoma. MRI Brain <Date>10-8</Date> Post-Op Status post resection of left temporal mass with expected post-surgical changes. There may be minimal residual enhancement in the anterior aspect of the previously noted enhancing lesion. This could also be postoperative in nature. No acute infarcts are seen. No hydrocephalus. Hemorrhagic contusions and right-sided subdural collections are noted. Labs: CBC 21.1/14.6/41.5/200 Coags: 13.7/22.0/1.2 UA: WBC 15 Bact many Leuk neg <Date>11-19</Date> ECHO:The left atrium is elongated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. <Date>12-21</Date> CTA CHEST: IMPRESSION: 1. No evidence of PE. 2. Moderate atherosclerosis and ulcerated plaques. 3. Emphysema. 4. Moderate hiatal hernia. 5. Right adrenal adenoma. <Date>12-21</Date> LENIS: IMPRESSION: No bilateral lower extremity DVT. Brief Hospital Course: 64M with h/o lung cancer in <Year>1976</Year> s/p resection, melanoma of left arm s/p excision in <Year>1976</Year>, who presented with left temporal hemorrhage, secondary to metastatic melanoma, s/p craniotomy with gross resection of lesion. He initially presented after being found down and was admitted to the ICU on neurosurgery service. He underwent craintomy for resection of his lesion and patholgoy returned as melanoma. His hospital course was complicated by Afib with RVR and ultimately rate controlled with oral diltizem and lopressor. He also developed enterobacter bacteremia and was treated for 14 days with meropenem. Neuro-Oncology was contact<Name>Noah Londrie</Name> to discuss the possibility of XRT or other chemotherapeutic <Doctor Name>Dr.Smith</Doctor Name> however, the patient was too agitated to tolerate mapping and sitting still long enough for XRT. Systemic chemotherapy was not considered given the patient's many co-morbidities. Several family meetings were held to discuss his prognosis. Initially the decision was made to wait to see if his mental status improved, unfortunately it did not. Another family meeting was held and the decision was made by his health care proxy to have him to go hospice and focus on comfort. He is being discharged to hospice. All non-comfort related medications were stopped prior to discharge. He should be continued on pain medication, medication for atrial fibrillation including aspirin, anti-seizure medication and GERD medication. Medications on Admission: Vicoden ES 7.5mg Q 4-6h, Xanax .5mg tid prn, MVI <Name>Belle</Name>, <Name>Zachary</Name> 81mg qd, citalopram 20mg daily, ProAir HFA 90mcg 2 IH Q 6h prn, Trazodone 200mg qhs, Gabapentin 300mg <Hospital>Goodwin-Miller Clinic</Hospital>, Lisinopril 5mg daily, Metoprolol ER 50mg daily,Albuterol neb Q 6h, nicoderm 7mg , symbicort 160 <Hospital>Goodwin-Miller Clinic</Hospital>, HFA Aerosol INH daily, Simvastatin 40mg daily Discharge Medications: 1. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for loose stool. 3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2 times a day): hold for loose stool. 5. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 1-10 mg PO Q4H (every 4 hours) as needed for pain. 9. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 10. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) mg PO Q8H (every 8 hours). 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to lower back. Discharge Disposition: Extended Care Facility: Life Care Center of <Location>362 Paul Motorway Suite 876 Waltersstad, VA 90362</Location> Discharge Diagnosis: Metastatic Melanoma Delirium Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted with bleeding in the head. Imaging showed that you had a mass and you part of it taken out. Pathology showed it was melanoma that was metastatic. Your mental status did not improve and the decision was made to focus on your comfort rather than treatment of your cancer. You are being discharged to hospice. It was a pleasure meeting you and participating in your care Followup Instructions: None	00000000000000000111111111000000000000000000000000000000001111111110000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111100111111111111110000000000011111111111101111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1910-5-15 Discharge Date: 1931-11-2 Date of Birth: 1919-11-4 Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:Michelle Chief Complaint: found down Major Surgical or Invasive Procedure: Left craniotomy History of Present Illness: In brief, this is a 64 yo M with hx of melanoma s/p craniotomy and resection of metastatic melanoma in brain. He was initially admitted after found down on 8-9. Had multiple intraparencymal hematomas, SAH, SDH. Underwent resection of tumor and cyst cavities on 3-13. S/p craniotomy which was done on 3-13 he has been aphasic and had ongoing myoclonic seizures. He was monitored on EEG and last seizure was 3 days ago, thought to be in setting of sepsis and lowered sz threshhold. He is currently on max doses of dilantin and Keppra and being followed by neuro for AED recommendations. He was transferred to MICU for management of septic shock after blood cx grew enterobacter cloacae (possibly spread from urine). He was on CTX but currently on meropenem, afebrile, and no leukocytosis. He has a PICC line in place for a 14-day course of meropenem. LP was done in MICU and was normal. Throughout the MICU stay he has been tachycardic with a fib and flutter intermittently on tele. On 12-21 he was ruled out for PE with negative CTA and LENIs. He responds to fluids and HR is currently in the 90s on PO diltiazem and metoprolol. Noah Londrie sister is his HCP and has recently made him DNR/DNI, she would like to discuss goals of care with the primary team. Neuro-oncology has been following and he may require XRT but there has been some discussion of his current poor performance status limiting gains of further therapy. ROS: as in HPI Past Medical History: HTN, Hypercholestolemia, lung CA, Asthma, Depression Social History: He is divorced and lives alone. He is a hairdresser, on disablity for the past seven years. He is a heavy smoker. He has one brother and one sister, both are healthy. He has no children. His health care proxy is her sister, Noah Londrie; Janice Turcios daughter, Meena Heflin Tammy Olles is closely involved as well. Family History: His father died at age 60; reportedly had a benign brain tumor. His mother died at 68 of complications of a stroke suffered during carotid endarterectomy. Physical Exam: DISCHAGE PHYSICAL: Vitals: T98 BP 110/76 HR 109 RR 20 99 on RA General: resting comfortably in bed. NEURO: Oriented to self, intermittently to place (sometimes knows he's in a hospital). Sometimes able to follow simple commands (raise 2 fingers). Strength 5/5 throughout. HEENT: Cranitomy scare C/D/I, mmm CV: irregularly irregular PULM: Clear bilaterally Abd: soft with normal bowel sounds Pertinent Results: CT:( wet read) Stable large left temporal lobe intraparenchymal hematoma, with surrounding edema and mass effect on the left lateral ventricle. Stable 4 mm rightward shift of midline structures, similar. 2. Mild increas in R hemispheric SAH. Mild increase in R Temporo parietal SDH. 3. Possible mild increase in the right temporal parenchymal hematoma and surrounding edema. 4, Stable left inferior frontal hemorrhagic contusion with surrounding edema. No evidence of herniation. No intraventricular bleed. MRI Brain 3-13 Pre-op Limited post-contrast images obtained for preoperative planning of left temporal lobe lesion which may represent hemorrhage or metastasis given patient's history of lung cancer. Stable foci of hemorrhagic contusions in the left frontal lobe and right temporal lobe. Stable right subdural hematoma. MRI Brain 10-8 Post-Op Status post resection of left temporal mass with expected post-surgical changes. There may be minimal residual enhancement in the anterior aspect of the previously noted enhancing lesion. This could also be postoperative in nature. No acute infarcts are seen. No hydrocephalus. Hemorrhagic contusions and right-sided subdural collections are noted. Labs: CBC 21.1/14.6/41.5/200 Coags: 13.7/22.0/1.2 UA: WBC 15 Bact many Leuk neg 11-19 ECHO:The left atrium is elongated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. 12-21 CTA CHEST: IMPRESSION: 1. No evidence of PE. 2. Moderate atherosclerosis and ulcerated plaques. 3. Emphysema. 4. Moderate hiatal hernia. 5. Right adrenal adenoma. 12-21 LENIS: IMPRESSION: No bilateral lower extremity DVT. Brief Hospital Course: 64M with h/o lung cancer in 1976 s/p resection, melanoma of left arm s/p excision in 1976, who presented with left temporal hemorrhage, secondary to metastatic melanoma, s/p craniotomy with gross resection of lesion. He initially presented after being found down and was admitted to the ICU on neurosurgery service. He underwent craintomy for resection of his lesion and patholgoy returned as melanoma. His hospital course was complicated by Afib with RVR and ultimately rate controlled with oral diltizem and lopressor. He also developed enterobacter bacteremia and was treated for 14 days with meropenem. Neuro-Oncology was contactNoah Londrie to discuss the possibility of XRT or other chemotherapeutic Dr.Smith however, the patient was too agitated to tolerate mapping and sitting still long enough for XRT. Systemic chemotherapy was not considered given the patient's many co-morbidities. Several family meetings were held to discuss his prognosis. Initially the decision was made to wait to see if his mental status improved, unfortunately it did not. Another family meeting was held and the decision was made by his health care proxy to have him to go hospice and focus on comfort. He is being discharged to hospice. All non-comfort related medications were stopped prior to discharge. He should be continued on pain medication, medication for atrial fibrillation including aspirin, anti-seizure medication and GERD medication. Medications on Admission: Vicoden ES 7.5mg Q 4-6h, Xanax .5mg tid prn, MVI Belle, Zachary 81mg qd, citalopram 20mg daily, ProAir HFA 90mcg 2 IH Q 6h prn, Trazodone 200mg qhs, Gabapentin 300mg Goodwin-Miller Clinic, Lisinopril 5mg daily, Metoprolol ER 50mg daily,Albuterol neb Q 6h, nicoderm 7mg , symbicort 160 Goodwin-Miller Clinic, HFA Aerosol INH daily, Simvastatin 40mg daily Discharge Medications: 1. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for loose stool. 3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2 times a day): hold for loose stool. 5. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 1-10 mg PO Q4H (every 4 hours) as needed for pain. 9. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 10. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) mg PO Q8H (every 8 hours). 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to lower back. Discharge Disposition: Extended Care Facility: Life Care Center of 362 Paul Motorway Suite 876 Waltersstad, VA 90362 Discharge Diagnosis: Metastatic Melanoma Delirium Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted with bleeding in the head. Imaging showed that you had a mass and you part of it taken out. Pathology showed it was melanoma that was metastatic. Your mental status did not improve and the decision was made to focus on your comfort rather than treatment of your cancer. You are being discharged to hospice. It was a pleasure meeting you and participating in your care Followup Instructions: None	['Admission Date: 1910-5-15 Discharge Date: 1931-11-2\n\nDate of Birth: 1919-11-4 Sex: M\n\nService: MEDICINE\n\nAllergies:\nCiprofloxacin\n\nAttending:Michelle\nChief Complaint:\nfound down\n\nMajor Surgical or Invasive Procedure:\nLeft craniotomy\n\n\nHistory of Present Illness:\nIn brief, this is a 64 yo M with hx of melanoma s/p craniotomy\nand resection of metastatic melanoma in brain. He was initially\nadmitted after found down on 8-9. Had multiple intraparencymal\nhematomas, SAH, SDH. Underwent resection of tumor and cyst\ncavities on 3-13. S/p craniotomy which was done on 3-13 he has\nbeen aphasic and had ongoing myoclonic seizures. He was\nmonitored on EEG and last seizure was 3 days ago, thought to be\nin setting of sepsis and lowered sz threshhold. He is currently\non max doses of dilantin and Keppra and being followed by neuro\nfor AED recommendations.', ' He was transferred to MICU for\nmanagement of septic shock after blood cx grew enterobacter\ncloacae (possibly spread from urine). He was on CTX but\ncurrently on meropenem, afebrile, and no leukocytosis. He has a\nPICC line in place for a 14-day course of meropenem. LP was done\nin MICU and was normal. Throughout the MICU stay he has been\ntachycardic with a fib and flutter intermittently on tele. On\n12-21 he was ruled out for PE with negative CTA and LENIs. He\nresponds to fluids and HR is currently in the 90s on PO\ndiltiazem and metoprolol. Noah Londrie sister is his HCP and has\nrecently made him DNR/DNI, she would like to discuss goals of\ncare with the primary team. Neuro-oncology has been following\nand he may require XRT but there has been some discussion of his\ncurrent poor performance status limiting gains of further\ntherapy.', "\n\nROS: as in HPI\n\n\nPast Medical History:\nHTN, Hypercholestolemia, lung CA, Asthma, Depression\n\nSocial History:\nHe is divorced and lives alone. He is a hairdresser, on\ndisablity for the past seven years. He is a heavy smoker. He has\none brother and one sister, both are healthy. He has no\nchildren. His health care proxy is her sister, Noah Londrie; Janice Turcios\ndaughter, Meena Heflin Tammy Olles is closely involved as well.\n\n\nFamily History:\nHis father died at age 60; reportedly had a benign brain tumor.\nHis mother died at 68 of complications of a stroke suffered\nduring carotid endarterectomy.\n\n\nPhysical Exam:\nDISCHAGE PHYSICAL:\n\nVitals: T98 BP 110/76 HR 109 RR 20 99 on RA\nGeneral: resting comfortably in bed.\nNEURO: Oriented to self, intermittently to place (sometimes\nknows he's in a hospital).", " Sometimes able to follow simple\ncommands (raise 2 fingers). Strength 5/5 throughout.\nHEENT: Cranitomy scare C/D/I, mmm\nCV: irregularly irregular\nPULM: Clear bilaterally\nAbd: soft with normal bowel sounds\n\n\nPertinent Results:\nCT:( wet read) Stable large left temporal lobe intraparenchymal\nhematoma, with surrounding edema and mass effect on the left\nlateral ventricle. Stable 4 mm rightward shift of midline\nstructures, similar.\n2. Mild increas in R hemispheric SAH. Mild increase in R Temporo\nparietal SDH.\n3. Possible mild increase in the right temporal parenchymal\nhematoma and surrounding edema.\n4, Stable left inferior frontal hemorrhagic contusion with\nsurrounding edema. No evidence of herniation. No\nintraventricular\nbleed.\n\nMRI Brain 3-13 Pre-op\nLimited post-contrast images obtained for preoperative planning\nof left temporal lobe lesion which may represent hemorrhage or\nmetastasis\ngiven patient's history of lung cancer.", ' Stable foci of\nhemorrhagic contusions in the left frontal lobe and right\ntemporal lobe. Stable right subdural hematoma.\n\nMRI Brain 10-8 Post-Op\nStatus post resection of left temporal mass with expected\npost-surgical changes. There may be minimal residual enhancement\nin the\nanterior aspect of the previously noted enhancing lesion. This\ncould also be postoperative in nature. No acute infarcts are\nseen. No hydrocephalus.\nHemorrhagic contusions and right-sided subdural collections are\nnoted.\n\nLabs: CBC 21.1/14.6/41.5/200\nCoags: 13.7/22.0/1.2\nUA: WBC 15 Bact many Leuk neg\n\n11-19 ECHO:The left atrium is elongated. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is\nnormal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal.', ' There is no aortic valve stenosis. No aortic\nregurgitation is seen. No mitral regurgitation is seen. The\npulmonary artery systolic pressure could not be determined.\nThere is no pericardial effusion.\n\n12-21 CTA CHEST: IMPRESSION:\n1. No evidence of PE.\n2. Moderate atherosclerosis and ulcerated plaques.\n3. Emphysema.\n4. Moderate hiatal hernia.\n5. Right adrenal adenoma.\n\n12-21 LENIS: IMPRESSION: No bilateral lower extremity DVT.\n\n\nBrief Hospital Course:\n64M with h/o lung cancer in 1976 s/p resection, melanoma of left\narm s/p excision in 1976, who presented with left temporal\nhemorrhage, secondary to metastatic melanoma, s/p craniotomy\nwith gross resection of lesion.\n\nHe initially presented after being found down and was admitted\nto the ICU on neurosurgery service. He underwent craintomy for\nresection of his lesion and patholgoy returned as melanoma.', "\n\nHis hospital course was complicated by Afib with RVR and\nultimately rate controlled with oral diltizem and lopressor. He\nalso developed enterobacter bacteremia and was treated for 14\ndays with meropenem.\n\nNeuro-Oncology was contactNoah Londrie to discuss the possibility of XRT\nor other chemotherapeutic Dr.Smith however, the patient was too\nagitated to tolerate mapping and sitting still long enough for\nXRT. Systemic chemotherapy was not considered given the\npatient's many co-morbidities. Several family meetings were\nheld to discuss his prognosis. Initially the decision was made\nto wait to see if his mental status improved, unfortunately it\ndid not. Another family meeting was held and the decision was\nmade by his health care proxy to have him to go hospice and\nfocus on comfort.\n\nHe is being discharged to hospice.", ' All non-comfort related\nmedications were stopped prior to discharge. He should be\ncontinued on pain medication, medication for atrial fibrillation\nincluding aspirin, anti-seizure medication and GERD medication.\n\n\nMedications on Admission:\nVicoden ES 7.5mg Q 4-6h, Xanax .5mg tid prn, MVI Belle, Zachary 81mg\nqd, citalopram 20mg daily, ProAir HFA 90mcg 2 IH Q 6h prn,\nTrazodone 200mg qhs, Gabapentin\n300mg Goodwin-Miller Clinic, Lisinopril 5mg daily, Metoprolol ER 50mg\ndaily,Albuterol neb Q 6h, nicoderm 7mg , symbicort 160 Goodwin-Miller Clinic, HFA\nAerosol INH daily, Simvastatin 40mg daily\n\nDischarge Medications:\n1. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)\nCapsule, Extended Release PO DAILY (Daily).\n2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday): Hold for loose stool.', '\n3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID\n(2 times a day).\n4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2\ntimes a day): hold for loose stool.\n5. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a\nday).\n6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\nCapsule, Delayed Release(E.C.) PO DAILY (Daily).\n7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n8. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:\n1-10 mg PO Q4H (every 4 hours) as needed for pain.\n9. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet\nExtended Release PO Q12H (every 12 hours).\n10. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2\ntimes a day).\n11. phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) mg\nPO Q8H (every 8 hours).', '\n12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H\n(every 6 hours).\n13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:\nOne (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply\nto lower back.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nLife Care Center of 362 Paul Motorway Suite 876\nWaltersstad, VA 90362\n\nDischarge Diagnosis:\nMetastatic Melanoma\nDelirium\n\n\nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Bedbound.\n\n\nDischarge Instructions:\nYou were admitted with bleeding in the head. Imaging showed\nthat you had a mass and you part of it taken out. Pathology\nshowed it was melanoma that was metastatic. Your mental status\ndid not improve and the decision was made to focus on your\ncomfort rather than treatment of your cancer.', '\n\nYou are being discharged to hospice.\n\nIt was a pleasure meeting you and participating in your care\n\nFollowup Instructions:\nNone\n\n\n\n']
222	93556	154802.0	2121-04-04	Discharge summary	Report	Admission Date: [2121-3-31] Discharge Date: [2121-4-4] Date of Birth: [2054-10-31] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [2121-3-31] - Coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery, saphenous vein graft to the diagonal, saphenous vein graft to the posterior descending artery. History of Present Illness: This 66 year old man has a history of hypertension, hyperlipidemia and obesity. He has been followed in the [Month/Day/Year 2200] clinic for quite some time. Over the summer the patient noticed several episodes of bilateral shoulder discomfort while walking up a slight incline on the golf course. These episodes would resolve quickly with rest and then he would be able to continue on with the rest of his game without symptoms. Several weeks ago the patient noticed similar bilateral shoulder discomfort after walking only 100 feet. He did not experience any chest discomfort, shortness of breath or other associated symptoms and again, after several minutes of rest his discomfort resolved. He sought consultation with Dr. [Last Name (STitle) 2201] who referred him for stress testing. He exercised 8.25 minutes of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] protocol, reaching 79% of his maximum predicted heart rate. At peak exercise there was diffuse 2.0-3.0 ST segment depression in the inferior leads and 1.0-2.0 mm depression in leads I and V3-V6. The rhythm was sinus with APB??????s and one PVC. Post exercise there were frequent PVC??????s noted including ventricular bigeminy and trigeminy. Imaging revealed a mostly reversible perfusion defect of the septum and apex. A fixed inferior wall defect was also noted. LVEF was 48%. He is now referred for cardiac catheterization to further evaluate. Past Medical History: Hypertension, osteoarthritis, hypercholesterol, basal cell carcinoma Social History: He is a retired owner of an auto radiator company. He drinks a couple of glasses of beer or wine weekdays. He does not smoke. He does like to exercise frequently with golf but finds that quite difficult these days with discomfort. He rates his pain as [8-8] with activity, [5-9] at rest. It is predominantly anterior medial. Family History: Father died at age 46 from "hardening of the arteries". Paternal aunt with carotid artery disease Physical Exam: GENERAL: Healthy-appearing male in no acute distress. VITAL SIGNS: Blood pressure 140/80, temperature 98, pulse 66, and weight 165. NEURO: He is walking without any limp or difficulty. BACK: There is no spinal tenderness. He is very minimally tender deep in his lower lumbosacral area on the right and over the buttocks. Fair reversible lumbar curvature of forward flexion. No pain with internal and external rotation at the hips. EXTREMITIES: Straight leg raising is to almost 85-90 degrees bilaterally. DTRs are diminished bilaterally, about [1-31]+ bilaterally symmetric. Ankle jerks are 2+ bilaterally. Sensation and strength are intact to resistance testing. Pulses are normal. No calf tenderness. No ankle swelling. No thigh tenderness and again, sensation is intact. Brief Hospital Course: Mr. [Known lastname 2202] was admitted to the [Hospital1 18] on [2121-3-31] for elective surgical management of his coronary artery disease. He was taken to the operating room where he underwent three vessel coronary artery bypass grafting. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. He had hypotension requiring pressors. He was transfused with a unit of packed red blood cells which. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy was consulted for assistance with his postoperative strength and mobility. Stopped [4-3] Medications on Admission: Simvastatin40mg/D,Lisinopril 40mg/D,HCTZ 25mg/D,Valtrex 500mg prn,ASA 325mg/D Discharge Medications: 1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 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). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x3 LIMA-LAD, SVG to diag, SVG to PDA on [3-31] Hyperlipidemia Hypertension Obesity Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Report any wound issues to your surgeon at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. Weigh yourself daily. 4) Wash your incision with soap and water daily. Shower daily. No bathing or swimming for 6 weeks. No lotions, creams or powders to incision. 5) No lifting greater the 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while ever taking narcotic pain medicine. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [Last Name (STitle) 2201] in 2 weeks. [Telephone/Fax (1) 62] Please follow-up with Dr. [Last Name (STitle) 2204] in [3-5] weeks. [Telephone/Fax (1) 2205] Scheduled appointments: Provider: [First Name8 (NamePattern2) 2206] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2121-11-14] 10:00 Provider: [Name10 (NameIs) ] NUTRITIONIST Phone:[Telephone/Fax (1) 2207] Date/Time:[2121-11-14] 11:00 Completed by:[2121-4-7]	Admission Date: <Date>1932-9-28</Date> Discharge Date: <Date>1929-8-29</Date> Date of Birth: <Date>1933-1-9</Date> Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Bo</Name> Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: <Date>1932-9-28</Date> - Coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery, saphenous vein graft to the diagonal, saphenous vein graft to the posterior descending artery. History of Present Illness: This 66 year old man has a history of hypertension, hyperlipidemia and obesity. He has been followed in the <Month>November</Month> clinic for quite some time. Over the summer the patient noticed several episodes of bilateral shoulder discomfort while walking up a slight incline on the golf course. These episodes would resolve quickly with rest and then he would be able to continue on with the rest of his game without symptoms. Several weeks ago the patient noticed similar bilateral shoulder discomfort after walking only 100 feet. He did not experience any chest discomfort, shortness of breath or other associated symptoms and again, after several minutes of rest his discomfort resolved. He sought consultation with Dr. <Name>Feguson</Name> who referred him for stress testing. He exercised 8.25 minutes of <Initial>RI</Initial> <Name>Miller</Name> protocol, reaching 79% of his maximum predicted heart rate. At peak exercise there was diffuse 2.0-3.0 ST segment depression in the inferior leads and 1.0-2.0 mm depression in leads I and V3-V6. The rhythm was sinus with APB??????s and one PVC. Post exercise there were frequent PVC??????s noted including ventricular bigeminy and trigeminy. Imaging revealed a mostly reversible perfusion defect of the septum and apex. A fixed inferior wall defect was also noted. LVEF was 48%. He is now referred for cardiac catheterization to further evaluate. Past Medical History: Hypertension, osteoarthritis, hypercholesterol, basal cell carcinoma Social History: He is a retired owner of an auto radiator company. He drinks a couple of glasses of beer or wine weekdays. He does not smoke. He does like to exercise frequently with golf but finds that quite difficult these days with discomfort. He rates his pain as <Date>3-23</Date> with activity, <Date>6-23</Date> at rest. It is predominantly anterior medial. Family History: Father died at age 46 from "hardening of the arteries". Paternal aunt with carotid artery disease Physical Exam: GENERAL: Healthy-appearing male in no acute distress. VITAL SIGNS: Blood pressure 140/80, temperature 98, pulse 66, and weight 165. NEURO: He is walking without any limp or difficulty. BACK: There is no spinal tenderness. He is very minimally tender deep in his lower lumbosacral area on the right and over the buttocks. Fair reversible lumbar curvature of forward flexion. No pain with internal and external rotation at the hips. EXTREMITIES: Straight leg raising is to almost 85-90 degrees bilaterally. DTRs are diminished bilaterally, about <Date>1-24</Date>+ bilaterally symmetric. Ankle jerks are 2+ bilaterally. Sensation and strength are intact to resistance testing. Pulses are normal. No calf tenderness. No ankle swelling. No thigh tenderness and again, sensation is intact. Brief Hospital Course: Mr. <Name>Ahmed</Name> was admitted to the <Hospital>Berry, Gibbs and Dunn Health System</Hospital> on <Date>1932-9-28</Date> for elective surgical management of his coronary artery disease. He was taken to the operating room where he underwent three vessel coronary artery bypass grafting. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. He had hypotension requiring pressors. He was transfused with a unit of packed red blood cells which. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy was consulted for assistance with his postoperative strength and mobility. Stopped <Date>8-1</Date> Medications on Admission: Simvastatin40mg/D,Lisinopril 40mg/D,HCTZ 25mg/D,Valtrex 500mg prn,ASA 325mg/D Discharge Medications: 1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 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). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Home With Service Facility: <Location>33712 Johnson Mills Reneemouth, ID 84457</Location> VNA Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x3 LIMA-LAD, SVG to diag, SVG to PDA on <Date>10-29</Date> Hyperlipidemia Hypertension Obesity Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Report any wound issues to your surgeon at (<Telephone>133-516-8947</Telephone>. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. Weigh yourself daily. 4) Wash your incision with soap and water daily. Shower daily. No bathing or swimming for 6 weeks. No lotions, creams or powders to incision. 5) No lifting greater the 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while ever taking narcotic pain medicine. Followup Instructions: Please follow-up with Dr. <Name>Mao</Name> in 1 month. (<Telephone>133-516-8947</Telephone> Please follow-up with Dr. <Name>Feguson</Name> in 2 weeks. <Telephone>643-600-2450</Telephone> Please follow-up with Dr. <Name>Walker</Name> in <Date>2-9</Date> weeks. <Telephone>142-903-4959</Telephone> Scheduled appointments: Provider: <Name>Alesha</Name> <Name>Judith</Name> <Name>Kiel</Name>, M.D. Phone:<Telephone>643-600-2450</Telephone> Date/Time:<Date>1949-10-11</Date> 10:00 Provider: <Name>Dat Abdullah</Name> NUTRITIONIST Phone:<Telephone>734-553-2092</Telephone> Date/Time:<Date>1949-10-11</Date> 11:00 Completed by:<Date>2009-12-14</Date>	00000000000000000111111111000000000000000000000000000000001111111110000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000110000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111100000000000000000000000000000000000000000000000000000000000000000001101111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111100000000000000000000011111111111111111111111111111111111000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1932-9-28 Discharge Date: 1929-8-29 Date of Birth: 1933-1-9 Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Bo Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: 1932-9-28 - Coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery, saphenous vein graft to the diagonal, saphenous vein graft to the posterior descending artery. History of Present Illness: This 66 year old man has a history of hypertension, hyperlipidemia and obesity. He has been followed in the November clinic for quite some time. Over the summer the patient noticed several episodes of bilateral shoulder discomfort while walking up a slight incline on the golf course. These episodes would resolve quickly with rest and then he would be able to continue on with the rest of his game without symptoms. Several weeks ago the patient noticed similar bilateral shoulder discomfort after walking only 100 feet. He did not experience any chest discomfort, shortness of breath or other associated symptoms and again, after several minutes of rest his discomfort resolved. He sought consultation with Dr. Feguson who referred him for stress testing. He exercised 8.25 minutes of RI Miller protocol, reaching 79% of his maximum predicted heart rate. At peak exercise there was diffuse 2.0-3.0 ST segment depression in the inferior leads and 1.0-2.0 mm depression in leads I and V3-V6. The rhythm was sinus with APB??????s and one PVC. Post exercise there were frequent PVC??????s noted including ventricular bigeminy and trigeminy. Imaging revealed a mostly reversible perfusion defect of the septum and apex. A fixed inferior wall defect was also noted. LVEF was 48%. He is now referred for cardiac catheterization to further evaluate. Past Medical History: Hypertension, osteoarthritis, hypercholesterol, basal cell carcinoma Social History: He is a retired owner of an auto radiator company. He drinks a couple of glasses of beer or wine weekdays. He does not smoke. He does like to exercise frequently with golf but finds that quite difficult these days with discomfort. He rates his pain as 3-23 with activity, 6-23 at rest. It is predominantly anterior medial. Family History: Father died at age 46 from "hardening of the arteries". Paternal aunt with carotid artery disease Physical Exam: GENERAL: Healthy-appearing male in no acute distress. VITAL SIGNS: Blood pressure 140/80, temperature 98, pulse 66, and weight 165. NEURO: He is walking without any limp or difficulty. BACK: There is no spinal tenderness. He is very minimally tender deep in his lower lumbosacral area on the right and over the buttocks. Fair reversible lumbar curvature of forward flexion. No pain with internal and external rotation at the hips. EXTREMITIES: Straight leg raising is to almost 85-90 degrees bilaterally. DTRs are diminished bilaterally, about 1-24+ bilaterally symmetric. Ankle jerks are 2+ bilaterally. Sensation and strength are intact to resistance testing. Pulses are normal. No calf tenderness. No ankle swelling. No thigh tenderness and again, sensation is intact. Brief Hospital Course: Mr. Ahmed was admitted to the Berry, Gibbs and Dunn Health System on 1932-9-28 for elective surgical management of his coronary artery disease. He was taken to the operating room where he underwent three vessel coronary artery bypass grafting. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. He had hypotension requiring pressors. He was transfused with a unit of packed red blood cells which. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy was consulted for assistance with his postoperative strength and mobility. Stopped 8-1 Medications on Admission: Simvastatin40mg/D,Lisinopril 40mg/D,HCTZ 25mg/D,Valtrex 500mg prn,ASA 325mg/D Discharge Medications: 1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 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). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Home With Service Facility: 33712 Johnson Mills Reneemouth, ID 84457 VNA Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x3 LIMA-LAD, SVG to diag, SVG to PDA on 10-29 Hyperlipidemia Hypertension Obesity Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Report any wound issues to your surgeon at (133-516-8947. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. Weigh yourself daily. 4) Wash your incision with soap and water daily. Shower daily. No bathing or swimming for 6 weeks. No lotions, creams or powders to incision. 5) No lifting greater the 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while ever taking narcotic pain medicine. Followup Instructions: Please follow-up with Dr. Mao in 1 month. (133-516-8947 Please follow-up with Dr. Feguson in 2 weeks. 643-600-2450 Please follow-up with Dr. Walker in 2-9 weeks. 142-903-4959 Scheduled appointments: Provider: Alesha Judith Kiel, M.D. Phone:643-600-2450 Date/Time:1949-10-11 10:00 Provider: Dat Abdullah NUTRITIONIST Phone:734-553-2092 Date/Time:1949-10-11 11:00 Completed by:2009-12-14	['Admission Date: 1932-9-28 Discharge Date: 1929-8-29\n\nDate of Birth: 1933-1-9 Sex: M\n\nService: CARDIOTHORACIC\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Bo\nChief Complaint:\nExertional chest pain\n\nMajor Surgical or Invasive Procedure:\n1932-9-28 - Coronary artery bypass grafting x3: Left internal\nmammary artery to left anterior descending artery, saphenous\nvein graft to the diagonal, saphenous vein graft to the\nposterior descending artery.\n\n\nHistory of Present Illness:\nThis 66 year old man has a history of hypertension,\nhyperlipidemia and obesity. He has been followed in the November\nclinic for quite some time. Over the summer the patient noticed\nseveral episodes of bilateral shoulder discomfort while walking\nup a slight incline on the golf course.', ' These episodes would\nresolve quickly with rest and then he would be able to continue\non with the rest of his game without symptoms.\n\nSeveral weeks ago the patient noticed similar bilateral shoulder\ndiscomfort after walking only 100 feet. He did not experience\nany chest discomfort, shortness of breath or other associated\nsymptoms and again, after several minutes of rest his discomfort\nresolved.\n\nHe sought consultation with Dr. Feguson who referred him for\nstress testing. He exercised 8.25 minutes of RI Miller protocol,\nreaching 79% of his maximum predicted heart rate. At peak\nexercise there was diffuse 2.0-3.0 ST segment depression in the\ninferior leads and 1.0-2.0 mm depression in leads I and V3-V6.\nThe rhythm was sinus with APB??????s and one PVC. Post exercise there\nwere frequent PVC??????s noted including ventricular bigeminy and\ntrigeminy.', ' Imaging revealed a mostly reversible perfusion defect\nof the septum and apex. A fixed inferior wall defect was also\nnoted. LVEF was 48%. He is now referred for cardiac\ncatheterization to further evaluate.\n\n\nPast Medical History:\nHypertension, osteoarthritis, hypercholesterol, basal cell\ncarcinoma\n\nSocial History:\nHe is a retired owner of an auto radiator\ncompany. He drinks a couple of glasses of beer or wine weekdays.\n\nHe does not smoke. He does like to exercise frequently with golf\n\nbut finds that quite difficult these days with discomfort. He\nrates his pain as 3-23 with activity, 6-23 at rest. It is\npredominantly anterior medial.\n\n\nFamily History:\nFather died at age 46 from "hardening of the arteries".\nPaternal aunt with carotid artery disease\n\n\nPhysical Exam:\nGENERAL: Healthy-appearing male in no acute distress.', '\nVITAL SIGNS: Blood pressure 140/80, temperature 98, pulse 66,\nand weight 165.\nNEURO: He is walking without any limp or difficulty.\nBACK: There is no spinal tenderness. He is very minimally\ntender deep in his lower lumbosacral area on the right and over\nthe buttocks. Fair reversible lumbar curvature of forward\nflexion. No pain with internal and external rotation at the\nhips.\nEXTREMITIES: Straight leg raising is to almost 85-90 degrees\nbilaterally. DTRs are diminished bilaterally, about 1-24+\nbilaterally symmetric. Ankle jerks are 2+ bilaterally.\nSensation and strength are intact to resistance testing. Pulses\nare normal. No calf tenderness. No ankle swelling. No thigh\ntenderness and again, sensation is intact.\n\n\nBrief Hospital Course:\nMr. Ahmed was admitted to the Berry, Gibbs and Dunn Health System on 1932-9-28 for elective\nsurgical management of his coronary artery disease.', ' He was taken\nto the operating room where he underwent three vessel coronary\nartery bypass grafting. Please see operative note for details.\nPostoperatively he was taken to the intensive care unit for\nmonitoring. Over the next several hours, he awoke neurologically\nintact and was extubated. He had hypotension requiring pressors.\nHe was transfused with a unit of packed red blood cells which.\nOn postoperative day two, he was transferred to the step down\nunit for further recovery. He was gently diuresed towards his\npreoperative weight. The physical therapy was consulted for\nassistance with his postoperative strength and mobility. Stopped\n8-1\n\nMedications on Admission:\nSimvastatin40mg/D,Lisinopril 40mg/D,HCTZ 25mg/D,Valtrex 500mg\nprn,ASA 325mg/D\n\nDischarge Medications:\n1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.', '\nDisp:30 Tablet(s) Refills:2\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).\nDisp:30 Tablet, Delayed Release (E.C.)(s) Refills:2\n4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO\nQ4H (every 4 hours) as needed for pain.\nDisp:75 Tablet(s) Refills:0\n5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:2\n6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\nDisp:60 Tablet(s) Refills:2\n7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once\na day.\nDisp:30 Tablet(s) Refills:2\n8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every\n4 hours) as needed.', '\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\n33712 Johnson Mills\nReneemouth, ID 84457 VNA\n\nDischarge Diagnosis:\nCoronary artery disease s/p coronary artery bypass graft x3\nLIMA-LAD, SVG to diag, SVG to PDA on 10-29\nHyperlipidemia\nHypertension\nObesity\n\n\nDischarge Condition:\nGood\n\n\nDischarge Instructions:\n1) Monitor wounds for signs of infection. These include redness,\ndrainage or increased pain. Report any wound issues to your\nsurgeon at (133-516-8947.\n2) Report any fever greater then 100.5.\n3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in\n1 week. Weigh yourself daily.\n4) Wash your incision with soap and water daily. Shower daily.\nNo bathing or swimming for 6 weeks. No lotions, creams or\npowders to incision.\n5) No lifting greater the 10 pounds for 10 weeks from date of\nsurgery.', '\n6) No driving for 1 month or while ever taking narcotic pain\nmedicine.\n\nFollowup Instructions:\nPlease follow-up with Dr. Mao in 1 month. (133-516-8947\nPlease follow-up with Dr. Feguson in 2 weeks. 643-600-2450\nPlease follow-up with Dr. Walker in 2-9 weeks. 142-903-4959\n\nScheduled appointments:\nProvider: Alesha Judith Kiel, M.D. Phone:643-600-2450\nDate/Time:1949-10-11 10:00\nProvider: Dat Abdullah NUTRITIONIST Phone:734-553-2092\nDate/Time:1949-10-11 11:00\n\n\n\nCompleted by:2009-12-14']
1	23224	174680.0	2147-12-05	Discharge summary	Report	Admission Date: [2147-11-17] Discharge Date: [2147-12-5] Date of Birth: [2092-11-28] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1] Chief Complaint: headache and neck stiffness Major Surgical or Invasive Procedure: central line placed, arterial line placed History of Present Illness: 54 year old female with recent diagnosis of ulcerative colitis on 6-mercaptopurine, prednisone 40-60 mg daily, who presents with a new onset of headache and neck stiffness. The patient is in distress, rigoring and has aphasia and only limited history is obtained. She reports that she was awaken 1AM the morning of [2147-11-16] with a headache which she describes as bandlike. She states that headaches are unusual for her. She denies photo- or phonophobia. She did have neck stiffness. On arrival to the ED at 5:33PM, she was afebrile with a temp of 96.5, however she later spiked with temp to 104.4 (rectal), HR 91, BP 112/54, RR 24, O2 sat 100 %. Head CT was done and relealved attenuation within the subcortical white matter of the right medial frontal lobe. LP was performed showing opening pressure 24 cm H2O WBC of 316, Protein 152, glucose 16. She was given Vancomycin 1 gm IV, Ceftriaxone 2 gm IV, Acyclovir 800 mg IV, Ambesone 183 IV, Ampicillin 2 gm IV q 4, Morphine 2-4 mg Q 4-6, Tylenol 1 gm , Decadron 10 mg IV. The patient was evaluated by Neuro in the ED. . Of note, the patient was recently diagnosed with UC and was started on 6MP and a prednisone taper along with steroid enemas for UC treatment. She was on Bactrim in past but stopped taking it for unclear reasons and unclear how long ago. . Past Medical History: chronic back pain, MRI negative osteopenia - fosamax d/c by PcP leg pain/parasthesias h/o hiatal hernia Social History: No tob, Etoh. Patient lives alone in a 2 family home w/ a friend. She is an administrative assistant Family History: brother w/ ulcerative proctitis, mother w/ severe arthritis, father w/ h/o colon polyps and GERD Physical Exam: VS: 101.4 ; 101/55; 87; 20; 100% at 2L NC Gen: Middle aged, ill-appearing woman, restless in bed, rigoring, in moderate distress HEENT: NC/AT, PEERL, MM dry, no lesions, OP clear, sclera non-icteric Neck: stiff; palpable small LN in right supraclavicular area CV: regular, Nl S1, S2, 3/6 systolic murmur at left lower sternal border Pulm: crackles at base of right lung Abd: + BS, soft, mildly tender in periumbilical area, ND, no rebound, no guarding Ext: 2+ bilateral pitting edema in lower extremities bilaterally, warm skin Skin: no exanthems Neuro: A&O x3, expressive aphasia, CN 2-12 intact, patient has 2+ patellar reflexes bilaterally, no gross motor or sensory deficits. Pertinent Results: [2147-11-16] 05:55PM BLOOD WBC-6.5 RBC-2.64* Hgb-8.2* Hct-24.6* MCV-93 MCH-31.0 MCHC-33.3 RDW-20.1* Plt Ct-577* [2147-11-16] 05:55PM BLOOD Neuts-92.2* Bands-0 Lymphs-5.3* Monos-1.4* Eos-0.9 Baso-0.2 [2147-11-16] 05:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL [2147-11-16] 05:55PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1 [2147-11-18] 04:52AM BLOOD Fibrino-782* [2147-11-16] 05:55PM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-140 K-3.7 Cl-99 HCO3-29 AnGap-16 [2147-11-16] 05:55PM BLOOD LD(LDH)-288* [2147-11-17] 05:14AM BLOOD ALT-28 AST-42* LD(LDH)-424* AlkPhos-33* Amylase-63 TotBili-0.6 [2147-11-18] 04:52AM BLOOD ALT-25 AST-25 LD(LDH)-315* AlkPhos-34* TotBili-0.3 [2147-11-17] 05:14AM BLOOD Lipase-25 [2147-11-17] 05:14AM BLOOD Albumin-2.2* Calcium-7.5* Phos-3.6 Mg-1.5* Iron-8* [2147-11-21] 06:43PM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.6 Mg-1.7 [2147-11-17] 05:14AM BLOOD calTIBC-152* Ferritn-298* TRF-117* [2147-11-17] 08:01PM BLOOD Type-ART Temp-38.9 Rates-/24 FiO2-100 pO2-58* pCO2-33* pH-7.47* calHCO3-25 Base XS-0 AADO2-645 REQ O2-100 Intubat-NOT INTUBA [2147-11-18] 12:44AM BLOOD Type-ART Temp-39.1 Rates-/24 FiO2-100 pO2-69* pCO2-35 pH-7.48* calHCO3-27 Base XS-2 AADO2-632 REQ O2-99 Intubat-NOT INTUBA Comment-NON-REBREA [2147-11-18] 04:18PM BLOOD Type-ART FiO2-100 pO2-222* pCO2-31* pH-7.47* calHCO3-23 Base XS-0 AADO2-478 REQ O2-79 Intubat-NOT INTUBA [2147-11-18] 04:38PM BLOOD Type-ART pO2-61* pCO2-33* pH-7.45 calHCO3-24 Base XS-0 Intubat-NOT INTUBA [2147-11-19] 12:11AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-350 FiO2-100 pO2-137* pCO2-35 pH-7.47* calHCO3-26 Base XS-2 AADO2-559 REQ O2-90 Intubat-NOT INTUBA Vent-SPONTANEOU [2147-11-19] 10:29AM BLOOD Type-ART PEEP-8 pO2-89 pCO2-33* pH-7.51* calHCO3-27 Base XS-3 Intubat-NOT INTUBA [2147-11-21] 05:25AM BLOOD Type-ART Temp-38.4 Rates-/24 FiO2-100 pO2-58* pCO2-36 pH-7.52* calHCO3-30 Base XS-5 AADO2-638 REQ O2-100 Intubat-NOT INTUBA [2147-11-22] 04:52AM BLOOD Type-ART Temp-37.3 Rates-0/24 O2 Flow-5 pO2-64* pCO2-29* pH-7.50* calHCO3-23 Base XS-0 [2147-11-16] 06:01PM BLOOD Lactate-2.1* K-3.4* [2147-11-21] 08:04PM BLOOD Lactate-0.8 [2147-11-18] 08:41AM BLOOD freeCa-1.01* [2147-11-22] 04:16AM BLOOD WBC-9.4# RBC-3.77* Hgb-11.5* Hct-33.4* MCV-89 MCH-30.5 MCHC-34.5 RDW-20.0* Plt Ct-597* [2147-11-17] 05:14AM BLOOD WBC-7.6 RBC-2.16* Hgb-6.8* Hct-20.0* MCV-92 MCH-31.6 MCHC-34.2 RDW-20.0* Plt Ct-415 [2147-11-17] 03:57PM BLOOD Hct-23.2* [2147-11-18] 04:11PM BLOOD WBC-5.1 RBC-2.60* Hgb-7.8* Hct-22.7* MCV-87 MCH-30.1 MCHC-34.4 RDW-21.0* Plt Ct-395 [2147-11-19] 05:52AM BLOOD WBC-4.8 RBC-3.08* Hgb-9.0* Hct-26.5* MCV-86 MCH-29.2 MCHC-33.9 RDW-20.7* Plt Ct-409 [2147-11-21] 06:43PM BLOOD Neuts-91.0* Bands-0 Lymphs-7.3* Monos-1.4* Eos-0.2 Baso-0 [2147-11-22] 04:16AM BLOOD Plt Ct-597* [2147-11-21] 04:39AM BLOOD PT-12.2 PTT-22.6 INR(PT)-1.0 [2147-11-21] 04:39AM BLOOD Plt Ct-498* [2147-11-18] 04:11PM BLOOD Plt Ct-395 [2147-11-22] 04:16AM BLOOD Glucose-104 UreaN-19 Creat-1.1 Na-136 K-4.1 Cl-104 HCO3-21* AnGap-15 [2147-11-21] 06:43PM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-133 K-4.3 Cl-100 HCO3-24 AnGap-13 [2147-11-20] 04:41PM BLOOD Glucose-161* UreaN-15 Creat-1.0 Na-138 K-4.3 Cl-99 HCO3-28 AnGap-15 [2147-11-19] 05:52AM BLOOD Glucose-81 UreaN-16 Creat-0.8 Na-138 K-5.0 Cl-106 HCO3-23 AnGap-14 [2147-11-18] 04:52AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-136 K-4.3 Cl-103 HCO3-23 AnGap-14 [2147-11-17] 05:14AM BLOOD Glucose-223* UreaN-21* Creat-1.0 Na-135 K-4.3 Cl-99 HCO3-27 AnGap-13 . . . Radiology: CXR [11-16]: Diffusely increased opacities at the lung fields bilaterally. In an immunocompromised patient, this is concerning for PCP [Name Initial (PRE) 2]. Radiographically, the differential includes pulmonary edema. Additionally, there is a faint opacity at the right lung base, which may represent atelectasis or focal pneumonic process. . CT-Head [11-16]: Focus of low attenuation within the subcortical white matter of the right medial frontal lobe. This may represent a subacute infarction; however, an underlying mass lesion cannot be completely excluded. An MRI examination with gadolinium and diffusion-weighted imaging is recommended for further evaluation. No intracranial hemorrhage noted. . MR-head-w&w/o gadolinium [11-18]: Signal abnormality in the medial right frontal lobe involving the corpus callosum does not demonstrate enhancement. This finding most likely represent a small infarct. However, in absence of ADC map, age of the infarct could not be determined. No abnormal enhancement is seen. Follow up is suggested, if clinically indicated. . Echo [11-18]: 1.The left atrium is mildly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. While difficult to assess given the limited views suspect Mild (1+) mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. . If clinically indicated, would recommend a TEE. . CXR [11-21]: Resolution of congestive failure with persistent small bilateral pleural effusions and bibasilar atelectasis . Studies: EEG [11-17]: This is a mildly abnormal EEG due to the presence of a slow and disorganized background with bursts of generalized slowing - all consistent with a mild encephalopathy of toxic, metabolic, or anoxic etiology. No evidence for ongoing seizures is seen. Brief Hospital Course: A/P: 54 woman on immunosuppressive therapy for UC (prednisone, 6MP) who presents with new onset HA, fever with bacterial meningitis and gram positive rod bacteremia. . #. Listeriosis - meningitis and bacteremia. Patient presented with headache, nuchal rigidity, expressive aphasia, afebrile on admission but temp to 104.4 in the ED, where she also started to have rigors. LP showed >300 WBC, poly predominant with 5% monocytes, protein 152 glucose 16. CSF gram stain showed gram positive rods, blood culture grew gram positive rods, speciation eventually grew listeria. Empiric treatment based on gram stain was started: ampicillin and bactrim (to cover both nocardia and question of PCP, [Name10 (NameIs) 3] below), vanc and ceftriaxone as well pending confirmation of gram stain and culture results. Once speciations was confirmed, a five day course of gentamicin was started for synergy, and vancomycin and ceftriaxone d/c'd. Bactrim was maintained on treatment dose for concern for PCP [Name Initial (PRE) 4] [11-21], when it was changed to prophylaxis dose. Early on admission, she developed hypotension that required levophed, but was weaned off of pressors within the first couple of days of admission with PRBCs (total of 4 units) and volume resussitation. Given bacteremia, TTE was done, no vegetations or lesions noted. Head CT on admission showed right medial frontal lobe likely infarct versus mass lesion, no hemorrhage. Subsequent MRI confirmed infarct, unclear date, and EEG consistent with meningitis. Neurology was consulted, and the patient was placed on dilantin for seizure prophylaxis given meningoencephalitis. She spiked fevers to 101-102 over the first several days of admission. By [11-19], her neurological exam was markedly improved, and by [11-21] her headache was gone, no meningeal signs noted, although her baseline essential tremor was slightly more severe. Surveillance blood cultures reamined negative from [11-17] on. Notably, she was transferred from ICU to floor on [11-21], but noninvasive BP was read as 60/d, patient mentating well, sent back to ICU. In the ICU, an arterial line was placed, and consistently read 20-30 mmHg higher than sphyngomanometer. This discrepancy was of unclear etiology, but persistent. Patient maintained normal mentation, good urine output, no tachycardia, and it was judged that, for some unclear reason, the cuff pressures underestimated by 20-30 points. On [11-23], she was sent to the floor for further care and management. . #. Bilateral lung opacities/hypoxia. Initial chest film read as increased opacities bilaterally concerning for PCP (given steroids and no PCP [Name Initial (PRE) 5]) vs. bacterial pneumonia vs. pulmonary edema. She had signifcant oxygen requirement, and her respiratory distress led to her being placed on CPAP+PS. The origin of her significant hypoxia was originally thought to be secondary to likely vascular leak from sepsis/CHF versus PCP. [Name10 (NameIs) 6] induced sputum was attempted, but was unsuccessful, and was not repeated initally given her unstable respiratory status, and susbsequent evaluation that likelihood of PCP was small. She responded well to lasix diuresis, with reduced O2 requirements. . #. UC: She continued to receive her outpatient dose of prednisone, which was changed on [11-22] to dexamethasone IV; her outpatient 6-MP was held. After several days with no diarrhea, it recurred on [11-22] soon after her diet had advanced. C.diff was negative. She was made NPO, and fed via TPN for bowel rest. On [11-24], it was noted that she began passing BRBRP, her hematocrit was noted to drop two points and pt was typed and crossed and consent for blood transfusion. . #. Anemia. On admission, she was found to be anemic. She received PRBCs for anemia on admission and again [11-19] for mixed venous sat <70%. She was found to have iron binding studies c/w anemia of chronic disease. Her HCT was followed closely, and remained stable for the remainder of her admission. . #. FEN: Her diet was advanced as tolerated, but she was made NPO with TPN on [11-22] after she developed diarrhea, thought secondary to continued UC activity. . #. Prophylaxis: PPI. Hold SQ Hep, pneumoboots. Initially on droplet precautions. . #. Code status: FULL . #. Communication: patient, her sister, brother, and mother . #. Lines: peripheral IV x 2. left subclavian CC. A-line. Eval for PICC; once in place, can d/c central line, a-line. Surgery Discharge part: Pt underwent total abdominal colectomy with ileoostomy on [2147-11-26]. She was on Clinda/Gent peri-procedure and Amplicillin for 21 days at first. She was seen by PT/OT and was NPO until the ostomy started to function. SHe had c/o nausea as diet was tolerated and it was slowed down. MRI was suspicious for an abcess and amplicillin was started for at least a total of 6 weeks as per ID. She was given a PICC. On [12-5] she was cleared by PT and was in good condition for d/c to rehab on [2147-12-5]. Medications on Admission: AMBIEN 10 mg--1 tablet(s) by mouth at bedtime CLONAZEPAM 1 MG--One twice a day FLUOXETINE 20 MG--2 every day FOSAMAX 70MG--One qweek as directed FUROSEMIDE 20 mg--1 tablet(s) by mouth once a day MERCAPTOPURINE 50 mg--1 tablet(s) by mouth twice a day PREDNISONE 20 mg--2 tablet(s) by mouth once a day as per gastroenterologist PROTONIX 40 mg--1 tablet(s) by mouth once a day Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2-4HPRN (). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every Thursday). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 13. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln Injection Q4H (every 4 hours): Please take until at least [12-28]. You will be further instructed by the infectious disease doctors. 14. PREDNISONE TAPER (see included sheet) 10 mg in morning and 10 mg in evening for 3 days Next take 10 mg in the morning and 7.5 mg in evening for 3 days Next take 7.5 mg in the morning and 7.5 mg in the eveing for 3 days Then take 7.5 mg in the morning and 5 mg in the evening Next take 5 mg in the morning and 5 mg in the evening for 3 days Then take 5 mg in the morning and 2.5 mg in the evening for 3 days Next take 2.5 mg in the morning and 2.5 mg in the evening for 3 days Finally take 2.5 mg in the morning and none in the evening for 3 days. Then take no more prednisone Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Listeria meningitis Ulcerative colitis Discharge Condition: Stable Discharge Instructions: Please call your doctor if you have a fever >101.4, inability to pass gas or stool into the ostomy, severe pain, persistent nausea, vomiting, or any other concerns. Please take all medications as prescribed and complete the course of antibiotics. Followup Instructions: Please make an appointment to see Dr. [Last Name (STitle) ] in 2 weeks, telephone [Telephone/Fax (1) 9]. Please follow up with your primary care MD in [1-22] weeks. You have an appointment with Infectious disease on [12-25] ([Telephone/Fax (1) 10]. You have an MRI scheduled on [2147-12-22] [Telephone/Fax (1) 11].	Admission Date: <Date>1969-8-24</Date> Discharge Date: <Date>1990-1-25</Date> Date of Birth: <Date>1950-4-13</Date> Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Amy</Name> Chief Complaint: headache and neck stiffness Major Surgical or Invasive Procedure: central line placed, arterial line placed History of Present Illness: 54 year old female with recent diagnosis of ulcerative colitis on 6-mercaptopurine, prednisone 40-60 mg daily, who presents with a new onset of headache and neck stiffness. The patient is in distress, rigoring and has aphasia and only limited history is obtained. She reports that she was awaken 1AM the morning of <Date>1910-9-21</Date> with a headache which she describes as bandlike. She states that headaches are unusual for her. She denies photo- or phonophobia. She did have neck stiffness. On arrival to the ED at 5:33PM, she was afebrile with a temp of 96.5, however she later spiked with temp to 104.4 (rectal), HR 91, BP 112/54, RR 24, O2 sat 100 %. Head CT was done and relealved attenuation within the subcortical white matter of the right medial frontal lobe. LP was performed showing opening pressure 24 cm H2O WBC of 316, Protein 152, glucose 16. She was given Vancomycin 1 gm IV, Ceftriaxone 2 gm IV, Acyclovir 800 mg IV, Ambesone 183 IV, Ampicillin 2 gm IV q 4, Morphine 2-4 mg Q 4-6, Tylenol 1 gm , Decadron 10 mg IV. The patient was evaluated by Neuro in the ED. . Of note, the patient was recently diagnosed with UC and was started on 6MP and a prednisone taper along with steroid enemas for UC treatment. She was on Bactrim in past but stopped taking it for unclear reasons and unclear how long ago. . Past Medical History: chronic back pain, MRI negative osteopenia - fosamax d/c by PcP leg pain/parasthesias h/o hiatal hernia Social History: No tob, Etoh. Patient lives alone in a 2 family home w/ a friend. She is an administrative assistant Family History: brother w/ ulcerative proctitis, mother w/ severe arthritis, father w/ h/o colon polyps and GERD Physical Exam: VS: 101.4 ; 101/55; 87; 20; 100% at 2L NC Gen: Middle aged, ill-appearing woman, restless in bed, rigoring, in moderate distress HEENT: NC/AT, PEERL, MM dry, no lesions, OP clear, sclera non-icteric Neck: stiff; palpable small LN in right supraclavicular area CV: regular, Nl S1, S2, 3/6 systolic murmur at left lower sternal border Pulm: crackles at base of right lung Abd: + BS, soft, mildly tender in periumbilical area, ND, no rebound, no guarding Ext: 2+ bilateral pitting edema in lower extremities bilaterally, warm skin Skin: no exanthems Neuro: A&O x3, expressive aphasia, CN 2-12 intact, patient has 2+ patellar reflexes bilaterally, no gross motor or sensory deficits. Pertinent Results: <Date>1910-9-21</Date> 05:55PM BLOOD WBC-6.5 RBC-2.64* Hgb-8.2* Hct-24.6* MCV-93 MCH-31.0 MCHC-33.3 RDW-20.1* Plt Ct-577* <Date>1910-9-21</Date> 05:55PM BLOOD Neuts-92.2* Bands-0 Lymphs-5.3* Monos-1.4* Eos-0.9 Baso-0.2 <Date>1910-9-21</Date> 05:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL <Date>1910-9-21</Date> 05:55PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1 <Date>1910-11-27</Date> 04:52AM BLOOD Fibrino-782* <Date>1910-9-21</Date> 05:55PM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-140 K-3.7 Cl-99 HCO3-29 AnGap-16 <Date>1910-9-21</Date> 05:55PM BLOOD LD(LDH)-288* <Date>1969-8-24</Date> 05:14AM BLOOD ALT-28 AST-42* LD(LDH)-424* AlkPhos-33* Amylase-63 TotBili-0.6 <Date>1910-11-27</Date> 04:52AM BLOOD ALT-25 AST-25 LD(LDH)-315* AlkPhos-34* TotBili-0.3 <Date>1969-8-24</Date> 05:14AM BLOOD Lipase-25 <Date>1969-8-24</Date> 05:14AM BLOOD Albumin-2.2* Calcium-7.5* Phos-3.6 Mg-1.5* Iron-8* <Date>1948-2-31</Date> 06:43PM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.6 Mg-1.7 <Date>1969-8-24</Date> 05:14AM BLOOD calTIBC-152* Ferritn-298* TRF-117* <Date>1969-8-24</Date> 08:01PM BLOOD Type-ART Temp-38.9 Rates-/24 FiO2-100 pO2-58* pCO2-33* pH-7.47* calHCO3-25 Base XS-0 AADO2-645 REQ O2-100 Intubat-NOT INTUBA <Date>1910-11-27</Date> 12:44AM BLOOD Type-ART Temp-39.1 Rates-/24 FiO2-100 pO2-69* pCO2-35 pH-7.48* calHCO3-27 Base XS-2 AADO2-632 REQ O2-99 Intubat-NOT INTUBA Comment-NON-REBREA <Date>1910-11-27</Date> 04:18PM BLOOD Type-ART FiO2-100 pO2-222* pCO2-31* pH-7.47* calHCO3-23 Base XS-0 AADO2-478 REQ O2-79 Intubat-NOT INTUBA <Date>1910-11-27</Date> 04:38PM BLOOD Type-ART pO2-61* pCO2-33* pH-7.45 calHCO3-24 Base XS-0 Intubat-NOT INTUBA <Date>2016-12-6</Date> 12:11AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-350 FiO2-100 pO2-137* pCO2-35 pH-7.47* calHCO3-26 Base XS-2 AADO2-559 REQ O2-90 Intubat-NOT INTUBA Vent-SPONTANEOU <Date>2016-12-6</Date> 10:29AM BLOOD Type-ART PEEP-8 pO2-89 pCO2-33* pH-7.51* calHCO3-27 Base XS-3 Intubat-NOT INTUBA <Date>1948-2-31</Date> 05:25AM BLOOD Type-ART Temp-38.4 Rates-/24 FiO2-100 pO2-58* pCO2-36 pH-7.52* calHCO3-30 Base XS-5 AADO2-638 REQ O2-100 Intubat-NOT INTUBA <Date>1954-8-8</Date> 04:52AM BLOOD Type-ART Temp-37.3 Rates-0/24 O2 Flow-5 pO2-64* pCO2-29* pH-7.50* calHCO3-23 Base XS-0 <Date>1910-9-21</Date> 06:01PM BLOOD Lactate-2.1* K-3.4* <Date>1948-2-31</Date> 08:04PM BLOOD Lactate-0.8 <Date>1910-11-27</Date> 08:41AM BLOOD freeCa-1.01* <Date>1954-8-8</Date> 04:16AM BLOOD WBC-9.4# RBC-3.77* Hgb-11.5* Hct-33.4* MCV-89 MCH-30.5 MCHC-34.5 RDW-20.0* Plt Ct-597* <Date>1969-8-24</Date> 05:14AM BLOOD WBC-7.6 RBC-2.16* Hgb-6.8* Hct-20.0* MCV-92 MCH-31.6 MCHC-34.2 RDW-20.0* Plt Ct-415 <Date>1969-8-24</Date> 03:57PM BLOOD Hct-23.2* <Date>1910-11-27</Date> 04:11PM BLOOD WBC-5.1 RBC-2.60* Hgb-7.8* Hct-22.7* MCV-87 MCH-30.1 MCHC-34.4 RDW-21.0* Plt Ct-395 <Date>2016-12-6</Date> 05:52AM BLOOD WBC-4.8 RBC-3.08* Hgb-9.0* Hct-26.5* MCV-86 MCH-29.2 MCHC-33.9 RDW-20.7* Plt Ct-409 <Date>1948-2-31</Date> 06:43PM BLOOD Neuts-91.0* Bands-0 Lymphs-7.3* Monos-1.4* Eos-0.2 Baso-0 <Date>1954-8-8</Date> 04:16AM BLOOD Plt Ct-597* <Date>1948-2-31</Date> 04:39AM BLOOD PT-12.2 PTT-22.6 INR(PT)-1.0 <Date>1948-2-31</Date> 04:39AM BLOOD Plt Ct-498* <Date>1910-11-27</Date> 04:11PM BLOOD Plt Ct-395 <Date>1954-8-8</Date> 04:16AM BLOOD Glucose-104 UreaN-19 Creat-1.1 Na-136 K-4.1 Cl-104 HCO3-21* AnGap-15 <Date>1948-2-31</Date> 06:43PM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-133 K-4.3 Cl-100 HCO3-24 AnGap-13 <Date>1901-10-29</Date> 04:41PM BLOOD Glucose-161* UreaN-15 Creat-1.0 Na-138 K-4.3 Cl-99 HCO3-28 AnGap-15 <Date>2016-12-6</Date> 05:52AM BLOOD Glucose-81 UreaN-16 Creat-0.8 Na-138 K-5.0 Cl-106 HCO3-23 AnGap-14 <Date>1910-11-27</Date> 04:52AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-136 K-4.3 Cl-103 HCO3-23 AnGap-14 <Date>1969-8-24</Date> 05:14AM BLOOD Glucose-223* UreaN-21* Creat-1.0 Na-135 K-4.3 Cl-99 HCO3-27 AnGap-13 . . . Radiology: CXR <Date>9-14</Date>: Diffusely increased opacities at the lung fields bilaterally. In an immunocompromised patient, this is concerning for PCP <Name>Stephanie Cobbs</Name>. Radiographically, the differential includes pulmonary edema. Additionally, there is a faint opacity at the right lung base, which may represent atelectasis or focal pneumonic process. . CT-Head <Date>9-14</Date>: Focus of low attenuation within the subcortical white matter of the right medial frontal lobe. This may represent a subacute infarction; however, an underlying mass lesion cannot be completely excluded. An MRI examination with gadolinium and diffusion-weighted imaging is recommended for further evaluation. No intracranial hemorrhage noted. . MR-head-w&w/o gadolinium <Date>4-18</Date>: Signal abnormality in the medial right frontal lobe involving the corpus callosum does not demonstrate enhancement. This finding most likely represent a small infarct. However, in absence of ADC map, age of the infarct could not be determined. No abnormal enhancement is seen. Follow up is suggested, if clinically indicated. . Echo <Date>4-18</Date>: 1.The left atrium is mildly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. While difficult to assess given the limited views suspect Mild (1+) mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. . If clinically indicated, would recommend a TEE. . CXR <Date>8-28</Date>: Resolution of congestive failure with persistent small bilateral pleural effusions and bibasilar atelectasis . Studies: EEG <Date>6-11</Date>: This is a mildly abnormal EEG due to the presence of a slow and disorganized background with bursts of generalized slowing - all consistent with a mild encephalopathy of toxic, metabolic, or anoxic etiology. No evidence for ongoing seizures is seen. Brief Hospital Course: A/P: 54 woman on immunosuppressive therapy for UC (prednisone, 6MP) who presents with new onset HA, fever with bacterial meningitis and gram positive rod bacteremia. . #. Listeriosis - meningitis and bacteremia. Patient presented with headache, nuchal rigidity, expressive aphasia, afebrile on admission but temp to 104.4 in the ED, where she also started to have rigors. LP showed >300 WBC, poly predominant with 5% monocytes, protein 152 glucose 16. CSF gram stain showed gram positive rods, blood culture grew gram positive rods, speciation eventually grew listeria. Empiric treatment based on gram stain was started: ampicillin and bactrim (to cover both nocardia and question of PCP, <Name>Kay Kenner</Name> below), vanc and ceftriaxone as well pending confirmation of gram stain and culture results. Once speciations was confirmed, a five day course of gentamicin was started for synergy, and vancomycin and ceftriaxone d/c'd. Bactrim was maintained on treatment dose for concern for PCP <Name>Ted Ornelas</Name> <Date>8-28</Date>, when it was changed to prophylaxis dose. Early on admission, she developed hypotension that required levophed, but was weaned off of pressors within the first couple of days of admission with PRBCs (total of 4 units) and volume resussitation. Given bacteremia, TTE was done, no vegetations or lesions noted. Head CT on admission showed right medial frontal lobe likely infarct versus mass lesion, no hemorrhage. Subsequent MRI confirmed infarct, unclear date, and EEG consistent with meningitis. Neurology was consulted, and the patient was placed on dilantin for seizure prophylaxis given meningoencephalitis. She spiked fevers to 101-102 over the first several days of admission. By <Date>3-12</Date>, her neurological exam was markedly improved, and by <Date>8-28</Date> her headache was gone, no meningeal signs noted, although her baseline essential tremor was slightly more severe. Surveillance blood cultures reamined negative from <Date>6-11</Date> on. Notably, she was transferred from ICU to floor on <Date>8-28</Date>, but noninvasive BP was read as 60/d, patient mentating well, sent back to ICU. In the ICU, an arterial line was placed, and consistently read 20-30 mmHg higher than sphyngomanometer. This discrepancy was of unclear etiology, but persistent. Patient maintained normal mentation, good urine output, no tachycardia, and it was judged that, for some unclear reason, the cuff pressures underestimated by 20-30 points. On <Date>3-17</Date>, she was sent to the floor for further care and management. . #. Bilateral lung opacities/hypoxia. Initial chest film read as increased opacities bilaterally concerning for PCP (given steroids and no PCP <Name>Samuel Kenner</Name>) vs. bacterial pneumonia vs. pulmonary edema. She had signifcant oxygen requirement, and her respiratory distress led to her being placed on CPAP+PS. The origin of her significant hypoxia was originally thought to be secondary to likely vascular leak from sepsis/CHF versus PCP. <Name>Odell Merino</Name> induced sputum was attempted, but was unsuccessful, and was not repeated initally given her unstable respiratory status, and susbsequent evaluation that likelihood of PCP was small. She responded well to lasix diuresis, with reduced O2 requirements. . #. UC: She continued to receive her outpatient dose of prednisone, which was changed on <Date>4-3</Date> to dexamethasone IV; her outpatient 6-MP was held. After several days with no diarrhea, it recurred on <Date>4-3</Date> soon after her diet had advanced. C.diff was negative. She was made NPO, and fed via TPN for bowel rest. On <Date>8-26</Date>, it was noted that she began passing BRBRP, her hematocrit was noted to drop two points and pt was typed and crossed and consent for blood transfusion. . #. Anemia. On admission, she was found to be anemic. She received PRBCs for anemia on admission and again <Date>3-12</Date> for mixed venous sat <70%. She was found to have iron binding studies c/w anemia of chronic disease. Her HCT was followed closely, and remained stable for the remainder of her admission. . #. FEN: Her diet was advanced as tolerated, but she was made NPO with TPN on <Date>4-3</Date> after she developed diarrhea, thought secondary to continued UC activity. . #. Prophylaxis: PPI. Hold SQ Hep, pneumoboots. Initially on droplet precautions. . #. Code status: FULL . #. Communication: patient, her sister, brother, and mother . #. Lines: peripheral IV x 2. left subclavian CC. A-line. Eval for PICC; once in place, can d/c central line, a-line. Surgery Discharge part: Pt underwent total abdominal colectomy with ileoostomy on <Date>1958-6-29</Date>. She was on Clinda/Gent peri-procedure and Amplicillin for 21 days at first. She was seen by PT/OT and was NPO until the ostomy started to function. SHe had c/o nausea as diet was tolerated and it was slowed down. MRI was suspicious for an abcess and amplicillin was started for at least a total of 6 weeks as per ID. She was given a PICC. On <Date>8-31</Date> she was cleared by PT and was in good condition for d/c to rehab on <Date>1990-1-25</Date>. Medications on Admission: AMBIEN 10 mg--1 tablet(s) by mouth at bedtime CLONAZEPAM 1 MG--One twice a day FLUOXETINE 20 MG--2 every day FOSAMAX 70MG--One qweek as directed FUROSEMIDE 20 mg--1 tablet(s) by mouth once a day MERCAPTOPURINE 50 mg--1 tablet(s) by mouth twice a day PREDNISONE 20 mg--2 tablet(s) by mouth once a day as per gastroenterologist PROTONIX 40 mg--1 tablet(s) by mouth once a day Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2-4HPRN (). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every Thursday). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 13. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln Injection Q4H (every 4 hours): Please take until at least <Date>2-24</Date>. You will be further instructed by the infectious disease doctors. 14. PREDNISONE TAPER (see included sheet) 10 mg in morning and 10 mg in evening for 3 days Next take 10 mg in the morning and 7.5 mg in evening for 3 days Next take 7.5 mg in the morning and 7.5 mg in the eveing for 3 days Then take 7.5 mg in the morning and 5 mg in the evening Next take 5 mg in the morning and 5 mg in the evening for 3 days Then take 5 mg in the morning and 2.5 mg in the evening for 3 days Next take 2.5 mg in the morning and 2.5 mg in the evening for 3 days Finally take 2.5 mg in the morning and none in the evening for 3 days. Then take no more prednisone Discharge Disposition: Extended Care Facility: <Hospital>Snyder Inc Health System</Hospital> & Rehab Center - <Hospital>Martin, Martin and Berry Medical Center</Hospital> Discharge Diagnosis: Listeria meningitis Ulcerative colitis Discharge Condition: Stable Discharge Instructions: Please call your doctor if you have a fever >101.4, inability to pass gas or stool into the ostomy, severe pain, persistent nausea, vomiting, or any other concerns. Please take all medications as prescribed and complete the course of antibiotics. Followup Instructions: Please make an appointment to see Dr. <Name>Salgado</Name> in 2 weeks, telephone <Telephone>532-827-1427</Telephone>. Please follow up with your primary care MD in <Date>2-13</Date> weeks. You have an appointment with Infectious disease on <Date>8-14</Date> (<Telephone>138-739-7593</Telephone>. You have an MRI scheduled on <Date>1910-1-2</Date> <Telephone>404-764-4837</Telephone>.	0000000000000000011111111100000000000000000000000000000000111111111000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000111111111100000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000111111111000000000000000000000000000111111111100000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000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Date: 1969-8-24 Discharge Date: 1990-1-25 Date of Birth: 1950-4-13 Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Amy Chief Complaint: headache and neck stiffness Major Surgical or Invasive Procedure: central line placed, arterial line placed History of Present Illness: 54 year old female with recent diagnosis of ulcerative colitis on 6-mercaptopurine, prednisone 40-60 mg daily, who presents with a new onset of headache and neck stiffness. The patient is in distress, rigoring and has aphasia and only limited history is obtained. She reports that she was awaken 1AM the morning of 1910-9-21 with a headache which she describes as bandlike. She states that headaches are unusual for her. She denies photo- or phonophobia. She did have neck stiffness. On arrival to the ED at 5:33PM, she was afebrile with a temp of 96.5, however she later spiked with temp to 104.4 (rectal), HR 91, BP 112/54, RR 24, O2 sat 100 %. Head CT was done and relealved attenuation within the subcortical white matter of the right medial frontal lobe. LP was performed showing opening pressure 24 cm H2O WBC of 316, Protein 152, glucose 16. She was given Vancomycin 1 gm IV, Ceftriaxone 2 gm IV, Acyclovir 800 mg IV, Ambesone 183 IV, Ampicillin 2 gm IV q 4, Morphine 2-4 mg Q 4-6, Tylenol 1 gm , Decadron 10 mg IV. The patient was evaluated by Neuro in the ED. . Of note, the patient was recently diagnosed with UC and was started on 6MP and a prednisone taper along with steroid enemas for UC treatment. She was on Bactrim in past but stopped taking it for unclear reasons and unclear how long ago. . Past Medical History: chronic back pain, MRI negative osteopenia - fosamax d/c by PcP leg pain/parasthesias h/o hiatal hernia Social History: No tob, Etoh. Patient lives alone in a 2 family home w/ a friend. She is an administrative assistant Family History: brother w/ ulcerative proctitis, mother w/ severe arthritis, father w/ h/o colon polyps and GERD Physical Exam: VS: 101.4 ; 101/55; 87; 20; 100% at 2L NC Gen: Middle aged, ill-appearing woman, restless in bed, rigoring, in moderate distress HEENT: NC/AT, PEERL, MM dry, no lesions, OP clear, sclera non-icteric Neck: stiff; palpable small LN in right supraclavicular area CV: regular, Nl S1, S2, 3/6 systolic murmur at left lower sternal border Pulm: crackles at base of right lung Abd: + BS, soft, mildly tender in periumbilical area, ND, no rebound, no guarding Ext: 2+ bilateral pitting edema in lower extremities bilaterally, warm skin Skin: no exanthems Neuro: A&O x3, expressive aphasia, CN 2-12 intact, patient has 2+ patellar reflexes bilaterally, no gross motor or sensory deficits. Pertinent Results: 1910-9-21 05:55PM BLOOD WBC-6.5 RBC-2.64* Hgb-8.2* Hct-24.6* MCV-93 MCH-31.0 MCHC-33.3 RDW-20.1* Plt Ct-577* 1910-9-21 05:55PM BLOOD Neuts-92.2* Bands-0 Lymphs-5.3* Monos-1.4* Eos-0.9 Baso-0.2 1910-9-21 05:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL 1910-9-21 05:55PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1 1910-11-27 04:52AM BLOOD Fibrino-782* 1910-9-21 05:55PM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-140 K-3.7 Cl-99 HCO3-29 AnGap-16 1910-9-21 05:55PM BLOOD LD(LDH)-288* 1969-8-24 05:14AM BLOOD ALT-28 AST-42* LD(LDH)-424* AlkPhos-33* Amylase-63 TotBili-0.6 1910-11-27 04:52AM BLOOD ALT-25 AST-25 LD(LDH)-315* AlkPhos-34* TotBili-0.3 1969-8-24 05:14AM BLOOD Lipase-25 1969-8-24 05:14AM BLOOD Albumin-2.2* Calcium-7.5* Phos-3.6 Mg-1.5* Iron-8* 1948-2-31 06:43PM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.6 Mg-1.7 1969-8-24 05:14AM BLOOD calTIBC-152* Ferritn-298* TRF-117* 1969-8-24 08:01PM BLOOD Type-ART Temp-38.9 Rates-/24 FiO2-100 pO2-58* pCO2-33* pH-7.47* calHCO3-25 Base XS-0 AADO2-645 REQ O2-100 Intubat-NOT INTUBA 1910-11-27 12:44AM BLOOD Type-ART Temp-39.1 Rates-/24 FiO2-100 pO2-69* pCO2-35 pH-7.48* calHCO3-27 Base XS-2 AADO2-632 REQ O2-99 Intubat-NOT INTUBA Comment-NON-REBREA 1910-11-27 04:18PM BLOOD Type-ART FiO2-100 pO2-222* pCO2-31* pH-7.47* calHCO3-23 Base XS-0 AADO2-478 REQ O2-79 Intubat-NOT INTUBA 1910-11-27 04:38PM BLOOD Type-ART pO2-61* pCO2-33* pH-7.45 calHCO3-24 Base XS-0 Intubat-NOT INTUBA 2016-12-6 12:11AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-350 FiO2-100 pO2-137* pCO2-35 pH-7.47* calHCO3-26 Base XS-2 AADO2-559 REQ O2-90 Intubat-NOT INTUBA Vent-SPONTANEOU 2016-12-6 10:29AM BLOOD Type-ART PEEP-8 pO2-89 pCO2-33* pH-7.51* calHCO3-27 Base XS-3 Intubat-NOT INTUBA 1948-2-31 05:25AM BLOOD Type-ART Temp-38.4 Rates-/24 FiO2-100 pO2-58* pCO2-36 pH-7.52* calHCO3-30 Base XS-5 AADO2-638 REQ O2-100 Intubat-NOT INTUBA 1954-8-8 04:52AM BLOOD Type-ART Temp-37.3 Rates-0/24 O2 Flow-5 pO2-64* pCO2-29* pH-7.50* calHCO3-23 Base XS-0 1910-9-21 06:01PM BLOOD Lactate-2.1* K-3.4* 1948-2-31 08:04PM BLOOD Lactate-0.8 1910-11-27 08:41AM BLOOD freeCa-1.01* 1954-8-8 04:16AM BLOOD WBC-9.4# RBC-3.77* Hgb-11.5* Hct-33.4* MCV-89 MCH-30.5 MCHC-34.5 RDW-20.0* Plt Ct-597* 1969-8-24 05:14AM BLOOD WBC-7.6 RBC-2.16* Hgb-6.8* Hct-20.0* MCV-92 MCH-31.6 MCHC-34.2 RDW-20.0* Plt Ct-415 1969-8-24 03:57PM BLOOD Hct-23.2* 1910-11-27 04:11PM BLOOD WBC-5.1 RBC-2.60* Hgb-7.8* Hct-22.7* MCV-87 MCH-30.1 MCHC-34.4 RDW-21.0* Plt Ct-395 2016-12-6 05:52AM BLOOD WBC-4.8 RBC-3.08* Hgb-9.0* Hct-26.5* MCV-86 MCH-29.2 MCHC-33.9 RDW-20.7* Plt Ct-409 1948-2-31 06:43PM BLOOD Neuts-91.0* Bands-0 Lymphs-7.3* Monos-1.4* Eos-0.2 Baso-0 1954-8-8 04:16AM BLOOD Plt Ct-597* 1948-2-31 04:39AM BLOOD PT-12.2 PTT-22.6 INR(PT)-1.0 1948-2-31 04:39AM BLOOD Plt Ct-498* 1910-11-27 04:11PM BLOOD Plt Ct-395 1954-8-8 04:16AM BLOOD Glucose-104 UreaN-19 Creat-1.1 Na-136 K-4.1 Cl-104 HCO3-21* AnGap-15 1948-2-31 06:43PM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-133 K-4.3 Cl-100 HCO3-24 AnGap-13 1901-10-29 04:41PM BLOOD Glucose-161* UreaN-15 Creat-1.0 Na-138 K-4.3 Cl-99 HCO3-28 AnGap-15 2016-12-6 05:52AM BLOOD Glucose-81 UreaN-16 Creat-0.8 Na-138 K-5.0 Cl-106 HCO3-23 AnGap-14 1910-11-27 04:52AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-136 K-4.3 Cl-103 HCO3-23 AnGap-14 1969-8-24 05:14AM BLOOD Glucose-223* UreaN-21* Creat-1.0 Na-135 K-4.3 Cl-99 HCO3-27 AnGap-13 . . . Radiology: CXR 9-14: Diffusely increased opacities at the lung fields bilaterally. In an immunocompromised patient, this is concerning for PCP Stephanie Cobbs. Radiographically, the differential includes pulmonary edema. Additionally, there is a faint opacity at the right lung base, which may represent atelectasis or focal pneumonic process. . CT-Head 9-14: Focus of low attenuation within the subcortical white matter of the right medial frontal lobe. This may represent a subacute infarction; however, an underlying mass lesion cannot be completely excluded. An MRI examination with gadolinium and diffusion-weighted imaging is recommended for further evaluation. No intracranial hemorrhage noted. . MR-head-w&w/o gadolinium 4-18: Signal abnormality in the medial right frontal lobe involving the corpus callosum does not demonstrate enhancement. This finding most likely represent a small infarct. However, in absence of ADC map, age of the infarct could not be determined. No abnormal enhancement is seen. Follow up is suggested, if clinically indicated. . Echo 4-18: 1.The left atrium is mildly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. While difficult to assess given the limited views suspect Mild (1+) mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. . If clinically indicated, would recommend a TEE. . CXR 8-28: Resolution of congestive failure with persistent small bilateral pleural effusions and bibasilar atelectasis . Studies: EEG 6-11: This is a mildly abnormal EEG due to the presence of a slow and disorganized background with bursts of generalized slowing - all consistent with a mild encephalopathy of toxic, metabolic, or anoxic etiology. No evidence for ongoing seizures is seen. Brief Hospital Course: A/P: 54 woman on immunosuppressive therapy for UC (prednisone, 6MP) who presents with new onset HA, fever with bacterial meningitis and gram positive rod bacteremia. . #. Listeriosis - meningitis and bacteremia. Patient presented with headache, nuchal rigidity, expressive aphasia, afebrile on admission but temp to 104.4 in the ED, where she also started to have rigors. LP showed >300 WBC, poly predominant with 5% monocytes, protein 152 glucose 16. CSF gram stain showed gram positive rods, blood culture grew gram positive rods, speciation eventually grew listeria. Empiric treatment based on gram stain was started: ampicillin and bactrim (to cover both nocardia and question of PCP, Kay Kenner below), vanc and ceftriaxone as well pending confirmation of gram stain and culture results. Once speciations was confirmed, a five day course of gentamicin was started for synergy, and vancomycin and ceftriaxone d/c'd. Bactrim was maintained on treatment dose for concern for PCP Ted Ornelas 8-28, when it was changed to prophylaxis dose. Early on admission, she developed hypotension that required levophed, but was weaned off of pressors within the first couple of days of admission with PRBCs (total of 4 units) and volume resussitation. Given bacteremia, TTE was done, no vegetations or lesions noted. Head CT on admission showed right medial frontal lobe likely infarct versus mass lesion, no hemorrhage. Subsequent MRI confirmed infarct, unclear date, and EEG consistent with meningitis. Neurology was consulted, and the patient was placed on dilantin for seizure prophylaxis given meningoencephalitis. She spiked fevers to 101-102 over the first several days of admission. By 3-12, her neurological exam was markedly improved, and by 8-28 her headache was gone, no meningeal signs noted, although her baseline essential tremor was slightly more severe. Surveillance blood cultures reamined negative from 6-11 on. Notably, she was transferred from ICU to floor on 8-28, but noninvasive BP was read as 60/d, patient mentating well, sent back to ICU. In the ICU, an arterial line was placed, and consistently read 20-30 mmHg higher than sphyngomanometer. This discrepancy was of unclear etiology, but persistent. Patient maintained normal mentation, good urine output, no tachycardia, and it was judged that, for some unclear reason, the cuff pressures underestimated by 20-30 points. On 3-17, she was sent to the floor for further care and management. . #. Bilateral lung opacities/hypoxia. Initial chest film read as increased opacities bilaterally concerning for PCP (given steroids and no PCP Samuel Kenner) vs. bacterial pneumonia vs. pulmonary edema. She had signifcant oxygen requirement, and her respiratory distress led to her being placed on CPAP+PS. The origin of her significant hypoxia was originally thought to be secondary to likely vascular leak from sepsis/CHF versus PCP. Odell Merino induced sputum was attempted, but was unsuccessful, and was not repeated initally given her unstable respiratory status, and susbsequent evaluation that likelihood of PCP was small. She responded well to lasix diuresis, with reduced O2 requirements. . #. UC: She continued to receive her outpatient dose of prednisone, which was changed on 4-3 to dexamethasone IV; her outpatient 6-MP was held. After several days with no diarrhea, it recurred on 4-3 soon after her diet had advanced. C.diff was negative. She was made NPO, and fed via TPN for bowel rest. On 8-26, it was noted that she began passing BRBRP, her hematocrit was noted to drop two points and pt was typed and crossed and consent for blood transfusion. . #. Anemia. On admission, she was found to be anemic. She received PRBCs for anemia on admission and again 3-12 for mixed venous sat 4-3 after she developed diarrhea, thought secondary to continued UC activity. . #. Prophylaxis: PPI. Hold SQ Hep, pneumoboots. Initially on droplet precautions. . #. Code status: FULL . #. Communication: patient, her sister, brother, and mother . #. Lines: peripheral IV x 2. left subclavian CC. A-line. Eval for PICC; once in place, can d/c central line, a-line. Surgery Discharge part: Pt underwent total abdominal colectomy with ileoostomy on 1958-6-29. She was on Clinda/Gent peri-procedure and Amplicillin for 21 days at first. She was seen by PT/OT and was NPO until the ostomy started to function. SHe had c/o nausea as diet was tolerated and it was slowed down. MRI was suspicious for an abcess and amplicillin was started for at least a total of 6 weeks as per ID. She was given a PICC. On 8-31 she was cleared by PT and was in good condition for d/c to rehab on 1990-1-25. Medications on Admission: AMBIEN 10 mg--1 tablet(s) by mouth at bedtime CLONAZEPAM 1 MG--One twice a day FLUOXETINE 20 MG--2 every day FOSAMAX 70MG--One qweek as directed FUROSEMIDE 20 mg--1 tablet(s) by mouth once a day MERCAPTOPURINE 50 mg--1 tablet(s) by mouth twice a day PREDNISONE 20 mg--2 tablet(s) by mouth once a day as per gastroenterologist PROTONIX 40 mg--1 tablet(s) by mouth once a day Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2-4HPRN (). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every Thursday). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 13. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln Injection Q4H (every 4 hours): Please take until at least 2-24. You will be further instructed by the infectious disease doctors. 14. PREDNISONE TAPER (see included sheet) 10 mg in morning and 10 mg in evening for 3 days Next take 10 mg in the morning and 7.5 mg in evening for 3 days Next take 7.5 mg in the morning and 7.5 mg in the eveing for 3 days Then take 7.5 mg in the morning and 5 mg in the evening Next take 5 mg in the morning and 5 mg in the evening for 3 days Then take 5 mg in the morning and 2.5 mg in the evening for 3 days Next take 2.5 mg in the morning and 2.5 mg in the evening for 3 days Finally take 2.5 mg in the morning and none in the evening for 3 days. Then take no more prednisone Discharge Disposition: Extended Care Facility: Snyder Inc Health System & Rehab Center - Martin, Martin and Berry Medical Center Discharge Diagnosis: Listeria meningitis Ulcerative colitis Discharge Condition: Stable Discharge Instructions: Please call your doctor if you have a fever >101.4, inability to pass gas or stool into the ostomy, severe pain, persistent nausea, vomiting, or any other concerns. Please take all medications as prescribed and complete the course of antibiotics. Followup Instructions: Please make an appointment to see Dr. Salgado in 2 weeks, telephone 532-827-1427. Please follow up with your primary care MD in 2-13 weeks. You have an appointment with Infectious disease on 8-14 (138-739-7593. You have an MRI scheduled on 1910-1-2 404-764-4837.	['Admission Date: 1969-8-24 Discharge Date: 1990-1-25\n\nDate of Birth: 1950-4-13 Sex: F\n\nService: SURGERY\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Amy\nChief Complaint:\nheadache and neck stiffness\n\nMajor Surgical or Invasive Procedure:\ncentral line placed, arterial line placed\n\nHistory of Present Illness:\n54 year old female with recent diagnosis of ulcerative colitis\non 6-mercaptopurine, prednisone 40-60 mg daily, who presents\nwith a new onset of headache and neck stiffness. The patient is\nin distress, rigoring and has aphasia and only limited history\nis obtained. She reports that she was awaken 1AM the morning of\n1910-9-21 with a headache which she describes as bandlike. She\nstates that headaches are unusual for her. She denies photo- or\nphonophobia.', ' She did have neck stiffness. On arrival to the ED\nat 5:33PM, she was afebrile with a temp of 96.5, however she\nlater spiked with temp to 104.4 (rectal), HR 91, BP 112/54, RR\n24, O2 sat 100 %. Head CT was done and relealved attenuation\nwithin the subcortical white matter of the right medial frontal\nlobe. LP was performed showing opening pressure 24 cm H2O WBC of\n316, Protein 152, glucose 16. She was given Vancomycin 1 gm IV,\nCeftriaxone 2 gm IV, Acyclovir 800 mg IV, Ambesone 183 IV,\nAmpicillin 2 gm IV q 4, Morphine 2-4 mg Q 4-6, Tylenol 1 gm ,\nDecadron 10 mg IV. The patient was evaluated by Neuro in the\nED.\n.\nOf note, the patient was recently diagnosed with UC and was\nstarted on 6MP and a prednisone taper along with steroid enemas\nfor UC treatment. She was on Bactrim in past but stopped taking\nit for unclear reasons and unclear how long ago.', '\n.\n\n\nPast Medical History:\nchronic back pain, MRI negative\nosteopenia - fosamax d/c by PcP\nleg pain/parasthesias\nh/o hiatal hernia\n\nSocial History:\nNo tob, Etoh. Patient lives alone in a 2 family home w/ a\nfriend. She is an administrative assistant\n\n\nFamily History:\nbrother w/ ulcerative proctitis, mother w/ severe arthritis,\nfather w/ h/o colon polyps and GERD\n\nPhysical Exam:\nVS: 101.4 ; 101/55; 87; 20; 100% at 2L NC\nGen: Middle aged, ill-appearing woman, restless in bed,\nrigoring, in moderate distress\t\nHEENT: NC/AT, PEERL, MM dry, no lesions, OP clear, sclera\nnon-icteric\nNeck: stiff; palpable small LN in right supraclavicular area\nCV: regular, Nl S1, S2, 3/6 systolic murmur at left lower\nsternal border\nPulm: crackles at base of right lung\t\t\nAbd: + BS, soft, mildly tender in periumbilical area, ND, no\nrebound, no guarding\t\nExt: 2+ bilateral pitting edema in lower extremities\nbilaterally, warm skin\t\nSkin: no exanthems\t\nNeuro: A&O x3, expressive aphasia, CN 2-12 intact, patient has\n2+ patellar reflexes bilaterally, no gross motor or sensory\ndeficits.', '\n\nPertinent Results:\n1910-9-21 05:55PM BLOOD WBC-6.5 RBC-2.64* Hgb-8.2* Hct-24.6\nMCV-93 MCH-31.0 MCHC-33.3 RDW-20.1 Plt Ct-577\n1910-9-21 05:55PM BLOOD Neuts-92.2 Bands-0 Lymphs-5.3\nMonos-1.4 Eos-0.9 Baso-0.2\n1910-9-21 05:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL\nMacrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL\n1910-9-21 05:55PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1\n1910-11-27 04:52AM BLOOD Fibrino-782\n1910-9-21 05:55PM BLOOD Glucose-111 UreaN-19 Creat-0.9 Na-140\nK-3.7 Cl-99 HCO3-29 AnGap-16\n1910-9-21 05:55PM BLOOD LD(LDH)-288\n1969-8-24 05:14AM BLOOD ALT-28 AST-42 LD(LDH)-424* AlkPhos-33\nAmylase-63 TotBili-0.6\n1910-11-27 04:52AM BLOOD ALT-25 AST-25 LD(LDH)-315 AlkPhos-34\nTotBili-0.3\n1969-8-24 05:14AM BLOOD Lipase-25\n1969-8-24 05:14AM BLOOD Albumin-2.2 Calcium-7.5* Phos-3.6\nMg-1.', '5* Iron-8\n1948-2-31 06:43PM BLOOD Albumin-1.8 Calcium-7.7* Phos-3.6 Mg-1.7\n1969-8-24 05:14AM BLOOD calTIBC-152* Ferritn-298* TRF-117\n1969-8-24 08:01PM BLOOD Type-ART Temp-38.9 Rates-/24 FiO2-100\npO2-58 pCO2-33* pH-7.47* calHCO3-25 Base XS-0 AADO2-645 REQ\nO2-100 Intubat-NOT INTUBA\n1910-11-27 12:44AM BLOOD Type-ART Temp-39.1 Rates-/24 FiO2-100\npO2-69* pCO2-35 pH-7.48* calHCO3-27 Base XS-2 AADO2-632 REQ\nO2-99 Intubat-NOT INTUBA Comment-NON-REBREA\n1910-11-27 04:18PM BLOOD Type-ART FiO2-100 pO2-222* pCO2-31\npH-7.47 calHCO3-23 Base XS-0 AADO2-478 REQ O2-79 Intubat-NOT\nINTUBA\n1910-11-27 04:38PM BLOOD Type-ART pO2-61* pCO2-33* pH-7.45\ncalHCO3-24 Base XS-0 Intubat-NOT INTUBA\n2016-12-6 12:11AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-350\nFiO2-100 pO2-137* pCO2-35 pH-7.47* calHCO3-26 Base XS-2\nAADO2-559 REQ O2-90 Intubat-NOT INTUBA Vent-SPONTANEOU\n2016-12-6 10:29AM BLOOD Type-ART PEEP-8 pO2-89 pCO2-33* pH-7.', '51\ncalHCO3-27 Base XS-3 Intubat-NOT INTUBA\n1948-2-31 05:25AM BLOOD Type-ART Temp-38.4 Rates-/24 FiO2-100\npO2-58 pCO2-36 pH-7.52* calHCO3-30 Base XS-5 AADO2-638 REQ\nO2-100 Intubat-NOT INTUBA\n1954-8-8 04:52AM BLOOD Type-ART Temp-37.3 Rates-0/24 O2 Flow-5\npO2-64* pCO2-29* pH-7.50* calHCO3-23 Base XS-0\n1910-9-21 06:01PM BLOOD Lactate-2.1* K-3.4\n1948-2-31 08:04PM BLOOD Lactate-0.8\n1910-11-27 08:41AM BLOOD freeCa-1.01\n1954-8-8 04:16AM BLOOD WBC-9.4# RBC-3.77* Hgb-11.5* Hct-33.4\nMCV-89 MCH-30.5 MCHC-34.5 RDW-20.0 Plt Ct-597\n1969-8-24 05:14AM BLOOD WBC-7.6 RBC-2.16 Hgb-6.8* Hct-20.0\nMCV-92 MCH-31.6 MCHC-34.2 RDW-20.0 Plt Ct-415\n1969-8-24 03:57PM BLOOD Hct-23.2\n1910-11-27 04:11PM BLOOD WBC-5.1 RBC-2.60 Hgb-7.8* Hct-22.7\nMCV-87 MCH-30.1 MCHC-34.4 RDW-21.0 Plt Ct-395\n2016-12-6 05:52AM BLOOD WBC-4.', '8 RBC-3.08* Hgb-9.0* Hct-26.5\nMCV-86 MCH-29.2 MCHC-33.9 RDW-20.7 Plt Ct-409\n1948-2-31 06:43PM BLOOD Neuts-91.0* Bands-0 Lymphs-7.3\nMonos-1.4 Eos-0.2 Baso-0\n1954-8-8 04:16AM BLOOD Plt Ct-597\n1948-2-31 04:39AM BLOOD PT-12.2 PTT-22.6 INR(PT)-1.0\n1948-2-31 04:39AM BLOOD Plt Ct-498\n1910-11-27 04:11PM BLOOD Plt Ct-395\n1954-8-8 04:16AM BLOOD Glucose-104 UreaN-19 Creat-1.1 Na-136\nK-4.1 Cl-104 HCO3-21* AnGap-15\n1948-2-31 06:43PM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-133\nK-4.3 Cl-100 HCO3-24 AnGap-13\n1901-10-29 04:41PM BLOOD Glucose-161* UreaN-15 Creat-1.0 Na-138\nK-4.3 Cl-99 HCO3-28 AnGap-15\n2016-12-6 05:52AM BLOOD Glucose-81 UreaN-16 Creat-0.8 Na-138\nK-5.0 Cl-106 HCO3-23 AnGap-14\n1910-11-27 04:52AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-136\nK-4.3 Cl-103 HCO3-23 AnGap-14\n1969-8-24 05:14AM BLOOD Glucose-223* UreaN-21* Creat-1.', '0 Na-135\nK-4.3 Cl-99 HCO3-27 AnGap-13\n.\n.\n.\nRadiology:\nCXR 9-14: Diffusely increased opacities at the lung fields\nbilaterally. In an immunocompromised patient, this is concerning\nfor PCP Stephanie Cobbs. Radiographically, the differential includes\npulmonary edema. Additionally, there is a faint opacity at the\nright lung base, which may represent atelectasis or focal\npneumonic process.\n.\nCT-Head 9-14: Focus of low attenuation within the subcortical\nwhite matter of the right medial frontal lobe. This may\nrepresent a subacute infarction; however, an underlying mass\nlesion cannot be completely excluded. An MRI examination with\ngadolinium and diffusion-weighted imaging is recommended for\nfurther evaluation. No intracranial hemorrhage noted.\n.\nMR-head-w&w/o gadolinium 4-18:\nSignal abnormality in the medial right frontal lobe involving\nthe corpus callosum does not demonstrate enhancement.', ' This\nfinding most likely represent a small infarct. However, in\nabsence of ADC map, age of the infarct could not be determined.\nNo abnormal enhancement is seen. Follow up is suggested, if\nclinically indicated.\n.\nEcho 4-18:\n1.The left atrium is mildly dilated.\n2. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Regional left ventricular\nwall motion is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%).\n3. Right ventricular chamber size and free wall motion are\nnormal.\n4. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. No masses or vegetations are seen on the\naortic valve. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen.\n5. The mitral valve leaflets are mildly thickened. No mass or\nvegetation is seen on the mitral valve.', ' While difficult to\nassess given the limited views suspect Mild (1+) mitral\nregurgitation is seen.\n6.The estimated pulmonary artery systolic pressure is normal.\n7.There is no pericardial effusion.\n.\nIf clinically indicated, would recommend a TEE.\n.\nCXR 8-28:\nResolution of congestive failure with persistent small bilateral\npleural effusions and bibasilar atelectasis\n.\nStudies:\nEEG 6-11: This is a mildly abnormal EEG due to the presence of\na slow\nand disorganized background with bursts of generalized slowing -\nall\nconsistent with a mild encephalopathy of toxic, metabolic, or\nanoxic\netiology. No evidence for ongoing seizures is seen.\n\n\nBrief Hospital Course:\nA/P: 54 woman on immunosuppressive therapy for UC (prednisone,\n6MP) who presents with new onset HA, fever with bacterial\nmeningitis and gram positive rod bacteremia.', "\n.\n#. Listeriosis - meningitis and bacteremia. Patient presented\nwith headache, nuchal rigidity, expressive aphasia, afebrile on\nadmission but temp to 104.4 in the ED, where she also started to\nhave rigors. LP showed >300 WBC, poly predominant with 5%\nmonocytes, protein 152 glucose 16. CSF gram stain showed gram\npositive rods, blood culture grew gram positive rods, speciation\neventually grew listeria. Empiric treatment based on gram stain\nwas started: ampicillin and bactrim (to cover both nocardia and\nquestion of PCP, Kay Kenner below), vanc and ceftriaxone as well pending\nconfirmation of gram stain and culture results. Once\nspeciations was confirmed, a five day course of gentamicin was\nstarted for synergy, and vancomycin and ceftriaxone d/c'd.\nBactrim was maintained on treatment dose for concern for PCP\nTed Ornelas 8-28, when it was changed to prophylaxis dose.", ' Early on\nadmission, she developed hypotension that required levophed, but\nwas weaned off of pressors within the first couple of days of\nadmission with PRBCs (total of 4 units) and volume\nresussitation. Given bacteremia, TTE was done, no vegetations\nor lesions noted. Head CT on admission showed right medial\nfrontal lobe likely infarct versus mass lesion, no hemorrhage.\nSubsequent MRI confirmed infarct, unclear date, and EEG\nconsistent with meningitis. Neurology was consulted, and the\npatient was placed on dilantin for seizure prophylaxis given\nmeningoencephalitis. She spiked fevers to 101-102 over the first\nseveral days of admission. By 3-12, her neurological exam was\nmarkedly improved, and by 8-28 her headache was gone, no\nmeningeal signs noted, although her baseline essential tremor\nwas slightly more severe.', ' Surveillance blood cultures reamined\nnegative from 6-11 on. Notably, she was transferred from ICU\nto floor on 8-28, but noninvasive BP was read as 60/d, patient\nmentating well, sent back to ICU. In the ICU, an arterial line\nwas placed, and consistently read 20-30 mmHg higher than\nsphyngomanometer. This discrepancy was of unclear etiology, but\npersistent. Patient maintained normal mentation, good urine\noutput, no tachycardia, and it was judged that, for some unclear\nreason, the cuff pressures underestimated by 20-30 points. On\n3-17, she was sent to the floor for further care and management.\n.\n#. Bilateral lung opacities/hypoxia. Initial chest film read as\nincreased opacities bilaterally concerning for PCP (given\nsteroids and no PCP Samuel Kenner) vs. bacterial pneumonia vs. pulmonary\nedema.', ' She had signifcant oxygen requirement, and her\nrespiratory distress led to her being placed on CPAP+PS. The\norigin of her significant hypoxia was originally thought to be\nsecondary to likely vascular leak from sepsis/CHF versus PCP. Odell Merino\ninduced sputum was attempted, but was unsuccessful, and was not\nrepeated initally given her unstable respiratory status, and\nsusbsequent evaluation that likelihood of PCP was small. She\nresponded well to lasix diuresis, with reduced O2 requirements.\n.\n#. UC: She continued to receive her outpatient dose of\nprednisone, which was changed on 4-3 to dexamethasone IV; her\noutpatient 6-MP was held. After several days with no diarrhea,\nit recurred on 4-3 soon after her diet had advanced. C.diff was\nnegative. She was made NPO, and fed via TPN for bowel rest.', ' On\n8-26, it was noted that she began passing BRBRP, her hematocrit\nwas noted to drop two points and pt was typed and crossed and\nconsent for blood transfusion.\n.\n#. Anemia. On admission, she was found to be anemic. She\nreceived PRBCs for anemia on admission and again 3-12 for mixed\nvenous sat 4-3 after she developed diarrhea, thought secondary\nto continued UC activity.\n.\n#. Prophylaxis: PPI. Hold SQ Hep, pneumoboots. Initially on\ndroplet precautions.\n.\n#. Code status: FULL\n.\n#. Communication: patient, her sister, brother, and mother\n.\n#. Lines: peripheral IV x 2. left subclavian CC. A-line. Eval\nfor PICC; once in place, can d/c central line, a-line.\n\nSurgery Discharge part:\nPt underwent total abdominal colectomy with ileoostomy on\n1958-6-29. She was on Clinda/Gent peri-procedure and Amplicillin\nfor 21 days at first.', ' She was seen by PT/OT and was NPO until\nthe ostomy started to function. SHe had c/o nausea as diet was\ntolerated and it was slowed down. MRI was suspicious for an\nabcess and amplicillin was started for at least a total of 6\nweeks as per ID. She was given a PICC. On 8-31 she was\ncleared by PT and was in good condition for d/c to rehab on\n1990-1-25.\n\n\nMedications on Admission:\nAMBIEN 10 mg--1 tablet(s) by mouth at bedtime\nCLONAZEPAM 1 MG--One twice a day\nFLUOXETINE 20 MG--2 every day\nFOSAMAX 70MG--One qweek as directed\nFUROSEMIDE 20 mg--1 tablet(s) by mouth once a day\nMERCAPTOPURINE 50 mg--1 tablet(s) by mouth twice a day\nPREDNISONE 20 mg--2 tablet(s) by mouth once a day as per\ngastroenterologist\nPROTONIX 40 mg--1 tablet(s) by mouth once a day\n\nDischarge Medications:\n1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H\n(every 4 to 6 hours) as needed.', '\n2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)\nTablet PO QMOWEFR (Monday -Wednesday-Friday).\n3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2-4HPRN ().\n\n4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).\n\n5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One\n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\n8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every\nThursday).\n9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed.\n11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed.', '\n12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN\n13. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln\nInjection Q4H (every 4 hours): Please take until at least\n2-24. You will be further instructed by the infectious\ndisease doctors.\n14. PREDNISONE TAPER\n(see included sheet)\n10 mg in morning and 10 mg in evening for 3 days\nNext take 10 mg in the morning and 7.5 mg in evening for 3 days\nNext take 7.5 mg in the morning and 7.5 mg in the eveing for 3\ndays\nThen take 7.5 mg in the morning and 5 mg in the evening\nNext take 5 mg in the morning and 5 mg in the evening for 3 days\nThen take 5 mg in the morning and 2.5 mg in the evening for 3\ndays\nNext take 2.5 mg in the morning and 2.5 mg in the evening for 3\ndays\nFinally take 2.5 mg in the morning and none in the evening for 3\ndays.\nThen take no more prednisone\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nSnyder Inc Health System & Rehab Center - Martin, Martin and Berry Medical Center\n\nDischarge Diagnosis:\nListeria meningitis\nUlcerative colitis\n\n\nDischarge Condition:\nStable\n\n\nDischarge Instructions:\nPlease call your doctor if you have a fever >101.', '4, inability to\npass gas or stool into the ostomy, severe pain, persistent\nnausea, vomiting, or any other concerns. Please take all\nmedications as prescribed and complete the course of\nantibiotics.\n\nFollowup Instructions:\nPlease make an appointment to see Dr. Salgado in 2 weeks,\ntelephone 532-827-1427. Please follow up with your primary care\nMD in 2-13 weeks.\nYou have an appointment with Infectious disease on 8-14 (138-739-7593.\nYou have an MRI scheduled on 1910-1-2 404-764-4837.\n\n\n\n']
2	23224	117806.0	2154-05-03	Discharge summary	Report	Admission Date: [2154-4-30] Discharge Date: [2154-5-3] Date of Birth: [2092-11-28] Sex: F Service: MEDICINE Allergies: Percocet Attending:[First Name3 (LF) 12] Chief Complaint: fever, chills, rigors Major Surgical or Invasive Procedure: Arterial line placement History of Present Illness: 61F w/ sign PMH for UC s/p colectomy, Stage II breast cancer presented on day 13 of second cycle of chemotherapy with fever to 100.6 at home w/ severe rigors. She took two Ibuprofen at home and then went to onc clinic today where she was then referred to the ED for admission. She stated that for the past two days she has noticed an increasing amount of stool output in her ostomy bag but denies abdominal discomfort or blood in her stool. She has had nausea but similar to how she has felt in the past with chemo. She also mentioned that she recently cut her finger in the garden on Sunday which is now red and slightly tender to the touch. She otherwise denies any vomiting, rash, rhinorrhea, dysuria, cough, SOB or abdominal discomfort. She denies any recent travel or sick contacts as well. . In the ED inital vitals were, Temp: 101 ??????F (38.3 ??????C), Pulse: 93, RR: 16, BP: 77/38, O2Sat: 94, O2Flow: RA. Her labs were notable for WBC of 0.7 and PMN count of 21. Her U/A was bland and two blood cultures were obtained and are pending. His CXR did not show definitive source of infection either. She was started on Cefepime for neutropenic fever. While in the ED she developed hypotension not responding to IVF boluses, the pt denied CVL placement and required the initiation of phenylepherine peripherially in order to maintain SBPs in the 90s-100s. She did not have a change in her mentation during these episodes of hypotension. . On arrival to the ICU, she was mentating normally and answering questions appropriately. She was in NAD. . Review of systems: (+) Per HPI (-) Denies current chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes. Past Medical History: Ulcerative colitis s/p Total colectomy with hartmanns pouch in [2147-11-26] Ileostomy revision for ileocutaneous fistula. Chronic back pain Right leg pain for which she underwent exploration for a possible reflex sympathetic dystrophy at [Hospital 13] Hospital. basal cell carcinoma of her right shoulder Left Colles fracture Depression Breast Cancer Diagnosed in [1-31] w/ biopsy currently in cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide, completed cycle 1 in [4-1] Social History: Lives alone, works for non-profit. - Tobacco:denies - Alcohol: denies - Illicits: denies No tob, Etoh. Patient lives alone in a 2 family home w/ a friend. She is an administrative assistant Family History: Mother had breast cancer in 70s. brother w/ ulcerative proctitis, mother w/ severe arthritis, father w/ h/o colon polyps and GERD Physical Exam: ADMISSION EXAM: Vitals: T:99.2 BP:78/34 P:71 R: 13 O2:94% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear no tonsilar exudate Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ileostomy in place in RLQ no erythema or tenderness to palpation on exam GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left fourth finger has erythematous area of skin measuring approx 2cm in diameter surrounding an scabbed over skin lesion, no swelling or purulent drainage noted DISCHARGE EXAM: Physical Exam: Vitals: 97.9 106/60 78 20 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear no tonsilar exudate Neck: supple, JVP 6-8, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ileostomy in place in RLQ no erythema or tenderness to palpation on exam GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left fourth finger has erythematous area of skin measuring approx 1cm in diameter surrounding an scabbed over skin lesion, no swelling or purulent drainage noted Pertinent Results: [2154-4-30] 10:45AM BLOOD WBC-0.7# RBC-3.19 Hgb-9.7* Hct-28.8* MCV-90 MCH-30.3 MCHC-33.5 RDW-13.1 Plt Ct-233 [2154-4-30] 11:43AM BLOOD WBC-1.0* RBC-3.10* Hgb-9.1* Hct-27.5* MCV-89 MCH-29.5 MCHC-33.2 RDW-12.9 Plt Ct-209 [2154-5-1] 04:12AM BLOOD WBC-2.3# RBC-2.59 Hgb-7.8* Hct-23.8* MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 Plt Ct-165 [2154-5-1] 05:36PM BLOOD WBC-4.2# RBC-2.70* Hgb-8.5* Hct-24.4* MCV-90 MCH-31.3 MCHC-34.7 RDW-13.6 Plt Ct-178 [2154-5-2] 03:49AM BLOOD WBC-5.6 RBC-2.77* Hgb-8.7* Hct-25.1* MCV-91 MCH-31.4 MCHC-34.6 RDW-13.2 Plt Ct-177 [2154-5-3] 09:00AM BLOOD WBC-4.9 RBC-3.02* Hgb-8.9* Hct-27.3* MCV-90 MCH-29.3 MCHC-32.5 RDW-13.6 Plt Ct-221 [2154-4-30] 10:45AM BLOOD Neuts-3* Bands-0 Lymphs-27 Monos-69* Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [2154-4-30] 11:43AM BLOOD Neuts-7* Bands-1 Lymphs-53* Monos-32* Eos-1 Baso-0 Atyps-6* Metas-0 Myelos-0 [2154-5-1] 04:12AM BLOOD Neuts-16* Bands-7* Lymphs-38 Monos-37* Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 [2154-5-2] 03:49AM BLOOD Neuts-67 Bands-0 Lymphs-22 Monos-11 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2154-5-3] 09:00AM BLOOD Neuts-77* Bands-0 Lymphs-14* Monos-7 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 [2154-4-30] 11:43AM BLOOD Glucose-112* UreaN-18 Creat-1.1 Na-137 K-4.5 Cl-105 HCO3-23 AnGap-14 [2154-5-1] 04:12AM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-142 K-3.6 Cl-115* HCO3-20* AnGap-11 [2154-5-2] 03:49AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-140 K-3.9 Cl-114* HCO3-21* AnGap-9 [2154-5-3] 09:00AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-143 K-4.0 Cl-115* HCO3-22 AnGap-10 Galactomannan - negative B-d-glucan - negative Cdiff - negative BCX - pending Brief Hospital Course: Ms. [Known lastname 14] is a 61 yo w/ Stage II breast cancer who was admitted on day 13 or cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide who developed fever to 100.6 at home with associated rigors in the setting of neutropenia. . #Neutropenic Fever- On presentation the pt's PMN count was 21 most likely from her most recent chemotherapy cycle and lack of Neulasta use. Two possible sources of infection existed including pulmonary or from a laceration on her finger suffered while gardening. She was broadly covered with Vancomycin and cefepime to cover both possible sources, as well as flagyl to cover for cdiff as the patient mentioned that she had increased ostomy output. When cdiff returned negative, flagyl was discontinued. Blood cultures were sent and a U/A was not concerning for infection. We also sent off galactomannan antigen and beta-D-glucan labs initially as part of her neutropenic fever workup which were negative. The following day after admission her WBC rose significantly and she no longer was neutropenic. As her WBC rose she started to develope a cough and he CXR became concerning for an infiltrate. She was continued on Vanc/Cefepime until afebrile and with ANC>1000 for greater than 48 hours, after which she was switched to PO levofloxacin to complete an 8 day total course for community acquired pneumonia. . # Hypotension- In the [Name (NI) ] pt's SBP dropped to 70s, not responding to IVF boluses. She refused central line placement in the ED and peripheral pressors were initiated. This is most likely related to her underlying infectious process. She was not administered any medications recently that could be accounting for her hypotension. Looking through OMR her baseline blood pressures are sbp of 90s-100s. An a-line was obtained which showed higher BP than what was being recorded by the blood pressure cuff. She was given several liters of IV fluid boluses and weaned off pressors the night of admission to the ICU. Her cuff and a-line pressures correlated after fluid resuscitation and the a-line was discontinued. . # Breast Cancer- currently in cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide. Most likely this current episode of neutropenia is due to the fact that Neulasta was not given during this cycle of chemo per pt's request, however due to the rapid rise in her WBC count myelosuppression from sepsis was also a possibility. . # Depression / Anxiety- Continue Duloxetine and clonazepam at home doses. . # Nausea- Continued compazine and PO zofran prn. Medications on Admission: CLONAZEPAM - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day anxiety DULOXETINE [CYMBALTA] - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth daily LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for nausea or insomnia METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 (One) Tablet(s) by mouth twice a day as needed PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for nausea ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for insomnia Medications - OTC CALCIUM [CALCIO [Doctor First Name 15] [Month (only) 16]] - (Prescribed by Other Provider) - 500 mg Tablet - Tablet(s) by mouth Total daily dose 1200 mg CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain OMEPRAZOLE - (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day Discharge Medications: 1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:4 Tablet(s) Refills:0 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for insomnia. 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 9. Vitamin-D + Omega-3 350 mg- 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: 1) Neutropenic fever 2) Community acquired pneumonia 3) Severe sepsis 4) Anemia 5) Stage II breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [Known firstname 17], It was a pleasure to take care of you here at [Hospital1 18]. You were admitted for low white cell (neutrophil count), fever, and pneumonia. You required monitoring with blood pressure supporting medications and IV antibiotics in the intensive care unit. Fortunately, your counts improved and you responded nicely to the antibiotics. Please continue to take levofloxacin to treat your pneumonia for a total of 8 days (last dose on [2154-5-7]). As we discussed if you notice fever, worsening breathing problems, or any other concerning symptoms to return to the emergency room immediately. We have made the following changes to your medications: START levofloxacin 750mg by mouth daily for 4 more days ([2154-5-7]) You should discuss with Dr. [Last Name (STitle) 19] the possibility of restarting neulasta with your next chemotherapy cycle. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2154-5-9] at 10:30 AM With: [First Name11 (Name Pattern1) 20] [Last Name (NamePattern1) 21], M.D. [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2154-5-9] at 10:30 AM With: [First Name8 (NamePattern2) 25] [First Name4 (NamePattern1) 26] [Last Name (NamePattern1) 27], NP [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2154-5-9] at 12:00 PM With: [Name6 (MD) 26] [Name8 (MD) 28], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	Admission Date: <Date>1967-11-13</Date> Discharge Date: <Date>1903-12-7</Date> Date of Birth: <Date>1907-3-17</Date> Sex: F Service: MEDICINE Allergies: Percocet Attending:<Name>Frank</Name> Chief Complaint: fever, chills, rigors Major Surgical or Invasive Procedure: Arterial line placement History of Present Illness: 61F w/ sign PMH for UC s/p colectomy, Stage II breast cancer presented on day 13 of second cycle of chemotherapy with fever to 100.6 at home w/ severe rigors. She took two Ibuprofen at home and then went to onc clinic today where she was then referred to the ED for admission. She stated that for the past two days she has noticed an increasing amount of stool output in her ostomy bag but denies abdominal discomfort or blood in her stool. She has had nausea but similar to how she has felt in the past with chemo. She also mentioned that she recently cut her finger in the garden on Sunday which is now red and slightly tender to the touch. She otherwise denies any vomiting, rash, rhinorrhea, dysuria, cough, SOB or abdominal discomfort. She denies any recent travel or sick contacts as well. . In the ED inital vitals were, Temp: 101 ??????F (38.3 ??????C), Pulse: 93, RR: 16, BP: 77/38, O2Sat: 94, O2Flow: RA. Her labs were notable for WBC of 0.7 and PMN count of 21. Her U/A was bland and two blood cultures were obtained and are pending. His CXR did not show definitive source of infection either. She was started on Cefepime for neutropenic fever. While in the ED she developed hypotension not responding to IVF boluses, the pt denied CVL placement and required the initiation of phenylepherine peripherially in order to maintain SBPs in the 90s-100s. She did not have a change in her mentation during these episodes of hypotension. . On arrival to the ICU, she was mentating normally and answering questions appropriately. She was in NAD. . Review of systems: (+) Per HPI (-) Denies current chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes. Past Medical History: Ulcerative colitis s/p Total colectomy with hartmanns pouch in <Date>1913-12-18</Date> Ileostomy revision for ileocutaneous fistula. Chronic back pain Right leg pain for which she underwent exploration for a possible reflex sympathetic dystrophy at <Hospital>Howell-Wolf Clinic</Hospital> Hospital. basal cell carcinoma of her right shoulder Left Colles fracture Depression Breast Cancer Diagnosed in <Date>5-27</Date> w/ biopsy currently in cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide, completed cycle 1 in <Date>12-12</Date> Social History: Lives alone, works for non-profit. - Tobacco:denies - Alcohol: denies - Illicits: denies No tob, Etoh. Patient lives alone in a 2 family home w/ a friend. She is an administrative assistant Family History: Mother had breast cancer in 70s. brother w/ ulcerative proctitis, mother w/ severe arthritis, father w/ h/o colon polyps and GERD Physical Exam: ADMISSION EXAM: Vitals: T:99.2 BP:78/34 P:71 R: 13 O2:94% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear no tonsilar exudate Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ileostomy in place in RLQ no erythema or tenderness to palpation on exam GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left fourth finger has erythematous area of skin measuring approx 2cm in diameter surrounding an scabbed over skin lesion, no swelling or purulent drainage noted DISCHARGE EXAM: Physical Exam: Vitals: 97.9 106/60 78 20 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear no tonsilar exudate Neck: supple, JVP 6-8, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ileostomy in place in RLQ no erythema or tenderness to palpation on exam GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left fourth finger has erythematous area of skin measuring approx 1cm in diameter surrounding an scabbed over skin lesion, no swelling or purulent drainage noted Pertinent Results: <Date>1967-11-13</Date> 10:45AM BLOOD WBC-0.7# RBC-3.19 Hgb-9.7* Hct-28.8* MCV-90 MCH-30.3 MCHC-33.5 RDW-13.1 Plt Ct-233 <Date>1967-11-13</Date> 11:43AM BLOOD WBC-1.0* RBC-3.10* Hgb-9.1* Hct-27.5* MCV-89 MCH-29.5 MCHC-33.2 RDW-12.9 Plt Ct-209 <Date>1923-2-25</Date> 04:12AM BLOOD WBC-2.3# RBC-2.59 Hgb-7.8* Hct-23.8* MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 Plt Ct-165 <Date>1923-2-25</Date> 05:36PM BLOOD WBC-4.2# RBC-2.70* Hgb-8.5* Hct-24.4* MCV-90 MCH-31.3 MCHC-34.7 RDW-13.6 Plt Ct-178 <Date>1943-11-7</Date> 03:49AM BLOOD WBC-5.6 RBC-2.77* Hgb-8.7* Hct-25.1* MCV-91 MCH-31.4 MCHC-34.6 RDW-13.2 Plt Ct-177 <Date>1903-12-7</Date> 09:00AM BLOOD WBC-4.9 RBC-3.02* Hgb-8.9* Hct-27.3* MCV-90 MCH-29.3 MCHC-32.5 RDW-13.6 Plt Ct-221 <Date>1967-11-13</Date> 10:45AM BLOOD Neuts-3* Bands-0 Lymphs-27 Monos-69* Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 <Date>1967-11-13</Date> 11:43AM BLOOD Neuts-7* Bands-1 Lymphs-53* Monos-32* Eos-1 Baso-0 Atyps-6* Metas-0 Myelos-0 <Date>1923-2-25</Date> 04:12AM BLOOD Neuts-16* Bands-7* Lymphs-38 Monos-37* Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 <Date>1943-11-7</Date> 03:49AM BLOOD Neuts-67 Bands-0 Lymphs-22 Monos-11 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 <Date>1903-12-7</Date> 09:00AM BLOOD Neuts-77* Bands-0 Lymphs-14* Monos-7 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 <Date>1967-11-13</Date> 11:43AM BLOOD Glucose-112* UreaN-18 Creat-1.1 Na-137 K-4.5 Cl-105 HCO3-23 AnGap-14 <Date>1923-2-25</Date> 04:12AM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-142 K-3.6 Cl-115* HCO3-20* AnGap-11 <Date>1943-11-7</Date> 03:49AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-140 K-3.9 Cl-114* HCO3-21* AnGap-9 <Date>1903-12-7</Date> 09:00AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-143 K-4.0 Cl-115* HCO3-22 AnGap-10 Galactomannan - negative B-d-glucan - negative Cdiff - negative BCX - pending Brief Hospital Course: Ms. <Name>Broadnax</Name> is a 61 yo w/ Stage II breast cancer who was admitted on day 13 or cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide who developed fever to 100.6 at home with associated rigors in the setting of neutropenia. . #Neutropenic Fever- On presentation the pt's PMN count was 21 most likely from her most recent chemotherapy cycle and lack of Neulasta use. Two possible sources of infection existed including pulmonary or from a laceration on her finger suffered while gardening. She was broadly covered with Vancomycin and cefepime to cover both possible sources, as well as flagyl to cover for cdiff as the patient mentioned that she had increased ostomy output. When cdiff returned negative, flagyl was discontinued. Blood cultures were sent and a U/A was not concerning for infection. We also sent off galactomannan antigen and beta-D-glucan labs initially as part of her neutropenic fever workup which were negative. The following day after admission her WBC rose significantly and she no longer was neutropenic. As her WBC rose she started to develope a cough and he CXR became concerning for an infiltrate. She was continued on Vanc/Cefepime until afebrile and with ANC>1000 for greater than 48 hours, after which she was switched to PO levofloxacin to complete an 8 day total course for community acquired pneumonia. . # Hypotension- In the <Name>Athanasios Hazelwood</Name> pt's SBP dropped to 70s, not responding to IVF boluses. She refused central line placement in the ED and peripheral pressors were initiated. This is most likely related to her underlying infectious process. She was not administered any medications recently that could be accounting for her hypotension. Looking through OMR her baseline blood pressures are sbp of 90s-100s. An a-line was obtained which showed higher BP than what was being recorded by the blood pressure cuff. She was given several liters of IV fluid boluses and weaned off pressors the night of admission to the ICU. Her cuff and a-line pressures correlated after fluid resuscitation and the a-line was discontinued. . # Breast Cancer- currently in cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide. Most likely this current episode of neutropenia is due to the fact that Neulasta was not given during this cycle of chemo per pt's request, however due to the rapid rise in her WBC count myelosuppression from sepsis was also a possibility. . # Depression / Anxiety- Continue Duloxetine and clonazepam at home doses. . # Nausea- Continued compazine and PO zofran prn. Medications on Admission: CLONAZEPAM - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day anxiety DULOXETINE [CYMBALTA] - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth daily LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for nausea or insomnia METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 (One) Tablet(s) by mouth twice a day as needed PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for nausea ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for insomnia Medications - OTC CALCIUM [CALCIO <Name>Shirley</Name> <Month>March</Month>] - (Prescribed by Other Provider) - 500 mg Tablet - Tablet(s) by mouth Total daily dose 1200 mg CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain OMEPRAZOLE - (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day Discharge Medications: 1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:4 Tablet(s) Refills:0 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for insomnia. 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 9. Vitamin-D + Omega-3 350 mg- 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: 1) Neutropenic fever 2) Community acquired pneumonia 3) Severe sepsis 4) Anemia 5) Stage II breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear <Name>Isabella</Name>, It was a pleasure to take care of you here at <Hospital>Martin Group Medical Center</Hospital>. You were admitted for low white cell (neutrophil count), fever, and pneumonia. You required monitoring with blood pressure supporting medications and IV antibiotics in the intensive care unit. Fortunately, your counts improved and you responded nicely to the antibiotics. Please continue to take levofloxacin to treat your pneumonia for a total of 8 days (last dose on <Date>1922-4-9</Date>). As we discussed if you notice fever, worsening breathing problems, or any other concerning symptoms to return to the emergency room immediately. We have made the following changes to your medications: START levofloxacin 750mg by mouth daily for 4 more days (<Date>1922-4-9</Date>) You should discuss with Dr. <Name>Kenner</Name> the possibility of restarting neulasta with your next chemotherapy cycle. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY <Date>1969-2-8</Date> at 10:30 AM With: <Name>Cameron</Name> <Name>Sakkas</Name>, M.D. <Telephone>776-516-3326</Telephone> Building: SC <Hospital>Gardner, Stewart and Kim Medical Center</Hospital> Clinical Ctr <Location>96521 Olson Prairie Shelbyside, ID 57492</Location> Campus: EAST Best Parking: <Hospital>Gardner, Stewart and Kim Medical Center</Hospital> Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY <Date>1969-2-8</Date> at 10:30 AM With: <Name>Amanda</Name> <Name>Henry</Name> <Name>Sakkas</Name>, NP <Telephone>776-516-3326</Telephone> Building: SC <Hospital>Gardner, Stewart and Kim Medical Center</Hospital> Clinical Ctr <Location>96521 Olson Prairie Shelbyside, ID 57492</Location> Campus: EAST Best Parking: <Hospital>Gardner, Stewart and Kim Medical Center</Hospital> Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY <Date>1969-2-8</Date> at 12:00 PM With: <Name>Arnaldo Demong</Name> <Name>Jacob Belle</Name>, RN <Telephone>776-516-3326</Telephone> Building: <Hospital>Wilkerson PLC Medical Center</Hospital> <Location>96521 Olson Prairie Shelbyside, ID 57492</Location> Campus: EAST Best Parking: <Hospital>Gardner, Stewart and Kim Medical Center</Hospital> 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Date: 1967-11-13 Discharge Date: 1903-12-7 Date of Birth: 1907-3-17 Sex: F Service: MEDICINE Allergies: Percocet Attending:Frank Chief Complaint: fever, chills, rigors Major Surgical or Invasive Procedure: Arterial line placement History of Present Illness: 61F w/ sign PMH for UC s/p colectomy, Stage II breast cancer presented on day 13 of second cycle of chemotherapy with fever to 100.6 at home w/ severe rigors. She took two Ibuprofen at home and then went to onc clinic today where she was then referred to the ED for admission. She stated that for the past two days she has noticed an increasing amount of stool output in her ostomy bag but denies abdominal discomfort or blood in her stool. She has had nausea but similar to how she has felt in the past with chemo. She also mentioned that she recently cut her finger in the garden on Sunday which is now red and slightly tender to the touch. She otherwise denies any vomiting, rash, rhinorrhea, dysuria, cough, SOB or abdominal discomfort. She denies any recent travel or sick contacts as well. . In the ED inital vitals were, Temp: 101 ??????F (38.3 ??????C), Pulse: 93, RR: 16, BP: 77/38, O2Sat: 94, O2Flow: RA. Her labs were notable for WBC of 0.7 and PMN count of 21. Her U/A was bland and two blood cultures were obtained and are pending. His CXR did not show definitive source of infection either. She was started on Cefepime for neutropenic fever. While in the ED she developed hypotension not responding to IVF boluses, the pt denied CVL placement and required the initiation of phenylepherine peripherially in order to maintain SBPs in the 90s-100s. She did not have a change in her mentation during these episodes of hypotension. . On arrival to the ICU, she was mentating normally and answering questions appropriately. She was in NAD. . Review of systems: (+) Per HPI (-) Denies current chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes. Past Medical History: Ulcerative colitis s/p Total colectomy with hartmanns pouch in 1913-12-18 Ileostomy revision for ileocutaneous fistula. Chronic back pain Right leg pain for which she underwent exploration for a possible reflex sympathetic dystrophy at Howell-Wolf Clinic Hospital. basal cell carcinoma of her right shoulder Left Colles fracture Depression Breast Cancer Diagnosed in 5-27 w/ biopsy currently in cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide, completed cycle 1 in 12-12 Social History: Lives alone, works for non-profit. - Tobacco:denies - Alcohol: denies - Illicits: denies No tob, Etoh. Patient lives alone in a 2 family home w/ a friend. She is an administrative assistant Family History: Mother had breast cancer in 70s. brother w/ ulcerative proctitis, mother w/ severe arthritis, father w/ h/o colon polyps and GERD Physical Exam: ADMISSION EXAM: Vitals: T:99.2 BP:78/34 P:71 R: 13 O2:94% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear no tonsilar exudate Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ileostomy in place in RLQ no erythema or tenderness to palpation on exam GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left fourth finger has erythematous area of skin measuring approx 2cm in diameter surrounding an scabbed over skin lesion, no swelling or purulent drainage noted DISCHARGE EXAM: Physical Exam: Vitals: 97.9 106/60 78 20 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear no tonsilar exudate Neck: supple, JVP 6-8, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ileostomy in place in RLQ no erythema or tenderness to palpation on exam GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left fourth finger has erythematous area of skin measuring approx 1cm in diameter surrounding an scabbed over skin lesion, no swelling or purulent drainage noted Pertinent Results: 1967-11-13 10:45AM BLOOD WBC-0.7# RBC-3.19 Hgb-9.7* Hct-28.8* MCV-90 MCH-30.3 MCHC-33.5 RDW-13.1 Plt Ct-233 1967-11-13 11:43AM BLOOD WBC-1.0* RBC-3.10* Hgb-9.1* Hct-27.5* MCV-89 MCH-29.5 MCHC-33.2 RDW-12.9 Plt Ct-209 1923-2-25 04:12AM BLOOD WBC-2.3# RBC-2.59 Hgb-7.8* Hct-23.8* MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 Plt Ct-165 1923-2-25 05:36PM BLOOD WBC-4.2# RBC-2.70* Hgb-8.5* Hct-24.4* MCV-90 MCH-31.3 MCHC-34.7 RDW-13.6 Plt Ct-178 1943-11-7 03:49AM BLOOD WBC-5.6 RBC-2.77* Hgb-8.7* Hct-25.1* MCV-91 MCH-31.4 MCHC-34.6 RDW-13.2 Plt Ct-177 1903-12-7 09:00AM BLOOD WBC-4.9 RBC-3.02* Hgb-8.9* Hct-27.3* MCV-90 MCH-29.3 MCHC-32.5 RDW-13.6 Plt Ct-221 1967-11-13 10:45AM BLOOD Neuts-3* Bands-0 Lymphs-27 Monos-69* Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 1967-11-13 11:43AM BLOOD Neuts-7* Bands-1 Lymphs-53* Monos-32* Eos-1 Baso-0 Atyps-6* Metas-0 Myelos-0 1923-2-25 04:12AM BLOOD Neuts-16* Bands-7* Lymphs-38 Monos-37* Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 1943-11-7 03:49AM BLOOD Neuts-67 Bands-0 Lymphs-22 Monos-11 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 1903-12-7 09:00AM BLOOD Neuts-77* Bands-0 Lymphs-14* Monos-7 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 1967-11-13 11:43AM BLOOD Glucose-112* UreaN-18 Creat-1.1 Na-137 K-4.5 Cl-105 HCO3-23 AnGap-14 1923-2-25 04:12AM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-142 K-3.6 Cl-115* HCO3-20* AnGap-11 1943-11-7 03:49AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-140 K-3.9 Cl-114* HCO3-21* AnGap-9 1903-12-7 09:00AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-143 K-4.0 Cl-115* HCO3-22 AnGap-10 Galactomannan - negative B-d-glucan - negative Cdiff - negative BCX - pending Brief Hospital Course: Ms. Broadnax is a 61 yo w/ Stage II breast cancer who was admitted on day 13 or cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide who developed fever to 100.6 at home with associated rigors in the setting of neutropenia. . #Neutropenic Fever- On presentation the pt's PMN count was 21 most likely from her most recent chemotherapy cycle and lack of Neulasta use. Two possible sources of infection existed including pulmonary or from a laceration on her finger suffered while gardening. She was broadly covered with Vancomycin and cefepime to cover both possible sources, as well as flagyl to cover for cdiff as the patient mentioned that she had increased ostomy output. When cdiff returned negative, flagyl was discontinued. Blood cultures were sent and a U/A was not concerning for infection. We also sent off galactomannan antigen and beta-D-glucan labs initially as part of her neutropenic fever workup which were negative. The following day after admission her WBC rose significantly and she no longer was neutropenic. As her WBC rose she started to develope a cough and he CXR became concerning for an infiltrate. She was continued on Vanc/Cefepime until afebrile and with ANC>1000 for greater than 48 hours, after which she was switched to PO levofloxacin to complete an 8 day total course for community acquired pneumonia. . # Hypotension- In the Athanasios Hazelwood pt's SBP dropped to 70s, not responding to IVF boluses. She refused central line placement in the ED and peripheral pressors were initiated. This is most likely related to her underlying infectious process. She was not administered any medications recently that could be accounting for her hypotension. Looking through OMR her baseline blood pressures are sbp of 90s-100s. An a-line was obtained which showed higher BP than what was being recorded by the blood pressure cuff. She was given several liters of IV fluid boluses and weaned off pressors the night of admission to the ICU. Her cuff and a-line pressures correlated after fluid resuscitation and the a-line was discontinued. . # Breast Cancer- currently in cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide. Most likely this current episode of neutropenia is due to the fact that Neulasta was not given during this cycle of chemo per pt's request, however due to the rapid rise in her WBC count myelosuppression from sepsis was also a possibility. . # Depression / Anxiety- Continue Duloxetine and clonazepam at home doses. . # Nausea- Continued compazine and PO zofran prn. Medications on Admission: CLONAZEPAM - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day anxiety DULOXETINE [CYMBALTA] - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth daily LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for nausea or insomnia METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 (One) Tablet(s) by mouth twice a day as needed PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for nausea ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for insomnia Medications - OTC CALCIUM [CALCIO Shirley March] - (Prescribed by Other Provider) - 500 mg Tablet - Tablet(s) by mouth Total daily dose 1200 mg CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain OMEPRAZOLE - (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day Discharge Medications: 1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:4 Tablet(s) Refills:0 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for insomnia. 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 9. Vitamin-D + Omega-3 350 mg- 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: 1) Neutropenic fever 2) Community acquired pneumonia 3) Severe sepsis 4) Anemia 5) Stage II breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Isabella, It was a pleasure to take care of you here at Martin Group Medical Center. You were admitted for low white cell (neutrophil count), fever, and pneumonia. You required monitoring with blood pressure supporting medications and IV antibiotics in the intensive care unit. Fortunately, your counts improved and you responded nicely to the antibiotics. Please continue to take levofloxacin to treat your pneumonia for a total of 8 days (last dose on 1922-4-9). As we discussed if you notice fever, worsening breathing problems, or any other concerning symptoms to return to the emergency room immediately. We have made the following changes to your medications: START levofloxacin 750mg by mouth daily for 4 more days (1922-4-9) You should discuss with Dr. Kenner the possibility of restarting neulasta with your next chemotherapy cycle. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY 1969-2-8 at 10:30 AM With: Cameron Sakkas, M.D. 776-516-3326 Building: SC Gardner, Stewart and Kim Medical Center Clinical Ctr 96521 Olson Prairie Shelbyside, ID 57492 Campus: EAST Best Parking: Gardner, Stewart and Kim Medical Center Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY 1969-2-8 at 10:30 AM With: Amanda Henry Sakkas, NP 776-516-3326 Building: SC Gardner, Stewart and Kim Medical Center Clinical Ctr 96521 Olson Prairie Shelbyside, ID 57492 Campus: EAST Best Parking: Gardner, Stewart and Kim Medical Center Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY 1969-2-8 at 12:00 PM With: Arnaldo Demong Jacob Belle, RN 776-516-3326 Building: Wilkerson PLC Medical Center 96521 Olson Prairie Shelbyside, ID 57492 Campus: EAST Best Parking: Gardner, Stewart and Kim Medical Center Garage	['Admission Date: 1967-11-13 Discharge Date: 1903-12-7\n\nDate of Birth: 1907-3-17 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPercocet\n\nAttending:Frank\nChief Complaint:\nfever, chills, rigors\n\nMajor Surgical or Invasive Procedure:\nArterial line placement\n\nHistory of Present Illness:\n61F w/ sign PMH for UC s/p colectomy, Stage II breast cancer\npresented on day 13 of second cycle of chemotherapy with fever\nto 100.6 at home w/ severe rigors. She took two Ibuprofen at\nhome and then went to onc clinic today where she was then\nreferred to the ED for admission. She stated that for the past\ntwo days she has noticed an increasing amount of stool output in\nher ostomy bag but denies abdominal discomfort or blood in her\nstool. She has had nausea but similar to how she has felt in the\npast with chemo.', ' She also mentioned that she recently cut her\nfinger in the garden on Sunday which is now red and slightly\ntender to the touch. She otherwise denies any vomiting, rash,\nrhinorrhea, dysuria, cough, SOB or abdominal discomfort. She\ndenies any recent travel or sick contacts as well.\n.\nIn the ED inital vitals were, Temp: 101 ??????F (38.3 ??????C), Pulse: 93,\nRR: 16, BP: 77/38, O2Sat: 94, O2Flow: RA. Her labs were notable\nfor WBC of 0.7 and PMN count of 21. Her U/A was bland and two\nblood cultures were obtained and are pending. His CXR did not\nshow definitive source of infection either. She was started on\nCefepime for neutropenic fever. While in the ED she developed\nhypotension not responding to IVF boluses, the pt denied CVL\nplacement and required the initiation of phenylepherine\nperipherially in order to maintain SBPs in the 90s-100s.', ' She did\nnot have a change in her mentation during these episodes of\nhypotension.\n.\nOn arrival to the ICU, she was mentating normally and answering\nquestions appropriately. She was in NAD.\n.\nReview of systems:\n(+) Per HPI\n(-) Denies current chills, night sweats. Denies headache, sinus\ntenderness, rhinorrhea or congestion. Denies cough, shortness of\nbreath, or wheezing. Denies chest pain, chest pressure,\npalpitations, or weakness. Denies vomiting, constipation,\nabdominal pain. Denies dysuria, frequency, or urgency. Denies\narthralgias or myalgias. Denies rashes.\n\nPast Medical History:\nUlcerative colitis s/p Total colectomy with hartmanns pouch in\n1913-12-18\nIleostomy revision for ileocutaneous fistula.\nChronic back pain\nRight leg pain for which she underwent exploration for a\npossible reflex sympathetic dystrophy at Howell-Wolf Clinic Hospital.', '\n\nbasal cell carcinoma of her right shoulder\nLeft Colles fracture\nDepression\nBreast Cancer Diagnosed in 5-27 w/ biopsy currently in cycle 2\nof Docetaxel (Taxotere) + Cyclophosphomide, completed cycle 1 in\n12-12\n\nSocial History:\nLives alone, works for non-profit.\n- Tobacco:denies\n- Alcohol: denies\n- Illicits: denies\n\nNo tob, Etoh. Patient lives alone in a 2 family home w/ a\nfriend. She is an administrative assistant\n\n\nFamily History:\nMother had breast cancer in 70s.\nbrother w/ ulcerative proctitis, mother w/ severe arthritis,\nfather w/ h/o colon polyps and GERD\n\nPhysical Exam:\nADMISSION EXAM:\nVitals: T:99.2 BP:78/34 P:71 R: 13 O2:94% RA\nGeneral: Alert, oriented, no acute distress\nHEENT: Sclera anicteric, dry MM, oropharynx clear no tonsilar\nexudate\nNeck: supple, JVP not elevated, no LAD\nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi\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, ileostomy in place in RLQ no\nerythema or tenderness to palpation on exam\nGU: no foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema, left fourth finger has erythematous area of skin\nmeasuring approx 2cm in diameter surrounding an scabbed over\nskin lesion, no swelling or purulent drainage noted\n\nDISCHARGE EXAM:\nPhysical Exam:\nVitals: 97.', '9 106/60 78 20 97%RA\nGeneral: Alert, oriented, no acute distress\nHEENT: Sclera anicteric, MMM, oropharynx clear no tonsilar\nexudate\nNeck: supple, JVP 6-8, no LAD\nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi\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, ileostomy in place in RLQ no\nerythema or tenderness to palpation on exam\nGU: no foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema, left fourth finger has erythematous area of skin\nmeasuring approx 1cm in diameter surrounding an scabbed over\nskin lesion, no swelling or purulent drainage noted\n\nPertinent Results:\n1967-11-13 10:45AM BLOOD WBC-0.7# RBC-3.19 Hgb-9.7* Hct-28.8\nMCV-90 MCH-30.', '3 MCHC-33.5 RDW-13.1 Plt Ct-233\n1967-11-13 11:43AM BLOOD WBC-1.0 RBC-3.10* Hgb-9.1* Hct-27.5\nMCV-89 MCH-29.5 MCHC-33.2 RDW-12.9 Plt Ct-209\n1923-2-25 04:12AM BLOOD WBC-2.3# RBC-2.59* Hgb-7.8* Hct-23.8\nMCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 Plt Ct-165\n1923-2-25 05:36PM BLOOD WBC-4.2# RBC-2.70 Hgb-8.5* Hct-24.4\nMCV-90 MCH-31.3 MCHC-34.7 RDW-13.6 Plt Ct-178\n1943-11-7 03:49AM BLOOD WBC-5.6 RBC-2.77 Hgb-8.7* Hct-25.1\nMCV-91 MCH-31.4 MCHC-34.6 RDW-13.2 Plt Ct-177\n1903-12-7 09:00AM BLOOD WBC-4.9 RBC-3.02 Hgb-8.9* Hct-27.3\nMCV-90 MCH-29.3 MCHC-32.5 RDW-13.6 Plt Ct-221\n1967-11-13 10:45AM BLOOD Neuts-3 Bands-0 Lymphs-27 Monos-69\nEos-0 Baso-1 Atyps-0 Metas-0 Myelos-0\n1967-11-13 11:43AM BLOOD Neuts-7 Bands-1 Lymphs-53* Monos-32\nEos-1 Baso-0 Atyps-6 Metas-0 Myelos-0\n1923-2-25 04:12AM BLOOD Neuts-16* Bands-7* Lymphs-38 Monos-37\nEos-0 Baso-0 Atyps-1 Metas-1* Myelos-0\n1943-11-7 03:49AM BLOOD Neuts-67 Bands-0 Lymphs-22 Monos-11 Eos-0\nBaso-0 Atyps-0 Metas-0 Myelos-0\n1903-12-7 09:00AM BLOOD Neuts-77* Bands-0 Lymphs-14* Monos-7\nEos-1 Baso-0 Atyps-1* Metas-0 Myelos-0\n1967-11-13 11:43AM BLOOD Glucose-112* UreaN-18 Creat-1.', "1 Na-137\nK-4.5 Cl-105 HCO3-23 AnGap-14\n1923-2-25 04:12AM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-142\nK-3.6 Cl-115* HCO3-20* AnGap-11\n1943-11-7 03:49AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-140\nK-3.9 Cl-114* HCO3-21* AnGap-9\n1903-12-7 09:00AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-143\nK-4.0 Cl-115* HCO3-22 AnGap-10\n\nGalactomannan - negative\nB-d-glucan - negative\nCdiff - negative\nBCX - pending\n\nBrief Hospital Course:\nMs. Broadnax is a 61 yo w/ Stage II breast cancer who was\nadmitted on day 13 or cycle 2 of Docetaxel (Taxotere) +\nCyclophosphomide who developed fever to 100.6 at home with\nassociated rigors in the setting of neutropenia.\n.\n#Neutropenic Fever- On presentation the pt's PMN count was 21\nmost likely from her most recent chemotherapy cycle and lack of\nNeulasta use. Two possible sources of infection existed\nincluding pulmonary or from a laceration on her finger suffered\nwhile gardening.", ' She was broadly covered with Vancomycin and\ncefepime to cover both possible sources, as well as flagyl to\ncover for cdiff as the patient mentioned that she had increased\nostomy output. When cdiff returned negative, flagyl was\ndiscontinued. Blood cultures were sent and a U/A was not\nconcerning for infection. We also sent off galactomannan antigen\nand beta-D-glucan labs initially as part of her neutropenic\nfever workup which were negative. The following day after\nadmission her WBC rose significantly and she no longer was\nneutropenic. As her WBC rose she started to develope a cough and\nhe CXR became concerning for an infiltrate. She was continued on\nVanc/Cefepime until afebrile and with ANC>1000 for greater than\n48 hours, after which she was switched to PO levofloxacin to\ncomplete an 8 day total course for community acquired pneumonia.', "\n.\n# Hypotension- In the Athanasios Hazelwood pt's SBP dropped to 70s, not responding\nto IVF boluses. She refused central line placement in the ED and\nperipheral pressors were initiated. This is most likely related\nto her underlying infectious process. She was not administered\nany medications recently that could be accounting for her\nhypotension. Looking through OMR her baseline blood pressures\nare sbp of 90s-100s. An a-line was obtained which showed higher\nBP than what was being recorded by the blood pressure cuff. She\nwas given several liters of IV fluid boluses and weaned off\npressors the night of admission to the ICU. Her cuff and a-line\npressures correlated after fluid resuscitation and the a-line\nwas discontinued.\n.\n# Breast Cancer- currently in cycle 2 of Docetaxel (Taxotere) +\nCyclophosphomide.", " Most likely this current episode of\nneutropenia is due to the fact that Neulasta was not given\nduring this cycle of chemo per pt's request, however due to the\nrapid rise in her WBC count myelosuppression from sepsis was\nalso a possibility.\n.\n# Depression / Anxiety- Continue Duloxetine and clonazepam at\nhome doses.\n.\n# Nausea- Continued compazine and PO zofran prn.\n\nMedications on Admission:\nCLONAZEPAM - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day\nanxiety\nDULOXETINE [CYMBALTA] - 20 mg Capsule, Delayed Release(E.C.) - 2\nCapsule(s) by mouth daily\nLORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day as\nneeded for nausea or insomnia\nMETOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg\nTablet - 1 (One) Tablet(s) by mouth twice a day as needed\nPROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth\ntwice a day as needed for nausea\nZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - 1\nTablet(s) by mouth at bedtime as needed for insomnia\n\nMedications - OTC\nCALCIUM [CALCIO Shirley March] - (Prescribed by Other Provider) - 500\nmg Tablet - Tablet(s) by mouth Total daily dose 1200 mg\nCHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by\nOther\nProvider) - Dosage uncertain\nMULTIVITAMIN - (Prescribed by Other Provider) - Dosage\nuncertain\nOMEPRAZOLE - (OTC) - 20 mg Capsule, Delayed Release(E.", 'C.) - 1\nCapsule(s) by mouth once a day\n\nDischarge Medications:\n1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n2. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)\nCapsule, Delayed Release(E.C.) PO DAILY (Daily).\n3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\nCapsule, Delayed Release(E.C.) PO DAILY (Daily).\n4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:4 Tablet(s) Refills:0\n5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as\nneeded for insomnia.\n6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice\na day.\n7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as\nneeded for insomnia.\n8. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)\nTablet PO once a day.\n9. Vitamin-D + Omega-3 350 mg- 1,000 unit Capsule Sig: One (1)\nCapsule PO once a day.', '\n10. multivitamin Tablet Sig: One (1) Tablet PO once a day.\n11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO\ntwice a day.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\n1) Neutropenic fever\n2) Community acquired pneumonia\n3) Severe sepsis\n4) Anemia\n5) Stage II breast cancer\n\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n\nDischarge Instructions:\nDear Isabella,\n\nIt was a pleasure to take care of you here at Martin Group Medical Center. You were\nadmitted for low white cell (neutrophil count), fever, and\npneumonia. You required monitoring with blood pressure\nsupporting medications and IV antibiotics in the intensive care\nunit. Fortunately, your counts improved and you responded nicely\nto the antibiotics.', ' Please continue to take levofloxacin to\ntreat your pneumonia for a total of 8 days (last dose on\n1922-4-9). As we discussed if you notice fever, worsening\nbreathing problems, or any other concerning symptoms to return\nto the emergency room immediately.\n\nWe have made the following changes to your medications:\n\nSTART levofloxacin 750mg by mouth daily for 4 more days\n(1922-4-9)\n\nYou should discuss with Dr. Kenner the possibility of restarting\nneulasta with your next chemotherapy cycle.\n\nFollowup Instructions:\nDepartment: HEMATOLOGY/ONCOLOGY\nWhen: THURSDAY 1969-2-8 at 10:30 AM\nWith: Cameron Sakkas, M.D. 776-516-3326\nBuilding: SC Gardner, Stewart and Kim Medical Center Clinical Ctr 96521 Olson Prairie\nShelbyside, ID 57492\nCampus: EAST Best Parking: Gardner, Stewart and Kim Medical Center Garage\n\nDepartment: HEMATOLOGY/ONCOLOGY\nWhen: THURSDAY 1969-2-8 at 10:30 AM\nWith: Amanda Henry Sakkas, NP 776-516-3326\nBuilding: SC Gardner, Stewart and Kim Medical Center Clinical Ctr 96521 Olson Prairie\nShelbyside, ID 57492\nCampus: EAST Best Parking: Gardner, Stewart and Kim Medical Center Garage\n\nDepartment: HEMATOLOGY/ONCOLOGY\nWhen: THURSDAY 1969-2-8 at 12:00 PM\nWith: Arnaldo Demong Jacob Belle, RN 776-516-3326\nBuilding: Wilkerson PLC Medical Center 96521 Olson Prairie\nShelbyside, ID 57492\nCampus: EAST Best Parking: Gardner, Stewart and Kim Medical Center Garage\n\n\n\n']
3	19051	184534.0	2172-04-23	Discharge summary	Report	Admission Date: [2172-3-26] Discharge Date: [2172-4-23] Date of Birth: [2109-12-16] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 30] Chief Complaint: Febrile, unresponsive--> GBS meningitis and bacteremia Major Surgical or Invasive Procedure: 1. Rigid bronchoscopy, debridement, T-tube placement. 2. Baclofen Pump Removal. 3. RUQ Hematoma Evacuation. 4. Percutaneous Gastrostomy Tube. 5. Left Antecubital PICC Line. History of Present Illness: Ms. [Known lastname 31] is a 62 y.o. woman with primary progressive MS [Name13 (STitle) 32] in [2143] with spasticity s/p intrathecal baclofen pump placment in '[64], s/p tracheostomy in '[65] [1-8] to chronic respiratory weakness, recurrent UTIs, aspiration PNAs, who presents after being found to be febrile and unresponsive at her nursing home. According to notes from [Hospital6 33], the pt was found at her nursing home yesterday ([3-26]) AM, shaking her head repeatedly, subsequently becoming obtunded (presumed seizure). She was taken by EMS to [Hospital1 34] ED. . In the ED at [Name (NI) 34], pts vitals were: Tm 103.6, HR 110-150s RR 12-18 SaO2 98-99%NRB. Soon after, pt supposedly seized in the ED, was given Ativan, Ambu'd and subsequently placed on SIMV ventilation. Pt was empirically started on Vancomycin, Levoquin, Ceftriaxone, Bactrim and Acyclovir. On exam, it was noted that the skin overlying the baclofen pump (RUQ) appeared inflamed. Labs were notable for a WBC of 25 with 68%polys and a bandemia of 20%. U/A with 50-100 WBC, +leukocyte esterase, +nitrite. LP was performed and CSF analysis showed 7,250 WBCs with 92% polys, glucose 10, TP 1440, and gm stain with many polys, few gm+ cocci. Bcx revealed gm+ cocci in chains in [3-9] bottles. Micro lab performed latex agglutination on CSF sample which was positive for group B strep. Vanc and Ceftriaxone were dc'd and ampicillin 2gm IV + benadryl given. Hydrocortisone 80mg was also given. Left SC line and NGT were also placed at [Hospital1 34]. CXR showed cardiomegaly but no infiltrate. Abdominal CT was negative for an abscess or fluid collection surrounding the pump. Head CT showed questionable changes from prior that might suggest the possibility of a right MCA infarct. Pt was transferred directly to the [Hospital1 18] MICU for further management. Past Medical History: PMH: 1. Chronic progressive multiple sclerosis - dx'd in [2143] when pt was 34 years old; on intrathecal baclofen pump ('[64]) for spasticity 2. Recurrent UTIs and hosp. for urosepsis - thought [1-8] to chronic indwelling Foley catheter for neurogenic bladder. Last admitted [Date range (3) 35] for urosepsis 3. Recurrent aspiration PNA - [3-/2162], [10/2166] - admitted both times requiring MICU stay, during '[65] admission trach was placed because was unable to clear secretions on her own [1-8] to respiratory weakness 1/03 admitted for lingular PNA, unclear if [1-8] to aspiration 4. COPD 5. HTN 6. Osteoporosis 7. Scarlet fever as a child 8. Chronic constipation 9. Hx of sacral decubitus ulcer Social History: Social History: Pt is widowed. She has no children. She currently lives in a nursing home. Has been there since '[65]? She has no hx of smoking, EtOH, IVDU. Will call sister tomorrow for more information. Family History: Noncontributory Physical Exam: PE: VS P 123 BP 129/73 O2Sat 97% on mechanical vent FiO2 0.50, 550, 15/5 General: older white female being mech ventilated through tracheostomy HEENT: pupils equal and reactive to light bilaterally 5-->3mm, MMM, trach site clean, attempted to bend pt's neck but remained stiff, unclear if that was volitional Chest: coarse breath sounds throughout Cardiac: sinus tach nl s1, s2, no s3, s4, no murmur appreciated Abd: soft, obese, distended +bowel sounds throughout; in RUQ, can appreciate outline of intrathecal baclofen pump, overlying skin appears mildly erythematous, feels warm to touch, but then again she feels warm to touch over the rest of her abdomen, erythema appears localized to skin overlying pump, no streaking. Ext: cool feet, faint DPs, legs appear thin and wizened. Neuro: Brisk reflexes RLE, unable to elicit on left side. Pt with Babinski bilaterally. Withdraws occasionally to noxious stimuli. Does not respond to verbal stimuli. Pertinent Results: admit labs [2172-3-26] 10:22PM LACTATE-2.4* [2172-3-26] 10:15PM ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-264* CK(CPK)-140 ALK PHOS-87 AMYLASE-214* TOT BILI-0.1 [2172-3-26] 10:15PM LIPASE-20 [2172-3-26] 10:15PM ALBUMIN-3.6 CALCIUM-8.6 PHOSPHATE-2.0* MAGNESIUM-1.6 IRON-13* [2172-3-26] 10:15PM calTIBC-265 VIT B12-428 FOLATE-17.0 FERRITIN-434* TRF-204 [2172-3-26] 10:15PM WBC-39.6# RBC-3.35 HGB-10.0* HCT-30.1* MCV-90 MCH-29.9 MCHC-33.3 RDW-15.4 [2172-3-26] 10:15PM NEUTS-83* BANDS-9* LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2172-3-26] 10:15PM PLT SMR-NORMAL PLT COUNT-517# [2172-3-26] 10:15PM PT-15.5 PTT-30.5 INR(PT)-1.5 [2172-3-26] 10:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2172-3-26] 10:15PM URINE RBC-[2-8]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-<1 . micro all blood cx no growth . GRAM STAIN (Final [2172-4-6]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2172-4-9]): >100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. -STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci -NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. pan [Last Name (un) 36] (except bactrim) . TTE on admission: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. No obvious mass or vegetation seen. . CT abd post-op: 1) Large hematoma in the superficial tissues of the right upper quadrant with associated edema and tracking into the abdominal wall. No extension into the peritoneal space is seen. The covering intern was notified by telephone at 10:30 a.m. on [3-28], [2171]. 2) Gallbladder with dense material . this could represent stones, sludge or vicarious excretion of iv contrast. If clinically indicated, an ultrasound can be obtained for further characterization. 3) Bilateral small kidneys with small nonobstructing stones. 4) Atelectasis and small pleural effusions at both lung bases. . EEG [2172-3-28]: This is a markedly abnormal portable EEG due to the presence of generalized bursts of polymorphic disorganized slowing followed by periods of suppression. In addition, there were independent bifrontal sharp slow waves seen. This finding suggests deep, midline subcortical dysfunction and is consistent with a severe encephalopathy. A repeat EEG may be helpful to further evaluate the severity of the encephalopathy. . EEG [2172-3-31]: This is an abnormal portable EEG obtained in stage II sleep with brief periods of drowsiness due to the presence of intermittent and independent shifting slowing in the parasagital region on both sides. This finding suggests deep, midline subcortical dysfunction and is consistent with the diagnosis of meningoencephalitis. In addition, exessive drowsiness was seen, perhaps also related to the underlying infection. . MRI [4-4]: Increased signal along the occipital horns could be due to cellular debris from meningitis. No evidence of acute infarct seen. Mild to moderate ventriculomegaly indicating mild communicating hydrocephalus. . MRV [4-4]: The head MRV demonstrates normal flow signal in the superior sagittal and transverse sinus without evidence of thrombosis. Deep venous system also demonstrates normal flow signal. . MRA [4-4]: Somewhat limited MRA of the head due to motion. No evidence of vascular occlusion seen. . TEE: 1.The left atrium is normal in size. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4.There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. 6.The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. 7.There is a trivial/physiologic pericardial effusion. . Head CT [4-7]: Stable appearance of the ventricles and sulci. Brief Hospital Course: 1. GBS meningitis/bactermia In the unit, the pt was continued on Ampicillin and started on Gentamicin (for synergy). Her intrathecal baclofen pump was thought to be infected (on exam, erythema and warmth overlying pump in RUQ). Pt went to surgery to have pump removed and the operation appeared to be without complication. The following day, pt had 11 point hematocrit drop and was noted to be hypotensive with an SBP of 70. After spiking a temp, it was thought that she might be septic. She was given fluids, PRBCs, FFP, and placed on Levophed. Abd CT demonstrated a 7 x 13x 11 cm hematoma in the RUQ at the former pump site. Pt was taken emergently to surgery where the hematoma was evacuated, slow ooze noted, and the bleeding vessel cauterized. She returned to the floor and remained hemodynamically stable. Given 1 additional unit of PRBCs. Her hct bumped appropriately and remained in the high 20s for the rest of her unit course. Pt developed erythematous macular rash on face, arms, knees thought to be [1-8] to PCN allergy. Amp was d/c'd and replaced briefly with Vanc and then changed permanently to Cefrtriaxone. Repeat LP was performed since the pt continued to be minimially responsive (withdrawing to pain, occ. opening eyes to name). CSF analysis showed a resolving bacterial meningitis. Prior to leaving the unit, pt spiked a temp to 101.2. She was pancultured and all cultures were negative. A TTE ruled out endocarditis in the setting of group B strep bacteremia. On day #12 of gentamycin, pt was changed to vanc/ceftaz for the completion of her treatment course. . 2. RUQ Hematoma: As above, after the removal of the baclofen pump, pt had a hct drop and hypotensive episode and was found to be bleeding into the RUQ pocket. She was taken to the OR for emergent evacuation of the hematoma. On POD #16, pt was noted to have oozing from the a site above the stitches in her RUQ. Neurosurgery was reconsulted and they recommended an abdominal ultrasound which showed vast improvement in the RUQ hematoma but found a new fluid collection. Surgery was consulted and they diagnosed a seroma and recommended conservative management given that it had no signs of infection. . 3. Pneumonia: Towards the end of the pt's ICU stay, she was evaluated by speech and swallow and she had a very difficult time with the passy-muir valve. She underwent bronchoscopy and BAL was sent for culture. The culture returned positive for MRSA and gram negative rods (not pseudomonas). She was started on vancomycin for MRSA and ceftaz/levaquin for double coverage of the GNR. Once the GNR sensitivities showed that it was not pseudomonas, ceftaz was stopped. Of note, pt had vancomycin troughs that were persistently high. Vancomycin troughs should be checked often and vanc should be adjusted for a level<15. After the pt's swallowing study, she was noted to have increased secretions and some food particles were suctioned up so it was assumed that the pt aspirated. That day she also spiked a temperature to 100 so Flagyl was added for anaerobic coverage. Vancomycin and Levaquin will be finished on [4-20] (14-day course) and Flagyl's course will be complete on [4-24] (after 10 days). . 4. Supraglottic edema As above, pt was evaluated by interventional pulmonary after she failed a passy-muir valve. On bronchoscopy it was noted that she had severe supraglottic edema with grabulation tissue and the vocal cords could only be minimally visualized. She was taken to the OR two days later for a rigid bronchoscopy where her granulation tissue was debrided and a t-tube was placed. ENT evaluated the patient and recommended a CT of the trachea to evaluate her anatomy. The CT showed tracheal bronchomalacia and narrowing of the glottic and subglottic airway. Ideally, she will get surgery by ENT to improve her subglottic edema when the patient has recovered from her acute illnesses. . 5. Anemia: Iron studies indicate anemia of chronic disease. Pt's baseline hct is between 26 and 29 and except for the hct drop after the bleed in the RUQ pocket, pt's hct remained stable. . 6. Multiple sclerosis Pt started on oral baclofen prior to pump removal. She was without signs of baclofen withdrawal (i.e. incr HR, temp, BP, seizures) once pump was removed. She continued on Baclofen 20mg qid po with an Ativan taper. PO baclofen was then tapered to 20mg tid. . 7. Mental status At baseline, although pt is significantly debilitated by MS, she is alert, oriented, and conversant. Her decreased responsiveness was thought to be [1-8] to meningitis, but although pt seemed to have resolving temp and WBC with Abx, her diminished reponsiveness persisted. Repeat LP in the unit suggested a resolving meningitis. Neurology was following the pt and recommended an MRI to rule out stroke (esp given her ? of stroke at OSH) an MRV to rule out sinus thrombosis and an EEG to rule out subclinical seizures. An EEG on HD #3 was consistent with severe encephalopathy and an EEG on HD #6 was consistent with meningoencephalitis with no evidence of seizures. An MRI was finally done on HD #10 and showed mild communicating hydrocephalus, no evidence of cavernous thrombosis or stroke. Towards the end of her unit stay pt opened eyes to name and eventually returned to her baseline mental status. Pt's mental status remained at baseline and pt will follow-up with neurology as an outpatient. . 8. Respiratory status After a supposed seizure at OSH pt was mechanically ventilated thru her trach site b/c no breath sounds were appreciated. (At baseline, pt has respiratory weakeness 2/2 to multiple sclerosis but does not require mechical ventilation. Trach in place to help with clearance of secretions.) Pt placed on A/C in unit, then transferred to CPAP and eventually placed on a trach mask with good results. At time of discharge, she was satting well on 40% trach mask. . 9. HTN In unit, pt initially normotensive, then mid-way through stay became hypertensive with SBPs in the 150-170s. Pt has hx of hypertension. Unclear whether BP was rebounding from baclofen d/c. BP became well-controlled with systolic BP in the 90s-110s on standing doses of Lisinopril 20mg po, Metoprolol 25mg [Hospital1 ]. . 10. Sacral decub ulcer: Stage 1-2. Wound care nurse followed while pt was in-house. . 11. FEN: During pt's acute illness, she had an NGT placed. Speech and swallow evaluated the pt and recommended thin liquids and pureed food. The following day, she was noted to have soup coming out of her trach so she was again made NPO. Pt then passed the video swallow but again had some signs of aspiration after trying some ground solids. She was made NPO and GI placed a PEG for feeding. Pt should remain on tube feeds until her tracheal swelling is much improved. At that point, another swallowing study can be performed and another trial of po feeding. . 12. Code: DNR/DNI Medications on Admission: per note from [Hospital6 33]: Bisacodyl 10mg Folic acid Vitamin B12 Gemfibrozil Combivent 2 puff qid Fe sulfate Baclfen pump Zantac 150mg qhs Lisinopril 5mg qhs Alprazolam 0.25 mg qhs Oxybutynin Discharge Medications: 1. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Acetaminophen 160 mg/5 mL Elixir Sig: 325-650 mg PO Q4-6H (every 4 to 6 hours) as needed. 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 11. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for SBP<100. 14. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily). 15. Lorazepam 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q8H (every 8 hours) as needed for anxiety. 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every four (4) hours as needed. 17. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 18. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed units Subcutaneous ASDIR (AS DIRECTED) as needed for hyperglycemia: per regular insulin sliding scale. 19. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: one gram Intravenous Q24H (every 24 hours) for 4 days: please check daily troughs and give dose if level<15. 20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Discharge Disposition: Extended Care Facility: [Doctor First Name 37] House Rehab & Nursing Center - [Location (un) 38] Discharge Diagnosis: Primary: 1. Group B Streptococcal Meningoencephalitis - Stable Hydrocephalus. 2. Group Streptococcal Bacteremia and Septicemia. 3. Infected Baclofen Pump, removal c/b hematoma and evacuation. 4. MRSA and GNR Ventilator Associated Pneumonia. 5. Subglottic stenosis s/p rigid bronchoscopy and debridement. 6. Dysphagia and Recurrent Aspiration. 7. Aspiration Pneumonia. 8. Blood Loss Anemia. 9. Stage II Sacral Decubitus Ulcer. 10. Thrush. 11. Drug rash to Ampicillin. Secondary/Past Medical History. 1. Chronic Progressive Multiple Sclerosis. 2. Neurogenic Bladder - chronic foley catheter. 3. Chronic Obstructive Pulmonary Disease. 4. Hypertension. 5. Tracheobronchomalacia. 6. Constipation. Discharge Condition: good, breathing well on 40% trach mask Discharge Instructions: Take all medications as prescribed and go to all follow-up appointments. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 39], [Name Initial (NameIs) ].D. Where: LM [Hospital Unit Name 40] (ENT) Phone:[Telephone/Fax (1) 41] Date/Time:[2172-5-27] 10:00 . Provider: [Name10 (NameIs) 42] [Name11 (NameIs) 43], MD Where: [Hospital6 29] NEUROLOGY Phone:[Telephone/Fax (1) 44] Date/Time:[2172-7-1] 1:00 . Please follow-up with your PCP in the next 1-2 weeks	Admission Date: <Date>1966-1-27</Date> Discharge Date: <Date>1928-3-11</Date> Date of Birth: <Date>1978-9-11</Date> Sex: F Service: MEDICINE Allergies: Penicillins Attending:<Name>Tamika</Name> Chief Complaint: Febrile, unresponsive--> GBS meningitis and bacteremia Major Surgical or Invasive Procedure: 1. Rigid bronchoscopy, debridement, T-tube placement. 2. Baclofen Pump Removal. 3. RUQ Hematoma Evacuation. 4. Percutaneous Gastrostomy Tube. 5. Left Antecubital PICC Line. History of Present Illness: Ms. <Name>Naegelin</Name> is a 62 y.o. woman with primary progressive MS <Name>Helen Kenner</Name> in <Year>1930</Year> with spasticity s/p intrathecal baclofen pump placment in '<Digit>21</Digit>, s/p tracheostomy in '<Digit>56</Digit> <Date>10-22</Date> to chronic respiratory weakness, recurrent UTIs, aspiration PNAs, who presents after being found to be febrile and unresponsive at her nursing home. According to notes from <Hospital>Reynolds, Marshall and Guerrero Clinic</Hospital>, the pt was found at her nursing home yesterday (<Date>11-31</Date>) AM, shaking her head repeatedly, subsequently becoming obtunded (presumed seizure). She was taken by EMS to <Hospital>Olsen Group Medical Center</Hospital> ED. . In the ED at <Name>Coral Loveland</Name>, pts vitals were: Tm 103.6, HR 110-150s RR 12-18 SaO2 98-99%NRB. Soon after, pt supposedly seized in the ED, was given Ativan, Ambu'd and subsequently placed on SIMV ventilation. Pt was empirically started on Vancomycin, Levoquin, Ceftriaxone, Bactrim and Acyclovir. On exam, it was noted that the skin overlying the baclofen pump (RUQ) appeared inflamed. Labs were notable for a WBC of 25 with 68%polys and a bandemia of 20%. U/A with 50-100 WBC, +leukocyte esterase, +nitrite. LP was performed and CSF analysis showed 7,250 WBCs with 92% polys, glucose 10, TP 1440, and gm stain with many polys, few gm+ cocci. Bcx revealed gm+ cocci in chains in <Date>10-29</Date> bottles. Micro lab performed latex agglutination on CSF sample which was positive for group B strep. Vanc and Ceftriaxone were dc'd and ampicillin 2gm IV + benadryl given. Hydrocortisone 80mg was also given. Left SC line and NGT were also placed at <Hospital>Olsen Group Medical Center</Hospital>. CXR showed cardiomegaly but no infiltrate. Abdominal CT was negative for an abscess or fluid collection surrounding the pump. Head CT showed questionable changes from prior that might suggest the possibility of a right MCA infarct. Pt was transferred directly to the <Hospital>Harmon, Brown and Joseph Health System</Hospital> MICU for further management. Past Medical History: PMH: 1. Chronic progressive multiple sclerosis - dx'd in <Year>1930</Year> when pt was 34 years old; on intrathecal baclofen pump ('<Digit>21</Digit>) for spasticity 2. Recurrent UTIs and hosp. for urosepsis - thought <Date>10-22</Date> to chronic indwelling Foley catheter for neurogenic bladder. Last admitted <Date Range>1910-5-27 to 1961-5-23</Date Range> for urosepsis 3. Recurrent aspiration PNA - <Date>4-1943</Date>, <Date>5/1929</Date> - admitted both times requiring MICU stay, during '<Digit>56</Digit> admission trach was placed because was unable to clear secretions on her own <Date>10-22</Date> to respiratory weakness 1/03 admitted for lingular PNA, unclear if <Date>10-22</Date> to aspiration 4. COPD 5. HTN 6. Osteoporosis 7. Scarlet fever as a child 8. Chronic constipation 9. Hx of sacral decubitus ulcer Social History: Social History: Pt is widowed. She has no children. She currently lives in a nursing home. Has been there since '<Digit>56</Digit>? She has no hx of smoking, EtOH, IVDU. Will call sister tomorrow for more information. Family History: Noncontributory Physical Exam: PE: VS P 123 BP 129/73 O2Sat 97% on mechanical vent FiO2 0.50, 550, 15/5 General: older white female being mech ventilated through tracheostomy HEENT: pupils equal and reactive to light bilaterally 5-->3mm, MMM, trach site clean, attempted to bend pt's neck but remained stiff, unclear if that was volitional Chest: coarse breath sounds throughout Cardiac: sinus tach nl s1, s2, no s3, s4, no murmur appreciated Abd: soft, obese, distended +bowel sounds throughout; in RUQ, can appreciate outline of intrathecal baclofen pump, overlying skin appears mildly erythematous, feels warm to touch, but then again she feels warm to touch over the rest of her abdomen, erythema appears localized to skin overlying pump, no streaking. Ext: cool feet, faint DPs, legs appear thin and wizened. Neuro: Brisk reflexes RLE, unable to elicit on left side. Pt with Babinski bilaterally. Withdraws occasionally to noxious stimuli. Does not respond to verbal stimuli. Pertinent Results: admit labs <Date>1966-1-27</Date> 10:22PM LACTATE-2.4* <Date>1966-1-27</Date> 10:15PM ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-264* CK(CPK)-140 ALK PHOS-87 AMYLASE-214* TOT BILI-0.1 <Date>1966-1-27</Date> 10:15PM LIPASE-20 <Date>1966-1-27</Date> 10:15PM ALBUMIN-3.6 CALCIUM-8.6 PHOSPHATE-2.0* MAGNESIUM-1.6 IRON-13* <Date>1966-1-27</Date> 10:15PM calTIBC-265 VIT B12-428 FOLATE-17.0 FERRITIN-434* TRF-204 <Date>1966-1-27</Date> 10:15PM WBC-39.6# RBC-3.35 HGB-10.0* HCT-30.1* MCV-90 MCH-29.9 MCHC-33.3 RDW-15.4 <Date>1966-1-27</Date> 10:15PM NEUTS-83* BANDS-9* LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 <Date>1966-1-27</Date> 10:15PM PLT SMR-NORMAL PLT COUNT-517# <Date>1966-1-27</Date> 10:15PM PT-15.5 PTT-30.5 INR(PT)-1.5 <Date>1966-1-27</Date> 10:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG <Date>1966-1-27</Date> 10:15PM URINE RBC-<Date>8-27</Date>* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-<1 . micro all blood cx no growth . GRAM STAIN (Final <Date>1912-8-26</Date>): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final <Date>1993-7-14</Date>): >100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. -STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci -NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. pan <Name>Waldon</Name> (except bactrim) . TTE on admission: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. No obvious mass or vegetation seen. . CT abd post-op: 1) Large hematoma in the superficial tissues of the right upper quadrant with associated edema and tracking into the abdominal wall. No extension into the peritoneal space is seen. The covering intern was notified by telephone at 10:30 a.m. on <Date>2-2</Date>, <Year>1930</Year>. 2) Gallbladder with dense material . this could represent stones, sludge or vicarious excretion of iv contrast. If clinically indicated, an ultrasound can be obtained for further characterization. 3) Bilateral small kidneys with small nonobstructing stones. 4) Atelectasis and small pleural effusions at both lung bases. . EEG <Date>2002-3-11</Date>: This is a markedly abnormal portable EEG due to the presence of generalized bursts of polymorphic disorganized slowing followed by periods of suppression. In addition, there were independent bifrontal sharp slow waves seen. This finding suggests deep, midline subcortical dysfunction and is consistent with a severe encephalopathy. A repeat EEG may be helpful to further evaluate the severity of the encephalopathy. . EEG <Date>1978-8-25</Date>: This is an abnormal portable EEG obtained in stage II sleep with brief periods of drowsiness due to the presence of intermittent and independent shifting slowing in the parasagital region on both sides. This finding suggests deep, midline subcortical dysfunction and is consistent with the diagnosis of meningoencephalitis. In addition, exessive drowsiness was seen, perhaps also related to the underlying infection. . MRI <Date>8-29</Date>: Increased signal along the occipital horns could be due to cellular debris from meningitis. No evidence of acute infarct seen. Mild to moderate ventriculomegaly indicating mild communicating hydrocephalus. . MRV <Date>8-29</Date>: The head MRV demonstrates normal flow signal in the superior sagittal and transverse sinus without evidence of thrombosis. Deep venous system also demonstrates normal flow signal. . MRA <Date>8-29</Date>: Somewhat limited MRA of the head due to motion. No evidence of vascular occlusion seen. . TEE: 1.The left atrium is normal in size. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4.There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. 6.The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. 7.There is a trivial/physiologic pericardial effusion. . Head CT <Date>3-23</Date>: Stable appearance of the ventricles and sulci. Brief Hospital Course: 1. GBS meningitis/bactermia In the unit, the pt was continued on Ampicillin and started on Gentamicin (for synergy). Her intrathecal baclofen pump was thought to be infected (on exam, erythema and warmth overlying pump in RUQ). Pt went to surgery to have pump removed and the operation appeared to be without complication. The following day, pt had 11 point hematocrit drop and was noted to be hypotensive with an SBP of 70. After spiking a temp, it was thought that she might be septic. She was given fluids, PRBCs, FFP, and placed on Levophed. Abd CT demonstrated a 7 x 13x 11 cm hematoma in the RUQ at the former pump site. Pt was taken emergently to surgery where the hematoma was evacuated, slow ooze noted, and the bleeding vessel cauterized. She returned to the floor and remained hemodynamically stable. Given 1 additional unit of PRBCs. Her hct bumped appropriately and remained in the high 20s for the rest of her unit course. Pt developed erythematous macular rash on face, arms, knees thought to be <Date>10-22</Date> to PCN allergy. Amp was d/c'd and replaced briefly with Vanc and then changed permanently to Cefrtriaxone. Repeat LP was performed since the pt continued to be minimially responsive (withdrawing to pain, occ. opening eyes to name). CSF analysis showed a resolving bacterial meningitis. Prior to leaving the unit, pt spiked a temp to 101.2. She was pancultured and all cultures were negative. A TTE ruled out endocarditis in the setting of group B strep bacteremia. On day #12 of gentamycin, pt was changed to vanc/ceftaz for the completion of her treatment course. . 2. RUQ Hematoma: As above, after the removal of the baclofen pump, pt had a hct drop and hypotensive episode and was found to be bleeding into the RUQ pocket. She was taken to the OR for emergent evacuation of the hematoma. On POD #16, pt was noted to have oozing from the a site above the stitches in her RUQ. Neurosurgery was reconsulted and they recommended an abdominal ultrasound which showed vast improvement in the RUQ hematoma but found a new fluid collection. Surgery was consulted and they diagnosed a seroma and recommended conservative management given that it had no signs of infection. . 3. Pneumonia: Towards the end of the pt's ICU stay, she was evaluated by speech and swallow and she had a very difficult time with the passy-muir valve. She underwent bronchoscopy and BAL was sent for culture. The culture returned positive for MRSA and gram negative rods (not pseudomonas). She was started on vancomycin for MRSA and ceftaz/levaquin for double coverage of the GNR. Once the GNR sensitivities showed that it was not pseudomonas, ceftaz was stopped. Of note, pt had vancomycin troughs that were persistently high. Vancomycin troughs should be checked often and vanc should be adjusted for a level<15. After the pt's swallowing study, she was noted to have increased secretions and some food particles were suctioned up so it was assumed that the pt aspirated. That day she also spiked a temperature to 100 so Flagyl was added for anaerobic coverage. Vancomycin and Levaquin will be finished on <Date>12-2</Date> (14-day course) and Flagyl's course will be complete on <Date>8-13</Date> (after 10 days). . 4. Supraglottic edema As above, pt was evaluated by interventional pulmonary after she failed a passy-muir valve. On bronchoscopy it was noted that she had severe supraglottic edema with grabulation tissue and the vocal cords could only be minimally visualized. She was taken to the OR two days later for a rigid bronchoscopy where her granulation tissue was debrided and a t-tube was placed. ENT evaluated the patient and recommended a CT of the trachea to evaluate her anatomy. The CT showed tracheal bronchomalacia and narrowing of the glottic and subglottic airway. Ideally, she will get surgery by ENT to improve her subglottic edema when the patient has recovered from her acute illnesses. . 5. Anemia: Iron studies indicate anemia of chronic disease. Pt's baseline hct is between 26 and 29 and except for the hct drop after the bleed in the RUQ pocket, pt's hct remained stable. . 6. Multiple sclerosis Pt started on oral baclofen prior to pump removal. She was without signs of baclofen withdrawal (i.e. incr HR, temp, BP, seizures) once pump was removed. She continued on Baclofen 20mg qid po with an Ativan taper. PO baclofen was then tapered to 20mg tid. . 7. Mental status At baseline, although pt is significantly debilitated by MS, she is alert, oriented, and conversant. Her decreased responsiveness was thought to be <Date>10-22</Date> to meningitis, but although pt seemed to have resolving temp and WBC with Abx, her diminished reponsiveness persisted. Repeat LP in the unit suggested a resolving meningitis. Neurology was following the pt and recommended an MRI to rule out stroke (esp given her ? of stroke at OSH) an MRV to rule out sinus thrombosis and an EEG to rule out subclinical seizures. An EEG on HD #3 was consistent with severe encephalopathy and an EEG on HD #6 was consistent with meningoencephalitis with no evidence of seizures. An MRI was finally done on HD #10 and showed mild communicating hydrocephalus, no evidence of cavernous thrombosis or stroke. Towards the end of her unit stay pt opened eyes to name and eventually returned to her baseline mental status. Pt's mental status remained at baseline and pt will follow-up with neurology as an outpatient. . 8. Respiratory status After a supposed seizure at OSH pt was mechanically ventilated thru her trach site b/c no breath sounds were appreciated. (At baseline, pt has respiratory weakeness 2/2 to multiple sclerosis but does not require mechical ventilation. Trach in place to help with clearance of secretions.) Pt placed on A/C in unit, then transferred to CPAP and eventually placed on a trach mask with good results. At time of discharge, she was satting well on 40% trach mask. . 9. HTN In unit, pt initially normotensive, then mid-way through stay became hypertensive with SBPs in the 150-170s. Pt has hx of hypertension. Unclear whether BP was rebounding from baclofen d/c. BP became well-controlled with systolic BP in the 90s-110s on standing doses of Lisinopril 20mg po, Metoprolol 25mg <Hospital>Cunningham LLC Clinic</Hospital>. . 10. Sacral decub ulcer: Stage 1-2. Wound care nurse followed while pt was in-house. . 11. FEN: During pt's acute illness, she had an NGT placed. Speech and swallow evaluated the pt and recommended thin liquids and pureed food. The following day, she was noted to have soup coming out of her trach so she was again made NPO. Pt then passed the video swallow but again had some signs of aspiration after trying some ground solids. She was made NPO and GI placed a PEG for feeding. Pt should remain on tube feeds until her tracheal swelling is much improved. At that point, another swallowing study can be performed and another trial of po feeding. . 12. Code: DNR/DNI Medications on Admission: per note from <Hospital>Reynolds, Marshall and Guerrero Clinic</Hospital>: Bisacodyl 10mg Folic acid Vitamin B12 Gemfibrozil Combivent 2 puff qid Fe sulfate Baclfen pump Zantac 150mg qhs Lisinopril 5mg qhs Alprazolam 0.25 mg qhs Oxybutynin Discharge Medications: 1. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Acetaminophen 160 mg/5 mL Elixir Sig: 325-650 mg PO Q4-6H (every 4 to 6 hours) as needed. 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 11. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for SBP<100. 14. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily). 15. Lorazepam 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q8H (every 8 hours) as needed for anxiety. 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every four (4) hours as needed. 17. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 18. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed units Subcutaneous ASDIR (AS DIRECTED) as needed for hyperglycemia: per regular insulin sliding scale. 19. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: one gram Intravenous Q24H (every 24 hours) for 4 days: please check daily troughs and give dose if level<15. 20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Discharge Disposition: Extended Care Facility: <Name>Aaron</Name> House Rehab & Nursing Center - <Location>872 Jessica Parks Suite 657 East Patricia, MN 51081</Location> Discharge Diagnosis: Primary: 1. Group B Streptococcal Meningoencephalitis - Stable Hydrocephalus. 2. Group Streptococcal Bacteremia and Septicemia. 3. Infected Baclofen Pump, removal c/b hematoma and evacuation. 4. MRSA and GNR Ventilator Associated Pneumonia. 5. Subglottic stenosis s/p rigid bronchoscopy and debridement. 6. Dysphagia and Recurrent Aspiration. 7. Aspiration Pneumonia. 8. Blood Loss Anemia. 9. Stage II Sacral Decubitus Ulcer. 10. Thrush. 11. Drug rash to Ampicillin. Secondary/Past Medical History. 1. Chronic Progressive Multiple Sclerosis. 2. Neurogenic Bladder - chronic foley catheter. 3. Chronic Obstructive Pulmonary Disease. 4. Hypertension. 5. Tracheobronchomalacia. 6. Constipation. Discharge Condition: good, breathing well on 40% trach mask Discharge Instructions: Take all medications as prescribed and go to all follow-up appointments. Followup Instructions: Provider: <Name>Norine</Name> <Name>Poff</Name>, <Name>Andrea Chowdhury</Name>.D. Where: LM <Hospital>Mckee-Mccullough Medical Center</Hospital> (ENT) Phone:<Telephone>883-848-9935</Telephone> Date/Time:<Date>1996-6-10</Date> 10:00 . Provider: <Name>Christian Blanchar</Name> <Name>Heath Sakkas</Name>, MD Where: <Hospital>Spears-Scott Clinic</Hospital> NEUROLOGY Phone:<Telephone>522-453-2157</Telephone> Date/Time:<Date>1930-10-21</Date> 1:00 . Please follow-up with your PCP in the next 1-2 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Date: 1966-1-27 Discharge Date: 1928-3-11 Date of Birth: 1978-9-11 Sex: F Service: MEDICINE Allergies: Penicillins Attending:Tamika Chief Complaint: Febrile, unresponsive--> GBS meningitis and bacteremia Major Surgical or Invasive Procedure: 1. Rigid bronchoscopy, debridement, T-tube placement. 2. Baclofen Pump Removal. 3. RUQ Hematoma Evacuation. 4. Percutaneous Gastrostomy Tube. 5. Left Antecubital PICC Line. History of Present Illness: Ms. Naegelin is a 62 y.o. woman with primary progressive MS Helen Kenner in 1930 with spasticity s/p intrathecal baclofen pump placment in '21, s/p tracheostomy in '56 10-22 to chronic respiratory weakness, recurrent UTIs, aspiration PNAs, who presents after being found to be febrile and unresponsive at her nursing home. According to notes from Reynolds, Marshall and Guerrero Clinic, the pt was found at her nursing home yesterday (11-31) AM, shaking her head repeatedly, subsequently becoming obtunded (presumed seizure). She was taken by EMS to Olsen Group Medical Center ED. . In the ED at Coral Loveland, pts vitals were: Tm 103.6, HR 110-150s RR 12-18 SaO2 98-99%NRB. Soon after, pt supposedly seized in the ED, was given Ativan, Ambu'd and subsequently placed on SIMV ventilation. Pt was empirically started on Vancomycin, Levoquin, Ceftriaxone, Bactrim and Acyclovir. On exam, it was noted that the skin overlying the baclofen pump (RUQ) appeared inflamed. Labs were notable for a WBC of 25 with 68%polys and a bandemia of 20%. U/A with 50-100 WBC, +leukocyte esterase, +nitrite. LP was performed and CSF analysis showed 7,250 WBCs with 92% polys, glucose 10, TP 1440, and gm stain with many polys, few gm+ cocci. Bcx revealed gm+ cocci in chains in 10-29 bottles. Micro lab performed latex agglutination on CSF sample which was positive for group B strep. Vanc and Ceftriaxone were dc'd and ampicillin 2gm IV + benadryl given. Hydrocortisone 80mg was also given. Left SC line and NGT were also placed at Olsen Group Medical Center. CXR showed cardiomegaly but no infiltrate. Abdominal CT was negative for an abscess or fluid collection surrounding the pump. Head CT showed questionable changes from prior that might suggest the possibility of a right MCA infarct. Pt was transferred directly to the Harmon, Brown and Joseph Health System MICU for further management. Past Medical History: PMH: 1. Chronic progressive multiple sclerosis - dx'd in 1930 when pt was 34 years old; on intrathecal baclofen pump ('21) for spasticity 2. Recurrent UTIs and hosp. for urosepsis - thought 10-22 to chronic indwelling Foley catheter for neurogenic bladder. Last admitted 1910-5-27 to 1961-5-23 for urosepsis 3. Recurrent aspiration PNA - 4-1943, 5/1929 - admitted both times requiring MICU stay, during '56 admission trach was placed because was unable to clear secretions on her own 10-22 to respiratory weakness 1/03 admitted for lingular PNA, unclear if 10-22 to aspiration 4. COPD 5. HTN 6. Osteoporosis 7. Scarlet fever as a child 8. Chronic constipation 9. Hx of sacral decubitus ulcer Social History: Social History: Pt is widowed. She has no children. She currently lives in a nursing home. Has been there since '56? She has no hx of smoking, EtOH, IVDU. Will call sister tomorrow for more information. Family History: Noncontributory Physical Exam: PE: VS P 123 BP 129/73 O2Sat 97% on mechanical vent FiO2 0.50, 550, 15/5 General: older white female being mech ventilated through tracheostomy HEENT: pupils equal and reactive to light bilaterally 5-->3mm, MMM, trach site clean, attempted to bend pt's neck but remained stiff, unclear if that was volitional Chest: coarse breath sounds throughout Cardiac: sinus tach nl s1, s2, no s3, s4, no murmur appreciated Abd: soft, obese, distended +bowel sounds throughout; in RUQ, can appreciate outline of intrathecal baclofen pump, overlying skin appears mildly erythematous, feels warm to touch, but then again she feels warm to touch over the rest of her abdomen, erythema appears localized to skin overlying pump, no streaking. Ext: cool feet, faint DPs, legs appear thin and wizened. Neuro: Brisk reflexes RLE, unable to elicit on left side. Pt with Babinski bilaterally. Withdraws occasionally to noxious stimuli. Does not respond to verbal stimuli. Pertinent Results: admit labs 1966-1-27 10:22PM LACTATE-2.4* 1966-1-27 10:15PM ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-264* CK(CPK)-140 ALK PHOS-87 AMYLASE-214* TOT BILI-0.1 1966-1-27 10:15PM LIPASE-20 1966-1-27 10:15PM ALBUMIN-3.6 CALCIUM-8.6 PHOSPHATE-2.0* MAGNESIUM-1.6 IRON-13* 1966-1-27 10:15PM calTIBC-265 VIT B12-428 FOLATE-17.0 FERRITIN-434* TRF-204 1966-1-27 10:15PM WBC-39.6# RBC-3.35 HGB-10.0* HCT-30.1* MCV-90 MCH-29.9 MCHC-33.3 RDW-15.4 1966-1-27 10:15PM NEUTS-83* BANDS-9* LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 1966-1-27 10:15PM PLT SMR-NORMAL PLT COUNT-517# 1966-1-27 10:15PM PT-15.5 PTT-30.5 INR(PT)-1.5 1966-1-27 10:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG 1966-1-27 10:15PM URINE RBC-8-27* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-1912-8-26): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final 1993-7-14): >100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. -STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci -NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. pan Waldon (except bactrim) . TTE on admission: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. No obvious mass or vegetation seen. . CT abd post-op: 1) Large hematoma in the superficial tissues of the right upper quadrant with associated edema and tracking into the abdominal wall. No extension into the peritoneal space is seen. The covering intern was notified by telephone at 10:30 a.m. on 2-2, 1930. 2) Gallbladder with dense material . this could represent stones, sludge or vicarious excretion of iv contrast. If clinically indicated, an ultrasound can be obtained for further characterization. 3) Bilateral small kidneys with small nonobstructing stones. 4) Atelectasis and small pleural effusions at both lung bases. . EEG 2002-3-11: This is a markedly abnormal portable EEG due to the presence of generalized bursts of polymorphic disorganized slowing followed by periods of suppression. In addition, there were independent bifrontal sharp slow waves seen. This finding suggests deep, midline subcortical dysfunction and is consistent with a severe encephalopathy. A repeat EEG may be helpful to further evaluate the severity of the encephalopathy. . EEG 1978-8-25: This is an abnormal portable EEG obtained in stage II sleep with brief periods of drowsiness due to the presence of intermittent and independent shifting slowing in the parasagital region on both sides. This finding suggests deep, midline subcortical dysfunction and is consistent with the diagnosis of meningoencephalitis. In addition, exessive drowsiness was seen, perhaps also related to the underlying infection. . MRI 8-29: Increased signal along the occipital horns could be due to cellular debris from meningitis. No evidence of acute infarct seen. Mild to moderate ventriculomegaly indicating mild communicating hydrocephalus. . MRV 8-29: The head MRV demonstrates normal flow signal in the superior sagittal and transverse sinus without evidence of thrombosis. Deep venous system also demonstrates normal flow signal. . MRA 8-29: Somewhat limited MRA of the head due to motion. No evidence of vascular occlusion seen. . TEE: 1.The left atrium is normal in size. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4.There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. 6.The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. 7.There is a trivial/physiologic pericardial effusion. . Head CT 3-23: Stable appearance of the ventricles and sulci. Brief Hospital Course: 1. GBS meningitis/bactermia In the unit, the pt was continued on Ampicillin and started on Gentamicin (for synergy). Her intrathecal baclofen pump was thought to be infected (on exam, erythema and warmth overlying pump in RUQ). Pt went to surgery to have pump removed and the operation appeared to be without complication. The following day, pt had 11 point hematocrit drop and was noted to be hypotensive with an SBP of 70. After spiking a temp, it was thought that she might be septic. She was given fluids, PRBCs, FFP, and placed on Levophed. Abd CT demonstrated a 7 x 13x 11 cm hematoma in the RUQ at the former pump site. Pt was taken emergently to surgery where the hematoma was evacuated, slow ooze noted, and the bleeding vessel cauterized. She returned to the floor and remained hemodynamically stable. Given 1 additional unit of PRBCs. Her hct bumped appropriately and remained in the high 20s for the rest of her unit course. Pt developed erythematous macular rash on face, arms, knees thought to be 10-22 to PCN allergy. Amp was d/c'd and replaced briefly with Vanc and then changed permanently to Cefrtriaxone. Repeat LP was performed since the pt continued to be minimially responsive (withdrawing to pain, occ. opening eyes to name). CSF analysis showed a resolving bacterial meningitis. Prior to leaving the unit, pt spiked a temp to 101.2. She was pancultured and all cultures were negative. A TTE ruled out endocarditis in the setting of group B strep bacteremia. On day #12 of gentamycin, pt was changed to vanc/ceftaz for the completion of her treatment course. . 2. RUQ Hematoma: As above, after the removal of the baclofen pump, pt had a hct drop and hypotensive episode and was found to be bleeding into the RUQ pocket. She was taken to the OR for emergent evacuation of the hematoma. On POD #16, pt was noted to have oozing from the a site above the stitches in her RUQ. Neurosurgery was reconsulted and they recommended an abdominal ultrasound which showed vast improvement in the RUQ hematoma but found a new fluid collection. Surgery was consulted and they diagnosed a seroma and recommended conservative management given that it had no signs of infection. . 3. Pneumonia: Towards the end of the pt's ICU stay, she was evaluated by speech and swallow and she had a very difficult time with the passy-muir valve. She underwent bronchoscopy and BAL was sent for culture. The culture returned positive for MRSA and gram negative rods (not pseudomonas). She was started on vancomycin for MRSA and ceftaz/levaquin for double coverage of the GNR. Once the GNR sensitivities showed that it was not pseudomonas, ceftaz was stopped. Of note, pt had vancomycin troughs that were persistently high. Vancomycin troughs should be checked often and vanc should be adjusted for a level12-2 (14-day course) and Flagyl's course will be complete on 8-13 (after 10 days). . 4. Supraglottic edema As above, pt was evaluated by interventional pulmonary after she failed a passy-muir valve. On bronchoscopy it was noted that she had severe supraglottic edema with grabulation tissue and the vocal cords could only be minimally visualized. She was taken to the OR two days later for a rigid bronchoscopy where her granulation tissue was debrided and a t-tube was placed. ENT evaluated the patient and recommended a CT of the trachea to evaluate her anatomy. The CT showed tracheal bronchomalacia and narrowing of the glottic and subglottic airway. Ideally, she will get surgery by ENT to improve her subglottic edema when the patient has recovered from her acute illnesses. . 5. Anemia: Iron studies indicate anemia of chronic disease. Pt's baseline hct is between 26 and 29 and except for the hct drop after the bleed in the RUQ pocket, pt's hct remained stable. . 6. Multiple sclerosis Pt started on oral baclofen prior to pump removal. She was without signs of baclofen withdrawal (i.e. incr HR, temp, BP, seizures) once pump was removed. She continued on Baclofen 20mg qid po with an Ativan taper. PO baclofen was then tapered to 20mg tid. . 7. Mental status At baseline, although pt is significantly debilitated by MS, she is alert, oriented, and conversant. Her decreased responsiveness was thought to be 10-22 to meningitis, but although pt seemed to have resolving temp and WBC with Abx, her diminished reponsiveness persisted. Repeat LP in the unit suggested a resolving meningitis. Neurology was following the pt and recommended an MRI to rule out stroke (esp given her ? of stroke at OSH) an MRV to rule out sinus thrombosis and an EEG to rule out subclinical seizures. An EEG on HD #3 was consistent with severe encephalopathy and an EEG on HD #6 was consistent with meningoencephalitis with no evidence of seizures. An MRI was finally done on HD #10 and showed mild communicating hydrocephalus, no evidence of cavernous thrombosis or stroke. Towards the end of her unit stay pt opened eyes to name and eventually returned to her baseline mental status. Pt's mental status remained at baseline and pt will follow-up with neurology as an outpatient. . 8. Respiratory status After a supposed seizure at OSH pt was mechanically ventilated thru her trach site b/c no breath sounds were appreciated. (At baseline, pt has respiratory weakeness 2/2 to multiple sclerosis but does not require mechical ventilation. Trach in place to help with clearance of secretions.) Pt placed on A/C in unit, then transferred to CPAP and eventually placed on a trach mask with good results. At time of discharge, she was satting well on 40% trach mask. . 9. HTN In unit, pt initially normotensive, then mid-way through stay became hypertensive with SBPs in the 150-170s. Pt has hx of hypertension. Unclear whether BP was rebounding from baclofen d/c. BP became well-controlled with systolic BP in the 90s-110s on standing doses of Lisinopril 20mg po, Metoprolol 25mg Cunningham LLC Clinic. . 10. Sacral decub ulcer: Stage 1-2. Wound care nurse followed while pt was in-house. . 11. FEN: During pt's acute illness, she had an NGT placed. Speech and swallow evaluated the pt and recommended thin liquids and pureed food. The following day, she was noted to have soup coming out of her trach so she was again made NPO. Pt then passed the video swallow but again had some signs of aspiration after trying some ground solids. She was made NPO and GI placed a PEG for feeding. Pt should remain on tube feeds until her tracheal swelling is much improved. At that point, another swallowing study can be performed and another trial of po feeding. . 12. Code: DNR/DNI Medications on Admission: per note from Reynolds, Marshall and Guerrero Clinic: Bisacodyl 10mg Folic acid Vitamin B12 Gemfibrozil Combivent 2 puff qid Fe sulfate Baclfen pump Zantac 150mg qhs Lisinopril 5mg qhs Alprazolam 0.25 mg qhs Oxybutynin Discharge Medications: 1. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Acetaminophen 160 mg/5 mL Elixir Sig: 325-650 mg PO Q4-6H (every 4 to 6 hours) as needed. 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 11. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for SBPAaron House Rehab & Nursing Center - 872 Jessica Parks Suite 657 East Patricia, MN 51081 Discharge Diagnosis: Primary: 1. Group B Streptococcal Meningoencephalitis - Stable Hydrocephalus. 2. Group Streptococcal Bacteremia and Septicemia. 3. Infected Baclofen Pump, removal c/b hematoma and evacuation. 4. MRSA and GNR Ventilator Associated Pneumonia. 5. Subglottic stenosis s/p rigid bronchoscopy and debridement. 6. Dysphagia and Recurrent Aspiration. 7. Aspiration Pneumonia. 8. Blood Loss Anemia. 9. Stage II Sacral Decubitus Ulcer. 10. Thrush. 11. Drug rash to Ampicillin. Secondary/Past Medical History. 1. Chronic Progressive Multiple Sclerosis. 2. Neurogenic Bladder - chronic foley catheter. 3. Chronic Obstructive Pulmonary Disease. 4. Hypertension. 5. Tracheobronchomalacia. 6. Constipation. Discharge Condition: good, breathing well on 40% trach mask Discharge Instructions: Take all medications as prescribed and go to all follow-up appointments. Followup Instructions: Provider: Norine Poff, Andrea Chowdhury.D. Where: LM Mckee-Mccullough Medical Center (ENT) Phone:883-848-9935 Date/Time:1996-6-10 10:00 . Provider: Christian Blanchar Heath Sakkas, MD Where: Spears-Scott Clinic NEUROLOGY Phone:522-453-2157 Date/Time:1930-10-21 1:00 . Please follow-up with your PCP in the next 1-2 weeks	["Admission Date: 1966-1-27 Discharge Date: 1928-3-11\n\nDate of Birth: 1978-9-11 Sex: F\n\nService: MEDICINE\n\nAllergies:\nPenicillins\n\nAttending:Tamika\nChief Complaint:\nFebrile, unresponsive--> GBS meningitis and bacteremia\n\nMajor Surgical or Invasive Procedure:\n1. Rigid bronchoscopy, debridement, T-tube placement.\n2. Baclofen Pump Removal.\n3. RUQ Hematoma Evacuation.\n4. Percutaneous Gastrostomy Tube.\n5. Left Antecubital PICC Line.\n\n\nHistory of Present Illness:\nMs. Naegelin is a 62 y.o. woman with primary progressive MS\nHelen Kenner in 1930 with spasticity s/p intrathecal baclofen pump\nplacment in '21, s/p tracheostomy in '56 10-22 to chronic\nrespiratory weakness, recurrent UTIs, aspiration PNAs, who\npresents after being found to be febrile and unresponsive at her\nnursing home.", " According to notes from Reynolds, Marshall and Guerrero Clinic, the\npt was found at her nursing home yesterday (11-31) AM, shaking\nher head repeatedly, subsequently becoming obtunded (presumed\nseizure). She was taken by EMS to Olsen Group Medical Center ED.\n.\nIn the ED at Coral Loveland, pts vitals were: Tm 103.6, HR 110-150s RR\n12-18 SaO2 98-99%NRB. Soon after, pt supposedly seized in the\nED, was given Ativan, Ambu'd and subsequently placed on SIMV\nventilation. Pt was empirically started on Vancomycin, Levoquin,\nCeftriaxone, Bactrim and Acyclovir. On exam, it was noted that\nthe skin overlying the baclofen pump (RUQ) appeared inflamed.\nLabs were notable for a WBC of 25 with 68%polys and a bandemia\nof 20%. U/A with 50-100 WBC, +leukocyte esterase, +nitrite. LP\nwas performed and CSF analysis showed 7,250 WBCs with 92% polys,\nglucose 10, TP 1440, and gm stain with many polys, few gm+\ncocci.", " Bcx revealed gm+ cocci in chains in 10-29 bottles. Micro\nlab performed latex agglutination on CSF sample which was\npositive for group B strep. Vanc and Ceftriaxone were dc'd and\nampicillin 2gm IV + benadryl given. Hydrocortisone 80mg was also\ngiven. Left SC line and NGT were also placed at Olsen Group Medical Center. CXR showed\ncardiomegaly but no infiltrate. Abdominal CT was negative for an\nabscess or fluid collection surrounding the pump. Head CT showed\nquestionable changes from prior that might suggest the\npossibility of a right MCA infarct. Pt was transferred directly\nto the Harmon, Brown and Joseph Health System MICU for further management.\n\n\nPast Medical History:\nPMH:\n1. Chronic progressive multiple sclerosis - dx'd in 1930 when pt\nwas 34 years old; on intrathecal baclofen pump ('21) for\nspasticity\n2.", " Recurrent UTIs and hosp. for urosepsis - thought 10-22 to\nchronic indwelling Foley catheter for neurogenic bladder. Last\nadmitted 1910-5-27 to 1961-5-23 for urosepsis\n3. Recurrent aspiration PNA - 4-1943, 5/1929 - admitted both times\nrequiring MICU stay, during '56 admission trach was placed\nbecause was unable to clear secretions on her own 10-22 to\nrespiratory weakness\n1/03 admitted for lingular PNA, unclear if 10-22 to aspiration\n4. COPD\n5. HTN\n6. Osteoporosis\n7. Scarlet fever as a child\n8. Chronic constipation\n9. Hx of sacral decubitus ulcer\n\n\nSocial History:\nSocial History: Pt is widowed. She has no children. She\ncurrently lives in a nursing home. Has been there since '56? She\nhas no hx of smoking, EtOH, IVDU. Will call sister tomorrow for\nmore information.\n\nFamily History:\nNoncontributory\n\nPhysical Exam:\nPE: VS P 123 BP 129/73 O2Sat 97% on mechanical vent FiO2 0.", "50,\n550, 15/5\nGeneral: older white female being mech ventilated through\ntracheostomy\nHEENT: pupils equal and reactive to light bilaterally 5-->3mm,\nMMM, trach site clean, attempted to bend pt's neck but remained\nstiff, unclear if that was volitional\nChest: coarse breath sounds throughout\nCardiac: sinus tach nl s1, s2, no s3, s4, no murmur appreciated\nAbd: soft, obese, distended +bowel sounds throughout; in RUQ,\ncan appreciate outline of intrathecal baclofen pump, overlying\nskin appears mildly erythematous, feels warm to touch, but then\nagain she feels warm to touch over the rest of her abdomen,\nerythema appears localized to skin overlying pump, no streaking.\nExt: cool feet, faint DPs, legs appear thin and wizened.\nNeuro: Brisk reflexes RLE, unable to elicit on left side. Pt\nwith Babinski bilaterally.", ' Withdraws occasionally to noxious\nstimuli. Does not respond to verbal stimuli.\n\n\nPertinent Results:\n admit labs \n1966-1-27 10:22PM LACTATE-2.4\n1966-1-27 10:15PM ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-264\nCK(CPK)-140 ALK PHOS-87 AMYLASE-214* TOT BILI-0.1\n1966-1-27 10:15PM LIPASE-20\n1966-1-27 10:15PM ALBUMIN-3.6 CALCIUM-8.6 PHOSPHATE-2.0\nMAGNESIUM-1.6 IRON-13\n1966-1-27 10:15PM calTIBC-265 VIT B12-428 FOLATE-17.0\nFERRITIN-434* TRF-204\n1966-1-27 10:15PM WBC-39.6# RBC-3.35 HGB-10.0* HCT-30.1\nMCV-90 MCH-29.9 MCHC-33.3 RDW-15.4\n1966-1-27 10:15PM NEUTS-83 BANDS-9* LYMPHS-4* MONOS-4 EOS-0\nBASOS-0 ATYPS-0 METAS-0 MYELOS-0\n1966-1-27 10:15PM PLT SMR-NORMAL PLT COUNT-517#\n1966-1-27 10:15PM PT-15.5 PTT-30.5 INR(PT)-1.5\n1966-1-27 10:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.', '0\nLEUK-NEG\n1966-1-27 10:15PM URINE RBC-8-27* WBC-0-2 BACTERIA-RARE\nYEAST-NONE EPI-1912-8-26):\n 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR\nLEUKOCYTES.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CHAINS.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).\n\n RESPIRATORY CULTURE (Final 1993-7-14):\n >100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.\n -STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..\n Oxacillin RESISTANT Staphylococci\n -NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. pan Waldon (except\nbactrim)\n.\nTTE on admission:\n1. Left ventricular wall thickness, cavity size, and systolic\nfunction are\nnormal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n2. No obvious mass or vegetation seen.\n.', '\nCT abd post-op:\n1) Large hematoma in the superficial tissues of the right upper\nquadrant with associated edema and tracking into the abdominal\nwall. No extension into the peritoneal space is seen. The\ncovering intern was notified by telephone at 10:30 a.m. on 2-2, 1930.\n\n2) Gallbladder with dense material . this could represent\nstones, sludge or vicarious excretion of iv contrast. If\nclinically indicated, an ultrasound can be obtained for further\ncharacterization.\n\n3) Bilateral small kidneys with small nonobstructing stones.\n\n4) Atelectasis and small pleural effusions at both lung bases.\n.\nEEG 2002-3-11: This is a markedly abnormal portable EEG due to the\n\npresence of generalized bursts of polymorphic disorganized\nslowing\nfollowed by periods of suppression. In addition, there were\nindependent\nbifrontal sharp slow waves seen.', ' This finding suggests deep,\nmidline\nsubcortical dysfunction and is consistent with a severe\nencephalopathy.\nA repeat EEG may be helpful to further evaluate the severity of\nthe encephalopathy.\n.\nEEG 1978-8-25: This is an abnormal portable EEG obtained in stage\nII sleep\nwith brief periods of drowsiness due to the presence of\nintermittent and\nindependent shifting slowing in the parasagital region on both\nsides.\nThis finding suggests deep, midline subcortical dysfunction and\nis\nconsistent with the diagnosis of meningoencephalitis. In\naddition,\nexessive drowsiness was seen, perhaps also related to the\nunderlying\ninfection.\n.\nMRI 8-29: Increased signal along the occipital horns could be\ndue to cellular debris from meningitis. No evidence of acute\ninfarct seen. Mild to moderate ventriculomegaly indicating mild\ncommunicating hydrocephalus.', '\n.\nMRV 8-29: The head MRV demonstrates normal flow signal in the\nsuperior sagittal and transverse sinus without evidence of\nthrombosis. Deep venous system also demonstrates normal flow\nsignal.\n.\nMRA 8-29: Somewhat limited MRA of the head due to motion. No\nevidence of vascular occlusion seen.\n.\nTEE:\n1.The left atrium is normal in size.\n2. Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n3. Right ventricular chamber size and free wall motion are\nnormal.\n4.There are simple atheroma in the descending thoracic aorta.\n5.The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. No masses or\nvegetations are seen on the aortic valve.\n6.The mitral valve appears structurally normal with trivial\nmitral\nregurgitation.', ' No mass or vegetation is seen on the mitral\nvalve.\n7.There is a trivial/physiologic pericardial effusion.\n.\nHead CT 3-23: Stable appearance of the ventricles and sulci.\n\n\nBrief Hospital Course:\n1. GBS meningitis/bactermia\nIn the unit, the pt was continued on Ampicillin and started on\nGentamicin (for synergy). Her intrathecal baclofen pump was\nthought to be infected (on exam, erythema and warmth overlying\npump in RUQ). Pt went to surgery to have pump removed and the\noperation appeared to be without complication. The following\nday, pt had 11 point hematocrit drop and was noted to be\nhypotensive with an SBP of 70. After spiking a temp, it was\nthought that she might be septic. She was given fluids, PRBCs,\nFFP, and placed on Levophed. Abd CT demonstrated a 7 x 13x 11 cm\nhematoma in the RUQ at the former pump site.', " Pt was taken\nemergently to surgery where the hematoma was evacuated, slow\nooze noted, and the bleeding vessel cauterized. She returned to\nthe floor and remained hemodynamically stable. Given 1\nadditional unit of PRBCs. Her hct bumped appropriately and\nremained in the high 20s for the rest of her unit course. Pt\ndeveloped erythematous macular rash on face, arms, knees thought\nto be 10-22 to PCN allergy. Amp was d/c'd and replaced briefly\nwith Vanc and then changed permanently to Cefrtriaxone. Repeat\nLP was performed since the pt continued to be minimially\nresponsive (withdrawing to pain, occ. opening eyes to name). CSF\nanalysis showed a resolving bacterial meningitis. Prior to\nleaving the unit, pt spiked a temp to 101.2. She was pancultured\nand all cultures were negative. A TTE ruled out endocarditis in\nthe setting of group B strep bacteremia.", " On day #12 of\ngentamycin, pt was changed to vanc/ceftaz for the completion of\nher treatment course.\n.\n2. RUQ Hematoma: As above, after the removal of the baclofen\npump, pt had a hct drop and hypotensive episode and was found to\nbe bleeding into the RUQ pocket. She was taken to the OR for\nemergent evacuation of the hematoma. On POD #16, pt was noted\nto have oozing from the a site above the stitches in her RUQ.\nNeurosurgery was reconsulted and they recommended an abdominal\nultrasound which showed vast improvement in the RUQ hematoma but\nfound a new fluid collection. Surgery was consulted and they\ndiagnosed a seroma and recommended conservative management given\nthat it had no signs of infection.\n.\n3. Pneumonia:\nTowards the end of the pt's ICU stay, she was evaluated by\nspeech and swallow and she had a very difficult time with the\npassy-muir valve.", " She underwent bronchoscopy and BAL was sent\nfor culture. The culture returned positive for MRSA and gram\nnegative rods (not pseudomonas). She was started on vancomycin\nfor MRSA and ceftaz/levaquin for double coverage of the GNR.\nOnce the GNR sensitivities showed that it was not pseudomonas,\nceftaz was stopped. Of note, pt had vancomycin troughs that\nwere persistently high. Vancomycin troughs should be checked\noften and vanc should be adjusted for a level12-2 (14-day course)\nand Flagyl's course will be complete on 8-13 (after 10 days).\n.\n4. Supraglottic edema\nAs above, pt was evaluated by interventional pulmonary after she\nfailed a passy-muir valve. On bronchoscopy it was noted that\nshe had severe supraglottic edema with grabulation tissue and\nthe vocal cords could only be minimally visualized.", " She was\ntaken to the OR two days later for a rigid bronchoscopy where\nher granulation tissue was debrided and a t-tube was placed.\nENT evaluated the patient and recommended a CT of the trachea to\nevaluate her anatomy. The CT showed tracheal bronchomalacia and\nnarrowing of the glottic and subglottic airway. Ideally, she\nwill get surgery by ENT to improve her subglottic edema when the\npatient has recovered from her acute illnesses.\n.\n5. Anemia: Iron studies indicate anemia of chronic disease.\nPt's baseline hct is between 26 and 29 and except for the hct\ndrop after the bleed in the RUQ pocket, pt's hct remained\nstable.\n.\n6. Multiple sclerosis\nPt started on oral baclofen prior to pump removal. She was\nwithout signs of baclofen withdrawal (i.e. incr HR, temp, BP,\nseizures) once pump was removed.", ' She continued on Baclofen 20mg\nqid po with an Ativan taper. PO baclofen was then tapered to\n20mg tid.\n.\n7. Mental status\nAt baseline, although pt is significantly debilitated by MS, she\nis alert, oriented, and conversant. Her decreased responsiveness\nwas thought to be 10-22 to meningitis, but although pt seemed to\nhave resolving temp and WBC with Abx, her diminished\nreponsiveness persisted. Repeat LP in the unit suggested a\nresolving meningitis. Neurology was following the pt and\nrecommended an MRI to rule out stroke (esp given her ? of stroke\nat OSH) an MRV to rule out sinus thrombosis and an EEG to rule\nout subclinical seizures. An EEG on HD #3 was consistent with\nsevere encephalopathy and an EEG on HD #6 was consistent with\nmeningoencephalitis with no evidence of seizures. An MRI was\nfinally done on HD #10 and showed mild communicating\nhydrocephalus, no evidence of cavernous thrombosis or stroke.', "\nTowards the end of her unit stay pt opened eyes to name and\neventually returned to her baseline mental status. Pt's mental\nstatus remained at baseline and pt will follow-up with neurology\nas an outpatient.\n.\n8. Respiratory status\nAfter a supposed seizure at OSH pt was mechanically ventilated\nthru her trach site b/c no breath sounds were appreciated. (At\nbaseline, pt has respiratory weakeness 2/2 to multiple sclerosis\nbut does not require mechical ventilation. Trach in place to\nhelp with clearance of secretions.) Pt placed on A/C in unit,\nthen transferred to CPAP and eventually placed on a trach mask\nwith good results. At time of discharge, she was satting well\non 40% trach mask.\n.\n9. HTN\nIn unit, pt initially normotensive, then mid-way through stay\nbecame hypertensive with SBPs in the 150-170s.", " Pt has hx of\nhypertension. Unclear whether BP was rebounding from baclofen\nd/c. BP became well-controlled with systolic BP in the 90s-110s\non standing doses of Lisinopril 20mg po, Metoprolol 25mg Cunningham LLC Clinic.\n.\n10. Sacral decub ulcer: Stage 1-2. Wound care nurse followed\nwhile pt was in-house.\n.\n11. FEN: During pt's acute illness, she had an NGT placed.\nSpeech and swallow evaluated the pt and recommended thin liquids\nand pureed food. The following day, she was noted to have soup\ncoming out of her trach so she was again made NPO. Pt then\npassed the video swallow but again had some signs of aspiration\nafter trying some ground solids. She was made NPO and GI placed\na PEG for feeding. Pt should remain on tube feeds until her\ntracheal swelling is much improved. At that point, another\nswallowing study can be performed and another trial of po\nfeeding.", '\n.\n12. Code: DNR/DNI\n\nMedications on Admission:\nper note from Reynolds, Marshall and Guerrero Clinic:\nBisacodyl 10mg\nFolic acid\nVitamin B12\nGemfibrozil\nCombivent 2 puff qid\nFe sulfate\nBaclfen pump\nZantac 150mg qhs\nLisinopril 5mg qhs\nAlprazolam 0.25 mg qhs\nOxybutynin\n\nDischarge Medications:\n1. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\n2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a\nday).\n3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID\n(3 times a day).\n4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\n5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n8. Bisacodyl 5 mg Tablet, Delayed Release (E.', 'C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.\n9. Acetaminophen 160 mg/5 mL Elixir Sig: 325-650 mg PO Q4-6H\n(every 4 to 6 hours) as needed.\n10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:\nThirty (30) mg PO DAILY (Daily).\n11. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)\nTablet Sustained Release PO BID (2 times a day).\n12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3\ntimes a day) for 4 days.\n13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3\ntimes a day): hold for SBPAaron House Rehab & Nursing Center - 872 Jessica Parks Suite 657\nEast Patricia, MN 51081\n\nDischarge Diagnosis:\nPrimary:\n1. Group B Streptococcal Meningoencephalitis - Stable\nHydrocephalus.\n2. Group Streptococcal Bacteremia and Septicemia.\n3. Infected Baclofen Pump, removal c/b hematoma and evacuation.', '\n4. MRSA and GNR Ventilator Associated Pneumonia.\n5. Subglottic stenosis s/p rigid bronchoscopy and debridement.\n6. Dysphagia and Recurrent Aspiration.\n7. Aspiration Pneumonia.\n8. Blood Loss Anemia.\n9. Stage II Sacral Decubitus Ulcer.\n10. Thrush.\n11. Drug rash to Ampicillin.\n\nSecondary/Past Medical History.\n1. Chronic Progressive Multiple Sclerosis.\n2. Neurogenic Bladder - chronic foley catheter.\n3. Chronic Obstructive Pulmonary Disease.\n4. Hypertension.\n5. Tracheobronchomalacia.\n6. Constipation.\n\n\nDischarge Condition:\ngood, breathing well on 40% trach mask\n\nDischarge Instructions:\nTake all medications as prescribed and go to all follow-up\nappointments.\n\nFollowup Instructions:\nProvider: Norine Poff, Andrea Chowdhury.D. Where: LM Mckee-Mccullough Medical Center (ENT) Phone:883-848-9935 Date/Time:1996-6-10 10:00\n.', '\nProvider: Christian Blanchar Heath Sakkas, MD Where: Spears-Scott Clinic NEUROLOGY\nPhone:522-453-2157 Date/Time:1930-10-21 1:00\n.\nPlease follow-up with your PCP in the next 1-2 weeks\n\n\n\n']
4	14605	195146.0	2198-11-27	Discharge summary	Report	Admission Date: [2198-11-23] Discharge Date: [2198-11-27] Date of Birth: [2135-1-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 45] Chief Complaint: PEA arrest . Major Surgical or Invasive Procedure: temporary pacemaker placement permanent Pacemaker placement [2198-11-26] History of Present Illness: Pt was in USOH, awaiting R THR, collapsed while celebrating a funeral mass, was down for 1 min prior to EMS arrival, found to be pulseless, atrial activity noted on stips but only occasional wide qrs complexes, could not transcut pace, got atropine and calcium gluc, went to [First Name4 (NamePattern1) 46] [Last Name (NamePattern1) ], was intubated for protection, K 6.6, HCO3 13, and Cr 2.7. Got kayexylate, bicarb gtt, lasix, and extubated. ECG w/RBBB, LAD, LAFB, and sig PR delay so sent here for pacer. R IJ pacer wire screwed in but still temporary. Transferred to [Hospital1 18] for permanent pacer and further managment. Past Medical History: PMH: HTN, dyslipidemia, CRI (not formally dx per pt), OA w/ hip pain awaiting R THR, h/o chronic low potassium and severe HTN per pt -baseline trifasicular block Social History: Pt is a priest Family History: non-contributory Physical Exam: t 98.9 BP 131/79 HR 64 Tele: v-paced/ few PVC's with compensatory pauses O2 sat 92%RA Gen: elder male, lying in bed, NAD HEENT: JVP flat, MMM, PERRLA, EOMI Heart: s1, s2, RRR. no MRG Lungs: bibasilar crackles, otherwise, CTAB Ext: 1+ pedal edema bilat Neuro: A&O x3 Pertinent Results: [2198-11-23] 05:40PM PT-14.2* PTT-26.9 INR(PT)-1.4 [2198-11-23] 05:40PM PLT COUNT-137* [2198-11-23] 05:40PM WBC-11.0 RBC-4.23* HGB-13.2* HCT-37.5* MCV-89 MCH-31.1 MCHC-35.2* RDW-13.9 [2198-11-23] 05:40PM GLUCOSE-111* UREA N-55* CREAT-2.6* SODIUM-141 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-31 ANION GAP-13 [2198-11-27] 09:00AM BLOOD WBC-6.5 RBC-4.38* Hgb-13.6* Hct-38.2* MCV-87 MCH-31.0 MCHC-35.5* RDW-13.4 Plt Ct-155 . Echo [2198-11-26] Conclusions: There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction. Resting regional wall motion abnormalities include inferior and inferolateral akinesis/hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [2193-4-18], left ventricular dysfunction is new and mild aortic regurgitation is now detected. Brief Hospital Course: A/P: 63 yo male with cardiac arrest [3-7] paroxysmal high degree AV block, s/p collapse with PEA arrest now with temp pacer transferred to [Hospital1 ] for further mgmt and permanent pacemaker placement. . 1. Rhythm: paroxysmal high degree block, temp pacer placed. reasons for initial collapse are unclear, possibly combination of high degree av block and electrolyte disturbances, since patient was on many K+sparing diuretics. Tele after admission showed V-paced with few PVCs. Pt underwent pacemaker placement on [2198-11-26] without complications. The next day device interrigation was satisfacotory. CXR did not show a pneumothorax or any acute processes. Pt remained without complaints and was discharged on [2198-11-27]. Indications for pacer was symptomatic with high degree block. . 2. Coronaries: risk factors, [Location (un) 47] risk 17%, ruled out for MI w/trop leak but flat CKs after arrest. -Cont ASA, BB, statin - lipids checked : total chol 122, HDL 36, LDL 68. Continued on lipitor 20. - initially held ACEI given [Doctor First Name 48] upto Creatinine of 2.2. Given his hyperkalemia on presentation pt was not restarted on ACE inhibitors as his BP was well controlled. - Repeat Echo (see below) showed EF of 50%. Given this event would recommend an outpatient evaluation by cardiologist for likely exercise stress test. . 3. Pump: EF [2193] was 60% w/LAE, likely diastolic dysfunction, mild hypervolemia w/?mild pulm edema causing mild hypoxia, initially gentle diuresis with goals -500cc to -1L. - Continued amlodipine and metoprolol for rate control - held ace/arbs due to [Doctor First Name 48] - echo [11-26] showed EF of 50%. - During the admission pt did not go onto complain any further of Chest pain or Shortness of breath. . 4. ARF/CRI: acute insult likely combo of triamterene and NSAIDS, aggrevated by diuretics and ACE-I. Baseline 1.3-1.5 with proteinuria long standing, should avoid NSAIDS for life. -Discontinued ACE-I/ARBa and diuretics. -Checked FeUrea, FeUrea: 36.5%, confirming ATN. spep and upep (given anemia, pending), had u/s at [Hospital1 46] but should have repeat as outpt to check complex cysts vs masses. Renal diet. . 5. Anemia: new, SPEP was negative, UPEP negative for bence [Doctor Last Name 49] proteins, and iron, shows anemia likely due to renal causes -PCP may consider [Name9 (PRE) 50] as outpt given pt's age and anemia. . 6. Thombocytopenia: new, mild and stable during the admission. . 7. Elevated glucose: possibly continued stress response, check FS wnl. . 8. h/o hypokalemia: PCP may consider Nephrologist follow up. Would Recommend outpt mineralocorticoid XS work-up once off K sparing diuretics for a while. . 9. Hip pain: awaiting THR. vicodin prn. No NSAIDs due to renal problems. 10. Communicate with friend, preferred HCP per pt, [Name (NI) 51] [Name (NI) 52] [Telephone/Fax (1) 53] and PCP [Name9 (PRE) 54] [Hospital1 18] [Location (un) 55] [Telephone/Fax (1) 56] Medications on Admission: Amlodipine 10 mg PO DAILY Metoprolol 100 mg PO BID Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days. Disp:10 Capsule(s) Refills:0 7. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: cardiac arrest high degree heart block acute renal failure hyperkalemia metabolic acidosis anemia with poor bone marrow response/insufficient production thrombocytopenia chronic renal insufficiency, stage 2-3 HTN dyslipidemia osteoarthritis w/ hip pain awaiting R THR h/o chronic low potassium Discharge Condition: good Discharge Instructions: You have had a pacemaker placed because of electrical block in your heart. This may have been precipitated by kidney failure and too much potassium in your blood. Do not take the medications you were taking prior to this event. We have enclosed a list of and prescriptions for your new medication needs. Please take these as directed and discuss any changes with your primary care doctor. . You have many risks for coronary heart disease. We feel you need a stress test with imaging in the next month to make sure that you do not have any significant need for a cardiac catheterization. Until then, taking aspirin, your Toprol XL (beta blocker safe in renal failure), your lipitor, and eventually starting your lisinopril again will protect you somewhat from heart attacks. . You must never take NSAID medications again. Your kidney disease makes this dangerous. Avoid ibuprofen, advil, motrin, aleve, naproxen, or ketoprofen. Talk with your doctor [First Name (Titles) ] [Last Name (Titles) 57] if you are unsure about any medications you are taking. Followup Instructions: 1. See your primary care doctor Dr. [Last Name (STitle) 58] on Friday 28th at 2:30pm, to check your potassium and creatinine levels and to discuss everything we recommended. Have your doctor follow up on the serum and urine protein electrophoresis that was pending when you were discharged as well as the final report of your echocardiogram. Talk with your doctor about your anemia and whether or not you would need a bone marrow biopsy. 2. Go to the pacemaker DEVICE CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2198-12-3] 11:30 3. You should see our nephrologists sometime for your kidney disease. Talk with your primary doctor about this and call for an appointment [Telephone/Fax (1) 60]. 4. You should also setup an appointment with a cardiologist to have a exercise stress test done as outpatient. You can speak with your PCP regarding [Name Initial (PRE) ] cardiologist or you can call [Hospital 61] at [Telephone/Fax (1) 62] to setup an appointment here. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [Doctor First Name 63] Completed by:[2198-11-28]	Admission Date: <Date>2009-11-8</Date> Discharge Date: <Date>1919-2-7</Date> Date of Birth: <Date>1968-12-17</Date> Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Tamika</Name> Chief Complaint: PEA arrest . Major Surgical or Invasive Procedure: temporary pacemaker placement permanent Pacemaker placement <Date>1990-5-21</Date> History of Present Illness: Pt was in USOH, awaiting R THR, collapsed while celebrating a funeral mass, was down for 1 min prior to EMS arrival, found to be pulseless, atrial activity noted on stips but only occasional wide qrs complexes, could not transcut pace, got atropine and calcium gluc, went to <Name>Joe</Name> <Name>Johnson</Name>, was intubated for protection, K 6.6, HCO3 13, and Cr 2.7. Got kayexylate, bicarb gtt, lasix, and extubated. ECG w/RBBB, LAD, LAFB, and sig PR delay so sent here for pacer. R IJ pacer wire screwed in but still temporary. Transferred to <Hospital>Mcneil PLC Clinic</Hospital> for permanent pacer and further managment. Past Medical History: PMH: HTN, dyslipidemia, CRI (not formally dx per pt), OA w/ hip pain awaiting R THR, h/o chronic low potassium and severe HTN per pt -baseline trifasicular block Social History: Pt is a priest Family History: non-contributory Physical Exam: t 98.9 BP 131/79 HR 64 Tele: v-paced/ few PVC's with compensatory pauses O2 sat 92%RA Gen: elder male, lying in bed, NAD HEENT: JVP flat, MMM, PERRLA, EOMI Heart: s1, s2, RRR. no MRG Lungs: bibasilar crackles, otherwise, CTAB Ext: 1+ pedal edema bilat Neuro: A&O x3 Pertinent Results: <Date>2009-11-8</Date> 05:40PM PT-14.2* PTT-26.9 INR(PT)-1.4 <Date>2009-11-8</Date> 05:40PM PLT COUNT-137* <Date>2009-11-8</Date> 05:40PM WBC-11.0 RBC-4.23* HGB-13.2* HCT-37.5* MCV-89 MCH-31.1 MCHC-35.2* RDW-13.9 <Date>2009-11-8</Date> 05:40PM GLUCOSE-111* UREA N-55* CREAT-2.6* SODIUM-141 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-31 ANION GAP-13 <Date>1919-2-7</Date> 09:00AM BLOOD WBC-6.5 RBC-4.38* Hgb-13.6* Hct-38.2* MCV-87 MCH-31.0 MCHC-35.5* RDW-13.4 Plt Ct-155 . Echo <Date>1990-5-21</Date> Conclusions: There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction. Resting regional wall motion abnormalities include inferior and inferolateral akinesis/hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of <Date>1961-3-11</Date>, left ventricular dysfunction is new and mild aortic regurgitation is now detected. Brief Hospital Course: A/P: 63 yo male with cardiac arrest <Date>10-20</Date> paroxysmal high degree AV block, s/p collapse with PEA arrest now with temp pacer transferred to <Hospital>Johnson, Molina and Hicks Medical Center</Hospital> for further mgmt and permanent pacemaker placement. . 1. Rhythm: paroxysmal high degree block, temp pacer placed. reasons for initial collapse are unclear, possibly combination of high degree av block and electrolyte disturbances, since patient was on many K+sparing diuretics. Tele after admission showed V-paced with few PVCs. Pt underwent pacemaker placement on <Date>1990-5-21</Date> without complications. The next day device interrigation was satisfacotory. CXR did not show a pneumothorax or any acute processes. Pt remained without complaints and was discharged on <Date>1919-2-7</Date>. Indications for pacer was symptomatic with high degree block. . 2. Coronaries: risk factors, <Location>070 Ryan Hollow Suite 058 Justinton, CA 34448</Location> risk 17%, ruled out for MI w/trop leak but flat CKs after arrest. -Cont ASA, BB, statin - lipids checked : total chol 122, HDL 36, LDL 68. Continued on lipitor 20. - initially held ACEI given <Name>Lisa</Name> upto Creatinine of 2.2. Given his hyperkalemia on presentation pt was not restarted on ACE inhibitors as his BP was well controlled. - Repeat Echo (see below) showed EF of 50%. Given this event would recommend an outpatient evaluation by cardiologist for likely exercise stress test. . 3. Pump: EF <Year>1920</Year> was 60% w/LAE, likely diastolic dysfunction, mild hypervolemia w/?mild pulm edema causing mild hypoxia, initially gentle diuresis with goals -500cc to -1L. - Continued amlodipine and metoprolol for rate control - held ace/arbs due to <Name>Lisa</Name> - echo <Date>12-13</Date> showed EF of 50%. - During the admission pt did not go onto complain any further of Chest pain or Shortness of breath. . 4. ARF/CRI: acute insult likely combo of triamterene and NSAIDS, aggrevated by diuretics and ACE-I. Baseline 1.3-1.5 with proteinuria long standing, should avoid NSAIDS for life. -Discontinued ACE-I/ARBa and diuretics. -Checked FeUrea, FeUrea: 36.5%, confirming ATN. spep and upep (given anemia, pending), had u/s at <Hospital>Lopez, Armstrong and Dixon Clinic</Hospital> but should have repeat as outpt to check complex cysts vs masses. Renal diet. . 5. Anemia: new, SPEP was negative, UPEP negative for bence <Doctor Name>Dr.Debelius</Doctor Name> proteins, and iron, shows anemia likely due to renal causes -PCP may consider <Name>Marek Casenhiser</Name> as outpt given pt's age and anemia. . 6. Thombocytopenia: new, mild and stable during the admission. . 7. Elevated glucose: possibly continued stress response, check FS wnl. . 8. h/o hypokalemia: PCP may consider Nephrologist follow up. Would Recommend outpt mineralocorticoid XS work-up once off K sparing diuretics for a while. . 9. Hip pain: awaiting THR. vicodin prn. No NSAIDs due to renal problems. 10. Communicate with friend, preferred HCP per pt, <Name>Sophia William</Name> <Name>Mari Waldon</Name> <Telephone>714-898-8277</Telephone> and PCP <Name>Alphonso Brown</Name> <Hospital>Mcneil PLC Clinic</Hospital> <Location>0721 Ronald Mountain Apt. 734 Lake Josephside, WY 94009</Location> <Telephone>114-177-1697</Telephone> Medications on Admission: Amlodipine 10 mg PO DAILY Metoprolol 100 mg PO BID Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days. Disp:10 Capsule(s) Refills:0 7. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: cardiac arrest high degree heart block acute renal failure hyperkalemia metabolic acidosis anemia with poor bone marrow response/insufficient production thrombocytopenia chronic renal insufficiency, stage 2-3 HTN dyslipidemia osteoarthritis w/ hip pain awaiting R THR h/o chronic low potassium Discharge Condition: good Discharge Instructions: You have had a pacemaker placed because of electrical block in your heart. This may have been precipitated by kidney failure and too much potassium in your blood. Do not take the medications you were taking prior to this event. We have enclosed a list of and prescriptions for your new medication needs. Please take these as directed and discuss any changes with your primary care doctor. . You have many risks for coronary heart disease. We feel you need a stress test with imaging in the next month to make sure that you do not have any significant need for a cardiac catheterization. Until then, taking aspirin, your Toprol XL (beta blocker safe in renal failure), your lipitor, and eventually starting your lisinopril again will protect you somewhat from heart attacks. . You must never take NSAID medications again. Your kidney disease makes this dangerous. Avoid ibuprofen, advil, motrin, aleve, naproxen, or ketoprofen. Talk with your doctor <Name>Tyler</Name> <Name>Dortch</Name> if you are unsure about any medications you are taking. Followup Instructions: 1. See your primary care doctor Dr. <Name>Post</Name> on Friday 28th at 2:30pm, to check your potassium and creatinine levels and to discuss everything we recommended. Have your doctor follow up on the serum and urine protein electrophoresis that was pending when you were discharged as well as the final report of your echocardiogram. Talk with your doctor about your anemia and whether or not you would need a bone marrow biopsy. 2. Go to the pacemaker DEVICE CLINIC Phone:<Telephone>233-438-4614</Telephone> Date/Time:<Date>1976-1-7</Date> 11:30 3. You should see our nephrologists sometime for your kidney disease. Talk with your primary doctor about this and call for an appointment <Telephone>366-501-7014</Telephone>. 4. You should also setup an appointment with a cardiologist to have a exercise stress test done as outpatient. You can speak with your PCP regarding <Name>Everardo Young</Name> cardiologist or you can call <Hospital>Harris-Williams Clinic</Hospital> at <Telephone>502-952-6422</Telephone> to setup an appointment here. <Name>Mirna</Name> <Name>Ivory</Name> Completed 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Date: 2009-11-8 Discharge Date: 1919-2-7 Date of Birth: 1968-12-17 Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Tamika Chief Complaint: PEA arrest . Major Surgical or Invasive Procedure: temporary pacemaker placement permanent Pacemaker placement 1990-5-21 History of Present Illness: Pt was in USOH, awaiting R THR, collapsed while celebrating a funeral mass, was down for 1 min prior to EMS arrival, found to be pulseless, atrial activity noted on stips but only occasional wide qrs complexes, could not transcut pace, got atropine and calcium gluc, went to Joe Johnson, was intubated for protection, K 6.6, HCO3 13, and Cr 2.7. Got kayexylate, bicarb gtt, lasix, and extubated. ECG w/RBBB, LAD, LAFB, and sig PR delay so sent here for pacer. R IJ pacer wire screwed in but still temporary. Transferred to Mcneil PLC Clinic for permanent pacer and further managment. Past Medical History: PMH: HTN, dyslipidemia, CRI (not formally dx per pt), OA w/ hip pain awaiting R THR, h/o chronic low potassium and severe HTN per pt -baseline trifasicular block Social History: Pt is a priest Family History: non-contributory Physical Exam: t 98.9 BP 131/79 HR 64 Tele: v-paced/ few PVC's with compensatory pauses O2 sat 92%RA Gen: elder male, lying in bed, NAD HEENT: JVP flat, MMM, PERRLA, EOMI Heart: s1, s2, RRR. no MRG Lungs: bibasilar crackles, otherwise, CTAB Ext: 1+ pedal edema bilat Neuro: A&O x3 Pertinent Results: 2009-11-8 05:40PM PT-14.2* PTT-26.9 INR(PT)-1.4 2009-11-8 05:40PM PLT COUNT-137* 2009-11-8 05:40PM WBC-11.0 RBC-4.23* HGB-13.2* HCT-37.5* MCV-89 MCH-31.1 MCHC-35.2* RDW-13.9 2009-11-8 05:40PM GLUCOSE-111* UREA N-55* CREAT-2.6* SODIUM-141 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-31 ANION GAP-13 1919-2-7 09:00AM BLOOD WBC-6.5 RBC-4.38* Hgb-13.6* Hct-38.2* MCV-87 MCH-31.0 MCHC-35.5* RDW-13.4 Plt Ct-155 . Echo 1990-5-21 Conclusions: There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction. Resting regional wall motion abnormalities include inferior and inferolateral akinesis/hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of 1961-3-11, left ventricular dysfunction is new and mild aortic regurgitation is now detected. Brief Hospital Course: A/P: 63 yo male with cardiac arrest 10-20 paroxysmal high degree AV block, s/p collapse with PEA arrest now with temp pacer transferred to Johnson, Molina and Hicks Medical Center for further mgmt and permanent pacemaker placement. . 1. Rhythm: paroxysmal high degree block, temp pacer placed. reasons for initial collapse are unclear, possibly combination of high degree av block and electrolyte disturbances, since patient was on many K+sparing diuretics. Tele after admission showed V-paced with few PVCs. Pt underwent pacemaker placement on 1990-5-21 without complications. The next day device interrigation was satisfacotory. CXR did not show a pneumothorax or any acute processes. Pt remained without complaints and was discharged on 1919-2-7. Indications for pacer was symptomatic with high degree block. . 2. Coronaries: risk factors, 070 Ryan Hollow Suite 058 Justinton, CA 34448 risk 17%, ruled out for MI w/trop leak but flat CKs after arrest. -Cont ASA, BB, statin - lipids checked : total chol 122, HDL 36, LDL 68. Continued on lipitor 20. - initially held ACEI given Lisa upto Creatinine of 2.2. Given his hyperkalemia on presentation pt was not restarted on ACE inhibitors as his BP was well controlled. - Repeat Echo (see below) showed EF of 50%. Given this event would recommend an outpatient evaluation by cardiologist for likely exercise stress test. . 3. Pump: EF 1920 was 60% w/LAE, likely diastolic dysfunction, mild hypervolemia w/?mild pulm edema causing mild hypoxia, initially gentle diuresis with goals -500cc to -1L. - Continued amlodipine and metoprolol for rate control - held ace/arbs due to Lisa - echo 12-13 showed EF of 50%. - During the admission pt did not go onto complain any further of Chest pain or Shortness of breath. . 4. ARF/CRI: acute insult likely combo of triamterene and NSAIDS, aggrevated by diuretics and ACE-I. Baseline 1.3-1.5 with proteinuria long standing, should avoid NSAIDS for life. -Discontinued ACE-I/ARBa and diuretics. -Checked FeUrea, FeUrea: 36.5%, confirming ATN. spep and upep (given anemia, pending), had u/s at Lopez, Armstrong and Dixon Clinic but should have repeat as outpt to check complex cysts vs masses. Renal diet. . 5. Anemia: new, SPEP was negative, UPEP negative for bence Dr.Debelius proteins, and iron, shows anemia likely due to renal causes -PCP may consider Marek Casenhiser as outpt given pt's age and anemia. . 6. Thombocytopenia: new, mild and stable during the admission. . 7. Elevated glucose: possibly continued stress response, check FS wnl. . 8. h/o hypokalemia: PCP may consider Nephrologist follow up. Would Recommend outpt mineralocorticoid XS work-up once off K sparing diuretics for a while. . 9. Hip pain: awaiting THR. vicodin prn. No NSAIDs due to renal problems. 10. Communicate with friend, preferred HCP per pt, Sophia William Mari Waldon 714-898-8277 and PCP Alphonso Brown Mcneil PLC Clinic 0721 Ronald Mountain Apt. 734 Lake Josephside, WY 94009 114-177-1697 Medications on Admission: Amlodipine 10 mg PO DAILY Metoprolol 100 mg PO BID Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days. Disp:10 Capsule(s) Refills:0 7. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: cardiac arrest high degree heart block acute renal failure hyperkalemia metabolic acidosis anemia with poor bone marrow response/insufficient production thrombocytopenia chronic renal insufficiency, stage 2-3 HTN dyslipidemia osteoarthritis w/ hip pain awaiting R THR h/o chronic low potassium Discharge Condition: good Discharge Instructions: You have had a pacemaker placed because of electrical block in your heart. This may have been precipitated by kidney failure and too much potassium in your blood. Do not take the medications you were taking prior to this event. We have enclosed a list of and prescriptions for your new medication needs. Please take these as directed and discuss any changes with your primary care doctor. . You have many risks for coronary heart disease. We feel you need a stress test with imaging in the next month to make sure that you do not have any significant need for a cardiac catheterization. Until then, taking aspirin, your Toprol XL (beta blocker safe in renal failure), your lipitor, and eventually starting your lisinopril again will protect you somewhat from heart attacks. . You must never take NSAID medications again. Your kidney disease makes this dangerous. Avoid ibuprofen, advil, motrin, aleve, naproxen, or ketoprofen. Talk with your doctor Tyler Dortch if you are unsure about any medications you are taking. Followup Instructions: 1. See your primary care doctor Dr. Post on Friday 28th at 2:30pm, to check your potassium and creatinine levels and to discuss everything we recommended. Have your doctor follow up on the serum and urine protein electrophoresis that was pending when you were discharged as well as the final report of your echocardiogram. Talk with your doctor about your anemia and whether or not you would need a bone marrow biopsy. 2. Go to the pacemaker DEVICE CLINIC Phone:233-438-4614 Date/Time:1976-1-7 11:30 3. You should see our nephrologists sometime for your kidney disease. Talk with your primary doctor about this and call for an appointment 366-501-7014. 4. You should also setup an appointment with a cardiologist to have a exercise stress test done as outpatient. You can speak with your PCP regarding Everardo Young cardiologist or you can call Harris-Williams Clinic at 502-952-6422 to setup an appointment here. Mirna Ivory Completed by:1902-5-31	['Admission Date: 2009-11-8 Discharge Date: 1919-2-7\n\nDate of Birth: 1968-12-17 Sex: M\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Tamika\nChief Complaint:\nPEA arrest\n.\n\n\nMajor Surgical or Invasive Procedure:\ntemporary pacemaker placement\npermanent Pacemaker placement 1990-5-21\n\n\nHistory of Present Illness:\nPt was in USOH, awaiting R THR, collapsed while celebrating a\nfuneral mass, was down for 1 min prior to EMS arrival, found to\nbe pulseless, atrial activity noted on stips but only occasional\nwide qrs complexes, could not transcut pace, got atropine and\ncalcium gluc, went to Joe Johnson, was intubated for protection, K\n6.6, HCO3 13, and Cr 2.7. Got kayexylate, bicarb gtt, lasix, and\nextubated. ECG w/RBBB, LAD, LAFB, and sig PR delay so sent here\nfor pacer.', " R IJ pacer wire screwed in but still temporary.\nTransferred to Mcneil PLC Clinic for permanent pacer and further managment.\n\nPast Medical History:\nPMH: HTN, dyslipidemia, CRI (not formally dx per pt), OA w/ hip\npain awaiting R THR, h/o chronic low potassium and severe HTN\nper pt\n-baseline trifasicular block\n\nSocial History:\nPt is a priest\n\n\nFamily History:\nnon-contributory\n\nPhysical Exam:\nt 98.9\nBP 131/79\nHR 64\nTele: v-paced/ few PVC's with compensatory pauses\nO2 sat 92%RA\nGen: elder male, lying in bed, NAD\nHEENT: JVP flat, MMM, PERRLA, EOMI\nHeart: s1, s2, RRR. no MRG\nLungs: bibasilar crackles, otherwise, CTAB\nExt: 1+ pedal edema bilat\nNeuro: A&O x3\n\nPertinent Results:\n2009-11-8 05:40PM PT-14.2* PTT-26.9 INR(PT)-1.4\n2009-11-8 05:40PM PLT COUNT-137\n2009-11-8 05:40PM WBC-11.0 RBC-4.23 HGB-13.", '2* HCT-37.5* MCV-89\nMCH-31.1 MCHC-35.2* RDW-13.9\n2009-11-8 05:40PM GLUCOSE-111* UREA N-55* CREAT-2.6* SODIUM-141\nPOTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-31 ANION GAP-13\n1919-2-7 09:00AM BLOOD WBC-6.5 RBC-4.38* Hgb-13.6* Hct-38.2\nMCV-87 MCH-31.0 MCHC-35.5 RDW-13.4 Plt Ct-155\n.\nEcho 1990-5-21\nConclusions:\nThere is moderate symmetric left ventricular hypertrophy. The\nleft ventricular cavity size is normal. There is mild regional\nleft ventricular systolic dysfunction. Resting regional wall\nmotion abnormalities include inferior and inferolateral\nakinesis/hypokinesis. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets are mildly\nthickened. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is a\ntrivial/physiologic pericardial effusion.', '\n\nCompared with the report of the prior study (tape unavailable\nfor review) of\n1961-3-11, left ventricular dysfunction is new and mild aortic\nregurgitation\nis now detected.\n\nBrief Hospital Course:\nA/P: 63 yo male with cardiac arrest 10-20 paroxysmal high degree\nAV block, s/p collapse with PEA arrest now with temp pacer\ntransferred to Johnson, Molina and Hicks Medical Center for further mgmt and permanent pacemaker\nplacement.\n.\n1. Rhythm: paroxysmal high degree block, temp pacer placed.\nreasons for initial collapse are unclear, possibly combination\nof high degree av block and electrolyte disturbances, since\npatient was on many K+sparing diuretics. Tele after admission\nshowed V-paced with few PVCs. Pt underwent pacemaker placement\non 1990-5-21 without complications. The next day device\ninterrigation was satisfacotory.', ' CXR did not show a\npneumothorax or any acute processes. Pt remained without\ncomplaints and was discharged on 1919-2-7. Indications for\npacer was symptomatic with high degree block.\n.\n2. Coronaries: risk factors, 070 Ryan Hollow Suite 058\nJustinton, CA 34448 risk 17%, ruled out for\nMI w/trop leak but flat CKs after arrest. -Cont ASA, BB, statin\n- lipids checked : total chol 122, HDL 36, LDL 68. Continued on\nlipitor 20.\n- initially held ACEI given Lisa upto Creatinine of 2.2. Given\nhis hyperkalemia on presentation pt was not restarted on ACE\ninhibitors as his BP was well controlled.\n- Repeat Echo (see below) showed EF of 50%. Given this event\nwould recommend an outpatient evaluation by cardiologist for\nlikely exercise stress test.\n.\n3. Pump: EF 1920 was 60% w/LAE, likely diastolic dysfunction,\nmild hypervolemia w/?mild pulm edema causing mild hypoxia,\ninitially gentle diuresis with goals -500cc to -1L.', "\n- Continued amlodipine and metoprolol for rate control\n- held ace/arbs due to Lisa\n- echo 12-13 showed EF of 50%.\n- During the admission pt did not go onto complain any further\nof Chest pain or Shortness of breath.\n.\n4. ARF/CRI: acute insult likely combo of triamterene and NSAIDS,\naggrevated by diuretics and ACE-I. Baseline 1.3-1.5 with\nproteinuria long standing, should avoid NSAIDS for life.\n-Discontinued ACE-I/ARBa and diuretics.\n-Checked FeUrea, FeUrea: 36.5%, confirming ATN. spep and upep\n(given anemia, pending), had u/s at Lopez, Armstrong and Dixon Clinic but should have\nrepeat as outpt to check complex cysts vs masses. Renal diet.\n.\n5. Anemia: new, SPEP was negative, UPEP negative for bence\nDr.Debelius proteins, and iron, shows anemia likely due to renal\ncauses\n-PCP may consider Marek Casenhiser as outpt given pt's age and anemia.", '\n.\n6. Thombocytopenia: new, mild and stable during the admission.\n.\n7. Elevated glucose: possibly continued stress response, check\nFS wnl.\n.\n8. h/o hypokalemia: PCP may consider Nephrologist follow up.\nWould Recommend outpt mineralocorticoid XS work-up once off K\nsparing diuretics for a while.\n.\n9. Hip pain: awaiting THR. vicodin prn. No NSAIDs due to renal\nproblems.\n\n10. Communicate with friend, preferred HCP per pt, Sophia William\nMari Waldon 714-898-8277 and PCP Alphonso Brown Mcneil PLC Clinic 0721 Ronald Mountain Apt. 734\nLake Josephside, WY 94009\n114-177-1697\n\n\n\nMedications on Admission:\nAmlodipine 10 mg PO DAILY\nMetoprolol 100 mg PO BID\n\n\nDischarge Medications:\n1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO\nQ4-6H (every 4 to 6 hours) as needed for pain.\nDisp:20 Tablet(s) Refills:0\n2.', ' Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H\n(every 4 to 6 hours) as needed.\n3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\nPO DAILY (Daily).\nDisp:30 Tablet, Chewable(s) Refills:0\n4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\nDisp:30 Tablet(s) Refills:0\n5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\nDisp:30 Tablet(s) Refills:0\n6. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every\n6 hours) for 2 days.\nDisp:10 Capsule(s) Refills:0\n7. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)\nTablet Sustained Release 24HR PO once a day.\nDisp:30 Tablet Sustained Release 24HR(s) Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\ncardiac arrest\nhigh degree heart block\nacute renal failure\nhyperkalemia\nmetabolic acidosis\nanemia with poor bone marrow response/insufficient production\nthrombocytopenia\nchronic renal insufficiency, stage 2-3\nHTN\ndyslipidemia\nosteoarthritis w/ hip pain awaiting R THR\nh/o chronic low potassium\n\n\nDischarge Condition:\ngood\n\n\nDischarge Instructions:\nYou have had a pacemaker placed because of electrical block in\nyour heart.', ' This may have been precipitated by kidney failure\nand too much potassium in your blood. Do not take the\nmedications you were taking prior to this event. We have\nenclosed a list of and prescriptions for your new medication\nneeds. Please take these as directed and discuss any changes\nwith your primary care doctor.\n.\nYou have many risks for coronary heart disease. We feel you need\na stress test with imaging in the next month to make sure that\nyou do not have any significant need for a cardiac\ncatheterization. Until then, taking aspirin, your Toprol XL\n(beta blocker safe in renal failure), your lipitor, and\neventually starting your lisinopril again will protect you\nsomewhat from heart attacks.\n.\nYou must never take NSAID medications again. Your kidney disease\nmakes this dangerous. Avoid ibuprofen, advil, motrin, aleve,\nnaproxen, or ketoprofen.', ' Talk with your doctor Tyler Dortch if\nyou are unsure about any medications you are taking.\n\n\nFollowup Instructions:\n1. See your primary care doctor Dr. Post on Friday 28th at\n2:30pm, to check your potassium and creatinine levels and to\ndiscuss everything we recommended. Have your doctor follow up on\nthe serum and urine protein electrophoresis that was pending\nwhen you were discharged as well as the final report of your\nechocardiogram. Talk with your doctor about your anemia and\nwhether or not you would need a bone marrow biopsy.\n\n2. Go to the pacemaker DEVICE CLINIC Phone:233-438-4614\nDate/Time:1976-1-7 11:30\n\n3. You should see our nephrologists sometime for your kidney\ndisease. Talk with your primary doctor about this and call for\nan appointment 366-501-7014.\n\n4. You should also setup an appointment with a cardiologist to\nhave a exercise stress test done as outpatient.', ' You can speak\nwith your PCP regarding Everardo Young cardiologist or you can call Harris-Williams Clinic at 502-952-6422 to setup an appointment here.\n\n\n Mirna Ivory\n\nCompleted by:1902-5-31']
5	9446	154895.0	2190-05-22	Discharge summary	Report	Admission Date: [2190-5-16] Discharge Date: [2190-5-22] Date of Birth: [2139-4-22] Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This 51 year-old female was admitted to an outside hospital with chest pain and ruled in for myocardial infarction. She was transferred here for a cardiac catheterization. PAST MEDICAL HISTORY: Hypertension, fibromyalgia, hypothyroidism, NASH and noninsulin dependent diabetes. PAST SURGICAL HISTORY: Hysterectomy and cholecystectomy. SOCIAL HISTORY: She smokes a pack per day. MEDICATIONS ON ADMISSION: Hydrochlorothiazide, Alprazolam, Ursodiol and Levoxyl. She was hospitalized with Aggrastat, nitroglycerin and heparin as she ruled in for myocardial infarction. ALLERGIES: No known drug allergies. Cardiac catheterization showed left anterior descending coronary artery diagonal 80% lesion, circumflex 90% lesion and 90% lesion of the right coronary artery with a normal ejection fraction. She was transferred from [Hospital3 68] to [Hospital1 69] for cardiac catheterization. The results as above. After catheterization she was referred to cardiothoracic surgery and was seen by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70] and Dr. [First Name4 (NamePattern1) 71] [Last Name (NamePattern1) 72]. Preoperative laboratories showed a sodium of 141, K 4.2, chloride 105, CO2 24, BUN 12, creatinine 0.6 with a blood sugar of 156. White count 8.9, hematocrit 44.2, platelet count 201,000. PT 13, PTT 26 with an INR of 1.2. CK was 1511 on [5-16]. She was also followed by Dr. [Last Name (STitle) 73] of cardiology and agreed to participate in both the Cariporide and Dermabond studies through cardiac surgery. The patient was taken to the Operating Room on [5-18] and underwent coronary artery bypass grafting times four with a left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to right posterior descending coronary artery, saphenous vein graft to diagonal two and a saphenous vein graft to the obtuse marginal by Dr. [Last Name (STitle) 70]. The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition. On postoperative day number one there were no events overnight. The patient was extubated and was on a neo-synephrine drip at 0.3 micrograms per kilo per minute with the Cariporide infusing. Nitroglycerin had been turned off. Postoperative hematocrit was 30 with a K of 4.2 and a blood sugar of 139. CPK trended down to 357 and 379 with an MB of 15 to 16. The patient was in sinus rhythm in the 80s with a stable blood pressure. She was alert and oriented. Her lungs were clear bilaterally. Heart was regular rate and rhythm. Her abdomen was benign. Her extremities were within normal limits. She was neurologically stable. Her chest tubes were pulled on postoperative day number three. She continued on perioperative antibiotics and was transferred out to the floor. She was seen by physical therapy for evaluation. On postoperative day two she had no events overnight. She had a temperature max of 100.6. Her JP drain from her leg site was removed as was her Foley. Her Lopresor was increased to 50 b.i.d. She began to ambulate and was out of bed. She had decreased at the bases, but was otherwise hemodynamically stable. Her dressings were clean, dry and intact. She was seen by case management to determine the need for rehab. Her pacing wires were discontinued on postoperative day three. She continued to advance her ambulation. She had decreased breath sounds a the bases again on postoperative day three, but was stable and continuing to increase her physical therapy. Her incision was were clean, dry and intact. Pain was managed with Percocet and Motrin. She was sating 92% on room air on postoperative day number four the day of discharge with a temperature max of 99.3, blood pressure 136/71, heart rate 93. She was alert, oriented and had been ambulating well. Her lungs were clear bilaterally. Her examination was otherwise benign. Her laboratories on the 9th showed a white count of 13.6, hematocrit 28.7, platelet count 153,000, BUN 15, creatinine 0.5, sodium 141, glucose 100, K 3.8, magnesium 1.7 for which she received 2 grams of repletion. Calcium 1.08 for which she received 2 grams of repletion. She was discharged to home on postoperative day four [5-22]. DISCHARGE MEDICATIONS: Lasix 20 mg po q.d. times one week, K-Ciel 20 milliequivalents po q day times one week. Colace 100 mg po q.d., Zantac 150 mg po b.i.d., enteric coated aspirin 325 mg po q day, Levoxyl 0.25 mg po q day, Lopressor 75 mg po b.i.d., Nicoderm 14 patch q.d., Xanax 2 mg q 4 to 6 hours prn, Ursodiol dosage not specified. The patient was instructed to return to preoperative dose. Percocet one to two tabs po prn q 4 to 6 hours. The patient was afebrile. Incisions were healing well. DISCHARGE DIAGNOSES: 1. Hypertension. 2. Status post coronary artery bypass grafting times four. 3. Fibromyalgia. 4. Hypothyroidism. 5. Noninsulin dependent diabetes mellitus. 6. Question NASH. She was also instructed to follow up with her primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 74] in two weeks and follow up with Dr. [Last Name (STitle) 70] in the office in six weeks for postop follow up. Again, the patient was discharged home on [2190-5-22]. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 76] MEDQUIST36 D: [2190-7-7] 08:16 T: [2190-7-7] 11:56 JOB#: [Job Number 77]	Admission Date: <Date>1937-2-15</Date> Discharge Date: <Date>1933-6-28</Date> Date of Birth: <Date>1906-5-19</Date> Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This 51 year-old female was admitted to an outside hospital with chest pain and ruled in for myocardial infarction. She was transferred here for a cardiac catheterization. PAST MEDICAL HISTORY: Hypertension, fibromyalgia, hypothyroidism, NASH and noninsulin dependent diabetes. PAST SURGICAL HISTORY: Hysterectomy and cholecystectomy. SOCIAL HISTORY: She smokes a pack per day. MEDICATIONS ON ADMISSION: Hydrochlorothiazide, Alprazolam, Ursodiol and Levoxyl. She was hospitalized with Aggrastat, nitroglycerin and heparin as she ruled in for myocardial infarction. ALLERGIES: No known drug allergies. Cardiac catheterization showed left anterior descending coronary artery diagonal 80% lesion, circumflex 90% lesion and 90% lesion of the right coronary artery with a normal ejection fraction. She was transferred from <Hospital>Perez, Torres and Anderson Medical Center</Hospital> to <Hospital>Becker-Walker Hospital</Hospital> for cardiac catheterization. The results as above. After catheterization she was referred to cardiothoracic surgery and was seen by Dr. <Name>Keiko</Name> <Name>Loveland</Name> and Dr. <Name>Franklin</Name> <Name>Thompson</Name>. Preoperative laboratories showed a sodium of 141, K 4.2, chloride 105, CO2 24, BUN 12, creatinine 0.6 with a blood sugar of 156. White count 8.9, hematocrit 44.2, platelet count 201,000. PT 13, PTT 26 with an INR of 1.2. CK was 1511 on <Date>9-14</Date>. She was also followed by Dr. <Name>Starks</Name> of cardiology and agreed to participate in both the Cariporide and Dermabond studies through cardiac surgery. The patient was taken to the Operating Room on <Date>12-24</Date> and underwent coronary artery bypass grafting times four with a left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to right posterior descending coronary artery, saphenous vein graft to diagonal two and a saphenous vein graft to the obtuse marginal by Dr. <Name>Kuykendall</Name>. The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition. On postoperative day number one there were no events overnight. The patient was extubated and was on a neo-synephrine drip at 0.3 micrograms per kilo per minute with the Cariporide infusing. Nitroglycerin had been turned off. Postoperative hematocrit was 30 with a K of 4.2 and a blood sugar of 139. CPK trended down to 357 and 379 with an MB of 15 to 16. The patient was in sinus rhythm in the 80s with a stable blood pressure. She was alert and oriented. Her lungs were clear bilaterally. Heart was regular rate and rhythm. Her abdomen was benign. Her extremities were within normal limits. She was neurologically stable. Her chest tubes were pulled on postoperative day number three. She continued on perioperative antibiotics and was transferred out to the floor. She was seen by physical therapy for evaluation. On postoperative day two she had no events overnight. She had a temperature max of 100.6. Her JP drain from her leg site was removed as was her Foley. Her Lopresor was increased to 50 b.i.d. She began to ambulate and was out of bed. She had decreased at the bases, but was otherwise hemodynamically stable. Her dressings were clean, dry and intact. She was seen by case management to determine the need for rehab. Her pacing wires were discontinued on postoperative day three. She continued to advance her ambulation. She had decreased breath sounds a the bases again on postoperative day three, but was stable and continuing to increase her physical therapy. Her incision was were clean, dry and intact. Pain was managed with Percocet and Motrin. She was sating 92% on room air on postoperative day number four the day of discharge with a temperature max of 99.3, blood pressure 136/71, heart rate 93. She was alert, oriented and had been ambulating well. Her lungs were clear bilaterally. Her examination was otherwise benign. Her laboratories on the 9th showed a white count of 13.6, hematocrit 28.7, platelet count 153,000, BUN 15, creatinine 0.5, sodium 141, glucose 100, K 3.8, magnesium 1.7 for which she received 2 grams of repletion. Calcium 1.08 for which she received 2 grams of repletion. She was discharged to home on postoperative day four <Date>7-23</Date>. DISCHARGE MEDICATIONS: Lasix 20 mg po q.d. times one week, K-Ciel 20 milliequivalents po q day times one week. Colace 100 mg po q.d., Zantac 150 mg po b.i.d., enteric coated aspirin 325 mg po q day, Levoxyl 0.25 mg po q day, Lopressor 75 mg po b.i.d., Nicoderm 14 patch q.d., Xanax 2 mg q 4 to 6 hours prn, Ursodiol dosage not specified. The patient was instructed to return to preoperative dose. Percocet one to two tabs po prn q 4 to 6 hours. The patient was afebrile. Incisions were healing well. DISCHARGE DIAGNOSES: 1. Hypertension. 2. Status post coronary artery bypass grafting times four. 3. Fibromyalgia. 4. Hypothyroidism. 5. Noninsulin dependent diabetes mellitus. 6. Question NASH. She was also instructed to follow up with her primary care physician <Name>Johnson</Name>. <Name>Bogle</Name> in two weeks and follow up with Dr. <Name>Kuykendall</Name> in the office in six weeks for postop follow up. Again, the patient was discharged home on <Date>1933-6-28</Date>. <Name>Emily</Name> <Initial>DN</Initial> <Name>Johnson</Name>, M.D. <MD Number>04710966</MD Number> Dictated By:<Name>Camargo</Name> MEDQUIST36 D: <Date>1933-7-25</Date> 08:16 T: <Date>1933-7-25</Date> 11:56 JOB#: <Job Number>Johnson, Carrillo and King-1928-255437</Job 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Date: 1937-2-15 Discharge Date: 1933-6-28 Date of Birth: 1906-5-19 Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This 51 year-old female was admitted to an outside hospital with chest pain and ruled in for myocardial infarction. She was transferred here for a cardiac catheterization. PAST MEDICAL HISTORY: Hypertension, fibromyalgia, hypothyroidism, NASH and noninsulin dependent diabetes. PAST SURGICAL HISTORY: Hysterectomy and cholecystectomy. SOCIAL HISTORY: She smokes a pack per day. MEDICATIONS ON ADMISSION: Hydrochlorothiazide, Alprazolam, Ursodiol and Levoxyl. She was hospitalized with Aggrastat, nitroglycerin and heparin as she ruled in for myocardial infarction. ALLERGIES: No known drug allergies. Cardiac catheterization showed left anterior descending coronary artery diagonal 80% lesion, circumflex 90% lesion and 90% lesion of the right coronary artery with a normal ejection fraction. She was transferred from Perez, Torres and Anderson Medical Center to Becker-Walker Hospital for cardiac catheterization. The results as above. After catheterization she was referred to cardiothoracic surgery and was seen by Dr. Keiko Loveland and Dr. Franklin Thompson. Preoperative laboratories showed a sodium of 141, K 4.2, chloride 105, CO2 24, BUN 12, creatinine 0.6 with a blood sugar of 156. White count 8.9, hematocrit 44.2, platelet count 201,000. PT 13, PTT 26 with an INR of 1.2. CK was 1511 on 9-14. She was also followed by Dr. Starks of cardiology and agreed to participate in both the Cariporide and Dermabond studies through cardiac surgery. The patient was taken to the Operating Room on 12-24 and underwent coronary artery bypass grafting times four with a left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to right posterior descending coronary artery, saphenous vein graft to diagonal two and a saphenous vein graft to the obtuse marginal by Dr. Kuykendall. The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition. On postoperative day number one there were no events overnight. The patient was extubated and was on a neo-synephrine drip at 0.3 micrograms per kilo per minute with the Cariporide infusing. Nitroglycerin had been turned off. Postoperative hematocrit was 30 with a K of 4.2 and a blood sugar of 139. CPK trended down to 357 and 379 with an MB of 15 to 16. The patient was in sinus rhythm in the 80s with a stable blood pressure. She was alert and oriented. Her lungs were clear bilaterally. Heart was regular rate and rhythm. Her abdomen was benign. Her extremities were within normal limits. She was neurologically stable. Her chest tubes were pulled on postoperative day number three. She continued on perioperative antibiotics and was transferred out to the floor. She was seen by physical therapy for evaluation. On postoperative day two she had no events overnight. She had a temperature max of 100.6. Her JP drain from her leg site was removed as was her Foley. Her Lopresor was increased to 50 b.i.d. She began to ambulate and was out of bed. She had decreased at the bases, but was otherwise hemodynamically stable. Her dressings were clean, dry and intact. She was seen by case management to determine the need for rehab. Her pacing wires were discontinued on postoperative day three. She continued to advance her ambulation. She had decreased breath sounds a the bases again on postoperative day three, but was stable and continuing to increase her physical therapy. Her incision was were clean, dry and intact. Pain was managed with Percocet and Motrin. She was sating 92% on room air on postoperative day number four the day of discharge with a temperature max of 99.3, blood pressure 136/71, heart rate 93. She was alert, oriented and had been ambulating well. Her lungs were clear bilaterally. Her examination was otherwise benign. Her laboratories on the 9th showed a white count of 13.6, hematocrit 28.7, platelet count 153,000, BUN 15, creatinine 0.5, sodium 141, glucose 100, K 3.8, magnesium 1.7 for which she received 2 grams of repletion. Calcium 1.08 for which she received 2 grams of repletion. She was discharged to home on postoperative day four 7-23. DISCHARGE MEDICATIONS: Lasix 20 mg po q.d. times one week, K-Ciel 20 milliequivalents po q day times one week. Colace 100 mg po q.d., Zantac 150 mg po b.i.d., enteric coated aspirin 325 mg po q day, Levoxyl 0.25 mg po q day, Lopressor 75 mg po b.i.d., Nicoderm 14 patch q.d., Xanax 2 mg q 4 to 6 hours prn, Ursodiol dosage not specified. The patient was instructed to return to preoperative dose. Percocet one to two tabs po prn q 4 to 6 hours. The patient was afebrile. Incisions were healing well. DISCHARGE DIAGNOSES: 1. Hypertension. 2. Status post coronary artery bypass grafting times four. 3. Fibromyalgia. 4. Hypothyroidism. 5. Noninsulin dependent diabetes mellitus. 6. Question NASH. She was also instructed to follow up with her primary care physician Johnson. Bogle in two weeks and follow up with Dr. Kuykendall in the office in six weeks for postop follow up. Again, the patient was discharged home on 1933-6-28. Emily DN Johnson, M.D. 04710966 Dictated By:Camargo MEDQUIST36 D: 1933-7-25 08:16 T: 1933-7-25 11:56 JOB#: Johnson, Carrillo and King-1928-255437	['Admission Date: 1937-2-15 Discharge Date: 1933-6-28\n\nDate of Birth: 1906-5-19 Sex: F\n\nService: CARDIOTHORACIC\n\nHISTORY OF PRESENT ILLNESS: This 51 year-old female was\nadmitted to an outside hospital with chest pain and ruled in\nfor myocardial infarction. She was transferred here for a\ncardiac catheterization.\n\nPAST MEDICAL HISTORY: Hypertension, fibromyalgia,\nhypothyroidism, NASH and noninsulin dependent diabetes.\n\nPAST SURGICAL HISTORY: Hysterectomy and cholecystectomy.\n\nSOCIAL HISTORY: She smokes a pack per day.\n\nMEDICATIONS ON ADMISSION: Hydrochlorothiazide, Alprazolam,\nUrsodiol and Levoxyl.\n\nShe was hospitalized with Aggrastat, nitroglycerin and\nheparin as she ruled in for myocardial infarction.\n\nALLERGIES: No known drug allergies.\n\nCardiac catheterization showed left anterior descending\ncoronary artery diagonal 80% lesion, circumflex 90% lesion\nand 90% lesion of the right coronary artery with a normal\nejection fraction.', ' She was transferred from Perez, Torres and Anderson Medical Center\nto Becker-Walker Hospital for cardiac\ncatheterization. The results as above. After\ncatheterization she was referred to cardiothoracic surgery\nand was seen by Dr. Keiko Loveland and Dr. Franklin Thompson.\nPreoperative laboratories showed a sodium of 141, K 4.2,\nchloride 105, CO2 24, BUN 12, creatinine 0.6 with a blood\nsugar of 156. White count 8.9, hematocrit 44.2, platelet\ncount 201,000. PT 13, PTT 26 with an INR of 1.2. CK was\n1511 on 9-14. She was also followed by Dr. Starks of\ncardiology and agreed to participate in both the Cariporide\nand Dermabond studies through cardiac surgery. The patient\nwas taken to the Operating Room on 12-24 and underwent\ncoronary artery bypass grafting times four with a left\ninternal mammary coronary artery to the left anterior\ndescending coronary artery, saphenous vein graft to right\nposterior descending coronary artery, saphenous vein graft to\ndiagonal two and a saphenous vein graft to the obtuse\nmarginal by Dr.', ' Kuykendall.\n\nThe patient was transferred to the Cardiothoracic Intensive\nCare Unit in stable condition. On postoperative day number\none there were no events overnight. The patient was\nextubated and was on a neo-synephrine drip at 0.3 micrograms\nper kilo per minute with the Cariporide infusing.\nNitroglycerin had been turned off. Postoperative hematocrit\nwas 30 with a K of 4.2 and a blood sugar of 139. CPK trended\ndown to 357 and 379 with an MB of 15 to 16. The patient was\nin sinus rhythm in the 80s with a stable blood pressure. She\nwas alert and oriented. Her lungs were clear bilaterally.\nHeart was regular rate and rhythm. Her abdomen was benign.\nHer extremities were within normal limits. She was\nneurologically stable. Her chest tubes were pulled on\npostoperative day number three. She continued on\nperioperative antibiotics and was transferred out to the\nfloor.', '\n\nShe was seen by physical therapy for evaluation. On\npostoperative day two she had no events overnight. She had a\ntemperature max of 100.6. Her JP drain from her leg site was\nremoved as was her Foley. Her Lopresor was increased to 50\nb.i.d. She began to ambulate and was out of bed. She had\ndecreased at the bases, but was otherwise hemodynamically\nstable. Her dressings were clean, dry and intact. She was\nseen by case management to determine the need for rehab. Her\npacing wires were discontinued on postoperative day three.\nShe continued to advance her ambulation. She had decreased\nbreath sounds a the bases again on postoperative day three,\nbut was stable and continuing to increase her physical\ntherapy. Her incision was were clean, dry and intact. Pain\nwas managed with Percocet and Motrin.', ' She was sating 92% on\nroom air on postoperative day number four the day of\ndischarge with a temperature max of 99.3, blood pressure\n136/71, heart rate 93. She was alert, oriented and had been\nambulating well. Her lungs were clear bilaterally. Her\nexamination was otherwise benign.\n\nHer laboratories on the 9th showed a white count of 13.6,\nhematocrit 28.7, platelet count 153,000, BUN 15, creatinine\n0.5, sodium 141, glucose 100, K 3.8, magnesium 1.7 for which\nshe received 2 grams of repletion. Calcium 1.08 for which\nshe received 2 grams of repletion. She was discharged to\nhome on postoperative day four 7-23.\n\nDISCHARGE MEDICATIONS: Lasix 20 mg po q.d. times one week,\nK-Ciel 20 milliequivalents po q day times one week. Colace\n100 mg po q.d., Zantac 150 mg po b.i.d., enteric coated\naspirin 325 mg po q day, Levoxyl 0.', '25 mg po q day, Lopressor\n75 mg po b.i.d., Nicoderm 14 patch q.d., Xanax 2 mg q 4 to 6\nhours prn, Ursodiol dosage not specified. The patient was\ninstructed to return to preoperative dose. Percocet one to\ntwo tabs po prn q 4 to 6 hours.\n\nThe patient was afebrile. Incisions were healing well.\n\nDISCHARGE DIAGNOSES:\n1. Hypertension.\n2. Status post coronary artery bypass grafting times four.\n3. Fibromyalgia.\n4. Hypothyroidism.\n5. Noninsulin dependent diabetes mellitus.\n6. Question NASH.\n\nShe was also instructed to follow up with her primary care\nphysician Johnson. Bogle in two weeks and follow up with Dr.\nKuykendall in the office in six weeks for postop follow up.\nAgain, the patient was discharged home on 1933-6-28.\n\n\n\n\n\n\n\n\n Emily DN Johnson, M.D. 04710966\n\nDictated By:Camargo\n\nMEDQUIST36\n\nD: 1933-7-25 08:16\nT: 1933-7-25 11:56\nJOB#: Johnson, Carrillo and King-1928-255437\n']
6	78149	133857.0	2175-03-24	Discharge summary	Report	Admission Date: [2175-3-12] Discharge Date: [2175-3-24] Date of Birth: [2105-11-5] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Progressive lethargy and collapse Major Surgical or Invasive Procedure: ACA aneursym coiling History of Present Illness: HPI: This is a 69 year old male who is primarily Russian speaking who was reportedly outside fishing when he slipped and fell.He now presents to the ED with his wife who reports that he has become progressively lethargic today. The patient is unable to report a review of systems due to his lethargy. Upon seeing the patient we recommended an emergent CTA. Past Medical History: PMHx:spondylosis, chronic low back pain associated with degenerative changes. Followed by Dr. [Last Name (STitle) 79] for prostate cancer. Chronic lymphocytic leukemia, which has been very stable. Social History: Lives with Wife Family History: NC Physical Exam: On Admition: Gen: lethargic, atraumatic HEENT: Pupils: PERRL 4-mm EOMs pt not participating in exam Neuro: Mental status: opens eyes to stimulation, lethargic. Orientation: not answering questions, but following simple commands Language:pt lethargic/non verbal at time of exam and emergently brought to CTA- Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields- not tested III, IV, VI: Extraocular movements- not tested V, VII: Facial strength and sensation intact and symmetric. VIII: [Name (NI) 80] pt did not participate IX, X: Palatal elevation- pt did not participate [Doctor First Name 81]: Sternocleidomastoid and trapezius- pt did not participate XII: [Name (NI) 82] pt did not participate. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength appears full, pt grips with bilat hands [5-9] lifts all extremities off the bed to command Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: pt too lethargic to perform Pertinent Results: CT head: Extensive bilateral subarachnoid hemorrhage. Recommend head CTA to evaluate for an intracranial aneurysm. Findings were discussed with Dr. CTA: FINDINGS: There is a 3 mm x 3 mm saccular outpouching from the region of the anterior communicating artery (2:317), consistent with aneurysm. This has a very narrow neck, and would be amenable to endovascular intervention. No other aneurysm or vascular abnormality is seen. There is stenosis at the origin of the right vertebral artery. Otherwise, the carotid and vertebral arteries and their major branches are patent, with no evidence of stenosis or occlusion. The distal cervical internal carotid arteries measure 5 mm on the right, and 5 mm on the left. Mild-to-moderate multilevel cervical spine degenerative changes are noted. IMPRESSION: 3 mm saccular aneurysm arising from the anterior communicating artery, with narrow neck. Brief Hospital Course: Mr. [Known lastname 83] was admited on [2175-3-12] and became increasingly lethargic and transferred to the ICU for further care under the Neurosurgery service. A diagnostic CTA revealed a large ACOM aneursym which was coiled the following day. Post Coiling the pt. was admitted to the ICU with a ventricular drain. There were no incidences of increased intracranial pressure or decline. A cerebral perfusion study performed [3-15] confirmed the lack of vasospasm and develoing strokes. He had some R shoulder weakness and shoulder X-ray was concerning for rotator cuff injury and orthopedics was consulted. On [2179-3-16]/14/15 his ventricular drain was clamped and reopened due to elevated ICP levels. On [3-19] he was transferred to the SDU and continued to remain stable. He had his ventricular drain clamped on [3-21] and after 48 hours of the clamping trial he had a CT done which was stable without any evidence of hydrocephalus. At this time the drain was pulled. He was placed on a fluid restriction for a brief period of time for a drop in his Na level, and also on salt tabs, upon discharge to rehab we have removed the fluid restriction, but we are continuing the salt tabs, we advise that the Na level be checked every other day, and the salt tabs may be d/c'ed when Na is stable on serial checks. Upon discharge his Na is 138. He is now ready for discharge to rehab. On discharge his exam is as follows: Alert and Oriented X2 Moving all extremities with full strength slight Right Drift, which has been persistant throughout his hospitalization, and possibly secondary to a rotator cuff injury. Medications on Admission: [Name (NI) 84] wife Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [1-6] Tablets PO Q4H (every 4 hours) as needed for Headaches. 11. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours): Continue for [2175-4-2]. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Acom Aneursym Subarachnoid Hemorrhage Discharge Condition: Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. You may have your staples removed at the rehab facility or you can make an appointment in our office to have them removed in 10 days from the date of discharge. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days for removal of your staples or sutures, or you may have them d/c'ed at rehab. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr.[First Name (STitle) ], to be seen in ___4____weeks. ??????You will not need a CT scan of the brain without contrast. Completed by:[2175-3-24]	Admission Date: <Date>1984-8-7</Date> Discharge Date: <Date>1983-12-23</Date> Date of Birth: <Date>2021-11-8</Date> Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Alesha</Name> Chief Complaint: Progressive lethargy and collapse Major Surgical or Invasive Procedure: ACA aneursym coiling History of Present Illness: HPI: This is a 69 year old male who is primarily Russian speaking who was reportedly outside fishing when he slipped and fell.He now presents to the ED with his wife who reports that he has become progressively lethargic today. The patient is unable to report a review of systems due to his lethargy. Upon seeing the patient we recommended an emergent CTA. Past Medical History: PMHx:spondylosis, chronic low back pain associated with degenerative changes. Followed by Dr. <Name>Meraz</Name> for prostate cancer. Chronic lymphocytic leukemia, which has been very stable. Social History: Lives with Wife Family History: NC Physical Exam: On Admition: Gen: lethargic, atraumatic HEENT: Pupils: PERRL 4-mm EOMs pt not participating in exam Neuro: Mental status: opens eyes to stimulation, lethargic. Orientation: not answering questions, but following simple commands Language:pt lethargic/non verbal at time of exam and emergently brought to CTA- Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields- not tested III, IV, VI: Extraocular movements- not tested V, VII: Facial strength and sensation intact and symmetric. VIII: <Name>Joan Demong</Name> pt did not participate IX, X: Palatal elevation- pt did not participate <Name>Asha</Name>: Sternocleidomastoid and trapezius- pt did not participate XII: <Name>Helen Pettway</Name> pt did not participate. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength appears full, pt grips with bilat hands <Date>7-23</Date> lifts all extremities off the bed to command Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: pt too lethargic to perform Pertinent Results: CT head: Extensive bilateral subarachnoid hemorrhage. Recommend head CTA to evaluate for an intracranial aneurysm. Findings were discussed with Dr. CTA: FINDINGS: There is a 3 mm x 3 mm saccular outpouching from the region of the anterior communicating artery (2:317), consistent with aneurysm. This has a very narrow neck, and would be amenable to endovascular intervention. No other aneurysm or vascular abnormality is seen. There is stenosis at the origin of the right vertebral artery. Otherwise, the carotid and vertebral arteries and their major branches are patent, with no evidence of stenosis or occlusion. The distal cervical internal carotid arteries measure 5 mm on the right, and 5 mm on the left. Mild-to-moderate multilevel cervical spine degenerative changes are noted. IMPRESSION: 3 mm saccular aneurysm arising from the anterior communicating artery, with narrow neck. Brief Hospital Course: Mr. <Name>Blanks</Name> was admited on <Date>1984-8-7</Date> and became increasingly lethargic and transferred to the ICU for further care under the Neurosurgery service. A diagnostic CTA revealed a large ACOM aneursym which was coiled the following day. Post Coiling the pt. was admitted to the ICU with a ventricular drain. There were no incidences of increased intracranial pressure or decline. A cerebral perfusion study performed <Date>8-23</Date> confirmed the lack of vasospasm and develoing strokes. He had some R shoulder weakness and shoulder X-ray was concerning for rotator cuff injury and orthopedics was consulted. On <Date>1913-4-31</Date>/14/15 his ventricular drain was clamped and reopened due to elevated ICP levels. On <Date>7-5</Date> he was transferred to the SDU and continued to remain stable. He had his ventricular drain clamped on <Date>5-5</Date> and after 48 hours of the clamping trial he had a CT done which was stable without any evidence of hydrocephalus. At this time the drain was pulled. He was placed on a fluid restriction for a brief period of time for a drop in his Na level, and also on salt tabs, upon discharge to rehab we have removed the fluid restriction, but we are continuing the salt tabs, we advise that the Na level be checked every other day, and the salt tabs may be d/c'ed when Na is stable on serial checks. Upon discharge his Na is 138. He is now ready for discharge to rehab. On discharge his exam is as follows: Alert and Oriented X2 Moving all extremities with full strength slight Right Drift, which has been persistant throughout his hospitalization, and possibly secondary to a rotator cuff injury. Medications on Admission: <Name>Chad Jain</Name> wife Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: <Date>5-13</Date> Tablets PO Q4H (every 4 hours) as needed for Headaches. 11. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours): Continue for <Date>1956-10-29</Date>. Discharge Disposition: Extended Care Facility: <Hospital>Flores, Huerta and Armstrong Clinic</Hospital> - <Location>42645 Hobbs Burgs Suite 651 East Elizabethborough, VA 22238</Location> Discharge Diagnosis: Acom Aneursym Subarachnoid Hemorrhage Discharge Condition: Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. You may have your staples removed at the rehab facility or you can make an appointment in our office to have them removed in 10 days from the date of discharge. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to <Telephone>248-395-6007</Telephone>. If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days for removal of your staples or sutures, or you may have them d/c'ed at rehab. ??????Please call (<Telephone>613-874-6509</Telephone> to schedule an appointment with Dr.<Name>Taylor</Name>, to be seen in ___4____weeks. ??????You will not need a CT scan of the brain without contrast. Completed 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Date: 1984-8-7 Discharge Date: 1983-12-23 Date of Birth: 2021-11-8 Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Alesha Chief Complaint: Progressive lethargy and collapse Major Surgical or Invasive Procedure: ACA aneursym coiling History of Present Illness: HPI: This is a 69 year old male who is primarily Russian speaking who was reportedly outside fishing when he slipped and fell.He now presents to the ED with his wife who reports that he has become progressively lethargic today. The patient is unable to report a review of systems due to his lethargy. Upon seeing the patient we recommended an emergent CTA. Past Medical History: PMHx:spondylosis, chronic low back pain associated with degenerative changes. Followed by Dr. Meraz for prostate cancer. Chronic lymphocytic leukemia, which has been very stable. Social History: Lives with Wife Family History: NC Physical Exam: On Admition: Gen: lethargic, atraumatic HEENT: Pupils: PERRL 4-mm EOMs pt not participating in exam Neuro: Mental status: opens eyes to stimulation, lethargic. Orientation: not answering questions, but following simple commands Language:pt lethargic/non verbal at time of exam and emergently brought to CTA- Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields- not tested III, IV, VI: Extraocular movements- not tested V, VII: Facial strength and sensation intact and symmetric. VIII: Joan Demong pt did not participate IX, X: Palatal elevation- pt did not participate Asha: Sternocleidomastoid and trapezius- pt did not participate XII: Helen Pettway pt did not participate. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength appears full, pt grips with bilat hands 7-23 lifts all extremities off the bed to command Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: pt too lethargic to perform Pertinent Results: CT head: Extensive bilateral subarachnoid hemorrhage. Recommend head CTA to evaluate for an intracranial aneurysm. Findings were discussed with Dr. CTA: FINDINGS: There is a 3 mm x 3 mm saccular outpouching from the region of the anterior communicating artery (2:317), consistent with aneurysm. This has a very narrow neck, and would be amenable to endovascular intervention. No other aneurysm or vascular abnormality is seen. There is stenosis at the origin of the right vertebral artery. Otherwise, the carotid and vertebral arteries and their major branches are patent, with no evidence of stenosis or occlusion. The distal cervical internal carotid arteries measure 5 mm on the right, and 5 mm on the left. Mild-to-moderate multilevel cervical spine degenerative changes are noted. IMPRESSION: 3 mm saccular aneurysm arising from the anterior communicating artery, with narrow neck. Brief Hospital Course: Mr. Blanks was admited on 1984-8-7 and became increasingly lethargic and transferred to the ICU for further care under the Neurosurgery service. A diagnostic CTA revealed a large ACOM aneursym which was coiled the following day. Post Coiling the pt. was admitted to the ICU with a ventricular drain. There were no incidences of increased intracranial pressure or decline. A cerebral perfusion study performed 8-23 confirmed the lack of vasospasm and develoing strokes. He had some R shoulder weakness and shoulder X-ray was concerning for rotator cuff injury and orthopedics was consulted. On 1913-4-31/14/15 his ventricular drain was clamped and reopened due to elevated ICP levels. On 7-5 he was transferred to the SDU and continued to remain stable. He had his ventricular drain clamped on 5-5 and after 48 hours of the clamping trial he had a CT done which was stable without any evidence of hydrocephalus. At this time the drain was pulled. He was placed on a fluid restriction for a brief period of time for a drop in his Na level, and also on salt tabs, upon discharge to rehab we have removed the fluid restriction, but we are continuing the salt tabs, we advise that the Na level be checked every other day, and the salt tabs may be d/c'ed when Na is stable on serial checks. Upon discharge his Na is 138. He is now ready for discharge to rehab. On discharge his exam is as follows: Alert and Oriented X2 Moving all extremities with full strength slight Right Drift, which has been persistant throughout his hospitalization, and possibly secondary to a rotator cuff injury. Medications on Admission: Chad Jain wife Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: 5-13 Tablets PO Q4H (every 4 hours) as needed for Headaches. 11. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours): Continue for 1956-10-29. Discharge Disposition: Extended Care Facility: Flores, Huerta and Armstrong Clinic - 42645 Hobbs Burgs Suite 651 East Elizabethborough, VA 22238 Discharge Diagnosis: Acom Aneursym Subarachnoid Hemorrhage Discharge Condition: Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. You may have your staples removed at the rehab facility or you can make an appointment in our office to have them removed in 10 days from the date of discharge. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to 248-395-6007. If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days for removal of your staples or sutures, or you may have them d/c'ed at rehab. ??????Please call (613-874-6509 to schedule an appointment with Dr.Taylor, to be seen in ___4____weeks. ??????You will not need a CT scan of the brain without contrast. Completed by:1983-12-23	['Admission Date: 1984-8-7 Discharge Date: 1983-12-23\n\nDate of Birth: 2021-11-8 Sex: M\n\nService: NEUROSURGERY\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Alesha\nChief Complaint:\nProgressive lethargy and collapse\n\nMajor Surgical or Invasive Procedure:\nACA aneursym coiling\n\nHistory of Present Illness:\nHPI: This is a 69 year old male who is primarily Russian\nspeaking\nwho was reportedly outside fishing when he slipped and fell.He\nnow presents to the ED with his wife who reports that he has\nbecome progressively lethargic today. The patient is unable to\nreport a review of systems due to his lethargy. Upon seeing the\npatient we recommended an emergent CTA.\n\n\nPast Medical History:\nPMHx:spondylosis, chronic low back pain associated with\ndegenerative changes.', ' Followed by Dr. Meraz for prostate cancer.\nChronic lymphocytic leukemia, which has been very stable.\n\nSocial History:\nLives with Wife\n\nFamily History:\nNC\n\nPhysical Exam:\nOn Admition:\n\nGen: lethargic, atraumatic\nHEENT: Pupils: PERRL 4-mm EOMs pt not participating in exam\nNeuro:\nMental status: opens eyes to stimulation, lethargic.\nOrientation: not answering questions, but following simple\ncommands\nLanguage:pt lethargic/non verbal at time of exam and emergently\nbrought to CTA-\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 4 to 3\nmm bilaterally. Visual fields- not tested\nIII, IV, VI: Extraocular movements- not tested\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Joan Demong pt did not participate\nIX, X: Palatal elevation- pt did not participate\nAsha: Sternocleidomastoid and trapezius- pt did not participate\nXII: Helen Pettway pt did not participate.', '\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength appears full, pt grips with bilat hands 7-23\nlifts all extremities off the bed to command\nSensation: Intact to light touch, proprioception, pinprick and\nvibration bilaterally.\nToes downgoing bilaterally\nCoordination: pt too lethargic to perform\n\n\nPertinent Results:\nCT head:\nExtensive bilateral subarachnoid hemorrhage. Recommend head CTA\nto evaluate for an intracranial aneurysm.\nFindings were discussed with Dr.\n\nCTA:\nFINDINGS: There is a 3 mm x 3 mm saccular outpouching from the\nregion of the anterior communicating artery (2:317), consistent\nwith aneurysm. This has a very narrow neck, and would be\namenable to endovascular intervention. No other aneurysm or\nvascular abnormality is seen.\nThere is stenosis at the origin of the right vertebral artery.', '\nOtherwise, the carotid and vertebral arteries and their major\nbranches are patent, with no evidence of stenosis or occlusion.\nThe distal cervical internal carotid arteries measure 5 mm on\nthe right, and 5 mm on the left.\nMild-to-moderate multilevel cervical spine degenerative changes\nare noted.\nIMPRESSION: 3 mm saccular aneurysm arising from the anterior\ncommunicating\nartery, with narrow neck.\n\n\nBrief Hospital Course:\nMr. Blanks was admited on 1984-8-7 and became increasingly\nlethargic and transferred to the ICU for further care under the\nNeurosurgery service. A diagnostic CTA revealed a large ACOM\naneursym which was coiled the following day.\n\nPost Coiling the pt. was admitted to the ICU with a ventricular\ndrain. There were no incidences of increased intracranial\npressure or decline. A cerebral perfusion study performed 8-23\nconfirmed the lack of vasospasm and develoing strokes.', "\n\nHe had some R shoulder weakness and shoulder X-ray was\nconcerning for rotator cuff injury and orthopedics was\nconsulted.\n\nOn 1913-4-31/14/15 his ventricular drain was clamped and reopened\ndue to elevated ICP levels. On 7-5 he was transferred to the\nSDU and continued to remain stable. He had his ventricular\ndrain clamped on 5-5 and after 48 hours of the clamping trial\nhe had a CT done which was stable without any evidence of\nhydrocephalus. At this time the drain was pulled.\n\nHe was placed on a fluid restriction for a brief period of time\nfor a drop in his Na level, and also on salt tabs, upon\ndischarge to rehab we have removed the fluid restriction, but we\nare continuing the salt tabs, we advise that the Na level be\nchecked every other day, and the salt tabs may be d/c'ed when Na\nis stable on serial checks.", ' Upon discharge his Na is 138.\n\nHe is now ready for discharge to rehab.\n\nOn discharge his exam is as follows:\n\nAlert and Oriented X2\nMoving all extremities with full strength\nslight Right Drift, which has been persistant throughout his\nhospitalization, and possibly secondary to a rotator cuff\ninjury.\n\n\nMedications on Admission:\nChad Jain wife\n\nDischarge Medications:\n1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday).\n2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\n3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)\nInjection ASDIR (AS DIRECTED).\n5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).', '\n7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2\ntimes a day).\n9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)\nInjection TID (3 times a day).\n10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: 5-13\nTablets PO Q4H (every 4 hours) as needed for Headaches.\n11. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every\n4 hours): Continue for 1956-10-29.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nFlores, Huerta and Armstrong Clinic - 42645 Hobbs Burgs Suite 651\nEast Elizabethborough, VA 22238\n\nDischarge Diagnosis:\nAcom Aneursym\nSubarachnoid Hemorrhage\n\n\nDischarge Condition:\nStable\n\nDischarge Instructions:\nGeneral Instructions\n\n??????\tHave a friend/family member check your incision daily for\nsigns of infection.', '\n??????\tTake your pain medicine as prescribed.\n??????\tExercise should be limited to walking; no lifting, straining,\nor excessive bending.\n??????\tYou may wash your hair only after sutures and/or staples have\nbeen removed. You may have your staples removed at the rehab\nfacility or you can make an appointment in our office to have\nthem removed in 10 days from the date of discharge.\n??????\tYou may shower before this time using a shower cap to cover\nyour head.\n??????\tIncrease your intake of fluids and fiber, as narcotic pain\nmedicine can cause constipation. We generally recommend taking\nan over the counter stool softener, such as Docusate (Colace)\nwhile taking narcotic pain medication.\n??????\tUnless directed by your doctor, do not take any\nanti-inflammatory medicines such as Motrin, Aspirin, Advil, and\nIbuprofen etc.', '\n??????\tIf you have been prescribed Dilantin (Phenytoin) for\nanti-seizure medicine, take it as prescribed and follow up with\nlaboratory blood drawing in one week. This can be drawn at your\nPCP??????s office, but please have the results faxed to 248-395-6007.\nIf you haven been discharged on Keppra (Levetiracetam), you will\nnot require blood work monitoring.\n??????\tClearance to drive and return to work will be addressed at\nyour post-operative office visit.\n??????\tMake sure to continue to use your incentive spirometer while\nat home, unless you have been instructed not to.\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, or drainage.\n??????\tFever greater than or equal to 101?????? F.\n\n\nFollowup Instructions:\nFollow-Up Appointment Instructions\n\n??????Please return to the office in 10 days for removal of your\nstaples or sutures, or you may have them d/c'ed at rehab.\n??????Please call (613-874-6509 to schedule an appointment with\nDr.Taylor, to be seen in ___4____weeks.\n??????You will not need a CT scan of the brain without contrast.\n\n\n\nCompleted by:1983-12-23"]
7	22615	138547.0	2199-02-12	Discharge summary	Report	Admission Date: [2199-1-22] Discharge Date: [2199-2-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: hypernatremia, unresponsiveness Major Surgical or Invasive Procedure: PEG/trach History of Present Illness: [Age over 90 ]yo F with history of dementia, diabetes mellitus, hypertension, CVA Russian speaking woman who was found unresponsive at [Hospital 100] Rehab. On [2199-1-21], she was noted to have difficulty in swallowing. She was placed on NC for 88%RA. On morning of [2199-1-22], she desaturated to low 90s on 5 L. She was then noted to be unresponsive with left eye sluggish, right faical droop, right arm flaccid, mottled right extremities and vitals 118/68, P104, RR40 T 99.8 and 90% on 5L. In ED, patient found to be hypernatremic and recieved 2L of NS. CXR was concerning for RLL PNA and she was started on levo/flagyl. She was also reported to be more lethargic in the past 1-2 weeks. Per PCP, [Name10 (NameIs) ] baseline 1 week ago, she has been sitting up in the chair, pleasantly demented but interactive. Past Medical History: 1. [2198-11-16] PRIF of left distal femur fracture with [Last Name (un) 101] plate(require 4 person lift, followed by ortho clinic) 2. [8-21]:ORIF of right intreathrochanteric hip fracture 3. osteoporosis 4. CVA in [2189] 5. hypertension 6. dementia 7. diabetes mellitus-diet controlled 8. h/o meningioma 9. history of falls 10. cataracts Dementia DM hypertension CVA Social History: TOB-deniesETOH-denies Family History: lives at [Hospital3 102] Physical Exam: T97.3 P88 BP112/32 NSRon NRB 100% Gen-elderly woman, NAD, pale and lethargic neuro-arousable, groans in response to pain, non-conversational, cannot assess orientation, cannot assess other neuro exam CV-faint heart sounds, RRR resp-rhonchi diffusely, no crackles, no accessory muscle use [Last Name (un) 103]-no BS, soft, NT/ND, no HSM skin-stage 2 decubitus ulcer at coccyx region Pertinent Results: CT head [2199-1-22]: No evidence of acute intracranial hemorrhage or major cortical territorial infarction. CXR [2199-1-22]: : New right lower lobe confluent opacity which may represent a developing area of pneumonia. Differential diagnosis includes aspiration and atelectasis. Dedicated PA and lateral chest radiograph is suggested for more complete characterization when the patient's condition permits. no contrast head CT [2199-1-28] FINDINGS: There has been interval development of an area of decreased attenuation at the left basal ganglia and periventricular white matter in the distribution of the left lenticulostriate artery consistent with a subacute infarct. There is associated swelling with mass effect on the left lateral ventricle. There is no shift of normally midline structures. Additional areas of hypodensity in the periventricular white matter and right centrum semiovale are unchanged and consistent with old infarctions. Two calcified meningiomas are again seen arising at the left frontal dura and anterior olfactory groove. They are unchanged from prior study. No intracranial hemorrhage was identified. Surrounding osseous and soft-tissue structures are unremarkable. IMPRESSION: Subacute left lenticulostriate infarction which was not present on head CT of [2199-1-22] echo [2199-1-28]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is a severe resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is probably mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is a significant left ventricular inflow gradient which may be due to mitral annular calcification and mitral valve calcification. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. LENI [2199-1-24]: No evidence of thrombus within the right upper extremity [2199-2-6] 05:00AM BLOOD WBC-5.9 RBC-2.79* Hgb-7.9* Hct-25.0* MCV-90 MCH-28.2 MCHC-31.4 RDW-16.7* Plt Ct-451* [2199-2-5] 04:03AM BLOOD WBC-7.6 RBC-2.94* Hgb-8.4* Hct-26.7* MCV-91 MCH-28.7 MCHC-31.7 RDW-18.0* Plt Ct-508* [2199-2-4] 04:40AM BLOOD WBC-10.1 RBC-2.80* Hgb-7.8* Hct-24.6* MCV-88 MCH-27.9 MCHC-31.7 RDW-16.6* Plt Ct-477* [2199-2-3] 05:00AM BLOOD WBC-15.5* RBC-2.97* Hgb-8.5* Hct-26.7* MCV-90 MCH-28.6 MCHC-31.8 RDW-17.4* Plt Ct-578* [2199-2-2] 04:42AM BLOOD WBC-18.8* RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.5 MCHC-32.2 RDW-16.5* Plt Ct-590* [2199-2-1] 04:10AM BLOOD WBC-14.4* RBC-3.40* Hgb-9.5* Hct-30.5* MCV-90 MCH-28.0 MCHC-31.2 RDW-15.2 Plt Ct-499* [2199-1-31] 04:19AM BLOOD WBC-11.6* RBC-3.31* Hgb-9.4* Hct-28.7* MCV-87 MCH-28.4 MCHC-32.8 RDW-15.1 Plt Ct-427 [2199-1-30] 03:45AM BLOOD WBC-9.7 RBC-3.31* Hgb-9.7* Hct-29.2* MCV-88 MCH-29.3 MCHC-33.2 RDW-15.9* Plt Ct-363 [2199-1-29] 05:43AM BLOOD WBC-12.2* RBC-3.21* Hgb-9.2* Hct-28.0* MCV-87 MCH-28.6 MCHC-32.7 RDW-14.7 Plt Ct-315# [2199-1-28] 02:53AM BLOOD WBC-9.1 RBC-2.97* Hgb-8.7* Hct-26.3* MCV-89 MCH-29.3 MCHC-33.1 RDW-15.4 Plt Ct-201 [2199-1-27] 03:56AM BLOOD WBC-11.1* RBC-3.13* Hgb-9.1* Hct-27.5* MCV-88 MCH-29.0 MCHC-33.1 RDW-15.1 Plt Ct-200 [2199-1-26] 03:22AM BLOOD WBC-13.6* RBC-3.18* Hgb-9.2* Hct-28.5* MCV-89 MCH-28.9 MCHC-32.3 RDW-15.1 Plt Ct-214 [2199-1-25] 04:57AM BLOOD WBC-15.7* RBC-3.55* Hgb-9.9* Hct-32.1* MCV-90 MCH-27.8 MCHC-30.8* RDW-14.0 Plt Ct-277 [2199-1-24] 04:58AM BLOOD WBC-10.9 RBC-3.65* Hgb-10.8* Hct-34.9* MCV-95 MCH-29.5 MCHC-30.9* RDW-14.8 Plt Ct-209 [2199-1-23] 02:10PM BLOOD WBC-11.5* RBC-3.76* Hgb-10.9* Hct-35.4* MCV-94 MCH-29.1 MCHC-30.9* RDW-14.9 Plt Ct-201 [2199-1-22] 10:00AM BLOOD WBC-13.5* RBC-4.20 Hgb-12.2 Hct-39.6 MCV-94 MCH-29.1 MCHC-30.9* RDW-14.2 Plt Ct-251 [2199-1-22] 10:00AM BLOOD Neuts-57 Bands-32* Lymphs-7* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2199-1-22] 04:07PM BLOOD PT-14.4* PTT-24.3 INR(PT)-1.3 [2199-2-6] 05:00AM BLOOD Glucose-91 UreaN-14 Creat-0.3* Na-139 K-4.3 Cl-110* HCO3-26 AnGap-7* [2199-2-5] 04:03AM BLOOD Glucose-103 UreaN-15 Creat-0.4 Na-139 K-4.5 Cl-109* HCO3-25 AnGap-10 [2199-2-4] 04:40AM BLOOD Glucose-116* UreaN-17 Creat-0.5 Na-140 K-3.7 Cl-110* HCO3-24 AnGap-10 [2199-2-3] 05:00AM BLOOD Glucose-119* UreaN-20 Creat-0.5 Na-139 K-3.9 Cl-109* HCO3-23 AnGap-11 [2199-2-2] 03:21PM BLOOD Glucose-111* UreaN-18 Creat-0.6 Na-141 K-4.8 Cl-111* HCO3-25 AnGap-10 [2199-2-2] 04:42AM BLOOD Glucose-110* UreaN-16 Creat-0.5 Na-137 K-4.2 Cl-108 HCO3-27 AnGap-6* [2199-2-1] 04:10AM BLOOD Glucose-108* UreaN-10 Creat-0.4 Na-140 K-4.2 Cl-108 HCO3-24 AnGap-12 [2199-1-31] 04:19AM BLOOD Glucose-97 UreaN-12 Creat-0.5 Na-140 K-3.9 Cl-109* HCO3-26 AnGap-9 [2199-1-30] 07:35PM BLOOD Glucose-62* UreaN-12 Creat-0.4 Na-141 K-4.0 Cl-110* HCO3-26 AnGap-9 [2199-1-30] 03:45AM BLOOD Glucose-49* UreaN-14 Creat-0.4 Na-140 K-3.5 Cl-111* HCO3-23 AnGap-10 [2199-1-29] 05:43AM BLOOD Glucose-126* UreaN-15 Creat-0.5 Na-140 K-3.9 Cl-111* HCO3-21* AnGap-12 [2199-1-28] 02:53AM BLOOD Glucose-81 UreaN-22* Creat-0.5 Na-140 K-3.7 Cl-114* HCO3-21* AnGap-9 [2199-1-27] 12:15AM BLOOD K-4.2 [2199-1-26] 06:03PM BLOOD Glucose-76 UreaN-21* Creat-0.5 Na-143 K-3.5 Cl-117* HCO3-20* AnGap-10 [2199-1-26] 03:22AM BLOOD Glucose-104 UreaN-22* Creat-0.5 Na-147* K-3.5 Cl-120* HCO3-21* AnGap-10 [2199-1-25] 05:52PM BLOOD K-4.2 [2199-1-25] 04:57AM BLOOD Glucose-193* UreaN-34* Creat-0.8 Na-143 K-3.5 Cl-115* HCO3-18* AnGap-14 [2199-1-24] 08:29PM BLOOD Glucose-140* UreaN-38* Creat-0.8 Na-144 K-4.0 Cl-114* HCO3-19* AnGap-15 [2199-1-24] 12:57AM BLOOD Glucose-109* UreaN-42* Creat-0.7 Na-153* K-4.0 Cl-123* HCO3-24 AnGap-10 [2199-1-23] 08:59PM BLOOD Glucose-161* UreaN-42* Creat-0.7 Na-156* K-4.1 Cl-124* HCO3-25 AnGap-11 [2199-1-23] 02:10PM BLOOD Glucose-92 UreaN-47* Creat-0.8 Na-163* K-4.5 Cl-130* HCO3-28 AnGap-10 [2199-1-23] 04:08AM BLOOD Glucose-235* UreaN-53* Creat-1.0 Na-168* K-4.3 Cl-130* HCO3-31* AnGap-11 [2199-1-22] 11:54PM BLOOD Glucose-61* UreaN-56* Creat-1.0 Na-169* K-3.2* Cl-132* HCO3-32* AnGap-8 [2199-1-22] 08:58PM BLOOD Glucose-184* UreaN-55* Creat-1.1 Na-170* K-3.1* Cl-131* HCO3-30* AnGap-12 [2199-1-22] 04:07PM BLOOD Glucose-399* UreaN-55* Creat-1.1 Na-167* K-4.0 Cl-131* HCO3-30* AnGap-10 [2199-1-22] 10:00AM BLOOD Glucose-427* UreaN-53* Creat-1.2* Na-167* K-4.1 Cl-127* HCO3-29 AnGap-15 [2199-2-2] 09:10PM BLOOD CK(CPK)-94 [2199-2-2] 03:21PM BLOOD CK(CPK)-80 [2199-1-24] 04:58AM BLOOD CK(CPK)-151* [2199-1-23] 08:59PM BLOOD CK(CPK)-176* [2199-1-23] 02:10PM BLOOD CK(CPK)-214* [2199-1-22] 04:07PM BLOOD CK(CPK)-206* [2199-1-22] 10:00AM BLOOD ALT-11 AST-15 LD(LDH)-227 CK(CPK)-205* AlkPhos-119* TotBili-0.4 [2199-2-2] 09:10PM BLOOD CK-MB-6 cTropnT-0.04* [2199-2-2] 03:21PM BLOOD CK-MB-8 cTropnT-0.06* [2199-1-24] 04:58AM BLOOD CK-MB-4 cTropnT-0.04* [2199-1-23] 08:59PM BLOOD CK-MB-4 cTropnT-0.06* [2199-1-23] 02:10PM BLOOD CK-MB-4 cTropnT-0.08* [2199-2-5] 04:03AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1 [2199-2-4] 04:40AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7 [2199-2-3] 05:00AM BLOOD Calcium-7.9* Phos-2.5# Mg-2.0 [2199-2-2] 03:21PM BLOOD Calcium-8.1 Phos-5.2* Mg-2.3 [2199-2-1] 04:10AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.9 [2199-1-31] 04:19AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.7 [2199-1-22] 04:07PM BLOOD Osmolal-369* [2199-1-25] 01:43PM BLOOD Cortsol-29.3* [2199-1-25] 01:04PM BLOOD Cortsol-25.1* [2199-1-25] 12:15PM BLOOD Cortsol-18.4 [2199-2-6] 05:16AM BLOOD Type-ART pO2-111* pCO2-38 pH-7.43 calHCO3-26 Base XS-0 [2199-2-5] 04:53PM BLOOD Type-ART Temp-36.6 PEEP-5 pO2-88 pCO2-34* pH-7.45 calHCO3-24 Base XS-0 Intubat-INTUBATED [2199-2-4] 07:09PM BLOOD Type-ART Temp-36.9 Rates-/24 PEEP-5 FiO2-40 pO2-80* pCO2-32* pH-7.47* calHCO3-24 Base XS-0 Intubat-INTUBATED [2199-2-4] 10:40AM BLOOD Type-ART Temp-35.0 Rates-/20 PEEP-5 FiO2-40 pO2-65* pCO2-30* pH-7.47* calHCO3-22 Base XS-0 Intubat-INTUBATED [2199-2-4] 04:54AM BLOOD Type-ART Temp-37.4 Rates-/14 Tidal V-400 PEEP-5 FiO2-40 pO2-67* pCO2-32* pH-7.49* calHCO3-25 Base XS-1 Intubat-INTUBATED [2199-2-3] 10:19PM BLOOD Type-ART Temp-37.2 pO2-65* pCO2-30* pH-7.50* calHCO3-24 Base XS-0 [2199-2-3] 03:48PM BLOOD Type-ART Temp-37.3 Rates-/20 Tidal V-330 PEEP-5 FiO2-40 pO2-97 pCO2-32* pH-7.48* calHCO3-25 Base XS-0 Intubat-INTUBATED Comment-PS 10 [2199-2-3] 01:10PM BLOOD Type-ART Temp-36.6 Rates-/12 Tidal V-500 PEEP-5 FiO2-40 pO2-108* pCO2-28* pH-7.54* calHCO3-25 Base XS-3 Intubat-INTUBATED Vent-SPONTANEOU [2199-2-2] 08:08PM BLOOD Type-ART Temp-38.0 Rates-16/ Tidal V-500 PEEP-5 FiO2-60 pO2-78* pCO2-30* pH-7.45 calHCO3-21 Base XS--1 -ASSIST/CON Intubat-INTUBATED [2199-2-2] 04:50PM BLOOD Type-ART Temp-36.1 Rates-20/0 Tidal V-500 PEEP-8 FiO2-60 pO2-83* pCO2-31* pH-7.45 calHCO3-22 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2199-1-24] 03:29PM BLOOD Type-ART Temp-36.2 O2 Flow-6 pO2-72* pCO2-33* pH-7.40 calHCO3-21 Base XS--2 Intubat-NOT INTUBA [2199-1-22] 04:11PM BLOOD Type-ART pO2-128* pCO2-48* pH-7.37 calHCO3-29 Base XS-2 Intubat-NOT INTUBA [2199-1-22] 10:04AM BLOOD Type-ART Temp-37.9 pO2-65* pCO2-45 pH-7.45 calHCO3-32* Base XS-6 [2199-2-2] 03:38PM BLOOD Lactate-1.5 [2199-1-24] 04:32PM BLOOD Lactate-3.0* [2199-1-22] 10:04AM BLOOD Lactate-3.0* [2199-2-2] 04:48PM BLOOD O2 Sat-69 [2199-2-6] 05:16AM BLOOD freeCa-1.19 Brief Hospital Course: Patient was admitted with hypernatremia and acute mental status changes and right sided paralysis. Her corrected sodium on admission was about 170s and her free water deficit was 5.5L. She was volume repleted with normal saline. She also recieved D51/4 NS for free water repletion initially and this was changed to free water boluses through nasogastric tube. Her sodium gradually trended down with free water repletion. She also was in pre-renal renal failure and her creatinine trended down with hydration. With regards to the acute mental changes, this is partially explained by the hypernatrmic state. However, she was also noted by the nursing home to have right sided weakness. CT head was performed on admission which was negative for stoke. Neurology was consulted and found that she has a MCA territory stroke by exam. A repeat CT head was performed on [1-28] which showed watershed infarct. TTE which was also obtained did not reveal any thrombus.Per neurology recommendation, all her hypertensive medication has been discontinued and she was started on aspirin. Chest XRay on admission was concerning for right lower lobe pneumonia. Her sputum culture grew MSSA for which she was on oxacillin. Levofloxacin was also started for community acquired pneumonia. Nasal aspirate was sent for influenza and was negative. She was intubated on [2199-1-24] for increased respiratory effort. Her resporatory decompensation was likely from aspiration pneumonia. She was extubated on [2199-1-31] when her lungs mechanic improved. However, given her depressed mental status and stroke, she was not able to clear her secretions well. SHe was intubated again on [2-2] after unsuccessful attempt to maintain her oxygen saturation with high flow mask. She recieved tracheostomy and G tube and tolerated well post procedure. Her nutrition status was maintained by tubefeeds and insulin sliding scale and NPH kept her glucose within range. Her blood pressure was initially low on admission. This responded well to hydration and brief use of levophed. Her [Last Name (un) 104] stimulation test was responsive. Admission EKG showed ST depression in V2-V3 and it was unsure if this is old. She had slightly elevated troponin, likely from acute renal failure which eventually trending down. Plastic surgery was consulted for decubitus ulcer. No debridement was indicated and their recommendation was to maxmize nutrition, wet to dry dressing and tight glucose control. She remained on sc heparin, lansoprazole, pneumoboots and bowel regimen as part of her porphylaxis. She had picc line placed upon discharge THere had been multiple discussion with her daughter, which is her health care proxy regarding code status. It was felt by the medical team that her condition will not likely improve despite optimal medical treatment. However, due to religious reasons, her family remained steadfast that everything should be done. However, her family agrees that should she go into cardiac arrest, there should be no chest compression or defibrillation. Medications on Admission: coumadin-d/c [2199-1-10] ASA 81 QD Calcium/vit D [Hospital1 ] enalapril 1.25 QD metorpolol 12.5 [Hospital1 ] sorbitol 30ml QD tylenol NKDA Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 Units/ml heparin (100 units heparin) each lumen Daily and PRN. Inspect site every shift 15. Insulin NPH Human Recomb Subcutaneous 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: 1. MRSA pneumonia 2. hypernatremia 3. acute renal failure 4. Left MCA territory watershed infarct 5. decubitus ulcer Discharge Condition: stable Discharge Instructions: You will be discharged to rehabilitation center. Please let the medical staff knows if you have any concerns at all. Followup Instructions: Your care will be transferred to the rehabilitation center. Completed by:[2199-2-12]	Admission Date: <Date>1979-4-12</Date> Discharge Date: <Date>1939-11-10</Date> Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Cedric</Name> Chief Complaint: hypernatremia, unresponsiveness Major Surgical or Invasive Procedure: PEG/trach History of Present Illness: <Age>85</Age>yo F with history of dementia, diabetes mellitus, hypertension, CVA Russian speaking woman who was found unresponsive at <Hospital>Morgan, Smith and Mathews Hospital</Hospital> Rehab. On <Date>1975-3-31</Date>, she was noted to have difficulty in swallowing. She was placed on NC for 88%RA. On morning of <Date>1979-4-12</Date>, she desaturated to low 90s on 5 L. She was then noted to be unresponsive with left eye sluggish, right faical droop, right arm flaccid, mottled right extremities and vitals 118/68, P104, RR40 T 99.8 and 90% on 5L. In ED, patient found to be hypernatremic and recieved 2L of NS. CXR was concerning for RLL PNA and she was started on levo/flagyl. She was also reported to be more lethargic in the past 1-2 weeks. Per PCP, <Name>Jamila Lofft</Name> baseline 1 week ago, she has been sitting up in the chair, pleasantly demented but interactive. Past Medical History: 1. <Date>1997-8-3</Date> PRIF of left distal femur fracture with <Name>Belle</Name> plate(require 4 person lift, followed by ortho clinic) 2. <Date>2-7</Date>:ORIF of right intreathrochanteric hip fracture 3. osteoporosis 4. CVA in <Year>1972</Year> 5. hypertension 6. dementia 7. diabetes mellitus-diet controlled 8. h/o meningioma 9. history of falls 10. cataracts Dementia DM hypertension CVA Social History: TOB-deniesETOH-denies Family History: lives at <Hospital>Rodriguez, Turner and Davis Medical Center</Hospital> Physical Exam: T97.3 P88 BP112/32 NSRon NRB 100% Gen-elderly woman, NAD, pale and lethargic neuro-arousable, groans in response to pain, non-conversational, cannot assess orientation, cannot assess other neuro exam CV-faint heart sounds, RRR resp-rhonchi diffusely, no crackles, no accessory muscle use <Name>Londrie</Name>-no BS, soft, NT/ND, no HSM skin-stage 2 decubitus ulcer at coccyx region Pertinent Results: CT head <Date>1979-4-12</Date>: No evidence of acute intracranial hemorrhage or major cortical territorial infarction. CXR <Date>1979-4-12</Date>: : New right lower lobe confluent opacity which may represent a developing area of pneumonia. Differential diagnosis includes aspiration and atelectasis. Dedicated PA and lateral chest radiograph is suggested for more complete characterization when the patient's condition permits. no contrast head CT <Date>1975-7-6</Date> FINDINGS: There has been interval development of an area of decreased attenuation at the left basal ganglia and periventricular white matter in the distribution of the left lenticulostriate artery consistent with a subacute infarct. There is associated swelling with mass effect on the left lateral ventricle. There is no shift of normally midline structures. Additional areas of hypodensity in the periventricular white matter and right centrum semiovale are unchanged and consistent with old infarctions. Two calcified meningiomas are again seen arising at the left frontal dura and anterior olfactory groove. They are unchanged from prior study. No intracranial hemorrhage was identified. Surrounding osseous and soft-tissue structures are unremarkable. IMPRESSION: Subacute left lenticulostriate infarction which was not present on head CT of <Date>1979-4-12</Date> echo <Date>1975-7-6</Date>: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is a severe resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is probably mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is a significant left ventricular inflow gradient which may be due to mitral annular calcification and mitral valve calcification. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. LENI <Date>1924-1-4</Date>: No evidence of thrombus within the right upper extremity <Date>1986-7-28</Date> 05:00AM BLOOD WBC-5.9 RBC-2.79* Hgb-7.9* Hct-25.0* MCV-90 MCH-28.2 MCHC-31.4 RDW-16.7* Plt Ct-451* <Date>1990-7-25</Date> 04:03AM BLOOD WBC-7.6 RBC-2.94* Hgb-8.4* Hct-26.7* MCV-91 MCH-28.7 MCHC-31.7 RDW-18.0* Plt Ct-508* <Date>1978-3-1</Date> 04:40AM BLOOD WBC-10.1 RBC-2.80* Hgb-7.8* Hct-24.6* MCV-88 MCH-27.9 MCHC-31.7 RDW-16.6* Plt Ct-477* <Date>2022-9-3</Date> 05:00AM BLOOD WBC-15.5* RBC-2.97* Hgb-8.5* Hct-26.7* MCV-90 MCH-28.6 MCHC-31.8 RDW-17.4* Plt Ct-578* <Date>1902-9-17</Date> 04:42AM BLOOD WBC-18.8* RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.5 MCHC-32.2 RDW-16.5* Plt Ct-590* <Date>1997-1-19</Date> 04:10AM BLOOD WBC-14.4* RBC-3.40* Hgb-9.5* Hct-30.5* MCV-90 MCH-28.0 MCHC-31.2 RDW-15.2 Plt Ct-499* <Date>2007-8-24</Date> 04:19AM BLOOD WBC-11.6* RBC-3.31* Hgb-9.4* Hct-28.7* MCV-87 MCH-28.4 MCHC-32.8 RDW-15.1 Plt Ct-427 <Date>1909-2-18</Date> 03:45AM BLOOD WBC-9.7 RBC-3.31* Hgb-9.7* Hct-29.2* MCV-88 MCH-29.3 MCHC-33.2 RDW-15.9* Plt Ct-363 <Date>1959-11-1</Date> 05:43AM BLOOD WBC-12.2* RBC-3.21* Hgb-9.2* Hct-28.0* MCV-87 MCH-28.6 MCHC-32.7 RDW-14.7 Plt Ct-315# <Date>1975-7-6</Date> 02:53AM BLOOD WBC-9.1 RBC-2.97* Hgb-8.7* Hct-26.3* MCV-89 MCH-29.3 MCHC-33.1 RDW-15.4 Plt Ct-201 <Date>1963-4-17</Date> 03:56AM BLOOD WBC-11.1* RBC-3.13* Hgb-9.1* Hct-27.5* MCV-88 MCH-29.0 MCHC-33.1 RDW-15.1 Plt Ct-200 <Date>1900-2-23</Date> 03:22AM BLOOD WBC-13.6* RBC-3.18* Hgb-9.2* Hct-28.5* MCV-89 MCH-28.9 MCHC-32.3 RDW-15.1 Plt Ct-214 <Date>1950-10-2</Date> 04:57AM BLOOD WBC-15.7* RBC-3.55* Hgb-9.9* Hct-32.1* MCV-90 MCH-27.8 MCHC-30.8* RDW-14.0 Plt Ct-277 <Date>1924-1-4</Date> 04:58AM BLOOD WBC-10.9 RBC-3.65* Hgb-10.8* Hct-34.9* MCV-95 MCH-29.5 MCHC-30.9* RDW-14.8 Plt Ct-209 <Date>1946-5-31</Date> 02:10PM BLOOD WBC-11.5* RBC-3.76* Hgb-10.9* Hct-35.4* MCV-94 MCH-29.1 MCHC-30.9* RDW-14.9 Plt Ct-201 <Date>1979-4-12</Date> 10:00AM BLOOD WBC-13.5* RBC-4.20 Hgb-12.2 Hct-39.6 MCV-94 MCH-29.1 MCHC-30.9* RDW-14.2 Plt Ct-251 <Date>1979-4-12</Date> 10:00AM BLOOD Neuts-57 Bands-32* Lymphs-7* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 <Date>1979-4-12</Date> 04:07PM BLOOD PT-14.4* PTT-24.3 INR(PT)-1.3 <Date>1986-7-28</Date> 05:00AM BLOOD Glucose-91 UreaN-14 Creat-0.3* Na-139 K-4.3 Cl-110* HCO3-26 AnGap-7* <Date>1990-7-25</Date> 04:03AM BLOOD Glucose-103 UreaN-15 Creat-0.4 Na-139 K-4.5 Cl-109* HCO3-25 AnGap-10 <Date>1978-3-1</Date> 04:40AM BLOOD Glucose-116* UreaN-17 Creat-0.5 Na-140 K-3.7 Cl-110* HCO3-24 AnGap-10 <Date>2022-9-3</Date> 05:00AM BLOOD Glucose-119* UreaN-20 Creat-0.5 Na-139 K-3.9 Cl-109* HCO3-23 AnGap-11 <Date>1902-9-17</Date> 03:21PM BLOOD Glucose-111* UreaN-18 Creat-0.6 Na-141 K-4.8 Cl-111* HCO3-25 AnGap-10 <Date>1902-9-17</Date> 04:42AM BLOOD Glucose-110* UreaN-16 Creat-0.5 Na-137 K-4.2 Cl-108 HCO3-27 AnGap-6* <Date>1997-1-19</Date> 04:10AM BLOOD Glucose-108* UreaN-10 Creat-0.4 Na-140 K-4.2 Cl-108 HCO3-24 AnGap-12 <Date>2007-8-24</Date> 04:19AM BLOOD Glucose-97 UreaN-12 Creat-0.5 Na-140 K-3.9 Cl-109* HCO3-26 AnGap-9 <Date>1909-2-18</Date> 07:35PM BLOOD Glucose-62* UreaN-12 Creat-0.4 Na-141 K-4.0 Cl-110* HCO3-26 AnGap-9 <Date>1909-2-18</Date> 03:45AM BLOOD Glucose-49* UreaN-14 Creat-0.4 Na-140 K-3.5 Cl-111* HCO3-23 AnGap-10 <Date>1959-11-1</Date> 05:43AM BLOOD Glucose-126* UreaN-15 Creat-0.5 Na-140 K-3.9 Cl-111* HCO3-21* AnGap-12 <Date>1975-7-6</Date> 02:53AM BLOOD Glucose-81 UreaN-22* Creat-0.5 Na-140 K-3.7 Cl-114* HCO3-21* AnGap-9 <Date>1963-4-17</Date> 12:15AM BLOOD K-4.2 <Date>1900-2-23</Date> 06:03PM BLOOD Glucose-76 UreaN-21* Creat-0.5 Na-143 K-3.5 Cl-117* HCO3-20* AnGap-10 <Date>1900-2-23</Date> 03:22AM BLOOD Glucose-104 UreaN-22* Creat-0.5 Na-147* K-3.5 Cl-120* HCO3-21* AnGap-10 <Date>1950-10-2</Date> 05:52PM BLOOD K-4.2 <Date>1950-10-2</Date> 04:57AM BLOOD Glucose-193* UreaN-34* Creat-0.8 Na-143 K-3.5 Cl-115* HCO3-18* AnGap-14 <Date>1924-1-4</Date> 08:29PM BLOOD Glucose-140* UreaN-38* Creat-0.8 Na-144 K-4.0 Cl-114* HCO3-19* AnGap-15 <Date>1924-1-4</Date> 12:57AM BLOOD Glucose-109* UreaN-42* Creat-0.7 Na-153* K-4.0 Cl-123* HCO3-24 AnGap-10 <Date>1946-5-31</Date> 08:59PM BLOOD Glucose-161* UreaN-42* Creat-0.7 Na-156* K-4.1 Cl-124* HCO3-25 AnGap-11 <Date>1946-5-31</Date> 02:10PM BLOOD Glucose-92 UreaN-47* Creat-0.8 Na-163* K-4.5 Cl-130* HCO3-28 AnGap-10 <Date>1946-5-31</Date> 04:08AM BLOOD Glucose-235* UreaN-53* Creat-1.0 Na-168* K-4.3 Cl-130* HCO3-31* AnGap-11 <Date>1979-4-12</Date> 11:54PM BLOOD Glucose-61* UreaN-56* Creat-1.0 Na-169* K-3.2* Cl-132* HCO3-32* AnGap-8 <Date>1979-4-12</Date> 08:58PM BLOOD Glucose-184* UreaN-55* Creat-1.1 Na-170* K-3.1* Cl-131* HCO3-30* AnGap-12 <Date>1979-4-12</Date> 04:07PM BLOOD Glucose-399* UreaN-55* Creat-1.1 Na-167* K-4.0 Cl-131* HCO3-30* AnGap-10 <Date>1979-4-12</Date> 10:00AM BLOOD Glucose-427* UreaN-53* Creat-1.2* Na-167* K-4.1 Cl-127* HCO3-29 AnGap-15 <Date>1902-9-17</Date> 09:10PM BLOOD CK(CPK)-94 <Date>1902-9-17</Date> 03:21PM BLOOD CK(CPK)-80 <Date>1924-1-4</Date> 04:58AM BLOOD CK(CPK)-151* <Date>1946-5-31</Date> 08:59PM BLOOD CK(CPK)-176* <Date>1946-5-31</Date> 02:10PM BLOOD CK(CPK)-214* <Date>1979-4-12</Date> 04:07PM BLOOD CK(CPK)-206* <Date>1979-4-12</Date> 10:00AM BLOOD ALT-11 AST-15 LD(LDH)-227 CK(CPK)-205* AlkPhos-119* TotBili-0.4 <Date>1902-9-17</Date> 09:10PM BLOOD CK-MB-6 cTropnT-0.04* <Date>1902-9-17</Date> 03:21PM BLOOD CK-MB-8 cTropnT-0.06* <Date>1924-1-4</Date> 04:58AM BLOOD CK-MB-4 cTropnT-0.04* <Date>1946-5-31</Date> 08:59PM BLOOD CK-MB-4 cTropnT-0.06* <Date>1946-5-31</Date> 02:10PM BLOOD CK-MB-4 cTropnT-0.08* <Date>1990-7-25</Date> 04:03AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1 <Date>1978-3-1</Date> 04:40AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7 <Date>2022-9-3</Date> 05:00AM BLOOD Calcium-7.9* Phos-2.5# Mg-2.0 <Date>1902-9-17</Date> 03:21PM BLOOD Calcium-8.1 Phos-5.2* Mg-2.3 <Date>1997-1-19</Date> 04:10AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.9 <Date>2007-8-24</Date> 04:19AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.7 <Date>1979-4-12</Date> 04:07PM BLOOD Osmolal-369* <Date>1950-10-2</Date> 01:43PM BLOOD Cortsol-29.3* <Date>1950-10-2</Date> 01:04PM BLOOD Cortsol-25.1* <Date>1950-10-2</Date> 12:15PM BLOOD Cortsol-18.4 <Date>1986-7-28</Date> 05:16AM BLOOD Type-ART pO2-111* pCO2-38 pH-7.43 calHCO3-26 Base XS-0 <Date>1990-7-25</Date> 04:53PM BLOOD Type-ART Temp-36.6 PEEP-5 pO2-88 pCO2-34* pH-7.45 calHCO3-24 Base XS-0 Intubat-INTUBATED <Date>1978-3-1</Date> 07:09PM BLOOD Type-ART Temp-36.9 Rates-/24 PEEP-5 FiO2-40 pO2-80* pCO2-32* pH-7.47* calHCO3-24 Base XS-0 Intubat-INTUBATED <Date>1978-3-1</Date> 10:40AM BLOOD Type-ART Temp-35.0 Rates-/20 PEEP-5 FiO2-40 pO2-65* pCO2-30* pH-7.47* calHCO3-22 Base XS-0 Intubat-INTUBATED <Date>1978-3-1</Date> 04:54AM BLOOD Type-ART Temp-37.4 Rates-/14 Tidal V-400 PEEP-5 FiO2-40 pO2-67* pCO2-32* pH-7.49* calHCO3-25 Base XS-1 Intubat-INTUBATED <Date>2022-9-3</Date> 10:19PM BLOOD Type-ART Temp-37.2 pO2-65* pCO2-30* pH-7.50* calHCO3-24 Base XS-0 <Date>2022-9-3</Date> 03:48PM BLOOD Type-ART Temp-37.3 Rates-/20 Tidal V-330 PEEP-5 FiO2-40 pO2-97 pCO2-32* pH-7.48* calHCO3-25 Base XS-0 Intubat-INTUBATED Comment-PS 10 <Date>2022-9-3</Date> 01:10PM BLOOD Type-ART Temp-36.6 Rates-/12 Tidal V-500 PEEP-5 FiO2-40 pO2-108* pCO2-28* pH-7.54* calHCO3-25 Base XS-3 Intubat-INTUBATED Vent-SPONTANEOU <Date>1902-9-17</Date> 08:08PM BLOOD Type-ART Temp-38.0 Rates-16/ Tidal V-500 PEEP-5 FiO2-60 pO2-78* pCO2-30* pH-7.45 calHCO3-21 Base XS--1 -ASSIST/CON Intubat-INTUBATED <Date>1902-9-17</Date> 04:50PM BLOOD Type-ART Temp-36.1 Rates-20/0 Tidal V-500 PEEP-8 FiO2-60 pO2-83* pCO2-31* pH-7.45 calHCO3-22 Base XS-0 -ASSIST/CON Intubat-INTUBATED <Date>1924-1-4</Date> 03:29PM BLOOD Type-ART Temp-36.2 O2 Flow-6 pO2-72* pCO2-33* pH-7.40 calHCO3-21 Base XS--2 Intubat-NOT INTUBA <Date>1979-4-12</Date> 04:11PM BLOOD Type-ART pO2-128* pCO2-48* pH-7.37 calHCO3-29 Base XS-2 Intubat-NOT INTUBA <Date>1979-4-12</Date> 10:04AM BLOOD Type-ART Temp-37.9 pO2-65* pCO2-45 pH-7.45 calHCO3-32* Base XS-6 <Date>1902-9-17</Date> 03:38PM BLOOD Lactate-1.5 <Date>1924-1-4</Date> 04:32PM BLOOD Lactate-3.0* <Date>1979-4-12</Date> 10:04AM BLOOD Lactate-3.0* <Date>1902-9-17</Date> 04:48PM BLOOD O2 Sat-69 <Date>1986-7-28</Date> 05:16AM BLOOD freeCa-1.19 Brief Hospital Course: Patient was admitted with hypernatremia and acute mental status changes and right sided paralysis. Her corrected sodium on admission was about 170s and her free water deficit was 5.5L. She was volume repleted with normal saline. She also recieved D51/4 NS for free water repletion initially and this was changed to free water boluses through nasogastric tube. Her sodium gradually trended down with free water repletion. She also was in pre-renal renal failure and her creatinine trended down with hydration. With regards to the acute mental changes, this is partially explained by the hypernatrmic state. However, she was also noted by the nursing home to have right sided weakness. CT head was performed on admission which was negative for stoke. Neurology was consulted and found that she has a MCA territory stroke by exam. A repeat CT head was performed on <Date>11-27</Date> which showed watershed infarct. TTE which was also obtained did not reveal any thrombus.Per neurology recommendation, all her hypertensive medication has been discontinued and she was started on aspirin. Chest XRay on admission was concerning for right lower lobe pneumonia. Her sputum culture grew MSSA for which she was on oxacillin. Levofloxacin was also started for community acquired pneumonia. Nasal aspirate was sent for influenza and was negative. She was intubated on <Date>1924-1-4</Date> for increased respiratory effort. Her resporatory decompensation was likely from aspiration pneumonia. She was extubated on <Date>2007-8-24</Date> when her lungs mechanic improved. However, given her depressed mental status and stroke, she was not able to clear her secretions well. SHe was intubated again on <Date>3-1</Date> after unsuccessful attempt to maintain her oxygen saturation with high flow mask. She recieved tracheostomy and G tube and tolerated well post procedure. Her nutrition status was maintained by tubefeeds and insulin sliding scale and NPH kept her glucose within range. Her blood pressure was initially low on admission. This responded well to hydration and brief use of levophed. Her <Name>Hui</Name> stimulation test was responsive. Admission EKG showed ST depression in V2-V3 and it was unsure if this is old. She had slightly elevated troponin, likely from acute renal failure which eventually trending down. Plastic surgery was consulted for decubitus ulcer. No debridement was indicated and their recommendation was to maxmize nutrition, wet to dry dressing and tight glucose control. She remained on sc heparin, lansoprazole, pneumoboots and bowel regimen as part of her porphylaxis. She had picc line placed upon discharge THere had been multiple discussion with her daughter, which is her health care proxy regarding code status. It was felt by the medical team that her condition will not likely improve despite optimal medical treatment. However, due to religious reasons, her family remained steadfast that everything should be done. However, her family agrees that should she go into cardiac arrest, there should be no chest compression or defibrillation. Medications on Admission: coumadin-d/c <Date>2016-11-18</Date> ASA 81 QD Calcium/vit D <Hospital>Farmer, Soto and Boyer Health System</Hospital> enalapril 1.25 QD metorpolol 12.5 <Hospital>Farmer, Soto and Boyer Health System</Hospital> sorbitol 30ml QD tylenol NKDA Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical <Hospital>Farmer, Soto and Boyer Health System</Hospital> (2 times a day). 13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 Units/ml heparin (100 units heparin) each lumen Daily and PRN. Inspect site every shift 15. Insulin NPH Human Recomb Subcutaneous 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: <Hospital>Fry, Smith and Harrison Hospital</Hospital> - <Location>283 Nelson Cliff Port Daniel, VI 92297</Location> Discharge Diagnosis: 1. MRSA pneumonia 2. hypernatremia 3. acute renal failure 4. Left MCA territory watershed infarct 5. decubitus ulcer Discharge Condition: stable Discharge Instructions: You will be discharged to rehabilitation center. Please let the medical staff knows if you have any concerns at all. Followup Instructions: Your care will be transferred to the rehabilitation center. Completed by:<Date>1939-11-10</Date>	000000000000000001111111110000000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111110000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000001110000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001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Date: 1979-4-12 Discharge Date: 1939-11-10 Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Cedric Chief Complaint: hypernatremia, unresponsiveness Major Surgical or Invasive Procedure: PEG/trach History of Present Illness: 85yo F with history of dementia, diabetes mellitus, hypertension, CVA Russian speaking woman who was found unresponsive at Morgan, Smith and Mathews Hospital Rehab. On 1975-3-31, she was noted to have difficulty in swallowing. She was placed on NC for 88%RA. On morning of 1979-4-12, she desaturated to low 90s on 5 L. She was then noted to be unresponsive with left eye sluggish, right faical droop, right arm flaccid, mottled right extremities and vitals 118/68, P104, RR40 T 99.8 and 90% on 5L. In ED, patient found to be hypernatremic and recieved 2L of NS. CXR was concerning for RLL PNA and she was started on levo/flagyl. She was also reported to be more lethargic in the past 1-2 weeks. Per PCP, Jamila Lofft baseline 1 week ago, she has been sitting up in the chair, pleasantly demented but interactive. Past Medical History: 1. 1997-8-3 PRIF of left distal femur fracture with Belle plate(require 4 person lift, followed by ortho clinic) 2. 2-7:ORIF of right intreathrochanteric hip fracture 3. osteoporosis 4. CVA in 1972 5. hypertension 6. dementia 7. diabetes mellitus-diet controlled 8. h/o meningioma 9. history of falls 10. cataracts Dementia DM hypertension CVA Social History: TOB-deniesETOH-denies Family History: lives at Rodriguez, Turner and Davis Medical Center Physical Exam: T97.3 P88 BP112/32 NSRon NRB 100% Gen-elderly woman, NAD, pale and lethargic neuro-arousable, groans in response to pain, non-conversational, cannot assess orientation, cannot assess other neuro exam CV-faint heart sounds, RRR resp-rhonchi diffusely, no crackles, no accessory muscle use Londrie-no BS, soft, NT/ND, no HSM skin-stage 2 decubitus ulcer at coccyx region Pertinent Results: CT head 1979-4-12: No evidence of acute intracranial hemorrhage or major cortical territorial infarction. CXR 1979-4-12: : New right lower lobe confluent opacity which may represent a developing area of pneumonia. Differential diagnosis includes aspiration and atelectasis. Dedicated PA and lateral chest radiograph is suggested for more complete characterization when the patient's condition permits. no contrast head CT 1975-7-6 FINDINGS: There has been interval development of an area of decreased attenuation at the left basal ganglia and periventricular white matter in the distribution of the left lenticulostriate artery consistent with a subacute infarct. There is associated swelling with mass effect on the left lateral ventricle. There is no shift of normally midline structures. Additional areas of hypodensity in the periventricular white matter and right centrum semiovale are unchanged and consistent with old infarctions. Two calcified meningiomas are again seen arising at the left frontal dura and anterior olfactory groove. They are unchanged from prior study. No intracranial hemorrhage was identified. Surrounding osseous and soft-tissue structures are unremarkable. IMPRESSION: Subacute left lenticulostriate infarction which was not present on head CT of 1979-4-12 echo 1975-7-6: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is a severe resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is probably mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is a significant left ventricular inflow gradient which may be due to mitral annular calcification and mitral valve calcification. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. LENI 1924-1-4: No evidence of thrombus within the right upper extremity 1986-7-28 05:00AM BLOOD WBC-5.9 RBC-2.79* Hgb-7.9* Hct-25.0* MCV-90 MCH-28.2 MCHC-31.4 RDW-16.7* Plt Ct-451* 1990-7-25 04:03AM BLOOD WBC-7.6 RBC-2.94* Hgb-8.4* Hct-26.7* MCV-91 MCH-28.7 MCHC-31.7 RDW-18.0* Plt Ct-508* 1978-3-1 04:40AM BLOOD WBC-10.1 RBC-2.80* Hgb-7.8* Hct-24.6* MCV-88 MCH-27.9 MCHC-31.7 RDW-16.6* Plt Ct-477* 2022-9-3 05:00AM BLOOD WBC-15.5* RBC-2.97* Hgb-8.5* Hct-26.7* MCV-90 MCH-28.6 MCHC-31.8 RDW-17.4* Plt Ct-578* 1902-9-17 04:42AM BLOOD WBC-18.8* RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.5 MCHC-32.2 RDW-16.5* Plt Ct-590* 1997-1-19 04:10AM BLOOD WBC-14.4* RBC-3.40* Hgb-9.5* Hct-30.5* MCV-90 MCH-28.0 MCHC-31.2 RDW-15.2 Plt Ct-499* 2007-8-24 04:19AM BLOOD WBC-11.6* RBC-3.31* Hgb-9.4* Hct-28.7* MCV-87 MCH-28.4 MCHC-32.8 RDW-15.1 Plt Ct-427 1909-2-18 03:45AM BLOOD WBC-9.7 RBC-3.31* Hgb-9.7* Hct-29.2* MCV-88 MCH-29.3 MCHC-33.2 RDW-15.9* Plt Ct-363 1959-11-1 05:43AM BLOOD WBC-12.2* RBC-3.21* Hgb-9.2* Hct-28.0* MCV-87 MCH-28.6 MCHC-32.7 RDW-14.7 Plt Ct-315# 1975-7-6 02:53AM BLOOD WBC-9.1 RBC-2.97* Hgb-8.7* Hct-26.3* MCV-89 MCH-29.3 MCHC-33.1 RDW-15.4 Plt Ct-201 1963-4-17 03:56AM BLOOD WBC-11.1* RBC-3.13* Hgb-9.1* Hct-27.5* MCV-88 MCH-29.0 MCHC-33.1 RDW-15.1 Plt Ct-200 1900-2-23 03:22AM BLOOD WBC-13.6* RBC-3.18* Hgb-9.2* Hct-28.5* MCV-89 MCH-28.9 MCHC-32.3 RDW-15.1 Plt Ct-214 1950-10-2 04:57AM BLOOD WBC-15.7* RBC-3.55* Hgb-9.9* Hct-32.1* MCV-90 MCH-27.8 MCHC-30.8* RDW-14.0 Plt Ct-277 1924-1-4 04:58AM BLOOD WBC-10.9 RBC-3.65* Hgb-10.8* Hct-34.9* MCV-95 MCH-29.5 MCHC-30.9* RDW-14.8 Plt Ct-209 1946-5-31 02:10PM BLOOD WBC-11.5* RBC-3.76* Hgb-10.9* Hct-35.4* MCV-94 MCH-29.1 MCHC-30.9* RDW-14.9 Plt Ct-201 1979-4-12 10:00AM BLOOD WBC-13.5* RBC-4.20 Hgb-12.2 Hct-39.6 MCV-94 MCH-29.1 MCHC-30.9* RDW-14.2 Plt Ct-251 1979-4-12 10:00AM BLOOD Neuts-57 Bands-32* Lymphs-7* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 1979-4-12 04:07PM BLOOD PT-14.4* PTT-24.3 INR(PT)-1.3 1986-7-28 05:00AM BLOOD Glucose-91 UreaN-14 Creat-0.3* Na-139 K-4.3 Cl-110* HCO3-26 AnGap-7* 1990-7-25 04:03AM BLOOD Glucose-103 UreaN-15 Creat-0.4 Na-139 K-4.5 Cl-109* HCO3-25 AnGap-10 1978-3-1 04:40AM BLOOD Glucose-116* UreaN-17 Creat-0.5 Na-140 K-3.7 Cl-110* HCO3-24 AnGap-10 2022-9-3 05:00AM BLOOD Glucose-119* UreaN-20 Creat-0.5 Na-139 K-3.9 Cl-109* HCO3-23 AnGap-11 1902-9-17 03:21PM BLOOD Glucose-111* UreaN-18 Creat-0.6 Na-141 K-4.8 Cl-111* HCO3-25 AnGap-10 1902-9-17 04:42AM BLOOD Glucose-110* UreaN-16 Creat-0.5 Na-137 K-4.2 Cl-108 HCO3-27 AnGap-6* 1997-1-19 04:10AM BLOOD Glucose-108* UreaN-10 Creat-0.4 Na-140 K-4.2 Cl-108 HCO3-24 AnGap-12 2007-8-24 04:19AM BLOOD Glucose-97 UreaN-12 Creat-0.5 Na-140 K-3.9 Cl-109* HCO3-26 AnGap-9 1909-2-18 07:35PM BLOOD Glucose-62* UreaN-12 Creat-0.4 Na-141 K-4.0 Cl-110* HCO3-26 AnGap-9 1909-2-18 03:45AM BLOOD Glucose-49* UreaN-14 Creat-0.4 Na-140 K-3.5 Cl-111* HCO3-23 AnGap-10 1959-11-1 05:43AM BLOOD Glucose-126* UreaN-15 Creat-0.5 Na-140 K-3.9 Cl-111* HCO3-21* AnGap-12 1975-7-6 02:53AM BLOOD Glucose-81 UreaN-22* Creat-0.5 Na-140 K-3.7 Cl-114* HCO3-21* AnGap-9 1963-4-17 12:15AM BLOOD K-4.2 1900-2-23 06:03PM BLOOD Glucose-76 UreaN-21* Creat-0.5 Na-143 K-3.5 Cl-117* HCO3-20* AnGap-10 1900-2-23 03:22AM BLOOD Glucose-104 UreaN-22* Creat-0.5 Na-147* K-3.5 Cl-120* HCO3-21* AnGap-10 1950-10-2 05:52PM BLOOD K-4.2 1950-10-2 04:57AM BLOOD Glucose-193* UreaN-34* Creat-0.8 Na-143 K-3.5 Cl-115* HCO3-18* AnGap-14 1924-1-4 08:29PM BLOOD Glucose-140* UreaN-38* Creat-0.8 Na-144 K-4.0 Cl-114* HCO3-19* AnGap-15 1924-1-4 12:57AM BLOOD Glucose-109* UreaN-42* Creat-0.7 Na-153* K-4.0 Cl-123* HCO3-24 AnGap-10 1946-5-31 08:59PM BLOOD Glucose-161* UreaN-42* Creat-0.7 Na-156* K-4.1 Cl-124* HCO3-25 AnGap-11 1946-5-31 02:10PM BLOOD Glucose-92 UreaN-47* Creat-0.8 Na-163* K-4.5 Cl-130* HCO3-28 AnGap-10 1946-5-31 04:08AM BLOOD Glucose-235* UreaN-53* Creat-1.0 Na-168* K-4.3 Cl-130* HCO3-31* AnGap-11 1979-4-12 11:54PM BLOOD Glucose-61* UreaN-56* Creat-1.0 Na-169* K-3.2* Cl-132* HCO3-32* AnGap-8 1979-4-12 08:58PM BLOOD Glucose-184* UreaN-55* Creat-1.1 Na-170* K-3.1* Cl-131* HCO3-30* AnGap-12 1979-4-12 04:07PM BLOOD Glucose-399* UreaN-55* Creat-1.1 Na-167* K-4.0 Cl-131* HCO3-30* AnGap-10 1979-4-12 10:00AM BLOOD Glucose-427* UreaN-53* Creat-1.2* Na-167* K-4.1 Cl-127* HCO3-29 AnGap-15 1902-9-17 09:10PM BLOOD CK(CPK)-94 1902-9-17 03:21PM BLOOD CK(CPK)-80 1924-1-4 04:58AM BLOOD CK(CPK)-151* 1946-5-31 08:59PM BLOOD CK(CPK)-176* 1946-5-31 02:10PM BLOOD CK(CPK)-214* 1979-4-12 04:07PM BLOOD CK(CPK)-206* 1979-4-12 10:00AM BLOOD ALT-11 AST-15 LD(LDH)-227 CK(CPK)-205* AlkPhos-119* TotBili-0.4 1902-9-17 09:10PM BLOOD CK-MB-6 cTropnT-0.04* 1902-9-17 03:21PM BLOOD CK-MB-8 cTropnT-0.06* 1924-1-4 04:58AM BLOOD CK-MB-4 cTropnT-0.04* 1946-5-31 08:59PM BLOOD CK-MB-4 cTropnT-0.06* 1946-5-31 02:10PM BLOOD CK-MB-4 cTropnT-0.08* 1990-7-25 04:03AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1 1978-3-1 04:40AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7 2022-9-3 05:00AM BLOOD Calcium-7.9* Phos-2.5# Mg-2.0 1902-9-17 03:21PM BLOOD Calcium-8.1 Phos-5.2* Mg-2.3 1997-1-19 04:10AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.9 2007-8-24 04:19AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.7 1979-4-12 04:07PM BLOOD Osmolal-369* 1950-10-2 01:43PM BLOOD Cortsol-29.3* 1950-10-2 01:04PM BLOOD Cortsol-25.1* 1950-10-2 12:15PM BLOOD Cortsol-18.4 1986-7-28 05:16AM BLOOD Type-ART pO2-111* pCO2-38 pH-7.43 calHCO3-26 Base XS-0 1990-7-25 04:53PM BLOOD Type-ART Temp-36.6 PEEP-5 pO2-88 pCO2-34* pH-7.45 calHCO3-24 Base XS-0 Intubat-INTUBATED 1978-3-1 07:09PM BLOOD Type-ART Temp-36.9 Rates-/24 PEEP-5 FiO2-40 pO2-80* pCO2-32* pH-7.47* calHCO3-24 Base XS-0 Intubat-INTUBATED 1978-3-1 10:40AM BLOOD Type-ART Temp-35.0 Rates-/20 PEEP-5 FiO2-40 pO2-65* pCO2-30* pH-7.47* calHCO3-22 Base XS-0 Intubat-INTUBATED 1978-3-1 04:54AM BLOOD Type-ART Temp-37.4 Rates-/14 Tidal V-400 PEEP-5 FiO2-40 pO2-67* pCO2-32* pH-7.49* calHCO3-25 Base XS-1 Intubat-INTUBATED 2022-9-3 10:19PM BLOOD Type-ART Temp-37.2 pO2-65* pCO2-30* pH-7.50* calHCO3-24 Base XS-0 2022-9-3 03:48PM BLOOD Type-ART Temp-37.3 Rates-/20 Tidal V-330 PEEP-5 FiO2-40 pO2-97 pCO2-32* pH-7.48* calHCO3-25 Base XS-0 Intubat-INTUBATED Comment-PS 10 2022-9-3 01:10PM BLOOD Type-ART Temp-36.6 Rates-/12 Tidal V-500 PEEP-5 FiO2-40 pO2-108* pCO2-28* pH-7.54* calHCO3-25 Base XS-3 Intubat-INTUBATED Vent-SPONTANEOU 1902-9-17 08:08PM BLOOD Type-ART Temp-38.0 Rates-16/ Tidal V-500 PEEP-5 FiO2-60 pO2-78* pCO2-30* pH-7.45 calHCO3-21 Base XS--1 -ASSIST/CON Intubat-INTUBATED 1902-9-17 04:50PM BLOOD Type-ART Temp-36.1 Rates-20/0 Tidal V-500 PEEP-8 FiO2-60 pO2-83* pCO2-31* pH-7.45 calHCO3-22 Base XS-0 -ASSIST/CON Intubat-INTUBATED 1924-1-4 03:29PM BLOOD Type-ART Temp-36.2 O2 Flow-6 pO2-72* pCO2-33* pH-7.40 calHCO3-21 Base XS--2 Intubat-NOT INTUBA 1979-4-12 04:11PM BLOOD Type-ART pO2-128* pCO2-48* pH-7.37 calHCO3-29 Base XS-2 Intubat-NOT INTUBA 1979-4-12 10:04AM BLOOD Type-ART Temp-37.9 pO2-65* pCO2-45 pH-7.45 calHCO3-32* Base XS-6 1902-9-17 03:38PM BLOOD Lactate-1.5 1924-1-4 04:32PM BLOOD Lactate-3.0* 1979-4-12 10:04AM BLOOD Lactate-3.0* 1902-9-17 04:48PM BLOOD O2 Sat-69 1986-7-28 05:16AM BLOOD freeCa-1.19 Brief Hospital Course: Patient was admitted with hypernatremia and acute mental status changes and right sided paralysis. Her corrected sodium on admission was about 170s and her free water deficit was 5.5L. She was volume repleted with normal saline. She also recieved D51/4 NS for free water repletion initially and this was changed to free water boluses through nasogastric tube. Her sodium gradually trended down with free water repletion. She also was in pre-renal renal failure and her creatinine trended down with hydration. With regards to the acute mental changes, this is partially explained by the hypernatrmic state. However, she was also noted by the nursing home to have right sided weakness. CT head was performed on admission which was negative for stoke. Neurology was consulted and found that she has a MCA territory stroke by exam. A repeat CT head was performed on 11-27 which showed watershed infarct. TTE which was also obtained did not reveal any thrombus.Per neurology recommendation, all her hypertensive medication has been discontinued and she was started on aspirin. Chest XRay on admission was concerning for right lower lobe pneumonia. Her sputum culture grew MSSA for which she was on oxacillin. Levofloxacin was also started for community acquired pneumonia. Nasal aspirate was sent for influenza and was negative. She was intubated on 1924-1-4 for increased respiratory effort. Her resporatory decompensation was likely from aspiration pneumonia. She was extubated on 2007-8-24 when her lungs mechanic improved. However, given her depressed mental status and stroke, she was not able to clear her secretions well. SHe was intubated again on 3-1 after unsuccessful attempt to maintain her oxygen saturation with high flow mask. She recieved tracheostomy and G tube and tolerated well post procedure. Her nutrition status was maintained by tubefeeds and insulin sliding scale and NPH kept her glucose within range. Her blood pressure was initially low on admission. This responded well to hydration and brief use of levophed. Her Hui stimulation test was responsive. Admission EKG showed ST depression in V2-V3 and it was unsure if this is old. She had slightly elevated troponin, likely from acute renal failure which eventually trending down. Plastic surgery was consulted for decubitus ulcer. No debridement was indicated and their recommendation was to maxmize nutrition, wet to dry dressing and tight glucose control. She remained on sc heparin, lansoprazole, pneumoboots and bowel regimen as part of her porphylaxis. She had picc line placed upon discharge THere had been multiple discussion with her daughter, which is her health care proxy regarding code status. It was felt by the medical team that her condition will not likely improve despite optimal medical treatment. However, due to religious reasons, her family remained steadfast that everything should be done. However, her family agrees that should she go into cardiac arrest, there should be no chest compression or defibrillation. Medications on Admission: coumadin-d/c 2016-11-18 ASA 81 QD Calcium/vit D Farmer, Soto and Boyer Health System enalapril 1.25 QD metorpolol 12.5 Farmer, Soto and Boyer Health System sorbitol 30ml QD tylenol NKDA Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical Farmer, Soto and Boyer Health System (2 times a day). 13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 Units/ml heparin (100 units heparin) each lumen Daily and PRN. Inspect site every shift 15. Insulin NPH Human Recomb Subcutaneous 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Fry, Smith and Harrison Hospital - 283 Nelson Cliff Port Daniel, VI 92297 Discharge Diagnosis: 1. MRSA pneumonia 2. hypernatremia 3. acute renal failure 4. Left MCA territory watershed infarct 5. decubitus ulcer Discharge Condition: stable Discharge Instructions: You will be discharged to rehabilitation center. Please let the medical staff knows if you have any concerns at all. Followup Instructions: Your care will be transferred to the rehabilitation center. Completed by:1939-11-10	['Admission Date: 1979-4-12 Discharge Date: 1939-11-10\n\n\nService: MEDICINE\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Cedric\nChief Complaint:\nhypernatremia, unresponsiveness\n\nMajor Surgical or Invasive Procedure:\nPEG/trach\n\nHistory of Present Illness:\n85yo F with history of dementia, diabetes mellitus,\nhypertension, CVA Russian speaking woman who was found\nunresponsive at Morgan, Smith and Mathews Hospital Rehab. On 1975-3-31, she was noted to have\ndifficulty in swallowing. She was placed on NC for 88%RA. On\nmorning of 1979-4-12, she desaturated to low 90s on 5 L. She was\nthen noted to be unresponsive with left eye sluggish, right\nfaical droop, right arm flaccid, mottled right extremities and\nvitals 118/68, P104, RR40 T 99.8 and 90% on 5L.\nIn ED, patient found to be hypernatremic and recieved 2L of NS.', '\nCXR was concerning for RLL PNA and she was started on\nlevo/flagyl. She was also reported to be more lethargic in the\npast 1-2 weeks.\nPer PCP, Jamila Lofft baseline 1 week ago, she has been sitting up in the\nchair, pleasantly demented but interactive.\n\nPast Medical History:\n1. 1997-8-3 PRIF of left distal femur fracture with Belle\nplate(require 4 person lift, followed by ortho clinic)\n2. 2-7:ORIF of right intreathrochanteric hip fracture\n3. osteoporosis\n4. CVA in 1972\n5. hypertension\n6. dementia\n7. diabetes mellitus-diet controlled\n8. h/o meningioma\n9. history of falls\n10. cataracts\n\nDementia\nDM\nhypertension\nCVA\n\nSocial History:\nTOB-deniesETOH-denies\n\nFamily History:\nlives at Rodriguez, Turner and Davis Medical Center\n\nPhysical Exam:\nT97.3 P88 BP112/32 NSRon NRB 100%\nGen-elderly woman, NAD, pale and lethargic\nneuro-arousable, groans in response to pain, non-conversational,\ncannot assess orientation, cannot assess other neuro exam\nCV-faint heart sounds, RRR\nresp-rhonchi diffusely, no crackles, no accessory muscle use\nLondrie-no BS, soft, NT/ND, no HSM\nskin-stage 2 decubitus ulcer at coccyx region\n\n\nPertinent Results:\nCT head 1979-4-12:\nNo evidence of acute intracranial hemorrhage or major cortical\nterritorial infarction.', "\n\nCXR 1979-4-12:\n: New right lower lobe confluent opacity which may represent a\ndeveloping area of pneumonia. Differential diagnosis includes\naspiration and\natelectasis. Dedicated PA and lateral chest radiograph is\nsuggested for more\ncomplete characterization when the patient's condition permits.\n\nno contrast head CT 1975-7-6\n FINDINGS: There has been interval development of an area of\ndecreased attenuation at the left basal ganglia and\nperiventricular white matter in the distribution of the left\nlenticulostriate artery consistent with a subacute infarct.\nThere is associated swelling with mass effect on the left\nlateral ventricle. There is no shift of normally midline\nstructures. Additional areas of hypodensity in the\nperiventricular white matter and right centrum semiovale are\nunchanged and consistent with old infarctions.", ' Two calcified\nmeningiomas are again seen arising at the left frontal dura and\nanterior olfactory groove. They are unchanged from prior study.\nNo intracranial hemorrhage was identified. Surrounding osseous\nand soft-tissue structures are unremarkable.\n\nIMPRESSION: Subacute left lenticulostriate infarction which was\nnot present on head CT of 1979-4-12\n\necho 1975-7-6:\n\nThe left atrium is normal in size. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is\nnormal. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Overall left\nventricular systolic function is normal (LVEF>55%). There is a\nsevere resting left ventricular outflow tract obstruction. Right\nventricular chamber size and free wall motion are normal. The\naortic valve is not well seen.', ' There is probably mild aortic\nvalve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are moderately thickened. Mild (1+) mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity\nof mitral regurgitation may be significantly UNDERestimated.]\nThere is a significant left ventricular inflow gradient which\nmay be due to mitral annular calcification and mitral valve\ncalcification. The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic\nhypertension.\nThere is a trivial/physiologic pericardial effusion.\n\nLENI 1924-1-4:\nNo evidence of thrombus within the right upper extremity\n\n1986-7-28 05:00AM BLOOD WBC-5.9 RBC-2.79* Hgb-7.9* Hct-25.0\nMCV-90 MCH-28.2 MCHC-31.4 RDW-16.7 Plt Ct-451\n1990-7-25 04:03AM BLOOD WBC-7.6 RBC-2.94 Hgb-8.', '4* Hct-26.7\nMCV-91 MCH-28.7 MCHC-31.7 RDW-18.0 Plt Ct-508\n1978-3-1 04:40AM BLOOD WBC-10.1 RBC-2.80 Hgb-7.8* Hct-24.6\nMCV-88 MCH-27.9 MCHC-31.7 RDW-16.6 Plt Ct-477\n2022-9-3 05:00AM BLOOD WBC-15.5 RBC-2.97* Hgb-8.5* Hct-26.7\nMCV-90 MCH-28.6 MCHC-31.8 RDW-17.4 Plt Ct-578\n1902-9-17 04:42AM BLOOD WBC-18.8 RBC-3.15* Hgb-9.3* Hct-29.0\nMCV-92 MCH-29.5 MCHC-32.2 RDW-16.5 Plt Ct-590\n1997-1-19 04:10AM BLOOD WBC-14.4 RBC-3.40* Hgb-9.5* Hct-30.5\nMCV-90 MCH-28.0 MCHC-31.2 RDW-15.2 Plt Ct-499\n2007-8-24 04:19AM BLOOD WBC-11.6* RBC-3.31* Hgb-9.4* Hct-28.7\nMCV-87 MCH-28.4 MCHC-32.8 RDW-15.1 Plt Ct-427\n1909-2-18 03:45AM BLOOD WBC-9.7 RBC-3.31 Hgb-9.7* Hct-29.2\nMCV-88 MCH-29.3 MCHC-33.2 RDW-15.9 Plt Ct-363\n1959-11-1 05:43AM BLOOD WBC-12.2* RBC-3.21* Hgb-9.2* Hct-28.0\nMCV-87 MCH-28.6 MCHC-32.', '7 RDW-14.7 Plt Ct-315#\n1975-7-6 02:53AM BLOOD WBC-9.1 RBC-2.97 Hgb-8.7* Hct-26.3\nMCV-89 MCH-29.3 MCHC-33.1 RDW-15.4 Plt Ct-201\n1963-4-17 03:56AM BLOOD WBC-11.1 RBC-3.13* Hgb-9.1* Hct-27.5\nMCV-88 MCH-29.0 MCHC-33.1 RDW-15.1 Plt Ct-200\n1900-2-23 03:22AM BLOOD WBC-13.6 RBC-3.18* Hgb-9.2* Hct-28.5\nMCV-89 MCH-28.9 MCHC-32.3 RDW-15.1 Plt Ct-214\n1950-10-2 04:57AM BLOOD WBC-15.7 RBC-3.55* Hgb-9.9* Hct-32.1\nMCV-90 MCH-27.8 MCHC-30.8 RDW-14.0 Plt Ct-277\n1924-1-4 04:58AM BLOOD WBC-10.9 RBC-3.65* Hgb-10.8* Hct-34.9\nMCV-95 MCH-29.5 MCHC-30.9 RDW-14.8 Plt Ct-209\n1946-5-31 02:10PM BLOOD WBC-11.5* RBC-3.76* Hgb-10.9* Hct-35.4\nMCV-94 MCH-29.1 MCHC-30.9 RDW-14.9 Plt Ct-201\n1979-4-12 10:00AM BLOOD WBC-13.5* RBC-4.20 Hgb-12.2 Hct-39.6\nMCV-94 MCH-29.1 MCHC-30.9* RDW-14.2 Plt Ct-251\n1979-4-12 10:00AM BLOOD Neuts-57 Bands-32* Lymphs-7* Monos-4\nEos-0 Baso-0 Atyps-0 Metas-0 Myelos-0\n1979-4-12 04:07PM BLOOD PT-14.', '4* PTT-24.3 INR(PT)-1.3\n1986-7-28 05:00AM BLOOD Glucose-91 UreaN-14 Creat-0.3* Na-139\nK-4.3 Cl-110* HCO3-26 AnGap-7\n1990-7-25 04:03AM BLOOD Glucose-103 UreaN-15 Creat-0.4 Na-139\nK-4.5 Cl-109 HCO3-25 AnGap-10\n1978-3-1 04:40AM BLOOD Glucose-116* UreaN-17 Creat-0.5 Na-140\nK-3.7 Cl-110* HCO3-24 AnGap-10\n2022-9-3 05:00AM BLOOD Glucose-119* UreaN-20 Creat-0.5 Na-139\nK-3.9 Cl-109* HCO3-23 AnGap-11\n1902-9-17 03:21PM BLOOD Glucose-111* UreaN-18 Creat-0.6 Na-141\nK-4.8 Cl-111* HCO3-25 AnGap-10\n1902-9-17 04:42AM BLOOD Glucose-110* UreaN-16 Creat-0.5 Na-137\nK-4.2 Cl-108 HCO3-27 AnGap-6\n1997-1-19 04:10AM BLOOD Glucose-108 UreaN-10 Creat-0.4 Na-140\nK-4.2 Cl-108 HCO3-24 AnGap-12\n2007-8-24 04:19AM BLOOD Glucose-97 UreaN-12 Creat-0.5 Na-140\nK-3.9 Cl-109* HCO3-26 AnGap-9\n1909-2-18 07:35PM BLOOD Glucose-62* UreaN-12 Creat-0.', '4 Na-141\nK-4.0 Cl-110* HCO3-26 AnGap-9\n1909-2-18 03:45AM BLOOD Glucose-49* UreaN-14 Creat-0.4 Na-140\nK-3.5 Cl-111* HCO3-23 AnGap-10\n1959-11-1 05:43AM BLOOD Glucose-126* UreaN-15 Creat-0.5 Na-140\nK-3.9 Cl-111* HCO3-21* AnGap-12\n1975-7-6 02:53AM BLOOD Glucose-81 UreaN-22* Creat-0.5 Na-140\nK-3.7 Cl-114* HCO3-21* AnGap-9\n1963-4-17 12:15AM BLOOD K-4.2\n1900-2-23 06:03PM BLOOD Glucose-76 UreaN-21* Creat-0.5 Na-143\nK-3.5 Cl-117* HCO3-20* AnGap-10\n1900-2-23 03:22AM BLOOD Glucose-104 UreaN-22* Creat-0.5 Na-147\nK-3.5 Cl-120 HCO3-21* AnGap-10\n1950-10-2 05:52PM BLOOD K-4.2\n1950-10-2 04:57AM BLOOD Glucose-193* UreaN-34* Creat-0.8 Na-143\nK-3.5 Cl-115* HCO3-18* AnGap-14\n1924-1-4 08:29PM BLOOD Glucose-140* UreaN-38* Creat-0.8 Na-144\nK-4.0 Cl-114* HCO3-19* AnGap-15\n1924-1-4 12:57AM BLOOD Glucose-109* UreaN-42* Creat-0.', '7 Na-153\nK-4.0 Cl-123 HCO3-24 AnGap-10\n1946-5-31 08:59PM BLOOD Glucose-161* UreaN-42* Creat-0.7 Na-156\nK-4.1 Cl-124 HCO3-25 AnGap-11\n1946-5-31 02:10PM BLOOD Glucose-92 UreaN-47* Creat-0.8 Na-163\nK-4.5 Cl-130 HCO3-28 AnGap-10\n1946-5-31 04:08AM BLOOD Glucose-235* UreaN-53* Creat-1.0 Na-168\nK-4.3 Cl-130 HCO3-31* AnGap-11\n1979-4-12 11:54PM BLOOD Glucose-61* UreaN-56* Creat-1.0 Na-169\nK-3.2 Cl-132* HCO3-32* AnGap-8\n1979-4-12 08:58PM BLOOD Glucose-184* UreaN-55* Creat-1.1 Na-170\nK-3.1 Cl-131* HCO3-30* AnGap-12\n1979-4-12 04:07PM BLOOD Glucose-399* UreaN-55* Creat-1.1 Na-167\nK-4.0 Cl-131 HCO3-30* AnGap-10\n1979-4-12 10:00AM BLOOD Glucose-427* UreaN-53* Creat-1.2* Na-167\nK-4.1 Cl-127 HCO3-29 AnGap-15\n1902-9-17 09:10PM BLOOD CK(CPK)-94\n1902-9-17 03:21PM BLOOD CK(CPK)-80\n1924-1-4 04:58AM BLOOD CK(CPK)-151\n1946-5-31 08:59PM BLOOD CK(CPK)-176\n1946-5-31 02:10PM BLOOD CK(CPK)-214\n1979-4-12 04:07PM BLOOD CK(CPK)-206\n1979-4-12 10:00AM BLOOD ALT-11 AST-15 LD(LDH)-227 CK(CPK)-205\nAlkPhos-119 TotBili-0.', '4\n1902-9-17 09:10PM BLOOD CK-MB-6 cTropnT-0.04\n1902-9-17 03:21PM BLOOD CK-MB-8 cTropnT-0.06\n1924-1-4 04:58AM BLOOD CK-MB-4 cTropnT-0.04\n1946-5-31 08:59PM BLOOD CK-MB-4 cTropnT-0.06\n1946-5-31 02:10PM BLOOD CK-MB-4 cTropnT-0.08\n1990-7-25 04:03AM BLOOD Calcium-7.7 Phos-3.8 Mg-2.1\n1978-3-1 04:40AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7\n2022-9-3 05:00AM BLOOD Calcium-7.9* Phos-2.5# Mg-2.0\n1902-9-17 03:21PM BLOOD Calcium-8.1 Phos-5.2* Mg-2.3\n1997-1-19 04:10AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.9\n2007-8-24 04:19AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.7\n1979-4-12 04:07PM BLOOD Osmolal-369\n1950-10-2 01:43PM BLOOD Cortsol-29.3\n1950-10-2 01:04PM BLOOD Cortsol-25.1\n1950-10-2 12:15PM BLOOD Cortsol-18.4\n1986-7-28 05:16AM BLOOD Type-ART pO2-111 pCO2-38 pH-7.43\ncalHCO3-26 Base XS-0\n1990-7-25 04:53PM BLOOD Type-ART Temp-36.', '6 PEEP-5 pO2-88 pCO2-34\npH-7.45 calHCO3-24 Base XS-0 Intubat-INTUBATED\n1978-3-1 07:09PM BLOOD Type-ART Temp-36.9 Rates-/24 PEEP-5\nFiO2-40 pO2-80 pCO2-32* pH-7.47* calHCO3-24 Base XS-0\nIntubat-INTUBATED\n1978-3-1 10:40AM BLOOD Type-ART Temp-35.0 Rates-/20 PEEP-5\nFiO2-40 pO2-65* pCO2-30* pH-7.47* calHCO3-22 Base XS-0\nIntubat-INTUBATED\n1978-3-1 04:54AM BLOOD Type-ART Temp-37.4 Rates-/14 Tidal V-400\nPEEP-5 FiO2-40 pO2-67* pCO2-32* pH-7.49* calHCO3-25 Base XS-1\nIntubat-INTUBATED\n2022-9-3 10:19PM BLOOD Type-ART Temp-37.2 pO2-65* pCO2-30\npH-7.50 calHCO3-24 Base XS-0\n2022-9-3 03:48PM BLOOD Type-ART Temp-37.3 Rates-/20 Tidal V-330\nPEEP-5 FiO2-40 pO2-97 pCO2-32* pH-7.48* calHCO3-25 Base XS-0\nIntubat-INTUBATED Comment-PS 10\n2022-9-3 01:10PM BLOOD Type-ART Temp-36.6 Rates-/12 Tidal V-500\nPEEP-5 FiO2-40 pO2-108* pCO2-28* pH-7.', '54* calHCO3-25 Base XS-3\nIntubat-INTUBATED Vent-SPONTANEOU\n1902-9-17 08:08PM BLOOD Type-ART Temp-38.0 Rates-16/ Tidal V-500\nPEEP-5 FiO2-60 pO2-78* pCO2-30* pH-7.45 calHCO3-21 Base XS--1\n-ASSIST/CON Intubat-INTUBATED\n1902-9-17 04:50PM BLOOD Type-ART Temp-36.1 Rates-20/0 Tidal V-500\nPEEP-8 FiO2-60 pO2-83* pCO2-31* pH-7.45 calHCO3-22 Base XS-0\n-ASSIST/CON Intubat-INTUBATED\n1924-1-4 03:29PM BLOOD Type-ART Temp-36.2 O2 Flow-6 pO2-72\npCO2-33 pH-7.40 calHCO3-21 Base XS--2 Intubat-NOT INTUBA\n1979-4-12 04:11PM BLOOD Type-ART pO2-128* pCO2-48* pH-7.37\ncalHCO3-29 Base XS-2 Intubat-NOT INTUBA\n1979-4-12 10:04AM BLOOD Type-ART Temp-37.9 pO2-65* pCO2-45\npH-7.45 calHCO3-32* Base XS-6\n1902-9-17 03:38PM BLOOD Lactate-1.5\n1924-1-4 04:32PM BLOOD Lactate-3.0\n1979-4-12 10:04AM BLOOD Lactate-3.0\n1902-9-17 04:48PM BLOOD O2 Sat-69\n1986-7-28 05:16AM BLOOD freeCa-1.', '19\n\nBrief Hospital Course:\nPatient was admitted with hypernatremia and acute mental status\nchanges and right sided paralysis. Her corrected sodium on\nadmission was about 170s and her free water deficit was 5.5L.\nShe was volume repleted with normal saline. She also recieved\nD51/4 NS for free water repletion initially and this was changed\nto free water boluses through nasogastric tube. Her sodium\ngradually trended down with free water repletion. She also was\nin pre-renal renal failure and her creatinine trended down with\nhydration.\n\nWith regards to the acute mental changes, this is partially\nexplained by the hypernatrmic state. However, she was also noted\nby the nursing home to have right sided weakness. CT head was\nperformed on admission which was negative for stoke. Neurology\nwas consulted and found that she has a MCA territory stroke by\nexam.', ' A repeat CT head was performed on 11-27 which showed\nwatershed infarct. TTE which was also obtained did not reveal\nany thrombus.Per neurology recommendation, all her hypertensive\nmedication has been discontinued and she was started on aspirin.\n\n\nChest XRay on admission was concerning for right lower lobe\npneumonia. Her sputum culture grew MSSA for which she was on\noxacillin. Levofloxacin was also started for community acquired\npneumonia. Nasal aspirate was sent for influenza and was\nnegative. She was intubated on 1924-1-4 for increased respiratory\neffort. Her resporatory decompensation was likely from\naspiration pneumonia. She was extubated on 2007-8-24 when her\nlungs mechanic improved. However, given her depressed mental\nstatus and stroke, she was not able to clear her secretions\nwell. SHe was intubated again on 3-1 after unsuccessful attempt\nto maintain her oxygen saturation with high flow mask.', ' She\nrecieved tracheostomy and G tube and tolerated well post\nprocedure.\n\nHer nutrition status was maintained by tubefeeds and insulin\nsliding scale and NPH kept her glucose within range.\n\nHer blood pressure was initially low on admission. This\nresponded well to hydration and brief use of levophed. Her Hui\nstimulation test was responsive. Admission EKG showed ST\ndepression in V2-V3 and it was unsure if this is old. She had\nslightly elevated troponin, likely from acute renal failure\nwhich eventually trending down.\n\nPlastic surgery was consulted for decubitus ulcer. No\ndebridement was indicated and their recommendation was to\nmaxmize nutrition, wet to dry dressing and tight glucose\ncontrol.\n\nShe remained on sc heparin, lansoprazole, pneumoboots and bowel\nregimen as part of her porphylaxis. She had picc line placed\nupon discharge\n\nTHere had been multiple discussion with her daughter, which is\nher health care proxy regarding code status.', ' It was felt by the\nmedical team that her condition will not likely improve despite\noptimal medical treatment. However, due to religious reasons,\nher family remained steadfast that everything should be done.\nHowever, her family agrees that should she go into cardiac\narrest, there should be no chest compression or defibrillation.\n\nMedications on Admission:\ncoumadin-d/c 2016-11-18\nASA 81 QD\nCalcium/vit D Farmer, Soto and Boyer Health System\nenalapril 1.25 QD\nmetorpolol 12.5 Farmer, Soto and Boyer Health System\nsorbitol 30ml QD\ntylenol\n\nNKDA\n\nDischarge Medications:\n1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)\nml Injection TID (3 times a day).\n2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\n3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).', '\n4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY\n(Daily).\n5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day).\n6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID\n(2 times a day).\n7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3\ntimes a day).\n8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\nday) as needed.\n9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)\nas needed.\n10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six\n(6) Puff Inhalation Q4H (every 4 hours).\n11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One\n(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).\n12. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical\nFarmer, Soto and Boyer Health System (2 times a day).\n13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every\n4 hours) as needed.', '\n14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN\n10ml NS followed by 1ml of 100 Units/ml heparin (100 units\nheparin) each lumen Daily and PRN. Inspect site every shift\n15. Insulin NPH Human Recomb Subcutaneous\n16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times\na day).\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nFry, Smith and Harrison Hospital - 283 Nelson Cliff\nPort Daniel, VI 92297\n\nDischarge Diagnosis:\n1. MRSA pneumonia\n2. hypernatremia\n3. acute renal failure\n4. Left MCA territory watershed infarct\n5. decubitus ulcer\n\n\nDischarge Condition:\nstable\n\nDischarge Instructions:\nYou will be discharged to rehabilitation center. Please let the\nmedical staff knows if you have any concerns at all.\n\n\nFollowup Instructions:\nYour care will be transferred to the rehabilitation center.', '\n\n\n\nCompleted by:1939-11-10']
8	31502	125483.0	2174-06-09	Discharge summary	Report	Admission Date: [2174-5-29] Discharge Date: [2174-6-9] Date of Birth: [2093-11-17] Sex: F Service: MEDICINE Allergies: Atorvastatin Attending:[First Name3 (LF) 134] Chief Complaint: cough, SOB Major Surgical or Invasive Procedure: RIJ placed Hemodialysis History of Present Illness: Pt is an 80F with a history of severe AS, CAD, s/p nephrectomy for RCC with ESRD recently started on HD and recent admission to [Hospital1 18] for cough [Date range (1) 135] p/w cough. Today she woke up from sleep with acute shortness of breath and cough. NO Chest pain. Husband called 911. In the ER, afebrile HR 120s, SBP 110s. CXR with ? PNA. She was given ceftriaxone 1 gram and levofloxacin 750mg IV X1. Given continued resp distress intubated (rocuronium and etomidate). On presentation to the CCU pt intubated unable to provide history. Per husbandpt has had a severe cough since discharge from hosp productive for clear sputum. Overall has had a cough for ~3 mos (had been treated for PNA X2 most recently [2174-5-15]). She saw her cardiologist and who stopped her ramipril and switched her to losartan 1 day PTA. She has not had any fevers, nausea, vomiting or diaphoresis. Of note she had aoritc valvuloplasty on [2174-5-10] (initially valve area 0.56cm2, gradient 27 -> after the procedure the calculated aortic valve area was 0.74 cm2 and gradient 12 mmHg.) Pt has been on dialysis in the past but with improvement in creatinine she was not dialysed on Thursday (last dialysis [2174-5-24]). Past Medical History: Percutaneous coronary intervention, in [2171] anatomy as follows: -- LMCA clean -- LAD: mild disease -- LCX: mild disease with origin OM1 and OM2 60-70% stenosis -- RCA: ulcerated 50% proximal plaque w/ mild disease -- severe AS: [Location (un) 109] 0.8 cm2, peak gradient 50 -- EF 60% . Other Past History: -- severe AS: cardiac investigation in [State 108] by [First Name8 (NamePattern2) 110] [Last Name (NamePattern1) 111] revealed calculated [Location (un) 109] of 1.0 cm2, valve gradient of 32 mm Hg. LVEF is 45-50% with apical akinesis. She has 1+ MR. Cath at [Hospital1 ] revealed [Location (un) 109] 0.8 cm2, moderate CAD at 30-40% except for 60-70% stenosis of OM1 and OM2. Peak aortic valve gradient is 50, cardiac output is 3.2 liters/min. No signficant carotid disease. -- h/o MRSA from LLE trauma in [2173-7-14] -- chronic systolic CHF, EF 30-40% -- right nephrectomy [2165] due to renal cell carcinoma -- ESRD on hemodialysis for one month -- h/o cholelithiasis -- osteoarthritis -- herpes zoster of the right which was intracostal -- h/o H. pylori -- anemia -- h/o right inguinal herniorrhaphy in [2156] -- myositis s/p muscle biopsy at [Hospital1 112], possibly related to statin use . Social History: Social history is significant for the absence of current tobacco use. She has a 50 pack-year smoking history but stopped in [2155]. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS Gen: Elderly woman in NAD, pleasant HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 7 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal [2-17] harsh early peaking systolic murmur. Chest: No chest wall deformities, slight kyphosis. Resp were unlabored, no accessory muscle use. CTAB, slight crackles at bases. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: DP 2+ Left: DP 2+ . Pertinent Results: Percutaneous coronary intervention, in [4-/2174]: COMMENTS: 1. Limited coronary angiography demonstrated heavily calcified left main, left anterior descending and left circumflex arteries. The left circumflex had a heavily calcified proximal lesion. 2. LV ventriculography was deferred. 3. Successful Rotational atherectomy, PTCA and stenting of the proximal left circumflex artery with a Cypher (3x13mm) drug eluting stent postdilated to 3.5mm. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA Comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful rotational atherectomy, PTCA and stenting of the proximal LCX with a drug eluting stent (Cypher). . . 2D-ECHOCARDIOGRAM performed on [2174-5-20] demonstrated:The left atrium and right atrium are normal in cavity size. There is moderate symmetric left ventricular hypertrophy with normal cavity size and moderate global hypokinesis (LVEF = 30-35 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area 0.7cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-15]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Moderate symmetric left ventricular hypertrophy with moderate global hypokinesis. Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. . [2174-5-29] 03:15AM BLOOD WBC-17.0# RBC-3.46 Hgb-9.3* Hct-29.7* MCV-86 MCH-26.9* MCHC-31.3 RDW-16.0* Plt Ct-567# [2174-5-29] 03:15AM BLOOD PT-14.1 PTT-22.3 INR(PT)-1.2* [2174-5-29] 03:15AM BLOOD Glucose-337* UreaN-46* Creat-1.9* Na-138 K-4.9 Cl-104 HCO3-16* AnGap-23* [2174-5-29] 03:15AM BLOOD CK(CPK)-21* Amylase-34 [2174-5-29] 03:15AM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-[Numeric Identifier 136]* [2174-5-29] 06:58AM BLOOD Type-ART Rates-14/22 FiO2-100 pO2-127* pCO2-42 pH-7.28* calTCO2-21 Base XS--6 AADO2-558 REQ O2-91 -ASSIST/CON Intubat-INTUBATED [2174-6-3] 04:06AM BLOOD WBC-6.5 RBC-3.06* Hgb-8.3* Hct-25.4* MCV-83 MCH-27.0 MCHC-32.5 RDW-15.4 Plt Ct-193 [2174-6-3] 04:06AM BLOOD PT-16.0* PTT-39.5* INR(PT)-1.4* [2174-6-3] 04:06AM BLOOD Glucose-96 UreaN-11 Creat-2.1* Na-139 K-4.2 Cl-105 HCO3-24 AnGap-14 [2174-6-4] 06:51AM BLOOD ALT-7 AST-13 LD(LDH)-176 AlkPhos-61 TotBili-0.3 [2174-6-2] 08:20AM BLOOD calTIBC-341 VitB12-963* Folate-6.6 Ferritn-41 TRF-262 [2174-6-2] 01:40AM BLOOD Type-ART pO2-104 pCO2-35 pH-7.46* calTCO2-26 Base XS-1 . EKG on admission-Sinus tachycardia with left bundle-branch block with secondary ST-T wave abnormalities. No diagnostic change from tracing #1. . [Month/Day/Year ] on admission - The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the inferior and inferolateral walls and mild-moderate hypokinesis of the remaining segments (LVEF = 30-35%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. At least mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. There is a small, primarily anterior (?loculated) pericardial effusion without evidence of hemodynamic compromise with a prominent anterior fat pad. . [6-6] EKG - Sinus tachycardia. Left atrial abnormality. Left bundle-branch block. Left axis deviation. Secondary repolarization abnormalities. Compared to the previous tracing of [2174-6-4] heart rate has increased. Otherwise, no major change. . CXRs over the course of admission showed slowly improving pulmonary edema, no major focal consolidations were seen. . Renal US - no hydronephrosis, patent renal artery. Brief Hospital Course: # PUMP/Chronic systolic congestive heart failure: Patient presented with presumed acute exacerbation of chronic systolic heart, which has improved after ultrafiltration. [Date Range ] with EF of 30-40% unchanged from prior. She currently appears fairly euvolemic, however her fluid status has remained difficult to manage given her low ejection fraction and poor urine output. - Continued home doses of carvedilol and losartan. Were held initially for low blood pressures, but both restarted during her admission. - Hemodialysis was considered for fluid managment, but a trial of lasix proved successful. She will now go home on 160 mg PO daily lasix and follow up with Dr. [Last Name (STitle) 118], her nephrologist. She will monitor daily weights/low sodium diet, pt had nutrition consult during stay. . # CAD: No evidence ACS during hospitalization. Patient is s/p recent LCx stent. She was continued on ASA, carvedilol, plavix, and Losartan. . #. Valves. No active issues. Severe AS a/p valvuloplasty [2174-5-11], stable AS per [Month/Day/Year ]. Discussed with patient and family: per their report, patient was previously evaluated by Dr. [Name (NI) 137] in cardiac surgery and was not a candidate for valve replacment due to "calcifications." Patient may be candidate for new cath-assisted valve replacement. Also has mild MR on last [Name (NI) 113]. Pt should likely be re-evaluated after discharge. . # Respiratory distress resolved - Respiratory distress was suspected to be likely multifactorial secondary to volume overload and also PNA as supported by elevated WBC on presentation, fever, and now GNR in sputum gram stain but not growing on culture. Increased sputum overnight while afebrile, non-elevated white count likely represents resolving infection. Received monotherapy with ceftazadime only given GNR in sputum may be pseudomonas; antibiotics started [5-29], continued for 7 days. She will continue lasix as outpatient to try and prevent pulm edema. . # ANEMIA/GIB: HCT drop was noted several two days into admission, unclear if represented true blood loss. NGT removed [5-31] and this demonstrated frank dark blood (+hemoccult) in NGT, likely representing bleed several days ago from gastritis. LDH and haptoglobin were checked with HCT drop and were within normal limits which is inconsistent with hemolysis. She received 1 u PRBCs soon after admission, and HCT has remained stable since. Her Hcts were between 26 and 28. Stools were checked for guiac, and were positive two days prior to dicharge. We discharged her home with protonix and recommend follow up with her PCP to continue to monitor CBCs for watch for blood loss. She is not actively losing blood as seen by her stable Hcts. We also recommend an outpatient colonoscopy. Although, she needs to be very careful with the bowel prep, as that can cause large fluid shifts and drive her into pulmonary edema. . # Acute on chronic renal failure (stable Cr): Acute on chronic renal failure likely due to ATN secondary to hypotension versus ongoing pre-renal state. Patient had been initiated on HD in [2174-3-15]; was taken off HD ~1 week prior to admission. Volume overload/CHF on admission, improved with UF, now appears euvolemic. Creatinine 1.... on discharge. Pt has history of RCC with nephrectomy. Renal function has seemed to normalize. Will continue follow up with nephrologist and he will also coordinate removal of dialysis catheter. # Pt was discharge to home with services for PT and home health care for dialysis catheter dressing changes. Medications on Admission: Aspirin 325 mg PO daily Carvedilol 3.125 mg PO BID Clopidogrel 75 mg PO daily Losartan (switched from ramipril 5 mg on [2174-5-27]) B Complex-Vitamin C-Folic Acid 1 mg daily Calcium Acetate 667 mg Capsule 1 po tid Fexofenadine 60 mg daily Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-15] Sprays Nasal QID Discharge Medications: . 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-15] Drops Ophthalmic PRN (as needed). 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 0.5-1 Tablet PO every four (4) hours as needed. Disp:30 Tablet(s) Refills:0 7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 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. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:0 12. Furosemide 40 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnoses: 1. Respiratory Failure 2. CHF 3. Renal Failure Secondary Diagnoses: 1. Aortic Stenosis 2. Anemia 3. HTN Discharge Condition: Stable, afebrile, pt walking with a walker, eating on her own, with a normal mental status. Discharge Instructions: You were admitted for respiratory distress due to fluid in your lungs from an acute episode of worsening heart failure. You were intubated at the time, and when you were able to breath on your own, we continued to remove fluid from your lungs with diuretics. We also are continuing to give you the medicines carvedilol and losartan for your heart failure. You also will start taking lasix daily to ensure fluid stays off your lungs. In addition, you had acute renal failure during this admission. Your kidney function improved, but you will continue to need follow up with Dr. [Last Name (STitle) 118]. You also have a dialysis catheter in your chest that will need to be taken care of by a home nurse. Dr. [Last Name (STitle) 118] will discuss removal of the catheter as an outpatient. We also found a trace amount of blood in your stool. You should meet with your PCP and discuss having a colonoscopy. Make sure to tell them you have heart failure because it does affect the bowel preparation they plan for you. Once at home, weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Call the nutritionist with any questions. Also, if you experience any worsening shortness of breath, chest pain, dizziness or fainting or any other worrisome symptoms, do not hesitate to call your doctor or call 911 in case of emergency. Completed by:[2174-6-14]	Admission Date: <Date>2012-6-6</Date> Discharge Date: <Date>1927-4-29</Date> Date of Birth: <Date>1999-8-24</Date> Sex: F Service: MEDICINE Allergies: Atorvastatin Attending:<Name>Han</Name> Chief Complaint: cough, SOB Major Surgical or Invasive Procedure: RIJ placed Hemodialysis History of Present Illness: Pt is an 80F with a history of severe AS, CAD, s/p nephrectomy for RCC with ESRD recently started on HD and recent admission to <Hospital>Cohen PLC Medical Center</Hospital> for cough <Date Range>1990-6-17 to 2021-1-2</Date Range> p/w cough. Today she woke up from sleep with acute shortness of breath and cough. NO Chest pain. Husband called 911. In the ER, afebrile HR 120s, SBP 110s. CXR with ? PNA. She was given ceftriaxone 1 gram and levofloxacin 750mg IV X1. Given continued resp distress intubated (rocuronium and etomidate). On presentation to the CCU pt intubated unable to provide history. Per husbandpt has had a severe cough since discharge from hosp productive for clear sputum. Overall has had a cough for ~3 mos (had been treated for PNA X2 most recently <Date>2004-9-15</Date>). She saw her cardiologist and who stopped her ramipril and switched her to losartan 1 day PTA. She has not had any fevers, nausea, vomiting or diaphoresis. Of note she had aoritc valvuloplasty on <Date>1911-11-25</Date> (initially valve area 0.56cm2, gradient 27 -> after the procedure the calculated aortic valve area was 0.74 cm2 and gradient 12 mmHg.) Pt has been on dialysis in the past but with improvement in creatinine she was not dialysed on Thursday (last dialysis <Date>1967-11-26</Date>). Past Medical History: Percutaneous coronary intervention, in <Year>1904</Year> anatomy as follows: -- LMCA clean -- LAD: mild disease -- LCX: mild disease with origin OM1 and OM2 60-70% stenosis -- RCA: ulcerated 50% proximal plaque w/ mild disease -- severe AS: <Location>331 Vanessa Mill North Miguel, PR 82709</Location> 0.8 cm2, peak gradient 50 -- EF 60% . Other Past History: -- severe AS: cardiac investigation in <State>Vermont</State> by <Name>Demetrius</Name> <Name>Benhamou</Name> revealed calculated <Location>331 Vanessa Mill North Miguel, PR 82709</Location> of 1.0 cm2, valve gradient of 32 mm Hg. LVEF is 45-50% with apical akinesis. She has 1+ MR. Cath at <Hospital>Poole, Barton and Watson Clinic</Hospital> revealed <Location>331 Vanessa Mill North Miguel, PR 82709</Location> 0.8 cm2, moderate CAD at 30-40% except for 60-70% stenosis of OM1 and OM2. Peak aortic valve gradient is 50, cardiac output is 3.2 liters/min. No signficant carotid disease. -- h/o MRSA from LLE trauma in <Date>1977-6-6</Date> -- chronic systolic CHF, EF 30-40% -- right nephrectomy <Year>1904</Year> due to renal cell carcinoma -- ESRD on hemodialysis for one month -- h/o cholelithiasis -- osteoarthritis -- herpes zoster of the right which was intracostal -- h/o H. pylori -- anemia -- h/o right inguinal herniorrhaphy in <Year>1904</Year> -- myositis s/p muscle biopsy at <Hospital>Brown PLC Hospital</Hospital>, possibly related to statin use . Social History: Social history is significant for the absence of current tobacco use. She has a 50 pack-year smoking history but stopped in <Year>1904</Year>. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS Gen: Elderly woman in NAD, pleasant HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 7 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal <Date>1-21</Date> harsh early peaking systolic murmur. Chest: No chest wall deformities, slight kyphosis. Resp were unlabored, no accessory muscle use. CTAB, slight crackles at bases. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: DP 2+ Left: DP 2+ . Pertinent Results: Percutaneous coronary intervention, in <Date>3-1948</Date>: COMMENTS: 1. Limited coronary angiography demonstrated heavily calcified left main, left anterior descending and left circumflex arteries. The left circumflex had a heavily calcified proximal lesion. 2. LV ventriculography was deferred. 3. Successful Rotational atherectomy, PTCA and stenting of the proximal left circumflex artery with a Cypher (3x13mm) drug eluting stent postdilated to 3.5mm. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA Comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful rotational atherectomy, PTCA and stenting of the proximal LCX with a drug eluting stent (Cypher). . . 2D-ECHOCARDIOGRAM performed on <Date>1953-11-20</Date> demonstrated:The left atrium and right atrium are normal in cavity size. There is moderate symmetric left ventricular hypertrophy with normal cavity size and moderate global hypokinesis (LVEF = 30-35 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area 0.7cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate (<Date>4-22</Date>+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Moderate symmetric left ventricular hypertrophy with moderate global hypokinesis. Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. . <Date>2012-6-6</Date> 03:15AM BLOOD WBC-17.0# RBC-3.46 Hgb-9.3* Hct-29.7* MCV-86 MCH-26.9* MCHC-31.3 RDW-16.0* Plt Ct-567# <Date>2012-6-6</Date> 03:15AM BLOOD PT-14.1 PTT-22.3 INR(PT)-1.2* <Date>2012-6-6</Date> 03:15AM BLOOD Glucose-337* UreaN-46* Creat-1.9* Na-138 K-4.9 Cl-104 HCO3-16* AnGap-23* <Date>2012-6-6</Date> 03:15AM BLOOD CK(CPK)-21* Amylase-34 <Date>2012-6-6</Date> 03:15AM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-<Numeric Identifier>3367275</Numeric Identifier>* <Date>2012-6-6</Date> 06:58AM BLOOD Type-ART Rates-14/22 FiO2-100 pO2-127* pCO2-42 pH-7.28* calTCO2-21 Base XS--6 AADO2-558 REQ O2-91 -ASSIST/CON Intubat-INTUBATED <Date>1956-3-29</Date> 04:06AM BLOOD WBC-6.5 RBC-3.06* Hgb-8.3* Hct-25.4* MCV-83 MCH-27.0 MCHC-32.5 RDW-15.4 Plt Ct-193 <Date>1956-3-29</Date> 04:06AM BLOOD PT-16.0* PTT-39.5* INR(PT)-1.4* <Date>1956-3-29</Date> 04:06AM BLOOD Glucose-96 UreaN-11 Creat-2.1* Na-139 K-4.2 Cl-105 HCO3-24 AnGap-14 <Date>1962-8-21</Date> 06:51AM BLOOD ALT-7 AST-13 LD(LDH)-176 AlkPhos-61 TotBili-0.3 <Date>1917-3-10</Date> 08:20AM BLOOD calTIBC-341 VitB12-963* Folate-6.6 Ferritn-41 TRF-262 <Date>1917-3-10</Date> 01:40AM BLOOD Type-ART pO2-104 pCO2-35 pH-7.46* calTCO2-26 Base XS-1 . EKG on admission-Sinus tachycardia with left bundle-branch block with secondary ST-T wave abnormalities. No diagnostic change from tracing #1. . <Month>March</Month> on admission - The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the inferior and inferolateral walls and mild-moderate hypokinesis of the remaining segments (LVEF = 30-35%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. At least mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. There is a small, primarily anterior (?loculated) pericardial effusion without evidence of hemodynamic compromise with a prominent anterior fat pad. . <Date>10-13</Date> EKG - Sinus tachycardia. Left atrial abnormality. Left bundle-branch block. Left axis deviation. Secondary repolarization abnormalities. Compared to the previous tracing of <Date>1962-8-21</Date> heart rate has increased. Otherwise, no major change. . CXRs over the course of admission showed slowly improving pulmonary edema, no major focal consolidations were seen. . Renal US - no hydronephrosis, patent renal artery. Brief Hospital Course: # PUMP/Chronic systolic congestive heart failure: Patient presented with presumed acute exacerbation of chronic systolic heart, which has improved after ultrafiltration. <Date Range>1931-4-17 to 2018-3-18</Date Range> with EF of 30-40% unchanged from prior. She currently appears fairly euvolemic, however her fluid status has remained difficult to manage given her low ejection fraction and poor urine output. - Continued home doses of carvedilol and losartan. Were held initially for low blood pressures, but both restarted during her admission. - Hemodialysis was considered for fluid managment, but a trial of lasix proved successful. She will now go home on 160 mg PO daily lasix and follow up with Dr. <Name>Gauthier</Name>, her nephrologist. She will monitor daily weights/low sodium diet, pt had nutrition consult during stay. . # CAD: No evidence ACS during hospitalization. Patient is s/p recent LCx stent. She was continued on ASA, carvedilol, plavix, and Losartan. . #. Valves. No active issues. Severe AS a/p valvuloplasty <Date>1943-8-10</Date>, stable AS per <Month>March</Month>. Discussed with patient and family: per their report, patient was previously evaluated by Dr. <Name>German Scheet</Name> in cardiac surgery and was not a candidate for valve replacment due to "calcifications." Patient may be candidate for new cath-assisted valve replacement. Also has mild MR on last <Name>Alyssa Ignacio</Name>. Pt should likely be re-evaluated after discharge. . # Respiratory distress resolved - Respiratory distress was suspected to be likely multifactorial secondary to volume overload and also PNA as supported by elevated WBC on presentation, fever, and now GNR in sputum gram stain but not growing on culture. Increased sputum overnight while afebrile, non-elevated white count likely represents resolving infection. Received monotherapy with ceftazadime only given GNR in sputum may be pseudomonas; antibiotics started <Date>2-14</Date>, continued for 7 days. She will continue lasix as outpatient to try and prevent pulm edema. . # ANEMIA/GIB: HCT drop was noted several two days into admission, unclear if represented true blood loss. NGT removed <Date>4-6</Date> and this demonstrated frank dark blood (+hemoccult) in NGT, likely representing bleed several days ago from gastritis. LDH and haptoglobin were checked with HCT drop and were within normal limits which is inconsistent with hemolysis. She received 1 u PRBCs soon after admission, and HCT has remained stable since. Her Hcts were between 26 and 28. Stools were checked for guiac, and were positive two days prior to dicharge. We discharged her home with protonix and recommend follow up with her PCP to continue to monitor CBCs for watch for blood loss. She is not actively losing blood as seen by her stable Hcts. We also recommend an outpatient colonoscopy. Although, she needs to be very careful with the bowel prep, as that can cause large fluid shifts and drive her into pulmonary edema. . # Acute on chronic renal failure (stable Cr): Acute on chronic renal failure likely due to ATN secondary to hypotension versus ongoing pre-renal state. Patient had been initiated on HD in <Date>2010-11-18</Date>; was taken off HD ~1 week prior to admission. Volume overload/CHF on admission, improved with UF, now appears euvolemic. Creatinine 1.... on discharge. Pt has history of RCC with nephrectomy. Renal function has seemed to normalize. Will continue follow up with nephrologist and he will also coordinate removal of dialysis catheter. # Pt was discharge to home with services for PT and home health care for dialysis catheter dressing changes. Medications on Admission: Aspirin 325 mg PO daily Carvedilol 3.125 mg PO BID Clopidogrel 75 mg PO daily Losartan (switched from ramipril 5 mg on <Date>1907-4-2</Date>) B Complex-Vitamin C-Folic Acid 1 mg daily Calcium Acetate 667 mg Capsule 1 po tid Fexofenadine 60 mg daily Sodium Chloride 0.65 % Aerosol, Spray Sig: <Date>4-22</Date> Sprays Nasal QID Discharge Medications: . 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: <Date>4-22</Date> Drops Ophthalmic PRN (as needed). 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 0.5-1 Tablet PO every four (4) hours as needed. Disp:30 Tablet(s) Refills:0 7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 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. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:0 12. Furosemide 40 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: <Hospital>Lewis-Brown Medical Center</Hospital> Homecare Discharge Diagnosis: Primary Diagnoses: 1. Respiratory Failure 2. CHF 3. Renal Failure Secondary Diagnoses: 1. Aortic Stenosis 2. Anemia 3. HTN Discharge Condition: Stable, afebrile, pt walking with a walker, eating on her own, with a normal mental status. Discharge Instructions: You were admitted for respiratory distress due to fluid in your lungs from an acute episode of worsening heart failure. You were intubated at the time, and when you were able to breath on your own, we continued to remove fluid from your lungs with diuretics. We also are continuing to give you the medicines carvedilol and losartan for your heart failure. You also will start taking lasix daily to ensure fluid stays off your lungs. In addition, you had acute renal failure during this admission. Your kidney function improved, but you will continue to need follow up with Dr. <Name>Gauthier</Name>. You also have a dialysis catheter in your chest that will need to be taken care of by a home nurse. Dr. <Name>Gauthier</Name> will discuss removal of the catheter as an outpatient. We also found a trace amount of blood in your stool. You should meet with your PCP and discuss having a colonoscopy. Make sure to tell them you have heart failure because it does affect the bowel preparation they plan for you. Once at home, weigh yourself every morning, <Name>Janice William</Name> MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Call the nutritionist with any questions. Also, if you experience any worsening shortness of breath, chest pain, dizziness or fainting or any other worrisome symptoms, do not hesitate to call your doctor or call 911 in case of emergency. Completed by:<Date>1956-11-16</Date>	0000000000000000011111111000000000000000000000000000000001111111110000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000011100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111110000000000011111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000>000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111000011111111101111111100000000000000000000011111111111111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111110000000000111111111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 2012-6-6 Discharge Date: 1927-4-29 Date of Birth: 1999-8-24 Sex: F Service: MEDICINE Allergies: Atorvastatin Attending:Han Chief Complaint: cough, SOB Major Surgical or Invasive Procedure: RIJ placed Hemodialysis History of Present Illness: Pt is an 80F with a history of severe AS, CAD, s/p nephrectomy for RCC with ESRD recently started on HD and recent admission to Cohen PLC Medical Center for cough 1990-6-17 to 2021-1-2 p/w cough. Today she woke up from sleep with acute shortness of breath and cough. NO Chest pain. Husband called 911. In the ER, afebrile HR 120s, SBP 110s. CXR with ? PNA. She was given ceftriaxone 1 gram and levofloxacin 750mg IV X1. Given continued resp distress intubated (rocuronium and etomidate). On presentation to the CCU pt intubated unable to provide history. Per husbandpt has had a severe cough since discharge from hosp productive for clear sputum. Overall has had a cough for ~3 mos (had been treated for PNA X2 most recently 2004-9-15). She saw her cardiologist and who stopped her ramipril and switched her to losartan 1 day PTA. She has not had any fevers, nausea, vomiting or diaphoresis. Of note she had aoritc valvuloplasty on 1911-11-25 (initially valve area 0.56cm2, gradient 27 -> after the procedure the calculated aortic valve area was 0.74 cm2 and gradient 12 mmHg.) Pt has been on dialysis in the past but with improvement in creatinine she was not dialysed on Thursday (last dialysis 1967-11-26). Past Medical History: Percutaneous coronary intervention, in 1904 anatomy as follows: -- LMCA clean -- LAD: mild disease -- LCX: mild disease with origin OM1 and OM2 60-70% stenosis -- RCA: ulcerated 50% proximal plaque w/ mild disease -- severe AS: 331 Vanessa Mill North Miguel, PR 82709 0.8 cm2, peak gradient 50 -- EF 60% . Other Past History: -- severe AS: cardiac investigation in Vermont by Demetrius Benhamou revealed calculated 331 Vanessa Mill North Miguel, PR 82709 of 1.0 cm2, valve gradient of 32 mm Hg. LVEF is 45-50% with apical akinesis. She has 1+ MR. Cath at Poole, Barton and Watson Clinic revealed 331 Vanessa Mill North Miguel, PR 82709 0.8 cm2, moderate CAD at 30-40% except for 60-70% stenosis of OM1 and OM2. Peak aortic valve gradient is 50, cardiac output is 3.2 liters/min. No signficant carotid disease. -- h/o MRSA from LLE trauma in 1977-6-6 -- chronic systolic CHF, EF 30-40% -- right nephrectomy 1904 due to renal cell carcinoma -- ESRD on hemodialysis for one month -- h/o cholelithiasis -- osteoarthritis -- herpes zoster of the right which was intracostal -- h/o H. pylori -- anemia -- h/o right inguinal herniorrhaphy in 1904 -- myositis s/p muscle biopsy at Brown PLC Hospital, possibly related to statin use . Social History: Social history is significant for the absence of current tobacco use. She has a 50 pack-year smoking history but stopped in 1904. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS Gen: Elderly woman in NAD, pleasant HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 7 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal 1-21 harsh early peaking systolic murmur. Chest: No chest wall deformities, slight kyphosis. Resp were unlabored, no accessory muscle use. CTAB, slight crackles at bases. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: DP 2+ Left: DP 2+ . Pertinent Results: Percutaneous coronary intervention, in 3-1948: COMMENTS: 1. Limited coronary angiography demonstrated heavily calcified left main, left anterior descending and left circumflex arteries. The left circumflex had a heavily calcified proximal lesion. 2. LV ventriculography was deferred. 3. Successful Rotational atherectomy, PTCA and stenting of the proximal left circumflex artery with a Cypher (3x13mm) drug eluting stent postdilated to 3.5mm. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA Comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful rotational atherectomy, PTCA and stenting of the proximal LCX with a drug eluting stent (Cypher). . . 2D-ECHOCARDIOGRAM performed on 1953-11-20 demonstrated:The left atrium and right atrium are normal in cavity size. There is moderate symmetric left ventricular hypertrophy with normal cavity size and moderate global hypokinesis (LVEF = 30-35 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area 0.7cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate (4-22+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Moderate symmetric left ventricular hypertrophy with moderate global hypokinesis. Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. . 2012-6-6 03:15AM BLOOD WBC-17.0# RBC-3.46 Hgb-9.3* Hct-29.7* MCV-86 MCH-26.9* MCHC-31.3 RDW-16.0* Plt Ct-567# 2012-6-6 03:15AM BLOOD PT-14.1 PTT-22.3 INR(PT)-1.2* 2012-6-6 03:15AM BLOOD Glucose-337* UreaN-46* Creat-1.9* Na-138 K-4.9 Cl-104 HCO3-16* AnGap-23* 2012-6-6 03:15AM BLOOD CK(CPK)-21* Amylase-34 2012-6-6 03:15AM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-3367275* 2012-6-6 06:58AM BLOOD Type-ART Rates-14/22 FiO2-100 pO2-127* pCO2-42 pH-7.28* calTCO2-21 Base XS--6 AADO2-558 REQ O2-91 -ASSIST/CON Intubat-INTUBATED 1956-3-29 04:06AM BLOOD WBC-6.5 RBC-3.06* Hgb-8.3* Hct-25.4* MCV-83 MCH-27.0 MCHC-32.5 RDW-15.4 Plt Ct-193 1956-3-29 04:06AM BLOOD PT-16.0* PTT-39.5* INR(PT)-1.4* 1956-3-29 04:06AM BLOOD Glucose-96 UreaN-11 Creat-2.1* Na-139 K-4.2 Cl-105 HCO3-24 AnGap-14 1962-8-21 06:51AM BLOOD ALT-7 AST-13 LD(LDH)-176 AlkPhos-61 TotBili-0.3 1917-3-10 08:20AM BLOOD calTIBC-341 VitB12-963* Folate-6.6 Ferritn-41 TRF-262 1917-3-10 01:40AM BLOOD Type-ART pO2-104 pCO2-35 pH-7.46* calTCO2-26 Base XS-1 . EKG on admission-Sinus tachycardia with left bundle-branch block with secondary ST-T wave abnormalities. No diagnostic change from tracing #1. . March on admission - The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the inferior and inferolateral walls and mild-moderate hypokinesis of the remaining segments (LVEF = 30-35%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. At least mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. There is a small, primarily anterior (?loculated) pericardial effusion without evidence of hemodynamic compromise with a prominent anterior fat pad. . 10-13 EKG - Sinus tachycardia. Left atrial abnormality. Left bundle-branch block. Left axis deviation. Secondary repolarization abnormalities. Compared to the previous tracing of 1962-8-21 heart rate has increased. Otherwise, no major change. . CXRs over the course of admission showed slowly improving pulmonary edema, no major focal consolidations were seen. . Renal US - no hydronephrosis, patent renal artery. Brief Hospital Course: # PUMP/Chronic systolic congestive heart failure: Patient presented with presumed acute exacerbation of chronic systolic heart, which has improved after ultrafiltration. 1931-4-17 to 2018-3-18 with EF of 30-40% unchanged from prior. She currently appears fairly euvolemic, however her fluid status has remained difficult to manage given her low ejection fraction and poor urine output. - Continued home doses of carvedilol and losartan. Were held initially for low blood pressures, but both restarted during her admission. - Hemodialysis was considered for fluid managment, but a trial of lasix proved successful. She will now go home on 160 mg PO daily lasix and follow up with Dr. Gauthier, her nephrologist. She will monitor daily weights/low sodium diet, pt had nutrition consult during stay. . # CAD: No evidence ACS during hospitalization. Patient is s/p recent LCx stent. She was continued on ASA, carvedilol, plavix, and Losartan. . #. Valves. No active issues. Severe AS a/p valvuloplasty 1943-8-10, stable AS per March. Discussed with patient and family: per their report, patient was previously evaluated by Dr. German Scheet in cardiac surgery and was not a candidate for valve replacment due to "calcifications." Patient may be candidate for new cath-assisted valve replacement. Also has mild MR on last Alyssa Ignacio. Pt should likely be re-evaluated after discharge. . # Respiratory distress resolved - Respiratory distress was suspected to be likely multifactorial secondary to volume overload and also PNA as supported by elevated WBC on presentation, fever, and now GNR in sputum gram stain but not growing on culture. Increased sputum overnight while afebrile, non-elevated white count likely represents resolving infection. Received monotherapy with ceftazadime only given GNR in sputum may be pseudomonas; antibiotics started 2-14, continued for 7 days. She will continue lasix as outpatient to try and prevent pulm edema. . # ANEMIA/GIB: HCT drop was noted several two days into admission, unclear if represented true blood loss. NGT removed 4-6 and this demonstrated frank dark blood (+hemoccult) in NGT, likely representing bleed several days ago from gastritis. LDH and haptoglobin were checked with HCT drop and were within normal limits which is inconsistent with hemolysis. She received 1 u PRBCs soon after admission, and HCT has remained stable since. Her Hcts were between 26 and 28. Stools were checked for guiac, and were positive two days prior to dicharge. We discharged her home with protonix and recommend follow up with her PCP to continue to monitor CBCs for watch for blood loss. She is not actively losing blood as seen by her stable Hcts. We also recommend an outpatient colonoscopy. Although, she needs to be very careful with the bowel prep, as that can cause large fluid shifts and drive her into pulmonary edema. . # Acute on chronic renal failure (stable Cr): Acute on chronic renal failure likely due to ATN secondary to hypotension versus ongoing pre-renal state. Patient had been initiated on HD in 2010-11-18; was taken off HD ~1 week prior to admission. Volume overload/CHF on admission, improved with UF, now appears euvolemic. Creatinine 1.... on discharge. Pt has history of RCC with nephrectomy. Renal function has seemed to normalize. Will continue follow up with nephrologist and he will also coordinate removal of dialysis catheter. # Pt was discharge to home with services for PT and home health care for dialysis catheter dressing changes. Medications on Admission: Aspirin 325 mg PO daily Carvedilol 3.125 mg PO BID Clopidogrel 75 mg PO daily Losartan (switched from ramipril 5 mg on 1907-4-2) B Complex-Vitamin C-Folic Acid 1 mg daily Calcium Acetate 667 mg Capsule 1 po tid Fexofenadine 60 mg daily Sodium Chloride 0.65 % Aerosol, Spray Sig: 4-22 Sprays Nasal QID Discharge Medications: . 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 4-22 Drops Ophthalmic PRN (as needed). 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 0.5-1 Tablet PO every four (4) hours as needed. Disp:30 Tablet(s) Refills:0 7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 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. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:0 12. Furosemide 40 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Lewis-Brown Medical Center Homecare Discharge Diagnosis: Primary Diagnoses: 1. Respiratory Failure 2. CHF 3. Renal Failure Secondary Diagnoses: 1. Aortic Stenosis 2. Anemia 3. HTN Discharge Condition: Stable, afebrile, pt walking with a walker, eating on her own, with a normal mental status. Discharge Instructions: You were admitted for respiratory distress due to fluid in your lungs from an acute episode of worsening heart failure. You were intubated at the time, and when you were able to breath on your own, we continued to remove fluid from your lungs with diuretics. We also are continuing to give you the medicines carvedilol and losartan for your heart failure. You also will start taking lasix daily to ensure fluid stays off your lungs. In addition, you had acute renal failure during this admission. Your kidney function improved, but you will continue to need follow up with Dr. Gauthier. You also have a dialysis catheter in your chest that will need to be taken care of by a home nurse. Dr. Gauthier will discuss removal of the catheter as an outpatient. We also found a trace amount of blood in your stool. You should meet with your PCP and discuss having a colonoscopy. Make sure to tell them you have heart failure because it does affect the bowel preparation they plan for you. Once at home, weigh yourself every morning, Janice William MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Call the nutritionist with any questions. Also, if you experience any worsening shortness of breath, chest pain, dizziness or fainting or any other worrisome symptoms, do not hesitate to call your doctor or call 911 in case of emergency. Completed by:1956-11-16	['Admission Date: 2012-6-6 Discharge Date: 1927-4-29\n\nDate of Birth: 1999-8-24 Sex: F\n\nService: MEDICINE\n\nAllergies:\nAtorvastatin\n\nAttending:Han\nChief Complaint:\ncough, SOB\n\nMajor Surgical or Invasive Procedure:\nRIJ placed\nHemodialysis\n\n\nHistory of Present Illness:\nPt is an 80F with a history of severe AS, CAD, s/p nephrectomy\nfor RCC with ESRD recently started on HD and recent admission to\nCohen PLC Medical Center for cough 1990-6-17 to 2021-1-2 p/w cough. Today she woke up from\nsleep with acute shortness of breath and cough. NO Chest pain.\nHusband called 911. In the ER, afebrile HR 120s, SBP 110s. CXR\nwith ? PNA. She was given ceftriaxone 1 gram and levofloxacin\n750mg IV X1. Given continued resp distress intubated (rocuronium\nand etomidate).\nOn presentation to the CCU pt intubated unable to provide\nhistory.', ' Per husbandpt has had a severe cough since discharge\nfrom hosp productive for clear sputum. Overall has had a cough\nfor ~3 mos (had been treated for PNA X2 most recently 2004-9-15).\nShe saw her cardiologist and who stopped her ramipril and\nswitched her to losartan 1 day PTA. She has not had any fevers,\nnausea, vomiting or diaphoresis. Of note she had aoritc\nvalvuloplasty on 1911-11-25 (initially valve area 0.56cm2, gradient\n27 -> after the procedure the calculated aortic valve area was\n0.74 cm2 and gradient 12 mmHg.) Pt has been on dialysis in the\npast but with improvement in creatinine she was not dialysed on\nThursday (last dialysis 1967-11-26).\n\n\nPast Medical History:\nPercutaneous coronary intervention, in 1904 anatomy as follows:\n-- LMCA clean\n-- LAD: mild disease\n-- LCX: mild disease with origin OM1 and OM2 60-70% stenosis\n-- RCA: ulcerated 50% proximal plaque w/ mild disease\n-- severe AS: 331 Vanessa Mill\nNorth Miguel, PR 82709 0.', '8 cm2, peak gradient 50\n-- EF 60%\n.\nOther Past History:\n-- severe AS: cardiac investigation in Vermont by Demetrius Benhamou\nrevealed calculated 331 Vanessa Mill\nNorth Miguel, PR 82709 of 1.0 cm2, valve gradient of 32 mm Hg.\nLVEF is 45-50% with apical akinesis. She has 1+ MR. Cath at Poole, Barton and Watson Clinic\nrevealed 331 Vanessa Mill\nNorth Miguel, PR 82709 0.8 cm2, moderate CAD at 30-40% except for 60-70%\nstenosis of OM1 and OM2. Peak aortic valve gradient is 50,\ncardiac output is 3.2 liters/min. No signficant carotid\ndisease.\n-- h/o MRSA from LLE trauma in 1977-6-6\n-- chronic systolic CHF, EF 30-40%\n-- right nephrectomy 1904 due to renal cell carcinoma\n-- ESRD on hemodialysis for one month\n-- h/o cholelithiasis\n-- osteoarthritis\n-- herpes zoster of the right which was intracostal\n-- h/o H.', ' pylori\n-- anemia\n-- h/o right inguinal herniorrhaphy in 1904\n-- myositis s/p muscle biopsy at Brown PLC Hospital, possibly related to statin\nuse\n.\n\n\nSocial History:\nSocial history is significant for the absence of current tobacco\nuse. She has a 50 pack-year smoking history but stopped in 1904.\nThere is no history of alcohol abuse.\n\n\nFamily History:\nThere is no family history of premature coronary artery disease\nor sudden death.\n\nPhysical Exam:\nVS\nGen: Elderly woman in NAD, pleasant\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 7 cm.\nCV: PMI located in 5th intercostal space, midclavicular line.\nRR, normal 1-21 harsh early peaking systolic murmur.\nChest: No chest wall deformities, slight kyphosis.', ' Resp were\nunlabored, no accessory muscle use. CTAB, slight crackles at\nbases.\nAbd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\npalpation. No abdominial bruits.\nExt: No c/c/e. No femoral bruits.\nSkin: No stasis dermatitis, ulcers, scars, or xanthomas.\n.\nPulses:\nRight: DP 2+\nLeft: DP 2+\n.\n\n\nPertinent Results:\nPercutaneous coronary intervention, in 3-1948:\nCOMMENTS:\n1. Limited coronary angiography demonstrated heavily calcified\nleft\nmain, left anterior descending and left circumflex arteries. The\nleft circumflex had a heavily calcified proximal lesion.\n2. LV ventriculography was deferred.\n3. Successful Rotational atherectomy, PTCA and stenting of the\nproximal left circumflex artery with a Cypher (3x13mm) drug\neluting stent postdilated to 3.5mm. Final angiography\ndemonstrated no\nangiographically apparent dissection, no residual stenosis and\nTIMI III flow throughout the vessel (See PTCA Comments).', '\nFINAL DIAGNOSIS:\n1. One vessel coronary artery disease.\n2. Successful rotational atherectomy, PTCA and stenting of the\nproximal LCX with a drug eluting stent (Cypher).\n.\n.\n2D-ECHOCARDIOGRAM performed on 1953-11-20 demonstrated:The left\natrium and right atrium are normal in cavity size. There is\nmoderate symmetric left ventricular hypertrophy with normal\ncavity size and moderate global hypokinesis (LVEF = 30-35 %).\nRight ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets are moderately thickened. There is\nsevere aortic valve stenosis (area 0.7cm2). Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Mild to moderate\n(4-22+) mitral regurgitation is seen. [Due to acoustic shadowing,\nthe severity of mitral regurgitation may be significantly\nUNDERestimated.', '] There is mild pulmonary artery systolic\nhypertension. There is a very small circumferential pericardial\neffusion.\nIMPRESSION: Severe aortic valve stenosis. Moderate symmetric\nleft ventricular hypertrophy with moderate global hypokinesis.\nMild-moderate mitral regurgitation. Pulmonary artery systolic\nhypertension.\n.\n\n2012-6-6 03:15AM BLOOD WBC-17.0# RBC-3.46 Hgb-9.3* Hct-29.7\nMCV-86 MCH-26.9 MCHC-31.3 RDW-16.0* Plt Ct-567#\n2012-6-6 03:15AM BLOOD PT-14.1 PTT-22.3 INR(PT)-1.2\n2012-6-6 03:15AM BLOOD Glucose-337 UreaN-46* Creat-1.9* Na-138\nK-4.9 Cl-104 HCO3-16* AnGap-23\n2012-6-6 03:15AM BLOOD CK(CPK)-21 Amylase-34\n2012-6-6 03:15AM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-3367275\n2012-6-6 06:58AM BLOOD Type-ART Rates-14/22 FiO2-100 pO2-127\npCO2-42 pH-7.28* calTCO2-21 Base XS--6 AADO2-558 REQ O2-91\n-ASSIST/CON Intubat-INTUBATED\n1956-3-29 04:06AM BLOOD WBC-6.', '5 RBC-3.06* Hgb-8.3* Hct-25.4\nMCV-83 MCH-27.0 MCHC-32.5 RDW-15.4 Plt Ct-193\n1956-3-29 04:06AM BLOOD PT-16.0 PTT-39.5* INR(PT)-1.4\n1956-3-29 04:06AM BLOOD Glucose-96 UreaN-11 Creat-2.1 Na-139\nK-4.2 Cl-105 HCO3-24 AnGap-14\n1962-8-21 06:51AM BLOOD ALT-7 AST-13 LD(LDH)-176 AlkPhos-61\nTotBili-0.3\n1917-3-10 08:20AM BLOOD calTIBC-341 VitB12-963* Folate-6.6\nFerritn-41 TRF-262\n1917-3-10 01:40AM BLOOD Type-ART pO2-104 pCO2-35 pH-7.46\ncalTCO2-26 Base XS-1\n.\nEKG on admission-Sinus tachycardia with left bundle-branch block\nwith secondary ST-T wave\nabnormalities. No diagnostic change from tracing #1.\n.\nMarch on admission - The left atrium is mildly dilated. Left\nventricular wall thicknesses and cavity size are normal. There\nis mild to moderate regional left ventricular systolic\ndysfunction with near akinesis of the inferior and inferolateral\nwalls and mild-moderate hypokinesis of the remaining segments\n(LVEF = 30-35%).', ' No masses or thrombi are seen in the left\nventricle. Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets are severely\nthickened/deformed. There is moderate to severe aortic valve\nstenosis (area 0.9cm2). Mild (1+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. At least mild\n(1+) mitral regurgitation is seen. [Due to acoustic shadowing,\nthe severity of mitral regurgitation may be significantly\nUNDERestimated.] There is borderline pulmonary artery systolic\nhypertension. There is a small, primarily anterior (?loculated)\npericardial effusion without evidence of hemodynamic compromise\nwith a prominent anterior fat pad.\n.\n10-13 EKG - Sinus tachycardia. Left atrial abnormality. Left\nbundle-branch block.\nLeft axis deviation. Secondary repolarization abnormalities.', '\nCompared to the\nprevious tracing of 1962-8-21 heart rate has increased. Otherwise,\nno major\nchange.\n.\nCXRs over the course of admission showed slowly improving\npulmonary edema, no major focal consolidations were seen.\n.\nRenal US - no hydronephrosis, patent renal artery.\n\nBrief Hospital Course:\n# PUMP/Chronic systolic congestive heart failure:\nPatient presented with presumed acute exacerbation of chronic\nsystolic heart, which has improved after ultrafiltration. 1931-4-17 to 2018-3-18\nwith EF of 30-40% unchanged from prior. She currently appears\nfairly euvolemic, however her fluid status has remained\ndifficult to manage given her low ejection fraction and poor\nurine output.\n- Continued home doses of carvedilol and losartan. Were held\ninitially for low blood pressures, but both restarted during her\nadmission.', '\n- Hemodialysis was considered for fluid managment, but a trial\nof lasix proved successful. She will now go home on 160 mg PO\ndaily lasix and follow up with Dr. Gauthier, her nephrologist.\nShe will monitor daily weights/low sodium diet, pt had nutrition\nconsult during stay.\n.\n# CAD: No evidence ACS during hospitalization. Patient is s/p\nrecent LCx stent. She was continued on ASA, carvedilol, plavix,\nand Losartan.\n\n.\n#. Valves. No active issues. Severe AS a/p valvuloplasty\n1943-8-10, stable AS per March. Discussed with patient and family:\nper their report, patient was previously evaluated by Dr.\nGerman Scheet in cardiac surgery and was not a candidate for valve\nreplacment due to "calcifications." Patient may be candidate for\nnew cath-assisted valve replacement. Also has mild MR on last\nAlyssa Ignacio.', ' Pt should likely be re-evaluated after discharge.\n.\n# Respiratory distress resolved -\nRespiratory distress was suspected to be likely multifactorial\nsecondary to volume overload and also PNA as supported by\nelevated WBC on presentation, fever, and now GNR in sputum gram\nstain but not growing on culture. Increased sputum overnight\nwhile afebrile, non-elevated white count likely represents\nresolving infection. Received monotherapy with ceftazadime only\ngiven GNR in sputum may be pseudomonas; antibiotics started\n2-14, continued for 7 days. She will continue lasix as\noutpatient to try and prevent pulm edema.\n.\n# ANEMIA/GIB:\nHCT drop was noted several two days into admission, unclear if\nrepresented true blood loss. NGT removed 4-6 and this\ndemonstrated frank dark blood (+hemoccult) in NGT, likely\nrepresenting bleed several days ago from gastritis.', ' LDH and\nhaptoglobin were checked with HCT drop and were within normal\nlimits which is inconsistent with hemolysis. She received 1 u\nPRBCs soon after admission, and HCT has remained stable since.\nHer Hcts were between 26 and 28. Stools were checked for guiac,\nand were positive two days prior to dicharge. We discharged her\nhome with protonix and recommend follow up with her PCP to\ncontinue to monitor CBCs for watch for blood loss. She is not\nactively losing blood as seen by her stable Hcts. We also\nrecommend an outpatient colonoscopy. Although, she needs to be\nvery careful with the bowel prep, as that can cause large fluid\nshifts and drive her into pulmonary edema.\n.\n# Acute on chronic renal failure (stable Cr):\nAcute on chronic renal failure likely due to ATN secondary to\nhypotension versus ongoing pre-renal state.', ' Patient had been\ninitiated on HD in 2010-11-18; was taken off HD ~1 week prior to\nadmission. Volume overload/CHF on admission, improved with UF,\nnow appears euvolemic. Creatinine 1.... on discharge. Pt has\nhistory of RCC with nephrectomy. Renal function has seemed to\nnormalize. Will continue follow up with nephrologist and he\nwill also coordinate removal of dialysis catheter.\n\n# Pt was discharge to home with services for PT and home health\ncare for dialysis catheter dressing changes.\n\nMedications on Admission:\nAspirin 325 mg PO daily\nCarvedilol 3.125 mg PO BID\nClopidogrel 75 mg PO daily\nLosartan (switched from ramipril 5 mg on 1907-4-2)\nB Complex-Vitamin C-Folic Acid 1 mg daily\nCalcium Acetate 667 mg Capsule 1 po tid\nFexofenadine 60 mg daily\nSodium Chloride 0.65 % Aerosol, Spray Sig: 4-22 Sprays Nasal QID\n\n\n\nDischarge Medications:\n.', '\n1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap\nPO DAILY (Daily).\n4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times\na day).\n5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 4-22\nDrops Ophthalmic PRN (as needed).\n6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 0.5-1 Tablet\nPO every four (4) hours as needed.\nDisp:30 Tablet(s)* Refills:0\n7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2\ntimes a day).\nDisp:60 Tablet(s) Refills:2\n8. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n9. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection\nQMOWEFR (Monday -Wednesday-Friday).\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. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed.\nDisp:1 inhaler Refills:0\n12. Furosemide 40 mg Tablet Sig: Four (4) Tablet PO DAILY\n(Daily).\nDisp:120 Tablet(s) Refills:2\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nLewis-Brown Medical Center Homecare\n\nDischarge Diagnosis:\nPrimary Diagnoses:\n1. Respiratory Failure\n2. CHF\n3. Renal Failure\n\nSecondary Diagnoses:\n1. Aortic Stenosis\n2. Anemia\n3. HTN\n\n\nDischarge Condition:\nStable, afebrile, pt walking with a walker, eating on her own,\nwith a normal mental status.\n\n\nDischarge Instructions:\nYou were admitted for respiratory distress due to fluid in your\nlungs from an acute episode of worsening heart failure.', ' You\nwere intubated at the time, and when you were able to breath on\nyour own, we continued to remove fluid from your lungs with\ndiuretics. We also are continuing to give you the medicines\ncarvedilol and losartan for your heart failure.\n\nYou also will start taking lasix daily to ensure fluid stays off\nyour lungs.\n\nIn addition, you had acute renal failure during this admission.\nYour kidney function improved, but you will continue to need\nfollow up with Dr. Gauthier. You also have a dialysis catheter in\nyour chest that will need to be taken care of by a home nurse.\nDr. Gauthier will discuss removal of the catheter as an\noutpatient.\n\nWe also found a trace amount of blood in your stool. You should\nmeet with your PCP and discuss having a colonoscopy. Make sure\nto tell them you have heart failure because it does affect the\nbowel preparation they plan for you.', '\n\nOnce at home, weigh yourself every morning, Janice William MD if weight >\n3 lbs.\nAdhere to 2 gm sodium diet. Call the nutritionist with any\nquestions.\n\nAlso, if you experience any worsening shortness of breath, chest\npain, dizziness or fainting or any other worrisome symptoms, do\nnot hesitate to call your doctor or call 911 in case of\nemergency.\n\n\n\nCompleted by:1956-11-16']
9	14291	139852.0	2188-11-08	Discharge summary	Report	Admission Date: [2188-11-1] Discharge Date: [2188-11-8] Service: Medicine [Hospital1 139] HISTORY OF PRESENT ILLNESS: The patient is a [Age over 90 ]-year-old female who has a past medical history significant for coronary artery disease, hypertension, dementia, recurrent pneumonia and recent gastrectomy for peptic ulcer disease, who presented to the emergency room with a complaint of increasing shortness of breath. The patient had been at home for approximately 2 days following discharge from rehab following gastrectomy when shortness of breath developed. Emergency medical services were called and the patient was found to have an oxygen saturation of 65% on room air and 85% on 100% non-re-breather. PAST MEDICAL HISTORY: 1. Hypothyroid. 2. Coronary artery disease. 3. Hypertension. 4. Peptic ulcer disease status post gastrectomy for perforated ulcer. 5. Dementia. 6. Esophageal motility disorder. 7. Recurrent pneumonia. SOCIAL HISTORY: Living situation - the patient at baseline resides at home with 24 hour home health assistance. There is extensive family involvement. The patient's code status is DNR, DNI. FAMILY HISTORY: Noncontributory. ALLERGIES: Sulfa. MEDICATIONS: 1. Aricept 10 mg. 2. Lasix 40 mg. 3. Prevacid 30 mg. 4. Lopressor 25 mg b.i.d. 5. Multi-vitamin. 6. Effexor 70 mg. 7. Prednisone 25 mg. 8. Zofran p.r.n. 9. Synthroid 15 mg. EXAM: On presentation to the emergency department the patient was found to have vital signs as follows: Temperature 98.7, heart rate 82, blood pressure 160/62, respiratory rate 25, oxygen saturation 87% on room air. In general, the patient is a well nourished but thin female in respiratory distress. There was no jugular venous distention on examination of the neck. Lung exam revealed decreased breath sounds bilaterally. Cardiovascular exam was unremarkable. The PEG site was clean, dry and intact. The patient was alert and oriented only to person. LABORATORY STUDIES: Admission CBC was unremarkable. Admission SMA-7 was significant for an elevated BUN to creatinine ratio consistent with dehydration. Urinalysis was unremarkable. Cardiac enzymes were significant for an isolated elevated troponin. Coagulation studies were unremarkable. Arterial blood gas on 100% oxygen was significant for a decreased pO2 of 70 and an elevated pCO2 of 59 with a normal pH. RADIOLOGY: Chest x-ray on admission revealed mild congestive heart failure, markedly improved since the prior study of [2188-8-17]. There was also bilateral lower lobe opacification concerning for pneumonia. CT angiogram revealed consolidations at both lung bases consistent with bibasilar pneumonia as well as subtle patchy opacifications in the upper lobes with air fluid levels in the esophagus suggesting possible aspiration. There was no evidence of pulmonary embolism. CARDIAC STUDIES: EKG on admission revealed sinus rhythm with mild left axis deviation. There was also felt to be possible left anterior fascicular block. The admitting MICU team noted possible ST elevations in V3 through V6. Echocardiogram revealed mild symmetric left ventricular hypertrophy with normal left ventricular cavity size. Overall left ventricular systolic function was normal. There was normal right ventricular systolic function. There was also moderate aortic regurgitation. No pericardial effusion. HOSPITAL COURSE: 1. Respiratory distress: On admission, the patient was felt to have bilateral pneumonia, most likely secondary to aspiration. The patient was started on IV Levaquin, Flagyl and Vancomycin to cover for likely aspiration in a setting of recent nursing home admission. The patient was kept on supplemental oxygen to keep oxygen saturations above 92% and was kept NPO on aspirations precautions. On day of admission antibiotics were changed to IV ceftazidine, Flagyl and Vancomycin. Vancomycin was dosed at 1 gram q24 hours in the setting of patient's decreased renal function, age and body size. On day two of admission the patient was also felt to be fluid over loaded and gentle diuresis was resumed. On day two of admission the patient was felt to be stable for transfer to the floor. On the floor, the patient was initially continued on IV antibiotics. On day five of admission the patient had a follow up chest x-ray which revealed marked improvement in bibasilar pneumonia. The patient also had improvement in oxygen saturation and was able to tolerate room air. As a result, the patient was transitioned to p.o. antibiotics and was given Augmentin and Flagyl through the PEG tube. The patient was discharged home on hospital day 9 with instructions to complete a 14 day course of p.o. antibiotics for presumed aspiration pneumonia. 2. Cardiovascular: Elevated troponin as well as possible ST elevations on admission were felt to reflect a demand ischemia. Cardiac enzymes and EKG changes stabilized. The patient was continued on aspirin, Lopressor throughout the admission. On day three of admission the patient had an episode of sinus tachycardia likely secondary to dehydration versus multi-focal atrial tachycardia secondary to pulmonary disease. This resolved following hydration. The patient's cardiovascular function remained stable for the rest of the admission. 3. Dementia: The patient was continued on Aricept throughout the admission. 4. Gastrointestinal: Following rehydration, the patient was found to have a mildly decreased hematocrit. As a result, the patient was received an elevation by gastroenterology to look for gastrointestinal bleeding as an etiology of decreased hematocrit. Given the patient's history of peptic ulcer disease, gastroenterology service recommended H. pylori serology, which was negative. Iron studies were sent, which revealed a decreased total iron binding capacity as well as decreased iron suggestive of a combination of both blood loss and chronic disease as etiologies of anemia. Gastroenterology service felt, however, that EGD and colonoscopy were not an option in setting of patient's recent ischemic cardiac disease. Furthermore, the patient refused gastroenterology work up. Gastroenterology service also asked to evaluate patient for possible contribution of reflux of jejunostomy tube feedings to development of aspiration pneumonia. Gastroenterology service felt that reflux of J-tube feedings was unlikely, however, felt that patient's long history of esophageal dysmotility could be contributing to aspiration. They recommended swallowing study. The patient received an oropharyngeal video fluoroscopic swallowing evaluation on day five of admission. This revealed mild oral with moderate to severe pharyngoesophageal dysphagia with significant impaired upper esophageal sphincter opening leading to severe residue of solids in the pharynx. However, there was no aspiration. Nevertheless, swallowing service recommended the patient in future have only thin liquids, pureed solids or very finely/minced meat in p.o. diet. They also recommended that the patient sit bolt upright at meals and for 45 minutes after meals. They recommended the patient remain at 45 degrees in bed at all times and should never lay flat in bed and recommended that if patient must remain flat in bed that tube feedings be discontinued for 30 minutes prior to patient laying flat in bed. 5. Endocrine: The patient was continued on Levothyroxine for hypothyroidism. 6. GU: The patient was placed on Foley catheter on admission to the hospital. On day seven of admission the patient was ready for discharge from a medical standpoint, but did not void in time status post discontinuation of the Foley catheter. As a result the patient remained in-house for an additional day to ensure the patient could void spontaneously following discontinuation of Foley catheter. POST DISCHARGE MEDICATIONS: Metronidazole 500 mg q8 hours x7 days, Augmentin 500/125 mg p.o. b.i.d. x7 days, furosemide 40 mg p.o. q.d., aspirin 325 mg p.o. q.d., metoprolol 25 mg p.o. b.i.d., Venlafaxine HCL 75 mg capsule p.o. q.d., Levothyroxine 150 mcg p.o. q.d., donepezile hydrochloride 10 mg p.o. q.h.s., Lansoprazole 30 mg q.d., iron sulfate 325 mg p.o. q.d., multi-vitamin. DISPOSITION: To home with visiting nurse as well as 24 hour home health assistance. DISCHARGE STATUS: On day of discharge, the patient was ambulating, voiding spontaneously and had oxygen saturation of 97% on two liters. The patient was demented in a manner consistent with baseline. DISCHARGE DIAGNOSES: 1. Aspiration pneumonia. 2. Coronary artery disease. 3. Hypertension. 4. Peptic ulcer disease status post gastrectomy. 5. Hypothyroidism. 6. Dementia. 7. Esophageal dysmotility. 8. Dehydration. CODE STATUS: DNR and DNI. RECOMMENDED FOLLOW UP: Follow up with Dr. [First Name4 (NamePattern1) 140] [Last Name (NamePattern1) 141] [Telephone/Fax (1) 142] if new problems arise. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 143], M.D. [MD Number(1) 144] Dictated By:[Last Name (NamePattern1) 145] MEDQUIST36 D: [2188-12-13] 16:12 T: [2188-12-15] 06:37 JOB#: [Job Number 146]	Admission Date: <Date>1932-8-27</Date> Discharge Date: <Date>2022-8-17</Date> Service: Medicine <Hospital>Foster-Harmon Health System</Hospital> HISTORY OF PRESENT ILLNESS: The patient is a <Age>44</Age>-year-old female who has a past medical history significant for coronary artery disease, hypertension, dementia, recurrent pneumonia and recent gastrectomy for peptic ulcer disease, who presented to the emergency room with a complaint of increasing shortness of breath. The patient had been at home for approximately 2 days following discharge from rehab following gastrectomy when shortness of breath developed. Emergency medical services were called and the patient was found to have an oxygen saturation of 65% on room air and 85% on 100% non-re-breather. PAST MEDICAL HISTORY: 1. Hypothyroid. 2. Coronary artery disease. 3. Hypertension. 4. Peptic ulcer disease status post gastrectomy for perforated ulcer. 5. Dementia. 6. Esophageal motility disorder. 7. Recurrent pneumonia. SOCIAL HISTORY: Living situation - the patient at baseline resides at home with 24 hour home health assistance. There is extensive family involvement. The patient's code status is DNR, DNI. FAMILY HISTORY: Noncontributory. ALLERGIES: Sulfa. MEDICATIONS: 1. Aricept 10 mg. 2. Lasix 40 mg. 3. Prevacid 30 mg. 4. Lopressor 25 mg b.i.d. 5. Multi-vitamin. 6. Effexor 70 mg. 7. Prednisone 25 mg. 8. Zofran p.r.n. 9. Synthroid 15 mg. EXAM: On presentation to the emergency department the patient was found to have vital signs as follows: Temperature 98.7, heart rate 82, blood pressure 160/62, respiratory rate 25, oxygen saturation 87% on room air. In general, the patient is a well nourished but thin female in respiratory distress. There was no jugular venous distention on examination of the neck. Lung exam revealed decreased breath sounds bilaterally. Cardiovascular exam was unremarkable. The PEG site was clean, dry and intact. The patient was alert and oriented only to person. LABORATORY STUDIES: Admission CBC was unremarkable. Admission SMA-7 was significant for an elevated BUN to creatinine ratio consistent with dehydration. Urinalysis was unremarkable. Cardiac enzymes were significant for an isolated elevated troponin. Coagulation studies were unremarkable. Arterial blood gas on 100% oxygen was significant for a decreased pO2 of 70 and an elevated pCO2 of 59 with a normal pH. RADIOLOGY: Chest x-ray on admission revealed mild congestive heart failure, markedly improved since the prior study of <Date>1926-2-24</Date>. There was also bilateral lower lobe opacification concerning for pneumonia. CT angiogram revealed consolidations at both lung bases consistent with bibasilar pneumonia as well as subtle patchy opacifications in the upper lobes with air fluid levels in the esophagus suggesting possible aspiration. There was no evidence of pulmonary embolism. CARDIAC STUDIES: EKG on admission revealed sinus rhythm with mild left axis deviation. There was also felt to be possible left anterior fascicular block. The admitting MICU team noted possible ST elevations in V3 through V6. Echocardiogram revealed mild symmetric left ventricular hypertrophy with normal left ventricular cavity size. Overall left ventricular systolic function was normal. There was normal right ventricular systolic function. There was also moderate aortic regurgitation. No pericardial effusion. HOSPITAL COURSE: 1. Respiratory distress: On admission, the patient was felt to have bilateral pneumonia, most likely secondary to aspiration. The patient was started on IV Levaquin, Flagyl and Vancomycin to cover for likely aspiration in a setting of recent nursing home admission. The patient was kept on supplemental oxygen to keep oxygen saturations above 92% and was kept NPO on aspirations precautions. On day of admission antibiotics were changed to IV ceftazidine, Flagyl and Vancomycin. Vancomycin was dosed at 1 gram q24 hours in the setting of patient's decreased renal function, age and body size. On day two of admission the patient was also felt to be fluid over loaded and gentle diuresis was resumed. On day two of admission the patient was felt to be stable for transfer to the floor. On the floor, the patient was initially continued on IV antibiotics. On day five of admission the patient had a follow up chest x-ray which revealed marked improvement in bibasilar pneumonia. The patient also had improvement in oxygen saturation and was able to tolerate room air. As a result, the patient was transitioned to p.o. antibiotics and was given Augmentin and Flagyl through the PEG tube. The patient was discharged home on hospital day 9 with instructions to complete a 14 day course of p.o. antibiotics for presumed aspiration pneumonia. 2. Cardiovascular: Elevated troponin as well as possible ST elevations on admission were felt to reflect a demand ischemia. Cardiac enzymes and EKG changes stabilized. The patient was continued on aspirin, Lopressor throughout the admission. On day three of admission the patient had an episode of sinus tachycardia likely secondary to dehydration versus multi-focal atrial tachycardia secondary to pulmonary disease. This resolved following hydration. The patient's cardiovascular function remained stable for the rest of the admission. 3. Dementia: The patient was continued on Aricept throughout the admission. 4. Gastrointestinal: Following rehydration, the patient was found to have a mildly decreased hematocrit. As a result, the patient was received an elevation by gastroenterology to look for gastrointestinal bleeding as an etiology of decreased hematocrit. Given the patient's history of peptic ulcer disease, gastroenterology service recommended H. pylori serology, which was negative. Iron studies were sent, which revealed a decreased total iron binding capacity as well as decreased iron suggestive of a combination of both blood loss and chronic disease as etiologies of anemia. Gastroenterology service felt, however, that EGD and colonoscopy were not an option in setting of patient's recent ischemic cardiac disease. Furthermore, the patient refused gastroenterology work up. Gastroenterology service also asked to evaluate patient for possible contribution of reflux of jejunostomy tube feedings to development of aspiration pneumonia. Gastroenterology service felt that reflux of J-tube feedings was unlikely, however, felt that patient's long history of esophageal dysmotility could be contributing to aspiration. They recommended swallowing study. The patient received an oropharyngeal video fluoroscopic swallowing evaluation on day five of admission. This revealed mild oral with moderate to severe pharyngoesophageal dysphagia with significant impaired upper esophageal sphincter opening leading to severe residue of solids in the pharynx. However, there was no aspiration. Nevertheless, swallowing service recommended the patient in future have only thin liquids, pureed solids or very finely/minced meat in p.o. diet. They also recommended that the patient sit bolt upright at meals and for 45 minutes after meals. They recommended the patient remain at 45 degrees in bed at all times and should never lay flat in bed and recommended that if patient must remain flat in bed that tube feedings be discontinued for 30 minutes prior to patient laying flat in bed. 5. Endocrine: The patient was continued on Levothyroxine for hypothyroidism. 6. GU: The patient was placed on Foley catheter on admission to the hospital. On day seven of admission the patient was ready for discharge from a medical standpoint, but did not void in time status post discontinuation of the Foley catheter. As a result the patient remained in-house for an additional day to ensure the patient could void spontaneously following discontinuation of Foley catheter. POST DISCHARGE MEDICATIONS: Metronidazole 500 mg q8 hours x7 days, Augmentin 500/125 mg p.o. b.i.d. x7 days, furosemide 40 mg p.o. q.d., aspirin 325 mg p.o. q.d., metoprolol 25 mg p.o. b.i.d., Venlafaxine HCL 75 mg capsule p.o. q.d., Levothyroxine 150 mcg p.o. q.d., donepezile hydrochloride 10 mg p.o. q.h.s., Lansoprazole 30 mg q.d., iron sulfate 325 mg p.o. q.d., multi-vitamin. DISPOSITION: To home with visiting nurse as well as 24 hour home health assistance. DISCHARGE STATUS: On day of discharge, the patient was ambulating, voiding spontaneously and had oxygen saturation of 97% on two liters. The patient was demented in a manner consistent with baseline. DISCHARGE DIAGNOSES: 1. Aspiration pneumonia. 2. Coronary artery disease. 3. Hypertension. 4. Peptic ulcer disease status post gastrectomy. 5. Hypothyroidism. 6. Dementia. 7. Esophageal dysmotility. 8. Dehydration. CODE STATUS: DNR and DNI. RECOMMENDED FOLLOW UP: Follow up with Dr. <Name>Arnaldo</Name> <Name>Deluna</Name> <Telephone>525-346-5064</Telephone> if new problems arise. <Name>Jai</Name> <Name>Brown</Name>, M.D. <MD Number>34863165</MD Number> Dictated By:<Name>Lees</Name> MEDQUIST36 D: <Date>1976-8-24</Date> 16:12 T: <Date>1917-11-12</Date> 06:37 JOB#: <Job Number>Johnson, Dodson and Gibson-1993-919242</Job 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Date: 1932-8-27 Discharge Date: 2022-8-17 Service: Medicine Foster-Harmon Health System HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old female who has a past medical history significant for coronary artery disease, hypertension, dementia, recurrent pneumonia and recent gastrectomy for peptic ulcer disease, who presented to the emergency room with a complaint of increasing shortness of breath. The patient had been at home for approximately 2 days following discharge from rehab following gastrectomy when shortness of breath developed. Emergency medical services were called and the patient was found to have an oxygen saturation of 65% on room air and 85% on 100% non-re-breather. PAST MEDICAL HISTORY: 1. Hypothyroid. 2. Coronary artery disease. 3. Hypertension. 4. Peptic ulcer disease status post gastrectomy for perforated ulcer. 5. Dementia. 6. Esophageal motility disorder. 7. Recurrent pneumonia. SOCIAL HISTORY: Living situation - the patient at baseline resides at home with 24 hour home health assistance. There is extensive family involvement. The patient's code status is DNR, DNI. FAMILY HISTORY: Noncontributory. ALLERGIES: Sulfa. MEDICATIONS: 1. Aricept 10 mg. 2. Lasix 40 mg. 3. Prevacid 30 mg. 4. Lopressor 25 mg b.i.d. 5. Multi-vitamin. 6. Effexor 70 mg. 7. Prednisone 25 mg. 8. Zofran p.r.n. 9. Synthroid 15 mg. EXAM: On presentation to the emergency department the patient was found to have vital signs as follows: Temperature 98.7, heart rate 82, blood pressure 160/62, respiratory rate 25, oxygen saturation 87% on room air. In general, the patient is a well nourished but thin female in respiratory distress. There was no jugular venous distention on examination of the neck. Lung exam revealed decreased breath sounds bilaterally. Cardiovascular exam was unremarkable. The PEG site was clean, dry and intact. The patient was alert and oriented only to person. LABORATORY STUDIES: Admission CBC was unremarkable. Admission SMA-7 was significant for an elevated BUN to creatinine ratio consistent with dehydration. Urinalysis was unremarkable. Cardiac enzymes were significant for an isolated elevated troponin. Coagulation studies were unremarkable. Arterial blood gas on 100% oxygen was significant for a decreased pO2 of 70 and an elevated pCO2 of 59 with a normal pH. RADIOLOGY: Chest x-ray on admission revealed mild congestive heart failure, markedly improved since the prior study of 1926-2-24. There was also bilateral lower lobe opacification concerning for pneumonia. CT angiogram revealed consolidations at both lung bases consistent with bibasilar pneumonia as well as subtle patchy opacifications in the upper lobes with air fluid levels in the esophagus suggesting possible aspiration. There was no evidence of pulmonary embolism. CARDIAC STUDIES: EKG on admission revealed sinus rhythm with mild left axis deviation. There was also felt to be possible left anterior fascicular block. The admitting MICU team noted possible ST elevations in V3 through V6. Echocardiogram revealed mild symmetric left ventricular hypertrophy with normal left ventricular cavity size. Overall left ventricular systolic function was normal. There was normal right ventricular systolic function. There was also moderate aortic regurgitation. No pericardial effusion. HOSPITAL COURSE: 1. Respiratory distress: On admission, the patient was felt to have bilateral pneumonia, most likely secondary to aspiration. The patient was started on IV Levaquin, Flagyl and Vancomycin to cover for likely aspiration in a setting of recent nursing home admission. The patient was kept on supplemental oxygen to keep oxygen saturations above 92% and was kept NPO on aspirations precautions. On day of admission antibiotics were changed to IV ceftazidine, Flagyl and Vancomycin. Vancomycin was dosed at 1 gram q24 hours in the setting of patient's decreased renal function, age and body size. On day two of admission the patient was also felt to be fluid over loaded and gentle diuresis was resumed. On day two of admission the patient was felt to be stable for transfer to the floor. On the floor, the patient was initially continued on IV antibiotics. On day five of admission the patient had a follow up chest x-ray which revealed marked improvement in bibasilar pneumonia. The patient also had improvement in oxygen saturation and was able to tolerate room air. As a result, the patient was transitioned to p.o. antibiotics and was given Augmentin and Flagyl through the PEG tube. The patient was discharged home on hospital day 9 with instructions to complete a 14 day course of p.o. antibiotics for presumed aspiration pneumonia. 2. Cardiovascular: Elevated troponin as well as possible ST elevations on admission were felt to reflect a demand ischemia. Cardiac enzymes and EKG changes stabilized. The patient was continued on aspirin, Lopressor throughout the admission. On day three of admission the patient had an episode of sinus tachycardia likely secondary to dehydration versus multi-focal atrial tachycardia secondary to pulmonary disease. This resolved following hydration. The patient's cardiovascular function remained stable for the rest of the admission. 3. Dementia: The patient was continued on Aricept throughout the admission. 4. Gastrointestinal: Following rehydration, the patient was found to have a mildly decreased hematocrit. As a result, the patient was received an elevation by gastroenterology to look for gastrointestinal bleeding as an etiology of decreased hematocrit. Given the patient's history of peptic ulcer disease, gastroenterology service recommended H. pylori serology, which was negative. Iron studies were sent, which revealed a decreased total iron binding capacity as well as decreased iron suggestive of a combination of both blood loss and chronic disease as etiologies of anemia. Gastroenterology service felt, however, that EGD and colonoscopy were not an option in setting of patient's recent ischemic cardiac disease. Furthermore, the patient refused gastroenterology work up. Gastroenterology service also asked to evaluate patient for possible contribution of reflux of jejunostomy tube feedings to development of aspiration pneumonia. Gastroenterology service felt that reflux of J-tube feedings was unlikely, however, felt that patient's long history of esophageal dysmotility could be contributing to aspiration. They recommended swallowing study. The patient received an oropharyngeal video fluoroscopic swallowing evaluation on day five of admission. This revealed mild oral with moderate to severe pharyngoesophageal dysphagia with significant impaired upper esophageal sphincter opening leading to severe residue of solids in the pharynx. However, there was no aspiration. Nevertheless, swallowing service recommended the patient in future have only thin liquids, pureed solids or very finely/minced meat in p.o. diet. They also recommended that the patient sit bolt upright at meals and for 45 minutes after meals. They recommended the patient remain at 45 degrees in bed at all times and should never lay flat in bed and recommended that if patient must remain flat in bed that tube feedings be discontinued for 30 minutes prior to patient laying flat in bed. 5. Endocrine: The patient was continued on Levothyroxine for hypothyroidism. 6. GU: The patient was placed on Foley catheter on admission to the hospital. On day seven of admission the patient was ready for discharge from a medical standpoint, but did not void in time status post discontinuation of the Foley catheter. As a result the patient remained in-house for an additional day to ensure the patient could void spontaneously following discontinuation of Foley catheter. POST DISCHARGE MEDICATIONS: Metronidazole 500 mg q8 hours x7 days, Augmentin 500/125 mg p.o. b.i.d. x7 days, furosemide 40 mg p.o. q.d., aspirin 325 mg p.o. q.d., metoprolol 25 mg p.o. b.i.d., Venlafaxine HCL 75 mg capsule p.o. q.d., Levothyroxine 150 mcg p.o. q.d., donepezile hydrochloride 10 mg p.o. q.h.s., Lansoprazole 30 mg q.d., iron sulfate 325 mg p.o. q.d., multi-vitamin. DISPOSITION: To home with visiting nurse as well as 24 hour home health assistance. DISCHARGE STATUS: On day of discharge, the patient was ambulating, voiding spontaneously and had oxygen saturation of 97% on two liters. The patient was demented in a manner consistent with baseline. DISCHARGE DIAGNOSES: 1. Aspiration pneumonia. 2. Coronary artery disease. 3. Hypertension. 4. Peptic ulcer disease status post gastrectomy. 5. Hypothyroidism. 6. Dementia. 7. Esophageal dysmotility. 8. Dehydration. CODE STATUS: DNR and DNI. RECOMMENDED FOLLOW UP: Follow up with Dr. Arnaldo Deluna 525-346-5064 if new problems arise. Jai Brown, M.D. 34863165 Dictated By:Lees MEDQUIST36 D: 1976-8-24 16:12 T: 1917-11-12 06:37 JOB#: Johnson, Dodson and Gibson-1993-919242	['Admission Date: 1932-8-27 Discharge Date: 2022-8-17\n\n\nService: Medicine Foster-Harmon Health System\n\nHISTORY OF PRESENT ILLNESS: The patient is a 44-year-old\nfemale who has a past medical history significant for\ncoronary artery disease, hypertension, dementia, recurrent\npneumonia and recent gastrectomy for peptic ulcer disease,\nwho presented to the emergency room with a complaint of\nincreasing shortness of breath. The patient had been at home\nfor approximately 2 days following discharge from rehab\nfollowing gastrectomy when shortness of breath developed.\nEmergency medical services were called and the patient was\nfound to have an oxygen saturation of 65% on room air and 85%\non 100% non-re-breather.\n\nPAST MEDICAL HISTORY:\n1. Hypothyroid.\n2. Coronary artery disease.\n3. Hypertension.', "\n4. Peptic ulcer disease status post gastrectomy for\nperforated ulcer.\n5. Dementia.\n6. Esophageal motility disorder.\n7. Recurrent pneumonia.\n\nSOCIAL HISTORY: Living situation - the patient at baseline\nresides at home with 24 hour home health assistance. There\nis extensive family involvement. The patient's code status\nis DNR, DNI.\n\nFAMILY HISTORY: Noncontributory.\n\nALLERGIES: Sulfa.\n\nMEDICATIONS:\n1. Aricept 10 mg.\n2. Lasix 40 mg.\n3. Prevacid 30 mg.\n4. Lopressor 25 mg b.i.d.\n5. Multi-vitamin.\n6. Effexor 70 mg.\n7. Prednisone 25 mg.\n8. Zofran p.r.n.\n9. Synthroid 15 mg.\n\nEXAM: On presentation to the emergency department the\npatient was found to have vital signs as follows:\nTemperature 98.7, heart rate 82, blood pressure 160/62,\nrespiratory rate 25, oxygen saturation 87% on room air.", ' In\ngeneral, the patient is a well nourished but thin female in\nrespiratory distress. There was no jugular venous distention\non examination of the neck. Lung exam revealed decreased\nbreath sounds bilaterally. Cardiovascular exam was\nunremarkable. The PEG site was clean, dry and intact. The\npatient was alert and oriented only to person.\n\nLABORATORY STUDIES: Admission CBC was unremarkable.\nAdmission SMA-7 was significant for an elevated BUN to\ncreatinine ratio consistent with dehydration. Urinalysis was\nunremarkable. Cardiac enzymes were significant for an\nisolated elevated troponin. Coagulation studies were\nunremarkable. Arterial blood gas on 100% oxygen was\nsignificant for a decreased pO2 of 70 and an elevated pCO2 of\n59 with a normal pH.\n\nRADIOLOGY: Chest x-ray on admission revealed mild congestive\nheart failure, markedly improved since the prior study of\n1926-2-24.', ' There was also bilateral lower lobe\nopacification concerning for pneumonia. CT angiogram\nrevealed consolidations at both lung bases consistent with\nbibasilar pneumonia as well as subtle patchy opacifications\nin the upper lobes with air fluid levels in the esophagus\nsuggesting possible aspiration. There was no evidence of\npulmonary embolism.\n\nCARDIAC STUDIES: EKG on admission revealed sinus rhythm with\nmild left axis deviation. There was also felt to be possible\nleft anterior fascicular block. The admitting MICU team\nnoted possible ST elevations in V3 through V6.\nEchocardiogram revealed mild symmetric left ventricular\nhypertrophy with normal left ventricular cavity size.\nOverall left ventricular systolic function was normal. There\nwas normal right ventricular systolic function. There was\nalso moderate aortic regurgitation.', " No pericardial effusion.\n\nHOSPITAL COURSE:\n1. Respiratory distress: On admission, the patient was felt\nto have bilateral pneumonia, most likely secondary to\naspiration. The patient was started on IV Levaquin, Flagyl\nand Vancomycin to cover for likely aspiration in a setting of\nrecent nursing home admission. The patient was kept on\nsupplemental oxygen to keep oxygen saturations above 92% and\nwas kept NPO on aspirations precautions. On day of admission\nantibiotics were changed to IV ceftazidine, Flagyl and\nVancomycin. Vancomycin was dosed at 1 gram q24 hours in the\nsetting of patient's decreased renal function, age and body\nsize. On day two of admission the patient was also felt to\nbe fluid over loaded and gentle diuresis was resumed. On day\ntwo of admission the patient was felt to be stable for\ntransfer to the floor.", ' On the floor, the patient was\ninitially continued on IV antibiotics. On day five of\nadmission the patient had a follow up chest x-ray which\nrevealed marked improvement in bibasilar pneumonia. The\npatient also had improvement in oxygen saturation and was\nable to tolerate room air. As a result, the patient was\ntransitioned to p.o. antibiotics and was given Augmentin and\nFlagyl through the PEG tube. The patient was discharged home\non hospital day 9 with instructions to complete a 14 day\ncourse of p.o. antibiotics for presumed aspiration pneumonia.\n\n2. Cardiovascular: Elevated troponin as well as possible ST\nelevations on admission were felt to reflect a demand\nischemia. Cardiac enzymes and EKG changes stabilized. The\npatient was continued on aspirin, Lopressor throughout the\nadmission.', " On day three of admission the patient had an\nepisode of sinus tachycardia likely secondary to dehydration\nversus multi-focal atrial tachycardia secondary to pulmonary\ndisease. This resolved following hydration. The patient's\ncardiovascular function remained stable for the rest of the\nadmission.\n\n3. Dementia: The patient was continued on Aricept\nthroughout the admission.\n\n4. Gastrointestinal: Following rehydration, the patient was\nfound to have a mildly decreased hematocrit. As a result,\nthe patient was received an elevation by gastroenterology to\nlook for gastrointestinal bleeding as an etiology of\ndecreased hematocrit. Given the patient's history of peptic\nulcer disease, gastroenterology service recommended H. pylori\nserology, which was negative. Iron studies were sent, which\nrevealed a decreased total iron binding capacity as well as\ndecreased iron suggestive of a combination of both blood loss\nand chronic disease as etiologies of anemia.", "\nGastroenterology service felt, however, that EGD and\ncolonoscopy were not an option in setting of patient's recent\nischemic cardiac disease. Furthermore, the patient refused\ngastroenterology work up. Gastroenterology service also\nasked to evaluate patient for possible contribution of reflux\nof jejunostomy tube feedings to development of aspiration\npneumonia. Gastroenterology service felt that reflux of\nJ-tube feedings was unlikely, however, felt that patient's\nlong history of esophageal dysmotility could be contributing\nto aspiration. They recommended swallowing study. The\npatient received an oropharyngeal video fluoroscopic\nswallowing evaluation on day five of admission. This\nrevealed mild oral with moderate to severe pharyngoesophageal\ndysphagia with significant impaired upper esophageal\nsphincter opening leading to severe residue of solids in the\npharynx.", ' However, there was no aspiration. Nevertheless,\nswallowing service recommended the patient in future have\nonly thin liquids, pureed solids or very finely/minced meat\nin p.o. diet. They also recommended that the patient sit\nbolt upright at meals and for 45 minutes after meals. They\nrecommended the patient remain at 45 degrees in bed at all\ntimes and should never lay flat in bed and recommended that\nif patient must remain flat in bed that tube feedings be\ndiscontinued for 30 minutes prior to patient laying flat in\nbed.\n\n5. Endocrine: The patient was continued on Levothyroxine\nfor hypothyroidism.\n\n6. GU: The patient was placed on Foley catheter on\nadmission to the hospital. On day seven of admission the\npatient was ready for discharge from a medical standpoint,\nbut did not void in time status post discontinuation of the\nFoley catheter.', ' As a result the patient remained in-house\nfor an additional day to ensure the patient could void\nspontaneously following discontinuation of Foley catheter.\n\nPOST DISCHARGE MEDICATIONS: Metronidazole 500 mg q8 hours x7\ndays, Augmentin 500/125 mg p.o. b.i.d. x7 days, furosemide 40\nmg p.o. q.d., aspirin 325 mg p.o. q.d., metoprolol 25 mg p.o.\nb.i.d., Venlafaxine HCL 75 mg capsule p.o. q.d.,\nLevothyroxine 150 mcg p.o. q.d., donepezile hydrochloride 10\nmg p.o. q.h.s., Lansoprazole 30 mg q.d., iron sulfate 325 mg\np.o. q.d., multi-vitamin.\n\nDISPOSITION: To home with visiting nurse as well as 24 hour\nhome health assistance.\n\nDISCHARGE STATUS: On day of discharge, the patient was\nambulating, voiding spontaneously and had oxygen saturation\nof 97% on two liters. The patient was demented in a manner\nconsistent with baseline.', '\n\nDISCHARGE DIAGNOSES:\n1. Aspiration pneumonia.\n2. Coronary artery disease.\n3. Hypertension.\n4. Peptic ulcer disease status post gastrectomy.\n5. Hypothyroidism.\n6. Dementia.\n7. Esophageal dysmotility.\n8. Dehydration.\n\nCODE STATUS: DNR and DNI.\n\nRECOMMENDED FOLLOW UP: Follow up with Dr. Arnaldo Deluna\n525-346-5064 if new problems arise.\n\n\n\n\n\n\n Jai Brown, M.D. 34863165\n\nDictated By:Lees\n\nMEDQUIST36\n\nD: 1976-8-24 16:12\nT: 1917-11-12 06:37\nJOB#: Johnson, Dodson and Gibson-1993-919242\n']
10	18961	199586.0	2196-08-23	Discharge summary	Report	Admission Date: [2196-8-20] Discharge Date: [2196-8-23] Date of Birth: [2121-4-19] Sex: M Service: OMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Central line placement at Right internal jugular History of Present Illness: 75 yo male with advanced gastric ca recently started on chemotherapy presenting and hypotensiona nd episode of unresponsivenes after diarrhea and narcotics + megace. Pt was seen on [8-17] by his oncologist where he was determine to be hypovolemic and received a total of 3 L IVF between We and Fri but still c/o poor po intake secondary to abdominal pain and fullness, nausea, and decreased appetite. This morning upon awakening pt was lethargic. He took MSO4, Dilaudid and an unspecified dose of Megace. He then became flushed and pale, had copious diarrhea (non-bloody), then became unresponsive. EMS called and he was found with SBP 80. Narcan given with improvement in mental status but in [Name (NI) ] pt was persistently hypotensive requiring 6 L IVF and Levophed. Labs notable for ANC 500 and lactate 17. Sepsis protocol was initiated. Pt given Flagyl, Levofloxacin, and cefepime and sent to [Hospital Unit Name 153]. Past Medical History: 1. Metastatic gastric adenocarcinoma 2. Portal vein obstruction 3. Portal hypertention 4. Biliary obstruction -s/p ERCP 5. Esophagitis 6. Gout Social History: lives with his wife at home. He has 1-2 drinks a night and denies any illicit drug use. He quit smoking in [2168], but has a 30 pack year history. Family History: Non contributory Physical Exam: VS: T96.7 BP 84/49 HR 112 RR20 T95% 15L mask Gen: Fatigued appearing, in NAD, feeling slightly confused but A+O HEENT: anicteric, OP dry Neck: supple, flat JVP CV: tachy RR, nl S1 S2, soft diastolic murmur at LSB Lungs: diminished BS @ bases Abd: soft, distended, tympanic on R epigastic, dull to percussion on LUQ and LLQ with mild TTP LLQ. No masses, well healed midline scar Ext: 1+ pitting edema BLE Neuro: A+Ox2, moving all extremities symmetrically Pertinent Results: [2196-8-20] 10:50PM LD(LDH)-300* [2196-8-20] 09:47PM LACTATE-10.1* [2196-8-20] 07:30PM TYPE-ART TEMP-37.3 RATES-/20 O2 FLOW-4 PO2-95 PCO2-31* PH-7.22* TOTAL CO2-13* BASE XS--13 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2196-8-20] 07:30PM LACTATE-11.1* [2196-8-20] 06:10PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2196-8-20] 06:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2196-8-20] 06:10PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0-2 [2196-8-20] 04:48PM LACTATE-16.5* [2196-8-20] 03:46PM LACTATE-17.2* [2196-8-20] 03:28PM GLUCOSE-539* UREA N-40* CREAT-2.2# SODIUM-127 POTASSIUM-4.5 CHLORIDE-86* TOTAL CO2-9* ANION GAP-37* [2196-8-20] 03:28PM ALT(SGPT)-16 AST(SGOT)-37 CK(CPK)-85 ALK PHOS-320* AMYLASE-47 TOT BILI-0.8 [2196-8-20] 03:28PM LIPASE-32 [2196-8-20] 03:28PM CK-MB-9 cTropnT-<0.01 [2196-8-20] 03:28PM ALBUMIN-3.0* CALCIUM-9.0 PHOSPHATE-6.5# MAGNESIUM-2.3 [2196-8-20] 03:28PM CORTISOL-57.9 [2196-8-20] 03:28PM CRP-6.18* [2196-8-20] 03:28PM PT-15.8* PTT-32.4 INR(PT)-1.7 [2196-8-20] 03:28PM GRAN CT-540* CXR ([2196-8-21]) IMPRESSION: The tip of the IJ line had advanced since the previous study and is in the right atrium. Worsening partial atelectasis of the lower lobes bilaterally as well as the right upper lobe. [2196-8-20] 4:25 pm BLOOD CULTURE #2. AEROBIC BOTTLE (Preliminary): REPORTED BY PHONE TO [Doctor First Name 156] [Doctor Last Name 157] AT 11:45 ON [8-21]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN-------------<=0.25 S PENICILLIN------------ 0.25 R ANAEROBIC BOTTLE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. [2196-8-21] 11:12 am STOOL CONSISTENCY: WATERY Source: Stool. FECAL CULTURE (Final [2196-8-23]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2196-8-23]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [2196-8-22]): NO OVA AND PARASITES SEEN. . FEW MACROPHAGES. . This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2196-8-22]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. VIRAL CULTURE (Preliminary): No Virus isolated so far. Brief Hospital Course: Pt admitted to the ICU after being hypotensive and being found with altered mental status. Pt received 6 L IV fluids in the ED and more aggressive volume rescuscitation was done at the floor. Pt's mental status improved but still oriented x2. Pt was requiring Levophed to keep the MAP>60. IV Zosyn was started to cover for gram negative enterococcus coverage due to history of . Patient was breathing in the 90's with Face mask. Immediately after pt was admitted, discussion was held with the family and patient management was changed to CMO. Pt was awake and alert during this discussion, and he was requesting for comfort measure only and did not want any more aggressive treatment. All of the medications were held except for the morphine drip. Blood cx result was positive for coag negative Staph aureus, but not treatment was initiated. Pt remained on morphine drip over 2 days without any oxygen support. Pt was transferred to the regular floor on the monrning of [8-23], and pt immediately passed away upon arrival. Discharge Disposition: Home Discharge Diagnosis: Sepsis Coag negative Staph bacteremia Gastric adenocarcinoma Discharge Condition: Pt deceased Completed by:[2196-8-23]	Admission Date: <Date>2022-10-26</Date> Discharge Date: <Date>2003-3-24</Date> Date of Birth: <Date>1984-8-18</Date> Sex: M Service: OMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:<Name>Todd</Name> Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Central line placement at Right internal jugular History of Present Illness: 75 yo male with advanced gastric ca recently started on chemotherapy presenting and hypotensiona nd episode of unresponsivenes after diarrhea and narcotics + megace. Pt was seen on <Date>9-8</Date> by his oncologist where he was determine to be hypovolemic and received a total of 3 L IVF between We and Fri but still c/o poor po intake secondary to abdominal pain and fullness, nausea, and decreased appetite. This morning upon awakening pt was lethargic. He took MSO4, Dilaudid and an unspecified dose of Megace. He then became flushed and pale, had copious diarrhea (non-bloody), then became unresponsive. EMS called and he was found with SBP 80. Narcan given with improvement in mental status but in <Name>Zhi Tamaro</Name> pt was persistently hypotensive requiring 6 L IVF and Levophed. Labs notable for ANC 500 and lactate 17. Sepsis protocol was initiated. Pt given Flagyl, Levofloxacin, and cefepime and sent to <Hospital>Harrell LLC Medical Center</Hospital>. Past Medical History: 1. Metastatic gastric adenocarcinoma 2. Portal vein obstruction 3. Portal hypertention 4. Biliary obstruction -s/p ERCP 5. Esophagitis 6. Gout Social History: lives with his wife at home. He has 1-2 drinks a night and denies any illicit drug use. He quit smoking in <Year>1996</Year>, but has a 30 pack year history. Family History: Non contributory Physical Exam: VS: T96.7 BP 84/49 HR 112 RR20 T95% 15L mask Gen: Fatigued appearing, in NAD, feeling slightly confused but A+O HEENT: anicteric, OP dry Neck: supple, flat JVP CV: tachy RR, nl S1 S2, soft diastolic murmur at LSB Lungs: diminished BS @ bases Abd: soft, distended, tympanic on R epigastic, dull to percussion on LUQ and LLQ with mild TTP LLQ. No masses, well healed midline scar Ext: 1+ pitting edema BLE Neuro: A+Ox2, moving all extremities symmetrically Pertinent Results: <Date>2022-10-26</Date> 10:50PM LD(LDH)-300* <Date>2022-10-26</Date> 09:47PM LACTATE-10.1* <Date>2022-10-26</Date> 07:30PM TYPE-ART TEMP-37.3 RATES-/20 O2 FLOW-4 PO2-95 PCO2-31* PH-7.22* TOTAL CO2-13* BASE XS--13 INTUBATED-NOT INTUBA COMMENTS-NASAL <Name>Thomas</Name> <Date>2022-10-26</Date> 07:30PM LACTATE-11.1* <Date>2022-10-26</Date> 06:10PM URINE COLOR-Yellow APPEAR-Clear SP <Name>Quinones</Name>-1.020 <Date>2022-10-26</Date> 06:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG <Date>2022-10-26</Date> 06:10PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0-2 <Date>2022-10-26</Date> 04:48PM LACTATE-16.5* <Date>2022-10-26</Date> 03:46PM LACTATE-17.2* <Date>2022-10-26</Date> 03:28PM GLUCOSE-539* UREA N-40* CREAT-2.2# SODIUM-127 POTASSIUM-4.5 CHLORIDE-86* TOTAL CO2-9* ANION GAP-37* <Date>2022-10-26</Date> 03:28PM ALT(SGPT)-16 AST(SGOT)-37 CK(CPK)-85 ALK PHOS-320* AMYLASE-47 TOT BILI-0.8 <Date>2022-10-26</Date> 03:28PM LIPASE-32 <Date>2022-10-26</Date> 03:28PM CK-MB-9 cTropnT-<0.01 <Date>2022-10-26</Date> 03:28PM ALBUMIN-3.0* CALCIUM-9.0 PHOSPHATE-6.5# MAGNESIUM-2.3 <Date>2022-10-26</Date> 03:28PM CORTISOL-57.9 <Date>2022-10-26</Date> 03:28PM CRP-6.18* <Date>2022-10-26</Date> 03:28PM PT-15.8* PTT-32.4 INR(PT)-1.7 <Date>2022-10-26</Date> 03:28PM GRAN CT-540* CXR (<Date>1974-9-6</Date>) IMPRESSION: The tip of the IJ line had advanced since the previous study and is in the right atrium. Worsening partial atelectasis of the lower lobes bilaterally as well as the right upper lobe. <Date>2022-10-26</Date> 4:25 pm BLOOD CULTURE #2. AEROBIC BOTTLE (Preliminary): REPORTED BY PHONE TO <Name>Arnaldo</Name> <Doctor Name>Dr.Islam</Doctor Name> AT 11:45 ON <Date>10-28</Date>. STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN-------------<=0.25 S PENICILLIN------------ 0.25 R ANAEROBIC BOTTLE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. <Date>1974-9-6</Date> 11:12 am STOOL CONSISTENCY: WATERY Source: Stool. FECAL CULTURE (Final <Date>2003-3-24</Date>): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final <Date>2003-3-24</Date>): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final <Date>1941-3-12</Date>): NO OVA AND PARASITES SEEN. . FEW MACROPHAGES. . This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final <Date>1941-3-12</Date>): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. VIRAL CULTURE (Preliminary): No Virus isolated so far. Brief Hospital Course: Pt admitted to the ICU after being hypotensive and being found with altered mental status. Pt received 6 L IV fluids in the ED and more aggressive volume rescuscitation was done at the floor. Pt's mental status improved but still oriented x2. Pt was requiring Levophed to keep the MAP>60. IV Zosyn was started to cover for gram negative enterococcus coverage due to history of . Patient was breathing in the 90's with Face mask. Immediately after pt was admitted, discussion was held with the family and patient management was changed to CMO. Pt was awake and alert during this discussion, and he was requesting for comfort measure only and did not want any more aggressive treatment. All of the medications were held except for the morphine drip. Blood cx result was positive for coag negative Staph aureus, but not treatment was initiated. Pt remained on morphine drip over 2 days without any oxygen support. Pt was transferred to the regular floor on the monrning of <Date>5-4</Date>, and pt immediately passed away upon arrival. Discharge Disposition: Home Discharge Diagnosis: Sepsis Coag negative Staph bacteremia Gastric adenocarcinoma Discharge Condition: Pt deceased Completed 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Date: 2022-10-26 Discharge Date: 2003-3-24 Date of Birth: 1984-8-18 Sex: M Service: OMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Todd Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Central line placement at Right internal jugular History of Present Illness: 75 yo male with advanced gastric ca recently started on chemotherapy presenting and hypotensiona nd episode of unresponsivenes after diarrhea and narcotics + megace. Pt was seen on 9-8 by his oncologist where he was determine to be hypovolemic and received a total of 3 L IVF between We and Fri but still c/o poor po intake secondary to abdominal pain and fullness, nausea, and decreased appetite. This morning upon awakening pt was lethargic. He took MSO4, Dilaudid and an unspecified dose of Megace. He then became flushed and pale, had copious diarrhea (non-bloody), then became unresponsive. EMS called and he was found with SBP 80. Narcan given with improvement in mental status but in Zhi Tamaro pt was persistently hypotensive requiring 6 L IVF and Levophed. Labs notable for ANC 500 and lactate 17. Sepsis protocol was initiated. Pt given Flagyl, Levofloxacin, and cefepime and sent to Harrell LLC Medical Center. Past Medical History: 1. Metastatic gastric adenocarcinoma 2. Portal vein obstruction 3. Portal hypertention 4. Biliary obstruction -s/p ERCP 5. Esophagitis 6. Gout Social History: lives with his wife at home. He has 1-2 drinks a night and denies any illicit drug use. He quit smoking in 1996, but has a 30 pack year history. Family History: Non contributory Physical Exam: VS: T96.7 BP 84/49 HR 112 RR20 T95% 15L mask Gen: Fatigued appearing, in NAD, feeling slightly confused but A+O HEENT: anicteric, OP dry Neck: supple, flat JVP CV: tachy RR, nl S1 S2, soft diastolic murmur at LSB Lungs: diminished BS @ bases Abd: soft, distended, tympanic on R epigastic, dull to percussion on LUQ and LLQ with mild TTP LLQ. No masses, well healed midline scar Ext: 1+ pitting edema BLE Neuro: A+Ox2, moving all extremities symmetrically Pertinent Results: 2022-10-26 10:50PM LD(LDH)-300* 2022-10-26 09:47PM LACTATE-10.1* 2022-10-26 07:30PM TYPE-ART TEMP-37.3 RATES-/20 O2 FLOW-4 PO2-95 PCO2-31* PH-7.22* TOTAL CO2-13* BASE XS--13 INTUBATED-NOT INTUBA COMMENTS-NASAL Thomas 2022-10-26 07:30PM LACTATE-11.1* 2022-10-26 06:10PM URINE COLOR-Yellow APPEAR-Clear SP Quinones-1.020 2022-10-26 06:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 2022-10-26 06:10PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0-2 2022-10-26 04:48PM LACTATE-16.5* 2022-10-26 03:46PM LACTATE-17.2* 2022-10-26 03:28PM GLUCOSE-539* UREA N-40* CREAT-2.2# SODIUM-127 POTASSIUM-4.5 CHLORIDE-86* TOTAL CO2-9* ANION GAP-37* 2022-10-26 03:28PM ALT(SGPT)-16 AST(SGOT)-37 CK(CPK)-85 ALK PHOS-320* AMYLASE-47 TOT BILI-0.8 2022-10-26 03:28PM LIPASE-32 2022-10-26 03:28PM CK-MB-9 cTropnT-2022-10-26 03:28PM ALBUMIN-3.0* CALCIUM-9.0 PHOSPHATE-6.5# MAGNESIUM-2.3 2022-10-26 03:28PM CORTISOL-57.9 2022-10-26 03:28PM CRP-6.18* 2022-10-26 03:28PM PT-15.8* PTT-32.4 INR(PT)-1.7 2022-10-26 03:28PM GRAN CT-540* CXR (1974-9-6) IMPRESSION: The tip of the IJ line had advanced since the previous study and is in the right atrium. Worsening partial atelectasis of the lower lobes bilaterally as well as the right upper lobe. 2022-10-26 4:25 pm BLOOD CULTURE #2. AEROBIC BOTTLE (Preliminary): REPORTED BY PHONE TO Arnaldo Dr.Islam AT 11:45 ON 10-28. STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN-----------8 R OXACILLIN-------------1974-9-6 11:12 am STOOL CONSISTENCY: WATERY Source: Stool. FECAL CULTURE (Final 2003-3-24): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final 2003-3-24): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final 1941-3-12): NO OVA AND PARASITES SEEN. . FEW MACROPHAGES. . This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final 1941-3-12): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. VIRAL CULTURE (Preliminary): No Virus isolated so far. Brief Hospital Course: Pt admitted to the ICU after being hypotensive and being found with altered mental status. Pt received 6 L IV fluids in the ED and more aggressive volume rescuscitation was done at the floor. Pt's mental status improved but still oriented x2. Pt was requiring Levophed to keep the MAP>60. IV Zosyn was started to cover for gram negative enterococcus coverage due to history of . Patient was breathing in the 90's with Face mask. Immediately after pt was admitted, discussion was held with the family and patient management was changed to CMO. Pt was awake and alert during this discussion, and he was requesting for comfort measure only and did not want any more aggressive treatment. All of the medications were held except for the morphine drip. Blood cx result was positive for coag negative Staph aureus, but not treatment was initiated. Pt remained on morphine drip over 2 days without any oxygen support. Pt was transferred to the regular floor on the monrning of 5-4, and pt immediately passed away upon arrival. Discharge Disposition: Home Discharge Diagnosis: Sepsis Coag negative Staph bacteremia Gastric adenocarcinoma Discharge Condition: Pt deceased Completed by:2003-3-24	['Admission Date: 2022-10-26 Discharge Date: 2003-3-24\n\nDate of Birth: 1984-8-18 Sex: M\n\nService: OMED\n\nAllergies:\nPatient recorded as having No Known Allergies to Drugs\n\nAttending:Todd\nChief Complaint:\nHypotension\n\nMajor Surgical or Invasive Procedure:\nCentral line placement at Right internal jugular\n\nHistory of Present Illness:\n75 yo male with advanced gastric ca recently started on\nchemotherapy presenting and hypotensiona nd episode of\nunresponsivenes after diarrhea and narcotics + megace. Pt was\nseen on 9-8 by his oncologist where he was determine to be\nhypovolemic and received a total of 3 L IVF between We and Fri\nbut still c/o poor po intake secondary to abdominal pain and\nfullness, nausea, and decreased appetite. This morning upon\nawakening pt was lethargic.', ' He took MSO4, Dilaudid and an\nunspecified dose of Megace. He then became flushed and pale, had\ncopious diarrhea (non-bloody), then became unresponsive. EMS\ncalled and he was found with SBP 80. Narcan given with\nimprovement in mental status but in Zhi Tamaro pt was persistently\nhypotensive requiring 6 L IVF and Levophed. Labs notable for ANC\n500 and lactate 17. Sepsis protocol was initiated. Pt given\nFlagyl, Levofloxacin, and cefepime and sent to Harrell LLC Medical Center.\n\nPast Medical History:\n1. Metastatic gastric adenocarcinoma\n2. Portal vein obstruction\n3. Portal hypertention\n4. Biliary obstruction -s/p ERCP\n5. Esophagitis\n6. Gout\n\nSocial History:\nlives with his wife at home. He has 1-2 drinks a night and\ndenies any illicit drug use. He quit smoking in 1996, but has a\n30 pack year history.', '\n\nFamily History:\nNon contributory\n\nPhysical Exam:\nVS: T96.7 BP 84/49 HR 112 RR20 T95% 15L mask\nGen: Fatigued appearing, in NAD, feeling slightly confused but\nA+O\nHEENT: anicteric, OP dry\nNeck: supple, flat JVP\nCV: tachy RR, nl S1 S2, soft diastolic murmur at LSB\nLungs: diminished BS @ bases\nAbd: soft, distended, tympanic on R epigastic, dull to\npercussion on LUQ and LLQ with mild TTP LLQ. No masses, well\nhealed midline scar\nExt: 1+ pitting edema BLE\nNeuro: A+Ox2, moving all extremities symmetrically\n\n\nPertinent Results:\n2022-10-26 10:50PM LD(LDH)-300\n2022-10-26 09:47PM LACTATE-10.1\n2022-10-26 07:30PM TYPE-ART TEMP-37.3 RATES-/20 O2 FLOW-4 PO2-95\nPCO2-31* PH-7.22* TOTAL CO2-13* BASE XS--13 INTUBATED-NOT INTUBA\nCOMMENTS-NASAL Thomas\n2022-10-26 07:30PM LACTATE-11.1\n2022-10-26 06:10PM URINE COLOR-Yellow APPEAR-Clear SP Quinones-1.', '020\n2022-10-26 06:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG\nGLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0\nLEUK-NEG\n2022-10-26 06:10PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE\nEPI-0-2\n2022-10-26 04:48PM LACTATE-16.5\n2022-10-26 03:46PM LACTATE-17.2\n2022-10-26 03:28PM GLUCOSE-539 UREA N-40* CREAT-2.2#\nSODIUM-127 POTASSIUM-4.5 CHLORIDE-86* TOTAL CO2-9* ANION\nGAP-37\n2022-10-26 03:28PM ALT(SGPT)-16 AST(SGOT)-37 CK(CPK)-85 ALK\nPHOS-320 AMYLASE-47 TOT BILI-0.8\n2022-10-26 03:28PM LIPASE-32\n2022-10-26 03:28PM CK-MB-9 cTropnT-2022-10-26 03:28PM ALBUMIN-3.0* CALCIUM-9.0 PHOSPHATE-6.5#\nMAGNESIUM-2.3\n2022-10-26 03:28PM CORTISOL-57.9\n2022-10-26 03:28PM CRP-6.18\n2022-10-26 03:28PM PT-15.8 PTT-32.4 INR(PT)-1.7\n2022-10-26 03:28PM GRAN CT-540*\n\nCXR (1974-9-6)\nIMPRESSION: The tip of the IJ line had advanced since the\nprevious study and is in the right atrium.', ' Worsening partial\natelectasis of the lower lobes bilaterally as well as the right\nupper lobe.\n\n2022-10-26 4:25 pm BLOOD CULTURE #2.\n\n AEROBIC BOTTLE (Preliminary):\n REPORTED BY PHONE TO Arnaldo Dr.Islam AT 11:45 ON 10-28.\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL\nSENSITIVITIES.\n\n SENSITIVITIES: MIC expressed in\nMCG/ML\n\n_________________________________________________________\n STAPHYLOCOCCUS, COAGULASE NEGATIVE\n \|\nCLINDAMYCIN-----------8 R\nOXACILLIN-------------1974-9-6 11:12 am STOOL CONSISTENCY: WATERY Source:\nStool.\n\n FECAL CULTURE (Final 2003-3-24):\n NO ENTERIC GRAM NEGATIVE RODS FOUND.\n NO SALMONELLA OR SHIGELLA FOUND.\n\n CAMPYLOBACTER CULTURE (Final 2003-3-24): NO CAMPYLOBACTER\nFOUND.', "\n\n OVA + PARASITES (Final 1941-3-12):\n NO OVA AND PARASITES SEEN.\n .\n FEW MACROPHAGES.\n .\n This test does not reliably detect Cryptosporidium,\nCyclospora or\n Microsporidium. While most cases of Giardia are detected\nby routine\n O+P, the Giardia antigen test may enhance detection when\norganisms\n are rare.\n\n CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final 1941-3-12):\n FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.\n Reference Range: Negative.\n\n VIRAL CULTURE (Preliminary): No Virus isolated so far.\n\n\nBrief Hospital Course:\nPt admitted to the ICU after being hypotensive and being found\nwith altered mental status. Pt received 6 L IV fluids in the ED\nand more aggressive volume rescuscitation was done at the floor.\n Pt's mental status improved but still oriented x2.", " Pt was\nrequiring Levophed to keep the MAP>60. IV Zosyn was started to\ncover for gram negative enterococcus coverage due to history of\n. Patient was breathing in the 90's with Face mask.\nImmediately after pt was admitted, discussion was held with the\nfamily and patient management was changed to CMO. Pt was awake\nand alert during this discussion, and he was requesting for\ncomfort measure only and did not want any more aggressive\ntreatment. All of the medications were held except for the\nmorphine drip. Blood cx result was positive for coag negative\nStaph aureus, but not treatment was initiated. Pt remained on\nmorphine drip over 2 days without any oxygen support. Pt was\ntransferred to the regular floor on the monrning of 5-4, and pt\nimmediately passed away upon arrival.\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nSepsis\nCoag negative Staph bacteremia\nGastric adenocarcinoma\n\n\nDischarge Condition:\nPt deceased\n\n\nCompleted by:2003-3-24"]
11	60614	116703.0	2175-09-28	Discharge summary	Report	Admission Date: [2175-9-27] Discharge Date: [2175-9-28] Date of Birth: [2101-11-11] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 158] Chief Complaint: rectal bleeding following prostate biopsy Major Surgical or Invasive Procedure: 1. prostate biopsy 2. exam under anesthesia 3. ligation of post-prostate biopsy bleeding History of Present Illness: The patient is a 73-year-old man who underwent a prostate biopsy in [Hospital 159] clinic complicated by immediate significant bright red blood bleeding. Attempts were made to stop the bleeding with a dilating Foley balloon and Surgicel packing without success. He was admitted for surgical management of bleeding. Past Medical History: hyperlipidemia, coronary artery disease, prostate cancer, gout Social History: Retired as a waiter in a Chinese restaurant. Patient is an accomplished poet who has published works in Chinese. Daughter is nurse. Tobacco none ETOH: None Drugs: None Family History: non-contributory Physical Exam: VS T 98.5 HR 68 BP 91/52 RR 18 SpO2 98%RA\ Gen: NAD, AOx3 Cv: RRR Pulm: CTAB Abd: soft, non-tender Rectal: no gross blood Ext: warm Pertinent Results: [2175-9-27] 05:16PM BLOOD WBC-13.0# RBC-3.64 Hgb-11.8* Hct-33.7* MCV-93 MCH-32.5* MCHC-35.1* RDW-13.0 Plt Ct-138* [2175-9-27] 08:54PM BLOOD WBC-11.9* RBC-3.61* Hgb-11.8* Hct-33.7* MCV-93 MCH-32.7* MCHC-35.0 RDW-12.9 Plt Ct-143* [2175-9-28] 01:45AM BLOOD Hct-29.6* [2175-9-28] 05:30AM BLOOD WBC-10.1 RBC-3.07* Hgb-10.1* Hct-28.6* MCV-93 MCH-32.9* MCHC-35.3* RDW-13.4 Plt Ct-144* Brief Hospital Course: The patient was admitted to the surgery service for management of rectal bleeding following prostate biopsy. He underwent a rectal exam under anesthesia followed by ligation of the bleeding biopsy site. He tolerated the procedure well and recovered briefly in the PACU before being transferred to the floor. Please see the operative report for further details. His hospital course was relatively uneventful. N: His pain was managed initially with IV pain medicines and then transitioned to po medicines with issue Cv: stable, no issues Pulm: Excellent oxygen saturations on room air GI: overnight the patient passed clotted blood per rectum several times. This resolved on POD #1 and no bright red blood was observed. Serial hematocrit values were obtained and shown to be stable in the AM compared to the post-operative value. He was started on a clear liquid diet and was advanced to a regular diet without issues. GU: voided without difficulty HEME: stable as described above. No transfusions required. ID: afebrile without issues DISPO: The patient was no longer bleeding and felt to be stable. He was tolerating a regular diet, voiding, and ambulating appropriately. He was discharged home with follow-up instructions. Medications on Admission: allopurinol, finasteride, metoprolol, simvastatin Discharge Medications: 1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 5. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: rectal bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Followup Instructions: Please call the surgery clinic at [Telephone/Fax (1) 160] to schedule follow-up with Dr. [Last Name (STitle) ] in [1-15] weeks or as necessary. Please also follow-up with your primary care physician. Provider [First Name8 (NamePattern2) 161] [Name9 (PRE) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 164] Date/Time:[2175-10-11] 1:00 Completed by:[2175-9-28]	Admission Date: <Date>1991-3-22</Date> Discharge Date: <Date>1961-10-25</Date> Date of Birth: <Date>1997-12-16</Date> Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Ava</Name> Chief Complaint: rectal bleeding following prostate biopsy Major Surgical or Invasive Procedure: 1. prostate biopsy 2. exam under anesthesia 3. ligation of post-prostate biopsy bleeding History of Present Illness: The patient is a 73-year-old man who underwent a prostate biopsy in <Hospital>Morris-Rivera Hospital</Hospital> clinic complicated by immediate significant bright red blood bleeding. Attempts were made to stop the bleeding with a dilating Foley balloon and Surgicel packing without success. He was admitted for surgical management of bleeding. Past Medical History: hyperlipidemia, coronary artery disease, prostate cancer, gout Social History: Retired as a waiter in a Chinese restaurant. Patient is an accomplished poet who has published works in Chinese. Daughter is nurse. Tobacco none ETOH: None Drugs: None Family History: non-contributory Physical Exam: VS T 98.5 HR 68 BP 91/52 RR 18 SpO2 98%RA\ Gen: NAD, AOx3 Cv: RRR Pulm: CTAB Abd: soft, non-tender Rectal: no gross blood Ext: warm Pertinent Results: <Date>1991-3-22</Date> 05:16PM BLOOD WBC-13.0# RBC-3.64 Hgb-11.8* Hct-33.7* MCV-93 MCH-32.5* MCHC-35.1* RDW-13.0 Plt Ct-138* <Date>1991-3-22</Date> 08:54PM BLOOD WBC-11.9* RBC-3.61* Hgb-11.8* Hct-33.7* MCV-93 MCH-32.7* MCHC-35.0 RDW-12.9 Plt Ct-143* <Date>1961-10-25</Date> 01:45AM BLOOD Hct-29.6* <Date>1961-10-25</Date> 05:30AM BLOOD WBC-10.1 RBC-3.07* Hgb-10.1* Hct-28.6* MCV-93 MCH-32.9* MCHC-35.3* RDW-13.4 Plt Ct-144* Brief Hospital Course: The patient was admitted to the surgery service for management of rectal bleeding following prostate biopsy. He underwent a rectal exam under anesthesia followed by ligation of the bleeding biopsy site. He tolerated the procedure well and recovered briefly in the PACU before being transferred to the floor. Please see the operative report for further details. His hospital course was relatively uneventful. N: His pain was managed initially with IV pain medicines and then transitioned to po medicines with issue Cv: stable, no issues Pulm: Excellent oxygen saturations on room air GI: overnight the patient passed clotted blood per rectum several times. This resolved on POD #1 and no bright red blood was observed. Serial hematocrit values were obtained and shown to be stable in the AM compared to the post-operative value. He was started on a clear liquid diet and was advanced to a regular diet without issues. GU: voided without difficulty HEME: stable as described above. No transfusions required. ID: afebrile without issues DISPO: The patient was no longer bleeding and felt to be stable. He was tolerating a regular diet, voiding, and ambulating appropriately. He was discharged home with follow-up instructions. Medications on Admission: allopurinol, finasteride, metoprolol, simvastatin Discharge Medications: 1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 5. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: rectal bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Followup Instructions: Please call the surgery clinic at <Telephone>173-222-7134</Telephone> to schedule follow-up with Dr. <Name>Shipley</Name> in <Date>9-18</Date> weeks or as necessary. Please also follow-up with your primary care physician. Provider <Name>Jamila</Name> <Name>Carol Tamaro</Name> <Name>Adam Amaro</Name>, MD Phone:<Telephone>557-255-4598</Telephone> Date/Time:<Date>1901-9-12</Date> 1:00 Completed by:<Date>1961-10-25</Date>	00000000000000000111111111000000000000000000000000000000001111111111000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111100000000000000000000000000000000111111100001111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111011111111111101111111111000000000001111111111110000000000011111111100000000000000000000001111111111	Admission Date: 1991-3-22 Discharge Date: 1961-10-25 Date of Birth: 1997-12-16 Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:Ava Chief Complaint: rectal bleeding following prostate biopsy Major Surgical or Invasive Procedure: 1. prostate biopsy 2. exam under anesthesia 3. ligation of post-prostate biopsy bleeding History of Present Illness: The patient is a 73-year-old man who underwent a prostate biopsy in Morris-Rivera Hospital clinic complicated by immediate significant bright red blood bleeding. Attempts were made to stop the bleeding with a dilating Foley balloon and Surgicel packing without success. He was admitted for surgical management of bleeding. Past Medical History: hyperlipidemia, coronary artery disease, prostate cancer, gout Social History: Retired as a waiter in a Chinese restaurant. Patient is an accomplished poet who has published works in Chinese. Daughter is nurse. Tobacco none ETOH: None Drugs: None Family History: non-contributory Physical Exam: VS T 98.5 HR 68 BP 91/52 RR 18 SpO2 98%RA\ Gen: NAD, AOx3 Cv: RRR Pulm: CTAB Abd: soft, non-tender Rectal: no gross blood Ext: warm Pertinent Results: 1991-3-22 05:16PM BLOOD WBC-13.0# RBC-3.64 Hgb-11.8* Hct-33.7* MCV-93 MCH-32.5* MCHC-35.1* RDW-13.0 Plt Ct-138* 1991-3-22 08:54PM BLOOD WBC-11.9* RBC-3.61* Hgb-11.8* Hct-33.7* MCV-93 MCH-32.7* MCHC-35.0 RDW-12.9 Plt Ct-143* 1961-10-25 01:45AM BLOOD Hct-29.6* 1961-10-25 05:30AM BLOOD WBC-10.1 RBC-3.07* Hgb-10.1* Hct-28.6* MCV-93 MCH-32.9* MCHC-35.3* RDW-13.4 Plt Ct-144* Brief Hospital Course: The patient was admitted to the surgery service for management of rectal bleeding following prostate biopsy. He underwent a rectal exam under anesthesia followed by ligation of the bleeding biopsy site. He tolerated the procedure well and recovered briefly in the PACU before being transferred to the floor. Please see the operative report for further details. His hospital course was relatively uneventful. N: His pain was managed initially with IV pain medicines and then transitioned to po medicines with issue Cv: stable, no issues Pulm: Excellent oxygen saturations on room air GI: overnight the patient passed clotted blood per rectum several times. This resolved on POD #1 and no bright red blood was observed. Serial hematocrit values were obtained and shown to be stable in the AM compared to the post-operative value. He was started on a clear liquid diet and was advanced to a regular diet without issues. GU: voided without difficulty HEME: stable as described above. No transfusions required. ID: afebrile without issues DISPO: The patient was no longer bleeding and felt to be stable. He was tolerating a regular diet, voiding, and ambulating appropriately. He was discharged home with follow-up instructions. Medications on Admission: allopurinol, finasteride, metoprolol, simvastatin Discharge Medications: 1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 5. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: rectal bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Followup Instructions: Please call the surgery clinic at 173-222-7134 to schedule follow-up with Dr. Shipley in 9-18 weeks or as necessary. Please also follow-up with your primary care physician. Provider Jamila Carol Tamaro Adam Amaro, MD Phone:557-255-4598 Date/Time:1901-9-12 1:00 Completed by:1961-10-25	['Admission Date: 1991-3-22 Discharge Date: 1961-10-25\n\nDate of Birth: 1997-12-16 Sex: M\n\nService: SURGERY\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Ava\nChief Complaint:\nrectal bleeding following prostate biopsy\n\nMajor Surgical or Invasive Procedure:\n1. prostate biopsy\n2. exam under anesthesia\n3. ligation of post-prostate biopsy bleeding\n\n\nHistory of Present Illness:\nThe patient is a 73-year-old man who underwent a prostate biopsy\nin Morris-Rivera Hospital clinic complicated by immediate significant bright\nred blood bleeding. Attempts were made to stop the bleeding with\na dilating Foley balloon and Surgicel packing without success.\nHe was admitted for surgical management of bleeding.\n\n\nPast Medical History:\nhyperlipidemia, coronary artery disease, prostate cancer, gout\n\nSocial History:\nRetired as a waiter in a Chinese restaurant.', ' Patient is an\naccomplished poet who has published works in Chinese. Daughter\nis nurse. Tobacco none ETOH: None Drugs: None\n\n\nFamily History:\nnon-contributory\n\nPhysical Exam:\nVS T 98.5 HR 68 BP 91/52 RR 18 SpO2 98%RA\\\nGen: NAD, AOx3\nCv: RRR\nPulm: CTAB\nAbd: soft, non-tender\nRectal: no gross blood\nExt: warm\n\nPertinent Results:\n1991-3-22 05:16PM BLOOD WBC-13.0# RBC-3.64 Hgb-11.8* Hct-33.7\nMCV-93 MCH-32.5 MCHC-35.1* RDW-13.0 Plt Ct-138\n1991-3-22 08:54PM BLOOD WBC-11.9 RBC-3.61* Hgb-11.8* Hct-33.7\nMCV-93 MCH-32.7 MCHC-35.0 RDW-12.9 Plt Ct-143\n1961-10-25 01:45AM BLOOD Hct-29.6\n1961-10-25 05:30AM BLOOD WBC-10.1 RBC-3.07* Hgb-10.1* Hct-28.6\nMCV-93 MCH-32.9 MCHC-35.3* RDW-13.4 Plt Ct-144\n\nBrief Hospital Course:\nThe patient was admitted to the surgery service for management\nof rectal bleeding following prostate biopsy.', ' He underwent a\nrectal exam under anesthesia followed by ligation of the\nbleeding biopsy site. He tolerated the procedure well and\nrecovered briefly in the PACU before being transferred to the\nfloor. Please see the operative report for further details. His\nhospital course was relatively uneventful.\n\nN: His pain was managed initially with IV pain medicines and\nthen transitioned to po medicines with issue\nCv: stable, no issues\nPulm: Excellent oxygen saturations on room air\nGI: overnight the patient passed clotted blood per rectum\nseveral times. This resolved on POD #1 and no bright red blood\nwas observed. Serial hematocrit values were obtained and shown\nto be stable in the AM compared to the post-operative value. He\nwas started on a clear liquid diet and was advanced to a regular\ndiet without issues.', '\nGU: voided without difficulty\nHEME: stable as described above. No transfusions required.\nID: afebrile without issues\nDISPO: The patient was no longer bleeding and felt to be stable.\nHe was tolerating a regular diet, voiding, and ambulating\nappropriately. He was discharged home with follow-up\ninstructions.\n\n\nMedications on Admission:\nallopurinol, finasteride, metoprolol, simvastatin\n\nDischarge Medications:\n1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\nTablet(s)\n2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:\nOne (1) Tablet Extended Release 24 hr PO DAILY (Daily).\n3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY\n(Daily).\n4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\nhours) as needed for pain/fever.\n5. allopurinol 100 mg Tablet Sig: 1.', '5 Tablets PO DAILY (Daily).\n\n6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as\nneeded for pain.\nDisp:45 Tablet(s)* Refills:0\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nrectal bleeding\n\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n\nDischarge Instructions:\nPlease resume all regular home medications, unless specifically\nadvised not to take a particular medication. Please take any\nnew medications as prescribed.\nPlease take the prescribed analgesic medications as needed. You\nmay not drive or heavy machinery while taking narcotic analgesic\nmedications. You may also take acetaminophen (Tylenol) as\ndirected, but do not exceed 4000 mg in one day.\nPlease get plenty of rest, continue to walk several times per\nday, and drink adequate amounts of fluids.', ' Avoid strenuous\nphysical activity and refrain from heavy lifting greater than 20\nlbs., until you follow-up with your surgeon, who will instruct\nyou further regarding activity restrictions. Please also\nfollow-up with your primary care physician.\n\n\nFollowup Instructions:\nPlease call the surgery clinic at 173-222-7134 to schedule\nfollow-up with Dr. Shipley in 9-18 weeks or as necessary. Please\nalso follow-up with your primary care physician.\n\nProvider Jamila Carol Tamaro Adam Amaro, MD Phone:557-255-4598\nDate/Time:1901-9-12 1:00\n\n\n\nCompleted by:1961-10-25']
12	60614	116703.0	2175-10-04	Discharge summary	Report	Admission Date: [2175-9-29] Discharge Date: [2175-10-4] Date of Birth: [2101-11-11] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: angina and STEMI Major Surgical or Invasive Procedure: [2175-9-29] cardiac cath [2175-9-29] CABG X5 (LIMA to LAD, SVG to DIAG, SVG to OM1>OM2; SVG to PDA) with pre-op IABP History of Present Illness: Mr. [Known lastname 166] is a 73 yo who underwent a prostate biopsy and OR for ligation of post prostate biopsy bleeding on [9-27] and was discharged on [9-28]. He awoke in the morning of [9-29] about 2am with crushing substernal chest pain. He presented to the ED with a STEMI and was taken emergently to the cath lab. He was found to have severe 3 vessel CAD. IABP was placed to support hemodynamics. Cardiac Surgery is consulted for surgical revascularization. Past Medical History: hyperlipidemia, coronary artery disease, prostate cancer, gout Social History: Retired as a waiter in a Chinese restaurant. Patient is an accomplished poet who has published works in Chinese. Daughter is nurse. Tobacco none ETOH: None Drugs: None Family History: non-contributory Physical Exam: Pulse: 81 SR Resp: 16 O2 sat: 98% B/P Right: Left: 118/59 Height: 5'4" Weight: 65lb Five Meter Walk Test: Bedrest (IABP) General: NAD, WGWN, supine with IABP Skin: Dry [x] intact [x] no rash HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right: 1+ Left:1+ PT [Name (NI) 167]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: no bruits Pertinent Results: Conclusions PRE-BYPASS: -No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. -No atrial septal defect is seen by 2D or color Doppler. - Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). -There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. -There is an intra-aortic balloon pump in the descending aorta with the tip termintating 3cm distal to the left subclavian artery. -The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Mild to moderate ([1-15]+) aortic regurgitation is seen. -The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. -There is a small pericardial effusion. -There is a left pleural effusion. POSTBYPASS: I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD, Interpreting physician [2175-10-4] 05:42AM BLOOD WBC-6.8 RBC-3.50* Hgb-11.0* Hct-30.7* MCV-88 MCH-31.5 MCHC-36.0* RDW-15.1 Plt Ct-130* [2175-10-3] 04:12AM BLOOD WBC-8.4 RBC-3.74* Hgb-11.3* Hct-32.5* MCV-87 MCH-30.3 MCHC-34.9 RDW-15.1 Plt Ct-128* [2175-10-2] 01:25AM BLOOD PT-12.4 PTT-30.7 INR(PT)-1.0 [2175-10-1] 01:28PM BLOOD PT-13.1 PTT-34.3 INR(PT)-1.1 [2175-10-4] 05:42AM BLOOD Glucose-120* UreaN-39* Creat-1.1 Na-141 K-3.7 Cl-105 HCO3-28 AnGap-12 [2175-10-3] 08:16PM BLOOD Na-144 K-3.4 Cl-106 [2175-10-3] 04:12AM BLOOD Glucose-131* UreaN-39* Creat-1.3* Na-146* K-3.6 Cl-106 HCO3-30 AnGap-14 Brief Hospital Course: Admitted to CCU after emergency cardiac cath/IABP placement. Pre-op w/u completed and taken to the OR directly for surgery with Dr. [First Name (STitle) ]. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. The patient was loaded with Plavix pre-cath, on the day of surgery. Out of the OR, he was coagulopathic, requiring multiple blood products. Hemodynamics improved and vasoactive drips were weaned by POD 1. The IABP was weaned and discontinued on POD 2. The patient was aggressively diuresed and extubated on POD 3. Beta blocker was initiated and titrated as tolerated. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. Norvasc and Lisinopril were added for hypertension. The patient has poor targets, and Plavix was initiated. By the time of discharge on POD 5 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [Hospital 169] Center of [Location (un) 55] in good condition with appropriate follow up instructions. Medications on Admission: allopurinol 300mg daily finasteride 5mg daily metoprolol succinate 50mg daily simvastatin 80mg daily aspirin Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for poor targets. 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 10 days. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: coronary artery disease s/p cabg x5 hyperlipidemia prostate CA gout Past Surgical History s/p prostate biopsy and surgery for ligation of bleeding [9-27] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [First Name (STitle) ] [Telephone/Fax (1) 170] Date/Time:[2175-11-6] 1:00 Cardiologist:Dr. [Last Name (STitle) 171] [Telephone/Fax (1) 62] Date/Time:[2175-12-11] 8:00 Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 172] [Telephone/Fax (1) 133] in [4-18] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2175-10-4]	Admission Date: <Date>1916-5-4</Date> Discharge Date: <Date>1973-11-24</Date> Date of Birth: <Date>1931-8-22</Date> Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:<Name>Alexander</Name> Chief Complaint: angina and STEMI Major Surgical or Invasive Procedure: <Date>1916-5-4</Date> cardiac cath <Date>1916-5-4</Date> CABG X5 (LIMA to LAD, SVG to DIAG, SVG to OM1>OM2; SVG to PDA) with pre-op IABP History of Present Illness: Mr. <Name>Loveland</Name> is a 73 yo who underwent a prostate biopsy and OR for ligation of post prostate biopsy bleeding on <Date>8-8</Date> and was discharged on <Date>10-8</Date>. He awoke in the morning of <Date>8-9</Date> about 2am with crushing substernal chest pain. He presented to the ED with a STEMI and was taken emergently to the cath lab. He was found to have severe 3 vessel CAD. IABP was placed to support hemodynamics. Cardiac Surgery is consulted for surgical revascularization. Past Medical History: hyperlipidemia, coronary artery disease, prostate cancer, gout Social History: Retired as a waiter in a Chinese restaurant. Patient is an accomplished poet who has published works in Chinese. Daughter is nurse. Tobacco none ETOH: None Drugs: None Family History: non-contributory Physical Exam: Pulse: 81 SR Resp: 16 O2 sat: 98% B/P Right: Left: 118/59 Height: 5'4" Weight: 65lb Five Meter Walk Test: Bedrest (IABP) General: NAD, WGWN, supine with IABP Skin: Dry [x] intact [x] no rash HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right: 1+ Left:1+ PT <Name>Uma Scheet</Name>: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: no bruits Pertinent Results: Conclusions PRE-BYPASS: -No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. -No atrial septal defect is seen by 2D or color Doppler. - Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). -There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. -There is an intra-aortic balloon pump in the descending aorta with the tip termintating 3cm distal to the left subclavian artery. -The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Mild to moderate (<Date>4-31</Date>+) aortic regurgitation is seen. -The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. -There is a small pericardial effusion. -There is a left pleural effusion. POSTBYPASS: I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to <Name>Chad</Name> <Name>Abdullah</Name>, MD, Interpreting physician <Date>1973-11-24</Date> 05:42AM BLOOD WBC-6.8 RBC-3.50* Hgb-11.0* Hct-30.7* MCV-88 MCH-31.5 MCHC-36.0* RDW-15.1 Plt Ct-130* <Date>1925-8-12</Date> 04:12AM BLOOD WBC-8.4 RBC-3.74* Hgb-11.3* Hct-32.5* MCV-87 MCH-30.3 MCHC-34.9 RDW-15.1 Plt Ct-128* <Date>1976-9-21</Date> 01:25AM BLOOD PT-12.4 PTT-30.7 INR(PT)-1.0 <Date>1990-12-4</Date> 01:28PM BLOOD PT-13.1 PTT-34.3 INR(PT)-1.1 <Date>1973-11-24</Date> 05:42AM BLOOD Glucose-120* UreaN-39* Creat-1.1 Na-141 K-3.7 Cl-105 HCO3-28 AnGap-12 <Date>1925-8-12</Date> 08:16PM BLOOD Na-144 K-3.4 Cl-106 <Date>1925-8-12</Date> 04:12AM BLOOD Glucose-131* UreaN-39* Creat-1.3* Na-146* K-3.6 Cl-106 HCO3-30 AnGap-14 Brief Hospital Course: Admitted to CCU after emergency cardiac cath/IABP placement. Pre-op w/u completed and taken to the OR directly for surgery with Dr. <Name>Diane</Name>. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. The patient was loaded with Plavix pre-cath, on the day of surgery. Out of the OR, he was coagulopathic, requiring multiple blood products. Hemodynamics improved and vasoactive drips were weaned by POD 1. The IABP was weaned and discontinued on POD 2. The patient was aggressively diuresed and extubated on POD 3. Beta blocker was initiated and titrated as tolerated. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. Norvasc and Lisinopril were added for hypertension. The patient has poor targets, and Plavix was initiated. By the time of discharge on POD 5 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to <Hospital>Martinez LLC Hospital</Hospital> Center of <Location>478 Joseph Mission Apt. 352 East Madison, OR 61917</Location> in good condition with appropriate follow up instructions. Medications on Admission: allopurinol 300mg daily finasteride 5mg daily metoprolol succinate 50mg daily simvastatin 80mg daily aspirin Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for poor targets. 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 10 days. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: coronary artery disease s/p cabg x5 hyperlipidemia prostate CA gout Past Surgical History s/p prostate biopsy and surgery for ligation of bleeding <Date>8-8</Date> Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns <Telephone>340-527-7593</Telephone> Please call cardiac surgery office with any questions or concerns <Telephone>340-527-7593</Telephone>. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. <Name>Diane</Name> <Telephone>340-527-7593</Telephone> Date/Time:<Date>1972-1-15</Date> 1:00 Cardiologist:Dr. <Name>Chin</Name> <Telephone>609-282-8821</Telephone> Date/Time:<Date>1955-8-16</Date> 8:00 Please call to schedule appointments with your Primary Care Dr. <Name>Chin</Name> <Telephone>930-443-6355</Telephone> in <Date>5-31</Date> weeks Please call cardiac surgery office with any questions or concerns <Telephone>340-527-7593</Telephone>. Answering service will contact on call person during off hours <Name>Bryan Chin</Name> <Name>Ulysses Negrete</Name> MD <MD Number>90394718</MD Number> Completed by:<Date>1973-11-24</Date>	0000000000000000011111111000000000000000000000000000000001111111111000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000111111110000000000000000000000000000000000000000000000>00000000000000000000000000000000000000000000000000000000000000000000111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111000000000000000000000001111000000000000000000000000000000111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000>000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111101111111100000000000000000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111110000000000011111111111111111111111111111111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1916-5-4 Discharge Date: 1973-11-24 Date of Birth: 1931-8-22 Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:Alexander Chief Complaint: angina and STEMI Major Surgical or Invasive Procedure: 1916-5-4 cardiac cath 1916-5-4 CABG X5 (LIMA to LAD, SVG to DIAG, SVG to OM1>OM2; SVG to PDA) with pre-op IABP History of Present Illness: Mr. Loveland is a 73 yo who underwent a prostate biopsy and OR for ligation of post prostate biopsy bleeding on 8-8 and was discharged on 10-8. He awoke in the morning of 8-9 about 2am with crushing substernal chest pain. He presented to the ED with a STEMI and was taken emergently to the cath lab. He was found to have severe 3 vessel CAD. IABP was placed to support hemodynamics. Cardiac Surgery is consulted for surgical revascularization. Past Medical History: hyperlipidemia, coronary artery disease, prostate cancer, gout Social History: Retired as a waiter in a Chinese restaurant. Patient is an accomplished poet who has published works in Chinese. Daughter is nurse. Tobacco none ETOH: None Drugs: None Family History: non-contributory Physical Exam: Pulse: 81 SR Resp: 16 O2 sat: 98% B/P Right: Left: 118/59 Height: 5'4" Weight: 65lb Five Meter Walk Test: Bedrest (IABP) General: NAD, WGWN, supine with IABP Skin: Dry [x] intact [x] no rash HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right: 1+ Left:1+ PT Uma Scheet: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: no bruits Pertinent Results: Conclusions PRE-BYPASS: -No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. -No atrial septal defect is seen by 2D or color Doppler. - Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). -There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. -There is an intra-aortic balloon pump in the descending aorta with the tip termintating 3cm distal to the left subclavian artery. -The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Mild to moderate (4-31+) aortic regurgitation is seen. -The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. -There is a small pericardial effusion. -There is a left pleural effusion. POSTBYPASS: I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to Chad Abdullah, MD, Interpreting physician 1973-11-24 05:42AM BLOOD WBC-6.8 RBC-3.50* Hgb-11.0* Hct-30.7* MCV-88 MCH-31.5 MCHC-36.0* RDW-15.1 Plt Ct-130* 1925-8-12 04:12AM BLOOD WBC-8.4 RBC-3.74* Hgb-11.3* Hct-32.5* MCV-87 MCH-30.3 MCHC-34.9 RDW-15.1 Plt Ct-128* 1976-9-21 01:25AM BLOOD PT-12.4 PTT-30.7 INR(PT)-1.0 1990-12-4 01:28PM BLOOD PT-13.1 PTT-34.3 INR(PT)-1.1 1973-11-24 05:42AM BLOOD Glucose-120* UreaN-39* Creat-1.1 Na-141 K-3.7 Cl-105 HCO3-28 AnGap-12 1925-8-12 08:16PM BLOOD Na-144 K-3.4 Cl-106 1925-8-12 04:12AM BLOOD Glucose-131* UreaN-39* Creat-1.3* Na-146* K-3.6 Cl-106 HCO3-30 AnGap-14 Brief Hospital Course: Admitted to CCU after emergency cardiac cath/IABP placement. Pre-op w/u completed and taken to the OR directly for surgery with Dr. Diane. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. The patient was loaded with Plavix pre-cath, on the day of surgery. Out of the OR, he was coagulopathic, requiring multiple blood products. Hemodynamics improved and vasoactive drips were weaned by POD 1. The IABP was weaned and discontinued on POD 2. The patient was aggressively diuresed and extubated on POD 3. Beta blocker was initiated and titrated as tolerated. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. Norvasc and Lisinopril were added for hypertension. The patient has poor targets, and Plavix was initiated. By the time of discharge on POD 5 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Martinez LLC Hospital Center of 478 Joseph Mission Apt. 352 East Madison, OR 61917 in good condition with appropriate follow up instructions. Medications on Admission: allopurinol 300mg daily finasteride 5mg daily metoprolol succinate 50mg daily simvastatin 80mg daily aspirin Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for poor targets. 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 10 days. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: coronary artery disease s/p cabg x5 hyperlipidemia prostate CA gout Past Surgical History s/p prostate biopsy and surgery for ligation of bleeding 8-8 Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns 340-527-7593 Please call cardiac surgery office with any questions or concerns 340-527-7593. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. Diane 340-527-7593 Date/Time:1972-1-15 1:00 Cardiologist:Dr. Chin 609-282-8821 Date/Time:1955-8-16 8:00 Please call to schedule appointments with your Primary Care Dr. Chin 930-443-6355 in 5-31 weeks Please call cardiac surgery office with any questions or concerns 340-527-7593. Answering service will contact on call person during off hours Bryan Chin Ulysses Negrete MD 90394718 Completed by:1973-11-24	['Admission Date: 1916-5-4 Discharge Date: 1973-11-24\n\nDate of Birth: 1931-8-22 Sex: M\n\nService: CARDIOTHORACIC\n\nAllergies:\nNo Known Allergies / Adverse Drug Reactions\n\nAttending:Alexander\nChief Complaint:\nangina and STEMI\n\nMajor Surgical or Invasive Procedure:\n1916-5-4 cardiac cath\n1916-5-4 CABG X5 (LIMA to LAD, SVG to DIAG, SVG to OM1>OM2; SVG\nto PDA) with pre-op IABP\n\n\nHistory of Present Illness:\nMr. Loveland is a 73 yo who underwent a\nprostate biopsy and OR for ligation of post prostate biopsy\nbleeding on 8-8 and was discharged on 10-8. He awoke in the\nmorning of 8-9 about 2am with crushing substernal chest pain.\nHe presented to the ED with a STEMI and was taken emergently to\nthe cath lab. He was found to have severe 3 vessel CAD. IABP\nwas placed to support hemodynamics.', ' Cardiac Surgery is\nconsulted\nfor surgical revascularization.\n\n\nPast Medical History:\nhyperlipidemia, coronary artery disease, prostate cancer, gout\n\nSocial History:\nRetired as a waiter in a Chinese restaurant. Patient is an\naccomplished poet who has published works in Chinese. Daughter\nis nurse. Tobacco none ETOH: None Drugs: None\n\n\nFamily History:\nnon-contributory\n\nPhysical Exam:\nPulse: 81 SR Resp: 16 O2 sat: 98%\nB/P Right: Left: 118/59\nHeight: 5\'4" Weight: 65lb\n\nFive Meter Walk Test: Bedrest (IABP)\n\nGeneral: NAD, WGWN, supine with IABP\nSkin: Dry [x] intact [x] no rash\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [] grade ______\nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+ [x]\nExtremities: Warm [x], well-perfused [x]\nEdema [] none\nVaricosities: None [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: Left:\nDP Right: 1+ Left:1+\nPT Uma Scheet: 1+ Left:1+\nRadial Right: 2+ Left:2+\n\nCarotid Bruit Right: Left:\nno bruits\n\n\nPertinent Results:\nConclusions\nPRE-BYPASS:\n-No spontaneous echo contrast or thrombus is seen in the body of\nthe left atrium or left atrial appendage.', '\n-No atrial septal defect is seen by 2D or color Doppler.\n- Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Left ventricular systolic\nfunction is hyperdynamic (EF>75%).\n-There are simple atheroma in the aortic arch. There are simple\natheroma in the descending thoracic aorta.\n-There is an intra-aortic balloon pump in the descending aorta\nwith the tip termintating 3cm distal to the left subclavian\nartery.\n-The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. There is no aortic valve stenosis. Mild\nto moderate (4-31+) aortic regurgitation is seen.\n-The mitral valve leaflets are mildly thickened. Mild (1+)\nmitral regurgitation is seen.\n-There is a small pericardial effusion.\n-There is a left pleural effusion.\n\nPOSTBYPASS:\n I certify that I was present for this procedure in compliance\nwith HCFA regulations.', '\n\nInterpretation assigned to Chad Abdullah, MD, Interpreting\nphysician\n\n1973-11-24 05:42AM BLOOD WBC-6.8 RBC-3.50* Hgb-11.0* Hct-30.7\nMCV-88 MCH-31.5 MCHC-36.0 RDW-15.1 Plt Ct-130\n1925-8-12 04:12AM BLOOD WBC-8.4 RBC-3.74 Hgb-11.3* Hct-32.5\nMCV-87 MCH-30.3 MCHC-34.9 RDW-15.1 Plt Ct-128\n1976-9-21 01:25AM BLOOD PT-12.4 PTT-30.7 INR(PT)-1.0\n1990-12-4 01:28PM BLOOD PT-13.1 PTT-34.3 INR(PT)-1.1\n1973-11-24 05:42AM BLOOD Glucose-120* UreaN-39* Creat-1.1 Na-141\nK-3.7 Cl-105 HCO3-28 AnGap-12\n1925-8-12 08:16PM BLOOD Na-144 K-3.4 Cl-106\n1925-8-12 04:12AM BLOOD Glucose-131* UreaN-39* Creat-1.3* Na-146\nK-3.6 Cl-106 HCO3-30 AnGap-14\n\nBrief Hospital Course:\nAdmitted to CCU after emergency cardiac cath/IABP placement.\nPre-op w/u completed and taken to the OR directly for surgery\nwith Dr. Diane. Transferred to the CVICU in stable condition on\ntitrated phenylephrine and propofol drips.', ' The patient was\nloaded with Plavix pre-cath, on the day of surgery. Out of the\nOR, he was coagulopathic, requiring multiple blood products.\nHemodynamics improved and vasoactive drips were weaned by POD 1.\n The IABP was weaned and discontinued on POD 2. The patient was\naggressively diuresed and extubated on POD 3. Beta blocker was\ninitiated and titrated as tolerated. The patient was\ntransferred to the telemetry floor for further recovery. Chest\ntubes and pacing wires were discontinued without complication.\nThe patient was evaluated by the physical therapy service for\nassistance with strength and mobility. Norvasc and Lisinopril\nwere added for hypertension. The patient has poor targets, and\nPlavix was initiated. By the time of discharge on POD 5 the\npatient was ambulating with assistance, the wound was healing\nand pain was controlled with oral analgesics.', ' The patient was\ndischarged to Martinez LLC Hospital Center of 478 Joseph Mission Apt. 352\nEast Madison, OR 61917 in good\ncondition with appropriate follow up instructions.\n\nMedications on Admission:\nallopurinol 300mg daily\nfinasteride 5mg daily\nmetoprolol succinate 50mg daily\nsimvastatin 80mg daily\naspirin\n\n\nDischarge Medications:\n1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)\nas needed for poor targets.\n2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\nML PO HS (at bedtime) as needed for constipation.\n4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\ntimes a day).\n5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every\n4 hours) as needed for pain, fever.\n6. aspirin 81 mg Tablet, Delayed Release (E.', 'C.) Sig: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\n7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY\n(Daily).\n8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).\n\n9. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY\n(Daily).\n10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO\nTID (3 times a day).\n11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal\nDAILY (Daily) as needed for constipation.\n12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).\n13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day\nfor 10 days.\n14. potassium chloride 10 mEq Tablet Extended Release Sig: Two\n(2) Tablet Extended Release PO once a day for 10 days.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\ntba\n\nDischarge Diagnosis:\ncoronary artery disease s/p cabg x5\nhyperlipidemia\nprostate CA\ngout\nPast Surgical History\ns/p prostate biopsy and surgery for ligation of bleeding 8-8\n\n\nDischarge Condition:\nAlert and oriented x3 nonfocal\nAmbulating, deconditioned\nIncisional pain managed with oral analgesics\nIncisions:\nSternal - healing well, no erythema or drainage\nLeg Left - healing well, no erythema or drainage.', '\nEdema 1+\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\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 and while taking\nnarcotics, will be discussed at follow up appointment with\nsurgeon when you will be able to drive\nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns 340-527-7593\nPlease call cardiac surgery office with any questions or\nconcerns 340-527-7593. Answering service will contact on call\nperson during off hours\n\n\nFollowup Instructions:\nYou are scheduled for the following appointments\nSurgeon: Dr.', ' Diane 340-527-7593 Date/Time:1972-1-15 1:00\nCardiologist:Dr. Chin 609-282-8821 Date/Time:1955-8-16 8:00\n\nPlease call to schedule appointments with your\nPrimary Care Dr. Chin 930-443-6355 in 5-31 weeks\n\nPlease call cardiac surgery office with any questions or\nconcerns 340-527-7593. Answering service will contact on call\nperson during off hours*\n\n\n Bryan Chin Ulysses Negrete MD 90394718\n\nCompleted by:1973-11-24']
13	15472	169182.0	2175-07-29	Discharge summary	Report	Admission Date: [2175-7-11] Discharge Date: [2175-7-29] Date of Birth: [2114-2-8] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with a past medical history significant for right upper lobe small cell cancer stage III, status post chemotherapy and radiation, status post right upper lobe sleeve resection [6-19], also with past medical history significant for diabetes mellitus, hypertension, prostate cancer status post radical prostatectomy, GERD, TIA 15 years ago, gout and COPD. The patient has no known drug allergies. The patient is status post right upper lobe lung sleeve resection on [6-19] for small cell lung cancer. The patient was discharged home doing well until four days prior to admission when he presented to the Emergency Room with shortness of breath and fevers. The patient was given Levaquin and was then discharged home again. He continued having shortness of breath and productive cough. He was admitted [7-11] for a follow-up bronchoscopy during which time they found a right middle lobe obstruction secondary to swelling. After the procedure the patient had shortness of breath with an oxygen saturation of 88 as well as rigors and chills. The patient was also found to have poor color. The patient's O2 saturation improved. Chest x-ray was obtained and the patient was admitted. The patient underwent surgery [2175-7-15]. The patient underwent completion pneumonectomy, bronchoscopy and serratus flap closure of right main stem bronchus. Postoperative day #1 the patient was afebrile with heart rate of 56, blood pressure 104/56, satting at 99%. Chest tube output 500 cc. Last gas 7.33, 56, 152, 31 and 100%. On exam lungs were clear to auscultation bilaterally. Incision, dressings were clean, dry and intact. Heart was regular rate and rhythm. Abdomen was soft, nontender, non distended. Extremities had no swelling. White count 13.4, hematocrit 38.5, platelet count 394,000, potassium 4.8, BUN 13, creatinine .6 with glucose of 188, magnesium 1.8 and CPK of 1410. Plan was to wean the oxygen and check an ABG later on and continue the pneumonectomy tube. To check an EKG because of the EKG change this morning in which patient had ST segment elevations, undergo rule out MI protocol. Postoperative day #2 the patient had no events over the last 24 hours, patient remained afebrile. Heart rate 60, normal sinus rhythm, blood pressure 105/58, satting at 97% on four liters, last gas 7.39, 52, 96, 33. Laboratory data revealed white count 13.2, hematocrit 33.8, platelet count 322,000, PT 12.9, PTT 25.7, INR 1.1, potassium 4.7, BUN 15, creatinine .5 with glucose 158 and magnesium 1.7. CK, 840. Chest x-ray pending. Physical exam was benign. Plan was to administer Lasix today after transfer to the floor. Infectious disease came by to see the patient postop day #2 as well because they were requested to recommend an antibiotic for the right infiltrate to prevent the possibility of a postoperative empyema. Their recommendation was to continue with the current IV antibiotics. Clindamycin and Ceftriaxone will be present. In the remote chance of postoperative infection empyema these antibiotics will be present in the cavity and also by peripheral circulation. Postoperative day #3, events over the last 24 hours include atrial fibrillation. Patient mildly febrile at 99.2, heart rate 57 and sinus rhythm, blood pressure 102/42, respirations 14, satting at 97% on four liters, last gas 7.47, 46, 86, 34, 8 and 97%. White count 10.9, hematocrit 31.5, platelet count 331,000, INR 1.1, PTT 28, potassium 3.9, BUN 14, creatinine .5, glucose 141. Physical exam was benign. Plan was to check the PT, PTT and to get a chest x-ray today and to continue 20 mg of Lasix. ID came by to see the patient again today at which time they stated that the patient is already on broad coverage for the lung abscess. Strep and staff improving, the tubes will be discontinued after the antibiotics. Follow-up of sensitivities on the culture and anticipate a three week course of antibiotics. Postoperative day #4, events overnight include a bronchoscopy which was negative for fistula. Stump was intact, positive secretions. The patient remained afebrile with a heart rate of 57, sinus rhythm, sinus brady. Blood pressure 136/68, satting at 100% on 4 liters nasal cannula. White count 8.8, hematocrit 29.8, platelet count 375,000, cultures from [7-15] grew out streptococcus, coag positive staph. Physical exam was benign. ID again came by to see the patient at which time they stated that they were awaiting final staph aureus sensitivities before providing the direction of therapy. Postoperative day #5 the patient remained afebrile, heart rate 65 and sinus, blood pressure 106/60, satting at 95% on room air. Chest tubes were discontinued. Urine output 1700. Physical exam was benign. White count 10.9, hematocrit 31.5, platelet count 337,000, potassium 3.9, BUN 14, creatinine .5 with a glucose of 141, magnesium 2.1. Postoperative day #6 on Ceftriaxone and Clindamycin overnight events include atrial fibrillation and heparinization for possible PE and a chest CT scan. Patient on Amio and Heparin, afebrile, heart rate 108 and atrial fibrillation, blood pressure 96/68, satting at 97% on three liters. Hematocrit 37, PTT 28.4, potassium 4.2. Physical exam, lungs were irregularly irregular, otherwise unremarkable. Postoperative day #7 the patient remained afebrile, heart rate 56, blood pressure 109/65, satting at 97% on two liters. On Lopressor, Lasix, Ceftriaxone, Clindamycin and Amiodarone, PTT of 28. Physical exam unremarkable. The day prior the patient underwent a spiral CT of the chest to rule out a PE. There was radiographic evidence for peripheral pulmonary emboli in the left lung, patient on Heparin. ID again came by to see the patient at which time they stated that the patient was clinically stable from an ID perspective and to continue the antibiotic regimen for a total of 14 days. If the patient spikes a fever they were to be consulted again. Postoperative day #8 the patient remained afebrile, vital signs stable, blood pressure 116/74, satting at 99% on 4 liters. Exam was benign. Plan was to check the PTT. Patient is still on Heparin. Postoperative day #9 the patient remained afebrile with a heart rate of 63 and sinus rhythm, respirations 18, satting at 96% on 3 liters, blood pressure 122/70. The patient was on Heparin, Lopressor, Amiodarone, Clindamycin, Ceftriaxone and Coumadin. On physical exam, exam was benign. Plan was to check the INR, PTT and to continue aggressive pulmonary PT. Postoperative day #9, overnight events include atrial fibrillation times one and an unchanged cough. The patient remained afebrile with heart rate of 55 and sinus brady, respirations 20, satting at 95% on three liters, blood pressure 139/88, white count 9.7, hematocrit 33, platelet count 490,000, potassium 4.6, BUN 8, creatinine .6 and glucose 115. Patient on Heparin, Coumadin, Lopressor, Amiodarone, Lidocaine, Xanax. Exam still remained unchanged. Postoperative day #10, overnight events included atrial fibrillation and a cough which is improving. The patient was afebrile, heart rate 63, respirations 22, satting at 90% on three liters with a blood pressure of 149/78, hematocrit 34.6, BUN 8, creatinine .6, PT 16.5, PTT 83.5 with INR 1.8. Patient on Heparin, Lidocaine, Coumadin, Xanax, Amiodarone. Exam, decreased breath sounds with crackles of the chest. Continue current management. Postoperative day #11 the patient remained afebrile with a heart rate of 62, respirations 18, satting at 94% on two liters, blood pressure 96/59, white count 8.5, hematocrit 30, PT 17.6, PTT 113, INR 2.1. Patient on Coumadin, Lopressor, Amiodarone, Xanax and Lidocaine. Exam remained unremarkable. Plan was to set up home VNA and chest x-ray today. Patient was discharged on [2175-7-29]. DISCHARGE DIAGNOSIS: 1. Right middle lobe abscess. DISCHARGE MEDICATIONS: The patient was stable on discharge and was discharged home on the following medications: Percocet 1-2 tablets po q 4 hours, Robitussin AC 10 cc po q 4 hours, Ambien 10 mg po q h.s., Glyburide 5 mg po q a.m., Amiodarone 400 mg po tid for two days, then 400 mg po bid for 7 days, then 400 mg po q a.m. for 7 days, Lopressor 12.5 mg po bid, Coumadin 2.5 mg po q h.s. and adjust to keep the INR around 2 to 2.5. [Known firstname 177] [Last Name (NamePattern4) 178], M.D. [MD Number(1) 179] Dictated By:[Doctor Last Name 182] MEDQUIST36 D: [2175-10-11] 11:01 T: [2175-10-12] 12:51 JOB#: [Job Number 183]	Admission Date: <Date>2005-5-17</Date> Discharge Date: <Date>1957-12-9</Date> Date of Birth: <Date>1979-3-17</Date> Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with a past medical history significant for right upper lobe small cell cancer stage III, status post chemotherapy and radiation, status post right upper lobe sleeve resection <Date>2-3</Date>, also with past medical history significant for diabetes mellitus, hypertension, prostate cancer status post radical prostatectomy, GERD, TIA 15 years ago, gout and COPD. The patient has no known drug allergies. The patient is status post right upper lobe lung sleeve resection on <Date>2-3</Date> for small cell lung cancer. The patient was discharged home doing well until four days prior to admission when he presented to the Emergency Room with shortness of breath and fevers. The patient was given Levaquin and was then discharged home again. He continued having shortness of breath and productive cough. He was admitted <Date>10-8</Date> for a follow-up bronchoscopy during which time they found a right middle lobe obstruction secondary to swelling. After the procedure the patient had shortness of breath with an oxygen saturation of 88 as well as rigors and chills. The patient was also found to have poor color. The patient's O2 saturation improved. Chest x-ray was obtained and the patient was admitted. The patient underwent surgery <Date>1930-3-8</Date>. The patient underwent completion pneumonectomy, bronchoscopy and serratus flap closure of right main stem bronchus. Postoperative day #1 the patient was afebrile with heart rate of 56, blood pressure 104/56, satting at 99%. Chest tube output 500 cc. Last gas 7.33, 56, 152, 31 and 100%. On exam lungs were clear to auscultation bilaterally. Incision, dressings were clean, dry and intact. Heart was regular rate and rhythm. Abdomen was soft, nontender, non distended. Extremities had no swelling. White count 13.4, hematocrit 38.5, platelet count 394,000, potassium 4.8, BUN 13, creatinine .6 with glucose of 188, magnesium 1.8 and CPK of 1410. Plan was to wean the oxygen and check an ABG later on and continue the pneumonectomy tube. To check an EKG because of the EKG change this morning in which patient had ST segment elevations, undergo rule out MI protocol. Postoperative day #2 the patient had no events over the last 24 hours, patient remained afebrile. Heart rate 60, normal sinus rhythm, blood pressure 105/58, satting at 97% on four liters, last gas 7.39, 52, 96, 33. Laboratory data revealed white count 13.2, hematocrit 33.8, platelet count 322,000, PT 12.9, PTT 25.7, INR 1.1, potassium 4.7, BUN 15, creatinine .5 with glucose 158 and magnesium 1.7. CK, 840. Chest x-ray pending. Physical exam was benign. Plan was to administer Lasix today after transfer to the floor. Infectious disease came by to see the patient postop day #2 as well because they were requested to recommend an antibiotic for the right infiltrate to prevent the possibility of a postoperative empyema. Their recommendation was to continue with the current IV antibiotics. Clindamycin and Ceftriaxone will be present. In the remote chance of postoperative infection empyema these antibiotics will be present in the cavity and also by peripheral circulation. Postoperative day #3, events over the last 24 hours include atrial fibrillation. Patient mildly febrile at 99.2, heart rate 57 and sinus rhythm, blood pressure 102/42, respirations 14, satting at 97% on four liters, last gas 7.47, 46, 86, 34, 8 and 97%. White count 10.9, hematocrit 31.5, platelet count 331,000, INR 1.1, PTT 28, potassium 3.9, BUN 14, creatinine .5, glucose 141. Physical exam was benign. Plan was to check the PT, PTT and to get a chest x-ray today and to continue 20 mg of Lasix. ID came by to see the patient again today at which time they stated that the patient is already on broad coverage for the lung abscess. Strep and staff improving, the tubes will be discontinued after the antibiotics. Follow-up of sensitivities on the culture and anticipate a three week course of antibiotics. Postoperative day #4, events overnight include a bronchoscopy which was negative for fistula. Stump was intact, positive secretions. The patient remained afebrile with a heart rate of 57, sinus rhythm, sinus brady. Blood pressure 136/68, satting at 100% on 4 liters nasal cannula. White count 8.8, hematocrit 29.8, platelet count 375,000, cultures from <Date>9-25</Date> grew out streptococcus, coag positive staph. Physical exam was benign. ID again came by to see the patient at which time they stated that they were awaiting final staph aureus sensitivities before providing the direction of therapy. Postoperative day #5 the patient remained afebrile, heart rate 65 and sinus, blood pressure 106/60, satting at 95% on room air. Chest tubes were discontinued. Urine output 1700. Physical exam was benign. White count 10.9, hematocrit 31.5, platelet count 337,000, potassium 3.9, BUN 14, creatinine .5 with a glucose of 141, magnesium 2.1. Postoperative day #6 on Ceftriaxone and Clindamycin overnight events include atrial fibrillation and heparinization for possible PE and a chest CT scan. Patient on Amio and Heparin, afebrile, heart rate 108 and atrial fibrillation, blood pressure 96/68, satting at 97% on three liters. Hematocrit 37, PTT 28.4, potassium 4.2. Physical exam, lungs were irregularly irregular, otherwise unremarkable. Postoperative day #7 the patient remained afebrile, heart rate 56, blood pressure 109/65, satting at 97% on two liters. On Lopressor, Lasix, Ceftriaxone, Clindamycin and Amiodarone, PTT of 28. Physical exam unremarkable. The day prior the patient underwent a spiral CT of the chest to rule out a PE. There was radiographic evidence for peripheral pulmonary emboli in the left lung, patient on Heparin. ID again came by to see the patient at which time they stated that the patient was clinically stable from an ID perspective and to continue the antibiotic regimen for a total of 14 days. If the patient spikes a fever they were to be consulted again. Postoperative day #8 the patient remained afebrile, vital signs stable, blood pressure 116/74, satting at 99% on 4 liters. Exam was benign. Plan was to check the PTT. Patient is still on Heparin. Postoperative day #9 the patient remained afebrile with a heart rate of 63 and sinus rhythm, respirations 18, satting at 96% on 3 liters, blood pressure 122/70. The patient was on Heparin, Lopressor, Amiodarone, Clindamycin, Ceftriaxone and Coumadin. On physical exam, exam was benign. Plan was to check the INR, PTT and to continue aggressive pulmonary PT. Postoperative day #9, overnight events include atrial fibrillation times one and an unchanged cough. The patient remained afebrile with heart rate of 55 and sinus brady, respirations 20, satting at 95% on three liters, blood pressure 139/88, white count 9.7, hematocrit 33, platelet count 490,000, potassium 4.6, BUN 8, creatinine .6 and glucose 115. Patient on Heparin, Coumadin, Lopressor, Amiodarone, Lidocaine, Xanax. Exam still remained unchanged. Postoperative day #10, overnight events included atrial fibrillation and a cough which is improving. The patient was afebrile, heart rate 63, respirations 22, satting at 90% on three liters with a blood pressure of 149/78, hematocrit 34.6, BUN 8, creatinine .6, PT 16.5, PTT 83.5 with INR 1.8. Patient on Heparin, Lidocaine, Coumadin, Xanax, Amiodarone. Exam, decreased breath sounds with crackles of the chest. Continue current management. Postoperative day #11 the patient remained afebrile with a heart rate of 62, respirations 18, satting at 94% on two liters, blood pressure 96/59, white count 8.5, hematocrit 30, PT 17.6, PTT 113, INR 2.1. Patient on Coumadin, Lopressor, Amiodarone, Xanax and Lidocaine. Exam remained unremarkable. Plan was to set up home VNA and chest x-ray today. Patient was discharged on <Date>1957-12-9</Date>. DISCHARGE DIAGNOSIS: 1. Right middle lobe abscess. DISCHARGE MEDICATIONS: The patient was stable on discharge and was discharged home on the following medications: Percocet 1-2 tablets po q 4 hours, Robitussin AC 10 cc po q 4 hours, Ambien 10 mg po q h.s., Glyburide 5 mg po q a.m., Amiodarone 400 mg po tid for two days, then 400 mg po bid for 7 days, then 400 mg po q a.m. for 7 days, Lopressor 12.5 mg po bid, Coumadin 2.5 mg po q h.s. and adjust to keep the INR around 2 to 2.5. <Name>Nicki</Name> <Name>Hui</Name>, M.D. <MD Number>75733659</MD Number> Dictated By:<Doctor Name>Dr.Archie</Doctor Name> MEDQUIST36 D: <Date>1909-10-20</Date> 11:01 T: <Date>1939-2-11</Date> 12:51 JOB#: <Job Number>Lee-Young-1946-184833</Job 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Date: 2005-5-17 Discharge Date: 1957-12-9 Date of Birth: 1979-3-17 Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with a past medical history significant for right upper lobe small cell cancer stage III, status post chemotherapy and radiation, status post right upper lobe sleeve resection 2-3, also with past medical history significant for diabetes mellitus, hypertension, prostate cancer status post radical prostatectomy, GERD, TIA 15 years ago, gout and COPD. The patient has no known drug allergies. The patient is status post right upper lobe lung sleeve resection on 2-3 for small cell lung cancer. The patient was discharged home doing well until four days prior to admission when he presented to the Emergency Room with shortness of breath and fevers. The patient was given Levaquin and was then discharged home again. He continued having shortness of breath and productive cough. He was admitted 10-8 for a follow-up bronchoscopy during which time they found a right middle lobe obstruction secondary to swelling. After the procedure the patient had shortness of breath with an oxygen saturation of 88 as well as rigors and chills. The patient was also found to have poor color. The patient's O2 saturation improved. Chest x-ray was obtained and the patient was admitted. The patient underwent surgery 1930-3-8. The patient underwent completion pneumonectomy, bronchoscopy and serratus flap closure of right main stem bronchus. Postoperative day #1 the patient was afebrile with heart rate of 56, blood pressure 104/56, satting at 99%. Chest tube output 500 cc. Last gas 7.33, 56, 152, 31 and 100%. On exam lungs were clear to auscultation bilaterally. Incision, dressings were clean, dry and intact. Heart was regular rate and rhythm. Abdomen was soft, nontender, non distended. Extremities had no swelling. White count 13.4, hematocrit 38.5, platelet count 394,000, potassium 4.8, BUN 13, creatinine .6 with glucose of 188, magnesium 1.8 and CPK of 1410. Plan was to wean the oxygen and check an ABG later on and continue the pneumonectomy tube. To check an EKG because of the EKG change this morning in which patient had ST segment elevations, undergo rule out MI protocol. Postoperative day #2 the patient had no events over the last 24 hours, patient remained afebrile. Heart rate 60, normal sinus rhythm, blood pressure 105/58, satting at 97% on four liters, last gas 7.39, 52, 96, 33. Laboratory data revealed white count 13.2, hematocrit 33.8, platelet count 322,000, PT 12.9, PTT 25.7, INR 1.1, potassium 4.7, BUN 15, creatinine .5 with glucose 158 and magnesium 1.7. CK, 840. Chest x-ray pending. Physical exam was benign. Plan was to administer Lasix today after transfer to the floor. Infectious disease came by to see the patient postop day #2 as well because they were requested to recommend an antibiotic for the right infiltrate to prevent the possibility of a postoperative empyema. Their recommendation was to continue with the current IV antibiotics. Clindamycin and Ceftriaxone will be present. In the remote chance of postoperative infection empyema these antibiotics will be present in the cavity and also by peripheral circulation. Postoperative day #3, events over the last 24 hours include atrial fibrillation. Patient mildly febrile at 99.2, heart rate 57 and sinus rhythm, blood pressure 102/42, respirations 14, satting at 97% on four liters, last gas 7.47, 46, 86, 34, 8 and 97%. White count 10.9, hematocrit 31.5, platelet count 331,000, INR 1.1, PTT 28, potassium 3.9, BUN 14, creatinine .5, glucose 141. Physical exam was benign. Plan was to check the PT, PTT and to get a chest x-ray today and to continue 20 mg of Lasix. ID came by to see the patient again today at which time they stated that the patient is already on broad coverage for the lung abscess. Strep and staff improving, the tubes will be discontinued after the antibiotics. Follow-up of sensitivities on the culture and anticipate a three week course of antibiotics. Postoperative day #4, events overnight include a bronchoscopy which was negative for fistula. Stump was intact, positive secretions. The patient remained afebrile with a heart rate of 57, sinus rhythm, sinus brady. Blood pressure 136/68, satting at 100% on 4 liters nasal cannula. White count 8.8, hematocrit 29.8, platelet count 375,000, cultures from 9-25 grew out streptococcus, coag positive staph. Physical exam was benign. ID again came by to see the patient at which time they stated that they were awaiting final staph aureus sensitivities before providing the direction of therapy. Postoperative day #5 the patient remained afebrile, heart rate 65 and sinus, blood pressure 106/60, satting at 95% on room air. Chest tubes were discontinued. Urine output 1700. Physical exam was benign. White count 10.9, hematocrit 31.5, platelet count 337,000, potassium 3.9, BUN 14, creatinine .5 with a glucose of 141, magnesium 2.1. Postoperative day #6 on Ceftriaxone and Clindamycin overnight events include atrial fibrillation and heparinization for possible PE and a chest CT scan. Patient on Amio and Heparin, afebrile, heart rate 108 and atrial fibrillation, blood pressure 96/68, satting at 97% on three liters. Hematocrit 37, PTT 28.4, potassium 4.2. Physical exam, lungs were irregularly irregular, otherwise unremarkable. Postoperative day #7 the patient remained afebrile, heart rate 56, blood pressure 109/65, satting at 97% on two liters. On Lopressor, Lasix, Ceftriaxone, Clindamycin and Amiodarone, PTT of 28. Physical exam unremarkable. The day prior the patient underwent a spiral CT of the chest to rule out a PE. There was radiographic evidence for peripheral pulmonary emboli in the left lung, patient on Heparin. ID again came by to see the patient at which time they stated that the patient was clinically stable from an ID perspective and to continue the antibiotic regimen for a total of 14 days. If the patient spikes a fever they were to be consulted again. Postoperative day #8 the patient remained afebrile, vital signs stable, blood pressure 116/74, satting at 99% on 4 liters. Exam was benign. Plan was to check the PTT. Patient is still on Heparin. Postoperative day #9 the patient remained afebrile with a heart rate of 63 and sinus rhythm, respirations 18, satting at 96% on 3 liters, blood pressure 122/70. The patient was on Heparin, Lopressor, Amiodarone, Clindamycin, Ceftriaxone and Coumadin. On physical exam, exam was benign. Plan was to check the INR, PTT and to continue aggressive pulmonary PT. Postoperative day #9, overnight events include atrial fibrillation times one and an unchanged cough. The patient remained afebrile with heart rate of 55 and sinus brady, respirations 20, satting at 95% on three liters, blood pressure 139/88, white count 9.7, hematocrit 33, platelet count 490,000, potassium 4.6, BUN 8, creatinine .6 and glucose 115. Patient on Heparin, Coumadin, Lopressor, Amiodarone, Lidocaine, Xanax. Exam still remained unchanged. Postoperative day #10, overnight events included atrial fibrillation and a cough which is improving. The patient was afebrile, heart rate 63, respirations 22, satting at 90% on three liters with a blood pressure of 149/78, hematocrit 34.6, BUN 8, creatinine .6, PT 16.5, PTT 83.5 with INR 1.8. Patient on Heparin, Lidocaine, Coumadin, Xanax, Amiodarone. Exam, decreased breath sounds with crackles of the chest. Continue current management. Postoperative day #11 the patient remained afebrile with a heart rate of 62, respirations 18, satting at 94% on two liters, blood pressure 96/59, white count 8.5, hematocrit 30, PT 17.6, PTT 113, INR 2.1. Patient on Coumadin, Lopressor, Amiodarone, Xanax and Lidocaine. Exam remained unremarkable. Plan was to set up home VNA and chest x-ray today. Patient was discharged on 1957-12-9. DISCHARGE DIAGNOSIS: 1. Right middle lobe abscess. DISCHARGE MEDICATIONS: The patient was stable on discharge and was discharged home on the following medications: Percocet 1-2 tablets po q 4 hours, Robitussin AC 10 cc po q 4 hours, Ambien 10 mg po q h.s., Glyburide 5 mg po q a.m., Amiodarone 400 mg po tid for two days, then 400 mg po bid for 7 days, then 400 mg po q a.m. for 7 days, Lopressor 12.5 mg po bid, Coumadin 2.5 mg po q h.s. and adjust to keep the INR around 2 to 2.5. Nicki Hui, M.D. 75733659 Dictated By:Dr.Archie MEDQUIST36 D: 1909-10-20 11:01 T: 1939-2-11 12:51 JOB#: Lee-Young-1946-184833	['Admission Date: 2005-5-17 Discharge Date: 1957-12-9\n\nDate of Birth: 1979-3-17 Sex: M\n\nService:\n\nHISTORY OF PRESENT ILLNESS: This is a 61-year-old male with\na past medical history significant for right upper lobe small\ncell cancer stage III, status post chemotherapy and\nradiation, status post right upper lobe sleeve resection\n2-3, also with past medical history significant for diabetes\nmellitus, hypertension, prostate cancer status post radical\nprostatectomy, GERD, TIA 15 years ago, gout and COPD. The\npatient has no known drug allergies. The patient is status\npost right upper lobe lung sleeve resection on 2-3 for small\ncell lung cancer. The patient was discharged home doing well\nuntil four days prior to admission when he presented to the\nEmergency Room with shortness of breath and fevers.', " The\npatient was given Levaquin and was then discharged home\nagain. He continued having shortness of breath and\nproductive cough. He was admitted 10-8 for a follow-up\nbronchoscopy during which time they found a right middle lobe\nobstruction secondary to swelling. After the procedure the\npatient had shortness of breath with an oxygen saturation of\n88 as well as rigors and chills. The patient was also found\nto have poor color. The patient's O2 saturation improved.\nChest x-ray was obtained and the patient was admitted. The\npatient underwent surgery 1930-3-8. The patient underwent\ncompletion pneumonectomy, bronchoscopy and serratus flap\nclosure of right main stem bronchus.\n\nPostoperative day #1 the patient was afebrile with heart rate\nof 56, blood pressure 104/56, satting at 99%. Chest tube\noutput 500 cc.", ' Last gas 7.33, 56, 152, 31 and 100%. On exam\nlungs were clear to auscultation bilaterally. Incision,\ndressings were clean, dry and intact. Heart was regular rate\nand rhythm. Abdomen was soft, nontender, non distended.\nExtremities had no swelling. White count 13.4, hematocrit\n38.5, platelet count 394,000, potassium 4.8, BUN 13,\ncreatinine .6 with glucose of 188, magnesium 1.8 and CPK of\n1410. Plan was to wean the oxygen and check an ABG later on\nand continue the pneumonectomy tube. To check an EKG because\nof the EKG change this morning in which patient had ST\nsegment elevations, undergo rule out MI protocol.\n\nPostoperative day #2 the patient had no events over the last\n24 hours, patient remained afebrile. Heart rate 60, normal\nsinus rhythm, blood pressure 105/58, satting at 97% on four\nliters, last gas 7.', '39, 52, 96, 33. Laboratory data revealed\nwhite count 13.2, hematocrit 33.8, platelet count 322,000, PT\n12.9, PTT 25.7, INR 1.1, potassium 4.7, BUN 15, creatinine .5\nwith glucose 158 and magnesium 1.7. CK, 840. Chest x-ray\npending. Physical exam was benign. Plan was to administer\nLasix today after transfer to the floor. Infectious disease\ncame by to see the patient postop day #2 as well because they\nwere requested to recommend an antibiotic for the right\ninfiltrate to prevent the possibility of a postoperative\nempyema. Their recommendation was to continue with the\ncurrent IV antibiotics. Clindamycin and Ceftriaxone will be\npresent. In the remote chance of postoperative infection\nempyema these antibiotics will be present in the cavity and\nalso by peripheral circulation.\n\nPostoperative day #3, events over the last 24 hours include\natrial fibrillation.', ' Patient mildly febrile at 99.2, heart\nrate 57 and sinus rhythm, blood pressure 102/42, respirations\n14, satting at 97% on four liters, last gas 7.47, 46, 86, 34,\n8 and 97%. White count 10.9, hematocrit 31.5, platelet count\n331,000, INR 1.1, PTT 28, potassium 3.9, BUN 14, creatinine\n.5, glucose 141. Physical exam was benign. Plan was to\ncheck the PT, PTT and to get a chest x-ray today and to\ncontinue 20 mg of Lasix. ID came by to see the patient again\ntoday at which time they stated that the patient is already\non broad coverage for the lung abscess. Strep and staff\nimproving, the tubes will be discontinued after the\nantibiotics. Follow-up of sensitivities on the culture and\nanticipate a three week course of antibiotics.\n\nPostoperative day #4, events overnight include a bronchoscopy\nwhich was negative for fistula.', ' Stump was intact, positive\nsecretions. The patient remained afebrile with a heart rate\nof 57, sinus rhythm, sinus brady. Blood pressure 136/68,\nsatting at 100% on 4 liters nasal cannula. White count 8.8,\nhematocrit 29.8, platelet count 375,000, cultures from 9-25\ngrew out streptococcus, coag positive staph. Physical exam\nwas benign. ID again came by to see the patient at which\ntime they stated that they were awaiting final staph aureus\nsensitivities before providing the direction of therapy.\n\nPostoperative day #5 the patient remained afebrile, heart\nrate 65 and sinus, blood pressure 106/60, satting at 95% on\nroom air. Chest tubes were discontinued. Urine output 1700.\nPhysical exam was benign. White count 10.9, hematocrit 31.5,\nplatelet count 337,000, potassium 3.9, BUN 14, creatinine .', '5\nwith a glucose of 141, magnesium 2.1.\n\nPostoperative day #6 on Ceftriaxone and Clindamycin overnight\nevents include atrial fibrillation and heparinization for\npossible PE and a chest CT scan. Patient on Amio and\nHeparin, afebrile, heart rate 108 and atrial fibrillation,\nblood pressure 96/68, satting at 97% on three liters.\nHematocrit 37, PTT 28.4, potassium 4.2. Physical exam, lungs\nwere irregularly irregular, otherwise unremarkable.\n\nPostoperative day #7 the patient remained afebrile, heart\nrate 56, blood pressure 109/65, satting at 97% on two liters.\nOn Lopressor, Lasix, Ceftriaxone, Clindamycin and Amiodarone,\nPTT of 28. Physical exam unremarkable. The day prior the\npatient underwent a spiral CT of the chest to rule out a PE.\nThere was radiographic evidence for peripheral pulmonary\nemboli in the left lung, patient on Heparin.', ' ID again came\nby to see the patient at which time they stated that the\npatient was clinically stable from an ID perspective and to\ncontinue the antibiotic regimen for a total of 14 days. If\nthe patient spikes a fever they were to be consulted again.\n\nPostoperative day #8 the patient remained afebrile, vital\nsigns stable, blood pressure 116/74, satting at 99% on 4\nliters. Exam was benign. Plan was to check the PTT.\nPatient is still on Heparin.\n\nPostoperative day #9 the patient remained afebrile with a\nheart rate of 63 and sinus rhythm, respirations 18, satting\nat 96% on 3 liters, blood pressure 122/70. The patient was\non Heparin, Lopressor, Amiodarone, Clindamycin, Ceftriaxone\nand Coumadin. On physical exam, exam was benign. Plan was\nto check the INR, PTT and to continue aggressive pulmonary\nPT.', ' Postoperative day #9, overnight events include atrial\nfibrillation times one and an unchanged cough. The patient\nremained afebrile with heart rate of 55 and sinus brady,\nrespirations 20, satting at 95% on three liters, blood\npressure 139/88, white count 9.7, hematocrit 33, platelet\ncount 490,000, potassium 4.6, BUN 8, creatinine .6 and\nglucose 115. Patient on Heparin, Coumadin, Lopressor,\nAmiodarone, Lidocaine, Xanax. Exam still remained unchanged.\n\nPostoperative day #10, overnight events included atrial\nfibrillation and a cough which is improving. The patient was\nafebrile, heart rate 63, respirations 22, satting at 90% on\nthree liters with a blood pressure of 149/78, hematocrit\n34.6, BUN 8, creatinine .6, PT 16.5, PTT 83.5 with INR 1.8.\nPatient on Heparin, Lidocaine, Coumadin, Xanax, Amiodarone.', '\nExam, decreased breath sounds with crackles of the chest.\nContinue current management.\n\nPostoperative day #11 the patient remained afebrile with a\nheart rate of 62, respirations 18, satting at 94% on two\nliters, blood pressure 96/59, white count 8.5, hematocrit 30,\nPT 17.6, PTT 113, INR 2.1. Patient on Coumadin, Lopressor,\nAmiodarone, Xanax and Lidocaine. Exam remained unremarkable.\nPlan was to set up home VNA and chest x-ray today.\n\nPatient was discharged on 1957-12-9.\n\nDISCHARGE DIAGNOSIS:\n1. Right middle lobe abscess.\n\nDISCHARGE MEDICATIONS: The patient was stable on discharge\nand was discharged home on the following medications:\nPercocet 1-2 tablets po q 4 hours, Robitussin AC 10 cc po q 4\nhours, Ambien 10 mg po q h.s., Glyburide 5 mg po q a.m.,\nAmiodarone 400 mg po tid for two days, then 400 mg po bid for\n7 days, then 400 mg po q a.', 'm. for 7 days, Lopressor 12.5 mg\npo bid, Coumadin 2.5 mg po q h.s. and adjust to keep the INR\naround 2 to 2.5.\n\n\n\n\n Nicki Hui, M.D. 75733659\n\nDictated By:Dr.Archie\n\nMEDQUIST36\n\nD: 1909-10-20 11:01\nT: 1939-2-11 12:51\nJOB#: Lee-Young-1946-184833\n']
14	15472	118185.0	2175-09-28	Discharge summary	Report	Admission Date: [2175-9-18] Discharge Date: [2175-9-28] Date of Birth: [2114-2-8] Sex: M Service: CCU/MEDICAL ICU/C-MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 61 year old man with a history of stage III squamous lung carcinoma, status post lobectomy and pneumonectomy on the right earlier this year, who was transferred to [Hospital1 188] for respiratory failure. Two weeks prior to admission, the patient began experiencing episodes of shortness of breath, cough and dyspnea. Echocardiogram and electrocardiogram performed at that time were reportedly unremarkable. On [2175-9-17], after coming home from his son's wedding, the patient became acutely short of breath, agitated and collapsed on the floor, stating that he could not breathe. His family called 911 and the patient was intubated in the field and taken to [Hospital 189] Hospital where a chest x-ray was reportedly normal but electrocardiogram showed transient new left bundle branch block, ST elevations in leads II through V4 and Q waves in the anterior precordial leads, all of which was new. He was transferred to the [Hospital1 190] and Coronary Care Unit for further evaluation and management. PAST MEDICAL HISTORY: 1. Stage III-A squamous cell lung carcinoma, status post right pneumonectomy, chemotherapy and radiation. 2. Transient ischemic attack. 3. Pulmonary embolism. 4. Atrial fibrillation, on Amiodarone. 5. Prostate cancer, status post radical prostatectomy. 6. Diabetes mellitus. 7. Negative exercise Thallium test in [2175-2-26]. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Amiodarone 400 mg p.o. b.i.d. 2. Coumadin 3 mg p.o. q.h.s. 3. Oxazepam p.r.n. 4. Lopressor 12.5 mg p.o. b.i.d. 5. Glyburide 5 mg p.o. q.d. 6. Neurontin 100 mg p.o. t.i.d. 7. Ambien 10 mg p.o. q.h.s. FAMILY HISTORY: The patient has a sister who died of cancer at the age of 39, and an older brother status post coronary artery bypass graft. His father also had coronary artery disease and a sister has cardiac valve disease. SOCIAL HISTORY: The patient quit smoking three months ago following three to four packs per day times forty years. He consumed two to three drinks per day. He is a construction worker. PHYSICAL EXAMINATION: On admission, temperature is 99, heart rate 70 to 80s, blood pressure 110/60, oxygen saturation 95%. In general, the patient was intubated and sedated. Head, eyes, ears, nose and throat examination indicated the pupils 2.0 millimeters and reactive bilaterally. Endotracheal tube is in place. Cardiovascular - tachycardia with no murmurs, rubs or gallops. Pulmonary examination - The patient had diffuse coarse rhonchi on the left and absent breath sounds on the right. The abdomen was soft, nontender, nondistended with normal bowel sounds. The extremities were warm with 1+ distal pulses. LABORATORY DATA: Initial laboratory studies at the outside hospital indicated that he had a white blood cell count of 11.4, hematocrit 41.0, platelets 466,000. The differential on the white blood cell count was 74% polys, 15% lymphocytes, and 8% monocytes. Chem7 indicated a sodium of 136, potassium 5.0, chloride 96, bicarbonate 35, blood urea nitrogen 12, creatinine 1.3, glucose 285. Prothrombin time was 22.4, partial thromboplastin time 37.4, INR 3.0. Arterial blood gases indicated a pH of 7.29, paCO2 of 54, paO2 of 506 on a 100% FIO2. Urinalysis was within normal limits. CKs were 41 and 57 with a troponin of 0.04 and then 0.6. Chest x-ray indicated status post right pneumonectomy with no infiltrate and mild vascular engorgement. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit where he later ruled in for myocardial infarction with a peak troponin of 4.5 and flat CKs. A Transesophageal echocardiogram indicated an ejection fraction of 25% and apical hypokinesis. The patient was also noted to develop new onset rapid atrial fibrillation with associated hypotension and was cardioverted to normal sinus rhythm but remained hypotensive requiring pressors. A CT angiogram was performed to rule out pulmonary embolism, which was negative. On [2175-9-19], a PA catheter was inserted which indicated decreased central venous pressure and decreased pulmonary capillary wedge pressure consistent with septic shock. The patient concurrently developed a temperature to 100 to 101 while urine culture grew E. coli. The patient was started on intravenous Levofloxacin, Vancomycin and Tobramycin and transferred to the Medical Intensive Care Unit where he received intravenous fluids and was changed from Levophed to vasopressin with good effect. On [2175-9-21], the pressors were weaned. Bronchoscopy was performed which indicated intact suture sites with some thick secretions. On [2175-9-22], the patient was successfully extubated. Over the weekend of [2175-9-23], and [2175-9-24], the patient defervesced with decreasing white blood count and was successfully switched to oral medications with stable blood pressure. His antibiotics other than Levaquin were discontinued. The patient was then transferred to the C-Medicine service for workup of coronary artery disease. Cardiac catheterization indicated 30% mid right coronary artery stenosis and mild irregularities in the left anterior descending and left circumflex arteries with a left ventricular ejection fraction of 60%. The patient was titrated up on a beta blocker ace inhibitor. Lipid panel indicated a total cholesterol of 201, triglycerides of 137, LDL of 133 and HDL of 41. He was therefore started on statin therapy for hypercholesterolemia. The patient was worked up for anemia with hematocrit in the 30.0s during his stay in the C-Medicine service and was found to have an iron of 22, ferritin of 459, TIBC of 228, transferrin of 175. These findings were consistent with anemia of chronic disease and thought secondary to his lung cancer. On the C-Medicine service, the patient was noted to have bilateral carotid bruits. Carotid Doppler studies were performed which indicated less than 40% bilateral stenosis and mild plaquing bilaterally. The patient was maintained on Heparin during his hospital course and started on Coumadin two days prior to anticipated discharge with plan to discharge to home on Lovenox until the patient reached a therapeutic INR of 2.0 to 3.0. From an endocrine perspective, the patient was treated with regular insulin sliding scale for his diabetes mellitus with a plan to transition back to his home regimen of Glyburide 5 mg p.o. q.d. Fingerstick blood sugar indicated good glycemic control during hospital course. A physical therapy consultation was arranged and at the time of discharge dictation, it was anticipated that the patient would be deemed safe for discharge to home with outpatient physical therapy follow-up. At the time of dictation, the patient was planned to be discharged to home with VNA. He was also to follow-up in [Hospital 191] Clinic for an INR check on the day following discharge and was to follow-up with his primary care physician in [Name9 (PRE) 191] firm. He was to complete a fourteen day course of Levaquin, which had been switched to p.o. on the day prior to his discharge in order to treat his urinary tract infection. DISCHARGE DIAGNOSES: 1. Urosepsis. 2. Acute myocardial infarction, status post cardiac catheterization indicating 30% mid right coronary artery stenosis and mild irregularities in the left anterior descending and left circumflex. 3. Stage III-A squamous cell lung carcinoma, status post right pneumonectomy. 4. Atrial fibrillation, status post cardioversion to normal sinus rhythm. 5. Prostate cancer, status post radical prostatectomy. 6. Diabetes mellitus. DISPOSITION: On discharge, it is anticipated at the time of dictation that the patient will be discharged to home with VNA and will require outpatient physical therapy. MEDICATIONS ON DISCHARGE: 1. Enteric Coated Aspirin 325 mg p.o. q.d. 2. Levaquin 500 mg p.o. q.d. for a total course of fourteen days. 3. Coumadin 3 mg p.o. q.h.s. 4. Amiodarone 400 mg p.o. b.i.d. 5. Atenolol 25 mg p.o. q.d. 6. Lisinopril 2.5 mg p.o. q.d. 7. Lipitor 10 mg p.o. q.h.s. 8. Percocet one to two tablets p.o. q4-6hours p.r.n. 9. Ambien 10 mg p.o. q.h.s. 10. Oxygen four liters nasal cannula. 11. Lovenox 80 mg subcutaneous b.i.d. until INR is greater than 2.0. 12. Albuterol and Atrovent nebulizer treatments q4hours p.r.n. 13. Glyburide 5 mg p.o. q.d. CONDITION ON DISCHARGE: Much improved. [Known firstname 177] [Last Name (NamePattern4) 192], M.D. [MD Number(1) 193] Dictated By:[Last Name (NamePattern1) 194] MEDQUIST36 D: [2175-9-28] 02:28 T: [2175-9-30] 10:33 JOB#: [Job Number 195]	Admission Date: <Date>1975-8-28</Date> Discharge Date: <Date>2013-1-6</Date> Date of Birth: <Date>2014-4-10</Date> Sex: M Service: CCU/MEDICAL ICU/C-MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 61 year old man with a history of stage III squamous lung carcinoma, status post lobectomy and pneumonectomy on the right earlier this year, who was transferred to <Hospital>Martin, Hammond and Simmons Medical Center</Hospital> for respiratory failure. Two weeks prior to admission, the patient began experiencing episodes of shortness of breath, cough and dyspnea. Echocardiogram and electrocardiogram performed at that time were reportedly unremarkable. On <Date>1914-9-11</Date>, after coming home from his son's wedding, the patient became acutely short of breath, agitated and collapsed on the floor, stating that he could not breathe. His family called 911 and the patient was intubated in the field and taken to <Hospital>Santana-Orr Clinic</Hospital> Hospital where a chest x-ray was reportedly normal but electrocardiogram showed transient new left bundle branch block, ST elevations in leads II through V4 and Q waves in the anterior precordial leads, all of which was new. He was transferred to the <Hospital>Roberson Ltd Health System</Hospital> and Coronary Care Unit for further evaluation and management. PAST MEDICAL HISTORY: 1. Stage III-A squamous cell lung carcinoma, status post right pneumonectomy, chemotherapy and radiation. 2. Transient ischemic attack. 3. Pulmonary embolism. 4. Atrial fibrillation, on Amiodarone. 5. Prostate cancer, status post radical prostatectomy. 6. Diabetes mellitus. 7. Negative exercise Thallium test in <Date>2012-7-14</Date>. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Amiodarone 400 mg p.o. b.i.d. 2. Coumadin 3 mg p.o. q.h.s. 3. Oxazepam p.r.n. 4. Lopressor 12.5 mg p.o. b.i.d. 5. Glyburide 5 mg p.o. q.d. 6. Neurontin 100 mg p.o. t.i.d. 7. Ambien 10 mg p.o. q.h.s. FAMILY HISTORY: The patient has a sister who died of cancer at the age of 39, and an older brother status post coronary artery bypass graft. His father also had coronary artery disease and a sister has cardiac valve disease. SOCIAL HISTORY: The patient quit smoking three months ago following three to four packs per day times forty years. He consumed two to three drinks per day. He is a construction worker. PHYSICAL EXAMINATION: On admission, temperature is 99, heart rate 70 to 80s, blood pressure 110/60, oxygen saturation 95%. In general, the patient was intubated and sedated. Head, eyes, ears, nose and throat examination indicated the pupils 2.0 millimeters and reactive bilaterally. Endotracheal tube is in place. Cardiovascular - tachycardia with no murmurs, rubs or gallops. Pulmonary examination - The patient had diffuse coarse rhonchi on the left and absent breath sounds on the right. The abdomen was soft, nontender, nondistended with normal bowel sounds. The extremities were warm with 1+ distal pulses. LABORATORY DATA: Initial laboratory studies at the outside hospital indicated that he had a white blood cell count of 11.4, hematocrit 41.0, platelets 466,000. The differential on the white blood cell count was 74% polys, 15% lymphocytes, and 8% monocytes. Chem7 indicated a sodium of 136, potassium 5.0, chloride 96, bicarbonate 35, blood urea nitrogen 12, creatinine 1.3, glucose 285. Prothrombin time was 22.4, partial thromboplastin time 37.4, INR 3.0. Arterial blood gases indicated a pH of 7.29, paCO2 of 54, paO2 of 506 on a 100% FIO2. Urinalysis was within normal limits. CKs were 41 and 57 with a troponin of 0.04 and then 0.6. Chest x-ray indicated status post right pneumonectomy with no infiltrate and mild vascular engorgement. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit where he later ruled in for myocardial infarction with a peak troponin of 4.5 and flat CKs. A Transesophageal echocardiogram indicated an ejection fraction of 25% and apical hypokinesis. The patient was also noted to develop new onset rapid atrial fibrillation with associated hypotension and was cardioverted to normal sinus rhythm but remained hypotensive requiring pressors. A CT angiogram was performed to rule out pulmonary embolism, which was negative. On <Date>1960-5-7</Date>, a PA catheter was inserted which indicated decreased central venous pressure and decreased pulmonary capillary wedge pressure consistent with septic shock. The patient concurrently developed a temperature to 100 to 101 while urine culture grew E. coli. The patient was started on intravenous Levofloxacin, Vancomycin and Tobramycin and transferred to the Medical Intensive Care Unit where he received intravenous fluids and was changed from Levophed to vasopressin with good effect. On <Date>1916-6-28</Date>, the pressors were weaned. Bronchoscopy was performed which indicated intact suture sites with some thick secretions. On <Date>1994-12-28</Date>, the patient was successfully extubated. Over the weekend of <Date>1908-12-5</Date>, and <Date>1922-5-1</Date>, the patient defervesced with decreasing white blood count and was successfully switched to oral medications with stable blood pressure. His antibiotics other than Levaquin were discontinued. The patient was then transferred to the C-Medicine service for workup of coronary artery disease. Cardiac catheterization indicated 30% mid right coronary artery stenosis and mild irregularities in the left anterior descending and left circumflex arteries with a left ventricular ejection fraction of 60%. The patient was titrated up on a beta blocker ace inhibitor. Lipid panel indicated a total cholesterol of 201, triglycerides of 137, LDL of 133 and HDL of 41. He was therefore started on statin therapy for hypercholesterolemia. The patient was worked up for anemia with hematocrit in the 30.0s during his stay in the C-Medicine service and was found to have an iron of 22, ferritin of 459, TIBC of 228, transferrin of 175. These findings were consistent with anemia of chronic disease and thought secondary to his lung cancer. On the C-Medicine service, the patient was noted to have bilateral carotid bruits. Carotid Doppler studies were performed which indicated less than 40% bilateral stenosis and mild plaquing bilaterally. The patient was maintained on Heparin during his hospital course and started on Coumadin two days prior to anticipated discharge with plan to discharge to home on Lovenox until the patient reached a therapeutic INR of 2.0 to 3.0. From an endocrine perspective, the patient was treated with regular insulin sliding scale for his diabetes mellitus with a plan to transition back to his home regimen of Glyburide 5 mg p.o. q.d. Fingerstick blood sugar indicated good glycemic control during hospital course. A physical therapy consultation was arranged and at the time of discharge dictation, it was anticipated that the patient would be deemed safe for discharge to home with outpatient physical therapy follow-up. At the time of dictation, the patient was planned to be discharged to home with VNA. He was also to follow-up in <Hospital>Clark-Gonzales Health System</Hospital> Clinic for an INR check on the day following discharge and was to follow-up with his primary care physician in <Name>Nora Kaur</Name> firm. He was to complete a fourteen day course of Levaquin, which had been switched to p.o. on the day prior to his discharge in order to treat his urinary tract infection. DISCHARGE DIAGNOSES: 1. Urosepsis. 2. Acute myocardial infarction, status post cardiac catheterization indicating 30% mid right coronary artery stenosis and mild irregularities in the left anterior descending and left circumflex. 3. Stage III-A squamous cell lung carcinoma, status post right pneumonectomy. 4. Atrial fibrillation, status post cardioversion to normal sinus rhythm. 5. Prostate cancer, status post radical prostatectomy. 6. Diabetes mellitus. DISPOSITION: On discharge, it is anticipated at the time of dictation that the patient will be discharged to home with VNA and will require outpatient physical therapy. MEDICATIONS ON DISCHARGE: 1. Enteric Coated Aspirin 325 mg p.o. q.d. 2. Levaquin 500 mg p.o. q.d. for a total course of fourteen days. 3. Coumadin 3 mg p.o. q.h.s. 4. Amiodarone 400 mg p.o. b.i.d. 5. Atenolol 25 mg p.o. q.d. 6. Lisinopril 2.5 mg p.o. q.d. 7. Lipitor 10 mg p.o. q.h.s. 8. Percocet one to two tablets p.o. q4-6hours p.r.n. 9. Ambien 10 mg p.o. q.h.s. 10. Oxygen four liters nasal cannula. 11. Lovenox 80 mg subcutaneous b.i.d. until INR is greater than 2.0. 12. Albuterol and Atrovent nebulizer treatments q4hours p.r.n. 13. Glyburide 5 mg p.o. q.d. CONDITION ON DISCHARGE: Much improved. <Name>Fannie</Name> <Name>Cobbs</Name>, M.D. <MD Number>49024928</MD Number> Dictated By:<Name>Jones</Name> MEDQUIST36 D: <Date>2013-1-6</Date> 02:28 T: <Date>1943-7-31</Date> 10:33 JOB#: <Job Number>Anderson-Potter-1997-216944</Job 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Date: 1975-8-28 Discharge Date: 2013-1-6 Date of Birth: 2014-4-10 Sex: M Service: CCU/MEDICAL ICU/C-MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 61 year old man with a history of stage III squamous lung carcinoma, status post lobectomy and pneumonectomy on the right earlier this year, who was transferred to Martin, Hammond and Simmons Medical Center for respiratory failure. Two weeks prior to admission, the patient began experiencing episodes of shortness of breath, cough and dyspnea. Echocardiogram and electrocardiogram performed at that time were reportedly unremarkable. On 1914-9-11, after coming home from his son's wedding, the patient became acutely short of breath, agitated and collapsed on the floor, stating that he could not breathe. His family called 911 and the patient was intubated in the field and taken to Santana-Orr Clinic Hospital where a chest x-ray was reportedly normal but electrocardiogram showed transient new left bundle branch block, ST elevations in leads II through V4 and Q waves in the anterior precordial leads, all of which was new. He was transferred to the Roberson Ltd Health System and Coronary Care Unit for further evaluation and management. PAST MEDICAL HISTORY: 1. Stage III-A squamous cell lung carcinoma, status post right pneumonectomy, chemotherapy and radiation. 2. Transient ischemic attack. 3. Pulmonary embolism. 4. Atrial fibrillation, on Amiodarone. 5. Prostate cancer, status post radical prostatectomy. 6. Diabetes mellitus. 7. Negative exercise Thallium test in 2012-7-14. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Amiodarone 400 mg p.o. b.i.d. 2. Coumadin 3 mg p.o. q.h.s. 3. Oxazepam p.r.n. 4. Lopressor 12.5 mg p.o. b.i.d. 5. Glyburide 5 mg p.o. q.d. 6. Neurontin 100 mg p.o. t.i.d. 7. Ambien 10 mg p.o. q.h.s. FAMILY HISTORY: The patient has a sister who died of cancer at the age of 39, and an older brother status post coronary artery bypass graft. His father also had coronary artery disease and a sister has cardiac valve disease. SOCIAL HISTORY: The patient quit smoking three months ago following three to four packs per day times forty years. He consumed two to three drinks per day. He is a construction worker. PHYSICAL EXAMINATION: On admission, temperature is 99, heart rate 70 to 80s, blood pressure 110/60, oxygen saturation 95%. In general, the patient was intubated and sedated. Head, eyes, ears, nose and throat examination indicated the pupils 2.0 millimeters and reactive bilaterally. Endotracheal tube is in place. Cardiovascular - tachycardia with no murmurs, rubs or gallops. Pulmonary examination - The patient had diffuse coarse rhonchi on the left and absent breath sounds on the right. The abdomen was soft, nontender, nondistended with normal bowel sounds. The extremities were warm with 1+ distal pulses. LABORATORY DATA: Initial laboratory studies at the outside hospital indicated that he had a white blood cell count of 11.4, hematocrit 41.0, platelets 466,000. The differential on the white blood cell count was 74% polys, 15% lymphocytes, and 8% monocytes. Chem7 indicated a sodium of 136, potassium 5.0, chloride 96, bicarbonate 35, blood urea nitrogen 12, creatinine 1.3, glucose 285. Prothrombin time was 22.4, partial thromboplastin time 37.4, INR 3.0. Arterial blood gases indicated a pH of 7.29, paCO2 of 54, paO2 of 506 on a 100% FIO2. Urinalysis was within normal limits. CKs were 41 and 57 with a troponin of 0.04 and then 0.6. Chest x-ray indicated status post right pneumonectomy with no infiltrate and mild vascular engorgement. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit where he later ruled in for myocardial infarction with a peak troponin of 4.5 and flat CKs. A Transesophageal echocardiogram indicated an ejection fraction of 25% and apical hypokinesis. The patient was also noted to develop new onset rapid atrial fibrillation with associated hypotension and was cardioverted to normal sinus rhythm but remained hypotensive requiring pressors. A CT angiogram was performed to rule out pulmonary embolism, which was negative. On 1960-5-7, a PA catheter was inserted which indicated decreased central venous pressure and decreased pulmonary capillary wedge pressure consistent with septic shock. The patient concurrently developed a temperature to 100 to 101 while urine culture grew E. coli. The patient was started on intravenous Levofloxacin, Vancomycin and Tobramycin and transferred to the Medical Intensive Care Unit where he received intravenous fluids and was changed from Levophed to vasopressin with good effect. On 1916-6-28, the pressors were weaned. Bronchoscopy was performed which indicated intact suture sites with some thick secretions. On 1994-12-28, the patient was successfully extubated. Over the weekend of 1908-12-5, and 1922-5-1, the patient defervesced with decreasing white blood count and was successfully switched to oral medications with stable blood pressure. His antibiotics other than Levaquin were discontinued. The patient was then transferred to the C-Medicine service for workup of coronary artery disease. Cardiac catheterization indicated 30% mid right coronary artery stenosis and mild irregularities in the left anterior descending and left circumflex arteries with a left ventricular ejection fraction of 60%. The patient was titrated up on a beta blocker ace inhibitor. Lipid panel indicated a total cholesterol of 201, triglycerides of 137, LDL of 133 and HDL of 41. He was therefore started on statin therapy for hypercholesterolemia. The patient was worked up for anemia with hematocrit in the 30.0s during his stay in the C-Medicine service and was found to have an iron of 22, ferritin of 459, TIBC of 228, transferrin of 175. These findings were consistent with anemia of chronic disease and thought secondary to his lung cancer. On the C-Medicine service, the patient was noted to have bilateral carotid bruits. Carotid Doppler studies were performed which indicated less than 40% bilateral stenosis and mild plaquing bilaterally. The patient was maintained on Heparin during his hospital course and started on Coumadin two days prior to anticipated discharge with plan to discharge to home on Lovenox until the patient reached a therapeutic INR of 2.0 to 3.0. From an endocrine perspective, the patient was treated with regular insulin sliding scale for his diabetes mellitus with a plan to transition back to his home regimen of Glyburide 5 mg p.o. q.d. Fingerstick blood sugar indicated good glycemic control during hospital course. A physical therapy consultation was arranged and at the time of discharge dictation, it was anticipated that the patient would be deemed safe for discharge to home with outpatient physical therapy follow-up. At the time of dictation, the patient was planned to be discharged to home with VNA. He was also to follow-up in Clark-Gonzales Health System Clinic for an INR check on the day following discharge and was to follow-up with his primary care physician in Nora Kaur firm. He was to complete a fourteen day course of Levaquin, which had been switched to p.o. on the day prior to his discharge in order to treat his urinary tract infection. DISCHARGE DIAGNOSES: 1. Urosepsis. 2. Acute myocardial infarction, status post cardiac catheterization indicating 30% mid right coronary artery stenosis and mild irregularities in the left anterior descending and left circumflex. 3. Stage III-A squamous cell lung carcinoma, status post right pneumonectomy. 4. Atrial fibrillation, status post cardioversion to normal sinus rhythm. 5. Prostate cancer, status post radical prostatectomy. 6. Diabetes mellitus. DISPOSITION: On discharge, it is anticipated at the time of dictation that the patient will be discharged to home with VNA and will require outpatient physical therapy. MEDICATIONS ON DISCHARGE: 1. Enteric Coated Aspirin 325 mg p.o. q.d. 2. Levaquin 500 mg p.o. q.d. for a total course of fourteen days. 3. Coumadin 3 mg p.o. q.h.s. 4. Amiodarone 400 mg p.o. b.i.d. 5. Atenolol 25 mg p.o. q.d. 6. Lisinopril 2.5 mg p.o. q.d. 7. Lipitor 10 mg p.o. q.h.s. 8. Percocet one to two tablets p.o. q4-6hours p.r.n. 9. Ambien 10 mg p.o. q.h.s. 10. Oxygen four liters nasal cannula. 11. Lovenox 80 mg subcutaneous b.i.d. until INR is greater than 2.0. 12. Albuterol and Atrovent nebulizer treatments q4hours p.r.n. 13. Glyburide 5 mg p.o. q.d. CONDITION ON DISCHARGE: Much improved. Fannie Cobbs, M.D. 49024928 Dictated By:Jones MEDQUIST36 D: 2013-1-6 02:28 T: 1943-7-31 10:33 JOB#: Anderson-Potter-1997-216944	["Admission Date: 1975-8-28 Discharge Date: 2013-1-6\n\nDate of Birth: 2014-4-10 Sex: M\n\nService: CCU/MEDICAL ICU/C-MEDICINE\n\nHISTORY OF PRESENT ILLNESS: The patient is a 61 year old man\nwith a history of stage III squamous lung carcinoma, status\npost lobectomy and pneumonectomy on the right earlier this\nyear, who was transferred to Martin, Hammond and Simmons Medical Center for respiratory failure. Two weeks prior to\nadmission, the patient began experiencing episodes of\nshortness of breath, cough and dyspnea. Echocardiogram and\nelectrocardiogram performed at that time were reportedly\nunremarkable.\n\nOn 1914-9-11, after coming home from his son's wedding, the\npatient became acutely short of breath, agitated and\ncollapsed on the floor, stating that he could not breathe.\nHis family called 911 and the patient was intubated in the\nfield and taken to Santana-Orr Clinic Hospital where a chest x-ray was\nreportedly normal but electrocardiogram showed transient new\nleft bundle branch block, ST elevations in leads II through\nV4 and Q waves in the anterior precordial leads, all of which\nwas new.", ' He was transferred to the Roberson Ltd Health System and Coronary Care Unit for further evaluation\nand management.\n\nPAST MEDICAL HISTORY:\n1. Stage III-A squamous cell lung carcinoma, status post\nright pneumonectomy, chemotherapy and radiation.\n2. Transient ischemic attack.\n3. Pulmonary embolism.\n4. Atrial fibrillation, on Amiodarone.\n5. Prostate cancer, status post radical prostatectomy.\n6. Diabetes mellitus.\n7. Negative exercise Thallium test in 2012-7-14.\n\nALLERGIES: The patient has no known drug allergies.\n\nMEDICATIONS ON ADMISSION:\n1. Amiodarone 400 mg p.o. b.i.d.\n2. Coumadin 3 mg p.o. q.h.s.\n3. Oxazepam p.r.n.\n4. Lopressor 12.5 mg p.o. b.i.d.\n5. Glyburide 5 mg p.o. q.d.\n6. Neurontin 100 mg p.o. t.i.d.\n7. Ambien 10 mg p.o. q.h.s.\n\nFAMILY HISTORY: The patient has a sister who died of cancer\nat the age of 39, and an older brother status post coronary\nartery bypass graft.', ' His father also had coronary artery\ndisease and a sister has cardiac valve disease.\n\nSOCIAL HISTORY: The patient quit smoking three months ago\nfollowing three to four packs per day times forty years. He\nconsumed two to three drinks per day. He is a construction\nworker.\n\nPHYSICAL EXAMINATION: On admission, temperature is 99, heart\nrate 70 to 80s, blood pressure 110/60, oxygen saturation 95%.\nIn general, the patient was intubated and sedated. Head,\neyes, ears, nose and throat examination indicated the pupils\n2.0 millimeters and reactive bilaterally. Endotracheal tube\nis in place. Cardiovascular - tachycardia with no murmurs,\nrubs or gallops. Pulmonary examination - The patient had\ndiffuse coarse rhonchi on the left and absent breath sounds\non the right. The abdomen was soft, nontender, nondistended\nwith normal bowel sounds.', ' The extremities were warm with 1+\ndistal pulses.\n\nLABORATORY DATA: Initial laboratory studies at the outside\nhospital indicated that he had a white blood cell count of\n11.4, hematocrit 41.0, platelets 466,000. The differential\non the white blood cell count was 74% polys, 15% lymphocytes,\nand 8% monocytes. Chem7 indicated a sodium of 136, potassium\n5.0, chloride 96, bicarbonate 35, blood urea nitrogen 12,\ncreatinine 1.3, glucose 285. Prothrombin time was 22.4,\npartial thromboplastin time 37.4, INR 3.0. Arterial blood\ngases indicated a pH of 7.29, paCO2 of 54, paO2 of 506 on a\n100% FIO2. Urinalysis was within normal limits. CKs were 41\nand 57 with a troponin of 0.04 and then 0.6.\n\nChest x-ray indicated status post right pneumonectomy with no\ninfiltrate and mild vascular engorgement.\n\nHOSPITAL COURSE: The patient was admitted to the Coronary\nCare Unit where he later ruled in for myocardial infarction\nwith a peak troponin of 4.', '5 and flat CKs. A Transesophageal\nechocardiogram indicated an ejection fraction of 25% and\napical hypokinesis. The patient was also noted to develop\nnew onset rapid atrial fibrillation with associated\nhypotension and was cardioverted to normal sinus rhythm but\nremained hypotensive requiring pressors. A CT angiogram was\nperformed to rule out pulmonary embolism, which was negative.\n\nOn 1960-5-7, a PA catheter was inserted which indicated\ndecreased central venous pressure and decreased pulmonary\ncapillary wedge pressure consistent with septic shock. The\npatient concurrently developed a temperature to 100 to 101\nwhile urine culture grew E. coli. The patient was started on\nintravenous Levofloxacin, Vancomycin and Tobramycin and\ntransferred to the Medical Intensive Care Unit where he\nreceived intravenous fluids and was changed from Levophed to\nvasopressin with good effect.', ' On 1916-6-28, the pressors were\nweaned.\n\nBronchoscopy was performed which indicated intact suture\nsites with some thick secretions. On 1994-12-28, the patient\nwas successfully extubated. Over the weekend of 1908-12-5,\nand 1922-5-1, the patient defervesced with decreasing white\nblood count and was successfully switched to oral medications\nwith stable blood pressure. His antibiotics other than\nLevaquin were discontinued. The patient was then transferred\nto the C-Medicine service for workup of coronary artery\ndisease.\n\nCardiac catheterization indicated 30% mid right coronary\nartery stenosis and mild irregularities in the left anterior\ndescending and left circumflex arteries with a left\nventricular ejection fraction of 60%. The patient was\ntitrated up on a beta blocker ace inhibitor. Lipid panel\nindicated a total cholesterol of 201, triglycerides of 137,\nLDL of 133 and HDL of 41.', ' He was therefore started on statin\ntherapy for hypercholesterolemia.\n\nThe patient was worked up for anemia with hematocrit in the\n30.0s during his stay in the C-Medicine service and was found\nto have an iron of 22, ferritin of 459, TIBC of 228,\ntransferrin of 175. These findings were consistent with\nanemia of chronic disease and thought secondary to his lung\ncancer.\n\nOn the C-Medicine service, the patient was noted to have\nbilateral carotid bruits. Carotid Doppler studies were\nperformed which indicated less than 40% bilateral stenosis\nand mild plaquing bilaterally.\n\nThe patient was maintained on Heparin during his hospital\ncourse and started on Coumadin two days prior to anticipated\ndischarge with plan to discharge to home on Lovenox until the\npatient reached a therapeutic INR of 2.0 to 3.', '0.\n\nFrom an endocrine perspective, the patient was treated with\nregular insulin sliding scale for his diabetes mellitus with\na plan to transition back to his home regimen of Glyburide 5\nmg p.o. q.d. Fingerstick blood sugar indicated good glycemic\ncontrol during hospital course.\n\nA physical therapy consultation was arranged and at the time\nof discharge dictation, it was anticipated that the patient\nwould be deemed safe for discharge to home with outpatient\nphysical therapy follow-up.\n\nAt the time of dictation, the patient was planned to be\ndischarged to home with VNA. He was also to follow-up in Clark-Gonzales Health System\nClinic for an INR check on the day following discharge and\nwas to follow-up with his primary care physician in Nora Kaur firm.\nHe was to complete a fourteen day course of Levaquin, which\nhad been switched to p.', 'o. on the day prior to his discharge\nin order to treat his urinary tract infection.\n\nDISCHARGE DIAGNOSES:\n1. Urosepsis.\n2. Acute myocardial infarction, status post cardiac\ncatheterization indicating 30% mid right coronary artery\nstenosis and mild irregularities in the left anterior\ndescending and left circumflex.\n3. Stage III-A squamous cell lung carcinoma, status post\nright pneumonectomy.\n4. Atrial fibrillation, status post cardioversion to normal\nsinus rhythm.\n5. Prostate cancer, status post radical prostatectomy.\n6. Diabetes mellitus.\n\nDISPOSITION: On discharge, it is anticipated at the time of\ndictation that the patient will be discharged to home with\nVNA and will require outpatient physical therapy.\n\nMEDICATIONS ON DISCHARGE:\n1. Enteric Coated Aspirin 325 mg p.o. q.d.\n2. Levaquin 500 mg p.', 'o. q.d. for a total course of fourteen\ndays.\n3. Coumadin 3 mg p.o. q.h.s.\n4. Amiodarone 400 mg p.o. b.i.d.\n5. Atenolol 25 mg p.o. q.d.\n6. Lisinopril 2.5 mg p.o. q.d.\n7. Lipitor 10 mg p.o. q.h.s.\n8. Percocet one to two tablets p.o. q4-6hours p.r.n.\n9. Ambien 10 mg p.o. q.h.s.\n10. Oxygen four liters nasal cannula.\n11. Lovenox 80 mg subcutaneous b.i.d. until INR is greater\nthan 2.0.\n12. Albuterol and Atrovent nebulizer treatments q4hours\np.r.n.\n13. Glyburide 5 mg p.o. q.d.\n\nCONDITION ON DISCHARGE: Much improved.\n\n\n Fannie Cobbs, M.D. 49024928\n\nDictated By:Jones\n\nMEDQUIST36\n\nD: 2013-1-6 02:28\nT: 1943-7-31 10:33\nJOB#: Anderson-Potter-1997-216944\n']
15	15472	166833.0	2176-08-04	Discharge summary	Report	Admission Date: [2176-7-30] Discharge Date: [2176-8-4] Date of Birth: [2114-2-8] Sex: M Service: [Hospital1 212] HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old male with a past medical history of squamous cell lung cancer treated with right total pneumonectomy, chronic obstructive pulmonary disease on 2 to 3 liters of home oxygen with saturations in the low 90s at baseline, congestive heart failure, and diabetes mellitus type 2 who was recently admitted from [7-15] to [2176-7-19] for presumed bronchitis or bronchiectasis flare here with recurrent cough, shortness of breath and fevers. During his last admission two weeks ago he was treated for chronic obstructive pulmonary disease flare versus bronchitis with a ten day Prednisone taper and Augmentin for one week. He underwent bronchoscopy due to concern for possible endobronchial lesion, which was normal. Sputum sample was done at that time showed no growth. He was discharged at his baseline function on [2176-7-19]. The plan was to treat him for one week of Augmentin, skip one week followed by Bactrim for one week, skip one week and then on Augmentin for two weeks for pneumonia prophylaxis. The last dose of Augmentin was [2176-7-22] after being on Augmentin for only three days. He was doing well until approximately one week ago when he developed mild spasms in the afternoon that he thought was due to low potassium. Within the following days he complained of worsening cough productive of clear sputum. He had a low grade temperature, mild headache and worsening cough and presented to the Emergency Department. He denied any sinus pain, sore throat, chest pain, abdominal pain, diarrhea, dysuria or joint pain. In the Emergency Department he was febrile to 102 orally and had a heart rate of 160 and a blood pressure of 118/56. Respiratory rate 28. Sating 88 to 98% on 100% nonrebreather. Initially he was stable, but then had a gradual change in mental status with hypoxia, which resulted in his elective intubation. He received Lasix 100 mg intravenous twice, 1 mg of Bumex and 1 gram of Ceftriaxone as well as 125 mg of Solu-Medrol. He was also placed on a heparin drip for a subtherapeutic INR and given morphine and Ativan for sedation. Chest x-ray showed no focal pneumonia or evidence of heart failure. The patient then underwent a CT angiogram of the chest that showed no evidence of pulmonary embolism. PAST MEDICAL HISTORY: 1. Stage three squamous cell lung cancer diagnosed in [2175-2-26], status post right pneumonectomy in [2175-6-28] treated with neoadjuvant radiation therapy and carboplatin and Taxol. 2. Chronic obstructive pulmonary disease. 3. Congestive heart failure, last echocardiogram [2176-6-18] with limited views showing grossly preserved left ventricular function and right ventricular function. 4. Atrial fibrillation in the postoperative period. 5. History of prostate cancer diagnosed in [2172-2-26], status post radical proctectomy with penile prosthesis in [2172-8-27]. 6. Diabetes mellitus type 2. 7. History of urosepsis. 8. History of pulmonary embolus postoperative in [2175-6-28]. 9. Myocardial infarction with a troponin of 4.1 in [2175-6-28]. Cardiac catheterization showed 30% right coronary lesion, normal left ventricular function with an ejection fraction of 50%. 10. Transient ischemic attack in [2165]. 11. Gout. 12. Gastroesophageal reflux disease. 13. Sleep apnea. 14. Colonic polyps discovered in [2173-5-27]. 15. Hypercholesterolemia. 16. Small pericardial effusion in [2176-5-27], which subsequently resolved. ALLERGIES: Doxepin causes delirium and Levaquin causes prolonged QTs. MEDICATIONS ON ADMISSION: Bactrim 800 mg/160 one tablet twice a day for one week skip one week and then Augmentin 500 mg three times a day. Potassium 40 milliequivalents twice a day. Protonix 40 mg once daily. Lasix 160 mg b.i.d., Uniphyl 200 mg q.d., Zestril 2.5 mg q.d., Serevent two puffs b.i.d., Flovent 110 micrograms four puffs twice a day. Combivent inhaler two puffs four times a day. Duo-neb solution four times a day as needed. Amiodarone 200 mg q.d., enteric coated aspirin 325 mg a day, Glyburide 5 mg once a day, Colace 100 mg twice a day, Senna prn, Coumadin 5 mg once a day except for 4 mg on Tuesday and Thursday, Neurontin 300 mg b.i.d., Oxycontin 20 mg t.i.d., Paxil 20 mg q.d., Lipitor 10 mg q.d., Ambien 15 mg q.h.s. and a regular insulin sliding scale. SOCIAL HISTORY: The patient quit smoking in [2175-5-28] following a forty year history of smoking three to four packs a day. He consumed two to three drinks alcoholic drinks per day and was a construction worker. FAMILY HISTORY: The patient has a sister who died of cancer at the age of 39 and an older brother who had a coronary artery bypass graft. His father also had coronary artery disease and he had a sister with cardiac valvular disease. PHYSICAL EXAMINATION: This was a gentleman who was intubated, sedated and responsive only to noxious stimuli. Pupils were unremarkable. There were no bruits in the neck. Heart had a regular rate and rhythm with normal S1 and S2 sounds, faint heart sounds overall. Occasional ectopic beats. Lungs were clear to auscultation on the left with transmitted breath sounds on the right. Abdomen was soft and mildly distended with decreased bowel sounds. Extremities showed no evidence of ulcers, trace edema in both lower extremities and no cyanosis or clubbing. Skin showed no evidence of rashes. LABORATORY EXAMINATION: Urinalysis was unremarkable. White blood cell count 23, hematocrit 42, platelets were 297. HOSPITAL COURSE: Upon admission to the hospital the patient was transferred to the Medical Intensive Care Unit where he was treated for presumed bronchitis versus tracheobronchitis versus atypical pneumonia. Blood sputum, urine and stool cultures were sent and Ceftriaxone and Azithromycin were started. 1. Infectious disease: The patient did not develop a focal infiltration throughout his hospitalization. His Ceftriaxone was stopped and he was continued on Azithromycin. He remained afebrile throughout the rest of his hospital stay and his white blood cell count decreased daily. On hospital day two he was stable for extubation and tolerated extubation very well. He was then transferred on hospital day number three out of the Intensive Care Unit to the medical floor. He continued to improve clinically with a decrease in his fever curve and decrease in his oxygen requirements. He also subjectively improved and on his last hospital day he was comfortable and ambulating without oxygen. He stated that he had come back to his baseline. White blood cell count returned to [Location 213] range, and cultures were negative except for one anaerobic bottle that was growing gram positive coxae that had been unidentified by the time of discharge. 2. Pulmonary: This was treated as possible tracheobronchitis versus chronic obstructive pulmonary disease versus atypical pneumonia. The patient was kept on his usual inhaler and nebulizing medications as well as Azithromycin and intravenous Solu-Medrol. After hospital day number two and the patient was extubated and improving the Solu-Medrol was switched to Prednisone and was rapidly tapered. The patient was encouraged to ambulate and was given regular respiratory treatment and chest physical therapy. By the end of the hospitalization the patient felt that he had returned to his baseline lung function, baseline pulmonary function and was coughing up less dark sputum. To manage his congestive heart failure Lasix was used judiciously in order to gently diurese him over the course of the hospitalization followed by urine output and daily weights. The patient responded to this well and felt overall that his symptoms of volume overload had improved. 3. Cardiovascular: Based on his presentation, it was not clear that there was not a cardiac component causing his change in his status, so cardiac enzymes were sent. Three sets of enzymes were negative and showed no evidence of myocardial infarction. He had a number of electrocardiograms that were checked to ensure that he did not have a significantly prolonged QTC interval and that it was not worse. 4. Endocrine: The patient was followed with blood glucose measurements that showed that his glucose was under poor control with the Glyburide and the regular insulin sliding scale. As the regular insulin sliding scale was increased and the Prednisone was tapered these values returned closer to normal. CONDITION ON DISCHARGE: Improved. DISCHARGE STATUS: To home. DISCHARGE MEDICATIONS: 1. Humibid LA 600 mg b.i.d. 2. Lasix 160 mg b.i.d. 3. Potassium 40 milliequivalents po b.i.d. 4. Uniphyll 200 mg q.d. 5. Protonix 40 mg q.d. 6. Zestril 2.5 mg q.d. 7. Serevent two puffs b.i.d. 8. Flovent 110 micrograms four puffs b.i.d. 9. Combivent two puffs q.i.d. 10. Scopolamine patch q 72 hours. 11. Albuterol nebulizer q 6 hours prn. 12. Amiodarone 200 mg po q.d. 13. Enteric coated aspirin 325 mg q.d. 14. Glyburide 5 mg q.a.m. 15. Regular insulin sliding scale as per previously. 16. Colace 100 mg po b.i.d. 17. Senna two tabs po b.i.d. 18. Coumadin on hold until [8-5]. 19. Prednisone taper over eight days. 20. Augmentin 500 mg t.i.d. 21. Lipitor 10 mg q.d. 22. Neurontin 300 mg po b.i.d. 23. Oxycodone 20 mg q 8 hours prn. 24. Paxil 20 mg po q.d. 25. Ambien 10 to 15 mg po q.h.s. prn. The patient had been using Care Group Respiratory Services at home for pulmonary physical therapy and O2 assistance and so this was arranged on an outpatient basis, with chest physical therapy and incentive spirometry and other pulmonary treatments. The plan was that he would follow up with Dr. [Last Name (STitle) ] in clinic the following week and that he would have an INR drawn on [8-6] calling the results to Dr. [Last Name (STitle) ]. DISCHARGE DIAGNOSES: 1. Bronchitis. 2. Possible atypical pneumonia. [First Name11 (Name Pattern1) 198] [Last Name (NamePattern4) 199], M.D. [MD Number(1) 200] Dictated By:[Last Name (NamePattern1) 214] MEDQUIST36 D: [2176-8-4] 15:11 T: [2176-8-12] 06:15 JOB#: [Job Number 215]	Admission Date: <Date>1911-1-24</Date> Discharge Date: <Date>1966-3-11</Date> Date of Birth: <Date>1970-8-7</Date> Sex: M Service: <Hospital>Roberts, Nash and Young Hospital</Hospital> HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old male with a past medical history of squamous cell lung cancer treated with right total pneumonectomy, chronic obstructive pulmonary disease on 2 to 3 liters of home oxygen with saturations in the low 90s at baseline, congestive heart failure, and diabetes mellitus type 2 who was recently admitted from <Date>4-19</Date> to <Date>1909-10-17</Date> for presumed bronchitis or bronchiectasis flare here with recurrent cough, shortness of breath and fevers. During his last admission two weeks ago he was treated for chronic obstructive pulmonary disease flare versus bronchitis with a ten day Prednisone taper and Augmentin for one week. He underwent bronchoscopy due to concern for possible endobronchial lesion, which was normal. Sputum sample was done at that time showed no growth. He was discharged at his baseline function on <Date>1909-10-17</Date>. The plan was to treat him for one week of Augmentin, skip one week followed by Bactrim for one week, skip one week and then on Augmentin for two weeks for pneumonia prophylaxis. The last dose of Augmentin was <Date>2004-6-10</Date> after being on Augmentin for only three days. He was doing well until approximately one week ago when he developed mild spasms in the afternoon that he thought was due to low potassium. Within the following days he complained of worsening cough productive of clear sputum. He had a low grade temperature, mild headache and worsening cough and presented to the Emergency Department. He denied any sinus pain, sore throat, chest pain, abdominal pain, diarrhea, dysuria or joint pain. In the Emergency Department he was febrile to 102 orally and had a heart rate of 160 and a blood pressure of 118/56. Respiratory rate 28. Sating 88 to 98% on 100% nonrebreather. Initially he was stable, but then had a gradual change in mental status with hypoxia, which resulted in his elective intubation. He received Lasix 100 mg intravenous twice, 1 mg of Bumex and 1 gram of Ceftriaxone as well as 125 mg of Solu-Medrol. He was also placed on a heparin drip for a subtherapeutic INR and given morphine and Ativan for sedation. Chest x-ray showed no focal pneumonia or evidence of heart failure. The patient then underwent a CT angiogram of the chest that showed no evidence of pulmonary embolism. PAST MEDICAL HISTORY: 1. Stage three squamous cell lung cancer diagnosed in <Date>2004-3-24</Date>, status post right pneumonectomy in <Date>1909-7-9</Date> treated with neoadjuvant radiation therapy and carboplatin and Taxol. 2. Chronic obstructive pulmonary disease. 3. Congestive heart failure, last echocardiogram <Date>2012-9-18</Date> with limited views showing grossly preserved left ventricular function and right ventricular function. 4. Atrial fibrillation in the postoperative period. 5. History of prostate cancer diagnosed in <Date>1975-8-2</Date>, status post radical proctectomy with penile prosthesis in <Date>1907-9-28</Date>. 6. Diabetes mellitus type 2. 7. History of urosepsis. 8. History of pulmonary embolus postoperative in <Date>1909-7-9</Date>. 9. Myocardial infarction with a troponin of 4.1 in <Date>1909-7-9</Date>. Cardiac catheterization showed 30% right coronary lesion, normal left ventricular function with an ejection fraction of 50%. 10. Transient ischemic attack in <Year>1908</Year>. 11. Gout. 12. Gastroesophageal reflux disease. 13. Sleep apnea. 14. Colonic polyps discovered in <Date>2017-2-19</Date>. 15. Hypercholesterolemia. 16. Small pericardial effusion in <Date>1987-3-24</Date>, which subsequently resolved. ALLERGIES: Doxepin causes delirium and Levaquin causes prolonged QTs. MEDICATIONS ON ADMISSION: Bactrim 800 mg/160 one tablet twice a day for one week skip one week and then Augmentin 500 mg three times a day. Potassium 40 milliequivalents twice a day. Protonix 40 mg once daily. Lasix 160 mg b.i.d., Uniphyl 200 mg q.d., Zestril 2.5 mg q.d., Serevent two puffs b.i.d., Flovent 110 micrograms four puffs twice a day. Combivent inhaler two puffs four times a day. Duo-neb solution four times a day as needed. Amiodarone 200 mg q.d., enteric coated aspirin 325 mg a day, Glyburide 5 mg once a day, Colace 100 mg twice a day, Senna prn, Coumadin 5 mg once a day except for 4 mg on Tuesday and Thursday, Neurontin 300 mg b.i.d., Oxycontin 20 mg t.i.d., Paxil 20 mg q.d., Lipitor 10 mg q.d., Ambien 15 mg q.h.s. and a regular insulin sliding scale. SOCIAL HISTORY: The patient quit smoking in <Date>1993-1-28</Date> following a forty year history of smoking three to four packs a day. He consumed two to three drinks alcoholic drinks per day and was a construction worker. FAMILY HISTORY: The patient has a sister who died of cancer at the age of 39 and an older brother who had a coronary artery bypass graft. His father also had coronary artery disease and he had a sister with cardiac valvular disease. PHYSICAL EXAMINATION: This was a gentleman who was intubated, sedated and responsive only to noxious stimuli. Pupils were unremarkable. There were no bruits in the neck. Heart had a regular rate and rhythm with normal S1 and S2 sounds, faint heart sounds overall. Occasional ectopic beats. Lungs were clear to auscultation on the left with transmitted breath sounds on the right. Abdomen was soft and mildly distended with decreased bowel sounds. Extremities showed no evidence of ulcers, trace edema in both lower extremities and no cyanosis or clubbing. Skin showed no evidence of rashes. LABORATORY EXAMINATION: Urinalysis was unremarkable. White blood cell count 23, hematocrit 42, platelets were 297. HOSPITAL COURSE: Upon admission to the hospital the patient was transferred to the Medical Intensive Care Unit where he was treated for presumed bronchitis versus tracheobronchitis versus atypical pneumonia. Blood sputum, urine and stool cultures were sent and Ceftriaxone and Azithromycin were started. 1. Infectious disease: The patient did not develop a focal infiltration throughout his hospitalization. His Ceftriaxone was stopped and he was continued on Azithromycin. He remained afebrile throughout the rest of his hospital stay and his white blood cell count decreased daily. On hospital day two he was stable for extubation and tolerated extubation very well. He was then transferred on hospital day number three out of the Intensive Care Unit to the medical floor. He continued to improve clinically with a decrease in his fever curve and decrease in his oxygen requirements. He also subjectively improved and on his last hospital day he was comfortable and ambulating without oxygen. He stated that he had come back to his baseline. White blood cell count returned to <Location>Unit 5552 Box 2008 DPO AP 48372</Location> range, and cultures were negative except for one anaerobic bottle that was growing gram positive coxae that had been unidentified by the time of discharge. 2. Pulmonary: This was treated as possible tracheobronchitis versus chronic obstructive pulmonary disease versus atypical pneumonia. The patient was kept on his usual inhaler and nebulizing medications as well as Azithromycin and intravenous Solu-Medrol. After hospital day number two and the patient was extubated and improving the Solu-Medrol was switched to Prednisone and was rapidly tapered. The patient was encouraged to ambulate and was given regular respiratory treatment and chest physical therapy. By the end of the hospitalization the patient felt that he had returned to his baseline lung function, baseline pulmonary function and was coughing up less dark sputum. To manage his congestive heart failure Lasix was used judiciously in order to gently diurese him over the course of the hospitalization followed by urine output and daily weights. The patient responded to this well and felt overall that his symptoms of volume overload had improved. 3. Cardiovascular: Based on his presentation, it was not clear that there was not a cardiac component causing his change in his status, so cardiac enzymes were sent. Three sets of enzymes were negative and showed no evidence of myocardial infarction. He had a number of electrocardiograms that were checked to ensure that he did not have a significantly prolonged QTC interval and that it was not worse. 4. Endocrine: The patient was followed with blood glucose measurements that showed that his glucose was under poor control with the Glyburide and the regular insulin sliding scale. As the regular insulin sliding scale was increased and the Prednisone was tapered these values returned closer to normal. CONDITION ON DISCHARGE: Improved. DISCHARGE STATUS: To home. DISCHARGE MEDICATIONS: 1. Humibid LA 600 mg b.i.d. 2. Lasix 160 mg b.i.d. 3. Potassium 40 milliequivalents po b.i.d. 4. Uniphyll 200 mg q.d. 5. Protonix 40 mg q.d. 6. Zestril 2.5 mg q.d. 7. Serevent two puffs b.i.d. 8. Flovent 110 micrograms four puffs b.i.d. 9. Combivent two puffs q.i.d. 10. Scopolamine patch q 72 hours. 11. Albuterol nebulizer q 6 hours prn. 12. Amiodarone 200 mg po q.d. 13. Enteric coated aspirin 325 mg q.d. 14. Glyburide 5 mg q.a.m. 15. Regular insulin sliding scale as per previously. 16. Colace 100 mg po b.i.d. 17. Senna two tabs po b.i.d. 18. Coumadin on hold until <Date>4-3</Date>. 19. Prednisone taper over eight days. 20. Augmentin 500 mg t.i.d. 21. Lipitor 10 mg q.d. 22. Neurontin 300 mg po b.i.d. 23. Oxycodone 20 mg q 8 hours prn. 24. Paxil 20 mg po q.d. 25. Ambien 10 to 15 mg po q.h.s. prn. The patient had been using Care Group Respiratory Services at home for pulmonary physical therapy and O2 assistance and so this was arranged on an outpatient basis, with chest physical therapy and incentive spirometry and other pulmonary treatments. The plan was that he would follow up with Dr. <Name>Starks</Name> in clinic the following week and that he would have an INR drawn on <Date>2-29</Date> calling the results to Dr. <Name>Starks</Name>. DISCHARGE DIAGNOSES: 1. Bronchitis. 2. Possible atypical pneumonia. <Name>Ollie</Name> <Name>Grier</Name>, M.D. <MD Number>65056966</MD Number> Dictated By:<Name>Starks</Name> MEDQUIST36 D: <Date>1966-3-11</Date> 15:11 T: <Date>1974-8-19</Date> 06:15 JOB#: <Job Number>Mcmahon, Hammond and Douglas-1981-268275</Job 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Date: 1911-1-24 Discharge Date: 1966-3-11 Date of Birth: 1970-8-7 Sex: M Service: Roberts, Nash and Young Hospital HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old male with a past medical history of squamous cell lung cancer treated with right total pneumonectomy, chronic obstructive pulmonary disease on 2 to 3 liters of home oxygen with saturations in the low 90s at baseline, congestive heart failure, and diabetes mellitus type 2 who was recently admitted from 4-19 to 1909-10-17 for presumed bronchitis or bronchiectasis flare here with recurrent cough, shortness of breath and fevers. During his last admission two weeks ago he was treated for chronic obstructive pulmonary disease flare versus bronchitis with a ten day Prednisone taper and Augmentin for one week. He underwent bronchoscopy due to concern for possible endobronchial lesion, which was normal. Sputum sample was done at that time showed no growth. He was discharged at his baseline function on 1909-10-17. The plan was to treat him for one week of Augmentin, skip one week followed by Bactrim for one week, skip one week and then on Augmentin for two weeks for pneumonia prophylaxis. The last dose of Augmentin was 2004-6-10 after being on Augmentin for only three days. He was doing well until approximately one week ago when he developed mild spasms in the afternoon that he thought was due to low potassium. Within the following days he complained of worsening cough productive of clear sputum. He had a low grade temperature, mild headache and worsening cough and presented to the Emergency Department. He denied any sinus pain, sore throat, chest pain, abdominal pain, diarrhea, dysuria or joint pain. In the Emergency Department he was febrile to 102 orally and had a heart rate of 160 and a blood pressure of 118/56. Respiratory rate 28. Sating 88 to 98% on 100% nonrebreather. Initially he was stable, but then had a gradual change in mental status with hypoxia, which resulted in his elective intubation. He received Lasix 100 mg intravenous twice, 1 mg of Bumex and 1 gram of Ceftriaxone as well as 125 mg of Solu-Medrol. He was also placed on a heparin drip for a subtherapeutic INR and given morphine and Ativan for sedation. Chest x-ray showed no focal pneumonia or evidence of heart failure. The patient then underwent a CT angiogram of the chest that showed no evidence of pulmonary embolism. PAST MEDICAL HISTORY: 1. Stage three squamous cell lung cancer diagnosed in 2004-3-24, status post right pneumonectomy in 1909-7-9 treated with neoadjuvant radiation therapy and carboplatin and Taxol. 2. Chronic obstructive pulmonary disease. 3. Congestive heart failure, last echocardiogram 2012-9-18 with limited views showing grossly preserved left ventricular function and right ventricular function. 4. Atrial fibrillation in the postoperative period. 5. History of prostate cancer diagnosed in 1975-8-2, status post radical proctectomy with penile prosthesis in 1907-9-28. 6. Diabetes mellitus type 2. 7. History of urosepsis. 8. History of pulmonary embolus postoperative in 1909-7-9. 9. Myocardial infarction with a troponin of 4.1 in 1909-7-9. Cardiac catheterization showed 30% right coronary lesion, normal left ventricular function with an ejection fraction of 50%. 10. Transient ischemic attack in 1908. 11. Gout. 12. Gastroesophageal reflux disease. 13. Sleep apnea. 14. Colonic polyps discovered in 2017-2-19. 15. Hypercholesterolemia. 16. Small pericardial effusion in 1987-3-24, which subsequently resolved. ALLERGIES: Doxepin causes delirium and Levaquin causes prolonged QTs. MEDICATIONS ON ADMISSION: Bactrim 800 mg/160 one tablet twice a day for one week skip one week and then Augmentin 500 mg three times a day. Potassium 40 milliequivalents twice a day. Protonix 40 mg once daily. Lasix 160 mg b.i.d., Uniphyl 200 mg q.d., Zestril 2.5 mg q.d., Serevent two puffs b.i.d., Flovent 110 micrograms four puffs twice a day. Combivent inhaler two puffs four times a day. Duo-neb solution four times a day as needed. Amiodarone 200 mg q.d., enteric coated aspirin 325 mg a day, Glyburide 5 mg once a day, Colace 100 mg twice a day, Senna prn, Coumadin 5 mg once a day except for 4 mg on Tuesday and Thursday, Neurontin 300 mg b.i.d., Oxycontin 20 mg t.i.d., Paxil 20 mg q.d., Lipitor 10 mg q.d., Ambien 15 mg q.h.s. and a regular insulin sliding scale. SOCIAL HISTORY: The patient quit smoking in 1993-1-28 following a forty year history of smoking three to four packs a day. He consumed two to three drinks alcoholic drinks per day and was a construction worker. FAMILY HISTORY: The patient has a sister who died of cancer at the age of 39 and an older brother who had a coronary artery bypass graft. His father also had coronary artery disease and he had a sister with cardiac valvular disease. PHYSICAL EXAMINATION: This was a gentleman who was intubated, sedated and responsive only to noxious stimuli. Pupils were unremarkable. There were no bruits in the neck. Heart had a regular rate and rhythm with normal S1 and S2 sounds, faint heart sounds overall. Occasional ectopic beats. Lungs were clear to auscultation on the left with transmitted breath sounds on the right. Abdomen was soft and mildly distended with decreased bowel sounds. Extremities showed no evidence of ulcers, trace edema in both lower extremities and no cyanosis or clubbing. Skin showed no evidence of rashes. LABORATORY EXAMINATION: Urinalysis was unremarkable. White blood cell count 23, hematocrit 42, platelets were 297. HOSPITAL COURSE: Upon admission to the hospital the patient was transferred to the Medical Intensive Care Unit where he was treated for presumed bronchitis versus tracheobronchitis versus atypical pneumonia. Blood sputum, urine and stool cultures were sent and Ceftriaxone and Azithromycin were started. 1. Infectious disease: The patient did not develop a focal infiltration throughout his hospitalization. His Ceftriaxone was stopped and he was continued on Azithromycin. He remained afebrile throughout the rest of his hospital stay and his white blood cell count decreased daily. On hospital day two he was stable for extubation and tolerated extubation very well. He was then transferred on hospital day number three out of the Intensive Care Unit to the medical floor. He continued to improve clinically with a decrease in his fever curve and decrease in his oxygen requirements. He also subjectively improved and on his last hospital day he was comfortable and ambulating without oxygen. He stated that he had come back to his baseline. White blood cell count returned to Unit 5552 Box 2008 DPO AP 48372 range, and cultures were negative except for one anaerobic bottle that was growing gram positive coxae that had been unidentified by the time of discharge. 2. Pulmonary: This was treated as possible tracheobronchitis versus chronic obstructive pulmonary disease versus atypical pneumonia. The patient was kept on his usual inhaler and nebulizing medications as well as Azithromycin and intravenous Solu-Medrol. After hospital day number two and the patient was extubated and improving the Solu-Medrol was switched to Prednisone and was rapidly tapered. The patient was encouraged to ambulate and was given regular respiratory treatment and chest physical therapy. By the end of the hospitalization the patient felt that he had returned to his baseline lung function, baseline pulmonary function and was coughing up less dark sputum. To manage his congestive heart failure Lasix was used judiciously in order to gently diurese him over the course of the hospitalization followed by urine output and daily weights. The patient responded to this well and felt overall that his symptoms of volume overload had improved. 3. Cardiovascular: Based on his presentation, it was not clear that there was not a cardiac component causing his change in his status, so cardiac enzymes were sent. Three sets of enzymes were negative and showed no evidence of myocardial infarction. He had a number of electrocardiograms that were checked to ensure that he did not have a significantly prolonged QTC interval and that it was not worse. 4. Endocrine: The patient was followed with blood glucose measurements that showed that his glucose was under poor control with the Glyburide and the regular insulin sliding scale. As the regular insulin sliding scale was increased and the Prednisone was tapered these values returned closer to normal. CONDITION ON DISCHARGE: Improved. DISCHARGE STATUS: To home. DISCHARGE MEDICATIONS: 1. Humibid LA 600 mg b.i.d. 2. Lasix 160 mg b.i.d. 3. Potassium 40 milliequivalents po b.i.d. 4. Uniphyll 200 mg q.d. 5. Protonix 40 mg q.d. 6. Zestril 2.5 mg q.d. 7. Serevent two puffs b.i.d. 8. Flovent 110 micrograms four puffs b.i.d. 9. Combivent two puffs q.i.d. 10. Scopolamine patch q 72 hours. 11. Albuterol nebulizer q 6 hours prn. 12. Amiodarone 200 mg po q.d. 13. Enteric coated aspirin 325 mg q.d. 14. Glyburide 5 mg q.a.m. 15. Regular insulin sliding scale as per previously. 16. Colace 100 mg po b.i.d. 17. Senna two tabs po b.i.d. 18. Coumadin on hold until 4-3. 19. Prednisone taper over eight days. 20. Augmentin 500 mg t.i.d. 21. Lipitor 10 mg q.d. 22. Neurontin 300 mg po b.i.d. 23. Oxycodone 20 mg q 8 hours prn. 24. Paxil 20 mg po q.d. 25. Ambien 10 to 15 mg po q.h.s. prn. The patient had been using Care Group Respiratory Services at home for pulmonary physical therapy and O2 assistance and so this was arranged on an outpatient basis, with chest physical therapy and incentive spirometry and other pulmonary treatments. The plan was that he would follow up with Dr. Starks in clinic the following week and that he would have an INR drawn on 2-29 calling the results to Dr. Starks. DISCHARGE DIAGNOSES: 1. Bronchitis. 2. Possible atypical pneumonia. Ollie Grier, M.D. 65056966 Dictated By:Starks MEDQUIST36 D: 1966-3-11 15:11 T: 1974-8-19 06:15 JOB#: Mcmahon, Hammond and Douglas-1981-268275	['Admission Date: 1911-1-24 Discharge Date: 1966-3-11\n\nDate of Birth: 1970-8-7 Sex: M\n\nService: Roberts, Nash and Young Hospital\n\nHISTORY OF PRESENT ILLNESS: The patient is a 62 year-old\nmale with a past medical history of squamous cell lung cancer\ntreated with right total pneumonectomy, chronic obstructive\npulmonary disease on 2 to 3 liters of home oxygen with\nsaturations in the low 90s at baseline, congestive heart\nfailure, and diabetes mellitus type 2 who was recently\nadmitted from 4-19 to 1909-10-17 for presumed\nbronchitis or bronchiectasis flare here with recurrent cough,\nshortness of breath and fevers. During his last admission\ntwo weeks ago he was treated for chronic obstructive\npulmonary disease flare versus bronchitis with a ten day\nPrednisone taper and Augmentin for one week.', ' He underwent\nbronchoscopy due to concern for possible endobronchial\nlesion, which was normal. Sputum sample was done at that\ntime showed no growth. He was discharged at his baseline\nfunction on 1909-10-17. The plan was to treat him for one\nweek of Augmentin, skip one week followed by Bactrim for one\nweek, skip one week and then on Augmentin for two weeks for\npneumonia prophylaxis. The last dose of Augmentin was\n2004-6-10 after being on Augmentin for only three days.\n\nHe was doing well until approximately one week ago when he\ndeveloped mild spasms in the afternoon that he thought was\ndue to low potassium. Within the following days he\ncomplained of worsening cough productive of clear sputum. He\nhad a low grade temperature, mild headache and worsening\ncough and presented to the Emergency Department.', ' He denied\nany sinus pain, sore throat, chest pain, abdominal pain,\ndiarrhea, dysuria or joint pain. In the Emergency Department\nhe was febrile to 102 orally and had a heart rate of 160 and\na blood pressure of 118/56. Respiratory rate 28. Sating 88\nto 98% on 100% nonrebreather. Initially he was stable, but\nthen had a gradual change in mental status with hypoxia,\nwhich resulted in his elective intubation. He received Lasix\n100 mg intravenous twice, 1 mg of Bumex and 1 gram of\nCeftriaxone as well as 125 mg of Solu-Medrol. He was also\nplaced on a heparin drip for a subtherapeutic INR and given\nmorphine and Ativan for sedation. Chest x-ray showed no\nfocal pneumonia or evidence of heart failure. The patient\nthen underwent a CT angiogram of the chest that showed no\nevidence of pulmonary embolism.', '\n\nPAST MEDICAL HISTORY: 1. Stage three squamous cell lung\ncancer diagnosed in 2004-3-24, status post right\npneumonectomy in 1909-7-9 treated with neoadjuvant\nradiation therapy and carboplatin and Taxol. 2. Chronic\nobstructive pulmonary disease. 3. Congestive heart failure,\nlast echocardiogram 2012-9-18 with limited views showing\ngrossly preserved left ventricular function and right\nventricular function. 4. Atrial fibrillation in the\npostoperative period. 5. History of prostate cancer\ndiagnosed in 1975-8-2, status post radical proctectomy\nwith penile prosthesis in 1907-9-28. 6. Diabetes\nmellitus type 2. 7. History of urosepsis. 8. History of\npulmonary embolus postoperative in 1909-7-9. 9.\nMyocardial infarction with a troponin of 4.1 in 1909-7-9. Cardiac catheterization showed 30% right coronary\nlesion, normal left ventricular function with an ejection\nfraction of 50%.', ' 10. Transient ischemic attack in 1908.\n11. Gout. 12. Gastroesophageal reflux disease. 13. Sleep\napnea. 14. Colonic polyps discovered in 2017-2-19. 15.\nHypercholesterolemia. 16. Small pericardial effusion in\n1987-3-24, which subsequently resolved.\n\nALLERGIES: Doxepin causes delirium and Levaquin causes\nprolonged QTs.\n\nMEDICATIONS ON ADMISSION: Bactrim 800 mg/160 one tablet\ntwice a day for one week skip one week and then Augmentin 500\nmg three times a day. Potassium 40 milliequivalents twice a\nday. Protonix 40 mg once daily. Lasix 160 mg b.i.d.,\nUniphyl 200 mg q.d., Zestril 2.5 mg q.d., Serevent two puffs\nb.i.d., Flovent 110 micrograms four puffs twice a day.\nCombivent inhaler two puffs four times a day. Duo-neb\nsolution four times a day as needed. Amiodarone 200 mg q.d.,\nenteric coated aspirin 325 mg a day, Glyburide 5 mg once a\nday, Colace 100 mg twice a day, Senna prn, Coumadin 5 mg once\na day except for 4 mg on Tuesday and Thursday, Neurontin 300\nmg b.', 'i.d., Oxycontin 20 mg t.i.d., Paxil 20 mg q.d., Lipitor\n10 mg q.d., Ambien 15 mg q.h.s. and a regular insulin sliding\nscale.\n\nSOCIAL HISTORY: The patient quit smoking in 1993-1-28\nfollowing a forty year history of smoking three to four packs\na day. He consumed two to three drinks alcoholic drinks per\nday and was a construction worker.\n\nFAMILY HISTORY: The patient has a sister who died of cancer\nat the age of 39 and an older brother who had a coronary\nartery bypass graft. His father also had coronary artery\ndisease and he had a sister with cardiac valvular disease.\n\nPHYSICAL EXAMINATION: This was a gentleman who was\nintubated, sedated and responsive only to noxious stimuli.\nPupils were unremarkable. There were no bruits in the neck.\nHeart had a regular rate and rhythm with normal S1 and S2\nsounds, faint heart sounds overall.', ' Occasional ectopic\nbeats. Lungs were clear to auscultation on the left with\ntransmitted breath sounds on the right. Abdomen was soft and\nmildly distended with decreased bowel sounds. Extremities\nshowed no evidence of ulcers, trace edema in both lower\nextremities and no cyanosis or clubbing. Skin showed no\nevidence of rashes.\n\nLABORATORY EXAMINATION: Urinalysis was unremarkable. White\nblood cell count 23, hematocrit 42, platelets were 297.\n\nHOSPITAL COURSE: Upon admission to the hospital the patient\nwas transferred to the Medical Intensive Care Unit where he\nwas treated for presumed bronchitis versus tracheobronchitis\nversus atypical pneumonia. Blood sputum, urine and stool\ncultures were sent and Ceftriaxone and Azithromycin were\nstarted.\n\n1. Infectious disease: The patient did not develop a focal\ninfiltration throughout his hospitalization.', ' His Ceftriaxone\nwas stopped and he was continued on Azithromycin. He\nremained afebrile throughout the rest of his hospital stay\nand his white blood cell count decreased daily. On hospital\nday two he was stable for extubation and tolerated extubation\nvery well. He was then transferred on hospital day number\nthree out of the Intensive Care Unit to the medical floor.\nHe continued to improve clinically with a decrease in his\nfever curve and decrease in his oxygen requirements. He also\nsubjectively improved and on his last hospital day he was\ncomfortable and ambulating without oxygen. He stated that he\nhad come back to his baseline. White blood cell count\nreturned to Unit 5552 Box 2008\nDPO AP 48372 range, and cultures were negative except\nfor one anaerobic bottle that was growing gram positive\ncoxae that had been unidentified by the time of discharge.', '\n\n2. Pulmonary: This was treated as possible\ntracheobronchitis versus chronic obstructive pulmonary\ndisease versus atypical pneumonia. The patient was kept on\nhis usual inhaler and nebulizing medications as well as\nAzithromycin and intravenous Solu-Medrol. After hospital day\nnumber two and the patient was extubated and improving the\nSolu-Medrol was switched to Prednisone and was rapidly\ntapered. The patient was encouraged to ambulate and was\ngiven regular respiratory treatment and chest physical\ntherapy. By the end of the hospitalization the patient felt\nthat he had returned to his baseline lung function, baseline\npulmonary function and was coughing up less dark sputum. To\nmanage his congestive heart failure Lasix was used\njudiciously in order to gently diurese him over the course of\nthe hospitalization followed by urine output and daily\nweights.', ' The patient responded to this well and felt overall\nthat his symptoms of volume overload had improved.\n\n3. Cardiovascular: Based on his presentation, it was not\nclear that there was not a cardiac component causing his\nchange in his status, so cardiac enzymes were sent. Three\nsets of enzymes were negative and showed no evidence of\nmyocardial infarction. He had a number of electrocardiograms\nthat were checked to ensure that he did not have a\nsignificantly prolonged QTC interval and that it was not\nworse.\n\n4. Endocrine: The patient was followed with blood glucose\nmeasurements that showed that his glucose was under poor\ncontrol with the Glyburide and the regular insulin sliding\nscale. As the regular insulin sliding scale was increased\nand the Prednisone was tapered these values returned closer\nto normal.', '\n\nCONDITION ON DISCHARGE: Improved.\n\nDISCHARGE STATUS: To home.\n\nDISCHARGE MEDICATIONS: 1. Humibid LA 600 mg b.i.d. 2.\nLasix 160 mg b.i.d. 3. Potassium 40 milliequivalents po\nb.i.d. 4. Uniphyll 200 mg q.d. 5. Protonix 40 mg q.d. 6.\nZestril 2.5 mg q.d. 7. Serevent two puffs b.i.d. 8.\nFlovent 110 micrograms four puffs b.i.d. 9. Combivent two\npuffs q.i.d. 10. Scopolamine patch q 72 hours. 11.\nAlbuterol nebulizer q 6 hours prn. 12. Amiodarone 200 mg po\nq.d. 13. Enteric coated aspirin 325 mg q.d. 14. Glyburide\n5 mg q.a.m. 15. Regular insulin sliding scale as per\npreviously. 16. Colace 100 mg po b.i.d. 17. Senna two\ntabs po b.i.d. 18. Coumadin on hold until 4-3. 19.\nPrednisone taper over eight days. 20. Augmentin 500 mg\nt.i.d. 21. Lipitor 10 mg q.d. 22. Neurontin 300 mg po\nb.', 'i.d. 23. Oxycodone 20 mg q 8 hours prn. 24. Paxil 20 mg\npo q.d. 25. Ambien 10 to 15 mg po q.h.s. prn.\n\nThe patient had been using Care Group Respiratory Services at\nhome for pulmonary physical therapy and O2 assistance and so\nthis was arranged on an outpatient basis, with chest physical\ntherapy and incentive spirometry and other pulmonary\ntreatments. The plan was that he would follow up with Dr.\nStarks in clinic the following week and that he would have\nan INR drawn on 2-29 calling the results to Dr. Starks.\n\nDISCHARGE DIAGNOSES:\n1. Bronchitis.\n2. Possible atypical pneumonia.\n\n\n\n\n\n\n\n Ollie Grier, M.D. 65056966\n\nDictated By:Starks\n\nMEDQUIST36\n\nD: 1966-3-11 15:11\nT: 1974-8-19 06:15\nJOB#: Mcmahon, Hammond and Douglas-1981-268275\n']
16	15472	153439.0	2176-08-21	Discharge summary	Report	Admission Date: [2176-8-17] Discharge Date: [2176-8-21] Date of Birth: [2114-2-8] Sex: M Service: CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old male with a past medical history significant for lung cancer status post right pneumonectomy in [2175-6-28], six hospitalizations since [2176-5-27], last discharged on [2176-8-4], with the diagnosis of tracheal bronchitis versus chronic obstructive pulmonary disease flare, versus atypical pneumonia, status post intubation in the MICU, chronic secretions/congestion-related problems, on alternating regimen of Augmentin and Bactrim since [2175-9-28] for multiple bronchitic-like infections, chronic obstructive pulmonary disease, congestive heart failure, atrial fibrillation, prior PEs, diabetes type 2, status post myocardial infarction, who presented with gradual shortness of breath beginning on the day of admission. The patient reported a [1-29] day history of general fatigue. On the day of admission, visiting nurse services reported a systolic blood pressure of 70. The wife drove the patient to the Emergency Room. The patient also complained of some dizziness, however denied other symptoms including fever, chills, sweats, chest pain, diarrhea, constipation, nausea, vomiting, or urinary symptoms. He reported good p.o. intake and appetite. The patient reported that he has a chronic, slight cough, however, denied any sputum production. He took his oral temperature at home and denied any fever. At home, the patient is on oxygen of [12-31] L via nasal cannula. The patient recently finished a steroid taper on [8-14] which was two weeks in length. He reported a usual SBP of 80-110. The patient did note that since [Month (only) 216], a Scopolamine patch was added to his regimen and has increased his secretions significantly. EMERGENCY DEPARTMENT COURSE: Per Emergency Room, the patient appeared close to intubation upon presentation and was placed on 100% oxygen via non-rebreather with an ABG of 7.46, pCO2 of 48, and pO2 of 33. There was a question if this was a venous gas or not. Lasix 100 mg IV, Albuterol nebs, Solu-Medrol 600 mg IV, and Ceftriaxone 1 g IV was given to the patient. When evaluated by the MICU shortly after arrival to the Emergency Room, the patient was weaned down to baseline of 2 L oxygen with oxygen saturation of 100% via nasal cannula. The patient was breathing comfortably at 18-20 breaths/min. The patient no longer complained of shortness of breath but did state that he felt slightly tired. Chest x-ray was negative, and a CT showed no acute PE. The patient reported that he was back to baseline in the Emergency Room. PAST MEDICAL HISTORY: 1. Stage III squamous cell lung cancer diagnosis in [2175-2-26], status post right pneumonectomy in [2175-6-28], with radiation, Carboplatin, and Taxol treatments. 2. Chronic obstructive pulmonary disease with PFTs in [2176-5-27] showing an FEV1 of 0.83 L, which is 25% of predicted, and FEV1 to FVC ration of 68% of predicted. 3. Congestive heart failure with preserved left ventricular function in [2176-5-27]. 4. Atrial fibrillation. This was noted perioperatively. 5. Prostate carcinoma diagnosed in [2172-2-26] status post radical prostatectomy in [2172-8-27]. 6. Diabetes type 2. 7. History of urosepsis. 8. History of PE during the patient's postoperative course in [2175-6-28]. 9. Status post myocardial infarction. This was also perioperative in [2175-6-28]. Catheterization at that time showed normal left ventricular function, ejection fraction of 50%, and a 30% right coronary artery lesion. 10. Status post transient ischemic attack in [2165]. 11. Gout. 12. Gastroesophageal reflux disease. 13. Sleep apnea. 14. Colonic polyps noted in [2173-5-27]. 15. Hypercholesterolemia. ALLERGIES: Doxepin causes delirium. Levaquin causes prolonged QTCs. OxyContin causes "spasms." MEDICATIONS ON ADMISSION: Augmentin 500 mg t.i.d. from [8-5], to [8-18], Bactrim 800/160 mg tab 1 tab p.o. q.d. from [8-26] to [9-1], Potassium 40 mEq b.i.d., Protonix 40 mg q.d., Lasix 160 mg b.i.d., Uniphyl 200 mg q.d., Zestril 2.5 mg q.d., Amiodarone 200 mg q.d., Aspirin 325 mg q.d., Glyburide 2.5 mg q.d., Neurontin 300 mg b.i.d., Paxil 20 mg q.d., Colace 100 mg b.i.d., Senna 2 tab b.i.d., Lipitor 10 mg q.d., Coumadin 5 mg q.d. with 4 mg every Tuesday and Thursday, Percocet p.r.n. back pain, Serevent 2 puffs b.i.d., Flovent 110 mcg 4 puffs b.i.d., Combivent 2 puffs 4 times a day, ................... q.i.d. p.r.n., Scopolamine patch q.72 hours, Insulin sliding scale, Ambien 5 mg q.h.s. SOCIAL HISTORY: The patient lives with wife and quit smoking in [2175-5-28]. He smoked 3-4 packs per day for 40 years. No alcohol abuse. He is a retired construction worker. FAMILY HISTORY: Sister died at age 39 of cancer. Brother is status post coronary artery bypass grafting. Father with history of coronary artery disease. Sister with heart valve disease. PHYSICAL EXAMINATION: Vital signs: Temperature 98.5??????, heart rate 70, blood pressure 89-122/60-77, respirations 19-20, oxygen saturation 100% on 2 L nasal cannula. General: The patient was in no apparent respiratory distress. He was comfortable. He was alert and awake. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Normocephalic, atraumatic. Moist mucous membranes. Oropharynx clear. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2. Distant heart sounds. Without murmurs, rubs or gallops. Lungs: Loud rhonchi throughout the left lung field. No apparent wheezing or rubs. Transmitted sounds to right side. Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly. Extremities: Without clubbing, cyanosis, or edema. LABORATORY DATA: White count 10.4, hematocrit 30.0, which is baseline, platelet count 388; CHEM7 was unremarkable; PT 22.5, PTT 31.3, INR 3.5; B12 327, folate 12.7. Electrocardiogram unchanged from prior. Theophylline level 4.3. Chest x-ray showed status post right pneumonectomy, left lung with no congestive heart failure, no pneumonia, no pneumothorax, no effusion. CT angiogram showed no acute PE, possible chronic PE in pulmonary artery segment in the left lower lobe that is not occlusive. HOSPITAL COURSE: This was a 62-year-old male with a past medical history of lung carcinoma status post right pneumonectomy, multiple recent hospitalizations since [Month (only) 205] for bronchitic-like infections, on chronic alternating antibiotic regimen of Augmentin and Bactrim, recent hospitalization in MICU with intubation, chronic secretions, and congestive-related problems, chronic obstructive pulmonary disease, on home oxygen, congestive heart failure, prior PEs, history of atrial fibrillation, who presented with respiratory distress. 1. Respiratory distress: The patient was given Lasix, Albuterol nebs, and Solu-Medrol in the Emergency Department and had rapid improvement of his symptoms. It was thought that the patient's acute respiratory distress was most likely secondary to mucous plugging. PE was ruled out by CTA. Chest x-ray showed no clear signs of congestive heart failure or pneumonia. The patient also recently completed a steroid taper for possible chronic obstructive pulmonary disease component and was not clearly bronchospastic during this admission. He had no cough and no sputum production and no fevers. The patient was rapidly tapered off of steroids, as it was thought that chronic obstructive pulmonary disease was unlikely to be the cause of his acute respiratory distress and because it was unclear whether steroids was really benefitting this patient. He continued to have aggressive chest physical therapy for secretion management and was continued on his Scopolamine patch, Serevent, Combivent, Atrovent/Albuterol nebs, and inhalers. He was also continued on his alternating prophylactic antibiotic regimen of Augmentin and Bactrim. He continued to do well and recorded oxygen saturations of greater than 92%. On the day of discharge, oxygen saturation was 97% on room air. Of note, the patient was observed in the MICU overnight but was discharged to the floor quickly and had no other episodes of respiratory distress. 2. Hypotension: The visiting nurse noted a systolic blood pressure of 70; however, by the time the patient came to the Emergency Room, he had an SBP of 90. It was thought that the patient's slightly decreased SBP was secondary to hypovolemia. He was given gentle fluid hydration. He also had a cortical stimulation test to assess for renal insufficiency given that he had just finished his steroid taper; however, this was done after Solu-Medrol had been given to the patient. It was reportedly negative, but it was unclear as to how accurate this is in the setting of recent Solu-Medrol dosing. His Lasix was decreased from 160 mg b.i.d. to 80 mg b.i.d., and his ACE inhibitor was discontinued. He continued to remain normovolemic during the rest of his hospitalization. 3. Cardiovascular: In terms of the patient's history of perioperative myocardial infarction, atrial fibrillation, and congestive heart failure, the patient was continued on his Amiodarone and Lasix 80 mg b.i.d. He also continued Aspirin and Lipitor. His electrocardiogram was unchanged, and it was thought that there was not any significant cardiac component to the patient's respiratory distress. 4. Endocrine: The patient was continued on his Glyburide and was covered with an Insulin sliding scale in the hospital. 5. History of pulmonary embolus: The patient was continued on his Coumadin while in-house. No further work-up was done. 6. CODE STATUS: THE PATIENT IS FULL CODE. DISPOSITION: He will be discharged to pulmonary rehabilitation to try to maximize his pulmonary status. He appears to be doing very well with physical therapy during this hospitalization and has slightly improved his exercise tolerance. He will also be started on a Morphine Elixir 5-10 mg sublingually p.r.n. q.6 hours for shortness of breath to relieve the patient's symptom of air hunger. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease. 2. Mucous plugging. 3. Congestive heart failure. 4. Hypotension. 5. Diabetes type 2. 6. History of pulmonary embolus on Coumadin therapy. CONDITION ON DISCHARGE: The patient will be discharged to pulmonary rehabilitation. FOLLOW-UP: He will follow-up with Dr. [Last Name (STitle) 217] and his primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. q.d., Theophylline, Slo-[Hospital1 ] 200 mg p.o. q.d., Amiodarone 200 mg p.o. q.d., Neurontin 300 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., Senna 2 tab p.o. b.i.d., Lipitor 10 mg p.o. q.d., Percocet [11-29] tab p.o. q.4 hours p.r.n. back pain, Glyburide 2.5 mg p.o. q.a.m., hold if patient is NPO, Augmentin 500 mg p.o. ti.d. until [2176-8-25], then Bactrim 800/160 mg tab 1 tab p.o. b.i.d. from [8-26], to [9-1], ................... inhaler 2 puffs b.i.d., Combivent inhaler 2 puffs q.i.d., Albuterol nebs q.4 hours p.r.n., Scopolamine patch q.72 hours, Morphine Elixir sublingual immediate release 5-10 mg sublingual p.r.n. q.6 hours shortness of breath, Flovent 110 mcg 4 puffs q.i.d., Coumadin 5 mg q.d., except for Tuesday and Thursday when the patient gets 4 mg q.d., Ambien 10 mg p.o. q.h.s., Paxil 20 mg p.o. q.d., Aspirin 325 mg p.o. q.d., ................... 20 mEq p.o. b.i.d. with Lasix, Lasix 80 mg p.o. b.i.d. [First Name11 (Name Pattern1) 198] [Last Name (NamePattern4) 199], M.D. [MD Number(1) 200] Dictated By:[Last Name (NamePattern1) 218] MEDQUIST36 D: [2176-8-20] 19:24 T: [2176-8-20] 19:38 JOB#: [Job Number 219]	Admission Date: <Date>1945-10-26</Date> Discharge Date: <Date>2016-12-3</Date> Date of Birth: <Date>2001-4-11</Date> Sex: M Service: CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old male with a past medical history significant for lung cancer status post right pneumonectomy in <Date>1955-6-27</Date>, six hospitalizations since <Date>1922-9-3</Date>, last discharged on <Date>1946-11-2</Date>, with the diagnosis of tracheal bronchitis versus chronic obstructive pulmonary disease flare, versus atypical pneumonia, status post intubation in the MICU, chronic secretions/congestion-related problems, on alternating regimen of Augmentin and Bactrim since <Date>1935-3-12</Date> for multiple bronchitic-like infections, chronic obstructive pulmonary disease, congestive heart failure, atrial fibrillation, prior PEs, diabetes type 2, status post myocardial infarction, who presented with gradual shortness of breath beginning on the day of admission. The patient reported a <Date>10-25</Date> day history of general fatigue. On the day of admission, visiting nurse services reported a systolic blood pressure of 70. The wife drove the patient to the Emergency Room. The patient also complained of some dizziness, however denied other symptoms including fever, chills, sweats, chest pain, diarrhea, constipation, nausea, vomiting, or urinary symptoms. He reported good p.o. intake and appetite. The patient reported that he has a chronic, slight cough, however, denied any sputum production. He took his oral temperature at home and denied any fever. At home, the patient is on oxygen of <Date>4-28</Date> L via nasal cannula. The patient recently finished a steroid taper on <Date>1-6</Date> which was two weeks in length. He reported a usual SBP of 80-110. The patient did note that since <Month>November</Month>, a Scopolamine patch was added to his regimen and has increased his secretions significantly. EMERGENCY DEPARTMENT COURSE: Per Emergency Room, the patient appeared close to intubation upon presentation and was placed on 100% oxygen via non-rebreather with an ABG of 7.46, pCO2 of 48, and pO2 of 33. There was a question if this was a venous gas or not. Lasix 100 mg IV, Albuterol nebs, Solu-Medrol 600 mg IV, and Ceftriaxone 1 g IV was given to the patient. When evaluated by the MICU shortly after arrival to the Emergency Room, the patient was weaned down to baseline of 2 L oxygen with oxygen saturation of 100% via nasal cannula. The patient was breathing comfortably at 18-20 breaths/min. The patient no longer complained of shortness of breath but did state that he felt slightly tired. Chest x-ray was negative, and a CT showed no acute PE. The patient reported that he was back to baseline in the Emergency Room. PAST MEDICAL HISTORY: 1. Stage III squamous cell lung cancer diagnosis in <Date>1949-1-6</Date>, status post right pneumonectomy in <Date>1955-6-27</Date>, with radiation, Carboplatin, and Taxol treatments. 2. Chronic obstructive pulmonary disease with PFTs in <Date>1922-9-3</Date> showing an FEV1 of 0.83 L, which is 25% of predicted, and FEV1 to FVC ration of 68% of predicted. 3. Congestive heart failure with preserved left ventricular function in <Date>1922-9-3</Date>. 4. Atrial fibrillation. This was noted perioperatively. 5. Prostate carcinoma diagnosed in <Date>2010-6-28</Date> status post radical prostatectomy in <Date>1936-4-27</Date>. 6. Diabetes type 2. 7. History of urosepsis. 8. History of PE during the patient's postoperative course in <Date>1955-6-27</Date>. 9. Status post myocardial infarction. This was also perioperative in <Date>1955-6-27</Date>. Catheterization at that time showed normal left ventricular function, ejection fraction of 50%, and a 30% right coronary artery lesion. 10. Status post transient ischemic attack in <Year>1900</Year>. 11. Gout. 12. Gastroesophageal reflux disease. 13. Sleep apnea. 14. Colonic polyps noted in <Date>1902-8-30</Date>. 15. Hypercholesterolemia. ALLERGIES: Doxepin causes delirium. Levaquin causes prolonged QTCs. OxyContin causes "spasms." MEDICATIONS ON ADMISSION: Augmentin 500 mg t.i.d. from <Date>9-23</Date>, to <Date>7-17</Date>, Bactrim 800/160 mg tab 1 tab p.o. q.d. from <Date>2-5</Date> to <Date>5-14</Date>, Potassium 40 mEq b.i.d., Protonix 40 mg q.d., Lasix 160 mg b.i.d., Uniphyl 200 mg q.d., Zestril 2.5 mg q.d., Amiodarone 200 mg q.d., Aspirin 325 mg q.d., Glyburide 2.5 mg q.d., Neurontin 300 mg b.i.d., Paxil 20 mg q.d., Colace 100 mg b.i.d., Senna 2 tab b.i.d., Lipitor 10 mg q.d., Coumadin 5 mg q.d. with 4 mg every Tuesday and Thursday, Percocet p.r.n. back pain, Serevent 2 puffs b.i.d., Flovent 110 mcg 4 puffs b.i.d., Combivent 2 puffs 4 times a day, ................... q.i.d. p.r.n., Scopolamine patch q.72 hours, Insulin sliding scale, Ambien 5 mg q.h.s. SOCIAL HISTORY: The patient lives with wife and quit smoking in <Date>1948-3-29</Date>. He smoked 3-4 packs per day for 40 years. No alcohol abuse. He is a retired construction worker. FAMILY HISTORY: Sister died at age 39 of cancer. Brother is status post coronary artery bypass grafting. Father with history of coronary artery disease. Sister with heart valve disease. PHYSICAL EXAMINATION: Vital signs: Temperature 98.5??????, heart rate 70, blood pressure 89-122/60-77, respirations 19-20, oxygen saturation 100% on 2 L nasal cannula. General: The patient was in no apparent respiratory distress. He was comfortable. He was alert and awake. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Normocephalic, atraumatic. Moist mucous membranes. Oropharynx clear. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2. Distant heart sounds. Without murmurs, rubs or gallops. Lungs: Loud rhonchi throughout the left lung field. No apparent wheezing or rubs. Transmitted sounds to right side. Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly. Extremities: Without clubbing, cyanosis, or edema. LABORATORY DATA: White count 10.4, hematocrit 30.0, which is baseline, platelet count 388; CHEM7 was unremarkable; PT 22.5, PTT 31.3, INR 3.5; B12 327, folate 12.7. Electrocardiogram unchanged from prior. Theophylline level 4.3. Chest x-ray showed status post right pneumonectomy, left lung with no congestive heart failure, no pneumonia, no pneumothorax, no effusion. CT angiogram showed no acute PE, possible chronic PE in pulmonary artery segment in the left lower lobe that is not occlusive. HOSPITAL COURSE: This was a 62-year-old male with a past medical history of lung carcinoma status post right pneumonectomy, multiple recent hospitalizations since <Month>September</Month> for bronchitic-like infections, on chronic alternating antibiotic regimen of Augmentin and Bactrim, recent hospitalization in MICU with intubation, chronic secretions, and congestive-related problems, chronic obstructive pulmonary disease, on home oxygen, congestive heart failure, prior PEs, history of atrial fibrillation, who presented with respiratory distress. 1. Respiratory distress: The patient was given Lasix, Albuterol nebs, and Solu-Medrol in the Emergency Department and had rapid improvement of his symptoms. It was thought that the patient's acute respiratory distress was most likely secondary to mucous plugging. PE was ruled out by CTA. Chest x-ray showed no clear signs of congestive heart failure or pneumonia. The patient also recently completed a steroid taper for possible chronic obstructive pulmonary disease component and was not clearly bronchospastic during this admission. He had no cough and no sputum production and no fevers. The patient was rapidly tapered off of steroids, as it was thought that chronic obstructive pulmonary disease was unlikely to be the cause of his acute respiratory distress and because it was unclear whether steroids was really benefitting this patient. He continued to have aggressive chest physical therapy for secretion management and was continued on his Scopolamine patch, Serevent, Combivent, Atrovent/Albuterol nebs, and inhalers. He was also continued on his alternating prophylactic antibiotic regimen of Augmentin and Bactrim. He continued to do well and recorded oxygen saturations of greater than 92%. On the day of discharge, oxygen saturation was 97% on room air. Of note, the patient was observed in the MICU overnight but was discharged to the floor quickly and had no other episodes of respiratory distress. 2. Hypotension: The visiting nurse noted a systolic blood pressure of 70; however, by the time the patient came to the Emergency Room, he had an SBP of 90. It was thought that the patient's slightly decreased SBP was secondary to hypovolemia. He was given gentle fluid hydration. He also had a cortical stimulation test to assess for renal insufficiency given that he had just finished his steroid taper; however, this was done after Solu-Medrol had been given to the patient. It was reportedly negative, but it was unclear as to how accurate this is in the setting of recent Solu-Medrol dosing. His Lasix was decreased from 160 mg b.i.d. to 80 mg b.i.d., and his ACE inhibitor was discontinued. He continued to remain normovolemic during the rest of his hospitalization. 3. Cardiovascular: In terms of the patient's history of perioperative myocardial infarction, atrial fibrillation, and congestive heart failure, the patient was continued on his Amiodarone and Lasix 80 mg b.i.d. He also continued Aspirin and Lipitor. His electrocardiogram was unchanged, and it was thought that there was not any significant cardiac component to the patient's respiratory distress. 4. Endocrine: The patient was continued on his Glyburide and was covered with an Insulin sliding scale in the hospital. 5. History of pulmonary embolus: The patient was continued on his Coumadin while in-house. No further work-up was done. 6. CODE STATUS: THE PATIENT IS FULL CODE. DISPOSITION: He will be discharged to pulmonary rehabilitation to try to maximize his pulmonary status. He appears to be doing very well with physical therapy during this hospitalization and has slightly improved his exercise tolerance. He will also be started on a Morphine Elixir 5-10 mg sublingually p.r.n. q.6 hours for shortness of breath to relieve the patient's symptom of air hunger. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease. 2. Mucous plugging. 3. Congestive heart failure. 4. Hypotension. 5. Diabetes type 2. 6. History of pulmonary embolus on Coumadin therapy. CONDITION ON DISCHARGE: The patient will be discharged to pulmonary rehabilitation. FOLLOW-UP: He will follow-up with Dr. <Name>Pettway</Name> and his primary care physician <Name>Quinones</Name>. <Name>Ulysses</Name> <Name>Debelius</Name>. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. q.d., Theophylline, Slo-<Hospital>Rojas, Lee and Hughes Hospital</Hospital> 200 mg p.o. q.d., Amiodarone 200 mg p.o. q.d., Neurontin 300 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., Senna 2 tab p.o. b.i.d., Lipitor 10 mg p.o. q.d., Percocet <Date>12-5</Date> tab p.o. q.4 hours p.r.n. back pain, Glyburide 2.5 mg p.o. q.a.m., hold if patient is NPO, Augmentin 500 mg p.o. ti.d. until <Date>1944-6-13</Date>, then Bactrim 800/160 mg tab 1 tab p.o. b.i.d. from <Date>2-5</Date>, to <Date>5-14</Date>, ................... inhaler 2 puffs b.i.d., Combivent inhaler 2 puffs q.i.d., Albuterol nebs q.4 hours p.r.n., Scopolamine patch q.72 hours, Morphine Elixir sublingual immediate release 5-10 mg sublingual p.r.n. q.6 hours shortness of breath, Flovent 110 mcg 4 puffs q.i.d., Coumadin 5 mg q.d., except for Tuesday and Thursday when the patient gets 4 mg q.d., Ambien 10 mg p.o. q.h.s., Paxil 20 mg p.o. q.d., Aspirin 325 mg p.o. q.d., ................... 20 mEq p.o. b.i.d. with Lasix, Lasix 80 mg p.o. b.i.d. <Name>Roger</Name> <Name>Miller</Name>, M.D. <MD Number>71790083</MD Number> Dictated By:<Name>Feguson</Name> MEDQUIST36 D: <Date>1927-9-6</Date> 19:24 T: <Date>1927-9-6</Date> 19:38 JOB#: <Job Number>Griffith, Harper and Martinez-1950-839711</Job 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Date: 1945-10-26 Discharge Date: 2016-12-3 Date of Birth: 2001-4-11 Sex: M Service: CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old male with a past medical history significant for lung cancer status post right pneumonectomy in 1955-6-27, six hospitalizations since 1922-9-3, last discharged on 1946-11-2, with the diagnosis of tracheal bronchitis versus chronic obstructive pulmonary disease flare, versus atypical pneumonia, status post intubation in the MICU, chronic secretions/congestion-related problems, on alternating regimen of Augmentin and Bactrim since 1935-3-12 for multiple bronchitic-like infections, chronic obstructive pulmonary disease, congestive heart failure, atrial fibrillation, prior PEs, diabetes type 2, status post myocardial infarction, who presented with gradual shortness of breath beginning on the day of admission. The patient reported a 10-25 day history of general fatigue. On the day of admission, visiting nurse services reported a systolic blood pressure of 70. The wife drove the patient to the Emergency Room. The patient also complained of some dizziness, however denied other symptoms including fever, chills, sweats, chest pain, diarrhea, constipation, nausea, vomiting, or urinary symptoms. He reported good p.o. intake and appetite. The patient reported that he has a chronic, slight cough, however, denied any sputum production. He took his oral temperature at home and denied any fever. At home, the patient is on oxygen of 4-28 L via nasal cannula. The patient recently finished a steroid taper on 1-6 which was two weeks in length. He reported a usual SBP of 80-110. The patient did note that since November, a Scopolamine patch was added to his regimen and has increased his secretions significantly. EMERGENCY DEPARTMENT COURSE: Per Emergency Room, the patient appeared close to intubation upon presentation and was placed on 100% oxygen via non-rebreather with an ABG of 7.46, pCO2 of 48, and pO2 of 33. There was a question if this was a venous gas or not. Lasix 100 mg IV, Albuterol nebs, Solu-Medrol 600 mg IV, and Ceftriaxone 1 g IV was given to the patient. When evaluated by the MICU shortly after arrival to the Emergency Room, the patient was weaned down to baseline of 2 L oxygen with oxygen saturation of 100% via nasal cannula. The patient was breathing comfortably at 18-20 breaths/min. The patient no longer complained of shortness of breath but did state that he felt slightly tired. Chest x-ray was negative, and a CT showed no acute PE. The patient reported that he was back to baseline in the Emergency Room. PAST MEDICAL HISTORY: 1. Stage III squamous cell lung cancer diagnosis in 1949-1-6, status post right pneumonectomy in 1955-6-27, with radiation, Carboplatin, and Taxol treatments. 2. Chronic obstructive pulmonary disease with PFTs in 1922-9-3 showing an FEV1 of 0.83 L, which is 25% of predicted, and FEV1 to FVC ration of 68% of predicted. 3. Congestive heart failure with preserved left ventricular function in 1922-9-3. 4. Atrial fibrillation. This was noted perioperatively. 5. Prostate carcinoma diagnosed in 2010-6-28 status post radical prostatectomy in 1936-4-27. 6. Diabetes type 2. 7. History of urosepsis. 8. History of PE during the patient's postoperative course in 1955-6-27. 9. Status post myocardial infarction. This was also perioperative in 1955-6-27. Catheterization at that time showed normal left ventricular function, ejection fraction of 50%, and a 30% right coronary artery lesion. 10. Status post transient ischemic attack in 1900. 11. Gout. 12. Gastroesophageal reflux disease. 13. Sleep apnea. 14. Colonic polyps noted in 1902-8-30. 15. Hypercholesterolemia. ALLERGIES: Doxepin causes delirium. Levaquin causes prolonged QTCs. OxyContin causes "spasms." MEDICATIONS ON ADMISSION: Augmentin 500 mg t.i.d. from 9-23, to 7-17, Bactrim 800/160 mg tab 1 tab p.o. q.d. from 2-5 to 5-14, Potassium 40 mEq b.i.d., Protonix 40 mg q.d., Lasix 160 mg b.i.d., Uniphyl 200 mg q.d., Zestril 2.5 mg q.d., Amiodarone 200 mg q.d., Aspirin 325 mg q.d., Glyburide 2.5 mg q.d., Neurontin 300 mg b.i.d., Paxil 20 mg q.d., Colace 100 mg b.i.d., Senna 2 tab b.i.d., Lipitor 10 mg q.d., Coumadin 5 mg q.d. with 4 mg every Tuesday and Thursday, Percocet p.r.n. back pain, Serevent 2 puffs b.i.d., Flovent 110 mcg 4 puffs b.i.d., Combivent 2 puffs 4 times a day, ................... q.i.d. p.r.n., Scopolamine patch q.72 hours, Insulin sliding scale, Ambien 5 mg q.h.s. SOCIAL HISTORY: The patient lives with wife and quit smoking in 1948-3-29. He smoked 3-4 packs per day for 40 years. No alcohol abuse. He is a retired construction worker. FAMILY HISTORY: Sister died at age 39 of cancer. Brother is status post coronary artery bypass grafting. Father with history of coronary artery disease. Sister with heart valve disease. PHYSICAL EXAMINATION: Vital signs: Temperature 98.5??????, heart rate 70, blood pressure 89-122/60-77, respirations 19-20, oxygen saturation 100% on 2 L nasal cannula. General: The patient was in no apparent respiratory distress. He was comfortable. He was alert and awake. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Normocephalic, atraumatic. Moist mucous membranes. Oropharynx clear. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2. Distant heart sounds. Without murmurs, rubs or gallops. Lungs: Loud rhonchi throughout the left lung field. No apparent wheezing or rubs. Transmitted sounds to right side. Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly. Extremities: Without clubbing, cyanosis, or edema. LABORATORY DATA: White count 10.4, hematocrit 30.0, which is baseline, platelet count 388; CHEM7 was unremarkable; PT 22.5, PTT 31.3, INR 3.5; B12 327, folate 12.7. Electrocardiogram unchanged from prior. Theophylline level 4.3. Chest x-ray showed status post right pneumonectomy, left lung with no congestive heart failure, no pneumonia, no pneumothorax, no effusion. CT angiogram showed no acute PE, possible chronic PE in pulmonary artery segment in the left lower lobe that is not occlusive. HOSPITAL COURSE: This was a 62-year-old male with a past medical history of lung carcinoma status post right pneumonectomy, multiple recent hospitalizations since September for bronchitic-like infections, on chronic alternating antibiotic regimen of Augmentin and Bactrim, recent hospitalization in MICU with intubation, chronic secretions, and congestive-related problems, chronic obstructive pulmonary disease, on home oxygen, congestive heart failure, prior PEs, history of atrial fibrillation, who presented with respiratory distress. 1. Respiratory distress: The patient was given Lasix, Albuterol nebs, and Solu-Medrol in the Emergency Department and had rapid improvement of his symptoms. It was thought that the patient's acute respiratory distress was most likely secondary to mucous plugging. PE was ruled out by CTA. Chest x-ray showed no clear signs of congestive heart failure or pneumonia. The patient also recently completed a steroid taper for possible chronic obstructive pulmonary disease component and was not clearly bronchospastic during this admission. He had no cough and no sputum production and no fevers. The patient was rapidly tapered off of steroids, as it was thought that chronic obstructive pulmonary disease was unlikely to be the cause of his acute respiratory distress and because it was unclear whether steroids was really benefitting this patient. He continued to have aggressive chest physical therapy for secretion management and was continued on his Scopolamine patch, Serevent, Combivent, Atrovent/Albuterol nebs, and inhalers. He was also continued on his alternating prophylactic antibiotic regimen of Augmentin and Bactrim. He continued to do well and recorded oxygen saturations of greater than 92%. On the day of discharge, oxygen saturation was 97% on room air. Of note, the patient was observed in the MICU overnight but was discharged to the floor quickly and had no other episodes of respiratory distress. 2. Hypotension: The visiting nurse noted a systolic blood pressure of 70; however, by the time the patient came to the Emergency Room, he had an SBP of 90. It was thought that the patient's slightly decreased SBP was secondary to hypovolemia. He was given gentle fluid hydration. He also had a cortical stimulation test to assess for renal insufficiency given that he had just finished his steroid taper; however, this was done after Solu-Medrol had been given to the patient. It was reportedly negative, but it was unclear as to how accurate this is in the setting of recent Solu-Medrol dosing. His Lasix was decreased from 160 mg b.i.d. to 80 mg b.i.d., and his ACE inhibitor was discontinued. He continued to remain normovolemic during the rest of his hospitalization. 3. Cardiovascular: In terms of the patient's history of perioperative myocardial infarction, atrial fibrillation, and congestive heart failure, the patient was continued on his Amiodarone and Lasix 80 mg b.i.d. He also continued Aspirin and Lipitor. His electrocardiogram was unchanged, and it was thought that there was not any significant cardiac component to the patient's respiratory distress. 4. Endocrine: The patient was continued on his Glyburide and was covered with an Insulin sliding scale in the hospital. 5. History of pulmonary embolus: The patient was continued on his Coumadin while in-house. No further work-up was done. 6. CODE STATUS: THE PATIENT IS FULL CODE. DISPOSITION: He will be discharged to pulmonary rehabilitation to try to maximize his pulmonary status. He appears to be doing very well with physical therapy during this hospitalization and has slightly improved his exercise tolerance. He will also be started on a Morphine Elixir 5-10 mg sublingually p.r.n. q.6 hours for shortness of breath to relieve the patient's symptom of air hunger. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease. 2. Mucous plugging. 3. Congestive heart failure. 4. Hypotension. 5. Diabetes type 2. 6. History of pulmonary embolus on Coumadin therapy. CONDITION ON DISCHARGE: The patient will be discharged to pulmonary rehabilitation. FOLLOW-UP: He will follow-up with Dr. Pettway and his primary care physician Quinones. Ulysses Debelius. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. q.d., Theophylline, Slo-Rojas, Lee and Hughes Hospital 200 mg p.o. q.d., Amiodarone 200 mg p.o. q.d., Neurontin 300 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., Senna 2 tab p.o. b.i.d., Lipitor 10 mg p.o. q.d., Percocet 12-5 tab p.o. q.4 hours p.r.n. back pain, Glyburide 2.5 mg p.o. q.a.m., hold if patient is NPO, Augmentin 500 mg p.o. ti.d. until 1944-6-13, then Bactrim 800/160 mg tab 1 tab p.o. b.i.d. from 2-5, to 5-14, ................... inhaler 2 puffs b.i.d., Combivent inhaler 2 puffs q.i.d., Albuterol nebs q.4 hours p.r.n., Scopolamine patch q.72 hours, Morphine Elixir sublingual immediate release 5-10 mg sublingual p.r.n. q.6 hours shortness of breath, Flovent 110 mcg 4 puffs q.i.d., Coumadin 5 mg q.d., except for Tuesday and Thursday when the patient gets 4 mg q.d., Ambien 10 mg p.o. q.h.s., Paxil 20 mg p.o. q.d., Aspirin 325 mg p.o. q.d., ................... 20 mEq p.o. b.i.d. with Lasix, Lasix 80 mg p.o. b.i.d. Roger Miller, M.D. 71790083 Dictated By:Feguson MEDQUIST36 D: 1927-9-6 19:24 T: 1927-9-6 19:38 JOB#: Griffith, Harper and Martinez-1950-839711	['Admission Date: 1945-10-26 Discharge Date: 2016-12-3\n\nDate of Birth: 2001-4-11 Sex: M\n\nService:\n\nCHIEF COMPLAINT: Respiratory distress.\n\nHISTORY OF PRESENT ILLNESS: The patient is a 62-year-old\nmale with a past medical history significant for lung cancer\nstatus post right pneumonectomy in 1955-6-27, six\nhospitalizations since 1922-9-3, last discharged on\n1946-11-2, with the diagnosis of tracheal bronchitis\nversus chronic obstructive pulmonary disease flare, versus\natypical pneumonia, status post intubation in the MICU,\nchronic secretions/congestion-related problems, on\nalternating regimen of Augmentin and Bactrim since 1935-3-12 for multiple bronchitic-like infections, chronic\nobstructive pulmonary disease, congestive heart failure,\natrial fibrillation, prior PEs, diabetes type 2, status post\nmyocardial infarction, who presented with gradual shortness\nof breath beginning on the day of admission.', '\n\nThe patient reported a 10-25 day history of general fatigue.\nOn the day of admission, visiting nurse services reported a\nsystolic blood pressure of 70. The wife drove the patient to\nthe Emergency Room. The patient also complained of some\ndizziness, however denied other symptoms including fever,\nchills, sweats, chest pain, diarrhea, constipation, nausea,\nvomiting, or urinary symptoms. He reported good p.o. intake\nand appetite.\n\nThe patient reported that he has a chronic, slight cough,\nhowever, denied any sputum production. He took his oral\ntemperature at home and denied any fever. At home, the\npatient is on oxygen of 4-28 L via nasal cannula. The patient\nrecently finished a steroid taper on 1-6 which was\ntwo weeks in length. He reported a usual SBP of 80-110. The\npatient did note that since November, a Scopolamine patch was\nadded to his regimen and has increased his secretions\nsignificantly.', '\n\nEMERGENCY DEPARTMENT COURSE: Per Emergency Room, the patient\nappeared close to intubation upon presentation and was placed\non 100% oxygen via non-rebreather with an ABG of 7.46, pCO2\nof 48, and pO2 of 33. There was a question if this was a\nvenous gas or not. Lasix 100 mg IV, Albuterol nebs,\nSolu-Medrol 600 mg IV, and Ceftriaxone 1 g IV was given to\nthe patient. When evaluated by the MICU shortly after\narrival to the Emergency Room, the patient was weaned down to\nbaseline of 2 L oxygen with oxygen saturation of 100% via\nnasal cannula. The patient was breathing comfortably at\n18-20 breaths/min. The patient no longer complained of\nshortness of breath but did state that he felt slightly\ntired. Chest x-ray was negative, and a CT showed no acute\nPE. The patient reported that he was back to baseline in the\nEmergency Room.', "\n\nPAST MEDICAL HISTORY: 1. Stage III squamous cell lung\ncancer diagnosis in 1949-1-6, status post right\npneumonectomy in 1955-6-27, with radiation, Carboplatin,\nand Taxol treatments. 2. Chronic obstructive pulmonary\ndisease with PFTs in 1922-9-3 showing an FEV1 of 0.83 L,\nwhich is 25% of predicted, and FEV1 to FVC ration of 68% of\npredicted. 3. Congestive heart failure with preserved left\nventricular function in 1922-9-3. 4. Atrial fibrillation.\nThis was noted perioperatively. 5. Prostate carcinoma\ndiagnosed in 2010-6-28 status post radical prostatectomy in\n1936-4-27. 6. Diabetes type 2. 7. History of\nurosepsis. 8. History of PE during the patient's\npostoperative course in 1955-6-27. 9. Status post\nmyocardial infarction. This was also perioperative in 1955-6-27. Catheterization at that time showed normal left\nventricular function, ejection fraction of 50%, and a 30%\nright coronary artery lesion.", ' 10. Status post transient\nischemic attack in 1900. 11. Gout. 12. Gastroesophageal\nreflux disease. 13. Sleep apnea. 14. Colonic polyps noted\nin 1902-8-30. 15. Hypercholesterolemia.\n\nALLERGIES: Doxepin causes delirium. Levaquin causes\nprolonged QTCs. OxyContin causes "spasms."\n\nMEDICATIONS ON ADMISSION: Augmentin 500 mg t.i.d. from\n9-23, to 7-17, Bactrim 800/160 mg tab 1 tab\np.o. q.d. from 2-5 to 5-14, Potassium 40 mEq\nb.i.d., Protonix 40 mg q.d., Lasix 160 mg b.i.d., Uniphyl 200\nmg q.d., Zestril 2.5 mg q.d., Amiodarone 200 mg q.d., Aspirin\n325 mg q.d., Glyburide 2.5 mg q.d., Neurontin 300 mg b.i.d.,\nPaxil 20 mg q.d., Colace 100 mg b.i.d., Senna 2 tab b.i.d.,\nLipitor 10 mg q.d., Coumadin 5 mg q.d. with 4 mg every\nTuesday and Thursday, Percocet p.r.n. back pain, Serevent 2\npuffs b.', 'i.d., Flovent 110 mcg 4 puffs b.i.d., Combivent 2\npuffs 4 times a day, ................... q.i.d. p.r.n.,\nScopolamine patch q.72 hours, Insulin sliding scale, Ambien 5\nmg q.h.s.\n\nSOCIAL HISTORY: The patient lives with wife and quit smoking\nin 1948-3-29. He smoked 3-4 packs per day for 40 years. No\nalcohol abuse. He is a retired construction worker.\n\nFAMILY HISTORY: Sister died at age 39 of cancer. Brother is\nstatus post coronary artery bypass grafting. Father with\nhistory of coronary artery disease. Sister with heart valve\ndisease.\n\nPHYSICAL EXAMINATION: Vital signs: Temperature 98.5??????, heart\nrate 70, blood pressure 89-122/60-77, respirations 19-20,\noxygen saturation 100% on 2 L nasal cannula. General: The\npatient was in no apparent respiratory distress. He was\ncomfortable.', ' He was alert and awake. HEENT: Pupils equal,\nround and reactive to light and accommodation. Extraocular\nmovements intact. Normocephalic, atraumatic. Moist mucous\nmembranes. Oropharynx clear. Cardiovascular: Regular, rate\nand rhythm. Normal S1 and S2. Distant heart sounds.\nWithout murmurs, rubs or gallops. Lungs: Loud rhonchi\nthroughout the left lung field. No apparent wheezing or\nrubs. Transmitted sounds to right side. Abdomen: Soft,\nnontender, nondistended. No hepatosplenomegaly.\nExtremities: Without clubbing, cyanosis, or edema.\n\nLABORATORY DATA: White count 10.4, hematocrit 30.0, which is\nbaseline, platelet count 388; CHEM7 was unremarkable; PT\n22.5, PTT 31.3, INR 3.5; B12 327, folate 12.7.\n\nElectrocardiogram unchanged from prior. Theophylline level\n4.3.\n\nChest x-ray showed status post right pneumonectomy, left lung\nwith no congestive heart failure, no pneumonia, no\npneumothorax, no effusion.', ' CT angiogram showed no acute PE,\npossible chronic PE in pulmonary artery segment in the left\nlower lobe that is not occlusive.\n\nHOSPITAL COURSE: This was a 62-year-old male with a past\nmedical history of lung carcinoma status post right\npneumonectomy, multiple recent hospitalizations since September\nfor bronchitic-like infections, on chronic alternating\nantibiotic regimen of Augmentin and Bactrim, recent\nhospitalization in MICU with intubation, chronic secretions,\nand congestive-related problems, chronic obstructive\npulmonary disease, on home oxygen, congestive heart failure,\nprior PEs, history of atrial fibrillation, who presented with\nrespiratory distress.\n\n1. Respiratory distress: The patient was given Lasix,\nAlbuterol nebs, and Solu-Medrol in the Emergency Department\nand had rapid improvement of his symptoms.', " It was thought\nthat the patient's acute respiratory distress was most likely\nsecondary to mucous plugging. PE was ruled out by CTA.\nChest x-ray showed no clear signs of congestive heart failure\nor pneumonia. The patient also recently completed a steroid\ntaper for possible chronic obstructive pulmonary disease\ncomponent and was not clearly bronchospastic during this\nadmission. He had no cough and no sputum production and no\nfevers. The patient was rapidly tapered off of steroids, as\nit was thought that chronic obstructive pulmonary disease was\nunlikely to be the cause of his acute respiratory distress\nand because it was unclear whether steroids was really\nbenefitting this patient.\n\nHe continued to have aggressive chest physical therapy for\nsecretion management and was continued on his Scopolamine\npatch, Serevent, Combivent, Atrovent/Albuterol nebs, and\ninhalers.", " He was also continued on his alternating\nprophylactic antibiotic regimen of Augmentin and Bactrim. He\ncontinued to do well and recorded oxygen saturations of\ngreater than 92%. On the day of discharge, oxygen saturation\nwas 97% on room air.\n\nOf note, the patient was observed in the MICU overnight but\nwas discharged to the floor quickly and had no other episodes\nof respiratory distress.\n\n2. Hypotension: The visiting nurse noted a systolic blood\npressure of 70; however, by the time the patient came to the\nEmergency Room, he had an SBP of 90. It was thought that the\npatient's slightly decreased SBP was secondary to\nhypovolemia. He was given gentle fluid hydration. He also\nhad a cortical stimulation test to assess for renal\ninsufficiency given that he had just finished his steroid\ntaper; however, this was done after Solu-Medrol had been\ngiven to the patient.", " It was reportedly negative, but it was\nunclear as to how accurate this is in the setting of recent\nSolu-Medrol dosing. His Lasix was decreased from 160 mg\nb.i.d. to 80 mg b.i.d., and his ACE inhibitor was\ndiscontinued. He continued to remain normovolemic during the\nrest of his hospitalization.\n\n3. Cardiovascular: In terms of the patient's history of\nperioperative myocardial infarction, atrial fibrillation, and\ncongestive heart failure, the patient was continued on his\nAmiodarone and Lasix 80 mg b.i.d. He also continued Aspirin\nand Lipitor. His electrocardiogram was unchanged, and it was\nthought that there was not any significant cardiac component\nto the patient's respiratory distress.\n\n4. Endocrine: The patient was continued on his Glyburide\nand was covered with an Insulin sliding scale in the\nhospital.", "\n\n5. History of pulmonary embolus: The patient was continued\non his Coumadin while in-house. No further work-up was done.\n\n6. CODE STATUS: THE PATIENT IS FULL CODE.\n\nDISPOSITION: He will be discharged to pulmonary\nrehabilitation to try to maximize his pulmonary status. He\nappears to be doing very well with physical therapy during\nthis hospitalization and has slightly improved his exercise\ntolerance. He will also be started on a Morphine Elixir 5-10\nmg sublingually p.r.n. q.6 hours for shortness of breath to\nrelieve the patient's symptom of air hunger.\n\nDISCHARGE DIAGNOSIS:\n1. Chronic obstructive pulmonary disease.\n2. Mucous plugging.\n3. Congestive heart failure.\n4. Hypotension.\n5. Diabetes type 2.\n6. History of pulmonary embolus on Coumadin therapy.\n\nCONDITION ON DISCHARGE: The patient will be discharged to\npulmonary rehabilitation.", '\n\nFOLLOW-UP: He will follow-up with Dr. Pettway and his\nprimary care physician Quinones. Ulysses Debelius.\n\nDISCHARGE MEDICATIONS: Protonix 40 mg p.o. q.d.,\nTheophylline, Slo-Rojas, Lee and Hughes Hospital 200 mg p.o. q.d., Amiodarone 200 mg\np.o. q.d., Neurontin 300 mg p.o. b.i.d., Colace 100 mg p.o.\nb.i.d., Senna 2 tab p.o. b.i.d., Lipitor 10 mg p.o. q.d.,\nPercocet 12-5 tab p.o. q.4 hours p.r.n. back pain, Glyburide\n2.5 mg p.o. q.a.m., hold if patient is NPO, Augmentin 500 mg\np.o. ti.d. until 1944-6-13, then Bactrim 800/160 mg\ntab 1 tab p.o. b.i.d. from 2-5, to 5-14,\n................... inhaler 2 puffs b.i.d., Combivent inhaler\n2 puffs q.i.d., Albuterol nebs q.4 hours p.r.n., Scopolamine\npatch q.72 hours, Morphine Elixir sublingual immediate\nrelease 5-10 mg sublingual p.r.n. q.6 hours shortness of\nbreath, Flovent 110 mcg 4 puffs q.', 'i.d., Coumadin 5 mg q.d.,\nexcept for Tuesday and Thursday when the patient gets 4 mg\nq.d., Ambien 10 mg p.o. q.h.s., Paxil 20 mg p.o. q.d.,\nAspirin 325 mg p.o. q.d., ................... 20 mEq p.o.\nb.i.d. with Lasix, Lasix 80 mg p.o. b.i.d.\n\n\n\n\n\n\n\n Roger Miller, M.D. 71790083\n\nDictated By:Feguson\nMEDQUIST36\n\nD: 1927-9-6 19:24\nT: 1927-9-6 19:38\nJOB#: Griffith, Harper and Martinez-1950-839711\n']
17	15472	109655.0	2177-12-05	Discharge summary	Report	Admission Date: [2177-11-25] Discharge Date: [2177-12-5] Date of Birth: [2114-2-8] Sex: M Service: [Hospital1 139] HISTORY OF PRESENT ILLNESS: The patient is a 63 year old male with a past medical history of chronic obstructive pulmonary disease, lung cancer, status post right pneumonectomy in [2175-1-26], complicated by pulmonary artery laceration, status post transtracheal catheter placement for oxygen and suctioning who was in his usual state of health until [2177-11-24] when he developed nausea, lower abdominal pain, and projectile vomiting of nonbloody emesis. He presented to the [Hospital6 256] Emergency Room on [2177-11-25]. At that time he denied diarrhea, constipation, fevers, chills, hematochezia and bright red blood per rectum. He had dark stools at baseline secondary to iron use. The stool was found to be guaiac positive in the Emergency Department. In the Emergency Department also his hematocrit value was 19, down from a baseline of 31 one month previously and he was coagulopathic with an INR of 9.8. Attempts to place a nasogastric tube in the Emergency Department were unsuccessful. While in the Emergency Department, he was transfused 4 units of packed red blood cells, 2 units of fresh frozen plasma, and got 2 mg of subcutaneous Vitamin K. The patient was admitted to the Medicine Floor. Repeat hematocrit several hours later dropped to a value of 13. The nasogastric tube was placed on the floor with nasogastric lavage negative for fresh blood. He was, at that point, transferred to the Medical Intensive Care Unit. Workup while in the Medical Intensive Care Unit included two esophagogastroduodenoscopies, both without fresh blood or old blood but demonstrating a single raised 5 to 7 cm esophageal nodule on an erythematous base at approximately 25 cm. There was no evidence of stigmata of recent bleeding. He was stabilized with a total of seven units of packed red blood cells, seven units of fresh frozen plasma and one unit of platelets. He also received intravenous fluid resuscitation with normal saline. Computerized tomography scan of the abdomen was performed which was negative for diverticuli, perforation or retroperitoneal bleed. Colonoscopy performed later in the hospital course showed some polyps, diverticulosis of the sigmoid colon and descending colon. Internal hemorrhoids were noted but no stigmata of recent bleeding. The patient's coagulopathy was improving. His hematocrit was stable, and he was transferred to the General Medicine Floor on [2177-11-28]. Of note, prior to transfer he developed swelling of the right upper extremity and complained of pain of the right upper extremity. Doppler ultrasound was performed which showed evidence of a right axillary deep vein thrombosis. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease; 2. Lung cancer, status post right pneumonectomy in [2175-1-26] complicated by pulmonary artery laceration; 3. Prostate cancer, status post prostatectomy; 4. History of perioperative pulmonary embolism; 5. Atrial fibrillation on Coumadin; 6. Hypertension; 7. Diabetes mellitus 2, insulin-requiring neuropathy; 8. Gastroesophageal reflux disease; 9. Status post transtracheal catheter placement for oxygen and suctioning; 10. Cataracts; 11. Anxiety; 12. History of transient ischemic attacks; 13. Obstructive sleep apnea; 14. Hypercholesterolemia; 15. Vitamin B12 deficiency. ALLERGIES: Levaquin causes QT interval prolongations. MEDICATIONS PRIOR TO ADMISSION: 1. Protonix 40 mg p.o. q.d.; 2. Lasix 80 mg p.o. b.i.d.; 3. Neurontin 100 mg p.o. q.d.; 4. Paroxetine 30 mg p.o. q.d.; 5. Iron sulfate 325 mg p.o. b.i.d.; 6. Colace 100 mg p.o. b.i.d.; 7. Glyburide 5 mg p.o. q.d.; 8. Vitamin B12 1000 mcg p.o. b.i.d.; 9. Amiodarone 200 mg p.o. q.d.; 10. Lipitor 10 mg p.o. q.d.; 11. Coumadin 5 mg p.o. q.d.; 12. Aspirin 325 mg p.o. q.d.; 13. Scopolamine patch transdermal, apply every three days; 14. Advair discus one puff b.i.d.; 15. Potassium chloride 40 mEq p.o. b.i.d.; 16. Senna 2 tablets p.o. b.i.d. as needed for constipation; 17. Percocet 1 to 2 tablets as needed for pain; 18. Ipratropium nebulizer t.i.d.; 19. Bactrim double strength p.o. b.i.d.; 20. Augmentin; 21. Multivitamin p.o. q.d.; 22. Regular insulin sliding scale. FAMILY HISTORY: The patient reports that his mother has coronary artery disease. SOCIAL HISTORY: The patient lives with his wife, retired, worked previously in construction. He reports a 160 pack year tobacco history, quit in [2174], quit alcohol in [2173]. No history of intravenous drug use. PHYSICAL EXAMINATION: Physical examination on admission revealed vital signs with temperature of 96.8, blood pressure 90/55, heart rate 90, respiratory rate 12, oxygen saturation 96% on 3 liters. General appearance: Well developed, obese white male, pleasant, comfortable in no acute distress. Head, eyes, ears, nose and throat: Normocephalic, atraumatic, pupils equal, round and reactive to light and accommodation. Sclera and conjunctiva anicteric. Conjunctiva not injected. Oropharynx clear. [Year (4 digits) ] mucosa dry. Neck: Supple, no masses or lymphadenopathy. Tracheostomy site, clean, dry and intact. Lungs: Right lung with no breath sounds, left lung with fair air movement, transmitted upper airway sounds, scattered rhonchi. Cardiovascular: Regular rate and rhythm, S1 and S2 heart sounds auscultated, no murmurs, rubs or gallops. Abdomen: Soft, mildly tender to palpation, nondistended, positive normoactive bowel sounds. No rebound or guarding. Extremities: No cyanosis, clubbing or edema. Neurological examination: Nonfocal. LABORATORY DATA: Laboratory data upon admission revealed complete blood count demonstrated a white blood cell count 19.2, hematocrit 19.0, platelets 381. Coagulation profile showed PT 38.5, PTT 38.0, INR 9.8. Serum chemistries showed sodium 139, potassium 3.7, chloride 96, bicarbonate 30, BUN 52, creatinine 1.3, glucose 196. Liver function tests showed ALT 18, AST 26, amylase 23, lipase 24, albumin 3.4, alkaline phosphatase 100. Cardiac enzymes showed creatinine kinase 82, troponin I 0.04. Chest x-ray was negative for any acute pulmonary process. Abdominal x-ray demonstrated opacification of the right lung base. The left lung base was clear. There was no free air in the abdomen. There was a large amount of fecal material in the right colon. There was a normal bowel gas pattern. There was no evidence of obstruction. Later computerized tomography scan of the abdomen and pelvis demonstrated no intra-abdominal abscess, bowel inflammation, evidence of perforated ulcer, appendicitis or diverticulitis. Electrocardiogram showed normal sinus rhythm at 93 beats/minute, normal axis, prolonged QT interval, no left ventricular hypertrophy, T wave inversions were noted in leads V1 and V2 which were new. No acute ST elevations or depressions noted. This was compared with the prior electrocardiogram from [2177-10-9]. HOSPITAL COURSE: In summary, this is a 63 year old male with past medical history of chronic obstructive pulmonary disease, lung cancer status post right pneumonectomy in [2175-1-26] complicated by a pulmonary artery laceration, status post transtracheal catheter placement for oxygen and suctioning. He was in his usual state of health until [2177-11-24] when he developed nausea, lower abdominal pain, projectile vomiting of nonbloody emesis. His hematocrit dropped from 31 to a nadir of 13. His gastrointestinal workup was unrevealing in the Medical Intensive Care Unit. 1. Anemia secondary to acute blood loss - The patient's gastrointestinal workup included two esophagogastroduodenoscopies and colonoscopy times one without source of frank bleed. However, in light of his initial complaints of nausea, abdominal pain, and guaiac positive stool a gastrointestinal source was still suspected. Physically the small bowel could be the source. After stabilization in the Medical Intensive Care Unit with blood products, fresh frozen plasma and platelets, he was transferred to the Medicine Floor after having stable hematocrit for greater than 24 hours. While on the floor, his hematocrit was checked initially every 12 hours. After demonstrating stability for a total of 72 hours it was spaced out to q. day hematocrit checks. All told the patient received 7 units of packed red blood cells, 7 units of fresh frozen plasma and one unit of platelets during his hospital stay. On [2177-12-3], the patient underwent repeat esophagogastroduodenoscopy in order to obtain biopsy samples of the esophageal nodule, not noted on previous study. At the time of this dictation results of those biopsies were pending. While in the Medical Intensive Care Unit the patient also had workup for hemolysis to evaluate whether hemolysis could be attributing to his anemia. He had a normal left ventricular hypertrophy, haptoglobin and bilirubin on admission, however, making hemolysis a very unlikely explanation for his presentation hematocrit of 19. Moreover, no schistocytes were seen on peripheral smear. Hemolysis laboratory data were checked several days into his hospital course and were consistent with changes status post large volume transfusion with no evidence of active ongoing hemolysis. 2. Right upper extremity deep vein thrombosis - On [2177-11-28] the patient began to complain of right upper extremity pain and swelling. Doppler ultrasound demonstrated an axillary deep vein thrombosis. In light of his recent bleeding episode, anticoagulation was held initially. Although upper extremity deep vein thromboses do not embolize as often as lower extremity deep vein thromboses, there was still a very high concern for pulmonary embolus in light of the patient's history of right pneumonectomy and the functionality of his one remaining lung. The computerized tomography scan was performed to better examine the right upper extremity soft tissues. In particular there was concern that the patient might have an obstructing mass lesion or fibrosis-post his pneumonectomy that could be contributing to venous stasis and obstruction leading to deep vein thrombosis formation. Computerized tomographic venogram was without evidence of obstructing lesion of fibrosis, however. The patient is likely hypercoagulable as evidenced by the development of this right upper extremity deep vein thrombosis spontaneously after being off anticoagulation in the setting of his acute bleed for only several days, there was concern for recurrent deep vein thromboses. Therefore, an inferior vena cava filter was placed on [2177-12-2]. The patient tolerated the procedure well. On [2177-12-4], the patient then began to complain of pain and swelling of the right lower extremity. Examination was consistent with possible thrombus of the right lower extremity. However, as the patient already had an inferior vena cava filter placed and delineation of a right lower extremity deep vein thrombosis would not change management plans at all, the decision was made not to undergo ultrasound doppler imaging of the right lower extremity. In light of his probable hypercoagulability, decision was made to reinitiate anticoagulation with the Coumadin. His Coumadin level will be followed by his outpatient physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. His INR should be checked remotely at the rehabilitation facility and his Coumadin dose adjusted accordingly for a goal INR of 2 to 3. 3. Chronic obstructive pulmonary disease/lung carcinoma status post right pneumonectomy - The patient was continued on aggressive regimen of chest physical therapy and pulmonary toilet. He was continued on his outpatient medicines, Combivent, Salmeterol, and Theophylline. He was continued on antibiotic prophylaxis with Bactrim Double Strength in light of his history of bronchiectasis. He was monitored for acute decompensation and his respiratory status, particularly concerning for pulmonary embolism in light of his right upper extremity deep vein thrombosis. He continued to improve from a respiratory standpoint. He was diuresed gently after arriving to the Medicine Floor status post fluid resuscitation and blood product administration in the Medical Intensive Care Unit in the setting of his acute bleed. With the diuresis, pulmonary toilet and supportive care, his respiratory status improved somewhat. However, he is not back to his baseline of 2 liters of oxygen nasal cannula at home. At the time of discharge he was maintaining saturations in the 97 to 100% range on 4 liters but he continued to complain of increased dyspnea with activity and shortness of breath, occasionally at rest. It was felt that a lot the patient's dyspnea was secondary to muscle deconditioning due to his prolonged illness and hospital stay. Therefore he will be discharged to a pulmonary rehabilitation program in hopes of increasing his conditioning and improving his overall pulmonary status. 4. Diabetes mellitus 2 - The patient was maintained on a diabetic diet, with q.i.d. fingersticks, fingerstick blood glucose testing and coverage with a regular insulin sliding scale. He was maintained on his outpatient dose of Neurontin for neuropathy. 5. Atrial fibrillation - He was continued on his outpatient dose of Amiodarone. Of note, he is currently in sinus rhythm. 6. Acute renal failure - The patient on admission had an elevated creatinine level above his baseline. This was likely secondary to prerenal causes, specifically hypovolemia and intravascular volume depletion in the setting of his acute bleeding episode. His acute renal failure resolved after fluid hydration. 7. Vitamin B12 deficiency - The patient was continued on his outpatient regimen of supplementation with Vitamin B12, 1000 mcg p.o. b.i.d. 8. Hypercholesterolemia - The patient was continued on his outpatient dose of Lipitor 10 mg p.o. q.d. 9. Depression/anxiety - The patient was continued on his outpatient dose of Paroxetine 20 mg p.o. q.d. 10. Fluids, electrolytes and nutrition - The patient was fed a diabetic heart-healthy diet. He received supplementation with multivitamins and Vitamin B12. Electrolytes were aggressively repleted. At the time of discharge he was tolerating regular diet without nausea, vomiting or other incident. DISPOSITION: With the patient's general deconditioning as well as his pulmonary status being slightly below his baseline I felt that he would benefit from an inpatient pulmonary rehabilitation program. He will be discharged to such a program. DISCHARGE CONDITION: Hemodynamically stable. Afebrile. Oxygen saturation stable on 4 liters of nasal cannula, ambulating independently, tolerating [Last Name (NamePattern1) 243] intake without nausea or vomiting. DISCHARGE STATUS: The patient is discharged to an extended care facility. DISCHARGE DIAGNOSIS: 1. Anemia due to acute blood loss, likely secondary to gastrointestinal bleed. 2. Chronic obstructive pulmonary disease 3. Lung carcinoma, status post right pneumonectomy 4. History of perioperative pulmonary embolism 5. Atrial fibrillation 6. Hypertension 7. Diabetes mellitus 2, insulin requiring with neuropathy 8. Gastroesophageal reflux disease 9. Status post transtracheal catheter placement and oxygen suctioning 10. Cataract 11. Anxiety 12. History of transient ischemic attack 13. Interrupted sleep apnea 14. Hypercholesterolemia 15. B12 deficiency 16. Right upper extremity deep vein thrombosis DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. q.d. 2. Regular insulin sliding scale 3. Atrovent nebulizer q. 6 hours as needed 4. Lasix 80 mg p.o. b.i.d. 5. Pantoprazole 40 mg p.o. q.d. 6. Gabapentin 100 mg p.o. q.d. 7. Paroxetine 20 mg p.o. q.d. 8. Colace 100 mg p.o. b.i.d. 9. Glyburide 5 mg p.o. q.d. 10. Vitamin B12 1000 mcg p.o. b.i.d. 11. Lipitor 10 mg p.o. q.d. 12. Scopolamine 1.5 mg transdermal patch one patch q. 72 hours as needed 13. Salmeterol discus q. 12 hours 14. Senna two tablets p.o. b.i.d. 15. Percocet 1 to 2 tablets p.o. q. 4-6 hours as needed for pain 16. Combivent 1 to 2 puffs inhaled q. 6 hours 17. Bactrim Double Strength one tablet p.o. b.i.d., last dose to be given on [2177-11-28] 18. Morphine Sulfate elixir 5 to 10 mg p.o. q. 4-6 hours as needed for pain, shortness of breath 19. Dulcolax 10 mg p.o. q.d. as needed for constipation 20. Ambien 5 to 10 mg p.o. q.h.s. as needed for insomnia 21. Multivitamin p.o. q.d. 22. Theophylline 400 mg sustained release 0.5 tablets p.o. q.d. 23. Albuterol nebulizer solution one nebulizer inhaled q. 6 hours as needed for shortness of breath 24. Ativan 0.5 mg one tablet p.o. q. 4-6 hours as needed for anxiety 25. Lactulose 30 ml p.o. q. 8 hours as needed for constipation 26. Nystatin suspension 5 mg p.o. q.i.d. as needed for [Year (4 digits) 243] thrush FOLLOW UP PLANS: The patient has a scheduled follow up appointment with Dr. [Last Name (STitle) ] after discharge from the rehabilitation facility. He will decide on the timing and the necessity of any further testing or studies that will be required including any further gastrointestinal workup for bleeding. He will follow up on the biopsy results from the patient's last esophagogastroduodenoscopy. The patient should have his INR level checked daily while at the rehabilitation facility and his Coumadin dose adjusted appropriately with goal INR of 2.0 to 3.0. [First Name11 (Name Pattern1) 198] [Last Name (NamePattern4) 199], M.D. [MD Number(1) 200] Dictated By:[Last Name (NamePattern1) 257] MEDQUIST36 D: [2177-12-4] 20:17 T: [2177-12-4] 21:42 JOB#: [Job Number 258]	Admission Date: <Date>1925-1-10</Date> Discharge Date: <Date>1966-7-14</Date> Date of Birth: <Date>1933-11-23</Date> Sex: M Service: <Hospital>Duncan, Robinson and Galloway Medical Center</Hospital> HISTORY OF PRESENT ILLNESS: The patient is a 63 year old male with a past medical history of chronic obstructive pulmonary disease, lung cancer, status post right pneumonectomy in <Date>1983-5-6</Date>, complicated by pulmonary artery laceration, status post transtracheal catheter placement for oxygen and suctioning who was in his usual state of health until <Date>1906-10-10</Date> when he developed nausea, lower abdominal pain, and projectile vomiting of nonbloody emesis. He presented to the <Hospital>Smith-Mcpherson Medical Center</Hospital> Emergency Room on <Date>1925-1-10</Date>. At that time he denied diarrhea, constipation, fevers, chills, hematochezia and bright red blood per rectum. He had dark stools at baseline secondary to iron use. The stool was found to be guaiac positive in the Emergency Department. In the Emergency Department also his hematocrit value was 19, down from a baseline of 31 one month previously and he was coagulopathic with an INR of 9.8. Attempts to place a nasogastric tube in the Emergency Department were unsuccessful. While in the Emergency Department, he was transfused 4 units of packed red blood cells, 2 units of fresh frozen plasma, and got 2 mg of subcutaneous Vitamin K. The patient was admitted to the Medicine Floor. Repeat hematocrit several hours later dropped to a value of 13. The nasogastric tube was placed on the floor with nasogastric lavage negative for fresh blood. He was, at that point, transferred to the Medical Intensive Care Unit. Workup while in the Medical Intensive Care Unit included two esophagogastroduodenoscopies, both without fresh blood or old blood but demonstrating a single raised 5 to 7 cm esophageal nodule on an erythematous base at approximately 25 cm. There was no evidence of stigmata of recent bleeding. He was stabilized with a total of seven units of packed red blood cells, seven units of fresh frozen plasma and one unit of platelets. He also received intravenous fluid resuscitation with normal saline. Computerized tomography scan of the abdomen was performed which was negative for diverticuli, perforation or retroperitoneal bleed. Colonoscopy performed later in the hospital course showed some polyps, diverticulosis of the sigmoid colon and descending colon. Internal hemorrhoids were noted but no stigmata of recent bleeding. The patient's coagulopathy was improving. His hematocrit was stable, and he was transferred to the General Medicine Floor on <Date>1953-8-29</Date>. Of note, prior to transfer he developed swelling of the right upper extremity and complained of pain of the right upper extremity. Doppler ultrasound was performed which showed evidence of a right axillary deep vein thrombosis. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease; 2. Lung cancer, status post right pneumonectomy in <Date>1983-5-6</Date> complicated by pulmonary artery laceration; 3. Prostate cancer, status post prostatectomy; 4. History of perioperative pulmonary embolism; 5. Atrial fibrillation on Coumadin; 6. Hypertension; 7. Diabetes mellitus 2, insulin-requiring neuropathy; 8. Gastroesophageal reflux disease; 9. Status post transtracheal catheter placement for oxygen and suctioning; 10. Cataracts; 11. Anxiety; 12. History of transient ischemic attacks; 13. Obstructive sleep apnea; 14. Hypercholesterolemia; 15. Vitamin B12 deficiency. ALLERGIES: Levaquin causes QT interval prolongations. MEDICATIONS PRIOR TO ADMISSION: 1. Protonix 40 mg p.o. q.d.; 2. Lasix 80 mg p.o. b.i.d.; 3. Neurontin 100 mg p.o. q.d.; 4. Paroxetine 30 mg p.o. q.d.; 5. Iron sulfate 325 mg p.o. b.i.d.; 6. Colace 100 mg p.o. b.i.d.; 7. Glyburide 5 mg p.o. q.d.; 8. Vitamin B12 1000 mcg p.o. b.i.d.; 9. Amiodarone 200 mg p.o. q.d.; 10. Lipitor 10 mg p.o. q.d.; 11. Coumadin 5 mg p.o. q.d.; 12. Aspirin 325 mg p.o. q.d.; 13. Scopolamine patch transdermal, apply every three days; 14. Advair discus one puff b.i.d.; 15. Potassium chloride 40 mEq p.o. b.i.d.; 16. Senna 2 tablets p.o. b.i.d. as needed for constipation; 17. Percocet 1 to 2 tablets as needed for pain; 18. Ipratropium nebulizer t.i.d.; 19. Bactrim double strength p.o. b.i.d.; 20. Augmentin; 21. Multivitamin p.o. q.d.; 22. Regular insulin sliding scale. FAMILY HISTORY: The patient reports that his mother has coronary artery disease. SOCIAL HISTORY: The patient lives with his wife, retired, worked previously in construction. He reports a 160 pack year tobacco history, quit in <Year>1968</Year>, quit alcohol in <Year>1968</Year>. No history of intravenous drug use. PHYSICAL EXAMINATION: Physical examination on admission revealed vital signs with temperature of 96.8, blood pressure 90/55, heart rate 90, respiratory rate 12, oxygen saturation 96% on 3 liters. General appearance: Well developed, obese white male, pleasant, comfortable in no acute distress. Head, eyes, ears, nose and throat: Normocephalic, atraumatic, pupils equal, round and reactive to light and accommodation. Sclera and conjunctiva anicteric. Conjunctiva not injected. Oropharynx clear. <Year>1903</Year> mucosa dry. Neck: Supple, no masses or lymphadenopathy. Tracheostomy site, clean, dry and intact. Lungs: Right lung with no breath sounds, left lung with fair air movement, transmitted upper airway sounds, scattered rhonchi. Cardiovascular: Regular rate and rhythm, S1 and S2 heart sounds auscultated, no murmurs, rubs or gallops. Abdomen: Soft, mildly tender to palpation, nondistended, positive normoactive bowel sounds. No rebound or guarding. Extremities: No cyanosis, clubbing or edema. Neurological examination: Nonfocal. LABORATORY DATA: Laboratory data upon admission revealed complete blood count demonstrated a white blood cell count 19.2, hematocrit 19.0, platelets 381. Coagulation profile showed PT 38.5, PTT 38.0, INR 9.8. Serum chemistries showed sodium 139, potassium 3.7, chloride 96, bicarbonate 30, BUN 52, creatinine 1.3, glucose 196. Liver function tests showed ALT 18, AST 26, amylase 23, lipase 24, albumin 3.4, alkaline phosphatase 100. Cardiac enzymes showed creatinine kinase 82, troponin I 0.04. Chest x-ray was negative for any acute pulmonary process. Abdominal x-ray demonstrated opacification of the right lung base. The left lung base was clear. There was no free air in the abdomen. There was a large amount of fecal material in the right colon. There was a normal bowel gas pattern. There was no evidence of obstruction. Later computerized tomography scan of the abdomen and pelvis demonstrated no intra-abdominal abscess, bowel inflammation, evidence of perforated ulcer, appendicitis or diverticulitis. Electrocardiogram showed normal sinus rhythm at 93 beats/minute, normal axis, prolonged QT interval, no left ventricular hypertrophy, T wave inversions were noted in leads V1 and V2 which were new. No acute ST elevations or depressions noted. This was compared with the prior electrocardiogram from <Date>1927-8-19</Date>. HOSPITAL COURSE: In summary, this is a 63 year old male with past medical history of chronic obstructive pulmonary disease, lung cancer status post right pneumonectomy in <Date>1983-5-6</Date> complicated by a pulmonary artery laceration, status post transtracheal catheter placement for oxygen and suctioning. He was in his usual state of health until <Date>1906-10-10</Date> when he developed nausea, lower abdominal pain, projectile vomiting of nonbloody emesis. His hematocrit dropped from 31 to a nadir of 13. His gastrointestinal workup was unrevealing in the Medical Intensive Care Unit. 1. Anemia secondary to acute blood loss - The patient's gastrointestinal workup included two esophagogastroduodenoscopies and colonoscopy times one without source of frank bleed. However, in light of his initial complaints of nausea, abdominal pain, and guaiac positive stool a gastrointestinal source was still suspected. Physically the small bowel could be the source. After stabilization in the Medical Intensive Care Unit with blood products, fresh frozen plasma and platelets, he was transferred to the Medicine Floor after having stable hematocrit for greater than 24 hours. While on the floor, his hematocrit was checked initially every 12 hours. After demonstrating stability for a total of 72 hours it was spaced out to q. day hematocrit checks. All told the patient received 7 units of packed red blood cells, 7 units of fresh frozen plasma and one unit of platelets during his hospital stay. On <Date>1950-11-17</Date>, the patient underwent repeat esophagogastroduodenoscopy in order to obtain biopsy samples of the esophageal nodule, not noted on previous study. At the time of this dictation results of those biopsies were pending. While in the Medical Intensive Care Unit the patient also had workup for hemolysis to evaluate whether hemolysis could be attributing to his anemia. He had a normal left ventricular hypertrophy, haptoglobin and bilirubin on admission, however, making hemolysis a very unlikely explanation for his presentation hematocrit of 19. Moreover, no schistocytes were seen on peripheral smear. Hemolysis laboratory data were checked several days into his hospital course and were consistent with changes status post large volume transfusion with no evidence of active ongoing hemolysis. 2. Right upper extremity deep vein thrombosis - On <Date>1953-8-29</Date> the patient began to complain of right upper extremity pain and swelling. Doppler ultrasound demonstrated an axillary deep vein thrombosis. In light of his recent bleeding episode, anticoagulation was held initially. Although upper extremity deep vein thromboses do not embolize as often as lower extremity deep vein thromboses, there was still a very high concern for pulmonary embolus in light of the patient's history of right pneumonectomy and the functionality of his one remaining lung. The computerized tomography scan was performed to better examine the right upper extremity soft tissues. In particular there was concern that the patient might have an obstructing mass lesion or fibrosis-post his pneumonectomy that could be contributing to venous stasis and obstruction leading to deep vein thrombosis formation. Computerized tomographic venogram was without evidence of obstructing lesion of fibrosis, however. The patient is likely hypercoagulable as evidenced by the development of this right upper extremity deep vein thrombosis spontaneously after being off anticoagulation in the setting of his acute bleed for only several days, there was concern for recurrent deep vein thromboses. Therefore, an inferior vena cava filter was placed on <Date>2006-3-28</Date>. The patient tolerated the procedure well. On <Date>1902-4-13</Date>, the patient then began to complain of pain and swelling of the right lower extremity. Examination was consistent with possible thrombus of the right lower extremity. However, as the patient already had an inferior vena cava filter placed and delineation of a right lower extremity deep vein thrombosis would not change management plans at all, the decision was made not to undergo ultrasound doppler imaging of the right lower extremity. In light of his probable hypercoagulability, decision was made to reinitiate anticoagulation with the Coumadin. His Coumadin level will be followed by his outpatient physician, <Name>Martin</Name>. <Name>Nicki</Name> <Name>Lenling</Name>. His INR should be checked remotely at the rehabilitation facility and his Coumadin dose adjusted accordingly for a goal INR of 2 to 3. 3. Chronic obstructive pulmonary disease/lung carcinoma status post right pneumonectomy - The patient was continued on aggressive regimen of chest physical therapy and pulmonary toilet. He was continued on his outpatient medicines, Combivent, Salmeterol, and Theophylline. He was continued on antibiotic prophylaxis with Bactrim Double Strength in light of his history of bronchiectasis. He was monitored for acute decompensation and his respiratory status, particularly concerning for pulmonary embolism in light of his right upper extremity deep vein thrombosis. He continued to improve from a respiratory standpoint. He was diuresed gently after arriving to the Medicine Floor status post fluid resuscitation and blood product administration in the Medical Intensive Care Unit in the setting of his acute bleed. With the diuresis, pulmonary toilet and supportive care, his respiratory status improved somewhat. However, he is not back to his baseline of 2 liters of oxygen nasal cannula at home. At the time of discharge he was maintaining saturations in the 97 to 100% range on 4 liters but he continued to complain of increased dyspnea with activity and shortness of breath, occasionally at rest. It was felt that a lot the patient's dyspnea was secondary to muscle deconditioning due to his prolonged illness and hospital stay. Therefore he will be discharged to a pulmonary rehabilitation program in hopes of increasing his conditioning and improving his overall pulmonary status. 4. Diabetes mellitus 2 - The patient was maintained on a diabetic diet, with q.i.d. fingersticks, fingerstick blood glucose testing and coverage with a regular insulin sliding scale. He was maintained on his outpatient dose of Neurontin for neuropathy. 5. Atrial fibrillation - He was continued on his outpatient dose of Amiodarone. Of note, he is currently in sinus rhythm. 6. Acute renal failure - The patient on admission had an elevated creatinine level above his baseline. This was likely secondary to prerenal causes, specifically hypovolemia and intravascular volume depletion in the setting of his acute bleeding episode. His acute renal failure resolved after fluid hydration. 7. Vitamin B12 deficiency - The patient was continued on his outpatient regimen of supplementation with Vitamin B12, 1000 mcg p.o. b.i.d. 8. Hypercholesterolemia - The patient was continued on his outpatient dose of Lipitor 10 mg p.o. q.d. 9. Depression/anxiety - The patient was continued on his outpatient dose of Paroxetine 20 mg p.o. q.d. 10. Fluids, electrolytes and nutrition - The patient was fed a diabetic heart-healthy diet. He received supplementation with multivitamins and Vitamin B12. Electrolytes were aggressively repleted. At the time of discharge he was tolerating regular diet without nausea, vomiting or other incident. DISPOSITION: With the patient's general deconditioning as well as his pulmonary status being slightly below his baseline I felt that he would benefit from an inpatient pulmonary rehabilitation program. He will be discharged to such a program. DISCHARGE CONDITION: Hemodynamically stable. Afebrile. Oxygen saturation stable on 4 liters of nasal cannula, ambulating independently, tolerating <Name>Kobayashi</Name> intake without nausea or vomiting. DISCHARGE STATUS: The patient is discharged to an extended care facility. DISCHARGE DIAGNOSIS: 1. Anemia due to acute blood loss, likely secondary to gastrointestinal bleed. 2. Chronic obstructive pulmonary disease 3. Lung carcinoma, status post right pneumonectomy 4. History of perioperative pulmonary embolism 5. Atrial fibrillation 6. Hypertension 7. Diabetes mellitus 2, insulin requiring with neuropathy 8. Gastroesophageal reflux disease 9. Status post transtracheal catheter placement and oxygen suctioning 10. Cataract 11. Anxiety 12. History of transient ischemic attack 13. Interrupted sleep apnea 14. Hypercholesterolemia 15. B12 deficiency 16. Right upper extremity deep vein thrombosis DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. q.d. 2. Regular insulin sliding scale 3. Atrovent nebulizer q. 6 hours as needed 4. Lasix 80 mg p.o. b.i.d. 5. Pantoprazole 40 mg p.o. q.d. 6. Gabapentin 100 mg p.o. q.d. 7. Paroxetine 20 mg p.o. q.d. 8. Colace 100 mg p.o. b.i.d. 9. Glyburide 5 mg p.o. q.d. 10. Vitamin B12 1000 mcg p.o. b.i.d. 11. Lipitor 10 mg p.o. q.d. 12. Scopolamine 1.5 mg transdermal patch one patch q. 72 hours as needed 13. Salmeterol discus q. 12 hours 14. Senna two tablets p.o. b.i.d. 15. Percocet 1 to 2 tablets p.o. q. 4-6 hours as needed for pain 16. Combivent 1 to 2 puffs inhaled q. 6 hours 17. Bactrim Double Strength one tablet p.o. b.i.d., last dose to be given on <Date>1953-8-29</Date> 18. Morphine Sulfate elixir 5 to 10 mg p.o. q. 4-6 hours as needed for pain, shortness of breath 19. Dulcolax 10 mg p.o. q.d. as needed for constipation 20. Ambien 5 to 10 mg p.o. q.h.s. as needed for insomnia 21. Multivitamin p.o. q.d. 22. Theophylline 400 mg sustained release 0.5 tablets p.o. q.d. 23. Albuterol nebulizer solution one nebulizer inhaled q. 6 hours as needed for shortness of breath 24. Ativan 0.5 mg one tablet p.o. q. 4-6 hours as needed for anxiety 25. Lactulose 30 ml p.o. q. 8 hours as needed for constipation 26. Nystatin suspension 5 mg p.o. q.i.d. as needed for <Year>2012</Year> thrush FOLLOW UP PLANS: The patient has a scheduled follow up appointment with Dr. <Name>Hasan</Name> after discharge from the rehabilitation facility. He will decide on the timing and the necessity of any further testing or studies that will be required including any further gastrointestinal workup for bleeding. He will follow up on the biopsy results from the patient's last esophagogastroduodenoscopy. The patient should have his INR level checked daily while at the rehabilitation facility and his Coumadin dose adjusted appropriately with goal INR of 2.0 to 3.0. <Name>Janell</Name> <Name>Cobbs</Name>, M.D. <MD Number>00649539</MD Number> Dictated By:<Name>Negrete</Name> MEDQUIST36 D: <Date>1902-4-13</Date> 20:17 T: <Date>1902-4-13</Date> 21:42 JOB#: <Job Number>Martin-Butler-1959-976819</Job 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Date: 1925-1-10 Discharge Date: 1966-7-14 Date of Birth: 1933-11-23 Sex: M Service: Duncan, Robinson and Galloway Medical Center HISTORY OF PRESENT ILLNESS: The patient is a 63 year old male with a past medical history of chronic obstructive pulmonary disease, lung cancer, status post right pneumonectomy in 1983-5-6, complicated by pulmonary artery laceration, status post transtracheal catheter placement for oxygen and suctioning who was in his usual state of health until 1906-10-10 when he developed nausea, lower abdominal pain, and projectile vomiting of nonbloody emesis. He presented to the Smith-Mcpherson Medical Center Emergency Room on 1925-1-10. At that time he denied diarrhea, constipation, fevers, chills, hematochezia and bright red blood per rectum. He had dark stools at baseline secondary to iron use. The stool was found to be guaiac positive in the Emergency Department. In the Emergency Department also his hematocrit value was 19, down from a baseline of 31 one month previously and he was coagulopathic with an INR of 9.8. Attempts to place a nasogastric tube in the Emergency Department were unsuccessful. While in the Emergency Department, he was transfused 4 units of packed red blood cells, 2 units of fresh frozen plasma, and got 2 mg of subcutaneous Vitamin K. The patient was admitted to the Medicine Floor. Repeat hematocrit several hours later dropped to a value of 13. The nasogastric tube was placed on the floor with nasogastric lavage negative for fresh blood. He was, at that point, transferred to the Medical Intensive Care Unit. Workup while in the Medical Intensive Care Unit included two esophagogastroduodenoscopies, both without fresh blood or old blood but demonstrating a single raised 5 to 7 cm esophageal nodule on an erythematous base at approximately 25 cm. There was no evidence of stigmata of recent bleeding. He was stabilized with a total of seven units of packed red blood cells, seven units of fresh frozen plasma and one unit of platelets. He also received intravenous fluid resuscitation with normal saline. Computerized tomography scan of the abdomen was performed which was negative for diverticuli, perforation or retroperitoneal bleed. Colonoscopy performed later in the hospital course showed some polyps, diverticulosis of the sigmoid colon and descending colon. Internal hemorrhoids were noted but no stigmata of recent bleeding. The patient's coagulopathy was improving. His hematocrit was stable, and he was transferred to the General Medicine Floor on 1953-8-29. Of note, prior to transfer he developed swelling of the right upper extremity and complained of pain of the right upper extremity. Doppler ultrasound was performed which showed evidence of a right axillary deep vein thrombosis. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease; 2. Lung cancer, status post right pneumonectomy in 1983-5-6 complicated by pulmonary artery laceration; 3. Prostate cancer, status post prostatectomy; 4. History of perioperative pulmonary embolism; 5. Atrial fibrillation on Coumadin; 6. Hypertension; 7. Diabetes mellitus 2, insulin-requiring neuropathy; 8. Gastroesophageal reflux disease; 9. Status post transtracheal catheter placement for oxygen and suctioning; 10. Cataracts; 11. Anxiety; 12. History of transient ischemic attacks; 13. Obstructive sleep apnea; 14. Hypercholesterolemia; 15. Vitamin B12 deficiency. ALLERGIES: Levaquin causes QT interval prolongations. MEDICATIONS PRIOR TO ADMISSION: 1. Protonix 40 mg p.o. q.d.; 2. Lasix 80 mg p.o. b.i.d.; 3. Neurontin 100 mg p.o. q.d.; 4. Paroxetine 30 mg p.o. q.d.; 5. Iron sulfate 325 mg p.o. b.i.d.; 6. Colace 100 mg p.o. b.i.d.; 7. Glyburide 5 mg p.o. q.d.; 8. Vitamin B12 1000 mcg p.o. b.i.d.; 9. Amiodarone 200 mg p.o. q.d.; 10. Lipitor 10 mg p.o. q.d.; 11. Coumadin 5 mg p.o. q.d.; 12. Aspirin 325 mg p.o. q.d.; 13. Scopolamine patch transdermal, apply every three days; 14. Advair discus one puff b.i.d.; 15. Potassium chloride 40 mEq p.o. b.i.d.; 16. Senna 2 tablets p.o. b.i.d. as needed for constipation; 17. Percocet 1 to 2 tablets as needed for pain; 18. Ipratropium nebulizer t.i.d.; 19. Bactrim double strength p.o. b.i.d.; 20. Augmentin; 21. Multivitamin p.o. q.d.; 22. Regular insulin sliding scale. FAMILY HISTORY: The patient reports that his mother has coronary artery disease. SOCIAL HISTORY: The patient lives with his wife, retired, worked previously in construction. He reports a 160 pack year tobacco history, quit in 1968, quit alcohol in 1968. No history of intravenous drug use. PHYSICAL EXAMINATION: Physical examination on admission revealed vital signs with temperature of 96.8, blood pressure 90/55, heart rate 90, respiratory rate 12, oxygen saturation 96% on 3 liters. General appearance: Well developed, obese white male, pleasant, comfortable in no acute distress. Head, eyes, ears, nose and throat: Normocephalic, atraumatic, pupils equal, round and reactive to light and accommodation. Sclera and conjunctiva anicteric. Conjunctiva not injected. Oropharynx clear. 1903 mucosa dry. Neck: Supple, no masses or lymphadenopathy. Tracheostomy site, clean, dry and intact. Lungs: Right lung with no breath sounds, left lung with fair air movement, transmitted upper airway sounds, scattered rhonchi. Cardiovascular: Regular rate and rhythm, S1 and S2 heart sounds auscultated, no murmurs, rubs or gallops. Abdomen: Soft, mildly tender to palpation, nondistended, positive normoactive bowel sounds. No rebound or guarding. Extremities: No cyanosis, clubbing or edema. Neurological examination: Nonfocal. LABORATORY DATA: Laboratory data upon admission revealed complete blood count demonstrated a white blood cell count 19.2, hematocrit 19.0, platelets 381. Coagulation profile showed PT 38.5, PTT 38.0, INR 9.8. Serum chemistries showed sodium 139, potassium 3.7, chloride 96, bicarbonate 30, BUN 52, creatinine 1.3, glucose 196. Liver function tests showed ALT 18, AST 26, amylase 23, lipase 24, albumin 3.4, alkaline phosphatase 100. Cardiac enzymes showed creatinine kinase 82, troponin I 0.04. Chest x-ray was negative for any acute pulmonary process. Abdominal x-ray demonstrated opacification of the right lung base. The left lung base was clear. There was no free air in the abdomen. There was a large amount of fecal material in the right colon. There was a normal bowel gas pattern. There was no evidence of obstruction. Later computerized tomography scan of the abdomen and pelvis demonstrated no intra-abdominal abscess, bowel inflammation, evidence of perforated ulcer, appendicitis or diverticulitis. Electrocardiogram showed normal sinus rhythm at 93 beats/minute, normal axis, prolonged QT interval, no left ventricular hypertrophy, T wave inversions were noted in leads V1 and V2 which were new. No acute ST elevations or depressions noted. This was compared with the prior electrocardiogram from 1927-8-19. HOSPITAL COURSE: In summary, this is a 63 year old male with past medical history of chronic obstructive pulmonary disease, lung cancer status post right pneumonectomy in 1983-5-6 complicated by a pulmonary artery laceration, status post transtracheal catheter placement for oxygen and suctioning. He was in his usual state of health until 1906-10-10 when he developed nausea, lower abdominal pain, projectile vomiting of nonbloody emesis. His hematocrit dropped from 31 to a nadir of 13. His gastrointestinal workup was unrevealing in the Medical Intensive Care Unit. 1. Anemia secondary to acute blood loss - The patient's gastrointestinal workup included two esophagogastroduodenoscopies and colonoscopy times one without source of frank bleed. However, in light of his initial complaints of nausea, abdominal pain, and guaiac positive stool a gastrointestinal source was still suspected. Physically the small bowel could be the source. After stabilization in the Medical Intensive Care Unit with blood products, fresh frozen plasma and platelets, he was transferred to the Medicine Floor after having stable hematocrit for greater than 24 hours. While on the floor, his hematocrit was checked initially every 12 hours. After demonstrating stability for a total of 72 hours it was spaced out to q. day hematocrit checks. All told the patient received 7 units of packed red blood cells, 7 units of fresh frozen plasma and one unit of platelets during his hospital stay. On 1950-11-17, the patient underwent repeat esophagogastroduodenoscopy in order to obtain biopsy samples of the esophageal nodule, not noted on previous study. At the time of this dictation results of those biopsies were pending. While in the Medical Intensive Care Unit the patient also had workup for hemolysis to evaluate whether hemolysis could be attributing to his anemia. He had a normal left ventricular hypertrophy, haptoglobin and bilirubin on admission, however, making hemolysis a very unlikely explanation for his presentation hematocrit of 19. Moreover, no schistocytes were seen on peripheral smear. Hemolysis laboratory data were checked several days into his hospital course and were consistent with changes status post large volume transfusion with no evidence of active ongoing hemolysis. 2. Right upper extremity deep vein thrombosis - On 1953-8-29 the patient began to complain of right upper extremity pain and swelling. Doppler ultrasound demonstrated an axillary deep vein thrombosis. In light of his recent bleeding episode, anticoagulation was held initially. Although upper extremity deep vein thromboses do not embolize as often as lower extremity deep vein thromboses, there was still a very high concern for pulmonary embolus in light of the patient's history of right pneumonectomy and the functionality of his one remaining lung. The computerized tomography scan was performed to better examine the right upper extremity soft tissues. In particular there was concern that the patient might have an obstructing mass lesion or fibrosis-post his pneumonectomy that could be contributing to venous stasis and obstruction leading to deep vein thrombosis formation. Computerized tomographic venogram was without evidence of obstructing lesion of fibrosis, however. The patient is likely hypercoagulable as evidenced by the development of this right upper extremity deep vein thrombosis spontaneously after being off anticoagulation in the setting of his acute bleed for only several days, there was concern for recurrent deep vein thromboses. Therefore, an inferior vena cava filter was placed on 2006-3-28. The patient tolerated the procedure well. On 1902-4-13, the patient then began to complain of pain and swelling of the right lower extremity. Examination was consistent with possible thrombus of the right lower extremity. However, as the patient already had an inferior vena cava filter placed and delineation of a right lower extremity deep vein thrombosis would not change management plans at all, the decision was made not to undergo ultrasound doppler imaging of the right lower extremity. In light of his probable hypercoagulability, decision was made to reinitiate anticoagulation with the Coumadin. His Coumadin level will be followed by his outpatient physician, Martin. Nicki Lenling. His INR should be checked remotely at the rehabilitation facility and his Coumadin dose adjusted accordingly for a goal INR of 2 to 3. 3. Chronic obstructive pulmonary disease/lung carcinoma status post right pneumonectomy - The patient was continued on aggressive regimen of chest physical therapy and pulmonary toilet. He was continued on his outpatient medicines, Combivent, Salmeterol, and Theophylline. He was continued on antibiotic prophylaxis with Bactrim Double Strength in light of his history of bronchiectasis. He was monitored for acute decompensation and his respiratory status, particularly concerning for pulmonary embolism in light of his right upper extremity deep vein thrombosis. He continued to improve from a respiratory standpoint. He was diuresed gently after arriving to the Medicine Floor status post fluid resuscitation and blood product administration in the Medical Intensive Care Unit in the setting of his acute bleed. With the diuresis, pulmonary toilet and supportive care, his respiratory status improved somewhat. However, he is not back to his baseline of 2 liters of oxygen nasal cannula at home. At the time of discharge he was maintaining saturations in the 97 to 100% range on 4 liters but he continued to complain of increased dyspnea with activity and shortness of breath, occasionally at rest. It was felt that a lot the patient's dyspnea was secondary to muscle deconditioning due to his prolonged illness and hospital stay. Therefore he will be discharged to a pulmonary rehabilitation program in hopes of increasing his conditioning and improving his overall pulmonary status. 4. Diabetes mellitus 2 - The patient was maintained on a diabetic diet, with q.i.d. fingersticks, fingerstick blood glucose testing and coverage with a regular insulin sliding scale. He was maintained on his outpatient dose of Neurontin for neuropathy. 5. Atrial fibrillation - He was continued on his outpatient dose of Amiodarone. Of note, he is currently in sinus rhythm. 6. Acute renal failure - The patient on admission had an elevated creatinine level above his baseline. This was likely secondary to prerenal causes, specifically hypovolemia and intravascular volume depletion in the setting of his acute bleeding episode. His acute renal failure resolved after fluid hydration. 7. Vitamin B12 deficiency - The patient was continued on his outpatient regimen of supplementation with Vitamin B12, 1000 mcg p.o. b.i.d. 8. Hypercholesterolemia - The patient was continued on his outpatient dose of Lipitor 10 mg p.o. q.d. 9. Depression/anxiety - The patient was continued on his outpatient dose of Paroxetine 20 mg p.o. q.d. 10. Fluids, electrolytes and nutrition - The patient was fed a diabetic heart-healthy diet. He received supplementation with multivitamins and Vitamin B12. Electrolytes were aggressively repleted. At the time of discharge he was tolerating regular diet without nausea, vomiting or other incident. DISPOSITION: With the patient's general deconditioning as well as his pulmonary status being slightly below his baseline I felt that he would benefit from an inpatient pulmonary rehabilitation program. He will be discharged to such a program. DISCHARGE CONDITION: Hemodynamically stable. Afebrile. Oxygen saturation stable on 4 liters of nasal cannula, ambulating independently, tolerating Kobayashi intake without nausea or vomiting. DISCHARGE STATUS: The patient is discharged to an extended care facility. DISCHARGE DIAGNOSIS: 1. Anemia due to acute blood loss, likely secondary to gastrointestinal bleed. 2. Chronic obstructive pulmonary disease 3. Lung carcinoma, status post right pneumonectomy 4. History of perioperative pulmonary embolism 5. Atrial fibrillation 6. Hypertension 7. Diabetes mellitus 2, insulin requiring with neuropathy 8. Gastroesophageal reflux disease 9. Status post transtracheal catheter placement and oxygen suctioning 10. Cataract 11. Anxiety 12. History of transient ischemic attack 13. Interrupted sleep apnea 14. Hypercholesterolemia 15. B12 deficiency 16. Right upper extremity deep vein thrombosis DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. q.d. 2. Regular insulin sliding scale 3. Atrovent nebulizer q. 6 hours as needed 4. Lasix 80 mg p.o. b.i.d. 5. Pantoprazole 40 mg p.o. q.d. 6. Gabapentin 100 mg p.o. q.d. 7. Paroxetine 20 mg p.o. q.d. 8. Colace 100 mg p.o. b.i.d. 9. Glyburide 5 mg p.o. q.d. 10. Vitamin B12 1000 mcg p.o. b.i.d. 11. Lipitor 10 mg p.o. q.d. 12. Scopolamine 1.5 mg transdermal patch one patch q. 72 hours as needed 13. Salmeterol discus q. 12 hours 14. Senna two tablets p.o. b.i.d. 15. Percocet 1 to 2 tablets p.o. q. 4-6 hours as needed for pain 16. Combivent 1 to 2 puffs inhaled q. 6 hours 17. Bactrim Double Strength one tablet p.o. b.i.d., last dose to be given on 1953-8-29 18. Morphine Sulfate elixir 5 to 10 mg p.o. q. 4-6 hours as needed for pain, shortness of breath 19. Dulcolax 10 mg p.o. q.d. as needed for constipation 20. Ambien 5 to 10 mg p.o. q.h.s. as needed for insomnia 21. Multivitamin p.o. q.d. 22. Theophylline 400 mg sustained release 0.5 tablets p.o. q.d. 23. Albuterol nebulizer solution one nebulizer inhaled q. 6 hours as needed for shortness of breath 24. Ativan 0.5 mg one tablet p.o. q. 4-6 hours as needed for anxiety 25. Lactulose 30 ml p.o. q. 8 hours as needed for constipation 26. Nystatin suspension 5 mg p.o. q.i.d. as needed for 2012 thrush FOLLOW UP PLANS: The patient has a scheduled follow up appointment with Dr. Hasan after discharge from the rehabilitation facility. He will decide on the timing and the necessity of any further testing or studies that will be required including any further gastrointestinal workup for bleeding. He will follow up on the biopsy results from the patient's last esophagogastroduodenoscopy. The patient should have his INR level checked daily while at the rehabilitation facility and his Coumadin dose adjusted appropriately with goal INR of 2.0 to 3.0. Janell Cobbs, M.D. 00649539 Dictated By:Negrete MEDQUIST36 D: 1902-4-13 20:17 T: 1902-4-13 21:42 JOB#: Martin-Butler-1959-976819	['Admission Date: 1925-1-10 Discharge Date: 1966-7-14\n\nDate of Birth: 1933-11-23 Sex: M\n\nService: Duncan, Robinson and Galloway Medical Center\n\nHISTORY OF PRESENT ILLNESS: The patient is a 63 year old\nmale with a past medical history of chronic obstructive\npulmonary disease, lung cancer, status post right\npneumonectomy in 1983-5-6, complicated by pulmonary artery\nlaceration, status post transtracheal catheter placement for\noxygen and suctioning who was in his usual state of health\nuntil 1906-10-10 when he developed nausea, lower\nabdominal pain, and projectile vomiting of nonbloody emesis.\nHe presented to the Smith-Mcpherson Medical Center\nEmergency Room on 1925-1-10. At that time he denied\ndiarrhea, constipation, fevers, chills, hematochezia and\nbright red blood per rectum.', ' He had dark stools at baseline\nsecondary to iron use. The stool was found to be guaiac\npositive in the Emergency Department. In the Emergency\nDepartment also his hematocrit value was 19, down from a\nbaseline of 31 one month previously and he was coagulopathic\nwith an INR of 9.8. Attempts to place a nasogastric tube in\nthe Emergency Department were unsuccessful. While in the\nEmergency Department, he was transfused 4 units of packed red\nblood cells, 2 units of fresh frozen plasma, and got 2 mg of\nsubcutaneous Vitamin K. The patient was admitted to the\nMedicine Floor. Repeat hematocrit several hours later\ndropped to a value of 13. The nasogastric tube was placed on\nthe floor with nasogastric lavage negative for fresh blood.\nHe was, at that point, transferred to the Medical Intensive\nCare Unit.', ' Workup while in the Medical Intensive Care Unit\nincluded two esophagogastroduodenoscopies, both without fresh\nblood or old blood but demonstrating a single raised 5 to 7\ncm esophageal nodule on an erythematous base at approximately\n25 cm. There was no evidence of stigmata of recent bleeding.\nHe was stabilized with a total of seven units of packed red\nblood cells, seven units of fresh frozen plasma and one unit\nof platelets. He also received intravenous fluid\nresuscitation with normal saline. Computerized tomography\nscan of the abdomen was performed which was negative for\ndiverticuli, perforation or retroperitoneal bleed.\nColonoscopy performed later in the hospital course showed\nsome polyps, diverticulosis of the sigmoid colon and\ndescending colon. Internal hemorrhoids were noted but no\nstigmata of recent bleeding.', " The patient's coagulopathy was\nimproving. His hematocrit was stable, and he was transferred\nto the General Medicine Floor on 1953-8-29. Of note,\nprior to transfer he developed swelling of the right upper\nextremity and complained of pain of the right upper\nextremity. Doppler ultrasound was performed which showed\nevidence of a right axillary deep vein thrombosis.\n\nPAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary\ndisease; 2. Lung cancer, status post right pneumonectomy in\n1983-5-6 complicated by pulmonary artery laceration; 3.\nProstate cancer, status post prostatectomy; 4. History of\nperioperative pulmonary embolism; 5. Atrial fibrillation on\nCoumadin; 6. Hypertension; 7. Diabetes mellitus 2,\ninsulin-requiring neuropathy; 8. Gastroesophageal reflux\ndisease; 9. Status post transtracheal catheter placement for\noxygen and suctioning; 10.", ' Cataracts; 11. Anxiety; 12.\nHistory of transient ischemic attacks; 13. Obstructive sleep\napnea; 14. Hypercholesterolemia; 15. Vitamin B12\ndeficiency.\n\nALLERGIES: Levaquin causes QT interval prolongations.\n\nMEDICATIONS PRIOR TO ADMISSION: 1. Protonix 40 mg p.o.\nq.d.; 2. Lasix 80 mg p.o. b.i.d.; 3. Neurontin 100 mg p.o.\nq.d.; 4. Paroxetine 30 mg p.o. q.d.; 5. Iron sulfate 325 mg\np.o. b.i.d.; 6. Colace 100 mg p.o. b.i.d.; 7. Glyburide 5\nmg p.o. q.d.; 8. Vitamin B12 1000 mcg p.o. b.i.d.; 9.\nAmiodarone 200 mg p.o. q.d.; 10. Lipitor 10 mg p.o. q.d.;\n11. Coumadin 5 mg p.o. q.d.; 12. Aspirin 325 mg p.o. q.d.;\n13. Scopolamine patch transdermal, apply every three days;\n14. Advair discus one puff b.i.d.; 15. Potassium chloride\n40 mEq p.o. b.i.d.; 16. Senna 2 tablets p.o. b.i.d. as\nneeded for constipation; 17.', ' Percocet 1 to 2 tablets as\nneeded for pain; 18. Ipratropium nebulizer t.i.d.; 19.\nBactrim double strength p.o. b.i.d.; 20. Augmentin; 21.\nMultivitamin p.o. q.d.; 22. Regular insulin sliding scale.\n\nFAMILY HISTORY: The patient reports that his mother has\ncoronary artery disease.\n\nSOCIAL HISTORY: The patient lives with his wife, retired,\nworked previously in construction. He reports a 160 pack\nyear tobacco history, quit in 1968, quit alcohol in 1968. No\nhistory of intravenous drug use.\n\nPHYSICAL EXAMINATION: Physical examination on admission\nrevealed vital signs with temperature of 96.8, blood pressure\n90/55, heart rate 90, respiratory rate 12, oxygen saturation\n96% on 3 liters. General appearance: Well developed, obese\nwhite male, pleasant, comfortable in no acute distress.\nHead, eyes, ears, nose and throat: Normocephalic,\natraumatic, pupils equal, round and reactive to light and\naccommodation.', ' Sclera and conjunctiva anicteric.\nConjunctiva not injected. Oropharynx clear. 1903 mucosa\ndry. Neck: Supple, no masses or lymphadenopathy.\nTracheostomy site, clean, dry and intact. Lungs: Right lung\nwith no breath sounds, left lung with fair air movement,\ntransmitted upper airway sounds, scattered rhonchi.\nCardiovascular: Regular rate and rhythm, S1 and S2 heart\nsounds auscultated, no murmurs, rubs or gallops. Abdomen:\nSoft, mildly tender to palpation, nondistended, positive\nnormoactive bowel sounds. No rebound or guarding.\nExtremities: No cyanosis, clubbing or edema. Neurological\nexamination: Nonfocal.\n\nLABORATORY DATA: Laboratory data upon admission revealed\ncomplete blood count demonstrated a white blood cell count\n19.2, hematocrit 19.0, platelets 381. Coagulation profile\nshowed PT 38.', '5, PTT 38.0, INR 9.8. Serum chemistries showed\nsodium 139, potassium 3.7, chloride 96, bicarbonate 30, BUN\n52, creatinine 1.3, glucose 196. Liver function tests showed\nALT 18, AST 26, amylase 23, lipase 24, albumin 3.4, alkaline\nphosphatase 100. Cardiac enzymes showed creatinine kinase\n82, troponin I 0.04. Chest x-ray was negative for any acute\npulmonary process. Abdominal x-ray demonstrated\nopacification of the right lung base. The left lung base was\nclear. There was no free air in the abdomen. There was a\nlarge amount of fecal material in the right colon. There was\na normal bowel gas pattern. There was no evidence of\nobstruction. Later computerized tomography scan of the\nabdomen and pelvis demonstrated no intra-abdominal abscess,\nbowel inflammation, evidence of perforated ulcer,\nappendicitis or diverticulitis.', ' Electrocardiogram showed\nnormal sinus rhythm at 93 beats/minute, normal axis,\nprolonged QT interval, no left ventricular hypertrophy, T\nwave inversions were noted in leads V1 and V2 which were new.\nNo acute ST elevations or depressions noted. This was\ncompared with the prior electrocardiogram from 1927-8-19.\n\nHOSPITAL COURSE: In summary, this is a 63 year old male with\npast medical history of chronic obstructive pulmonary\ndisease, lung cancer status post right pneumonectomy in\n1983-5-6 complicated by a pulmonary artery laceration,\nstatus post transtracheal catheter placement for oxygen and\nsuctioning. He was in his usual state of health until\n1906-10-10 when he developed nausea, lower abdominal\npain, projectile vomiting of nonbloody emesis. His\nhematocrit dropped from 31 to a nadir of 13.', " His\ngastrointestinal workup was unrevealing in the Medical\nIntensive Care Unit.\n\n1. Anemia secondary to acute blood loss - The patient's\ngastrointestinal workup included two\nesophagogastroduodenoscopies and colonoscopy times one\nwithout source of frank bleed. However, in light of his\ninitial complaints of nausea, abdominal pain, and guaiac\npositive stool a gastrointestinal source was still suspected.\nPhysically the small bowel could be the source. After\nstabilization in the Medical Intensive Care Unit with blood\nproducts, fresh frozen plasma and platelets, he was\ntransferred to the Medicine Floor after having stable\nhematocrit for greater than 24 hours. While on the floor,\nhis hematocrit was checked initially every 12 hours. After\ndemonstrating stability for a total of 72 hours it was spaced\nout to q.", ' day hematocrit checks. All told the patient\nreceived 7 units of packed red blood cells, 7 units of fresh\nfrozen plasma and one unit of platelets during his hospital\nstay. On 1950-11-17, the patient underwent repeat\nesophagogastroduodenoscopy in order to obtain biopsy samples\nof the esophageal nodule, not noted on previous study. At\nthe time of this dictation results of those biopsies were\npending. While in the Medical Intensive Care Unit the\npatient also had workup for hemolysis to evaluate whether\nhemolysis could be attributing to his anemia. He had a\nnormal left ventricular hypertrophy, haptoglobin and\nbilirubin on admission, however, making hemolysis a very\nunlikely explanation for his presentation hematocrit of 19.\nMoreover, no schistocytes were seen on peripheral smear.\nHemolysis laboratory data were checked several days into his\nhospital course and were consistent with changes status post\nlarge volume transfusion with no evidence of active ongoing\nhemolysis.', "\n\n2. Right upper extremity deep vein thrombosis - On 1953-8-29 the patient began to complain of right upper\nextremity pain and swelling. Doppler ultrasound demonstrated\nan axillary deep vein thrombosis. In light of his recent\nbleeding episode, anticoagulation was held initially.\nAlthough upper extremity deep vein thromboses do not embolize\nas often as lower extremity deep vein thromboses, there was\nstill a very high concern for pulmonary embolus in light of\nthe patient's history of right pneumonectomy and the\nfunctionality of his one remaining lung. The computerized\ntomography scan was performed to better examine the right\nupper extremity soft tissues. In particular there was\nconcern that the patient might have an obstructing mass\nlesion or fibrosis-post his pneumonectomy that could be\ncontributing to venous stasis and obstruction leading to deep\nvein thrombosis formation.", ' Computerized tomographic venogram\nwas without evidence of obstructing lesion of fibrosis,\nhowever. The patient is likely hypercoagulable as evidenced\nby the development of this right upper extremity deep vein\nthrombosis spontaneously after being off anticoagulation in\nthe setting of his acute bleed for only several days, there\nwas concern for recurrent deep vein thromboses. Therefore,\nan inferior vena cava filter was placed on 2006-3-28.\nThe patient tolerated the procedure well. On 1902-4-13, the patient then began to complain of pain and swelling\nof the right lower extremity. Examination was consistent\nwith possible thrombus of the right lower extremity.\nHowever, as the patient already had an inferior vena cava\nfilter placed and delineation of a right lower extremity deep\nvein thrombosis would not change management plans at all, the\ndecision was made not to undergo ultrasound doppler imaging\nof the right lower extremity.', ' In light of his probable\nhypercoagulability, decision was made to reinitiate\nanticoagulation with the Coumadin. His Coumadin level will\nbe followed by his outpatient physician, Martin. Nicki Lenling.\nHis INR should be checked remotely at the rehabilitation\nfacility and his Coumadin dose adjusted accordingly for a\ngoal INR of 2 to 3.\n\n3. Chronic obstructive pulmonary disease/lung carcinoma\nstatus post right pneumonectomy - The patient was continued\non aggressive regimen of chest physical therapy and pulmonary\ntoilet. He was continued on his outpatient medicines,\nCombivent, Salmeterol, and Theophylline. He was continued on\nantibiotic prophylaxis with Bactrim Double Strength in light\nof his history of bronchiectasis. He was monitored for acute\ndecompensation and his respiratory status, particularly\nconcerning for pulmonary embolism in light of his right upper\nextremity deep vein thrombosis.', " He continued to improve from\na respiratory standpoint. He was diuresed gently after\narriving to the Medicine Floor status post fluid\nresuscitation and blood product administration in the Medical\nIntensive Care Unit in the setting of his acute bleed. With\nthe diuresis, pulmonary toilet and supportive care, his\nrespiratory status improved somewhat. However, he is not\nback to his baseline of 2 liters of oxygen nasal cannula at\nhome. At the time of discharge he was maintaining\nsaturations in the 97 to 100% range on 4 liters but he\ncontinued to complain of increased dyspnea with activity and\nshortness of breath, occasionally at rest. It was felt that\na lot the patient's dyspnea was secondary to muscle\ndeconditioning due to his prolonged illness and hospital\nstay. Therefore he will be discharged to a pulmonary\nrehabilitation program in hopes of increasing his\nconditioning and improving his overall pulmonary status.", '\n\n4. Diabetes mellitus 2 - The patient was maintained on a\ndiabetic diet, with q.i.d. fingersticks, fingerstick blood\nglucose testing and coverage with a regular insulin sliding\nscale. He was maintained on his outpatient dose of Neurontin\nfor neuropathy.\n\n5. Atrial fibrillation - He was continued on his outpatient\ndose of Amiodarone. Of note, he is currently in sinus\nrhythm.\n\n6. Acute renal failure - The patient on admission had an\nelevated creatinine level above his baseline. This was\nlikely secondary to prerenal causes, specifically hypovolemia\nand intravascular volume depletion in the setting of his\nacute bleeding episode. His acute renal failure resolved\nafter fluid hydration.\n\n7. Vitamin B12 deficiency - The patient was continued on his\noutpatient regimen of supplementation with Vitamin B12, 1000\nmcg p.', "o. b.i.d.\n\n8. Hypercholesterolemia - The patient was continued on his\noutpatient dose of Lipitor 10 mg p.o. q.d.\n\n9. Depression/anxiety - The patient was continued on his\noutpatient dose of Paroxetine 20 mg p.o. q.d.\n\n10. Fluids, electrolytes and nutrition - The patient was fed\na diabetic heart-healthy diet. He received supplementation\nwith multivitamins and Vitamin B12. Electrolytes were\naggressively repleted. At the time of discharge he was\ntolerating regular diet without nausea, vomiting or other\nincident.\n\nDISPOSITION: With the patient's general deconditioning as\nwell as his pulmonary status being slightly below his\nbaseline I felt that he would benefit from an inpatient\npulmonary rehabilitation program. He will be discharged to\nsuch a program.\n\nDISCHARGE CONDITION: Hemodynamically stable.", ' Afebrile.\nOxygen saturation stable on 4 liters of nasal cannula,\nambulating independently, tolerating Kobayashi intake without\nnausea or vomiting.\n\nDISCHARGE STATUS: The patient is discharged to an extended\ncare facility.\n\nDISCHARGE DIAGNOSIS:\n1. Anemia due to acute blood loss, likely secondary to\ngastrointestinal bleed.\n2. Chronic obstructive pulmonary disease\n3. Lung carcinoma, status post right pneumonectomy\n4. History of perioperative pulmonary embolism\n5. Atrial fibrillation\n6. Hypertension\n7. Diabetes mellitus 2, insulin requiring with neuropathy\n8. Gastroesophageal reflux disease\n9. Status post transtracheal catheter placement and oxygen\nsuctioning\n10. Cataract\n11. Anxiety\n12. History of transient ischemic attack\n13. Interrupted sleep apnea\n14. Hypercholesterolemia\n15. B12 deficiency\n16.', ' Right upper extremity deep vein thrombosis\n\nDISCHARGE MEDICATIONS:\n1. Amiodarone 200 mg p.o. q.d.\n2. Regular insulin sliding scale\n3. Atrovent nebulizer q. 6 hours as needed\n4. Lasix 80 mg p.o. b.i.d.\n5. Pantoprazole 40 mg p.o. q.d.\n6. Gabapentin 100 mg p.o. q.d.\n7. Paroxetine 20 mg p.o. q.d.\n8. Colace 100 mg p.o. b.i.d.\n9. Glyburide 5 mg p.o. q.d.\n10. Vitamin B12 1000 mcg p.o. b.i.d.\n11. Lipitor 10 mg p.o. q.d.\n12. Scopolamine 1.5 mg transdermal patch one patch q. 72\nhours as needed\n13. Salmeterol discus q. 12 hours\n14. Senna two tablets p.o. b.i.d.\n15. Percocet 1 to 2 tablets p.o. q. 4-6 hours as needed for\npain\n16. Combivent 1 to 2 puffs inhaled q. 6 hours\n17. Bactrim Double Strength one tablet p.o. b.i.d., last dose\nto be given on 1953-8-29\n18. Morphine Sulfate elixir 5 to 10 mg p.', 'o. q. 4-6 hours as\nneeded for pain, shortness of breath\n19. Dulcolax 10 mg p.o. q.d. as needed for constipation\n20. Ambien 5 to 10 mg p.o. q.h.s. as needed for insomnia\n21. Multivitamin p.o. q.d.\n22. Theophylline 400 mg sustained release 0.5 tablets p.o.\nq.d.\n23. Albuterol nebulizer solution one nebulizer inhaled q. 6\nhours as needed for shortness of breath\n24. Ativan 0.5 mg one tablet p.o. q. 4-6 hours as needed for\nanxiety\n25. Lactulose 30 ml p.o. q. 8 hours as needed for\nconstipation\n26. Nystatin suspension 5 mg p.o. q.i.d. as needed for 2012\nthrush\n\nFOLLOW UP PLANS: The patient has a scheduled follow up\nappointment with Dr. Hasan after discharge from the\nrehabilitation facility. He will decide on the timing and\nthe necessity of any further testing or studies that will be\nrequired including any further gastrointestinal workup for\nbleeding.', " He will follow up on the biopsy results from the\npatient's last esophagogastroduodenoscopy. The patient\nshould have his INR level checked daily while at the\nrehabilitation facility and his Coumadin dose adjusted\nappropriately with goal INR of 2.0 to 3.0.\n\n\n\n\n Janell Cobbs, M.D. 00649539\n\nDictated By:Negrete\nMEDQUIST36\n\nD: 1902-4-13 20:17\nT: 1902-4-13 21:42\nJOB#: Martin-Butler-1959-976819\n"]
18	15472	170963.0	2178-01-23	Discharge summary	Report	Admission Date: [2178-1-18] Discharge Date: [2178-1-23] Date of Birth: [2114-2-8] Sex: M Service: [Location (un) 259] HISTORY OF PRESENT ILLNESS: This is a 63-year-old male with history of multiple medical problems who was recently admitted to the [Hospital6 256] from [2178-11-26] to [2177-12-5] with projectile vomiting and hematocrit of 13. He had negative hemolysis workup and negative EGD times two and a colonoscopy times one. Found to have a right upper and right lower extremity deep venous thrombosis. [Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter was placed, and he was transferred to [Hospital ] Rehab and went home in late 01/[2177]. He received seven units of packed red blood cells, seven units of fresh frozen plasma, and one unit during previous hospitalization and two units of packed red blood cells while he was at [Hospital1 ]. He had no nausea, vomiting, diarrhea, abdominal pain, bright red blood per rectum. Ten days ago his Coumadin and aspirin were continued for planned EGD and colonoscopy with good prep. On [2178-1-15] he had an EGD polyp removed from the esophagus which was negative. His colonoscopy revealed two polyps which were adenomatous without any complications. Then, on [2178-1-17] at about 10 p.m. he developed severe bilateral lower abdominal pain and bright red blood per rectum times three at home and times two in the Emergency Room. He denies nausea but vomited once after GoLYTELY in the Emergency Room. He had no change in shortness of breath. Denies chest pain, fever, chills, cough, wheezing, dysuria. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Lung cancer status post right pneumonectomy in [1-/2175] complicated by the PA laceration. 3. Prostate cancer status post prostatectomy six years ago but has had recently increasing prostate specific antigen and was scheduled for an outpatient bone scan. 4. History of perioperative pulmonary embolism. Had [Location (un) 260] filter placed. 5. Atrial fibrillation sinus rhythm with Amiodarone. 6. Hypertension but has recently been hypotensive. 7. Diabetes type 2 complicated by neuropathy. 8. Gastroesophageal reflux disease and negative history for peptic ulcer disease. 9. Obstructive sleep apnea but does not tolerate continuous positive air pressure. 10. Hypercholesterolemia. 11. Vitamin B12 deficiency. 12. History of transient ischemic attacks. 13. Cataracts. 14. Trach placement for suctioning and oxygen requirement in 07/[2176]. ALLERGIES: 1. Doxepin. 2. Levofloxacin. 3. OxyContin. MEDICATIONS ON ADMISSION: 1. Potassium chloride. 2. Colchicine. 3. Protonix. 4. Lasix. 5. Paxil. 6. Multivitamin. 7. Colace. 8. Senna. 9. Roxanol. 10. Tylenol with Codeine. 11. Combivent. 12. Amiodarone. 13. Neurontin. 14. Ferrous Sulfate. 15. Vitamin B12. 16. Glyburide. 17. Lipitor. 18. Scopolamine patch. 19. Advair. 20. Combivent nebulizer. FAMILY HISTORY: Mother with coronary artery disease. SOCIAL HISTORY: Lives with his wife. Is retired. Does tobacco, 160-pack-year history but quit in [2174]. Quit alcohol in [2173]. No drug use. PHYSICAL EXAMINATION ON ADMISSION: Vitals: Temperature 98.4, pulse 94, blood pressure 100/65, respiratory rate 18, sat 96% on room air. In general, he is well developed, well nourished male; awake, alert, and oriented times three; in no acute distress. Appears dry. HEENT: Pupils are minimally reactive. Extraocular muscles are intact. Oropharynx is slightly dry; no lesions. Neck is supple; no lymphadenopathy; trach catheter in place; no jugular venous distention. Chest: With referred breath sounds on the right; left with firm rales, no wheezes. Heart is regular; normal S1, S2; no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended; positive tenderness to palpation in the right lower quadrant severely and tender to palpation generalized throughout. Positive bowel sounds; no rebound or guarding; guaiac positive with red stool. Extremities: No edema; 5/5 strength in all extremities. LABORATORY DATA ON ADMISSION: White count of 13, hematocrit of 30, MCV of 90, platelets 272, sodium 141, potassium 3.8, chloride 96, bicarbonate 35, BUN 20, creatinine 1.0, glucose 149, CK 96, troponin 0.06. EKG with sinus rhythm at 94 with normal axis; poor baseline; no other ST-T wave changes. HOSPITAL COURSE: This is a 63-year-old man with multiple medical problems who was recently admitted with severe anemia and likely lower gastrointestinal bleed who had multiple polypectomies in the ascending and transverse colon on [2178-1-15] and represented with lower abdominal pain and bright red blood per rectum and anemia. 1. Gastrointestinal bleed and blood loss anemia: Most likely secondary to complication from recent colonoscopy and polypectomy. Patient had a negative EGD and then had a colonoscopy which did show a bleeding vessel at the site of previous polypectomy. This was clipped with two clips with good control of the bleeding. Patient's hematocrit remained stable. He did receive a total of four units of packed red blood cells on this admission. After colonoscopy with clipping, no further melena or bright red blood per rectum was noted. Patient's hematocrits were followed serially and remained in the 26, 27 range and eventually was transfused the fourth unit day prior to discharge, but his hematocrit remained 29 and 31 on day of discharge. Otherwise, symptomatically much improved and slowly advanced his diet from liquids to soft mechanical diet, which he tolerated well with no further episodes of melena or bright red blood per rectum. Patient was initially started on Protonix 40 intravenously b.i.d. as his EGD was negative. Eventually was switched back to his 40 p.o. q. day regimen which he continued even as an outpatient for his gastroesophageal reflux disease. Patient's blood pressure remained stable after transfused with blood. He also had a negative tagged red cell scan and negative EGD. Eventually, after colonoscopy, had a small bowel follow through to rule out any source of blood loss as in his previous admission. This was also negative. Patient could not have a Meckel scan during this stay because of barium and can have it at least one week after barium ingestion. Because of the recent colonoscopy and the bleed, patient's Lovenox dose and Coumadin dose were continued to be held. Patient's anticoagulation, including aspirin, Coumadin, and Lovenox, were to be held for at least one week and can be restarted on [2178-1-27] per GI. 2. Chronic obstructive pulmonary disease: Patient's respiratory status was stable and at baseline. Continued his home regimen of Advair, Combivent, and Theophylline and p.r.n. nebulizers as needed, although his pulmonary exam remained stable and he was at his baseline home oxygen of 2 liters and will be discharged on the same regimen. 3. Status post lung cancer, status post pneumonectomy: Was stable with tracheostomy. Continued b.i.d. suctioning with good results. Continue the Scopolamine patch for antiemetics. 4. Prostate cancer: He does have recently rising PSA most recently 8.9 in 02/[2177]. Patient was eventually able to have a bone scan during the course of his stay which was negative for metastases, only positive for previous post surgical bony changes. Patient will be followed up with urologist, Dr. [Last Name (STitle) 261], in terms of his prostate cancer follow up. 5. Troponin leak: This was attributed to demand ischemia. He had negative EKG changes, and he had a catheterization in [1-/2175] which revealed 30% mid lesion but no flow-limiting disease. His enzymes remained stable through the course of his stay and was attributed to his anemia. Patient's aspirin was held because of the bleeding and can be restarted [2178-1-27]. Patient was continued on his statin. 6. Atrial fibrillation: Patient was in sinus rhythm throughout the course of his stay and was stable on Amiodarone. Again, his Coumadin was held for concerns with bleeding. 7. Deep venous thrombosis/pulmonary embolus: He has a history of [Location (un) 260] filter and right upper and right lower extremity deep venous thrombosis. His hypercoagulable state is likely attributed to the prostate cancer, but otherwise his Coumadin was held for the bleeding reasons, and patient did have increasing amounts of swelling of his right upper and right lower extremity. Patient was taken off his Lasix dose through the course of the stay because of concern for hemodynamic instability. Was given p.r.n. doses of Lasix throughout the stay and continued to elevate his extremities with good results of them. Patient did have both upper and lower extremity ultrasounds done to rule out new deep venous thrombosis. The right lower extremity ultrasound was negative. The right upper extremity did show the old known thrombus in the right basilic vein but no progression or change from previous studies, and this otherwise was stable throughout the course of his stay. 8. Diabetes: He has fairly good control with hemoglobin A1C most recently at 6.0. He was continued on his home regimen of Glyburide once he was taking p.o. and covered with sliding scale as needed. For his neuropathy patient was continued on his Tylenol Number 3 and was discharged with a prescription for Morphine sulfate per his request, although he was not continued on this during the course of his stay. 9. Gout: This was stable throughout the course of his admission, but patient was continued on his home dose of Colchicine. DISCHARGE DIAGNOSES: 1. Lower gastrointestinal bleed. 2. Blood loss anemia. 3. History of deep venous thrombosis. 4. Chronic obstructive pulmonary disease. 5. Status post lung cancer. 6. Status post prostate cancer. 7. Atrial fibrillation. 8. Diabetes mellitus. 9. Gout. 10. Hyperlipidemia. 11. Neuropathy. 12. Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: 1. Paxil 20 mg p.o. q. day. 2. Multivitamin, one, p.o. q. day. 3. Tylenol Number 3, one to two, p.o. q. 4 to 6 hours. 4. Combivent, one to two puffs inhaled, q. 6 hours p.r.n. 5. Theophylline 200 mg p.o. q. day. 6. Amiodarone 200 mg p.o. q. day. 7. Gabapentin 100 mg p.o. q. day. 8. Ferrous Sulfate 325 mg p.o. t.i.d. 9. Vitamin B12, 250 mcg, p.o. q.d. 10. Atorvastatin 10 mg p.o. q. day. 11. Scopolamine patch q. 72 hours. 12. Advair 500/50 mcg dose, one diskus, b.i.d. 13. Colchicine 0.6 mg p.o. t.i.d. 14. Vioxx 12.5 mg p.o. q. day. 15. Ambien 15 mg p.o. q. h.s. 16. Pantoprazole 40 mg p.o. q. day. 17. Morphine sulfate 10 mg/5 ml p.o. q. 4 hours p.r.n. pain. 18. Lasix 80 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: 1. Patient is to follow up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 262], on [2178-2-19]. 2. Patient is to follow up with his urologist, Dr. [Last Name (STitle) 261], on [2178-1-28]. 3. Patient is to follow up with his [Hospital 263] clinic to have his INR checked after restarting Coumadin and Lovenox. DISCHARGE CONDITION: Good; patient ambulating with 2 liters oxygen requirement at home; patient with stable hematocrit of 31; no further events of bright bleeding per rectum; pain well controlled. DISPOSITION: Discharged to home. [First Name11 (Name Pattern1) 198] [Last Name (NamePattern4) 199], M.D. [MD Number(1) 200] Dictated By:[Name8 (MD) 264] MEDQUIST36 D: [2178-1-23] 16:52 T: [2178-1-25] 13:25 JOB#: [Job Number 265]	Admission Date: <Date>1943-2-15</Date> Discharge Date: <Date>2009-10-20</Date> Date of Birth: <Date>1980-8-11</Date> Sex: M Service: <Location>41321 Angela Center Stacyburgh, NJ 00674</Location> HISTORY OF PRESENT ILLNESS: This is a 63-year-old male with history of multiple medical problems who was recently admitted to the <Hospital>Graham-Fields Health System</Hospital> from <Date>2009-3-5</Date> to <Date>1986-2-3</Date> with projectile vomiting and hematocrit of 13. He had negative hemolysis workup and negative EGD times two and a colonoscopy times one. Found to have a right upper and right lower extremity deep venous thrombosis. <Initial>ON</Initial> <Name>Clapp</Name> filter was placed, and he was transferred to <Hospital>Holmes LLC Hospital</Hospital> Rehab and went home in late 01/<Year>1987</Year>. He received seven units of packed red blood cells, seven units of fresh frozen plasma, and one unit during previous hospitalization and two units of packed red blood cells while he was at <Hospital>Brooks-Taylor Health System</Hospital>. He had no nausea, vomiting, diarrhea, abdominal pain, bright red blood per rectum. Ten days ago his Coumadin and aspirin were continued for planned EGD and colonoscopy with good prep. On <Date>1916-10-17</Date> he had an EGD polyp removed from the esophagus which was negative. His colonoscopy revealed two polyps which were adenomatous without any complications. Then, on <Date>1959-10-2</Date> at about 10 p.m. he developed severe bilateral lower abdominal pain and bright red blood per rectum times three at home and times two in the Emergency Room. He denies nausea but vomited once after GoLYTELY in the Emergency Room. He had no change in shortness of breath. Denies chest pain, fever, chills, cough, wheezing, dysuria. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Lung cancer status post right pneumonectomy in <Date>10-1953</Date> complicated by the PA laceration. 3. Prostate cancer status post prostatectomy six years ago but has had recently increasing prostate specific antigen and was scheduled for an outpatient bone scan. 4. History of perioperative pulmonary embolism. Had <Location>994 Gonzalez Fall Suite 288 Stevenmouth, CO 22187</Location> filter placed. 5. Atrial fibrillation sinus rhythm with Amiodarone. 6. Hypertension but has recently been hypotensive. 7. Diabetes type 2 complicated by neuropathy. 8. Gastroesophageal reflux disease and negative history for peptic ulcer disease. 9. Obstructive sleep apnea but does not tolerate continuous positive air pressure. 10. Hypercholesterolemia. 11. Vitamin B12 deficiency. 12. History of transient ischemic attacks. 13. Cataracts. 14. Trach placement for suctioning and oxygen requirement in 07/<Year>1987</Year>. ALLERGIES: 1. Doxepin. 2. Levofloxacin. 3. OxyContin. MEDICATIONS ON ADMISSION: 1. Potassium chloride. 2. Colchicine. 3. Protonix. 4. Lasix. 5. Paxil. 6. Multivitamin. 7. Colace. 8. Senna. 9. Roxanol. 10. Tylenol with Codeine. 11. Combivent. 12. Amiodarone. 13. Neurontin. 14. Ferrous Sulfate. 15. Vitamin B12. 16. Glyburide. 17. Lipitor. 18. Scopolamine patch. 19. Advair. 20. Combivent nebulizer. FAMILY HISTORY: Mother with coronary artery disease. SOCIAL HISTORY: Lives with his wife. Is retired. Does tobacco, 160-pack-year history but quit in <Year>1987</Year>. Quit alcohol in <Year>1987</Year>. No drug use. PHYSICAL EXAMINATION ON ADMISSION: Vitals: Temperature 98.4, pulse 94, blood pressure 100/65, respiratory rate 18, sat 96% on room air. In general, he is well developed, well nourished male; awake, alert, and oriented times three; in no acute distress. Appears dry. HEENT: Pupils are minimally reactive. Extraocular muscles are intact. Oropharynx is slightly dry; no lesions. Neck is supple; no lymphadenopathy; trach catheter in place; no jugular venous distention. Chest: With referred breath sounds on the right; left with firm rales, no wheezes. Heart is regular; normal S1, S2; no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended; positive tenderness to palpation in the right lower quadrant severely and tender to palpation generalized throughout. Positive bowel sounds; no rebound or guarding; guaiac positive with red stool. Extremities: No edema; 5/5 strength in all extremities. LABORATORY DATA ON ADMISSION: White count of 13, hematocrit of 30, MCV of 90, platelets 272, sodium 141, potassium 3.8, chloride 96, bicarbonate 35, BUN 20, creatinine 1.0, glucose 149, CK 96, troponin 0.06. EKG with sinus rhythm at 94 with normal axis; poor baseline; no other ST-T wave changes. HOSPITAL COURSE: This is a 63-year-old man with multiple medical problems who was recently admitted with severe anemia and likely lower gastrointestinal bleed who had multiple polypectomies in the ascending and transverse colon on <Date>1916-10-17</Date> and represented with lower abdominal pain and bright red blood per rectum and anemia. 1. Gastrointestinal bleed and blood loss anemia: Most likely secondary to complication from recent colonoscopy and polypectomy. Patient had a negative EGD and then had a colonoscopy which did show a bleeding vessel at the site of previous polypectomy. This was clipped with two clips with good control of the bleeding. Patient's hematocrit remained stable. He did receive a total of four units of packed red blood cells on this admission. After colonoscopy with clipping, no further melena or bright red blood per rectum was noted. Patient's hematocrits were followed serially and remained in the 26, 27 range and eventually was transfused the fourth unit day prior to discharge, but his hematocrit remained 29 and 31 on day of discharge. Otherwise, symptomatically much improved and slowly advanced his diet from liquids to soft mechanical diet, which he tolerated well with no further episodes of melena or bright red blood per rectum. Patient was initially started on Protonix 40 intravenously b.i.d. as his EGD was negative. Eventually was switched back to his 40 p.o. q. day regimen which he continued even as an outpatient for his gastroesophageal reflux disease. Patient's blood pressure remained stable after transfused with blood. He also had a negative tagged red cell scan and negative EGD. Eventually, after colonoscopy, had a small bowel follow through to rule out any source of blood loss as in his previous admission. This was also negative. Patient could not have a Meckel scan during this stay because of barium and can have it at least one week after barium ingestion. Because of the recent colonoscopy and the bleed, patient's Lovenox dose and Coumadin dose were continued to be held. Patient's anticoagulation, including aspirin, Coumadin, and Lovenox, were to be held for at least one week and can be restarted on <Date>1983-7-13</Date> per GI. 2. Chronic obstructive pulmonary disease: Patient's respiratory status was stable and at baseline. Continued his home regimen of Advair, Combivent, and Theophylline and p.r.n. nebulizers as needed, although his pulmonary exam remained stable and he was at his baseline home oxygen of 2 liters and will be discharged on the same regimen. 3. Status post lung cancer, status post pneumonectomy: Was stable with tracheostomy. Continued b.i.d. suctioning with good results. Continue the Scopolamine patch for antiemetics. 4. Prostate cancer: He does have recently rising PSA most recently 8.9 in 02/<Year>1987</Year>. Patient was eventually able to have a bone scan during the course of his stay which was negative for metastases, only positive for previous post surgical bony changes. Patient will be followed up with urologist, Dr. <Name>Pegram</Name>, in terms of his prostate cancer follow up. 5. Troponin leak: This was attributed to demand ischemia. He had negative EKG changes, and he had a catheterization in <Date>10-1953</Date> which revealed 30% mid lesion but no flow-limiting disease. His enzymes remained stable through the course of his stay and was attributed to his anemia. Patient's aspirin was held because of the bleeding and can be restarted <Date>1983-7-13</Date>. Patient was continued on his statin. 6. Atrial fibrillation: Patient was in sinus rhythm throughout the course of his stay and was stable on Amiodarone. Again, his Coumadin was held for concerns with bleeding. 7. Deep venous thrombosis/pulmonary embolus: He has a history of <Location>994 Gonzalez Fall Suite 288 Stevenmouth, CO 22187</Location> filter and right upper and right lower extremity deep venous thrombosis. His hypercoagulable state is likely attributed to the prostate cancer, but otherwise his Coumadin was held for the bleeding reasons, and patient did have increasing amounts of swelling of his right upper and right lower extremity. Patient was taken off his Lasix dose through the course of the stay because of concern for hemodynamic instability. Was given p.r.n. doses of Lasix throughout the stay and continued to elevate his extremities with good results of them. Patient did have both upper and lower extremity ultrasounds done to rule out new deep venous thrombosis. The right lower extremity ultrasound was negative. The right upper extremity did show the old known thrombus in the right basilic vein but no progression or change from previous studies, and this otherwise was stable throughout the course of his stay. 8. Diabetes: He has fairly good control with hemoglobin A1C most recently at 6.0. He was continued on his home regimen of Glyburide once he was taking p.o. and covered with sliding scale as needed. For his neuropathy patient was continued on his Tylenol Number 3 and was discharged with a prescription for Morphine sulfate per his request, although he was not continued on this during the course of his stay. 9. Gout: This was stable throughout the course of his admission, but patient was continued on his home dose of Colchicine. DISCHARGE DIAGNOSES: 1. Lower gastrointestinal bleed. 2. Blood loss anemia. 3. History of deep venous thrombosis. 4. Chronic obstructive pulmonary disease. 5. Status post lung cancer. 6. Status post prostate cancer. 7. Atrial fibrillation. 8. Diabetes mellitus. 9. Gout. 10. Hyperlipidemia. 11. Neuropathy. 12. Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: 1. Paxil 20 mg p.o. q. day. 2. Multivitamin, one, p.o. q. day. 3. Tylenol Number 3, one to two, p.o. q. 4 to 6 hours. 4. Combivent, one to two puffs inhaled, q. 6 hours p.r.n. 5. Theophylline 200 mg p.o. q. day. 6. Amiodarone 200 mg p.o. q. day. 7. Gabapentin 100 mg p.o. q. day. 8. Ferrous Sulfate 325 mg p.o. t.i.d. 9. Vitamin B12, 250 mcg, p.o. q.d. 10. Atorvastatin 10 mg p.o. q. day. 11. Scopolamine patch q. 72 hours. 12. Advair 500/50 mcg dose, one diskus, b.i.d. 13. Colchicine 0.6 mg p.o. t.i.d. 14. Vioxx 12.5 mg p.o. q. day. 15. Ambien 15 mg p.o. q. h.s. 16. Pantoprazole 40 mg p.o. q. day. 17. Morphine sulfate 10 mg/5 ml p.o. q. 4 hours p.r.n. pain. 18. Lasix 80 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: 1. Patient is to follow up with his primary care physician, <Name>Ngo</Name>. <Name>Lyna</Name>, on <Date>1916-10-14</Date>. 2. Patient is to follow up with his urologist, Dr. <Name>Pegram</Name>, on <Date>1958-11-30</Date>. 3. Patient is to follow up with his <Hospital>Sanchez, Jacobs and Kennedy Clinic</Hospital> clinic to have his INR checked after restarting Coumadin and Lovenox. DISCHARGE CONDITION: Good; patient ambulating with 2 liters oxygen requirement at home; patient with stable hematocrit of 31; no further events of bright bleeding per rectum; pain well controlled. DISPOSITION: Discharged to home. <Name>Alexis</Name> <Name>Lees</Name>, M.D. <MD Number>03869207</MD Number> Dictated By:<Name>Celeste Salgado</Name> MEDQUIST36 D: <Date>2009-10-20</Date> 16:52 T: <Date>1983-8-17</Date> 13:25 JOB#: <Job Number>Payne and Sons-1989-488095</Job 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Date: 1943-2-15 Discharge Date: 2009-10-20 Date of Birth: 1980-8-11 Sex: M Service: 41321 Angela Center Stacyburgh, NJ 00674 HISTORY OF PRESENT ILLNESS: This is a 63-year-old male with history of multiple medical problems who was recently admitted to the Graham-Fields Health System from 2009-3-5 to 1986-2-3 with projectile vomiting and hematocrit of 13. He had negative hemolysis workup and negative EGD times two and a colonoscopy times one. Found to have a right upper and right lower extremity deep venous thrombosis. ON Clapp filter was placed, and he was transferred to Holmes LLC Hospital Rehab and went home in late 01/1987. He received seven units of packed red blood cells, seven units of fresh frozen plasma, and one unit during previous hospitalization and two units of packed red blood cells while he was at Brooks-Taylor Health System. He had no nausea, vomiting, diarrhea, abdominal pain, bright red blood per rectum. Ten days ago his Coumadin and aspirin were continued for planned EGD and colonoscopy with good prep. On 1916-10-17 he had an EGD polyp removed from the esophagus which was negative. His colonoscopy revealed two polyps which were adenomatous without any complications. Then, on 1959-10-2 at about 10 p.m. he developed severe bilateral lower abdominal pain and bright red blood per rectum times three at home and times two in the Emergency Room. He denies nausea but vomited once after GoLYTELY in the Emergency Room. He had no change in shortness of breath. Denies chest pain, fever, chills, cough, wheezing, dysuria. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Lung cancer status post right pneumonectomy in 10-1953 complicated by the PA laceration. 3. Prostate cancer status post prostatectomy six years ago but has had recently increasing prostate specific antigen and was scheduled for an outpatient bone scan. 4. History of perioperative pulmonary embolism. Had 994 Gonzalez Fall Suite 288 Stevenmouth, CO 22187 filter placed. 5. Atrial fibrillation sinus rhythm with Amiodarone. 6. Hypertension but has recently been hypotensive. 7. Diabetes type 2 complicated by neuropathy. 8. Gastroesophageal reflux disease and negative history for peptic ulcer disease. 9. Obstructive sleep apnea but does not tolerate continuous positive air pressure. 10. Hypercholesterolemia. 11. Vitamin B12 deficiency. 12. History of transient ischemic attacks. 13. Cataracts. 14. Trach placement for suctioning and oxygen requirement in 07/1987. ALLERGIES: 1. Doxepin. 2. Levofloxacin. 3. OxyContin. MEDICATIONS ON ADMISSION: 1. Potassium chloride. 2. Colchicine. 3. Protonix. 4. Lasix. 5. Paxil. 6. Multivitamin. 7. Colace. 8. Senna. 9. Roxanol. 10. Tylenol with Codeine. 11. Combivent. 12. Amiodarone. 13. Neurontin. 14. Ferrous Sulfate. 15. Vitamin B12. 16. Glyburide. 17. Lipitor. 18. Scopolamine patch. 19. Advair. 20. Combivent nebulizer. FAMILY HISTORY: Mother with coronary artery disease. SOCIAL HISTORY: Lives with his wife. Is retired. Does tobacco, 160-pack-year history but quit in 1987. Quit alcohol in 1987. No drug use. PHYSICAL EXAMINATION ON ADMISSION: Vitals: Temperature 98.4, pulse 94, blood pressure 100/65, respiratory rate 18, sat 96% on room air. In general, he is well developed, well nourished male; awake, alert, and oriented times three; in no acute distress. Appears dry. HEENT: Pupils are minimally reactive. Extraocular muscles are intact. Oropharynx is slightly dry; no lesions. Neck is supple; no lymphadenopathy; trach catheter in place; no jugular venous distention. Chest: With referred breath sounds on the right; left with firm rales, no wheezes. Heart is regular; normal S1, S2; no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended; positive tenderness to palpation in the right lower quadrant severely and tender to palpation generalized throughout. Positive bowel sounds; no rebound or guarding; guaiac positive with red stool. Extremities: No edema; 5/5 strength in all extremities. LABORATORY DATA ON ADMISSION: White count of 13, hematocrit of 30, MCV of 90, platelets 272, sodium 141, potassium 3.8, chloride 96, bicarbonate 35, BUN 20, creatinine 1.0, glucose 149, CK 96, troponin 0.06. EKG with sinus rhythm at 94 with normal axis; poor baseline; no other ST-T wave changes. HOSPITAL COURSE: This is a 63-year-old man with multiple medical problems who was recently admitted with severe anemia and likely lower gastrointestinal bleed who had multiple polypectomies in the ascending and transverse colon on 1916-10-17 and represented with lower abdominal pain and bright red blood per rectum and anemia. 1. Gastrointestinal bleed and blood loss anemia: Most likely secondary to complication from recent colonoscopy and polypectomy. Patient had a negative EGD and then had a colonoscopy which did show a bleeding vessel at the site of previous polypectomy. This was clipped with two clips with good control of the bleeding. Patient's hematocrit remained stable. He did receive a total of four units of packed red blood cells on this admission. After colonoscopy with clipping, no further melena or bright red blood per rectum was noted. Patient's hematocrits were followed serially and remained in the 26, 27 range and eventually was transfused the fourth unit day prior to discharge, but his hematocrit remained 29 and 31 on day of discharge. Otherwise, symptomatically much improved and slowly advanced his diet from liquids to soft mechanical diet, which he tolerated well with no further episodes of melena or bright red blood per rectum. Patient was initially started on Protonix 40 intravenously b.i.d. as his EGD was negative. Eventually was switched back to his 40 p.o. q. day regimen which he continued even as an outpatient for his gastroesophageal reflux disease. Patient's blood pressure remained stable after transfused with blood. He also had a negative tagged red cell scan and negative EGD. Eventually, after colonoscopy, had a small bowel follow through to rule out any source of blood loss as in his previous admission. This was also negative. Patient could not have a Meckel scan during this stay because of barium and can have it at least one week after barium ingestion. Because of the recent colonoscopy and the bleed, patient's Lovenox dose and Coumadin dose were continued to be held. Patient's anticoagulation, including aspirin, Coumadin, and Lovenox, were to be held for at least one week and can be restarted on 1983-7-13 per GI. 2. Chronic obstructive pulmonary disease: Patient's respiratory status was stable and at baseline. Continued his home regimen of Advair, Combivent, and Theophylline and p.r.n. nebulizers as needed, although his pulmonary exam remained stable and he was at his baseline home oxygen of 2 liters and will be discharged on the same regimen. 3. Status post lung cancer, status post pneumonectomy: Was stable with tracheostomy. Continued b.i.d. suctioning with good results. Continue the Scopolamine patch for antiemetics. 4. Prostate cancer: He does have recently rising PSA most recently 8.9 in 02/1987. Patient was eventually able to have a bone scan during the course of his stay which was negative for metastases, only positive for previous post surgical bony changes. Patient will be followed up with urologist, Dr. Pegram, in terms of his prostate cancer follow up. 5. Troponin leak: This was attributed to demand ischemia. He had negative EKG changes, and he had a catheterization in 10-1953 which revealed 30% mid lesion but no flow-limiting disease. His enzymes remained stable through the course of his stay and was attributed to his anemia. Patient's aspirin was held because of the bleeding and can be restarted 1983-7-13. Patient was continued on his statin. 6. Atrial fibrillation: Patient was in sinus rhythm throughout the course of his stay and was stable on Amiodarone. Again, his Coumadin was held for concerns with bleeding. 7. Deep venous thrombosis/pulmonary embolus: He has a history of 994 Gonzalez Fall Suite 288 Stevenmouth, CO 22187 filter and right upper and right lower extremity deep venous thrombosis. His hypercoagulable state is likely attributed to the prostate cancer, but otherwise his Coumadin was held for the bleeding reasons, and patient did have increasing amounts of swelling of his right upper and right lower extremity. Patient was taken off his Lasix dose through the course of the stay because of concern for hemodynamic instability. Was given p.r.n. doses of Lasix throughout the stay and continued to elevate his extremities with good results of them. Patient did have both upper and lower extremity ultrasounds done to rule out new deep venous thrombosis. The right lower extremity ultrasound was negative. The right upper extremity did show the old known thrombus in the right basilic vein but no progression or change from previous studies, and this otherwise was stable throughout the course of his stay. 8. Diabetes: He has fairly good control with hemoglobin A1C most recently at 6.0. He was continued on his home regimen of Glyburide once he was taking p.o. and covered with sliding scale as needed. For his neuropathy patient was continued on his Tylenol Number 3 and was discharged with a prescription for Morphine sulfate per his request, although he was not continued on this during the course of his stay. 9. Gout: This was stable throughout the course of his admission, but patient was continued on his home dose of Colchicine. DISCHARGE DIAGNOSES: 1. Lower gastrointestinal bleed. 2. Blood loss anemia. 3. History of deep venous thrombosis. 4. Chronic obstructive pulmonary disease. 5. Status post lung cancer. 6. Status post prostate cancer. 7. Atrial fibrillation. 8. Diabetes mellitus. 9. Gout. 10. Hyperlipidemia. 11. Neuropathy. 12. Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: 1. Paxil 20 mg p.o. q. day. 2. Multivitamin, one, p.o. q. day. 3. Tylenol Number 3, one to two, p.o. q. 4 to 6 hours. 4. Combivent, one to two puffs inhaled, q. 6 hours p.r.n. 5. Theophylline 200 mg p.o. q. day. 6. Amiodarone 200 mg p.o. q. day. 7. Gabapentin 100 mg p.o. q. day. 8. Ferrous Sulfate 325 mg p.o. t.i.d. 9. Vitamin B12, 250 mcg, p.o. q.d. 10. Atorvastatin 10 mg p.o. q. day. 11. Scopolamine patch q. 72 hours. 12. Advair 500/50 mcg dose, one diskus, b.i.d. 13. Colchicine 0.6 mg p.o. t.i.d. 14. Vioxx 12.5 mg p.o. q. day. 15. Ambien 15 mg p.o. q. h.s. 16. Pantoprazole 40 mg p.o. q. day. 17. Morphine sulfate 10 mg/5 ml p.o. q. 4 hours p.r.n. pain. 18. Lasix 80 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: 1. Patient is to follow up with his primary care physician, Ngo. Lyna, on 1916-10-14. 2. Patient is to follow up with his urologist, Dr. Pegram, on 1958-11-30. 3. Patient is to follow up with his Sanchez, Jacobs and Kennedy Clinic clinic to have his INR checked after restarting Coumadin and Lovenox. DISCHARGE CONDITION: Good; patient ambulating with 2 liters oxygen requirement at home; patient with stable hematocrit of 31; no further events of bright bleeding per rectum; pain well controlled. DISPOSITION: Discharged to home. Alexis Lees, M.D. 03869207 Dictated By:Celeste Salgado MEDQUIST36 D: 2009-10-20 16:52 T: 1983-8-17 13:25 JOB#: Payne and Sons-1989-488095	['Admission Date: 1943-2-15 Discharge Date: 2009-10-20\n\nDate of Birth: 1980-8-11 Sex: M\n\nService: 41321 Angela Center\nStacyburgh, NJ 00674\n\nHISTORY OF PRESENT ILLNESS: This is a 63-year-old male with\nhistory of multiple medical problems who was recently\nadmitted to the Graham-Fields Health System from\n2009-3-5 to 1986-2-3 with projectile vomiting and\nhematocrit of 13.\n\nHe had negative hemolysis workup and negative EGD times two\nand a colonoscopy times one. Found to have a right upper and\nright lower extremity deep venous thrombosis. ON Clapp\nfilter was placed, and he was transferred to Holmes LLC Hospital Rehab\nand went home in late 01/1987.\n\nHe received seven units of packed red blood cells, seven\nunits of fresh frozen plasma, and one unit during previous\nhospitalization and two units of packed red blood cells while\nhe was at Brooks-Taylor Health System.', ' He had no nausea, vomiting, diarrhea,\nabdominal pain, bright red blood per rectum.\n\nTen days ago his Coumadin and aspirin were continued for\nplanned EGD and colonoscopy with good prep. On 1916-10-17 he\nhad an EGD polyp removed from the esophagus which was\nnegative. His colonoscopy revealed two polyps which were\nadenomatous without any complications.\n\nThen, on 1959-10-2 at about 10 p.m. he developed severe\nbilateral lower abdominal pain and bright red blood per\nrectum times three at home and times two in the Emergency\nRoom. He denies nausea but vomited once after GoLYTELY in\nthe Emergency Room. He had no change in shortness of breath.\nDenies chest pain, fever, chills, cough, wheezing, dysuria.\n\nPAST MEDICAL HISTORY:\n1. Chronic obstructive pulmonary disease.\n2. Lung cancer status post right pneumonectomy in 10-1953\ncomplicated by the PA laceration.', '\n3. Prostate cancer status post prostatectomy six years ago\nbut has had recently increasing prostate specific antigen and\nwas scheduled for an outpatient bone scan.\n4. History of perioperative pulmonary embolism. Had\n994 Gonzalez Fall Suite 288\nStevenmouth, CO 22187 filter placed.\n5. Atrial fibrillation sinus rhythm with Amiodarone.\n6. Hypertension but has recently been hypotensive.\n7. Diabetes type 2 complicated by neuropathy.\n8. Gastroesophageal reflux disease and negative history for\npeptic ulcer disease.\n9. Obstructive sleep apnea but does not tolerate continuous\npositive air pressure.\n10. Hypercholesterolemia.\n11. Vitamin B12 deficiency.\n12. History of transient ischemic attacks.\n13. Cataracts.\n14. Trach placement for suctioning and oxygen requirement in\n07/1987.\n\nALLERGIES:\n1.', ' Doxepin.\n2. Levofloxacin.\n3. OxyContin.\n\nMEDICATIONS ON ADMISSION:\n1. Potassium chloride.\n2. Colchicine.\n3. Protonix.\n4. Lasix.\n5. Paxil.\n6. Multivitamin.\n7. Colace.\n8. Senna.\n9. Roxanol.\n10. Tylenol with Codeine.\n11. Combivent.\n12. Amiodarone.\n13. Neurontin.\n14. Ferrous Sulfate.\n15. Vitamin B12.\n16. Glyburide.\n17. Lipitor.\n18. Scopolamine patch.\n19. Advair.\n20. Combivent nebulizer.\n\nFAMILY HISTORY: Mother with coronary artery disease.\n\nSOCIAL HISTORY: Lives with his wife. Is retired. Does\ntobacco, 160-pack-year history but quit in 1987. Quit\nalcohol in 1987. No drug use.\n\nPHYSICAL EXAMINATION ON ADMISSION: Vitals: Temperature\n98.4, pulse 94, blood pressure 100/65, respiratory rate 18,\nsat 96% on room air. In general, he is well developed, well\nnourished male; awake, alert, and oriented times three; in no\nacute distress.', ' Appears dry. HEENT: Pupils are minimally\nreactive. Extraocular muscles are intact. Oropharynx is\nslightly dry; no lesions. Neck is supple; no\nlymphadenopathy; trach catheter in place; no jugular venous\ndistention. Chest: With referred breath sounds on the\nright; left with firm rales, no wheezes. Heart is regular;\nnormal S1, S2; no murmurs, rubs, or gallops. Abdomen is\nsoft, nontender, nondistended; positive tenderness to\npalpation in the right lower quadrant severely and tender to\npalpation generalized throughout. Positive bowel sounds; no\nrebound or guarding; guaiac positive with red stool.\nExtremities: No edema; 5/5 strength in all extremities.\n\nLABORATORY DATA ON ADMISSION: White count of 13, hematocrit\nof 30, MCV of 90, platelets 272, sodium 141, potassium 3.8,\nchloride 96, bicarbonate 35, BUN 20, creatinine 1.', "0, glucose\n149, CK 96, troponin 0.06.\n\nEKG with sinus rhythm at 94 with normal axis; poor baseline;\nno other ST-T wave changes.\n\nHOSPITAL COURSE: This is a 63-year-old man with multiple\nmedical problems who was recently admitted with severe anemia\nand likely lower gastrointestinal bleed who had multiple\npolypectomies in the ascending and transverse colon on\n1916-10-17 and represented with lower abdominal pain and\nbright red blood per rectum and anemia.\n\n1. Gastrointestinal bleed and blood loss anemia: Most\nlikely secondary to complication from recent colonoscopy and\npolypectomy. Patient had a negative EGD and then had a\ncolonoscopy which did show a bleeding vessel at the site of\nprevious polypectomy. This was clipped with two clips with\ngood control of the bleeding.\n\nPatient's hematocrit remained stable.", " He did receive a total\nof four units of packed red blood cells on this admission.\nAfter colonoscopy with clipping, no further melena or bright\nred blood per rectum was noted. Patient's hematocrits were\nfollowed serially and remained in the 26, 27 range and\neventually was transfused the fourth unit day prior to\ndischarge, but his hematocrit remained 29 and 31 on day of\ndischarge.\n\nOtherwise, symptomatically much improved and slowly advanced\nhis diet from liquids to soft mechanical diet, which he\ntolerated well with no further episodes of melena or bright\nred blood per rectum.\n\nPatient was initially started on Protonix 40 intravenously\nb.i.d. as his EGD was negative. Eventually was switched back\nto his 40 p.o. q. day regimen which he continued even as an\noutpatient for his gastroesophageal reflux disease.", "\n\nPatient's blood pressure remained stable after transfused\nwith blood. He also had a negative tagged red cell scan and\nnegative EGD. Eventually, after colonoscopy, had a small\nbowel follow through to rule out any source of blood loss as\nin his previous admission. This was also negative. Patient\ncould not have a Meckel scan during this stay because of\nbarium and can have it at least one week after barium\ningestion.\n\nBecause of the recent colonoscopy and the bleed, patient's\nLovenox dose and Coumadin dose were continued to be held.\nPatient's anticoagulation, including aspirin, Coumadin, and\nLovenox, were to be held for at least one week and can be\nrestarted on 1983-7-13 per GI.\n\n2. Chronic obstructive pulmonary disease: Patient's\nrespiratory status was stable and at baseline. Continued his\nhome regimen of Advair, Combivent, and Theophylline and\np.", 'r.n. nebulizers as needed, although his pulmonary exam\nremained stable and he was at his baseline home oxygen of 2\nliters and will be discharged on the same regimen.\n\n3. Status post lung cancer, status post pneumonectomy: Was\nstable with tracheostomy. Continued b.i.d. suctioning with\ngood results. Continue the Scopolamine patch for\nantiemetics.\n\n4. Prostate cancer: He does have recently rising PSA most\nrecently 8.9 in 02/1987. Patient was eventually able to have\na bone scan during the course of his stay which was negative\nfor metastases, only positive for previous post surgical bony\nchanges. Patient will be followed up with urologist, Dr.\nPegram, in terms of his prostate cancer follow up.\n\n5. Troponin leak: This was attributed to demand ischemia.\nHe had negative EKG changes, and he had a catheterization in\n10-1953 which revealed 30% mid lesion but no flow-limiting\ndisease.', " His enzymes remained stable through the course of\nhis stay and was attributed to his anemia. Patient's aspirin\nwas held because of the bleeding and can be restarted\n1983-7-13. Patient was continued on his statin.\n\n6. Atrial fibrillation: Patient was in sinus rhythm\nthroughout the course of his stay and was stable on\nAmiodarone. Again, his Coumadin was held for concerns with\nbleeding.\n\n7. Deep venous thrombosis/pulmonary embolus: He has a\nhistory of 994 Gonzalez Fall Suite 288\nStevenmouth, CO 22187 filter and right upper and right lower\nextremity deep venous thrombosis. His hypercoagulable state\nis likely attributed to the prostate cancer, but otherwise\nhis Coumadin was held for the bleeding reasons, and patient\ndid have increasing amounts of swelling of his right upper\nand right lower extremity.", '\n\nPatient was taken off his Lasix dose through the course of\nthe stay because of concern for hemodynamic instability. Was\ngiven p.r.n. doses of Lasix throughout the stay and continued\nto elevate his extremities with good results of them.\n\nPatient did have both upper and lower extremity ultrasounds\ndone to rule out new deep venous thrombosis. The right lower\nextremity ultrasound was negative. The right upper extremity\ndid show the old known thrombus in the right basilic vein but\nno progression or change from previous studies, and this\notherwise was stable throughout the course of his stay.\n\n8. Diabetes: He has fairly good control with hemoglobin A1C\nmost recently at 6.0. He was continued on his home regimen\nof Glyburide once he was taking p.o. and covered with sliding\nscale as needed.\n\nFor his neuropathy patient was continued on his Tylenol\nNumber 3 and was discharged with a prescription for Morphine\nsulfate per his request, although he was not continued on\nthis during the course of his stay.', '\n\n9. Gout: This was stable throughout the course of his\nadmission, but patient was continued on his home dose of\nColchicine.\n\nDISCHARGE DIAGNOSES:\n1. Lower gastrointestinal bleed.\n2. Blood loss anemia.\n3. History of deep venous thrombosis.\n4. Chronic obstructive pulmonary disease.\n5. Status post lung cancer.\n6. Status post prostate cancer.\n7. Atrial fibrillation.\n8. Diabetes mellitus.\n9. Gout.\n10. Hyperlipidemia.\n11. Neuropathy.\n12. Gastroesophageal reflux disease.\n\nDISCHARGE MEDICATIONS:\n1. Paxil 20 mg p.o. q. day.\n2. Multivitamin, one, p.o. q. day.\n3. Tylenol Number 3, one to two, p.o. q. 4 to 6 hours.\n4. Combivent, one to two puffs inhaled, q. 6 hours p.r.n.\n5. Theophylline 200 mg p.o. q. day.\n6. Amiodarone 200 mg p.o. q. day.\n7. Gabapentin 100 mg p.o. q. day.\n8. Ferrous Sulfate 325 mg p.', 'o. t.i.d.\n9. Vitamin B12, 250 mcg, p.o. q.d.\n10. Atorvastatin 10 mg p.o. q. day.\n11. Scopolamine patch q. 72 hours.\n12. Advair 500/50 mcg dose, one diskus, b.i.d.\n13. Colchicine 0.6 mg p.o. t.i.d.\n14. Vioxx 12.5 mg p.o. q. day.\n15. Ambien 15 mg p.o. q. h.s.\n16. Pantoprazole 40 mg p.o. q. day.\n17. Morphine sulfate 10 mg/5 ml p.o. q. 4 hours p.r.n. pain.\n18. Lasix 80 mg p.o. b.i.d.\n\nDISCHARGE INSTRUCTIONS:\n1. Patient is to follow up with his primary care physician,\nNgo. Lyna, on 1916-10-14.\n2. Patient is to follow up with his urologist, Dr. Pegram,\non 1958-11-30.\n3. Patient is to follow up with his Sanchez, Jacobs and Kennedy Clinic clinic to have his\nINR checked after restarting Coumadin and Lovenox.\n\nDISCHARGE CONDITION: Good; patient ambulating with 2 liters\noxygen requirement at home; patient with stable hematocrit of\n31; no further events of bright bleeding per rectum; pain\nwell controlled.', '\n\nDISPOSITION: Discharged to home.\n\n\n\n\n Alexis Lees, M.D. 03869207\n\nDictated By:Celeste Salgado\n\nMEDQUIST36\n\nD: 2009-10-20 16:52\nT: 1983-8-17 13:25\nJOB#: Payne and Sons-1989-488095\n']
19	15472	115683.0	2178-06-03	Discharge summary	Report	Admission Date: [2178-5-28] Discharge Date: [2178-6-3] Date of Birth: [2114-2-8] Sex: M Service: MED Allergies: Doxepin / Levofloxacin / Oxycontin Attending:[First Name3 (LF) 242] Chief Complaint: SOB x 2d Major Surgical or Invasive Procedure: none History of Present Illness: 64 yo M w/ PMHx as below presented to ED on [5-29] w/ hypercarbic respiratory failure (initial ABG [5-28]: 7/29/92/~200 on NRB; baseline pco2 ~50-60); - CXR (? LLL opacity on [5-28] not well visualized on [5-29] CXR) in ED where he received 1 dose ctx and azithro. Likely [12-29] tracheobronchitis. Placed on AC 400/20/5/0.6--> improved ventilation (PC02 70). Hemodynamically stable throughout. Transferred to MICU for further management. Pt extubated on [5-29]. Past Medical History: Lung carcinoma, status post right pneumonectomy. Prostate cancer, status post resection. History of perioperative PE, on anticoagulation. Atrial fibrillation, on anticoagulation. Hypertension. Diabetes, type II. Obstructive sleep apnea. Hypercholesterolemia. B12 deficiency. Cataracts. Status post trach placement Social History: He lives with his wife. [Name (NI) ] has a 3-pack-per- day tobacco history but quit in [2174] and an overall 160-pack- per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: In general, the patient was lying in bed, in no acute distress. His pupils were equal, round, and reactive to light. He had moist mucous membranes. His neck was supple. He had no JVD. He had no breath sounds on chest exam on the right. Positive rhonchi on the left with some upper airway noise that was transmitted downward. Cardiac exam showed regular, rate, and rhythm nl S1 S2 no m/r/g. His abdomen was soft and nontender. Bowel sounds were present. Extremities were warm without edema. Neurological, he was alert and oriented x 3. Pertinent Results: [2178-5-28] 06:20PM PLT SMR-NORMAL PLT COUNT-330 [2178-5-28] 06:20PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2178-5-28] 06:20PM NEUTS-76* BANDS-22* LYMPHS-1* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2178-5-28] 06:20PM WBC-33.7# RBC-4.55 HGB-13.9* HCT-41.8 MCV-92 MCH-30.6 MCHC-33.3 RDW-14.0 [2178-5-28] 06:20PM GLUCOSE-137* UREA N-21* CREAT-1.2 SODIUM-139 POTASSIUM-6.0* CHLORIDE-90* TOTAL CO2-39* ANION GAP-16 [2178-5-28] 06:29PM LACTATE-2.7* [2178-5-28] 08:01PM K+-3.9 [2178-5-28] 08:01PM TYPE-ART PO2-224* PCO2-92* PH-7.29* TOTAL CO2-46* BASE XS-13 [2178-5-28] 10:00PM URINE MUCOUS-FEW [2178-5-28] 10:00PM URINE HYALINE-0-2 [2178-5-28] 10:00PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [2178-5-28] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2178-5-28] 10:00PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.015 [2178-5-28] 10:00PM URINE GR HOLD-HOLD [2178-5-28] 10:00PM URINE HOURS-RANDOM Brief Hospital Course: The patient was intubated in the ER with hypercarbic respiratory. He was given antibiotics, steroids, and bronchodilators, transferred to the MICU A mini-trach was placed on [5-28]. Pt was extubated on in the MICU [5-29] as his respiratory status stabilized. He was eventually transferred to the floor where he continued to improve. He received physical therapy until he was satisfacorily ambulatory and was d/c'd to home. Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) [Month/Day (2) ]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO TID (3 times a day). 3. Senna 8.6 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day) as needed. 4. Amiodarone HCl 200 mg Tablet [Month/Day (2) ]: One (1) Tablet PO QD (once a day). 5. Atorvastatin Calcium 10 mg Tablet [Month/Day (2) ]: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Gabapentin 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO HS (at bedtime). 7. Multivitamin Capsule [Month/Day (2) ]: One (1) Cap PO QD (once a day). 8. Cyanocobalamin 100 mcg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 9. Ferrous Sulfate 325 (65) mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 10. Paroxetine HCl 20 mg Tablet [Month/Day (2) ]: One (1) Tablet PO QD (once a day). 11. Bupropion HCl 150 mg Tablet Sustained Release [Month/Day (2) ]: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 12. Doxycycline Hyclate 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO Q12H (every 12 hours) for 7 days. Disp:14 Capsule(s) Refills:0 13. Theophylline 400 mg Tablet Sustained Release [Month/Day (2) ]: 0.5 Tablet Sustained Release PO QD (once a day). 14. Glyburide 5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO QD (once a day). 15. Furosemide 80 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 16. Lactulose 10 g/15 mL Syrup [Month/Day (2) ]: Thirty (30) ML PO TID (3 times a day). 17. Advair Diskus 500-50 mcg/DOSE Disk with Device [Month/Day (2) ]: One (1) Inhalation twice a day. 18. Coumadin 3 mg Tablet [Month/Day (2) ]: One (1) Tablet PO q Mon, [Initials (NamePattern4) ] [Last Name (NamePattern4) ]. 19. Coumadin 5 mg Tablet [Last Name (NamePattern4) ]: One (1) Tablet PO on Tues, Wed, Fri, Sat, and Sun. 20. Prednisone 10 mg Tablet [Last Name (NamePattern4) ]: One (1) Tablet PO taper: Please take 4 tabs x 4 days, 2 tabs x 4 days, and 1 tab x 4 days. Disp:30 Tablet(s) Refills:0 21. Lovenox 80 mg/0.8 mL Syringe [Last Name (NamePattern4) ]: One (1) Subcutaneous twice a day for 10 days. Disp:10 syringes Refills:0 22. Percocet 5-325 mg Tablet [Last Name (NamePattern4) ]: One (1) Tablet PO every [3-3] hours as needed for fever or pain. Disp:80 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 269] Hospice [Location (un) 270] East Discharge Diagnosis: Hypercarbic respiratory failure COPD Tracheobronchitis DM II A fib OSA Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1.5 L/d Please continue with [Hospital1 ] Lovenox until you have your INR re-checked by [Hospital3 271]. Followup Instructions: Provider: [Name Initial (NameIs) 272]/UROLOGY UROLOGY CC3 (NHB) Where: [Hospital 273] SURGICAL SPECIALTIES Phone:[Telephone/Fax (1) 274] Date/Time:[2178-7-1] 11:30 Provider: [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 276], M.D. Where: [Hospital6 29] SURGICAL SPECIALTIES Phone:[Telephone/Fax (1) 277] Date/Time:[2178-7-1] 10:30 Provider: [First Name8 (NamePattern2) 278] [Last Name (NamePattern1) 279], [Name12 (NameIs) 280] Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2178-6-19] 1:20	Admission Date: <Date>1962-5-15</Date> Discharge Date: <Date>1945-12-9</Date> Date of Birth: <Date>1923-10-20</Date> Sex: M Service: MED Allergies: Doxepin / Levofloxacin / Oxycontin Attending:<Name>Carol</Name> Chief Complaint: SOB x 2d Major Surgical or Invasive Procedure: none History of Present Illness: 64 yo M w/ PMHx as below presented to ED on <Date>4-30</Date> w/ hypercarbic respiratory failure (initial ABG <Date>10-3</Date>: 7/29/92/~200 on NRB; baseline pco2 ~50-60); - CXR (? LLL opacity on <Date>10-3</Date> not well visualized on <Date>4-30</Date> CXR) in ED where he received 1 dose ctx and azithro. Likely <Date>9-6</Date> tracheobronchitis. Placed on AC 400/20/5/0.6--> improved ventilation (PC02 70). Hemodynamically stable throughout. Transferred to MICU for further management. Pt extubated on <Date>4-30</Date>. Past Medical History: Lung carcinoma, status post right pneumonectomy. Prostate cancer, status post resection. History of perioperative PE, on anticoagulation. Atrial fibrillation, on anticoagulation. Hypertension. Diabetes, type II. Obstructive sleep apnea. Hypercholesterolemia. B12 deficiency. Cataracts. Status post trach placement Social History: He lives with his wife. <Name>Rebecca Medrano</Name> has a 3-pack-per- day tobacco history but quit in <Year>1986</Year> and an overall 160-pack- per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: In general, the patient was lying in bed, in no acute distress. His pupils were equal, round, and reactive to light. He had moist mucous membranes. His neck was supple. He had no JVD. He had no breath sounds on chest exam on the right. Positive rhonchi on the left with some upper airway noise that was transmitted downward. Cardiac exam showed regular, rate, and rhythm nl S1 S2 no m/r/g. His abdomen was soft and nontender. Bowel sounds were present. Extremities were warm without edema. Neurological, he was alert and oriented x 3. Pertinent Results: <Date>1962-5-15</Date> 06:20PM PLT SMR-NORMAL PLT COUNT-330 <Date>1962-5-15</Date> 06:20PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL <Date>1962-5-15</Date> 06:20PM NEUTS-76* BANDS-22* LYMPHS-1* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 <Date>1962-5-15</Date> 06:20PM WBC-33.7# RBC-4.55 HGB-13.9* HCT-41.8 MCV-92 MCH-30.6 MCHC-33.3 RDW-14.0 <Date>1962-5-15</Date> 06:20PM GLUCOSE-137* UREA N-21* CREAT-1.2 SODIUM-139 POTASSIUM-6.0* CHLORIDE-90* TOTAL CO2-39* ANION GAP-16 <Date>1962-5-15</Date> 06:29PM LACTATE-2.7* <Date>1962-5-15</Date> 08:01PM K+-3.9 <Date>1962-5-15</Date> 08:01PM TYPE-ART PO2-224* PCO2-92* PH-7.29* TOTAL CO2-46* BASE XS-13 <Date>1962-5-15</Date> 10:00PM URINE MUCOUS-FEW <Date>1962-5-15</Date> 10:00PM URINE HYALINE-0-2 <Date>1962-5-15</Date> 10:00PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 <Date>1962-5-15</Date> 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG <Date>1962-5-15</Date> 10:00PM URINE COLOR-Straw APPEAR-Clear SP <Name>Abdullah</Name>-1.015 <Date>1962-5-15</Date> 10:00PM URINE GR HOLD-HOLD <Date>1962-5-15</Date> 10:00PM URINE HOURS-RANDOM Brief Hospital Course: The patient was intubated in the ER with hypercarbic respiratory. He was given antibiotics, steroids, and bronchodilators, transferred to the MICU A mini-trach was placed on <Date>10-3</Date>. Pt was extubated on in the MICU <Date>4-30</Date> as his respiratory status stabilized. He was eventually transferred to the floor where he continued to improve. He received physical therapy until he was satisfacorily ambulatory and was d/c'd to home. Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) <Month>December</Month>: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule <Month>December</Month>: One (1) Capsule PO TID (3 times a day). 3. Senna 8.6 mg Tablet <Month>December</Month>: One (1) Tablet PO BID (2 times a day) as needed. 4. Amiodarone HCl 200 mg Tablet <Month>December</Month>: One (1) Tablet PO QD (once a day). 5. Atorvastatin Calcium 10 mg Tablet <Month>December</Month>: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Gabapentin 100 mg Capsule <Month>December</Month>: One (1) Capsule PO HS (at bedtime). 7. Multivitamin Capsule <Month>December</Month>: One (1) Cap PO QD (once a day). 8. Cyanocobalamin 100 mcg Tablet <Month>December</Month>: One (1) Tablet PO BID (2 times a day). 9. Ferrous Sulfate 325 (65) mg Tablet <Month>December</Month>: One (1) Tablet PO BID (2 times a day). 10. Paroxetine HCl 20 mg Tablet <Month>December</Month>: One (1) Tablet PO QD (once a day). 11. Bupropion HCl 150 mg Tablet Sustained Release <Month>December</Month>: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 12. Doxycycline Hyclate 100 mg Capsule <Month>December</Month>: One (1) Capsule PO Q12H (every 12 hours) for 7 days. Disp:14 Capsule(s) Refills:0 13. Theophylline 400 mg Tablet Sustained Release <Month>December</Month>: 0.5 Tablet Sustained Release PO QD (once a day). 14. Glyburide 5 mg Tablet <Month>December</Month>: One (1) Tablet PO QD (once a day). 15. Furosemide 80 mg Tablet <Month>December</Month>: One (1) Tablet PO BID (2 times a day). 16. Lactulose 10 g/15 mL Syrup <Month>December</Month>: Thirty (30) ML PO TID (3 times a day). 17. Advair Diskus 500-50 mcg/DOSE Disk with Device <Month>December</Month>: One (1) Inhalation twice a day. 18. Coumadin 3 mg Tablet <Month>December</Month>: One (1) Tablet PO q Mon, <Initial>HL</Initial> <Name>Kiel</Name>. 19. Coumadin 5 mg Tablet <Name>Kiel</Name>: One (1) Tablet PO on Tues, Wed, Fri, Sat, and Sun. 20. Prednisone 10 mg Tablet <Name>Kiel</Name>: One (1) Tablet PO taper: Please take 4 tabs x 4 days, 2 tabs x 4 days, and 1 tab x 4 days. Disp:30 Tablet(s) Refills:0 21. Lovenox 80 mg/0.8 mL Syringe <Name>Kiel</Name>: One (1) Subcutaneous twice a day for 10 days. Disp:10 syringes Refills:0 22. Percocet 5-325 mg Tablet <Name>Kiel</Name>: One (1) Tablet PO every <Date>8-4</Date> hours as needed for fever or pain. Disp:80 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: <Hospital>Payne, Morales and Johnson Medical Center</Hospital> Hospice <Location>356 Cole Branch Apt. 951 Amberchester, ME 19911</Location> East Discharge Diagnosis: Hypercarbic respiratory failure COPD Tracheobronchitis DM II A fib OSA Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, <Name>Latrice Amaro</Name> MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1.5 L/d Please continue with <Hospital>Roberts-Torres Hospital</Hospital> Lovenox until you have your INR re-checked by <Hospital>Gomez, Clark and Jackson Hospital</Hospital>. Followup Instructions: Provider: <Name>Jessie Pegram</Name>/UROLOGY UROLOGY CC3 (NHB) Where: <Hospital>Smith, Bradshaw and Benson Hospital</Hospital> SURGICAL SPECIALTIES Phone:<Telephone>264-497-6043</Telephone> Date/Time:<Date>1990-6-28</Date> 11:30 Provider: <Name>Austin</Name> <Name>Caro</Name>, M.D. Where: <Hospital>Larson LLC Health System</Hospital> SURGICAL SPECIALTIES Phone:<Telephone>371-851-2098</Telephone> Date/Time:<Date>1990-6-28</Date> 10:30 Provider: <Name>Isabella</Name> <Name>Demong</Name>, <Name>Jackson Demong</Name> Where: <Hospital>Larson LLC Health System</Hospital> <Hospital>Hamilton-Johnson Clinic</Hospital> Phone:<Telephone>437-253-3253</Telephone> Date/Time:<Date>1968-3-12</Date> 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Date: 1962-5-15 Discharge Date: 1945-12-9 Date of Birth: 1923-10-20 Sex: M Service: MED Allergies: Doxepin / Levofloxacin / Oxycontin Attending:Carol Chief Complaint: SOB x 2d Major Surgical or Invasive Procedure: none History of Present Illness: 64 yo M w/ PMHx as below presented to ED on 4-30 w/ hypercarbic respiratory failure (initial ABG 10-3: 7/29/92/~200 on NRB; baseline pco2 ~50-60); - CXR (? LLL opacity on 10-3 not well visualized on 4-30 CXR) in ED where he received 1 dose ctx and azithro. Likely 9-6 tracheobronchitis. Placed on AC 400/20/5/0.6--> improved ventilation (PC02 70). Hemodynamically stable throughout. Transferred to MICU for further management. Pt extubated on 4-30. Past Medical History: Lung carcinoma, status post right pneumonectomy. Prostate cancer, status post resection. History of perioperative PE, on anticoagulation. Atrial fibrillation, on anticoagulation. Hypertension. Diabetes, type II. Obstructive sleep apnea. Hypercholesterolemia. B12 deficiency. Cataracts. Status post trach placement Social History: He lives with his wife. Rebecca Medrano has a 3-pack-per- day tobacco history but quit in 1986 and an overall 160-pack- per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: In general, the patient was lying in bed, in no acute distress. His pupils were equal, round, and reactive to light. He had moist mucous membranes. His neck was supple. He had no JVD. He had no breath sounds on chest exam on the right. Positive rhonchi on the left with some upper airway noise that was transmitted downward. Cardiac exam showed regular, rate, and rhythm nl S1 S2 no m/r/g. His abdomen was soft and nontender. Bowel sounds were present. Extremities were warm without edema. Neurological, he was alert and oriented x 3. Pertinent Results: 1962-5-15 06:20PM PLT SMR-NORMAL PLT COUNT-330 1962-5-15 06:20PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL 1962-5-15 06:20PM NEUTS-76* BANDS-22* LYMPHS-1* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 1962-5-15 06:20PM WBC-33.7# RBC-4.55 HGB-13.9* HCT-41.8 MCV-92 MCH-30.6 MCHC-33.3 RDW-14.0 1962-5-15 06:20PM GLUCOSE-137* UREA N-21* CREAT-1.2 SODIUM-139 POTASSIUM-6.0* CHLORIDE-90* TOTAL CO2-39* ANION GAP-16 1962-5-15 06:29PM LACTATE-2.7* 1962-5-15 08:01PM K+-3.9 1962-5-15 08:01PM TYPE-ART PO2-224* PCO2-92* PH-7.29* TOTAL CO2-46* BASE XS-13 1962-5-15 10:00PM URINE MUCOUS-FEW 1962-5-15 10:00PM URINE HYALINE-0-2 1962-5-15 10:00PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 1962-5-15 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG 1962-5-15 10:00PM URINE COLOR-Straw APPEAR-Clear SP Abdullah-1.015 1962-5-15 10:00PM URINE GR HOLD-HOLD 1962-5-15 10:00PM URINE HOURS-RANDOM Brief Hospital Course: The patient was intubated in the ER with hypercarbic respiratory. He was given antibiotics, steroids, and bronchodilators, transferred to the MICU A mini-trach was placed on 10-3. Pt was extubated on in the MICU 4-30 as his respiratory status stabilized. He was eventually transferred to the floor where he continued to improve. He received physical therapy until he was satisfacorily ambulatory and was d/c'd to home. Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) December: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule December: One (1) Capsule PO TID (3 times a day). 3. Senna 8.6 mg Tablet December: One (1) Tablet PO BID (2 times a day) as needed. 4. Amiodarone HCl 200 mg Tablet December: One (1) Tablet PO QD (once a day). 5. Atorvastatin Calcium 10 mg Tablet December: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Gabapentin 100 mg Capsule December: One (1) Capsule PO HS (at bedtime). 7. Multivitamin Capsule December: One (1) Cap PO QD (once a day). 8. Cyanocobalamin 100 mcg Tablet December: One (1) Tablet PO BID (2 times a day). 9. Ferrous Sulfate 325 (65) mg Tablet December: One (1) Tablet PO BID (2 times a day). 10. Paroxetine HCl 20 mg Tablet December: One (1) Tablet PO QD (once a day). 11. Bupropion HCl 150 mg Tablet Sustained Release December: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 12. Doxycycline Hyclate 100 mg Capsule December: One (1) Capsule PO Q12H (every 12 hours) for 7 days. Disp:14 Capsule(s) Refills:0 13. Theophylline 400 mg Tablet Sustained Release December: 0.5 Tablet Sustained Release PO QD (once a day). 14. Glyburide 5 mg Tablet December: One (1) Tablet PO QD (once a day). 15. Furosemide 80 mg Tablet December: One (1) Tablet PO BID (2 times a day). 16. Lactulose 10 g/15 mL Syrup December: Thirty (30) ML PO TID (3 times a day). 17. Advair Diskus 500-50 mcg/DOSE Disk with Device December: One (1) Inhalation twice a day. 18. Coumadin 3 mg Tablet December: One (1) Tablet PO q Mon, HL Kiel. 19. Coumadin 5 mg Tablet Kiel: One (1) Tablet PO on Tues, Wed, Fri, Sat, and Sun. 20. Prednisone 10 mg Tablet Kiel: One (1) Tablet PO taper: Please take 4 tabs x 4 days, 2 tabs x 4 days, and 1 tab x 4 days. Disp:30 Tablet(s) Refills:0 21. Lovenox 80 mg/0.8 mL Syringe Kiel: One (1) Subcutaneous twice a day for 10 days. Disp:10 syringes Refills:0 22. Percocet 5-325 mg Tablet Kiel: One (1) Tablet PO every 8-4 hours as needed for fever or pain. Disp:80 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Payne, Morales and Johnson Medical Center Hospice 356 Cole Branch Apt. 951 Amberchester, ME 19911 East Discharge Diagnosis: Hypercarbic respiratory failure COPD Tracheobronchitis DM II A fib OSA Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, Latrice Amaro MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1.5 L/d Please continue with Roberts-Torres Hospital Lovenox until you have your INR re-checked by Gomez, Clark and Jackson Hospital. Followup Instructions: Provider: Jessie Pegram/UROLOGY UROLOGY CC3 (NHB) Where: Smith, Bradshaw and Benson Hospital SURGICAL SPECIALTIES Phone:264-497-6043 Date/Time:1990-6-28 11:30 Provider: Austin Caro, M.D. Where: Larson LLC Health System SURGICAL SPECIALTIES Phone:371-851-2098 Date/Time:1990-6-28 10:30 Provider: Isabella Demong, Jackson Demong Where: Larson LLC Health System Hamilton-Johnson Clinic Phone:437-253-3253 Date/Time:1968-3-12 1:20	['Admission Date: 1962-5-15 Discharge Date: 1945-12-9\n\nDate of Birth: 1923-10-20 Sex: M\n\nService: MED\n\nAllergies:\nDoxepin / Levofloxacin / Oxycontin\n\nAttending:Carol\nChief Complaint:\nSOB x 2d\n\nMajor Surgical or Invasive Procedure:\nnone\n\n\nHistory of Present Illness:\n64 yo M w/ PMHx as below presented to ED on 4-30 w/ hypercarbic\nrespiratory failure (initial ABG 10-3: 7/29/92/~200 on NRB;\nbaseline pco2 ~50-60); - CXR (? LLL opacity on 10-3 not well\nvisualized on 4-30 CXR) in ED where he received 1 dose ctx and\nazithro. Likely 9-6 tracheobronchitis. Placed on AC\n400/20/5/0.6--> improved ventilation (PC02 70). Hemodynamically\nstable throughout. Transferred to MICU for further management.\nPt extubated on 4-30.\n\nPast Medical History:\nLung carcinoma, status post right pneumonectomy.', '\nProstate cancer, status post resection.\nHistory of perioperative PE, on anticoagulation.\nAtrial fibrillation, on anticoagulation.\nHypertension.\nDiabetes, type II.\nObstructive sleep apnea.\nHypercholesterolemia.\nB12 deficiency.\nCataracts.\nStatus post trach placement\n\nSocial History:\nHe lives with his wife. Rebecca Medrano has a 3-pack-per-\nday tobacco history but quit in 1986 and an overall 160-pack-\nper-year history. No recent history of alcohol use.\n\n\nFamily History:\nMother with coronary artery disease.\n\n\nPhysical Exam:\nIn general, the patient was lying in bed, in no acute distress.\nHis\npupils were equal, round, and reactive to light. He had\nmoist mucous membranes. His neck was supple. He had no JVD.\nHe had no breath sounds on chest exam on the right. Positive\nrhonchi on the left with some upper airway noise that was\ntransmitted downward.', ' Cardiac exam showed regular, rate, and\nrhythm nl S1 S2 no m/r/g. His abdomen was soft and nontender.\nBowel sounds were present. Extremities were warm without\nedema. Neurological, he was alert and oriented x 3.\n\n\nPertinent Results:\n1962-5-15 06:20PM PLT SMR-NORMAL PLT COUNT-330\n1962-5-15 06:20PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL\nMACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL\n1962-5-15 06:20PM NEUTS-76* BANDS-22* LYMPHS-1* MONOS-1* EOS-0\nBASOS-0 ATYPS-0 METAS-0 MYELOS-0\n1962-5-15 06:20PM WBC-33.7# RBC-4.55 HGB-13.9* HCT-41.8\nMCV-92 MCH-30.6 MCHC-33.3 RDW-14.0\n1962-5-15 06:20PM GLUCOSE-137* UREA N-21* CREAT-1.2 SODIUM-139\nPOTASSIUM-6.0* CHLORIDE-90* TOTAL CO2-39* ANION GAP-16\n1962-5-15 06:29PM LACTATE-2.7\n1962-5-15 08:01PM K+-3.9\n1962-5-15 08:01PM TYPE-ART PO2-224 PCO2-92* PH-7.', "29* TOTAL\nCO2-46* BASE XS-13\n1962-5-15 10:00PM URINE MUCOUS-FEW\n1962-5-15 10:00PM URINE HYALINE-0-2\n1962-5-15 10:00PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE\nEPI-0\n1962-5-15 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0\nLEUK-NEG\n1962-5-15 10:00PM URINE COLOR-Straw APPEAR-Clear SP Abdullah-1.015\n1962-5-15 10:00PM URINE GR HOLD-HOLD\n1962-5-15 10:00PM URINE HOURS-RANDOM\n\nBrief Hospital Course:\nThe patient was intubated in the ER with hypercarbic\nrespiratory. He was given antibiotics, steroids, and\nbronchodilators, transferred to the MICU A mini-trach was\nplaced on 10-3. Pt was extubated on in the MICU 4-30 as his\nrespiratory status stabilized. He was eventually transferred to\nthe floor where he continued to improve. He received physical\ntherapy until he was satisfacorily ambulatory and was d/c'd to\nhome.", '\n\nDischarge Medications:\n1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) December:\nOne (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).\n\n2. Docusate Sodium 100 mg Capsule December: One (1) Capsule PO TID (3\ntimes a day).\n3. Senna 8.6 mg Tablet December: One (1) Tablet PO BID (2 times a\nday) as needed.\n4. Amiodarone HCl 200 mg Tablet December: One (1) Tablet PO QD (once\na day).\n5. Atorvastatin Calcium 10 mg Tablet December: One (1) Tablet PO QHS\n(once a day (at bedtime)).\n6. Gabapentin 100 mg Capsule December: One (1) Capsule PO HS (at\nbedtime).\n7. Multivitamin Capsule December: One (1) Cap PO QD (once a day).\n\n8. Cyanocobalamin 100 mcg Tablet December: One (1) Tablet PO BID (2\ntimes a day).\n9. Ferrous Sulfate 325 (65) mg Tablet December: One (1) Tablet PO BID\n(2 times a day).', '\n10. Paroxetine HCl 20 mg Tablet December: One (1) Tablet PO QD (once\na day).\n11. Bupropion HCl 150 mg Tablet Sustained Release December: Two (2)\nTablet Sustained Release PO QAM (once a day (in the morning)).\n12. Doxycycline Hyclate 100 mg Capsule December: One (1) Capsule PO\nQ12H (every 12 hours) for 7 days.\nDisp:14 Capsule(s) Refills:0\n13. Theophylline 400 mg Tablet Sustained Release December: 0.5 Tablet\nSustained Release PO QD (once a day).\n14. Glyburide 5 mg Tablet December: One (1) Tablet PO QD (once a\nday).\n15. Furosemide 80 mg Tablet December: One (1) Tablet PO BID (2 times\na day).\n16. Lactulose 10 g/15 mL Syrup December: Thirty (30) ML PO TID (3\ntimes a day).\n17. Advair Diskus 500-50 mcg/DOSE Disk with Device December: One (1)\nInhalation twice a day.\n18. Coumadin 3 mg Tablet December: One (1) Tablet PO q Mon, HL Kiel.', '\n19. Coumadin 5 mg Tablet Kiel: One (1) Tablet PO on Tues, Wed,\nFri, Sat, and Sun.\n20. Prednisone 10 mg Tablet Kiel: One (1) Tablet PO taper: Please\ntake 4 tabs x 4 days, 2 tabs x 4 days, and 1 tab x 4 days.\nDisp:30 Tablet(s) Refills:0\n21. Lovenox 80 mg/0.8 mL Syringe Kiel: One (1) Subcutaneous\ntwice a day for 10 days.\nDisp:10 syringes Refills:0\n22. Percocet 5-325 mg Tablet Kiel: One (1) Tablet PO every 8-4\nhours as needed for fever or pain.\nDisp:80 Tablet(s) Refills:0\n\n\nDischarge Disposition:\nHome With Service\n\nFacility:\nPayne, Morales and Johnson Medical Center Hospice 356 Cole Branch Apt. 951\nAmberchester, ME 19911 East\n\nDischarge Diagnosis:\nHypercarbic respiratory failure\nCOPD\nTracheobronchitis\nDM II\nA fib\nOSA\n\n\nDischarge Condition:\nstable\n\nDischarge Instructions:\nWeigh yourself every morning, Latrice Amaro MD if weight > 3 lbs.', '\nAdhere to 2 gm sodium diet\nFluid Restriction:1.5 L/d\nPlease continue with Roberts-Torres Hospital Lovenox until you have your INR\nre-checked by Gomez, Clark and Jackson Hospital.\n\nFollowup Instructions:\nProvider: Jessie Pegram/UROLOGY UROLOGY CC3 (NHB) Where: Smith, Bradshaw and Benson Hospital SURGICAL SPECIALTIES Phone:264-497-6043\nDate/Time:1990-6-28 11:30\nProvider: Austin Caro, M.D. Where: Larson LLC Health System\nSURGICAL SPECIALTIES Phone:371-851-2098 Date/Time:1990-6-28 10:30\nProvider: Isabella Demong, Jackson Demong Where: Larson LLC Health System\nHamilton-Johnson Clinic Phone:437-253-3253 Date/Time:1968-3-12 1:20\n\n\n\n']
20	15472	148372.0	2178-12-02	Discharge summary	Report	Admission Date: [2178-11-15] Discharge Date: [2178-12-2] Date of Birth: [2114-2-8] Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:[First Name3 (LF) 281] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Tracheostomy Placement [First Name3 (LF) 282] tube placement History of Present Illness: 64 yo man with h/o lung CA s/p R pneumonectomy, COPD, mini-trach to manage secretions, on home O2 who presents c/o 4 days progressively worsening SOB. Need to increase home O2 from 2 to 3 liters. In ED ABG 7.39/62/163 on 2L NC (which is basically his baseline). Given combivent, solumedrol, clinda, and azithro for presumed COPD exacerbation. Initially admitted to MICU for close monitoring, started on Azithromycin and CTX, switched to Ceftaz given past history of Pseudomonas. Transferred to floor on [11-17], stable and at baseline. On floor, patient had repeated episodes of desaturation, with tachypnea. Became SOB on [11-18] in AM, given Ativan 1, Morphine 2 and Valium 5, with some initial improvement. Then found to be lethargic, and ABG with PCO2 102, pH 7.22. Brought to the ICU for further management. Past Medical History: Lung carcinoma, status post right pneumonectomy. Prostate cancer, status post resection. History of perioperative PE, on anticoagulation. Atrial fibrillation, on anticoagulation. Hypertension. Diabetes, type II. Obstructive sleep apnea. Hypercholesterolemia. B12 deficiency. Cataracts Social History: He lives with his wife. [Name (NI) ] has a 3-pack-per-day tobacco history but quit in [2174] and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: Upon Discharge: Gen: Alert, NAD, cooperative, well appearing HEENT: PERRLA, [Year (4 digits) ] MMM/clear, trach in place CV: irreg rhythym, reg rate, no m/r/JVD Pulm: coarse BS on the left, transmitted BS on R Ab: s/nd/[Last Name (LF) ], [First Name3 (LF) 282] in place Ext: no LE edema, 2+DPPBL Pertinent Results: [2178-11-15] 11:21PM TYPE-ART PO2-172* PCO2-59* PH-7.34* TOTAL CO2-33* BASE XS-4 [2178-11-15] 09:04PM TYPE-ART PO2-163* PCO2-62* PH-7.39 TOTAL CO2-39* BASE XS-10 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2178-12-1] 04:00AM 9.3 2.83* 8.4* 26.9* 95 29.7 31.2 14.4 284 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2178-12-2] 04:11AM 17.6* 2.0 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2178-12-1] 04:00AM 133* 20 0.8 147* 5.0 107 36* 9 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili [2178-12-2] 04:11AM 46* 20 219 128* 18 0.4 OTHER ENZYMES & BILIRUBINS Lipase [2178-12-2] 04:11AM 19 CHEMISTRY TotProt Albumin [2178-12-2] 04:11AM 2.8* Blood Gas BLOOD GASES Type Rates Tidal V PEEP FiO2 pO2 pCO2 pH calHCO3 [2178-12-1] 04:32AM 18 500-600 5 0.50 92 68.1 7.42 46 Brief Hospital Course: 1) Respiratory distress: Improved with face mask. Serial ABGs showed hypercarbic failure, improved with face mask. Switched to nasal cannula in PM [11-18], but ABGs with ongoing hypercarbia in the 80s. At night, patient had sub-acute worsening respiratory status, with desaturation and tachypnea, along with agitation and confusion. pH with PCO2 in 90s. Placed on CPAP, unsuccessfully. Repeat ABG with PaCO2 87, pH 7.29. Patient intubated. Arterial line finally placed successfully. Extubated on [11-19] but extremely anxious and hypertensive and hypercarbic. Placed on BIPAP and reintubated. [2178-11-23] trach placed. Pt was stable with the trach and venitilator support. Pt has been maintaining stable oxygenation and ventilation on pressure controlled ventilation with PS 3, PEEP 5, Fi02 0.5, PIP 22, TV 500-600, RR18. He benefited from albuterol/atrovent nebs, suction, steroids. At the time of discharge he was on day 4 of prednisone taper. Pt was also on Zosyn for GNR, has h/o pseudomonas. No further abx at the time of discharge. 2) [Name (NI) 283] Pt was placed on amiodarone for afib, but this was discontinued when he developed persistent bradycardia to the 30's-40's on [2177-11-29]. Pt was also anticoagulated on a heparin drip and on [11-24] began coumadin loading. 3)bradycardia- likely [12-30] amiodarone; resolved after holding this med ([2178-11-30]). pt will follow up with Dr [Last Name (STitle) 284] and will likely need a Holter Monitor as an outpt. TFT's pending at time of discharge. 4) agitation: likely due to hypercarbic reso drive, controlled with haldol and then resolved completely when respiratory status stabilized. 5) DM: controlled on RISS with standing dose of NPH. 6) FEN: [Last Name (STitle) 282] tube placed on [2177-11-29] without complication. Tubefeeds started through the [Date Range 282] on [2177-11-30]. Discharge Medications: 1)Praoxetine 20mg QD 2)Ferrous Sulfate 3)Colace 100mg [Hospital1 ] 4)MVI 5)Atorvastatin 10mg QD 6)B12 7)Combivent neb q2-4 hr 8)Senna 1tab [Hospital1 ] 9)Coumadin 5mg QD titrate to INR 10)Insulin SS + NPH fixed dose 11)Prednisone taper (starting [12-3] as 20,20,10,10,5,5, off) 12)Ambien 10mg qhs prn insomnia Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Hypercarbic respiratory Failure s/p trach placement Discharge Condition: Stable Discharge Instructions: 1)Trach care as per rehab facility protocol. 2)[Location (un) 282] tube care and use as per rehab facility protocol. 3)Titrate INR to 1.5 for a fib. 4)Wean ventilator as tolerated. Followup Instructions: 1)Follow up with Dr [Last Name (STitle) 284] ([Telephone/Fax (1) 285]) later this week for further evaluation of your atrial fibrillation, bradycardia. 2)Follow up for weekly INR checks and titrate for a fib to INR >1.5 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 286]	Admission Date: <Date>1937-6-25</Date> Discharge Date: <Date>1938-3-18</Date> Date of Birth: <Date>1997-6-1</Date> Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:<Name>Tyrone</Name> Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Tracheostomy Placement <Name>Griselda</Name> tube placement History of Present Illness: 64 yo man with h/o lung CA s/p R pneumonectomy, COPD, mini-trach to manage secretions, on home O2 who presents c/o 4 days progressively worsening SOB. Need to increase home O2 from 2 to 3 liters. In ED ABG 7.39/62/163 on 2L NC (which is basically his baseline). Given combivent, solumedrol, clinda, and azithro for presumed COPD exacerbation. Initially admitted to MICU for close monitoring, started on Azithromycin and CTX, switched to Ceftaz given past history of Pseudomonas. Transferred to floor on <Date>12-8</Date>, stable and at baseline. On floor, patient had repeated episodes of desaturation, with tachypnea. Became SOB on <Date>8-19</Date> in AM, given Ativan 1, Morphine 2 and Valium 5, with some initial improvement. Then found to be lethargic, and ABG with PCO2 102, pH 7.22. Brought to the ICU for further management. Past Medical History: Lung carcinoma, status post right pneumonectomy. Prostate cancer, status post resection. History of perioperative PE, on anticoagulation. Atrial fibrillation, on anticoagulation. Hypertension. Diabetes, type II. Obstructive sleep apnea. Hypercholesterolemia. B12 deficiency. Cataracts Social History: He lives with his wife. <Name>Michelle Naegelin</Name> has a 3-pack-per-day tobacco history but quit in <Year>1915</Year> and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: Upon Discharge: Gen: Alert, NAD, cooperative, well appearing HEENT: PERRLA, <Year>1949</Year> MMM/clear, trach in place CV: irreg rhythym, reg rate, no m/r/JVD Pulm: coarse BS on the left, transmitted BS on R Ab: s/nd/<Name>Edward</Name>, <Name>Griselda</Name> in place Ext: no LE edema, 2+DPPBL Pertinent Results: <Date>1937-6-25</Date> 11:21PM TYPE-ART PO2-172* PCO2-59* PH-7.34* TOTAL CO2-33* BASE XS-4 <Date>1937-6-25</Date> 09:04PM TYPE-ART PO2-163* PCO2-62* PH-7.39 TOTAL CO2-39* BASE XS-10 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct <Date>1956-11-2</Date> 04:00AM 9.3 2.83* 8.4* 26.9* 95 29.7 31.2 14.4 284 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) <Date>1938-3-18</Date> 04:11AM 17.6* 2.0 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap <Date>1956-11-2</Date> 04:00AM 133* 20 0.8 147* 5.0 107 36* 9 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili <Date>1938-3-18</Date> 04:11AM 46* 20 219 128* 18 0.4 OTHER ENZYMES & BILIRUBINS Lipase <Date>1938-3-18</Date> 04:11AM 19 CHEMISTRY TotProt Albumin <Date>1938-3-18</Date> 04:11AM 2.8* Blood Gas BLOOD GASES Type Rates Tidal V PEEP FiO2 pO2 pCO2 pH calHCO3 <Date>1956-11-2</Date> 04:32AM 18 500-600 5 0.50 92 68.1 7.42 46 Brief Hospital Course: 1) Respiratory distress: Improved with face mask. Serial ABGs showed hypercarbic failure, improved with face mask. Switched to nasal cannula in PM <Date>8-19</Date>, but ABGs with ongoing hypercarbia in the 80s. At night, patient had sub-acute worsening respiratory status, with desaturation and tachypnea, along with agitation and confusion. pH with PCO2 in 90s. Placed on CPAP, unsuccessfully. Repeat ABG with PaCO2 87, pH 7.29. Patient intubated. Arterial line finally placed successfully. Extubated on <Date>9-18</Date> but extremely anxious and hypertensive and hypercarbic. Placed on BIPAP and reintubated. <Date>1959-5-9</Date> trach placed. Pt was stable with the trach and venitilator support. Pt has been maintaining stable oxygenation and ventilation on pressure controlled ventilation with PS 3, PEEP 5, Fi02 0.5, PIP 22, TV 500-600, RR18. He benefited from albuterol/atrovent nebs, suction, steroids. At the time of discharge he was on day 4 of prednisone taper. Pt was also on Zosyn for GNR, has h/o pseudomonas. No further abx at the time of discharge. 2) <Name>German Poff</Name> Pt was placed on amiodarone for afib, but this was discontinued when he developed persistent bradycardia to the 30's-40's on <Date>1915-6-22</Date>. Pt was also anticoagulated on a heparin drip and on <Date>10-14</Date> began coumadin loading. 3)bradycardia- likely <Date>10-18</Date> amiodarone; resolved after holding this med (<Date>1963-3-29</Date>). pt will follow up with Dr <Name>Grier</Name> and will likely need a Holter Monitor as an outpt. TFT's pending at time of discharge. 4) agitation: likely due to hypercarbic reso drive, controlled with haldol and then resolved completely when respiratory status stabilized. 5) DM: controlled on RISS with standing dose of NPH. 6) FEN: <Name>Tennity</Name> tube placed on <Date>1915-6-22</Date> without complication. Tubefeeds started through the <Date Range>1917-12-10 to 1999-4-25</Date Range> on <Date>1982-10-17</Date>. Discharge Medications: 1)Praoxetine 20mg QD 2)Ferrous Sulfate 3)Colace 100mg <Hospital>Hart LLC Hospital</Hospital> 4)MVI 5)Atorvastatin 10mg QD 6)B12 7)Combivent neb q2-4 hr 8)Senna 1tab <Hospital>Hart LLC Hospital</Hospital> 9)Coumadin 5mg QD titrate to INR 10)Insulin SS + NPH fixed dose 11)Prednisone taper (starting <Date>3-10</Date> as 20,20,10,10,5,5, off) 12)Ambien 10mg qhs prn insomnia Discharge Disposition: Extended Care Facility: <Hospital>Lopez-Smith Health System</Hospital> - <Location>206 Harold Road Apt. 441 Garciaton, MO 42626</Location> Discharge Diagnosis: Hypercarbic respiratory Failure s/p trach placement Discharge Condition: Stable Discharge Instructions: 1)Trach care as per rehab facility protocol. 2)<Location>8259 Mark Drives Robertton, IN 84252</Location> tube care and use as per rehab facility protocol. 3)Titrate INR to 1.5 for a fib. 4)Wean ventilator as tolerated. Followup Instructions: 1)Follow up with Dr <Name>Grier</Name> (<Telephone>116-355-9157</Telephone>) later this week for further evaluation of your atrial fibrillation, bradycardia. 2)Follow up for weekly INR checks and titrate for a fib to INR >1.5 <Name>Sammie Braswell</Name> <Name>Mabel Moore</Name> MD <MD Number>77968949</MD 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Date: 1937-6-25 Discharge Date: 1938-3-18 Date of Birth: 1997-6-1 Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:Tyrone Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Tracheostomy Placement Griselda tube placement History of Present Illness: 64 yo man with h/o lung CA s/p R pneumonectomy, COPD, mini-trach to manage secretions, on home O2 who presents c/o 4 days progressively worsening SOB. Need to increase home O2 from 2 to 3 liters. In ED ABG 7.39/62/163 on 2L NC (which is basically his baseline). Given combivent, solumedrol, clinda, and azithro for presumed COPD exacerbation. Initially admitted to MICU for close monitoring, started on Azithromycin and CTX, switched to Ceftaz given past history of Pseudomonas. Transferred to floor on 12-8, stable and at baseline. On floor, patient had repeated episodes of desaturation, with tachypnea. Became SOB on 8-19 in AM, given Ativan 1, Morphine 2 and Valium 5, with some initial improvement. Then found to be lethargic, and ABG with PCO2 102, pH 7.22. Brought to the ICU for further management. Past Medical History: Lung carcinoma, status post right pneumonectomy. Prostate cancer, status post resection. History of perioperative PE, on anticoagulation. Atrial fibrillation, on anticoagulation. Hypertension. Diabetes, type II. Obstructive sleep apnea. Hypercholesterolemia. B12 deficiency. Cataracts Social History: He lives with his wife. Michelle Naegelin has a 3-pack-per-day tobacco history but quit in 1915 and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: Upon Discharge: Gen: Alert, NAD, cooperative, well appearing HEENT: PERRLA, 1949 MMM/clear, trach in place CV: irreg rhythym, reg rate, no m/r/JVD Pulm: coarse BS on the left, transmitted BS on R Ab: s/nd/Edward, Griselda in place Ext: no LE edema, 2+DPPBL Pertinent Results: 1937-6-25 11:21PM TYPE-ART PO2-172* PCO2-59* PH-7.34* TOTAL CO2-33* BASE XS-4 1937-6-25 09:04PM TYPE-ART PO2-163* PCO2-62* PH-7.39 TOTAL CO2-39* BASE XS-10 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 1956-11-2 04:00AM 9.3 2.83* 8.4* 26.9* 95 29.7 31.2 14.4 284 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) 1938-3-18 04:11AM 17.6* 2.0 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap 1956-11-2 04:00AM 133* 20 0.8 147* 5.0 107 36* 9 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili 1938-3-18 04:11AM 46* 20 219 128* 18 0.4 OTHER ENZYMES & BILIRUBINS Lipase 1938-3-18 04:11AM 19 CHEMISTRY TotProt Albumin 1938-3-18 04:11AM 2.8* Blood Gas BLOOD GASES Type Rates Tidal V PEEP FiO2 pO2 pCO2 pH calHCO3 1956-11-2 04:32AM 18 500-600 5 0.50 92 68.1 7.42 46 Brief Hospital Course: 1) Respiratory distress: Improved with face mask. Serial ABGs showed hypercarbic failure, improved with face mask. Switched to nasal cannula in PM 8-19, but ABGs with ongoing hypercarbia in the 80s. At night, patient had sub-acute worsening respiratory status, with desaturation and tachypnea, along with agitation and confusion. pH with PCO2 in 90s. Placed on CPAP, unsuccessfully. Repeat ABG with PaCO2 87, pH 7.29. Patient intubated. Arterial line finally placed successfully. Extubated on 9-18 but extremely anxious and hypertensive and hypercarbic. Placed on BIPAP and reintubated. 1959-5-9 trach placed. Pt was stable with the trach and venitilator support. Pt has been maintaining stable oxygenation and ventilation on pressure controlled ventilation with PS 3, PEEP 5, Fi02 0.5, PIP 22, TV 500-600, RR18. He benefited from albuterol/atrovent nebs, suction, steroids. At the time of discharge he was on day 4 of prednisone taper. Pt was also on Zosyn for GNR, has h/o pseudomonas. No further abx at the time of discharge. 2) German Poff Pt was placed on amiodarone for afib, but this was discontinued when he developed persistent bradycardia to the 30's-40's on 1915-6-22. Pt was also anticoagulated on a heparin drip and on 10-14 began coumadin loading. 3)bradycardia- likely 10-18 amiodarone; resolved after holding this med (1963-3-29). pt will follow up with Dr Grier and will likely need a Holter Monitor as an outpt. TFT's pending at time of discharge. 4) agitation: likely due to hypercarbic reso drive, controlled with haldol and then resolved completely when respiratory status stabilized. 5) DM: controlled on RISS with standing dose of NPH. 6) FEN: Tennity tube placed on 1915-6-22 without complication. Tubefeeds started through the 1917-12-10 to 1999-4-25 on 1982-10-17. Discharge Medications: 1)Praoxetine 20mg QD 2)Ferrous Sulfate 3)Colace 100mg Hart LLC Hospital 4)MVI 5)Atorvastatin 10mg QD 6)B12 7)Combivent neb q2-4 hr 8)Senna 1tab Hart LLC Hospital 9)Coumadin 5mg QD titrate to INR 10)Insulin SS + NPH fixed dose 11)Prednisone taper (starting 3-10 as 20,20,10,10,5,5, off) 12)Ambien 10mg qhs prn insomnia Discharge Disposition: Extended Care Facility: Lopez-Smith Health System - 206 Harold Road Apt. 441 Garciaton, MO 42626 Discharge Diagnosis: Hypercarbic respiratory Failure s/p trach placement Discharge Condition: Stable Discharge Instructions: 1)Trach care as per rehab facility protocol. 2)8259 Mark Drives Robertton, IN 84252 tube care and use as per rehab facility protocol. 3)Titrate INR to 1.5 for a fib. 4)Wean ventilator as tolerated. Followup Instructions: 1)Follow up with Dr Grier (116-355-9157) later this week for further evaluation of your atrial fibrillation, bradycardia. 2)Follow up for weekly INR checks and titrate for a fib to INR >1.5 Sammie Braswell Mabel Moore MD 77968949	['Admission Date: 1937-6-25 Discharge Date: 1938-3-18\n\nDate of Birth: 1997-6-1 Sex: M\n\nService: MEDICINE\n\nAllergies:\nDoxepin / Levofloxacin / Oxycontin\n\nAttending:Tyrone\nChief Complaint:\nRespiratory Failure\n\nMajor Surgical or Invasive Procedure:\nTracheostomy Placement\nGriselda tube placement\n\nHistory of Present Illness:\n64 yo man with h/o lung CA s/p R pneumonectomy, COPD, mini-trach\nto manage secretions, on home O2 who presents c/o 4 days\nprogressively worsening SOB. Need to increase home O2 from 2 to\n3 liters. In ED ABG 7.39/62/163 on 2L NC (which is basically his\nbaseline). Given combivent, solumedrol, clinda, and azithro for\npresumed COPD exacerbation. Initially admitted to MICU for close\nmonitoring, started on Azithromycin and CTX, switched to Ceftaz\ngiven past history of Pseudomonas.', ' Transferred to floor on\n12-8, stable and at baseline. On floor, patient had repeated\nepisodes of desaturation, with tachypnea. Became SOB on 8-19 in\nAM, given Ativan 1, Morphine 2 and Valium 5, with some initial\nimprovement. Then found to be lethargic, and ABG with PCO2 102,\npH 7.22. Brought to the ICU for further management.\n\nPast Medical History:\nLung carcinoma, status post right pneumonectomy.\nProstate cancer, status post resection.\nHistory of perioperative PE, on anticoagulation.\nAtrial fibrillation, on anticoagulation.\nHypertension.\nDiabetes, type II.\nObstructive sleep apnea.\nHypercholesterolemia.\nB12 deficiency.\nCataracts\n\nSocial History:\nHe lives with his wife. Michelle Naegelin has a 3-pack-per-day tobacco history\nbut quit in 1915 and an overall 160-pack-per-year history. No\nrecent history of alcohol use.', '\n\nFamily History:\nMother with coronary artery disease.\n\n\nPhysical Exam:\nUpon Discharge:\nGen: Alert, NAD, cooperative, well appearing\nHEENT: PERRLA, 1949 MMM/clear, trach in place\nCV: irreg rhythym, reg rate, no m/r/JVD\nPulm: coarse BS on the left, transmitted BS on R\nAb: s/nd/Edward, Griselda in place\nExt: no LE edema, 2+DPPBL\n\nPertinent Results:\n1937-6-25 11:21PM TYPE-ART PO2-172* PCO2-59* PH-7.34* TOTAL\nCO2-33* BASE XS-4\n1937-6-25 09:04PM TYPE-ART PO2-163* PCO2-62* PH-7.39 TOTAL\nCO2-39* BASE XS-10\n\n\nHematology\nCOMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct\n1956-11-2 04:00AM 9.3 2.83* 8.4* 26.9* 95 29.7 31.2 14.4\n284\n BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)\n\n1938-3-18 04:11AM 17.6* 2.0\n\nChemistry\nRENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3\nAnGap\n1956-11-2 04:00AM 133* 20 0.', '8 147* 5.0 107 36* 9\nENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase\nTotBili\n1938-3-18 04:11AM 46* 20 219 128* 18\n0.4\nOTHER ENZYMES & BILIRUBINS Lipase\n1938-3-18 04:11AM 19\n CHEMISTRY TotProt Albumin\n1938-3-18 04:11AM 2.8*\n\n\nBlood Gas\nBLOOD GASES Type Rates Tidal V PEEP FiO2 pO2 pCO2 pH\ncalHCO3\n1956-11-2 04:32AM 18 500-600 5 0.50 92 68.1 7.42\n46\n\n\n\n\n\n\n\nBrief Hospital Course:\n\n1) Respiratory distress: Improved with face mask. Serial ABGs\nshowed hypercarbic failure, improved with face mask. Switched to\nnasal cannula in PM 8-19, but ABGs with ongoing hypercarbia in\nthe 80s. At night, patient had sub-acute worsening respiratory\nstatus, with desaturation and tachypnea, along with agitation\nand confusion. pH with PCO2 in 90s. Placed on CPAP,\nunsuccessfully.', " Repeat ABG with PaCO2 87, pH 7.29. Patient\nintubated. Arterial line finally placed successfully. Extubated\non 9-18 but extremely anxious and hypertensive and hypercarbic.\nPlaced on BIPAP and reintubated. 1959-5-9 trach placed. Pt was\nstable with the trach and venitilator support. Pt has been\nmaintaining stable oxygenation and ventilation on pressure\ncontrolled ventilation with PS 3, PEEP 5, Fi02 0.5, PIP 22, TV\n500-600, RR18.\nHe benefited from albuterol/atrovent nebs, suction, steroids. At\nthe time of discharge he was on day 4 of prednisone taper. Pt\nwas also on Zosyn for GNR, has h/o pseudomonas. No further abx\nat the time of discharge.\n\n2) German Poff Pt was placed on amiodarone for afib, but this was\ndiscontinued when he developed persistent bradycardia to the\n30's-40's on 1915-6-22.", " Pt was also anticoagulated on a heparin\ndrip and on 10-14 began coumadin loading.\n\n3)bradycardia- likely 10-18 amiodarone; resolved after holding\nthis med (1963-3-29). pt will follow up with Dr Grier and will\nlikely need a Holter Monitor as an outpt. TFT's pending at time\nof discharge.\n\n4) agitation: likely due to hypercarbic reso drive, controlled\nwith haldol and then resolved completely when respiratory status\nstabilized.\n\n5) DM: controlled on RISS with standing dose of NPH.\n\n6) FEN: Tennity tube placed on 1915-6-22 without complication.\nTubefeeds started through the 1917-12-10 to 1999-4-25 on 1982-10-17.\n\n\n\nDischarge Medications:\n1)Praoxetine 20mg QD\n2)Ferrous Sulfate\n3)Colace 100mg Hart LLC Hospital\n4)MVI\n5)Atorvastatin 10mg QD\n6)B12\n7)Combivent neb q2-4 hr\n8)Senna 1tab Hart LLC Hospital\n9)Coumadin 5mg QD titrate to INR\n10)Insulin SS + NPH fixed dose\n11)Prednisone taper (starting 3-10 as 20,20,10,10,5,5, off)\n12)Ambien 10mg qhs prn insomnia\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nLopez-Smith Health System - 206 Harold Road Apt.", ' 441\nGarciaton, MO 42626\n\nDischarge Diagnosis:\nHypercarbic respiratory Failure s/p trach placement\n\nDischarge Condition:\nStable\n\nDischarge Instructions:\n1)Trach care as per rehab facility protocol.\n2)8259 Mark Drives\nRobertton, IN 84252 tube care and use as per rehab facility protocol.\n3)Titrate INR to 1.5 for a fib.\n4)Wean ventilator as tolerated.\n\n\nFollowup Instructions:\n1)Follow up with Dr Grier (116-355-9157) later this week\nfor further evaluation of your atrial fibrillation, bradycardia.\n2)Follow up for weekly INR checks and titrate for a fib to INR\n>1.5\n\n\n Sammie Braswell Mabel Moore MD 77968949\n\n']
21	15472	188190.0	2178-12-09	Discharge summary	Report	Admission Date: [2178-12-5] Discharge Date: [2178-12-21] Date of Birth: [2114-2-8] Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:[First Name3 (LF) 287] Chief Complaint: sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 64 year-old gentleman with history of lung cancer s/p right pneumonectomy in [2174], severe COPD, recently discharged from [Hospital1 18] MICU [2178-12-2] s/p tracheostomy and [Month/Day/Year 282] placement after admission for respiratory failure due to pneumonia, now re-admitted to [Hospital1 18] with fever, hypotension. On last admission, patient unabled to be weaned from the ventilator. After tracheostomy and [Hospital1 282] tube placement, he was discharged to [Hospital1 ] on [2178-12-2] for vent weaning. While there, was constipated according to wife. On [2178-12-4], patient became agitated and hypotensive to 82/58 and transferred back to [Hospital1 18] ED. On presentation to the [Hospital1 18] ED, he was found to be hypotensive to 64/56, tachycardic to 120, febrile to 102.8F and agitated. Patient had several large loose bowel movements in the ED. Also found to have a drop in hct from 27.8 on arrival to ED to 22.9 on repeat draw one hour later. (Hct 26.9 on discharge.) Of note, femoral line attempted at [Hospital1 ] but unsuccessful due to patient's agitation. In the [Last Name (LF) ], [First Name3 (LF) ] attempt at IJ central line placement was unsuccessful. A femoral central intravenous catheter was placed. He was given IVF and started on Neosynephrine for blood pressure support with good response. He received a total of 4 Liters of normal saline, flagyl 500mg IV x1, vancomycin 1 gram IV x1, ceftriaxone 1gram IV x1, 2U PRBC. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in [2174]. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus [2174]. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in [2165]. 8. Gout. 9. Atypical chest pain since [2164]. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in [10-31] resulting in ventilator dependence, trach and [Date Range 282] placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo [7-31]: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to [Hospital ] rehab s/p trach and [Hospital 282]. He has a 3-pack-per-day tobacco history but quit in [2174] and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: Agitated on arrival, kicking leg with femoral line. Sedated on versed drip. Vital signs: temp: 99.0F BP: 110/70 on 1.5mcg/kg/min of Neosynephrine HR: 46 Vent settings: AC 0.40, 18x550, PEEP 5 Gen: sedated on versed drip. HEENT: pinpoint pupils (fentanyl given in the ED. Chest: absent breath sounds on right, transmitted upper airway sounds on left, otherwise clear. Bruising on right upper chest with guaze taped. Heart: bradycardic, regular rhythm, exam limited by breath sounds Abd: soft, nontender, normoactive bowel sounds, G-tube site clean, without erythema or induration Extr: 2+ DP and radial pulses bilaterally, symmetric bilateral 1+ pitting edema in upper extremities, symmetric bilateral trace pitting edema in lower extremity. Left femoral line site with some oozing, but no ecchymosis or palpable hematoma or bruits. 2x2cm midline coccyx decubitus ulcer, green exudative material- exam limited by patient's agitation. ?stage 3 or 4 Neuro: sedated Pertinent Results: [2178-12-5] 12:52AM HGB-7.6* calcHCT-23 [2178-12-5] 12:40AM HCT-22.9* [2178-12-5] 12:18AM COMMENTS-GREEN TOP [2178-12-5] 12:18AM LACTATE-2.2* [2178-12-5] 12:18AM HGB-9.0* calcHCT-27 [2178-12-4] 11:50PM GLUCOSE-205* UREA N-23* CREAT-1.1 SODIUM-144 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-40* ANION GAP-11 [2178-12-4] 11:50PM ALT(SGPT)-40 AST(SGOT)-30 ALK PHOS-142* AMYLASE-16 TOT BILI-0.7 [2178-12-4] 11:50PM LIPASE-16 [2178-12-4] 11:50PM ALBUMIN-3.4 CALCIUM-8.5 [2178-12-4] 11:50PM WBC-19.5# RBC-2.91 HGB-8.7* HCT-27.8* MCV-96 MCH-29.8 MCHC-31.2 RDW-14.4 [2178-12-4] 11:50PM NEUTS-97.3* BANDS-0 LYMPHS-1.2* MONOS-1.5* EOS-0 BASOS-0.1 [2178-12-4] 11:50PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2178-12-4] 11:50PM PLT SMR-NORMAL PLT COUNT-321 [2178-12-4] 11:50PM PT-21.3* PTT-54.3* INR(PT)-2.9 CXR: complete white out of the right hemithorax, clear left hemithorax. no pneumothorax. EKG: NSR at 78 bpm with first degree AV block, no changes from baseline. Brief Hospital Course: 64 year-old male with history of lung cancer post-right pneumonectomy, severe COPD, recent trach and [Year/Month/Day 282] placement and antibiotic course for pneumonia, now returns from [Hospital ] rehab with diarrhea, stage IV sacral decubitus ulcer, and sepsis. No source of infection had been identified so far. He was C-diff negative, blood/urine/sputum culture had not yield any organism. He was treated empirically with ceftazidime, vancomycin and metronidazole for 7 days. His blood pressure responded to fluid challenge and he has been normotensive since then. He was started on stress dose steroid which was weaned off. He was gradually weaned off ventilation and tolerated trach mask well. His blood sugar was well controlled with glargine and sliding scale. He was also noted to have decubitus ulcer. Plastic surgery was consulted and felt that debridement was not necessary. Therefore, he was cotinued on wet to dry dressing, Kinair bed and his nutrition was optimized. He remiained in normal sinus rhythm and is on coumadin for history of atrial fibrillation. He was very agitated in the ICU. He was weaned off fentanyl drip and put on fentanyl patch. He also was put on standing zyprexa and prn haldol, morphine. He was also on standing valium and was actually thought to be in benzo withdrawal as his wife claims that he was on valium at home.He is full code and his health care proxy is his wife. . Medications on Admission: 1)Paroxetine 20mg QD 2)Ferrous Sulfate 3)Colace 100mg [Hospital1 ] 4)MVI 5)Atorvastatin 10mg QD 6)vitamin B12 [2173] mcg PO QD 7)Combivent neb q2-4 hr 8)Senna 1tab [Hospital1 ] 9)Coumadin titrate to INR 10)Insulin SS + NPH fixed dose 11)Prednisone taper (starting [12-3] as 20,20,10,10,5,5, off) 12)Ambien 10mg qhs prn insomnia 13) Flovent 2 puffs [Hospital1 ] 14) Fentanyl 75 mcg/hr Patch Q72HR 15) Lactulose 16) Percocet prn 17) Valium PRN Discharge Medications: 1. Acetaminophen 325 mg Tablet [Hospital1 ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Paroxetine HCl 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation Q6H (every 6 hours). 5. Albuterol 90 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 6. Fentanyl 75 mcg/hr Patch 72HR [Hospital1 ]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Senna 8.6 mg Tablet [Hospital1 ]: Two (2) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Lactulose 10 g/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO TID (3 times a day). 10. Warfarin Sodium 2.5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 11. Olanzapine 10 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 12. Ascorbic Acid 100 mg/mL Drops [Hospital1 ]: 2.5 ml PO DAILY (Daily). 13. Diazepam 10 mg Tablet [Hospital1 ]: One (1) Tablet PO Q8H (every 8 hours). 14. Zinc Sulfate 220 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 15. Haloperidol 3-5 mg IV Q4H:PRN 16. Morphine Sulfate 2 mg/mL Syringe [Hospital1 ]: [12-2] ml [Month/Day (1) ] Q4H (every 4 hours) as needed. 17. Insulin Glargine 100 unit/mL Solution [Month/Day (1) ]: Twenty Eight (28) unit Subcutaneous at breakfast. 18. Ceftazidime 1 g Recon Soln [Month/Day (1) ]: One (1) Recon Soln Intravenous every eight (8) hours for 4 days. 19. Vancocin HCl 1,000 mg Recon Soln [Month/Day (1) ]: One (1) Recon Soln Intravenous every twelve (12) hours for 4 days. 20. Flagyl 500 mg Tablet [Month/Day (1) ]: One (1) Tablet PO three times a day for 4 days. Discharge Disposition: Extended Care Discharge Diagnosis: 1. sepsis secondary: 1. lung cancer post right pneumonectomy 2. type 2 diabetes 3. COPD 4. atrial afibrillation 5. gout 6. GERD 7. hypertension 8. hypercholesterolemia Discharge Condition: stable Discharge Instructions: Please return to the hospital if you have shortness of breath, fever or if there are any cocnerns at all. PLease take all your prescribed medication Followup Instructions: to rehab [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288] MD, [MD Number(3) 289] Completed by:[2178-12-9]	Admission Date: <Date>1974-12-21</Date> Discharge Date: <Date>2006-12-25</Date> Date of Birth: <Date>2001-12-28</Date> Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:<Name>Estrella</Name> Chief Complaint: sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 64 year-old gentleman with history of lung cancer s/p right pneumonectomy in <Year>1946</Year>, severe COPD, recently discharged from <Hospital>Davis, Smith and Knight Hospital</Hospital> MICU <Date>1973-7-17</Date> s/p tracheostomy and <Month>August</Month> placement after admission for respiratory failure due to pneumonia, now re-admitted to <Hospital>Davis, Smith and Knight Hospital</Hospital> with fever, hypotension. On last admission, patient unabled to be weaned from the ventilator. After tracheostomy and <Hospital>Harris, Horne and Henderson Health System</Hospital> tube placement, he was discharged to <Hospital>Reynolds, Webster and Kelly Hospital</Hospital> on <Date>1973-7-17</Date> for vent weaning. While there, was constipated according to wife. On <Date>2000-2-18</Date>, patient became agitated and hypotensive to 82/58 and transferred back to <Hospital>Davis, Smith and Knight Hospital</Hospital> ED. On presentation to the <Hospital>Davis, Smith and Knight Hospital</Hospital> ED, he was found to be hypotensive to 64/56, tachycardic to 120, febrile to 102.8F and agitated. Patient had several large loose bowel movements in the ED. Also found to have a drop in hct from 27.8 on arrival to ED to 22.9 on repeat draw one hour later. (Hct 26.9 on discharge.) Of note, femoral line attempted at <Hospital>Reynolds, Webster and Kelly Hospital</Hospital> but unsuccessful due to patient's agitation. In the <Name>Pegram</Name>, <Name>Joan</Name> attempt at IJ central line placement was unsuccessful. A femoral central intravenous catheter was placed. He was given IVF and started on Neosynephrine for blood pressure support with good response. He received a total of 4 Liters of normal saline, flagyl 500mg IV x1, vancomycin 1 gram IV x1, ceftriaxone 1gram IV x1, 2U PRBC. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in <Year>1946</Year>. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus <Year>1946</Year>. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in <Year>1946</Year>. 8. Gout. 9. Atypical chest pain since <Year>1946</Year>. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in <Date>7-18</Date> resulting in ventilator dependence, trach and <Date Range>1907-11-28 to 1964-9-31</Date Range> placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo <Date>12-18</Date>: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to <Hospital>Sanchez-Montgomery Health System</Hospital> rehab s/p trach and <Hospital>Stewart-Mitchell Hospital</Hospital>. He has a 3-pack-per-day tobacco history but quit in <Year>1946</Year> and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: Agitated on arrival, kicking leg with femoral line. Sedated on versed drip. Vital signs: temp: 99.0F BP: 110/70 on 1.5mcg/kg/min of Neosynephrine HR: 46 Vent settings: AC 0.40, 18x550, PEEP 5 Gen: sedated on versed drip. HEENT: pinpoint pupils (fentanyl given in the ED. Chest: absent breath sounds on right, transmitted upper airway sounds on left, otherwise clear. Bruising on right upper chest with guaze taped. Heart: bradycardic, regular rhythm, exam limited by breath sounds Abd: soft, nontender, normoactive bowel sounds, G-tube site clean, without erythema or induration Extr: 2+ DP and radial pulses bilaterally, symmetric bilateral 1+ pitting edema in upper extremities, symmetric bilateral trace pitting edema in lower extremity. Left femoral line site with some oozing, but no ecchymosis or palpable hematoma or bruits. 2x2cm midline coccyx decubitus ulcer, green exudative material- exam limited by patient's agitation. ?stage 3 or 4 Neuro: sedated Pertinent Results: <Date>1974-12-21</Date> 12:52AM HGB-7.6* calcHCT-23 <Date>1974-12-21</Date> 12:40AM HCT-22.9* <Date>1974-12-21</Date> 12:18AM COMMENTS-GREEN TOP <Date>1974-12-21</Date> 12:18AM LACTATE-2.2* <Date>1974-12-21</Date> 12:18AM HGB-9.0* calcHCT-27 <Date>2000-2-18</Date> 11:50PM GLUCOSE-205* UREA N-23* CREAT-1.1 SODIUM-144 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-40* ANION GAP-11 <Date>2000-2-18</Date> 11:50PM ALT(SGPT)-40 AST(SGOT)-30 ALK PHOS-142* AMYLASE-16 TOT BILI-0.7 <Date>2000-2-18</Date> 11:50PM LIPASE-16 <Date>2000-2-18</Date> 11:50PM ALBUMIN-3.4 CALCIUM-8.5 <Date>2000-2-18</Date> 11:50PM WBC-19.5# RBC-2.91 HGB-8.7* HCT-27.8* MCV-96 MCH-29.8 MCHC-31.2 RDW-14.4 <Date>2000-2-18</Date> 11:50PM NEUTS-97.3* BANDS-0 LYMPHS-1.2* MONOS-1.5* EOS-0 BASOS-0.1 <Date>2000-2-18</Date> 11:50PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL <Date>2000-2-18</Date> 11:50PM PLT SMR-NORMAL PLT COUNT-321 <Date>2000-2-18</Date> 11:50PM PT-21.3* PTT-54.3* INR(PT)-2.9 CXR: complete white out of the right hemithorax, clear left hemithorax. no pneumothorax. EKG: NSR at 78 bpm with first degree AV block, no changes from baseline. Brief Hospital Course: 64 year-old male with history of lung cancer post-right pneumonectomy, severe COPD, recent trach and <Year>1970</Year> placement and antibiotic course for pneumonia, now returns from <Hospital>Sanchez-Montgomery Health System</Hospital> rehab with diarrhea, stage IV sacral decubitus ulcer, and sepsis. No source of infection had been identified so far. He was C-diff negative, blood/urine/sputum culture had not yield any organism. He was treated empirically with ceftazidime, vancomycin and metronidazole for 7 days. His blood pressure responded to fluid challenge and he has been normotensive since then. He was started on stress dose steroid which was weaned off. He was gradually weaned off ventilation and tolerated trach mask well. His blood sugar was well controlled with glargine and sliding scale. He was also noted to have decubitus ulcer. Plastic surgery was consulted and felt that debridement was not necessary. Therefore, he was cotinued on wet to dry dressing, Kinair bed and his nutrition was optimized. He remiained in normal sinus rhythm and is on coumadin for history of atrial fibrillation. He was very agitated in the ICU. He was weaned off fentanyl drip and put on fentanyl patch. He also was put on standing zyprexa and prn haldol, morphine. He was also on standing valium and was actually thought to be in benzo withdrawal as his wife claims that he was on valium at home.He is full code and his health care proxy is his wife. . Medications on Admission: 1)Paroxetine 20mg QD 2)Ferrous Sulfate 3)Colace 100mg <Hospital>Reynolds, Webster and Kelly Hospital</Hospital> 4)MVI 5)Atorvastatin 10mg QD 6)vitamin B12 <Year>1946</Year> mcg PO QD 7)Combivent neb q2-4 hr 8)Senna 1tab <Hospital>Reynolds, Webster and Kelly Hospital</Hospital> 9)Coumadin titrate to INR 10)Insulin SS + NPH fixed dose 11)Prednisone taper (starting <Date>6-27</Date> as 20,20,10,10,5,5, off) 12)Ambien 10mg qhs prn insomnia 13) Flovent 2 puffs <Hospital>Reynolds, Webster and Kelly Hospital</Hospital> 14) Fentanyl 75 mcg/hr Patch Q72HR 15) Lactulose 16) Percocet prn 17) Valium PRN Discharge Medications: 1. Acetaminophen 325 mg Tablet <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Paroxetine HCl 20 mg Tablet <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: Two (2) Puff Inhalation Q6H (every 6 hours). 5. Albuterol 90 mcg/Actuation Aerosol <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 6. Fentanyl 75 mcg/hr Patch 72HR <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Senna 8.6 mg Tablet <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: Two (2) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Lactulose 10 g/15 mL Syrup <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: Thirty (30) ML PO TID (3 times a day). 10. Warfarin Sodium 2.5 mg Tablet <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: One (1) Tablet PO HS (at bedtime). 11. Olanzapine 10 mg Tablet <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: One (1) Tablet PO once a day. 12. Ascorbic Acid 100 mg/mL Drops <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: 2.5 ml PO DAILY (Daily). 13. Diazepam 10 mg Tablet <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: One (1) Tablet PO Q8H (every 8 hours). 14. Zinc Sulfate 220 mg Capsule <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: One (1) Capsule PO DAILY (Daily). 15. Haloperidol 3-5 mg IV Q4H:PRN 16. Morphine Sulfate 2 mg/mL Syringe <Hospital>Reynolds, Webster and Kelly Hospital</Hospital>: <Date>7-29</Date> ml <Month>March</Month> Q4H (every 4 hours) as needed. 17. Insulin Glargine 100 unit/mL Solution <Month>March</Month>: Twenty Eight (28) unit Subcutaneous at breakfast. 18. Ceftazidime 1 g Recon Soln <Month>March</Month>: One (1) Recon Soln Intravenous every eight (8) hours for 4 days. 19. Vancocin HCl 1,000 mg Recon Soln <Month>March</Month>: One (1) Recon Soln Intravenous every twelve (12) hours for 4 days. 20. Flagyl 500 mg Tablet <Month>March</Month>: One (1) Tablet PO three times a day for 4 days. Discharge Disposition: Extended Care Discharge Diagnosis: 1. sepsis secondary: 1. lung cancer post right pneumonectomy 2. type 2 diabetes 3. COPD 4. atrial afibrillation 5. gout 6. GERD 7. hypertension 8. hypercholesterolemia Discharge Condition: stable Discharge Instructions: Please return to the hospital if you have shortness of breath, fever or if there are any cocnerns at all. PLease take all your prescribed medication Followup Instructions: to rehab <Name>Karissa</Name> <Name>Sakkas</Name> MD, <MD Number>50638088</MD Number> Completed by:<Date>1954-6-25</Date>	00000000000000000111111111100000000000000000000000000000000111111111100000000000000000011111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000001111111111111111111111111111111100000011111111100000000000000000000001111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111111111111111111111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111111111100000000000000000000000000000000000000111111111111111111111111111111111111000011111111100000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111000000000000000000000000000001111111111111111111111111111111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111111111111111111111111111111110000000000000000000000000000000000000000000000000000001111110011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000111100000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000011111111111111111111111000000000000000000000000000000000000000000000000000000000000000000000000011111000000>000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111111111111111111111111111000000000000000000000111111111111111111111111100000000000000000000000000000000000000000000000000000011110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111110000000000000000000000000000000111111111100000000000000000000011111111110000000000000000000000000000001111111111000000000000000000000000111111111100000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000000111111111000000000000000000000111111111000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000011111111100000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111110000000000000000000000000000000000000000111111111000000000000000000000000000000000000000000000000000000000000000000000000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Date: 1974-12-21 Discharge Date: 2006-12-25 Date of Birth: 2001-12-28 Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:Estrella Chief Complaint: sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 64 year-old gentleman with history of lung cancer s/p right pneumonectomy in 1946, severe COPD, recently discharged from Davis, Smith and Knight Hospital MICU 1973-7-17 s/p tracheostomy and August placement after admission for respiratory failure due to pneumonia, now re-admitted to Davis, Smith and Knight Hospital with fever, hypotension. On last admission, patient unabled to be weaned from the ventilator. After tracheostomy and Harris, Horne and Henderson Health System tube placement, he was discharged to Reynolds, Webster and Kelly Hospital on 1973-7-17 for vent weaning. While there, was constipated according to wife. On 2000-2-18, patient became agitated and hypotensive to 82/58 and transferred back to Davis, Smith and Knight Hospital ED. On presentation to the Davis, Smith and Knight Hospital ED, he was found to be hypotensive to 64/56, tachycardic to 120, febrile to 102.8F and agitated. Patient had several large loose bowel movements in the ED. Also found to have a drop in hct from 27.8 on arrival to ED to 22.9 on repeat draw one hour later. (Hct 26.9 on discharge.) Of note, femoral line attempted at Reynolds, Webster and Kelly Hospital but unsuccessful due to patient's agitation. In the Pegram, Joan attempt at IJ central line placement was unsuccessful. A femoral central intravenous catheter was placed. He was given IVF and started on Neosynephrine for blood pressure support with good response. He received a total of 4 Liters of normal saline, flagyl 500mg IV x1, vancomycin 1 gram IV x1, ceftriaxone 1gram IV x1, 2U PRBC. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in 1946. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus 1946. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in 1946. 8. Gout. 9. Atypical chest pain since 1946. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in 7-18 resulting in ventilator dependence, trach and 1907-11-28 to 1964-9-31 placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo 12-18: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to Sanchez-Montgomery Health System rehab s/p trach and Stewart-Mitchell Hospital. He has a 3-pack-per-day tobacco history but quit in 1946 and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: Agitated on arrival, kicking leg with femoral line. Sedated on versed drip. Vital signs: temp: 99.0F BP: 110/70 on 1.5mcg/kg/min of Neosynephrine HR: 46 Vent settings: AC 0.40, 18x550, PEEP 5 Gen: sedated on versed drip. HEENT: pinpoint pupils (fentanyl given in the ED. Chest: absent breath sounds on right, transmitted upper airway sounds on left, otherwise clear. Bruising on right upper chest with guaze taped. Heart: bradycardic, regular rhythm, exam limited by breath sounds Abd: soft, nontender, normoactive bowel sounds, G-tube site clean, without erythema or induration Extr: 2+ DP and radial pulses bilaterally, symmetric bilateral 1+ pitting edema in upper extremities, symmetric bilateral trace pitting edema in lower extremity. Left femoral line site with some oozing, but no ecchymosis or palpable hematoma or bruits. 2x2cm midline coccyx decubitus ulcer, green exudative material- exam limited by patient's agitation. ?stage 3 or 4 Neuro: sedated Pertinent Results: 1974-12-21 12:52AM HGB-7.6* calcHCT-23 1974-12-21 12:40AM HCT-22.9* 1974-12-21 12:18AM COMMENTS-GREEN TOP 1974-12-21 12:18AM LACTATE-2.2* 1974-12-21 12:18AM HGB-9.0* calcHCT-27 2000-2-18 11:50PM GLUCOSE-205* UREA N-23* CREAT-1.1 SODIUM-144 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-40* ANION GAP-11 2000-2-18 11:50PM ALT(SGPT)-40 AST(SGOT)-30 ALK PHOS-142* AMYLASE-16 TOT BILI-0.7 2000-2-18 11:50PM LIPASE-16 2000-2-18 11:50PM ALBUMIN-3.4 CALCIUM-8.5 2000-2-18 11:50PM WBC-19.5# RBC-2.91 HGB-8.7* HCT-27.8* MCV-96 MCH-29.8 MCHC-31.2 RDW-14.4 2000-2-18 11:50PM NEUTS-97.3* BANDS-0 LYMPHS-1.2* MONOS-1.5* EOS-0 BASOS-0.1 2000-2-18 11:50PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL 2000-2-18 11:50PM PLT SMR-NORMAL PLT COUNT-321 2000-2-18 11:50PM PT-21.3* PTT-54.3* INR(PT)-2.9 CXR: complete white out of the right hemithorax, clear left hemithorax. no pneumothorax. EKG: NSR at 78 bpm with first degree AV block, no changes from baseline. Brief Hospital Course: 64 year-old male with history of lung cancer post-right pneumonectomy, severe COPD, recent trach and 1970 placement and antibiotic course for pneumonia, now returns from Sanchez-Montgomery Health System rehab with diarrhea, stage IV sacral decubitus ulcer, and sepsis. No source of infection had been identified so far. He was C-diff negative, blood/urine/sputum culture had not yield any organism. He was treated empirically with ceftazidime, vancomycin and metronidazole for 7 days. His blood pressure responded to fluid challenge and he has been normotensive since then. He was started on stress dose steroid which was weaned off. He was gradually weaned off ventilation and tolerated trach mask well. His blood sugar was well controlled with glargine and sliding scale. He was also noted to have decubitus ulcer. Plastic surgery was consulted and felt that debridement was not necessary. Therefore, he was cotinued on wet to dry dressing, Kinair bed and his nutrition was optimized. He remiained in normal sinus rhythm and is on coumadin for history of atrial fibrillation. He was very agitated in the ICU. He was weaned off fentanyl drip and put on fentanyl patch. He also was put on standing zyprexa and prn haldol, morphine. He was also on standing valium and was actually thought to be in benzo withdrawal as his wife claims that he was on valium at home.He is full code and his health care proxy is his wife. . Medications on Admission: 1)Paroxetine 20mg QD 2)Ferrous Sulfate 3)Colace 100mg Reynolds, Webster and Kelly Hospital 4)MVI 5)Atorvastatin 10mg QD 6)vitamin B12 1946 mcg PO QD 7)Combivent neb q2-4 hr 8)Senna 1tab Reynolds, Webster and Kelly Hospital 9)Coumadin titrate to INR 10)Insulin SS + NPH fixed dose 11)Prednisone taper (starting 6-27 as 20,20,10,10,5,5, off) 12)Ambien 10mg qhs prn insomnia 13) Flovent 2 puffs Reynolds, Webster and Kelly Hospital 14) Fentanyl 75 mcg/hr Patch Q72HR 15) Lactulose 16) Percocet prn 17) Valium PRN Discharge Medications: 1. Acetaminophen 325 mg Tablet Reynolds, Webster and Kelly Hospital: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Paroxetine HCl 20 mg Tablet Reynolds, Webster and Kelly Hospital: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Reynolds, Webster and Kelly Hospital: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Reynolds, Webster and Kelly Hospital: Two (2) Puff Inhalation Q6H (every 6 hours). 5. Albuterol 90 mcg/Actuation Aerosol Reynolds, Webster and Kelly Hospital: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 6. Fentanyl 75 mcg/hr Patch 72HR Reynolds, Webster and Kelly Hospital: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Senna 8.6 mg Tablet Reynolds, Webster and Kelly Hospital: Two (2) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Reynolds, Webster and Kelly Hospital: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Lactulose 10 g/15 mL Syrup Reynolds, Webster and Kelly Hospital: Thirty (30) ML PO TID (3 times a day). 10. Warfarin Sodium 2.5 mg Tablet Reynolds, Webster and Kelly Hospital: One (1) Tablet PO HS (at bedtime). 11. Olanzapine 10 mg Tablet Reynolds, Webster and Kelly Hospital: One (1) Tablet PO once a day. 12. Ascorbic Acid 100 mg/mL Drops Reynolds, Webster and Kelly Hospital: 2.5 ml PO DAILY (Daily). 13. Diazepam 10 mg Tablet Reynolds, Webster and Kelly Hospital: One (1) Tablet PO Q8H (every 8 hours). 14. Zinc Sulfate 220 mg Capsule Reynolds, Webster and Kelly Hospital: One (1) Capsule PO DAILY (Daily). 15. Haloperidol 3-5 mg IV Q4H:PRN 16. Morphine Sulfate 2 mg/mL Syringe Reynolds, Webster and Kelly Hospital: 7-29 ml March Q4H (every 4 hours) as needed. 17. Insulin Glargine 100 unit/mL Solution March: Twenty Eight (28) unit Subcutaneous at breakfast. 18. Ceftazidime 1 g Recon Soln March: One (1) Recon Soln Intravenous every eight (8) hours for 4 days. 19. Vancocin HCl 1,000 mg Recon Soln March: One (1) Recon Soln Intravenous every twelve (12) hours for 4 days. 20. Flagyl 500 mg Tablet March: One (1) Tablet PO three times a day for 4 days. Discharge Disposition: Extended Care Discharge Diagnosis: 1. sepsis secondary: 1. lung cancer post right pneumonectomy 2. type 2 diabetes 3. COPD 4. atrial afibrillation 5. gout 6. GERD 7. hypertension 8. hypercholesterolemia Discharge Condition: stable Discharge Instructions: Please return to the hospital if you have shortness of breath, fever or if there are any cocnerns at all. PLease take all your prescribed medication Followup Instructions: to rehab Karissa Sakkas MD, 50638088 Completed by:1954-6-25	['Admission Date: 1974-12-21 Discharge Date: 2006-12-25\n\nDate of Birth: 2001-12-28 Sex: M\n\nService: MEDICINE\n\nAllergies:\nDoxepin / Levofloxacin / Oxycontin\n\nAttending:Estrella\nChief Complaint:\nsepsis\n\nMajor Surgical or Invasive Procedure:\nnone\n\n\nHistory of Present Illness:\n64 year-old gentleman with history of lung cancer s/p right\npneumonectomy in 1946, severe COPD, recently discharged from\nDavis, Smith and Knight Hospital MICU 1973-7-17 s/p tracheostomy and August placement after\nadmission for respiratory failure due to pneumonia, now\nre-admitted to Davis, Smith and Knight Hospital with fever, hypotension.\n\nOn last admission, patient unabled to be weaned from the\nventilator. After tracheostomy and Harris, Horne and Henderson Health System tube placement, he was\ndischarged to Reynolds, Webster and Kelly Hospital on 1973-7-17 for vent weaning.', " While there,\nwas constipated according to wife. On 2000-2-18, patient became\nagitated and hypotensive to 82/58 and transferred back to Davis, Smith and Knight Hospital\nED.\n\nOn presentation to the Davis, Smith and Knight Hospital ED, he was found to be hypotensive\nto 64/56, tachycardic to 120, febrile to 102.8F and agitated.\nPatient had several large loose bowel movements in the ED. Also\nfound to have a drop in hct from 27.8 on arrival to ED to 22.9\non repeat draw one hour later. (Hct 26.9 on discharge.)\nOf note, femoral line attempted at Reynolds, Webster and Kelly Hospital but unsuccessful due\nto patient's agitation.\n\nIn the Pegram, Joan attempt at IJ central line placement was\nunsuccessful. A femoral central intravenous catheter was\nplaced. He was given IVF and started on Neosynephrine for blood\npressure support with good response.", ' He received a total of 4\nLiters of normal saline, flagyl 500mg IV x1, vancomycin 1 gram\nIV x1, ceftriaxone 1gram IV x1, 2U PRBC.\n\n\nPast Medical History:\n1. Squamous cell lung carcinoma, status post right\npneumonectomy in 1946.\n2. Prostate cancer, status post radical prostatectomy.\n3. Perioperative pulmonary embolus 1946.\n4. Type 2 diabetes mellitus.\n5. Chronic obstructive pulmonary disease.\n6. Atrial fibrillation.\n7. Transient ischemic attack in 1946.\n8. Gout.\n9. Atypical chest pain since 1946.\n10. Gastroesophageal reflux disease.\n11. Obstructive sleep apnea. unable to tolerate BiPAP.\n12. Hypertension.\n13. Colonic polyps.\n14. Hypercholesterolemia.\n15. Basal cell carcinoma on his back.\n16. Anxiety.\n17. Sciatica.\n18. History of herpes zoster.\n19. multiple admissions for pneumonia (including pseudomonas)\nand bronchitis, last in 7-18 resulting in ventilator\ndependence, trach and 1907-11-28 to 1964-9-31 placement\n20.', ' vitamin B12 deficiency.\n21. Diastolic heart failure. Echo 12-18: LVEF>55%\n21. Cataracts\n22. bradycardia on amiodarone\n\nSocial History:\nRecently discharged to Sanchez-Montgomery Health System rehab s/p trach and Stewart-Mitchell Hospital.\nHe has a 3-pack-per-day tobacco history but quit in 1946 and an\noverall 160-pack-per-year history.\nNo recent history of alcohol use.\n\nFamily History:\nMother with coronary artery disease.\n\n\nPhysical Exam:\nAgitated on arrival, kicking leg with femoral line. Sedated on\nversed drip.\n\nVital signs: temp: 99.0F BP: 110/70 on 1.5mcg/kg/min of\nNeosynephrine HR: 46\nVent settings: AC 0.40, 18x550, PEEP 5\nGen: sedated on versed drip.\nHEENT: pinpoint pupils (fentanyl given in the ED.\nChest: absent breath sounds on right, transmitted upper airway\nsounds on left, otherwise clear.', " Bruising on right upper chest\nwith guaze taped.\nHeart: bradycardic, regular rhythm, exam limited by breath\nsounds\nAbd: soft, nontender, normoactive bowel sounds, G-tube site\nclean, without erythema or induration\nExtr: 2+ DP and radial pulses bilaterally, symmetric bilateral\n1+ pitting edema in upper extremities, symmetric bilateral trace\npitting edema in lower extremity. Left femoral line site with\nsome oozing, but no ecchymosis or palpable hematoma or bruits.\n2x2cm midline coccyx decubitus ulcer, green exudative material-\nexam limited by patient's agitation. ?stage 3 or 4\nNeuro: sedated\n\n\nPertinent Results:\n1974-12-21 12:52AM HGB-7.6* calcHCT-23\n1974-12-21 12:40AM HCT-22.9\n1974-12-21 12:18AM COMMENTS-GREEN TOP\n1974-12-21 12:18AM LACTATE-2.2\n1974-12-21 12:18AM HGB-9.0* calcHCT-27\n2000-2-18 11:50PM GLUCOSE-205* UREA N-23* CREAT-1.", '1 SODIUM-144\nPOTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-40* ANION GAP-11\n2000-2-18 11:50PM ALT(SGPT)-40 AST(SGOT)-30 ALK PHOS-142\nAMYLASE-16 TOT BILI-0.7\n2000-2-18 11:50PM LIPASE-16\n2000-2-18 11:50PM ALBUMIN-3.4 CALCIUM-8.5\n2000-2-18 11:50PM WBC-19.5# RBC-2.91* HGB-8.7* HCT-27.8\nMCV-96 MCH-29.8 MCHC-31.2 RDW-14.4\n2000-2-18 11:50PM NEUTS-97.3 BANDS-0 LYMPHS-1.2* MONOS-1.5\nEOS-0 BASOS-0.1\n2000-2-18 11:50PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL\nMACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL\n2000-2-18 11:50PM PLT SMR-NORMAL PLT COUNT-321\n2000-2-18 11:50PM PT-21.3 PTT-54.3* INR(PT)-2.9\n\nCXR: complete white out of the right hemithorax, clear left\nhemithorax. no pneumothorax.\n\nEKG: NSR at 78 bpm with first degree AV block, no changes from\nbaseline.\n\nBrief Hospital Course:\n64 year-old male with history of lung cancer post-right\npneumonectomy, severe COPD, recent trach and 1970 placement and\nantibiotic course for pneumonia, now returns from Sanchez-Montgomery Health System rehab\nwith diarrhea, stage IV sacral decubitus ulcer, and sepsis.', ' No\nsource of infection had been identified so far. He was C-diff\nnegative, blood/urine/sputum culture had not yield any organism.\nHe was treated empirically with ceftazidime, vancomycin and\nmetronidazole for 7 days. His blood pressure responded to fluid\nchallenge and he has been normotensive since then. He was\nstarted on stress dose steroid which was weaned off. He was\ngradually weaned off ventilation and tolerated trach mask well.\n\nHis blood sugar was well controlled with glargine and sliding\nscale. He was also noted to have decubitus ulcer. Plastic\nsurgery was consulted and felt that debridement was not\nnecessary. Therefore, he was cotinued on wet to dry dressing,\nKinair bed and his nutrition was optimized. He remiained in\nnormal sinus rhythm and is on coumadin for history of atrial\nfibrillation.', '\n\nHe was very agitated in the ICU. He was weaned off fentanyl drip\nand put on fentanyl patch. He also was put on standing zyprexa\nand prn haldol, morphine. He was also on standing valium and was\nactually thought to be in benzo withdrawal as his wife claims\nthat he was on valium at home.He is full code and his health\ncare proxy is his wife.\n\n.\n\n\nMedications on Admission:\n1)Paroxetine 20mg QD\n2)Ferrous Sulfate\n3)Colace 100mg Reynolds, Webster and Kelly Hospital\n4)MVI\n5)Atorvastatin 10mg QD\n6)vitamin B12 1946 mcg PO QD\n7)Combivent neb q2-4 hr\n8)Senna 1tab Reynolds, Webster and Kelly Hospital\n9)Coumadin titrate to INR\n10)Insulin SS + NPH fixed dose\n11)Prednisone taper (starting 6-27 as 20,20,10,10,5,5, off)\n12)Ambien 10mg qhs prn insomnia\n13) Flovent 2 puffs Reynolds, Webster and Kelly Hospital\n14) Fentanyl 75 mcg/hr Patch Q72HR\n15) Lactulose\n16) Percocet prn\n17) Valium PRN\n\n\nDischarge Medications:\n1.', ' Acetaminophen 325 mg Tablet Reynolds, Webster and Kelly Hospital: 1-2 Tablets PO Q4-6H (every\n4 to 6 hours) as needed.\n2. Paroxetine HCl 20 mg Tablet Reynolds, Webster and Kelly Hospital: One (1) Tablet PO DAILY\n(Daily).\n3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Reynolds, Webster and Kelly Hospital: One\n(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).\n4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Reynolds, Webster and Kelly Hospital: Two\n(2) Puff Inhalation Q6H (every 6 hours).\n5. Albuterol 90 mcg/Actuation Aerosol Reynolds, Webster and Kelly Hospital: Two (2) Puff\nInhalation Q4-6H (every 4 to 6 hours) as needed.\n6. Fentanyl 75 mcg/hr Patch 72HR Reynolds, Webster and Kelly Hospital: One (1) Patch 72HR\nTransdermal Q72H (every 72 hours).\n7. Senna 8.6 mg Tablet Reynolds, Webster and Kelly Hospital: Two (2) Tablet PO BID (2 times a\nday).', '\n8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Reynolds, Webster and Kelly Hospital: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.\n9. Lactulose 10 g/15 mL Syrup Reynolds, Webster and Kelly Hospital: Thirty (30) ML PO TID (3\ntimes a day).\n10. Warfarin Sodium 2.5 mg Tablet Reynolds, Webster and Kelly Hospital: One (1) Tablet PO HS (at\nbedtime).\n11. Olanzapine 10 mg Tablet Reynolds, Webster and Kelly Hospital: One (1) Tablet PO once a day.\n12. Ascorbic Acid 100 mg/mL Drops Reynolds, Webster and Kelly Hospital: 2.5 ml PO DAILY (Daily).\n\n13. Diazepam 10 mg Tablet Reynolds, Webster and Kelly Hospital: One (1) Tablet PO Q8H (every 8\nhours).\n14. Zinc Sulfate 220 mg Capsule Reynolds, Webster and Kelly Hospital: One (1) Capsule PO DAILY\n(Daily).\n15. Haloperidol 3-5 mg IV Q4H:PRN\n16.', ' Morphine Sulfate 2 mg/mL Syringe Reynolds, Webster and Kelly Hospital: 7-29 ml March Q4H\n(every 4 hours) as needed.\n17. Insulin Glargine 100 unit/mL Solution March: Twenty Eight (28)\nunit Subcutaneous at breakfast.\n18. Ceftazidime 1 g Recon Soln March: One (1) Recon Soln\nIntravenous every eight (8) hours for 4 days.\n19. Vancocin HCl 1,000 mg Recon Soln March: One (1) Recon Soln\nIntravenous every twelve (12) hours for 4 days.\n20. Flagyl 500 mg Tablet March: One (1) Tablet PO three times a\nday for 4 days.\n\n\nDischarge Disposition:\nExtended Care\n\nDischarge Diagnosis:\n1. sepsis\nsecondary:\n1. lung cancer post right pneumonectomy\n2. type 2 diabetes\n3. COPD\n4. atrial afibrillation\n5. gout\n6. GERD\n7. hypertension\n8. hypercholesterolemia\n\n\nDischarge Condition:\nstable\n\nDischarge Instructions:\nPlease return to the hospital if you have shortness of breath,\nfever or if there are any cocnerns at all.', ' PLease take all your\nprescribed medication\n\n\nFollowup Instructions:\nto rehab\n\n Karissa Sakkas MD, 50638088\n\nCompleted by:1954-6-25']
22	15472	104146.0	2179-02-08	Discharge summary	Report	Admission Date: [2179-2-1] Discharge Date: [2179-2-8] Date of Birth: [2114-2-8] Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:[Last Name (NamePattern4) 290] Chief Complaint: chest pain Major Surgical or Invasive Procedure: stenting of SVC History of Present Illness: 64 yo man with h/o lung CA s/p R pneumonectomy, severe COPD, with prolonged respiratory failure requiring prolonged trach (2 months ago) wean presents from rehab with increased bilateral upper extremety edema (present since [10-31] admission) and left sided chest pain for 2 days(continuous for about 20hrs). Patient denies any fevers, chills, cough, radiation, diaphoeris, no similar pain in past, no pleuritic nature, n/v/diaphoresis. No associated triggers or change with positions, no pain currently. He had been doing well at rehab this past week after ativan and valium were stopped and started on haldol with good relief. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in [2174]. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus [2174]. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in [2165]. 8. Gout. 9. Atypical chest pain since [2164]. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in [10-31] resulting in ventilator dependence, trach and [Date Range 282] placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo [7-31]: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to [Hospital ] rehab s/p trach and [Hospital 282]. He has a 3-pack-per-day tobacco history but quit in [2174] and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: VS: T 99.2 P 72-91 BP 129/75 R19 Sat 100% on AC 500/20/5/40% GEN aao, nad, able to mouth responses to questions HEENT PERRL, MMM, +trach in place CHEST CTAB with diffuse expiratory wheezes bilaterally posteriorly CV RRR- no murmurs ABD soft, +[Year (4 digits) 282] in place, +BS, nontender EXT no edema BLE, +edema BUE with scabs and excoriations Pertinent Results: [2179-2-1] 05:00PM CK(CPK)-54 CK-MB-NotDone cTropnT-0.09* [2179-2-2] 12:00AM CK(CPK)-55 CK-MB-NotDone cTropnT-0.12* [2179-2-2] 05:25AM BLOOD CK(CPK)-56 CK-MB-NotDone cTropnT-0.14* [2179-2-2] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.12* [2179-2-2] 08:12PM BLOOD CK-MB-NotDone cTropnT-0.11* [2179-2-3] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.12* . [2179-2-1] 05:00PM GLUCOSE-77 UREA N-18 CREAT-0.6 SODIUM-137 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-43* ANION GAP-3* [2179-2-1] 05:00PM WBC-9.1 RBC-3.36* HGB-9.3* HCT-30.4* MCV-91 MCH-27.8 MCHC-30.7* RDW-13.9 [2179-2-1] 05:00PM NEUTS-87.3* LYMPHS-7.4* MONOS-3.7 EOS-1.2 BASOS-0.3 [2179-2-1] 05:00PM PLT COUNT-358 [2179-2-1] 05:00PM PT-18.0* PTT-31.0 INR(PT)-2.0 . CTA 1. No CT evidence of pulmonary embolism. 2. Stable right pneumonectomy changes. 3. Stable left upper lobe pulmonary nodule. 4. Small mediastinal lymph nodes, none of which meet criteria for pathologic enlargement. 5. Stable appearance of the superior vena cava which is patent throughout, but compressed proximally to a slit-like lumen. 5. Chronic occlusion of the left subclavian artery and vein with numerous vascular collaterals demonstrated within the anterior chest wall. . Brief Hospital Course: A/P: 64 yo man s/p lung ca s/p pneumonectomy and severe COPD here after prolonged admission for respiratory failure requiring tracheostomy placement here with new left sided chest pain. . 1. Chest pain: Multiple sets of cardiac enzymes were cycled and CK/MB remained flat while troponin increased slightly and then remained stable at 0.12. Repeat EKGs showed no changes. Cardiology was consulted and agreed that there was no evidence of an acute ischemic event. Pt was continued on ASA. The pt's chest pain may be related to his chronic SVC syndrome. . 2. Respiratory Failure: Pt on a prolonged ventilator wean secondary to COPD, pneumonectomy, lung cancer and hx of recurrent pneumonias. Pt was continued on AC at night and pressure support during the day. He will continued to wean at rehab. . 3. Bilateral upper extremety swelling: This has been chronic since last admission w/o evidence of DVT. Pt had another CTA in the ER that showed no PE but did show a narrowing of the SVC. Interventional radiology placed a stent in the SVC and over the next several days, the pt's upper ext swelling improved. . 4. Atrial fibrillation: Pt remained in normal sinus rhythm for most of the hospital stay except for a brief episode of a fib with rapid ventricular rate which resolved on its own. Pt was continued on his coumadin. . 5. Anxiety: Pt has a long history of anxiety controlled on fentanyl, morphine prn, haldol. AVOID benzos as pt has paradoxical response. * 6. Anemia: Likely secondary to chronic disease- baseline around 28. Iron studies were sent and revealed a low iron with normal TIBC, ferritin. He was transfused once to [Last Name (un) 291] hct>30. . 7. DM type 2: Pt's glucose was controlled with glargine and an insulin sliding scale. . 8. Access: A PICC line was placed by IR when pt was having his SVC stented. If this line is not needed, it should be pulled to decrease infection risk. It was placed on [2179-2-4]. Medications on Admission: haldol 2mg at q800/1400 and 5mg qhs and 1mg prn tid bacitracin, clotrimazole/betamethasone, albuterol neb q4hrs, budesonide 0.5mg neb q12hrs, ipratropium neb q4hrs, casec powder wafarin 7mg qd, colace 100mg [Hospital1 ], glargine 14units qam, glycerin suppository daily, MVI qd, magnes hydroxide 30ml qd lactulose 20gm tid, acetaminaphen 650mg q4hr prn, SSI, ambien 10mg qhs prn, ascorbic acid 500mg [Hospital1 ], zinc sulfate 220mg qd, sodium bicarbonate 10cc qd, lansoprazole 30mg qd, fentanyl 75mcg patch q72hrs, morphine 2-4mg IV prn Discharge Medications: 1. Haloperidol 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 2. Haloperidol 2 mg Tablet [Hospital1 ]: One (1) Tablet PO Q8AM/2PM (). 3. Haloperidol 1 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day) as needed for agitation. 4. Docusate Sodium 150 mg/15 mL Liquid [Hospital1 ]: Fifteen (15) mL PO BID (2 times a day). 5. Zolpidem Tartrate 5 mg Tablet [Hospital1 ]: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 6. Lactulose 10 g/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Fentanyl 75 mcg/hr Patch 72HR [Hospital1 ]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual [Hospital1 ]: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 11. Multivitamin Capsule [Hospital1 ]: One (1) Cap PO DAILY (Daily). 12. Ascorbic Acid 100 mg/mL Drops [Hospital1 ]: One (1) mL PO BID (2 times a day). 13. Zinc Sulfate 220 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 14. Clotrimazole 1 % Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 15. Betamethasone Dipropionate 0.05 % Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 16. Bacitracin Zinc 500 unit/g Ointment [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 17. Warfarin Sodium 5 mg Tablet [Hospital1 ]: 1.5 Tablets PO HS (at bedtime): goal INR [12-31]. 18. Albuterol 90 mcg/Actuation Aerosol [Month/Day (3) ]: Four (4) Puff Inhalation Q4H (every 4 hours). 19. Ipratropium Bromide 18 mcg/Actuation Aerosol [Month/Day (3) ]: Two (2) Puff Inhalation QID (4 times a day). 20. Fluticasone Propionate 110 mcg/Actuation Aerosol [Month/Day (3) ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 21. Insulin Glargine 100 unit/mL Solution [Hospital1 ]: Fourteen (14) units Subcutaneous at bedtime. 22. Bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal DAILY (Daily) as needed. 23. Senna 8.8 mg/5 mL Syrup [Hospital1 ]: Five (5) mL) PO BID (2 times a day) as needed. 24. Morphine Sulfate 2 mg/mL Syringe [Hospital1 ]: [11-29] mL [Month/Day (2) ] Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary Diagnosis: 1. SVC syndrome 2. Angina Secondary Diagnosis: 1. Respiratory Failure s/p trach 2. Anxiety Discharge Condition: good Discharge Instructions: take all medications as prescribed and go to all follow-up appointments Followup Instructions: Follow-up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ], as needed [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	Admission Date: <Date>1944-4-27</Date> Discharge Date: <Date>2010-1-27</Date> Date of Birth: <Date>1907-10-5</Date> Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:<Name>Shipley</Name> Chief Complaint: chest pain Major Surgical or Invasive Procedure: stenting of SVC History of Present Illness: 64 yo man with h/o lung CA s/p R pneumonectomy, severe COPD, with prolonged respiratory failure requiring prolonged trach (2 months ago) wean presents from rehab with increased bilateral upper extremety edema (present since <Date>5-27</Date> admission) and left sided chest pain for 2 days(continuous for about 20hrs). Patient denies any fevers, chills, cough, radiation, diaphoeris, no similar pain in past, no pleuritic nature, n/v/diaphoresis. No associated triggers or change with positions, no pain currently. He had been doing well at rehab this past week after ativan and valium were stopped and started on haldol with good relief. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in <Year>1900</Year>. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus <Year>1900</Year>. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in <Year>1900</Year>. 8. Gout. 9. Atypical chest pain since <Year>1900</Year>. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in <Date>5-27</Date> resulting in ventilator dependence, trach and <Date Range>1909-10-9 to 1942-4-9</Date Range> placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo <Date>6-5</Date>: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to <Hospital>Morales-Boone Hospital</Hospital> rehab s/p trach and <Hospital>Brown-Johnson Hospital</Hospital>. He has a 3-pack-per-day tobacco history but quit in <Year>1900</Year> and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: VS: T 99.2 P 72-91 BP 129/75 R19 Sat 100% on AC 500/20/5/40% GEN aao, nad, able to mouth responses to questions HEENT PERRL, MMM, +trach in place CHEST CTAB with diffuse expiratory wheezes bilaterally posteriorly CV RRR- no murmurs ABD soft, +<Year>2014</Year> in place, +BS, nontender EXT no edema BLE, +edema BUE with scabs and excoriations Pertinent Results: <Date>1944-4-27</Date> 05:00PM CK(CPK)-54 CK-MB-NotDone cTropnT-0.09* <Date>1976-4-27</Date> 12:00AM CK(CPK)-55 CK-MB-NotDone cTropnT-0.12* <Date>1976-4-27</Date> 05:25AM BLOOD CK(CPK)-56 CK-MB-NotDone cTropnT-0.14* <Date>1976-4-27</Date> 01:10PM BLOOD CK-MB-NotDone cTropnT-0.12* <Date>1976-4-27</Date> 08:12PM BLOOD CK-MB-NotDone cTropnT-0.11* <Date>2011-11-2</Date> 03:59AM BLOOD CK-MB-NotDone cTropnT-0.12* . <Date>1944-4-27</Date> 05:00PM GLUCOSE-77 UREA N-18 CREAT-0.6 SODIUM-137 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-43* ANION GAP-3* <Date>1944-4-27</Date> 05:00PM WBC-9.1 RBC-3.36* HGB-9.3* HCT-30.4* MCV-91 MCH-27.8 MCHC-30.7* RDW-13.9 <Date>1944-4-27</Date> 05:00PM NEUTS-87.3* LYMPHS-7.4* MONOS-3.7 EOS-1.2 BASOS-0.3 <Date>1944-4-27</Date> 05:00PM PLT COUNT-358 <Date>1944-4-27</Date> 05:00PM PT-18.0* PTT-31.0 INR(PT)-2.0 . CTA 1. No CT evidence of pulmonary embolism. 2. Stable right pneumonectomy changes. 3. Stable left upper lobe pulmonary nodule. 4. Small mediastinal lymph nodes, none of which meet criteria for pathologic enlargement. 5. Stable appearance of the superior vena cava which is patent throughout, but compressed proximally to a slit-like lumen. 5. Chronic occlusion of the left subclavian artery and vein with numerous vascular collaterals demonstrated within the anterior chest wall. . Brief Hospital Course: A/P: 64 yo man s/p lung ca s/p pneumonectomy and severe COPD here after prolonged admission for respiratory failure requiring tracheostomy placement here with new left sided chest pain. . 1. Chest pain: Multiple sets of cardiac enzymes were cycled and CK/MB remained flat while troponin increased slightly and then remained stable at 0.12. Repeat EKGs showed no changes. Cardiology was consulted and agreed that there was no evidence of an acute ischemic event. Pt was continued on ASA. The pt's chest pain may be related to his chronic SVC syndrome. . 2. Respiratory Failure: Pt on a prolonged ventilator wean secondary to COPD, pneumonectomy, lung cancer and hx of recurrent pneumonias. Pt was continued on AC at night and pressure support during the day. He will continued to wean at rehab. . 3. Bilateral upper extremety swelling: This has been chronic since last admission w/o evidence of DVT. Pt had another CTA in the ER that showed no PE but did show a narrowing of the SVC. Interventional radiology placed a stent in the SVC and over the next several days, the pt's upper ext swelling improved. . 4. Atrial fibrillation: Pt remained in normal sinus rhythm for most of the hospital stay except for a brief episode of a fib with rapid ventricular rate which resolved on its own. Pt was continued on his coumadin. . 5. Anxiety: Pt has a long history of anxiety controlled on fentanyl, morphine prn, haldol. AVOID benzos as pt has paradoxical response. * 6. Anemia: Likely secondary to chronic disease- baseline around 28. Iron studies were sent and revealed a low iron with normal TIBC, ferritin. He was transfused once to <Name>Merino</Name> hct>30. . 7. DM type 2: Pt's glucose was controlled with glargine and an insulin sliding scale. . 8. Access: A PICC line was placed by IR when pt was having his SVC stented. If this line is not needed, it should be pulled to decrease infection risk. It was placed on <Date>1952-1-26</Date>. Medications on Admission: haldol 2mg at q800/1400 and 5mg qhs and 1mg prn tid bacitracin, clotrimazole/betamethasone, albuterol neb q4hrs, budesonide 0.5mg neb q12hrs, ipratropium neb q4hrs, casec powder wafarin 7mg qd, colace 100mg <Hospital>Smith Group Medical Center</Hospital>, glargine 14units qam, glycerin suppository daily, MVI qd, magnes hydroxide 30ml qd lactulose 20gm tid, acetaminaphen 650mg q4hr prn, SSI, ambien 10mg qhs prn, ascorbic acid 500mg <Hospital>Smith Group Medical Center</Hospital>, zinc sulfate 220mg qd, sodium bicarbonate 10cc qd, lansoprazole 30mg qd, fentanyl 75mcg patch q72hrs, morphine 2-4mg IV prn Discharge Medications: 1. Haloperidol 5 mg Tablet <Hospital>Smith Group Medical Center</Hospital>: One (1) Tablet PO HS (at bedtime). 2. Haloperidol 2 mg Tablet <Hospital>Smith Group Medical Center</Hospital>: One (1) Tablet PO Q8AM/2PM (). 3. Haloperidol 1 mg Tablet <Hospital>Smith Group Medical Center</Hospital>: One (1) Tablet PO TID (3 times a day) as needed for agitation. 4. Docusate Sodium 150 mg/15 mL Liquid <Hospital>Smith Group Medical Center</Hospital>: Fifteen (15) mL PO BID (2 times a day). 5. Zolpidem Tartrate 5 mg Tablet <Hospital>Smith Group Medical Center</Hospital>: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 6. Lactulose 10 g/15 mL Syrup <Hospital>Smith Group Medical Center</Hospital>: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) <Hospital>Smith Group Medical Center</Hospital>: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Fentanyl 75 mcg/hr Patch 72HR <Hospital>Smith Group Medical Center</Hospital>: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) <Hospital>Smith Group Medical Center</Hospital>: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual <Hospital>Smith Group Medical Center</Hospital>: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 11. Multivitamin Capsule <Hospital>Smith Group Medical Center</Hospital>: One (1) Cap PO DAILY (Daily). 12. Ascorbic Acid 100 mg/mL Drops <Hospital>Smith Group Medical Center</Hospital>: One (1) mL PO BID (2 times a day). 13. Zinc Sulfate 220 mg Capsule <Hospital>Smith Group Medical Center</Hospital>: One (1) Capsule PO DAILY (Daily). 14. Clotrimazole 1 % Cream <Hospital>Smith Group Medical Center</Hospital>: One (1) Appl Topical <Hospital>Smith Group Medical Center</Hospital> (2 times a day). 15. Betamethasone Dipropionate 0.05 % Cream <Hospital>Smith Group Medical Center</Hospital>: One (1) Appl Topical <Hospital>Smith Group Medical Center</Hospital> (2 times a day). 16. Bacitracin Zinc 500 unit/g Ointment <Hospital>Smith Group Medical Center</Hospital>: One (1) Appl Topical <Hospital>Smith Group Medical Center</Hospital> (2 times a day). 17. Warfarin Sodium 5 mg Tablet <Hospital>Smith Group Medical Center</Hospital>: 1.5 Tablets PO HS (at bedtime): goal INR <Date>2-7</Date>. 18. Albuterol 90 mcg/Actuation Aerosol <Month>May</Month>: Four (4) Puff Inhalation Q4H (every 4 hours). 19. Ipratropium Bromide 18 mcg/Actuation Aerosol <Month>May</Month>: Two (2) Puff Inhalation QID (4 times a day). 20. Fluticasone Propionate 110 mcg/Actuation Aerosol <Month>May</Month>: Two (2) Puff Inhalation <Hospital>Smith Group Medical Center</Hospital> (2 times a day). 21. Insulin Glargine 100 unit/mL Solution <Hospital>Smith Group Medical Center</Hospital>: Fourteen (14) units Subcutaneous at bedtime. 22. Bisacodyl 10 mg Suppository <Hospital>Smith Group Medical Center</Hospital>: One (1) Suppository Rectal DAILY (Daily) as needed. 23. Senna 8.8 mg/5 mL Syrup <Hospital>Smith Group Medical Center</Hospital>: Five (5) mL) PO BID (2 times a day) as needed. 24. Morphine Sulfate 2 mg/mL Syringe <Hospital>Smith Group Medical Center</Hospital>: <Date>2-30</Date> mL <Month>January</Month> Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: <Hospital>Kim, Richardson and Phelps Health System</Hospital> & Rehab Center - <Hospital>Johnson, Myers and Oconnor Hospital</Hospital> Discharge Diagnosis: Primary Diagnosis: 1. SVC syndrome 2. Angina Secondary Diagnosis: 1. Respiratory Failure s/p trach 2. Anxiety Discharge Condition: good Discharge Instructions: take all medications as prescribed and go to all follow-up appointments Followup Instructions: Follow-up with your PCP, <Name>Olles</Name>. <Name>Pleasant</Name>, as needed <Initial>PA</Initial> <Name>Olles</Name> <Name>Alexander Ornelas</Name> MD <MD Number>29518168</MD 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Date: 1944-4-27 Discharge Date: 2010-1-27 Date of Birth: 1907-10-5 Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:Shipley Chief Complaint: chest pain Major Surgical or Invasive Procedure: stenting of SVC History of Present Illness: 64 yo man with h/o lung CA s/p R pneumonectomy, severe COPD, with prolonged respiratory failure requiring prolonged trach (2 months ago) wean presents from rehab with increased bilateral upper extremety edema (present since 5-27 admission) and left sided chest pain for 2 days(continuous for about 20hrs). Patient denies any fevers, chills, cough, radiation, diaphoeris, no similar pain in past, no pleuritic nature, n/v/diaphoresis. No associated triggers or change with positions, no pain currently. He had been doing well at rehab this past week after ativan and valium were stopped and started on haldol with good relief. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in 1900. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus 1900. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in 1900. 8. Gout. 9. Atypical chest pain since 1900. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in 5-27 resulting in ventilator dependence, trach and 1909-10-9 to 1942-4-9 placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo 6-5: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to Morales-Boone Hospital rehab s/p trach and Brown-Johnson Hospital. He has a 3-pack-per-day tobacco history but quit in 1900 and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: VS: T 99.2 P 72-91 BP 129/75 R19 Sat 100% on AC 500/20/5/40% GEN aao, nad, able to mouth responses to questions HEENT PERRL, MMM, +trach in place CHEST CTAB with diffuse expiratory wheezes bilaterally posteriorly CV RRR- no murmurs ABD soft, +2014 in place, +BS, nontender EXT no edema BLE, +edema BUE with scabs and excoriations Pertinent Results: 1944-4-27 05:00PM CK(CPK)-54 CK-MB-NotDone cTropnT-0.09* 1976-4-27 12:00AM CK(CPK)-55 CK-MB-NotDone cTropnT-0.12* 1976-4-27 05:25AM BLOOD CK(CPK)-56 CK-MB-NotDone cTropnT-0.14* 1976-4-27 01:10PM BLOOD CK-MB-NotDone cTropnT-0.12* 1976-4-27 08:12PM BLOOD CK-MB-NotDone cTropnT-0.11* 2011-11-2 03:59AM BLOOD CK-MB-NotDone cTropnT-0.12* . 1944-4-27 05:00PM GLUCOSE-77 UREA N-18 CREAT-0.6 SODIUM-137 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-43* ANION GAP-3* 1944-4-27 05:00PM WBC-9.1 RBC-3.36* HGB-9.3* HCT-30.4* MCV-91 MCH-27.8 MCHC-30.7* RDW-13.9 1944-4-27 05:00PM NEUTS-87.3* LYMPHS-7.4* MONOS-3.7 EOS-1.2 BASOS-0.3 1944-4-27 05:00PM PLT COUNT-358 1944-4-27 05:00PM PT-18.0* PTT-31.0 INR(PT)-2.0 . CTA 1. No CT evidence of pulmonary embolism. 2. Stable right pneumonectomy changes. 3. Stable left upper lobe pulmonary nodule. 4. Small mediastinal lymph nodes, none of which meet criteria for pathologic enlargement. 5. Stable appearance of the superior vena cava which is patent throughout, but compressed proximally to a slit-like lumen. 5. Chronic occlusion of the left subclavian artery and vein with numerous vascular collaterals demonstrated within the anterior chest wall. . Brief Hospital Course: A/P: 64 yo man s/p lung ca s/p pneumonectomy and severe COPD here after prolonged admission for respiratory failure requiring tracheostomy placement here with new left sided chest pain. . 1. Chest pain: Multiple sets of cardiac enzymes were cycled and CK/MB remained flat while troponin increased slightly and then remained stable at 0.12. Repeat EKGs showed no changes. Cardiology was consulted and agreed that there was no evidence of an acute ischemic event. Pt was continued on ASA. The pt's chest pain may be related to his chronic SVC syndrome. . 2. Respiratory Failure: Pt on a prolonged ventilator wean secondary to COPD, pneumonectomy, lung cancer and hx of recurrent pneumonias. Pt was continued on AC at night and pressure support during the day. He will continued to wean at rehab. . 3. Bilateral upper extremety swelling: This has been chronic since last admission w/o evidence of DVT. Pt had another CTA in the ER that showed no PE but did show a narrowing of the SVC. Interventional radiology placed a stent in the SVC and over the next several days, the pt's upper ext swelling improved. . 4. Atrial fibrillation: Pt remained in normal sinus rhythm for most of the hospital stay except for a brief episode of a fib with rapid ventricular rate which resolved on its own. Pt was continued on his coumadin. . 5. Anxiety: Pt has a long history of anxiety controlled on fentanyl, morphine prn, haldol. AVOID benzos as pt has paradoxical response. * 6. Anemia: Likely secondary to chronic disease- baseline around 28. Iron studies were sent and revealed a low iron with normal TIBC, ferritin. He was transfused once to Merino hct>30. . 7. DM type 2: Pt's glucose was controlled with glargine and an insulin sliding scale. . 8. Access: A PICC line was placed by IR when pt was having his SVC stented. If this line is not needed, it should be pulled to decrease infection risk. It was placed on 1952-1-26. Medications on Admission: haldol 2mg at q800/1400 and 5mg qhs and 1mg prn tid bacitracin, clotrimazole/betamethasone, albuterol neb q4hrs, budesonide 0.5mg neb q12hrs, ipratropium neb q4hrs, casec powder wafarin 7mg qd, colace 100mg Smith Group Medical Center, glargine 14units qam, glycerin suppository daily, MVI qd, magnes hydroxide 30ml qd lactulose 20gm tid, acetaminaphen 650mg q4hr prn, SSI, ambien 10mg qhs prn, ascorbic acid 500mg Smith Group Medical Center, zinc sulfate 220mg qd, sodium bicarbonate 10cc qd, lansoprazole 30mg qd, fentanyl 75mcg patch q72hrs, morphine 2-4mg IV prn Discharge Medications: 1. Haloperidol 5 mg Tablet Smith Group Medical Center: One (1) Tablet PO HS (at bedtime). 2. Haloperidol 2 mg Tablet Smith Group Medical Center: One (1) Tablet PO Q8AM/2PM (). 3. Haloperidol 1 mg Tablet Smith Group Medical Center: One (1) Tablet PO TID (3 times a day) as needed for agitation. 4. Docusate Sodium 150 mg/15 mL Liquid Smith Group Medical Center: Fifteen (15) mL PO BID (2 times a day). 5. Zolpidem Tartrate 5 mg Tablet Smith Group Medical Center: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 6. Lactulose 10 g/15 mL Syrup Smith Group Medical Center: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Smith Group Medical Center: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Fentanyl 75 mcg/hr Patch 72HR Smith Group Medical Center: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Smith Group Medical Center: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual Smith Group Medical Center: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 11. Multivitamin Capsule Smith Group Medical Center: One (1) Cap PO DAILY (Daily). 12. Ascorbic Acid 100 mg/mL Drops Smith Group Medical Center: One (1) mL PO BID (2 times a day). 13. Zinc Sulfate 220 mg Capsule Smith Group Medical Center: One (1) Capsule PO DAILY (Daily). 14. Clotrimazole 1 % Cream Smith Group Medical Center: One (1) Appl Topical Smith Group Medical Center (2 times a day). 15. Betamethasone Dipropionate 0.05 % Cream Smith Group Medical Center: One (1) Appl Topical Smith Group Medical Center (2 times a day). 16. Bacitracin Zinc 500 unit/g Ointment Smith Group Medical Center: One (1) Appl Topical Smith Group Medical Center (2 times a day). 17. Warfarin Sodium 5 mg Tablet Smith Group Medical Center: 1.5 Tablets PO HS (at bedtime): goal INR 2-7. 18. Albuterol 90 mcg/Actuation Aerosol May: Four (4) Puff Inhalation Q4H (every 4 hours). 19. Ipratropium Bromide 18 mcg/Actuation Aerosol May: Two (2) Puff Inhalation QID (4 times a day). 20. Fluticasone Propionate 110 mcg/Actuation Aerosol May: Two (2) Puff Inhalation Smith Group Medical Center (2 times a day). 21. Insulin Glargine 100 unit/mL Solution Smith Group Medical Center: Fourteen (14) units Subcutaneous at bedtime. 22. Bisacodyl 10 mg Suppository Smith Group Medical Center: One (1) Suppository Rectal DAILY (Daily) as needed. 23. Senna 8.8 mg/5 mL Syrup Smith Group Medical Center: Five (5) mL) PO BID (2 times a day) as needed. 24. Morphine Sulfate 2 mg/mL Syringe Smith Group Medical Center: 2-30 mL January Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: Kim, Richardson and Phelps Health System & Rehab Center - Johnson, Myers and Oconnor Hospital Discharge Diagnosis: Primary Diagnosis: 1. SVC syndrome 2. Angina Secondary Diagnosis: 1. Respiratory Failure s/p trach 2. Anxiety Discharge Condition: good Discharge Instructions: take all medications as prescribed and go to all follow-up appointments Followup Instructions: Follow-up with your PCP, Olles. Pleasant, as needed PA Olles Alexander Ornelas MD 29518168	['Admission Date: 1944-4-27 Discharge Date: 2010-1-27\n\nDate of Birth: 1907-10-5 Sex: M\n\nService: MEDICINE\n\nAllergies:\nDoxepin / Levofloxacin / Oxycontin\n\nAttending:Shipley\nChief Complaint:\nchest pain\n\nMajor Surgical or Invasive Procedure:\nstenting of SVC\n\n\nHistory of Present Illness:\n64 yo man with h/o lung CA s/p R pneumonectomy, severe COPD,\nwith prolonged respiratory failure requiring prolonged trach (2\nmonths ago) wean presents from rehab with increased bilateral\nupper extremety edema (present since 5-27 admission) and left\nsided chest pain for 2 days(continuous for about 20hrs). Patient\ndenies any fevers, chills, cough, radiation, diaphoeris, no\nsimilar pain in past, no pleuritic nature, n/v/diaphoresis. No\nassociated triggers or change with positions, no pain currently.', '\nHe had been doing well at rehab this past week after ativan and\nvalium were stopped and started on haldol with good relief.\n\nPast Medical History:\n1. Squamous cell lung carcinoma, status post right\npneumonectomy in 1900.\n2. Prostate cancer, status post radical prostatectomy.\n3. Perioperative pulmonary embolus 1900.\n4. Type 2 diabetes mellitus.\n5. Chronic obstructive pulmonary disease.\n6. Atrial fibrillation.\n7. Transient ischemic attack in 1900.\n8. Gout.\n9. Atypical chest pain since 1900.\n10. Gastroesophageal reflux disease.\n11. Obstructive sleep apnea. unable to tolerate BiPAP.\n12. Hypertension.\n13. Colonic polyps.\n14. Hypercholesterolemia.\n15. Basal cell carcinoma on his back.\n16. Anxiety.\n17. Sciatica.\n18. History of herpes zoster.\n19. multiple admissions for pneumonia (including pseudomonas)\nand bronchitis, last in 5-27 resulting in ventilator\ndependence, trach and 1909-10-9 to 1942-4-9 placement\n20.', ' vitamin B12 deficiency.\n21. Diastolic heart failure. Echo 6-5: LVEF>55%\n21. Cataracts\n22. bradycardia on amiodarone\n\nSocial History:\nRecently discharged to Morales-Boone Hospital rehab s/p trach and Brown-Johnson Hospital. He has\na 3-pack-per-day tobacco history but quit in 1900 and an overall\n160-pack-per-year history. No recent history of alcohol use.\n\nFamily History:\nMother with coronary artery disease.\n\n\nPhysical Exam:\nVS: T 99.2 P 72-91 BP 129/75 R19 Sat 100% on AC 500/20/5/40%\nGEN aao, nad, able to mouth responses to questions\nHEENT PERRL, MMM, +trach in place\nCHEST CTAB with diffuse expiratory wheezes bilaterally\nposteriorly\nCV RRR- no murmurs\nABD soft, +2014 in place, +BS, nontender\nEXT no edema BLE, +edema BUE with scabs and excoriations\n\n\nPertinent Results:\n1944-4-27 05:00PM CK(CPK)-54 CK-MB-NotDone cTropnT-0.', '09\n1976-4-27 12:00AM CK(CPK)-55 CK-MB-NotDone cTropnT-0.12\n1976-4-27 05:25AM BLOOD CK(CPK)-56 CK-MB-NotDone cTropnT-0.14\n1976-4-27 01:10PM BLOOD CK-MB-NotDone cTropnT-0.12\n1976-4-27 08:12PM BLOOD CK-MB-NotDone cTropnT-0.11\n2011-11-2 03:59AM BLOOD CK-MB-NotDone cTropnT-0.12\n.\n\n1944-4-27 05:00PM GLUCOSE-77 UREA N-18 CREAT-0.6 SODIUM-137\nPOTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-43* ANION GAP-3\n1944-4-27 05:00PM WBC-9.1 RBC-3.36 HGB-9.3* HCT-30.4* MCV-91\nMCH-27.8 MCHC-30.7* RDW-13.9\n1944-4-27 05:00PM NEUTS-87.3* LYMPHS-7.4* MONOS-3.7 EOS-1.2\nBASOS-0.3\n1944-4-27 05:00PM PLT COUNT-358\n1944-4-27 05:00PM PT-18.0* PTT-31.0 INR(PT)-2.0\n.\nCTA\n1. No CT evidence of pulmonary embolism.\n2. Stable right pneumonectomy changes.\n3. Stable left upper lobe pulmonary nodule.\n4. Small mediastinal lymph nodes, none of which meet criteria\nfor pathologic enlargement.', "\n5. Stable appearance of the superior vena cava which is patent\nthroughout, but compressed proximally to a slit-like lumen.\n5. Chronic occlusion of the left subclavian artery and vein with\nnumerous vascular collaterals demonstrated within the anterior\nchest wall.\n.\n\n\nBrief Hospital Course:\nA/P: 64 yo man s/p lung ca s/p pneumonectomy and severe COPD\nhere after prolonged admission for respiratory failure requiring\ntracheostomy placement here with new left sided chest pain.\n.\n1. Chest pain: Multiple sets of cardiac enzymes were cycled and\nCK/MB remained flat while troponin increased slightly and then\nremained stable at 0.12. Repeat EKGs showed no changes.\nCardiology was consulted and agreed that there was no evidence\nof an acute ischemic event. Pt was continued on ASA. The pt's\nchest pain may be related to his chronic SVC syndrome.", "\n.\n2. Respiratory Failure: Pt on a prolonged ventilator wean\nsecondary to COPD, pneumonectomy, lung cancer and hx of\nrecurrent pneumonias. Pt was continued on AC at night and\npressure support during the day. He will continued to wean at\nrehab.\n.\n3. Bilateral upper extremety swelling: This has been chronic\nsince last admission w/o evidence of DVT. Pt had another CTA in\nthe ER that showed no PE but did show a narrowing of the SVC.\nInterventional radiology placed a stent in the SVC and over the\nnext several days, the pt's upper ext swelling improved.\n.\n4. Atrial fibrillation: Pt remained in normal sinus rhythm for\nmost of the hospital stay except for a brief episode of a fib\nwith rapid ventricular rate which resolved on its own. Pt was\ncontinued on his coumadin.\n.\n5. Anxiety: Pt has a long history of anxiety controlled on\nfentanyl, morphine prn, haldol.", " AVOID benzos as pt has\nparadoxical response.\n*\n6. Anemia: Likely secondary to chronic disease- baseline around\n28. Iron studies were sent and revealed a low iron with normal\nTIBC, ferritin. He was transfused once to Merino hct>30.\n.\n7. DM type 2: Pt's glucose was controlled with glargine and an\ninsulin sliding scale.\n.\n8. Access: A PICC line was placed by IR when pt was having his\nSVC stented. If this line is not needed, it should be pulled to\ndecrease infection risk. It was placed on 1952-1-26.\n\n\nMedications on Admission:\nhaldol 2mg at q800/1400 and 5mg qhs and 1mg prn tid\nbacitracin, clotrimazole/betamethasone, albuterol neb q4hrs,\nbudesonide 0.5mg neb q12hrs, ipratropium neb q4hrs, casec powder\n\nwafarin 7mg qd, colace 100mg Smith Group Medical Center, glargine 14units qam, glycerin\nsuppository daily, MVI qd, magnes hydroxide 30ml qd\nlactulose 20gm tid, acetaminaphen 650mg q4hr prn, SSI, ambien\n10mg qhs prn, ascorbic acid 500mg Smith Group Medical Center, zinc sulfate 220mg qd,\nsodium bicarbonate 10cc qd, lansoprazole 30mg qd, fentanyl 75mcg\npatch q72hrs, morphine 2-4mg IV prn\n\n\nDischarge Medications:\n1.", ' Haloperidol 5 mg Tablet Smith Group Medical Center: One (1) Tablet PO HS (at\nbedtime).\n2. Haloperidol 2 mg Tablet Smith Group Medical Center: One (1) Tablet PO Q8AM/2PM ().\n3. Haloperidol 1 mg Tablet Smith Group Medical Center: One (1) Tablet PO TID (3 times a\nday) as needed for agitation.\n4. Docusate Sodium 150 mg/15 mL Liquid Smith Group Medical Center: Fifteen (15) mL PO\nBID (2 times a day).\n5. Zolpidem Tartrate 5 mg Tablet Smith Group Medical Center: Two (2) Tablet PO HS (at\nbedtime) as needed for insomnia.\n6. Lactulose 10 g/15 mL Syrup Smith Group Medical Center: Thirty (30) ML PO Q8H (every\n8 hours) as needed for constipation.\n7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Smith Group Medical Center: One\n(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).\n8. Fentanyl 75 mcg/hr Patch 72HR Smith Group Medical Center: One (1) Patch 72HR\nTransdermal Q72H (every 72 hours).', '\n9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Smith Group Medical Center: One (1)\nTablet, Delayed Release (E.C.) PO DAILY (Daily).\n10. Nitroglycerin 0.3 mg Tablet, Sublingual Smith Group Medical Center: One (1) Tablet,\nSublingual Sublingual PRN (as needed) as needed for chest pain.\n\n11. Multivitamin Capsule Smith Group Medical Center: One (1) Cap PO DAILY (Daily).\n\n12. Ascorbic Acid 100 mg/mL Drops Smith Group Medical Center: One (1) mL PO BID (2\ntimes a day).\n13. Zinc Sulfate 220 mg Capsule Smith Group Medical Center: One (1) Capsule PO DAILY\n(Daily).\n14. Clotrimazole 1 % Cream Smith Group Medical Center: One (1) Appl Topical Smith Group Medical Center (2\ntimes a day).\n15. Betamethasone Dipropionate 0.05 % Cream Smith Group Medical Center: One (1) Appl\nTopical Smith Group Medical Center (2 times a day).', '\n16. Bacitracin Zinc 500 unit/g Ointment Smith Group Medical Center: One (1) Appl\nTopical Smith Group Medical Center (2 times a day).\n17. Warfarin Sodium 5 mg Tablet Smith Group Medical Center: 1.5 Tablets PO HS (at\nbedtime): goal INR 2-7.\n18. Albuterol 90 mcg/Actuation Aerosol May: Four (4) Puff\nInhalation Q4H (every 4 hours).\n19. Ipratropium Bromide 18 mcg/Actuation Aerosol May: Two (2)\nPuff Inhalation QID (4 times a day).\n20. Fluticasone Propionate 110 mcg/Actuation Aerosol May: Two\n(2) Puff Inhalation Smith Group Medical Center (2 times a day).\n21. Insulin Glargine 100 unit/mL Solution Smith Group Medical Center: Fourteen (14)\nunits Subcutaneous at bedtime.\n22. Bisacodyl 10 mg Suppository Smith Group Medical Center: One (1) Suppository Rectal\nDAILY (Daily) as needed.\n23. Senna 8.8 mg/5 mL Syrup Smith Group Medical Center: Five (5) mL) PO BID (2 times a\nday) as needed.', '\n24. Morphine Sulfate 2 mg/mL Syringe Smith Group Medical Center: 2-30 mL January Q4H\n(every 4 hours) as needed for pain.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nKim, Richardson and Phelps Health System & Rehab Center - Johnson, Myers and Oconnor Hospital\n\nDischarge Diagnosis:\nPrimary Diagnosis:\n1. SVC syndrome\n2. Angina\n\nSecondary Diagnosis:\n1. Respiratory Failure s/p trach\n2. Anxiety\n\n\nDischarge Condition:\ngood\n\nDischarge Instructions:\ntake all medications as prescribed and go to all follow-up\nappointments\n\nFollowup Instructions:\nFollow-up with your PCP, Olles. Pleasant, as needed\n\n\n PA Olles Alexander Ornelas MD 29518168\n\n']
23	15472	143651.0	2179-03-26	Discharge summary	Report	Admission Date: [2179-3-21] Discharge Date: [2179-3-26] Date of Birth: [2114-2-8] Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan Attending:[Last Name (NamePattern1) 293] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right Internal Jugular Central Venous Catheter Placement [2179-3-21] Tracheal Tube Change History of Present Illness: 64 year-old gentleman with MMP, history of lung cancer s/p right pneumonectomy in [2174], severe COPD, recently discharged from [Hospital1 18] MICU [2178-12-2] s/p tracheostomy and [Month/Day/Year 282] placement after admission for respiratory failure due to pneumonia, now re-admitted to [Hospital1 18] with hypotension, tachycardia and UTI. . In the ED, RIJ placed, he was given 4L IVF and started on CTX. CT head no ICH, CXR ? infiltrate vs CHF. CTA neg for PE (prelim) with clear lung fields, no infiltrates. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in [2174]. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus [2174]. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in [2165]. 8. Gout. 9. Atypical chest pain since [2164]. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in [10-31] resulting in ventilator dependence, trach and [Date Range 282] placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo [7-31]: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to [Hospital ] rehab s/p trach and [Hospital 282]. He has a 3-pack-per-day tobacco history but quit in [2174] and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: AF, 80, 112/52, 99% on vent gen: a/o, rouses to voice; no acute distress heent: eomi, perrla, mm slightly dry neck: trach in place, RIJ in place cv: rrr, no m/r/g pulm: left lung field with mild rhonchi at lung base abd: NABS, soft, NT, ND; [Year (4 digits) 282] tube in place extr: trace peripheral edema neuro: CN in tact, non-focal Pertinent Results: [2179-3-21] 06:33PM PO2-132* PCO2-78* PH-7.31* TOTAL CO2-41* BASE XS-9 [2179-3-21] 04:57PM PO2-87 PCO2-78* PH-7.33* TOTAL CO2-43* BASE XS-10 [2179-3-21] 04:26PM LACTATE-0.7 [2179-3-21] 04:23PM GLUCOSE-93 UREA N-18 CREAT-0.5 SODIUM-141 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-40* ANION GAP-9 [2179-3-21] 04:23PM CK(CPK)-33* [2179-3-21] 04:23PM cTropnT-0.13* [2179-3-21] 04:23PM CK-MB-NotDone [2179-3-21] 04:23PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-1.8 [2179-3-21] 04:23PM TSH-1.7 [2179-3-21] 04:23PM CORTISOL-35.6* [2179-3-21] 04:23PM WBC-15.6# RBC-3.89 HGB-10.2* HCT-34.5* MCV-89 MCH-26.4* MCHC-29.7* RDW-14.1 [2179-3-21] 04:23PM NEUTS-91.0* LYMPHS-4.5* MONOS-3.9 EOS-0.4 BASOS-0.1 [2179-3-21] 04:23PM HYPOCHROM-3+ [2179-3-21] 04:23PM PLT COUNT-420# [2179-3-21] 04:23PM PT-20.5* PTT-32.2 INR(PT)-2.7 [2179-3-21] 04:23PM URINE COLOR-Amber APPEAR-Cloudy SP [Last Name (un) 155]-1.020 [2179-3-21] 04:23PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-SM [2179-3-21] 04:23PM URINE RBC->50 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-[1-30] [2179-3-21] 04:23PM URINE AMORPH-MANY [2179-3-21] 04:23PM URINE COMMENT-0-2 COARSE GRANULAR CASTS Brief Hospital Course: 65yo man with many medical problems p/w hypotension in the setting of rapid aitral flutter. Also with a Urinary Tract Infection. Assessment/Plan: 64 year-old male w/ history of lung ca s/p right pneumonectomy, severe COPD, recent trach and [Month/Day/Year 282] [Hospital ] rehab with a flutter 2:1, leukocytosis, hypotension and UTI. . 1. Hypotension: [Month (only) 116] have been due to infection from UTI vs. symptomatic tachycardia. Responded to aggresive fluid resusciation and rate control. Remained normotensive for the rest of hospitalization. Of note, his blood pressures were lower in left arm and family reported that this is a [Last Name 294] problem for him. . 2. Atrial Flutter: He has a known history of paroxysmal Atrial Fibrillation.His was initially in rapid Atrial Fluuter with 2:1 conduction. This initially responded to diltiazem. On hopital day #2 he went back into artial flutter and in consultation with Electrophysiology service Amiodarone was initiated and diltiazem was stopped (as he had been on Amiodarone for 3.5 years in the past, and it had to be discontinued [10-31] due to bradycardia when lopressor was added). He remained in sinus rhythm for the remainder of the hospitalization. Plan is continue Amiodarone 400mg TID x 1 week then 400mg [Hospital1 ] x 1 week then 200mg po QD thereafter. He is to avoid beta blockers and calcium channel blockers. 3. Respiratory Failure: His chest x-ray showed no evidence of Pneumonia. Due to a notable trach leak, his trach was changed by respiraotory. An interventional Pulmonolgy consult was obtained due to concern of cuff leak and possible tracheomalacia. Dr. [Last Name (STitle) ] recommended keeping the cuff pressures low with a cuff leak to prevent further tracheamalacia-- he would be willing to change the trach to a foam-filled trach ([Last Name (un) 295] tube) in the future if the cuff leak is interfering with the ability to ventilate. He was continued on PS as tolerated with periods of rest on Assist Control. . 4. Klebsiella Urinary Tract Infection: He was initally started on ceftriaxone which was changed to levofloxacin but given history of heart block to levo, he was changed to Bactrim to complete a 7-day course for complicated UTI. The Urine Culture grew Klebsiella which is sensitive to Bactrim.His foley catheter was discontinued. . 5.Acute Blood Loss Anemia: His baseline hematocrit was 28-30. He was initially hemo-concentrated, but then on hospital day #3, his hematorcit dropped to 19. due to extensive bleeding from site of central line, he was transfused 2 UPRBC and had an appropriate bump in his hematocrit. He was noted to have [Known lastname ] guaiac positive stool, but this was in the setting of extensive bleeding from Internal Jugular catheter site into his trach/mouth. His hematocrit should be followed as an outpatient, and his stools should be continued to check guauic studies for trace blood. . 6. Bleeding from Central Line site. He is maintained on coumadin for Atrial Fibrillation and his inital INR was therapeutic. After IJ placement, he had continued oozing from IJ site leading to anemia with hct 19. He was given FFP and vitamin K (0.5 mg iv) to reverse his coagultopathy. He should be restarted on coumadin for Atrial Fibrillation at rehab. . 5. Diabetes Mellitis: He was continued on glargine and regular insulin sliding scale. His sugars were in good control. . 6. Pain/anxiety/depression: He was continued on his outpatient doses of Fentanyl 75mcg/q72hours, Haldol for anxiety 5mg hs, 2mg 8am/2pm, 1mg tid/prn, and paxil. His pain is from his scaral decubitus ulcer. . 7. Sacral Decubitus: He was seen by wound care nurse and continued on DSD for sacral wound. . 8. Left Upper Extremity Swelling: He had U/S which showed... . 9. Diastolic Congestive Heart Failure: He was given lasix prn to keep fluid even. . 10.Code: FULL . 11. Dispo: Discharged to [Hospital ] Rehab. . 12. Access: The Right Internal Jugular Vein triple lumen catheter was not discontinued per [Hospital1 296] request. This was placed on [2179-3-21]. ------ Outstanding issues on discharge: 1.The pt was started on coumadin at 5 mg qday on day of discharge [3-26]. Please monitor his INR and adjust dose accordingly. 2.The pt has a swollen L arm and had U/S on day of discharge to r/o clot. No read has been given yet. Please call [Hospital1 18] to follow this up. Regardless, he is being restarted on anticoagulation which would be treatment of choice. Medications on Admission: fentanyl 75mcg q72h haldol 5 HS lantus 16U HS ISS atrovent QID prevacid 30 qD ASA 325 qD vit C 500 [Hospital1 ] MVI paxil 20 qD vit D 800 U zinc 220 levalbuterol cardizem 30 TID coumadin 7.5 HS haldol 2mg (8am/2pm) Haldol 1mg prn Discharge Medications: 1. Fentanyl 75 mcg/hr Patch 72HR [Hospital1 ]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Paroxetine HCl 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 4. Zolpidem Tartrate 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 5. Haloperidol 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 6. Haloperidol 2 mg Tablet [Hospital1 ]: One (1) Tablet PO AT 8AM AND 2PM (). 7. Haloperidol 1 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day) as needed. 8. Zinc Sulfate 220 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 10. Multivitamin Capsule [Hospital1 ]: One (1) Cap PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day). 12. Ascorbic Acid 500 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 13. Ipratropium Bromide 18 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation QID (4 times a day). 14. Albuterol 90 mcg/Actuation Aerosol [Hospital1 ]: 2-4 Puffs Inhalation Q6H (every 6 hours). 15. Fluticasone Propionate 110 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 16. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. Morphine Sulfate 10 mg/5 mL Solution [Hospital1 ]: Five (5) mg PO Q4H (every 4 hours) as needed for back pain. 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 20. Amiodarone HCl 200 mg Tablet [Hospital1 ]: Two (2) Tablet PO three times a day: 400mg TID x 7 days then 400mg [Hospital1 ] x 7 days then 200mg qd ongoing. 21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) for 1 weeks: Last dose on [3-28]. 22. Insulin Glargine 100 unit/mL Solution [Month (only) ]: Seven (7) units Subcutaneous at bedtime. units 23. Insulin Regular Human 100 unit/mL Cartridge [Month (only) ]: per sliding scale units [Month (only) ] four times a day: 0-60 mg/dL -->[11-29] amp D50 61-150 mg/dL--> 0 Units 151-200 mg/dL--> 2 Units 201-250 mg/dL--> 4 Units 251-300 mg/dL--> 6 Units > 300 mg/dL Notify M.D. . 24. Coumadin 5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO once a day: Please monitor INR and adjust as needed. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Rapid Atrial Flutter Hypotension Klebsiella Urinary Tract Infection Left Upper Extremity Swelling Acute Blood Loss Anemia Diastolic CHF Discharge Condition: Stable on the following vent settings:Assist Control TV 450 x RR 12 with PEEP 8 and Fi02 40% Discharge Instructions: Weigh pt q morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1500cc If you experience any increasing fever, chills, chest pain Followup Instructions: Follow up with your PCP [Last Name (NamePattern4) ] [11-29] weeks	Admission Date: <Date>1908-9-31</Date> Discharge Date: <Date>2018-1-20</Date> Date of Birth: <Date>2019-6-22</Date> Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan Attending:<Name>Grier</Name> Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right Internal Jugular Central Venous Catheter Placement <Date>1908-9-31</Date> Tracheal Tube Change History of Present Illness: 64 year-old gentleman with MMP, history of lung cancer s/p right pneumonectomy in <Year>1902</Year>, severe COPD, recently discharged from <Hospital>Martinez PLC Medical Center</Hospital> MICU <Date>2015-10-20</Date> s/p tracheostomy and <Month>July</Month> placement after admission for respiratory failure due to pneumonia, now re-admitted to <Hospital>Martinez PLC Medical Center</Hospital> with hypotension, tachycardia and UTI. . In the ED, RIJ placed, he was given 4L IVF and started on CTX. CT head no ICH, CXR ? infiltrate vs CHF. CTA neg for PE (prelim) with clear lung fields, no infiltrates. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in <Year>1902</Year>. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus <Year>1902</Year>. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in <Year>1902</Year>. 8. Gout. 9. Atypical chest pain since <Year>1902</Year>. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in <Date>9-10</Date> resulting in ventilator dependence, trach and <Date Range>1943-5-15 to 1945-12-26</Date Range> placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo <Date>12-21</Date>: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to <Hospital>Williams-Trujillo Medical Center</Hospital> rehab s/p trach and <Hospital>Dickerson LLC Medical Center</Hospital>. He has a 3-pack-per-day tobacco history but quit in <Year>1902</Year> and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: AF, 80, 112/52, 99% on vent gen: a/o, rouses to voice; no acute distress heent: eomi, perrla, mm slightly dry neck: trach in place, RIJ in place cv: rrr, no m/r/g pulm: left lung field with mild rhonchi at lung base abd: NABS, soft, NT, ND; <Year>1947</Year> tube in place extr: trace peripheral edema neuro: CN in tact, non-focal Pertinent Results: <Date>1908-9-31</Date> 06:33PM PO2-132* PCO2-78* PH-7.31* TOTAL CO2-41* BASE XS-9 <Date>1908-9-31</Date> 04:57PM PO2-87 PCO2-78* PH-7.33* TOTAL CO2-43* BASE XS-10 <Date>1908-9-31</Date> 04:26PM LACTATE-0.7 <Date>1908-9-31</Date> 04:23PM GLUCOSE-93 UREA N-18 CREAT-0.5 SODIUM-141 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-40* ANION GAP-9 <Date>1908-9-31</Date> 04:23PM CK(CPK)-33* <Date>1908-9-31</Date> 04:23PM cTropnT-0.13* <Date>1908-9-31</Date> 04:23PM CK-MB-NotDone <Date>1908-9-31</Date> 04:23PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-1.8 <Date>1908-9-31</Date> 04:23PM TSH-1.7 <Date>1908-9-31</Date> 04:23PM CORTISOL-35.6* <Date>1908-9-31</Date> 04:23PM WBC-15.6# RBC-3.89 HGB-10.2* HCT-34.5* MCV-89 MCH-26.4* MCHC-29.7* RDW-14.1 <Date>1908-9-31</Date> 04:23PM NEUTS-91.0* LYMPHS-4.5* MONOS-3.9 EOS-0.4 BASOS-0.1 <Date>1908-9-31</Date> 04:23PM HYPOCHROM-3+ <Date>1908-9-31</Date> 04:23PM PLT COUNT-420# <Date>1908-9-31</Date> 04:23PM PT-20.5* PTT-32.2 INR(PT)-2.7 <Date>1908-9-31</Date> 04:23PM URINE COLOR-Amber APPEAR-Cloudy SP <Name>Lofft</Name>-1.020 <Date>1908-9-31</Date> 04:23PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-SM <Date>1908-9-31</Date> 04:23PM URINE RBC->50 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-<Date>11-2</Date> <Date>1908-9-31</Date> 04:23PM URINE AMORPH-MANY <Date>1908-9-31</Date> 04:23PM URINE COMMENT-0-2 COARSE GRANULAR CASTS Brief Hospital Course: 65yo man with many medical problems p/w hypotension in the setting of rapid aitral flutter. Also with a Urinary Tract Infection. Assessment/Plan: 64 year-old male w/ history of lung ca s/p right pneumonectomy, severe COPD, recent trach and <Month>July</Month> <Hospital>Williams-Trujillo Medical Center</Hospital> rehab with a flutter 2:1, leukocytosis, hypotension and UTI. . 1. Hypotension: <Month>November</Month> have been due to infection from UTI vs. symptomatic tachycardia. Responded to aggresive fluid resusciation and rate control. Remained normotensive for the rest of hospitalization. Of note, his blood pressures were lower in left arm and family reported that this is a <Name>Walker</Name> problem for him. . 2. Atrial Flutter: He has a known history of paroxysmal Atrial Fibrillation.His was initially in rapid Atrial Fluuter with 2:1 conduction. This initially responded to diltiazem. On hopital day #2 he went back into artial flutter and in consultation with Electrophysiology service Amiodarone was initiated and diltiazem was stopped (as he had been on Amiodarone for 3.5 years in the past, and it had to be discontinued <Date>9-10</Date> due to bradycardia when lopressor was added). He remained in sinus rhythm for the remainder of the hospitalization. Plan is continue Amiodarone 400mg TID x 1 week then 400mg <Hospital>White, Casey and Terrell Clinic</Hospital> x 1 week then 200mg po QD thereafter. He is to avoid beta blockers and calcium channel blockers. 3. Respiratory Failure: His chest x-ray showed no evidence of Pneumonia. Due to a notable trach leak, his trach was changed by respiraotory. An interventional Pulmonolgy consult was obtained due to concern of cuff leak and possible tracheomalacia. Dr. <Name>Islam</Name> recommended keeping the cuff pressures low with a cuff leak to prevent further tracheamalacia-- he would be willing to change the trach to a foam-filled trach (<Name>Blanks</Name> tube) in the future if the cuff leak is interfering with the ability to ventilate. He was continued on PS as tolerated with periods of rest on Assist Control. . 4. Klebsiella Urinary Tract Infection: He was initally started on ceftriaxone which was changed to levofloxacin but given history of heart block to levo, he was changed to Bactrim to complete a 7-day course for complicated UTI. The Urine Culture grew Klebsiella which is sensitive to Bactrim.His foley catheter was discontinued. . 5.Acute Blood Loss Anemia: His baseline hematocrit was 28-30. He was initially hemo-concentrated, but then on hospital day #3, his hematorcit dropped to 19. due to extensive bleeding from site of central line, he was transfused 2 UPRBC and had an appropriate bump in his hematocrit. He was noted to have <Name>Cobbs</Name> guaiac positive stool, but this was in the setting of extensive bleeding from Internal Jugular catheter site into his trach/mouth. His hematocrit should be followed as an outpatient, and his stools should be continued to check guauic studies for trace blood. . 6. Bleeding from Central Line site. He is maintained on coumadin for Atrial Fibrillation and his inital INR was therapeutic. After IJ placement, he had continued oozing from IJ site leading to anemia with hct 19. He was given FFP and vitamin K (0.5 mg iv) to reverse his coagultopathy. He should be restarted on coumadin for Atrial Fibrillation at rehab. . 5. Diabetes Mellitis: He was continued on glargine and regular insulin sliding scale. His sugars were in good control. . 6. Pain/anxiety/depression: He was continued on his outpatient doses of Fentanyl 75mcg/q72hours, Haldol for anxiety 5mg hs, 2mg 8am/2pm, 1mg tid/prn, and paxil. His pain is from his scaral decubitus ulcer. . 7. Sacral Decubitus: He was seen by wound care nurse and continued on DSD for sacral wound. . 8. Left Upper Extremity Swelling: He had U/S which showed... . 9. Diastolic Congestive Heart Failure: He was given lasix prn to keep fluid even. . 10.Code: FULL . 11. Dispo: Discharged to <Hospital>Williams-Trujillo Medical Center</Hospital> Rehab. . 12. Access: The Right Internal Jugular Vein triple lumen catheter was not discontinued per <Hospital>Carter, Mendez and Gutierrez Hospital</Hospital> request. This was placed on <Date>1908-9-31</Date>. ------ Outstanding issues on discharge: 1.The pt was started on coumadin at 5 mg qday on day of discharge <Date>1-28</Date>. Please monitor his INR and adjust dose accordingly. 2.The pt has a swollen L arm and had U/S on day of discharge to r/o clot. No read has been given yet. Please call <Hospital>Martinez PLC Medical Center</Hospital> to follow this up. Regardless, he is being restarted on anticoagulation which would be treatment of choice. Medications on Admission: fentanyl 75mcg q72h haldol 5 HS lantus 16U HS ISS atrovent QID prevacid 30 qD ASA 325 qD vit C 500 <Hospital>White, Casey and Terrell Clinic</Hospital> MVI paxil 20 qD vit D 800 U zinc 220 levalbuterol cardizem 30 TID coumadin 7.5 HS haldol 2mg (8am/2pm) Haldol 1mg prn Discharge Medications: 1. Fentanyl 75 mcg/hr Patch 72HR <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Aspirin 325 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Tablet PO DAILY (Daily). 3. Paroxetine HCl 20 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Tablet PO DAILY (Daily). 4. Zolpidem Tartrate 5 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Tablet PO HS (at bedtime). 5. Haloperidol 5 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Tablet PO HS (at bedtime). 6. Haloperidol 2 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Tablet PO AT 8AM AND 2PM (). 7. Haloperidol 1 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Tablet PO TID (3 times a day) as needed. 8. Zinc Sulfate 220 mg Capsule <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Capsule PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: Two (2) Tablet PO DAILY (Daily). 10. Multivitamin Capsule <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Cap PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Capsule PO BID (2 times a day). 12. Ascorbic Acid 500 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Tablet PO BID (2 times a day). 13. Ipratropium Bromide 18 mcg/Actuation Aerosol <Hospital>White, Casey and Terrell Clinic</Hospital>: Two (2) Puff Inhalation QID (4 times a day). 14. Albuterol 90 mcg/Actuation Aerosol <Hospital>White, Casey and Terrell Clinic</Hospital>: 2-4 Puffs Inhalation Q6H (every 6 hours). 15. Fluticasone Propionate 110 mcg/Actuation Aerosol <Hospital>White, Casey and Terrell Clinic</Hospital>: Two (2) Puff Inhalation <Hospital>White, Casey and Terrell Clinic</Hospital> (2 times a day). 16. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. Morphine Sulfate 10 mg/5 mL Solution <Hospital>White, Casey and Terrell Clinic</Hospital>: Five (5) mg PO Q4H (every 4 hours) as needed for back pain. 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) <Hospital>White, Casey and Terrell Clinic</Hospital>: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Senna 8.6 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Tablet PO BID (2 times a day). 20. Amiodarone HCl 200 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: Two (2) Tablet PO three times a day: 400mg TID x 7 days then 400mg <Hospital>White, Casey and Terrell Clinic</Hospital> x 7 days then 200mg qd ongoing. 21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet <Hospital>White, Casey and Terrell Clinic</Hospital>: One (1) Tablet PO BID (2 times a day) for 1 weeks: Last dose on <Date>6-15</Date>. 22. Insulin Glargine 100 unit/mL Solution <Month>June</Month>: Seven (7) units Subcutaneous at bedtime. units 23. Insulin Regular Human 100 unit/mL Cartridge <Month>June</Month>: per sliding scale units <Month>June</Month> four times a day: 0-60 mg/dL --><Date>6-14</Date> amp D50 61-150 mg/dL--> 0 Units 151-200 mg/dL--> 2 Units 201-250 mg/dL--> 4 Units 251-300 mg/dL--> 6 Units > 300 mg/dL Notify M.D. . 24. Coumadin 5 mg Tablet <Month>September</Month>: One (1) Tablet PO once a day: Please monitor INR and adjust as needed. Discharge Disposition: Extended Care Facility: <Hospital>Johnston-Sullivan Clinic</Hospital> & Rehab Center - <Hospital>Anderson-Schmitt Health System</Hospital> Discharge Diagnosis: Rapid Atrial Flutter Hypotension Klebsiella Urinary Tract Infection Left Upper Extremity Swelling Acute Blood Loss Anemia Diastolic CHF Discharge Condition: Stable on the following vent settings:Assist Control TV 450 x RR 12 with PEEP 8 and Fi02 40% Discharge Instructions: Weigh pt q morning, <Name>Heath Scheet</Name> MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1500cc If you experience any increasing fever, chills, chest pain Followup Instructions: Follow up with your PCP <Name>Hui</Name> <Date>6-14</Date> 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Date: 1908-9-31 Discharge Date: 2018-1-20 Date of Birth: 2019-6-22 Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan Attending:Grier Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right Internal Jugular Central Venous Catheter Placement 1908-9-31 Tracheal Tube Change History of Present Illness: 64 year-old gentleman with MMP, history of lung cancer s/p right pneumonectomy in 1902, severe COPD, recently discharged from Martinez PLC Medical Center MICU 2015-10-20 s/p tracheostomy and July placement after admission for respiratory failure due to pneumonia, now re-admitted to Martinez PLC Medical Center with hypotension, tachycardia and UTI. . In the ED, RIJ placed, he was given 4L IVF and started on CTX. CT head no ICH, CXR ? infiltrate vs CHF. CTA neg for PE (prelim) with clear lung fields, no infiltrates. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in 1902. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus 1902. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in 1902. 8. Gout. 9. Atypical chest pain since 1902. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in 9-10 resulting in ventilator dependence, trach and 1943-5-15 to 1945-12-26 placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo 12-21: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to Williams-Trujillo Medical Center rehab s/p trach and Dickerson LLC Medical Center. He has a 3-pack-per-day tobacco history but quit in 1902 and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: AF, 80, 112/52, 99% on vent gen: a/o, rouses to voice; no acute distress heent: eomi, perrla, mm slightly dry neck: trach in place, RIJ in place cv: rrr, no m/r/g pulm: left lung field with mild rhonchi at lung base abd: NABS, soft, NT, ND; 1947 tube in place extr: trace peripheral edema neuro: CN in tact, non-focal Pertinent Results: 1908-9-31 06:33PM PO2-132* PCO2-78* PH-7.31* TOTAL CO2-41* BASE XS-9 1908-9-31 04:57PM PO2-87 PCO2-78* PH-7.33* TOTAL CO2-43* BASE XS-10 1908-9-31 04:26PM LACTATE-0.7 1908-9-31 04:23PM GLUCOSE-93 UREA N-18 CREAT-0.5 SODIUM-141 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-40* ANION GAP-9 1908-9-31 04:23PM CK(CPK)-33* 1908-9-31 04:23PM cTropnT-0.13* 1908-9-31 04:23PM CK-MB-NotDone 1908-9-31 04:23PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-1.8 1908-9-31 04:23PM TSH-1.7 1908-9-31 04:23PM CORTISOL-35.6* 1908-9-31 04:23PM WBC-15.6# RBC-3.89 HGB-10.2* HCT-34.5* MCV-89 MCH-26.4* MCHC-29.7* RDW-14.1 1908-9-31 04:23PM NEUTS-91.0* LYMPHS-4.5* MONOS-3.9 EOS-0.4 BASOS-0.1 1908-9-31 04:23PM HYPOCHROM-3+ 1908-9-31 04:23PM PLT COUNT-420# 1908-9-31 04:23PM PT-20.5* PTT-32.2 INR(PT)-2.7 1908-9-31 04:23PM URINE COLOR-Amber APPEAR-Cloudy SP Lofft-1.020 1908-9-31 04:23PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-SM 1908-9-31 04:23PM URINE RBC->50 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-11-2 1908-9-31 04:23PM URINE AMORPH-MANY 1908-9-31 04:23PM URINE COMMENT-0-2 COARSE GRANULAR CASTS Brief Hospital Course: 65yo man with many medical problems p/w hypotension in the setting of rapid aitral flutter. Also with a Urinary Tract Infection. Assessment/Plan: 64 year-old male w/ history of lung ca s/p right pneumonectomy, severe COPD, recent trach and July Williams-Trujillo Medical Center rehab with a flutter 2:1, leukocytosis, hypotension and UTI. . 1. Hypotension: November have been due to infection from UTI vs. symptomatic tachycardia. Responded to aggresive fluid resusciation and rate control. Remained normotensive for the rest of hospitalization. Of note, his blood pressures were lower in left arm and family reported that this is a Walker problem for him. . 2. Atrial Flutter: He has a known history of paroxysmal Atrial Fibrillation.His was initially in rapid Atrial Fluuter with 2:1 conduction. This initially responded to diltiazem. On hopital day #2 he went back into artial flutter and in consultation with Electrophysiology service Amiodarone was initiated and diltiazem was stopped (as he had been on Amiodarone for 3.5 years in the past, and it had to be discontinued 9-10 due to bradycardia when lopressor was added). He remained in sinus rhythm for the remainder of the hospitalization. Plan is continue Amiodarone 400mg TID x 1 week then 400mg White, Casey and Terrell Clinic x 1 week then 200mg po QD thereafter. He is to avoid beta blockers and calcium channel blockers. 3. Respiratory Failure: His chest x-ray showed no evidence of Pneumonia. Due to a notable trach leak, his trach was changed by respiraotory. An interventional Pulmonolgy consult was obtained due to concern of cuff leak and possible tracheomalacia. Dr. Islam recommended keeping the cuff pressures low with a cuff leak to prevent further tracheamalacia-- he would be willing to change the trach to a foam-filled trach (Blanks tube) in the future if the cuff leak is interfering with the ability to ventilate. He was continued on PS as tolerated with periods of rest on Assist Control. . 4. Klebsiella Urinary Tract Infection: He was initally started on ceftriaxone which was changed to levofloxacin but given history of heart block to levo, he was changed to Bactrim to complete a 7-day course for complicated UTI. The Urine Culture grew Klebsiella which is sensitive to Bactrim.His foley catheter was discontinued. . 5.Acute Blood Loss Anemia: His baseline hematocrit was 28-30. He was initially hemo-concentrated, but then on hospital day #3, his hematorcit dropped to 19. due to extensive bleeding from site of central line, he was transfused 2 UPRBC and had an appropriate bump in his hematocrit. He was noted to have Cobbs guaiac positive stool, but this was in the setting of extensive bleeding from Internal Jugular catheter site into his trach/mouth. His hematocrit should be followed as an outpatient, and his stools should be continued to check guauic studies for trace blood. . 6. Bleeding from Central Line site. He is maintained on coumadin for Atrial Fibrillation and his inital INR was therapeutic. After IJ placement, he had continued oozing from IJ site leading to anemia with hct 19. He was given FFP and vitamin K (0.5 mg iv) to reverse his coagultopathy. He should be restarted on coumadin for Atrial Fibrillation at rehab. . 5. Diabetes Mellitis: He was continued on glargine and regular insulin sliding scale. His sugars were in good control. . 6. Pain/anxiety/depression: He was continued on his outpatient doses of Fentanyl 75mcg/q72hours, Haldol for anxiety 5mg hs, 2mg 8am/2pm, 1mg tid/prn, and paxil. His pain is from his scaral decubitus ulcer. . 7. Sacral Decubitus: He was seen by wound care nurse and continued on DSD for sacral wound. . 8. Left Upper Extremity Swelling: He had U/S which showed... . 9. Diastolic Congestive Heart Failure: He was given lasix prn to keep fluid even. . 10.Code: FULL . 11. Dispo: Discharged to Williams-Trujillo Medical Center Rehab. . 12. Access: The Right Internal Jugular Vein triple lumen catheter was not discontinued per Carter, Mendez and Gutierrez Hospital request. This was placed on 1908-9-31. ------ Outstanding issues on discharge: 1.The pt was started on coumadin at 5 mg qday on day of discharge 1-28. Please monitor his INR and adjust dose accordingly. 2.The pt has a swollen L arm and had U/S on day of discharge to r/o clot. No read has been given yet. Please call Martinez PLC Medical Center to follow this up. Regardless, he is being restarted on anticoagulation which would be treatment of choice. Medications on Admission: fentanyl 75mcg q72h haldol 5 HS lantus 16U HS ISS atrovent QID prevacid 30 qD ASA 325 qD vit C 500 White, Casey and Terrell Clinic MVI paxil 20 qD vit D 800 U zinc 220 levalbuterol cardizem 30 TID coumadin 7.5 HS haldol 2mg (8am/2pm) Haldol 1mg prn Discharge Medications: 1. Fentanyl 75 mcg/hr Patch 72HR White, Casey and Terrell Clinic: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Aspirin 325 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO DAILY (Daily). 3. Paroxetine HCl 20 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO DAILY (Daily). 4. Zolpidem Tartrate 5 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO HS (at bedtime). 5. Haloperidol 5 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO HS (at bedtime). 6. Haloperidol 2 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO AT 8AM AND 2PM (). 7. Haloperidol 1 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO TID (3 times a day) as needed. 8. Zinc Sulfate 220 mg Capsule White, Casey and Terrell Clinic: One (1) Capsule PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet White, Casey and Terrell Clinic: Two (2) Tablet PO DAILY (Daily). 10. Multivitamin Capsule White, Casey and Terrell Clinic: One (1) Cap PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule White, Casey and Terrell Clinic: One (1) Capsule PO BID (2 times a day). 12. Ascorbic Acid 500 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO BID (2 times a day). 13. Ipratropium Bromide 18 mcg/Actuation Aerosol White, Casey and Terrell Clinic: Two (2) Puff Inhalation QID (4 times a day). 14. Albuterol 90 mcg/Actuation Aerosol White, Casey and Terrell Clinic: 2-4 Puffs Inhalation Q6H (every 6 hours). 15. Fluticasone Propionate 110 mcg/Actuation Aerosol White, Casey and Terrell Clinic: Two (2) Puff Inhalation White, Casey and Terrell Clinic (2 times a day). 16. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) White, Casey and Terrell Clinic: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. Morphine Sulfate 10 mg/5 mL Solution White, Casey and Terrell Clinic: Five (5) mg PO Q4H (every 4 hours) as needed for back pain. 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) White, Casey and Terrell Clinic: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Senna 8.6 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO BID (2 times a day). 20. Amiodarone HCl 200 mg Tablet White, Casey and Terrell Clinic: Two (2) Tablet PO three times a day: 400mg TID x 7 days then 400mg White, Casey and Terrell Clinic x 7 days then 200mg qd ongoing. 21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO BID (2 times a day) for 1 weeks: Last dose on 6-15. 22. Insulin Glargine 100 unit/mL Solution June: Seven (7) units Subcutaneous at bedtime. units 23. Insulin Regular Human 100 unit/mL Cartridge June: per sliding scale units June four times a day: 0-60 mg/dL -->6-14 amp D50 61-150 mg/dL--> 0 Units 151-200 mg/dL--> 2 Units 201-250 mg/dL--> 4 Units 251-300 mg/dL--> 6 Units > 300 mg/dL Notify M.D. . 24. Coumadin 5 mg Tablet September: One (1) Tablet PO once a day: Please monitor INR and adjust as needed. Discharge Disposition: Extended Care Facility: Johnston-Sullivan Clinic & Rehab Center - Anderson-Schmitt Health System Discharge Diagnosis: Rapid Atrial Flutter Hypotension Klebsiella Urinary Tract Infection Left Upper Extremity Swelling Acute Blood Loss Anemia Diastolic CHF Discharge Condition: Stable on the following vent settings:Assist Control TV 450 x RR 12 with PEEP 8 and Fi02 40% Discharge Instructions: Weigh pt q morning, Heath Scheet MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1500cc If you experience any increasing fever, chills, chest pain Followup Instructions: Follow up with your PCP Hui 6-14 weeks	['Admission Date: 1908-9-31 Discharge Date: 2018-1-20\n\nDate of Birth: 2019-6-22 Sex: M\n\nService: MEDICINE\n\nAllergies:\nDoxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan\n\nAttending:Grier\nChief Complaint:\nHypotension\n\nMajor Surgical or Invasive Procedure:\nRight Internal Jugular Central Venous Catheter Placement 1908-9-31\nTracheal Tube Change\n\n\nHistory of Present Illness:\n64 year-old gentleman with MMP, history of lung cancer s/p right\npneumonectomy in 1902, severe COPD, recently discharged from\nMartinez PLC Medical Center MICU 2015-10-20 s/p tracheostomy and July placement after\nadmission for respiratory failure due to pneumonia, now\nre-admitted to Martinez PLC Medical Center with hypotension, tachycardia and UTI.\n.\n\nIn the ED, RIJ placed, he was given 4L IVF and started on CTX.', '\nCT head no ICH, CXR ? infiltrate vs CHF. CTA neg for PE (prelim)\nwith clear lung fields, no infiltrates.\n\nPast Medical History:\n1. Squamous cell lung carcinoma, status post right\npneumonectomy in 1902.\n2. Prostate cancer, status post radical prostatectomy.\n3. Perioperative pulmonary embolus 1902.\n4. Type 2 diabetes mellitus.\n5. Chronic obstructive pulmonary disease.\n6. Atrial fibrillation.\n7. Transient ischemic attack in 1902.\n8. Gout.\n9. Atypical chest pain since 1902.\n10. Gastroesophageal reflux disease.\n11. Obstructive sleep apnea. unable to tolerate BiPAP.\n12. Hypertension.\n13. Colonic polyps.\n14. Hypercholesterolemia.\n15. Basal cell carcinoma on his back.\n16. Anxiety.\n17. Sciatica.\n18. History of herpes zoster.\n19. multiple admissions for pneumonia (including pseudomonas)\nand bronchitis, last in 9-10 resulting in ventilator\ndependence, trach and 1943-5-15 to 1945-12-26 placement\n20.', ' vitamin B12 deficiency.\n21. Diastolic heart failure. Echo 12-21: LVEF>55%\n21. Cataracts\n22. bradycardia on amiodarone\n\nSocial History:\nRecently discharged to Williams-Trujillo Medical Center rehab s/p trach and Dickerson LLC Medical Center. He has\na 3-pack-per-day tobacco history but quit in 1902 and an overall\n160-pack-per-year history. No recent history of alcohol use.\n\nFamily History:\nMother with coronary artery disease.\n\n\nPhysical Exam:\nAF, 80, 112/52, 99% on vent\n\ngen: a/o, rouses to voice; no acute distress\nheent: eomi, perrla, mm slightly dry\nneck: trach in place, RIJ in place\ncv: rrr, no m/r/g\npulm: left lung field with mild rhonchi at lung base\nabd: NABS, soft, NT, ND; 1947 tube in place\nextr: trace peripheral edema\nneuro: CN in tact, non-focal\n\nPertinent Results:\n1908-9-31 06:33PM PO2-132* PCO2-78* PH-7.', '31* TOTAL CO2-41* BASE\nXS-9\n1908-9-31 04:57PM PO2-87 PCO2-78* PH-7.33* TOTAL CO2-43* BASE\nXS-10\n1908-9-31 04:26PM LACTATE-0.7\n1908-9-31 04:23PM GLUCOSE-93 UREA N-18 CREAT-0.5 SODIUM-141\nPOTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-40* ANION GAP-9\n1908-9-31 04:23PM CK(CPK)-33\n1908-9-31 04:23PM cTropnT-0.13\n1908-9-31 04:23PM CK-MB-NotDone\n1908-9-31 04:23PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-1.8\n1908-9-31 04:23PM TSH-1.7\n1908-9-31 04:23PM CORTISOL-35.6\n1908-9-31 04:23PM WBC-15.6# RBC-3.89* HGB-10.2* HCT-34.5\nMCV-89 MCH-26.4 MCHC-29.7* RDW-14.1\n1908-9-31 04:23PM NEUTS-91.0* LYMPHS-4.5* MONOS-3.9 EOS-0.4\nBASOS-0.1\n1908-9-31 04:23PM HYPOCHROM-3+\n1908-9-31 04:23PM PLT COUNT-420#\n1908-9-31 04:23PM PT-20.5* PTT-32.2 INR(PT)-2.7\n1908-9-31 04:23PM URINE COLOR-Amber APPEAR-Cloudy SP Lofft-1.', '020\n1908-9-31 04:23PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30\nGLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-SM\n1908-9-31 04:23PM URINE RBC->50 WBC-21-50* BACTERIA-MANY\nYEAST-NONE EPI-11-2\n1908-9-31 04:23PM URINE AMORPH-MANY\n1908-9-31 04:23PM URINE COMMENT-0-2 COARSE GRANULAR CASTS\n\nBrief Hospital Course:\n65yo man with many medical problems p/w hypotension in the\nsetting of rapid aitral flutter. Also with a Urinary Tract\nInfection.\n\nAssessment/Plan: 64 year-old male w/ history of lung ca s/p\nright pneumonectomy, severe COPD, recent trach and July Williams-Trujillo Medical Center\nrehab with a flutter 2:1, leukocytosis, hypotension and UTI.\n.\n1. Hypotension: November have been due to infection from UTI vs.\nsymptomatic tachycardia.\nResponded to aggresive fluid resusciation and rate control.', '\nRemained normotensive for the rest of hospitalization. Of note,\nhis blood pressures were lower in left arm and family reported\nthat this is a Walker problem for him.\n.\n2. Atrial Flutter: He has a known history of paroxysmal Atrial\nFibrillation.His was initially in rapid Atrial Fluuter with 2:1\nconduction. This initially responded to diltiazem. On hopital\nday #2 he went back into artial flutter and in consultation with\nElectrophysiology service Amiodarone was initiated and diltiazem\nwas stopped (as he had been on Amiodarone for 3.5 years in the\npast, and it had to be discontinued 9-10 due to bradycardia\nwhen lopressor was added). He remained in sinus rhythm for the\nremainder of the hospitalization. Plan is continue Amiodarone\n400mg TID x 1 week then 400mg White, Casey and Terrell Clinic x 1 week then 200mg po QD\nthereafter.', ' He is to avoid beta blockers and calcium channel\nblockers.\n\n3. Respiratory Failure: His chest x-ray showed no evidence of\nPneumonia. Due to a notable trach leak, his trach was changed by\nrespiraotory. An interventional Pulmonolgy consult was obtained\ndue to concern of cuff leak and possible tracheomalacia. Dr.\nIslam recommended keeping the cuff pressures low with a cuff\nleak to prevent further tracheamalacia-- he would be willing to\nchange the trach to a foam-filled trach (Blanks tube) in the\nfuture if the cuff leak is interfering with the ability to\nventilate. He was continued on PS as tolerated with periods of\nrest on Assist Control.\n.\n4. Klebsiella Urinary Tract Infection: He was initally started\non ceftriaxone which was changed to levofloxacin but given\nhistory of heart block to levo, he was changed to Bactrim to\ncomplete a 7-day course for complicated UTI.', ' The Urine Culture\ngrew Klebsiella which is sensitive to Bactrim.His foley catheter\nwas discontinued.\n.\n5.Acute Blood Loss Anemia: His baseline hematocrit was 28-30. He\nwas initially hemo-concentrated, but then on hospital day #3,\nhis hematorcit dropped to 19. due to extensive bleeding from\nsite of central line, he was transfused 2 UPRBC and had an\nappropriate bump in his hematocrit. He was noted to have Cobbs\nguaiac positive stool, but this was in the setting of extensive\nbleeding from Internal Jugular catheter site into his\ntrach/mouth. His hematocrit should be followed as an outpatient,\nand his stools should be continued to check guauic studies for\ntrace blood.\n.\n6. Bleeding from Central Line site. He is maintained on coumadin\nfor Atrial Fibrillation and his inital INR was therapeutic.\nAfter IJ placement, he had continued oozing from IJ site leading\nto anemia with hct 19.', ' He was given FFP and vitamin K (0.5 mg\niv) to reverse his coagultopathy. He should be restarted on\ncoumadin for Atrial Fibrillation at rehab.\n.\n5. Diabetes Mellitis: He was continued on glargine and regular\ninsulin sliding scale. His sugars were in good control.\n.\n6. Pain/anxiety/depression:\nHe was continued on his outpatient doses of Fentanyl\n75mcg/q72hours, Haldol for anxiety 5mg hs, 2mg 8am/2pm, 1mg\ntid/prn, and paxil. His pain is from his scaral decubitus\nulcer.\n.\n7. Sacral Decubitus: He was seen by wound care nurse and\ncontinued on DSD for sacral wound.\n.\n8. Left Upper Extremity Swelling: He had U/S which showed...\n.\n9. Diastolic Congestive Heart Failure: He was given lasix prn to\nkeep fluid even.\n.\n10.Code: FULL\n.\n11. Dispo: Discharged to Williams-Trujillo Medical Center Rehab.\n.', '\n12. Access: The Right Internal Jugular Vein triple lumen\ncatheter was not discontinued per Carter, Mendez and Gutierrez Hospital request. This was\nplaced on 1908-9-31.\n------\nOutstanding issues on discharge:\n1.The pt was started on coumadin at 5 mg qday on day of\ndischarge 1-28. Please monitor his INR and adjust dose\naccordingly.\n2.The pt has a swollen L arm and had U/S on day of discharge to\nr/o clot. No read has been given yet. Please call Martinez PLC Medical Center to\nfollow this up. Regardless, he is being restarted on\nanticoagulation which would be treatment of choice.\n\n\nMedications on Admission:\nfentanyl 75mcg q72h\nhaldol 5 HS\nlantus 16U HS\nISS\natrovent QID\nprevacid 30 qD\nASA 325 qD\nvit C 500 White, Casey and Terrell Clinic\nMVI\npaxil 20 qD\nvit D 800 U\nzinc 220\nlevalbuterol\ncardizem 30 TID\ncoumadin 7.', '5 HS\nhaldol 2mg (8am/2pm)\nHaldol 1mg prn\n\nDischarge Medications:\n1. Fentanyl 75 mcg/hr Patch 72HR White, Casey and Terrell Clinic: One (1) Patch 72HR\nTransdermal Q72H (every 72 hours).\n2. Aspirin 325 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO DAILY (Daily).\n3. Paroxetine HCl 20 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO DAILY\n(Daily).\n4. Zolpidem Tartrate 5 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO HS (at\nbedtime).\n5. Haloperidol 5 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO HS (at\nbedtime).\n6. Haloperidol 2 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO AT 8AM AND 2PM\n().\n7. Haloperidol 1 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO TID (3 times a\nday) as needed.\n8. Zinc Sulfate 220 mg Capsule White, Casey and Terrell Clinic: One (1) Capsule PO DAILY\n(Daily).', '\n9. Cholecalciferol (Vitamin D3) 400 unit Tablet White, Casey and Terrell Clinic: Two (2)\nTablet PO DAILY (Daily).\n10. Multivitamin Capsule White, Casey and Terrell Clinic: One (1) Cap PO DAILY (Daily).\n\n11. Docusate Sodium 100 mg Capsule White, Casey and Terrell Clinic: One (1) Capsule PO BID\n(2 times a day).\n12. Ascorbic Acid 500 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO BID (2\ntimes a day).\n13. Ipratropium Bromide 18 mcg/Actuation Aerosol White, Casey and Terrell Clinic: Two (2)\nPuff Inhalation QID (4 times a day).\n14. Albuterol 90 mcg/Actuation Aerosol White, Casey and Terrell Clinic: 2-4 Puffs Inhalation\nQ6H (every 6 hours).\n15. Fluticasone Propionate 110 mcg/Actuation Aerosol White, Casey and Terrell Clinic: Two\n(2) Puff Inhalation White, Casey and Terrell Clinic (2 times a day).', '\n16. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) White, Casey and Terrell Clinic: One\n(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).\n17. Morphine Sulfate 10 mg/5 mL Solution White, Casey and Terrell Clinic: Five (5) mg PO Q4H\n(every 4 hours) as needed for back pain.\n18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) White, Casey and Terrell Clinic: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.\n19. Senna 8.6 mg Tablet White, Casey and Terrell Clinic: One (1) Tablet PO BID (2 times a\nday).\n20. Amiodarone HCl 200 mg Tablet White, Casey and Terrell Clinic: Two (2) Tablet PO three\ntimes a day: 400mg TID x 7 days then 400mg White, Casey and Terrell Clinic x 7 days then\n200mg qd ongoing.\n21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet White, Casey and Terrell Clinic: One (1)\nTablet PO BID (2 times a day) for 1 weeks: Last dose on 6-15.', '\n22. Insulin Glargine 100 unit/mL Solution June: Seven (7) units\nSubcutaneous at bedtime. units\n23. Insulin Regular Human 100 unit/mL Cartridge June: per sliding\nscale units June four times a day:\n0-60 mg/dL -->6-14 amp D50\n61-150 mg/dL--> 0 Units\n151-200 mg/dL--> 2 Units\n201-250 mg/dL--> 4 Units\n251-300 mg/dL--> 6 Units\n> 300 mg/dL Notify M.D.\n.\n24. Coumadin 5 mg Tablet September: One (1) Tablet PO once a day:\nPlease monitor INR and adjust as needed.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nJohnston-Sullivan Clinic & Rehab Center - Anderson-Schmitt Health System\n\nDischarge Diagnosis:\nRapid Atrial Flutter\nHypotension\nKlebsiella Urinary Tract Infection\nLeft Upper Extremity Swelling\nAcute Blood Loss Anemia\nDiastolic CHF\n\n\nDischarge Condition:\nStable on the following vent settings:Assist Control TV 450 x RR\n12 with PEEP 8 and Fi02 40%\n\nDischarge Instructions:\nWeigh pt q morning, Heath Scheet MD if weight > 3 lbs.', '\nAdhere to 2 gm sodium diet\nFluid Restriction:1500cc\nIf you experience any increasing fever, chills, chest pain\n\nFollowup Instructions:\nFollow up with your PCP Hui 6-14 weeks\n\n\n\n']
24	15472	184486.0	2179-04-15	Discharge summary	Report	Admission Date: [2179-4-12] Discharge Date: [2179-4-15] Date of Birth: [2114-2-8] Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan Attending:[First Name3 (LF) 297] Chief Complaint: altered mental status and hypotension Major Surgical or Invasive Procedure: picc line and central access History of Present Illness: 65 year-old gentleman with multiple medical problem including history of lung cancer post right pneumonectomy in [2174], severe COPD, post tracheostomy and [Year (4 digits) 282] placement(respiratory failure due to pneumonia) recently admitted to [Hospital1 18] for urosepsis, now presenting yet again with hypotension and altered mental status. Patient unable to give a history at this time so obtained from records. Pt was admitted to [Hospital1 ] on [3-26] after an admission at [Hospital1 18] for a Klebsiella UTI and hypotension. Since his admission there, the pt has been alert and getting out of bed to the commode with assistance. On [4-11], the pt became lethargic and then gradually unresponsive. On [4-12], his BP decreased to 60 over palp and the pt was noted to be diaphoretic. He received a 500 cc bolus with an increase in his BP to 90/40. He remained unresponsive during this time. ABG showed 7.265/92.7/82 on an FiO2 of 0.50 with a temperature of 99.4. Of note, pt's triple lumen was placed [2179-3-21]. . Wife later arrived at the hospital and was able to provide additional history. She reports that he had been doing very well until Friday. They were working on weaning him and he was able to be on the trach mask for 1-2 hours at a time. However, on Friday, the pt felt mildly more SOB per his report. He was maintained exclusively on the vent over the rest of the weekend. Yesterday, the pt's wife reports that he looked "very scared" and would often stare at the ceiling. He also had periods of his eyes "rolling back in his head". He was occasionally responsive to her. She reports that they had been checking ABGs over the last 24 hours and his CO2 had been elevated. When they changed the vent settings to decrease the CO2, she felt that he was slightly less confused. She also notes that he was very diaphoretic yesterday and his faced appeared red and swollen. The pt's BP has always been very low in his left arm and she reports that they just starting taking his pressure there due to a skin tear on the right. . In the ED, the pt's VS were, 99.8 85 80/60-L 150/80-R 20 100% AC 400/20/100%/PEEP 5. He received vancomyicin and zosyn. Pt was initially started on levophed for hypotension. However, after learning that his BP has always been considered to be abnormally low in the left arm, it was checked in the right and has been stable in the 120s off of pressors. No new consolidation on CXR. Normal lactate. Currently getting a liter of NS . Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in [2174]. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus [2174]. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in [2165]. 8. Gout. 9. Atypical chest pain since [2164]. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in [10-31] resulting in ventilator dependence, trach and [Date Range 282] placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo [7-31]: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to [Hospital ] rehab s/p trach and [Hospital 282]. He has a 3-pack-per-day tobacco history but quit in [2174] and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: 99.8 85 80/60-L 150/80-R 20 100% AC 400/20/100%/PEEP 5 Gen- Lethargic appearing man on strecher. Will occasionally look in your dirrection to his name. Does not follow simple commands. Does not answer any questions. HEENT- NC AT. Trach in place. Pinpoint pupils that are minimally reactive to light. Anicteric sclera. Right subcalvian triple lumen without erythema or other signs of infection. Cardiac- RRR. Pulm- Coarse breath sounds throughout. Difficult to detect decreased breath sounds on the left. Abdomen- Soft. Does not respond to palpation. ND. Minimal bowel sounds. [Year (4 digits) 282] in place with no erythema or discharge. Extremities- No c/c/e. 2+ DP pulses bilaterally. Feet are warm. [Name (NI) 298] Pt [Last Name (un) 299] frequent twiching. Moderate rigidity with movement of his limbs. Positive clonus. Downgoing toes bilaterally. Pertinent Results: [2179-4-12] 09:35PM TYPE-ART TEMP-37.8 RATES-25/ TIDAL VOL-450 PEEP-5 O2-40 PO2-98 PCO2-54* PH-7.43 TOTAL CO2-37* BASE XS-9 -ASSIST/CON INTUBATED-INTUBATED [2179-4-12] 09:35PM K+-3.8 [2179-4-12] 09:17PM CK(CPK)-33* [2179-4-12] 09:17PM CK-MB-4 cTropnT-0.13* [2179-4-12] 06:45PM TYPE-ART TEMP-38.5 RATES-25/0 TIDAL VOL-450 PEEP-5 O2-40 PO2-66* PCO2-68* PH-7.35 TOTAL CO2-39* BASE XS-8 -ASSIST/CON INTUBATED-INTUBATED [2179-4-12] 02:44PM TYPE-ART TEMP-38.3 RATES-25/ TIDAL VOL-485 PEEP-5 O2-100 PO2-68* PCO2-71* PH-7.36 TOTAL CO2-42* BASE XS-10 AADO2-589 REQ O2-95 INTUBATED-INTUBATED VENT-CONTROLLED [2179-4-12] 11:54AM GLUCOSE-77 UREA N-28* CREAT-0.6 SODIUM-148* POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-37* ANION GAP-11 [2179-4-12] 11:54AM CK-MB-4 cTropnT-0.16* [2179-4-12] 09:05AM TYPE-ART RATES-/24 PO2-401* PCO2-88* PH-7.25* TOTAL CO2-40* BASE XS-7 -ASSIST/CON INTUBATED-INTUBATED [2179-4-12] 07:07AM TYPE-ART O2-100 PO2-439* PCO2-107* PH-7.21* TOTAL CO2-45* BASE XS-10 AADO2-186 REQ O2-39 INTUBATED-INTUBATED [2179-4-12] 06:20AM URINE HOURS-RANDOM [2179-4-12] 06:20AM URINE UHOLD-HOLD [2179-4-12] 06:20AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.019 [2179-4-12] 06:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2179-4-12] 06:20AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [2179-4-12] 05:36AM O2 SAT-84 [2179-4-12] 05:34AM GLUCOSE-186* UREA N-28* CREAT-0.5 SODIUM-148* POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-40* ANION GAP-8 [2179-4-12] 05:34AM ALT(SGPT)-73* AST(SGOT)-50* CK(CPK)-32* ALK PHOS-328* AMYLASE-42 TOT BILI-0.6 [2179-4-12] 05:34AM LIPASE-18 [2179-4-12] 05:34AM CK-MB-NotDone cTropnT-0.08* [2179-4-12] 05:34AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-2.2 [2179-4-12] 05:34AM WBC-14.2# RBC-3.23 HGB-8.7* HCT-29.1* MCV-90 MCH-26.8* MCHC-29.8* RDW-14.3 [2179-4-12] 05:34AM NEUTS-93.2* BANDS-0 LYMPHS-2.4* MONOS-4.1 EOS-0.1 BASOS-0.1 [2179-4-12] 05:34AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-3+ STIPPLED-OCCASIONAL ENVELOP-2+ [2179-4-12] 05:34AM PLT COUNT-332 [2179-4-12] 05:34AM PT-16.0* PTT-28.5 INR(PT)-1.7 [2179-4-12] 05:30AM LACTATE-1.3 studies: ECG- Sinus rhythm at 72 beats per minute. Nonspecific ST-T wave changes but no major changes since previous studies. . CXR- Stent projecting over the right brachiocephalic vein. Right lung remains opacified with shift of the cardiac and mediastinal contours toward the right consistent with previous pneumonectomy. There is blunting of the left costophrenic angle which could represent pleural thickening or small left pleural effusion. Slightly increased interstitial markings int he left lung which appear stable. No new left pneumo or focal consolidation. . Head CT (WET READ)- No hemorrhage, shift, mass effect, or evidence of hydrocephalus. No evidence of a major CVA. US upper extremity:IMPRESSION: 1) Nonocclusive thrombus in the left cephalic vein. 2) Nonocclusive thrombus in the distal left brachial veins Transabdominal ultrasound examination was performed. The gallbladder is not distended. There is an 8-9 mm stone located at the neck of the gallbladder. The gallbladder wall is thickened. There are possible crystal or tiny cholesterol polyps located at the fundus of the gallbladder. No intra or extrahepatic biliary ductal dilatation is identified. The common duct is not dilated and measures 3 mm. Flow in the portal vein is anterograde. Limited evaluation of the liver demonstrates no focal abnormality. IMPRESSION: Thickened gallbladder wall with a stone in the gallbladder neck in a nondistended gallbladder. In the proper clinical setting, these findings may be consistent with cholecystitis. They are not completely typical for acute cholecystitis. Gallbladder wall thickening may also be produced by third spacing of fluids. If there is continued clinical concern for cholecystitis, a HIDA scan may be performed for further evaluation. TECHNIQUE: CT images of the chest without the administration of IV contrast. COMPARISON: [2176-9-11] and [2179-3-21]. FINDINGS: Soft tissue window images demonstrate changes of prior right pneumonectomy and mediastinal shift towards the right. There is no pathologic axillary, mediastinal, or hilar lymphadenopathy. There is a left pleural effusion. The patient is intubated with a tracheostomy tube. A stent is again identified within the right brachiocephalic vein. The heart demonstrates coronary calcifications, but is normal in size. The main pulmonary artery appears prominent measuring 3.5 cm. Lung window images demonstrate multifocal nodular opacities seen scattered throughout the left lung. No specific areas of cavitation are identified within these nodules. Atelectasis is also seen at the left lung base. There is no focal consolidation or pneumothorax. Septal thickening is seen throughout the left lung field. A small 3-mm nodule seen on the prior studies is again seen, though slightly difficult to discern given the surrounding septal thickening and nodular opacities. However, on the study from [2179-3-21], this nodule was clearly seen and appears stable dating back to [2176-9-11]. The bronchi appear patent to the segmental level within the left lung. Images of the upper abdomen demonstrate high-density material within dependent portion of the gallbladder, probably relating to sludge. A percutaneous gastrostomy tube is seen within the stomach. The remainder of the visualized portion of the upper abdomen is unremarkable other than arterial calcifications. The soft tissues are unremarkable. Degenerative changes are seen throughout the thoracic spine. IMPRESSION: 1) Multifocal nodular opacities seen scattered throughout the entire left lung. These most likely represent aspiration pneumonia. Septic emboli are considered less likely based on the CT appearance. 2) Mild CHF. 3) Left upper lobe nodule seen on the prior study of [2179-3-21] demonstrates stability dating back to [2176-9-11]. 4) Probable sludge within the gallbladder. 5) Findings suggestive of underlying pulmonary arterial hypertension. Brief Hospital Course: 65 y/o man with PMH significant for squamous cell lung CA, type 2 DM, atrial fib, and multiple past pneumonias admitted from [Hospital1 ] with mental status change and hypotension. #ID/sepsis Patient had fever and leukocytosis initially with fluctuating blood pressure, lactate 1.3. His blood pressure in the ED was measured on the left arm (which is typically much lower). His blood pressure on the right was found to be normal and pressors were off. Sputum culture was sent(colonized with pseudomonas), blood culture, urine culture and cath tip culture negative on discharge. His decubitus ulcer looks clean. His line was resited line to the right femoral. Chest CT was consistent with aspiration pneumonia. He will be continued on zosyn for 14 days. He remained afebrile and no pressors required throughout the rest of his hospital stay. #Mental status changes: His mental status improved with decreasing CO2 and also with narcan. His CO2 remained well controlled in the hospital and was at baseline in 70s. CT head was negative. Narcotics was taken into consideration as possible cause of mental status changes. Patient's duragesic patch was removed in the ED. #anemia/coagulation Patient has history of deep venous thrombosis with IVC filter and SVC clot and also atrial fibrillation for which he was on coumadin. COumadin was taken off 3 days prior to hospital admission because he had blood oozing from his trach and foley. In hospital, central line was attempted intially on the right subclavian but the artery was puctured. His right femoral artery was also punctured and he did lose a signifcant amount of blood. The 2 arterial puncture was tamponaded and there was no hematoma. He also got an ultrasound of uppper extremity which revealed DVT in left arm for which he was started on heparin drip. He then had mild guiac negative stool and oozing from arterial line site. Heparin drip was then stopped and he was given 2 unit of transfusion. His hematocrit had been stable since then. On discharge, coumadin was not restarted. It should be restarted in 1-2days time if the hematocrit remain stable. . #transaminitis He presented intially with transaminitis likely from hypotension. LFTS trended down on discharge. RUQ ultrasound was done which showed gallstone at neck of GB, no distension, thickened gallbladder. He remained afebrile and has no abdominal tenderness #respiratory: Patient has squamous cell lung CA post right pneumonectomy and post tracheostomy. During his past admission there was concern about cuff leak and possible tracheomalacia. Dr. [Last Name (STitle) ] recommended keeping the cuff pressures low with a cuff leak to prevent further tracheamalacia. Possible change the trach to a foam-filled trach ([Last Name (un) 295] tube) in the future if the cuff leak is interfering with the ability to ventilate. He remained on assist control ventilation. . # [Name (NI) 300] Pt with mildly elevated Na at 148. This is most likely due to water deficit as he can not drink to replace his needs. He recieved free water through G tube. . # Cardiac Patient has long history of atypical chest pain but has no such complain during this hospitalization. Cardiac enzymes were unremarkable. He was continued on aspirin and also amiodarone for atrial fibrillation. He is to avoid beta blockers and calcium channel blockers because of profound bradycardia. . #Type 2 diabetes mellitus Patient was continued on standing 8U glargine and sliding scale while in hospital. #Anxiety/pain Patient's family reports that he is extemely anxious at baseline. He was continues on his outpatient doses of Haldol for anxiety 5mg hs, 2mg 8am/2pm, 1mg tid/prn, and paxil. His pain is from his scaral decubitus ulcer and back pain. Anxiety has been severely worsened in the past with ativan. Would avoid further ativan. Fentanyl patch was discontinued since there was a concern regarding narcotic overdose. He was on prn morphine. THis should be adjusted in [Hospital1 ]. # Sacral Decubitus: He had Kinair bed # FEN Tube feeds was continued with no residual #access He had picc line on discharge #code OK with pressor, do not resuscitate(confirmed again with family meeting) Medications on Admission: 1. Xopenex 1.2 mg inhaled Q4H 2. Atrovent neb Q6H PRN 3. Haldol 1 mg 0800 and 1400 4. Haldol 5 mg QHS 5. Casec powder 2 tablespoons TID 6. Lantus insulin 8 units QHS 7. Ambien 5 mg QHS 8. Flovent 110 mcg 2 puffs Q12H 9. Lactulose 20 gm daily 10. Glycerin suppository daily Allergies: 1. Doxepin 2. Levofloxacin 3. Oxycontin 4. Benzodiazepines 5. Ativan 11. Colace 100 mg [Hospital1 ] 12. Dulcolax 10 mg suppository daily 13. Theravite liquid 5 ml daily 14. MOM 30 ml daily 15. Paxil 20 mg daily 16. Vitamin C 500 mg daily 17. Vitamin D 800 units daily 18. Zinc 220 mg daily 19. ASA 325 mg daily 20. Prevacid 30 mg daily 21. Humulin SS 22. Atrovent nebs Q4H PRN 23. Xopenex 1.25 mg Q4H PRN 24. Tylenol 650 mg Q4H PRN 25. Haldol 1 mg Q8H PRN 26. Duragesic patch 75 mcg Q72H 27. Amiodarone 400 mg daily Discharge Medications: 1. Fluticasone Propionate 110 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 2. Lactulose 10 g/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO TID (3 times a day). 3. Glycerin (Adult) 3 g Suppository [Hospital1 ]: One (1) Suppository Rectal PRN (as needed). 4. Docusate Sodium 150 mg/15 mL Liquid [Hospital1 ]: One Hundred (100) mg PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet [Hospital1 ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Paroxetine HCl 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Amiodarone HCl 200 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol [Hospital1 ]: Six (6) Puff Inhalation Q4H (every 4 hours). 12. Ipratropium Bromide 18 mcg/Actuation Aerosol [Hospital1 ]: Six (6) Puff Inhalation Q4H (every 4 hours). 13. Haloperidol Lactate 2 mg/mL Concentrate [Hospital1 ]: Five (5) mg PO HS (at bedtime). 14. Haloperidol Lactate 2 mg/mL Concentrate [Hospital1 ]: One (1) mg PO BID (2 times a day): at 8AM and 2PM. 15. Heparin Sodium (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) ml [Hospital1 ] TID (3 times a day). 16. Zolpidem Tartrate 5 mg Tablet [Hospital1 ]: Two (2) Tablet PO HS (at bedtime). 17. Nitroglycerin 0.3 mg Tablet, Sublingual [Hospital1 ]: One (1) Tablet, Sublingual Sublingual PRN (as needed). 18. Morphine Sulfate 10 mg/5 mL Solution [Hospital1 ]: Five (5) mg PO Q6H (every 6 hours) as needed for pain. 19. Piperacillin-Tazobactam 4.5 g Recon Soln [Hospital1 ]: 4.5 gm Intravenous Q8H (every 8 hours) for 10 days. 20. Insulin Glargine 100 unit/mL Solution [Hospital1 ]: Eight (8) unit Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: hypotension and altered mental status likely from narcotic overdose +/- aspiration pneumonia Discharge Condition: stable Discharge Instructions: please return to the hospital or call your doctor if you have more shortness of breath, confusion, hypotension, chest pain, fever or if there are any concerns at all. Please take all prescribed medication Followup Instructions: PLease follow up with doctors [First Name (Titles) ] [Last Name (Titles) ]. Coumadin has been discontinued because you had significnant bleeding from arterial punctures from attempted central line insertion. This should be restarted at a lower dose in [11-29] days time given the history of DVT and also atrial fibrillation Fentanyl patch has been discontinued due to concern about narcotic overdose. Morphine IV prn has been used. Total morphine use should be calculated and patient can be started on standing morphine if necessary Patient should continue zosyn for a total of 14 days(started on [2179-4-12]) Completed by:[2179-4-15]	Admission Date: <Date>1908-12-25</Date> Discharge Date: <Date>1982-2-19</Date> Date of Birth: <Date>1996-9-26</Date> Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan Attending:<Name>Neha</Name> Chief Complaint: altered mental status and hypotension Major Surgical or Invasive Procedure: picc line and central access History of Present Illness: 65 year-old gentleman with multiple medical problem including history of lung cancer post right pneumonectomy in <Year>1954</Year>, severe COPD, post tracheostomy and <Year>1996</Year> placement(respiratory failure due to pneumonia) recently admitted to <Hospital>Soto, Tanner and Harris Medical Center</Hospital> for urosepsis, now presenting yet again with hypotension and altered mental status. Patient unable to give a history at this time so obtained from records. Pt was admitted to <Hospital>Anderson Group Hospital</Hospital> on <Date>7-21</Date> after an admission at <Hospital>Soto, Tanner and Harris Medical Center</Hospital> for a Klebsiella UTI and hypotension. Since his admission there, the pt has been alert and getting out of bed to the commode with assistance. On <Date>4-26</Date>, the pt became lethargic and then gradually unresponsive. On <Date>9-19</Date>, his BP decreased to 60 over palp and the pt was noted to be diaphoretic. He received a 500 cc bolus with an increase in his BP to 90/40. He remained unresponsive during this time. ABG showed 7.265/92.7/82 on an FiO2 of 0.50 with a temperature of 99.4. Of note, pt's triple lumen was placed <Date>1934-6-18</Date>. . Wife later arrived at the hospital and was able to provide additional history. She reports that he had been doing very well until Friday. They were working on weaning him and he was able to be on the trach mask for 1-2 hours at a time. However, on Friday, the pt felt mildly more SOB per his report. He was maintained exclusively on the vent over the rest of the weekend. Yesterday, the pt's wife reports that he looked "very scared" and would often stare at the ceiling. He also had periods of his eyes "rolling back in his head". He was occasionally responsive to her. She reports that they had been checking ABGs over the last 24 hours and his CO2 had been elevated. When they changed the vent settings to decrease the CO2, she felt that he was slightly less confused. She also notes that he was very diaphoretic yesterday and his faced appeared red and swollen. The pt's BP has always been very low in his left arm and she reports that they just starting taking his pressure there due to a skin tear on the right. . In the ED, the pt's VS were, 99.8 85 80/60-L 150/80-R 20 100% AC 400/20/100%/PEEP 5. He received vancomyicin and zosyn. Pt was initially started on levophed for hypotension. However, after learning that his BP has always been considered to be abnormally low in the left arm, it was checked in the right and has been stable in the 120s off of pressors. No new consolidation on CXR. Normal lactate. Currently getting a liter of NS . Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in <Year>1954</Year>. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus <Year>1954</Year>. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in <Year>1954</Year>. 8. Gout. 9. Atypical chest pain since <Year>1954</Year>. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in <Date>12-8</Date> resulting in ventilator dependence, trach and <Date Range>1963-2-19 to 2010-5-12</Date Range> placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo <Date>7-1</Date>: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to <Hospital>Duran-Kim Health System</Hospital> rehab s/p trach and <Hospital>Campbell PLC Medical Center</Hospital>. He has a 3-pack-per-day tobacco history but quit in <Year>1954</Year> and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: 99.8 85 80/60-L 150/80-R 20 100% AC 400/20/100%/PEEP 5 Gen- Lethargic appearing man on strecher. Will occasionally look in your dirrection to his name. Does not follow simple commands. Does not answer any questions. HEENT- NC AT. Trach in place. Pinpoint pupils that are minimally reactive to light. Anicteric sclera. Right subcalvian triple lumen without erythema or other signs of infection. Cardiac- RRR. Pulm- Coarse breath sounds throughout. Difficult to detect decreased breath sounds on the left. Abdomen- Soft. Does not respond to palpation. ND. Minimal bowel sounds. <Year>1996</Year> in place with no erythema or discharge. Extremities- No c/c/e. 2+ DP pulses bilaterally. Feet are warm. <Name>Mirna Deng</Name> Pt <Name>Pegram</Name> frequent twiching. Moderate rigidity with movement of his limbs. Positive clonus. Downgoing toes bilaterally. Pertinent Results: <Date>1908-12-25</Date> 09:35PM TYPE-ART TEMP-37.8 RATES-25/ TIDAL VOL-450 PEEP-5 O2-40 PO2-98 PCO2-54* PH-7.43 TOTAL CO2-37* BASE XS-9 -ASSIST/CON INTUBATED-INTUBATED <Date>1908-12-25</Date> 09:35PM K+-3.8 <Date>1908-12-25</Date> 09:17PM CK(CPK)-33* <Date>1908-12-25</Date> 09:17PM CK-MB-4 cTropnT-0.13* <Date>1908-12-25</Date> 06:45PM TYPE-ART TEMP-38.5 RATES-25/0 TIDAL VOL-450 PEEP-5 O2-40 PO2-66* PCO2-68* PH-7.35 TOTAL CO2-39* BASE XS-8 -ASSIST/CON INTUBATED-INTUBATED <Date>1908-12-25</Date> 02:44PM TYPE-ART TEMP-38.3 RATES-25/ TIDAL VOL-485 PEEP-5 O2-100 PO2-68* PCO2-71* PH-7.36 TOTAL CO2-42* BASE XS-10 AADO2-589 REQ O2-95 INTUBATED-INTUBATED VENT-CONTROLLED <Date>1908-12-25</Date> 11:54AM GLUCOSE-77 UREA N-28* CREAT-0.6 SODIUM-148* POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-37* ANION GAP-11 <Date>1908-12-25</Date> 11:54AM CK-MB-4 cTropnT-0.16* <Date>1908-12-25</Date> 09:05AM TYPE-ART RATES-/24 PO2-401* PCO2-88* PH-7.25* TOTAL CO2-40* BASE XS-7 -ASSIST/CON INTUBATED-INTUBATED <Date>1908-12-25</Date> 07:07AM TYPE-ART O2-100 PO2-439* PCO2-107* PH-7.21* TOTAL CO2-45* BASE XS-10 AADO2-186 REQ O2-39 INTUBATED-INTUBATED <Date>1908-12-25</Date> 06:20AM URINE HOURS-RANDOM <Date>1908-12-25</Date> 06:20AM URINE UHOLD-HOLD <Date>1908-12-25</Date> 06:20AM URINE COLOR-Yellow APPEAR-Clear SP <Name>Islam</Name>-1.019 <Date>1908-12-25</Date> 06:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG <Date>1908-12-25</Date> 06:20AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 <Date>1908-12-25</Date> 05:36AM O2 SAT-84 <Date>1908-12-25</Date> 05:34AM GLUCOSE-186* UREA N-28* CREAT-0.5 SODIUM-148* POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-40* ANION GAP-8 <Date>1908-12-25</Date> 05:34AM ALT(SGPT)-73* AST(SGOT)-50* CK(CPK)-32* ALK PHOS-328* AMYLASE-42 TOT BILI-0.6 <Date>1908-12-25</Date> 05:34AM LIPASE-18 <Date>1908-12-25</Date> 05:34AM CK-MB-NotDone cTropnT-0.08* <Date>1908-12-25</Date> 05:34AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-2.2 <Date>1908-12-25</Date> 05:34AM WBC-14.2# RBC-3.23 HGB-8.7* HCT-29.1* MCV-90 MCH-26.8* MCHC-29.8* RDW-14.3 <Date>1908-12-25</Date> 05:34AM NEUTS-93.2* BANDS-0 LYMPHS-2.4* MONOS-4.1 EOS-0.1 BASOS-0.1 <Date>1908-12-25</Date> 05:34AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-3+ STIPPLED-OCCASIONAL ENVELOP-2+ <Date>1908-12-25</Date> 05:34AM PLT COUNT-332 <Date>1908-12-25</Date> 05:34AM PT-16.0* PTT-28.5 INR(PT)-1.7 <Date>1908-12-25</Date> 05:30AM LACTATE-1.3 studies: ECG- Sinus rhythm at 72 beats per minute. Nonspecific ST-T wave changes but no major changes since previous studies. . CXR- Stent projecting over the right brachiocephalic vein. Right lung remains opacified with shift of the cardiac and mediastinal contours toward the right consistent with previous pneumonectomy. There is blunting of the left costophrenic angle which could represent pleural thickening or small left pleural effusion. Slightly increased interstitial markings int he left lung which appear stable. No new left pneumo or focal consolidation. . Head CT (WET READ)- No hemorrhage, shift, mass effect, or evidence of hydrocephalus. No evidence of a major CVA. US upper extremity:IMPRESSION: 1) Nonocclusive thrombus in the left cephalic vein. 2) Nonocclusive thrombus in the distal left brachial veins Transabdominal ultrasound examination was performed. The gallbladder is not distended. There is an 8-9 mm stone located at the neck of the gallbladder. The gallbladder wall is thickened. There are possible crystal or tiny cholesterol polyps located at the fundus of the gallbladder. No intra or extrahepatic biliary ductal dilatation is identified. The common duct is not dilated and measures 3 mm. Flow in the portal vein is anterograde. Limited evaluation of the liver demonstrates no focal abnormality. IMPRESSION: Thickened gallbladder wall with a stone in the gallbladder neck in a nondistended gallbladder. In the proper clinical setting, these findings may be consistent with cholecystitis. They are not completely typical for acute cholecystitis. Gallbladder wall thickening may also be produced by third spacing of fluids. If there is continued clinical concern for cholecystitis, a HIDA scan may be performed for further evaluation. TECHNIQUE: CT images of the chest without the administration of IV contrast. COMPARISON: <Date>1980-6-17</Date> and <Date>1934-6-18</Date>. FINDINGS: Soft tissue window images demonstrate changes of prior right pneumonectomy and mediastinal shift towards the right. There is no pathologic axillary, mediastinal, or hilar lymphadenopathy. There is a left pleural effusion. The patient is intubated with a tracheostomy tube. A stent is again identified within the right brachiocephalic vein. The heart demonstrates coronary calcifications, but is normal in size. The main pulmonary artery appears prominent measuring 3.5 cm. Lung window images demonstrate multifocal nodular opacities seen scattered throughout the left lung. No specific areas of cavitation are identified within these nodules. Atelectasis is also seen at the left lung base. There is no focal consolidation or pneumothorax. Septal thickening is seen throughout the left lung field. A small 3-mm nodule seen on the prior studies is again seen, though slightly difficult to discern given the surrounding septal thickening and nodular opacities. However, on the study from <Date>1934-6-18</Date>, this nodule was clearly seen and appears stable dating back to <Date>1980-6-17</Date>. The bronchi appear patent to the segmental level within the left lung. Images of the upper abdomen demonstrate high-density material within dependent portion of the gallbladder, probably relating to sludge. A percutaneous gastrostomy tube is seen within the stomach. The remainder of the visualized portion of the upper abdomen is unremarkable other than arterial calcifications. The soft tissues are unremarkable. Degenerative changes are seen throughout the thoracic spine. IMPRESSION: 1) Multifocal nodular opacities seen scattered throughout the entire left lung. These most likely represent aspiration pneumonia. Septic emboli are considered less likely based on the CT appearance. 2) Mild CHF. 3) Left upper lobe nodule seen on the prior study of <Date>1934-6-18</Date> demonstrates stability dating back to <Date>1980-6-17</Date>. 4) Probable sludge within the gallbladder. 5) Findings suggestive of underlying pulmonary arterial hypertension. Brief Hospital Course: 65 y/o man with PMH significant for squamous cell lung CA, type 2 DM, atrial fib, and multiple past pneumonias admitted from <Hospital>Anderson Group Hospital</Hospital> with mental status change and hypotension. #ID/sepsis Patient had fever and leukocytosis initially with fluctuating blood pressure, lactate 1.3. His blood pressure in the ED was measured on the left arm (which is typically much lower). His blood pressure on the right was found to be normal and pressors were off. Sputum culture was sent(colonized with pseudomonas), blood culture, urine culture and cath tip culture negative on discharge. His decubitus ulcer looks clean. His line was resited line to the right femoral. Chest CT was consistent with aspiration pneumonia. He will be continued on zosyn for 14 days. He remained afebrile and no pressors required throughout the rest of his hospital stay. #Mental status changes: His mental status improved with decreasing CO2 and also with narcan. His CO2 remained well controlled in the hospital and was at baseline in 70s. CT head was negative. Narcotics was taken into consideration as possible cause of mental status changes. Patient's duragesic patch was removed in the ED. #anemia/coagulation Patient has history of deep venous thrombosis with IVC filter and SVC clot and also atrial fibrillation for which he was on coumadin. COumadin was taken off 3 days prior to hospital admission because he had blood oozing from his trach and foley. In hospital, central line was attempted intially on the right subclavian but the artery was puctured. His right femoral artery was also punctured and he did lose a signifcant amount of blood. The 2 arterial puncture was tamponaded and there was no hematoma. He also got an ultrasound of uppper extremity which revealed DVT in left arm for which he was started on heparin drip. He then had mild guiac negative stool and oozing from arterial line site. Heparin drip was then stopped and he was given 2 unit of transfusion. His hematocrit had been stable since then. On discharge, coumadin was not restarted. It should be restarted in 1-2days time if the hematocrit remain stable. . #transaminitis He presented intially with transaminitis likely from hypotension. LFTS trended down on discharge. RUQ ultrasound was done which showed gallstone at neck of GB, no distension, thickened gallbladder. He remained afebrile and has no abdominal tenderness #respiratory: Patient has squamous cell lung CA post right pneumonectomy and post tracheostomy. During his past admission there was concern about cuff leak and possible tracheomalacia. Dr. <Name>Son</Name> recommended keeping the cuff pressures low with a cuff leak to prevent further tracheamalacia. Possible change the trach to a foam-filled trach (<Name>Meraz</Name> tube) in the future if the cuff leak is interfering with the ability to ventilate. He remained on assist control ventilation. . # <Name>Lorena Abdullah</Name> Pt with mildly elevated Na at 148. This is most likely due to water deficit as he can not drink to replace his needs. He recieved free water through G tube. . # Cardiac Patient has long history of atypical chest pain but has no such complain during this hospitalization. Cardiac enzymes were unremarkable. He was continued on aspirin and also amiodarone for atrial fibrillation. He is to avoid beta blockers and calcium channel blockers because of profound bradycardia. . #Type 2 diabetes mellitus Patient was continued on standing 8U glargine and sliding scale while in hospital. #Anxiety/pain Patient's family reports that he is extemely anxious at baseline. He was continues on his outpatient doses of Haldol for anxiety 5mg hs, 2mg 8am/2pm, 1mg tid/prn, and paxil. His pain is from his scaral decubitus ulcer and back pain. Anxiety has been severely worsened in the past with ativan. Would avoid further ativan. Fentanyl patch was discontinued since there was a concern regarding narcotic overdose. He was on prn morphine. THis should be adjusted in <Hospital>Anderson Group Hospital</Hospital>. # Sacral Decubitus: He had Kinair bed # FEN Tube feeds was continued with no residual #access He had picc line on discharge #code OK with pressor, do not resuscitate(confirmed again with family meeting) Medications on Admission: 1. Xopenex 1.2 mg inhaled Q4H 2. Atrovent neb Q6H PRN 3. Haldol 1 mg 0800 and 1400 4. Haldol 5 mg QHS 5. Casec powder 2 tablespoons TID 6. Lantus insulin 8 units QHS 7. Ambien 5 mg QHS 8. Flovent 110 mcg 2 puffs Q12H 9. Lactulose 20 gm daily 10. Glycerin suppository daily Allergies: 1. Doxepin 2. Levofloxacin 3. Oxycontin 4. Benzodiazepines 5. Ativan 11. Colace 100 mg <Hospital>Anderson Group Hospital</Hospital> 12. Dulcolax 10 mg suppository daily 13. Theravite liquid 5 ml daily 14. MOM 30 ml daily 15. Paxil 20 mg daily 16. Vitamin C 500 mg daily 17. Vitamin D 800 units daily 18. Zinc 220 mg daily 19. ASA 325 mg daily 20. Prevacid 30 mg daily 21. Humulin SS 22. Atrovent nebs Q4H PRN 23. Xopenex 1.25 mg Q4H PRN 24. Tylenol 650 mg Q4H PRN 25. Haldol 1 mg Q8H PRN 26. Duragesic patch 75 mcg Q72H 27. Amiodarone 400 mg daily Discharge Medications: 1. Fluticasone Propionate 110 mcg/Actuation Aerosol <Hospital>Anderson Group Hospital</Hospital>: Two (2) Puff Inhalation <Hospital>Anderson Group Hospital</Hospital> (2 times a day). 2. Lactulose 10 g/15 mL Syrup <Hospital>Anderson Group Hospital</Hospital>: Thirty (30) ML PO TID (3 times a day). 3. Glycerin (Adult) 3 g Suppository <Hospital>Anderson Group Hospital</Hospital>: One (1) Suppository Rectal PRN (as needed). 4. Docusate Sodium 150 mg/15 mL Liquid <Hospital>Anderson Group Hospital</Hospital>: One Hundred (100) mg PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet <Hospital>Anderson Group Hospital</Hospital>: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) <Hospital>Anderson Group Hospital</Hospital>: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Paroxetine HCl 20 mg Tablet <Hospital>Anderson Group Hospital</Hospital>: One (1) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet <Hospital>Anderson Group Hospital</Hospital>: One (1) Tablet PO DAILY (Daily). 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) <Hospital>Anderson Group Hospital</Hospital>: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Amiodarone HCl 200 mg Tablet <Hospital>Anderson Group Hospital</Hospital>: Two (2) Tablet PO DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol <Hospital>Anderson Group Hospital</Hospital>: Six (6) Puff Inhalation Q4H (every 4 hours). 12. Ipratropium Bromide 18 mcg/Actuation Aerosol <Hospital>Anderson Group Hospital</Hospital>: Six (6) Puff Inhalation Q4H (every 4 hours). 13. Haloperidol Lactate 2 mg/mL Concentrate <Hospital>Anderson Group Hospital</Hospital>: Five (5) mg PO HS (at bedtime). 14. Haloperidol Lactate 2 mg/mL Concentrate <Hospital>Anderson Group Hospital</Hospital>: One (1) mg PO BID (2 times a day): at 8AM and 2PM. 15. Heparin Sodium (Porcine) 5,000 unit/mL Solution <Hospital>Anderson Group Hospital</Hospital>: One (1) ml <Hospital>Anderson Group Hospital</Hospital> TID (3 times a day). 16. Zolpidem Tartrate 5 mg Tablet <Hospital>Anderson Group Hospital</Hospital>: Two (2) Tablet PO HS (at bedtime). 17. Nitroglycerin 0.3 mg Tablet, Sublingual <Hospital>Anderson Group Hospital</Hospital>: One (1) Tablet, Sublingual Sublingual PRN (as needed). 18. Morphine Sulfate 10 mg/5 mL Solution <Hospital>Anderson Group Hospital</Hospital>: Five (5) mg PO Q6H (every 6 hours) as needed for pain. 19. Piperacillin-Tazobactam 4.5 g Recon Soln <Hospital>Anderson Group Hospital</Hospital>: 4.5 gm Intravenous Q8H (every 8 hours) for 10 days. 20. Insulin Glargine 100 unit/mL Solution <Hospital>Anderson Group Hospital</Hospital>: Eight (8) unit Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: <Hospital>Day-Hess Medical Center</Hospital> & Rehab Center - <Hospital>Baird-Jacobs Hospital</Hospital> Discharge Diagnosis: hypotension and altered mental status likely from narcotic overdose +/- aspiration pneumonia Discharge Condition: stable Discharge Instructions: please return to the hospital or call your doctor if you have more shortness of breath, confusion, hypotension, chest pain, fever or if there are any concerns at all. Please take all prescribed medication Followup Instructions: PLease follow up with doctors <Name>Brian</Name> <Name>Post</Name>. Coumadin has been discontinued because you had significnant bleeding from arterial punctures from attempted central line insertion. This should be restarted at a lower dose in <Date>7-26</Date> days time given the history of DVT and also atrial fibrillation Fentanyl patch has been discontinued due to concern about narcotic overdose. Morphine IV prn has been used. Total morphine use should be calculated and patient can be started on standing morphine if necessary Patient should continue zosyn for a total of 14 days(started on <Date>1908-12-25</Date>) Completed 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Date: 1908-12-25 Discharge Date: 1982-2-19 Date of Birth: 1996-9-26 Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan Attending:Neha Chief Complaint: altered mental status and hypotension Major Surgical or Invasive Procedure: picc line and central access History of Present Illness: 65 year-old gentleman with multiple medical problem including history of lung cancer post right pneumonectomy in 1954, severe COPD, post tracheostomy and 1996 placement(respiratory failure due to pneumonia) recently admitted to Soto, Tanner and Harris Medical Center for urosepsis, now presenting yet again with hypotension and altered mental status. Patient unable to give a history at this time so obtained from records. Pt was admitted to Anderson Group Hospital on 7-21 after an admission at Soto, Tanner and Harris Medical Center for a Klebsiella UTI and hypotension. Since his admission there, the pt has been alert and getting out of bed to the commode with assistance. On 4-26, the pt became lethargic and then gradually unresponsive. On 9-19, his BP decreased to 60 over palp and the pt was noted to be diaphoretic. He received a 500 cc bolus with an increase in his BP to 90/40. He remained unresponsive during this time. ABG showed 7.265/92.7/82 on an FiO2 of 0.50 with a temperature of 99.4. Of note, pt's triple lumen was placed 1934-6-18. . Wife later arrived at the hospital and was able to provide additional history. She reports that he had been doing very well until Friday. They were working on weaning him and he was able to be on the trach mask for 1-2 hours at a time. However, on Friday, the pt felt mildly more SOB per his report. He was maintained exclusively on the vent over the rest of the weekend. Yesterday, the pt's wife reports that he looked "very scared" and would often stare at the ceiling. He also had periods of his eyes "rolling back in his head". He was occasionally responsive to her. She reports that they had been checking ABGs over the last 24 hours and his CO2 had been elevated. When they changed the vent settings to decrease the CO2, she felt that he was slightly less confused. She also notes that he was very diaphoretic yesterday and his faced appeared red and swollen. The pt's BP has always been very low in his left arm and she reports that they just starting taking his pressure there due to a skin tear on the right. . In the ED, the pt's VS were, 99.8 85 80/60-L 150/80-R 20 100% AC 400/20/100%/PEEP 5. He received vancomyicin and zosyn. Pt was initially started on levophed for hypotension. However, after learning that his BP has always been considered to be abnormally low in the left arm, it was checked in the right and has been stable in the 120s off of pressors. No new consolidation on CXR. Normal lactate. Currently getting a liter of NS . Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in 1954. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus 1954. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in 1954. 8. Gout. 9. Atypical chest pain since 1954. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in 12-8 resulting in ventilator dependence, trach and 1963-2-19 to 2010-5-12 placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo 7-1: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to Duran-Kim Health System rehab s/p trach and Campbell PLC Medical Center. He has a 3-pack-per-day tobacco history but quit in 1954 and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: 99.8 85 80/60-L 150/80-R 20 100% AC 400/20/100%/PEEP 5 Gen- Lethargic appearing man on strecher. Will occasionally look in your dirrection to his name. Does not follow simple commands. Does not answer any questions. HEENT- NC AT. Trach in place. Pinpoint pupils that are minimally reactive to light. Anicteric sclera. Right subcalvian triple lumen without erythema or other signs of infection. Cardiac- RRR. Pulm- Coarse breath sounds throughout. Difficult to detect decreased breath sounds on the left. Abdomen- Soft. Does not respond to palpation. ND. Minimal bowel sounds. 1996 in place with no erythema or discharge. Extremities- No c/c/e. 2+ DP pulses bilaterally. Feet are warm. Mirna Deng Pt Pegram frequent twiching. Moderate rigidity with movement of his limbs. Positive clonus. Downgoing toes bilaterally. Pertinent Results: 1908-12-25 09:35PM TYPE-ART TEMP-37.8 RATES-25/ TIDAL VOL-450 PEEP-5 O2-40 PO2-98 PCO2-54* PH-7.43 TOTAL CO2-37* BASE XS-9 -ASSIST/CON INTUBATED-INTUBATED 1908-12-25 09:35PM K+-3.8 1908-12-25 09:17PM CK(CPK)-33* 1908-12-25 09:17PM CK-MB-4 cTropnT-0.13* 1908-12-25 06:45PM TYPE-ART TEMP-38.5 RATES-25/0 TIDAL VOL-450 PEEP-5 O2-40 PO2-66* PCO2-68* PH-7.35 TOTAL CO2-39* BASE XS-8 -ASSIST/CON INTUBATED-INTUBATED 1908-12-25 02:44PM TYPE-ART TEMP-38.3 RATES-25/ TIDAL VOL-485 PEEP-5 O2-100 PO2-68* PCO2-71* PH-7.36 TOTAL CO2-42* BASE XS-10 AADO2-589 REQ O2-95 INTUBATED-INTUBATED VENT-CONTROLLED 1908-12-25 11:54AM GLUCOSE-77 UREA N-28* CREAT-0.6 SODIUM-148* POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-37* ANION GAP-11 1908-12-25 11:54AM CK-MB-4 cTropnT-0.16* 1908-12-25 09:05AM TYPE-ART RATES-/24 PO2-401* PCO2-88* PH-7.25* TOTAL CO2-40* BASE XS-7 -ASSIST/CON INTUBATED-INTUBATED 1908-12-25 07:07AM TYPE-ART O2-100 PO2-439* PCO2-107* PH-7.21* TOTAL CO2-45* BASE XS-10 AADO2-186 REQ O2-39 INTUBATED-INTUBATED 1908-12-25 06:20AM URINE HOURS-RANDOM 1908-12-25 06:20AM URINE UHOLD-HOLD 1908-12-25 06:20AM URINE COLOR-Yellow APPEAR-Clear SP Islam-1.019 1908-12-25 06:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG 1908-12-25 06:20AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 1908-12-25 05:36AM O2 SAT-84 1908-12-25 05:34AM GLUCOSE-186* UREA N-28* CREAT-0.5 SODIUM-148* POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-40* ANION GAP-8 1908-12-25 05:34AM ALT(SGPT)-73* AST(SGOT)-50* CK(CPK)-32* ALK PHOS-328* AMYLASE-42 TOT BILI-0.6 1908-12-25 05:34AM LIPASE-18 1908-12-25 05:34AM CK-MB-NotDone cTropnT-0.08* 1908-12-25 05:34AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-2.2 1908-12-25 05:34AM WBC-14.2# RBC-3.23 HGB-8.7* HCT-29.1* MCV-90 MCH-26.8* MCHC-29.8* RDW-14.3 1908-12-25 05:34AM NEUTS-93.2* BANDS-0 LYMPHS-2.4* MONOS-4.1 EOS-0.1 BASOS-0.1 1908-12-25 05:34AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-3+ STIPPLED-OCCASIONAL ENVELOP-2+ 1908-12-25 05:34AM PLT COUNT-332 1908-12-25 05:34AM PT-16.0* PTT-28.5 INR(PT)-1.7 1908-12-25 05:30AM LACTATE-1.3 studies: ECG- Sinus rhythm at 72 beats per minute. Nonspecific ST-T wave changes but no major changes since previous studies. . CXR- Stent projecting over the right brachiocephalic vein. Right lung remains opacified with shift of the cardiac and mediastinal contours toward the right consistent with previous pneumonectomy. There is blunting of the left costophrenic angle which could represent pleural thickening or small left pleural effusion. Slightly increased interstitial markings int he left lung which appear stable. No new left pneumo or focal consolidation. . Head CT (WET READ)- No hemorrhage, shift, mass effect, or evidence of hydrocephalus. No evidence of a major CVA. US upper extremity:IMPRESSION: 1) Nonocclusive thrombus in the left cephalic vein. 2) Nonocclusive thrombus in the distal left brachial veins Transabdominal ultrasound examination was performed. The gallbladder is not distended. There is an 8-9 mm stone located at the neck of the gallbladder. The gallbladder wall is thickened. There are possible crystal or tiny cholesterol polyps located at the fundus of the gallbladder. No intra or extrahepatic biliary ductal dilatation is identified. The common duct is not dilated and measures 3 mm. Flow in the portal vein is anterograde. Limited evaluation of the liver demonstrates no focal abnormality. IMPRESSION: Thickened gallbladder wall with a stone in the gallbladder neck in a nondistended gallbladder. In the proper clinical setting, these findings may be consistent with cholecystitis. They are not completely typical for acute cholecystitis. Gallbladder wall thickening may also be produced by third spacing of fluids. If there is continued clinical concern for cholecystitis, a HIDA scan may be performed for further evaluation. TECHNIQUE: CT images of the chest without the administration of IV contrast. COMPARISON: 1980-6-17 and 1934-6-18. FINDINGS: Soft tissue window images demonstrate changes of prior right pneumonectomy and mediastinal shift towards the right. There is no pathologic axillary, mediastinal, or hilar lymphadenopathy. There is a left pleural effusion. The patient is intubated with a tracheostomy tube. A stent is again identified within the right brachiocephalic vein. The heart demonstrates coronary calcifications, but is normal in size. The main pulmonary artery appears prominent measuring 3.5 cm. Lung window images demonstrate multifocal nodular opacities seen scattered throughout the left lung. No specific areas of cavitation are identified within these nodules. Atelectasis is also seen at the left lung base. There is no focal consolidation or pneumothorax. Septal thickening is seen throughout the left lung field. A small 3-mm nodule seen on the prior studies is again seen, though slightly difficult to discern given the surrounding septal thickening and nodular opacities. However, on the study from 1934-6-18, this nodule was clearly seen and appears stable dating back to 1980-6-17. The bronchi appear patent to the segmental level within the left lung. Images of the upper abdomen demonstrate high-density material within dependent portion of the gallbladder, probably relating to sludge. A percutaneous gastrostomy tube is seen within the stomach. The remainder of the visualized portion of the upper abdomen is unremarkable other than arterial calcifications. The soft tissues are unremarkable. Degenerative changes are seen throughout the thoracic spine. IMPRESSION: 1) Multifocal nodular opacities seen scattered throughout the entire left lung. These most likely represent aspiration pneumonia. Septic emboli are considered less likely based on the CT appearance. 2) Mild CHF. 3) Left upper lobe nodule seen on the prior study of 1934-6-18 demonstrates stability dating back to 1980-6-17. 4) Probable sludge within the gallbladder. 5) Findings suggestive of underlying pulmonary arterial hypertension. Brief Hospital Course: 65 y/o man with PMH significant for squamous cell lung CA, type 2 DM, atrial fib, and multiple past pneumonias admitted from Anderson Group Hospital with mental status change and hypotension. #ID/sepsis Patient had fever and leukocytosis initially with fluctuating blood pressure, lactate 1.3. His blood pressure in the ED was measured on the left arm (which is typically much lower). His blood pressure on the right was found to be normal and pressors were off. Sputum culture was sent(colonized with pseudomonas), blood culture, urine culture and cath tip culture negative on discharge. His decubitus ulcer looks clean. His line was resited line to the right femoral. Chest CT was consistent with aspiration pneumonia. He will be continued on zosyn for 14 days. He remained afebrile and no pressors required throughout the rest of his hospital stay. #Mental status changes: His mental status improved with decreasing CO2 and also with narcan. His CO2 remained well controlled in the hospital and was at baseline in 70s. CT head was negative. Narcotics was taken into consideration as possible cause of mental status changes. Patient's duragesic patch was removed in the ED. #anemia/coagulation Patient has history of deep venous thrombosis with IVC filter and SVC clot and also atrial fibrillation for which he was on coumadin. COumadin was taken off 3 days prior to hospital admission because he had blood oozing from his trach and foley. In hospital, central line was attempted intially on the right subclavian but the artery was puctured. His right femoral artery was also punctured and he did lose a signifcant amount of blood. The 2 arterial puncture was tamponaded and there was no hematoma. He also got an ultrasound of uppper extremity which revealed DVT in left arm for which he was started on heparin drip. He then had mild guiac negative stool and oozing from arterial line site. Heparin drip was then stopped and he was given 2 unit of transfusion. His hematocrit had been stable since then. On discharge, coumadin was not restarted. It should be restarted in 1-2days time if the hematocrit remain stable. . #transaminitis He presented intially with transaminitis likely from hypotension. LFTS trended down on discharge. RUQ ultrasound was done which showed gallstone at neck of GB, no distension, thickened gallbladder. He remained afebrile and has no abdominal tenderness #respiratory: Patient has squamous cell lung CA post right pneumonectomy and post tracheostomy. During his past admission there was concern about cuff leak and possible tracheomalacia. Dr. Son recommended keeping the cuff pressures low with a cuff leak to prevent further tracheamalacia. Possible change the trach to a foam-filled trach (Meraz tube) in the future if the cuff leak is interfering with the ability to ventilate. He remained on assist control ventilation. . # Lorena Abdullah Pt with mildly elevated Na at 148. This is most likely due to water deficit as he can not drink to replace his needs. He recieved free water through G tube. . # Cardiac Patient has long history of atypical chest pain but has no such complain during this hospitalization. Cardiac enzymes were unremarkable. He was continued on aspirin and also amiodarone for atrial fibrillation. He is to avoid beta blockers and calcium channel blockers because of profound bradycardia. . #Type 2 diabetes mellitus Patient was continued on standing 8U glargine and sliding scale while in hospital. #Anxiety/pain Patient's family reports that he is extemely anxious at baseline. He was continues on his outpatient doses of Haldol for anxiety 5mg hs, 2mg 8am/2pm, 1mg tid/prn, and paxil. His pain is from his scaral decubitus ulcer and back pain. Anxiety has been severely worsened in the past with ativan. Would avoid further ativan. Fentanyl patch was discontinued since there was a concern regarding narcotic overdose. He was on prn morphine. THis should be adjusted in Anderson Group Hospital. # Sacral Decubitus: He had Kinair bed # FEN Tube feeds was continued with no residual #access He had picc line on discharge #code OK with pressor, do not resuscitate(confirmed again with family meeting) Medications on Admission: 1. Xopenex 1.2 mg inhaled Q4H 2. Atrovent neb Q6H PRN 3. Haldol 1 mg 0800 and 1400 4. Haldol 5 mg QHS 5. Casec powder 2 tablespoons TID 6. Lantus insulin 8 units QHS 7. Ambien 5 mg QHS 8. Flovent 110 mcg 2 puffs Q12H 9. Lactulose 20 gm daily 10. Glycerin suppository daily Allergies: 1. Doxepin 2. Levofloxacin 3. Oxycontin 4. Benzodiazepines 5. Ativan 11. Colace 100 mg Anderson Group Hospital 12. Dulcolax 10 mg suppository daily 13. Theravite liquid 5 ml daily 14. MOM 30 ml daily 15. Paxil 20 mg daily 16. Vitamin C 500 mg daily 17. Vitamin D 800 units daily 18. Zinc 220 mg daily 19. ASA 325 mg daily 20. Prevacid 30 mg daily 21. Humulin SS 22. Atrovent nebs Q4H PRN 23. Xopenex 1.25 mg Q4H PRN 24. Tylenol 650 mg Q4H PRN 25. Haldol 1 mg Q8H PRN 26. Duragesic patch 75 mcg Q72H 27. Amiodarone 400 mg daily Discharge Medications: 1. Fluticasone Propionate 110 mcg/Actuation Aerosol Anderson Group Hospital: Two (2) Puff Inhalation Anderson Group Hospital (2 times a day). 2. Lactulose 10 g/15 mL Syrup Anderson Group Hospital: Thirty (30) ML PO TID (3 times a day). 3. Glycerin (Adult) 3 g Suppository Anderson Group Hospital: One (1) Suppository Rectal PRN (as needed). 4. Docusate Sodium 150 mg/15 mL Liquid Anderson Group Hospital: One Hundred (100) mg PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Anderson Group Hospital: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Anderson Group Hospital: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Paroxetine HCl 20 mg Tablet Anderson Group Hospital: One (1) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet Anderson Group Hospital: One (1) Tablet PO DAILY (Daily). 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Anderson Group Hospital: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Amiodarone HCl 200 mg Tablet Anderson Group Hospital: Two (2) Tablet PO DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol Anderson Group Hospital: Six (6) Puff Inhalation Q4H (every 4 hours). 12. Ipratropium Bromide 18 mcg/Actuation Aerosol Anderson Group Hospital: Six (6) Puff Inhalation Q4H (every 4 hours). 13. Haloperidol Lactate 2 mg/mL Concentrate Anderson Group Hospital: Five (5) mg PO HS (at bedtime). 14. Haloperidol Lactate 2 mg/mL Concentrate Anderson Group Hospital: One (1) mg PO BID (2 times a day): at 8AM and 2PM. 15. Heparin Sodium (Porcine) 5,000 unit/mL Solution Anderson Group Hospital: One (1) ml Anderson Group Hospital TID (3 times a day). 16. Zolpidem Tartrate 5 mg Tablet Anderson Group Hospital: Two (2) Tablet PO HS (at bedtime). 17. Nitroglycerin 0.3 mg Tablet, Sublingual Anderson Group Hospital: One (1) Tablet, Sublingual Sublingual PRN (as needed). 18. Morphine Sulfate 10 mg/5 mL Solution Anderson Group Hospital: Five (5) mg PO Q6H (every 6 hours) as needed for pain. 19. Piperacillin-Tazobactam 4.5 g Recon Soln Anderson Group Hospital: 4.5 gm Intravenous Q8H (every 8 hours) for 10 days. 20. Insulin Glargine 100 unit/mL Solution Anderson Group Hospital: Eight (8) unit Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: Day-Hess Medical Center & Rehab Center - Baird-Jacobs Hospital Discharge Diagnosis: hypotension and altered mental status likely from narcotic overdose +/- aspiration pneumonia Discharge Condition: stable Discharge Instructions: please return to the hospital or call your doctor if you have more shortness of breath, confusion, hypotension, chest pain, fever or if there are any concerns at all. Please take all prescribed medication Followup Instructions: PLease follow up with doctors Brian Post. Coumadin has been discontinued because you had significnant bleeding from arterial punctures from attempted central line insertion. This should be restarted at a lower dose in 7-26 days time given the history of DVT and also atrial fibrillation Fentanyl patch has been discontinued due to concern about narcotic overdose. Morphine IV prn has been used. Total morphine use should be calculated and patient can be started on standing morphine if necessary Patient should continue zosyn for a total of 14 days(started on 1908-12-25) Completed by:1982-2-19	['Admission Date: 1908-12-25 Discharge Date: 1982-2-19\n\nDate of Birth: 1996-9-26 Sex: M\n\nService: MEDICINE\n\nAllergies:\nDoxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan\n\nAttending:Neha\nChief Complaint:\naltered mental status and hypotension\n\nMajor Surgical or Invasive Procedure:\npicc line and central access\n\n\nHistory of Present Illness:\n65 year-old gentleman with multiple medical problem including\nhistory of lung cancer post right pneumonectomy in 1954, severe\nCOPD, post tracheostomy and 1996 placement(respiratory failure\ndue to pneumonia) recently admitted to Soto, Tanner and Harris Medical Center for urosepsis, now\npresenting yet again with hypotension and altered mental status.\n\nPatient unable to give a history at this time so obtained from\nrecords.', " Pt was admitted to Anderson Group Hospital on 7-21 after an admission\nat Soto, Tanner and Harris Medical Center for a Klebsiella UTI and hypotension. Since his\nadmission there, the pt has been alert and getting out of bed to\nthe commode with assistance. On 4-26, the pt became lethargic\nand then gradually unresponsive. On 9-19, his BP decreased to\n60 over palp and the pt was noted to be diaphoretic. He received\na 500 cc bolus with an increase in his BP to 90/40. He remained\nunresponsive during this time. ABG showed 7.265/92.7/82 on an\nFiO2 of 0.50 with a temperature of 99.4. Of note, pt's triple\nlumen was placed 1934-6-18.\n.\nWife later arrived at the hospital and was able to provide\nadditional history. She reports that he had been doing very well\nuntil Friday. They were working on weaning him and he was able\nto be on the trach mask for 1-2 hours at a time.", ' However, on\nFriday, the pt felt mildly more SOB per his report. He was\nmaintained exclusively on the vent over the rest of the weekend.\nYesterday, the pt\'s wife reports that he looked "very scared"\nand would often stare at the ceiling. He also had periods of his\neyes "rolling back in his head". He was occasionally responsive\nto her. She reports that they had been checking ABGs over the\nlast 24 hours and his CO2 had been elevated. When they changed\nthe vent settings to decrease the CO2, she felt that he was\nslightly less confused. She also notes that he was very\ndiaphoretic yesterday and his faced appeared red and swollen.\nThe pt\'s BP has always been very low in his left arm and she\nreports that they just starting taking his pressure there due to\na skin tear on the right.\n.\nIn the ED, the pt\'s VS were, 99.', '8 85 80/60-L 150/80-R 20 100% AC\n400/20/100%/PEEP 5. He received vancomyicin and zosyn. Pt was\ninitially started on levophed for hypotension. However, after\nlearning that his BP has always been considered to be abnormally\nlow in the left arm, it was checked in the right and has been\nstable in the 120s off of pressors. No new consolidation on CXR.\nNormal lactate.\nCurrently getting a liter of NS\n.\n\n\nPast Medical History:\n1. Squamous cell lung carcinoma, status post right\npneumonectomy in 1954.\n2. Prostate cancer, status post radical prostatectomy.\n3. Perioperative pulmonary embolus 1954.\n4. Type 2 diabetes mellitus.\n5. Chronic obstructive pulmonary disease.\n6. Atrial fibrillation.\n7. Transient ischemic attack in 1954.\n8. Gout.\n9. Atypical chest pain since 1954.\n10. Gastroesophageal reflux disease.', '\n11. Obstructive sleep apnea. unable to tolerate BiPAP.\n12. Hypertension.\n13. Colonic polyps.\n14. Hypercholesterolemia.\n15. Basal cell carcinoma on his back.\n16. Anxiety.\n17. Sciatica.\n18. History of herpes zoster.\n19. multiple admissions for pneumonia (including pseudomonas)\nand bronchitis, last in 12-8 resulting in ventilator\ndependence, trach and 1963-2-19 to 2010-5-12 placement\n20. vitamin B12 deficiency.\n21. Diastolic heart failure. Echo 7-1: LVEF>55%\n21. Cataracts\n22. bradycardia on amiodarone\n\nSocial History:\nRecently discharged to Duran-Kim Health System rehab s/p trach and Campbell PLC Medical Center. He has\na 3-pack-per-day tobacco history but quit in 1954 and an overall\n160-pack-per-year history. No recent history of alcohol use.\n\n\nFamily History:\nMother with coronary artery disease.', '\n\n\nPhysical Exam:\n99.8 85 80/60-L 150/80-R 20 100% AC 400/20/100%/PEEP 5\nGen- Lethargic appearing man on strecher. Will occasionally look\nin your dirrection to his name. Does not follow simple commands.\nDoes not answer any questions.\nHEENT- NC AT. Trach in place. Pinpoint pupils that are minimally\nreactive to light. Anicteric sclera. Right subcalvian triple\nlumen without erythema or other signs of infection.\nCardiac- RRR.\nPulm- Coarse breath sounds throughout. Difficult to detect\ndecreased breath sounds on the left.\nAbdomen- Soft. Does not respond to palpation. ND. Minimal bowel\nsounds. 1996 in place with no erythema or discharge.\nExtremities- No c/c/e. 2+ DP pulses bilaterally. Feet are warm.\n\nMirna Deng Pt Pegram frequent twiching. Moderate rigidity with\nmovement of his limbs. Positive clonus.', ' Downgoing toes\nbilaterally.\n\n\nPertinent Results:\n1908-12-25 09:35PM TYPE-ART TEMP-37.8 RATES-25/ TIDAL VOL-450\nPEEP-5 O2-40 PO2-98 PCO2-54* PH-7.43 TOTAL CO2-37* BASE XS-9\n-ASSIST/CON INTUBATED-INTUBATED\n1908-12-25 09:35PM K+-3.8\n1908-12-25 09:17PM CK(CPK)-33\n1908-12-25 09:17PM CK-MB-4 cTropnT-0.13\n1908-12-25 06:45PM TYPE-ART TEMP-38.5 RATES-25/0 TIDAL VOL-450\nPEEP-5 O2-40 PO2-66* PCO2-68* PH-7.35 TOTAL CO2-39* BASE XS-8\n-ASSIST/CON INTUBATED-INTUBATED\n1908-12-25 02:44PM TYPE-ART TEMP-38.3 RATES-25/ TIDAL VOL-485\nPEEP-5 O2-100 PO2-68* PCO2-71* PH-7.36 TOTAL CO2-42* BASE XS-10\nAADO2-589 REQ O2-95 INTUBATED-INTUBATED VENT-CONTROLLED\n1908-12-25 11:54AM GLUCOSE-77 UREA N-28* CREAT-0.6 SODIUM-148\nPOTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-37 ANION GAP-11\n1908-12-25 11:54AM CK-MB-4 cTropnT-0.', '16\n1908-12-25 09:05AM TYPE-ART RATES-/24 PO2-401 PCO2-88* PH-7.25\nTOTAL CO2-40 BASE XS-7 -ASSIST/CON INTUBATED-INTUBATED\n1908-12-25 07:07AM TYPE-ART O2-100 PO2-439* PCO2-107* PH-7.21\nTOTAL CO2-45 BASE XS-10 AADO2-186 REQ O2-39 INTUBATED-INTUBATED\n1908-12-25 06:20AM URINE HOURS-RANDOM\n1908-12-25 06:20AM URINE UHOLD-HOLD\n1908-12-25 06:20AM URINE COLOR-Yellow APPEAR-Clear SP Islam-1.019\n1908-12-25 06:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500\nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0\nLEUK-NEG\n1908-12-25 06:20AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE\nEPI-0-2\n1908-12-25 05:36AM O2 SAT-84\n1908-12-25 05:34AM GLUCOSE-186* UREA N-28* CREAT-0.5 SODIUM-148\nPOTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-40 ANION GAP-8\n1908-12-25 05:34AM ALT(SGPT)-73* AST(SGOT)-50* CK(CPK)-32* ALK\nPHOS-328* AMYLASE-42 TOT BILI-0.', '6\n1908-12-25 05:34AM LIPASE-18\n1908-12-25 05:34AM CK-MB-NotDone cTropnT-0.08\n1908-12-25 05:34AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.1\nMAGNESIUM-2.2\n1908-12-25 05:34AM WBC-14.2# RBC-3.23* HGB-8.7* HCT-29.1\nMCV-90 MCH-26.8 MCHC-29.8* RDW-14.3\n1908-12-25 05:34AM NEUTS-93.2* BANDS-0 LYMPHS-2.4* MONOS-4.1\nEOS-0.1 BASOS-0.1\n1908-12-25 05:34AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+\nMACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-3+ STIPPLED-OCCASIONAL\nENVELOP-2+\n1908-12-25 05:34AM PLT COUNT-332\n1908-12-25 05:34AM PT-16.0* PTT-28.5 INR(PT)-1.7\n1908-12-25 05:30AM LACTATE-1.3\n\nstudies:\nECG- Sinus rhythm at 72 beats per minute. Nonspecific ST-T wave\nchanges but no major changes since previous studies.\n.\nCXR- Stent projecting over the right brachiocephalic vein. Right\nlung remains opacified with shift of the cardiac and mediastinal\ncontours toward the right consistent with previous\npneumonectomy.', ' There is blunting of the left costophrenic angle\nwhich could represent pleural thickening or small left pleural\neffusion. Slightly increased interstitial markings int he left\nlung which appear stable. No new left pneumo or focal\nconsolidation.\n.\nHead CT (WET READ)- No hemorrhage, shift, mass effect, or\nevidence of hydrocephalus. No evidence of a major CVA.\n\nUS upper extremity:IMPRESSION:\n1) Nonocclusive thrombus in the left cephalic vein.\n2) Nonocclusive thrombus in the distal left brachial veins\n\nTransabdominal ultrasound examination was performed. The\ngallbladder is not distended. There is an 8-9 mm stone located\nat the neck of the gallbladder. The gallbladder wall is\nthickened. There are possible crystal or tiny cholesterol polyps\nlocated at the fundus of the gallbladder. No intra or\nextrahepatic biliary ductal dilatation is identified.', ' The common\nduct is not dilated and measures 3 mm. Flow in the portal vein\nis anterograde. Limited evaluation of the liver demonstrates no\nfocal abnormality.\n\nIMPRESSION: Thickened gallbladder wall with a stone in the\ngallbladder neck in a nondistended gallbladder. In the proper\nclinical setting, these findings may be consistent with\ncholecystitis. They are not completely typical for acute\ncholecystitis. Gallbladder wall thickening may also be produced\nby third spacing of fluids. If there is continued clinical\nconcern for cholecystitis, a HIDA scan may be performed for\nfurther evaluation.\n\nTECHNIQUE: CT images of the chest without the administration of\nIV contrast.\n\nCOMPARISON: 1980-6-17 and 1934-6-18.\n\nFINDINGS:\nSoft tissue window images demonstrate changes of prior right\npneumonectomy and mediastinal shift towards the right.', ' There is\nno pathologic axillary, mediastinal, or hilar lymphadenopathy.\nThere is a left pleural effusion. The patient is intubated with\na tracheostomy tube. A stent is again identified within the\nright brachiocephalic vein. The heart demonstrates coronary\ncalcifications, but is normal in size. The main pulmonary artery\nappears prominent measuring 3.5 cm.\n\nLung window images demonstrate multifocal nodular opacities seen\nscattered throughout the left lung. No specific areas of\ncavitation are identified within these nodules. Atelectasis is\nalso seen at the left lung base. There is no focal consolidation\nor pneumothorax. Septal thickening is seen throughout the left\nlung field. A small 3-mm nodule seen on the prior studies is\nagain seen, though slightly difficult to discern given the\nsurrounding septal thickening and nodular opacities.', ' However, on\nthe study from 1934-6-18, this nodule was clearly seen and appears\nstable dating back to 1980-6-17. The bronchi appear patent to the\nsegmental level within the left lung.\n\nImages of the upper abdomen demonstrate high-density material\nwithin dependent portion of the gallbladder, probably relating\nto sludge. A percutaneous gastrostomy tube is seen within the\nstomach. The remainder of the visualized portion of the upper\nabdomen is unremarkable other than arterial calcifications. The\nsoft tissues are unremarkable. Degenerative changes are seen\nthroughout the thoracic spine.\n\nIMPRESSION:\n1) Multifocal nodular opacities seen scattered throughout the\nentire left lung. These most likely represent aspiration\npneumonia. Septic emboli are considered less likely based on the\nCT appearance.', '\n2) Mild CHF.\n3) Left upper lobe nodule seen on the prior study of 1934-6-18\ndemonstrates stability dating back to 1980-6-17.\n4) Probable sludge within the gallbladder.\n5) Findings suggestive of underlying pulmonary arterial\nhypertension.\n\n\nBrief Hospital Course:\n65 y/o man with PMH significant for squamous cell lung CA, type\n2 DM, atrial fib, and multiple past pneumonias admitted from\nAnderson Group Hospital with mental status change and hypotension.\n\n#ID/sepsis\nPatient had fever and leukocytosis initially with fluctuating\nblood pressure, lactate 1.3. His blood pressure in the ED was\nmeasured on the left arm (which is typically much lower). His\nblood pressure on the right was found to be normal and pressors\nwere off. Sputum culture was sent(colonized with pseudomonas),\nblood culture, urine culture and cath tip culture negative on\ndischarge.', " His decubitus ulcer looks clean. His line was resited\nline to the right femoral. Chest CT was consistent with\naspiration pneumonia. He will be continued on zosyn for 14 days.\nHe remained afebrile and no pressors required throughout the\nrest of his hospital stay.\n\n#Mental status changes:\nHis mental status improved with decreasing CO2 and also with\nnarcan. His CO2 remained well controlled in the hospital and was\nat baseline in 70s. CT head was negative. Narcotics was taken\ninto consideration as possible cause of mental status changes.\nPatient's duragesic patch was removed in the ED.\n\n#anemia/coagulation\nPatient has history of deep venous thrombosis with IVC filter\nand SVC clot and also atrial fibrillation for which he was on\ncoumadin. COumadin was taken off 3 days prior to hospital\nadmission because he had blood oozing from his trach and foley.", '\nIn hospital, central line was attempted intially on the right\nsubclavian but the artery was puctured. His right femoral artery\nwas also punctured and he did lose a signifcant amount of blood.\nThe 2 arterial puncture was tamponaded and there was no\nhematoma. He also got an ultrasound of uppper extremity which\nrevealed DVT in left arm for which he was started on heparin\ndrip. He then had mild guiac negative stool and oozing from\narterial line site. Heparin drip was then stopped and he was\ngiven 2 unit of transfusion. His hematocrit had been stable\nsince then. On discharge, coumadin was not restarted. It should\nbe restarted in 1-2days time if the hematocrit remain stable.\n.\n#transaminitis\nHe presented intially with transaminitis likely from\nhypotension. LFTS trended down on discharge. RUQ ultrasound was\ndone which showed gallstone at neck of GB, no distension,\nthickened gallbladder.', ' He remained afebrile and has no abdominal\ntenderness\n\n#respiratory:\nPatient has squamous cell lung CA post right pneumonectomy and\npost tracheostomy. During his past admission there was concern\nabout cuff leak and possible tracheomalacia. Dr. Son\nrecommended keeping the cuff pressures low with a cuff leak to\nprevent further tracheamalacia. Possible change the trach to a\nfoam-filled trach (Meraz tube) in the future if the cuff leak\nis interfering with the ability to ventilate. He remained on\nassist control ventilation.\n.\n# Lorena Abdullah Pt with mildly elevated Na at 148. This is most\nlikely due to water deficit as he can not drink to replace his\nneeds. He recieved free water through G tube.\n.\n# Cardiac\nPatient has long history of atypical chest pain but has no such\ncomplain during this hospitalization.', " Cardiac enzymes were\nunremarkable. He was continued on aspirin and also amiodarone\nfor atrial fibrillation. He is to avoid beta blockers and\ncalcium channel blockers because of profound bradycardia.\n.\n#Type 2 diabetes mellitus\nPatient was continued on standing 8U glargine and sliding scale\nwhile in hospital.\n\n#Anxiety/pain\nPatient's family reports that he is extemely anxious at\nbaseline. He was continues on his outpatient doses of Haldol for\nanxiety 5mg hs, 2mg 8am/2pm, 1mg tid/prn, and paxil. His pain is\nfrom his scaral decubitus ulcer and back pain. Anxiety has been\nseverely worsened in the past with ativan. Would avoid further\nativan. Fentanyl patch was discontinued since there was a\nconcern regarding narcotic overdose. He was on prn morphine.\nTHis should be adjusted in Anderson Group Hospital.", '\n\n# Sacral Decubitus:\nHe had Kinair bed\n\n# FEN\nTube feeds was continued with no residual\n\n#access\nHe had picc line on discharge\n\n#code\nOK with pressor, do not resuscitate(confirmed again with family\nmeeting)\n\n\nMedications on Admission:\n1. Xopenex 1.2 mg inhaled Q4H\n2. Atrovent neb Q6H PRN\n3. Haldol 1 mg 0800 and 1400\n4. Haldol 5 mg QHS\n5. Casec powder 2 tablespoons TID\n6. Lantus insulin 8 units QHS\n7. Ambien 5 mg QHS\n8. Flovent 110 mcg 2 puffs Q12H\n9. Lactulose 20 gm daily\n10. Glycerin suppository daily\n\n Allergies:\n1. Doxepin\n2. Levofloxacin\n3. Oxycontin\n4. Benzodiazepines\n5. Ativan\n\n11. Colace 100 mg Anderson Group Hospital\n12. Dulcolax 10 mg suppository daily\n13. Theravite liquid 5 ml daily\n14. MOM 30 ml daily\n15. Paxil 20 mg daily\n16. Vitamin C 500 mg daily\n17. Vitamin D 800 units daily\n18.', ' Zinc 220 mg daily\n19. ASA 325 mg daily\n20. Prevacid 30 mg daily\n21. Humulin SS\n22. Atrovent nebs Q4H PRN\n23. Xopenex 1.25 mg Q4H PRN\n24. Tylenol 650 mg Q4H PRN\n25. Haldol 1 mg Q8H PRN\n26. Duragesic patch 75 mcg Q72H\n27. Amiodarone 400 mg daily\n\n\nDischarge Medications:\n1. Fluticasone Propionate 110 mcg/Actuation Aerosol Anderson Group Hospital: Two (2)\nPuff Inhalation Anderson Group Hospital (2 times a day).\n2. Lactulose 10 g/15 mL Syrup Anderson Group Hospital: Thirty (30) ML PO TID (3\ntimes a day).\n3. Glycerin (Adult) 3 g Suppository Anderson Group Hospital: One (1) Suppository\nRectal PRN (as needed).\n4. Docusate Sodium 150 mg/15 mL Liquid Anderson Group Hospital: One Hundred (100) mg\nPO BID (2 times a day).\n5. Acetaminophen 325 mg Tablet Anderson Group Hospital: 1-2 Tablets PO Q4-6H (every\n4 to 6 hours) as needed.', '\n6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Anderson Group Hospital: Two (2)\nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.\n7. Paroxetine HCl 20 mg Tablet Anderson Group Hospital: One (1) Tablet PO DAILY\n(Daily).\n8. Aspirin 325 mg Tablet Anderson Group Hospital: One (1) Tablet PO DAILY (Daily).\n9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Anderson Group Hospital: One\n(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).\n10. Amiodarone HCl 200 mg Tablet Anderson Group Hospital: Two (2) Tablet PO DAILY\n(Daily).\n11. Albuterol 90 mcg/Actuation Aerosol Anderson Group Hospital: Six (6) Puff\nInhalation Q4H (every 4 hours).\n12. Ipratropium Bromide 18 mcg/Actuation Aerosol Anderson Group Hospital: Six (6)\nPuff Inhalation Q4H (every 4 hours).\n13. Haloperidol Lactate 2 mg/mL Concentrate Anderson Group Hospital: Five (5) mg PO\nHS (at bedtime).', '\n14. Haloperidol Lactate 2 mg/mL Concentrate Anderson Group Hospital: One (1) mg PO\nBID (2 times a day): at 8AM and 2PM.\n15. Heparin Sodium (Porcine) 5,000 unit/mL Solution Anderson Group Hospital: One (1)\nml Anderson Group Hospital TID (3 times a day).\n16. Zolpidem Tartrate 5 mg Tablet Anderson Group Hospital: Two (2) Tablet PO HS (at\nbedtime).\n17. Nitroglycerin 0.3 mg Tablet, Sublingual Anderson Group Hospital: One (1) Tablet,\nSublingual Sublingual PRN (as needed).\n18. Morphine Sulfate 10 mg/5 mL Solution Anderson Group Hospital: Five (5) mg PO Q6H\n(every 6 hours) as needed for pain.\n19. Piperacillin-Tazobactam 4.5 g Recon Soln Anderson Group Hospital: 4.5 gm\nIntravenous Q8H (every 8 hours) for 10 days.\n20. Insulin Glargine 100 unit/mL Solution Anderson Group Hospital: Eight (8) unit\nSubcutaneous at bedtime.', '\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nDay-Hess Medical Center & Rehab Center - Baird-Jacobs Hospital\n\nDischarge Diagnosis:\nhypotension and altered mental status likely from narcotic\noverdose +/- aspiration pneumonia\n\n\nDischarge Condition:\nstable\n\nDischarge Instructions:\nplease return to the hospital or call your doctor if you have\nmore shortness of breath, confusion, hypotension, chest pain,\nfever or if there are any concerns at all.\n\nPlease take all prescribed medication\n\nFollowup Instructions:\nPLease follow up with doctors Brian Post.\n\nCoumadin has been discontinued because you had significnant\nbleeding from arterial punctures from attempted central line\ninsertion. This should be restarted at a lower dose in 7-26 days\ntime given the history of DVT and also atrial fibrillation\n\nFentanyl patch has been discontinued due to concern about\nnarcotic overdose.', ' Morphine IV prn has been used. Total morphine\nuse should be calculated and patient can be started on standing\nmorphine if necessary\n\nPatient should continue zosyn for a total of 14 days(started on\n1908-12-25)\n\n\n\nCompleted by:1982-2-19']

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